Trip Answers

Question answered:13/02/07 Warning! this question is over two years old.

Our literature search undertaken in the NLH guidelines and TRIP databases identified three British guidelines on alcohol dependence. None of these guidelines discuss or propose a recommended rate for reducing alcohol to balance the likelihood of withdrawal syndromes in patients with moderate to severe alcohol dependence. However, the following information may be of interest.

 

The guideline by the UK WHO Collaborating Centre notes in its section on detoxification:

 

“Patients with a moderate withdrawal syndrome may require benzodiazepines and vitamins in addition. Most can be detoxified, with a good outcome, as outpatients or at home.  Community detoxification should only be undertaken by practitioners with appropriate training and supervision.
Patients at risk of a complicated withdrawal syndrome (e.g. with a history of fits or delirium tremens, very heavy use and high tolerance, significant polydrug use, benzodiazepine dependence, severe co-morbid medical or psychiatric disorder) who lack social support or are a significant suicide risk may require specialist input and likely inpatient detoxification, which should be carried out in liaison with specialist alcohol services.”

 

If there is no evidence of physical or psychological harm due to drinking and the patient is not dependent, a controlled drinking programme is a reasonable goal:
- negotiate a clear goal for decreased use (e.g. no more than two drinks per day,  with two alcohol-free days per week).
discuss strategies to avoid or cope with high-risk situations (e.g. social situations  and stressful events)
- introduce self-monitoring procedures (e.g. a drinking diary) and safer drinking behaviour (e.g. time restrictions, drinking more slowly, interspersing with non-alcoholic drinks).

 
For patients with physical or mental illness and/or dependency, or failed attempts at controlled drinking, an abstinence programme is indicated. [1]

 

PRODIGY also recommends:

 

“Abstinence (long-term) is usually recommended if alcohol dependence is established or if there is marked physical damage.”

 

The section on pharmacological dependence states:

 

• “Abrupt cessation of alcohol can lead to withdrawal symptoms, and many people with alcohol dependence require controlled pharmacological detoxification to avoid discomfort, and to prevent the occurrence of seizures or delirium tremens [SIGN, 2003].
• In milder degrees of dependence, stopping drinking is unlikely to be complicated, and pharmacological detoxification may not be necessary

 

if:

o The person has no recent withdrawal symptoms, has not recently needed to drink to prevent withdrawal symptoms, and reported consumption of alcohol is < 15 units per day (men) or < 10 units/day (women).
o The person has no alcohol on breath test, and no signs or symptoms of withdrawal.
• Binge drinkers whose bouts last less than a week and people who are sober at interview, without withdrawal symptoms, seldom need medication unless drinking is extremely heavy (> 20 units/day).
• Most regular heavy drinkers will require controlled detoxification with pharmacological intervention.
• When medication to manage withdrawal is not needed, the person should be informed that at the start of detoxification they may feel nervous or anxious for several days, with difficulty in going to sleep for several nights (D)."

 

Concerning medication to reduce withdrawal symptoms, PRODIGY recommends:

 

“Benzodiazepines should be used in primary care to manage withdrawal symptoms in alcohol detoxification, but for a maximum period of 7 days (A) [DH et al, 1999; SIGN, 2003]. There is evidence from randomized, controlled trials to show that benzodiazepines reduce the signs and symptoms of alcohol withdrawal and the risk of seizures or delirium tremens, and they are currently considered the drugs of choice in the treatment of acute alcohol detoxification.”

 

Chlordiazepoxide is the preferred benzodiazepine for people managed in the community (D)…

 
But:

 

• “Clomethiazole (chlormethiazole) should not be used in alcohol detoxification in primary care (D). Although clomethiazole is an effective treatment for alcohol detoxification, it should only be used under close supervision due to the risk of respiratory depression in combination with alcohol, and the danger of dependence [SIGN, 2003].

 

SIGN has also produced a guideline on the management of harmful drinking and alcohol dependence in primary care. Annex 7 provides a management algorithm for determining the settings in which patients should be cared for plus the requirement for pharmacological detoxification." [3]

References
1. WHO UK Collaborating Centre. Introduction to alcohol misuse. February 2005. (http://www.library.nhs.uk/mentalHealth/viewResource.aspx?resID=79021).
2. PRODIGY. Alcohol – problem drinking. Last revised June 2004. (http://www.prodigy.nhs.uk/alcohol_problem_drinking/).
3. SIGN. The management of harmful drinking and alcohol dependence in primary care. September 2003. (http://www.sign.ac.uk/guidelines/fulltext/74/).

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