Alcohal Dependence

STANDARD TREATMENT
GUIDELINES
Management of Alcohol
Dependence
Quick Reference Guide
February 2016
Ministry of Health & Family Welfare

Government of India
1
Management of Alcohol Dependence -–QRG Version 17th Feb 2016
Table of Contents
Objectives- ................................................................................................................................................... 3
Diagnosis ...................................................................................................................................................... 3
ASSESSMENT ................................................................................................................................................ 3
Screening: ..................................................................................................................................................... 4
History taking: .............................................................................................................................................. 4
Physical examination: ................................................................................................................................... 4
Mental Status Examination (MSE): ............................................................................................................... 5
Investigations: .............................................................................................................................................. 5
TREATMENT ................................................................................................................................................. 5
Short- term management phase .................................................................................................................. 5
Simple alcohol withdrawal ........................................................................................................................... 6
Complicated alcohol withdrawal ................................................................................................................ 6
Medications .................................................................................................................................................. 6
Treatment regimen ...................................................................................................................................... 7
I A. Fixed dose schedule: .......................................................................................................................... 7
I B. Symptom triggered dosing: ................................................................................................................ 7
I C. Front loading schedule: ...................................................................................................................... 7
II Thiamine Supplementation: .................................................................................................................. 7
Nursing care ................................................................................................................................................. 8
Motivational Enhancement Therapy (MET) ................................................................................................. 8
Management of alcohol withdrawal seizure: ............................................................................................... 8
Management of delirium tremens ............................................................................................................... 9
Long-term management phase .................................................................................................................... 9
Referral to secondary or tertiary care: ......................................................................................................... 9
Clinical Pathway of Management of Alcohol Dependence ........................................................................ 11
Quality Standards for Management of Alcohol Dependence .................................................................... 12
2
Objectives-
• The guideline will provide advice on assessment, investigations, short term and long- term
medical management of individuals presenting with alcohol dependence.
• The guideline will also provide advice on psycho-social interventions for patients with
alcohol dependence.
Diagnosis
The diagnosis of alcohol dependence can be done using ICD-10 diagnostic criteria which are as
follows.
Table 1. Diagnostic criteria for alcohol dependence syndrome as specified in The ICD-10
Classification of Mental and Behavioral Disorders (adapted for alcohol)
A cluster of physiological, behavioral, and cognitive phenomena in which the use of alcohol
takes on a much higher priority for a given individual than other behaviors that once had greater
value. A central descriptive characteristic of the dependence syndrome is the desire (often
strong, sometimes overpowering) to take alcohol. There may be evidence that return to alcohol
use after a period of abstinence leads to a more rapid reappearance of other features of the
syndrome than occurs with nondependent individuals.
A definite diagnosis of alcohol dependence should usually be made only if three or more of the
following have been present together at some time during the previous year:
(a)a strong desire or sense of compulsion to take alcohol;
(b)difficulties in controlling alcohol-taking behavior in terms of its onset, termination, or levels
of use;
(c)a physiological withdrawal state when alcohol use has ceased or been reduced, as evidenced
by: the characteristic withdrawal syndrome for alcohol; or use of alcohol (or a closely related)
substance with the intention of relieving or avoiding withdrawal symptoms;
(d)evidence of tolerance, such that increased doses of alcohol are required in order to achieve
effects originally produced by lower doses;
(e)progressive neglect of alternative pleasures or interests because of alcohol use, increased
amount of time necessary to obtain or take alcohol or to recover from its effects;
(f)persisting with alcohol use despite clear evidence of overtly harmful consequences, such as
harm to the liver through excessive drinking, depressive mood states consequent to periods of
heavy alcohol use, or alcohol-related impairment of cognitive functioning; efforts should be
made to determine that the user was actually, or could be expected to be, aware of the nature
and extent of the harm.
ASSESSMENT
This includes medical history, physical examination, mental status examination (MSE)
and investigations. Assessment is targeted:
3
• To ascertain the diagnosis of alcohol dependence
• To establish rapport with the patient
• To assess complications associated with alcohol use (including physical and
psychological)
• To assess level of motivation
• To assess support and resources available
• To assess suitable setting for management
• To assess need for referral
Screening:
As there is a significant time lag between emergence of alcohol dependence and treatment seeking
for the same, it is important for the clinician to enquire about alcohol use from every patient to
catch them early.
History taking:
Following information should be obtained during history taking.
• Socio-demographic details
• Pattern of alcohol use (Amount, timing, frequency, place, etc)
• Type of alcohol beverage used
• Duration of use
• Features of alcohol dependence (craving, tolerance, withdrawal, physical or psychological
symptoms, etc.)
• Alcohol related complications (physical, psychological, familial, social, vocational,
financial, legal)
• Past abstinence attempts
• Level of motivation (coming by self or family or on being referred by another specialist/
employer/ legal agency)
• Past history of any medical & psychiatric illness, family history
Physical examination:
Physical examination should be done to find out
-Features of alcohol intoxication: unsteady gait, difficulty standing, slurred speech, nystagmus,
decreased level of consciousness (e.g. stupor, coma), flushed face, and conjunctival injection.
-Features of alcohol withdrawal: Tremors, sweating, nausea, vomiting, tachycardia or
hypertension, psychomotor agitation and generalized seizures.
-Physical complications: associated with alcohol use. Eg. liver enlargement, pedal edema
4
Mental Status Examination (MSE):
• Assessment of general appearance and behavior, psychomotor activity, speech, affect,
thought, perception, orientation, attention and concentration, memory, intelligence,
abstraction, judgment, insight and level of motivation.
MSE is aimed at identifying the presence of any co-occurring psychiatric disorders and presence
of complicated alcohol withdrawal.
Investigations:
• Haemogram (including hemoglobin, total leucocytes count, differential leukocyte count,
peripheral blood smear)
• Random blood sugar
• Liver function tests (serum bilirubin, SGOT, SGPT);
• Renal function test (serum creatinine, blood urea)
TREATMENT
Phases of treatment
• Initial short- term management phase (also known as detoxification)
• Long- term management phase
Short- term management phase

Treatment for alcohol dependence can be carried out in the out-patient as well as in-
patient settings. Some of the indicators for in-patient management are as follows
• Presence of severe alcohol dependence (drinks over 30 units of alcohol per day
or regularly drinks between 15 and 30 units of alcohol per day)
• Presence of or anticipated severe withdrawal or complicated withdrawal
(withdrawal with seizures or delirium)
• Co-occurring significant physical and psychiatric illness
• Poor psychosocial support
• Distance from treatment centre that precludes regular follow up
• Failure of out-patient detoxification in past
• Pregnancy, children and adolescents and elderly
5
Simple alcohol withdrawal
• There is history of recent cessation of alcohol use that has been heavy and
prolonged. -Alcohol withdrawal typically develops 6 to 8 hours after the
cessation of drinking. -There is presence of clinical features associated with
alcohol withdrawal.
• These include tremor of the outstretched hands, tongue or eyelids, sweating,
nausea, retching or vomiting, tachycardia or hypertension, psychomotor
agitation, headache, insomnia, malaise or weakness, transient visual, tactile or
auditory hallucinations or illusions and grand mal convulsions.
• These clinical features should be clinically significant means due to these
symptoms there is distress and dysfunction to the patient.
Complicated alcohol withdrawal

• Characterized by presence of seizures or delirium (known as delirium tremens)
along with other features associated with alcohol withdrawal.
• The alcohol withdrawal seizures typically develop 12 to 24 hours after cessation
of drinking. These are generalized and tonic-clonic in character.
• Delirium tremens is characterized by disturbance of consciousness, reduced
ability to focus, to sustain, or to shift attention, a change in cognition (such as
memory deficit, disorientation, or language disturbance), and perceptual
disturbance, severe agitation and coarse tremors of limbs and body.
Medications
• Benzodiazepines are recommended as the first line of treatment of alcohol
withdrawal.
• Long acting benzodiazepines (such as chlordiazepoxide and diazepam) are
preferred over short acting benzodiazepine for this purpose.
• Short acting benzodiazepines (such as oxazepam and lorazepam) are preferred
in liver damage, in elderly people.
The equivalent dose of different benzodiazepines that are commonly used in

management of alcohol withdrawal are given in table.
Table 2 Approximate therapeutic dose equivalent of different benzodiazepines commonly

used in management of alcohol withdrawal
Benzodiazepine Dose equivalent (mg)
6
Chlordiazepoxide 25
Diazepam 10
Lorazepam 2
Oxazepam 30
Treatment regimen
I. Benzodiazepines for management of alcohol withdrawal can be administered
using either of the following three administration regimens.
I A. Fixed dose schedule:

• This involves starting treatment with a standard dose determined by the recent
severity of alcohol dependence and/or typical level of daily alcohol
consumption, followed by reducing the dose to zero usually over 7 to 10 days.
• The starting dose of benzodiazepine can vary from 15 mg four times a day
(q.d.s.) to 50 mg four times a day (q.d.s.) of chlordiazepoxide dose equivalent
(or 10 mg three times a day to 25 mg three times a day of diazepam dose
equivalent).
• The same dose is usually maintained over the next two days. The dose reduction
is made at the rate of 20% every day or 25% every alternate day.
I B. Symptom triggered dosing:
• Benzodiazepine is administered according to the patient’s level of withdrawal
symptoms (ranging from 10-20 mg dose equivalent of diazepam per
administration).
• Pharmacotherapy continues as long as the patient is displaying withdrawal
symptoms and the administered dose depends on the assessed level of alcohol
withdrawal.
I C. Front loading schedule:
• This involves providing the patient with an initially high dose of medication
(30-40 mg dose equivalent of diazepam), and then using either a fixed dose
schedule or symptom triggered dosing approach.
II Thiamine Supplementation:
Along with benzodiazepines, the alcohol withdrawal management includes general
nursing care in form of maintaining hydration and nutritional status.
• It is recommended to give oral thiamine for minimum of three months.
• All patients in alcohol withdrawal should receive at least 250 mg thiamine by
the parenteral route once a day for the first 3-5 days.
• Any parenteral administration of glucose during withdrawal management
should not be done without addition of thiamine.
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Nursing care
• Restraints: The critically ill patient experiencing moderate to severe alcohol
withdrawal symptoms may require both chemical and physical restraints to avoid
immediate threat behavior to self and others. Use of bed rails is advisable.
• Managing behavioural disturbance: If the patient is confused and disoriented or
hallucinating, a supportive and reassuring approach is to be used and patient should
not be confronted.
• Managing environment. The patient’s room should be kept quiet everyone should
move around quietly. Interaction should be minimal and questions limited.
• Nutritional needs. The patient may be malnourished, causing folate, thiamine, or
vitamin B12 deficiency. If the patient is unable to eat, tube feedings or total parenteral
nutrition (TPN) should be initiated early. If a feeding Ryle’s tube is used it is taped at
the nose and cheek area, with the tubing running toward the head and behind the bed.
• Involving family: A complete care plan should involve family members in a
therapeutic alliance to provide optimal symptom relief and formulate acceptable
behavior objectives for the patient.
Motivational Enhancement Therapy (MET)
It utilizes different principles as follows

• Expressing empathy through reflective listening
• Developing discrepancy between clients' goals or values and their current behavior
• Avoiding argument and direct confrontation
• Adjust to client resistance rather than opposing it directly
• Supporting self-efficacy and optimism
Management of alcohol withdrawal seizure:

• Effective management of alcohol withdrawal is preventive against emergence of
withdrawal seizures.
• The alcohol withdrawal seizures can be managed by both short acting (lorazepam-
considered to be more effective by some) and long acting (diazepam) benzodiazepines.
• Benzodiazepines can be given either orally or parenterally.
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Management of delirium tremens
• Delirium tremens should be managed in inpatient setting. Safety of the patient against
any physical harm should be ensured.
• Water and electrolyte balance and nutritional status should be maintained.
• The benzodiazepines are to be administered through parenteral route in sufficient
dosages with an aim to make the patient clam and sedated.
• An initial dose of 10 mg diazepam is given intravenously. Further doses of 10 mg can
be repeated every 5-20 min interval. The dose can be increased to 20 mg per bolus for
the subsequent boluses if the first two boluses do not calm the patient down.
• Subsequently the patient can be shifted to oral benzodiazepines and the dose can be
gradually tapered down.
Long-term management phase
• This phase begins after the initial withdrawal management from alcohol has been
achieved
• The aim is to maintain abstinence from alcohol and to prevent and delay relapse
Medications used in long term management of alcohol dependence are summarized in table
3
Referral to secondary or tertiary care:

• Presence of co-morbid psychiatric condition that cannot be managed at the primary care or
secondary care level
• Complicated withdrawal like delirium or withdrawal seizures
• Physical comorbidity of serious nature for which adequate infrastructure and support may
not be available
• Presence of a co-morbid substance use disorder for which treatment is not available at
primary/secondary hospital setting
• Non-availability of professionals to administer psycho-social interventions
• A complete care plan should involve family members to identify treatment options,
appropriate supportive care beyond medication and monitoring may help decrease
morbidity and mortality rates.
•
Table 3 Medications used in long term management of alcohol dependence
Medicine Common side-effects and Dose Frequency Duration

contraindications to use
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Acamprosate Diarrhea with abdominal pain, nausea, 1332 TDS One year
vomiting, pruritus Contraindications- mg/day
hypersensitivity reaction, pregnancy (body
and breastfeeding, renal insufficiency weight <
(serum creatinine more than 120 50 kg) to
micromoles per litre), severe hepatic 1998
failure mg/day
FDA pregnancy category C (body
weight> 50
kg
Disulfiram Drowsiness, fatigue, abdominal pain, 250mg/day OD One year
headache, nausea, diarrhea, allergic
dermatitis, metallic or garlic like after
taste
Contraindications (absolute)-
hypersensitivity reaction , pregnancy
and breast feeding
Contraindications (relative)-
cardiovascular problems, severe
personality disorder, suicidal risk,
psychosis
FDA pregnancy category C
Naltrexone Nausea, headache, abdominal pain, 50 mg/day OD One year
reduced appetite and tiredness
Contraindications- acute liver failure
(caution is suggested when serum
aminotransferases are four to five
times above normal)
FDA pregnancy category C
10
Clinical Pathway of Management of Alcohol Dependence
Individual with alcohol use
Assess for problematic use
Non- dependent use Alcohol depend ence
Assess for
Severity of dependence
Severity of withdrawal
Presence of complicated withdrawal
Severity of withdrawal in past
Mild to moderate
Severe dependence
dependence
Severe withdrawal Mild to moderate
withdrawal
Presence of complicated Absence of complicated
withdrawal withdrawal
Poor social support and
Severe withdrawal in past supervision
Absence of comorbid use
History of complicated withdrawal
of other substances
Personal preference
Presence of Comorbid medical/
psychiatric illness
Brief I ntervention
In-patient with drawal management Outpati ent withdrawal
management
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Quality Standards for Management of Alcohol Dependence
Standard Statement
Quality Standard 1 All patients reporting to health facility should be screened for
Screening presence of alcohol dependence.
Quality Standard 2 All patients reporting current alcohol use and scoring high on the
Assessment screening tests or having problems due to alcohol use should be
assessed for presence of alcohol dependence and physical
complications associated with long term alcohol use .
Quality Standard 3 All patients with alcohol dependence should be assessed for
Investigations presence of physical complications using laboratory investigations.
Quality Standard 4 All patients with alcohol dependence should be offered short term
Short term management (detoxification) in the out-patient, or the inpatient
management setting.
Quality Standard 5 All patients with alcohol dependence should be offered long term
Long term management.
management
12
Quality Standard-1 - Screening for alcohol dependence
1. Statement All patients reporting to health facility should be screened for presence
of alcohol dependence.
2. Rationale Problematic use of alcohol is a common medical disorder that can go
undetected even among those seeking treatment for some unrelated
medical disorder. Hence, all patients in contact with health care
systems should be screened for presence of alcohol dependence.
3. Quality Measure
3a. Structure Availability of screening instruments (scales) and trained health
professionals at the medical facility.
3b. Process Proportion of patients seeking medical care being screened for
problematic alcohol use.
Numerator- Number of patients screened for problem drinking
amongst those seeking care.
Denominator- Total number of patients seeking medical care.
3c. Outcome Proportion of patients who are likely to have problematic alcohol use.
Numerator- Number of patients who are likely to have problematic
alcohol use.
Denominator –Total number of patients screened for problematic
alcohol use.
4. What Quality Service Provider –Ensure that all patients seeking medical care are
Measure means for screened for problematic alcohol use.
each audience Health Administrator- Ensure that adequate screening facility is
available at the designated facility.
Patient and Community – Patients and caregivers should participate in
the screening process.
5. Data Source Out-patient register
In-patient register
6. Definitions Health Facility- Any public health care facility (PHC, CHC, District
Hospitals, Tertiary care Centers/ Teaching Hospitals) or their equivalent
in private sector
13
Quality Standard-2 - Assessment for alcohol dependence
1. Statement All patients reporting current alcohol use and scoring high on the
screening tests or having problems due to alcohol use should be
assessed for presence of alcohol dependence.
2. Rationale Patients with current alcohol use and scoring high on the screening test
or having problems due to alcohol use are likely to be dependent on
alcohol and consequently require medical intervention.
3. Quality Measure
3a. Structure Availability of trained health professionals at the medical facility.
3b. Process Proportion of patients reporting current alcohol use and scoring high
on screening test or having problems due to alcohol use assessed
thoroughly for presence of alcohol dependence.
Numerator- Total number of patients assessed thoroughly for
presence of alcohol dependence.
Denominator- Total number of patients reporting current alcohol use
and scoring high on screening tests or having problems due to alcohol
use.
3c. Outcome Proportion of patients who have alcohol use in dependent pattern.
Numerator- Total number of patients who have alcohol use in
dependent pattern.
Denominator –Total number of patients assessed for alcohol use in
dependent pattern.
4. What Quality Service Provider –Ensure that all patients with current alcohol use and
Measure means for scoring high on screening tests or having problems due to alcohol use
each audience seeking medical care are screened for problematic alcohol use.
Health Administrator- Ensure that trained health professionals are
available at the designated facility.
the assessment process.
In-patient register
in private sector
14
Quality Standard-3 - Investigations for alcohol dependence
1. Statement All patients with alcohol dependence should be assessed for presence
of physical complications using laboratory investigations.
2. Rationale Patients with alcohol dependence are likely to experience the physical
complications associated with alcohol use. Also it is important to
exclude the possible medical causes of delirium observed during
alcohol withdrawal. Finally, it is important to monitor for emergence of
side effects associated with medicines used for managing alcohol
dependence. Hence it is important to assess these patients with
appropriate laboratory investigations.
3. Quality Measure
3a. Structure Availability of laboratory facilities at the medical facility.
3b. Process Proportion of patients advised investigations for presence of physical
complications associated with alcohol use, possible medical causes of
delirium observed during alcohol withdrawal and monitoring for
emergence of side effects of medicines used for managing alcohol
dependence.
Numerator- Total number of patients advised investigations.
Denominator- Total number of patients being managed for alcohol
dependence.
3c. Outcome Proportion of patients with deranged biochemical investigation results.
Numerator- Total number of patients who have deranged biochemical
investigation results.
Denominator –Total number of patients investigated.
4. What Quality Service Provider –Ensure that all patients with alcohol dependence are
Measure means for recommended appropriate laboratory investigations.
each audience Health Administrator- Ensure that adequate laboratory services are
available at the facility.
the investigations.
In-patient register
Laboratory register
in private sector
15
Quality Standard-4 - Short term management of alcohol dependence
1. Statement All patients with alcohol dependence should be offered short term
management (detoxification) in the in-patient or the out-patient
setting.
2. Rationale Patients with alcohol dependence are likely to experience withdrawals
when they quit alcohol use. Hence it is important to offer medical
management for alcohol withdrawals. Also it is important to prevent
emergence of complicated alcohol withdrawal and manage the same
whenever they emerge.
3. Quality Measure
3a. Structure Availability of short-term management facilities (in patient and out
patient) at the medical facility.
3b. Process Proportion of patients offered short-term management for alcohol
dependence.
Numerator- Total number of patients offered short-term management
for alcohol dependence.
Denominator- Total number of patients diagnosed with alcohol
dependence.
3c. Outcome Proportion of patients who receive short-term management for alcohol
dependence.
Numerator- Total number of patients who receive short-term
management for alcohol dependence.
dependence.
Measure means for offered short-term management.
each audience Health Administrator- Ensure that adequate short-term management
facilities (pharmacological and non pharmacological; from in-patient
and out-patient setting) are available at the facility.
the short-term management.
In-patient register
Pharmacy register
in private sector
16
Quality Standard-5 - Long term management of alcohol dependence
1. Statement All patients with alcohol dependence should be offered long term
management.
2. Rationale Patients with alcohol dependence are likely to relapse even after a
successful short-term management. Hence it is important to offer long
term management to all these patients.
3. Quality Measure
3a. Structure Availability of long-term management facilities at the medical facility.
3b. Process Proportion of patients offered long-term management for alcohol
dependence.
Numerator- Total number of patients offered long-term management
for alcohol dependence.
dependence.
3c. Outcome Proportion of patients who receive long-term management for alcohol
dependence.
Numerator- Total number of patients who receive long-term
management for alcohol dependence.
dependence.
Measure means for offered long-term management.
each audience Health Administrator- Ensure that adequate long-term management
facilities (pharmacological and non pharmacological) are available at
the facility.
the long-term management.
In-patient register
Pharmacy register
in private sector
17

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STANDARD TREATMENT

Ministry of Health & Family Welfare

Short- term management phase

Complicated alcohol withdrawal

The equivalent dose of different benzodiazepines that are commonly used in

Table 2 Approximate therapeutic dose equivalent of different benzodiazepines commonly

Benzodiazepine Dose equivalent (mg)

I A. Fixed dose schedule:

Motivational Enhancement Therapy (MET)

It utilizes different principles as follows

Management of alcohol withdrawal seizure:

Long-term management phase

Referral to secondary or tertiary care:

Medicine Common side-effects and Dose Frequency Duration

Assess for problematic use

Non- dependent use Alcohol depend ence

Presence of complicated withdrawal

Severity of withdrawal in past

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