Sir: I would like to comment on the data of Naik et al (Psychiatric Bulletin, June 2000, 24, 214-215). The initial mean daily dose of chlordiazepoxide equivalents used by general practitioners and specialist alcohol services — namely 45.8 mg and 98.1 mg — approximates to 12 mg four times daily (q.d.s.) and 25 mg q.d.s. respectively. The former is very low, the latter low in more severe dependence.

An inadequate initial daily prescription of chlordiazepoxide can have two adverse consequences:

1. (a) the emergence of aversive (e.g. agitation and/or withdrawal hallucinations) and/or dangerous (e.g. withdrawal seizures) complications;

2. (b) an inability of the patient to cope with the withdrawal symptoms, resulting in the resumption of drinking.

Moderate to severely dependent individuals (as judged by the Severity of Alcohol Dependence Questionnaire, Reference Stockwell, Murphy and HodgsonStockwell et al, 1979) may require in the order of 40 mg of chlordiazepoxide q.d.s. and one or two extra ‘as required doses of 40 mg’ for comfortable withdrawal in the first one to two days. Patients and their carers can be given the advice to reduce the amount of chlordiazepoxide if it causes excessive sedation or ataxia. Experience suggests that the as-required medication is needed by most patients at least in the first night when withdrawal symptoms are worse.

Initial undermedication is an iatrogenic cause of non-adherence and needs to be emphasised in the training of those undertaking alcohol detoxification. Furthermore, clinicians managing a patient defaulting after the first day of detoxification should establish (by assertively seeking the patient) whether their initial daily prescription was too low.