assisted alcohol withdrawal · 8. medically assisted alcohol withdrawal – setting . 7 ....

Assisted alcohol withdrawal Assisted alcohol withdrawal

NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/alcohol-use-disorders NICE Pathway last updated: 24 June 2020

This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations.

Alcohol-use disordersAlcohol-use disorders© NICE 2020. All rights reserved. Subject to Notice of rights.

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Assisted alcohol withdrawal Assisted alcohol withdrawal NICE Pathways


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1 Person aged 10 or over who drinks more than 15 units of alcohol per day or scores 20 or more on AUDIT

No additional information

2 Principles of care

Service users who need assisted withdrawal should usually be offered a community-based

programme, which should vary in intensity according to the severity of the dependence,

available social support and the presence of comorbidities.

3 Assessment

For service users who typically drink over 15 units of alcohol per day and/or who score 20 or

more on the AUDIT, consider offering:

an assessment for and delivery of a community-based assisted withdrawal, or

assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

Alcohol-use disorders: diagnosis and management

3. Referral to specialist alcohol services

4 Outpatient programme

When to offer outpatient programmes

For people with mild to moderate dependence, offer an outpatient-based assisted withdrawal

programme in which contact between staff and the service user averages 2–4 meetings per

week over the first week.

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Treatment

Outpatient-based community assisted withdrawal programmes should consist of a drug regimen

and psychosocial support including motivational interviewing.

When conducting community-based assisted withdrawal programmes, use fixed-dose

medication regimens.

Prescribe and administer medication for assisted withdrawal within a standard clinical protocol.

The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or

diazepam).

In a fixed-dose medication regimen, titrate the initial dose of medication to the severity of

alcohol dependence and/or regular daily level of alcohol consumption. Gradually reduce the

dose of the benzodiazepine over 7-10 days to avoid alcohol withdrawal recurring.

Be aware that benzodiazepine doses may need to be reduced for older people.

When managing alcohol withdrawal in the community, avoid giving people who misuse alcohol

large quantities of medication to take home to prevent overdose or diversion. Prescribe for

instalment dispensing, with no more than 2 days' medication supplied at any time.

In a community-based assisted withdrawal programme, monitor the service user every other

day during assisted withdrawal. A family member or carer should preferably oversee the

administration of medication. Adjust the dose if severe withdrawal symptoms or over-sedation

occur.

Do not offer clomethiazole for community-based assisted withdrawal because of the risk of

overdose and misuse.

Monitoring

For service users having assisted withdrawal, particularly those who are more severely alcohol

dependent or those undergoing a symptom-triggered regimen, consider using a formal measure

of withdrawal symptoms such as the CIWA–Ar.

Quality standards




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8. Medically assisted alcohol withdrawal – setting

5 Inpatient programmes for person aged 10-17

When to offer inpatient programmes

Offer inpatient care to children and young people who need assisted withdrawal.

Medication

Consult the SPC and adjust drug regimens to take account of age, height and body mass, and

stage of development of the child or young person1.

Fixed-dose medication regimens or symptom-triggered medication regimens [See page 17] can

be used in assisted withdrawal programmes in inpatient settings.



diazepam).




In severe alcohol dependence higher doses will be required to adequately control withdrawal

and should be prescribed according to the SPC. Make sure there is adequate supervision if high

doses are administered.

Be aware that benzodiazepine doses may need to be reduced for children and young people2.

Monitoring





1 If a drug does not have UK marketing authorisation for use in children and young people under 18, informed

consent should be obtained and documented.


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2 At the time this guidance was created (May 2011), benzodiazepines did not have UK marketing authorisation for

use in children and young people under 18. Informed consent should be obtained and documented.


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Quality standards




6 Inpatient or residential programme for person aged 18 or over

When to consider inpatient or residential programmes

Consider inpatient or residential assisted withdrawal if a service user meets one or more of the

following criteria. They:

drink over 30 units of alcohol per day

have a score of more than 30 on the SADQ

have a history of epilepsy, or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes

need concurrent withdrawal from alcohol and benzodiazepines

regularly drink between 15 and 30 units of alcohol per day and have:

significant psychiatric or physical comorbidities (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or

a significant learning disability or cognitive impairment.

Consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups,

for example, homeless and older people.

For people with alcohol dependence who are homeless, consider offering residential

rehabilitation for a maximum of 3 months. Help the service user find stable accommodation

before discharge.

See the NICE Pathway on service user experience in adult mental health services.

Medication

Fixed-dose medication regimens or symptom-triggered medication regimens [See page 17] can

be used in assisted withdrawal programmes in inpatient or residential settings.



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diazepam).




In severe alcohol dependence higher doses will be required to adequately control withdrawal

and should be prescribed according to the SPC. Make sure there is adequate supervision if high

doses are administered.

Be aware that benzodiazepine doses may need to be reduced for older people.

Monitoring




Quality standards




7 Additional considerations for complex needs

Malnourishment or decompensated liver disease

Offer parenteral thiamine followed by oral thiamine to prevent Wernicke-Korsakoff syndrome in

people who are entering planned assisted alcohol withdrawal in specialist inpatient alcohol

services or prison settings and who are malnourished or at risk of malnourishment (for example,

people who are homeless) or have decompensated liver disease.

Liver impairment

Be aware that benzodiazepine doses may need to be reduced for people with liver impairment.



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If benzodiazepines are used for people with liver impairment, consider one requiring limited liver

metabolism (for example, lorazepam); start with a reduced dose and monitor liver function

carefully. Avoid using benzodiazepines for people with severe liver impairment.

Coexisting benzodiazepine and alcohol dependence

When managing withdrawal from co-existing benzodiazepine and alcohol dependence increase

the dose of benzodiazepine medication used for withdrawal. Calculate the initial daily dose

based on the requirements for alcohol withdrawal plus the equivalent regularly used daily dose

of benzodiazepine1. This is best managed with one benzodiazepine (chlordiazepoxide or

diazepam) rather than multiple benzodiazepines. Inpatient withdrawal regimens should last for

2–3 weeks or longer, depending on the severity of co-existing benzodiazepine dependence.

When withdrawal is managed in the community, and/or where there is a high level of

benzodiazepine dependence, the regimen should last for longer than 3 weeks, tailored to the

service user's symptoms and discomfort.

Other complications

For managing unplanned acute alcohol withdrawal and complications including delirium tremens

and withdrawal-related seizures, see acute alcohol withdrawal.

Quality standards



10. Wernicke's encephalopathy

8 Intensive community programmes following successful withdrawal

Intensive community programmes following assisted withdrawal should consist of a drug

regimen supported by psychological interventions including individual treatments, group

treatments, psychoeducational interventions, help to attend self-help groups, family and carer

support and involvement, and case management.

Person aged 16–17

After a careful review of the risks and benefits, specialists may consider offering acamprosate2



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1 At the time this guidance was created (May 2011), benzodiazepines did not have UK marketing authorisation for

this indication, or for use in children and young people under 18. Informed consent should be obtained and

documented. This should be done in line with normal standards of care for patients who may lack capacity (see the

Department of Health's advice on consent or NHS Wales) or in line with normal standards in emergency care. 2 At the time of this guidance was created (May 2011), acamprosate did not have UK marketing authorisation for

use longer than 12 months. Informed consent should be obtained and documented.


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http://www.wales.nhs.uk/


or oral naltrexone1 in combination with cognitive behavioural therapy to young people who have

not engaged with or benefited from a multicomponent treatment programme.

Mild alcohol dependence

For harmful drinkers and people with mild alcohol dependence who have not responded to

psychological interventions alone, or who have specifically requested a pharmacological

intervention, consider offering acamprosate2 or oral naltrexone in combination with an individual

psychological intervention (cognitive behavioural therapies, behavioural therapies or social

network and environment-based therapies) or behavioural couples therapy.

Moderate and severe alcohol dependence

Consider offering interventions to promote abstinence and prevent relapse as part of an

intensive structured community-based intervention for people with moderate and severe alcohol

dependence who have:

very limited social support (for example, they are living alone or have very little contact with family or friends) or

complex physical or psychiatric comorbidities or

not responded to initial community-based interventions.

Consider offering acamprosate or oral naltrexone in combination with an individual

psychological intervention (cognitive behavioural therapies, behavioural therapies or social

network and environment-based therapies) focused specifically on alcohol misuse (see

psychological interventions for adults).

Consider offering acamprosate or oral naltrexone in combination with behavioural couples

therapy to service users who have a regular partner and whose partner is willing to participate in

treatment (see psychological interventions for adults).

Consider offering disulfiram3 in combination with a psychological intervention to service users

who:

have a goal of abstinence but for whom acamprosate and oral naltrexone are not suitable, or

prefer disulfiram and understand the relative risks of taking the drug.

Mild to moderate alcohol dependence and complex needs or severe dependence

For people with mild to moderate dependence and complex needs, or severe dependence, offer



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1 At the time this guidance was created (May 2011), oral naltrexone did not have UK marketing authorisation for this

indication. Informed consent should be obtained and documented. 2 Note that the evidence for acamprosate in the treatment of harmful drinkers (high-risk drinkers) and people who

are mildly alcohol dependent is less robust than that for naltrexone. At the time this guidance was created (May

2011), acamprosate did not have UK marketing authorisation for this indication. Informed consent should be

obtained and documented. 3 All prescribers should consult the SPC for a full description of the contraindications and the special considerations

of the use of disulfiram.


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an intensive community programme following assisted withdrawal in which the service user may

attend a day programme lasting between 4 and 7 days per week over a 3-week period.

Quality standards



11. Psychological interventions and relapse prevention medication for adults

9 Acamprosate or naltrexone

Conduct a comprehensive medical assessment before starting treatment

Before starting treatment with acamprosate or oral naltrexone conduct a comprehensive

medical assessment (baseline urea and electrolytes and liver function tests including GGT). In

particular, consider any contraindications or cautions (see the SPC), and discuss these with the

service user.

Acamprosate

If using acamprosate, start treatment as soon as possible after assisted withdrawal. Usually

prescribe at a dose of 1998 mg (666 mg three times a day) unless the service user weighs less

than 60 kg, and then a maximum of 1332 mg should be prescribed per day. Acamprosate

should:

usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it1

be stopped if drinking persists 4–6 weeks after starting the drug.

Service users taking acamprosate should stay under supervision, at least monthly, for 6 months,

and at reduced but regular intervals if the drug is continued after 6 months. Do not use blood

tests routinely, but consider them to monitor for recovery of liver function and as a motivational

aid for service users to show improvement.

Naltrexone

If using oral naltrexone2, start treatment after assisted withdrawal. Start prescribing at a dose of

25 mg per day and aim for a maintenance dose of 50 mg per day. Draw the service user's



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1 At the time of publication (February 2011), acamprosate did not have UK marketing authorisation for use longer than 12 months. Informed consent should be obtained and documented. 2 At the time of publication (February 2011), oral naltrexone did not have UK marketing authorisation for this

indication. Informed consent should be obtained and documented.


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attention to the information card that is issued with oral naltrexone about its impact on opioid-

based analgesics. Oral naltrexone should:

usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it

be stopped if drinking persists 4–6 weeks after starting the drug.

Service users taking oral naltrexone should stay under supervision, at least monthly, for 6

months, and at reduced but regular intervals if the drug is continued after 6 months. Do not use

blood tests routinely, but consider them for older people, for people with obesity, for monitoring

recovery of liver function and as a motivational aid for service users to show improvement. If the

service user feels unwell advise them to stop the oral naltrexone immediately.

10 Disulfiram

Before starting treatment with disulfiram, conduct a comprehensive medical assessment

(baseline urea and electrolytes and liver function tests including GGT). In particular, consider

any contraindications or cautions (see the SPC), and discuss these with the service user.

If using disulfiram, start treatment at least 24 hours after the last alcoholic drink consumed.

Usually prescribe at a dose of 200 mg per day. For service users who continue to drink, if a

dose of 200 mg (taken regularly for at least 1 week) does not cause a sufficiently unpleasant

reaction to deter drinking, consider increasing the dose in consultation with the service user.

Before starting treatment with disulfiram, test liver function, urea and electrolytes to assess for

liver or renal impairment. Check the SPC for warnings and contraindications in pregnancy and

in the following conditions: a history of severe mental illness, stroke, heart disease or

hypertension.

Make sure that service users taking disulfiram:

stay under supervision, at least every 2 weeks for the first 2 months, then monthly for the following 4 months

if possible, have a family member or carer, who is properly informed about the use of disulfiram, oversee the administration of the drug

are medically monitored at least every 6 months after the initial 6 months of treatment and monitoring.

Warn service users taking disulfiram, and their families and carers, about:



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the interaction between disulfiram and alcohol (which may also be found in food, perfume, aerosol sprays and so on), the symptoms of which may include flushing, nausea, palpitations and, more seriously, arrhythmias, hypotension and collapse

the rapid and unpredictable onset of the rare complication of hepatotoxicity; advise service users that if they feel unwell or develop a fever or jaundice that they should stop taking disulfiram and seek urgent medical attention.

11 Drugs not to be routinely used

Do not use antidepressants (including SSRIs) routinely for the treatment of alcohol misuse

alone.

Do not use GHB for the treatment of alcohol misuse.

Benzodiazepines should only be used for managing alcohol withdrawal and not as ongoing

treatment for alcohol dependence.

12 Staff competencies

Staff responsible for assessing and managing assisted alcohol withdrawal should be competent

in the diagnosis and assessment of alcohol dependence and withdrawal symptoms and the use

of drug regimens appropriate to the settings (for example, inpatient or community) in which the

withdrawal is managed.

If a symptom-triggered medication regimen [See page 17] is used, all staff should be competent

in monitoring symptoms effectively and the unit should have sufficient resources to allow them

to do so frequently and safely.



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A symptom-triggered approach involves tailoring the drug regimen according to the severity of

withdrawal and any complications. The service user is monitored on a regular basis and

pharmacotherapy only continues as long as the service user is showing withdrawal symptoms.

A symptom-triggered approach involves tailoring the drug regimen according to the severity of

withdrawal and any complications. The service user is monitored on a regular basis and

pharmacotherapy only continues as long as the service user is showing withdrawal symptoms.

Glossary

ADI

adolescent diagnostic interview

Alcohol dependence

(a cluster of behavioural, cognitive and physiological factors that typically include a strong

desire to drink alcohol and difficulties in controlling its use: someone who is alcohol-dependent

may persist in drinking, despite harmful consequences; they will also give alcohol a higher

priority than other activities and obligations; for further information please refer to: 'Diagnostic

and statistical manual of mental disorders' (DSM-IV) (American Psychiatric Association 2000)

and 'International statistical classification of diseases and related health problems – 10th

revision' (ICD-10) (WHO 2007))

Alcohol treatment

(a programme designed to reduce alcohol consumption or any related problems; it could involve

a combination of counselling and medicinal solutions)

Alcohol-related harm

(physical or mental harm caused either entirely or partly by alcohol: if it is entirely as a result of

alcohol, it is known as 'alcohol-specific'; if it is only partly caused by alcohol it is described as

'alcohol-attributable')

Alcohol-use disorders

(alcohol-use disorders cover a wide range of mental health problems as recognised within the

international disease classification systems (ICD-10, DSM-IV): these include hazardous and

Assisted alcohol withdrAssisted alcohol withdraawalwal NICE Pathways


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harmful drinking and alcohol dependence)

APQ

alcohol problems questionnaire

ASA

Advertising Standards Authority

AUDIT

(alcohol use disorders identification test: an alcohol screening test designed to see if people are

drinking harmful or hazardous amounts of alcohol; it can also be used to identify people who

warrant further diagnostic tests for alcohol dependence)

BAC

blood alcohol concentration

Brief intervention

(this can comprise either a short session of structured brief advice or a longer, more

motivationally-based session (that is, an extended brief intervention): both aim to help someone

reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-

alcohol specialists)

Brief interventions

(this can comprise either a short session of structured brief advice or a longer, more

motivationally-based session (that is, an extended brief intervention): both aim to help someone

reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-

alcohol specialists)

CAMHS

child and adolescent mental health service



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CIWA–Ar

(the Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA–Ar) scale is a validated

10-item assessment tool that can be used to quantify the severity of the alcohol withdrawal

syndrome, and to monitor and medicate patients throughout withdrawal)

Decompensated liver disease

(liver disease complicated by jaundice, ascites, variceal bleeding or hepatic encephalopathy)

Diversion

(when the drug is being taken by someone other than for whom it was prescribed)

Extended brief intervention

(this is motivationally-based and can take the form of motivational-enhancement therapy or

motivational interviewing: the aim is to motivate people to change their behaviour by exploring

with them why they behave the way they do and identifying positive reasons for making change)

Extended brief interventions

(this is motivationally-based and can take the form of motivational-enhancement therapy or

motivational interviewing: the aim is to motivate people to change their behaviour by exploring

with them why they behave the way they do and identifying positive reasons for making change)

Fixed-dose medication regimen

(involves starting treatment with a standard dose, not defined by the level of alcohol withdrawal,

and reducing the dose to zero over 7-10 days according to a standard protocol)

Fixed-dose medication regimens

(involve starting treatment with a standard dose, not defined by the level of alcohol withdrawal,

and reducing the dose to zero over 7-10 days according to a standard protocol)

FRAMES

(FRAMES is an acronym summarising the components of a brief intervention: feedback (on the

client's risk of having alcohol problems), responsibility (change is the client's responsibility),



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advice (provision of clear advice when requested), menu (what are the options for change?),

empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism

about the behaviour change))

GHB

gammahydroxybutyrate

GGT

gamma glutamyl transferase

GUM

genito-urinary medicine

LDQ

Leeds dependence questionnaire

Looked-after children

(the term 'looked after' has a specific legal meaning: it refers to children and young people who

are provided with accommodation on a voluntary basis for more than 24 hours; this compares

with the term 'in care' which refers to those who are compulsorily removed from home and

placed in care under a court order)

LSCB

local safeguarding children board

MMSE

mini-mental state examination

PAT

Paddington alcohol test



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PSHE

Personal, Social and Health Education

Responsible authorities

(responsible authorities have to be notified of all licence variations and new applications and

can make representations regarding them: the Licensing Act 2003 lists responsible authorities;

they include the police, environmental health, child protection service, fire and rescue and

trading standards)

RSE

relationships and sex education

SADQ

severity of alcohol dependence questionnaire

Saturated

(in relation to licensed premises, this describes a specific geographical area where there are

already a lot of premises selling alcohol – and where the awarding of any new licences to sell

alcohol may contribute to an increase in alcohol-related disorder)

Screening

(for the purposes of this guidance, screening involves identifying people who are not seeking

treatment for alcohol problems but who may have an alcohol-use disorder: practitioners may

use any contact with clients to carry out this type of screening; the term is not used here to refer

to national screening programmes such as those recommended by the UK National Screening

Committee)

SSRIs

selective serotonin reuptake inhibitors

SPC

summary of product characteristics



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Spiral curriculum

(a course of study in which pupils study the same topics in ever-increasing complexity

throughout their time at school to reinforce previous lessons)

Structured brief advice

(a brief intervention that takes only a few minutes to deliver)

T-ASI

teen addiction severity index

Targeted intervention

(intervention for children and young people who are not necessarily seeking help but who have

risk factors that make them vulnerable to alcohol misuse)

Targeted interventions

(interventions for children and young people who are not necessarily seeking help but who have

risk factors that make them vulnerable to alcohol misuse)

Treatment

(a programme designed to reduce alcohol consumption or any related problems. It could involve

a combination of counselling and medicinal solutions)

Unit

(in the UK, alcoholic drinks are measured in units: each unit corresponds to approximately 8 g

or 10 ml of ethanol; the same volume of similar types of alcohol (for example, 2 pints of lager)

can comprise a different number of units depending on the drink's strength (that is, its

percentage concentration of alcohol))

Universal

(education that addresses all pupils in the school. It is delivered to groups of pupils without

assessing their risk)



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Universal education

(education that addresses all pupils in the school. It is delivered to groups of pupils without

assessing their risk)

Sources

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk

drinking) and alcohol dependence (2011) NICE guideline CG115

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful

consideration of the evidence available. When exercising their judgement, professionals and

practitioners are expected to take this guideline fully into account, alongside the individual

needs, preferences and values of their patients or the people using their service. It is not

mandatory to apply the recommendations, and the guideline does not override the responsibility

to make decisions appropriate to the circumstances of the individual, in consultation with them

and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline

to be applied when individual professionals and people using services wish to use it. They

should do so in the context of local and national priorities for funding and developing services,

and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to

advance equality of opportunity and to reduce health inequalities. Nothing in this guideline

should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of

implementing NICE recommendations wherever possible.



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http://www.nice.org.uk/Guidance/CG115

https://www.nice.org.uk/about/who-we-are/sustainability



Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after

careful consideration of the evidence available. When exercising their judgement, health

professionals are expected to take these recommendations fully into account, alongside the

individual needs, preferences and values of their patients. The application of the

recommendations in this interactive flowchart is at the discretion of health professionals and

their individual patients and do not override the responsibility of healthcare professionals to

make decisions appropriate to the circumstances of the individual patient, in consultation with

the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable

the recommendations to be applied when individual health professionals and their patients wish

to use it, in accordance with the NHS Constitution. They should do so in light of their duties to

have due regard to the need to eliminate unlawful discrimination, to advance equality of

opportunity and to reduce health inequalities.




Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after

careful consideration of the evidence available. When exercising their judgement, healthcare

professionals are expected to take these recommendations fully into account. However, the

interactive flowchart does not override the individual responsibility of healthcare professionals to

make decisions appropriate to the circumstances of the individual patient, in consultation with

the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful

discrimination, advance equality of opportunity, and foster good relations. Nothing in this

interactive flowchart should be interpreted in a way that would be inconsistent with compliance

with those duties.



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