Alcohol management York Service Alcohol management - medically assisted alcohol withdrawal and supported reduction

Transcription

1 Alcohol management York Service Alcohol management - medically assisted alcohol withdrawal and supported reduction Version 4 JT January 2014 page 1

2 Alcohol Management York Service assessment of alcohol use disorders The assessment of alcohol use disorders and related conditions relies on bringing multiple sources of information: Alcohol units/week (consider using drink diaries) Health check: nutritional status, pulse and blood pressure History and listening to the client: to identify harm associated with alcohol use, drinking pattern, how many hours sleep without needing alcohol, morning withdrawal symptoms etc Alcohol AUDIT: is a screening test for hazardous and harmful drinking, and can suggest dependence (though does not diagnose it) SADQ: can help assess the severity of dependence as mild, moderate or severe. Blood tests: Some blood tests including FBC (for MCV), LFT and GGT can suggest alcohol problems, but many who are dependent drinkers have normal tests, and many who don t drink have some abnormality. Liver function tests such as bilirubin and clotting can help to identify the severity of liver disease caused by alcohol use Alcometer: can assess the blood alcohol level at any instant. It is not of great value in assessing alcohol misuse, though a negative test in a client who is not showing withdrawal makes dependence unlikely, and a high result without signs of intoxication suggests tolerance. CIWA-A: can help assess the severity of any alcohol withdrawal Version 4 JT January 2014 page 2

3 Alcohol Management York Service assessment of alcohol use disorders Alcohol use problems can be broadly classified as: Lower risk drinking: men <3-4u/d regularly or 21u/w, women <2-3u/d regularly or 14u/w. Special cases include pregnancy and hepatitis C infection where lower levels can have high risk Hazardous drinking: greater than the recommendations above, at risk of developing harm but no actual harm currently Harmful drinking: experiencing harm directly related to higher levels of drinking (most usually physical or mental health harms, but might include social harms) Binge drinking: variable, but >8u in any drinking episode for men, and >6u for women Dependent drinking: one of the harms has become dependence on alcohol ICD-10 dependence criteria 3 or more occurring together for at least 1 month of: strong desire or compulsion to use alcohol; difficulties in controlling use; physical withdrawal when use stops or reduces; tolerance to effects; neglect of other pleasures or interests; persisting use despite clear harm Dependent drinking may be classified as mild, moderate or severe. Version 4 JT January 2014 page 3

4 Alcohol Management York Service interventions Information and brief advice: appropriate for hazardous, binge and harmful drinkers who are not dependent Supported alcohol reduction: appropriate for mild and some low-moderate dependent drinkers. May include prescribing support for clients finding it hard to achieve goals with psychosocial support alone Community detoxification: appropriate for moderate and some severely dependent drinkers without contraindications, following adequate preparation and identification of aftercare Residential detoxification: appropriate for severely and some moderately dependent drinkers, for whom community detoxification is contraindicated, and following adequate preparation and identification of aftercare Residential rehabilitation: may follow community or residential detoxification as part of some clients aftercare Version 4 JT January 2014 page 4

5 Alcohol Management York Service supported alcohol reduction The client goal may be abstinence, or may be regaining controlled drinking. Suitable for some clients who have mild or low moderate dependence (SADQ <25), no alcohol-related complications, and no other significant substance or health problems. Reductions are planned, and aim to reduce drinking by around 10% every week or fortnight, until the client s goal of abstinence or controlled drinking is achieved. The client must see the R+D nurse as part of planning for supported alcohol reduction Clients who are actively reducing need to spread their alcohol use through the day so there are no long periods without alcohol when withdrawal symptoms may occur. Reduction should be tried with psychosocial support, including mutual aid and groups. If the client is unable to achieve planned reductions, and is fully engaged with psychosocial aspects of treatment the reduction programme may be supported by acamprosate or naltrexone prescribing in dependent clients (SADQ minimum 16). Prescribing in this way is off license and the client s informed consent must be recorded in the care record. When considering naltrexone take a careful history of opioid use, always perform an on site test before starting treatment, consider an oral naltrexone challenge if there is any concern. Prescribing is used only during an active planned reduction phase. If the client reaches the agreed goal, prescribing will be tailed off and stopped as the client uses alternative resources to maintain their goal. If the supported reduction is not successful, prescribing should be stopped. Thiamine should be prescribed for dependent clients while they are reducing. Version 4 JT January 2014 page 5

6 Alcohol Management York Service MAAW alcohol withdrawal syndrome Alcohol withdrawal in a dependent drinker is associated with a range of unpleasant symptoms, and more importantly a range of serious and potentially life-threatening medical complications. Typical alcohol withdrawal symptoms: Begin typically 6-12 hours after last alcoholic drink, peak at hours, may last 5-7 days Symptoms include headache, anxiety, anorexia, nausea, vomiting, sweating, sleeplessness, shaking and sweating. More serious complications require urgent hospital admission: Generalised (grand mal) convulsions. Typically occur hours after last drink, they are more likely if there is a previous history of epilepsy or withdrawal fits Delirium tremens (DTs). Occur in about 5% of those withdrawing from alcohol. Symptoms can begin within hours of withdrawal, peak at 48 hours and subside over 3-4 days. DT s are more likely to occur in very heavy drinkers. In addition to the symptoms of alcohol withdrawal above, the symptoms of DT s are severe tremor, agitation, marked anxiety, confusion, disorientation in time and place, visual and auditory hallucinations and occasional paranoid ideas. Fever can feature. Wernicke-Korsakov Syndrome. This is related to thiamine deficiency and can be precipitated by alcohol withdrawal. Wernicke s encephalopathy should be suspected and acted upon urgently whenever there is ataxia, hypothermia, hypotension, confusion, ophthalmoplegia (difficulty moving eyes), nystagmus (wobbling of eyes), memory disturbance, vomiting, coma or unconsciousness during detoxification. Untreated it can result in permanent brain damage or death. York Service in M Version 4 JT January 2014 page 6

7 Alcohol Management York Service MAAW rationale symptoms and risks troduction, The medical management of community alcohol withdrawal is focused on four principles: Assessment and preparation: To ensure only the right clients are accepted for community detoxification, and that community detoxification is safe Aftercare It is crucial that aftercare is fully planned before starting any detoxification. Aftercare is central to helping the client to maintain abstinence after detoxification Reduction of risk: Benzodiazepine prescribing reduces the risk of withdrawal fits, and is time-limited to cover the duration of withdrawal symptoms, while minimising the risk of developing dependence. Chlordiazepoxide is the benzodiazepine of choice even if the client is prescribed low dose diazepam (diazepam prescribing can continue unchanged throughout detoxification if necessary) Thiamine prescribing 100mg three times daily (long-term in malnourished harmful or dependent drinkers); starting a minimum of four weeks before any planned detoxification, continuing through detoxification and for four weeks after detoxification is completed, reduces the risk of Wernicke s encephalopathy Reduction of symptoms: Time-limited chlordiazepoxide prescribing reduces the severity of withdrawal symptoms Version 4 JT January 2014 page 7

8 Alcohol Management York Service MAAW suitability for community detoxification To be suitable for community alcohol detoxification the client must be assessed as dependent, motivated, supported and safe. The client must see the R+D nurse. Ask: Is the client motivated to stop or control alcohol use now? Is there a good chance of successfully completing detoxification and maintaining abstinence? Is the client fully engaged with support options including groups? Is the client assessed and recorded as alcohol dependent? Alcohol AUDIT test>20 SADQ>15 Alcohol units (<15u/d (men) and <10u/d (women) significant withdrawal and need for MAAW is not likely) Is MAAW the best option for the client, or would supported alcohol reduction work better? This may be appropriate in mild dependence and when controlled drinking is the client s goal What other medication or substances is the client taking? Are there any contraindications to community detoxification (consider managing contraindications before considering detoxification, or referral to CAT or for inpatient detoxification) Cognitive impairment or confusion (perform GPCOG if unsure Age > 65 Repeated, failed community detoxification Epilepsy or previous fit during alcohol withdrawal Previous delirium tremens or Wernicke s during alcohol withdrawal Malnourishment (BMI<18.5 or recent significant weight loss) Significant mental health needs or suicide/self harm risk Unstable, complex or poly-drug misuse, illicit benzodiazepine use, high dose methadone (>60mg/d), diazepam prescribing >5mg/d Significant medical problems, liver impairment, or acute physical illness, vomiting or diarrhoea Social instability or lives alone/no responsible person at home to support Pregnancy or any chance of pregnancy Recent head injury High level dependence or alcohol use (SADQ > 30, Alcohol units > 30/d) Version 4 JT January 2014 page 8

9 Alcohol Management York Service MAAW initial preparation Once accepted for preparation for community alcohol detoxification, the R+D nurse will organise, or ask: Has thiamine been started? If not start it. Ask to make sure the client is actually taking it as prescribed. Give the client the thiamine leaflet to underscore the verbal information given Has the GP been written to? This will alert the GP that alcohol detoxification is imminent Have baseline assessments been done and recorded on Theseus? Blood tests (FBC, U/E, LFT, GGT, BBV) Baseline pulse/bp BMI and basic nutritional assessment Urine toxicology test (must include benzodiazepine) Doctor appointment if necessary to assess complications or health issues Assessment of support and home circumstances Has the aftercare plan been agreed and documented? Consider prescribing interventions prior to detoxification (off license indication, see above) (acamprosate (see Lifeline guidance) or naltrexone, or after detoxification: acamprosate, naltrexone or disulfiram (see Lifeline guidance), mutual aid, day care, key worker support. When considering naltrexone take a careful history of opioid use, always perform an on site test before starting treatment, consider an oral naltrexone challenge if there is any concern. Make sure that methadone is alcohol free mixture if client considering disulfiram Have timing issues been considered? Eg child care, time off from work, availability of appointments Have plans been made to book appointments with doctors/nurses? Has the client been given appropriate information and advice? Has the client been given the appropriate leaflets? Version 4 JT January 2014 page 9

10 Alcohol Management York Service MAAW advice to clients and carers Client name Your detox is due to start Monday..at.am Try to drink as little as you can after midnight on Sunday before your detox starts. You may need a small amount to stop withdrawal before the first appointment. You have agreed not to drink any alcohol after the detox has started. Your detox can only continue if you stay off drink. Do not drive while you are on an alcohol detox. Medication Prescribed medication can help reduce the symptoms while your body adjusts to being without alcohol. The symptoms get less every day through the detox, and last less than a week. That s why prescriptions are only for about a week, and the dose gets less through the course. You must attend all your appointments, or the detox will have to stop Thiamine Please keep taking your thiamine tablets throughout your detox and for at least four weeks after it finishes. This can help prevent serious health problems Thirst You may get thirsty while on your detox. Drink fruit juices and water but do not overdo it. You do not have to flush alcohol out of the body. Keep fluids to less than three litres of fluid (five pints) per day. Don t drink more than three cups of coffee or five cups of tea per day. These contain caffeine which disturbs sleep and causes nervousness. Avoiding stress The important task is not to give in to the urge to take alcohol. Help yourself relax by going for a walk, talking to a friend, listening to music, or taking a bath. Resting and sleeping You may find that even with the medication your sleep is not good. Don t worry about this not sleeping for a few days won t hurt you. Your sleep will return to normal in a few days. Make sure you take the opportunity to get some rest and quiet in the daytime. Try not to take sleeping tablets, and let your sleep get back to normal naturally. Take a bedtime snack or milky drink late evening to help you sleep better. Eating Even when you are not hungry, try to eat small amounts regularly. Your body needs extra energy during an alcohol detoxification. Problems It s rare for a detox not to go well. Potential problems include vomiting that won t stop, fits, severe anxiety, confusion, hallucinations, difficulty seeing, difficulty walking, drowsiness or unconsciousness. If you get any problems (or if you are a carer you notice any problems) get urgent medical advice. Version 4 JT January 2014 page 10

11 Alcohol Management York Service MAAW information about thiamine Thiamine is one of the B vitamins. When you drink heavily for a while, your body gets very low on thiamine This can have really serious consequences. You could end up with permanent brain damage. You can get brain damage at any time when you are drinking. Stopping alcohol or doing a detox puts you at greatest risk. You could even die during a detox from lack of thiamine. The solution is simple We have prescribed you thiamine tablets to reduce the risk and to help keep you healthy. Taking them when you are drinking, throughout an alcohol detox, and for at least four weeks afterwards is important. Take one tablet three times a day, with a meal if you can. Version 4 JT January 2014 page 11

12 Alcohol Management York Service MAAW appointments and monitoring Med Detoxification appointments must be booked in advance. All community alcohol detoxifications start on a Monday morning, with the Monday appointment early in the morning before the risk of severe withdrawal symptoms developing Wherever possible, the recovery coordinator should attend detoxification appointments, and will take the primary role of supporting the client through and after the detox Week prior to detox Detox day 1 (Prescriber, 30 minutes) Ensure advice leaflet given and all advice discussed, detoxification assessment checked complete, client taking thiamine, all appointments booked, GP letter sent, and all aftercare in place Baseline withdrawal assessment (formal using CIWA-A or informal), baseline BP and pulse Ask when last drank alcohol and take baseline breath alcometer (consider cancelling if alcometer > 0.6mg/l [drink driving limit equivalent 0.35mg/l] or the client is significantly intoxicated the client may not be in a position to start detoxification) Complete medication chart with client name and dates. 7 day detox is suitable for lower moderate dependence (eg SADQ 16-24, and 10 day for higher moderate dependence (eg SADQ 25-30). Ask the client to tick each dose of chlordiazepoxide as it is taken. One copy is given to the patient to take home, and a copy retained in the client s file. Advise the client that no alcohol should be consumed once the first dose of chlordiazepoxide has been taken. Prescribe chlordiazepoxide on daily green scripts up to the next prescriber appointment. Give the client one day, and put the second day in the file to be issued at the day 2 appointment Version 4 JT January 2014 page 12

13 Day 2 (R+D nurse, 15 minutes) Monitor withdrawal (formally with CIWA A or informally) Monitor for oversedation on medication, history or presentation suggestive of fit, DT, Wernicke s encephalopathy, intractable vomiting or dehydration, other illness Measure P, BP, alcometer Contact prescriber for advice to: stop detox if alcometer>0; adjust medication if over sedated or uncontrolled withdrawal Day 3 (Prescriber, 15 mins) Day 4 (R+D nurse, 15 minutes) Day 5 (Prescriber, 15 mins) Issue pre-prepared chlordiazepoxide prescription Monitoring as day 2 Prescribe chlordiazepoxide on daily green scripts up to the next prescriber appointment. Give the client one day, and put the second day in the file to be issued at the day 2 appointment Monitoring and prescription as day 2 Monitoring as day 2 Prescribe chlordiazepoxide on daily green scripts up to the next prescriber appointment. Give the client prescriptions for the weekend Day 8 (Prescriber, 15 mins) 10 day detox only Discuss plan for relapse prevention medication if detox is ending Monitoring as day 2 Prescribe chlordiazepoxide on daily green scripts to complete the detox (10 day detoxes) Discuss starting relapse prevention medication if detox is ending Version 4 JT January 2014 page 13

14 Alcohol Management York Service MAAW stopping community detoxification Stopping detoxification Detoxification should not be started if the day 1 alcometer is >0.6mg/l or the client is significantly intoxicated at the first appointment. Detoxification should be stopped if an alcometer is positive during monitoring of a detoxification Detoxification should be stopped if a client DNAs an appointment, or shows sign of other risky illicit use Managing serious complications/admission to hospital About 5% of cases develop significant complications during alcohol detoxification. If any significant complications develop, the client should be admitted to hospital on an urgent basis Complicated withdrawal includes: Failure to respond as expected to adequate treatment, persistent severe withdrawal symptoms Patient or relative no longer able to support detoxification Withdrawal fit Acute mental health problems or identified suicide risk Altered consciousness level Intractable vomiting or dehydration Suspected delerium tremens/alcoholic hallucinations Suspected Wernicke s encephalopathy. Wernicke s encephalopathy should be suspected and acted upon urgently whenever there is ataxia, hypothermia, hypotension, confusion, ophthalmoplegia, nystagmus, memory disturbance, vomiting, coma or unconsciousness during detoxification. The classic diagnostic triad of symptoms (confusion, ataxia and ophthalmoplegia) occurs in only 10% of cases. Suspected hepatic decompensation Version 4 JT January 2014 page 14

15 Alcohol Management York Service 7 day chlordiazepoxide chart Please take your medication only as shown. It is dangerous to take more or less tablets than the chart. Tick each dose off when you ve taken it so you don t get mixed up. The capsules may make you a bit drowsy so you must not drive or operate machinery or drive while taking them. If you feel unwell, please get medical advice urgently (see leaflet for more details) Make sure you are taking thiamine three times a day as well Client name: Day of detox Date Number of tablets (chlordiazepoxide 10mg) Number of tablets (chlordiazepoxide 10mg) Number of tablets (chlordiazepoxide 10mg) Number of tablets (chlordiazepoxide 10mg) MORNING LUNCH TEATIME BEDTIME Day Day Day Day Day Day Day Version 4 JT January 2014 page 15

16 Alcohol Management York Service 10 day chlordiazepoxide chart Please take your medication only as shown. It is dangerous to take more or less tablets than the chart. Tick each dose off when you ve taken it so you don t get mixed up. The capsules may make you a bit drowsy so you must not drive or operate machinery or drive while taking them. If you feel unwell, please get medical advice urgently (see leaflet for more details) Make sure you are taking thiamine three times a day as well Client name: Day of detox Date Number of tablets (chlordiazepoxide 10mg) Number of tablets (chlordiazepoxide 10mg) Number of tablets (chlordiazepoxide 10mg) Number of tablets (chlordiazepoxide 10mg) MORNING LUNCH TEATIME BEDTIME Day Day Day Day Day Day Day Day Day Day Version 4 JT January 2014 page 16

17 Alcohol Management York Service MAAW managing other symptoms Sometimes clients have withdrawal symptoms that are not relieved by chlordiazepoxide. It is possible to give advice or prescribe other medication as symptomatic relief during a detox, but best to keep the number of medications and doses to a minimum Poor sleep: Do not prescribe hypnotics, use non-pharmacological approaches, advice and reassurance. If severe, consider loading the total daily dose of chlordiazepoxide towards the evening or increasing the night time dose for 1-2 days, or extending the period of detoxification Poor appetite: Encourage good diet, small amounts and often. Sip feeds shouldn t be necessary, if the client is malnourished, they shouldn t be having a community detox Nausea and vomiting : Metoclopramide 10 mg qds prn or buccastem 3-6mg bd. Admit if persistent or severe vomiting Diarrhoea: If severe use loperamide 2-4 mgs prn Heartburn: Gaviscon 10 ml prn Itching: Check for signs of liver disease, review LFT results. If necessary chlorphenamine 2-4 mg tds Headache: Paracetamol, with caution in liver disease or history of peptic ulcer or haematemesis (vomiting blood) Anxiety: Information, reassurance and non-pharmacological approaches. If severe may need to consider whether this is a presentation of DTs Depression: This is common for the few weeks after detox. Give reassurance, monitor for severe persistent symptoms and suicidal ideas and act as necessary. If persists after detoxification the client may need referral. Version 4 JT January 2014 page 17

18 Alcohol Management York Service supported alcohol reduction summary and check-list 1 Ensure plans for alcohol reduction have been discussed with the recovery coordinator and form part of the client s care plan 2 Ensure the client has had an appointment with the R+D nurse to plan preparation, reduction and aftercare, health check 3 Ensure alcohol use fully assessed, including bloods, and SADQ to establish dependence. Level of dependence is suitable for supported alcohol reduction (low and low-moderate dependence) 4 Significant alcohol-related complications and risks excluded 5 Client taking thiamine 6 Client motivated to reduce alcohol use NOW, engaged with psychosocial input, attending groups, AA, SMART etc 7 Client informed, and chooses supported alcohol reduction as the management of choice. The client has made clear the management goal controlled drinking or a period of abstinence 8 Aftercare fully planned including prescribing options 9 The client must have no other unmanaged or unstable substance misuse problems (including benzodiazepine or pregabalin misuse) 10 Alcohol reduction timetable documented, reduction aimed to be around 10% current consumption weekly until goal achieved 11 If client unable to achieve goal with psychosocial support alone, see R+D nurse to consider if addition of prescribing may be of value 12 If naltrexone or acamprosate prescribing started, obtain and document client s consent for off license treatment When considering naltrexone take a careful history of opioid use, always perform an on site test before starting treatment, consider an oral naltrexone challenge if there is any concern. 13 When goal achieved prescribing will be tailed off and stopped over a month or two as the client uses other resources to maintain goal. If goals are not being achieved despite prescribing, prescribing will stop and alternative plans considered Version 4 JT January 2014 page 18

19 Alcohol Management York Service MAAW summary and check-list 1 Ensure any plans for detoxification have been discussed with the recovery coordinator and form part of the client s care plan 2 Ensure the client has had an appointment with the R+D nurse to plan preparation, detoxification and aftercare 3 The client has had a health check 4 Ensure alcohol use has been fully assessed, including bloods, and SADQ to establish dependence, urine toxicology test. Level of dependence is suitable for community alcohol detoxification (low and moderate dependence, units >15/d for men, 10/d for women) 5 The client must have no other unmanaged or unstable substance misuse problems (including benzodiazepine or pregabalin misuse) 6 There are no contraindications to community alcohol detoxification (see list in guidance) 7 Options have been discussed with the client and community alcohol detoxification is the first choice for management 8 The client is taking thiamine 9 The client is well engaged with psychosocial aspects of the treatment programme, including groups and mutual aid. 10 Aftercare has been planned and structured (this may sometimes include planning for residential rehabilitation) 11 Prescribing aftercare options have been discussed and planned for (LFT/U/E if considering prescribing) 12 GP has been written to 13 The client has been given the relevant information leaflets (thiamine, alcohol detoxification) 14 Necessary support and monitoring appointments for detoxification have been planned for 15 Practical aspects, including work and childcare have been thought through Version 4 JT January 2014 page 19

20 Med Withdrawal York Service d York Service disulfiram information What is disulfiram? Disulfiram is a tablet used to help someone who has come off alcohol to stay off drinking. The other name for disulfiram is antabuse. It works by interfering with the way your body breaks down alcohol. If you drink even a small amount of alcohol when you ve taken disulfiram the reaction will be very unpleasant. The reaction can be very dangerous. You might get throbbing headache, flushed face, palpitations and sickness. The knowledge that you may get this reaction will help stop you from wanting to drink alcohol. Before taking disulfiram Before taking disulfiram make sure you re the service knows: If you are pregnant, trying for a baby or breast-feeding. If you have heart failure or heart disease. If you have high blood pressure. If you have mental health problems. If you have ever had a stroke or transient ischaemic attack (TIA). If you have liver or kidney problems. If you have diabetes If you have epilepsy. If you have breathing problems. If you are taking other medicines. That includes prescribed, and those you buy without a prescription, herbal and complementary medicines. If you have ever had an allergic reaction to this or any other medicine. We will ask you to have a blood test to check your liver before we prescribe disulfiram How do I take disulfiram? It is important that you have not drunk alcohol for at least 24 hours before taking your first dose. Take disulfiram exactly as you have been advised by the prescriber. Version 4 JT January 2014 page 20

21 You must not drink ANY alcohol during this treatment. Even a small amount can produce a potentially dangerous reaction, and you may end up in hospital Some foods, liquid medicines, toiletries, perfumes, mouthwashes and aerosol sprays may contain enough alcohol to cause al reaction with disulfiram. Before buying any medicines or toiletries, check the label to make sure they are alcohol-free. Low alcohol and "non-alcohol" or "alcohol-free" beers and wines still contain alcohol, and can cause a reaction. Make sure your family and friends know how important it is that you do not drink any alcohol while you are taking disulfiram so they can be a support to you. If you forget to take a dose, take it as soon as you remember if it is still within 12 hours of when the dose was due. If you do not remember until after 12 hours, skip the missed dose. Do not take two doses together to make up for a forgotten dose. Disulfiram can stay in your system for a while. You shouldn t drink alcohol for a week after your last disulfiram tablet. Can disulfiram cause problems? Most people don t have any problems taking disulfiram. If you do get a problem, it is usually mild, and improves as your body adjusts to the new medicine. Speak with your doctor or pharmacist if any of the following side-effects continue or become troublesome. If you feel or are sick, eat little and often. Stick to simple or bland foods and avoid rich, spicy foods. If you are sick, drink plenty of liquid If you feel drowsy you should not drive, operate machinery or do any other jobs which could be dangerous. In summary You must not drink alcohol when you re taking disulfiram you may become very ill You also have to avoid some toiletries as they may contain alcohol, and the alcohol can be absorbed by your skin: Deodorants. (Many are now alcohol free. Check the labels) Perfumes/aftershaves Mouthwashes check labels. Many are alcohol free Cough medicines check labels Soap free hand cleaners I have read and understood the above advice Name date. Version 4 JT January 2014 page 21