Alcohol Dependence Inpatient management of Alcohol Withdrawal

NHS Fife Community Health Partnerships Addiction Services Alcohol Dependence Inpatient management of Alcohol Withdrawal Intranet Procedure No A9 Author Dr. A. Baldacchino Copy No Lead Clinician Implementation Date January 2007 Status Authorised 2011 Last Review Date April 2011 Approved By: Medical Director Primary Care Next Review Date April 2013 Head of Nursing NHS Fife 1 Function 1.1 To ensure the safe and appropriate detoxification and treatment of inpatients with alcohol dependence. 2 Location 2.1 NHS Fife Hospitals 3 Responsibility 3.1 Nursing, medical and pharmacy staff 4 Operational System 4.1 In alcohol-dependent drinkers, withdrawal symptoms can start from 6 to 24 hours after the last alcoholic drink and usually last 5 7 days, occasionally longer. Early symptoms include tremor, sweating, anorexia, nausea, insomnia and anxiety. It is vital to detect symptoms early thus having a high level of suspicion and taking a comprehensive history helps. Withdrawal seizures are a risk between 10 and 60 hours after cessation. These may precede or accompany life threatening Delirium Tremens, which may develop after 72 hours if withdrawal symptoms persist. Predisposing factors include hypoglycemia, hypocalcaemia, hypomagnesaemia. Where possible, patients should be managed in an environment with adequate lighting, cool ambient temperature, good ventilation and supportive nursing care. 5 Assessment 5.1 All patients should be asked about how many units of alcohol they normally consume in a typical or average week (see Appendix 1 for information regarding units of alcohol). Page 1 of 10

Patients drinking in excess of 21 units (males) or 14 units (females) per week and answering positively to two or more questions in the FAST questionnaire (Fast Alcohol Screening Test for the Detection of Probable Hazardous Drinking) (Appendix 2) should have a more detailed drinking history taken. 5.2 Patients who are assessed as having a recent history of probable hazardous drinking should complete the self-assessed Severity of Alcohol Dependence Questionnaire (SADQ) (Appendix 3) and be examined fully. The SADQ is a reliable instrument to measure the severity of alcohol dependence. Using the SADQ, the degree of severity of alcohol dependence can be classified as moderate (up to 30), severe (31-40) and very severe (41-60). 6 Management of Alcohol Withdrawal 6.1 Referral should be made to the Alcohol Liaison Nursing Team (ALNT) at Ward 11, Cameron Hospital. Page 2 of 10

Flow sheet for Inpatient Assessment and Treatment of Alcohol Dependence Suspicion of Alcohol Misuse Abnormal LFT s / raised MCV. Clinical Signs of Alcohol Withdrawal FAST Administered & suggests hazardous drinking. Complete the Severity of Alcohol Dependence Questionnaire and Severity of Withdrawal Symptoms Checklist Screen for Encephalopathy Wernicke s Suspicion of emergent Wernicke s At least 2 pairs Pabrinex I.V. three times daily for at least three days as per NHS Fife Guidance No suspicion Prevention dosage required 1 pair Pabrinex IM/IV for 3-5 days Emergent Wernicke s Acute confusion /memory disturbance/reduced consciousness; Ataxia, Opthalmopegia Nystagmus; Unexplained Hypotension with Hypothermia. SADQ Moderate dependence High dependence Severe dependence SWSC <10 10-20 >20 Recommended minimum starting dose Chlordiazepoxide 10-15mg four times daily 20-30mg four times daily 30-40mg four times daily Review at least four hourly for first 48 hours:- Symptom control; Signs of Wernicke s. Withdrawals under control? No Augment Chlordiazepoxide (max 250mg/24hrs total dose), consider Lorazepam or Haloperidol Yes Reassess after 4 hours Start detoxification regime based on total required over last 24 hours detoxification usually over 5 days; Refer to the Alcohol Liaison Service; Doses above 250mg should not be prescribed without prior discussion with a Consultant or Specialist Registrar. 6.2 Alcohol dependent patients exhibiting withdrawal features or those assessed at high risk of developing withdrawal symptoms should undergo the following alcohol detoxification process. Page 3 of 10

6.3 In order to manage the withdrawal safely and effectively, a baseline withdrawal score, using the Severity of Withdrawal Symptom Checklist (SWSC) (Appendix 4) must be performed prior to commencing treatment and repeated at least every six hours for the first 24 hours. Thereafter, withdrawal symptoms should be measured twice daily. The current clinical symptoms of the patient must also be taken into consideration. 7 Prevention and Recognition of Wernicke s Korsakoff Syndrome 7.1 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. 7.2 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. Korsakoff s psychosis is a preventable dementia, 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. 7.3 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 Opthalmopegia/Nystagmus Ataxia/unsteadiness Memory disturbance Decreased consciousness level including unconsciousness/coma Unexplained hypotension with hypothermia 8 Prophylaxis for Wernicke s Encephalopathy 8.1 All in-patients presenting in alcohol withdrawal should be considered at risk of developing Wernicke's Encephalopathy and should be prescribed prophylactic parenteral vitamins as follows: Administer ONE pair of IV or IM Pabrinex ampoules (High Potency Parenteral B- Complex Vitamins) ONCE DAILY for 3 days. 8.2 Patients with symptoms consistent with Wernicke s Encephalopathy: Administer 2 pairs of IV Pabrinex Ampoules (High Potency Parenteral B Complex Vitamins) THREE TIMES DAILY for at least 2 DAYS. No Response after 72 hours: Review diagnosis. Consider augmentation with i.v. magnesium or discontinue supplementation unless comatose/unconscious. Response: At least 1 pair IV or IM Pabrinex amps ONCE daily for 5 DAYS, in patients with ataxia, polyneuritis, memory disturbance - continue treatment until clinical improvement ceases. 8.3 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 preparations. Patients who have a chronic alcohol problem and whose diet may be deficient should be given oral thiamine indefinitely after parenteral vitamin supplementation (SIGN 74). For this group a dose of thiamine 50mg three times daily is recommended. Page 4 of 10

9 Treatment Regimens for Detoxification in Alcohol Dependence. 9.1. Oral chlordiazepoxide is the treatment of choice for detoxification in Fife. Optimal management involves the individual titration of chlordiazepoxide dosage against withdrawal severity. See table 1 below. Chlordiazepoxide should be prescribed on the REGULAR AND AS REQUIRED sections of the medicine prescription sheet. 9.2. Special caution is necessary in the case of severe liver impairment as the metabolism of benzodiazepines may be reduced and lead to over sedation. 9.3 The majority of patients will begin treatment with chlordiazepoxide at least 20mg four times a day. Adequate control of withdrawal symptoms is paramount and the dose should be reviewed if symptoms are not controlled and the dose increased until objective signs of withdrawal are alleviated. Table 1 suggested dosing for treatment of alcohol withdrawal. The total daily dose of chlordiazepoxide (i.e. regular and as required ) should not routinely exceed 250mg. Consultant or SpR advice should be obtained prior to using doses about 250mg. Table 1 Titrated fixed-dose chlordiazepoxide protocol for treatment of alcohol withdrawal (South West London & St Georges Mental Health NHS Trust, 2010) Typical recent daily consumption Severity of alcohol dependence Starting dose of chlordiazepoxide 15 to 25 units 30 to 49 units 50 to 60 units MODERATE SADQ score 16 to 30 15 to 25mg four times daily SEVERE SADQ score 31 to 40 30 to 40mg four times daily VERY SEVERE SADQ score 41 to 60 50mg four times daily Day 1 (starting dose) 15 q.d.s. 25 q.d.s. 30 q.d.s. 40 q.d.s.* 50 q.d.s.* Day 2 10 q.d.s. ¹ 20 q.d.s. 25 q.d.s. 35 q.d.s. 45 q.d.s. Day 3 10 t.d.s. ² 15 q.d.s. 20 q.d.s. 30 q.d.s. 40 q.d.s. Day 4 5 t.d.s. 10 q.d.s. 15 q.d.s. 25 q.d.s. 35 q.d.s. Day 5 5 b.d. ³ 10 t.d.s. 10 q.d.s. 20 q.d.s. 30 q.d.s. Day 6 5 at night 5 t.d.s. 10 t.d.s. 15 q.d.s. 25 q.d.s. Day 7 5 b.d. 5 t.d.s. 10 q.d.s. 20 q.d.s. Day 8 5 at night 5 b.d. 10 t.d.s. 15 q.d.s. Day 9 5 at night 5 t.d.s. 10 q.d.s. Day 10 5 b.d. 10 t.d.s. Day 11 5 at night 5 t.d.s. Day 12 5 b.d. Day 13 5 at night * Doses of chlordiazepoxide in excess of 30mg q.d.s should only be prescribed in cases where severe withdrawal symptoms are expected and the patient s response to the treatment should always be regularly and closely monitored. Doses in excess of 40mg q.d.s. should only be prescribed where there is clear evidence of very severe alcohol dependence. ¹ Four times a day; ² Three times a day;³ Twice daily 9.4 If a patient is vomiting, an antiemetic e.g. intramuscular metoclopramide 10mg injection may be administered 30 minutes prior to the administration of chlordiazepoxide. If this is inappropriate, or fails, lorazepam 1-2mg by intramuscular injection (up to a maximum of two doses in 24 hours) may be used. 9.5 If agitation remains uncontrolled, haloperidol 5mg by intramuscular injection may be administered. Acute dystonia may be treated with procyclidine 5-10mg by intramuscular injection. 9.6 Patients who are being discharged during alcohol detoxification treatment must be supplied with oral chlordiazepoxide to complete the reducing regimen. The reducing regimen must be written clearly, signed by the prescriber and given to the patient. Chlordiazepoxide must Page 5 of 10

also be prescribed on the immediate discharge and prescription sheet as chlordiazepoxide 10mg capsules as per reducing regimen and specify a total quantity to be supplied. 10 Provision of patient Information Advice should be provided to patients on community-based Alcohol Support Agencies and/or Community Alcohol Service, NHS Addiction Services where appropriate 11 Related Documents Appendix 1 Appendix 2 Appendix 3 Appendix 4 Units of Alcohol FAST Severity of Alcohol Dependence Questionnaire (SADQ) Severity of Withdrawal Symptom Checklist (SWSC) 12 References Scottish Intercollegiate Guidelines Network (SIGN) No 74 The Management of Harmful Drinking and Alcohol Dependence in Primary Care A National Clinical Guideline http://www.sign.ac.uk McIntosh, C., Chick, J., Alcohol and the Nervous System, JNNP 2004;(suppl III): iii16-iii213 Slattery J, Chick J, Cochrane M, Craig J, Godfrey C, Macpherson K, Parrott S. Health Technology Assessment of Prevention of relapse in alcohol dependence. HTBS (2002). http://www.htbs.co.uk/docs/pdf/alcohol%20report.pdf Gossop M. et al. A short alcohol withdrawal scale (SAWS): development and psychometric properties. Addict Biol 2002; 7:37-43 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 Thomson AD et al. The natural history and path physiology of Wernicke s encephalopathy and Korsakoff s psychosis. Alcohol 2006; 41:151-8 Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence based practice guideline. American society of addiction working group on pharmacological management of alcohol withdrawal. JAMA 1997;278:4=144- Stockwell, T., Sitharan, T., McGrath, D. & Lang (1994). The measurement of alcohol dependence and impaired control in community samples. Addiction, 89, 167 174. 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 Lingford-Hughes A.R., Welch S., Nutt D.J., Evidence-based guidelines for the Pharmacological management of substance misuse, addiction and co morbidity: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2004 18(3); 293-335 South West London and St George's Mental Health NHS Trust (2010) The Blue Book: Guidelines for the Management of Common/Selected Psychiatric Emergencies and Certain Trust Policies and Procedures. 13th Edition. South West London and St Georges Mental Health NHS Trust, London. Appendix 1 Page 6 of 10

UNITS OF ALCOHOL 8G (10mL) PURE ALCOHOL ONE UNIT ½ PINT ORDINARY STRENGTH BEER (3-4% alcohol by volume) ONE UNIT ONE PUB MEASURE (25ml) SPIRITS (40%alcohol by volume) ONE UNIT ONE SMALL GLASS (125ml) TABLE WINE (10-12% alcohol by volume) 0NE AND A HALF UNITS ONE CAN (50OMLS) STRONG LAGER/CIDER (8% alcohol by volume) 4 UNITS ONE BOTTLE TABLE WINE (750mL of 12-14% alcohol by volume) 9 10.5 UNITS SHERRY (750ML of 20% alcohol by volume) SPIRITS (75OmL of 40% alcohol by volume) 15 UNITS 30 UNITS Page 7 of 10

Appendix 2 The Fast Alcohol Screening Test (FAST) for the detection of probable hazardous drinking For the following questions please circle the answer which best applies. 1 drink = 1 unit = ½ pint of beer or 1 glass of wine or 1 single spirits 1. MEN : How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? Never Less than Monthly Weekly Daily or Monthly almost daily Only ask Questions 2, 3 & 4 if the response to Question 1 is Less than monthly or Monthly 2. How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than Monthly Weekly Daily or Monthly almost daily 3. How often during the last year have you failed to do what was normally expected of you because of drink? Never Less than Monthly Weekly Daily or Monthly almost daily 4. In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? No Yes, on Yes, on more than Occasion one occasion Scoring is quick and can be completed with just a glance at the pattern of responses as follows: Stage 1 The first stage only involves question 1. If the response to question 1 is never then the patient is not misusing alcohol. If the response to question 1 is Weekly/Daily or Almost Daily then the patient is a hazardous, harmful or dependent drinker. Over 50% of people will be classified using just this one question. Only consider Questions 2, 3 & 4 if the response to Question 1 is Less than monthly or Monthly. Stage 2 If the response to Question 1 is Less than monthly or Monthly then each of the four questions is scored 0 to 4. These are then added resulting in a total score between 0 and 16. The person is misusing alcohol if the total score for all four questions is 3 or more. Score Questions 1, 2 & 3 as follows: Never = 0 Less than monthly = 1 Monthly = 2 Weekly = 3 Daily or almost daily = 4 Score Question 4 as follows: No = 0 Yes, on one occasion = 2 Yes, on more than one occasion = 4 In summary, score Questions 1, 2 & 3: 0, 1,2,3,4. Score Question 4: 0,2,4 The minimum score is 0 The maximum score is 16 The score for hazardous drinking is 3 or more Page 8 of 10

Appendix 3 SEVERITY OF ALCOHOL DEPENDENCE QUESTIONNAIRE (SADQ) Patient Details: ALMOST NEVER (0) SOME TIMES (1) OFTEN NEARLY ALWAYS (3) Date: (2) During a heavy drinking period do you/ does your /are you wake up feeling sweaty. have hands that shake first thing in the morning whole body shakes violently first thing in the morning if you don t have a drink. wake up absolutely drenched in sweat. dread waking up in the morning. frightened of meeting people first thing in the morning. feel at the edge of despair when you awake. feel very frightened when you awake. like to have a morning drink. gulp my first few morning drinks down as quickly as possible. drink in the morning to get rid of the shakes. have a very strong craving for a drink when you awake. drink more than a quarter of a bottle of spirits per day (4 doubles or 1 bottle of wine or 4 pints of beer). During a heavy drinking period, I drink more than half a bottle of spirits per day (or 2 bottles of wine or 8 pints of beer). drink more than one bottle of spirits per day (or 4 bottles of wine or 15 pints of beer). drink more than two bottles of spirits per day (or 8 bottles of wine or 30 pints of beer). 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 heavy drinking? Not at all (0) I would start to sweat. My hands would shake. My body would shake. I would be craving for a drink. Slightly (1) Moderately (2) Quite a lot (3) Total score (Scores lower than or equal to 15 indicate low dependence, 16 to 30 indicates moderate dependence, 31 to 40 indicates a severe dependence and 41 to 60 indicates a very severe level of dependence Page 9 of 10

Patient details: Appendix 4 Severity of Withdrawal Symptom Checklist (SWSC) (abbreviated) Date and time Orientation Consciousness Agitation Hallucinations Sweating Tremor Mood Anxiety Sleep Appetite SWSC-total Blood pressure : Pulse GI Disturbance Commitment to Detox TOTAL SCORE Scoring Guidance: ORIENTATION LEVEL OF CONSCIOUSNESS Fully orientated 0 Fully alert 0 Mildly disorientated 1 Slightly drowsy 1 Obviously disorientated 2 Very drowsy 2 Totally disorientated 3 Roused with difficulty 3 AGITATION HALLUCINATIONS No signs 0 No hallucinations 0 Slight 1 Unstructured 1 Moderate restlessness 2 Intermittent structured 2 Constant restlessness 3 Frequently structured 3 SWEATING TREMOR No sweating 0 None 0 Slight 1 Slight 1 Moderate 2 Moderate 2 Profuse 3 Marked 3 MOOD ANXIETY Cheerful/appropriate 0 Find it easy to relax 0 Sometimes low 1 Find it difficult to relax 1 Often low 2 Hardly ever relaxed 2 Despondent 3 Cannot relax 3 SLEEP Slept well 0 Broken sleep 1 Difficulty in sleeping 2 Score / 30 Insomnia 3 GI DISTURBANCE Mild = up to 10 No abnormalities 0 Moderate = 11 20 Mild nausea 1 Severe = over 20 Persistent nausea 2 Vomiting 2+ times 3 Page 10 of 10