Withdrawal Management Assistant

Thiamine

Prophylaxis (Standard Regimen): To prevent Wernicke's Encephalopathy (WE), all patients undergoing alcohol withdrawal should receive parenteral thiamine. Commence thiamine 300mg IV/IM daily for 3-5 days. Crucially, always administer thiamine BEFORE any glucose-containing fluids.

Suspected Wernicke-Korsakov Syndrome (WKS): Have a high index of suspicion for WKS in any patient with confusion, ataxia, ophthalmoplegia, memory disturbance, or malnutrition. The classic triad is rare. Treatment requires high-dose thiamine: 500mg IV TDS for a minimum of 5 days, followed by oral supplementation.

Caveat: Patients must be magnesium replete for adequate thiamine absorption and activation.

1. Benzodiazepine Choice

Diazepam: The standard choice due to its long half-life, which provides a smooth, self-tapering effect and reduces the risk of breakthrough symptoms and seizures.

Oxazepam: Preferred in specific situations as it has no active metabolites and is less likely to accumulate.

Use Oxazepam in cases of:
• Significant liver impairment (e.g., cirrhosis, high bilirubin, coagulopathy).
• Respiratory insufficiency or risk of respiratory depression (e.g., COPD).
• Elderly or frail patients who are more sensitive to sedative effects.
• Cerebral trauma / CVA where over-sedation is a risk.

Conversion: Diazepam 10mg is approximately equivalent to Oxazepam 30mg.

Current Selection: Diazepam

2. Regimens (CIWA-Ar)

Displaying Regimens for: Diazepam

Ensure CIWA-Ar done q2hrly at least initially for all patients commenced on regimen. Check BAC before commencing. Do not start CIWA-Ar or benzodiazepines until 6+ hours post last drink. Regularly review patient and adjust as per clinical judgement.

Do not give regular or PRN doses if patient is sedated. If multiple doses are not able to be given, review regular dosing schedule.

Special Cases

Seizures (current or past): Consider loading with benzodiazepines as for severe withdrawal

Alcohol Withdrawal Delirium: Needs ICU/HDU or 1:1 nursing

Adjunctive Medications for Severe Symptoms: In cases of delirium or severe agitation/psychosis poorly responsive to benzodiazepines, other agents may be considered after specialist consultation. Examples include low-dose antipsychotics (e.g., Haloperidol, Olanzapine). These are not first-line and require careful risk/benefit assessment.

General Notes: If total daily diazepam equivalent exceeds 80mg, contact specialist service (e.g. D&A CL service, Drug and Alcohol State Advisory Service (DASAS) - 1800 023 687)

Example Daily Protocol

This is an example process for a structured outpatient detox program.

• All detoxes start on Monday, cease on Friday, and are organised the week prior.
• Scripts for the weaning regimen are written by the patient's GP or a service medical officer.
• Patient must present daily for review:
  • Nursing staff perform a CIWA-Ar assessment in the AM before the first dose of the day.
  • Nursing staff perform a brief delirium screen daily (e.g., 4AT screen).
  • Nursing staff perform a breathalyser test (or if unavailable, an alternative screening method for recent alcohol consumption). All patients must have an undetectable BAL to qualify for further benzodiazepines.
  • Basic observations are taken (HR, BP, RR, temperature).
  • If all checks are satisfactory, staff will call the nominated pharmacy to authorise the dispensing of the next day's supply of medication.
  • In the absence of complicating factors, reviews on days 4-5 may be via phone or video call.
• Medical Officer Review Triggers:
  • Nursing staff should call the AOD medical officer if CIWA-Ar score is >20 or other complications arise.
  • If any concerns arise (e.g., high CIWA-Ar score, positive BAL, signs of delirium), the patient should be referred to a medical officer for review and the detox protocol should be ceased.
  • The medical officer should consider calling a specialist service (e.g., DASAS 1800 023 687) if withdrawal appears severe despite treatment.
  • Top-up doses may be considered in rare circumstances via a separate, specific script.

Medication Regimen

Example Diazepam Regimen (Fixed-Dose):

A common approach is a 5-day fixed-dose weaning regimen. This must be adjusted based on clinical assessment. Staged, daily supply from a pharmacy is essential.

• Day 1: 10mg QID (four times a day)
• Day 2: 10mg TDS (three times a day)
• Day 3: 10mg BD (twice a day)
• Day 4: 5mg BD (twice a day)
• Day 5: 5mg Nocte (at night), then cease.

Ensure that in addition to the above patients receive thiamine 300mg oral tablets daily

Dosing Times:

A QID (four times a day) schedule can be challenging. While ideal times might be 0600, 1200, 1800, 2200, a more realistic schedule based on service opening hours might be:

09:00, 13:00, 18:00, 22:00

It is helpful to provide the patient with a pictorial or clearly written schedule of their dosing times.

When to Cease or Escalate Care

Situations Triggering Protocol to be Aborted

• Patient has a positive BAL (Blood Alcohol Level).
• Patient does not present for reviews or is not taking diazepam as directed (e.g., taking takeaway doses all at once).
• Use of other interacting substances (e.g., opioids, illicit drugs).
• Verbal abuse or violence towards staff.
• Oversedation despite the clinician decreasing doses.

Situations Triggering Presentation to Hospital

• Seizures
• Delirium
• Hallucinations
• Suicidality
• Other acute medical concerns