7 - Management of alcohol detoxification

Summary

Summary In many respects detoxification is a stand-alone medical procedure. None the less, the key to successful detoxification is preparation and a clear understanding of how the detoxification procedure fits in with the overall care plan. Detoxification is often straightforward, but clinicians need to be aware of potential risks and monitor accordingly. The problem for the clinician is predicting the severity of the withdrawal syndrome and anticipating the individual's response to medication when there are complicating factors such as other medication and mental or physical health problems. Depending on the level of risk, detoxification can be undertaken in a variety of settings, ranging from in-patient monitoring to self-directed home detoxification. Chlordiazepoxide or diazepam remain the firstline pharmacotherapies.

The majority of people with an alcohol dependence problem that is uncomplicated by serious mental illness or social chaos receive treatment in the community. There is strong evidence supporting the move towards briefer and community-based treatments, although intensive and in-patient treatments are needed for people with more complicated problems (Raistrick et al, 2006). It follows that the traditional sequencing of care, which might be characterised as having four phases – assessing and engaging service users, detoxification, specific therapy and aftercare – is less tidy than it used to be. Detoxification is seen much more as a stand-alone procedure that should be undertaken when the service user is ready, rather than as a prerequisite of starting treatment. Of course, there are also instances where detoxification may be required as an expedient, for example during an unplanned admission to hospital, or where regular high levels of intoxication are a barrier to effective intervention. Equally, where the focus of treatment is on mental illness rather than alcohol dependence, then detoxification may well be viewed as a necessary first step.

Given the high proportion of people who have a combined problem of mental illness and alcohol dependence, it is inevitable that general psychiatrists will need to be skilled in the management of detoxification, but whether they should also have skills specific to substance misuse treatments is more contentious.