NHS FORTH VALLEY Alcohol Dependence: Community Management of Alcohol Withdrawal Approved 14 / 11 / 2012 Version 2 Date of First Issue April 2008 Review Date 28 / 11 / 2014 Date of Issue 28 / 11 / 2012 EQIA Yes 28 / 11 / 2012 Author / Contact Leslie Cruickshank, Jean Logan, Claire McIntosh, Group / Committee Final Approval NHS Forth Valley Area Drug & Therapeutics Committee Version 2 November 2012 page 1 of 12
Consultation and Change Record Contributing Authors: Norrie Moane, Eddie Sutherland, Lesley White Consultation Process: Substance Misuse Integrated Clinical Governance Group Primary Care Prescribing Group Primary Care Drug & Therapeutics Committee Area Drug & Therapeutics Committee Distribution: GP Practices Forth Valley Substance Misuse Services Acute Care Physicians Via QI website Change Record Date Author Change Version Nov 2012 JBL Reformat in guideline template 2 Intro/scope: reference to relating documents Assessment changed to bullets Treatment flow chart amended SADQ added Annex 6 SIGN amended and blank chart included in appendix Version 2 November 2012 page 2 of 12
1. Introduction Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences. NICE clinical guideline 115 explains that dependence exists on a continuum of severity and subdivides it into categories. People with mild dependence usually do not require assisted alcohol withdrawal. Those with moderate dependence usually need assisted withdrawal, which can typically be managed in the community setting via a planned process unless there are other risks. People who are severely alcohol dependent will need assisted alcohol withdrawal, typically in an in-patient setting. SIGN 74 defines clear criteria for those who are not suitable for outpatient alcohol detoxification. This guideline is part of a suite of documents which aim to ensure NHS Forth Valley provides safe, effective and person centred care and services for people who misuse alcohol. This guideline outlines how services will manage alcohol withdrawal in the community and links to other relevant guidance below: Alcohol dependence: screening and identification (in development) Alcohol dependence: management of Alcohol Withdrawal in the in-patient setting. (under revision) Alcohol dependence: maintenance of abstinence 2. Scope This guideline applies to General Practice and other community based services for the management of people with alcohol dependence. It primarily provides advice for General Practitioners in the assessment of alcohol dependence and management of alcohol withdrawal. Signpost Recovery will provide structured support and care co-ordination as part of the community programme. This guideline pertains to patients with alcohol dependence in primary care. This may include those who typically drink over 15 units of alcohol per day and/or who score 20 or more on the AUDIT (refer to guidance on screening and identification). Pregnant women with alcohol dependence should be referred to the Community Alcohol & Drug Service (telephone 01324 678504). 3. Assessment It is important to take a clear history of alcohol use and multiple areas of need to determine if community management of alcohol withdrawal is a viable treatment option. A comprehensive assessment should include: Alcohol consumption from patient/other informant in units of alcohol per week History of withdrawal seizures or withdrawal complications Dependence using Short Alcohol Dependence Questionnaire (appendix 1) Record of other substances of misuse Blood tests including FBC, U&E, LFT, γgt. Home situation/support available Motivation to change Recent weight loss and poor diet Version 2 November 2012 page 3 of 12
3. Replacement of alcohol with an alternative CNS depressant Determine if medication is required? Yes, if recent withdrawal symptoms, or drinking >15 units/day (men) >10 units/day (women) +/or SADQ >15 No, if patient sober and has no withdrawal symptoms Is admission necessary? Yes Yes, if patient fulfils one of these criteria: Is confused or has hallucinations Has a history of withdrawal complications Has epilepsy or history of fits Has severe vomiting or diarrhoea Is at risk of suicide Has previously failed home-assisted withdrawal Has uncontrollable withdrawal symptoms Has an acute physical or psychiatric illness Has multiple substance misuse Has home environment unsupportive of abstinence Clinically jaundiced or bilirubin >34umol/L Na+ < 130mmol/L or K+<3mmol/L SADQ >30 Adapted from Sign/NICE & advice from Hepatologist Caution in Elderly who may have no support and additional co-morbidities No Community Detox Refer to Signpost Arrange appointment with patient and signpost keyworker Prescribe chlordiazepoxide Issue chlordiazepoxide fact sheet Issue advice to patients withdrawing from alcohol at home (appendix 2/3) Assess risk of Wernicke-Korsakoff syndrome (see 4.) Assess support for maintenance of abstinence Advise the patient that he/she may have mild anxiety/insomnia for a few days Signpost to: Signpost Recovery 0845 673 1774 Alcoholics Anon. 0845 769 7555 Addictions Support & Counselling (ASC) 01786 450721 01324 874969 Prescribe: The 'Standard Chlordiazepoxide Reducing Schedule' (appendix 2). Some patients may need a smaller starting dose which may be annotated on the blank chlordiazepoxide reducing chart (appendix 3). In the frail or elderly a lower starting dose should be considered where appropriate (for example 10mg instead of 30mg) using the blank chart (appendix 3). An "as required" dose of chlordiazepoxide may be prescribed in addition to regular, up to two doses in 24 hours. If risk of medicine misuse, prescribe chlordiazepoxide in instalments. Version 2 November 2012 page 4 of 12
4. Recognition of Wernicke-Korsakoff Syndrome Wernicke s encephalopathy is a reversible biochemical lesion of the CNS caused by overwhelming metabolic demands being made upon depleted B-vitamin reserves, in particular thiamine. Wernicke s encephalopathy is most common in chronic alcohol misusers. Wernicke s encephalopathy is an acute illness, precipitated by alcohol withdrawal, which is often under treated or missed. It should be suspected and treated in any patients undergoing alcohol detoxification who develop confusion, memory problems or difficulties with their gait or co-ordination. A presumptive diagnosis of Wernicke s encephalopathy should be made in patients with a history of alcohol abuse and one or more of the following otherwise unexplained symptoms: Acute confusion Ophthalmoplegia / nystagmus Ataxia/unsteadiness Memory disturbance Decreased consciousness level including unconsciousness / coma Unexplained hypotension with hypothermia Korsakoff s psychosis is described as an amnesic syndrome with impaired recent memory, and relatively intact intellectual function. It occurs after one or more inadequately treated episodes of Wernicke s encephalopathy. Patients rarely have a discrete deficit in forming new memories and often present with more global deficits along a spectrum of severity. Korsakoff s psychosis is a preventable dementia, by prompt treatment where Wernicke s is suspected, with high dose parenteral vitamin preparations. If patients undergoing Community Detoxification develop signs of Wernicke s encephalopathy they should be admitted to hospital as an emergency for intravenous vitamin supplementation. It is also important to elucidate, from a careful history, patients who are at risk of developing Wernicke-Korsakoff syndrome. These would include patients who have physical illness, weight loss, poor diet, diarrhoea and vomiting. These at risk patients should also be treated with parenteral vitamins, as detailed below. It is anticipated that patients in some of these categories may be considered for community alcohol detoxification, it is therefore important to look at adequate prophylaxis with parenteral vitamins. Prophylaxis Administer ONE pair of IM PABRINEX Ampoules (High Potency Parenteral B-Complex Vitamins) ONCE DAILY for 3 days. Version 2 November 2012 page 5 of 12
It should be noted, as per CSM advice, that there is a small risk of anaphylactic reactions with parenteral vitamin preparations. Facilities for treatment of anaphylaxis should be available, so it is anticipated that these treatments will occur in settings such as in any setting where routine vaccinations are administered. Oral preparations of thiamine are poorly absorbed in alcohol misusers, and will not adequately replace depleted thiamine stores. They should not be used as a substitute for parenteral vitamin supplementation. Patients who have a chronic alcohol problem and whose diet may be deficient should be given oral thiamine indefinitely after parenteral (SIGN 74). For this group a dose of thiamine 100mg three times daily is recommended. 5. Support During detoxification the patient will be seen by the community substance misuse worker who will breathalyse and check observations daily. Severity of withdrawal symptom checklist should be used daily during detoxification. 6. Forward Planning The need for alcohol detoxification means that the patient has a dependency on alcohol and by definition a severe alcohol problem. It is important that all avenues to prevent relapse are explored, and that patients are offered pharmacological, psychological and social help for their dependence. For further details, refer to Alcohol Dependence: Maintenance of Abstinence. Signpost Recovery will assess the requirement for support in maintenance of abstinence. Other agencies in Forth Valley who offer counselling and support to substance users include Alcoholics Anonymous (AA) and Addictions Support & Counselling (ASC). Version 2 November 2012 page 6 of 12
7. References 1. Cook, C.H., Thomson, A.D., B-Complex Vitamins in the prophylaxis and treatment of Wernicke-Korsakoff syndrome, Br J Hosp Med 1997 ;57: 461-465 2. Lingford-Hughes A.R., Welch S., Nutt D.J., Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2004 18(3); 293-335 3. Mayo-Smith, M.F., Pharmacological management of alcohol withdrawal. A meta-analysis and evidenced-based practice guideline. American Society of Addiction working group on pharmacological management of alcohol withdrawal. JAMA 1997; 278:144-51 4. McIntosh, C., Chick, J., Alcohol and the Nervous System, JNNP 2004;(suppl III): iii16-iii213 5. Raistrick D., Heather N., Godfray C. Review of the effectiveness of treatment for alcohol problems. National Treatment Agency. 6. Scottish Intercollegiate Guidelines Network (SIGN). The management of harmful drinking and alcohol dependence in primary care, 2003 7. Slattery, J., Chick, J., et al Prevention of relapse in alcohol dependence, Health Technology Assessment Report 3, 2003, NHS-QIS 8. Thomson A.D., Marshall E.J., The natural history and pathophysiology of Wernicke s Encephalopathy and Korsakoff s Psychosis. Alcohol & Alcoholism 2006 41, No 2, 151-158 9. Thomson A.D., Marshall E.J., The treatment of patients at risk of developing Wernicke s Encephalopathy in the community, Alcohol & Alcoholism 2006 41, No 2, 159-167 10. Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115. February 2011. www.nice.org.uk 11. Alcohol-use disorders: sample chlordiazepoxide dosing regimens for use in managing alcohol withdrawal. NICE clinical guidelines 100 and 115. February 2010. http://www.nice.org.uk/nicemedia/live/13337/53105/53105.pdf Version 2 November 2012 page 7 of 12
SEVERITY OF ALCOHOL DEPENDENCE QUESTIONAIRE (SADQ-C) Appendix 1 Stockwell, T., Sitharan, T., McGrath, D.& Lang,. (1994). The measurement of alcohol dependence and impaired control in community samples. Addiction, 89, 167-174. NAME AGE No. DATE: Please recall a typical period of heavy drinking in the last 6 months. When was this? Month:. Year.. Please answer all the following questions about your drinking by ticking your most appropriate response. During that period of heavy drinking 1. The day after drinking alcohol, I woke up feeling sweaty. Almost never Sometimes Often Nearly always 2. The day after drinking alcohol, my hands shook first thing in the morning. 3. The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn't have a drink. 4. The day after drinking alcohol, I woke up absolutely drenched in sweat. 5. The day after drinking alcohol, I dread waking up in the morning. 6. The day after drinking alcohol, I was frightened of meeting people first thing in the morning. 7. The day after drinking alcohol, I felt at the edge of despair when I awoke. 8. The day after drinking alcohol, I felt very frightened when I awoke. 9. The day after drinking alcohol, I liked to have an alcoholic drink in the morning. 10. The day after drinking alcohol, I always gulped my first few alcoholic drinks down as quickly as possible. 11. The day after drinking alcohol, I drank more alcohol to get rid of the shakes. 12. The day after drinking alcohol, I had a very strong craving for a drink when I awoke. 13. I drank more than a quarter of a bottle of spirits in a day (OR 1 bottle of wine OR 7 beers). 14. I drank more than half a bottle of spirits per day (OR 2 bottles of wine OR 15 beers). 15. I drank more than one bottle of spirits per day (OR 4 bottles of wine OR 30 beers). 16. I drank more than two bottles of spirits per day (OR 8 bottles of wine OR 60 beers) Version 2 November 2012 page 8 of 12
Imagine the following situation: 1. You have been completely off drink for a few weeks 2. You then drink very heavily for two days How would you feel the morning after those two days of drinking? 17. I would start to sweat. Not at all Slightly Moderately A lot 18. My hands would shake. 19. My body would shake. 20. I would be craving for a drink. Total Score Checked by: Alcohol Detoxification prescribed? Yes No NOTES ON THE USE OF THE SADQ The Severity of Alcohol Dependence Questionnaire is a measure of the severity of dependence. The SADQ questions cover the following aspects of dependency syndrome: physical withdrawal symptoms affective withdrawal symptoms relief drinking frequency of alcohol consumption speed of onset of withdrawal symptoms. Scoring Answers to each question are rated on a four-point scale: Almost never - 0 Sometimes 1 Often 2 Nearly always 3 A score of 31 or higher indicates "severe alcohol dependence". A score of 16-30 indicates "moderate dependence" A score of below 16 usually indicates only a mild physical dependency. A chlordiazepoxide detoxification regime is usually indicated for someone who scores 16 or over. It is essential to take account of the amount of alcohol that the patient reports drinking prior to admission as well as the result of the SADQ. Version 2 November 2012 page 9 of 12
Annex 6, SIGN 74 Appendix 2 Advice to patients on withdrawing from alcohol at home 1. If you have been chemically dependent on alcohol, stopping drinking causes you to get tense, edgy, perhaps shaky or sweaty, and unable to sleep. There can be vomiting or diarrhoea. This "rebound" of the nervous system can be severe. Medication controls the symptoms while the body adjusts to being without alcohol. This usually takes three to seven days from the time of your last alcoholic drink. If you don't take medication, the symptoms would be worst in the first 48 hours, and then gradually disappear. This is why, if you do take medication, the dose starts high and then reduces. 2. YOU HAVE AGREED NOT TO DRINK ALCOHOL. You may get thirsty. Drink fruit juices and water but do not overdo it. You do not have to "flush" alcohol out of the body. More than three litres of fluid could be too much. Don't drink more than three cups of coffee or five cups of tea. These contain caffeine which disturbs sleep and causes nervousness. 3. AIM TO AVOID STRESS. The important task is not to give in to the urge to take alcohol. Help yourself relax by going for a walk, listening to music, or taking a bath. 4. SLEEP. You may find that even with the capsules, or as they are reduced, your sleep is disturbed. You need not worry about this - lack of sleep does not seriously harm you, starting to drink again does. Your sleep pattern will return to normal in a month or so. It is better not to take sleeping pills so that your natural sleep rhythm returns. Try going to bed later. Take a bedtime snack or milky drink. 5. The chlordiazepoxide capsules/tablets may make you drowsy so you must not drive or operate machinery. If you get drowsy, miss out a dose. 6. MEALS. Even when you are not hungry, try to eat small amounts regularly. Your appetite will return. Chlordiazepoxide First thing Lunch time Tea time Bedtime Day 1-30mg 30mg 30mg Day 2 20mg 20mg 20mg 30mg Day 3 20mg 10mg 10mg 20mg Day 4 10mg 10mg - 20mg Day 5-10mg - 10mg NB. The above table is a guide for the number of capsules/ tablets required to complete the reducing course. This regime totals 30 x 10mg chlordiazepoxide capsules/tablets which may be prescribed as: To be taken as directed on medication chart. In addition consider as required doses as outlined in section 3. Version 2 November 2012 page 10 of 12
Annex 6, SIGN 74 Appendix 3 Advice to patients on withdrawing from alcohol at home 7. If you have been chemically dependent on alcohol, stopping drinking causes you to get tense, edgy, perhaps shaky or sweaty, and unable to sleep. There can be vomiting or diarrhoea. This "rebound" of the nervous system can be severe. Medication controls the symptoms while the body adjusts to being without alcohol. This usually takes three to seven days from the time of your last alcoholic drink. If you don't take medication, the symptoms would be worst in the first 48 hours, and then gradually disappear. This is why, if you do take medication, the dose starts high and then reduces. 8. YOU HAVE AGREED NOT TO DRINK ALCOHOL. You may get thirsty. Drink fruit juices and water but do not overdo it. You do not have to "flush" alcohol out of the body. More than three litres of fluid could be too much. Don't drink more than three cups of coffee or five cups of tea. These contain caffeine which disturbs sleep and causes nervousness. 9. AIM TO AVOID STRESS. The important task is not to give in to the urge to take alcohol. Help yourself relax by going for a walk, listening to music, or taking a bath. 10. SLEEP. You may find that even with the capsules, or as they are reduced, your sleep is disturbed. You need not worry about this - lack of sleep does not seriously harm you, starting to drink again does. Your sleep pattern will return to normal in a month or so. It is better not to take sleeping pills so that your natural sleep rhythm returns. Try going to bed later. Take a bedtime snack or milky drink. 11. The chlordiazepoxide capsules/tablets may make you drowsy so you must not drive or operate machinery. If you get drowsy, miss out a dose. 12. MEALS. Even when you are not hungry, try to eat small amounts regularly. Your appetite will return. Chlordiazepoxide First thing Lunch time Tea time Bedtime Day 1 Day 2 Day 3 Day 4 Day 5 Version 2 November 2012 page 11 of 12
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