Author: Daniel Carlat M.D.
Last Updated: 4/1/20
How to decide if your patient will need detox
Ask the following questions:
“Are you going to be detoxing?” Most patients will know.
“When was your last drink?” It usually takes 6-12 hours for withdrawal symptoms to start, and the first symptoms are generally insomnia, anxiety, and tremor. If the last drink was over 2 days ago and there hasn’t been any significant withdrawal, it’s unlikely that it will happen.
“How many drink per day were you having, and for how long?” The more consistent the drinking, the worse will be the withdrawal. A rule of thumb is that if your patient has been drinking at least 5 drinks per day for at least 2 weeks, some withdrawal is likely.
“What kind of withdrawal symptoms have you had before? Have you ever had a seizure?” This is important to ask because a history of severe detox symptoms predicts future symptoms.
What detox protocol should you order?
Most detox protocols are symptom-triggered, meaning that benzodiazepines are dosed based on the severity of withdrawal symptoms.
Use the CIWA scale (Clinical Institute Withdrawal Protocol for Alcohol), which is a 10 item scale of alcohol withdrawal symptoms. Each item is scored from 0-7. Patients are evaluated with the scale every 2 hours. The 10 CIWA symptoms are listed below; you can download a copy of the CIWA scale here.
–Nausea/vomiting
–Anxiety
–Agitation
–Sweating
–Tremors
–Orientation problems
–Headache
–Visual symptoms (hallucinations or sensitivity to light)
–Tactile symptoms (itching, hallucinations)
–Auditory symptoms
Typical symptom triggered dosing:
- CIWA 5-12 (mild withdrawal): Librium 25 mg or Serax 15 mg
- CIWA 12-20, (moderate withdrawal): Librium 50 mg or Serax 30 mg
- CIWA>20, (severe withdrawal): Librium 75 mg or Serax 45 mg, consider transfer to medicine for detox
What other medications should you order for patients undergoing detox?
Comfort meds are usually prescribed to treat withdrawal symptoms that occur despite sedatives:
- Metoclopramide (Reglan) 10 mg or Zofran 4 mg q 6 hours prn nausea
- Clonidine 0.1 mg q 6 hours prn anxiety
- Loperimide 4 mg q 4 hours prn diarrhea
- For patients with a history of withdrawal seizures, prescribe Depakote 500 mg po BID x 5 days, or Keppra 250 mg po BID x 5 days for patients with liver impairment.
The following vitamins are usually ordered because alcoholism can interfere with intestinal absorption of nutrients.
- Vitamin B1 (thiamine) 100 mg daily (one dose should be given immediately to prevent Wernicke syndrome)
- Folic acid 1 mg daily
- Multivitamin 1 tab daily
How to interpret vital signs when a patient is detoxing
The most informative vital sign is the pulse rate. Alcohol withdrawal often leads to tachycardia (defined as pulse rate of 100 or above.) Hypertension is less helpful because many patients have baseline hypertension, which can worsen due to excessive drinking (rather than due to withdrawal).
How to decide which benzodiazepine to use
In the absence of liver disease, it’s best to use benzos that are relatively long acting and that have active metabolites—such as Librium and Valium. This prevents rebound withdrawal symptoms between doses, and patients will be much more comfortable as they are detoxing.
However, patients who have liver disease may not be able to metabolize sedatives efficiently, and in these patients it’s best to give short acting drugs (Ativan) or those that do not have active metabolites (Serax, or oxazepam). Elevated liver function tests are a clue, and when the AST/ALT ratio is two or more, you can be pretty sure the origin of the elevation is alcohol. Levels less than five times normal are generally considered “mild” elevations and are unlikely to cause impaired liver function. Another common clue to significant liver disease is thrombocytopenia (platelet count below 150).
How to distinguish med seeking from actual detox symptoms
Since many of the CIWA scale symptoms are subjective, some patients may fake symptoms to get more benzos. The easiest to fake are anxiety and headache. If you’re concerned about med seeking, ask nurses to pay closer attention to the vital signs (tachycardia and hypertension) and the more objective symptoms such as tremor, sweating, and nausea. Also note that the typical detox takes 3-5 days, so if patients are asking for meds after that, they may be malingering.