What are appropriate discharge instructions for a patient with alcohol use disorder and illicit drug use?

Discharge Instructions for a Patient with Alcohol Use Disorder and Illicit Drug Use

Patients with alcohol use disorder and illicit drug use must receive comprehensive discharge planning that includes medication-assisted treatment initiation, structured psychosocial support arrangements, and specific relapse prevention strategies to reduce mortality and hospital readmission.

Immediate Discharge Medications

For Alcohol Use Disorder

Initiate medication-assisted treatment at discharge - this reduces 30-day readmission rates by 42% and emergency department visits by 44% 1, 2.

• Acamprosate (preferred if liver disease present): 1,998 mg/day for patients ≥60 kg (reduce by one-third if <60 kg), started 3-7 days after last alcohol use, continue 3-6 months 3
• Naltrexone (avoid if advanced liver disease due to hepatotoxicity risk): 25 mg for 1-3 days, then 50 mg daily for 3-12 months 3
• Baclofen (safe option for advanced liver disease/cirrhosis): Dosing per specialist consultation 4, 5
• Thiamine 100-300 mg daily for 2-3 months to prevent Wernicke encephalopathy 3

Critical caveat: Naltrexone is contraindicated in patients with alcoholic liver disease due to hepatotoxicity 3. Disulfiram is not recommended due to poor tolerability and safety concerns 3.

For Opioid Use (if present)

Buprenorphine initiation significantly improves outcomes and should be started in the emergency department or at discharge 6:

• Confirm patient is in active withdrawal (COWS score >8)
• Give buprenorphine 4-8 mg sublingual based on withdrawal severity
• Prescribe buprenorphine/naloxone 8 mg/2 mg sublingual: Take 2 tablets once daily, dispense 6-21 tablets (3-7 day supply), no refills 6
• Provide naloxone kit for overdose prevention 6

Structured Discharge Instructions

Abstinence Counseling

Strict abstinence from alcohol is mandatory - continued use leads to disease progression and increased mortality 4, 3. Use the FRAMES model for brief intervention 3:

• Feedback: "Your liver enzymes show alcohol damage"
• Responsibility: "The choice to stop is yours"
• Advice: "Complete abstinence is necessary"
• Menu: Provide treatment options (medications, AA, counseling)
• Empathy: "I understand this is difficult"
• Self-efficacy: "You can succeed with support"

Mandatory Follow-up Arrangements

Schedule before discharge (not "arrange follow-up"):

• Addiction psychiatry or substance use clinic appointment within 7 days - patients discharged to substance treatment facilities have lower blood alcohol on readmission despite higher initial readmission rates 7
• Primary care appointment within 14 days for medication monitoring
• First Alcoholics Anonymous or mutual help group meeting - provide specific meeting location, time, and contact information 3

Harm Reduction Strategies

Provide specific written instructions:

• Never drive after any alcohol or drug use
• Do not use substances alone - risk of fatal overdose
• Avoid triggers: List patient's specific high-risk situations (bars, certain friends, stress)
• Emergency contacts: Crisis hotline numbers, local emergency department address

Psychosocial Support Documentation

Provide written referrals (not just verbal recommendations):

• Individual cognitive behavioral therapy: Specific therapist name and phone number
• Family therapy referral: Address codependency and family dysfunction 3
• Community alcohol counseling center: Provide address and intake phone number 3
• Psychiatric consultation if comorbid depression, anxiety, or other mental health conditions 3

Withdrawal Management Instructions

If Withdrawal Symptoms Develop at Home

Return to emergency department immediately if:

• Confusion or hallucinations (delirium tremens)
• Seizures
• Severe tremors preventing eating/drinking
• Heart rate >120 or fever >101°F

Benzodiazepines should NOT be prescribed at discharge for outpatient withdrawal management due to misuse risk - withdrawal requires inpatient monitoring 3, 5.

Screening and Prevention

Document and provide results:

• Hepatitis C screening (if not done)
• HIV screening (if not done)
• Reproductive health counseling for women of childbearing age 6

Critical Pitfalls to Avoid

1. Do not discharge without medication-assisted treatment - only 2% of patients historically receive it, but it reduces readmissions by 42% 1, 8
2. Do not prescribe benzodiazepines for outpatient withdrawal - high misuse potential 3
3. Do not use naltrexone if any liver disease present - hepatotoxic 3
4. Do not rely on "willpower alone" - medication plus counseling is evidence-based standard 4, 9
5. Do not discharge to involuntary commitment facilities - 100% relapse rate within one year with significant morbidity 10

Specific Discharge Prescription Example

Acamprosate 333 mg tablets
Take 2 tablets three times daily
Dispense: 180 tablets (30-day supply)
Refills: 5

Thiamine 100 mg tablets
Take 1 tablet three times daily
Dispense: 90 tablets (30-day supply)
Refills: 2

Naloxone nasal spray 4 mg
Use as directed for overdose emergency
Dispense: 2 devices
Refills: 0

This evidence-based approach combining pharmacotherapy with structured psychosocial support reduces 30-day readmissions from 23.4% to 8.2% and emergency department visits from 18.8% to 6.1% 2.