Diagnosis and clinical management of alcohol related physical complications: summary of NICE guidanceBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2942 (Published 16 June 2010) Cite this as: BMJ 2010;340:c2942
All rapid responses
Recent guidelines from the National Institute for Clinical Excellence
(NICE) on the physical complications of alcohol use disorders (1) have
begun to revolutionise the treatment of acute alcohol withdrawal in
settings where 24 hour monitoring and dispensing is available. These
changes have significant benefits for patients undergoing detoxification
and also potential savings in treatment costs. This is being achieved by
using a symptom triggered treatment regime rather than a fixed reduction
as was most commonly used previously.
In our unit - the Huntercombe Centre, Sunderland - we have used the
symptom triggered method (based on the Clinical Institute Withdrawal
Assessment tool - CIWA) (2) for 12 years and have found it extremely
effective. We use Diazepam according to a CIWA based protocol and clinical
judgement, in a standard one week inpatient stay. This is combined with
protocols for vitamin supplementation and symptomatic treatment as
required and 24 hour nursing care and daily medical input as needed.
We performed an audit of 105 consecutive admissions for alcohol
detoxification for the 6 months from 4.2010 - 9.2010 inclusive. Of these,
93% of patients were alcohol dependant only and 7% were on concurrent
opiate substitution treatment. The average age was 41 years old (range 19-
77) made up of 66% males and 34% females.
97% of patients successfully completed the alcohol detoxification
with no episodes of fitting, delirium tremens, Wernicke's encephalopathy
or hospitalisations. The other 3% either left before treatment started,
or part way through treatment, feeling they were not ready to do the
The average time on Diazepam was 2.2 days (53 hours) and the range
for 98% of people was 1-4 days on treatment. The average daily dose of
Diazepam was 73mg and the average total dose was 162mg with a range of
40mg - 420mg. Patient satisfaction with the management of their
detoxification was consistently high in discharge questionnaires.
These figures support the research review done for the NICE
guidelines which showed that using a symptom triggered approach tended to
produce a shorter duration of treatment with a reduced amount of
medication needed as compared to standard fixed dose reduction regimes,
with good patient acceptability and no increase in significant
We believe that this way of managing alcohol detoxification is a
quiet revolution which is becoming increasingly accepted as the gold
standard where it can be implemented and we would encourage its continued
and more widespread use.
Dr Joss Bray. MRCPsych. MRCGP.
Medical Director for Addictions - the Huntercombe Group.
Jacqui Mcloughlin. RGN. BSc Hons. Diploma in Addiction Studies.
Clinical Nurse Lead - the Huntercombe Centre, Sunderland.
Dr Joss Bray was part of the NICE Guideline Development Group for the
Diagnosis and Clinical Management of alcohol related physical
1. NICE Guideline CG100 - "Alcohol-use disorders: physical
complications" June 2010
2. Sullivan J,T et al (1989) Assessment of Alcohol Withdrawal: the revised
clinical institute withdrawal assessment for alcohol scale. British
Journal of Addiction 84 1353-1357
3. Daeppen ,J. et al (2002) Symptom Triggered vs Fixed Schedule Doses of
Benzodiazepine for Alcohol Withdrawal. A randomised Treatment Trial. Arch
intern Med. Vol162. May 27
The Huntercombe Centre,
Competing interests: No competing interests
I was interested to read that the annual cost to the NHS of treating
acute and chronic drinking is £2.7 billion pounds.(BMJ 2010: 340: 1412-
1413) Clearly alcohol use results in significant demands on increasingly
limited NHS resources. I believe the time is right for a review of the
price structure of alcohol so that alcohol use is cost neutral to the NHS.
The purchase cost of alcohol should be increased to reflect the NHS
“cost” per unit of alcohol consumed. I estimate that this is likely to add
approximately 5 pence per unit of alcohol to the retail purchase price of
alcohol. While accepting that alcohol is already significantly taxed it
can be argued that alcohol is more affordable now than for many years.
Increasing the cost of alcohol is therefore acceptable, is likely to have
public health benefits and the additional £2.7 billion raised could be
ringfenced for the NHS.
Surely in the present climate few would disagree with an "NHS tax" on
Competing interests: No competing interests