Ketamine vs. Placebo as Adjunctive Therapies for Severe Alcohol Withdrawal

Inclusion Criteria: 1. Severe alcohol withdrawal defined by a CIWA score ≥ 15 and the need for at least 16 mg of lorazepam equivalents over a four-hour period. All benzodiazepine and barbiturate doses, whether oral or intravenous, will contribute to the cumulative amount using the following conversion: 1 mg lorazepam = 2 mg midazolam = 7.5 mg clorazepate = 15 mg phenobarbital. 2. Patients receiving standard therapy for severe alcohol withdrawal according to the UCH-specific, symptom-triggered alcohol withdrawal protocol in the ICU (or admission to the ICU is anticipated). Lorazepam is the preferred benzodiazepine agent for patients requiring ICU admission due to alcohol withdrawal. 3. Informed consent within 36 hours of qualifying for the study. Exclusion Criteria: 1. Patients \< 18 years of age or \> 85 years of age. 2. Patients receiving benzodiazepine therapy for purposes other than alcohol withdrawal (e.g. sedation, seizure control other than alcohol withdrawal). 3. Patients with alcohol withdrawal not requiring ICU admission. 4. Patients receiving epidural administration of medication(s). 5. Comatose patients by metabolic or neurologic affectation. 6. Patients with active myocardial ischemia or second- or third-degree heart block. 7. Patients with Child-Pugh score of C. 8. Moribund state with planned withdrawal of life support. 9. Patient pending transfer to another facility. 10. Patients with known or suspected severe adverse reactions to dexmedetomidine (or clonidine) or ketamine. 11. Pregnant females or females suspected of being pregnant. 12. Prisoners or active parolees. 13. Previous study participation. 14. Patients already receiving ketamine for alcohol withdrawal. Patients receiving dexmedetomidine will be excluded if the infusion exceeds 1 µg/kg per hour for more than two hours or any rate for a cumulative duration of 12 hours.