Drug & Alcohol Awareness Workbook Turning Point, Standon House 21 Mansell Street London, E1 8AA

Transcription

1 Drug & Alcohol Awareness Workbook Turning Point, Standon House 21 Mansell Street London, E1 8AA Turning Point is a registered charity No , a registered social landlord and a company limited by guarantee no (England and Wales).

2 Contents Introduction 4 Drug Awareness 4 Drugs and the Law (from Gov.UK) 6 Types of drugs 6 Possessing drugs 7 Dealing or supplying drugs 7 Medications for Recovery 8 Rationale for Opiate Substitution Treatment (OST) 8 The Administration of OST 8 Substitute and Detox Medication 10 Health Professionals Role and Responsibilities 11 Alcohol Awareness 16 Drinking Behaviours 16 Psychological vs. Physical Dependency 20 Medically Assisted Withdrawal Prescribing 25 Relapse Prevention Prescribing 25 Drug and Alcohol Awanress final - 2

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4 Introduction This workbook is intended to be an introduction to drug and alcohol awareness prior to the completion of your face to face training. It covers some of the basics of drug and alcohol awareness and is a starting point on which you can build your knowledge. If new to the treatment field, you may need to seek advice from colleagues on some of the practical exercises that form part of this workbook. Access to in-house expertise and face to face training will form part of your wider development plan. Self directed learning, in order to remain up to date on drug and alcohol trends, both nationally and locally, is critical in order to remain responsive to all service users. This document should be read in conjunction with Standard Operating Procedures (SOPs) and best practice guidance documents specifically the Recovery Academy Guidance for Practitioners available on IRIS. Drug Awareness Most psychoactive drugs fall into the categories of stimulants, depressants, opiates, hallucinogens and performance and image enhancing substances. Psychoactive drugs affect the central nervous system and alter a person's mood, thinking and behaviour. Psychoactive drugs may be divided into several categories but frequently the effect of the drug can cross over more than one category. The effects may also be affected by the mood and predisposition of the user and other environmental factors for example, alcohol although a depressant can also makes people reduce social inhibitions and so can be seen to stimulate people within a social context: Depressants: Drugs that decrease alertness by slowing down the activity of the central nervous system (e.g. heroin, alcohol, benzodiazepines, some analgesics, GHB). Stimulants: Drugs that increase the body's state of arousal by increasing the activity of the central nervour system (e.g. caffeine, cocaine and amphetamines). Hallucinogens: Drugs that alter perception and can cause hallucinations, such as seeing or hearing something that is not there (e.g. LSD and 'magic mushrooms'). Other: Some drugs fall into the 'other' category, as they may have properties of more than one of the above categories (e.g. cannabis has depressive, hallucinogenic and some stimulant properties). Ecstasy has a stimulent effect but can also be partially hallucinagenic. Ketamine has an number of effects i.e. anaesthetic and analgesic (pain killing) but also causing dissociation and hallucinations. Novel Psychoactive Substances (NPS) - sometimes referred to incorrectly as legal highs. They are a large and growing group of substances which are specifically tailored by chemists to produce pleasurable psychological effects. Some mimic cannabis effects, many are stimulants and some are hallucinogenic. Drug and Alcohol Awanress final - 4

5 Performance and Image Enhancing Drugs (PIED) Some people take these substances to improve their apperance, others take them to improve how they perform in sports. Anabolic steroids fall into this category and are drugs that mimic certain natural hormones in the body that regulate and control how the body works and develops. For each of the categories select 2 example of substances for each and research the following Classification Drug Effects Routes of administration Risks Legal status Also known as (street names) Withdrawal symptoms if any Depressant Stimulant Halluncinogen Other NPS PIED Drug and Alcohol Awanress final - 5

6 Drugs and the Law (from Gov.UK) Types of drugs The maximum penalties for drug possession, supply (dealing) and production depend on what type or class the drug is. Class Drug Possession Supply and production A Crack cocaine, cocaine, ecstasy (MDMA), heroin, LSD, magic mushrooms, methadone, methamphetamine (crystal meth) Up to 7 years in prison, an unlimited fine or both Up to life in prison, an unlimited fine or both B Amphetamines, barbiturates, cannabis, codeine, ketamine, methylphenidate (Ritalin), synthetic cannabinoids, synthetic cathinones (eg mephedrone, methoxetamine) Up to 5 years in prison, an unlimited fine or both Up to 14 years in prison, an unlimited fine or both C Anabolic steroids, benzodiazepines (diazepam), gamma hydroxybutyrate (GHB), gamma-butyrolactone (GBL), piperazines (BZP), khat Up to 2 years in prison, an unlimited fine or both (except anabolic steroids - it s not an offence to possess them for personal use) Up to 14 years in prison, an unlimited fine or both *The government can ban new drugs for 1 year under a temporary banning order while they decide how the drugs should be classified. Drug and Alcohol Awanress final - 6

7 Possessing drugs You may be charged with possessing an illegal substance if you re caught with drugs, whether they re yours or not. If you re under 18, the police are allowed to tell your parent, guardian or carer that you ve been caught with drugs. Your penalty will depend on: the class and quantity of drug where you and the drugs were found your personal history (previous crimes, including any previous drug offences) other aggravating or mitigating factors Cannabis Police can issue a warning or an on-the-spot fine of 90 if you re found with cannabis. Khat Police can issue a warning or an on-the-spot fine of 60 on the first 2 times that you re found with khat. If you re found with khat more than twice, you could get a maximum penalty of up to 2 years in prison, an unlimited fine, or both. Dealing or supplying drugs The penalty is likely to be more severe if you are found to be supplying or dealing drugs. Sharing drugs is also considered supplying. The police will probably charge you if they suspect you of supplying drugs. The amount of drugs found and whether you have a criminal record will affect your penalty Drug and Alcohol Awanress final - 7

8 Medications for Recovery Rationale for Opiate Substitution Treatment (OST) OST is in widespread use because of its significant scientific evidence base as a cornerstone of harm reduction in those who are addicted to opioids, typically heroin. Abstinence may be the most desirable outcome for most service users in the long run but that point may take some time to achieve, perhaps even years. In that time, continued heroin use, particularly injecting heroin use, can be very harmful including blood borne virus (BBV) transmission, deep vein thrombosis, abscesses or bacterial infection and potential overdose. OST medications (methadone or buprenorphine) are long acting opioids and once the optimum dose has been reached withdrawal symptoms will not occur. OST medication provides the service user with a stable platform upon which the individual can start to recover. OST medications are no less addictive than heroin and to achieve total abstinence, users will have to be withdrawn from them at some stage. As long acting drugs of consistent pharmaceutical quality, the withdrawal process can be managed in a controlled way and at a pace that is matched to the service users progress. Whilst OST is enormously useful at removing the single most powerful driver of heroin use (withdrawal symptoms), there is much more to treatment than OST alone. The Administration of OST OST medications are drugs controlled by the Misuse of Drugs Act they are potentially toxic in their own right, have the potential for misuse, and as controlled drugs they have particular responsibilities for prescribers, pharmacists and those that they are prescribed to. Unless under extremely unusual circumstances, all OST doses at the commencement of treatment are consumed daily in pharmacies under the supervision of the pharmacist. Supervised consumption (mostly) ensures that prescribed doses are taken by the Service User and not diverted to others. As stability follows, doses may be prescribed to be taken away for home consumption, whereupon Service Users have obligations to keep these medicines safely, away from access by unauthorised individuals, especially children for whom they can be extremely dangerous. Prescribers and services have obligations around recording of prescriptions issued, and the safe storage and handling of blank prescription forms. The Standard Operating Procedures (SOPs) for your service should be followed. scenarios detailed as part of this workbook are directly related to SOPs. All Drug and Alcohol Awanress final - 8

9 At the outset of OST prescribing, the Service User should be reminded to: Read the information leaflet about the medication To comply with service and pharmacist conditions To keep take away doses safely To notify DVLA (if they are licensed to drive a motor vehicle) of their drug misuse, and that they are being prescribed OST To inform any other health professional they come into contact with that they are being prescribed OST Avoid using any other drugs or alcohol on top because of the risk of accidental overdose The giving of this information to service users should be documented in their notes if they have not signed an agreement detailing the above. The above reminders should be re-issued from time to time throughout treatment. Prior to the first prescribing appointment, the worker should as a minimum ensure they: Have completed a comprehensive assessment Opened a specialist prescribing modality in the electronic patient record (EPR) Have a GP letter faxed to inform the GP of prescribing and toprevent dual prescribing TOPs done Completed and signed Service User Treatment Contract Signed Information sharing consent Have a multi bar urine toxicology screen no less than 48 hours old (but preferably that day) Have discussed the relative merits of buprenorphine and methadone with the Service User, and preferably been given information leaflets. Have decided upon a pharmacy acceptable to the Service User and agreed by the pharmacist Have booked a further titration appointment no less than three days and no more than 7 days hence Be present to give the prescriber a short hand account of the important features of the Service User s case and any potential risks Have the beginnings of a care plan in place Once stable, a Service User on OST should be reviewed by a prescriber at least every 3 months, and as often as necessary if not stable. At prescribing review, the worker should: Be present this is an invaluable opportunity to review progress against recovery plan, and to inform the prescriber of significant changes in all dimensions of the Service User s health and recovery Provide the prescriber with the results of drug screens since the last review Drug and Alcohol Awanress final - 9

10 Inform the prescriber about any other agencies involved in the Service User s care (as these may need to be informed of the outcome of the review) NOTE: if it is not possible for the worker to be present at the review, all relevant information must be available for the prescriber, in writing, on the date of the review. Substitute and Detox Medication Medically assisted Withdrawal from Opioid dependency ( Detox ) When and who? there is much about detoxing from opioids that is not known and where evidence is not yet established. Amongst these are when is the right time to go for abstinence, and which Service Users are most likely to succeed? It is generally considered that those with more recent short term opioid using histories have a better chance of success, as do those who have strong recovery capital e.g. positive family support, stable housing, and employment. However there are many Service Users with significant social support who repeatedly relapse, and there are others who despite years of very problematic drug use and repeated efforts, suddenly just manage to achieve and maintain abstinence despite nothing in their lives appearing to change significantly. If Service Users ask us to help them to achieve abstinence, it is essential that we help them to realise this ambition and support them to build the best circumstances for them to both achieve and maintain abstinence by building positive support networks and wider recovery capital. Weshould also counselt service users to be realistic and plan relapse prevention strategies. How? Most opioid users have had experience of short and longer periods of withdrawal it is extremely unpleasant and the fear of severe unending withdrawal is profound. It is widely believed that coming off, say, 100mg methadone is twice as painful as coming off 50mg, yet there is absolutely no evidence to say that this is so, nor to suggest that symptoms would last twice as long. The severity and duration of the withdrawal syndrome is more a factor of motivation than anything else, but belief (of the Service User) is also highly important, and supporting a plan that the Service User believes will work is likely to be more successful than imposing plans we approve of but which the Service User does not. For the above reason, the vast majority of detox plans are simply slow reductions in the dose of OST, at a rate that the Service User can tolerate. Intuitively this seems the most sensible and pragmatic way to ease out of dependency and because so many believe this most people do achieve abstinence this way. However, slow reductions that are stretched out over weeks and months almost invariably will cover times when crises occur, when there may be the temptation to use heroin which is all the more likely to be succumbed to because the Service User is still on OST, is still in treatment, and can be justified because they feel that the reduction is happening too quickly. In some circumstnaces stability on a higher dose can give way to months of instability as doses go up and down following lapses to heroin. It may be that building up motivation, enlisting the support of family and friends, perhaps going away somewhere and/or maximising service interventions, groups, NA etc and then going through a rapid, albeit difficult withdrawal, will bring about a restoration of stability and being symptom free much more quickly. This is the method used in residential Drug and Alcohol Awanress final - 10

11 detox centres, and has a high level of achievement of abstinence in the short term there is not yet evidence to show that it is more successful at achieving durable abstinence. Medications: Most Service Users will opt for a slow reduction of OST at whatever rate they have faith in NICE guidance endorses both methadone and buprenorphine for this purpose. There is a belief that methadone is more difficult to withdraw from than buprenorphine again this is not a scientific observation but one which has become received wisdom to the point that some will ask to be switched from methadone to buprenorphine to help them to finish their detox. There are other medications that can aid withdrawal symptoms such as diarrhoea, nausea and stomach cramps. There is also a medication called lofexidine, a non addictive non opioid which helps with some symptoms of withdrawal. Service Users contemplating withdrawal in the near term should be invited to discuss these matters in a prescribing review. In all cases, ANY Service User contemplating withdrawal MUST be fully advised about the risks of loss of tolerance, and of the consequent risk of overdose and death from relapse. They should also be advised about naloxone and supplied with it if appropriate. The above advice must be given and recorded in service users records. It is negligent not to provide this information. Health Professionals Role and Responsibilities Role Responsibility Populate with information for your locality Service Users GP The Service User s GP has a unique long term relationship with the Service User: they will normally know the Service User well, know his/her family and personal circumstances, and be aware of co-existing health concerns. GPs are easily accessible both geographically and in terms of hours of appointments, they are highly skilled in co-morbid conditions that are very important to our Service Users such as sexual health including contraception, wound care, liver disease etc. The GP is a key person in our Service User s care it is incumbent upon us to keep the GP informed of significant events, prescribing and so forth and for us to ask the GP for similar relevant information. Consent from our Service Users to share information with the GP is mandatory. Shared Care GP s Some Shared Care GPs train (by their choice) in managing drug users and so may qualify for extra payments if a Service User s Where are the GP shared care practices in your area? Drug and Alcohol Awanress final - 11

12 GP s with Special Interest (GPwSI) OST prescribing is transferred to their care in arrangements where the care is shared between the GP and the specialist service. They will be expected to also manage things like BBV immunisations and to do simple audits of their care. Most importantly, they will be expected to cooperate with our recovery workers and to share the goals of the care plans. The service Shared Care worker will coordinate reviews, manage the care plan, submit NDTMS data and do the drugs testing. These GPs will have taken higher level additional training and may perhaps be employed by commissioners to run special clinics and to treat the substance misusing Service Users of other GPs. Turning Point frequently employs GPwSIs on a sessional basis to run prescribing review clinics in our services. Who are the GPwSI s in your area? Primary Care Addiction Specialists Consultant Psychiatrists There are a small number of GPs who have moved into substance misuse entirely and no longer work in general practice (or keep their hands in with a handful of GP sessions a year). These doctors acquire very considerable experience and skills and some are described as Primary Care Addiction Specialists. Turning Point employs some Consultant Psychiatrists, as well as Speciality Doctors who are often psychiatrically trained. Psychiatrists usually have high levels of competencies to work with substance misusers. Psychologists Psychologists do not have prescribing rights but are skilled in treating mental and behavioural disorders using non pharmaceutical approaches. Psychologists in TP sometimes train our workforce in how to deliver the interventions that are most effective. They may deliver therapies to a small number of Service Users as well as providing assessments of complex cases, and advice on care plans. Who are the doctors that work in your service or in your specialist clinical service for your area? Who are the doctors that work in your service or in your specialist clinical service for your area? Do you have a psychologist in your service and what do they do? Drug and Alcohol Awanress final - 12

13 Non-Medical Prescribers (NMP s) Clinicians who have gained supplementary qualifications to prescribe drugs within their sphere of expertise. Turning Point employs NMPs of nursing and pharmacist background. These NMPs will usually be familiar with and competent to prescribe OST and the few other drugs that we use in substance misuse treatment. NMPs are a great enhancement to the services we provide by being available more of the time, waiting times for prescribing reviews are shorter and urgent prescribing changes are managed more easily. Are there any NMP s in your service? Prescribing Policies: Turning Points prescribing policies can be found on IRIS, Documents Centre, Operational Policies and includes: Core Policey on Prescribing Appendix 1. A Single Competency Framework Appendix 2. Guidelines for Methadone prescribing Appendix 3. Guidelines for Buprenorphine prescribing Appendix 4. Guidelines for prescribing Benzodiazepines Appendix 5. Guidelines for prescribing to pregnant service users Appendix 6. Guidelines for the symptomatic treatment of withdrawal using Lofexidine Appendix 7. Standard operating procedure for Naltrexone prescribing for opiate users Appendix 8. Guidelines for treatment with Acamprosate (Campral EC) Appendix 9. Guidelines for treatment with Disulfiram 200mgs (Antabuse) Appendix 10. Standard operating procedure for administration of Naloxone Appendix 11. Standard operating procedure for alcohol home detoxification Appendix 12. Standard operating procedure for responding to opiate overdose Appendix 13. Standard operating procedures for Hepatitis B and C Appendix 14. NICE audit criteria for Methadone and Buprenorphine Appendix 15. FP10 Example Prescription Record Form Appendix 16. Holiday Prescribing Guidelines Drug and Alcohol Awanress final - 13

14 A Service User has not picked up their prescription for 3 days what action should you take? (discuss this with your manager to understand what the local proceedure is) A Service User is going on holiday and will be out of the area for a week. What action should you take? Drug and Alcohol Awanress final - 14

15 A Service User is not engaging in treatment and has not attended their prescribing review. What action should you take? A Social Worker asks you to regularly test a Service User to inform them of any illicit substance use. How would you deal with this conversation and what action would you take? Drug and Alcohol Awanress final - 15

16 Alcohol Awareness Alcohol continues to remain the most prevalent drug of misuse for Service Users who present to treatment services. As practitioners on the frontline it is important that we feel confident enough to have useful conversations with our Service Users about their alcohol use, are able to obtain accurate information that supports our decision making, and that we are able to provide advice that is appropriate to the needs of the Service User with an overarching aim of reducing harm. National guidelines recommend that men should not consume more then 3-4 units each day, women 2-3 and people should aim for at least 3 consecutive alcohol free days per week. 24% of the population consumes alcohol in hazardous way (33% males, 16% females) 5.9% of the English population is estimated to be alcohol dependent Source Statistics on Alcohol: England 2014, Health and Social Care Information Centre. Drinking Behaviours The Service Users you meet will present with different drinking behaviours and patterns. This can sometimes give an indication of the impact of the alcohol use on their physical and mental health. Binge drinking is often characterised by repeated use of alcohol, above recommended limits for at least two days, these Service Users are unlikely to be physically dependent but remain at risk physically and will often describe periods of low mood and increased anxiety. Other Service Users will present with daily drinking above recommended limits with no alcohol free days, these Service Users are at significant risk of developing physical dependency and developing chronic/ acute physical health conditions attributable to their alcohol use. Calculating the number of alcohol units a Service User consumes on an average day of drinking can be useful in many ways. For the Service User this may give them an opportunity to compare their consumption against safe recommended limits both at assessment and during treatment reviews. Recording the number of Units the Service User consumes should give us a more accurate picture of their actual use which is measurable over time. However, many studies have shown that Service Users consciously and unconsciously under-report the number of units they consume. With this in mind it is important when planning treatment with the Service User that other screening tools and assessment information is utilised. To calculate units: Units = number of millilitres x % alcohol by volume divided by 1000, thus: A glass of wine: 125ml x 12% = 1.5 units Drug and Alcohol Awanress final - 16

17 A half bottle gin: 375ml x 37% = 13.8 units A 2 litre bottle of white cider: 2000 x 7.5% = 15 units A can of Stella: 500ml x 5.4% = 2.7 units Drinking alcohol above recommended limits has been linked to a number of physical and mental health risks. It is useful to know these in order to support the Service User when making an informed decision around their drinking behaviour. Damage from alcohol: Short term exposure: injuries from accidents and violence, poisoning, acute vascular effects- cardiac arrhythmias, ischaemic stroke, depression, death including suicide Long term exposure: chronic conditions e.g. Liver cirrhosis or cancer. Effects on other parts of the body - Brain: headaches, delusions, paranoia, decline in IQ, dementia, epileptic fits, haemorrhage, peripheral neuritis, death. Throat and gullet: increased risk of cancer. Heart: Weak and fatty heart, weakened heart, muscles, hypertension, oedema. Liver: Fatty cells, scarring, jaundice, hepatitis, cirrhosis, liver failure and liver cancer. Pancreas: Poor digestion, malnutrition, diabetes. Stomach: Gastritis, peptic ulcer. Intestines: inflammation. Nervous system: peripheral neuropathy, tremors. Sexual organs: Men Depressed testicular production, impotence. Women failure to ovulate, miscarriage. Bones and muscles: Degeneration, weakness, pain. Drug and Alcohol Awanress final - 17

18 Liver: The most common alcohol-related death in Great Britain was alcoholic liver disease which accounted for 63% (4,075) of alcohol-related deaths in Drinking excessive amounts of alcohol over the course of many years can damage the liver, leading to hepatitis (inflammation of the Liver). This type of hepatitis is known as alcoholic hepatitis. This inflammation is often reversible following cessation from alcohol and should not be confused with infective hepatitis such as hepatitis C.. It is estimated that as many as one in four moderate to heavy drinkers has some degree of alcohol hepatitis. The condition does not usually cause any symptoms and is often not detected with a blood test. If a person with alcoholic hepatitis continues to drink alcohol, there is a real risk that they will go on to develop cirrhosis (scarring on the liver) and possibly liver failure. Scarring to the Liver is not reversible. Vitamin B depletion: Moderate to severe depletion of Vitamin B and C is commonly seen in Service Users who problematically use alcohol. This can be due to a number of factors which include, but are not limited to poor absorption in the body and reduced dietary intake which means the essential vitamins needed to protect the brain and central nervous system are diminished. Initially Service Users and/ or their family and friends may notice memory problems. The Service User may also experience numbness or tingling in their hands and feet. This is an early sign of central nervous system damage. Much more serious damage to the brain from vitamin B deficiency can occur suddenly during alcohol withdrawal, or more chronically, and is known as Wernickes Korsakoffs syndrome. Long term use of alcohol may result in increased damage to the brain further impacting on the Service Users memory and cognitive function. Most Service Users report an improvement in their memory following the cessation of alcohol, coupled with an increase in balanced meals containing essential vitamins. National guidelines also recommend the prescribing of Vitamin B complex and Thiamine for these Service Users. Screening Tools The uses of evidence based alcohol screening tools are critical to accurately identify the Service Users needs and can guide us to provide appropriate advice. AUDIT: The Alcohol Use Disorder Identification Test is widely used and endorsed by the World Health Orgnisation (WHO). This is seen as the gold standard in screening tools, has been validated in more than 22 countries and has a high sensitivity in accurately identifying hazardous alcohol use. It takes 5 minutes to complete and interpret. Drug and Alcohol Awanress final - 18

19 The AUDIT is made up of 10 questions. Questions 1-3 measure the quantity and frequency of regular/ occasional use. Questions 4 6 measure the occurrence of possible dependence and questions 7-10 look at recent problems associated with alcohol use. The Audit produces the score below and categorises the Service User based on risk. Score DH Terminology NICE Terminology 0-7 Lower Risk 8-15 Increasing Risk Hazardous Drinking Higher Risk Harmful Drinking Possible Dependence The table below describes the type of interventions that are delivered based on someones AUDIT score. Discuss with other staff and you manager the types of interventions provided for different levels of AUDIT score within your service? Classification of alcohol use Definition Intervention offered Interventions in my service Hazardous Audit score 8-15 One off, brief intervention. Simple, structured information and advice. Use of screening and brief intervention pro forma with consent. Harmful Audit score sessions of extended brief interventions. Structured information and advice, focused activities and access to resources and strategies. Moderate Dependence Audit score 20 + Care planned approach, PSI, MI, CBT, MET access to specialist treatment and wrap around support. Drug and Alcohol Awanress final - 19

20 Harm reduction advice The assessment process is an opportunity to deliver harm reduction advice based on the most up to date and accurate information. Advice should be tailored based on the needs identified. If you are unsure if the advice you are planning to provide is appropriate you must always discuss this with another member of your team, a nurse or doctor. Harm reduction advice should address ways to (not exhaustive): Avoid vitamin B depletion and/ or further CNS damage through changes in diet and the prophylactic prescribing of Vitamin B and Thiamine by the Service Users General Practitioner, or the administration of Pabrinex injections by a trained nurse. When it is considered safe reduce the amount drunk and risk taking behaviours including further damage through changing alcohol beverages or otherwise reducing the total number of units consumed each day. This can be achieved by establishing an accurate baseline by providing the Service User with a drink diary, followed by negotiating controlled reductions with the Service User. Avoid the Service User s experience of moderate to severe alcohol withdrawal state by advising the Service User to avoid sudden cessation of alcohol consumption if after discussion with the doctor/ nurse it is felt that the Service User is physically dependent on alcohol. Psychological vs. Physical Dependency The International Classification of Disease (ICD), a tool used to guide practitioners when making medical diagnosis, states that the Service User must meet a specific number of criteria in order to be considered for a diagnosis of dependency. The criteria are a mix of physical and psychological symptoms. The Service User can display either or both physical and psychological symptoms to be diagnosed with dependency. Treatment interventions are aimed at the types of symptoms displayed by the Service User, a single intervention alone does not treat all symptoms of dependency. The risks to the Service User are also very different for a Service User who may be physically dependent compared to psychological dependency. Below is the ICD classification for Dependency. ICD 10 classification Three or more of the following have been present together at some time during the previous year: A strong desire or sense of compulsion to consume alcohol; Difficulties in controlling drinking behavior in terms of its onset, termination, or levels of use; Drug and Alcohol Awanress final - 20

21 A physiological withdrawal state when alcohol use has ceased or reduced Evidence of tolerance, such that increased doses of alcohol are required in order to achieve Progressive neglect of alternative pleasures or interests because of alcohol use, increased amount of time necessary to obtain or take alcohol or to recover from its effects; Persisting with alcohol use despite clear evidence of overtly harmful consequences effects originally produced by lower doses Place each of the above criterion under the heading Psychological or Physical and see if you re right. Psychological Physical Drug and Alcohol Awanress final - 21

22 Physical Dependency As shown previously Service Users who are physically dependent will demonstrate a physical withdrawal when alcohol has stopped, and evidence of tolerance. These are the Service Users most at risk of harm if they suddenly stop drinking. When you see these symptoms always seek advice from a doctor or nurse. Alcohol Withdrawal State For a Service User who is addicted to alcohol stopping alcohol can cause significant distress ranging from increased levels of anxiety, agitation and restlessness (Psychological) too hallucinations, tremors, disorientation and seizures (physical). Onset and duration of withdrawal symptoms differs among individuals. The table below shows the average onset and duration for recognised withdrawal symptoms: IMPORTANT: If your Service User attends an appointment or group, is known to be problematically drinking alcohol and demonstrates any of the withdrawal symptoms described it is best to contact emergency services. Treatment Options: Psychological Dependency Treatment interventions provided to the Service User are evidence based and should be chosen to meet Service User needs through care planning processes. They include the provision of brief advice as detailed in the following table, counselling sessions, structured groups and key working sessions. Relapse prevention models, Motivational Interviewing Principles and Motivational enhancement Therapy can all be utilised to support the Service User in their recovery. Many service users also benefit from attendance at mutual aid groups such as Alcoholics Anonymous and SMART. Service users can also benefit from attendance at MOPSI based groups and other interventions available in services. They are most effective at addressing the contributory factors relating to the Service Users alcohol Drug and Alcohol Awanress final - 22

23 use and can also support the Service Users to manage the psychological symptoms of addiction. These interventions are also critical for Service Users who are physically dependent. Treatment Options: Physical Dependency Service Users who are physically dependent will need to be seen by a health professional to determine the most appropriate and safest treatment option that aims to remove the risk of moderate to severe withdrawal symptoms. Two common approaches exist and choice is determined by the Service Users physical health, mental health and social factors. Drink Diary and controlled reductions Many Service Users achieve abstinence from alcohol using a Drink Diary to record the units of alcohol they use, and then use this with their key worker to create a slow reduction plan. The reduction plan will be negotiated between the Service User, key worker and doctor/ nurse. The reduction plan must be reviewed regularly and if the Service User shows signs of withdrawal symptoms further reductions should be stopped until the Service User is reviewed by a healthcare professional. Medically Assisted Withdrawal ( Detoxification ) This involves the provision of medication for a time-limited period following the cessation of alcohol, aimed at decreasing the risk of serious adverse health consequences, and reducing the Service User s experience of alcohol withdrawal symptoms until all symptoms stop. Detoxification from opiates and alcohol are two very different events. Detoxification from opiates is uncomfortable, but fairly safe, whilst detoxification from alcohol is potentially dangerous, and can (unusually) be permanently disabling or fatal. Thus assessment for an alcohol detox is focussed on assessing health risks and how to conduct the process safely. For a Service User to benefit most from a detox it should be viewed as a planned intervention and subject to care co-ordination and recovery care planning processes. During the planning processing contingency and aftercare plan must be in place to support continued abstinence. If a Service User remains ambivalent about the need for a detox or resolving their alcohol dependency it may be appropriate to delay detoxification and continue to explore their problems. Repeated unsupported and unplanned detoxes may be harmful to the Service User and as such all care provided to Service Users in treatment should seek to prevent this occurring. However, supported detoxes should be carefully planned and appropriate for the Service User. Through assessment a health professional must be assured that motivation and circumstances are conducive to detoxification. Drug and Alcohol Awanress final - 23

24 Should a Service User fail to complete a planned detox, you will need to explore the circumstances to try and avoid the same problem(s) occurring with subsequent detox attempts. Type of Detox GP led detox Description A supported community detox for the least complex of Service Users with alcohol dependency. It is provided in the community, perhaps with the Service User attending the surgery on a daily basis for monitoring by the Practice Nurse/ GP during the course of the detox, typically for 5 days. It is dependent on the Service User having a responsible carer who can support them throughout the course of detox including the management of their withdrawal medication. The detox is usually provided in partnership with the local treatment provider. Chlordiazepoxide is the withdrawal medication used in dosing regimens chosen according to Service User presentation. Supported outreach community detox Residential Detox A supported community detox for Service Users who can be managed in the community whilst remaining in their own accommodation with care provided by a Community Detox Nurse. Service Users can be seen either at home or at the local drug service base. Contraindications to this detox are similar to those for the GP led detox but as support is offered in the Service User s own home then it is suitable for Service Users who are unable to attend their GP surgery. Also the skills of the Community Detox Nurse allow more flexibility to support Service Users with mental health and other substance misuse problems. Residential detoxes are for Service Users who are not suitable for community detox. These may include Service Users who have specific complicating problems including those with concomitant substance misuse Drug and Alcohol Awanress final - 24

25 who want to stabilise or detox their drug problem as well as detox from alcohol. They may also be suitable for Service Users who need to progress to secondary rehabilitation and support as part of their recovery. These residential units may be particularly suitable for those with mental health problems, learning disability problems or couples who both require detox/stabilisation. Medically Assisted Withdrawal Prescribing The principle of alcohol detoxification sounds complicated but is in fact very simple: alcohol is a powerful short acting sedative and many years of heavy use causes the brain to fight this sedation by producing a stimulating chemical (glutamate). So when the sedative alcohol is stopped there is a large amount of residual glutamate that overstimulates the nervous system causing anxiety, tremors, sweating, and more serious health risks described elsewhere. Thus the purpose of detox is to replace the dangerous short acting sedative (alcohol) with a predictable safer long acting sedative such as chlordiazepoxide or diazepam, and wean this away at a rate that does not allow severe withdrawal symptoms to return - a process typically taking 3-8 days. Relapse Prevention Prescribing Prescribing medication to reduce the severity and frequency of cravings and urges to use alcohol has been shown to be effective for many Service Users who have shown a desire to stop using alcohol. Medication should not be used in isolation and Service Users achieve far better outcomes when they also undertake psychological work to address their relationship with alcohol. Some of the medications used to halp to support reduction and abstinence from alcohol are described in the following table: Naltrexone Naltrexone works by blocking the opioid receptor in the brain. This medication has been used for many years with Service Users dependent on opiates such as heroin. Blocking the opioid receptor for these Service Users stops heroin and other opiates such as Methadone, codeine and Tramadol from attaching to the receptors in the brain and producing the desired effect. One of the effects of alcohol which the recently abstinent alcoholic misses the most is the sensation of euphoria from an Drug and Alcohol Awanress final - 25

26 alcoholic drink. This euphoria seems to be in part mediated through brain opiate receptors which naltrexone block. Naltrexone is licenced to be given to those abstinent from alcohol to reduce both cravings and the sensation of euphoria from alcohol, thus making the experience less leasurable and a lapse less likely to become a relapse. Service Users are usually prescribed one 50mg tablet each day. On the first day of prescribing they are issued a 25mg dose. Due to its blocking effect on opioid receptors some Service Users will not be appropriate for this intervention such as Service Users who regularly take opioid medication for pain relief. Nalmefene This medication works in a very similar way to Naltrexone. But its licence differs in that it is indicated for use with Service Users who problematically continue to use alcohol who may not yet be physically dependent. It reduces cravings and evidence shows that it can reduce the amount of alcohol consumed to less harmful levels. Service Users are usually prescribed 18mg each day. Acamprosate (Campral) Acamprosate is the most commonly prescribed relapse prevention medication. Its pharmacology is not as clear as that for Naltrexone and Nalmefene, however its evidence base is greater in its ability to reduce cravings and urges to use alcohol.. It is recommended that this medication is started on the Service Users first day of detox due to its theoretical neuroprotection qualities, continued through the detox Drug and Alcohol Awanress final - 26

27 process and prescribed for a further 6 months to support the Service User in remaining abstinent. The dose prescribed is dependent on the Service Users weight and they take doses three times per day. Disulfiram (Antabuse) Disulfiram is taken once daily and is an aversive drug in that if alcohol is taken, it causes extremely unpleasant side effects of flushing, headaches, nausea etc. This medication also interacts with other substances containing alcohol such as perfumes, food, and aerosol spray and so on. Exposure to these substances can also trigger a toxic effect. As a result of this great consideration is taken when selecting appropriate Service Users for this treatment intervention. What are the treatment options in your service for someone who is physically dependant on alcohol? Drug and Alcohol Awanress final - 27

28 A service users is assessed as being physically dependent on alcohol but is inssitant that they want to stop drinking immediatley. What advice would you give and what would be the risks? What action might you take? Drug and Alcohol Awanress final - 28