CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.
Alcohol - problem drinking - Management
Basis for recommendation
These recommendations are consistent with those made by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003]. With the exception of the use of benzodiazepines in assisted withdrawal, they are largely based on expert and consensus opinion formed from clinical experience with alcohol-dependent people. Assisted withdrawal in primary care is not covered by current guidelines from the National Institute for Health and Clinical Excellence (NICE) concerning alcohol misuse [NICE, 2010a; NICE, 2010c]. However, this issue will be addressed in the forthcoming NICE clinical guideline Alcohol-use disorders: diagnosis and clinical management of harmful drinking and alcohol dependence, due to be published in January 2011 [NICE, 2010e].
- It is important to prepare a person for detoxification by ensuring they have adequate support and giving them advice on what to expect from the process, including dispelling excessively negative expectations so they have the best chance of achieving success [DTB, 2000].
- There is evidence from a large number of randomized controlled trials that benzodiazepines are highly effective in achieving alcohol withdrawal compared with controls [Ntais et al, 2005]. Usually, chlordiazepoxide is the preferred choice (see Choice of benzodiazepine). Drugs other than benzodiazepines are not generally recommended.
- Clomethiazole may be superior to benzodiazepines in preventing alcoholic delirium, but has a greater potential for dependence, and may accumulate to toxic levels if significant hepatic impairment is present. For these reasons it should be reserved for second-line use in an inpatient setting.
- Carbamazepine may be useful if there is a history of withdrawal seizures. However, it prolongs abnormal brain activity and is more likely to lead to relapse, so it is not recommended for routine use.
- Antipsychotic drugs may be indicated if there are coexistent mental problems, but they are not as effective as benzodiazepines in reducing seizures or delirium [Mayo-Smith, 1997] and should not be used routinely.
© NHS Institute for Innovation and Improvement