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Many individuals who have sustained serious problems as a result of their drinking have not developed dependence and will not experience significant physiological disturbance upon withdrawal. A further important group will show dependence to a slight or moderate degree but will still not suffer from withdrawal symptoms that are to any major extent debilitating. On the other hand, there are individuals who will feel wretched during withdrawal, and a small group for whom withdrawal will precipitate life-threatening disturbances. Many individuals who are problem drinkers may not know about alcohol withdrawal symptoms, and therefore exploration of symptoms is required.
Given the diversity in possible withdrawal experiences, it makes no sense to approach the clinical management of withdrawal in terms of a fixed regime for all comers. A spectrum of likely withdrawal experiences suggests a corresponding need for a spectrum of clinical approaches. Many patients will need no medication at all to help them come off alcohol, whereas, for many others, withdrawal can be safely managed on an out-patient basis with appropriate medication. In only a minority will safe withdrawal from alcohol require admission to either a hospital or residential rehabilitation setting to receive more intensive monitoring of a withdrawal and medication regimen. The clinical significance of withdrawal is, first, therefore, the demand it makes on the clinician to see the different needs of different patients and to manage minor withdrawal states without unnecessary fuss while at the same time learning to recognize the necessity for very great care in managing the potentially dangerous situation. This chapter discusses clinical management of withdrawal in terms of different regimes for different intensities of need.
Significance of withdrawal as a barrier to “coming off”
Some patients will present themselves as unable to come off alcohol because of their incapacity to cope with the withdrawal symptoms. This plea may be entirely genuine, but their degree of withdrawal and any associated complications should be confirmed by appropriate assessment. A patient who has previously experienced an attack of delirium tremens (DTs; “the horrors”) may know full well that when they are in a state of severe relapse there is a grave risk of precipitating a further attack of delirium if they attempt to stop drinking abruptly. For such individuals – and similarly for those who have experienced a seizure during alcohol withdrawal – their request for in-patient admission should be carefully considered. On the other hand, there are patients with less severe degrees of dependence whose belief that they cannot stop drinking without being hospitalized should be kindly resisted. It is important for such patients to learn that they can cope with withdrawal at home, with appropriate medication and support. This will result in minimal upheaval and will also not reinforce the idea that they are incapable of dealing with withdrawal and relapse themselves without repeated admissions. Unnecessary admissions, which engender sickness behaviour, are best avoided. In any case, with fewer dedicated units for alcohol detoxification available in the United Kingdom and United States, safe and appropriate out-patient management is increasingly required.
Withdrawal and clinical teamwork
Given that medication may be prescribed for out-patient withdrawal, and given also the potential seriousness of the major withdrawal experience that demands in-patient admission, the medical practitioner clearly has an important role to play in treatment. If the patient is being handled primarily by nonmedical staff, this implies the need for good medical liaison. The counsellor in an agency with no medically trained staff must, for instance, know when to make the rapid out-patient/community alcohol team referral or call on the advice of the general practitioner with whom there is a working relationship.
Withdrawal in context
Mere stopping drinking or drying out is not by itself an effective way of helping a patient, and whatever is done about withdrawal only has its meaning within the context of other strategies for aiding the patient. Clinical management of withdrawal, although essential, does not in itself constitute treatment of the drinking problem. When plans for withdrawal are being made during their initial assessment and goal-setting, the withdrawal phase is easily placed within the wider frame about what relapse prevention support they require. When, however, withdrawal is being dealt with in response to relapse and in an atmosphere of crisis, it is easy to react precipitously and forget the context within which decisions about withdrawal management ought to be made. Questions that should be asked in such circumstances centre on what relapse prevention plans the patient had and what happened, as well as what needs to be done differently and what use the patient is to make of this help. There should be as much discussion as possible about the patient’s expectations and their responsibility in this particular aspect of the contract to help. What plans has the patient got for the far side of withdrawal?
A checklist for managing alcohol withdrawal
Does the patient want to stop drinking?
To put this item first in the checklist may seem an overemphasis of the obvious, but it is not uncommon for an individual to not realize that “detox” means they have agreed to stop drinking. It may be that the doctor has given the patient medication to treat withdrawal because the doctor believes that the patient ought to come off alcohol, rather than because the patient seriously intends to come off alcohol. The patient leaves the interview with a prescription for a bottle of benzodiazepines, which they will use to supplement continued alcohol consumption at even greater risk than before.
Is it safe to conduct withdrawal in an out-patient setting?
This decision is made without difficulty when, as commonly happens, the patient is not severely dependent. They are, for instance, suffering from morning shakes of only moderate intensity that have been present for not much longer than 6 months, and they came off alcohol for 2 weeks on their own initiative and without any untoward happenings a month ago. A brief review with the patient of such points as these will usually settle the question of whether out-patient withdrawal is appropriate and whether medication should be prescribed. A similarly quick answer can be reached in the other direction if there is a previous history of major withdrawal experience and the patient has now reinstated dependence of serious degree. It is decisions lying in the middle ground that can be challenging to the novice clinician, who should discuss the situation with those experienced in managing alcohol withdrawal. Handling this problem will, as ever, depend on a relationship with the patient that allows open discussion of the issues involved. Nevertheless, it should be possible to manage safely and effectively the majority of patients in the community (Collins, Burns, Van den Berk, & Tubman, 1990; Stockwell et al., 1991).
In addition to severity of dependence, a number of other specific pointers may offer further guidance regarding the safety of a community detox. Has out-patient management failed previously, and, if so, why? Is there any specific medical reason why community detoxification may be hazardous; for example, a history of DTs or withdrawal seizures? Is the home environment sufficiently supportive, both in terms of family or friends who may summon help if needed and in terms of support for treatment of the drinking problem? This is discussed further later.
A summary of the indicators that suggest detoxification might be more safely and effectively conducted in an in-patient setting is given in Table 11.1. These are only an indication though, and, particularly during assessment, it is important to ascertain if complications of alcohol withdrawal occurred with medication for detoxification or not. Many patients may experience complications that, in the presence of such medication, are much reduced or absent and therefore in-patient admission may not be required. In addition, in-patient facilities range from general medical hospitals to psychiatric nonspecialist wards to residential rehabilitation facilities. Therefore, the clinician needs to carefully consider what treatment and support the available in-patient facilities offer in relation to what their patient requires.
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Are there likely to be withdrawal symptoms that require clinical management?
Just as a clinician would not admit a patient for in-patient detoxification without first ensuring that it is needed (i.e., severe withdrawal symptoms are likely), a medically managed out-patient detoxification should not be undertaken without first determining that withdrawal symptoms are likely to be more than minimal. Some patients will be able to stop drinking with only minimal discomfort, and the clinician’s job is to reassure, support, and reassess if symptoms worsen. This might seem a too obvious point if it were not common to find patients routinely being offered benzodiazepines without any enquiry being made into their true needs.
What is the best time?
Completing successful alcohol withdrawal without adequate time or support is likely to be challenging. For instance, those who want to detox in the midst of a busy job or childcare commitments and in the full setting of usual drinking pressures are not giving themselves the best chance of success. Discussion may suggest that they set aside time or take time off work or use holiday leave especially for this purpose. To suggest this degree of planning may usefully help to focus commitment.
Is the environment and support adequate?
The environment should be properly supportive whether the patient is detoxifying at home or as an in-patient. Support includes not just emotional and practical help but also an environment free from problem drinkers and from people who encourage problem drinking by the patient. General and psychiatric nursing skills have to be employed to help the patient through what may be a few unpleasant days, and the ability of the patient to tolerate this experience will depend in part on the sort of friendliness and support which they are being offered. To mobilize support from other patients and from visiting relatives can also be valuable.
Although there are plenty of people who at some time in their lives have been so determined to deal with their drinking that they have come off alcohol in such adverse surroundings as a “wet” or drinking hostel for the homeless, it is always useful to think through with the patient how environmental supports may be deployed to maximize the chances of success. If there is a partner available to give support, that person should be brought into the discussion, and his or her active engagement may have benefit for both partners. This may also be the moment when a patient will be particularly able to accept the usefulness of Alcoholics Anonymous (AA) or similar organization: getting out perhaps to a meeting and hearing how others dealt with this problem or receiving a phone call from another member to give a feeling of contact and fellowship, with a follow-through to more continuing involvement. The patient should have had a physical examination and recent blood tests. It is important that his or her general practitioner is kept in the picture. For those undertaking their detoxification in the community, what support can the community alcohol team offer (e.g., daily appointments over the period of a few days or daily visits from a nurse as well as low-intensity support groups)?
Which medication?
Some practical aspects for the use of medication for medically assisted withdrawal will be discussed in this section, both to provide background information for the person other than the doctor who wants to understand this aspect of the patient’s treatment and to emphasize points of immediate medical concern.
Benzodiazepines
A drug of the benzodiazepine group is commonly the first choice for clinical management of alcohol withdrawal, although alternatives are available (e.g., anticonvulsants; see Kosten & O’Connor, 2003; Lingford-Hughes, Welch, Peters, & Nutt, 2012; Management of Substance Use Disorders Workgroup, 2009; National Institute for Health and Clinical Excellence, 2011). Longer acting benzodiazepines such as chlordiazepoxide or diazepam are helpful in preventing alcohol withdrawal seizures and delirium. It is best for the prescribing clinician to become familiar with one medication from this group to develop a sense of the likely needed dosages in particular circumstances, rather than switching medications. The skilled use of medication to ameliorate severe withdrawal distress or limit risk of seizures or delirium is a matter of titrating the dose against the symptoms. The withdrawal symptoms occur because the level of alcohol in the brain is falling, and these symptoms will be ameliorated when the level of prescribed medication is high enough to compensate. What one is in fact doing is substituting the alcohol with the medication, and it is often necessary and rational in the severe case to increase the medication dose boldly. Particularly with larger doses of medication, appropriate and competent monitoring should be conducted.
The dose and frequency of medication should be discussed with the patient and, if they are an out-patient, with anyone else supporting them. Instructions should written down as well as communicated verbally.
Prescribing regimes
Benzodiazepines can be prescribed in a number of ways. The most common mode of treatment is a tapering dose regime. For instance, chlordiazepoxide (Librium) may be prescribed in an initial dose of say 10–30 mg 3 or 4 times per day in an out-patient setting, reducing by 10 mg/d. Lower doses may be indicated for less severely dependent individuals, whereas higher starting doses may be required by in-patients due to their severe dependence and high risk of complications (e.g., 40–60 mg 3 or 4 times per day). Diazepam (Valium) is also commonly used. If there is an immediate need to bring severe symptoms under control, lorazepam may be given by intramuscular injection, with an initial dose of 25–30 μg/kg. Alternatively, diazepam may be given by slow intravenous injection or as a rectal suppository or enema.
A prescription should not be given for more than 3–7 days, and prescribing should not be allowed to trail on unnecessarily once the patient has withdrawn. A community or in-patient detoxification regime generally lasts about a week and rarely longer than 10 days (Lingford-Hughes et al., 2012).
Alternatively, in patients without a history of complications, a symptom-triggered regime can be instituted whereby medication is only given when symptoms emerge (Saitz et al., 1994). This approach requires skilled monitoring and should not be undertaken in its absence (Lingford-Hughes, et al., 2012; National Institute for Health and Clinical Excellence, 2010, 2011). A third method is “front-loading,” which involves giving a loading dose of diazepam and following this with doses every 90 minutes or so until the patient is lightly sedated (Sellers et al., 1983).
It should again be stressed that what is “enough” is determined by clinical observation of response rather than by any rulebook. If the patient becomes excessively drowsy or if there is a large fall in blood pressure, drugs should be cut back or temporarily withheld. Such an approach is far more in the patient’s interests than a blind reliance on heavy mixed medication schedules that will be unnecessarily extreme in many instances and yet insufficient in other cases.
If it has been necessary in the acute phase to load the patient with medication, one is then in effect subsequently carrying out medication withdrawal rather than an alcohol withdrawal procedure. This implies gradually tailing off the drug dose at a rate that will not produce significant additional withdrawal symptoms. The rate of reduction must once more be patient-specific and in accord with monitored symptoms.
Special populations
Healthy older patients going through managed withdrawal should be able to tolerate longer-acting benzodiazepines. However, they are more likely to experience concurrent physical illness, are at higher risk of developing medical complications (e.g., delirium), and are vulnerable to oversedation. Close monitoring is therefore advisable, although using short-acting benzodiazepines such as oxazepam or lorazepam in this age group can also be considered (Lingford-Hughes et al., 2012).
Short-acting benzodiazepines should also be considered in patients with alcohol-related liver disease. The extent of the elevation in biochemical markers (γ-glutamyl transferase [GGT], aspartate aminotransferase [AST]) will help guide decisions about dose level.
Medically supervised withdrawal of alcohol dependent pregnant women is ideally carried out in an in-patient setting, with input from medical and obstetric services to maximizes the health and safety of both the mother and the fetus. Pregnant women with alcohol dependence are likely to present later in the pregnancy (e.g., mid to late second trimester) and may be using other drugs as well. A risk–benefit assessment of alcohol withdrawal symptoms versus the prescription of benzodiazepines should be carried out. This involves taking a comprehensive history of alcohol and drug use and of withdrawal symptoms, carrying out a physical examination and obtaining laboratory investigations. The trimester of pregnancy should be noted. The use of benzodiazepines should be avoided where possible. However, they are less teratogenic than anticonvulsants and are only needed for a short period of time. If they are required, it is probably wise to use a short-acting variety (Flannery, Wolff, & Marshall, 2006; Substance Abuse and Mental Health Services Administration, 1993).
Monitoring is very important
Competent routine monitoring provides the basis for clinical management that is alert, flexible, and able to be rapidly escalated in case of need. There is much to be said for the use of standardized scales to facilitate this process, and a number of suitable instruments are available. The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar; Sullivan et al., 1989) is a 10-item scale that can be completed in about 5 minutes. It scores the severity of nausea, tremor, sweating, anxiety, agitation, headache, orientation, and sensory disturbances. A brief online course providing training in the CIWA-Ar is available at no charge (http://www.ci2i.research.va.gov/paws/default.htm). The 8-item Mainz Alcohol Withdrawal Scale is also available (Banger et al., 1992). Careful monitoring, combined with supportive care, can reduce the need for medication (Shaw et al., 1981).
In an in-patient setting, a sensible procedure may be for the nurses to make at least 8-hourly observations on all withdrawing patients for the first 3 days, but this may need to be more frequent during the first 24 hours. If seen daily in an out-patient setting, it is similarly sensible to check blood pressure, pulse, and temperature. Observations may be discontinued with the agreement of the medical and nursing team once readings are stable and within normal range. Every now and then, a patient who has given an incomplete history and who is expected to show only mild withdrawal will unexpectedly develop more severe symptoms. Routine observations over the first few days are therefore essential. If, however, a patient is not being seen daily, they and whoever is supporting them should be advised to seek urgent medical review if symptoms do not respond to medication.
In addition to rating withdrawal symptoms, at the start of alcohol detoxification, breath alcohol should be measured. Taking two measurements at least 20 minutes apart allows an estimation of the actual blood alcohol concentration and also confirms the rate of fall of blood alcohol. This is important for several reasons. First, if estimated blood or breath alcohol is high, there may be a danger of interaction with prescribed medication during the first few hours of detoxification and particular care must be taken with prescribing during this period. Second, if the patient has consumed a significant amount of alcohol immediately before arriving, their blood alcohol levels may still be rising. This should generate even greater caution in the immediate prescribing and administration of medication. However, there is no “safe” breath alcohol level because an alcohol dependent patient may have high levels (e.g., three times the legal driving limit) and yet experience significant withdrawal symptoms. Therefore, when deciding whether to give medication, the breathalyzer level and whether it is changing, and the severity of withdrawal symptoms should be taken into account.
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