Alcohol withdrawal

Preparation for detoxification

The key to a successful, planned detoxification is preparation. The first job of therapy is to bring the patient to a point of readiness to change their drinking behaviour. In terms of the popular ‘stages of change’ model (DiClemente & Prochaska, 1998: pp. 3-24) this means at least reaching the determination stage. At this stage, patients are sufficiently well motivated to make a sustained effort to change. In other words, they have reached a good quality decision to change rather than opting for detoxification because they feel physically unwell, are under pressure from family or work, or simply feel the need for a temporary break from drinking. Motivation is not necessarily something that patients either have or do not have - rather, there are specific, typically brief interventions designed to enhance motivation; the UK Alcohol Treatment Trial is using a manual-based therapy called Motivational Enhancement Therapy for this purpose. Once the therapist is certain that the patient has reached the determination stage there is, ideally, a second step which involves more detailed and more practical preparation work.

This more detailed preparation for detoxification is probably best handled with the assistance of a leaflet or checklist that the patient can take away to work on alone. It is important for the doctor or therapist to work in a motivational style (Reference Rollnick, Bell, Miller and RollnickRollnick & Bell, 1991) with the aim of moving the patient through to the action stage of change prior to commencing detoxification. The hallmark feature of the action stage is having a positive outcome expectancy or, more simply, the patient needs to believe that life is going to be better after detoxification. Often, patients assume that this will be the case, but have not really thought through the implications of not drinking, which will often mean not seeing friends or drinking mates and having unfilled time. Not doing something is inherently unrewarding and it is crucial that positive alternatives to drinking are planned.

Second, patients need to be given accurate information about what to expect during detoxification. Information-giving is likely to reduce the severity of the withdrawal and increase compliance (Reference Phillips, Gossop and BradleyPhillips et al, 1986). In the course of this discussion, it is often useful to map out a timetable for the week in which detoxification will take place and for the following week. Filling out such a timetable in some detail is a convenient way to bring up a number of important issues. For example, if the patient is working, have they planned to take time off? If the patient has childcare responsibilities, have these been met? If the patient is travelling to an out-patient unit daily, are there any transport difficulties? Is there someone who is willing to support the patient throughout the first week of detoxification? The timetable for week two of detoxification raises rather different issues, which are generally in the area of relapse prevention. For example, has there been a discussion about prescribing disulfiram? Does the patient have leisure or work activities to pursue or is there a need to plan new activities? If the detoxification team does not include the patient's usual therapist, have hand-over arrangements been made? Local custom and practice determine to what extent relapse prevention work is integral to detoxification. What matters is that patients do not return to their usual drinking friends and environment, or at least that they do not do so without some preparation.

The most suitable setting for detoxification needs to be discussed, but safety and economic (rather than convenience) considerations are foremost. The need for admission into a medical in-patient facility is a matter of clinical judgement and depends upon social as well as medical risk factors. See Box 2 for factors predicting severe withdrawal.

For those people who are homeless or socially disorganised, detoxification may best be carried out in a non-medical residential facility (Reference Mortimer and EdwardsMortimer & Edwards, 1994), provided that the staff are trained to pick up medical complications on the rare occasions that these occur. The elderly are likely to experience a prolonged withdrawal syndrome and to be sensitive to the side-effects of medication, so detoxification should always be supervised either at home or in a residential facility.

For the majority of people, a community-based detoxification delivered in the home, or on an out-patient or day patient basis, is ideal. Home detoxification is relatively expensive and cannot usually be offered as an option for patients, but rather is reserved for people who would have difficulty attending a central unit, for example, people with a disability or who have childcare commitments. In rural areas, there may be a cost-efficiency as well as a convenience case for home detoxification. The model developed by Stockwell et al (1990) involves daily visits from a trained psychiatric nurse who assesses the severity of withdrawal and monitors for complications; any medication is prescribed on a shared-care basis with a general practitioner or by a consultant-led team. In the future, there is an opportunity here to use the extended nurse prescribing role with uncomplicated cases (Reference Ryan, Cash and HannisRyan et al, 1999).

The configuration of services within a health district depends upon local need and local preference. There needs to be agreement, however, about who looks after people with different kinds of problem. The small number of patients who experience marked withdrawal, including seizures, delirium and the potential for medical complications, may best be managed in a liaison psychiatry setting. For people with severe mental illness, there is a choice between general psychiatry, addiction psychiatry or a shared-care approach, which might include both out-patient and in-patient settings. A day care facility as part of the specialist addiction psychiatry team may well be able to handle surprisingly severe problems of alcohol withdrawal. Voluntary sector agencies are probably best positioned to provide non-medical facilities for homeless people and those with unstable social circumstances for whom accommodation is the primary need - supported sobering up, rather than detoxification, being the principal intervention.

Measuring the severity of withdrawal

It is good practice to use a standardised rating scale to measure the severity of alcohol withdrawal. The rating is used as one of the clinical indicators that informs prescribing and to pick up any complications that might arise during detoxification. The most commonly used scales are all derived from a 20-item instrument developed by Gross et al (1971). The different scales have broadly similar items for rating mild to moderate severities of alcohol withdrawal, but diverge on items such as ‘seizures’, ‘quality of contact’ and ‘thought disturbance’, which some authors claim have predictive validity. Metcalfe et al (1995) have developed a 10-item scale which has been validated for use in the UK (see Box 3). Of course, any rating scale must be interpreted in the light of the whole clinical picture. For example, patients with the dual diagnosis of anxiety disorder and alcohol dependence can be expected to experience significantly greater levels of anxiety throughout detoxification than patients with alcohol dependence only (Reference Johnston, Thevos and RandallJohnston et al, 1991).

An accurate examination of mental state leading to a diagnosis of psychiatric disorder is problematic in people who are drinking heavily or going through a detoxification programme. Up to 80% of problem drinkers entering into treatment experience psychiatric symptoms that typically fall short of a mental illness and commonly disappear after a period of total abstinence from alcohol. Symptoms are often non-specific and include dysphoria, anxiety, depression, panic, insomnia and in severe cases ideas of self-harm or hopelessness or even disturbances of thought or perception. Driessen et al (1996) found that for alcohol misuse in-patients, who are expected to have high rates of comorbidity, the prevalence of psychiatric disorder 2 weeks post-detoxification was 3% schizophrenia, 13% affective disorder, 22% phobic disorders and 2% generalised anxiety. It follows that clinicians need to exercise caution when making a mental illness diagnosis in people who are also problem drinkers. Ideally, diagnosis should be delayed for a period of 3-4 weeks post-detoxification (Reference Raimo and SchuckitRaimo & Schuckit, 1998). Getting the balance right is a difficult clinical judgement: on the one hand, there is a huge waste of resource from both unnecessary prescribing and unnecessary psychological therapies given prematurely to people who, it transpires, have an uncomplicated problem of alcohol dependence; on the other hand, delaying treatment may be harmful or be viewed as unacceptable.

Treatment

Treatment of alcohol withdrawal is usually uneventful and the clinician has a generous margin of error within which to work. Where mistakes are made, they are usually in the related areas of insufficient prescribing and insufficient observation for the level of risk. In the four tiers of service delivery described below (and see Box 4), it is the two variables ‘amount of treatment’ and ‘amount of observation’ that determine the appropriate level of intervention.

Audit

Most patients receiving treatment for alcohol dependence at some time enter a detoxification programme. Achieving successful detoxification is an important part of the overall treatment plan. Failure in detoxification is likely to engender a sense of hopelessness among both patients and staff. Significant resources are used for detoxification. For all these reasons, it is important that an effective audit system is in place. Audit should be a routine part of practice in specialist units, but is more difficult to organise in general psychiatry or primary care settings.

On the face of it, detoxification has a clearly defined end-point - being alcohol-free - and is therefore easy to evaluate. Certainly, it is important to know how many people successfully become alcohol-free, but equally it is important to know what quality of detoxification was delivered. There is a further problem in that most clinicians see completion of detoxification, that is reaching an alcohol-free state, to be an unsatisfactory end-point. Although not strictly part of detoxification, it is certainly part of the overall programme to see that effective steps have been taken to prevent relapse in the immediate post-detoxification period. Exactly what these steps might be varies from one service to another but might, for example, include prescribing disulfiram and ensuring attendance at an after-care appointment. Table 2 summarises the audit measures used by the Leeds Addiction Unit. A follow-up at one month post-detoxification has been judged to be a long enough time period to check that the detoxification team succeeded in starting after-care plans, but a short enough period that the outcome will not be unduly contaminated by factors beyond the control of the detoxification programme.

Conclusion

Detoxification is not usually a technically difficult procedure. Whether detoxification is an expedience, or part of a planned care programme, it is always an opportunity to help people change their drinking behaviour. There is a persuasive argument in favour of selecting chlordiazepoxide as the first-line pharmacotherapy for most alcohol withdrawal problems. Other benzodiazepines have equal efficacy and may be preferred by clinicians, but their pharmacokinetics are generally less suitable than those of chlordiazepoxide. It may be necessary to prescribe high doses in order to achieve rapid containment of the withdrawal syndrome.

What has changed in recent years is the pattern and range of alcohol treatment services. There has been a broadening of the base of treatment both in terms of the settings in which it commonly occurs and also the variety of staff now involved in therapy. This all means that integrating detoxification into an overall care plan becomes more difficult. Wherever practical, detoxification followed by a 3- to 4-week period of abstinence from psychoactive drugs should precede making any definitive diagnosis or commencing treatment for mental illness.

Multiple choice questions

1. 1. Where depression and anxiety are prominent pre-detoxification features, they:

   1. a should be treated with standard pharmacotherapy

   2. b should receive an ICD diagnosis immediately

   3. c commonly disappear three weeks post-detoxification

   4. d indicate the need for in-patient detoxification

   5. e predict drop-out from detoxification.

2. 2. The following items are part of the Windsor Clinic Alcohol Withdrawal Assessment Scale that predict serious withdrawal problems:

   1. a quality of contact

   2. b tremulousness

   3. c thought disturbance

   4. d seizures

   5. e pulse rate.

3. 3. Severe withdrawal is often associated with the following medical complications:

   1. a Wernicke's encephalopathy

   2. b magnesium deficiency

   3. c hyperglycaemia

   4. d hypotension

   5. e polydrug use.

4. 4. Preparation for detoxification should include:

   1. a checking the patient is at the determination or action stage of change

   2. b planning the post-detoxification week

   3. c identifying a support person

   4. d agreeing the detoxification regimen

   5. e making an after-care appointment.

5. 5. The following can be considered as suitable first-line drugs for detoxification:

   1. a carbamazepine

   2. b chlordiazepoxide

   3. c clomethiazole

   4. d chlorpromazine

   5. e clonidine.