Facilitating Links with Other Services for Further Treatment and Support

A focus of counselling strategies during withdrawal is examining post-withdrawal treatment options, and facilitating engagement with these services. This may include:

primary care
counselling (for example, relapse prevention)
residential rehabilitation
self-help
medications for relapse prevention.

Chapter	Recommendation	Grade of recommendation
8.14	Clinicians should facilitate links to post-withdrawal treatment services during withdrawal treatment.	D

Box 8.1: Coping With Cravings

‘Cravings’ are urges to drink alcohol. They are a normal part of any addiction and withdrawal. Cravings vary in intensity with time, and are only severe for short periods (for example, less than one hour). Cravings are often triggered by opportunities to drink, physical or psychological discomfort. Cravings generally get easier to deal with the longer a person goes without drinking.

It is important that patients are prepared for cravings. The goal is to see through the brief period of severe craving. The Three-D method has been successful for many people when they are experiencing severe cravings, specifically:

Delay the decision as to whether you will drink for one hour. You may or may not drink, but that is something to be decided later (when the severity of the craving has reduced).
Distract yourself with an activity during this hour that will take your mind off whether you will drink or not.
Desist: After the hour, say to yourself: ‘Why I don’t want to drink’ and ‘What have I got to lose?’

By this stage the craving should have settled down – although probably not gone away. The patient should re-examine the reasons they want to stop drinking, why they are trying to withdraw, and importantly, what they will be returning to if they start drinking again.

Diet, Nutrition and Rehydration

Many people with chronic heavy alcohol use suffer from nutritional deficits, and can become dehydrated during alcohol withdrawal. Patients should be assessed for dehydration, and their fluid intake and output monitored. Oral fluid intake is generally preferred, usually in excess of 2 litres per day (up to 5 litres if the patient is suffering diarrhoea, nausea or profuse sweating). Patients with severe dehydration and/or those unable to tolerate oral fluids will require hospitalisation, investigation and correction of electrolyte abnormalities intravenous fluid replacement and 24-hour fluid monitoring.

Magnesium is an important cofactor for thiamine absorption and function and is often deficient in people with alcohol use disorder (AUD) presenting to the Emergency Department. Recent evidence indicates an association between magnesium deficiency and increased mortality. Accordingly, it appears appropriate to offer magnesium supplementation in this setting, but no direct evidence of benefit has been reported to date.

Patient’s nutritional intake should be monitored. Many experience nausea and/or diarrhoea during withdrawal, and frequent, light meals are generally better tolerated in the first few days of withdrawal than infrequent, large meals (see ‘Intravenous fluids and nutritional supplements’ below).

Chapter	Recommendation	Grade of recommendation
8.15	Clinicians should ensure oral rehydration is adequate. Intravenous fluids may be necessary in severe dehydration and/or in those not tolerating oral fluids.	GPP
8.16	Magnesium levels should be check on hospital admission and replaced if deficiency identified.	GPP