Alcohol Dependence

General Notes

Patients in the community requesting alcohol detoxification should be referred for full assessment by the NHS Lanarkshire Addiction Service.

Benzodiazepines have dependence potential. To minimise risk of dependence, administer short-term only. Benzodiazepines should not be prescribed if the patient is likely to drink alcohol concomitantly.

Choice of benzodiazepine:

In alcohol withdrawal, chlordiazepoxide is the first choice oral agent for outpatients and in general practice as it has a lower abuse potential and ‘street value’ than diazepam.
For the inpatient setting, local guidelines should be followed for alcohol detoxification.
In liver failure, lorazepam should be considered due to its shorter duration of action and fewer active metabolites.

Management of Alcohol Withdrawal within NHS Lanarkshire Mental Health & Learning Disabilities Inpatient

Alcohol Withdrawal – Outpatients, General Practice and Elective Inpatients

Preferred list (P)

CHLORDIAZEPOXIDE

Specialist use only (S²)

PABRINEX^® intramuscular or intravenous solution for injection

Intramuscular (gluteal muscle) - the contents of one pair of ampoules (7ml) twice daily for a minimum of 5 days (up to 7 days).
Intravenous – two to three pairs of ampoules administered over 30 minutes every 8 hours, or at the discretion of the physician, for 3 to 5 days.
Pabrinex^® should only be administered where facilities for treating anaphylaxis are available.
At least 3 daily doses of Pabrinex^® I/M high potency injection are recommended to prevent Wernicke’s encephalopathy.

There are ongoing supply issues with Pabrinex® (Vitamins B and C) Intravenous and Intramuscular High Potency solution for injection ampoules.

See Medicine Supply Notification MSN/2024/038 for more information.
Pabrinex® Intravenous (IV) injection will be out of stock from August 2024 until at least September 2025.
Pabrinex® Intramuscular (IM) injection is being discontinued, with stock exhaustion expected from December 2024.
There are no other licensed parenteral alternatives to Pabrinex® IV and IM injections.
Thiamine 50mg and 100mg tablets remain available and should be used where clinically appropriate.

Alcohol Withdrawal – Inpatients (Acute)

Specialist use only (S²)

DIAZEPAM

See local hospital guidelines for inpatient dosing

CHLORDIAZEPOXIDE

See local hospital guidelines for inpatient dosing

PABRINEX^® intramuscular or intravenous solution for injection

Intramuscular (gluteal muscle) - the contents of one pair of ampoules (7ml) twice daily for a minimum of 5 days (up to 7 days).
Intravenous – two to three pairs of ampoules administered over 30 minutes every 8 hours, or at the discretion of the physician, for 3 to 5 days.
At least 3 daily doses of Pabrinex^® I/M high potency injection are recommended to prevent Wernicke’s encephalopathy.

There are ongoing supply issues with Pabrinex® (Vitamins B and C) Intravenous and Intramuscular High Potency solution for injection ampoules.

See Medicine Supply Notification MSN/2024/038 for more information.
Pabrinex® Intravenous (IV) injection will be out of stock from August 2024 until at least September 2025.
Pabrinex® Intramuscular (IM) injection is being discontinued, with stock exhaustion expected from December 2024.
There are no other licensed parenteral alternatives to Pabrinex® IV and IM injections.
Thiamine 50mg and 100mg tablets remain available and should be used where clinically appropriate.

General Notes: Maintenance of Abstinence and Relapse Prevention

The treatments detailed below are an adjunct to counselling and psychosocial interventions. Choice of treatment will be influenced by patient acceptability.

Disulfiram is prescribed for patients who would benefit from a deterrent, particularly if they can nominate a partner who can help them to take it regularly. Patients receiving disulfiram suffer unpleasant systemic reactions if alcohol is consumed. Disulfiram self-administration should ideally be supervised e.g. by a partner or an appropriate nurse, or at a day hospital. However this may not always be possible and the decision to prescribe must always be based on clinical assessment of the patients’ needs and risks.

Acamprosate can be useful for patients who suffer strong cravings. It should be initiated as soon as possible after alcohol withdrawal and maintained if the patient relapses. Repeated relapsing to heavy drinking indicates non-efficacy. Recommended treatment period is 1 year.

Naltrexone is an alternative to acamprosate and should only be commenced under specialist advice. An initial treatment period of three months should be considered. However, prolonged administration may be necessary.

Nalmefene is an opioid receptor modulator which is licensed for the reduction of alcohol consumption in adult patients with alcohol dependence who have a high drinking risk level; ≥60g (7.5 units) per day for men and ≥ 40g (5 units) per day for women, without physical withdrawal symptoms and who do not require immediate detoxification. Nalmefene should only be initiated in patients who continue to have a high drinking risk level two weeks after initial assessment. Not to be used in patients taking opioid medication.

Nalmefene should only be prescribed in conjunction with continuous psychological support – provision of which is the responsibility of the prescriber. It is expected that nalmefene will be prescribed in general practice and referral to tier two or three substance misuse services simply to facilitate prescribing of this drug is not required. Psychological support should focus on treatment adherence and reducing alcohol consumption.

Maintenance of Abstinence and Relapse Prevention

Specialist initiation (S¹)

DISULFIRAM

Starting dose normally 200mg daily with further titration to a stabilising dose if required.
Initiation with a loading dose of 800mg is possible in an inpatient setting where close monitoring is available.
Not to be continued for longer than 6 months without review, normally by Addictions Psychiatry.
Higher maintenance dose may be required if there is no adverse reaction, on advice from the addiction service only.

ACAMPROSATE CALCIUM

Recommended treatment period is 1 year.

NALTREXONE (Adepend^®)

Initial treatment period of three months however, prolonged administration may be necessary.

NALMEFENE (Selincro^®)

One tablet daily when patient perceives a risk of drinking alcohol, preferably 1 to 2 hours before anticipated drinking.
Evaluate response to treatment and need for continued therapy regularly.

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S¹): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S²): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.