RESEARCH

Outpatient alcohol withdrawal

management for Aboriginal and
Jonathan Brett
Leanne Lawrence
Rowena Ivers
Torres Strait Islander peoples
Katherine Conigrave

Background There is significant concern from within severe, complicated withdrawal including alcohol
There is concern from within Aboriginal Aboriginal and Torres Strait Islander withdrawal delirium (delirium tremens).
and Torres Strait Islander communities communities about the harms associated Outpatient alcohol withdrawal is a treatment
about the lack of access to alcohol with alcohol consumption. Although approach used around the world. It is included
withdrawal management (‘detox’) more Aboriginal and Torres Strait Islander in Australian national treatment guidelines4 and
services. Outpatient detox is described
peoples abstain from alcohol, compared Alcohol Treatment Guidelines for Indigenous
within national Australian guidelines
with non-indigenous Australians, those Australians.5 Criteria must be met to be eligible
as a safe option for selected drinkers.
who do drink are twice as likely to have for this (Table 1). At conferences, clinicians have
However, uncertainly exists as to how
suited Aboriginal and Torres Strait consumed alcohol at levels that place expressed concerns about the safety of outpatient
Islander peoples are to this approach. 
 them at risk of harm.1 In keeping with withdrawal management for Aboriginal and
this, Aboriginal and Torres Strait Islander Torres Strait Islanders who consume alcohol.
Methods
peoples experience alcohol-related harms These concerns are likely to have arisen from
Consultations were conducted with
at 2–3 times the rate of that for non- observations of disadvantaged areas with large,
stakeholders of four health services
Indigenous Australians.2 Factors that crowded households containing multiple drinkers.
providing outpatient detox for Aboriginal
and Torres Strait Islander peoples in contribute to this situation include stress, However, Aboriginal community members in
NSW. Thematic analysis was performed disadvantage and ongoing trauma. Despite one urban region have expressed an interest
to determine elements perceived as this increased risk, however, reportedly in outpatient withdrawal management6 and a
important for success. 
 there is a significant gap between service number of urban and regional services anecdotally
need and its provision and accessibility.3 occasionally provide this service to Aboriginal
Results
Key themes that emerged were This means that many Aboriginal and patients with successful outcomes. Here we
individual engagement, flexibility, Torres Strait Islander peoples who are discuss the potential role of outpatient withdrawal
assessment of suitability, Aboriginal staff alcohol-dependent are unlikely to receive management services for Aboriginal and Torres
and community engagement, practical treatment. Strait Islander peoples. Mainstream models of
support, counselling, staff education outpatient withdrawal management services are
and support, coping with relapse and Withdrawal management can be an essential step examined. We then describe selected services
contingency planning. 
 on the path to abstinence but may also help to with experience in providing outpatient alcohol
Discussion interrupt a pattern of heavy and dependent use, withdrawal for Aboriginal and Torres Strait Islander
There is a need to improve access to and facilitate engagement in further treatment. peoples, and highlight elements perceived by
alcohol detox services for Aboriginal Medical management of withdrawal involves service providers as important for success.
and Torres Strait Islander peoples. The assessing the severity of alcohol dependence,
outpatient setting seems to be a feasible other drug use, medical and mental health Alcohol withdrawal
and safe environment to provide this kind problems and social problems, and determining the management: current
of service for selected drinkers. appropriate environment for withdrawal to occur. services and barriers
Keywords Management of withdrawal includes prescribing At present, alcohol withdrawal management often
population groups; alcohol drinking; short-course diazepam where indicated to reduce occurs in a residential setting (in a general hospital
outpatients withdrawal severity, and thiamine to reduce or a specialist withdrawal management facility).
the risk of the Wernicke-Korsakoff syndrome. These expensive beds are in high demand,7 leading
This approach reduces the risk of serious to long waiting lists. Some people who are alcohol-
complications such as withdrawal seizures and dependent may prefer residential care as a ‘time

AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 8, AUGUST 2014 563

RESEARCH Outpatient alcohol withdrawal management for Aboriginal and Torres Strait Islander peoples

out’ from challenging circumstances, or a setting Current mainstream literature supports provided outpatient withdrawal safely and
in which it is easier to avoid alcohol; in other cases many individuals being suitable for outpatient effectively for carefully selected Aboriginal and
they simply may not know that outpatient treatment management.11 Australian guidelines provide clear Torres Strait Islander peoples. To our knowledge,
options exist.6 selection criteria for this pathway.4 Individuals however, there are no formal outpatient withdrawal
There are many barriers to accessing residential meeting these criteria include those who are management programs specific for Aboriginal and
treatment services, including distance from the alcohol-dependent, have a predicted mild-to- Torres Strait Islander peoples. The aim of this paper
nearest service, transport difficulties, childcare,6 moderate withdrawal, a safe, alcohol-free ‘home’ is to determine the successful components of a
language, and shame and fear of stigmatisation. environment and a reliable support person. In selection of urban and regional services that provide
There is also a dearth of easily accessible, culturally Aboriginal and Torres Strait Islander communities, outpatient alcohol withdrawal management to
secure services. relatives can often provide such a safe environment Aboriginal and Torres Strait Islander peoples on an
A recent national report identified a deficiency even if a person’s primary residence is overcrowded ad hoc basis.
in the availability of withdrawal management or contains drinkers. However, significant medical
services for Aboriginal and Torres Strait Islander or psychiatric comorbidities and unstable social Methods
peoples, and prioritised this as a key area environments may exclude some Aboriginal and Service providers’ experiences
for development.8 It also recognised the role Torres Strait Islander peoples from outpatient
of outpatient withdrawal management from management. As part of the consultation to inform the design
mainstream literature.9 To our knowledge, however, Not all Aboriginal and Torres Strait Islander of an outpatient withdrawal management
there are no formal residential withdrawal peoples will experience withdrawal symptoms service specific for Aboriginal and Torres Strait
management programs currently operating within when they stop consuming alcohol. The episodic Islander peoples, one author (JB) contacted five
NSW specifically for Aboriginal and Torres Strait drinking patterns observed in Aboriginal services that had been identified by colleagues as
Islander peoples. communities1 often mean that risk of tolerance, sporadically providing outpatient alcohol withdrawal
and hence withdrawal, is lower.13 However, those management to Aboriginal and Torres Strait
Outpatient withdrawal who do experience withdrawal symptoms may be Islander peoples. These services, which are urban
management: likely more at risk of complications due to higher rates of or regional, include Illawarra Aboriginal Medical
applicability to Aboriginal medical and psychiatric comorbidities. Service (AMS), La Perouse Aboriginal Community
and Torres Strait Islander There is a dearth of research examining which Health Centre, Bowral Community Health Centre,
peoples alcohol interventions or models of care work best Wyong Hospital and Canterbury Hospital. The
A variety of models for mainstream non- for Aboriginal and Torres Strait Islander peoples.14 Aboriginal Health & Medical Research Council
residential alcohol withdrawal management Consequently, it is not known which outpatient (AH&MRC) ethics committee granted approval for
services have been evaluated. Ambulatory withdrawal management model would best suit this project (Approval number 965/13).
withdrawal management involves patients visiting Aboriginal and Torres Strait Islander peoples. Semi-structured interviews were performed in
appropriately trained staff at a local clinic daily.10 Health services specifically for Aboriginal and person or by telephone with 1–3 key staff members
Home withdrawal management involves health Torres Strait Islander peoples, which are community involved with delivering outpatient withdrawal
professionals travelling regularly to patients’ homes controlled and include trained Aboriginal alcohol management (doctors, nurses and Aboriginal alcohol
after an initial assessment.11 Home withdrawal workers, may be well placed to provide outpatient and/or drug workers) at each site. Participants were
management has the advantage of optimising withdrawal management. On the other hand, some asked how their service was delivered, about any
engagement, particularly for individuals who are patients prefer the anonymity of a mainstream problems they had encountered and features they
less able to attend the clinic daily. The disadvantage service where they are less likely to meet friends considered important for successful delivery. Notes
of this approach is the cost and additional risk to or relatives.15 It may be important to have a range were taken during the consultations and thematic
staff. Models include those which are nurse led of options. analysis of these notes was conducted by one
and involve partnerships with primary healthcare Anecdotally, community controlled Aboriginal investigator (JB). Resulting themes were checked
providers.11,12 health services and mainstream services have by two other authors (KC and LL), one of whom is an
Aboriginal health professional.

Table 1. Eligibility criteria for outpatient alcohol withdrawal management Results

• No previous severe withdrawal including seizures or delirium tremens
Several key themes were
• No concurrent acute medical illness
identified
• No evidence of suicidal thoughts, severe depression or psychosis
• No evidence of other drug use (except cannabis) Initial individual engagement
• Supportive, stable and drug- and alcohol-free home environment (this could be a Staff of all services stressed the importance
friend or relative’s home temporarily) of patient engagement. Staff described the

564 AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 8, AUGUST 2014

 Outpatient alcohol withdrawal management for Aboriginal and Torres Strait Islander peoples RESEARCH

development of rapport and trust, which may take from Aboriginal staff members whom they know before the program to improve engagement and
several consultations, before the discussion of personally. Staff at most services identified a motivation.
withdrawal management. This process involves community ownership of the service as being
Staff education and support
listening to the individual’s issues and story as the important and that this empowers the community
patient wants to tell it, as well as helping with to prioritise and tailor treatment approaches on the All services commented that cultural awareness
practical problem-solving, for example linking to basis of their values and so improve acceptability of non-Indigenous staff is important to reduce
social services, financial supports and other health and engagement. One service felt strongly that barriers to treatment access. In non-community
services specific for Aboriginal and Torres Strait ongoing community involvement and feedback are controlled services this was typically achieved
Islanders. A feeling of trust and commitment can important to maintain, as any negative experiences through the involvement of Aboriginal health staff
then lead to better program completion rates and a could otherwise threaten the continuity of the and partnership with community. It was observed
longer lasting therapeutic relationship. program. that appropriate professional development or
continuing education for Aboriginal Alcohol and
Flexibility Practical support, transport and
other drugs (AOD) workers, and their having a sense
medicines
Most services felt that being able to facilitate of being supported by medical staff and of program
assessment for withdrawal management as soon It was reported that many patients do not have ownership were important for program success and
as the patient is ready (without waiting lists) was access to private vehicles and so rely on public sustainability.
important. Flexibility can reduce the chance of a transport, which can be costly, time-consuming
Coping with relapse
window of opportunity being missed and the patient or simply unavailable. Staff at most services
disengaging. On the other hand, all services aimed stated that either offering a transport service or When an individual slips back to drinking they
to start withdrawal management at the beginning reimbursement for travel improves engagement. often experience shame that can itself increase
of the working week so that early monitoring Free access to medicines used during the the risk of a full relapse. Accordingly, a non-
would be possible. This also avoids the risk of withdrawal process and free or concessional judgmental, accepting approach should be used
complications arising over the weekend when staff access to relapse prevention medicines such as to sustain patient engagement. For example, one
are not available. Staff encourage patients to use naltrexone and acamprosate was also reported to service described that if a patient reported having
the gap between assessment and initiation for help engagement. Access to programs such as the had two or three drinks during the program, the
preparation. Close the Gap Medicare co-payment scheme has patient’s honesty was applauded, and motivation
helped with this. and commitment to the program encouraged. In the
Initial assessment of suitability
One service observed that having medicines event of a relapse to heavy drinking, the program
Australian national guidelines for alcohol available on site removes the barrier of the need could be postponed to a later date to maintain
treatment4 were used as a basis for deciding to travel to a pharmacy. However, as only doctors, patient engagement.
suitability for outpatient withdrawal at all centres pharmacists or nurse practitioners are able to
Planning for when things go
and service-specific guidelines were also created. dispense prescription medicines in most Australian
wrong
Of particular importance was ensuring the states, this can pose a practical challenge. At
patient was staying at a safe, ‘dry’ house with a one service, doctors or a pharmacist prepackage Through careful patient selection, medical
responsible person during the program. This may medicines in envelopes for nurses to hand out daily. emergencies such as unanticipated severe
have been at their home or with a relative. Another option is for patients to pick up medicines withdrawal or seizures were very rare.
Services indicated that sometimes the risk of daily from a local pharmacist. One service However, staff typically felt it was important for
undertaking outpatient withdrawal in an individual emphasised the importance of engaging with local community-based services to be supported by a
with chronic disease had to be balanced against the pharmacies regularly to receive feedback on patient 24-hour hospital inpatient service in the case of
risk of continued drinking if no inpatient services progress and provide advice and support. emergencies. A clear plan was also provided to
were available; it is often a case of choosing patients in case of deterioration or emergency.
Counselling
the ‘least worst’ option. They also indicated
that patients with stable chronic diseases had Counseling was seen as important for patient Discussion
successfully completed outpatient withdrawal. engagement and program completion at most There is a great need to improve access to alcohol
services and was delivered on either a formal treatment services for Aboriginal and Torres Strait
Aboriginal staff and community
or informal basis. Counselling often included Islander peoples. Current inpatient withdrawal
engagement
practical and supportive elements, and was not management services have many barriers to
Staff reported that some patients prefer to see confined to one modality (eg cognitive behavioral or accessibility. Outpatient withdrawal management
Aboriginal alcohol and other drug (AOD) workers motivational) but tailored to the needs of the patient seems to be a safe and feasible treatment
who understand culture and community. However, by drug and alcohol workers, nurses or counsellors. option for a selected group of urban and regional
other patients may prefer to keep some distance One service also provided formal counselling Aboriginal and Torres Strait Islander peoples

AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 8, AUGUST 2014 565

RESEARCH Outpatient alcohol withdrawal management for Aboriginal and Torres Strait Islander peoples

in NSW and is sporadically being successfully Leanne Lawrence DipComServices, Cert III Health specific alcohol and other drug interventions:
Office Procedures, Illawarra AMS Community continuities, changes and areas of greatest need.
provided by a range of community-based services. Report prepared for National Indigenous Drug and
Services Team Manager, Drug and Alcohol Program,
A range of models have been used, all involving a Alcohol Council, Australian National Council on
Ilawarra Aboriginal Medical Service, Wollongong, Drugs, 2010. Available at www.nidac.org.au/images/
team approach where, often, GPs play a key part, NSW PDFs/rp20_indigenous.pdf [Accessed March 2014].
either within AMSs or in partnership with nurses Rowena Ivers MBBS, FRACGP, FAFPHM, PhD MPH, 9. Hayashida M, Alterman AI, McLellan AT, et al.
in community health centres and pharmacists. Key general practitioner, Ilawarra Aboriginal Medical Comparative effectiveness and costs of inpatient
and outpatient detoxification of patients with mild-
principles for effective delivery of such services are Service, Wollongong, Associate Professor, Graduate
to-moderate alcohol withdrawal syndrome. N Engl J
presented in this paper. School of Medicine, University of Wollongong, Med 1989;320:358–65.
NSW 10. Blondell RD. Ambulatory detoxification of patients
This study is limited by the non-random
Katherine Conigrave FAChAM, FAFPHM, PhD with alcohol dependence. AmFam Physician
selection of services and so generalisability of these 2005;71:495–502.
Senior Staff Specialist, Drug Health Services, Royal
approaches to other services and regions cannot 11. Carlebach S, Wake D, Hamilton S. Experiences of
Prince Alfred Hospital, Sydney, Professor, Faculty of home detoxification for alcohol dependency. Nurs
be assumed. Remote areas may pose particular Medicine, University of Sydney, NSW Stand 2011;26:41–47.
challenges, including crowded housing, cultural and 12. Sannibale C, Fucito L, O’Connor D, Curry K. Process
language differences, lack of specialist or inpatient Acknowledgements evaluation of an out-patient detoxification service.
We are grateful to the staff of the services that Drug Alcohol Rev 2005;24:475–81.
services for backup and, in some cases, a whole 13. Margolis SA, Ypinazar VA, Clough AR, Hunter E.
community affected by alcohol. There are anecdotal were consulted and to the AH&MRC for checking Absence of alcohol withdrawal syndrome in a remote
a draft of this paper. Funding for this project was Indigenous community. Med J Aust 2008;189:596.
reports, however, of successful management by
provided by the Foundation for Alcohol Research 14. Gray D, Saggers S, Sputore B, Bourbon D. What
GPS of outpatient withdrawal, even in remote and Education (FARE). works? A review of evaluated alcohol misuse inter-
settings. Competing interests: None. ventions among Aboriginal Australians. Addiction
In general practice, cultural appropriateness Provenance and peer review: Not commissioned; 2000;95:11–22.
15. Taylor K, Thompson S, Davis R. Delivering cultur-
and accessibility of services can be improved by externally peer reviewed. ally appropriate residential rehabilitation for urban
partnerships with Aboriginal and Torres Strait Indigenous Australians: a review of the chal-
References lenges and opportunities. Aust N Z J Public Health
Islander staff, or consultation with local Aboriginal 1. Chikritzhs T, Brady M. Fact or fiction? A critique of 2010;34:S36–40.
controlled community health services.16 To support the National Aboriginal and Torres Strait Islander 16. Teasdale KE, Conigrave KM, Kiel KA, Freeburn B,
Social Survey 2002. Drug Alcohol Rev 2006;25:277– Long G, Becker K. Improving services for prevention
delivery of alcohol services, health professionals 87. and treatment of substance misuse for Aboriginal
in all states and territories have access to 24-hour 2. MacRae A, Thomson N, Burns J, et al. Overview of communities in a Sydney Area Health Service. Drug
phone support services such as the Drug and Australian Indigenous health status, 2012. Australian Alcohol Rev 2008;27:152–59.
Indigenous HealthInfoNet, 2013. Available at www. 17. Australian National Council on Drugs. Information
Alcohol Specialist Advisory Service.17 We hope healthinfonet.ecu.edu.au/overview_2013.pdf services for professionals. Available at www.ancd.
this work will assist the further development [Accessed March 2014]. org.au/aod-sector/health-professionals [Accessed
and evaluation of outpatient alcohol withdrawal 3. Wilkes E, Gray D, Saggers S, Casey W, Stearne March 2014].
A. Substance misuse and mental health among
management services for Aboriginal and Torres Aborigianl Australians. In: Purdie N, Dudgeon P,
Strait Islander peoples. Walker R (eds.) Working Together: Aboriginal and
Torres Strait Islander Mental Health and Wellbeing
Implications for general Principles and Practice. 2nd edn. Canberra:
Australian Government Department of Health and
practice Ageing, 2010;117–34.
4. Guidelines for the Treatment of Alcohol Problems.
• Outpatient alcohol withdrawal is a safe and
Canberra: Australian Government Department
feasible option for a selected group of Aboriginal of Health and Ageing, 2009. Available at www.
and Torres Strait Islander peoples in urban and drugsandalcohol.ie/20201/1/Gudelines_for_treat-
ment_of_alcohol_problems.pdf [Accessed March
regional NSW. 2014].
• Accessibility to such programs can be improved 5. Alcohol Treatment Guidelines for Indigenous
by working in partnership with Aboriginal staff Australians. Canberra: Australian Government
Department of Health and Aging. Last updated:
and community. 3 February, 2014. Available at www.alcohol.gov.
• Principles of these programs may be used to au/internet/alcohol/publishing.nsf/Content/AGI02
[Accessed March 2014].
adapt similar models of care for Aboriginal and
6. Conigrave K, Freeman B, Caroll T, et al. The Alcohol
Torres Strait Islander peoples in other areas of Awareness project: community education and brief
Australia. intervention in an urban Aboriginal setting. Health
Promot J Austr 2012;23:219–25.
Authors 7. Australian Insititute of Health and Welfare.
Substance use among Aboriginal and Torres Strait
Jonathan Brett MBBS (Hons), BMedSci (Hons),
Islander people. AIHW, 2011. Available at www.
DMM, Advanced Trainee Addiction Medicine, aihw.gov.au/publication-detail/?id=10737418268
Drug Health Services, Royal Prince Alfred Hospital, [Accessed March 2014].
Sydney, NSW. [email protected] 8. Gray D, Stearne A, Wilson M, Doyle M. Indigenous-

566 AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 8, AUGUST 2014