1. The patient has a detectable breath or blood alcohol level

2. The patient has a history of alcohol and/or illicit drug use

3. The patient has a history of alcohol withdrawal treatment

4. It is the MD’s opinion that detoxification is warranted

5. The patient has a Clinical Withdrawal Assessment Score (CWAS) of >10

Dose:

The choice of benzodiazepine and the exact dose are patient specific. Generally, long acting benzodiazepines (e.g. chlordiazepoxide, diazepam, etc.) are used in the detoxification process. Short acting benzodiazepines (e.g. lorazepam) may also be used, especially if the patient has a history of liver dysfunction.

Benzodiazepines should be ordered initially as a PRN medication if alcohol withdrawal is suspected but not evident. If patients exhibit withdrawal, the benzodiazepine should then be ordered on a scheduled basis.

For mild withdrawal, examples of dosing are as follows:

chlordiazepoxide 25mg PO q6h

diazepam 10mg PO/IV q6h

lorazepam 2mg PO/IV q6h

For moderate to severe withdrawal, examples of dosing are as follows:

chlordiazepoxide 25-100mg PO q1h until stabilized

diazepam 10-20mg PO/IV q1h until stabilized

lorazepam 2-4mg PO/IV q1h until stabilized

Once stabilized, benzodiazepines are tapered approximately 50% or more per day until taken off. This procedure may be done in as little as 3-4 days.

Monitor:

1. If used, maintain a CWAS score of <10

2. Evidence of acute intoxication - hold dose and restart at lowest stabilizing dose and continue taper

3. Evidence of breakthrough withdrawal - add dose to maintain stabilization and continue taper

4. Respiratory depression - lower dose and rescue with flumazenil as necessary

Outcome:

Successful detoxification of patient in reasonably rapid amount of time without complication

Note:

There is little evidence that haloperidol contributes directly to the detoxification process, and there is evidence that it can lower the seizure threshold. Therefore, haloperidol is not recommended or indicated for routine use in the prevention/treatment of alcohol withdrawal or delirium tremens in this institution (see haloperidol Guidelines for Use published in the hospital formulary)