Drug and Alcohol Dependence

Warning

Alcohol in the acute hospital

It is important to distinguish between alcohol dependence and harmful use/misuse in hospital patients.

Those who are dependent on alcohol are at risk of medical complications (see Alcohol Withdrawal section).

Dependence includes:

  • strong desire to drink
  • difficulty controlling drinking 
  • persistent use despite harm
  • neglect of other interests/obligations
  • increased tolerance 
  • withdrawal states (very important in the acute hospital setting)

Alcohol Withdrawal

Alcohol withdrawal is a life-threatening medical emergency. There can be delay between stopping drinking and severe complications. Delirium tremens may appear after 48 – 72 hours and seizures after 24 – 48 hours.

Recognising dependence means that action can be taken early before patients start to withdraw or whilst the withdrawal is still mild.

Protocols differ by hospital - check your local guidelines. 

General principles include:

  • treatment with parenteral thiamine (Pabrinex) to prevent Wernicke’s encephalopathy and progression to Korsakoff’s
  • plus long-acting benzodiazepines to treat withdrawal symptoms

Some hospitals use the CIWA protocol (see Resources below) to tailor benzodiazepine treatment and others use fixed regimes.

CIWA typically involves Diazepam. In liver failure, use Oxazepam or Lorazepam.

Utilise the alcohol liaison service to provide on-going support and relapse prevention options, especially on discharge. Remember to prescribe ongoing oral thiamine. 

Alcohol in the community

  • The principles of recognising dependence are the same as in the hospital setting (see above).
  • Utilise opportunities for screening such as using the CAGE questionnaire (see Resources below).
  • Support patients to reduce drinking but never to stop abruptly outside of a detox programme due to the risk of seizures and death.
  • Patients must not drive and must notify DVLA in both misuse and dependence.
  • Beware of any child protection issues.
  • For support, advice and potential detox refer to your local Hub.
  • Signpost to support groups such as Alcoholics Anonymous and SMART. 

Drug dependence

  • The principles of assessing drug use and dependence are similar to alcohol.
  • With both misuse and dependence DVLA must be notified and patients must not drive.
  • Be vigilant for any child protection issues and ensure safe storage of drugs.

Opioid replacement

It is crucial to contact the pharmacy and the prescriber to confirm:

  1. which drug the person is prescribed
  2. the dose
  3. dispensing arrangements
  4. last collection

Opioid withdrawal might be uncomfortable, however, inappropriately prescribed opioids can be fatal.

Never prescribe without confirmation of the above information and objective evidence of opioid dependence using a drug screen and Clinical Opiate Withdrawal Scale (COWS) score (See Resources below). If you are unable to contact the pharmacist/prescriber, and you have a confirmed positive drug screen, treat withdrawals symptomatically e.g. Loperamide, Zopiclone. If in severe withdrawal, Dihydrocodeine can be prescribed - check your local guidelines and continue monitoring COWS.

Refer the person to your local community addiction service and consider discussion with drug liaison team if your hospital has access to this service. 

Seek advice from local services for ongoing management - remember take home Naloxone kits, advice on needle exchange, local relapse prevention groups, BBV screening, contraception and STI testing. 

Last reviewed: 21/02/2024

Next review date: 21/08/2024

Author(s): Core Trainee in Psychiatry, NHS Lothian & Medical Education Fellow, NHS Lothian.

Author email(s): mypsych@ggc.scot.nhs.uk.

Reviewer name(s): Medical Education Fellow, NHS Lothian.