CALDERDALE ALCOHOL TEAM & Calderdale Substance Misuse Service COMMUNITY ALCOHOL DETOXIFICATION GUIDELINE

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1 CALDERDALE ALCOHOL TEAM & Calderdale Substance Misuse Service COMMUNITY ALCOHOL DETOXIFICATION GUIDELINE Unique Identifier Number: Approved By: NYA Effective From July 2010 Review Date: July 2012 Review Lead: Dr S Harris

2 CONTENTS Purpose of guidance...page 3 Consultation process..page 3 Aims of community alcohol detoxification Page 3 Scope of Document...Page 3 Knowledge, skills and competence...page 3 Clinical Risks.Page 4 Consent to detoxification.page 6 Health & Safety aspects..page 6 Record keeping.page 6 Equipment to be used..page 6 Protocol for alcohol detoxification...page 7 2

3 PURPOSE OF THIS GUIDANCE The purpose of this document is twofold: To ensure consistency in clinical practice across SMS teams To ensure effective liaison and partnership working with Calderdale GPs with respect to community alcohol detoxification CONSULTATION PROCESS CSMS alcohol worker and nurses involved in initial phase of consultation All frontline SMS staff involved in second phase of consultation Calderdale LMC, local consultant psychiatrist and CSMS doctors involved in 3 rd phase of consultation Relevant SIGN (No 74) and NICE (CG 100) guidance used to inform this guideline AIMS OF COMMUNITY ALCOHOL DETOXIFICATION The principle aims of community alcohol detoxification are: To allow patients who are dependent on alcohol to stop drinking safely To allow patients to stay in their own homes so long as it is safe to do so SCOPE OF DOCUMENT Staff Groups: Calderdale Substance Misuse Service frontline clinical staff (including volunteers and students on placement) Local Calderdale GPs Client Group: Clients who are dependent on alcohol and wish to stop drinking and who meet all the inclusion criteria and who do not fall into the exclusion criteria (see below) 3

4 KNOWLEDGE, SKILLS AND COMPETENCE Core Skills Assessment of patterns of alcohol and substance misuse and degree of dependence/withdrawal problems using CIWA-Ar tool Assessment of physical problems, particularly Wernicke s encephalopathy and Delerium Tremens Assessment of social problems. Assessment of treatment history Determination of individual s expectation of treatment and their degree of motivation for change. Understanding of mental health problems and the relationship between these and substance and alcohol misuse and dependence. Assessment of carer involvement and need. Consideration of any likely interaction between medication and other substances. Assessment of knowledge of harm minimisation in relation to alcohol and substance misuse. The need for, and understanding of, pharmacological treatment for alcohol dependence and detoxification. An understanding of risk assessment and risk management will be required using the (Sainsbury s risk assessment tool) This will include social exclusion, criminality, violence, suicidality and physical health (E.g. Liver damage/disease, Hepatitis B & C and HIV infection). Confidence in challenging and negotiating and managing difficult situations. Awareness of the lone working policy and that staff safety should be maintained at all times, This is the responsibility of all staff. 4

5 CLINICAL RISKS Grand mal seizure Alcohol withdrawal can lead to grand mal fits, which may occasionally be fatal Delirium tremens Alcohol withdrawal can lead to delirium tremens (DTs) which makes patients vulnerable and a potential danger to themselves. Overdose Taking alcohol and benzodiazepines together in large doses can lead to fatal overdose Wernicke s encephalopathy Alcohol withdrawal in the presence of thiamine deficiency can lead to Wernicke s encephalopathy, which is reversible if it is caught in time. Kindling Grand mal fits in withdrawal can cause the kindling effect: alcohol withdrawals are more likely to be complicated by fitting in future Anaphylaxis Intramusucular high-potency vitamin B complex injections (Pabrinex) carry a risk of anaphylaxis (thought to be low, of the order of 1 in 5 million) Risk reduction measures: There should be someone at home who is able to monitor and supervise the withdrawal process. This should ideally be over a full hour period. In situations where the supporter cannot be present full-time, there should be high level of home supervision. Patient to be seen on daily basis for the five days of the community detoxification. Worker competent to assess severity of withdrawal symptoms and use the recommended assessment tool CIWA-Ar to rate these. Patient must be seen by a worker competent to assess for onset of Wernicke s encephalopathy daily for the first five days if suspected, patient must be admitted to medical ward immediately. If at all possible family/carer (or very occasionally a trustworthy friend) should hold the patient s medication, and administer daily supplies. In practice, most patients agree to this readily (although they have a right to refuse) and those that do not can be given daily scripts. Benzodiazepines should be stopped immediately if the patient relapses 5

6 Patients should be given high-dose thiamine as part of pre-detox package (ideally all those with alcohol problems should have thiamine supplements indefinitely) Staff to undertake basic observations i.e Blood pressure, Pulse, CONSENT TO ALCOHOL DETOXIFICATION Refer to Calderdale Primary Care Trust Consent Policy (2005) Ensure clinical contract has been agreed and signed with the client HEALTH AND SAFETY ASPECTS See above RECORD KEEPING Staff should record all interventions on client s history sheet in accordance with NMC Record Keeping guidance (2009) Copies of all correspondence and prescriptions should be filed in the patient s records and clearly documented. EQUIPMENT TO BE USED Alcometer Sphygmomanometer Stethoscope 6

7 PROTOCOL FOR ALCOHOL DETOXIFICATION Patient inclusion criteria: Not had detoxification for at least 12 months. (If Practitioners wish to undertake detoxification sooner than this, they must make a clearly documented clinical judgement about this regarding risks/benefits). Regular heavy drinker (usually >15 units a day for men, >10 units a day for women) who has recently needed to drink to prevent withdrawal symptoms Carer available and willing to stay with them first 48 hours and they have continued support for at least the first 3-5 days. Patient agrees to be visited/contacted by health worker for 5 days Patient agrees to being breathalysed if necessary Exclusion criteria Any history of fits, seizures or epilepsy Patient on regular benzodiazepines (bz s) already (If taking occasional bz s needs to stop for at least a week, and provide bz-free urine test) Any history of delirium tremens Current confusion or hallucinations, increased suicide risk or other major psychiatric illness Any acute physical illness such as pancreatitis, severe liver disease, peripheral neuropathy, active GI bleeding, Wernicke s encephalopathy, severe vomiting or diarrhoea Severe malnourishment (increased risk of Wernicke s encephalopathy Patients who are excluded from community detox need to be referred for inpatient detox. Medication may not be necessary if: The patient reports consumption is less than 15 units/day in men/10 units a day in women, and reports neither recent withdrawal symptoms nor recent drinking to prevent withdrawal symptoms The patient has no alcohol on breath test, and no withdrawal signs or symptoms In this case advise patient they may feel nervous or anxious and have trouble sleeping for 3-5 days Staffing criteria Keyworker supports idea of patient going for alcohol detox at this time 7

8 Sufficient staffing to allow daily visits for 5 days and more if necessary if client is alcohol only all visits are undertaken by alcohol detox worker only, if also in drug treatment, usually alcohol detox worker and keyworker will alternate, former visits days 1,3,5, latter days 2 and 4. Clients are required to continue attending keyworking sessions at SMS for relapse prevention with their original keyworker. Preparation for treatment Advise patient detox can take up to10 days in total Ensure patient aware of need for high dose thiamine for 3 days prior to detox Plan date for detoxification to start on a Monday, on a week when both alcohol worker and carer will be available, (for opiate clients who are receiving an alcohol detox, usual keyworker also needs to be available) Give full information on and agree aftercare, including; Keyworking arrangements post-detox Structured daycare, progress to work support Post-detox group support eg at School House, Basement Mutual aid support, eg Alcoholics anonymous Relapse prevention treatments, eg acamprosate, naltrexone, disulfiram Request advance prescription from usual GP this should be IN WRITING, if possible, or by telephone if not. Patients should never be sent directly to the GP without prior communication. If GP refuses, or if patient has no GP, request CAT doctor or Nurse prescriber to prescribe (but NB issues with clinical time) Management of patients who present to GP in acute withdrawal requesting symptomatic relief 1. Assess severity of withdrawals If in Delirium Tremens, (DTs) or there are signs of Wernicke s encephalopathy, admit immediately 2. Assess motivation: Does the patient want to carry on with detox or are they considering going back to drinking at this stage? 3. Assess exclusion criteria: If withdrawals appear less severe, and patient wants to continue with detox, assess for exclusion criteria for home detox. (see above). 4. Ensure patient meets inclusion criteria. If no exclusion criteria, are present, assess inclusion criteria. In practice, the need for a carer can often be a limiting factor. The patient should be advised that community detox is not possible at this time. Refer to CAT worker to arrange appropriate detox. 8

9 If exclusion criteria are present, or if patient does not meet all inclusion criteria, they should be advised that community detox is not possible at this time. Advise them that it is unsafe to continue withdrawals and that a temporary return to drinking at the lowest level they can manage may be safer for them at this stage. Be careful how you put this - it is unwise to be seen to be actively encouraging the patient to drink, this is usually remembered as unhelpful later on. Refer to CAT for onward referral for inpatient detox. 5. If patient meets all inclusion criteria, home detox at this time is possible if staffing allows. They should be seen at regular intervals (preferably daily) by a competent health professional for the first five days, following the protocol set out below. This could be a GP or other member of the primary healthcare team, or a competent drugs worker. DO NOT GIVE PRESCRIPTION UNTIL ARRANGEMENTS FOR REGULAR REVIEW HAVE BEEN FULLY AGREED. CONSIDER ISSUING MEDICATION IN ONE OR TWO DAY AMOUNTS. Drugs for management of pre-detoxification period Ideally at least one week s worth of the following: Thiamine 100mg tds Vitamin B Co forte 2 tablets tds Ascorbic acid 100mg tds NB for patients in whom established nutritional compromise is present, either on history (anorexia, poor diet, weight loss) or examination (emaciation, muscle wasting, angular stomatitis) it may be necessary to refer to A&E for high potency B vitamin complex (Pabrinex) and on the wards this should be given daily for 5 days BUT, NB can cause anaphylaxis and large volume injection (7mls) may be painful Drugs for management of alcohol withdrawal period: o Chlordiazepoxide 5mg capsules x 160, or 10mg x 80 o Thiamine at least 300mg daily (as 100mg tds) o Vitamin B Co forte 2 tablets tds o Ascorbic acid 100mg tds In addition, if problems with insomnia persist during detoxification add o Zopiclone 7.5 mg 1-2 at night for 7 nights maximum (In practice this is very rarely needed) Further adjunctive medication for diarrhoea and vomiting can be given as follows: o Metoclopramide 10mg tds for vomiting o Lomotil 4 tabs stat then 2 every 6hours until diarrhoea controlled Drugs for relapse prevention o Refer to separate protocol on pharmacological interventions for relapse prevention. The drugs used are: 9

10 Acamprosate Disulfiram Naltrexone o These drugs may be prescribed in advance by the CAT doctor to be commenced once detoxification is complete. It is essential that the patient is fully informed, understands and accepts the risks involved. o The GP may be asked to initiate acamprosate prescribing, for patients who are immediately post-detox. They should NOT be asked to initiate disulfiram or naltrexone prescribing, these treatments should always be initiated by a CAT doctor. Keyworker/alcohol worker to hold the medication and take it to the client on a daily basis for the 1 st 5 days. Treatment plan Visit daily Monitor withdrawal signs and symptoms using CIWA-Ar chart. The keyworker maintains this chart when in it their turn to visit and report any large discrepancies from the previous day. Encourage the patient to assess own symptoms around 4 hours after last seen to check if as required dose of chlordiazepoxide is needed, Advise re chlordiazepoxide dosing according to severity of withdrawals, and leave patient with medication to cover the next 24 hours, with clear written instructions Breathalyse if there are signs suspicious of relapse Typical chlordiazepoxide treatment regime NB this is only a guide, doses should be titrated according to withdrawal severity Table 1. Reducing dose of chlordiazepoxide over 7 days. First 12 noon 6 pm Bedtime thing Day mg mg mg mg Day mg mg mg mg Day mg mg mg mg Day mg mg mg mg Day 5 10 mg 10 mg 10 mg mg Day 6 10 mg mg Day mg (Adapted from DH guidance) Total capsules = 94 x 5mg, or 46 x 10mg. (In practice prescribe 120 x 5mg or 60 x 10mg, to leave an emergency dose for patient, to be given under clear instructions: To leave at least 4 hours between doses 10

11 Not to be taken if started drinking again, or if used sedating drugs eg heroin, methadone or non-prescribed bz s. There are usually a few capsules left over which can be used to taper down over next few days. Many patients are well-suited by finishing the detoxification with 4 days of 5mg chlordiazepoxide daily. Daily visits from Monday to Friday, leave Friday, Saturday and Sunday s medication with patient on Friday. Contact following Monday either by patient coming in (for further rx) or by phone (if rx not needed). After initial 5 day period patients should be encouraged to continue medication for a further month as follows: Thiamine 100mg tds Vit B co strong 2 tabs tds Management of complications during alcohol detoxification For advice, carers should contact SMS in working hours, and speak to duty keyworker. Contact NHS direct out of hours Fits: - Carer to ensure patient taken to A&E immediately - no need for prior advice Wernicke s: - Diagnosis of Wernicke s encephalopathy clinicians should have a high index of suspicion because the classic triad of ophthalmoplegia, ataxia and confusion is rarely present a presumptive diagnosis should be made if the patient experiences any of the following: o Severe confusion (may appear drunk) not responding to chlordiazepoxide alone in adequate doses o Ataxia o Ophthalmoplegia / nystagmus (esp. ophlamoplegia on upward gaze and/or rotatory nystagmus) o Hypothermia and hypotension o Memory disturbance o Coma/unconsciousness Patient should be admitted immediately to hospital medical ward for iv B vitamins (Pabrinex) Relapse:- stop the medication immediately or as soon as possible. Aftercare Patient should continue to see alcohol worker 2-weekly if alcohol-only problems, until deemed fit for discharge back to GP Patients should see OWN keyworker if coexisting drug misuse problem, until deemed fit for discharge back to GP 11

12 Relapse prevention medication will normally be initiated by SMS doctor, and may be continued by GP in certain circumstances (see separate protocol) Letter to GP upon discharge 12

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