Dealing With Alcohol And Other Drug Withdrawal

Since the pioneering Canadian and Australian development of 'social setting' detoxification services to assist people safely through alcohol withdrawal, a variety of other non-medical approaches have been developed. Really, detoxification services should be seen as being on a continuum ranging from supervision by an informed 'lay person'—a relative, a recovered problem drinker or user or non-medical professionals—all the way to 24 hour nursing and medical care in a specialist hospital unit. Even in the latter case substantial variations exist regarding the amount of medication used during withdrawal—or even whether any medication is used at all. Detoxification services designed to minimize discomfort and the possibility of actual harm occurring during withdrawal may be 'non-medical' in several senses: by, variously, using nonmedical settings (e.g. hostels, the client's home), non-medical personnel (e.g. relatives, ex-problem drinkers) or non-medical procedures. There is wide consensus that medical assistance needs to be available if required but the responsibility for accessing this need not be left only with medical personnel.

The Ontario model of non-medical detoxification was created following the results of a study reported in 1970. It found in the relative safety of an alcoholism treatment unit that only 5 percent of admissions required any form of medical assistance. In addition to the residential 'social setting' model of detoxification, 'ambulatory' or outpatient detoxification procedures were developed which relied on the drinker calling in daily to a clinic to collect their medication and receive a brief check-up. Evaluations of these types of service conducted in several countries have demonstrated that their success rate in terms of both safety and effectiveness is at least the equal of inpatient care—and is considerably cheaper.

A variation of this approach is 'home detoxification', an approach developed initially in the UK with problem drinkers and now widely used in many other countries. This usually involves a community alcohol worker (e.g. nurse, counselor or psychologist) assisting a family practitioner to assess a drinker who wishes to stop drinking alcohol but who may experience severe withdrawal symptoms in the process. Providing the home environment is deemed to be supportive and the client sufficiently motivated to stop drinking the detoxification then occurs in the patient's home with supportive visits from the alcohol worker. The family doctor's telephone number is provided to the client and any close relative or partner in case of emergency. A particular effort is made to screen out drinkers with a history of withdrawal fits, delerium tremens or Korsakoff's Psychosis. In order to reduce the real risk of overdose with some types of medication (notably chlormethiazole) either the alcohol worker or a relative holds the medication. An important reason for developing this service in the UK was the discovery that many family doctors were already prescribing chlormethiazole to cover alcohol withdrawal but in the absence of any supervision and frequently longer than the recommended maximum period— sometimes even indefinitely. It was found that this was the single most common method of managing alcohol withdrawal among a group of patients who, for many reasons, were loathe to attend a psychiatric hospital or specialized treatment unit. Later studies have found evidence that home detoxification is more acceptable to groups that are frequently under-represented in traditional settings such as the young, the elderly and women. Home detoxification therefore offered a safe alternative to completely unsupervised withdrawal on the one hand and a cost-effective alternative to inpatient hospital care. The cost of Home Detoxification per client has been estimated to be approximately a quarter that of inpatient hospital care. Formal evaluations of the UK service suggest that not only is there no loss in terms of either safety or efficacy but that the clients prefer to be treated at home and that many would refuse to attend a hospital facility.

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