BCUHB SUBSTANCE MISUSE SERVICE INPATIENT DETOXIFICATION PRESCRIBING GUIDELINES

Transcription

1 BCUHB SUBSTANCE MISUSE SERVICE INPATIENT DETOXIFICATION PRESCRIBING GUIDELINES Authors: Dr Julian H Race, Dr Susan Ruben, Dr Jim O Toole, Jill Timmins Produced: June 2011

2 Contents Introduction 3 Pre-Admission Process 4 Detoxification from Alcohol 5 Detoxification from Opiates 7 Detoxification using Methadone 8 Detoxification using Lofexidine 9 Detoxification using Subutex (Buprenorphine) 10 Detoxification from Stimulants Drugs 11 Benzodiazepines 12 Night Sedation 13 Medical Emergencies 14 Relapse Prevention 15 Naltrexone: for opiate dependent patients 15 Acamprosate 15 Disulfiram 15 Baclofen 16 Naltrexone: following alcohol detoxification 16 Discharge Arrangements 17 References 19 Appendices 20 2

3 Introduction These guidelines apply to all staff working in the BCUHB Substance Misuse Service and refer to inpatient detoxifications carried out at Hafan Wen and the two detoxification beds at the Hergest Unit and all staff in those units responsible for monitoring detoxifications. Inpatient detoxification is undertaken in a 24-hour staffed service with specialist medical supervision to individuals with severe dependency that cannot be managed safely in the community. There is provision for assessment, stabilisation and assisted withdrawal from a range of substances including alcohol. Patients may be dependent on more than one substance and if this is the case a longer period of admission may be required, or more than one admission to achieve realistic goals. In conjunction with pharmacological interventions the provision of a robust psychological programme is key to successful outcomes, so patients will be expected to engage in all aspects of their individual inpatient therapeutic programme on a mandatory basis. In addition all patients will be encouraged to be involved with a range of psychosocial recovery interventions with a number of partner agencies as part of their post discharge plan which will be agreed before admission by their keyworker. There is evidence that outcomes are better if patients are well prepared prior to admission, have a clear understanding of the systems of the unit, and are well informed as to the range of prescribed medications available, as well as the importance of non-pharmacological interventions. It is not possible to prevent all withdrawal symptoms; however the aim of prescribing is to offer a safe and supportive inpatient stay with the long term aim of assisting the recovery journey. All admissions will be processed via the Substance Misuse Service Community Teams and managed under the agreed BCUHB Integrated Care Pathway. Individual keyworkers will produce in conjunction with the patient, carer if appropriate, and the relevant team senior doctor, a pre-admission, admission and post-admission plan of care, utilising a range of other services. Where appropriate this will detail the length of stay, goals of admission and expected medication regime during admission. After inpatient treatment all patients will receive a 7 day follow-up appointment with their community keyworker from the BCUHB substance misuse service, which will be agreed before discharge. For female patients, the opportunity should be taken for discussion with regard to pregnancy and current contraception, as well as advice about cervical screening. For patients not using contraception, inpatient admission can be an appropriate opportunity to initiate contraception. In this document, reference to senior medical staff means Consultant or senior trainee (ST4-6). 3

4 Pre-Admission Process Development of admission and post-admission care plan Agreement with senior team doctor of proposed medication regime, length of stay Completion of the ICP Routine blood investigations within 2 weeks prior to admission; FBC, U&E, LFT; and for alcohol admission Gamma GT INR Two full urine screenings in 4 weeks prior to admission for individuals using illicit substances or on substitute medication, including benzodiazepines and opiate-based pain relief For female patients requiring lofexidine detoxification or treatment with buprenorphine, it is important to rule out pregnancy before admission. A pregnancy test should be carried out prior to admission if appropriate. If a patient is open to a CMHT and requires inpatient treatment at Hafan Wen for detoxification or stabilisation, the following pre-admission steps should be taken: Keyworker to liaise with CMHT care co-ordinator to ensure 1) Up to date sharing of risk assessment and other clinical information. 2) Confirmation of medication prescribed for treatment of the patient s mental illness, and agreement on which medications need to be continued during admission. (This may include benzodiazepines and night sedation). 3) A copy of the patient s early warning signs and crisis plan to be shared with Hafan Wen staff during admission. If the case is complex a pre-admission multidisciplinary or CPA meeting should be held. For some admissions it is recognised that blood screening may not have occurred. This will not prevent admission for any patient. 4

5 Detoxification from Alcohol Inpatient Detoxification The majority of patients can be detoxified safely in the community following the agreed BCUHB guidelines. Inpatient treatment is indicated where there is: History of withdrawal fits and/or delirium tremens Current, severe polydrug use in addition to alcohol Psychiatric co-morbidity that increases risk to self or others Poor physical health e.g. diabetes, liver disease, hypertension, malnutrition Lack of appropriate home support or suitable accommodation History of failed community detoxification over last 12 months There is no routine medical cover at weekends. Patients with alcohol problems should not be admitted on a Friday, to ensure that there is maximum medical supervision for the early and most risky period of withdrawal. This applies unless the admission plan is agreed by senior staff. Process 1 History, physical examination, review/repeat FBC U&E LFT Gamma GT INR. 2 Time of most recent drink and breath alcohol concentration(brac); (NB: The body can metabolise approx 1 unit/hour hence the BRAC falls by mg/dl per hour) 3 Chlordiazepoxide is the drug of first choice. Benzodiazepines exhibit crosstolerance with alcohol, are anxiolytic, sedative, anticonvulsant and have a high safety to toxicity ratio. If liver function is severely compromised oxazepam may be used on advice of senior staff. 4 If patients are on prescribed benzodiazepines prior to admission, these should not be routinely continued. NICE guidelines advise detoxification using one benzodiazepine and this would normally be chlordiazepoxide, the dose required would cover the use of another benzodiazepine and the detoxification would progress as detailed in point 5 below. (See guidance on patients with severe mental illness for exceptions to this guidance). 5 The dose of chlordiazepoxide required will vary. Withdrawal symptoms usually commence within 4-12 hours after the last drink when blood concentration of alcohol has sharply declined. Before any medication is administered staff should undertake the CIWA-AR (appendix). The dose prescribed in the first hours will be flexibly determined against the CIWA-AR scale. Chlordiazepoxide should not be commenced if the patient is intoxicated with alcohol, or sedated with any depressant drug. 6 The maximum dose of chlordiazepoxide should be 200 mg in a twenty four hour period. If a patient is still experiencing significant withdrawal on this 5

6 dose, as evidenced by CIWA-AR staff should consult senior medical staff for advice and review. 7 Before any medication is administered nursing staff should undertake the CIWA-AR. For the first 48 hours nursing staff should complete the CIWA-AR four times a day; alongside 4 hourly observations of temperature, respirations, and blood pressure. The amount of Chlordiazepoxide prescribed will depend on the rated CIWA-AR score in the first 24 hours and should avoid both under treatment and over medication (there is a risk of excessive sedation and possible interaction with alcohol recently consumed pre-admission). For some patients with severe dependency it may take 48 hours to achieve control of withdrawal symptoms. Most individuals should be off all benzodiazepines within 7 days although a minority of severely dependent patients may require up to 10 days. CIWA-AR Score Severity of withdrawal Dose range of Chlordiazepoxide (mg) < 10 Mild Moderate Severe 40 The prescriber will specify the maximum dose each day allowing for PRN if indicated by the CIWA-AR score. After the first hours no PRN should be required and a reduction regime is commenced at approximately 20% less Chlordiazepoxide each day, aiming at reducing off within seven days. Chlordiazepoxide is prescribed QDS on the basis of the CIWA-AR. 8 Where patients have a clear history of recent alcohol withdrawal convulsions during previous detoxifications, give carbamazepine 200mg bd, tapering off in week two. Patients should not be discharged on this medication. N.B. Patients who are being treated for epilepsy should have their usual anticonvulsant medication prescribed. 9 Night sedation will not be prescribed during the detoxification period. 10 Dehydration can occur during alcohol detoxification and nursing staff must ensure adequate fluid intake. Commencement of a fluid intake chart may be useful and should be implemented if patients are observed to be not drinking, in these circumstances staff should oversee intake and monitor patients carefully until a light diet and normal fluid intake is tolerated. Vitamins All patients undergoing alcohol detoxification who score as severely dependent on the CIWA-AR, patients with less severe dependency with a BMI less than 18, patients suffering from peripheral neuropathy and those with any suspicion of Wernicke s encephalopathy (confusional state, opthalmoplegia & ataxia), Korsakoff s psychosis or other alcohol-related neurological condition, should be commenced on a course of intramuscular vitamins (Pabrinex), 1&2 amps, daily for 3-5 days by deep intramuscular injection. This will be followed by oral Thiamine 100mg bd. 6

7 All other patients should receive oral thiamine 100mg bd. Other vitamins may be required based on the clinical judgement of the inpatient medical team. The therapeutic treatment for presumed/diagnosed Wernicke s encephalopathy and delirium tremens requires transfer to a general medical setting. Contact Medical Registrar for advice, or if there is delay, transfer to A&E. Detoxification from Opiates 1. Withdrawal from opiates can be unpleasant but it is not life threatening, whilst opiate toxicity is potentially fatal. All patients completing detoxification must be warned that their tolerance to opiates is likely to have reduced and that they are at increased risk of accidental opiate (and polydrug) overdose. 2. No injectable preparations will be prescribed during inpatient detoxification and patients will be transferred to an agreed oral preparation. The oral preparation agreed and dosage should be discussed with the relevant community Consultant and inpatient medical team prior to admission. 3. Patients who are polysubstance dependant prior to opiate detoxification should complete an alcohol/benzodiazepine detoxification before they commence their opiate detoxification. This may require a longer admission period or more than one admission to achieve drug free status. 4. Consideration should be given to current Hepatitis B vaccination status and the inpatient opportunity utilised to address any due boosters or to commence vaccination if not previously received. Whilst discussion should take place around blood-borne virus risk factors, screening while undertaking a detoxification may not be suitable for some patients and the decision to routinely screen at this stage needs careful consideration. Symptomatic Treatment Any patient withdrawing from opiates may benefit from symptomatic relief of the following symptoms with the following non-opiate drugs: Abdominal cramps: Diarrhoea: Muscle and joint pain: Anxiety and agitation: Night muscle cramps mebeverine 135mg tds loperamide 4mg initially then 2mg with each loose stool paracetamol or NSAIDS promazine 25 mg tds prn (maximum 200mg/day) quetiapine 25-50mg tds (second line) quinine sulphate 200mg nocte (should not be needed at the start of detoxification). These preparations should be prescribed in the as required section of the drug sheet in accordance with current BNF and product specification. 7

8 Detoxification using Methadone The proposed length of stay and proposed treatment regime should be agreed prior to admission and should enable the patient to realistically achieve their admission goals. It is imperative that current dose details and information of last dose administered are given to the inpatient staff by the keyworker prior to admission. Process 1 On admission nursing staff will check current dose of any prescribed medication with keyworker or community pharmacy. Ascertain from patient whether the full dose has been taken in the last 7 days. Take history of other substances used, prescribed and unprescribed, and check medication prescribed by GP. 2 If the patient has collected and taken their dose of methadone on the day of admission no dose will be prescribed. 3 Review urinalysis results provided by keyworker over last two weeks and repeat urinalysis on admission. 4 History, physical examination, review/repeat FBC U&E LFT. 5 For methadone detoxification, consideration should be given to current dose taken (not necessarily the prescribed dose) and other substances used, evidenced by urinalysis results. Withdrawal symptoms should be measured using the Clinical Opioid Withdrawal Scale (COWS) (appendix). This should be carried out four times a day for the first 48 hours and then less frequently throughout the detoxification period to inform the prescribing practice. 6 If patients are on prescribed methadone, even if they give a history of taking additional methadone, the initial dose is their usual prescribed dose (or the dose they have been taking if it is lower). The methadone dose should not be increased unless withdrawal symptoms are objectively moderate in accordance with the COWS (score 13-24). Any increase in methadone must be discussed with and agreed by senior staff. 7 The usual rate of methadone reduction is 5-10 mg/day, and should be in line with the pre-admission plan. There may be some flexibility. It is desirable for patients to have 7 days methadone-free prior to discharge, to enable initiation on to treatment with naltrexone if required, as a relapse-prevention intervention. 8 Usually patients prefer to take their methadone dose in the morning and for some patients splitting the daily dose (bd) can be beneficial, however methadone should not be prescribed at night. 8

9 9 If any patient requires a dose of methadone over 100 mg/day they must have an ECG. In addition patients with other risk factors for QT interval disturbance should have an ECG either prior to admission or at admission. 10 Methadone must not be prescribed PRN. If an extra amount is needed it should be recorded as a single dose on the front of the drug card. 11 Patients who are not prescribed methadone before admission who make an informed choice to use methadone as their detoxification agent will not be given a first dose until they exhibit clear objective opiate withdrawal symptoms (COWS score 13-24). For these patients methadone doses will be titrated against withdrawal symptoms, as the risk of opiate toxicity which can be fatal outweighs the risk of unpleasant opiate withdrawal symptoms. The initial dose will be low, maximum 30 mg/day, and will be reviewed in line with the withdrawal scale monitoring. If this does not manage withdrawal symptoms adequately as evidenced by the use of the scale, discuss the patient and regime with senior staff and always consider the benefits of nonpharmacological supports and symptomatic relief with non-opiates as described above. After 48 hours the detoxification regime will commence as in point 7 above. Detoxification using Lofexidine Although lofexidine is not useful for detoxification for patients with very severe opiate dependence, there are circumstances where it may have a role. For example, where the patient has made an informed and clinically appropriate decision not to use methadone or buprenorphine, where they have made a decision to detoxify in a short time period, or where there is only evidence of mild or uncertain dependence. For patients who are prescribed methadone who wish to detoxify with lofexidine, treatment is more comfortable the lower the dose of methadone taken. Patients wanting lofexidine detoxification should first aim to reduce their dose of methadone to 40mls/day or less. Lofexidine is also useful as brief low-dose treatment for residual withdrawal symptoms after patients have stopped either methadone or buprenorphine. Process 1 On admission check current dose of any prescribed medication with keyworker or community pharmacy. Ascertain from patient whether full dose has been taken in the last 7 days and take history of other substances used prescribed and unprescribed and check medication prescribed by GP. 2 Review urinalysis results provided by keyworker over last 2 weeks and repeat urinalysis on admission. 3 History, examination, review/repeat FBC U&E LFT. 9

10 4 Consideration should be given to the proposed treatment regime agreed prior to admission detoxification. 5 Prior to commencing treatment, measure baseline B.P., sitting and standing. Treatment should not be started unless the systolic blood pressure is 90 mmhg or over, and the diastolic 55 mmhg or over. For the first 48 hours temp, blood pressure, respirations and pulse should be monitored four times a day by nursing staff. After 48 hours, BP and pulse to be monitored twice daily throughout the course of treatment. The systolic blood pressure should not fall more than 30 mmhg below the baseline level before giving the next dose. The diastolic should not fall below 50 mmhg and the pulse should not be less than 55 beats per minute. Omit next dose if BP or pulse are too low and discuss with prescribing medical team. 6 Patients who have been receiving methadone or Subutex may commence lofexidine on the last day of treatment. 7 For regime see table below. 8 The dose for lofexidine on drug sheets should be written as micrograms. Abbreviations are not acceptable. 9 Lofexidine may be introduced into a methadone reduction schedule at a dose of mg methadone mixture. The methadone is discontinued abruptly. Typical Lofexidine Regime, N.B. Doses to be omitted if low pulse/blood pressure as above. Day Morning Lunch Teatime Bedtime micrograms 200 micrograms micrograms 200 micrograms 200 micrograms 200 micrograms micrograms 200 micrograms 200 micrograms 400 micrograms micrograms 400 micrograms 400 micrograms 400 micrograms micrograms 400 micrograms 400 micrograms 800 micrograms micrograms 400 micrograms 400 micrograms 400 micrograms micrograms 200 micrograms 200 micrograms 400 micrograms micrograms 200 micrograms 200 micrograms 200 micrograms micrograms 200 micrograms 10 Detoxification using Subutex (Buprenorphine) Buprenorphine can be used effectively for short term inpatient detoxification. It is an alternative to methadone, although if patients are on doses of methadone greater than 30mg/day it is not recommended because of the risk of precipitated withdrawal symptoms. Buprenorphine is a partial opiate agonist with mild opiate-blocking properties. Prescriptions should be written as Buprenorphine S/L. Pregnant women should not be commenced on Subutex but if they are already prescribed when they become pregnant they can continue. 10

11 Process 1 On admission check current dose of any prescribed medication with keyworker or community pharmacy. Ascertain from patient whether full dose has been taken in the last 7 days and take history of other substances used prescribed and unprescribed, and check medication prescribed by GP. 2 Review urinalysis results provided by keyworker over last 2 weeks and repeat urinalysis on admission. 3 History, physical examination, review/repeat FBC U&E LFT. 4 Consideration should be given to the proposed treatment regime agreed prior to admission detoxification. 5 Patients can transfer to buprenorphine during a methadone detoxification if the methadone dose is reduced to 30mg/day (although transfer is easier if the dose of methadone is 15-20mg/day. Methadone is stopped and buprenorphine can not be initiated until the patient displays clear withdrawal symptoms, which may not be seen for hours (COWS score 13-24). Once in withdrawal the starting dose is 2-4 mg, and if tolerated an additional 2-4 mg can be dispensed on the same day. The dose can be titrated up on day 2 against opiate withdrawal symptoms using the objective opioid withdrawal scale. On day 3 the dose is reduced by 0.8 mg/day until drug free. 6 Patients on street heroin or other non-prescribed opiates/opioids or over-thecounter opiates/opiods may be commenced on buprenorphine once they have displayed clear moderate/severe opiate withdrawal symptoms as described in point 5 above. Detoxification from Stimulant Drugs Patients with a predominantly opiate or alcohol problem often abuse stimulant drugs. The detoxification regime to be followed is for their primary drug of dependence. For patients who are dependent on street stimulants (mostly cocaine or amfetamines) there is no specific medication which has an evidence base. Detoxification from stimulant drug use is usually managed symptomatically. The patients need to be reviewed on a regular basis by the inpatient doctor who can assess any problematic symptoms and prescribe accordingly. Consideration needs to be given to the physical problems associated with long term use of stimulants. Should symptoms persist, then the Consultant should be made aware and appropriate advice taken. NICE guidance indicates that psychosocial interventions are appropriate with stimulant drug use, and one of the best forms of assistance is to provide a safe place where the resultant symptoms of withdrawal can be dealt with. Relaxation 11

12 techniques and complementary therapies are particularly useful for this group of patients. Withdrawal symptoms include low mood, agitation, lifelessness, fatigue and insomnia, are generally self limiting and short lived. These symptoms can be treated symptomatically; however the mainstay is psychological support from staff. Low mood should not be assumed to be assisted by anti-depressant medication unless there is evidence after a minimum of 2 weeks, post completed detoxification, of depressive symptoms. Sedative antidepressants are not appropriate just to treat insomnia. Short term night sedation may be used in line with the night sedation policy (page 13). If patients are on prescribed dexamfetamine prior to admission, the withdrawal regime should be agreed prior to admission as part of the pre-admission process. The options are to abruptly stop dexamfetamine on admission for small doses (5-10mg/day) or to reduce the dexamfetamine prescription, aiming at a rate of 5mg per day. Agree the starting dose, max 60mg per day. Doses to be given early in the day, not at night and reduce over 5-10 days. If patients are not prescribed dexamfetamine prior to admission, dexamfetamine will not be initiated and their withdrawal symptoms will be treated symptomatically. Process 1 On admission check current dose of any prescribed medication with keyworker or community pharmacy. Ascertain from patient whether full dose has been taken in the last 7 days and take history of other substances used prescribed and unprescribed and check medication prescribed by GP. 2 Review urinalysis results provided by keyworker over last 2 weeks and repeat urinalysis on admission. If urine is negative for amfetamines on admission, review the necessity for ongoing dexamfetamine and review starting dose with advice from senior clinician. 3 History, physical examination, review/repeat FBC U&E LFT. 4 Consideration should be given to the proposed treatment regime agreed prior to admission detoxification, as above. Benzodiazepines 1 Benzodiazepines will not be routinely prescribed or initiated during detoxification. In exceptional circumstances, if prescribing is commenced they will not be continued after the inpatient admission and should be stopped prior to discharge. If patients are prescribed benzodiazepines in conjunction with methadone prior to admission, it is recommended that the benzodiazepines will be reduced first and this can be achieved in the community prior to detoxification in some cases. 12

13 2 Patients who use illicit benzodiazepines are unlikely to require a prescription of benzodiazepines, as while use is common, dependence in this patient group is rare; refer to Benzodiazepine Guidance (appendix). Benzodiazepines can only be prescribed if there are clear withdrawal symptoms. The dose of diazepam must be titrated against symptoms: Start with diazepam 5mg bd, morning and evening. Do not give at night. Maximum dose 30mg/day. Evidence suggests this dose will prevent withdrawal seizures after 24 hours. 3. Reduce the diazepam at approximately 20 percent of the dose each day. If 30 mg/day is not controlling withdrawal symptoms/signs, an urgent review is required by senior staff. Night Sedation All patients withdrawing from substances will inevitably experience sleep disturbance to varying extents; they cannot expect to have normal sleep every night of their stay on the unit. Therefore night sedation will not be regular and should not be expected routinely as part of a patient s treatment plan. 1 Every patient should receive a sleep hygiene leaflet and education during admission outlining non-medical methods of promoting a healthy sleep pattern. 2 If, despite these measures, the patient is still unable to sleep and has not slept for two consecutive nights evidenced by sleep charts (less than 4 hours sleep), zopiclone may be prescribed. 3 Zopiclone dose range mg for a maximum of seven nights on a PRN basis, to be taken on evidence of sleep charts confirming sleep deprivation. All attempts to resolve sleep issues should be supported by good sleep hygiene. 4 If patients are admitted on prescribed night sedation, confirm dose and length of treatment with their keyworker/gp and record any relevant information in the case notes. They should not be prescribed any additional night sedation. Attempts should be made to reduce/stop this medication if at all possible. 5 Pregnant patients should be discouraged from using night sedation unless essential (evidenced by sleep charts). If so, prescribe promethazine hydrochloride 25mg nocte. 6 Under no circumstances should patients be discharged on night sedation that is initiated during their stay at Hafan Wen. Medical Emergencies 13

14 Collapse If a patient collapses, opiate overdose must be considered. Signs and symptoms will include: Pinpoint pupils Respiratory depression < 8 breaths per minute Cold to touch or blue lips Unconsciousness Actions to be taken 1 Try to rouse patient 2 Call for help or ambulance 3 Check airway and breathing if not breathing follow CPR protocol if breathing place in recovery position 4 Administer 0.4 mg of Naloxone im, or iv if doctor present 5 Repeat doses every 2-3 minutes if there is response (max 10 mgs) 6 If respiratory function does not improve then question diagnosis 7 Consider use of high flow oxygen 8 Await ambulance NB. Naloxone poorly overrides buprenorphine overdose so always consider this as a possibility if there is a poor response to Naloxone. Seizure Management Convulsions in alcohol withdrawal are typically grand mal. They are most likely to occur 6-48 hours after stopping or reducing drinking. They can also occur during withdrawal from benzodiazepines and barbiturates. It should be noted that antipsychotic medication lowers seizure threshold. Staff should follow first aid procedures: Give a single dose of oral diazepam 20 mg on recovery, or rectal diazepam 10 mg. In the event of multiple convulsions or status epilepticus: Telephone 999 as this is a medical emergency requiring urgent transfer to A & E. Relapse Prevention 14

15 Relapse prevention medication should be seen as an adjunct to psychosocial interventions and not as an alternative. Naltrexone: For Opiate Dependant Patients Naltrexone is an opiate antagonist used to reinforce abstinence in opiate users. It should be initiated by specialist services. Patients need to be opiate-free, confirmed by urinalysis for methadone which has a long half-life. Methadone Buprenorphine Naltrexone test dose after 7-10 days. Naltrexone test dose after 3-5 days. Patients must be fully informed of the risks and benefits and observed closely for 4 hours following the test dose of 25mg naltrexone. They may experience mild withdrawal symptoms. If this dose is tolerated the dose is increased to 50mg daily. Long-term prescribing is arranged with the Community Drug and Alcohol Service. Check LFT and gamma GT before starting naltrexone. Naltrexone can be given with mild abnormalities of liver function after a risk/benefit analysis. LFTs should be checked 3 monthly in the community while on this medication. Taking large amounts of opiates can overcome the effects of naltrexone and cause fatal overdose. Patients should be advised of this and should sign a consent form. Acamprosate Acamprosate is currently licensed for relapse prevention in alcohol use disorders in the UK. Acamprosate primarily reduces glutaminergic activity in the brain with some effect on increasing GABA-ergic activity. Clinical evidence for acamprosate suggests an increased chance of remaining completely abstinent from alcohol in subjects classed as at least moderately dependent on alcohol. Acamprosate is usually prescribed at 666mg tds (for patients >60kg) and 666mg morning, 333mg lunchtime and night (for patients <60kg). It is normally prescribed for 3-6 months but could be longer for patients who are benefitting and wish to continue. Disulfiram Disulfiram is an alcohol dehydrogenase inhibitor and is licensed for relapse prevention in alcohol use disorders in the UK. Disulfiram taken supervised can be an effective component of relapse prevention strategies. The decision to start treatment is complex. Discuss with senior staff and document. NICE guidance suggests it is a second line treatment if naltraxone/acamprosate is not suitable or the patient prefers disulfiram. Supervising arrangements should be agreed and documented; a carer if agreeable can supervise if they are fully informed and understand the risks if the patient drinks alcohol. 15

16 Disulfiram therapy can be started towards the end of inpatient treatment. It should be started only after the patient has abstained from alcohol for at least 24 hours, ideally hours. The dose is 200mg daily. The patient must be aware of the potentially serious consequences of drinking alcohol with disulfiram. Disulfiram may react even with small amounts of alcohol found in over-the-counter cough and cold preparations and any medication that comes in an elixir form. Alcohol may also be found in some toiletries e.g. aftershave. Baclofen There is some evidence to support the use of the GABA-B agonist baclofen in relapse prevention for alcohol dependent patients following detoxification. The limited evidence available to date suggests that baclofen may be more effective in severe dependence. Baclofen is not currently licensed in the UK for alcohol use disorders. It does appear to reduce alcohol craving and reduce anxiety in alcohol dependent patients post detoxification. Baclofen is a second line treatment for relapse prevention, always discuss with senior staff before commencement. Starting dose 5mg tds. The usual treatment dose of baclofen would be in the range of 20mg to 40mg daily in divided doses. Common side effects include fatigue, headache and constipation but most patients tolerate the drug well. Baclofen should be prescribed for 3-6 months (or possibly longer in some cases). It is important for the patient to remain under review and to maintain regular contact with the keyworker. Naltrexone following alcohol detoxification Naltrexone can also be used as relapse prevention medication in alcohol dependence following detoxification. Naltrexone is not licensed in UK for alcohol use disorders but is licensed in US and is approved by NICE. The dose of naltrexone is 25mg daily increased to 50mg daily if tolerated. Side effects include nausea, headache and hepatotoxicity. LFT monitoring should be arranged as indicated above. Patients also need to be aware of the blockade effect on opiate analgesics. Treatment is usually for 3-6 months but may be continued for longer in some cases. The main evidence for naltrexone is reduced rate of relapse to heavy drinking and reduced alcohol consumption. The evidence for abstinence is more limited. Naltrexone is a second line treatment for relapse prevention. Discuss with senior staff. 16

17 Discharge Arrangements All discharges require careful consideration and robust risk assessment as per agreed ICP. In all patients pre-admission, a discharge date should be planned and agreed with the patient as part of the agreed treatment plan. There are four types of discharge: 1 Planned discharge Discharge date agreed with patient, staff in inpatient unit and keyworker in Community Drug and Alcohol Team. Aftercare plan agreed and in place following discharge. 2 Early/late discharge with medical agreement Discharge date brought forward or delayed with agreement of patient and staff. Inpatient staff must ensure that keyworker in Community Drug and Alcohol Team is informed and aware of rationale for decision. Aftercare plan agreed and in place following discharge. 3 Discharge against medical advice Patient leaves early against advice of inpatient team. They should be asked to sign the relevant form. If they refuse this should be documented or have already left the unit. Inpatient staff must liaise with keyworker in the community who should offer a rapid appointment to reassess the care plan. If possible, arrangements for ongoing medication should be made with GP or CDAT. 4 Discharge for breech of unit rules This should be a rare event and such discharges are accountable to both the senior management of the unit and the inpatient Consultant and should involve them. If inpatient Consultant is not available, staff should discuss with other senior medical staff. Urine screening alone should not be sufficient to precipitate discharge for breech of rules and it should be recognised that urine screening can lead to false positive and false negative results and potential legal redress. Staff should discuss with senior management and if necessary the Consultant if there are identified risks and in the case of vulnerable adults, pregnant women, and parents where there are safeguarding children issues. Violent episodes and threats to others will not be tolerated and staff should utilise police support where necessary. The keyworker must be informed and the reason for discharge shared with the keyworker. The inpatient team still must carry out a risk assessment and 17

18 support the service user as appropriate, to minimise any risk in relation to this discharge. The keyworker must offer a rapid appointment after discharge to reassess needs and review care plan. Discharge Summary For all discharges the short discharge summary is fully completed by inpatient nursing staff immediately and a copy faxed over to the GP and the CDAT keyworker. A full discharge letter should be completed by the medical team within BCU agreed timescales and sent to GP and keyworker. Discharge medication BCU policy is that no more than 7 days medication should be given to take home. For medication to be continued by the CDAT prescribers (methadone, subutex, benzodiazepines), the inpatient team should liaise with the CDAT keyworker so that a community prescription can be organised prior to discharge. The short discharge summary must make it clear who will be responsible for ongoing prescribing to stop the risk of double scripting. Ideally there should be no need to take home controlled drugs or benzodiazepines following discharge, but if a community prescription cannot be arranged these may be given for a short time (no longer than 1-3 days), to allow for an appropriate community prescription to be organised. The 7 day follow up date should be agreed by inpatient staff with keyworker prior to discharge and the patient should be given this appointment date, time and place, prior to discharge if possible. 18

19 References Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. (1989) British National Formulary (BNF) 60. (2010) Drug misuse: Opioid detoxification. NICE Clinical Guideline 52. (2007) Drug Misuse and Dependence: UK Guidelines on Clinical Management (2007) Maudsley, Prescribing Guidelines 10th Edition, David Taylor, Carol Paton, Shitij Kapur (2009) Methadone and buprenorphine for the management of opioid dependence. NICE Technology Appraisal 114 (2007). Available from Naltrexone for the management of opioid dependence. NICE Technology Appraisal 115 (2007). Available from 19

20 Appendix CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT OF ALCOHOL SCORE (Revised Ed) GRADING THE SEVERITY OF EACH WITHDRAWAL SYMPTOM Nausea and vomiting: Ask do you feel sick to your stomach? Have you vomited? Observation 0 No nausea with no vomiting 1 Mild Nausea with no vomiting Intermittent nausea with dry heaves Constant nausea, frequent dry heaves and vomiting Tactile disturbance: Ask have you any itching, pins and needles sensations, any burning, any numbness or do you feel bugs crawling on or under your skin? Observation 0 None 1 Very mild itching, pins and needles, burning or numbness 2 Mild itching, pins and needles, burning or numbness 3 Moderate itching, pins and needles, burning or numbness 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations Tremor: Arms extended and fingers spread wide Observation: 0 No tremor 1 Not visible, but can be felt fingertip to fingertip 2 X 3 X 4 Moderate, with patients arms extended Severe, even with arms not extended Paroxysmal sweats: Observation 0. No seat visible 1. Barely perceptible sweating, palms moist Beads of sweat obvious on forehead Drenching sweats Auditory disturbance: Ask Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing? Are you hearing things you know are not there? Observation: 0 Not present 1 Very mild harshness and ability to frighten 2 Mild harshness or ability to frighten 3 Moderate harshness or ability to frighten 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations Visual disturbances: Ask Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you seeing anything that you know is not there? Observation: 0. Not present 1. Very mild sensitivity 3. Moderate sensitivity 4. Moderately severe hallucinations 5. Severe hallucinations 6. Extremely severe hallucinations 7. Continuous hallucinations 20

21 Anxiety: Ask Do you feel nervous? Observation 0. No anxiety, at ease 1. Mildly anxious Moderately anxious or guarded, so anxiety is suggested Equivalent to acute panic states as seen in severe delirium or acute schizophrenic states Headaches, fullness in head Ask Does your head feel different? Does it feel like there is a band around your head? (do not rate for dizziness or lightheadedness) Observations 0. Not present 1. Very mild 2. Mild 3. Moderate 4. Moderately severe 5. Severe 6. Very severe 7. Extremely severe Agitations Observation 0. Normal activity 1. Somewhat more than normal activity Moderate fidgety and restless Paces back and forth during interview, or constantly thrashes about Orientation and clouding of sensorium Ask What day is this? Where are you? Who am I? Observation 0. Orientated and can do serial additions 1. Cannot do serial additions or is uncertain about date 2. Disorientated for date by no more than 2 calendar days 3. Disorientated for date by more than 2 calendar days 4. Disorientated for place or person ITEMS 1-9 ARE SCORED FROM 0-7 AND ITEM 10 FROM 0-4 Severity of alcohol withdrawal Mild <10 Moderate Severe >20 CIWA-Ar score 21

22 CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT OF ALCOHOL SCALE Name.d.o.b.. Baseline pulse & BP (before any chlordiazepoxide taken): Date & Time Nausea & Vomiting Tactile disturbance Tremor Auditory disturbance Paroxysmal sweats Visual disturbance Anxiety Headache, fullness in head Agitation Orientation & clouding of sensorium TOTAL SCORE Pulse & BP, Sig: 22

23 Clinical Opiate Withdrawal Scale (COWS) Flow-sheet for measuring symptoms over a period of time. Enter score into patients case notes after administration must include time and date of scoring. For each item, write in the number that best describes the client s signs or symptoms. Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the client was jogging just prior to assessment, the increase in pulse rate would not add to the score. COWS Resting pulse rate: (record beats per minute) Measured after client is sitting or lying for one minute 0 pulse rate 80 or below 1 pulse rate pulse rate pulse rate greater than 120 Sweating: over past ½ hour not accounted for by room temperature or client activity 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face Restlessness: observation during assessment 0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or extraneous movements of legs/arms 5 unable to sit still for more than a few seconds Pupil size 0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible Bone or joint aches: if client was having pain previously, only the additional component attributed to opiates withdrawal is scored 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort 23

24 Runny nose or tearing: not accounted for by cold symptoms or allergies 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks GI Upset: over last ½ hour 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhoea 5 multiple episodes or diarrhoea or vomiting Tremor: observation of outstretched hands 0 no tremor 1 tremor can be felt, but not observed 2 slight tremor or observable 4 gross tremor or muscle twitching Yawning: observation during assessment 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute Anxiety or irritability 0 none 1 client reports increasing irritability or anxiousness 2 client obviously irritable/anxious 4 client so irritable or anxious that participation in the assessment is difficult Gooseflesh skin 0 skin is smooth 3 piloerection of skin can be felt or hairs standing up on arms 5 prominent piloerection Total scores With observers initials Score: 5-12 = mild, = moderate, = moderately severe, more than 36 = severe withdrawal 24