YCN Head & Neck NSSG Alcohol Assessment and Detoxification Management Guidelines

YCN Head & Neck NSSG Alcohol Assessment and Detoxification Management Guidelines *** VALID ON DATE OF PRINTING ONLY - all guidelines available at http://www.ycn.nhs.uk/ *** page 1 of 18

i Document Control Title Author(s) Owner Alcohol Assessment and Detoxification Management Guidelines Rosie Ratcliffe & Caroline Salt YCN Head & Neck NSSG Version Control Version/ Draft Date Revision summary 1.0 01.05.2005 Initial draft version 1.1 01.05.2010 Minor update 2.0 17.06.2010 Final agreed first version 3.0 07.02.2012 Final agreed second version Contributors to current version Contributor Author/Editor Section/Contribution YCN Head & Neck NSSG Rosie Ratcliffe & Caroline Salt Karen Williams, Advanced Clinical Nurse Specialist - Substance Misuse Liaison Service, York Hospital YCN Head & Neck NSSG YCN Head & Neck NSSG YCN Head & Neck NSSG General General General *** VALID ON DATE OF PRINTING ONLY - all guidelines available at http://www.ycn.nhs.uk/ *** page 2 of 18

ii Information Reader Box Title Author(s) Alcohol Assessment and Detoxification Management Guidelines YCN Head & Neck NSSG Publication date 7 th February 2012 Review date 7 th February 2015 Proposed Target Audience for Consultation / Final Statement Proposed Circulation List for Final Statement Contact details All consultations and e-mail notification of updated guidelines from the YCN Head and Neck group will be consulted to: YCN Head and Neck group All YCN Head and Neck Group guidelines will be made available electronically at http://www.ycn.nhs.uk. No hard copies will be circulated by the Group. Yorkshire Cancer Network 21 Wetherby Road Harrogate HG2 7RY 01423 555 705 *** VALID ON DATE OF PRINTING ONLY - all guidelines available at http://www.ycn.nhs.uk/ *** page 3 of 18

iii Table of Contents I DOCUMENT CONTROL... 2 II INFORMATION READER BOX... 3 III TABLE OF CONTENTS... 4 1 INTRODUCTION... 5 1.1 KEY AIMS AND OBJECTIVES... 5 2 ASSESSMENT OF ALCOHOL USE... 6 2.1 ASSESSMENT... 6 2.2 ALCOHOL UNIT CONVERSION CHART... 7 2.3 AUDIT-C... 8 2.3.1 Scoring:... 8 2.4 REMAINING AUDIT QUESTIONS... 8 3 CLINICAL MANAGEMENT FOLLOWING ASSESSMENT... 10 3.1 NEGATIVE SCREENING (AUDIT-C SCORE < 5)... 10 3.2 POSITIVE SCREENING (AUDIT-C SCORE > 5)... 10 3.2.1 Clinical management for patients drinking at increasing and high risk levels or who are potentially dependent includes... 10 Brief interventions and advice... 10 Clinical markers... 10 4 ALCOHOL WITHDRAWAL ASSESSMENT AND CLINICAL MANAGEMENT... 11 4.1 THE CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT ALCOHOL REVISED (CIWA-AR)... 11 4.2 DETOXIFICATION PRESCRIPTION REGIMES... 12 4.3 EXCEPTIONAL CASES... 12 5 WERNICKES ENCEPHALOPATHY... 13 5.1 PROPHYLAXIS... 13 5.2 TREATMENT... 13 6 KEY RECOMMENDATIONS... 14 7 REFERENCES... 15 8 APPENDIX... 16 8.1 IMPLEMENTED PATHWAYS FOR ALCOHOL ASSESSMENT AND DETOXIFICATION... 16 8.1.1 WISMS pathway... 16 8.1.2 York pathway... 18 *** VALID ON DATE OF PRINTING ONLY - all guidelines available at http://www.ycn.nhs.uk/ *** page 4 of 18

1 Introduction High levels of alcohol consumption is a significant problem among patients with head and neck cancer (NICE, 2004). Evidence suggests that as well as being a contributing factor in the development of head and head and neck squamous cell carcinomas, chronic consumption has a significant effect on post-operative morbidity and mortality among surgical patients (Lansford et al., 2008). Management of alcohol withdrawal in this patient group can be a time consuming process, associated with prolonged in-patient stays, intensive care requirements and the potential risk of serious adverse events (Lansford et al., 2008). Consequently, risk stratification through prompt assessment and appropriate clinical management is key to delivering safe and effective care. 1.1 Key aims and objectives Effectively assess and identify head and neck cancer patients at increasing and higher risk of alcohol withdrawal Effectively assess and identify head and neck cancer patients who are drinking high levels of alcohol which could potentially be harmful to their well being Implement a validated and evidence based assessment tool for use in head and neck cancer care Promote best practice across the Yorkshire Cancer Network in the delivery of safe and effective clinical management of patients at risk of alcohol withdrawal page 5 of 18

2 Assessment of Alcohol Use 2.1 Assessment Assessment Intervention Rationale Assessment of alcohol consumption and the implications for the patient s safety when admitted to hospital or when treatment commences Ask all patients about alcohol consumption, using a validated screening tool to identify patients at risk e.g. The AUDIT tool. Provide information to patients about the health risks associated with excessive drinking Identify patients who may be at risk of alcohol withdrawal on admission to hospital, or whose treatment may be affected by their use of alcohol Identify those patients that need referral to Alcohol Misuse / Addiction Services page 6 of 18

2.2 Alcohol Unit Conversion Chart This tool has been adapted from the NHS website www.nhs.uk and can be used by healthcare professionals to identify the amount of alcohol units consumed by individuals. Each of these drinks is one unit of alcohol. Half pint of regular beer, lager or cider 1 very small glass of wine 1 single measure of spirits 1 small glass of sherry 1 single measure of aperitifs...and each of these is more than one unit A pint of regular beer, lager or cider www.nhs.uk A pint of strong / premium beer, lager or cider Alcopop or a 275ml bottle of regular lager 440ml can of regular lager or cider 440ml can of super strength lager 250ml glass of wine (12%) Bottle of wine (12%) The NHS recommends that the maximum weekly alcohol consumption is 21 units for males and 14 units for females. page 7 of 18

2.3 Audit-C This is a validated alcohol screening tool used to identify increasing and higher risk drinkers. It is recommended that the AUDIT-C or full AUDIT tool should be used as part of the pretreatment holistic assessment to prevent complications post treatment. Questions How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? Scoring system 0 1 2 3 4 Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week 1-2 3-4 5-6 7-9 10+ Your score How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily 2.3.1 Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive. 2.4 Remaining AUDIT questions Questions How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? Scoring system 0 1 2 3 4 Never Never Never Never Less than monthly Less than monthly Less than monthly Less than monthly Monthly Monthly Monthly Monthly Weekly Weekly Weekly Weekly Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Your score page 8 of 18

How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or somebody else been injured as a result of your drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? Never No No Less than monthly Monthly Weekly Yes, but not in the last year Yes, but not in the last year Daily or almost daily Yes, during the last year Yes, during the last year Scoring: 0 7 Lower risk, 8 15 Increasing risk, 16 19 Higher risk, 20+ Possible dependence The health care professional carrying out the assessment will complete either the AUDIT-C or the full AUDIT and refer to the appropriate service according to local alcohol assessment and detoxification pathways, where implemented (See appendix 1 for implemented local pathways). page 9 of 18

3 Clinical Management Following Assessment 3.1 Negative Screening (AUDIT-C score < 5) Patients who score less than 5 on the AUDIT-C tool are deemed AUDIT-C negative. This patient group require no further clinical intervention. Reinforcement of safe drinking should be delivered throughout the patient pathway. If alcohol misuse is suspected, despite negative screening, it is still important to observe for relevant clinical signs and treat as necessary. It may be useful to ask relatives and friends for information, with consent. If in doubt, seek advice from medical staff or local misuse/addiction service or refer to section 3.2. 3.2 Positive Screening (AUDIT-C score > 5) Patients who score more than 5 on the AUDIT-C tool are deemed AUDIT-C positive. This includes patients drinking at increasing and high risk levels and also those potentially alcohol dependent. Patients who are drinking more than 6 units (women) or 8 units (men) daily or almost daily with an AUDIT-C score of 5 or above should be treated as potentially dependent. According to local alcohol and detoxification pathways, referral to specialist services may be made at this point. 3.2.1 Clinical management for patients drinking at increasing and high risk levels or who are potentially dependent includes Brief interventions and advice For patients identified as potentially dependent on alcohol, reducing and/or stopping drinking prior to surgery is preferable. Some patients may feel confident to reduce / stop drinking without specialist support. These patients should be given information about alcohol including health risks, how to cope with symptoms of withdrawal and local service details. Clinical markers Biochemistry markers may be elevated in patients drinking excessively, these include GGT, LFT s and MCV. It is recommended that an alcohol blood set be requested for suspected increasing or higher risk patients. Following these interventions, if high risk of alcohol withdrawal is suspected, advice from specialist services and/or medically assisted alcohol detoxification may be recommended. In these cases, clinical management should be in accordance to local trust policy. Further guidance is available from NICE, (NICE, 2010). page 10 of 18

4 Alcohol withdrawal assessment and clinical management 4.1 The Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-AR) The CIWA-AR scale is a validated assessment tool that can be used to quantify the severity of alcohol withdrawal syndrome, and to monitor and medicate patients through withdrawal (NICE, 2010). Insert patient details/id label here: Date Assess and rate each of following: Time NAUSEA /VOMITING (0-7) (0) No nausea and no vomiting, (1) Mild nausea, no vomiting, (3) Intermittent nausea, dry heaves, (7) Constant nausea, frequent dry heaves and vomiting, TREMOR (0-7) (0)No tremor, (1) Not visible but can be felt at fingertip, (4) Moderate with arms not extended, (7) Severe even with arms not extended PAROXYSMAL SWEATS (0-7) (0)No sweat visible, (1) Barely perceptible sweating, palms moist, (4) Beads of sweat obvious on forehead, (7) Drenching sweats ANXIETY (0-7) (0)No anxiety, (1) Mildly anxious, (4)Moderately anxious or guarded so anxiety is inferred, (7) Equivalent to acute panic states as in severe delirium/acute schizophrenic reactions AGGITATION (0-7) (0)Normal activity, (1) Somewhat more than normal activity, (4) Moderately fidgety and restless, (7) Paces back and forth or constantly thrashes about TACTILE DISTURBANCES (0-7) (0)None, (1) Very mild itching, pins and needles or numbness, (4)Moderately severe hallucinations, (7) Continuous hallucinations AUDITORY HALLUCINATIONS (0-7) (0)Not present, (1)Very mild harshness or ability to frighten, (4) Moderately severe hallucinations, (7) Continuous hallucinations VISUAL HALLUCINATIONS (0-7) (0)Not present, (1) Very mild sensitivity, (4) Moderately severe hallucinations, (7) Continuous hallucinations HEADACHE, FULLNESS IN HEAD (0-7) (0)Not present, (1) Very mild, (4) Moderately severe, (7) Extremely severe ORIENTATION/CLOUDING SENSORIUM (0-4) (0)Orientated and can do serial additions, (1) Cannot do serial additions or uncertain about date, (2) Disorientated for date by no more than 2 calendar days, (3) Disorientated by more than 2 calendar days, ***VALID (4) Disorientated ON DATE for OF place PRINTING and/or ONLY person - all guidelines available at http://www.ycn.nhs.uk/ *** page 11 of 18

TOTAL SCORE Record action taken (i.e. amount chlordiazepoxide given/when next score due) It can be used in the acute setting when withdrawal is suspected or elective admission is indicated for detoxification prior to treatment for a head and neck cancer. 4.2 Detoxification prescription regimes Fixed dose or symptom triggered dosing regimes may be used, this is dependent on local policy and should be in accordance with NICE guidelines, (NICE, 2010). 4.3 Exceptional cases Where safe medically assisted alcohol withdrawal detoxification is indicated but cannot be carried out prior to surgical treatment, prophylactic post-surgical detoxification is suggested (Kuo et al., 2007, Neyman et al., 2005 and Weinfield et al., 2000). page 12 of 18

5 Wernickes Encephalopathy Wernickes encephalopathy is a serious neurological disorder caused by a thiamine deficiency due to reduced dietary intake and alcohol-induced impaired absorption. Clinical abnormalities may develop acutely or evolve over several days. These can be:- triad of confusion, cerebellar ataxia, ocular signs (ocular abnormalities include nystagmus, oculomotor palsies especially of sixth cranial nerve, ophthalmoplegia). A confusional state accompanied by apathy, drowsiness, disorientation and amnesia may also lead to stupor or coma (NICE, 2010). 5.1 Prophylaxis Head and neck cancer patients may be more susceptible to developing Wernickes Encephalopathy, due to the potential high risk factors often associated with this patient group, such as:- alcohol-related liver disease medically assisted withdrawal from alcohol (planned / unplanned) acute alcohol withdrawal malnourishment or risk of malnourishment due to weight loss in past year reduced BMI loss of appetite nausea and vomiting a general impression of malnourishment, hospitalised for acute illness hospitalised for co-morbidity or another alcohol issue. (NICE, 2010) For high risk patients, the prophylactic use of Thiamine is recommended (NICE, 2010). For dosing please refer to local trust policy. 5.2 Treatment Wernickes Encephalopathy is a medical emergency. If untreated, it may lead to death or Korsakoffs syndrome (permanent anterograde amnesia, usually irreversible). This requires urgent medical treatment. Please refer to local trust policy. page 13 of 18

6 Key recommendations Local policies should be updated in accordance with the Alcohol-use disorders guidelines (NICE, 2010). Develop links with local community addiction teams in order to promote safe and effective management of this patient group. Implement care pathways between primary and secondary care, enabling safe delivery of services. Health care professionals who care for people in acute alcohol withdrawal should be skilled in the assessment and monitoring of withdrawal symptoms and signs (NICE, 2010). page 14 of 18

7 References Kuo, Y., Jeng, S., Lin, K., Hou, S., Su, C., Chien, C., Hsueh, K and Huang, E. (2007). Microsurgical Tissue Transfers for Head and Neck Reconstruction in Patients with Alcohol Induced Mental Disorder. Annals of Surgical Oncology. 15 (1) pp371-377 Lansford, C.D., Guerriero, C.H., Kocan, M.J., Turley, R., Groves, M.W., Bahl, V., Abrahamse, P., Bradford, C.R., Chepeha, D.B., Moyer, J., Prince, M.E., Wolf, G.T., Aebersold, M.L. & Tekons, T.N. (2008). Improved Outcomes in Patients with Head and Neck Cancer using a Standardised Care Protocol for Post-operative Alcohol Withdrawal. Archives of Otolaryngology Head and Neck Surgery 134 (8) pp865-872 National Institute for Clinical Excellence. NICE. (2010). Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications. DOH, London. National Institute for Clinical Excellence. NICE. (2004) Improving Outcomes Guidance in Head and Neck Cancer. The Manual. DOH, London Neyman, K.M., Gourin, C.G. and Terris, D.J. (2005). Alcohol Withdrawal Prophylaxis in Patients undergoing Surgical Treatment of Head and Neck Squamous Cell Carcinoma. The Laryngoscope. 115 pp786-790 Sullivan, J.T., Sykora, K., Schneiderman, J., Naranjo, C.A and Sellers E.M. (1989). Assessment of Alcohol Withdrawal: the revised clinical withdrawal assessment for alcohol scale (CIWA-AR). British Journal of Addiction. 84 (11) pp1353-1357. [Accessed online] http://onlinelibrary.wiley.com Weinfield, A.B., Davison, S.P., Mason, A.C., Manders, E.K. and Russavage, J.M. (2000). Management of Alcohol Withdrawal in Microvascular Head and Neck Reconstruction.The Journal of Reconstructive Microsurgery. 16 (3) pp201-206 page 15 of 18

8 Appendix 8.1 Implemented pathways for Alcohol Assessment and Detoxification 8.1.1 WISMS pathway page 16 of 18

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8.1.2 York pathway page 18 of 18