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How
can I choose an appropriate level of care for my patient?
You
can make a decision about appropriate level of care considering
the following primary patient dimensions:
1. Acute intoxication and/or withdrawal potential, especially
history of withdrawal seizures
2. Biomedical conditions and complications
3. Emotional/behavioral conditions and complications including:
-
Psychiatric conditions
- Psychological or emotional/behavioral complications of known
or unknown origin
- Poor impulse control
- Change in mental status
- Transient neuropsychiatric complications
4.
Treatment acceptance/resistance
5. Relapse/continued use potential
6. Recovery/living environment
Standardized assessments, such as the CIWA-Ar, may be used in
addition to monitoring vital sign status and evidence of severe
withdrawal by history. The patient's potential to complete detoxification
should also be evaluated to determine the appropriate setting
for stabilization
What
are some detoxification protocols that I can use?
The
follow PDF documents outline detoxification protocols for inpatient
settings:
Alcohol
Withdrawal Guidelines: Portland VA Medical Center
Alcohol
Withdrawal Orders - VA Palo Alto Health Care System
Inpatient
Alcohol Withdrawal Guidelines (VA Puget Sound)
Detoxification
protocols for outpatient settings:
- Medical
or nursing staff should assess the patient in person, either daily
or every other day (patient contact may be made by telephone on
other days), to include:
- Patient
report of any alcohol use the previous day
- Reported medication intake compared to the medication dispensed
the previous day
- Tremor, restlessness, and previous night's sleep
- Observation of skin (e.g., color and turgor)
- Urine
toxicology or a breathalyzer test of BAC should be completed.
- The
patient should be medically cleared before initiating or continuing
outpatient
detoxification,
if the daily screening is positive for any one of the following:
- Blood sugar > 400 or positive anion gap
- History of recent hematemesis or other GI bleeding disorder
- Bilirubin > 3.0
- Creatinine > 2.0
- Systolic blood pressure > 180 or diastolic blood pressure
> 110
- Unstable angina
- Temperature > 101 degrees
- BAC > 0.08 on two outpatient visits
What medications should I use for detoxification?
- For
the treatment of alcohol withdrawal, use benzodiazepines over
non-benzodiazepine sedative-hypnotics because of documented efficacy,
decreased abuse potential, and a greater margin of safety. Benzodiazepines
are the drug of choice because they reduce withdrawal severity,
incidence of delirium, and seizures. All benzodiazepines appear
to be effective.
- For
geriatric patients, start with lower doses of benzodiazepines
than for younger adults.
- Shorter
acting benzodiazepines that are metabolized by conjugation only
(e.g. lorazepam) will have lower risk for acculation in populations
possessing a significantly decreased capacity for metabolism by
hepatic oxidation (e.g. end stage liver disease, elderly).
- For
managing alcohol withdrawal, carbamazepine can be used as an effective
alternative to benzodiazepines.
-
Other agents, such as beta-blockers, dilantin, and clonidine,
are generally not considered as appropriate monotherapy for alcohol
withdrawal, but may be considered in conjunction with benzodiazepines
in certain patients.
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