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Alcohol detoxification in primary care

Community detoxification is an effective treatment for patients with mild to moderate withdrawal symptoms. GP Dr Clare Gerada uses a case study to outline the basic principles

Community detoxification is an effective treatment for patients with mild to moderate withdrawal symptoms. GP Dr Clare Gerada uses a case study to outline the basic principles

Charles is a 43-year-old alcohol-dependent patient. You have been seeing him on and off for a number of medical problems and what has emerged is that he is a heavy drinker; in fact he is dependent on alcohol in that he drinks in the morning to prevent the shakes and finds that he cannot go without drinking. He is drinking around 20 units per day. He comes requesting that you help him come off alcohol – he is frightened to do it without medication as whenever he tries he gets very shaky and anxious. He has come to this consultation with his wife who is happy to supervise any medication. You agree to do this.

Detoxification is the planned withdrawal of alcohol and is a necessary step to achieving abstinence. I have carried out many successful home detoxifications on alcohol dependent patients but I am acutely aware that many GPs lack the skills, experience and confidence to do the same.

Most patients can be safely detoxified in community settings but if in doubt consult your local alcohol service to support you and the patient through the process. Community detoxification is as effective as an inpatient detoxification with studies showing no difference in the number of patients remaining sober six months later.

Who is suitable?

There are no established criteria for determining patients best suited to hospital rather than community detoxification. However, consider hospital detoxification for patients shown in the box on page 54.

In the end the clinical decision as to whether a patient is suitable for community detoxification will depend on the skills and experience of the GP, the availability of shared-care support, the needs of the patient and the support available to the patient to supervise the medication.

Pharmacological detoxification

Charles has no risk factors that would preclude a community detoxification and you agree to carry this out with the support of his wife (supervising the medication) and the local alcohol shared-care worker. You arrange to see him on Monday morning and advise that over the weekend he begins to reduce his alcohol consumption to the lowest he can tolerate, and to abstain from drinking from Sunday night.

I almost always start an alcohol detoxification on a Monday morning. This makes supervision much easier through the working week. Having assessed Charles as suitable for community detoxification it is important to recruit the help of a family member or carer to supervise.

Before undertaking a medically assisted detoxification it is important to explain to the patient and their family or carer the following points.

• The medication is not designed to sedate – just to offset the withdrawal symptoms. If there are signs that the patient is becoming overly drowsy then they must omit or reduce the next dose. At all times the patient should be easily rousable and able to walk, talk, eat, drink, and communicate. The aim is to produce a relaxed rather than sedated state.

• A patient using benzodiazepines MUST not drink on top of the medication. They should be warned that this can be dangerous and may cause serious problems and at worst could result in death from over sedation.

Patients undergoing an alcohol detoxification in the community should be reviewed on a daily basis by the prescriber or by the alcohol shared-care nurse. The consultations do not need to be long , but they will allow the early detection of complications and encourage the patients to persevere with the process. It maybe necessary to make adjustments to the medication if the patient is over-sedated or experiencing uncomfortable withdrawal symptoms. In unusual situations the detoxification may need to be terminated.

Benzodiazepines

The BNF advises that short-acting benzodiazepines are used to minimise the risk of dependence and that administration should be for a limited period only, for example chlordiazepoxide 10 to 50mg, four times daily, gradually reducing over seven to 14 days. Long-acting benzodiazepines such as diazepam can be used, but they also have a greater dependence potential than shorter acting benzodiazepines. Benzodiazepines should not be prescribed if the patient is likely to continue drinking.

Although clomethiazole (former name chlormethiazole) is an effective treatment for alcohol withdrawal, there are well-documented fatal interactions with alcohol that render it unsafe to use without close supervision and it should not be used for detoxification in primary care.

You decide to use a tapering dose of chlordiazepoxide and issue Charles's wife with a prescription for seven days' supply of a reducing dose of chlordiazepoxide. See box below.

Physical illness sometimes increases the risk of acute confusional states and 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, compared with younger patients.

Vitamin supplements

There are very few high quality studies on which to base recommendations in this area. To do such studies now would be inappropriate. Detoxification may precipitate Wernicke's encephalopathy, which must be treated urgently with parenteral thiamine (see below).

No studies 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 it should be given in divided doses to maximise absorption. The BNF recommended dose for treatment of severe deficiency is 200-300mg daily.

GP support

Community detoxification is a useful intervention for alcohol dependent individuals wishing to tackle their addiction problem, and GPs have a crucial role in supporting patients and their families.

Dr Clare Gerada is a GP in south London, RCGP lead on substance misuse and chair of the RCGP medical ethics committee

Competing interests None declared


Indications for hospital detoxification

Where a patient:

• is confused or has hallucinations

• has a history of previously complicated withdrawal

• has epilepsy or a history of fits

• 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

Charles's detox regime

• Chlordiazepoxide capsules 30mg qds day one and two

• Chlordiazepoxide capsules 20mg qds day three and four

• Chlordiazepoxide capsules 10mg qds day five and six

• Chlordiazepoxide capsules 10mg bd day seven

Signs of Wernicke-Korsakov syndrome

• Confusion

• Ataxia, especially truncal ataxia

• Ophthalmoplegia

• Nystagmus

• Memory disturbance

• Hypothermia and hypotension

• Coma

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