Applied Evidence

3 Regimens for alcohol withdrawal and detoxification

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Inpatient vs outpatient treatment

Most patients undergoing alcohol withdrawal may be treated safely in either an inpatient or out-patient setting (SOR=A).40 Treatment professionals should assess whether inpatient or outpatient treatment would contribute more therapeutically to an alcoholic’s recovery process.41

Patients with severe alcohol withdrawal symptoms (CIWA-Ar ≥15), previous history of DTs or seizures, or those with serious psychiatric or medical comorbidities should be considered for detoxification in an inpatient setting (SOR=B) (Table 3).10,42 The main advantage of inpatient detoxification is the availability of constant medical care, supervision, and treatment of serious complications.

A major disadvantage is the high cost of inpatient treatment. Hayashida and colleagues found inpatient treatment to be significantly more costly than outpatient treatment ($3,319–$3,665 vs $175–$388).43 Additionally, while inpatient care may temporarily relieve people from the social stressors that contribute to their alcohol problem, repeated inpatient detoxification may not provide an overall therapeutic benefit.

Most alcohol treatment programs find that <10% of patients need admission to an inpatient unit for treatment of withdrawal symptoms.44 For patients with mild-to-moderate alcohol withdrawal symptoms (CIWA-Ar <15), and no serious psychiatric or medical comorbidities, outpatient detoxification has been shown to be as safe and effective as inpatient detoxification (SOR=A).40 Additionally, most patients in an outpatient setting experience greater social support, and maintain the freedom to continue working or maintaining day-to-day activities with fewer disruptions, and incur fewer treatment costs.41 When assessing a patient for suitability for outpatient detoxification, it is important to ascertain motivation to stay sober, ability to return for daily nursing checks, and presence of a supportive observer at home.

TABLE 3
Criteria for inpatient alcohol detoxification

Consider transfer for inpatient detoxification if the patient:
  • Has current symptoms of moderate to severe alcohol withdrawal (CIWA 15)
  • Has a known history of delirium tremens (DTs) or alcohol withdrawal seizure
  • Needs and is unable to tolerate oral medication
  • Is in imminent risk of harm to self or others
  • Has had recurrent unsuccessful attempts
  • Has had multiple past detoxifications
  • Has a reasonable likelihood that he will not complete the ambulatory detoxification
  • Has active psychosis or severe cognitive impairment
  • Has concomitant medical or psychological illness
  • Has recent high levels of alcohol consumption
  • Has lack or reliable support network
  • Is pregnant

Corresponding author
Chad Asplund, MD, 5663 Marshall Road, Fort Belvoir, VA 22060. E-mail: chad.asplund@na.amedd.army.mil.

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