DETOXIFICATION FROM ALCOHOL - typical uk hospital guidelines

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THE MANAGEMENT OF WITHDRAWAL SYNDROMES

DETOXIFICATION FROM ALCOHOL

Detoxification is only indicated in those who experience physical withdrawal symptoms such as shakes, sweats, panic, anxiety or withdrawal fits after a period of abstinence (e.g. overnight), or in those that drink to avoid such symptoms. As a rule of thumb, medication may not be required for women who drink less than 12 units per day, or men who drink less than 16 units per day. The final decision will be based on the elicitation of a history of alcohol withdrawal symptoms. No patient should ever be advised to stop drinking immediately due to the potentially lifethreatening complications of Delirium Tremens, seizures and Wernicke's Encephalopathy. Patients who do not require a detoxification can be advised to slowly reduce their daily intake of alcohol over a period of days or weeks, as can patients who are physically dependent but cannot or will not access detoxification.

MEDICATION

The drug of choice for control of withdrawal is chlordiazepoxide (Librium). Oxazepam may be the drug of choice for alcohol detoxification in patients with hepatic insufficiency, as it is not metabolised by the liver. epam should be avoided where possible in the treatment of addictive disorders due to its greater addictive potential as compared to chlordiazepoxide. Chlormethiazole (Heminevrin) which has been associated with a risk of death due to respiratory depression when combined with alcohol, should also be avoided.

A course of parenteral thiamine (Pabrinex) should be given over the first several days of detoxification as prophylaxis against the development of Wernicke's Encephalopathy and chronic memory deficits. Wernicke's-type brain damage is highly prevalent in alcoholics as are associated memory deficits which cause permanent disability (Ambrose et al, 2001). The process of detoxification is liable to precipitate acute loss of thiamine (vitamin B1) stores in patients who are already chronically thiamine deficient. The acute effects are often subclinical, but it is likely that many chronic memory problems in alcoholic patients are the direct result of episodes of withdrawal whether this is medically assisted or not. Oral thiamine preparations may be poorly absorbed in the alcoholic patient; administration by the intramuscular or intravenous route is essential for effectiveness. The administration of glucose for the treatment of hypoglycaemia may exacerbate the acute loss of thiamine even further in the detoxifying alcoholic, and it is essential that parenteral thiamine is administered before the glucose load. Due to the small risk of anaphylaxis associated with parenteral thiamine administration, this should only be given where medication for treatment of anaphylaxis is available on-site.

A presumptive diagnosis of Wernicke's Encephalopathy should be made if any of the following supervene during detoxification: ataxia, confusion, memory disturbance, hypothermia, hypotension, opthalmoplegia or nystagmus, coma/ unconsciousness. This represents a medical emergency and should result in immediate transfer to hospital, and treatment with high dose Pabrinex.

DOSAGE & REGIMES

'Symptom-triggered' regimes should ideally be used for in-patient detoxification (see Section D2, page 56 / appendix 10, page 130), and where day-care detoxification is available. Standard symptom-triggered regimes should not be used for community detoxification due to the reduced availability of nursing staff for regular monitoring of the severity of alcohol withdrawal. Advice should be sought from the local specialist team as to the regime to use in a particular patient. The following provide a 'rule of thumb' guide only for community alcohol detoxification.

Chlordiazepoxide - fixed-schedule regimes:

For the mildly dependent alcoholic (SADQ* 10-20): 20mg qds tapered to zero over 5 to7 days.

For the moderately dependent alcoholic (SADQ 20-30): 30mg qds tapered to zero over 7 days.

For the severely dependent alcoholic (SADQ > 30): up to 50mg qds tapered to zero over 10 days.

*Symptoms of Alcohol Dependence Questionnaire (appendix 10, page 130).

The effect of dosages will vary from individual to individual due to physiological variations in metabolism and the effect of liver disease and cognitive deficits on sensitivity to medication. Regular monitoring by a nurse from the specialist team will allow adjustment of dosage as necessary. Patients that appear over-sedated should be advised to omit a dose of medication. Patients whose CIWA-Ar (see appendix 10, page 130) (Sullivan et al, 1989) scores are consistently less than ten after the third day of detoxification should have their dosage schedule reviewed with a view to a more rapid completion of detoxification.

No patient should ever be advised to stop drinking immediately.

Patients who do not require a detoxification can be advised to slowly reduce their daily intake of alcohol over a period of days or weeks, as can patients who are physically dependent but cannot or will not access detoxification.

The drug of choice for control of withdrawal is chlordiazepoxide (Librium).

Chlormethiazole (Heminevrin) should be avoided due to enhanced risk of respiratory depression if used together with alcohol.

A course of parenteral thiamine (Pabrinex) should be given over the first several days of detoxification as prophylaxis against the development of chronic memory deficits which are highly prevalent in alcoholics.

Oral thiamine preparations are often poorly absorbed in the alcoholic patient; administration by the intramuscular or intravenous route is essential for effectiveness.

Pabrinex injections:

One pair IM ampoules daily for the first 3 days of treatment as prophylaxis - this should be administered in the GP's surgery or specialist team base if the detoxification is taking place in the community, due to the unlikely eventuality of anaphylaxis occurring following IM injection.

Other medication:

For fits: diazepam 10mg PR or IV followed by transfer to A & E (unless on medical ward).

For insomnia: zopiclone 7.5-15mg nocte prn for a maximum of four weeks.

General Care.

Clients undergoing detoxification require lots of fluid with sugary fluids available in case of hypoglycaemia and light regular meals despite feeling anorexic.

Caffeine intake should be cut down to 4-5 cups of tea or coffee a day.

Agitation can be reduced if there is a quiet and ordered environment.

MONITORING REQUIREMENTS

Each set of observations should include:

Alcometer reading.

Alcohol withdrawal scale (CIWA-Ar).

Observation of level of consciousness and orientation.

Pulse, blood pressure and temperature

Observation for nystagmus & opthalmoplegia & ataxia.

Observation for dehydration & marked tremor.

With fixed-dose regimes used in community detoxification observations should be performed:

Immediately before the start of the detoxification.

Twice daily on days one to five.

As indicated thereafter.

In the presence of a positive alcometer reading, chlordiazepoxide should only be commenced if withdrawal symptoms are significant (i.e. CIWA-Ar of more than 15). Patients should always be requested to have their last alcoholic drink on the night before detoxification is due to commence.

If the detoxification is occurring at home, then a nurse from the local specialist substance misuse team will act as the observer, and arrange with the GP for the administration of Pabrinex in the surgery on days one to three of detoxification, and for the dispensing of chlordiazepoxide. In addition, home detoxification should only be commenced if there is a supportive spouse, family member or friend who is willing to remain continuously with the client for a minimum of 72 hours, and for the majority of the rest of the week.

>> > http://www.thedailybeast.com/cheats/2011/09/10/perscription-drug-found-in-winehouse-s-system.html> > Prescription Drug Found in Winehouse's System > > In an interview airing Monday on 's new talk show, Mitch Winehouse says that while toxicologists didn't find any illegal drugs in Amy's system at the time of her death, they did find traces of a prescription drug she had been using to help detox from alcohol. Mitch explains she was taking Librium, an anti-anxiety medication that he describes as a "normal drug given to people who are detoxing [from alcohol] that decreases the risk of people having seizures." He speculates that she may have died from a detox seizure: "Everything Amy did she did to excess. She drank to excess and did detox to excess." An official inquest will determine her final cause of death.> Sent via BlackBerry by AT & T>