11. Community based medically assisted withdrawal
How to provide medically assisted alcohol withdrawal in community settings for people with moderate or, in some cases, severe alcohol dependence. It outlines when this approach is appropriate, covering assessment criteria, safety considerations, preparation and monitoring.
Community based medically assisted withdrawal should be available within every local treatment system. People should be able to access it easily and promptly.
People with moderate alcohol dependence (who typically drink 15 to 30 units per day and score between 15 and 30 on the Severity of Alcohol Dependence Questionnaire (SADQ) should be offered an assessment for community medically assisted withdrawal.
People with severe alcohol dependence (who typically drink 30 units or more per day and score 30 or more on SADQ) should normally be considered for a specialist inpatient withdrawal. However, where the person does not have complex needs or significant comorbidities, an appropriately competent clinician can assess the individual risks and benefits of a community based medically assisted withdrawal with them.
Staff responsible for assessing and managing community medically assisted withdrawal should be clinicians who are competent in diagnosing and assessing alcohol dependence and withdrawal symptoms. They should also be competent using recommended drug regimens appropriate for a community setting and trained in the use of a validated tool for measuring withdrawal symptoms.
Clinicians responsible for assessing and managing medically assisted withdrawal should have access to regular clinical supervision and where necessary, consultation with a senior clinician or a multidisciplinary team (MDT).
Specialist assessment for medically assisted withdrawal should include assessing the appropriateness of a community setting against criteria based on specific safety considerations. This includes:
- severity of alcohol dependence
- history of withdrawal symptoms
- co-occurring physical and mental health conditions
- other risk factors
Where the person has experienced medically assisted withdrawal in recent months, the clinician should carefully assess the risk-benefit ratio of offering the intervention.
There should normally be someone (for example, a family member or friend) to stay with the person during the medically assisted withdrawal process, to support the person and call an ambulance in an emergency. Where the person meets the criteria for a community medically assisted withdrawal but appropriate support is not available, the person should normally be offered it in a residential setting where staff can support them. However, the clinician can assess individual relative risks and benefits of a community based medically assisted withdrawal for the person.
The clinician or keyworker and the person should agree a plan for organising their support and their time during the medically assisted withdrawal, and the ongoing treatment they will move on to immediately after completion.
The clinician should discuss and provide accessible verbal and written information on the medically assisted withdrawal process and on severe complications that should trigger a call for an ambulance, including:
- symptoms worsening to the point of severe shaking and very heavy sweating
- seizures
- delirium tremens
- incipient Wernicke’s encephalopathy
The clinician should prescribe prophylactic oral thiamine or consider administering parenteral (intramuscular) thiamine to reduce the risk of Wernicke’s encephalopathy based on individual assessment or risk level.
Clinicians should follow guidance on prescribing and managing alcohol withdrawal in sections 10.3 and 10.4 of chapter 10 on pharmacological interventions.
For people with mild or moderate alcohol dependence without complex needs, the clinician should be in daily contact with the person during the first 3 days of the medically assisted withdrawal and should see the person face to face at least every other day during the first week. On the days when the clinician does not see the person, they should monitor the person’s condition remotely. The frequency of in- person monitoring should be increased in some cases, based on individual assessment.
Clinical monitoring should include using a breathalyser, assessing withdrawal symptoms using a validated measure of withdrawal symptoms, such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) and monitoring the effects of medication.
If a person has complex needs or is severely dependent and is assessed as suitable for community based medically assisted withdrawal, there is likely to be increased risk to them. Assessment, prescribing and monitoring should be carried out by clinicians who have appropriate training and expertise in managing medically assisted alcohol withdrawal for people with severe dependence and comorbidities. The clinician will need to monitor the person closely.
People with severe alcohol dependence will require higher doses of benzodiazepines to adequately control withdrawal and increased supervision. The doctor with clinical responsibility for the intervention should determine the programme, including the drug regimen, on a case-by-case basis.
Clinicians should normally prescribe for short dispensing intervals, with no more than 2 days medication supplied per prescription. This will help to prevent overdose or diversion (the drug being taken by someone other than the person it was prescribed for).
If the person drinks alcohol, the medically assisted withdrawal should generally be discontinued. If this happens, the alcohol treatment service should offer the person alternative psychosocial support within the service and collaboratively re-assess their needs for medically assisted withdrawal.
After completing a successful community based medically assisted withdrawal, the treatment service should offer the person:
- psychosocial interventions
- relapse prevention medication, unless otherwise indicated
See section 10.5 in chapter 10 on pharmacological interventions for guidance on prescribing for relapse prevention.
This chapter describes the broader context of care in which community medically assisted withdrawal is provided.
You should read this chapter with chapter 10 on pharmacological interventions, which provides detailed guidance on prescribing for the management of withdrawal from alcohol, including for preventing and managing specific complications.
11.3.1 Overview
Most people with moderate dependence on alcohol (who typically drink 15 to 30 units per day and score between 15 to 30 on the SADQ) and some people with mild dependence (who typically drink less than 15 units per day with some signs of dependence) will need medically assisted withdrawal to prevent significant withdrawal symptoms when stopping drinking. It will be appropriate to carry this out in the community unless there are safety concerns that indicate that the person needs more specialised medical and nursing care, or the more intensive monitoring provided in an inpatient setting.
You can find more information on the indications for providing medically assisted withdrawal in an inpatient or residential setting rather than a community setting in section 11.5.5 below.
11.3.2 A range of clinical teams and different settings
A range of clinical teams may provide community based medically assisted withdrawal in several different settings, including:
- specialist community alcohol (and drug) treatment services delivering the intervention at the service or in the person’s home
- primary care where GPs have the appropriate specialist competencies, or where GPs work with specialist community alcohol treatment services (see chapter 15 on primary care and community health services)
- some hospital-based alcohol care teams offer planned community based medically assisted withdrawal
11.3.3 Home based medically assisted withdrawal
Some local alcohol (and drug) treatment systems provide community based medically assisted withdrawal in the home to people who are assessed as eligible. In other areas, services usually deliver the intervention from a service base. Services have a duty to ensure their activities offered to people without protected characteristics are equally accessible to people with protected characteristics (see information and guidance on the Equality Act 2010). So, the treatment system should be able to provide medically assisted withdrawal in the home for people who cannot attend the service base because of a disability, including a long-term mental health condition.
Home based medically assisted withdrawal can help reduce barriers to accessing medically assisted withdrawal, such as cost and difficulties in travel.
It may be appropriate in rural areas where travel to the service base several days a week may be impossible or difficult enough to deter people from attending.
Home-based medically assessed withdrawal also allows the clinician to make an assessment of risks in the home environment.
The service procedure for delivering home based medically assisted withdrawal should be aligned with its home-based working and lone working procedures.
11.3.4 The treatment pathway
People should be able to easily access community based medically assisted withdrawal wherever they are in the treatment and recovery system and at the stage in their treatment journey when they need it. A suitably qualified and experienced clinician should assess the person’s suitability for medically assisted withdrawal and deliver this intervention.
If there are no exclusionary factors (see section 11.5.5 for a summary of criteria for considering inpatient or residential medically assisted withdrawal), a person may be offered planned community based medically assisted withdrawal at any of the stages below. So, this could be after:
- initial assessment
- comprehensive assessment
- a period of engagement with harm reduction interventions
- a relapse into dependent drinking during a treatment episode
The referral pathways between different parts of the treatment and recovery system should be effective and clear to everyone who works within it and to the referring agencies.
The clinician who delivers community based medically assisted withdrawal is often not the person’s keyworker and may be based in a different part of the alcohol treatment system. It is essential to have good communication and joint planning between staff, and to involve the person (and family member or support person where appropriate), before, during and after community based medically assisted withdrawal. There should be a seamless transition to ongoing treatment and support following community based medically assisted withdrawal, because gaps in treatment can increase the risk of returning to problematic drinking.
Occasionally it may be possible to continue a medically assisted withdrawal in the community that has been started in a hospital. In this situation, both the hospital and community should agree that this is suitable and appropriate to the clinical needs of the person. Both services should also agree the plan for transition to the community. And with the person’s consent, hospital clinicians should share relevant clinical information with community clinicians before they discharge the person from hospital.
11.4.1 Staff competence
Staff responsible for assessing and managing community based medically assisted withdrawal should be suitably qualified clinicians. They should be specialist and competent in diagnosing and assessing alcohol dependence and withdrawal symptoms and using recommended drug regimens appropriate for a community setting. They should also be trained in the use of a validated measure of withdrawal symptoms, such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar). Staff should have access to regular clinical supervision and when necessary, consultation from a senior clinician or MDT.
11.4.2 Written procedure
Service providers should have a written procedure that covers all elements of delivering and supervising community based medically assisted withdrawal within their service.
11.4.3 Access to medically assisted withdrawal
Services should offer assessment for community based medically assisted withdrawal as quickly as possible as there is evidence that a prompt offer of treatment at a point when the person is open to changing their drinking can increase the likelihood that they will engage in treatment (Passetti and others, 2008). There is also a risk that the person’s health could deteriorate if access to the intervention is delayed.
Services should provide medically assisted withdrawal as soon as a competent clinician has assessed a person as needing it, the person consents, and adequate preparations are in place. In cases where the person has had repeated episodes of medically assisted withdrawal, the clinician will need to assess relative risks and benefits of proceeding. This is discussed in section 11.5.6 below.
Services should minimise any barriers to accessing medically assisted withdrawal. These barriers might include:
- lack of staff capacity within the service, including lack of specialist clinicians
- long waiting times for assessment and referral for the intervention
- excessive requirements for people to show they are motivated, such as a requirement to attend a series of groups or appointments
Excessive requirements that people need to attend a fixed number of appointments or groups can put people at risk, because their condition may deteriorate while they attempt to meet these requirements.
11.4.4 Integrating pharmacological and psychosocial interventions
Community based medically assisted withdrawal is centred around a pharmacological intervention, but psychosocial interventions should be an integral part of the treatment programme. Both these elements are important and can reinforce one another. The psychosocial element may be particularly important to maximise chances of maintaining abstinence for people who have undergone several previous episodes of community based medically assisted withdrawal.
People will often be anxious about stopping drinking. Taking an empathic, supportive, and collaborative approach will help to engage and encourage the person, as well as family members supporting them. Preparation, assessment and monitoring of medically assisted withdrawal should always involve motivational interventions.
You can find more information on motivational interventions in section 5.5.6 in chapter 5 on psychosocial interventions.
The medically assisted withdrawal process also presents an opportunity for brief psychosocial interventions, like providing information on physical and mental health harms and considering how the person might reduce or manage some of the harms they experience.
Giving the person feedback on tests can be helpful in showing care and activating behaviour change. This might include:
- breathalyser readings
- blood test results
- liver testing results
- blood pressure readings
- cognitive tests
You should read this section along with chapter 10 on pharmacological interventions.
The following recommendations on assessment for community based medically assisted withdrawal draw on the National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment, and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) and on the clinical consensus of the alcohol guidelines development group.
11.5.1 Assessing severity of dependence
Initial assessment should include assessing the severity of the person’s dependence and their need for medically assisted alcohol withdrawal. You can find guidance on assessing severity of dependence in section 4.8.3 and 4.9.5 in chapter 4 on assessment and treatment and recovery planning. Services should offer an assessment for medically assisted alcohol withdrawal to people with a goal of abstinence who typically drink:
- over 15 units of alcohol per day or score over 20 on the ‘Alcohol use disorders identification test’ (AUDIT), available in the guidance Alcohol use screening tests
- under 15 units a day but have a previous history of significant withdrawal symptoms (for example, people with a low body weight)
Community based medically assisted withdrawal will usually be suitable for people who are moderately dependent (typically drink 15 to 30 units daily or score between 15 and 30 on SADQ) and do not have complex needs that require the intensive monitoring provided in an inpatient setting. It may also be suitable for people drinking less than 15 units per day with a previous history of significant withdrawal symptoms. You can find a summary of criteria for inpatient or residential medically assisted withdrawal in section 11.5.5 below.
A breathalyser reading of breath alcohol provides additional information at assessment for medically assisted withdrawal. Breath alcohol is used to estimate blood alcohol concentration. A breathalyser reading correlated with the level of intoxication can indicate the likely severity of withdrawal symptoms. For example, if the person has a high blood alcohol concentration reading and does not appear intoxicated, this may indicate tolerance to alcohol and an increased risk of severe withdrawal.
When assessing the severity of alcohol dependence and the need for assisted withdrawal, clinicians should adjust the criteria for:
- women
- pregnant women and other people who are pregnant
- older people
- children and young people
- people with advanced alcohol related liver disease who may have problems with the metabolism of alcohol
You should seek specialist advice from an experienced senior specialist clinician or MDT when assessing pregnant women and other people who are pregnant, young people, older people, people with liver disease, people with concurrent drug use and people with concurrent mental health conditions for medically assisted withdrawal.
You should read the guidance on prescribing and managing withdrawal for these groups in section 10. 6 in chapter 10 on pharmacological interventions.
For children and young people aged between 10 and 17 years old, NICE CG115 recommends inpatient medically assisted withdrawal in an age-appropriate setting with access to staff with specialist expertise.
You can find guidance on medically assisted withdrawal for young people in section 23.14.1 of chapter 23 on specialist alcohol interventions and support for children and young people.
The clinician should ask about previous periods of abstinence or low risk drinking. If the person has managed periods of abstinence or low risk drinking in the past, this can add additional information about the person’s potential suitability for community medically assisted withdrawal.
11.5.2 Assessing risk that severe medical complications will occur in withdrawal
You should read this section along with sections 10.3.1 to 10.3.7 and 10.4.1 to 10.4.3 in chapter 10 on pharmacological interventions. These sections provide detailed guidance on assessing severity of risk of complications in withdrawal, as well as prescribing and managing withdrawal.
The main complications in withdrawal that can occur are:
- seizures
- delirium tremens
- Wernicke-Korsakoff syndrome
You should assess the risk that these complications may occur during medically assisted withdrawal. Factors that contribute to the level of risk include:
- severity of dependence
- history of severe withdrawals
- the above complications during previous medically assisted withdrawal
- individual health factors
If there are factors that indicate the risk is high, the service should offer the person a referral for medically assisted withdrawal in an inpatient setting instead of a community based intervention. You can find a summary of criteria for considering medically assisted withdrawal in an inpatient or residential setting in section 11.5.5 below.
11.5.3 General medical history and current health
The clinician should take a general medical history and assess the person’s current physical and mental health. There is more detailed guidance on assessing physical and mental health in chapter 4 on assessment. The potential impact of medically assisted withdrawal on any physical or mental health condition will inform decisions about prescribing and managing withdrawal, including the setting. Section 10.6 in chapter 10 on pharmacological interventions provides guidance on prescribing medically assisted withdrawal for specific groups of people.
The clinician should assess whether the person will need oral thiamine or parenteral intramuscular thiamine. They should also assess what setting is best to administer this. You should follow the guidance on prescribing and administering thiamine to reduce the risk of Wernicke’s encephalopathy and Wernicke-Korsakoff syndrome in section 10.4.3 of chapter 10 on pharmacological interventions.
The clinician should arrange for blood tests to be carried out before starting the intervention to help identify any clinical issues. Blood tests usually include (but do not have to be limited to):
- full blood count (FBC)
- liver function test (LFT)
- urea, creatinine and electrolytes (U&E)
- international normalised ratio (INR)
- total protein and albumin
These blood tests should be taken no more than 3 months before the start of the medically assisted withdrawal.
The clinician should consider carrying out a baseline assessment of cognitive function using a validated tool, such as the mini-Addenbrooke’s cognitive examination III (mini-ACE) assessment tool (PDF, 65.1KB) or the Montreal Cognitive Assessment (MoCA). This baseline cognitive assessment, along with other elements of the assessment and the clinician’s observations, can show any difficulties the person has retaining information in the short term. This might affect their ability to consent to treatment, even if their cognitive function will improve in the longer term.
The clinician will need to consider the impact of a person’s substance use on prescribing and managing withdrawal, including:
- illicit drug use
- prescribed medication
- misusing prescribed or over the counter medication
The impact will depend on the substance and pattern of use. If the person has a drug dependence as well as an alcohol dependence, the clinician should consider an inpatient setting. Community medically assisted withdrawal should only be offered after a thorough assessment of risks and benefits for the person, and only where the staff are sufficiently skilled, trained and resourced to manage the complexity of concurrent drug use. You should follow the guidance on medically assisted withdrawal where there is concurrent drug use or dependence in section 10.6.1 of chapter 10 on pharmacological interventions.
Where the person requires medically assisted withdrawal from benzodiazepines in addition to alcohol, services should normally offer this in an inpatient setting. A clinician with competencies in managing withdrawal for people with co-occurring alcohol and benzodiazepine dependence may decide to offer withdrawal management in the community after carrying out a careful assessment of risk and benefit. In this case, they should follow the guidance in section 10.6.1 of chapter 10 on pharmacological interventions.
With consent, the clinician should inform the person’s GP that they plan to deliver a community based medically assisted withdrawal and obtain information on any medication the GP is prescribing and any relevant health information.
11.5.4 Level of support and identifying barriers
Services should generally only offer community based medically assisted withdrawal where there is someone (for example, a family member or friend) available to supervise the process and to call an ambulance if the person experiences severe complications. It is preferable if a family member, friend or another support person supervises the medication. However, if the clinician is considering offering community based medically assisted withdrawal where this support is not available, they should follow the guidance in section 11.5.5.
The clinician should establish what level of support is available to the person. Comprehensive assessment of the person should include an assessment of the strengths and any risks (such as intimate partner violence) they face within the family and their support network. If the clinician is not the practitioner who carried out that assessment, they should refer to it, to ensure that the family member is appropriate to provide support to the person during medically assisted withdrawal. The clinician should also consider any potential risks to the family member or support person from the person undergoing the medically assisted withdrawal that could make it inappropriate to involve them. You can find more information about involving a person’s partners, family and friends in section 5.6.6 in chapter 5 on psychosocial interventions.
The clinician should consider how any individual barriers to maximising the person’s chances of completing the process can be addressed. Barriers might include personal issues such as needing to assertively set boundaries with friends drinking at harmful levels who may want to visit, or practical issues such as pressure not to be absent from work or caring responsibilities.
11.5.5 Summary of criteria for offering medically assisted withdrawal in a specialist inpatient or residential setting and not in the community
It is important to determine whether medically assisted withdrawal can be carried out safely in the community or whether they should be offered specialist inpatient medically assisted withdrawal or residential withdrawal. This will depend on a person’s:
- severity of dependence
- withdrawal history, including any complications in withdrawal
- assessed risk factors, including co-occurring physical and mental health conditions
- needs and circumstances
Specialist inpatient medically assisted withdrawal: criteria
Clinicians should base decisions on whether to refer people for specialist inpatient medically assisted withdrawal on individual clinical assessment. But they should consider specialist inpatient withdrawal, weighing up the risks and benefits of that setting for people who meet one or more of the following criteria.
The person drinks over 30 units of alcohol per day or has a score of more than 30 on SADQ (indicating severe dependence). People with severe dependence should normally be considered for inpatient medically assisted withdrawal. But if the person does not have any complex needs or significant comorbidities, it can be appropriate to offer them a community based medically assisted withdrawal. Any decision to do this should be based on individual assessment by a clinician with appropriate training and expertise in managing withdrawal for people with severe dependence and comorbidities.
The person has a history of seizures, or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes.
The person is assessed as being at high risk of Wernicke’s encephalopathy. Based on individual assessment, it may be possible to offer them medically assisted withdrawal in the community if parenteral (intramuscular) thiamine is available on site and there is a sufficiently skilled, trained, and resourced team to administer it. Clinicians should follow guidance in section 10.4.3 on Wernicke’s encephalopathy and medically assisted withdrawal in chapter 10 on pharmacological interventions.
The person is experiencing co-occurring harmful or dependent substance use (including prescribed and over the counter medication) which requires management, or concurrent medically assisted withdrawal from alcohol and one or more substances.
The person has a severe mental health condition (for example, psychosis, severe depression or suicidal ideation) that makes medically assisted withdrawal in a community or residential setting potentially unsafe.
The person has a significant physical health condition (for example, chronic liver disease, malnutrition, congestive cardiac failure, unstable angina or chronic lung disease) that makes medically assisted withdrawal in a community or residential setting potentially unsafe.
The person has a significant learning disability or cognitive impairment.
They are pregnant (see more information on pregnancy and medically assisted withdrawal in section 10.6.4 of chapter 10 on pharmacological interventions).
Specialist inpatient medically assisted withdrawal: vulnerable groups
Clinicians should consider a lower threshold for referring vulnerable groups and people who are frail to specialist inpatient medically assisted withdrawal. This includes:
- people experiencing homelessness
- older people
- children and young people
- people with established liver disease
People in each of these groups are very likely to require closer monitoring (for safety reasons) than can be provided in a community medically assisted withdrawal. Also, people experiencing homelessness are unlikely to have a sufficiently safe and stable home environment to manage community based medically assisted withdrawal.
Medically assisted withdrawal in a residential setting
People who meet the criteria for community based medically assisted withdrawal but do not have a family member or other support person to stay with them during it, should normally be offered medically assisted withdrawal in a residential setting and not a community based setting (see section 12.6 in chapter 12 on specialist inpatient medically assisted withdrawal for a description of residential medically assisted withdrawal and the distinction between specialist inpatient withdrawal and residential medically assisted withdrawal).
Where a family member or other support person is not available, but the person meets all other criteria for community based withdrawal, the clinician can consider a community based medically assisted withdrawal in some circumstances. The clinician can assess the individual relative risks and benefits of a community based medically assisted withdrawal with the person (see the ‘individual assessment of risks and benefits of the setting for the person’ section below). Increased monitoring is likely to be required.
There are other reasons that people should be considered for residential medically assisted withdrawal when they would otherwise meet the criteria for community medically assisted withdrawal. For example, people should be considered for residential medically assisted withdrawal if they are:
- at risk of domestic abuse, or their home environment is not safe
- caring for children or vulnerable adults, so they do not have to carry out caring responsibilities while going through medically assisted withdrawal
Individual assessment of risks and benefits of the setting for the person
In some circumstances, clinicians with appropriate training and expertise in managing medically assisted withdrawal for people with severe dependence and significant comorbidities can offer community based medically assisted withdrawal to people who meet one of the criteria listed above for inpatient or residential medically assisted withdrawal. They should base this decision on a careful assessment of the risks and benefits of providing this intervention taking into account:
- severity of dependence
- withdrawal history
- co-occurring physical and mental health conditions
- other risk factors
They should also consider what the person wants.
For more guidance on managing community based medically assisted withdrawal for people with severe dependence or significant co-occurring physical or mental health conditions, see section 11.7.1.
11.5.6 Repeated episodes of medically assisted withdrawal
During the assessment, the clinician should consider the number of previous medically assisted withdrawal episodes (either community based or inpatient) the person has experienced. There is evidence that repeated withdrawal episodes at relatively short intervals can cause damage to cognitive functioning and is associated with more severe withdrawal symptoms (Booth and Blow, 1993; Becker, 1998; Ooms and others, 2021). This process is sometimes referred as ‘kindling’. Repeated episodes of both untreated withdrawal and medically assisted withdrawal pose risks. But careful planning so the right psychosocial support is in place, and well managed medically assisted withdrawal (with appropriate dosing), can help to reduce those risks.
Where the person has experienced medically assisted withdrawal in recent months, the clinician should carefully assess the risk-benefit ratio of offering the intervention. There are risks involved with frequent periods of withdrawal at short intervals, but there are also risks involved if the person cannot access medically assisted withdrawal and continues to drink. The clinician should discuss relative risks and benefits with the person and inform them of the increasing risks. This includes seizures and cognitive impairment associated with repeated episodes of both untreated withdrawal and medically assisted withdrawal.
11.6.1 Preparing a person for medically assisted withdrawal
Preparing a person for medically assisted withdrawal should take place during assessment or shortly after the assessment in a follow up appointment.
The clinician should prescribe prophylactic oral thiamine or consider administering parenteral (intramuscular) thiamine to reduce risk of Wernicke’s encephalopathy, based on the guidance in section 10.4.3 of chapter 10 on pharmacological interventions.
Where possible, clinicians should explore options for medication to support relapse prevention and promote abstinence with the person before making plans for medically assisted withdrawal. This allows clinicians to carry out baseline assessments, so they are ready to prescribe in a seamless plan after the end of the person’s community medically assisted withdrawal. This also allows (off-label) acamprosate treatment to begin before withdrawal. If a clinician needs to carry out medically assisted withdrawal without prior planning, they should consider relapse prevention medication before the patient completes withdrawal.
Community based medically assisted withdrawal is a significant undertaking. People (including family members or others supporting the person) will need information and a chance to ask questions and discuss anxieties. They will also need to make practical arrangements such as organising support and cancelling commitments for the duration of the medically assisted withdrawal.
Preparation for community based medically assisted withdrawal should include:
- identifying an appropriate family member or support person to stay with the person during the process for support, and to call an ambulance if the person experiences complications
- discussing results of blood tests with the person
- psychosocial support including motivational interventions
- meeting with the person and family member or support person so they can ask questions and raise concerns
- a mutually agreed plan detailing how the person will organise their support and manage their time during the medically assisted withdrawal
- a mutually agreed plan for ongoing treatment and support immediately after completing medically assisted withdrawal
- an offer of peer support as this may be useful to reduce anxiety and support motivation
Clinicians should also communicate verbal and written information to the person who will go through medically assisted withdrawal and to the person supporting them on:
- the medically assisted withdrawal process and arrangements for monitoring meetings
- any support they will need from a family member or support person
- managing their medication
- advice to avoid activities that could be dangerous if the person has a seizure, such as swimming or driving
- severe complications that should trigger a call for an ambulance (see section 10.4 on prescribing medication to prevent and to manage specific complications of withdrawal in chapter 10 on pharmacological interventions)
Clinicians should make the information fully accessible for the person. For example, they should consider the person’s:
- preferred language
- literacy
- sensory disability
- cognitive impairment
- neurodiversity
11.6.2 Additional preparation on a case-by-case basis
Some people may need additional preparation between assessment and receiving community medically assisted withdrawal for practical reasons, due to complex needs, or because they are ambivalent about starting. Clinicians should only delay the start of medically assisted withdrawal if an assessment of the person’s individual needs shows it is in their interest to do this.
Commissioners and services should work to reduce any barriers that prevent people having rapid access to community based medically assisted withdrawal, such as prolonged assessments or standard requirements. Clinicians should determine the urgency of each person’s need for rapid access.
There is little evidence to suggest that people always need to attend a series of preparation groups or appointments before accessing medically assisted withdrawal. This may be very difficult for some people who are physically dependent or have complex needs. Having a requirement like this risks excluding some people who could and should benefit from medically assisted withdrawal. It also puts people at risk as their health can deteriorate.
Preparation groups can be helpful for people who are not sure if they are ready for medically assisted withdrawal. For people in this situation, the groups can provide support in thinking through pros and cons and discussing any fears. Support from members of peer-based support services may also be helpful so the person can hear from others who have experienced community based medically assisted withdrawal and are now in recovery.
If a waiting list is unavoidable, the service should offer the person individual support and some services offer the option of additional group support while waiting. Services should make it clear to people on waiting lists that the wait is due to limited resources and any offer of group support is optional. They do not have to attend groups to access medically assisted withdrawal.
Clinicians should review the assessments of people on a waiting list regularly in an in-person meeting. This is because:
- a person’s level of risk may change
- community based medically assisted withdrawal might no longer be suitable
- a person may require urgent treatment
They should review the assessment as close as possible to the start of medically assisted withdrawal.
11.6.3 Safeguarding children and vulnerable adults
Where the person is caring for children or a vulnerable adult, preparation for medically assisted withdrawal should include arrangements for a trusted and responsible person to care for the children or vulnerable adult where necessary. Where children’s social care or adult safeguarding services are working with the family, the clinician should involve them in these arrangements. Clinicians must work within statutory guidance and their organisational safeguarding procedures for children and vulnerable adults.
With consent, clinicians should support the person who will undergo medically assisted withdrawal to discuss the plans for this with their children and other family members in an appropriate way.
Children and adult family members, including vulnerable adults, may also benefit from support outside of the medically assisted withdrawal process. Staff should offer support to family members or provide phone and online contact details for relevant support organisations. There is guidance on support for families in section 5.8 in chapter 5 on psychosocial interventions.
A community based medically assisted withdrawal programme should vary in intensity according to a person’s:
- severity of dependence
- available social support
- co-occurring conditions, such as physical or mental health conditions
11.7.1 Monitoring medically assisted withdrawal and severity of dependence
People with mild or moderate dependence (without complex needs)
The clinician delivering the medically assisted withdrawal to people with mild or moderate dependence (without complex needs) should be in daily contact with them during the first 3 days when risks are likely to be highest and should then monitor every other day during the medically assisted withdrawal. Where possible, monitoring meetings should be in-person for the first 3 days. If this is not possible, clinicians should have an in-person monitoring meeting at least every other day during the first 5 days. On the days when the clinician does not offer an in-person monitoring meeting, they should monitor the person’s condition remotely.
Severe dependence or mild or moderate dependence with complex needs
If a person has complex needs or has a severe dependence and is assessed as suitable for community based medically assisted withdrawal, there is likely to be increased risk to them and they should be closely monitored.
Assessment, prescribing and monitoring should be carried out by specialist clinicians with appropriate training and expertise in managing medically assisted alcohol withdrawal for people with severe dependence and significant co-occurring physical health or mental health conditions. Where the clinician is not a doctor, then a doctor with appropriate training and expertise should have overall clinical responsibility for managing the intervention and prescribing. Clinicians should provide an increased level of monitoring. This can include, for example, daily in-person monitoring checks or treatment within a day programme.
People with severe alcohol dependence will normally require higher doses of benzodiazepines than those set out in the drug regimens in section 10.7 in chapter 10 on pharmacological interventions. This is so the clinician can adequately control withdrawal. Benzodiazepines should be prescribed according to the summary of product characteristics for the chosen medication. Clinicians should make sure the person receives adequate supervision if the person is administered high doses, and gradually reduce the dose over 7 to 10 days to avoid alcohol withdrawal recurring. A specialist doctor with appropriate training and expertise should have clinical responsibility for determining the drug regimen, on a case-by-case basis. Clinicians should provide an increased level of monitoring, for example, daily in-person monitoring checks or treatment within a day programme.
Immediately after medically assisted withdrawal, NICE CG115 recommends that people with complex needs or severe dependence should have access to a day programme for 4 to 7 days a week over a 3-week period. This day programme should include:
- keywork (case management) support
- individual psychosocial interventions
- group support
- psychoeducational interventions
- facilitated access to peer support and mutual aid where appropriate
- family and carer support and involvement where appropriate
11.7.2 Monitoring meetings
Monitoring meetings should include:
- an assessment of withdrawal symptoms using a validated measure of withdrawal symptoms, such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) and of the effects of medication
- being very alert for signs of incipient Wernicke’s encephalopathy and for delirium tremens
- using a breathalyser to confirm the person is alcohol free
- monitoring blood pressure, respiration rate and heart rate
- a chance for the person to share their experience and ask any questions
- a chance for the family member or support person to share observations and ask questions (with consent from the person)
- psychosocial support such as motivational interventions and cravings management
- issuing of prescriptions (where there are no safety concerns)
- discussion with the clinical supervisor or MDT if there are any other concerns
The clinician should call an ambulance immediately if the person is experiencing complications such as:
- symptoms worsening to the point of severe shaking and very heavy sweating
- seizures
- delirium tremens
- incipient Wernicke’s encephalopathy
See section 10.4.1 to 10.4.3 in chapter 10 on pharmacological interventions for detailed guidance on prescribing for and managing these serious complications.
If the person reports drinking or the breathalyser shows that they have been drinking alcohol, the medically assisted withdrawal should generally be discontinued. If this happens, the service should offer the person alternative psychosocial support (see chapter 5 on psychosocial interventions) and appropriate harm reduction advice (see chapter 8 on harm reduction).
People with alcohol dependence may need several attempts to become abstinent but they may feel a sense of failure or shame at not completing a medically assisted withdrawal. The clinician or keyworker should offer encouragement and using a non-judgemental approach, review with the person what additional or alternative support they might need for a future attempt at stopping drinking. They should also determine whether or when it might be appropriate to assess the person for another medically assisted withdrawal.
If the medically assisted withdrawal is stopped, the clinician should make sure the person returns any medication prescribed for managing withdrawal.
If the person continues to drink, the clinician should consider continuing to prescribe oral thiamine and, where appropriate, parenteral (intramuscular) thiamine to prevent Wernicke’s encephalopathy. They should follow the guidance on preventing and managing Wernicke-Korsakoff syndrome in section 10.4.3 of chapter 10 on pharmacological interventions. The clinician should regularly review the person’s health as it can deteriorate.
If the person manages to remain alcohol free throughout the medically assisted withdrawal and they feel well enough, encourage them to access additional support between monitoring appointments, such as a keywork session, support groups, peer support or mutual aid (see section 11.7.1).
After completing a successful community based medically assisted withdrawal, the treatment service should offer the person psychosocial interventions. You can find guidance on psychosocial interventions in chapter 5.
Services should also offer relapse prevention medication unless there are concerns about the safety of prescribing this for the person. You can find guidance on prescribing relapse prevention medication, including contraindications in sections 10.5.1 to 10.5.5 in chapter 10 on pharmacological interventions.
You should follow guidance on prescribing and managing alcohol withdrawal in sections 10.3.1 to 10.3.7 and 10.4.1 to 10.4.3 in chapter 10 on pharmacological interventions.
When managing alcohol withdrawal in the community, avoid giving people large quantities of medication to take home. This will help to prevent overdose or diversion (the drug being taken by someone other than the person it was prescribed for). Prescribe for short dispensing intervals, with no more than 2 days’ medication supplied per prescription.
The clinician who prescribes the medication should discuss whether short interval prescribing could pose difficulties for the person. This includes weighing up the risk that the person may not complete the treatment programme if there are reasons like cost or difficulty travelling to a pharmacy that could prevent them receiving their medication. If this is the case, the team should find an alternative where possible, such as a staff member delivering the medication.
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