St Vincent's Hospital, FairviewSubstance Abuse Service

Detoxification

Stopping drinking suddenly or a severe reduction in intake can cause withdrawal symptoms, particularly for the dependent drinker. These symptoms vary from mild e.g. insomnia and mild anxiety to symptoms as severe as withdrawal seizures and delirium tremens (D.T.’s)

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The purpose of detoxification is to reduce or minimise the occurrence of withdrawal symptoms. Although detoxification from alcohol is a relatively common occurrence, vigilance is still required to ensure that it is safely managed and to detect complications.

Detoxification as an outpatient is effective and safe for people with mild to moderate symptoms and may, but not always, include the prescribing of medications to ameliorate symptoms.

St. Vincents Hospital, Fairview uses a combination of clinical assessment and objective screening tools to assist with determining the need for any such medication. The Clinical Institute Withdrawal from Alcohol – Revised (CIWA-R) is a validated tool and free to use

CIWA-AR scores:
8 points or less = mild withdrawal
9 –15 points       = moderate withdrawal
Greater than 15  = Severe withdrawal with increased risk of seizures and D.T.’s
Note: A patient may present initially with mild symptoms of withdrawal because their blood alcohol level is still high. Hence the value of daily assessment.

The total clinical picture must be considered for each patient – for example, some medical and psychiatric conditions may mimic withdrawal symptoms and some medications may slow down or mask the emergence of symptoms. If a person appears drunk at initial assessment, it is important to rule out Korsakoff / Wernickes syndromes, particularly if they or their relatives state that alcohol was not recently consumed.

Before prescribing medication to aid safe detoxification from alcohol it is necessary to pay particular attention to the following:

1.   Is the patient currently taking other medication?
      This includes both prescribed, over the counter and herbal preparations
2.   Is the patient using any drugs other than alcohol e.g. cannabis, ecstasy, cocaine etc.?
3.   Is the patient motivated to abstain from alcohol
4.   Is there a previous history of failed outpatient detoxifications?
5.   When was the last drink taken?
6.   Is the patient benzodiazepine dependent?

This publication by the NIAAA indicates some alcohol / drug interactions.
(Note: names /availability of drugs can be different in Ireland to America)

Factors that may predict severe withdrawal are

(a)   Recent levels of high alcohol consumption
(b)   Previous history of severe withdrawals
(c)   Previous history of seizures or delirium
(d)   Concomitant use of psychoactive drugs
(e)   Poor physical health
(f)    High levels of anxiety and other psychiatric disorder
(Rastrick, 2001)

Also see: Parker, A., Marshall,J., Bell, D.  Diagnosis and management of alcohol use disorders (2008) available to download from www.bmj.com.

Repeated withdrawals /detoxifications, over time may increase the likelihood of severity – known as the kindling effect. For more information on this topic see: www.niaaa.org and use their search facility

 

Medications Used in Outpatient Alcohol Detoxification:

Benzodiazepines are the main group of drugs used in outpatient settings.
There is evidence to support the use of Chlordiazepoxide as the first drug of choice for the management of alcohol withdrawal. (Williams & McBride, 1998, Rastrick, 2001)
    1.   It has a high margin of safety when taken with alcohol
    2.   Has a low addictive potential and
    3.   Can be uniquely identified in toxicology screening

As its half-life is 6–30hrs and has active metabolites with half-lives of up to 78 hours, there is a risk of accumulation, particularly in the elderly. Lower dosages may be used in the elderly or for persons with liver damage

Shorter acting benzodiazepines may be preferred with the elderly or in patients with markedly impaired liver function however; their short half-life increases the addictive potential and also risks the occurrence of seizures if tapered too severely.
(Rastrick, 2001)
Where high dosages of chlordiazepoxide are required, it may be preferable to use Diazepam.

For full prescribing information on these and other medications visit www.imb.ie or www.medicines.ie