Selecting Withdrawal Settings

The choice of withdrawal setting requires a comprehensive clinical assessment and discussion with the patient (and where possible family or carers) about the advantages and disadvantages of each approach. Factors to be considered in determining the most appropriate withdrawal setting for an individual include: 

      • likely severity of alcohol withdrawal and risk of severe withdrawal complications (seizures, delirium, hallucinations);

      • use of other substances: people who report heavy use of other drugs (such as benzodiazepines, psychostimulants, opiates) may be at increased risk of withdrawal complications and generally need close monitoring and supervision (usually an inpatient unit);

      • patients with significant comorbidity may need hospital admission until medically cleared. Patients may be able to ‘step-down’ to less intensive withdrawal settings to complete withdrawal once medically stable and reduce length of stay in hospital. 

      • social circumstances, the availability of a safe environment and ‘home’ supports;

      • outcome of prior withdrawal attempts: repeated failure at ambulatory withdrawal may indicate the need for referral to a residential detoxification unit;

      • patient preference and availability of resources.

Table 8.3: A summary of the admission criteria for different withdrawal settings.

  Ambulatory Community residential Inpatient hospital
Predicted alcohol withdrawal severity Mild–moderate Moderate–severe Moderate–severe
Likelihood of severe withdrawal complications No Withdrawal complications not expected Withdrawal complications (delirium, seizures)
Medical or psychiatric comorbidity None or minor comorbidity Minor comorbidity Significant comorbidity
Other substance use No heavy drug use Heavy or unstable use of other drugs Heavy or unstable use of other drugs
Social environment
  • Stable housing that is alcohol-free
  • Daily monitoring by reliable support people
  • Good access to health care service
Home environment support insufficient Unsupportive home environment
Previous attempts None or few attempts at ambulatory withdrawal Repeated failure at ambulatory withdrawal Previously required hospitalisation

Some patients wish to attempt ambulatory withdrawal despite multiple failed previous attempts. Further attempts at outpatient withdrawal may be appropriate, if safety concerns are not evident. Clinicians should identify how this attempt will be different to previous attempts (for example, increased home supports and monitoring; closer engagement with ongoing care), and negotiate with the patient mutually agreed criteria to be met in order to continue with the withdrawal attempt (for example, no alcohol use in first 2 days). Consider whether there is cognitive impairment that may impact on decision making (Chapter 19). 

Patients on waiting lists for residential withdrawal units may need support to maintain motivation and avoid high-risk activities until admission. Care is required to minimise treatment delay for high risk patients. 

It is not recommended that benzodiazepines be prescribed in an attempt to alleviate withdrawal symptoms before admission as this may increase the risk of adverse events from the combination of alcohol and benzodiazepines.

Chapter Recommendation Grade of recommendation
8.4 Ambulatory withdrawal is appropriate for those with mild to moderate predicted withdrawal severity, a safe ‘home’ environment and social supports, no history of severe withdrawal complications, and no severe concomitant medical, psychiatric or other substance use disorders. B
8.5 Community residential withdrawal is appropriate for those with predicted moderate to severe withdrawal, a history of severe withdrawal complications, withdrawing from multiple substances, no safe environment or social supports, repeated failed ambulatory withdrawal attempts, and with no severe medical or psychiatric co-morbidity. B
8.6 Inpatient hospital treatment is appropriate for those with severe withdrawal complications (e.g. delirium or seizures of unknown cause), and/or severe medical or psychiatric co-morbidity. GPP