Symptom Triggered Therapy

Symptom triggered therapy administers medication only when the patient develops moderate alcohol withdrawal symptoms, and relies upon linking medication (for example, diazepam doses) with scores on a frequently administered withdrawal scale (such as CIWA-Ar or AWS; Table 8.4 shows an example of a symptom-triggered regimen). Symptom triggered regimens have the advantage of better tailoring medication to the needs of individuals, and have been shown – in specialist residential detoxification settings – to result in less benzodiazepine use than fixed-dose regimens. However, symptom-triggered regimens: 

• are generally not suited to ambulatory withdrawal settings; they require a residential withdrawal setting 
• should not be used in patients with a history of withdrawal seizures, as seizures may occur before the onset of other withdrawal features 
• should not be used in patients with heavy use of other drugs or significant concomitant medical or psychiatric conditions that may invalidate use of withdrawal scales (see ‘Limitations of withdrawal scales’ above); this will include many people undergoing alcohol withdrawal in general or psychiatric hospital settings 
• require good protocol adherence, including regular patient monitoring by staff trained in the use of scales and symptom triggered regimens. Where this cannot be guaranteed, a fixed regimen is preferable.

Note: * Some patients have low tolerance of withdrawal symptoms and may need additional doses of diazepam (for example, 5 to 10 mg) or other symptomatic medication on an as-needed basis. CIWA-Ar – Clinical Institute Withdrawal Assessment for Alcohol Scale; AWS – Alcohol Withdrawal Symptoms – Rating Scale

The typical duration of diazepam treatment is 1 to 2 days. More prolonged treatment is needed for unusually severe withdrawal but the possibility of benzodiazepine dependence and/or mental comorbidity should be considered; both are common. Excessively prolonged therapy can also contribute to sedation, drug-induced delirium, and extended hospitalisation.