4.10.4.1 Acute alcohol withdrawal

General Prescribing Notes

  • Refer to local trust policy.
  • Refer to NICE pathway on alcohol-use disorders.
  • Patients should be assessed to determine if they require in-patient treatment rather than out-patient care (see criteria in NICE CG115).
  • Risk factors for complicated withdrawal include very heavy alcohol consumption, history of delirium tremens (DTs) or alcohol withdrawal seizures.
  • A benzodiazepine should be used in a sufficient dose to produce sedation for the initial 24-48 hours, then gradually withdrawn over 4-5 days, e.g. chlordiazepoxide (oral) 20-40 mg 4 times daily for the initial 24-48 hours then reduce.
  • If patient still hallucinating despite high dose benzodiazepines, consider haloperidol orally or IM (in secondary care only). See the BNF.
  • If patient is not settling seek senior medical advice.
  • If patient is very disturbed despite oral therapy or if withdrawal seizures occur, consider diazepam (Diazemuls®) as slow IV injection 10 mg initially, repeated if necessary. Be aware of respiratory depression and increasing drowsiness.
  • Attention needs to be given to nutrition, electrolyte and fluid balance. Vitamins B and C injection is indicated in patients with alcohol-induced encephalopathy and should also be administered to all in-patients for prophylaxis.
  • Acamprosate is not of value in alcohol withdrawal. It is used in conjunction with psychological management of alcoholism for a selected group of patients under specialist care.
  • To gain control of severe symptoms, adjunctive treatment may be necessary.
  • Benzodiazepines have dependence potential. To minimise risk of dependence, administer short-term only. Benzodiazepines should not be prescribed if the patient is likely to drink alcohol concomitantly.
  • Choice of benzodiazepines:
    • chlordiazepoxide is first choice oral agent for outpatients and general practice alcohol withdrawal, because it has less abuse potential and ‘street value’ than diazepam
    • chlordiazepoxide is used for in-patients
    • diazepam is first choice for in-patients if the parenteral route is required
  • Short acting benzodiazepines such as oxazepam or lorazepam may be preferred in those for whom over sedation must be avoided, in patients with liver disease, COPD or a history of alcohol related DTs and seizures.
  • For advice see co-existing alcohol and benzodiazepine dependence.
  • For people with depression or anxiety disorders, treat the alcohol misuse first.
  • If depression or anxiety continues after 3 to 4 weeks of abstinence, assess and consider referral and treatment.
  • For people with a significant co-morbid mental health disorder, and those at high risk of suicide – refer to a psychiatrist.
  • For alcohol misuse with opioid, stimulant, cannabis or benzodiazepine misuse – actively treat both conditions.
  • Encourage people with nicotine dependence to stop smoking.

Assisted alcohol withdrawal for moderate to severe alcohol dependence

Consider an assisted withdrawal programme if a person drinks >15 units alcohol per day and/or scores ≥20 on AUDIT (Alcohol Use Disorders Identification Test).

ChoiceDrugDosage
1st choice

Chlordiazepoxide capsules 5mg, 10mg; tablets 10mg
AND psychosocial support

Dose: 20-40mg four times daily for first 24 to 48 hours, then once stabilised, gradually reduce dose over 4 to 5 days. In severe cases 250mg daily in divided doses
Or
In-patient only if withdrawal seizures occur

Diazepam emulsion injection 5ml/ml (Diazemuls®)
AND psychosocial support

Dose:
By slow intravenous injection, 10mg initially with respiratory monitoring

Prescribing Notes

Community-based assisted withdrawal

  • Use fixed-dose drug regimens; start treatment with a standard dose then reduce dose to zero over 7 to 10 days according to a standard protocol.
  • Initial dose should be based on severity of alcohol dependence and/or regular daily level of alcohol consumption.
  • Prescribe for instalment dispensing; no more than 2 days medication to be supplied at any time.
  • A family member/carer should preferably oversee the administration of medication.
  • Monitor the service user at least every other day, ideally daily for the first 3 days.
  • Adjust the dose if severe withdrawal symptoms or over-sedation occur.

In-patient / residential assisted withdrawal

  • Refer to local trust policy.
  • Use a fixed-dose or symptom-triggered regimen.
  • A symptom-triggered approach involves tailoring the drug regimen according to the severity of withdrawal symptoms. All staff should be competent in monitoring symptoms effectively and a valid withdrawal scale (e.g. CIWA or GWAS) should be used to support clinical assessment and decisions.

Co-existing benzodiazepine and alcohol dependence

  • Strongly consider in-patient management or secondary care involvement.
  • Manage with one benzodiazepine, normally chlordiazepoxide (diazepam is an alternative if the patient is already taking), NOT multiple benzodiazepines.
  • Increase the dose of benzodiazepine used for withdrawal:
    • For example, an option for patients taking concurrent diazepam is to calculate the daily dose based on the summated alcohol and diazepam (equivalent) requirement. The diazepam can then be gradually reduced to assist alcohol withdrawal. This avoids multiple benzodiazepines being prescribed simultaneously.
  • calculate initial daily dose based on requirement for alcohol withdrawal plus equivalent regularly used daily dose of benzodiazepine.
  • Community-based withdrawal should last longer than 3 weeks and be tailored to the person’s symptoms and discomfort.
  • In-patient regimens should last for 2 to 3 weeks or longer depending on the severity of benzodiazepine dependence.