Audit of Alcohol Detoxification Prescribing Observatory for Mental Health (POMH-UK) Regional Event

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1 Audit of Alcohol Detoxification Prescribing Observatory for Mental Health (POMH-UK) Regional Event Wakefield 4th December 2013 definition and guidance Duncan Raistrick Leeds Addiction Unit Detoxification What... Detoxification is the process of rapidly achieving a drug free state normally 7-14 days. It is different to slow reduction programmes and requires good preparation work between therapist and service user. When... Action stage: self efficacy, self esteem and positive outcome expectancy or expedience Where... Assess risk and determine level of supervision required Lifetime prevalence and odds ratio of Mental Illness and Substance Misuse alcohol cannabis cocaine opiates Schizophrenia Affective Anxiety Antisocial Note the range of prevalence both by mental illness category and substance use category look down and across the pale yellow numbers. The OR for the general population is 1. Source: Kessler et al. Archives of General Psychiatry

2 Some Problems in Working with Comorbidity Organisational range of competencies needed multi-agency working communication barriers, differing ethos clarity of roles at agency and practitioner levels Service users utility of substance use substance use and mental illness feed each other inconvenience of going to several agencies need to build therapeutic alliance at agency and therapist levels Practitioners training to develop a range of skills need for support and supervision to deal with complex cases therapeutic pessimism British Association of Psychopharmacology 2012: Strength of BAP recommendations rated A to D based on evidence NICE Guidelines on Alcohol Use Disorders: 2011 Diagnosis, assessment and management of harmful drinking and alcohol dependence 2010 Diagnosis and clinical management of alcohol-related physical complications 2010 Preventing harmful drinking summarising guidelines... Treatment of uncomplicated withdrawal... Benzodiazepines are efficacious in reducing signs and symptoms of withdrawal (A); fixed-dose regimens are recommended for routine use with symptom-triggered dosing reserved for use only with adequate monitoring (D) Carbamazepine has also been shown to be equally efficacious to benzodiazepines (A) Clomethiazole is reserved for inpatient settings only after due consideration of its safety (A) Treatment of complicated withdrawal... Seizures Benzodiazepines, particularly diazepam, prevent de novo seizures (A) Anticonvulsants are equally as efficacious as benzodiazepines in seizure prevention, but there is no advantage when combined (A) In preventing a second seizure in the same withdrawal episode, lorazepam but not phenytoin has been shown to be effective (A) Delirium Benzodiazepines, particularly those with longer half-life prevent delirium (A) and should be used for treatment (B) 2

3 Alcohol Withdrawal Symptoms Tremulousness (6-12hrs) Seizures (24-36 hrs) Delirium (48-72 hrs) basic pharmacotherapy Most Common Most Specific 1 Depression Whole body shakes 2 Anxiety Facial tremulousness 3 Irritability Hand and finger shakes 4 Tiredness Cannot face the day 5 Craving Panicky 6 Restlessness Guilt 7 Insomnia Nausea 8 Confusion Visual hallucinations 9 Sweating Weakness 10 Weakness Depression Source: Hershon (1977) J Stud Alc General Methods of Detoxification Front loading Repeat dosage eg for alcohol diazepam 20mg every 90min until severity of withdrawal score below preset level. No further medication given. Efficient in staff time and reduces total dose. Fixed dose reduction A predetermined regimen for a given severity of withdrawal. Does not require experienced staff. Not sensitive to need and unlikely to pick up complications. Variable dose reduction Dose of medication is determined by the severity of withdrawal. Requires experienced and trained staff. Best method where the course of detoxification is uncertain. Typical Withdrawal Medication Chlordiazepoxide (or diazepam in half the dose) severe withdrawal 30mg qds reduce over 5days moderate withdrawal 20mg qds reduce over 5days Oxazepam (liver disease) severe withdrawal 30mg qds reduce over 5days moderate withdrawal 20mg qds reduce over 5days Lorazepam (seizures or delirium) 30mcg/kg = mg IM or slow IV repeat 6hrly Chlormethiazole (in patient only) very severe withdrawal with history of seizures/delirium 2-4 caps day1 6-8 day2 reduce over 9days Oxcarbamazepine (2 nd line drug) mg daily reducing over 5days 3

4 Front loading method of detox Prevention of Wernicke s encephalopathy... Low risk: healthy uncomplicated alcohol-dependent/heavy drinkers - oral thiamine 300 mg/day during detoxification (D) High risk: malnourished, unwell - prophylactic parenteral treatment 250 mg thiamine (one pair of ampoules Pabrinex ) i.m. or i.v. once daily for 3 5 days or until no further improvement (D) Assessed every 90mins 20mg of diazepam if CIWA score >=11 stop after x2 CIWA scores <=10. Total 222mg chlordiazepoxide vs 700mg standard Rx Suspected WE: parenteral thiamine (i.m. or i.v.) 500 mg daily for 3 5 days (two pairs of ampoules Pabrinex ), followed by one pair of ampoules daily for a further 3 5 days depending on response (D) Source: Day et al. (2004) Psychiatric Bulletin Wernicke-Korsakoff Syndrome 25-30mg thiamine stored in liver, heart, brain and kidneys. Daily turnover approx 1mg - absorption from 10mg thiamine or more is 4-5mg in healthy individuals, mg in heavy drinkers Diagnosis (only 10% have full triad): Ophthalmoplegia 29%. Ataxia (not due to intoxication) 23%. Impaired memory function. Confusion or impaired consciousness (not due to intoxication) 82%. Unexplained hypotension or hypothermia. >85% cases are subclinical or undiagnosed. Prevention of Neurotoxicity there is insufficient clinical trial evidence to include in guidance Acamprosate may be effective at blocking the neurotoxicity caused by glutamate during alcohol withdrawal other anti-glutamatergic agents also effective Mifepristone may be effective at blocking the neurotoxicity caused by corticosterone during alcohol withdrawal there are other possible targets to block the stress reaction 4

5 In alcohol withdrawal the brain is both over-stimulated (high glutamate) and under-inhibited (low GABA). Too much glutamate may cause cell death. relapse prevention Acamprosate may reduce this damage during alcohol withdrawal. Dead Control Alcohol Withdrawal Alcohol Withdrawal + Acamprosate Alive courtesy of Prendergast & Littleton Relapse prevention - guidance is inconsistent and needs clinical view... Offer pharmacotherapy to everyone (A) Alcohol Neurochemistry The pharmacology of alcohol is not well understood. There are four known effects of alcohol albeit these may be partial effects. Acamprosate improves abstinence rates (A) and reduces alcohol consumption (A) Naltrexone reduce risk of lapse becoming a relapse - less evidence of maintaining abstinence (A) Disulfiram to maintain abstinence if no contraindications (B) Baclofen to maintain abstinence if high levels of anxiety (C) SSRIs should be avoided Source: BAP (2012) J Psychopharmacology Acamprosate has one agonist and one antagonist effect just like alcohol. It is not itself intoxicating any effect is by changing the natural tonic status of GABA and glutamate systems. The rationale for naltrexone is that it blocks the mu effect of alcohol and so is only needed when drinking occurs. 5

6 Acamprosate vs Disulfiram vs Naltrexone a randomised controlled trial Days to Heavy Drinking Days to Drinking Days Abstinence /wk Disulfiram blocks aldehyde dehydrogenase causing a build up of acetaldehyde blocks dopamine-bhydroxylase causing a build up of dopamine Acamprosate Disulfiram Naltrexone 243 subjects randomised 1:1:1 supervised medication + manualised CBT. Alcohol consumption reduced from approx 580gm weekly to 195gm (ACA) 109gm (DIS) 229gm (NTX) at 2yr follow-up Caution in psychotic mental illness Caution with cardiovascular disease Source: Laaksonen et al. (2008) Alcohol and Alcoholism Suicidal Behaviour Post Detoxification n=470 Suicidal Ideation Suicide Attempt points to consider preparation timing of follow up staff attitudes Lifetime 28.5% 21.9% 24mths Post Detox 19.9% 9% 6.9% prior ideation 46.5% 24.1% no prior ideation 8.4% 2.3% Source: Wines et al., (2004) Drug and Alcohol Dependence 6

7 Detoxification Preparation Preparation is based on a dialogue between the keyworker, service user and other carers. o Determining readiness for detoxification and highlighting positive outcomes. o Coping strategies other than pharmacotherapy for dealing with withdrawal symptoms. o Identifying a support person and plan for the detoxification period. o o Identifying a post detoxification plan. o Revisiting learning points from previous detoxifications. o Assessing risks. o Making a follow on keyworker appointment. Audit outcome at 1month Doing anything depends on staff attitudes... Max score = 25 On each subscale Role adequacy Role legitimacy Positive expectancy Self efficacy Overall therapeutic attitude Health Care Assistants Nurses Doctors % % % % % % Thank you. Any questions? Doctors under 30yrs scored OTA = 41.0 older doctors OTA = 23.8 Source: Raistrick et al. (2007) J Substance Use and submitted

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