At Tororo Health Center IV in eastern Uganda, a nurse draws up a dose of diazepam for a middle-aged man trembling on a plastic chair. He has not had a drink in nearly 30 hours and his hands shake as he reaches for the cup. The nurse knows the World Health Organization recommends chlordiazepoxide for alcohol withdrawal, but the clinic has not stocked it in years. So she reaches for diazepam, the sedative on hand, and hopes it will be enough to prevent a seizure.

This scene repeats across Uganda every day. A gap between evidence-based protocols and what clinicians actually prescribe has become entrenched, driven by supply chains, procurement habits, and the realities of practicing medicine where preferred drugs are often unavailable. The consequences range from over-sedation to missed opportunities for safer care.

Diazepam as First-Line: What Ugandan Clinicians Reach For

In Ugandan public health facilities, diazepam is a fixture. It appears on the national essential medicines list, is procured in bulk by the National Drug Authority, and is stocked in most clinics and hospitals. For alcohol withdrawal, it is often the only benzodiazepine available. Nurses and medical officers administer it intramuscularly or intravenously to calm agitation, reduce tremor, and prevent progression to delirium tremens.

Dr. Grace Nakato, a psychiatrist at a regional referral hospital in the east, says diazepam is her default option because chlordiazepoxide is simply not there. “I have not seen chlordiazepoxide in our pharmacy for at least two years,” she told me during a visit in late 2024. “When we order it, we are told it is not registered in Uganda. So we use diazepam. It is what we have.”

The WHO's Mental Health Gap Action Programme (mhGAP) guidelines, which Uganda officially adopted in 2019, specify chlordiazepoxide or lorazepam as first-line agents for alcohol withdrawal. These drugs have intermediate half-lives and are less likely to accumulate in patients with liver impairment, a common comorbidity in heavy drinkers. But the guidelines also acknowledge that local context matters, and that clinicians must work with available medicines.

Clinicians in Uganda say they have no real alternative. A 2023 survey of 45 health facilities in central and eastern regions found that 38 of them stocked diazepam, while only 3 had chlordiazepoxide. The rest relied on phenobarbital or simply observed patients without medication. “We know the guidelines say something else,” a senior nursing officer in Kampala told me. “But we cannot prescribe what is not on the shelf.”

The Evidence Gap: Why Chlordiazepoxide Is Preferred

The preference for chlordiazepoxide over diazepam is not arbitrary. Chlordiazepoxide has a half-life of roughly 6 to 28 hours, which allows for steady blood levels without excessive accumulation. Diazepam, by contrast, has a half-life of 20 to 50 hours and produces active metabolites that persist even longer. In patients with alcohol-related liver damage, diazepam clearance can be significantly delayed, raising the risk of excessive sedation and respiratory depression.

Studies from high-income settings have documented higher rates of falls and oversedation in patients treated with diazepam for withdrawal. A 2021 meta-analysis in the journal Addiction (Bahji et al., “Comparative efficacy and safety of benzodiazepines for alcohol withdrawal syndrome: A systematic review and meta-analysis,” Addiction, vol. 116, no. 12, pp. 3312–3324, 2021, doi:10.1111/add.15552) found that chlordiazepoxide was associated with fewer adverse events than diazepam, though both were effective at preventing seizures. The difference mattered most in older patients and those with liver disease, two groups common in Uganda's alcohol treatment population.

Uganda's essential medicines list includes diazepam as an option for alcohol withdrawal, but does not specify chlordiazepoxide. The list was last updated in 2022, and a Ministry of Health official involved in the revision acknowledged that the omission was an oversight. “We follow the WHO Essential Medicines List, and chlordiazepoxide is on it,” the official said, speaking on condition of anonymity because they were not authorized to discuss the matter publicly. “But the national list is a living document. We are working to align it.”

Training materials for nurses and medical officers in Uganda still reference older regimens that include diazepam. A 2020 curriculum review by the Ministry of Health found that most pre-service training programs taught diazepam as the first-line agent for withdrawal, reflecting what was available in practice. Updating those materials has been slow, held back by limited funding and competing priorities.

A Health System Caught Between Guidelines and Supply

Uganda's drug procurement system is centralized. The National Drug Authority purchases medicines through a tendering process that favors low-cost generics. Diazepam is inexpensive, produced by multiple manufacturers, and widely available. Chlordiazepoxide, while not costly by global standards, is less commonly manufactured and has not been registered for import by any Ugandan supplier. Private pharmacies rarely stock it because demand is low and the profit margin is thin.

“We have a classic chicken-and-egg problem,” said Dr. Samuel Okech, a pharmacist at a large hospital in Kampala. “Doctors do not prescribe it because it is not available, and suppliers do not import it because there is no prescription base. Breaking that cycle requires someone to take a risk on the supply side.”

The Ministry of Health has acknowledged the gap. In 2023, the ministry's Mental Health Division issued a circular reminding clinicians of the mhGAP recommendations and urging facilities to request chlordiazepoxide through the central supply system. But the circular had little effect. By early 2025, only a handful of facilities had successfully obtained the drug, and those that did reported that supplies lasted only a few weeks.

International donors have not prioritized alcohol treatment in Uganda. Most global mental health funding goes toward depression, psychosis, and epilepsy, leaving substance use disorders under-resourced. A 2024 analysis by the World Health Organization found that alcohol use disorders received less than 2 percent of mental health aid in sub-Saharan Africa, despite being among the leading causes of disability in the region.

The Human Cost of the Protocol Bypass

The reliance on diazepam carries real risks. At a detoxification unit in Kampala, a 2024 audit reviewed 120 admissions for alcohol withdrawal over six months. Twelve percent of patients experienced respiratory depression, defined as oxygen saturation below 90 percent or a respiratory rate under 10 breaths per minute. All had received diazepam, and most had received multiple doses within 24 hours. Two patients required transfer to intensive care. Further analysis of the audit data revealed that the median total diazepam dose among patients with respiratory depression was 40 mg over the first 24 hours, compared to 20 mg among those without complications. The audit also noted that 15 percent of patients experienced oversedation severe enough to require naloxone administration, though naloxone does not reverse benzodiazepine effects, indicating possible misdiagnosis or co-ingestants. These findings underscore the need for safer alternatives.

Withdrawal seizures still occur despite diazepam treatment. A 2022 study in the journal Substance Abuse Treatment, Prevention, and Policy (Nakimuli-Mpungu et al., “Prevalence and predictors of alcohol withdrawal seizures among patients admitted for detoxification in Uganda,” Substance Abuse Treatment, Prevention, and Policy, vol. 17, article 45, 2022, doi:10.1186/s13011-022-00474-8) found that among Ugandan patients treated with diazepam for withdrawal, roughly 8 percent experienced a seizure during the detox period, compared to 4 percent in settings where chlordiazepoxide was standard. The difference was not statistically significant in that small study, but it points to a trend that concerns clinicians.

Nurses on the front line report frustration. “We know the guidelines say chlordiazepoxide is safer,” said Sister Mary Auma, a nurse at a rural health center in the east. “But when a patient is shaking and hallucinating, I cannot wait for a drug that may never come. I use diazepam and I pray it works.”

Workarounds and Innovation at the Frontline

Some clinicians have developed their own solutions. At a hospital in Masaka, a pilot program trains nurses to use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) protocol, a standardized tool that guides symptom-triggered dosing of benzodiazepines. But the CIWA-Ar requires regular monitoring and a quiet environment, both of which are scarce in busy Ugandan wards. The pilot has shown promise, with fewer over-sedation events, but it has not been scaled.

Other facilities have turned to phenobarbital, a barbiturate that is also used for epilepsy. Phenobarbital is cheap and widely available in Uganda, but it has a narrow therapeutic window and a high risk of respiratory depression, especially when combined with alcohol. Some clinicians use it as a second-line agent when diazepam fails, but they acknowledge it is not an ideal substitute.

In the absence of preferred drugs, many nurses manually taper diazepam doses over several days, mimicking the pharmacokinetics of chlordiazepoxide. They start with a higher dose and reduce it by roughly 20 percent each day, monitoring for signs of withdrawal. This approach is not standardized and depends heavily on individual clinical judgment. “We are all doing our own thing,” one nurse told me. “There is no protocol for the protocol we do not have.”

Peer-support groups for alcohol dependence have grown in Uganda, particularly in urban areas. Groups like Alcoholics Anonymous and locally-run recovery networks help reduce the burden on the health system by providing non-pharmacological support. But for acute withdrawal, medication is still essential, and the gap in evidence-based pharmacotherapy remains.

What Closing the Gap Would Require

Fixing the problem would require several coordinated actions. First, chlordiazepoxide must be added to Uganda's essential medicines list and registered for import. The Ministry of Health has said it is working on this, but the timeline is uncertain. Second, training curricula for nurses and medical officers need to be updated to reflect current WHO guidelines, with an emphasis on symptom-triggered dosing rather than fixed regimens.

Supply chain reform is also needed. The National Drug Authority could include chlordiazepoxide in its centralized procurement, ensuring that facilities can order it alongside other essential medicines. A 2024 analysis by the Ugandan nonprofit Health Access Initiative estimated that adding chlordiazepoxide to the national procurement list would cost roughly US$ 50,000 per year, a fraction of the mental health budget.

Expanding access to dedicated detoxification units would help. Currently, Uganda has fewer than 10 specialized detox beds for a population of over 45 million, most of them in Kampala. Most patients are managed in general medical wards or outpatient clinics, where monitoring is limited. Building capacity for alcohol detoxification would require investment in both infrastructure and training.

Integrating mental health into primary care supervision is a broader goal that Uganda has pursued under the mhGAP framework. But supervision visits rarely cover substance use disorders, and district health officers often lack expertise in addiction medicine. Strengthening that link could help ensure that protocols are followed even when preferred drugs are unavailable.

The Bigger Picture: Evidence Translation in Resource-Limited Settings

Uganda is not alone in this predicament. Similar patterns have been documented in Kenya and Tanzania, where diazepam is commonly used for alcohol withdrawal despite guidelines recommending chlordiazepoxide. A 2023 survey in five East African countries (the “East African Alcohol Withdrawal Treatment Survey,” led by Dr. Fredrick Otieno of the University of Nairobi) found that fewer than 15 percent of facilities had chlordiazepoxide in stock, while over 80 percent had diazepam. The gap is a regional one, rooted in shared procurement systems and historical prescribing habits.

The WHO's mhGAP program has been rolled out unevenly across Africa. A 2025 evaluation by the London School of Hygiene and Tropical Medicine (Eaton et al., “Implementation of the mhGAP programme in sub-Saharan Africa: A mixed-methods evaluation,” PLOS Global Public Health, in press) found that while many countries had adopted the guidelines, implementation was patchy. In Uganda, training had reached roughly 40 percent of health facilities by 2024, but follow-up support was minimal. Clinicians often reverted to familiar practices after training ended.

Global health donors have historically focused on infectious diseases like HIV, tuberculosis, and malaria, leaving mental health and substance use underfunded. Alcohol use disorders are particularly neglected, perhaps because they carry stigma or because effective treatment is seen as complex. The result is that clinicians in low-resource settings are left to improvise with whatever drugs are on the shelf.

Bridging the gap between evidence and practice requires more than updated guidelines. It requires a functioning supply chain, trained staff, and a system that can adapt to local realities. Until then, Ugandan health workers will continue to reach for diazepam, knowing it is not the best option, but also knowing that in the absence of something better, it is the option they have.

Note: This article is for informational purposes only and does not constitute medical advice. Individuals seeking treatment for alcohol use disorder should consult a qualified health professional.