Should I continue diazepam (Valium) after discharge for alcohol withdrawal detox, and what is the appropriate taper regimen?

Post-Discharge Diazepam Continuation for Alcohol Withdrawal

Yes, continue diazepam after hospital discharge with a structured taper over 7–10 days maximum, limiting total benzodiazepine exposure to 10–14 days from initiation to avoid iatrogenic dependence. 1

Discharge Taper Protocol

Begin tapering diazepam immediately upon discharge if the patient has already received 3–5 days of inpatient treatment. 1 The acute withdrawal phase peaks at days 3–5 and typically resolves within one week, so most patients discharged after initial stabilization are already past peak severity. 1

Specific Taper Schedule

• Reduce the daily diazepam dose by approximately 25% every 2–3 days during the outpatient taper phase. 1
• Monitor for rebound symptoms (increased tremor, tachycardia, anxiety, sweating) at each dose reduction; if these occur, hold at the current dose for an additional 1–2 days before continuing the taper. 1
• Complete discontinuation must occur by day 10–14 from the initial dose to prevent benzodiazepine dependence. 1, 2

Example Outpatient Regimen

If a patient is discharged on diazepam 10 mg three times daily (30 mg/day total):

• Days 1–2 post-discharge: 10 mg three times daily (30 mg/day)
• Days 3–4: 10 mg twice daily + 5 mg once daily (25 mg/day)
• Days 5–6: 5 mg three times daily (15 mg/day)
• Days 7–8: 5 mg twice daily (10 mg/day)
• Days 9–10: 5 mg once daily (5 mg/day)
• Day 11: Discontinue 1, 3

Mandatory Concurrent Interventions

Thiamine Continuation

Continue thiamine 100–300 mg orally daily for 2–3 months after discharge to prevent Wernicke-Korsakoff syndrome, as 30–80% of alcohol-dependent patients have thiamine deficiency. 1, 2

Daily Monitoring Requirements

• Schedule daily or every-other-day follow-up visits for the first 5–7 days post-discharge to assess vital signs (heart rate, blood pressure), tremor severity, and withdrawal symptom progression. 1
• Use CIWA-Ar scoring at each visit; if the score rises to ≥8 despite the taper, temporarily hold dose reduction and consider increasing the dose back to the previous level. 1

Dispensing Strategy

Dispense benzodiazepines in small quantities (3–5 days maximum) with supervised administration when feasible to minimize diversion and misuse risk. 1, 2

Critical Safety Considerations

Hepatic Dysfunction

If the patient has known cirrhosis or significant liver disease, diazepam remains safe when using symptom-triggered dosing with assessment before each dose, contrary to older teaching. 4 The rapid time-to-peak effect of diazepam (within 2 hours orally) allows accurate titration to avoid over-sedation even in hepatic impairment. 4 However, avoid chlordiazepoxide in severe liver disease due to high risk of "dose-stacking" from delayed metabolism. 1, 4

When NOT to Continue Outpatient Taper

Readmit immediately if any of the following develop:

• New-onset confusion or hallucinations (possible delirium tremens, which peaks 48–72 hours but can occur up to day 5–7) 1
• Seizure activity 1
• Severe autonomic instability (heart rate >120, systolic BP >180, temperature >38.5°C) despite medication 1
• Inability to tolerate oral intake due to persistent vomiting 1

Post-Withdrawal Relapse Prevention

Mandatory Psychiatric Consultation

Arrange psychiatric evaluation within 1–2 weeks of discharge for alcohol use disorder severity assessment and long-term abstinence planning. 1, 2

Pharmacologic Relapse Prevention (Initiate After Benzodiazepine Completion)

Start one of the following medications after the benzodiazepine taper is complete (day 10–14):

• Acamprosate 666 mg three times daily (for patients ≥60 kg) – safe in liver disease, reduces craving 1, 2
• Baclofen 10–20 mg three times daily (up to 80 mg/day total) – the only medication with proven safety in cirrhotic patients 1, 2
• Naltrexone 50 mg daily – contraindicated if alcoholic liver disease present due to hepatotoxicity risk 1, 2, 5
• Disulfiram 250 mg daily – contraindicated in severe liver disease 1, 2, 5

Common Pitfalls to Avoid

• Never extend benzodiazepine therapy beyond 14 days total from initial hospital dose, as this creates a second dependence requiring months-long specialist-supervised taper. 1
• Never discontinue diazepam abruptly even after short courses; always taper gradually over at least 7–10 days. 1, 3
• Do not assume all discharged patients need the full 10–14 days; over 70% of patients (especially those with cirrhosis) may require only 3–7 days total if symptoms resolve quickly with symptom-triggered dosing. 1, 2
• Do not prescribe naltrexone to patients with any degree of alcoholic liver disease – use acamprosate or baclofen instead. 1, 2, 5