4.10.4.1 Acute alcohol withdrawal

General Prescribing Notes

  • 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)
  • Refer to NI Alcohol Use Disorders Care Pathway – management in the acute hospital setting
  • 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 • A benzodiazepine should be used in a sufficient dose to produce sedation for the initial 24-48 hours, then gradually withdrawn over 4-5 days, e.g. chlordiazepoxide (oral) 20-40 mg 4 times daily for the initial 24-48 hours then reduce
  • 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
  • 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 on co-existing alcohol and benzodiazepine dependence click here
  • For people with a significant co-morbid mental health disorder, and those at high risk of suicide – refer to a psychiatrist

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 AND psychosocial support

Prescribe as capsules not tablets (high cost 'special')

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

Prescribing notes

Community-based assisted withdrawal

  • See NI Drugs & Alcohol Services directory for information on treatment and support services available across Northern Ireland
  • 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 NI Alcohol Use Disorders Care Pathway – management in the acute hospital setting

Co-existing benzodiazepine and alcohol dependence

  • Consider in-patient management or secondary care involvement
  • Ideally manage with one benzodiazepine, normally chlordiazepoxide (diazepam is an alternative if the patient is already taking), not multiple benzodiazepines
  • It may be prudent to seek specialist advice. One option may be to increase the dose of benzodiazepine used for withdrawal: calculate initial daily dose based on requirement for alcohol withdrawal plus equivalent regularly used daily dose of benzodiazepine
    • 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
  • Community-based withdrawal should last longer than 3 weeks and be tailored to the person’s symptoms and discomfort
  • In-patient regiments should last for 2 to 3 weeks or longer depending on the severity of benzodiazepine dependence