Assisted alcohol withdrawal

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1 A NICE pathway brings together all NICE guidance, quality standards and materials to support implementation on a specific topic area. The pathways are interactive and designed to be used online. This pdf version gives you a single pathway diagram and uses numbering to link the boxes in the diagram to the associated recommendations. To view the online version of this pathway visit: Pathway last updated: 21 July To see details of any updates to this pathway since its launch, visit: About this Pathway. For information on the NICE guidance used to create this path, see: Sources. All rights reserved NICEPathways

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3 1 Person who drinks more than 15 units of alcohol per day or scores 20 or more on AUDIT No additional information 2 Assessment Consider offering: assessment for and delivery of a community-based assisted withdrawal, or assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal. Quality standards The following quality statement is relevant to this part of the pathway. Alcohol dependence and harmful alcohol use quality standard 8. Medically assisted alcohol withdrawal setting Resources The following implementation tools are relevant to this part of the pathway. Alcohol dependence: baseline assessment tool Alcohol dependence: audit support Alcohol dependence: costing report Alcohol dependence: costing template Alcohol dependence: slide set Page 3 of 20

4 3 Community-based assisted withdrawal Service users who need assisted withdrawal should usually be offered a community-based programme vary in intensity according to the severity of the dependence, available social support and comorbidities. Offer an outpatient-based programme for people with mild to moderate dependence in which contact between staff and the service user averages 2 4 meetings per week over the first week. Outpatient-based community assisted withdrawal programmes should consist of a drug regimen (see drug regimens for assisted withdrawal) and psychosocial support including motivational interviewing. Quality standards The following quality statement is relevant to this part of the pathway. Alcohol dependence and harmful alcohol use quality standard 8. Medically assisted alcohol withdrawal setting 4 Inpatient and residential withdrawal Consider inpatient or residential assisted withdrawal if a service user meets one or more of the following criteria. They: drink over 30 units of alcohol per day have a score of more than 30 on the SADQ have a history of epilepsy or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes need concurrent withdrawal from alcohol and benzodiazepines regularly drink between 15 and 30 units of alcohol per day and have: significant psychiatric or physical comorbidities (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or a significant learning disability or cognitive impairment. Page 4 of 20

5 Consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups, for example, homeless and older people. See also special considerations for children and young people aged years and acute alcohol withdrawal. Quality standards The following quality statement is relevant to this part of the pathway. Alcohol dependence and harmful alcohol use quality standard 8. Medically assisted alcohol withdrawal setting 5 Intensive community programmes After assisted withdrawal for severe dependence or mild to moderate dependence with complex needs, offer an intensive community programme in which the service user may attend a day programme lasting between 4 and 7 days per week over a 3-week period. Intensive community programmes should consist of a drug regimen (see the drug regimens for assisted withdrawal) supported by psychological interventions including individual treatments (see interventions for moderate and severe alcohol dependence after successful withdrawal), group treatments, psychoeducational interventions, help to attend self-help groups, family and carer support and involvement, and case management (see care coordination and case management). Quality standards The following quality statement is relevant to this part of the pathway. Alcohol dependence and harmful alcohol use quality standard 8. Medically assisted alcohol withdrawal setting Page 5 of 20

6 6 Drug regimens for assisted withdrawal Staff responsible for managing assisted alcohol withdrawal should be competent in using drug regimens appropriate to the setting. Prescribe and administer medication for assisted withdrawal within a standard clinical protocol. Use a benzodiazepine (chlordiazepoxide or diazepam) as the preferred medication. Consider using a formal measure of withdrawal symptoms such as the CIWA Ar, particularly for people who are more severely alcohol dependent or those having a symptom-triggered regimen 1. Be aware that benzodiazepine doses may need to be reduced for children and young people 2 (see also 'Use of off-label drugs for children and young people' below), older people, and people with liver impairment. If benzodiazepines are used for people with liver impairment, consider one needing limited liver metabolism (for example, lorazepam), start with a reduced dose and monitor liver function carefully. Avoid using benzodiazepines for people with severe liver impairment. Assisted withdrawal in the community Use fixed-dose medication regimens 3. Monitor the service user every other day. A family member or carer should preferably oversee the administration of medication. Adjust the dose if severe withdrawal symptoms or over-sedation occur. Avoid giving people large quantities of medication to take home to prevent overdose or diversion. Prescribe for installment dispensing, with no more than 2 days' medication supplied at any time. Do not offer clomethiazole because of the risk of overdose and misuse. Page 6 of 20

7 1 A symptom-triggered approach involves tailoring the drug regimen according to the severity of withdrawal and any complications. The service user is monitored on a regular basis and pharmacotherapy only continues as long as there are withdrawal symptoms. 2 At the time this pathway was created (May 2011), benzodiazepines did not have UK marketing authorisation for use in children and young people under 18. Informed consent should be obtained and documented. 3 A fixed-dose regimen involves starting treatment with a standard dose, not defined by the level of alcohol withdrawal, and reducing the dose to zero over 7 10 days according to a standard protocol. Page 7 of 20

8 Assisted withdrawal in inpatient or residential settings Fixed-dose or symptom-triggered medication regimens can be used. If a symptom-triggered regimen is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely. Using fixed-dose regimens Titrate the initial dose to the severity of alcohol dependence and/or regular daily level of alcohol consumption. In severe alcohol dependence higher doses will be required to adequately control withdrawal and should be prescribed according to the summary of product characteristics (SPC). Make sure there is adequate supervision if high doses are administered. Gradually reduce the dose of the benzodiazepine over 7 10 days to avoid alcohol withdrawal recurring. Co-existing benzodiazepine and alcohol dependence Increase the dose of benzodiazepine used for withdrawal. Calculate the initial daily dose based on the requirements for alcohol withdrawal plus the equivalent regularly used daily dose of benzodiazepine 1. This is best managed with one benzodiazepine (chlordiazepoxide or diazepam) rather than multiple benzodiazepines. Inpatient regimens should last for 2 3 weeks or longer, depending on the severity of co-existing benzodiazepine dependence. Withdrawal managed in the community and/or in people with a high level of benzodiazepine dependence should last for longer than 3 weeks, and be tailored to the person's symptoms and discomfort. 1 At the time this pathway was created (May 2011), benzodiazepines did not have UK marketing authorisation for this indication, or for use in children and young people under 18. Informed consent should be obtained and documented. This should be done in line with normal standards of care for patients who may lack capacity (see the Page 8 of 20

9 Department of Health's advice on consent or or in line with normal standards in emergency care. Page 9 of 20

10 Unplanned acute alcohol withdrawal and complications of withdrawal For managing unplanned acute alcohol withdrawal, and complications including delirium tremens and withdrawal-related seizures, see acute alcohol withdrawal. Use of off-label drugs for children and young people At the time this pathway was created, no drugs recommended for the treatment of harmful drinking or alcohol dependence had a UK marketing authorisation for use in children and young people under the age of 18. However, in 2000, the Royal College of Paediatrics and Child Health issued a policy statement on the use of unlicensed medicines, or the use of licensed medicines for unlicensed applications, in children and young people. This states that such use is necessary in paediatric practice and that doctors are legally allowed to prescribe unlicensed medicines where there are no suitable alternatives and where the use is justified by a responsible body of professional opinion. Quality standards The following quality statement is relevant to this part of the pathway. Alcohol dependence and harmful alcohol use quality standard 9. Medically assisted alcohol withdrawal drug regimens Resources The following implementation tool is relevant to this part of the pathway. Alcohol dependence: sample chlordiazepoxide dosing regimens for use in managing alcohol withdrawal 7 Interventions for moderate and severe dependence after successful withdrawal See Alcohol-use disorders / Interventions for harmful drinking and alcohol dependence / Interventions for moderate and severe dependence after successful withdrawal 8 Page 10 of 20

11 Special considerations for children and young people aged years See Alcohol-use disorders / Special considerations for children and young people with alcoholuse disorders Page 11 of 20

12 Glossary Acute alcohol withdrawal The physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time. Alcohol dependence A cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. For further information please refer to: 'Diagnostic and statistical manual of mental disorders' (DSM-IV) (American Psychiatric Association 2000) and 'International statistical classification of diseases and related health problems 10th revision' (ICD-10) (World Health Organization 2007). Alcohol misuse Used in this pathway to refer to harmful drinking and alcohol dependence. Alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as 'alcohol-specific'. If it is only partly caused by alcohol it is described as 'alcohol-attributable'. CI Confidence interval. There is always some uncertainty in research. This is because a small group of people is studied to predict the effects of an intervention on the wider population. The confidence interval is a way of expressing how certain we are about the findings from a study, using statistics. It gives a range of results that is likely to include the 'true' value for the population. The CI is usually stated as '95% CI', which means that the range of values has a 95 in a 100 chance of including the 'true' value. For example, a study may state that 'based on our sample Page 12 of 20

13 findings, we are 95% certain that the 'true' population blood pressure is not higher than 150 and not lower than 110'. In such a case the 95% CI would be 110 to 150. A wide confidence interval indicates a lack of certainty about the true effect of the test or treatment often because a small group of patients has been studied. A narrow confidence interval indicates a more precise estimate (for example, if a large number of patients have been studied). Alcohol-use disorders Alcohol-use disorders cover a wide range of mental health problems as recognised within the international disease classification systems (ICD-10, DSM-IV). These include hazardous and harmful drinking and alcohol dependence. See 'Harmful' and 'Hazardous' drinking and 'Alcohol dependence'. APQ Alcohol Problems Questionnaire AUDIT AUDIT is an alcohol screening test designed to see if people are drinking harmful or hazardous amounts of alcohol. It can also be used to identify people who warrant further diagnostic tests for alcohol dependence. ES Effect size. A measure that shows the magnitude of the outcome in one group compared with that in a control group. For example, if the absolute risk reduction is shown to be 5% and it is the outcome of interest, the effect size is 5%. The effect size is usually tested, using statistics, to find out how likely it is that the effect is a result of the treatment and has not just happened by chance (that is, to see if it is statistically significant). Page 13 of 20

14 Brief interventions This can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention see also below). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists. CIWA Ar The Clinical Institute Withdrawal Assessment Alcohol, revised (CIWA Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of the alcohol withdrawal syndrome, and to monitor and medicate patients throughout withdrawal. i NICE analysts have calculated this figure using data from the original study. Coeliac axis block Pain relief by nerve block of the coeliac plexus. ICER Incremental cost effectiveness ratio. A measure of the cost effectiveness of a treatment or health intervention. It estimates how much more the benefits of a certain treatment cost, compared with other treatments or health interventions. Decompensated liver disease Liver disease complicated by the development of jaundice, ascites, bruising or abnormal bleeding and/or hepatic encephalopathy. NNT Number needed to treat. The average number of people who need to receive an intervention to get a positive outcome. For example, if the NNT is four, then 4 people would have to receive the intervention to ensure one of them gets better. The closer the NNT is to one, the better the intervention. However, as with most data, caution is needed when considering whether results apply to populations beyond the sample described in the original study. Page 14 of 20

15 Extended brief interventions This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. OR Odds ratio. Odds are a way to represent how likely it is that something will happen (the probability). An odds ratio compares the probability of something in one group with the probability of the same thing in another. An odds ratio of 1 between two groups would show that the probability of the event (for example a person developing a disease, or an intervention working) is the same for both. Sometimes probability can be compared across more than two groups in this case, one of the groups is chosen as the 'reference category', and the odds ratio is calculated for each group compared with the reference category. For example, to compare the risk of dying from lung cancer for non-smokers, occasional smokers and regular smokers, non-smokers could be used as the reference category. Odds ratios would be worked out for occasional smokers compared with non-smokers and for regular smokers compared with non-smokers. FRAMES FRAMES is an acronym summarising the components of a brief intervention. Feedback (on the client's risk of having alcohol problems), responsibility (change is the client's responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change). Harmful drinking A pattern of alcohol consumption that is causing mental or physical damage. Hazardous drinking A pattern of alcohol consumption that increases someone's risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would Page 15 of 20

16 include the social consequences. The term is currently used by WHO to describe this pattern of alcohol consumption. It is not a diagnostic term. QALY Quality-adjusted life year. A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health. QALYS are calculated by estimating the years of life remaining for a person following a particular treatment or intervention and weighting each year with a quality of life score (on a zero to one scale). It is often measured in terms of the person's ability to perform the activities of daily life, freedom from pain and mental disturbance. LDQ Leeds Dependence Questionnaire RCT Randomised controlled trial. A study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or intervention. One group (the experimental group) receives the intervention being tested, the other (the comparison or control group) receives an alternative intervention, a dummy intervention (placebo) or no intervention at all. The groups are followed up to see how effective the experimental intervention was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias. Looked-after children The term 'looked after' has a specific legal meaning. It refers to children and young people who are provided with accommodation on a voluntary basis for more than 24 hours. This compares with the term 'in care' which refers to those who are compulsorily removed from home and placed in care under a court order. Lower-risk drinking Regularly consuming 21 units per week or less (adult men) or 14 units per week or less (adult women). It is also known as 'sensible' or 'responsible' drinking. Page 16 of 20

17 SD Standard deviation. A measure used to summarise numerical data and describe how 'spread out' a set of measures (or 'values') are from the average. For example, the average height of a group of schoolchildren can be calculated using the total of all their heights added together and then divided by the number of schoolchildren in the group. Standard deviation measures the 'spread' of those heights. So, in the example it tells you whether all those in the group were about the same height or whether some were very tall and some were short. Medically assisted alcohol withdrawal The deliberate withdrawal from alcohol by a dependent drinker under the supervision of medical staff. Prescribed medication may be needed to relieve the symptoms. It can be carried out at home, in the community or in a hospital or other inpatient facility. Mild alcohol dependence A score of 15 or less on the Severity of Alcohol Dependence Questionnaire (SADQ). MMSE Mini-Mental State Examination Moderate alcohol dependence A score of on the Severity of Alcohol Dependence Questionnaire (SADQ). Responsible authorities Responsible authorities have to be notified of all licence variations and new applications and can make representations regarding them. The Licensing Act 2003 lists responsible authorities. They include the police, environmental health, child protection service, fire and rescue and trading standards. SADQ Severity of Alcohol Dependence Questionnaire Page 17 of 20

18 Saturated In relation to licensed premises, this describes a specific geographical area where there are already a lot of premises selling alcohol and where the awarding of any new licences to sell alcohol may contribute to an increase in alcohol-related disorder. Screening For the purposes of this pathway, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. The term is not used here to refer to national screening programmes such as those recommended by the UK National Screening Committee (UK NSC). Severe alcohol dependence A score of 31 or more on the Severity of Alcohol Dependence Questionnaire (SADQ). SPC Summary of product characteristics Splanchnicectomy Surgical division of the splanchnic nerves and coeliac ganglion. Structured brief advice A brief intervention that takes only a few minutes to deliver. Treatment A programme designed to reduce alcohol consumption or any related problems. It could involve a combination of counselling and medicinal solutions. Unit In the UK, alcoholic drinks are measured in units. Each unit corresponds to approximately 8 g or 10 ml of ethanol. The same volume of similar types of alcohol (for example, 2 pints of lager) can Page 18 of 20

19 comprise a different number of units depending on the drink's strength (that is, its percentage concentration of alcohol). Schools For the purposes of this pathway, schools include: state-sector, special and independent primary and secondary schools; city technology colleges, academies and grammar schools; pupil referral units, secure training and local authority secure units; and further education colleges. Sources Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) NICE guideline CG115 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Page 19 of 20

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