This guidance is primarily for addiction specialists and non-specialist community psychiatric teams as liaison teams in general hospitals will largely be able to follow usual practice regarding managing alcohol problems and detox.
It focuses on management of alcohol problems; however assessment of mental health (e.g. of anxiety, depression) and of physical health must be conducted to develop an appropriate management plan. How to best support families, friends etc should also be considered.
This guidance should be read in conjunction with local or national policies, including Scottish guidance from SHAAP as well as existing pre-COVID-19 guidance including NICE guidance on alcohol-use disorders as well as our guidance on working with vulnerable people, which includes specific guidance on those with alcohol dependence. Please also refer to our guidance on remote consultations.
1. Assessment: Is the individual dependent on alcohol?
Use screening questionnaires such as AUDIT to determine whether person presenting is likely to be drinking at harmful levels or is dependent on alcohol (AUDIT score >20). It is crucial to determine if someone is dependent since this puts them at risk of complications from alcohol withdrawal which need managing appropriately.
2. Harmful consumption
If an individual is drinking at a harmful level but is not dependent they should be given advice – a brief intervention – about their consumption and pointed to online resources about how to manage or reduce their drinking (e.g. by 10% every
day/few days; swapping to lower % alcohol; not drinking during day; having alcohol free days) etc. This may include 1: keeping a drink diary, 2: read up about adverse impact on health (e.g. hypertension, fatty liver, anxiety, depression) 2:
writing down the pros and cons about drinking; 3: writing down goals, any potential barriers/challenges and how to overcome them (e.g. distraction activities); 4: involve family or friends to support aims. See here for further resources.
3. Dependent consumption
If an individual is dependent on alcohol (i.e. ‘alcoholic’) a key risk to manage is alcohol withdrawal. They should be advised not to just stop drinking alcohol. Reducing consumption gradually may also not be possible for them as a cardinal feature of being dependent is ‘lack of control’ over their consumption. Alcohol withdrawal and any associated complications may be more likely during current situation due to no/limited access to alcohol, self-isolation, reduced income or illness due to COVID-19. In addition inpatient or rehabilitation facilities are currently unavailable or extremely limited so that any management plan must be feasible in a community setting. This may mean that the threshold for admission to such a setting would ordinarily be met but that treatment must currently be undertaken in the community. Consideration of setting and support (e.g. what materials can be offered, online support etc) is therefore crucial to determine appropriate course of action. Services will have to consider how individuals will receive prescription/access to pharmacy, safe storage of any medication, remote assessment of detoxification etc.
Appropriate assessment and management of their alcohol withdrawal is necessary to avoid complications (e.g. withdrawal seizure (likely 24-48hrs post alcohol) or delirium tremens (48-72hrs post alcohol) or Wernicke’s encephalopathy (WE – see below) or presenting to other NHS services in acute withdrawal where they may not be able to access treatment.
The following focuses on medical management of alcohol withdrawal. The medication and regimen used should be one that is familiar to staff involved e.g. reducing regimen of chlordiazepoxide or diazepam. Consider if any other sedative drugs are being prescribed/taken e.g. methadone.
For all presentations, complete a triage assessment, to include:
- if they are currently dependent or not (e.g. using AUDIT with a score >20 and Severity of Alcohol Dependence Questionnaire Score >15 as an initial screen)
- whether they are withdrawing from alcohol and require medication
- risks of alcohol withdrawal ie previous seizures, DTs etc (and did they occur in presence or absence of detox medication e.g. a benzodiazepine) and medical history (acknowledging likely inability to assess recent bloods, LFTs, etc)
- risk of WE based on history and clinical presentation (see above)
Presenting acutely in alcohol withdrawal
If an individual is unknown to the service: assess degree of withdrawal, time of last drink and reason for presentation to formulate plan (e.g advise harm reduction leaflet (PHE/ SHAAP as above) or start detox if being admitted).
If an individual is known and is re-presenting to service but with no preparation for detox, assess whether they need medication to reduce imminent risk of a complication from alcohol withdrawal or suggest advise harm reduction leaflet (PHE/ SHAAP as above), and arrange review (in person or remotely) . Alternatively consider starting a full alcohol detox regimen if enough relapse prevention resources are in place. For information on remote consultations, please refer to our digital guidance. Please also refer to guidance on Personal Protective Equipment for face-to-face consultations.
Planned detoxification from alcohol
Ideally detoxification from alcohol should only occur with a plan for relapse prevention in place (e.g. 1:1 or (virtual) group support, medication (see below)) Anyone undertaking a detox should be strongly encouraged and supported to achieve this prior to starting. It may be appropriate to give out 2-3 days of medication rather than the full detox regimen if uncertain whether individual will complete detox or are concerned about how much medication they should have access to.
Assessment of WE needs to be considered in all individuals undergoing alcohol withdrawal or detox as it may develop due to the increased metabolic load on the brain during withdrawal. Importantly WE may also develop if their thiamine intake reduces eg poor diet or not eating due to being unwell or in presence of infection e.g. COVID-19. A high index of suspicion must be maintained for any signs of WE – ataxia, confusion, ophthalmoplegia.
If WE is present, it is a medical emergency and the individual should be referred immediately to hospital as per local protocol to receive parenteral thiamine.
If an individual is at risk of WE – missing meals, signs of peripheral neuropathy (pins & needles). Give Pabrinex IM one pair of ampoules/day for 3 days (need not be consecutive but ideally within a week; consider if can be given prior to detox). Check if individual is receiving ongoing oral supplementation. Whilst poor absorption of oral thiamine means it is not equivalent to Pabrinex for those clearly at risk, consider role for oral thiamine supplementation in reducing risk longer-term. Remain vigilant for WE developing.
Relapse prevention medication
This should be considered as part of pre-detox preparation and as an adjunct to psychosocial support/treatment. Licensed medications include acamprosate and naltrexone as first-line treatments (NICE) followed by disulfiram due to potential for interactions. Baclofen is an unlicensed medication used by some services. Nalmefene is a medication that can be given to individuals to help them stop drinking alcohol if they do not immediately require alcohol detox. Consult BNF to confirm medication can be prescribed and guidelines for further information including NICE and British Association of Psychopharmacology.
Resources for clinicians
- Alcohol Change UK
- Collective Voice
- Scottish guidance from SHAAP
- NICE guidance on alcohol-use disorders.
For individuals with alcohol dependence:
Resources for carers, family, children etc: