(Based on recommendations made by Institute of medicine 1990)

1. Emergency treatment (often medical or

2. Detoxification.

3.Assessment of alcohol related problems.

(Can be considered under the headings of Physical, Psychological and Social.)

1. Development of an individual treatment strategy based on assessment

2. Primary care which may include brief intervention.

3. Stabilisation of what has been achieved in primary care.

1. long-term support to maintain what was achieved.

2. Relapse prevention. .

3. Consider the need of residential care.

The majority of alcoholics do not need detoxification, the weekly bout drinker has experience of withdrawal on a regular basis. It is only when there is definite evidence of dependence that detoxification is needed. Outpatient and home detoxification are possible in the majority of cases seen in primary care, but the following basic requirements are needed

1. Medication must be prescribed on a diminishing scale regime. This must be tailored for the patients needs.

2. Close supervision is essential, to ensure that instructions are obeyed, and problems are quickly observed and dealt with.

3. There should be an ~ of physical complications, and reasonable confidence that these will not arise, e.g. epileptic fits.

4. There should also be an absence of co-presenting psychiatric symptoms, e.g. depression and the danger of suicide attempts.

5. There should be no clouding of consciousness, confusion or evidence of brain damage.

6. there should be adequate social support, i.e. somebody with whom the patient has had a healthy relationship at home to supervise him taking medication and report complications. Thus out patient or home detoxification is not ideally suited to those living with fellow drinkers, in an antagonistic relationship, on their own or in bed and breakfast accommodation.

The ideal detoxification medication should sedate without suppressing respiration, have anticonvulsant properties, and not be addictive. There is no drug that fulfils all these properties and many substances have been tried. long acting benzodiazepines e.g. diazepam and chlordiazepoxide are in fashion at present with chlordiazepoxide leading the list especially for home detoxification, needing to be given in daily doses of 80-4()()mgs. divided if necessarily in equal doses, the largest dose can be given at night. Mild cases may only need five days treatment, but more severe cases may need 10 or more days. Chlormethiazole should not usually be given for home detoxification, but still remains a useful drug to be given under hospital supervision, especially as it can be given in liquid form, which makes swallowing easy, and supervision cheat proof even to the point of ensuring that second hand tablets do not reach the black market.