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Guide to Smashing Through Alcohol Detoxes

September 20, 2016

Warning: Information contained in this guide is for educational purposes only. Please do not substitute official medical guidelines with information contained in this guide. Cassiobury Court cannot be held responsible for your actions linked to information contained in this guide.

If you've attended an alcohol rehab centre in the past, you may be familiar with a process known as 'alcohol withdrawal' or 'alcohol detoxification'. However, you may require additional information in order to learn more about this life-saving procedure.

In this handy guide, we outline factors and procedures you really should consider if you are considering tackling and alcohol withdrawal.

By the time you've finished reading this guide, you will have discovered:

  • The two types of alcohol detox you really must know
  • How to define an alcohol detox
  • Inpatient vs. outpatient detoxification programmes
  • What is Alcohol Withdrawal Syndrome
  • How to conduct a pre-detox assessment
  • How to conduct a pre-detox physical examination
  • The importance of hydration and electrolyte therapy
  • How to conduct a patient risk assessment 
  • How to determine which medication is suitable for a detox
  • How to determine the correct dosage of drugs
  • When to begin taking medication How to treat severe and uncontrollable withdrawal symptoms
  • How to detox a patient with liver disease
  • How to detox a pregnant patient How to detox elderly patients
  • How to detox patients who are addicted to benzodiazepines
  • Why you should administer Thiamine during an alcohol detox

What is an alcohol detox programme?

An alcohol detox programme aims to safely manage the physical and mental symptoms that arise when a person has consumed a great quantity of alcohol for a long period of time. These symptoms include seizures, delirium tremens and Alcohol-Related Brain Damage (ARBD). These symptoms are potentially life-threatening and thus justify the need for a medically supervised alcohol detox programme.

When people are addicted to alcohol, they may attempt to detoxify themselves without the aid of drugs designed to reduce these withdrawal symptoms. As these withdrawal symptoms arise, people addicted to alcohol are known to continue to drink alcohol in order to treat these withdrawal symptoms.

It's usually sound advice for the person to continue to drink alcohol until a full medical assessment is carried out. This avoids the risk of deadly withdrawal symptoms from arising in an unmedically supervised environment. A sudden reduction in alcohol consumption must be avoided at all costs when a person has a suspected addicted to alcohol.

Types of alcohol detoxifications

Essentially, there exist two types of alcohol detoxification programmes including:

  1. Fixed dose detoxification: This is when patients receive a fixed dose during their detox. This does is reduced over the course of several days. Patients may be given a top up dose in order to treat 'breakthrough symptoms'
  2. Symptom-triggered detoxification: This is when patient's treatment programme is designed to match the patient's needs. These needs are assessed accord to the severity of withdrawal symptoms the patient experiences. This is generally the preferred form of alcohol detoxification.

Assessing the need for an alcohol detoxification programme

If you've read this far, you may wonder the criteria we apply when determining the need for an alcohol detoxification programme in the first place. There is no exact science for determining the need for an alcohol detoxification programme. Sound observation and clinical judgment are key.

However, here's some tell-tale signs that may signal the need for an alcohol detoxification programme:

  1. The patient drinks more than 15 units of alcohol per day on a regular basis
  2. The patient drinks alcohol for a continuous amount of time and shows signs of alcohol dependence/withdrawal symptoms e.g. hallucinations, tremors, and autonomic disturbance

You may also make use of our alcohol addiction questionnaire when assessing whether a patient is need of an alcohol detoxification programme.

The venue for alcohol withdrawal

The vast majority of people receiving an alcohol detoxification programme in the United Kingdom do so in the community. This means the person is not removed from their 'using environment' whilst the detoxification is administered.

Typically, an Alcohol Detox Nurse will visit the patient each day in order to administer drugs designed to reduce the risks of detoxification. The first 24-49 hours of an outpatient detoxification programme is typically administered inside an inpatient environment.

By far the better option is to administer an alcohol detox via an inpatient unit. This typically takes place within a hospital or an alcohol rehab centre. This reduces the risk of relapse and other complications so the detoxification may be completed without set back.

This guide is intended for alcohol detoxifications taking place in an inpatient setting.

What is Alcohol Withdrawal Syndrome?

Alcohol Withdrawal Syndrome (AWS) is a term used to describe the various symptoms experienced when alcohol is withdrawn from a person who has developed an addiction to alcohol. These symptoms arise within as little as 6 hours after alcohol was last consumed. In some cases, withdrawal symptoms may not arise for up to 72 hours after alcohol was last consumed.

How long do these symptoms last for? The duration of symptoms will vary for each patient. Symptoms generally peak within 10-20 hours after the last drink was consumed. These symptoms may last for around 4-7 days.

Moderate alcohol withdrawal symptoms include:

  • Sweating
  • Shaking hands, arms and legs
  • Nausea, vomiting and diarrhea
  • Muscle pain
  • Agitation and anxiety
  • Autonomic disturbances

Severe alcohol withdrawal symptoms include:

  • Delirium tremens (DTs)
  • Seizures
  • Wernicke's Encephalopathy

Pre-detoxification assessment stages

Before an alcohol detoxification is carried out, we recommend you carry out a full assessment of your patient. Click here to read the assessment our patients must complete before an admission is accepted.

You may also make good use of the Clinical Institute Withdrawal Assessment of Alcohol Scale. This scale allows you to measure the severity of potential alcohol withdrawal symptoms that are likely to arise during an alcohol detoxification programme.

The scale also offers guidance on the recommended amount of benzodiazepine you should prescribe to your patient. The maximum score of this scale is 67. This is known as the patient's CIWA-Ar score. A score over 15 means the patient is likely to suffer from severe withdrawal symptoms if drugs to counteract these symptoms are not administered.

Physical and mental examination before a detoxification takes place

Before an alcohol detoxification programme begins, you should carry out the below tests if you have access to the required equipment:

  • Liver profiling
  • Serum glucose levels
  • Serum ethanol levels
  • Renal function and electrolyte profile (calcium, phosphate and magnesium)
  • Full blood picture
  • Coagulation screen

Dehydration and Electrolyte depletion

One particular issue affecting people suffering from an alcohol dependency is dehydration and electrolyte depletion. This is treated by ensuring the patient is given potassium, magnesium and phosphate supplements. Crystalloid fluids, sodium chloride, glucose and V thiamine (Pabrinex®) are commonly administered to help combat electrolyte depletion.

Determine the severity of alcohol withdrawal symptoms

When you assess the patients before a withdrawal programme is initiated, it's important you categories the potential severity of the patients' AWS. Here, we categorise the risk of AWS into three different categories: low, medium and high risk.

Low-risk patients

Patients considered 'low risk' are likely to exhibit some of the below:

  • No continuous use of alcohol
  • Reports low levels of dependency
  • No withdrawal symptoms
  • No alcohol in breath when given breath test
  • Drinks less than 15 units/week

Medium risk patients

Patients considered 'medium risk' are likely to exhibit some of the below:

  • Consumes alcohol to continuous pattern
  • Drinks 15-30 units/day
  • Drinks alcohol to medicate withdrawal symptoms
  • Reports significant alcohol withdrawal symptoms
  • No history of severe withdrawals (e.g. DTs/seizures)

High high patients

Patients considered 'high high' are likely to exhibit some of the below:

  • History of severe withdrawal symptoms
  • Profuse sweating
  • Auditory or visual hallucinations
  • High levels of confusion or agitation
  • Benzodiazepine use
  • Symptoms of Wernicke's encephalopathy

Prescribing medication for an alcohol detoxification

Medication is prescribed during an alcohol detoxification programme to prevent the occurrence of potentially fatal withdrawal symptoms. Medication helps to stabalise withdrawal symptoms to a safe level. Deadly symptoms these drugs prevent include DTs, seizures and sickness. The medication is gradually reduced to nil over a 5-10 day period.

The vast majority of alcohol detoxification programmes are treated with benzodiazepines. This allows the patient to experience a state of minor sedation.

The use of Chlordiazepoxide during an alcohol withdrawal

Chlordiazepoxide (Librium) is by far the most common medication to help people withdrawing from alcohol. Why? Because Librium has a long 'half-life' and 'late onset'. This means there is a reduced risk of rebound symptoms occurring during an alcohol detoxification when Librium is administered. Diazepam may also used during an alcohol withdrawal. However, compared to Librium, Diazepam has a greater abuse potential.

When not to use Librium

Librium should not be used for an alcohol detoxification in certain circumstances. For instance, if a patient suffers from liver disease, Librium may cause problems. Why? Because a compromised liver may struggle to metabolise long acting agents such as Librium. In this situation, short acting benzodiazepines such as Oxazepam or Lorazepam should be given.

Furthermore, Librium should be avoided for people suffering from chronic obstructive pulmonary disease (COPD).

Dosage recommendations

Stage 1: Initial stabilisation

The goal of any dosage regime is to assist the patient in gaining stability and control over alcohol withdrawal symptoms. A starting dosage is given that reflects the clinical picture that's determined during the assessment. The initial dosage must be sufficient to combat severe withdrawal symptoms.

Depending on the severity of the patient's addiction, the patient may initially be given between 20mg-40mg doses of Librium. The patient's withdrawal symptoms must then be closely monitored. It's important to ensure the patient is not over-sedated. It's also important the patient is not given too little Librium since this could result in the onset of severe withdrawal symptoms.

This initial dosage is then followed with a prn dosage to reflect the ongoing withdrawal symptoms the patient is experiencing. A prn dosage should cease after the first 24-48 hours have passed. The patient will experience minor but repeat minimal withdrawal symptoms following the initial 24-48 hours into the alcohol detoxification programme. This is when a fixed but reducing dosage regime should be initiated.

If a community detox is to be attempted, it's common for the initial stabalising regime to take place in inpatient settings. The patient then returns home to complete the rest of his or her alcohol detoxification programme.

Stage 2: Fixed dose reduction

When this initial 24-48 hours of an alcohol detoxification programme has passed, a fixed but reducing dosage regime may be established. Within three days of the detox, the blood will experience a steady level of blood chlordiazepoxide. Now, the dose of chlordiazepoxide should be reduced by around 20% a day. This prevents the patient from developing a dependency for chlordiazepoxide.

Fixed dose Chlordiazepoxide reducing regime

Below we outline a fixed dose Chlordiazepoxide reducing regimen that's commonly used for alcohol detoxification purposes:

  1. Day 1 - 40mg 4 times a day
  2. Day 2 - 30mg 4 times a day
  3. Day 3 - 20mg 4 times a day
  4. Day 4 - 20mg 3 times a day
  5. Day 5 - 10mg 4 times a day
  6. Day 6 - 10mg twice daily

Factors to consider when prescribing medication

Before a starting dose is given, you should consider the below factors:

  • The severity of withdrawal symptoms
  • The patient's age, weight, size and state of physical health
  • Whether the patient suffers from liver disease
  • Other medications the patient may be taking
  • History of addiction to alcohol and the severity of this addiction

When to begin taking medication

Pharmacotherapy should be initiated before withdrawal symptoms arise. This avoids the situation where significant withdrawal symptoms such as DTs or seizures arise. However, benzodiazepines must not be given to the patient whilst the patient is acutely intoxicated. Why? Because benzodiazepine sedation may cause respiratory depression when mixed with alcohol. This can cause the patient to suffocate and die.

It's common to delay prescribing benzodiazepines until 6-8 hours after the patient last consumed alcohol. This ensures blood ethanol levels are close to zero before benzodiazepines are given.

Furthermore, personal clinical judgment must be exercised before an alcohol detoxification programme begins, given patients with a severe alcohol dependency may suffer from severe withdrawal symptoms with a blood alcohol concentration of 100 mg per 100 ml. This may necessitate this use of Chlordiazepoxide even when the patient is clearly intoxicated.

Treating serve and uncontrollable withdrawal symptoms

If a patient suffers from uncontrollable withdrawal symptoms, you must first increase the dose of Chlordiazepoxide to 40 mg/hour for a maximum of three doses. When giving regular prn doses, monitor the patient carefully to avoid over-sedation.

This also helps reduce the risk of a paradoxical reaction.

You may wish to increase the dose of Chlordiazepoxide up to 50-60 mg 4 times a day for the initial 24-28 hours. Please note, this will exceed the BNF recommended maximum of 250 mg of Chlordiazepoxide in a 24 hour period, so please consult with a senior doctor.

When a patient suffers from delirium tremens or acute disturbances, it may be better to prescribe lorazepam rather than Chlordiazepoxide. Why? Because lorazepam has a much faster onset when compared with Chlordiazepoxide. This means lorazepam tackles and extinguishes acute withdrawal symptoms far quicker than does Chlordiazepoxide.

If a patient is still suffering with withdrawal symptoms after consuming three 40mg doses of chlordiazepoxide, you may consider giving the patient 2-4mg of lorazepam. This dose maybe repeated twice at fifteen minute intervals. Lorazepam is administered either orally, intramuscularly or intravenously.

You may also consider administering an anti-psychotic such as haloperidol when patients suffer from severe and uncontrollable withdrawal symptoms. This is particularly useful when the patient is suffering from severe hallucinations or agitation.

Detoxification when patients suffer from liver disease

If the patient suffers from liver disease, it's essential additional safeguards are put in place. For instance, you must first assess the severity of the patient's liver disease. If the patient suffers from mild to moderate liver disease, you could consider giving half the usual dose of chlordiazepoxide or use lorazepam instead. If the patient suffers from severe liver disease, switch to a "symptom triggered approach" using a low prn dosage.

Detoxification when patients are pregnant

If a pregnant patient requires an alcohol detoxification programme, benzodiazepine treatment should be avoided. This position is supported by the BNF. This is because benzodiazepines are known to be teratogenic. If benzodiazepines are used, the lowest possible dose should be given. Diazepam should be favoured over chlordiazepoxide.

Detoxification when patients are elderly

Elderly patients are at greater risk of over-sedation. Over-sedation is known to cause falls and fractures. Furthermore, elderly patients are less able to metabolise benzodiazepines.

To reduce the risk of accumulation, consider using lorazepam rather than chlordiazepoxide for reducing alcohol withdrawal symptoms. It's thus essential to monitor elderly patients whilst an alcohol detoxification programme is attempted. Many doctors choose to reduce sedation medication doses by half when treating elderly patients during an alcohol detoxification programme.

Detoxification when patients are addicted to benzodiazepines

When patients are addicted to benzodiazepines, it's important to allow them to continue using benzodiazepines along side a reducing dose of Chlordiazepoxide or lorazepam. This avoids the onset of symptoms associated with a benzodiazepine withdrawal.

Benzodiazepine addiction may mean the patient requires a higher dose of Chlordiazepoxide than usual. This is because the patient will exhibit tolerance towards benzodiazepines due to the co-occurring addiction.

The importance of Thiamine during an alcohol detoxification programme

The vast majority of people receiving an alcohol detoxification programme will suffer from a co-morbidity such as a vitamin B deficiency. It's thus recommended patients receive Thiamine (Pabrinex®) to reduce the risk of Wernicke's encephalopathy.

Thiamine should be administered using intravenous infusion or deep intramuscular injection. Injections should continue for around five days, or longer when the patient has suspected Wernicke's.

If you intend to give your patients IV glucose during an alcohol detoxification, IV thiamine should always be given beforehand. This prevents the patient from experiencing pain in the abdominal region when IV glucose is administered.

100mg of oral thiamine should be given to the patient twice a day up to 2-6 months once abstinence is achieved.

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