Check list for pt presenting ETOH alcohol use help discussion.

Glenda case Addiction CHECK

After you develop some rapport with Glenda, it is important to explore specific aspects of her drinking, if
she has not already disclosed this information to you.
o Alcohol itself: The quantity, frequency, duration and pattern of drinking, as well as the type of
alcoholic beverages consumed, are all important initial aspects to ask her about. Further
questioning should look at the
o context of her drinking (eg when, where and why), any problems Glenda has encountered as a
result of her drinking (physical, psychological and/or social), and
o features of tolerance or withdrawal she may have experienced. You may wish to use the Alcohol
Use Disorders Identification Test (AUDIT), 1 which identifies dependent and at-risk drinkers in
primary care settings,2 as part of your assessment.
ANSWER 2
Other aspects of Glenda’s history to consider that are essential in patients who have
difficulties with alcohol use include inquiring about:2
o other substance use – illicit and licit substances, which may include prescription drugs

o any history of mental health comorbidities – depression, anxiety, psychosis, suicide risk

o social circumstances – relationships, violence, housing,financial,legal,occupational aspects.

Additionally, assessing Glenda’s motivation – both her
o motivation for presenting to you and her motivation for change – is vital. As with all behavioural
change interventions, an assessment of a patient’s motivation to make any suggested changes is
important. Understanding Glenda’s motivational state will permit more targeted and effective
treatment planning.2,3
ANSWER 3_ aspects of physical examination. While alcohol can potentially affect almost every body
system,4 (figure) and practitioners need to be systematic in physically assessing patients such as
Glenda, specific attention should focus on:
o nutrition assessment

o neurological function

o endocrine system

o gastrointestinal system

o cardiovascular system

o mental state.
These areas are commonly affected (see figure 1)
An outpatient alcohol withdrawal setting would be appropriate for a patient who2:
o drinks <30 units of alcohol a day3
o has no past history of severe withdrawal complications (eg seizures, delirium, hallucinations) or
o significant medical or
o psychiatric comorbidities (Glenda does not have any of this significant past history)
o has a safe, alcohol-free environment (eg Sally’s house, if all the family members agree to this)
o has reliable ‘lay people’ who can regularly monitor (at least daily during the first three or four
days) and support the patient (Sally agrees to fulfil this role, with your advice and help)
o has regular monitoring by a suitably skilled health professional (eg a general practitioner [GP],
alcohol and drug worker, nurse), who is available for daily review (face-to-face, telephone) for first
three or four days.
Depending on the location of the general practice, the GP may have allied health support, or may be
in a position to provide this monitoring themselves
• has close supervision of medication (eg daily supplies) –benzodiazepines, if used to assist with cessation,
can be withheld if the patient resumes alcohol use
• access to 24-hour telephone ‘crisis’ support. All states and territories in Australia have such services (refer
to Resources for patients).

CASE 1
GLENDA HAS A DRINKING PROBLEM
Glenda is a new patient, 56 years of age, who has
come to see you on the recommendation of her
sister, Sally. She has brought Sally along as her
support person. Glenda starts the consultation with
‘I need help. Sally told me to see a doctor about my
drinking problem.’.

QUESTION 1
What questions would you ask Glenda about her alcohol use?
QUESTION 2
What other aspects of Glenda’s history would you explore with her?
QUESTION 3
What aspects of physical examination would you focus on when
considering problematic alcohol use in a patient?

FURTHER INFORMATION
Glenda’s history reveals that she recently separated from her
abusive husband and moved in with her sister, Sally, Sally’s
husband and two pre-school children. In the two weeks since she
has been living with Sally’s family, Glenda admits she has been
‘drinking heavily’ and embarrassed herself in front of the children
by vomiting at dinner time, walking into a wall and often slurring
her words, which the children found frightening.
Sally and Glenda deny any direct risk to the children. On further
questioning, Glenda admits to secretly drinking heavily for a
number of months ‘to feel numb’ in the context of her husband’s
verbal abuse. She has recently been drinking two bottles of red
wine per day and has lost contact with her friends. Glenda lost
her job as a clerk three months ago after frequent periods of
absenteeism. She has not encountered any legal issues related to
her drinking, although she admits to drink driving a few times in
the past month.
Physical examination findings include:
• hypertension (Glenda’s blood pressure is 159/92 mmHg)
• a tender, non-enlarged liver
• bruised knees (apparently from falling over)
• an anxious affect.
Glenda’s breath smells of alcohol and she admits to drinking each
morning after experiencing strong cravings and anxiety when she
awakes.
QUESTION 4
Against what criteria would you assess whether Glenda is alcohol
dependent?
FURTHER INFORMATION
Your clinical assessment confirms that Glenda fulfils the criteria
of alcohol dependence (three or more features from either criteria
in Table 1). On discussing this further with Glenda, she explains ‘I
desperately want to stop the secrecy and regain the trust of my
sister and her family … I need to sort my life out’. She also explains
that she knew that alcohol was taking a big toll on her life but, until
now, never had the courage to admit this to herself or others. As
she is expressing a strong desire for change and appears ready to
make this change, you conclude that Glenda is strongly motivated to
address her alcohol use. Glenda states that she would like to stop
drinking altogether and has Sally supporting her decision.
QUESTION 5
What are some of the clinical features of alcohol withdrawal that Glenda is likely to experience?
FURTHER INFORMATION
You assess that Glenda is at low risk for alcohol withdrawal complications and is suitable for
outpatient withdrawal. Sally agrees to help support Glenda and bring her to the clinic for daily
review.
QUESTION 6
What are some of the factors that should be considered when
determining whether an outpatient setting is appropriate for a patient?
QUESTION 7
Outline the features of an alcohol withdrawal treatment program.
FURTHER INFORMATION
Glenda, with Sally’s at-home support, finds that her first week
of withdrawal was not as bad as she imagined, with what was
eventually a five-day course of diazepam. She attends your practice,
justifiably nervous about ‘whether I can keep this [abstinence] up’.
QUESTION 8
Relapsing to problem drinking is common after alcohol withdrawal.
Outline your approach to helping Glenda minimise her chance of
relapse in the initial few months after her withdrawal program.
QUESTION 9
Alcohol dependence is commonly a chronic relapsing condition.2
Outline your longer term follow-up plan for Glenda.

ANSWER 1
Although you could proceed straight into taking a formal alcohol history, you are more likely to obtain an
honest and accurate picture of Glenda if you spend a little time developing rapport with her. An open
question such as ‘Please tell me more about yourself?’ is likely to help Glenda convey her agenda within her
personal context. Patients with substance use problems, including alcohol, often feel a sense of shame and
embarrassment when asked to discuss their consumption. Providing permission (eg ‘It’s okay to tell me how
this is affecting you’) and keeping the line of questioning open (‘Please tell me more about your
drinking and why you feel it’s a problem’) can assist in breaking down this stigma in patients with substance
use problems such as alcohol. After you develop some rapport with Glenda, it is important to explore
specific aspects of her drinking, if she has not already disclosed this information to you. The quantity,
frequency, duration and pattern of drinking, as well as the type of alcoholic beverages consumed, are all
important initial aspects to ask her about. Further questioning should look at the context of her drinking (eg
when, where and why), any problems Glenda has encountered as a result of her drinking (physical,
psychological and/or social), and features of tolerance or withdrawal she may have experienced. You may
wish to use the Alcohol Use Disorders Identification Test (AUDIT),1 which identifies dependent and at-risk
drinkers in primary care settings,2 as part of your assessment.

ANSWER 3
While alcohol can potentially affect almost every body system,4 and
practitioners need to be systematic in physically assessing patients
such as Glenda, specific attention should focus on:
• nutrition assessment
• neurological function
• endocrine system
• gastrointestinal system
• cardiovascular system
• mental state.

These areas are commonly affected by, or have serious consequences of complications from, alcohol (Figure
1 ).2,4
1. Aggressive, irrational
behaviour.Arguments.
Violence.Depression. Nervousness.
2. Cancer of throatand mouth.
3. Frequent colds.Reduced resistance to
infection.Increased risk of pneumonia.
4. Trembling hands.Tingling fingers.
Numbness.Painful nerves.
5. Impaired sensation leading to falls,legs
6. Numb, tingling toes. Painful nerves.
7. In men: Impaired sexual performance.
In women: Risk of giving birth to
deformed, retarded babies or low birth
weight babies.
8. Inflammation of the pancreas.
9. Vitamin deficiency.Bleeding. Severe
inflammation of the stomach. Vomiting.
Diarrhoea. Malnutrition.
10. Weakness of heart muscle. Heart failure.
Anaemia. Impaired blood clotting.
Breast cancer.
11. Face:Premature ageing. Drinker’s nose.
12. Alcohol dependence. Memory loss.
13. Ulcer.
14. Liver damage.
Figure 1. Effects of high-risk drinking4
High-risk drinking may lead to social, legal, medical,
domestic, job and financial
problems. It may also cut your lifespan and lead to
accidents and death from
drunken driving.
Reproduced with permission from Babor T, Higgins-
Biddle JC, Saunders J,
Monteiro, MG. The Alcohol Use Disorders
Identification Test (AUDIT): Guidelines for
use in primary care. 2nd edn. Geneva: World Health
Organization – Department of
Mental Health and Substance Dependence, 2001.
ANSWER 4
Alcohol dependence creates a cluster of physiological, behavioural and cognitive phenomena in
which alcohol use takes on a much higher priority for a given individual than other behaviours that
once had greater value.5
The International classification of diseases, 10thedition (ICD-10) and Diagnostic and statistical
manual of mental disorders, 5th edition (DSM-5) have similar criteria for assessing alcohol
dependence. Either set of criteria would be appropriate to assess dependence in Glenda (Table1).

ANSWER 5
Symptoms of alcohol withdrawal usually commence 24 (6-24hr) hours after
the last drink; the type and severity of symptoms varies between patients and with their history of
alcohol intake2. Symptoms can range from:
 mild (eg anxiety, agitation, tremor, nausea, tachycardia, hypertension, disturbed sleep,
raised temperature) to
 more severe (eg extreme agitation, dehydration and electrolyte disturbances,
disorientation, confusion, paranoia, hallucinations, delirium tremens*, seizures). 2
The history of
 current drinking patterns,
 past withdrawal experience(s),
 concomitant substance use, and
 medical or psychiatric comorbidities
increase the risk of more severe withdrawal syndromes.2
As Glenda wishes to cease alcohol altogether, she should be advised
to undergo a detoxification program to minimise the severity of any
potential alcohol withdrawal syndrome. She is at higher risk of a more
severe withdrawal due to her history of morning cravings and anxiety,
which are relieved by drinking.2
Withdrawal programs can occur in
I. outpatient,
II. community residential or
III. inpatient hospital settings.

ANSWER 6
An outpatient alcohol withdrawal setting would be appropriate for a patient who2:
• drinks <30 units of alcohol a day3
• has no past history of severe withdrawal complications (eg seizures, delirium, hallucinations) or significant
medical or psychiatric comorbidities (Glenda does not have any of this significant past history)
• has a safe, alcohol-free environment (eg Sally’s house, if all the family members agree to this)
• has reliable ‘lay people’ who can regularly monitor (at least daily during the first three or four days) and
support the patient (Sally agrees to fulfil this role, with your advice and help)
• has regular monitoring by a suitably skilled health professional (eg a general practitioner [GP], alcohol and
drug worker, nurse), who is available for daily review (face-to-face, telephone) for first three or four
days.
Depending on the location of the general practice, the GP may have allied health support, or may be in
a position to provide this monitoring themselves
• has close supervision of medication (eg daily supplies) –benzodiazepines, if used to assist with cessation,
can be withheld if the patient resumes alcohol use
• access to 24-hour telephone ‘crisis’ support. All states and territories in Australia have such services (refer to
Resources for patients).
QUESTION 7
Outline the features of an alcohol withdrawal treatment program.
FURTHER INFORMATION
Glenda, with Sally’s at-home support, finds that her first week of withdrawal was not as bad as
she imagined, with what was eventually a five-day course of diazepam. She attends your practice,
justifiably nervous about ‘whether I can keep this [abstinence] up’.
QUESTION 8
Relapsing to problem drinking is common after alcohol withdrawal.
Outline your approach to helping Glenda minimise her chance of
relapse in the initial few months after her withdrawal program.
QUESTION 9
Alcohol dependence is commonly a chronic relapsing condition.2
Outline your longer term follow-up plan for Glenda.

ANSWER 7
Alcohol withdrawal treatment should include:2
• supportive counselling (eg withdrawal education, dealing with cravings, sleep advice) –
patients are often very anxious about entering a detox program, and supportive education can help
them and their carers to know what to expect and how to deal with common concerns
• assessment and management of diet, nutrition and hydration – alcohol-dependent patients
have often neglected their diet, and addressing this is a vital component of medical care during detox .
In addition, some patients can encounter more severe electrolyte disturbances, which can lead to
further complications
• thiamine supplementation – used to reduce the risk of Wernicke- Korsakoff syndrome. The
suggested dosing is 300 mg daily for several weeks, with the initial few days via parental route 6
• diazepam – used for symptomatic treatment of withdrawal symptoms and to minimise the risk of
withdrawal complications. A suggested regime is 20 mg of diazepam orally, two-hourly until
symptoms subside.6 A cumulative dose of 60 mg daily is usually adequate
• a post-withdrawal rehabilitation plan.

ANSWER 8
Post-withdrawal interventions (medium and long term Mx of Alcoholism) include both
pharmacological and nonpharmacological (psychosocial) approaches.
Pharmacological approaches
There is good evidence of improved treatment outcomes (maintaining abstinence and reduced rates of relapse)
with oral naltrexone and/or acamprosate medications.7
Both of these medications are on the Pharmaceutical Benefits Scheme (PBS) for the treatment of alcohol
dependence. Naltrexone is appropriate provided Glenda is not on opioids (as naltrexone is an opioid receptor
antagonist) or have severe liver disease, as it is metabolised by the liver. Naltrexone should be taken
as a 50 mg daily dose.7
Acamprosate is excreted through the kidneys and would not be suitable if Glenda had renal impairment. The
dosing is 666 mg orally, three times daily for patients ≥60 kg, or 666 mg orally, in the morning, 333 mg at
midday and 333 mg at night for patients <60 kg, and should be commenced one week after abstinence, if it is
achieved.7
There is little evidence of sustained benefit for the use of the older medication, disulfiram, which acts as a
deterrent to drinking because of the unpleasant effects when co-administered with alcohol. It has poor patient
adherence and potentially harmful, life-threatening effects,8 and is therefore not recommended as the first-line
relapse prevention treatment.2,7
Other agents have shown promise for the prevention of post-withdrawal relapse but are not yet recommended
in the primary care setting until further research has been undertaken.2,7 (aamer-see aafp article)

Non-pharmacological approaches
Psychosocial interventions and support are vital in post-withdrawal treatment planning.2 Patients such as
Glenda often have a number of predisposing factors that lead to their drinking.
These predisposing factors need to be addressed to maximise the chance of sustained abstinence.
GPs should discuss potential referrals to services such as drug and alcohol counselling, self-help peer groups
and psychologists, depending on the patient’s needs and preferences.
Glenda’s family should also be offered support. GPs are ideally placed to identify the family’s needs and
coordinate assistance through counselling services, peer support groups or organisations such as Family Drug
Help (http://sharc.org.au/program/family-drug-help) and Family Drug Support Australia (www.fds.org.au).

ANSWER 9
The chronic nature of alcohol dependence necessitates a long-term approach.
GPs are ideally placed to coordinate and deliver this care.
In developing a relationship with patients through their initial alcohol
management, GPs are well placed and ideally situated to help them
begin addressing their overall health needs. Glenda’s hypertension, potential
liver disease and mental health are obvious places to start clinically
assessing and managing. This may involve referral, depending on
the problems found and the resources you have available to you.
Social issues (eg her relationship with her sister’s family, housing,
relationship issues and employment) are also areas where her GP can
provide guidance and help or referral to appropriate services.

Finally, if Glenda relapses to problematic alcohol consumption, it is

important not to despair or give up. There are a number of areas where
GPs can make a big difference to persistent or relapsing drinkers:2
• continuing to provide encouragement to stop drinking and providing feedback on
the ongoing problems caused by alcohol
• harm minimisation approaches, which can include reviewing interactions of prescribed
medications with alcohol, ensuring adequate nutritional support, and focusing
upon falls and accident prevention
• continuing to address other medical issues or barriers to maintaining abstinence (eg
o persisting or new psychiatric,
o medical,
o social problems)
• enlisting family or friends to help, and supporting them throughout this process
• ensuring we also meet our medico-legal ethical obligations (e.g. fitness to drive,
potential children safety issues, safety within the workplace etc).

CONCLUSION
Alcohol contributes to a large burden of disease in Australia. Alcohol is
the most widely used drug in Australia, with over 85% of Australians
aged 14 years and over reporting consuming alcohol one or more times
in their lives, and over a third consuming alcohol on a weekly basis.9
Alcohol dependence is a common problem (estimated to affect 2–6%
of the population)10 and all doctors should be prepared to assess
and arrange treatment for the serious complications of alcohol use.
Patients such as Glenda can do well with appropriate support, but
dependence is a chronic, relapsing condition and she will need longterm
follow-up and support.
RESOURCES FOR PATIENTS
• The DrugInfo website has excellent information about alcohol (and other
drugs), www.druginfo.adf.org.au/drug-facts/alcohol
• The Australia Alcohol Guidelines, www.alcohol.gov.au
• Self-help peer groups for patients include Alcoholics Anonymous, www.
aa.org.au and SMART Recovery, http://smartrecoveryaustralia.com.au
• Peer group support for families dealing with the effects of living with
someone whose drinking is a problem include Al-Anon for families of
recovering alcoholics, www.al-anon.org/australia, and Alateen, similar to
Al-anon but specifically for teenagers, www.al-anon.org/australia/alateen
• The Centre for Education and Information on Drugs and Alcohol has a
useful alcohol guide for patients and families, www.ceida.net.au/alcohol
RESOURCES FOR DOCTORS
• Each region in Australia has a clinical advisory service for doctors to call to
obtain advice and information related to alcohol (and other drugs; Table 2 )
• The Federal Government’s Guidelines for the treatment of alcohol problems, www.
alcohol.gov.au/internet/alcohol/publishing.nsf/Content/guidelines-treat-alc-09
• The RACGP Victoria Faculty’s Drug and Alcohol Committee produced a
webinar on alcohol and other drugs in 2015, www.racgp.org.au/yourracgp/
faculties/victoria/daupdate (video and slides at bottom of the page)

ANSWER 2
Other aspects of Glenda’s history to consider that are essential in
patients who have difficulties with alcohol use include inquiring about:2
• other substance use – illicit and licit substances, which may
include prescription drugs
• any history of mental health comorbidities – depression, anxiety,
psychosis, suicide risk
• social circumstances – relationships, violence, housing, financial,
legal, occupational aspects.
Additionally, assessing Glenda’s motivation – both her motivation
for presenting to you and her motivation for change – is vital. As
with all behavioural change interventions, an assessment of a
patient’s motivation to make any suggested changes is important.
Understanding Glenda’s motivational state will permit more targeted
and effective treatment planning.2,3

Alcohol: problem use eTG 8/2018

Introduction
According to the National Health and Medical Research Council (NHMRC) guidelines,
average
daily consumption of alcohol in excess of two standard drinks is a health risk for men
and women
[Note 1]. In addition, they state that on any given day consumption should not exceed
four standard drinks, a lower maximum alcohol consumption than previously. A
standard drink contains 10 g of alcohol, the amount in 285 mL of full-strength beer, 100
mL of wine, 60 mL of fortified wine and 30 mL of spirits. Significant dependence
associated with a withdrawal syndrome on cessation is more likely in those whose
regular consumption is greater than eight
standard drinks per day, and is increased if they also use other sedatives.
Note 1: National Health and Medical Research Council. Australian guidelines to reduce
health
risks from drinking alcohol. Canberra: Commonwealth of Australia; 2009. [URL]
Acute alcohol intoxication and overdose
Alcohol overdose is potentially fatal; death is usually due to inhalation of vomitus or to
respiratory depression. The average lethal blood alcohol concentration (BAC) is around
0.45% to 0.5% (450 to 500 mg/100 mL). However, people who have developed high
tolerance to alcohol will be able to cope with higher BACs. Death may result from a
much lower BAC if other sedative drugs have been taken.
Clinical estimation grossly underestimates the prevalence and severity of alcohol
intoxication so a breathalyser should be used routinely to estimate the BAC. Observe
the patient at least until the BAC falls below 0.2%. Ideally, monitoring should continue
until the BAC has dropped to 0.05% and there is no evidence of the onset of a
withdrawal syndrome. Withdrawal may begin at a BAC
of 0.1% and usually starts before the BAC reaches zero. BAC normally declines at a rate
of0.015% to 0.02% per hour, although the rate of decline may be increased in heavy
drinkers.
However, it should be noted that alcohol in the gastrointestinal tract may continue to
be absorbed and hence the BAC could rise even if there is no further alcohol ingestion.
Treatment of intoxication and overdose is supportive and symptomatic, with careful
 • monitoring of the BAC,
• airway,
• level of consciousness and responsiveness, and
• oxygen saturation.
• Alcohol overdose may cause hypoglycaemia and metabolic acidosis.
• Stimulants should not be given.

Acute alcohol withdrawal

The alcohol withdrawal syndrome is characterised by anxiety, tremor, sweating, nausea
and vomiting, agitation, headache and perceptual disturbances.
Seizures are occasionally observed. Fifty per cent of patients who experience a seizure
only suffer a single fit. Some highly dependent patients will progress to an alcohol
withdrawal delirium. Symptoms usually appear within 6 to 24 hours of the last
consumption of alcohol and typically persist for up to 72 hours, but may last for
several weeks.
Many alcohol-dependent people require no medication when withdrawing from alcohol.
Supportive care including information on the withdrawal syndrome, monitoring,
reassurance and a low-stimulus environment are effective in reducing withdrawal
severity.
If medication is required, a benzodiazepine loading dose technique may be used. The
patient is given repeated doses of diazepam until symptoms have diminished to an
acceptable level. Diazepam is effective in the prevention and treatment of acute
alcohol withdrawal seizures.
Because of the relatively large doses usually given, and the long half-life of diazepam,
it may not be necessary to give any further medication for withdrawal relief.
If the patient has not settled with 60 mg diazepam, review the diagnosis and consider
the possibility of other conditions. Do not exceed 100 mg daily without seeking
specialist advice.
Free telephone advice is available 24 hours a day from drug and alcohol specialist
advisory services for all Australian states and territories, see detail in Appendix 8.2.
Diazepam may be administered over the subsequent 2 to 7 days if symptoms
return but should not be continued beyond that. Patients with favourable home
conditions can be treated at home without admission for residential care. If diazepam is
needed, it can be collected daily by the patient or administration can be supervised by
a reliable person living with the patient.
In patients with severe liver disease, a short-acting benzodiazepine without active
metabolites should be considered (eg oxazepam). Specialist advice and hospitalisation
would be preferred.
As alcohol-dependent patients are usually deficient in thiamine, use:
Initial dosing is with parenteral thiamine as absorption of oral thiamine is slow and may
be incomplete in patients with poor nutritional status. Higher doses and a longer period
of parenteral administration may be appropriate in those with Wernicke
encephalopathy or suspected
malnutrition, see Thiamine supplementation.
Always give thiamine before administering glucose (including dextrose 5%
IV) for hypoglycaemia.
Give thiamine before administering glucose (including intravenous 5% dextrose) for
hypoglycaemia because giving glucose in the presence of thiamine deficiency may
precipitate Wernicke encephalopathy.
o Consideration should also be given to the setting in which withdrawal occurs. In
all cases careful monitoring of withdrawal severity is essential and more severe
withdrawal requires inpatient care.
o Specialist alcohol treatment services and most hospitals can provide charts to
be used in the monitoring of symptom severity, although a common error is to
assume that higher scores are diagnostic of alcohol withdrawal.
o Filling in monitoring charts should not be used as a substitute for talking with
the patient and engaging them in their recovery.
 diazepam 20 mg orally, every 2 hours until symptoms subside. A cumulative
dose of 60 mg daily is usually adequate.
thiamine 300 mg IM or IV, daily for 3 to 5 days then thiamine 300 mg orally,
daily for several weeks [Note 2].

Note 2: If thiamine ampoules are unavailable, ‘B-Dose Forte’ ampoules (containing 250
mg/2.5 mL thiamine) are a suitable alternative.

Alcohol withdrawal delirium

Alcohol withdrawal delirium (also known as delirium tremens) is the
most severe manifestation of alcohol withdrawal. It usually commences
72 to 96 hours after cessation of drinking and is characterised by:
1. gross tremors and
2. fluctuating levels of agitation,
3. hallucinations (usually tactile),
4. disorientation and impaired attention.
5. Fever, tachycardia and dehydration may be present.
o It is a medical emergency that always requires hospitalisation and, if
inadequately treated, has a high mortality rate, mainly from heart
failure. Alcohol withdrawal delirium is rarely uncomplicated; i.e usually
complicated by:
o it is usually associated with
 infections,
 anaemia,
 metabolic disturbances and
 head injury.
o It may be associated with a range of other disorders including
 Wernicke encephalopathy and
 hepatic encephalopathy.
The principles of treatment (including appropriate supportive care and
the use of thiamine and diazepam) are the same as those for milder
withdrawal syndromes (see Acute alcohol withdrawal, above). Use:
Very high doses of diazepam (greater than 100 mg daily) may be
required, but seek specialist advice. Free telephone advice is available
24 hours a day from drug and alcohol specialist advisory services for all
Australian states and territories, see detail in Appendix 8.2. See above
for thiamine regimen.

Intravenous injection of diazepam should be avoided if possible. Onset of

action is not much faster than with oral administration and there is a
greater likelihood of causing severe adverse effects such as respiratory
depression. If an injection of diazepam is necessary, it must not be
diluted and it must be given slowly over several minutes to minimise the
risk of respiratory depression or arrest. Close cardiorespiratory
monitoring is essential.
An alternative would be to cautiously use parenteral midazolam as
given for agitation in behavioural emergencies (see Behavioural
emergencies: acute medical settings).
If an antipsychotic drug is required, use:
For severe psychotic symptoms when oral administration is not possible,
cautiously use:
 diazepam 20 mg orally, every 2 hours until symptoms subside.
 haloperidol 0.5 to 2 mg orally, repeated every 2 hours and titrated
to clinical response, up to 10 mg in 24 hours.
 droperidol 5 mg IM, as a single dose (see droperidol warnings, Box
8.21)
OR
 haloperidol 5 mg IM, as a single dose.
 Droperidol is similar to haloperidol but is more sedating;
haloperidol is less likely to lower seizure
 threshold.
Avoid chlorpromazine as it lowers seizure threshold.
If extrapyramidal adverse effects emerge with droperidol or haloperidol,
use:
 benztropine 1 to 2 mg orally
OR
 benztropine 1 to 2 mg IM.

Diazepam and, to a lesser extent, haloperidol and droperidol, may worsen

symptoms of hepatic encephalopathy.
Administration of diazepam and, to a lesser extent, haloperidol and
droperidol, may worsen the symptoms of hepatic encephalopathy.

Long-term management of alcohol dependence

Introduction
Group or individual support and counselling programs form the basis of
long-term management of alcohol dependence.
Three drugs with different modes of action may be used in treatment:
disulfiram, acamprosate and
naltrexone. Choice of drug needs to be individualised, depending on the
person's circumstances.
Disulfiram gives good results but treatment must be closely supervised.
It may be hard to achieve
compliance with acamprosate because of the need to take six tablets
daily; however, it will not
affect treatment for pain relief. Naltrexone can interfere with treatment
for pain relief but dosing
with one tablet daily may aid compliance. For each of these drugs,
treatment duration of 6 months
or more is recommended.

virtual classroom notes from lecture d&A and Tobacco addiction

fever in withdrawal from ETOH is never > 38.5, if more  lok for another foci/cause
seizures,
90% occur between 24-48hrs from last drink
2-9% of pt with ETOH withdrawal
Usually tonic-clonic
, max EEG changes researched n found during 24hrs, return to normal after 48hrs
May recur 1-6 hrs after first one
R is to load pt up with Diazepam, very rarely we need Keppra or phenytoin infusion, when seizure aren’t
controlled by diazepam
1st p/w seizure , ever, for alcoholic withdrawal  work up as of first seizure for anyone (complete
assessment)
Hallucination  treat with diazepam
Delirium: mortality n morbidity  highly controversial area, restless n agitation , visual n tactile
hallucination, fragmented delusions
Prevented by diazepam , but once started, we should avoid diazepam  Haloperidol, Olanzapine etc (we
could use very low diazepam though)

Diazepam metabolised in liver, so in Hepatic compromised pt use Oxazepam or Lorazepam instead as they
are not metabolised by liver.

DT: give thiamine in high dose asap, immediately, otherwise pt develops Korsakoff and peripheral
neuropathy

The triad of Wernicke’s encephalopathy of: confusion, Ataxia and ophthalmoplegia is rarely seen
25% of WE pt p/w ataxia

The key point of treating withdrawal is using it to help pt engaging in long-treatment for alcoholism.
e.g: if pt stated controlled-drinking, ask him “What do you mean? Safe drinking is less than 2 a day or 8 a
week
When there is chronic Hx of use/dependency, chances are 1:20 to be successful to quit or control

Advice pt to have 3/12 of absolute abstinence before making decision to go on such a “controlled drinking”

Options for alcohol dependency:

1. -Residential program
2. -AA: works very well for a significant No of people, but certainly does not suit everybody (provides
group support, social interaction, is a 12 steps spiritual program etc)
3. -SMART Recovery _ Cognitive Behavior, GP and people recovery supporting each other
4. -Medication to reduce relapse Naltrexone, Antabuse, (Baclofen off label)4-6/12 duration

Acamprosate is safe and easy to use, unfortunately the least effective of them
Naltrexone effective. It also reduce cravings for alcohol, very well, at also reduce the rewired people
Disulfiram (Antabuse) is the most effective of them, not on PBS and not manufactured anymore, so
pharmacist need to construct it, cost $70/month
Can cause hepatitis, so check liver
Peripheral neuropathy rare
dose 200mg daily

baclofen, used overseas, very dangerous, overdose risk, specialist /authority prescriped only