SPECIFICATION FOR THE LOCAL COMMISSIONED SERVICE FOR THE MANAGEMENT ALCOHOL MISUSE

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1 SPECIFICATION FOR THE LOCAL COMMISSIONED SERVICE FOR THE MANAGEMENT OF ALCOHOL MISUSE Date: March

2 1. Introduction Alcohol misuse is a major public health problem in Camden with high rates of hospital admission and mortality related to alcohol. Camden has around 12,000 higher risk drinkers who are drinking above recommended limits, of whom around 4,000 have developed a dependency. The impact is considerable: higher than average rates of alcohol related crimes, rates of mortality from chronic liver disease that are nearly double the regional average, and alcohol related hospital admissions are nearly one third higher. Addressing alcohol misuse is one of the key priorities for Camden Health and Wellbeing Board, Camden Clinical Commissioning Group (CCCG) and Community Safety Partnerships. Interventions that are known to be effective in reducing alcohol misuse include: 1) Targeted screening of at-risk groups using a standard screening tool to identify alcohol misuse 2) Brief interventions for hazardous and harmful drinkers 3) Specialist alcohol treatment and support for dependent drinkers This Local Commissioned Service (LCS) will support these interventions in Camden GP Practices with input from the Camden Integrated Alcohol Service. This specification is based on the following clinical guidance from the National Institute of Clinical Excellence (NICE): CG115 Alcohol use and disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) The Camden Alcohol LCS is specifically for the delivery of home detoxification intervention. Screening, brief interventions and extended brief interventions are commissioned nationally by NHS England through a Direct Enhanced Service (DES) scheme. Definitions Hazardous Drinking: Drink over sensible limits but have not yet sustained adverse health outcomes Harmful Drinking: Drink over sensible limits and have begun to experience adverse health outcomes Dependent Drinking: Increased drive to use alcohol. More severe dependence is associated with physical withdrawal symptoms. 2. Eligibility Assisted alcohol withdrawal can be considered for people who typically drink 15 units of alcohol per day and / or who score 20 or more on the AUDIT. Where there are safety concerns, the community based assisted withdrawal should be managed through a specialist alcohol service, and patients should be supported to access these services. This includes patients with moderate dependence and 2

3 complex needs, or severe dependence, where the assisted withdrawal should be offered alongside an intensive community programme. Please see Appendix 1 and also NICE CG 115, sections and for exclusion criteria for community based referral. 3. Service specification 3.1 Delivery of Home Detox Intervention Requirements People needing medically assisted alcohol withdrawal should be offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric co-morbidities. The assisted withdrawal should be usually offered as part of a community-based programme which should vary in intensity according to the severity of dependence, available social support and the present of co-morbidities. The assisted withdrawal programme should consist of a drug regime (see Appendix 1) and psychosocial support, including motivational interviewing. Camden Integrated Alcohol Service is able to provide GPs additional support in delivering motivational interventions and psychosocial support to patients who are going through assisted withdrawal programmes. Effective and reliable Triage Assessment should have already been carried out to ensure only appropriate patients receive this treatment. The assessment will cover at minimum: Risk plan (including risk to self and risk to others) Extend of any associated health problems Needs for assisted withdrawal Interventions required Please refer to NICE CG115, 1.2 Identification and assessment. The medically assisted alcohol withdrawal in primary care should take place as part of an overall integrated service offer for people who misuse alcohol. Patients who present to medically assisted withdrawal in primary care should be offered referral to specialist services for relapse prevention and recovery support. Where patients refuse this type of referral, at minimum they should be encouraged to engage with local mutual aid support groups (AA, NA) as part of the relapse prevention plan. Further information is provided in Appendix 1. Competency for Home Detox Intervention All interventions for people who misuse alcohol should be delivered by appropriately trained and competent staff. Pharmacological interventions should be administered by a specialist and competent staff. Staff who deliver interventions should: receive regular supervision from individuals competent in both the intervention and supervision provided through the specialist alcohol treatment 3

4 services (this can be delivered as part of the team discussion regarding the detoxification request). routinely use outcome measurements to make sure that person who misuses alcohol is involved in reviewing the effectiveness of treatment (the specialist alcohol service will lead on the development of these) engage in monitoring and evaluation of treatment adherence and practice competence. This could be e.g. using available data on engagement with treatment and also repeat requests for assisted withdrawal interventions, as well as improvements in general physical and mental health. The clinical lead is expected to have acquired and be able to demonstrate the clinical competencies to deliver the service and to assess the training needs of themselves and other staff involved. Basic training in contraindications and prescribing, plus motivational interviewing techniques, relapse prevention and management, and appropriate referral decisions through approved training will be required. GPs should work with a named advisor from Camden Integrated Alcohol Service. Practices will need to demonstrate that they are competent in line with The Drug and Alcohol National Occupational Standards (DANOS) to provide the home detoxification service (either alone or in partnership with Camden Integrated Alcohol Service). Payment is a fixed IoS per patient per year 1. Delivery by competent staff member 200 Monitoring There is currently ongoing collaboration with Camden Clinical Commissioning Group (CCG) Contracts and Performance and Camden Public Health regarding the monitoring. Practices are to be advised of the quality monitoring for Home Detox Interventions. Read codes 9NJz: - In house alcohol detoxification and any of the following: 8HkG - Referral to specialist alcohol treatment service 8IAJ - Declined referral to specialist alcohol treatment service Specialist Alcohol Treatment Service refers mainly to the Camden Integrated Alcohol Service, including Assertive Outreach Team. This service provides interventions ranging from brief interventions to relapse prevention, as well as specialist clinical interventions. The service also provides access to peer led interventions, and referral to peer led interventions through the specialist alcohol team will be considered as a relevant onward referral. Other treatment providers can be considered, including Data Collection 4

5 Performance data will be collated quarterly via EMIS Payment will be made based on the above read codes. Practices will be advised on their progress at the end of each quarter through a feedback report containing the alcohol misuse balanced scorecard results. Practices will be expected to take appropriate action for the following quarterly monitoring and show improvement, where appropriate. 4. Payment for the Management of Alcohol Misusers LCS Payment Practices will be paid 200 per patient for completion of a home detox intervention. Once per year per patient. This is capped at a total maximum expenditure of 11,000 across Camden. 5

6 Appendix 1 Home Detox Mild/moderate dependence is psychological dependence with an increased drive to use alcohol and difficulty in controlling its use. More severe dependence is usually associated with physical withdrawal upon cessation. Detoxification is only suitable for those seeking abstinence and should be seen as the first step towards achieving this. 1 Detoxification should be used alongside psychosocial therapies in the context of a structured care plan. 2 Medication may not be necessary if: The patient reports consumption is less than 15 units a day (men) or 10 units a day (women) and report neither recent withdrawal symptoms nor recent drinking to prevent withdrawal symptoms The patient has no alcohol on breath test and no withdrawal symptoms 1 Community detoxification is an effective and safe treatment for patients with mild to moderate withdrawal symptoms. Inpatient detoxification is advised if: Is confused/has hallucinations Has a history of previously complicated withdrawal Has epilepsy/history of fits In undernourished Has severe vomiting/diarrhoea Is at risk of suicide Has severe dependence coupled with unwillingness to be seen daily Has previous failed home-assisted withdrawal Has uncontrollable withdrawal symptoms Has an acute physical/psychiatric illness Has multiple substance misuse Has an unsupportive home environment for abstinence 1 Three types of pharmacotherapy: Medications for treatment of withdrawal symptoms Medications to promote abstinence or prevent relapse Nutritional supplements (e.g. vitamin supplements) Home detox should be provided according to the protocol and include: Confirm level and recency of drinking and review contraindications Confirm understanding and agreement to the terms and conditions before prescribing commences (i.e. goal is abstinence, drinking must cease when medication starts, social support is in place and significant other(s) have received instruction, what to do if there are any untoward events / emergencies). Ensure referral to post-detox psycho-social intervention is in place, with no or very short waiting time. Prescription of a reducing regime of chlordiazepoxide over 3 7 days plus vitamin supplementation Daily review by GP/PN or nurse from specialist service to assess withdrawal and monitor for complications 1 SIGN, MoCAM,

7 Follow-up and review: Prescription medications to prevent relapse acamprosate or disulfiram). Reassurance & discussion of depression. (If necessary) prescription of antidepressants at one month. Ensure engagement with psycho-social support. Drug regimens for assisted withdrawal (NICE CG115) When conducting community-based assisted withdrawal programmes, use fixeddose medication regimens3. Fixed-dose or symptom-triggered medication regimens 4 can be used in assisted withdrawal programmes in inpatient or residential settings. If a symptom-triggered regimen is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely. Prescribe and administer medication for assisted withdrawal within a standard clinical protocol. The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam). In a fixed-dose regimen, titrate the initial dose of medication to the severity of alcohol dependence and/or regular daily level of alcohol consumption. In severe alcohol dependence higher doses will be required to adequately control withdrawal and should be prescribed according to the SPC. Make sure there is adequate supervision if high doses are administered. Gradually reduce the dose of the benzodiazepine over 7 10 days to avoid alcohol withdrawal recurring. When managing alcohol withdrawal in the community, avoid giving people who misuse alcohol large quantities of medication to take home to prevent overdose or diversion5. Prescribe for instalment dispensing, with no more than 2 days' medication supplied at any time. In a community-based assisted withdrawal programme, monitor the service user every other day during assisted withdrawal. A family member or carer should preferably oversee the administration of medication. Adjust the dose if severe withdrawal symptoms or over-sedation occur. Do not offer clomethiazole for community-based assisted withdrawal because of the risk of overdose and misuse. For service users having assisted withdrawal, particularly those who are more severely alcohol dependent or those undergoing a symptom-triggered regimen, consider using a formal measure of withdrawal symptoms such as the CIWA-Ar. 3 A fixed-dose regimen involves starting treatment with a standard dose, not defined by the level of alcohol withdrawal, and reducing the dose to zero over 7 10 days according to a standard protocol. 4 A symptom-triggered approach involves tailoring the drug regimen according to the severity of withdrawal and any complications. The service user is monitored on a regular basis and pharmacotherapy only continues as long as the service user is showing withdrawal symptoms. 5 When the drug is being taken by someone other than for whom it was prescribed 7

8 If benzodiazepines are used for people with liver impairment, consider one requiring limited liver metabolism (for example, lorazepam); start with a reduced dose and monitor liver function carefully. Avoid using benzodiazepines for people with severe liver impairment. When managing withdrawal from co-existing benzodiazepine and alcohol dependence increase the dose of benzodiazepine medication used for withdrawal. Calculate the initial daily dose based on the requirements for alcohol withdrawal plus the equivalent regularly used daily dose of benzodiazepine6. This is best managed with one benzodiazepine (chlordiazepoxide or diazepam) rather than multiple benzodiazepines. Inpatient withdrawal regimens should last for 2 3 weeks or longer, depending on the severity of co-existing benzodiazepine dependence. When withdrawal is managed in the community, and/or where there is a high level of benzodiazepine dependence, the regimen should last for longer than 3 weeks, tailored to the service user's symptoms and discomfort. For managing unplanned acute alcohol withdrawal and complications including delirium tremens and withdrawal-related seizures, refer to NICE clinical guideline At the time of publication of NICE CG115 (February 2011), benzodiazepines did not have UK marketing authorisation for this indication or for use in children and young people under 18. Informed consent should be obtained and documented. This should be done in line with normal standards of care for patients who may lack capacity (or see NHS Wales) or in line with normal standards in emergency care. 8

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