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PRACTICE GUIDELINES
OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES:
A GUIDE - ALCOHOL
The TSPP Executive Council approved the Guidelines during its
meeting on November 16, 2002. The Guidelines were tentatively approved on April
21, 2002 by the Executive Council. The Guidelines were published in the
April/May 2002 TSPP Newsletter for review and comment by TSPP members.
The psychiatrist practicing in an office-based setting can expect to encounter
patients with alcoholism. According to The National Comorbidity Study 14% of
adults develop alcohol dependence over the course of a lifetime.
There are several reasons why a patient may prefer office-based outpatient
detoxification and refuse inpatient or partial hospitalization:
Has no insurance or has used up previous benefits
Fear of stigma if hospitalized or enrolled in a formal treatment program
Does not want to lose time from work or wants to minimize time away from work
Prefers or needs to stay with family
The appropriateness, safety, and effectiveness of this procedure will depend on
several variables. First, those variables which favor office-based outpatient
detoxification:
Cooperative patient
Lives with or can be monitored by a responsible adult
No acute medical conditions that in and of themselves would require
hospitalization
No coexisting psychiatric disorders (Axis I or II) which in and of themselves
would require hospitalization
Variables which weigh against office-based outpatient detoxification:
A history of being uncooperative with medication schedule
Lives alone and has no social network available for assessment
Has acute medical problems (e.g. infections, pain symptoms) or unstable
chronic medical problem (e.g. hypertension, diabetes mellitus)
Has a co-occurring psychiatric disorder that may compromise judgment or that
requires close monitoring.
Past pattern of life threatening complications of alcohol withdrawal (for
example: repeated seizures; emerging delirium tremens; hyperthermia; hepatic
failure; esophageal varices)
Likelihood of additional withdrawal syndromes due to other substance
dependencies
Physical and laboratory tests must be available and used as indicated
I. The decision to proceed with office-based outpatient detoxification is a
judgment the psychiatrist must make. Knowledge of the patient, consideration of
the variables listed above, and ability to monitor the course of treatment will
influence the decision. Please keep in mind, detoxification is only the
introduction to addiction treatment and a treatment plan for continuing
rehabilitation should be implemented.
Initiation of Detoxification - Look For:
Physical Exam:
Heart disease (arrhythmia, congestive heart failure)
Infections
Gastro-intestinal bleeding
Liver disease
Pancreaticis
Nervous system impairment (e.g., signs of head injury, stroke, subdural hematoma)
Laboratory:
Complete blood count
Liver Enzymes
Urine drug screen
Blood alcohol level
Electrolytes including potassium, calcium, magnesium, phosphate
II. Educate patient and family member or other supportive persons regarding
alcohol withdrawal symptoms and time course (see chart below).
Need for hospitalization if symptoms of delirium tremens (DTs) occur
(disorientation, confusion, persistent hallucinations)
Possibility of seizures
Lay frame work for need for further rehabilitation treatment following
detoxification
Advise against driving or operating dangerous equipment; Assess safety of
patients work situation
III. Patient should be seen as needed in office; Access to physician must be
available.
Daily monitoring of symptoms by responsible adult (pulse, temperature, blood
pressure); blood pressure monitoring is possible through pharmacy and
super-markets which have blood pressure machines; blood pressure monitoring
equipment can be purchased inexpensively; or visits to primary care office for
determination of vital signs
If pulse, temperature or diastolic blood pressure exceed 100 report results to
a physician.
Table 1
Symptoms of Alcohol Withdrawal (AW)*
Time of Appearance: Start: 6-8 hours
Symptoms (mild to moderate AW): Nausea; Vomiting; Tremor; Insomnia;
Decreased Appetite; Pulse increase
Symptoms (Severe AW ) **: Same as mild-to-moderate AW plus: Visual and
auditory hallucinations
Time of Appearance: Next 1-2 Days: intensifies, then diminishes
Symptoms (mild to moderate AW): Anxiety; Irritability; Headache;
Agitation; Sensitivity to light and sound; Concentration and orientation
problems
Symptoms (Severe AW ) **: Seizures ***
Time of Appearance: 2-4 Days
Symptoms (mild to moderate AW):
Symptoms (Severe AW ) **: Seizures ***; Delirium Tremens (DTs): Increase
agitation, tremulousness and disorientation; Large increases in BP, pulse, and
breathing rate; Autonomic instability; Hyperpyrexia; Persistent visual and
auditory hallucinations; Disorientation
Time of Appearance: Up to 6 days
Symptoms (mild to moderate AW):
Symptoms (Severe AW ) **: Seizures ***
* From Anton and Myrick, 2000
** Emergence of severe AW indicates hospitalization rather than outpatient
detoxification
*** Seizures may not warrant hospitalization but Neurology consultation is
indicated
IV. Pharmacotherapy
1. Vitamins:
a. Thiamin 100 mg daily x3 days
b. Multivitamin, one daily
2. Benzodiazepines (BZs) are the most commonly used agent
Advantages:
Well tolerated
Proven efficacy
Can be used to treat break-through sxs
Can prevent seizures
Disadvantages:
Dangerous if mixed with alcohol
Side effects include amnesia, sedation, motor
incoordination
Potentially addictive if used for long periods
a. Chlordiazepoxide: (preferred regimen)
Advantages:
Long-acting
Unlikely to be abused
Day 1: 50 mg po q 6 hours
Day 2: 25 mg po q 6 hours
Day 3: 25 mg po q 6 hours
Day 4: 25 mg po bid (if necessary)
Supplement with 25 mg to 50 mg every one hour if symptoms of withdrawal are not
abating. Decrease dose if patient is over-sedated.
or
b. Lorazepam:
Advantage:
Can be given even if cirrhotic liver disease present
Disadvantage:
Short-acting
Day One: 2 mg po q6h
Day Two: 2 mg po q6h
Day Three: 1 mg po q6h
Day Four: 1 mg po q6h
Day Five: 0.5 mg q 6h
Day Six: 0.5 mg q 12h
Supplement with 0.5 to 1.0 mg every one hour if withdrawal symptoms are not
abating. Decrease dose if patient is over-sedated
c. Oxazepam:
Advantage:
Can be given with liver disease
Intermedicate acting
Unlikely to be abused
Day One: 30 mg q 6h
Day Two: 30 mg q6h
Day Three: 15 mg q6h
Day Four: 15 mg q6h
Day Five: 15 mg q12h
Supplement with 15-30 mg every hour if symptoms of withdrawal are not abating.
Decrease dose if patient is over-sedated.
To avoid benzodiazepine abuse or dependence, prescribe only enough for the
number of days of expected use; no refills.
Other Agents that May be Used for Detoxification:
1. Carbamazepine (Tegretal):
Advantages:
No adverse interaction if alcohol ingested
Disadvantages:
Efficacy not as well documented as BZs
Break-through symptoms must be treated with BZs
Cannot be given if LFTs>3 x normal
Not effective for DTs
Day 1-2: 200 mg qid
Day 3-4: 200 mg tid
Day 5-6: 200 mg bid
Day 7-8 200 mg daily
2. Divalproex Sodium (Depakote)
Advantages:
Can prevent seizures
Disadvantages:
Efficacy not as well documented as BZs
Break-through symptoms must be treated with BZs
Not effective for DTs
Day 1: 500 mg po start loading dose, followed by 500mg po 6 hours later
Day 2: 500 mg po bid
Day 3: 500mg po bid
Day 4: 250 mg po bid
Day 5: 250 mg po one dose
Other potentially useful medications:
Neurontin- for anxiety or sleep disturbance
Phenergan suppository (25 or 50 mg), prn, for nausea or vomiting
Over the counter (eg. Kaopectate ) or prescribed (Lomotil) anti-diarrheals.
References:
Anton RF and Myrick DL. Pharmacological Management of Alcohol Withdrawal. 1999
CME Monograph Series. Danne Miller Memorial Educational Foundation and Alpha and
Omega Worldwide, LLC, Jan 2000.
Claassen C, Adinoff B. Alcohol withdrawal syndrome: Guidelines for management.
CNS Drugs. 12(4): 279-291, 1999
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