Guideline 74: The management of harmful drinking and alcohol dependence in primary care

The management of harmful drinking and alcohol dependence in primary care
Section 4: Detoxification

4.1 Introduction

Detoxification refers to the planned withdrawal of alcohol. Alcohol withdrawal carries risks and requires carefulclinical management.

The choice of timing for a preplanned detoxification is important, in relation to the patient’s commitment and medium term plans. Detoxification should be seen as the first step towards achieving abstinence.

4.2 Primary care detoxification versus inpatient detoxification

A comparison between community and inpatient detoxification of alcohol dependent patients found no difference in the number of patients remaining sober six months later.⁸² At least three out of four such patients can be detoxified successfully in the community.⁸² Evidence level 1++

No studies of outpatient detoxification using medication were identified where fits occurred but studies had, appropriately, excluded patients with a history of withdrawal seizures or with impending delirium.⁸³ Evidence level 1++

Home detoxification does not appear to have any clinical advantages but may offer cost savings.^{82,
83, 84,
85} There are too few reports to be able to show rare serious events and publication bias may contribute to the current favouring of home detoxification as the first line. Evidence level 1++,1+,2-,3

There is evidence that many patients prefer home detoxification.⁸⁶ Evidence level 2+

Community detoxification is an effective and safe treatment for patients with mild to moderate withdrawal symptoms. Personnel involved in detoxification may include GPs, community psychiatric nurses, primary care nurses and community pharmacists. There are resource implications, including the cost of a breathalyser.

Where community detoxification is offered, it should be delivered using protocols specifying daily monitoring of breath alcohol level and withdrawal symptoms, and dosage adjustment.

Every GP practice (and out-of-hours service) would benefit from access to a breathalyser for use in the acute situation and for follow up.

Intoxicated patients presenting in GP practices, out-of-hours services and A&E, requesting detoxification should be advised to make a primary care appointment and be given written information about available community agencies.

See Annex 6 for advice to give to patients who undergo home detoxification.

4.2.1 SITUATIONS WHERE INPATIENT DETOXIFICATION WOULD BE ADVISED

The following list is based on expert opinion and comprises validated and best practice contraindications to managing withdrawal at home:³⁵

Hospital detoxification is advised if the patient:

is confused or has hallucinations
has a history of previously complicated withdrawal
has epilepsy or a history of fits⁸⁷
is undernourished
has severe vomiting or diarrhoea
is at risk of suicide
has severe dependence coupled with unwillingness to be seen daily
has a previously failed home-assisted withdrawal
has uncontrollable withdrawal symptoms
has an acute physical or psychiatric illness
has multiple substance misuse
has a home environment unsupportive of abstinence.
Evidence level 4

If admission to hospital is unavailable or the patient refuses, specialist opinion should be sought to aid risk assessment.

4.3 Pharmacological detoxification

4.3.1 WHEN IS MEDICATION FOR WITHDRAWAL INAPPROPRIATE?

Cessation of drinking is unlikely to be complicated in milder dependence.³⁵

Medication may not be necessary if:

the patient reports consumption is less than 15 units/day in men / 10 units/day in women and reports neither recent withdrawal symptoms nor recent drinking to prevent withdrawal symptoms
the patient has no alcohol on breath test, and no withdrawal signs or symptoms.
Evidence level 4

Among periodic drinkers, whose last bout was less than one week long, medication is seldom necessary unless drinking was extremely heavy (over 20 units/day).³⁵ Patients need to be informed of the likely symptoms if medication for withdrawal is not given. Annex 7 may be used to assist in deciding whether medication for withdrawal and admission are necessary. Evidence level 4

When medication to manage withdrawal is not needed, patients should be informed that at the start of detoxification they may feel nervous or anxious for several days, with difficulty in going to sleep for several nights.

4.3.2 THE EFFICACY OF BENZODIAZEPINES IN DECREASING ALCOHOL WITHDRAWAL SYMPTOMS

A body of evidence, based on randomised controlled trials (RCTs), has shown that benzodiazepines are currently the best drug group for alcohol dependence detoxification. The studies are of variable quality, with some reporting on small numbers of patients. Although the evidence is mostly derived from inpatient studies, the conclusions are generalisable to primary care.^{88,
89, 90,
91, 92} Evidence level 1++,1+

Benzodiazepines can cause temporary cognitive slowing and may interfere with learning and planning.⁹³ This, and the need to avoid benzodiazepine dependence, are reasons for keeping the length of treatment to a maximum of seven days. Evidence level 1++,1+

Benzodiazepines should be used in primary care to manage withdrawal symptoms in alcohol detoxification, but for a maximum period of seven days.

4.3.3 LONGACTING VERSUS SHORTACTING BENZODIAZEPINES

There is insufficient consistent evidence to make a recommendation about the use of longacting versus shortacting benzodiazepines.^{88,
94, 95,
96} Evidence level 1+,2+,4

4.3.4 MISUSE OF BENZODIAZEPINES

All benzodiazepines have a potential for misuse, but diazepam is the benzodiazepine most associated with misuse and alcohol related fatality.^{97,
98} If used in community detoxification, diazepam requires supervision to avoid misuse.⁹⁹ Chlordiazepoxide has a more gradual onset of its psychotropic effects and therefore may be less toxic in overdose. These factors probably contribute to chlordiazepoxide being less often misused and having less ‘street’ resale value. Evidence level 3,4

For patients managed in the community, chlordiazepoxide is the preferred benzodiazepine.

4.3.5 THE ROLE OF CLOMETHIAZOLE IN PRIMARY CARE ALCOHOL DETOXIFICATION

Although clomethiazole (former name chlormethiazole) is an effective treatment for alcohol withdrawal, there are well documented fatal interactions with alcohol which render it unsafe to use without close supervision.^{90,
98, 100,
101, 102,
103} Evidence level 1-,3,4

Clomethiazole should not be used in alcohol detoxification in primary care.

4.3.6 DO ELDERLY PEOPLE REQUIRE DIFFERENT PHARMACOLOGICAL MANAGEMENT?

Physical illness sometimes increases the risk of delirium in the elderly, but otherwise there is no difference between alcohol withdrawal symptoms in the elderly, or the amount of benzodiazepine required for detoxification, as compared to younger patients.^{104,
105} Nevertheless, the risk of accumulation of a drug in the elderly patient needs to be considered. Evidence level 2+

Provided attention is paid to any acute or chronic physical illness, elderly patients should be managed the same way as younger patients.

4.3.7 ANTIEPILEPTIC MEDICATION

There is insufficient evidence to support the use of antiepileptic medication as the sole treatment for the management of alcohol withdrawal or in the prevention of alcohol withdrawal seizures.^{106,
107} Evidence level 1+

Antiepileptic medication should not be used as the sole medication for alcohol detoxification in primary care.

People with a history of alcohol related seizures should be referred to specialist services for detoxification management.

4.3.8 ANTIPSYCHOTIC DRUGS

Antipsychotic drugs have been shown to prevent delirium but increase the incidence of seizures.⁸⁸ Evidence level 1+

Antipsychotic drugs should not be used as first line treatment for alcohol detoxification.

Delusions and hallucinations due to alcohol withdrawal, which would indicate the need for antipsychotic drugs, should be managed by specialist services.

4.3.9 SYMPTOM-TRIGGERED DOSING

Although there are studies of the efficacy of symptom-triggered dosing and/or loading dosing in inpatients, there is no evidence regarding the use of these methods in primary care.^{92,
108, 109,
110} Tapered fixed dose benzodiazepine regimen is likely to be as effective in primary care. Evidence level 1+,2+

Tapered fixed dose regimen of a benzodiazepine is recommended for primary care alcohol detoxification, with daily monitoring whenever possible.

4.4 The role of vitamin supplements in detoxification

There are very few high quality studies on which to base recommendations in this area. To do such studies now would be inappropriate.

4.4.1 TREATMENT OF ACUTE WERNICKE-KORSAKOV SYNDROME

Detoxification may precipitate Wernicke’s encephalopathy (see Box 2), which must be treated urgently with parenteral thiamine.¹¹¹ There is a very small risk of anaphylaxis with parenteral vitamin supplementation. This is less likely with the intramuscular route. There has been one case of anaphylaxis solely attributable to intramuscular Pabrinex since 1996.¹¹² Evidence level 4

Box 2: Pointers to diagnosis of Wernicke-Korsakov syndrome

Signs of possible Wernicke-Korsakov syndrome in a patient undergoing detoxification

confusion
ataxia, especially truncal ataxia
ophthalmoplegia
nystagmus
memory disturbance
hypothermia and hypotension
coma

One RCT has examined the role of parenteral vitamin supplements in inpatient alcohol detoxification using memory function as the outcome.¹¹³ This study was done in people who did not have Wernicke-Korsakov symptoms. Evidence level 1+

Any patient who presents with unexplained neurological symptoms or signs during detoxification should be referred for specialist assessment.

Patients with any sign of Wernicke-Korsakov syndrome should receive Pabrinex in a setting with adequate resuscitation facilities. The treatment should be according to British National Formulary (BNF) recommendations and should continue over several days, ideally in an inpatient setting.

4.4.2 TREATMENT OF THOSE AT RISK OF WERNICKE-KORSAKOV SYNDROME

There is no published evidence and conflicting expert opinion on the treatment of malnourished patients, and the specification and treatment of “at-risk” patients (those with diarrhoea, vomiting, physical illness, weight loss, poor diet), with the majority of experts recommending parenteral vitamin supplementation during detoxification.¹¹¹ Evidence level 4

For the malnourished patient in the community, intramuscular Pabrinex given in the GP surgery, A&E department, outpatient clinic or day hospital is indicated if facilities for treating anaphylactic reactions are available, such as in any setting where routine immunisations take place.

Patients detoxifying in the community should be given intramuscular Pabrinex (one pair of ampoules daily for three days) if they present with features which put them at risk of Wernicke-Korsakov syndrome.

4.4.3 ORAL SUPPLEMENTATION

No studies were identified that have looked at oral thiamine and its benefit to memory in either the recovering alcoholic or those who continue to drink in general practice. Absorption is diminished when patients continue to drink and should be given in divided doses to maximise absorption. The BNF recommended dose for treatment of severe deficiency is 200-300 mg daily.¹¹⁴

Patients who have a chronic alcohol problem and whose diet may be deficient should be given oral thiamine indefinitely.

4.5 The preferred setting for treating delirium tremens

Delirium tremens is defined here as withdrawal symptoms complicated by disorientation, hallucinations or delusions. Autonomic overactivity is a potentially fatal aspect of this condition.

A Clinical Resource and Audit Group (now part of NHS Quality Improvement Scotland) good practice statement on delirium tremens recognises the serious medical aspects of this syndrome and recommends that local protocols for admitting patients with delirium tremens are used.⁸⁷ Evidence level 4

Although the proportion of such patients seen by psychiatrists varies across Scotland, the majority of cases are treated by the acute medical service. This is because there is often a coexisting medical condition such as pancreatitis, pneumonia or other infection and there may be life threatening complications.

Local protocols for admitting patients with delirium tremens should be in place.