Management of alcohol detoxification

The huge majority of people with an alcohol dependence problem that is uncomplicated by serious mental illness or social chaos receive treatment in the community. Tackling Alcohol Together: The Evidence Base of a UK Alcohol Policy (Raistrick et al, 1999, chapter 9) provides strong evidence supporting the move towards briefer and community-based treatments, while at the same time recognising the need for intensive and inpatient treatments for people with more complicated problems. It follows that the traditional sequencing of care, which might be characterised as having four phases – assessing and engaging patients, detoxification, specific therapy and aftercare – is less tidy than it used to be. Detoxification is seen much more as a standalone procedure that should be undertaken when the patient is ready, rather than as a prerequisite of starting treatment. Of course, there are also instances where detoxification may be required as an expedience, for example during an unplanned admission into hospital, or where regular high levels of intoxication are a barrier to treatment. Equally, where the focus of treatment is on mental illness rather than alcohol dependence, then detoxification may well be viewed as a necessary first step. A debate is gathering momentum, not just in psychiatry, about the future role of the generalist. Given the high proportion of people who have a combined problem of mental illness and alcohol dependence, it is inevitable that general psychiatrists will need to be skilled in the management of detoxification, but whether they should also have skills in specific substance misuse treatments is more contentious. Patients, their friends or relatives and sometimes also doctors become so desperate when faced with a catalogue of alcohol-related harms that they seek a solution in detoxification; in itself, this may provide respite and be a caring intervention, but it cannot be expected to have a significant effect on drinking behaviour. The point to be made here is that detoxification should not take place in isolation, but rather should be integrated with a suitable psychosocial therapy or, where mental illness is judged the primary problem, with the usual treatment for the mental illness. The particular purpose of detoxification is to minimise the severity of withdrawal symptoms that occur when alcohol consumption is abruptly stopped or markedly reduced, and thereby to achieve an alcohol-free state with maximum safety and minimum discomfort to the patient. The Substance Misuse Advisory Service (Health Advisory Service 2000, 1999) has set out guidelines for commissioning alcohol detoxification services and stresses that a variety of settings are an important component of a district alcohol treatment system.