Guidance for community alcohol detoxification in clients with complex needs

Transcription

1 Document level: Clinical Service Unit (CSU) Code: DA3 Issue number: 1 Guidance for community alcohol detoxification in clients with complex needs Lead executive Medical Director Author and contact number Clinical Director Type of document Target audience Document purpose Guidance Medical officers / substance misuse practitioners within drug and alcohol treatment services To provide accessible, non-judgmental and holistic care which will enable this patient group to access an alcohol detoxification when all other avenues have been explored. Thus achieving optimum well being in this client group and reduce hospitalisation. Document consultation Clinical directors and CWP doctors, Drug & Alcohol Clinical Service Unit Staff, Inpatient Staff Approving meeting Medicines Management Group 4-Aug-11 Ratification Document Quality Group (DQG) 16-Mar-12 Original issue date Mar-12 Implementation date Mar-12 Review date Mar-17 CWP documents to be read in conjunction with HR6 MP1 Trust-wide learning and development requirements including the training needs analysis (TNA) Medicines Policy Training requirements Financial resource implications There are no specific training requirements for this document. No Equality Impact Assessment (EIA) Initial assessment Yes/No Comments Does this document affect one group less or more favourably than another on the basis of: Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender No Culture No Religion or belief No Sexual orientation including lesbian, gay and bisexual people No Age No Disability - learning disabilities, physical disability, sensory impairment and mental health problems No Is there any evidence that some groups are affected differently? No If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? N/A Is the impact of the document likely to be negative? No Page 1 of 19

2 If so can the impact be avoided? No What alternatives are there to achieving the document without N/A the impact? Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? What is the level of impact? No Low Monitoring compliance with the processes outlined within this document Is this document linked to the No NHS litigation authority (NHSLA) risk management NB - The standards in bold above are those standards which are standards assessment? assessed at the level 2 and 3 NHSLA accreditation. Who is responsible for undertaking the monitoring? How are they going to monitor the document? What are they going to monitor within the document? Where will the results be reviewed? When will this be monitored and how often? If deficiencies are identified how will these be dealt with? Who and where will the findings be communicated to? How does learning occur? How are the board of directors assured? Clinical Directors, Drug & Alcohol Services Monitoring of clinical incidents related to non-adherence of this policy document. Review and update policy in line with national guidance and changes in clinical practice. CWP Drug & Alcohol Serivce Management Meetings and consultation with Medical Staffing. 2 Yearly Via an action plan falling out of the audits which each service unit will have to implement and give assurance to the Trust MMG upon implementation. Feedback through MMG to all service units. It is the duty and responsibility of all CWP Drug and Alcohol Services Specialist Team's to keep up to date with this policy. Line Managers have the responsibility to cascade information on the revised policy, ensuring any training needs are identified. All action plans are registered via the Trust compliance and performance sub-committee which reports to the Board via the Quality committee. There is also an annual medicines management report to the Board that gives assurances of the work completed in each 12 month cycle on mediicnes management. Document change history Changes made with rationale and impact on practice 1. No No 4.14 moved to the end of paragraph 2. No Added: with regular venous bloods being taken during this period 3. No Removed: or a shorter acting benzodiazepine such as lorazepam 4. No Reference made to Appendix 7 5. No Removed: Prophylaxis from title Page 2 of 19

3 Changes made with rationale and impact on practice 6. No Changed: 4 week prophylaxis course of zoton fastab to 7 day prophylactic course of a dispersible proton pump inhibitor e.g lansoprazole, for the relief of symptoms the recommended dose is 15 to 30mgs daily, omeprazole 20mg daily 7. Appendix 1 - Amended score layout 8. Appendix 7 - Added: Management Algorithm for Vitamin Supplementation & Prevention and/or treatment for Wernicke's Encephalopathy Flowchart External references References 1. The Alcohol Harm reduction Stratergy for England. DOH Nice Guidelines on Alcohol Detoxification 3. Stockwell T, Murphy D, Morgan R, (1983)The Severity of Alcohol Dependence questionnaire: its use, reliability and validity. British Journal of Addiction 78 pg Taylor DJ, (2003) Alcohol Consumption in Pregnancy, Guidelines and Audit Sub committee of the Royal College of Obstetricians and Gynaecologists. 5. M.F. mayo-smith et al. Pharmacological Management of alcohol Withdrawal: A Meta- Analysis and Evidence- Based Practice Guideline. JAMA July 9,1997 Vol 278, No 2 6. J.T.Sullivan et al. Assessment of alcohol Withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British Journal of Addiction (1989) 84, Ballinger. JC, & Post, RM. Carbamazepine in alcohol withdrawal syndromes and schizophrenic psychosis. Pschopharmacol, Bull 1984, 20: Sign (Scottish Intercollegiate Guidelines Network) Guidelines 2003, the management of Harmful drinking and Alcohol Dependence in Primary Health Care: A National Clinical Guidelines. 9. Smith SS, Gong QH, Hsu FC, Markowitz RS, French-Mullen JM, Li X. GABAA receptor α4 subunit suppression prevents withdrawal properties of an endogenous steroid. Nature. 1998;392: [PubMed] 10. Löscher W, Rogawski MA. Epilepsy. In: Lodge D, Danysz W, Parsons CG, editors. Ionotropic Glutamate Receptors as Therapeutic Targets. Johnson City, TN: FP Graham Publishing; pp Ballenger JC, Post RM. Kindling as a model for alcohol withdrawal syndromes. Br J Psychiatry. 1978;133:1 14. [PubMed] 12. Duka T, Gentry J, Malcolm R, Ripley TL, Borlikova G, Stephens DN, Veatch LM, Becker HC, Crews FT. Consequences of multiple withdrawals from alcohol. Alcohol Clin Exp Res. 2004;28: [PubMed] 13. Becker HC, Hale RL. Repeated episodes of ethanol withdrawal potentiate the severity of subsequent withdrawal seizures: an animal model of alcohol withdrawal kindling. Alcohol Clin Exp Res. 1993;17:94 [PubMed] Page 3 of 19

4 Content 1. Introduction Background Screening and assessment The Shortened Audit (Alcohol Use Disorders Identification Test) Severity of Alcohol Dependence Questionnaire (SADQ) Clinical Institute Withdrawal Assessment for alcohol Scale (CIW-AR) (appendix 6) Blood and breath alcohol Clinical examination Haematological Investigation Alcohol Withdrawal Syndrome (AWS) Levels of withdrawal and management Hallucinations Withdrawal seizures Delirium Tremens (DTs) Fluids and electrolytes Prescribing Vitamin supplements Withdrawal seizures Treatment of reflux oesophagitis Nausea and vomiting Acamprosate Duties and responsibilities Clinical Director Line Managers Trust Staff Appendix 1 - Alcohol Use Disorders Identification Test (AUDIT) Appendix 2 - Severity of Alcohol Dependence Questionnaire Appendix 3 - Prescribing for alcohol dependence Appendix 4 - Table showing benzodiazepine equivalents used in alcohol detoxification Appendix 5 - Recommended reducing Regime Appendix 6 - Clinical Institute Withdrawal Assessment of Alcohol Scale (Ciawa Ar) Appendix 7 - Management Algorithm for Vitamin Supplementation and Prevention and/or treatment for Wernicke s Encephalopathy Page 4 of 19

5 1. Introduction There are often multiple psychosocial and health related problems associated with polydrug use. Poly drug use is defined as the concurrent misuse of two or more substances. This pattern of using two or more substances is becoming increasingly common with the combining of one substance and alcohol becoming the norm. Managing the polydrug using client brings various challenges such as increased risk of drug interactions and has implications for prescribing of central nervous system depressant drugs such as methadone and benzodiazepines. These guidelines are intended to act as comprehensive structured treatment interventions. The aim is to achieve optimum well being in clients presenting with alcohol related problems and to reduce the need for hospital admission. 2. Background The national agenda to improve the quality and capacity for alcohol misuse treatment has been heavily influenced by The Alcohol Harm Reduction Strategy for England [DOH 2004], which draws together a range of government interventions to prevent, minimize and manage alcohol related harm into a single strategy. The new strategy, Safe, Sensible, Social - The next steps in the national alcohol strategy [DOH 2008] builds on the foundations laid and lessons learnt since 2004, with its long term goal being: To minimize the health harms and antisocial behaviour associated with alcohol, while ensuring that people are able to enjoy alcohol safely and responsibly. It is important with this group of clients that standards for safe prescribing should be rigorously implemented due to the enhanced risk. This may conflict the need to detoxify a client quickly due to failing health or deterioration in the family unit. However there is always a balance to be attained. Within a high threshold context, safe practice should always be placed before other concerns in situations where there is doubt as to the way forward. Setting clear boundaries at the commencement of any intervention related to a clients alcohol use, with a clear route to detoxification is an essential element of effective practice. 3. Screening and assessment Screening for harmful drinking within services offering alcohol detoxification should be widely promoted as more and more individuals fall into this category. Clients should be screened in an attempt to benefit those with alcohol related problems as this enables any deleterious effects of the alcohol consumption, to be identified early and interventions offered (RCP 2001). These clients may already suffer from liver disease, swelling, insomnia, poor memory and lack of enthusiasm for life. In the most severe cases, they may already have extensive cirrhosis or hepatocarcinoma. There is an obvious increased risk of disease progression with an existing infection from Hepatitis B or C, for these reasons an effective alcohol detoxification program in which assessment and screening play a key role is required allowing the individual to be monitored for level of urgency of treatment, motivation and readiness to change. 3.1 The Shortened Audit (Alcohol Use Disorders Identification Test) Appendix 1 is a questionnaire which can be used to screen for excessive alcohol consumption, taking less than 2 minutes to complete. It aims to differentiate between those who are hazardous users (at risk of future harm), from those who are harmful users (presently incurring, psychosocial harm) and from those who are alcohol dependant. [HAD 2002] 3.2 Severity of Alcohol Dependence Questionnaire (SADQ) Appendix 2 can be helpful in measuring the severity of alcohol dependence. Where there is a history of alcohol dependency, a benzodiazepine withdrawal schedule as outlined in appendix 3 and appendix 4 and this may be used in conjunction, taking into consideration the investigations below to produce a regime that is most appropriate to meet the individual need. [Stockwell T, Murphy D, Morgan R, 1983]. Page 5 of 19

6 3.3 Clinical Institute Withdrawal Assessment for Alcohol Scale (CIW-AR) The Clinical institute Withdrawal Assessment for Alcohol Scale, appendix 6 [Sullivan et al.1992] can be completed in about 5 minutes. It scores the severity of nausea, tremor, sweating, anxiety, agitation, headache, orientation and sensory disturbances. The specialist practitioner would call upon additional medical support and intervention if an individual score was reaching a score of 33 and hospitalization may be required at this stage. 4. Blood and Breath Alcohol Breath alcohol should be measured on commencement of an alcohol detoxification. This allows an estimation of the actual blood alcohol concentration (BAC) and can be used to estimate the rate of fall of blood alcohol. The average clearance rate of alcohol from blood is 15mg/100ml or very approximately, 1 unit per hour. This is important for a number of reasons. Firstly, if estimated blood or breath alcohol is too high, there may be a danger of interaction with prescribed medication in the first few hours of detoxification. The practitioner will need to monitor closely the medication prescribed during this period. Secondly, if the individual has consumed a significant amount of alcohol immediately before commencement, their blood alcohol levels may still be rising. This will require the practitioner to be cautious when providing the prescribed medication at this time. The blood alcohol can be undertaken by using the formula below. In addition the practitioner needs to be aware that the alcohol level in blood (BAC in milligrams alcohol /100 ml blood) is 2300 times higher than the level in Breath Alcohol Concentration (BrAC in micrograms /100 ml breath), noting that the much smaller units used in expressing BrAC. 1 milligram (mg) = 1000 micrograms (μg). 1unit = 8g alcohol WF = Widmark factor is an estimation of body water content (male=0.68/female= 0.55 The conversion is simple in practice: BAC = 2.3 x BrAC and BrAC = BAC / 2.3 Formula to work out the BAC = no. of units consumed x 8g x 100 / WF x body weight (kg) 4.1 Clinical examination A comprehensive alcohol clinical examination is important to undertake as it provides valuable data and the basis of a care plan for management. [NTA 2005] Virtually every system in the human body can be damaged by alcohol. Although there are a number of specific physical signs that are highly suggestive of alcohol misuse and should be specifically sought and recorded if this diagnosis is being considered. These include: Spider naevi; Telangiectasia; Moon like face; Parotid enlargement; Palmer erythema; Dupuytren s contracture; Gynaecomastia. 4.2 Haematological Investigation It is important before any screening takes place that the client has given consent. The analysis of biochemical markers of alcohol consumption should not be used for screening in isolation, as some markers can be raised for other reasons other than alcohol [SIGN 2003, Coulton et al, 2006]. Gamma-glutamyl transpeptidase (GGT) can be raised with other causes of liver disease and less commonly with pancreatic disease or following a heart attack. MCV can increase in people with vitamin B12 deficiency, folic acid deficiency, thyroid disease, chronic liver disease, and during pregnancy. False positive results for Carbohydrate Deficiency Transferrin (CDT) are very low. However, biochemical markers are useful for monitoring the effect of treatment on excess alcohol consumption. All tests reflect heavy drinking in the preceding weeks and if elevated, are useful to help motivate a reduction in alcohol consumption [SIGN 2003]. Page 6 of 19

7 A standard set of bloods that would be recommended prior to detoxification are; Liver function & U&Es; CDT will increase within 3 4 weeks of the onset of heavy drinking; Full Blood Count; Random / Fasting Cholesterol; Random / Fasting Glucose; Prothrombin time if there is evidence of significant liver disease; Blood alcohol levels prior to detoxification; Vitamin B12; Folate. Management of alcohol withdrawal is required when: An individual is severely dependent on alcohol and therefore likely to have moderate to severe withdrawal symptoms; Is suffering from serious or life threatening medical or psychiatric condition or is at risk of self harm or suicide, aggression or violence; Is currently having or had in the past severe withdrawal symptoms or withdrawal complications by alcohol withdrawal seizures, delirium tremens (DTs) or gastric bleeding. 4.3 Alcohol Withdrawal Syndrome Alcohol withdrawal syndrome (AWS) is the clinical syndrome that occurs when an individual is physically dependent on alcohol and they stop drinking or reduce their alcohol consumption. [Burns 2004] Acute AWS will present with a wide range of severity of withdrawal symptoms and in some cases can be life-threatening, although the risk of withdrawal is not directly related to intake [DTB, 1991, Morgan 1998]. Alcohol withdrawal is a continuum from simple tremors, with relatively mild signs or symptoms from autonomic overactivity through to hallucinations and seizures and life threatening delirium tremens [Hall 1997, Rubino 1992, Turner 1989]. It is, therefore, important that clinicians recognize complications early and manage appropriately. 4.4 Levels of withdrawal and management Uncomplicated alcohol withdrawal occurs within hours (typically 6-8 hours) of removal of the last alcoholic drink and may develop before the blood alcohol level has fallen to zero, commonly peaking at hours and usually subsiding by 40 to 50 hours [Adinoff 1988, DTB 1991, Hall 1997, Morgan, 1998]. Signs and symptoms of autonomic arousal: Sweating; Tachycardia (100+bpm); Raised BP (>15mg/hg from original baseline); Fever (37-38C); Hyperflexia; Characteristic tremor, starting in the hands but progressing to the head and trunk as severity worsens; Anxiety, restlessness, irritability, depression, insomnia and tiredness; Anorexia, nausea and weakness; Confusion. The greater the number of withdrawal symptoms the greater the risk of seizures and delirium tremens. In moderate withdrawal, the signs are more marked. Transient auditory hallucinations may also occur despite the individual appearing lucid. Page 7 of 19

8 4.5 Hallucinations If hallucinations occur, in the majority of cases it will be within 24 hours of the last alcoholic drink, stopping within another 24 to 48 hours [Turner, 1998]. 4.6 Withdrawal seizures Will often occur 6-48 hours after alcohol cessation and are more likely if there is a previous history of withdrawal fits or epilepsy. Fits are rare beyond 48 hours following cessation (Morgan, 1998) and if a seizure should occur then one needs to look at possible other causes. It is important to note repeated alcohol detoxification augments the likelihood of alcohol withdrawal seizures. 4.7 Delirium Tremens (DTs) This is the most severe manifestation of alcohol withdrawal, occurring in around 5% of individuals detoxifying from alcohol. It accounts for the highest level of morbidity and mortality (5% to 20% mortality inappropriately managed patients) with appropriate management this reduces to 1-5%. DTs have an onset of 2 to 5 days most common at 2 to 3 days following cessation and represent a medical emergency [Adinoff 1988, Erwin 1998, Crag 1994, Morgan 1998, Rubino 1992]. During screening and assessment clients reporting to be consuming more than 16 units per day are particularly at risk. More and more commonly, services are seeing clients using 30 units plus daily. The characteristic symptoms are: Agitation; Apprehension; Confusion; Disorientation in time and place; Visual and auditory hallucinations; Insomnia, nausea; Vomiting; Poor coordination; Paranoia; Fever; Poor concentration; Intermittent disorientation and agitation lasting possibly 1-2 weeks post recovery. Management of DTs in the community is not an option in view of the high associated risks. It would require the individual to be hospitalized where adequate prescribed oral, rectal or IV medication can be prescribed and administered. 4.8 Fluids and electrolytes This applies to inpatient detoxification. Some individuals may experience problems with over active sweating, fever or gastro-intestinal disturbance. Thy may be at risk of serious disturbance in fluid and electrolyte balance, which will require close monitoring. In such circumstances there is a danger of fall in potassium levels and a possible fall in magnesium levels which should be averted, as it could lead to an increased likelihood of DTs [Turner ET al.1989]. Blood sugars also require monitoring during the initial stages of an alcohol detoxification, as there is an increase risk of hypoglycaemia. For those at risk of imbalance it may be necessary to set up a subcutaneous line, to support electrolyte and glucose correction, where oral management is not possible with regular venous bloods being taken during this period. 4.9 Prescribing Before undertaking any prescribing the following needs to be taken into consideration. In the management of alcohol detoxification in individuals with complex needs or polydrug use, it is important where possible to stabilize any opiate use first, preferably with the use of a stabilizing substitute. This is due to the increased risk of overdose and poor clinical outcomes attributed to the existence of other substances and pre existing health complications. Page 8 of 19

9 Prior to a planned alcohol detoxification, clients should be supported in reducing to safer levels of alcohol consumption, without causing acute withdrawal. Once an individual has some level of control in their alcohol use, i.e. not appearing intoxicated and there is improvement in other measures of stability, a detoxification can be considered. If assessed as appropriate, a community detoxification can be undertaken effectively and safely. It will be undertaken, using a reducing regime of chlordiazepoxide (in the majority of clients) based on the SADQ assessment, the blood profiling results, current blood alcohol and breathe alcohol levels (appendix 5). Where there is known hepatic insufficiency, oxazepam is the drug of choice for alcohol detoxification. All regimes will be tailored to the need of the individual within the parameters of medical prescribing. They will be given at set times during the day with no PRN dosing. It may be necessary to add additional medication to counter act any potential problems. For those requiring immediate intervention, a risk assessment will be required before commencement of an alcohol detoxification. For those at high risk of alcohol seizures and as deemed appropriate, by the specialist practitioners, it may be that diazepam is the drug of choice used intravenously or intramuscularly to reduce the risk of seizures and severe withdrawal symptoms. Then an oral reducing regime will be commenced 48 hours later. High levels of monitoring and support will be required for these individuals by specialist practitioners in the field of alcohol detoxification Vitamin supplements Adequate vitamin supplementation is vital to reduce the risk of Wernicke s encephalopathy. Oral thiamine 100mg tablets twice daily Plus Vitamin B Compound strong 1 tablet three times daily should be provided, but they may be inadequate because of poor enteral absorption. Absorption of oral thiamine from the GI tract is poor and saturates at 5-10mg thiamine. The parenteral route should be used in the treatment of established incipient or established Wernicke's encephalopathy +/- severe AWS with the classic signs of ataxia, confusion and opthalmoplegia present in only 10% of Wernicke s encephalopathy. The most common features are: Reduced consciousness; Hypotension; Hypothermia; Memory disturbance. Wernicke s encephalopathy is a medical emergency requiring hospitalization. Treatment with parenteral Pabrinex is required. In individuals who are deemed high risk of Wernicke's encephalopathy then Pabrinex should be considered as prophylaxis, for appropriate dosage see Pabrinex Algorithm (appendix 7). During inpatient detoxification the additional vitamin supplements, electrolyte disturbances can be a concern in this group of individuals, as serum potassium levels can fall increasing the risk of seizure. The specialist practitioner should be aware of the signs of hypokalaemia and were possible commence potassium oral supplements or subcutaneous fluid therapy if not suitable initially Withdrawal seizures Where there has been a confirmed previous episode of withdrawal seizure during a past detoxification, prophylaxis treatment needs to be considered. The most effective and safest medication is carbamazepine. It can be used where there is a past history or risk of seizures, as it is non addictive and its metabolism is unaffected by poor function often found in chronic alcohol users [Ballinger, J.C. et al 1984]. A loading dose of 600mgs is advised with the regime being reduced over the subsequent 4 days, 400mg once a day. Alternatively Gabapentin, which is structurally similar to gammaaminobutyric acid (GABA), has been effective in the treatment of alcohol withdrawal in small studies. The low toxicity of gabapentin makes it a promising agent [Ballengerjc et al 1978, Duka,t 2004,Loscherw,2002]. Page 9 of 19

10 4.12 Treatment of reflux oesophagitis During the alcohol detoxification clients may exhibit signs of oesophageal refluxes. These clients would benefit from a 7 day prophylactic course of a dispersible proton pump inhibitor. The recommended dose of Lansoprazole is 15 to 30mgs daily and Omeprazole 20mg daily for the relief of symptoms. Patients with moderate or severe liver disease should be kept under regular supervision and a 50% reduction of the daily dose is recommended Nausea and vomiting It is not unusual for clients to experience some degree of nausea and vomiting in the initial phase of an alcohol detoxification, which could have implications for those on long term prescribed medication including methadone. The medication of choice will be metoclopramide 10mg tablets three times a day or alternatively buccal prochlorperazine 3mg 1-2 tablets twice daily Acamprosate Acamprosate (Campral EC) is a drug that has been shown to double the abstinence rate in people receiving treatment for alcohol use, i.e. from10% to 20% or at best 40%. Although its mechanism of action is not clearly defined, acamprosate appears to block the excitatory activity in the brain (Nmethyl D-aspartate - NMDA glutamate) and enhance the inhibitory system (gamma-aminobutyric acid - GABA). More recently it has been shown that acamprosate has a neuro-protective effect by reducing the number of brain cells that die during alcohol detoxification. Acamprosate is prescribed to those clients two weeks prior to an alcohol detoxification being commenced. Acamprosate will be regularly reviewed and maintained up to 12 months following detoxification if client remains abstinent [Bouza et al 2004: Lingford Hughes, Welch & Nutt, 2004]. Acamprosate is a safe medication that improves adherence to treatment. It does not interact with alcohol or benzodiazepines and appears to have no addictive potential itself. It has also been used safely with antidepressants. The recommended treatment dose of acamprosate is given as two tablets (333mgs) three times a day for those more than 60kgs and two tablets at breakfast, 1 tablet at midday and 1 at night for those less than 60kgs. 5. Duties and responsibilities 5.1 Clinical Director Clinical Director is responsible for development, implementation and review of approved documents, which fall within their remit. The Clinical Director will take a uniform approach towards the complex issues in this guidance. They will ensure training is implemented across CWP Drug & Alcohol services through their monthly managers meeting. 5.2 Line Managers Line Managers have the responsibility to highlight the guidance to all drug and alcohol practitoners and to ensure that they have received adequate training. 5.3 Drug and Alcohol Practitioners It is the responsibility of drug & alcohol practitioners to keep up to date with the approved document relevant to their working environment and to attend required training. Page 10 of 19

11 Appendix 1 - Alcohol Use Disorders Identification Test (AUDIT) Clients Name: DOB: Date: How often do you have a drink containing alcohol? Never (0) 2 to 4 2 to 3 Monthly or 4 or more times Times times a less (1) a week (4) month (2) week (3) How many standard drinks containing alcohol do you have on a typical day when you are drinking? How often do you have 6 or more standard drinks on one occasion? 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? 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 someone 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 suggest you cut down? 1 or 2 (0) 3 or 4 (1) 5 or 6 (2) 7 or 9 (3) 10 or more (4) Never (0) Never (0) Never (0) Never (0) Never (0) Never (0) Never (0) Never (0) Less than monthly (1) Less than monthly (1) Less than monthly (1) Less than monthly (1) Less than monthly (1) Less than monthly (1) Monthly (2) Monthly (2) Monthly (2) Monthly (2) Monthly (2) Monthly (2) Yes, but not in the last year (2) Yes, but not in the last year (2) Weekly (3) Weekly (3) Weekly (3) Weekly (3) Weekly (3) Weekly (3) Daily or almost daily (4) Daily or almost daily (4) Daily or almost daily (4) Daily or almost daily (4) Daily or almost daily (4) Daily or almost daily (4) Yes, during the last year (4) Yes, during the last year (4) SCORING -The scores for each question are shown under each response. -The minimum score: (for non-drinkers) is 0 and the maximum possible score is Low risk Dependent 8-15 Hazardous Harmful Refer to Dependant team if detox required then refer to alcohol detox team 20+ Refer to Specialist Service Page 11 of 19

12 Appendix 2 - Severity of Alcohol Dependence Questionnaire Name No Date Instructions: The following questions cover a wide range of topics to do with drinking. Please read each question carefully but do not think too much about exact meaning. Think about your most recent drinking habits and answer each question by placing a tick under the most appropriate heading. If you have any difficulties ask for help. Question Never Sometimes Often 1. Do you have difficulty in getting the thought of drinking out of your mind 2. Is drinking more important than your next meal? 3. Do you plan your day around when and where you can drink? 4. Do you drink in the morning, afternoon and evening? 5. Do you drink for the effect of alcohol without caring what the drink is? 6. Do you drink as much as you want regardless of what you are doing the next day? 7. Given that many problems might be caused by alcohol do you still drink too much? 8. Do you know that you won t be able to stop drinking once you start? 9. Do you try to control your drinking by giving it up completely for days or weeks at a time? 10. First thing in the morning after drinking do you need a first drink to get yourself going? 11. First thing in the morning after drinking do you wake up with a definite shakiness of your hands? 12. First thing in the morning after drinking do you wake up retching or vomit? 13. First thing in the morning after drinking do you go out of your way to avoid people? 14. After a drinking session do you see frightening things or hear things that later you realise weren t real? 15. After drinking, do you find you have forgotten what happened the night before? 16. First thing in the morning after drinking alcohol, do you wake up sweating? 17. First thing in the morning after drinking alcohol, do you have a strong craving for drink? 18. First thing in the morning do you need to gulp your first few drinks down to get you sorted? 19. First thing in the morning after drinking does your whole body shake? 20. First thing in the morning do you need to drink more to get rid of the shakes? Nearly always Clients Name File Number Scoring: The 20 items summed for a total score that can range from 0 to 60. Scale totals are interpreted as follows: medium dependence and 20 or greater high dependence. Scoring as Follows: Never = 0 Sometimes = 1 Often = 2 Nearly always = 3 (Reprinted with permission from D.Raistrick (1991) & Alcohol Concern) Page 12 of 19

13 Appendix 3 - Prescribing for alcohol dependence Alcohol withdrawal Alcohol dependence and withdrawal may be treated in inpatient settings. Alcohol dependence may occur in combination with dependence on other classes of drugs. Where there is a history of alcohol and benzodiazepine use, a benzodiazepine withdrawal schedule as outlined above may be used. The Severity of Alcohol Dependence Questionnaire (SADQ) (stockwell et al 1979) can be helpful in measuring the severity of alcohol dependence. Alcohol withdrawal regimes: Dosages of chlordiazepoxide SADQ Moderate (SADQ 20-30) Severe (SADQ 30-40) Very Severe (SADQ 40-60) Day 1 10mg qds 15mg qds 20mg qds 30mg qds 40mg qds 50mg qds Day 2 10mg tds 10mg qds 15mg qds 25mg qds 30mg qds 40mg qds Day 3 5mg tds 10mg tds 10mg qds 20mg qds 25mg qds 30mg qds Day 4 5mg bd 5mg tds 10mg tds 15mg qds 20mg qds 25mg qds Day 5 5mg nocte 5mg bd 5mg tds 10mg qds 15mg qds 20mg qds Day 6 5mg nocte 5mg bd 10mg tds 10mg qds 15mg qds Day 7 5mg nocte 5mg tds 10mg tds 10mg qds Day 8 5mg bd 5mg tds 10mg tds Day 9 5mg nocte 5mg bd 5mg tds Day 10 5mg nocte 5mg bd Day 11 5mg nocte Qds = 4 x daily Tds = 3 x daily Bd = 2 x daily Nocte = at night Page 13 of 19

14 Appendix 4 - Table showing benzodiazepine equivalents used in alcohol detoxification Name of drug Dose equivalent Half life (range) Duration of detectability Diazepam 5mg 32hrs (21-50) hrs Chlordiazepoxide 15mg 12hrs (6-30) hrs Oxazepam 15mg 8hrs (5-15) - Lorazepam 0.5mg 12hrs (8-25) - Page 14 of 19

15 Appendix 5 - Recommended reducing regime Name DOB ID Number reducing plan starting at mg Starting dose Morning Midday Early Eve Night Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Total daily dose Some ground rules This is intended to be a slow process. Do not try to speed it up in anyway. If you are struggling, then mention it to the nurse and adjustments to the regime or extension may be required. Ensue that you have a supportive friend who is a none drinker for the first stage of your detoxification. Be prepared to consult with a doctor / nurse if you experience any problems. It is important that you do not drink while being prescribed benzodiazepines due to the potential risk of overdose. Page 15 of 19

16 Appendix 6 - Clinical Institute Withdrawal Assessment of Alcohol Scale (Ciawa Ar) Client name Date of Birth Client No Starting date of detox Please score one number in each case Day 1 Day 2 Day 3 Day 4 Day 1 Day 2 Day 3 Day 4 Nausea & Vomiting (Ask do you feel sick to your stomach? Have you Vomited?) Page 16 of 19 Tremor Arms extended and fingers spread apart. 0- no nausea / vomiting 0- no tremor 1- mild nausea with no vomiting 1- not visible, but can be felt fingertip to fingertip intermittent nausea 4- moderate, with patient s arm extended with dry heaves severe even with arms not extended 7- constant nausea, frequent dry heaves and vomiting Level of consciousness (Ask what day is this/ where are you/ Who am I ) 0- orientated & can do serial additions 1- cannot do serial additions / 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 / person Tactile Disturbances (Ask Have you any itching, pins & needles sensations, any numbness / do you feel bugs crawling on / under your skin?) Auditory disturbances (Ask are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing you? Are you hearing things you know are not there?) 0-not present 1-very mild harshness/ability to frighten 2- mild harshness / ability to frighten 3- moderate harshness/ ability to frighten 4- moderately severe hallucinations Sweating

17 Day 1 Day 2 Day 3 Day 4 Day 1 Day 2 Day 3 Day 4 0- none 0-no sweating 1- very mild itching, pins & needles, burning / numbness 2- mild itching, pins & needles, burning / numbness 3- moderate itching, pins & needles, burning / numbness Page 17 of barely perceptible sweating, palms moist 4- moderately severe 4- beads of sweat obvious on hallucinations forehead 5- severe hallucinations 5-6- extremely severe 6- hallucinations 7- continuous 7-drenching sweats hallucinations Agitation Anxiety (ask do you feel nervous?) 0-Normal activity 0- no anxiety. at ease 1 somewhat more than 1- mild anxiety normal activity moderately fidgety and restless paces back & forth during most of the interview, or constantly thrashes about 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 things you know are not there? ) moderately anxious, or guarded, so anxiety is inferred 7- equivalent to acute panic states as seen in severe delirium Headache, Fullness in head (ask does your head feel different? Does it feel like there is a band around your head?) 0- not present 0- not present 1- very mild sensitivity 1-1 very mild 2- mild sensitivity 2- Mild 3- moderate sensitivity 3- Moderate 4- moderately severe 4- Moderately severe hallucinations 5- severe hallucinations 5- Severe 6- extremely severe 6- Very severe hallucinations 7- Continuous 7- Extremely severe hallucinations A total score of <10 continue as per regime Total score

18 Day 1 Day 2 Day 3 Day 4 Day 1 Day 2 Day 3 Day 4 score of 33+ indicates concern consult the doctor Total CIWA-AR maximum score is 67 CIWA-AR Date BAC BP Pulse Temp Comment score Page 18 of 19

19 Appendix 7 - Management Algorithm for Vitamin Supplementation and Prevention and/or treatment for Wernicke s Encephalopathy Every client being considered for an alcohol detoxification using a benzodiazepine reducing regime IF client presents with evidence of a decompensate liver, or presents with one or more from the list below: - Acute confusion; - Ophthalmoplegia; - Nystagmus; - Unexplained hypotension with hypothermia; - Decreased Conscious level; - Memory disturbance; - Ataxia / unsteadiness. Yes No Presume Wernicke s Encephalopathy - Pabrinex HP amps 2 pairs (4 ampoules) IM BD for 3 days; - Then Pabrinex amps 1 pair (2 ampoules) for 2-4 days; - Then thiamine Oral 100mg twice daily and Vit. B compound strong 1 tablet TDS. Are there any further risk factors that suggest Wernicke s Encephalopathy? - Intercurrent illness; - Past history of DTs / Treatment for DTS; - Past history of alcohol related seizures; - Significant weight loss; - Peripheral neuropathy; - Drinking > 20 units daily; - Recent diarrhoea / vomiting; - Signs of malnutrition; - Poor diet. Yes Risk of Wernicke s Encephalopathy No Then thiamine Oral 100mg twice daily and Vit B compound strong 1 tablet TDS - Then Pabrinex amps: 1 pair (2 ampoules) 5 days; - Then thiamine oral 100mg twice daily and Vit B compound strong 1 tablet TDS. Consider Pyridoxine 20mg once a day for 3 weeks - as it has been shown to be beneficial with hepatic impairment or evidence of neuropathy features e.g. deranged Liver functions, jaundice and hypoalbumaenia Page 19 of 19