Medically Assisted Alcohol Withdrawals

1. Medically Assisted Alcohol Withdrawals

2. Medically Assisted Withdrawal • What does it do? • Enables alcohol dependent to stop drinking without severe withdrawal symptoms. • What it does not do? • Provide a cure for alcohol misuse. • Alcohol dependency is chronic relapsing condition with relapse of 85%. • Relapse rate reduced by psychosocial support to develop coping skills pre-detox, attending Mutual Aid Groups and pos detox support.

3. Rational for Medically Assisted Withdrawal • Brain adapts to suppressant effects of alcohol on CNS activity (activates GABA receptors). When alcohol is withdrawn, increased CNS activity results in tremor , agitation and fits.

4. Community Medically Assisted Withdrawal • Fixed reducing doses of Chlordiazepoxide over 5-10 days. • Daily visits from detox nurse to review medication and monitor for serious problems requiring urgent admission. • -Risk of fits (0-4 hrs) • - DTs (48-72 hrs) 35% MR. • - Wernicke’s Encephalopathy. Requires urgent admission for iv Pabrinex to avoid permanent damage, Korsakov’s Psychosis. • - Autonomic and Psychological Instability (10-30 hrs) Inc HR ,BP, sweating and anxiety. (REDUCES RELAPSE RATE) • Supervision reduces risk of respiratory depression by overdose of benzodiazepines or drinking with Chlordiazepoxide

5. Why not provide detox in Primary Care? • Specialist services provide a comprehensive assessment of needs and psychosocial interventions to prepare for detox and provide post detox support. This and attendance of Mutual Aid groups reduce relapse rate avoiding “kindling effect”. Repeated detoxes more likely to cause complications. Provide the psychosocial support for the 6-12 months that relapse prevention intervention medication required. • Specialist Services will assess where detox can safely take place and arrange admission for medically managed detox if required. Malnourished require parenteral vitamins to avoid Wernicke’s Encephalopathy. Very high alcohol consumption (SADQ> 40) require higher doses of medication. Over 65s likely to have more difficult detox.

6. Role of Primary Care • Identify those with severe alcohol dependency for further assessment and treatment advising that Medically Assisted Withdrawal is only a part; IT IS NOT A CURE. • Advise attendance of Mutual Aid Groups. • Prescribing Chlordiazepoxide in an unsupervised way without Psychosocial interventions is not safe practice. • If MAW likely to be required, prescribe Thiamine Hydrochloride 100mg bd to reduce risk of Wernicke’s Encephalopathy. • Relapse prevention medication should only be prescribed if there is ongoing Psychosocial support. • Refer those with cirrhosis/ severe liver dysfunction to hepatologist for surveillance for hepatoma and varices. • Frequently require ongoing treatment for anxiety and depression. • Re-refer in case of relapse.

7. Learning Points • Medically Assisted Withdrawals are not an emergency but are safe interventions as part of treatment for severe alcohol dependency. • Preparation with pre and post detox psychosocial\interventions reduce the risk of relapse as does attendance of Mutual Aid Groups. • Relapse rate after MAW without support is 85%. • Repeated detoxes result in increased risk of both relapse and complicated, more risky detoxes.