For further information refer to:

Acamprosate, disulfiram and naltrexone are licensed for maintenance of abstinence after alcohol withdrawal.  Baclofen is also used [off-label] in the treatment of alcohol dependency. See http://www.choiceandmedication.org/nhs24/pdf/pillbaclofen.pdf.

Alcohol withdrawal: seek specialist advice:

  • vitamin supplementation: alcohol dependent individuals requiring detoxification should be offered Pabrinex® in addition to oral thiamine. Patients detoxifying in the community should be given Pabrinex® if they present with features which put them at risk of Wernicke’s encephalopathy (those with diarrhoea, vomiting, physical illness, weight loss, poor diet). Refer to Formulary: vitamins, and Unplanned alcohol withdrawal guideline. There is a PGD for the administration of Pabrinex® in primary care settings (NHS Highland intranet access required).
  • consider choice of drug for alcohol withdrawal:
    • chlordiazepoxide is preferred for alcohol withdrawal in the community because of lesser toxicity in overdose and a lower street resale value. 
    • diazepam is recommended if there is a risk of seizures; it should be used in secondary care facilities only.
  • consider choice of medication regimen: there are two approaches to alcohol withdrawal: symptom trigger (ST) or fixed dose (FD) regimens.
    ST is the 'gold standard' (shorter ‘detox’ and less benzodiazepine use) but requires staff to be trained in the assessment of the symptoms, the administration of medication and to consider whether they have sufficient time in their jobs to be able to do this and use the scoring sheets (without this level of training and time then there is a risk of a paradoxical increase in the length of ‘detox’ and the amount of benzodiazepines used).
    The following medication regimens are available on the intranet (NHS Highland intranet access required):

ACAMPROSATE

Therapy notes

  • Acamprosate treatment, in combination with counselling, should be initiated during or immediately after the alcohol withdrawal period.  Maintain treatment during relapse, unless clinical judgement is that acamprosate has led to no change in pattern of substance use.  The recommended period of treatment is one year.

Formulation and dosage details

Formulation:

Enteric coated tablets 333mg

Dosage:

18 to 65 years, 60kg and over, 666mg 3 times daily; less than 60kg, 666mg at breakfast, 333mg at midday and 333mg at night.

DISULFIRAM

Therapy notes

  • Warn those taking disulfiram, and their families and carers, about:
    • The interaction between disulfiram and alcohol (which may also be found in food, perfume, aerosol sprays etc), the symptoms of which may include flushing, nausea, palpitations and, more seriously, arrhythmias, hypotension and collapse.
    • The rapid and unpredictable onset of the rare complication of hepatoxicity; advise patients that if they feel unwell or develop a fever or jaundice that they should stop taking disulfiram and seek urgent medical attention.
  • In the initial stages of treatment, Community Nurse (Addictions) involvement is desirable. Follow specialist advice on monitoring and during treatment: monitor patients at least every 2 weeks for the first 2 months, then each month for the following 4 months, and at least every 6 months thereafter.
  • In order for this treatment to be successful the patient must be motivated; offer the information leaflet available at http://www.choiceandmedication.org. Maximum benefit is achieved with supervised treatment.

Formulation and dosage details

Formulation:

Tablets 200mg

Dosage:

200mg daily, should not be continued for longer than 6 months without review.  Only use a loading dose with specialist advice. Ensure that alcohol is not consumed for at least 24 hours before initiating treatment.

NALTREXONE

Therapy notes

  • Warn patients against use of opioids, eg in OTC cough medication and analgesics.

Formulation and dosage details

Formulation:

Tablets 50mg (s)

Dosage:

Relapse prevention in alcohol dependence in patients free of opioids, 50mg daily as a maintenance dose.  Check liver function before starting naltrexone and at 3-monthly intervals for one year. 

Editorial Information

Last reviewed: 14/05/2024

Next review date: 27/06/2024

Version: V1.1

Document Id: F104