Assessment and management of alcohol dependence and withdrawal in the acute hospital: concise guidance
Abstract
Alcohol dependence is common among patients attending acute hospitals. It can be the major reason for attendance or a significant cofactor. Assessment of these patients in the acute setting can be challenging owing to the multidisciplinary approach required. Doctors in acute hospitals are often inexperienced in managing dependence, a mental health problem. They might focus on the physical harms or the withdrawal, a consequence of the dependence. For this reason, assessment of dependence and prevention and management of acute alcohol withdrawal are often suboptimal. There is little existing guidance on how to manage this patient population, especially in non-specialist settings. With recently published National Institute for Health and Clinical Excellence (NICE) guidance on the management of dependence and withdrawal, now is the perfect time to produce concise guidelines in the hope that a more succinct suite of guidance can reach a larger audience.
Introduction and aims
When the National Institute for Health and Clinical Excellence (NICE) guidance for the management of alcohol-use disorders was divided into three separate components,1–3 this was in recognition of the multidisciplinary nature of these problems. Mental health and ‘physical health’ staff are both involved in caring for these patients, and hazardous and harmful drinking is a major public health issue.
We now have three comprehensive full guidelines1–3 and three quick reference guides.4–6 Continued effort is required to further integrate these guidelines and to increase their utility to the busy doctor at the coal face.
This concise guideline is provided for doctors who encounter alcohol dependence and withdrawal in the course of their generic medical practice. It will specifically cover:
the assessment of alcohol dependence
the assessment of withdrawal, including the asssessment of need for admission to hospital
the management of alcohol withdrawal, including delirium tremens and alcohol withdrawal seizures
prophylaxis and treatment of Wernicke's encephalopathy.
Methods
The guidelines were developed in accordance with the relevant NICE guidelines manual.7,8
Identification and assessment of harmful drinking and alcohol dependence
The assessment of harmful drinking and alcohol dependence starts with the taking of an alcohol history. Recent and long-term alcohol consumption is often assessed in the emergency department or medical and/or surgical admission units with one or two questions. In some cases, this is adequate, but in many patients, more detailed assessment is required. This is particularly important in cases where alcohol is a contributing factor to the admission, but in any patient, there might be hazardous or harmful drinking that could be managed with brief intervention if brought to light.
Staff in acute settings need to be able to recognise the alcohol-dependent patient. This requires vigilance and an index of suspicion and can be aided by standardised tools (see guidance in Fig. 1 and Fig. 2). Once these patients are recognised, they can then be channelled towards help for their addiction and monitored for signs and symptoms of withdrawal.
1. Use formal assessment tools to assess the nature and severity of alcohol misuse, including the:
Alcohol Use Disorders Identification Test (AUDIT) for identification and as a routine outcome measure (Fig. 1)
Severity of Alcohol Dependence Questionnaire (SADQ) (Fig. 2)13 or Leeds Dependency Questionnaire (LDQ)9 for severity of dependence
Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar)10 for severity of withdrawal
Alcohol Problems Questionnaire (APQ)11 for the nature and extent of the problems arising from alcohol misuse.1
2. When assessing the severity of alcohol dependence and determining the need for assisted withdrawal, adjust the criteria for women, older people, children and young people, and people with established liver disease who might have problems with the metabolism of alcohol.1
Assessment for the need to admit for medically assisted withdrawal
Not all patients attending an acute setting with alcohol withdrawal need to be admitted to hospital. The decision around admission can be complex and the recommendations are to provide guidance rather than to act as strict criteria.
Many dependent patients manage their alcohol withdrawal symptoms every day with continued alcohol consumption and it is often appropriate to continue this until they can be assessed formally by addiction services to determine the best treatment for their alcohol dependence. There are situations in which this is inappropriate:
severe, or impending severe, withdrawal is the main reason to admit
delirium tremens and seizures are absolute criteria for admission
autonomic overactivity and evidence of withdrawal with a high blood alcohol concentration would raise concerns about impending severe withdrawal
a history of seizures or delirium tremens would raise concerns but not mandate admission.
As with all patients, a general assessment of risk should be undertaken and certain vulnerable groups, such as the very young or the frail, would have a lower threshold for admission.
Admission to hospital
3. Make sure that assessment of risk is part of any assessment, that it informs the development of the overall care plan and that it covers risk to self (including unplanned withdrawal, suicidality and neglect) and risk to others.1
4. For people in acute alcohol withdrawal with, or who are assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, offer admission to hospital for medically assisted alcohol withdrawal.2
5. For young people under 16 years who are in acute alcohol withdrawal, offer admission to hospital for physical and psychosocial assessment, in addition to medically assisted alcohol withdrawal.2
6. For certain vulnerable people who are in acute alcohol withdrawal (eg those who are frail, have cognitive impairment or multiple comorbidities, lack social support, have learning difficulties or are 16 or 17 years old), consider a lower threshold for admission to hospital for medically assisted alcohol withdrawal.2
7. For people who are alcohol dependent but not admitted to hospital, offer advice to avoid a sudden reduction in alcohol intake and information about how to contact local alcohol support services.2
The assessment and management of alcohol withdrawal
Not all patients attending the acute setting with acute alcohol withdrawal will need pharmacotherapy. When patients do need medication, benzodiazepines are a good choice, with chlordiazepoxide and diazepam being the most commonly used. Pharmacotherapy should be delivered in a symptom-triggered manner, with the dose tailored to the patient's requirements. To individualise treatment, several factors have to be taken into account, including:
the severity of dependence (discussed above)
the severity of the withdrawal episode
the patient's comorbidities.
For example, a young man with a high alcohol intake, a history of withdrawal seizures and normal liver function should be prescribed much higher doses of pharmacotherapy than a small older lady with cirrhosis who develops mild withdrawal on the background of a moderate alcohol intake. This might seem obvious, but many local hospital withdrawal treatment protocols will result in these patients getting the same dose of chlordiazepoxide.
There is evidence to support the use of tools to monitor the severity of withdrawal, such as the Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA-Ar)10 (Fig. 3). This is not a substitute for the experience of a dedicated alcohol nurse specialist, but can be a useful adjunct to care for staff who might not have the same experience. In addition, these tools can be used repeatedly to monitor the course of the withdrawal and the results linked directly to the pharmacotherapy dose in a symptom-triggered regimen.
If alcohol withdrawal is managed well, delirium tremens and seizures should not be seen outside the setting of presentation to the acute hospital. However, these conditions are also seen if dependence is not recognised in a patient presenting with another condition or if withdrawal is suboptimally managed. The management then is to initiate pharmacotherapy or to increase the already initiated withdrawal regimen dose. In addition, lorazepam can be added as a short-acting benzodiazepine to halt or prevent further seizures or to control agitation in delirium. Haloperidol or olanzapine can be useful adjunctive treatments in delirium tremens. Anticonvulsants have no proven benefit in alcohol withdrawal seizures.
Assessment and monitoring
8. People in acute alcohol withdrawal should be assessed immediately on admission to hospital by a healthcare professional skilled in the management of alcohol withdrawal.2
9. Follow locally specified protocols to assess and monitor patients in acute alcohol withdrawal. Consider using a tool (eg the CIWA–Ar scale; Fig. 3) as an adjunct to clinical judgement.2
Management of withdrawal
10. Offer drug treatment for the symptoms of acute alcohol withdrawal, as follows:
consider offering a benzodiazepine or carbamazepine
clomethiazole can be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, in inpatient settings only and according to the summary of product characteristics (SPC).
Follow a symptom-triggered regimen for the drug treatment of acute alcohol withdrawal in people who are:
in hospital; or
in other settings where 24 h assessment and monitoring are available.
11. In people with delirium tremens, offer oral lorazepam as first-line treatment. If symptoms persist or oral medication is declined, give parenteral lorazepam, haloperidol or olanzapine.
12. If delirium tremens develops in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen.
13. In people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures.
14. If alcohol withdrawal seizures develop in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen.
15. Do not offer phenytoin to treat alcohol withdrawal seizures.
The prophylaxis and management of Wernicke's encephalopathy
It is essential to consider the diagnosis of Wernicke's encephalopathy in any confused dependent patient attending the acute hospital. The classic triad of ophthalmoplegia, ataxia and confusion is rarely seen and a high index of suspicion must be maintained along with a low threshold for treatment. The diagnosis of Wernicke's encephalopathy can be particularly challenging in patients who have another cause for their confusion, such as intoxication or hepatic encephalopathy. If there is any suspicion of Wernicke's, these patients should be treated with parenteral thiamine.
Prophylaxis is equally important. Decompensated liver disease, malnutrition or acute withdrawal mandates the use of prophylactic thiamine in the harmful or dependent drinker. Although this can be given orally in the community, it is recommended that, if a harmful or dependent drinker has either decompensated liver disease or evidence of malnutrition and attends the emergency department or is admitted to hospital, the opportunity to give at least one prophylactic dose of thiamine intravenously is taken.
Wernicke's encephalopathy
16. Offer thiamine to people at high risk of developing, or with suspected, Wernicke's encephalopathy. Thiamine should be given in doses toward the upper end of the British National Formulary range (200 mg/day in divided doses). It should be given orally or parenterally, as described in the recommendations below. Offer prophylactic oral thiamine to harmful or dependent drinkers:
if they are malnourished or at risk of malnourishment; or
if they have decompensated liver disease; or
if they are in acute withdrawal; or
before and during a planned medically assisted alcohol withdrawal.
17. Offer prophylactic parenteral thiamine followed by oral thiamine to harmful or dependent drinkers:
if they are malnourished or at risk of malnourishment; or
if they have decompensated liver disease; and in addition
they attend an emergency department; or
are admitted to hospital with an acute illness or injury.
18. Offer parenteral thiamine to people with suspected Wernicke's encephalopathy. Maintain a high level of suspicion for the possibility of Wernicke's encephalopathy, particularly if the person is intoxicated. Parenteral treatment should be given for a minimum of five days, unless Wernicke's encephalopathy is excluded. Oral thiamine treatment should follow parenteral therapy.
Footnotes
Adaptation from the original NICE guidelines commissioned by the Royal College of Physicians, as part of its Concise Guidance programme; on behalf of a multidisciplinary Guideline Development Group convened by the National Clinical Guidelines Centre and National Collaborating Centre for Mental Health; commissioned by the National Institute for Health and Clinical Excellence, and in association with the Clinical Effectiveness and Evaluation Unit of The Royal College of Physicians
- © 2012 Royal College of Physicians
References
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- National Institute for Health and Clinical Excellence
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- National Institute for Health and Clinical Excellence
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- National Institute for Health and Clinical Excellence
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- National Institute for Health and Clinical Excellence
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- National Institute for Health and Clinical Excellence
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- National Institute for Health and Clinical Excellence
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- National Institute for Health and Clinical Excellence
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- National Institute for Health and Clinical Excellence
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- Barbor TF,
- Higgins-Biddle JC,
- Saunders JB,
- Montera MG
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