Prerequisites
Diagnosis: Establish diagnosis of alcohol withdrawal using DSM-5 criteria. It is crucial to rule out other medical conditions that can mimic withdrawal, such as sepsis, metabolic disturbances, or intracranial events.
BAL (Blood Alcohol Level): While not a contraindication to starting treatment, it is preferable to begin dosing when the BAL is low or falling (e.g., < 0.1 g/dL). This helps differentiate symptoms of intoxication from true withdrawal.
Liver Function: Assess liver function (LFTs, INR, Albumin) to guide benzodiazepine choice. Severe liver impairment may necessitate using a drug with no active metabolites, like Oxazepam.
CIWA-Ar Scale: Commence CIWA-Ar monitoring every 2-4 hours. This objective scale guides symptom-triggered therapy, allowing for tailored dosing and preventing both under- and over-sedation.
Post-withdrawal plan: Ensure there is a follow-up plan in place for ongoing support and monitoring after the withdrawal process. To withdraw without a plan is to risk (1) relapse and broader treatment futility (2) reducing alcohol tolerance and temporarily worsening risks of intoxication.
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.
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
Special Cases
Seizures (current or past): Consider loading with benzodiazepines as for severe withdrawal
Alcohol Withdrawal Delirium: Needs ICU/HDU or 1:1 nursing
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)
Patient Selection Criteria
The following criteria should be met for a patient to be considered for an outpatient (ambulatory) detox.
Inclusion Criteria
- Age > 18-years-old.
- Has undertaken a comprehensive AOD assessment.
- Patient has up-to-date FBC, LFTs, EUCs, INR, and these have been reviewed by the AOD clinician.
- Patient is diagnosed with an alcohol use disorder.
- Mild to moderate alcohol withdrawal severity expected, defined by:
- Average or low risk on Prediction of Alcohol Withdrawal Severity Scale (PAWSS), OR a clear clinical rationale exists for proceeding despite a higher score.
- Patient’s average alcohol intake is ≤15 standard drinks per day.
- Patient agrees to daily review at the service.
- Patient has nominated a pharmacy or other suitable location (e.g. clinic or practice where medicines have been left) for DAILY pickup of medication, and the dispensing location has agreed.
- Patient has a reasonably safe home environment or supervision.
- Patient has reliable means for daily reviews (e.g., transport to review or clinician will go to patient).
- Patient has a reasonable plan for service engagement after detox (e.g., outpatient services, rehabilitation).
- There is no alcohol remaining in the house prior to detox commencing.
Exclusion Criteria (Contraindications)
- Medical or psychiatric contraindications, including but not limited to: a seizure disorder, prior or current Wernicke-Korsakoff syndrome, history of suicide attempts, cognitive impairment, or recurrent delirium.
- Major unmanaged hepatic or renal disease. If present, discussion with an addiction medicine specialist is required regarding regimen modification (e.g., using oxazepam instead of diazepam).
- Patient is on regular opioids, beta-blockers, or alpha-adrenergic acting agents (e.g., clonidine, prazosin) due to potential interactions and/or masking of alcohol withdrawal symptoms.
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. 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.
- Medical Officer Review Triggers:
- Nursing staff should call the AOD medical officer if CIWA-Ar score is >20 or other complications arise.
- 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.
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
Calculate by Volume and ABV
Alcohol Withdrawal Scale (AWS)
CIWA-Ar
SAWS (Short Alcohol Withdrawal Scale)
COWS (Clinical Opiate Withdrawal Scale)
CIWA-B (Benzodiazepine)
Cannabis Withdrawal Scale
Note: This is a monitoring tool, not a diagnostic one. Higher scores indicate greater severity.
Cannabis Withdrawal Assessment Scale (CWAS)
Note: This is a monitoring tool. Higher scores indicate greater severity.