Trust Guideline for the Management of: Acute Alcohol withdrawal (excluding pregnancy)

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1 A clinical guideline recommended for use In: By: For: Key words: Written by: Supported by: Medical and Surgical Wards All Medical Staff Adult Alcohol dependent patients Alcohol, Withdrawal, Detoxification Dr. Hayley Pinto, Consultant Psychiatrist TADS Mr J Harris, Pharmacy Team Dr. A Wagle, Consultant Psychiatrist, Lead Clincian TADS Approved by: Dr N Pinto March 2014 Chair of Clinical Guidelines Assessment Panel (CGAP) 04 March 2014 and reported to 19 March 2014 meeting Reported as approved to the: Clinical Standards Group Effectiveness Executive Sub-Board Date of approval March 2014 To be reviewed before: March 2017 To be reviewed by: Trust Alcohol And Drug Service (TADS) Guideline supersedes: CA2074v2 Guideline Reg. No: CA2074v3.1 This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Copy of complete document available from: Trust Intranet Page 1 of 18

2 MANAGEMENT ALGORITHM FOR THE ACUTE MANAGEMENT OF ALCOHOL WITHDRAWAL SYNDROME ON MEDICAL AND SURGICAL WARDS For the use of all Medical Staff Suspicion of Heavy Drinking or Signs of Alcohol Withdrawal? YES TAKE AN ALCOHOL HISTORY Current daily intake (No. of units ~ %alcohol in 1 Litre e.g. 500ml can of 8% lager = 4 units) Pattern of drinking and experience of withdrawals e.g. morning shakes, sweats, vomiting Length of history Any previous complications of withdrawal DTs, fits, Wernicke s encephalopathy? Check Bloods :- Check LFT, Clotting, U+E, Mg2+ and FBC, MCV Monitor closely - consider mg chlordiazepoxide QDS PRN NO Probable alcohol dependence Exhibiting withdrawal symptoms? Y YES Refer to Substance Misuse Liaison Nurse, Ext. 4874, Bleep 0439 Prescribe Pabrinex 1 pair ampoules IV od for 3 days. Increase to bd for 5 days if at high risk of Wernicke s Encephalopathy. Increase to 2 pairs tds IV (30min infusion) if symptoms of Wernicke s Encephalopathy (confusion, ocular abnormalities, ataxia) Elderly, liver failure or risk of respiratory depression? NO YES Substitute oxazepam for chlordiazepoxide at the same dose but monitor closely for breakthrough withdrawal symptoms PRESCRIBE CHLORDIAZEPOXIDE reducing daily according to schedule below Doses to be given at 08:00; 12:00; 18:00and 24:00. Choose start point on basis of predicted severity of withdrawals (1= mild - 3 severe). Review over first 24 hours and adjust if necessary. PRN doses up to 20mg qds should be available for first 72 hours. Doses above 200mg / day may be required if significant symptoms of withdrawal or signs suggestive of DTs at this dose seek senior review. Observe for over sedation. Day Schedule 1 Schedule 2 Schedule 3 (mg) (mg) (mg) Alcohol Withdrawal Symptoms Anxiety/agitation Tachycardia Sweating Systolic hypertension Tremor Symptoms of DTs Profuse sweating Impaired attention Severe tremor Disorientation Tachypnoea Paranoid ideas Insomnia Marked anxiety Marked systolic hypertension Reversal of sleep pattern Hallucinations/confusion Copy of complete document available from: Trust Intranet Page 2 of 18

3 Objective of Guideline To assist in the assessment and treatment of patients with alcohol dependency during an acute admission on a medical or surgical ward. To minimise the risk of patients experiencing complications of acute alcohol withdrawal. Goals To minimize morbidity and mortality and maximize treatment quality through: recognition of alcohol misuse in hospital in-patients; identification of sub-groups with, or at risk of, potentially life-threatening complications; prompt initiation of appropriate medical management to eliminate physiological dependence without allowing the development of withdrawal symptoms. Rationale for the recommendations This guideline has been developed to improve appropriate care and treatment of this specific patient group and is based on a review of current literature. Broad recommendations Recognition and Assessment Alcohol withdrawal can be associated with significant morbidity and even mortality if improperly managed. A major concern is to prevent development of delirium tremens (DTs), seizures or Wernicke s encephalopathy Alcohol withdrawal may be the presenting feature or may occur as an unexplained development in a patient who has been admitted for other reasons. The symptoms may start within a few hours of cessation or significant reduction of alcohol use, peak between hours and begin to subside by hours 1. Whilst the NICE guideline Alcohol-use disorders: Diagnosis and clinical management of alcohol-related Physical Complications PH24 recommends symptom triggered treatment, the decision has been made to used fixed dose detoxification regimens at the Norfolk and Norwich Hospital with additional flexibility in giving when required chlordiazepoxide. Symptoms of Alcohol Withdrawal (adapted from Hershon 6 ) Craving Mood changes - Depression, Anxiety, Irritability, agitation Copy of complete document available from: Trust Intranet Page 3 of 18

4 Restlessness, Insomnia Sweating Tremor (range from fingers to whole body) Nausea +/- vomiting Confusion (fluctuating intensity) Hallucinations (tactile, auditory, visual; may be fleeting) Generalized seizures occur in 1-15%; usually between hours from the last drink, but can occur during the course of DT 2. A history of seizures increases the risk of further seizures during any subsequent episode of alcohol withdrawal. Delirium tremens (DTs) occurs uncommonly (< 5% of patients) but is associated with a risk of mortality up to 15-20%. This can be reduced to 0-1% with appropriate treatment. Onset is usually between hours, but can occur any time between 1-5 days 3. It is characterised by: fluctuating levels of confusion and disorientation Severe tremor and autonomic disturbance Visual and auditory hallucinations Delusional beliefs Wernicke s Encephalopathy (WE) is an acute neuropsychiatric disorder resulting from thiamine deficiency. WE is initially reversible with parenteral Vitamin B. It carries an estimated mortality rate of 17% and approximately 80% of survivors develop Korsakoff s syndrome 4. The classical triad of signs (acute confusion, ataxia and ophthalmoplegia) occurs in only 16% 4 of patients. Given the associated morbidity and mortality and the rapid responsiveness to treatment early in the disorder a high level of clinical suspicion and low threshold for treatment should be maintained. Medical Assessment Take a history and examine the patient to establish: The presence and severity of alcohol dependence History of complications of alcohol use e.g. o Liver disease o GI bleed o Seizures o Delirium Tremens o Peripheral neuropathy Copy of complete document available from: Trust Intranet Page 4 of 18

5 o Malnutrition Presence of cognitive impairment or psychiatric co-morbidity Misuse of and/or dependence on other substances, including benzodiazepines, opiates and stimulants. Concurrent physical illness Clinically assess signs of alcohol withdrawal where present (It may be helpful to use the CIWA-Ar as an adjunct 5 see appendix 1). Check LFT, Clotting, U+E, Mg2+ and FBC, MCV. Pregnancy All patients who are pregnant and are withdrawing from alcohol or likely to withdraw from alcohol should be urgently referred to TADS at the first opportunity before initiating treatment. Factors predicting severe withdrawal:- The following list is based on expert opinion and comprises validated and best practice indications for managing alcohol detox in the inpatient setting 6,7 Recent history of severe or complicated withdrawals Severe withdrawal symptoms when presenting for treatment Recent high levels of alcohol intake Poor physical health Concurrent use of other psychoactive drugs (e.g. opiate, benzodiazepines) Very high levels of anxiety and/or other psychiatric conditions Completion of the SAD-Q 8 (appendix 2) can assist in predicting the severity of dependence: SAD-Q Score Predicted severity of dependence Mild < 16 Moderate Severe >30 Treatment The aim of the medically treated withdrawal is to prevent, rather than respond to, withdrawal symptoms. Additional (PRN) medication should be offered if withdrawals symptoms are increasing as this indicates an increasing risk of complications. Copy of complete document available from: Trust Intranet Page 5 of 18

6 Benzodiazepines are currently considered the most effective drugs for management of alcohol withdrawal 9. Evidence suggests that long-acting benzodiazepines (such as chlordiazepoxide) may be more effective than short-acting ones in preventing seizure and delirium and allow a smoother withdrawal with less rebound 10. They are also less prone to potential misuse 11. However there is risk of accumulation in the elderly and those with significant liver failure in whom short acting benzodiazepines may be used 10,12. Chlordiazepoxide is the currently preferred benzodiazepine as it has a more gradual onset of psychotropic effects, is perhaps less toxic in overdose, and has less potential for misuse (compared with diazepam 11 ). Diazepam has a longer half-life and so is more prone to accumulation and toxicity. A similar reducing regime should be used, remembering that 5mg Diazepam is equivalent to 10-15mg Chlordiazepoxide. Oxazepam has a shorted half-life and is therefore less prone to accumulation and toxicity. This should be considered as an alternative to chlordiazepoxide in the elderly or when there is significant liver damage. Close observation is required to avoid alcohol withdrawal symptoms 7. Clomethiazole (formerly chlormethiozole) - is as effective as chlordiazepoxide; however it is not recommended as the first choice drug for alcohol detox, as it is associated with a greater risk of respiratory depression, there are documented cases in the community of fatal interaction with alcohol, and its half life is short increasing the risk of complications. It s use therefore requires skilled staff and close monitoring 13,14,15. Clomethiazole may be considered if there are specific contraindications for chlordiazepoxide (e.g. history of allergic reaction, which is rare), or if the patient expresses a strong preference for the medication. Chlordiazepoxide dosage schedule Alcohol withdrawal symptoms can vary widely and the amount of benzodiazepine required for symptom amelioration can also vary. There is no fixed, standardised regime for all patients so regular assessment is mandatory 16. First 24 hours The dose should be estimated by initial assessment of predicted withdrawal intensity based on current level of use and previous experience of withdrawal; and will usually be in the range of mg QDS. PRN chlordiazepoxide (10-20mg QDS) should be available The card should be clearly marked for omission of doses if the patient becomes sedated Cumulative dose in the first 24 hours Copy of complete document available from: Trust Intranet Page 6 of 18

7 The cumulative chlordiazepoxide dose administered during the first 24 hours is the baseline dose, and this is used to calculate the subsequent reduction regime. Generally a cumulative (regular + PRN) dose of up to 200 mg will cover almost all circumstances. If symptoms do not appear adequately controlled at this level higher doses may be used but advice of a consultant, Associate Specialist or specialist registrar should be sought. Subsequent reduction regime (from day 2 onwards) Most inpatient alcohol detox should be completed in 7-10 days. Occasionally, however, detox regimes of longer duration may be required especially for those patients with very severe dependence or past history of DT. The reduction schedule may have to be modified depending on the patient s clinical presentation and severity of withdrawal. The night time dose should be proportionately higher to provide good night sedation. Example schedules of fixed-dose reducing regimes with Chlordiazepoxide Schedule 1 (mg) Schedule 2 (mg) Schedule 3 (mg) Day Oxazepam The same dose regimes can be used with oxazepam as 15mg chlordiazepoxide is roughly equivalent to 15mg of oxazepam. However due to the shorter half-life close observation is required to identify breakthrough withdrawal symptoms. If this occurs more frequent doses may be required with an accumulated daily dose equivalence in a range of 15mg chlordiazepoxide to 15-40mg oxazepam. The above schedules serve as a guide only; individual variation in withdrawal severity and medication requirement should be expected. Vitamin Supplementation (see also Guidelines for management of Wernicke s Encephalopathy) Parenteral vitamins Copy of complete document available from: Trust Intranet Page 7 of 18

8 Prophylactic treatment with thiamine is recommended for all the patients undergoing inpatient alcohol detoxification to prevent Wernicke-Korsakoff syndrome. Oral thiamine is poorly absorbed especially in alcohol dependent individuals with poor diet. Dextrose/Glucose can further deplete thiamine stores, precipitating Wernicke- Korsakoff syndrome so it is mandatory that IV Pabrinex (high-potency B-complex vitamins) should precede this in the treatment of alcohol induced hypoglycaemia 4. If IV access is unavailable, a special intramuscular Pabrinex formulation may be given IM this may cause significant discomfort in high dose regimens. Parenteral administration of Pabrinex is generally safe % incidence of severe reaction (generalised pruritis 4 ). The recommended regime for prophylaxis during alcohol detoxification is Pabrinex 1 pair of ampoules IM or IV daily, for 3-5 days. IV administration is preferred as IM can cause some discomfort. The first dose should be given prior to emergence of withdrawal symptoms In those with the following risk factors consider increasing to 1 pair IV bd for 3-5 days High risk 4 Severe alcohol dependence Poor diet Abnormal liver function Not prescribed or not taking oral thiamine treatment Symptoms of peripheral neuropathy Impaired memory Concurrent physical illness Magnesium deficiency The administration should always be IM or IV, as anaphylaxis is extremely rare after IM administration and oral thiamine is inadequately absorbed 4. After detoxification oral thiamine 100mg twice daily should be continued for 1 month 17. Oral vitamin B co-strong is no longer recommended for prescribing and can be stopped if only indicated for previous alcohol excess. If Pabrinex is refused give oral thiamine at a dose of 100 mg three times a day and document attempts to obtain consent for parenteral treatment. Copy of complete document available from: Trust Intranet Page 8 of 18

9 Treatment of Wernicke s Encephalopathy Where signs indicative of Wernicke s Encephalopathy are present the regime should be increased to 2 pairs of pabrinex ampoules given by iv infusion over 30 mins tds for 2-3 days 16. Where clinical improvement is observed, continue 1 pair daily until improvement ceases. Where no improvement occurs discontinue treatment after 3 days. 4 Check magnesium levels as hypomagnesia may contribute to the disorder and lead to refractory response to thiamine 4. Presenting symptoms of Wernicke s Encephalopathy 4 :- Change in mental status (seen in 82%) may present as mental sluggishness and apathy through to marked confusion and or decreased level of consciousness Ocular abnormalities (seen in 29%) - nystagmus. ophthalmoplegia, sluggish papillary reflexes, papilloedema. Truncal Ataxia / incoordination of gait (seen in 23%) Uncommon: Stupor Hypotension with Tachycardia Hypothermia Seizures Late stage: Hearing loss Hallucinations and behavioural disturbance Hyperthermia Increased muscle tone and spastic paresis Coma Copy of complete document available from: Trust Intranet Page 9 of 18

10 Additional Medications for Symptomatic Relief of Alcohol Withdrawal Pain Nausea and vomiting Diarrhoea Insomnia NSAIDs, e.g. ibuprofen 400mg tds Simple anti-emetics e.g. prochlorperazine Prophylaxis: 5-10 mg tds Acute attack: 20 mg stat, then 10 mg after 2 hours If patient can t take orally: 12.5 mg (1 ampoule) deep IM, followed, if necessary, after 6 hours, by an oral dose. Loperamide: 2 capsules initially, then 1 capsule after each loose stool. Zopiclone ( mg Nocte) or Nitrazepam (5-10 mg Nocte) or Only one sedative to be prescribed at a time General Monitoring and Support The following set of observations should be recorded at least 8 hourly in the first 72 hours and then at least once daily: o Pulse, blood pressure, temperature o record of the severity of observed withdrawal symptoms and signs (CIWA-Ar or alternative may be used) Ensure adequate nutrition. Ensure adequate fluid intake to maintain hydration and electrolyte balance. Seek further assessment (U&Es and clinical assessment), if hydration appears compromised. Useful Contacts Substance Misuse Liaison Nurse: Mon-Fri 9-5pm Bleep 0439 On-call Gastroenterology registrar via NNUH switchboard Trust Drug and Alcohol Service: (formerly Bure Centre) NORCAS: Matthew Project Alcoholics Anonymous: Al-Anon (Support for Carers): Copy of complete document available from: Trust Intranet Page 10 of 18

11 Clinical Audit Standards derived from guideline a) All patients should have an accurate alcohol history documented in their medical notes b) Patients identified as heavy drinkers at risk of thiamine deficiency should be prescribed thiamine prophylaxis at a level appropriate to their level of risk. c) Patients identified as probably dependent should be prescribed an adequate detoxification regime. d) Patients identified as probably dependent should have documented evidence of monitoring for level of withdrawal and complications of withdrawal. Summary of development and consultation process undertaken before registration and dissemination The authors listed above have agreed the final content of the drafted guideline. During its development it has been circulated for comment to: the membership of the TADS service governance committee and the NWMHFT Pharmacy Advisory Committee and the Consultant Gastroenterologists at NNUH. Feedback has been incorporated into the submission. Dr H Pinto and the TADS team and Dr J Harris reviewed in March 2013; the draft was also shown to the Trust Hepatologists whose comments were incorporated in version 3. Distribution list/ dissemination method Norfolk and Norwich University Foundation Trust Intranet. References 1. Morgan M & Ritson B (1998) medical student s handbook: alcohol and health. The medical Council on Alcoholism Publications, Turner RC, Lichstein PR, peden JG et al (1989) Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. Journal of Internal medicine, 4, Manyo-Smith MF et al (2004) Management of Alcohol Withdrawal Delirium Arch. Int Med. 164: Sechi G and Serra A (2007) Wernicke s Encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol 6: Sullivan JT, Sykora K, Schneiderman J et al (1989) Assessment of alcohol withdrawal: the revised Clinical Institute of Withdrawal Scale (CIWA-Ar). British Journal of Addiction, 84, Hershon, H. I. (1977) Alcohol withdrawal symptoms and drinking behavior. Journal of Studies on Alcohol, 38, Copy of complete document available from: Trust Intranet Page 11 of 18

12 7. Taylor D, Paton C, Kerwin R (2005) Prescribing guidelines, 8 th edn, Taylor & Francis Publications, p Stockwell T, Hodgson R, Edwards G et al (1979) The development of a questionnaire to measure severity of alcohol dependence. British Journal of Addiction, 74, Raistrick D, Heather N and Godfrey C. (2006) Review of the effectiveness of Treatment for Alcohol Problems. NTA. 10. Mayo-Smith MF (1997) Pharmacological management of alcohol withdrawal. A metaanalysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA;278(2): Griffiths RR, Wolf B. (1990) Relative abuse liability of different benzodiazepines in drug abusers. Journal of Clinical Psychopharmacology;10(4): Kosten T, O Connor P (2003) Management of drug and alcohol withdrawal. NEJM 348: Serfaty M, Masterton G. (1993) Fatal poisonings attributed to benzodiazepines in Britain during the 1980s British journal of Psychiatry, 163: McInnes GT. Chlormethiazole and alcohol: a lethal cocktail. (1987) BMJ (Clin Res Ed), 294(6572): Duncan D, Taylor D (1996) Chlormethiazole or chlordiazepoxide in alcohol detoxification. Psychiatr Bull 20: Burroughs AK, Morgan MY, Sherlock S. (1985) Double-blind controlled trial of bromocriptine, chlordiazepoxide and chlormethiazole for alcohol withdrawal symptoms. Alcohol Alcohol, 20(3): Raistrick R (2000) Management of alcohol detoxification. Advances in Psychiatric Treatment, 6, Lingford-Hughes AR, Welch S, Nutt DJ (2004) Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology Journal of Psychopharmacology 18(3) (2004) Raistrick D., Alcohol Withdrawal and Detoxification. In Heather N., Peters T., Stockwell T. (eds) International Handbook of Alcohol Dependence and Problems, 2001 pp John Wiley & sons Ltd.Chichester, UK Copy of complete document available from: Trust Intranet Page 12 of 18

13 Appendix I Addiction Research Foundation Clinical Institute Withdrawal Assessment Alcohol (CIWA-Ar) Patient Date Time Pulse Blood Pressure NAUSEA AND VOMITING Ask DO you feel sick to your stomach? Have you vomited? Observation. 0 no nausea and no vomiting 1 mild nausea with no vomiting intermittent nausea with dry heaves constant nausea, frequent dry heaves and vomiting TREMOR arms extended and fingers spread apart. Observation 0 no tremor 1 not visible, but can be felt fingertips to fingertips 2 3 moderate, with patient s arms extended severe, even with arms not extended PAROXYSMAL SWEATS Observation 0 no sweat visible 1 barely perceptible sweating, palms moist beads of sweat obvious on the forehead drenching sweats Copy of complete document available from: Trust Intranet Page 13 of 18

14 ANXIETY Ask Do you feel nervous? 0 no anxiety, at ease 1 mildly anxious moderately anxious or guarded, so anxiety is inferred equivalent to acute panic states, as seen in severe delirium tremens or acute schizophrenic reactions AGITATION Observation 0 normal activity 1 somewhat more than normal activity moderately fidgety or restless paces back and forth during most of the interview, or constantly thrashes about TACTILE DISTURBANCES Ask Have you any itching, pins and needle sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin? Observation. 0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 constant hallucinations Copy of complete document available from: Trust Intranet Page 14 of 18

15 AUDITORY DISTURBANCE Ask Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing you? Are you hearing things you know are not there? Observation. 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations VISUAL DISTURBANCE Ask Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there? Observation. 0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations HEADACHE AND FULLENSS IN THE HEAD Ask Does your head feel different? Does it feel like there is a band around your head? Do not rate for dizziness or light headedness. Otherwise rate severity. 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe Copy of complete document available from: Trust Intranet Page 15 of 18

16 ORIENTATION AND CLOUDING OF SENSORIUM Ask What day is this? Where are you? Who am I? 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about the date 2 disoriented for date by no more than two calendar days 3 disoriented for date by more than two calendar days 4 disoriented for place and person Total CIWA score Rater s initials Maximum possible score 67 Mild severity CIWA-Ar < 10 Moderate severity CIWA-Ar Severe CIWA-Ar > 20 Copy of complete document available from: Trust Intranet Page 16 of 18

17 Appendix 2 Severity of Alcohol Dependence Questionnaire (SAD-Q) Please recall a typical period of heavy drinking in the last 6 months. When was this? Month Year Please select a number (either 0,1, 2 or 3) to show how often each of the following statements applied to you. Almost never Sometimes Often Nearly always I woke up feeling sweaty My hands shook first thing in the morning My whole body shook first thing in the morning I woke up absolutely drenched in sweat I was frightened of meeting people first thing in the morning I felt at the edge of despair when I woke I felt very frightened when I woke I liked to have a morning drink I always gulped my first few drinks down as quickly as possible I drank in the morning to get rid of shakes I had a very strong craving for drink when I awoke I drank more than 1/4 th bottle of Spirits a day (or 4 pints of beer/ 1 bottle of wine) Copy of complete document available from: Trust Intranet Page 17 of 18

18 I drank more than 1/2 bottle of Spirits a day (or 8 pints of beer/ 2 bottles of wine) I drank more than 1 bottle of Spirits a day (or 15 pints of beer/ 3 bottles of wine) I drank more than 2 bottles of Spirits a day (or 30 pints of beer/ 4 bottles of wine) Imagine the following situation: (a) (b) (c) You have been completely off drink for a few weeks. You then drink very heavily for two days. How would you feel the morning after those two days of heavy drinking? No Slight Moderate A lot I would start to sweat My hands would shake My body would shake I would be craving for a drink A score of 31 or higher indicates severe alcohol dependence. A score of indicates moderate alcohol dependence. A score of less than 16 usually indicates only a mild physical dependency. (A chlordiazepoxide detoxification regime should be considered for someone who scores 16 or over.) Copy of complete document available from: Trust Intranet Page 18 of 18

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