THE MANAGEMENT OF WITHDRAWAL SYNDROMES
STABILISATION
The patient's social circumstances and psychological state should be as stable as possible before commencing detoxification. Stabilisation of the patient's substance misusing behaviour through a counselling process and through the prescription of substitute medication is also likely to improve the outcome of detoxification.
DECISION
The patient must be crystal clear that they are ready for detoxification and prepared for abstinence. If there is doubt, then wait.
PREPARATION
Preparation involves planning the most suitable time for the detoxification (for example to fit in with childcare or work arrangements), setting a specific date to commence detoxification (usually a Monday to avoid reduced availability of medical cover during the earlier stages of the detoxification), and most importantly agreeing the aftercare arrangements. A full physical assessment with baseline blood tests (FBC, U&E, LFT, GGT, glucose,TFT, clotting screen) and urine drugs of abuse screen should be performed as part of the planning process. The patient should be warned that the detoxification itself is 'the easy part' and that remaining abstinent is much harder.
Most patients who are physically dependent on a substance will experience a protracted withdrawal syndrome that can last many months after detoxification. Insomnia, agitation and craving are all common complaints during this period.
DETOXIFICATION
Decisions will need to be made regarding the setting (community or in-patient detoxification), the agent to be used, adjunctive medication to be prescribed, and the necessary degree of monitoring during detoxification. In general, in-patient as opposed to community detoxification is indicated in the following circumstances:
- There is a past history of delirium tremens or fits during withdrawals.
- There is concurrent severe medical illness.
- There is concurrent severe psychiatric illness or suicide risk.
- The patient has cognitive deficits.
- The patient has insufficient social support available at home.
- There is a past history of failed community detoxification.
Medical ward.
Patients with any of the serious medical consequences of alcohol misuse should be considered for detoxification on a medical ward. The stress of detoxification and the prescription of medication which is metabolised by the liver can precipitate a number of complications such as Wernicke's Encephalopathy or hepatic encephalopathy in the medically ill patient. For example liver failure with abnormal clotting profiles, or a recent history of bleeding from oesphageal varices, indicates the need for hospital medical supervision.
Psychiatric ward.
Patients with concurrent severe psychiatric illness, or those at acute risk of suicide should receive detoxification as an in-patient on a psychiatric ward.
Specialist in-patient detoxification unit.
Rates of completion of detoxification are typically in the region of 80 - 100% for specialist in-patient detoxification and 50% for community detoxification. However some clients will prefer the option of home (community) detoxification and the cost of in-patient detoxification precludes its automatic availability. A history of previous complicated withdrawal, insufficient social support at home, cognitive impairment or a previous failure to complete community detoxification are all indications for an in-patient as opposed to a community detoxification.
Community.
Community detoxification is appropriate for those who have sufficient social support at home and who have no serious concurrent psychiatric or medical illness. Community detoxification should always take place with the support of staff from the local specialist substance misuse service.
RELAPSE PREVENTION
Prevention of relapse may involve the prescription of medication (see Section C6, page 41), counselling interventions, attendance of self-help groups such as AA and NA, and social interventions aimed at enhancing purposeful activity and relieving stressful social circumstances.
Some patients will be suitable for an extended period of rehabilitation in a specialist unit, either on a residential or day-care basis.
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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.
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