• Behavioural and/or cognitive behavioural therapy (CBT)
• Social network and environment-based therapies
• Behavioural couples therapy (where relevant)

Detoxification can minimise withdrawal symptoms, prevent complications and hasten the process of abstinence from alcohol in a more humane way. 

Many treatment regimens may be used in alcohol withdrawal states; fixed dose regimens allow a fixed daily dose of benzodiazepines to be administered in four divided doses, loaded dose regimens require less benzodiazepines but require an oral loading dose of 20 mg diazepam every two hours with very close monitoring, and Symptom-triggered Treatment (STT) where chlordiazepoxide is given when CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised) ratings are above eight or more.¹

The following should be considered for patients who have any one of the following risk factors:

• Drink over 15 units of alcohol per day and/or score 20 or more on AUDIT²
• High levels of anxiety or confusion³
• Psychiatric disorders³
• Poor physical health³
• Low blood sugars³
• History of severe withdrawal includes seizures/DTs³
• Wernicke’s encephalopathy³
• Hypocalcaemia Hypokalaemia³
• Respiratory alkalosis³
• Use of other psychotropic drugs³

Any patient withdrawing from alcohol use in an outpatient detox are likely to experience contraindications like delirium tremens (DTs) and withdrawal seizures. Withdrawal monitoring scale such as the CIWA-Ar or the AWS are appropriate tools to use for inpatient withdrawal. 

The following steps will aid your patients with withdrawal:

• Take a detailed alcohol history
• Use a withdrawal scale for patients at risk of withdrawal
• Consider a fixed taper regime:
  • Diazepam 10mgs qds or
  • Chlordiazepoxide 30-40mgs qds
  • Reducing over 5 – 7 days
• DTs are an acute medical emergency
• Stable accommodation and support partner are important for community detox
• Stop detox if patient returns to drinking because of risk of respiratory depression

Consider inpatient or residential assisted withdrawal if a client meets one or more of the following criteria:

• Drinks over 30 units of alcohol per day.
• Has a score of more than 30 on the SADQ.
• Has a history of epilepsy, or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes.
• Needs concurrent withdrawal from alcohol and benzodiazepines.
• Regularly drinks between 15 and 30 units of alcohol per day and has:
  • Significant psychiatric or physical comorbidities e.g., chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease OR
  • A significant learning disability or cognitive impairment.
• Consider a lower threshold for vulnerable groups, e.g., homeless and older populations.

Symptoms of alcohol withdrawal:^3,4

• Heightened autonomic activity
• Elevated pulse
• Elevated blood pressure
• Agitation
• Restlessness
• Sweating
• Feeling tremulous
• Vomiting
• Disorientation
• Sensitivity to light and sound