Managing alcohol dependence

Detoxification

Alcohol dependence usually requires controlled withdrawal (detoxifi cation) with an attenuation therapy (such as a benzodiazepine), as abrupt cessation of alcohol can induce one of the withdrawal states (Box 14.5). Detoxifi cation is increasingly taking place in the community, but inpatient detoxifi cation is recommended for those at risk of suicide, lacking social support or giving a history of severe withdrawal reactions including fi ts and delirium tremens.

The important principles of community detoxifi cation are: Daily supervision in order to allow early detection of complica• • tions such as delirium tremens, continuous vomiting or deterioration in mental state (confusion or drowsiness) The vitamin B preparation, thiamine 50 mg twice daily for three weeks, is needed to prevent Wernicke’s encephalopathy. This should be given to all patients undergoing withdrawal. Severely alcohol-dependent patients will need initial treatment with parenteral vitamins (such as Pabrinex™), which, because of the risk of anaphylaxis, makes this category of patients unsuitable for a community detoxifi cation • Benzodiazepines to prevent a withdrawal syndrome. Because of the potential for dependence, benzodiazepines should be prescribed for a limited period only. The most commonly used benzodiazepine is chlordiazepoxide at a starting dose of 10 mg four times daily and reducing over seven days. Larger doses are used in severe withdrawal – for example, 40 mg four times daily reducing over 14 days. On the other hand, large doses may accumulate to dangerous levels if there is signifi cant liver disease, and, in these circumstances, oxazepam is preferred.

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