NHS Fife Guidance for the Identification, Assessment and Management of Harmful Drinking and Alcohol Dependence

Transcription

1 NHS Fife Guidance for the Identification, Assessment and Management of Harmful Drinking and Alcohol Dependence Staff working in services provided and funded by the NHS who care for people who potentially misuse should be competent to identify harmful drinking and dependence. They should be competent to initially assess the need for an intervention or, if they are not competent, they should refer people who misuse to a service that can provide an assessment of need NICE clinical guideline 115 Alcohol-use disorders, Feb 2011 Introduction This guidance is intended for use throughout the NHS Fife - in Primary Care, Secondary Care and specialist services - to identify, assess and manage patients who misuse. People who misuse may access: Primary Care General Practice: for related conditions resulting from harmful or dependent drinking. Primary Care General Practice: for assessment and management of harmful or dependent drinking. Primary Care Specialist service: for assessment and management of harmful or dependent drinking. Secondary Care admission for planned inpatient detoxification. Secondary Care Accident and Emergency: for related conditions resulting from harmful or dependent drinking. Secondary Care admission for treatment of unrelated condition during which evidence of harmful or dependent drinking emerges. Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 1

2 Contents Algorithm for screening, assessment and treatment of misuse... 3 Screening... 4 Assessment... 5 Controlled drinking... 6 Community Based Detoxification... 7 Planned Inpatient Detoxification... 8 Unplanned Inpatient Management of Alcohol Withdrawal... 9 Prophylaxis and Treatment of Wernicke s Encephalopathy Management of complex needs Psychological support Pharmacological Support Appendix 1 ALCOHOL CONSUMPTION CALCULATOR Appendix 2 FAST ALCOHOL SCREENING TEST (FAST) Appendix 3 Alcohol Use Disorders Identification Test (AUDIT) Appendix 4 Severity of Alcohol Dependence Questionnaire (SADQ) Appendix 5 Personal Drinking Questionnaire (SOCRATES) Appendix 6 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) Appendix 7 Inpatient: Alcohol withdrawal observation chart (based on CIWA-Ar scale) Appendix 8 Inpatient symptom triggered chlordiazepoxide schedule Appendix 9 Community detoxification fixed dose chlordiazepoxide schedule Appendix 10 NHS Fife Addiction Services References 1. NICE Guideline (CG115): Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and dependence. Available at 2. NICE Guideline (CG 110): Alcohol-use disorders: Diagnosis and clinical management of related physical complications. Available at 3. BAP Guidelines. Journal of Psycopharmacology 26(7) , BNF 4.8 Substance dependence. Available at Substance dependence: BNF Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 2

3 Algorithm for screening, assessment and treatment of misuse All patients asked about consumption and complete Fast Alcohol Screening Test. Patient exceeds recommended drinking limits but scores < 3 with FAST Patient exceeds recommended drinking limits and scores 3 with FAST Deliver Alcohol Brief Intervention or refer to ADAPT Further assessment to evaluate severity of dependence plus complexity of needs. pattern of consumption (AUDIT) degree of dependency (SADQ) readiness to change (SOCRATES) withdrawal symptoms (CIWA-Ar) physical and/or mental co-morbidity cognitive function drug use home environment risk of harm to self and others urgency of treatment Physical examination and Biological Tests Breath Alcohol Concentration, FBC (inc MCV), U&Es, LFTs (inc γgt), Glucose + drug screen NO DEPENDENCE or MILD DEPENDENCE MODERATE DEPENDENCE with no complex needs SEVERE DEPENDENCE and/or COMPLEX NEEDS Controlled drinking 1. ALCOHOL consumption: 8-15 units/day men 6-10 units/day women 2. AUDIT score < SADQ score <15 4. No physical withdrawal symptoms 5. Requires psychosocial counselling. Psychosocial counselling & relapse prevention Behavioural Self Control Training, Motivational Enhancement Training, Family Therapy, Coping/Social Skills Training are recommended counselling options for the prevention of relapse. Community based detox. 1. ALCOHOL consumption: >15 units/day men >10 units/day women 2. AUDIT SCORE and/or SADQ CIWA-Ar score Manage withdrawal symptoms with fixed dose schedule of chlordiazepoxide for max. of 7 days. Daily monitoring of Breath Alcohol Concentration, withdrawal symptoms and dosage adjustment Planned inpatient detox. 1. ALCOHOL consumption: >15 units/day men >10 units/day women 2. AUDIT SCORE SADQ > CIWA-Ar score 15 History of complicated withdrawal and/or seizures Previous failed community detoxes Multiple substance use High risk of self harm or suicide Non-supportive home environment see page 8 for full list Manage withdrawal symptoms with symptom-triggered chlordiazepoxide schedule. VITAMIN SUPPLEMENTATION for WERNICKE S ENCEPHALOPATHY Detoxification may precipitate Wernicke s encephalopathy. Those at risk should receive prophylactic dose and those with symptoms receive treatment dose of Pabrinex Psychosocial counselling may be supported by pharmacological interventions: acamprosate, disulfirum, naltrexone or baclofen as appropriate. Alcohol dependent patients should be encouraged to access mutual self-help groups or 12 step facilitation such as Smart Recovery and Alcoholics Anonymous as they are beneficial in relapse prevention. PROPHYLAXIS patient with any of: history of misuse/ recent weight loss/vomiting/diarrhoea/malnutrition/ peripheral neuropathy/chronic ill-health. TREATMENT patient with history of misuse and displaying any of symptoms of WE: confusion/ataxia/opthalmoplegia/nystagmus ONE pair of Pabrinex IVHP or IMHP ONCE daily for 3 5 days TWO pairs of Pabrinex IVHP THREE times daily for 3 days If response noted continue with ONE pair of Pabrinex IVHP or IMHP ONCE daily for 5 days Small risk of anaphylaxis. Facilities to manage anaphylaxis must be available. Continue with oral thiamine 100mg THREE times daily 3

4 Screening 1. All patients should be asked how many units of they normally consume in a typical day and week. (Alcohol Consumption Calculator) - appendix All patients should complete a Fast Alcohol Screening Test (FAST) appendix 2. Female patients consuming: more than 2-3 units daily and/or more than 6 units on one occasion but scoring less than 3 with FAST Male patients consuming: more than 3-4 units daily and/or more than 8 units on one occasion but scoring less than 3 with FAST Alcohol Brief Intervention (ABI)* Remind patient of recommended drinking limits Facilitate calculation of consumption in units by providing unit calculator or referring to Suggest ways of reducing intake. 3. Female patients consuming more than 2-3 units daily or male patients consuming more than 3-4 units daily AND scoring 3 or more with FAST (defined as hazardous drinking) should undergo further assessment. NB. In settings where further assessment is inappropriate but the patient s pattern of consumption and FAST score indicates hazardous drinking, in addition to a brief intervention, the patient should be advised to seek further information and assistance from their GP or: Local Services FASS ADAPT RECOVERY SERVICES Drug and Alcohol Project Limited National Services Drinkline Alcohol Focus *Alcohol Brief Intervention An brief intervention is a short evidence-based conversation with a patient/client about consumption which is structured and non-confrontational and seeks to motivate and support the person to think about and/or plan behaviour change. Half-day and full day training courses are available in the Health Improvement Training Programme. Contact: Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 4

5 Assessment Patients drinking >21 units/week (male) or >14 units/week (female) and with a FAST score of 3 should be asked: 1. about historical and recent patterns of drinking using the Alcohol Use Disorders Identification Test (AUDIT) appendix to establish degree of dependency by completing a Severity of Alcohol Dependence Questionnaire (SADQ) -appendix 4 3. about other medication and/or drugs misused (including over-the-counter medication) 4. about physical and/or mental co-morbidity Assessment should also include: 5. Physical examination 6. Biological tests: 7. Urine - Drug Screen Breath - Breath Alcohol Concentration¹ (BAC) Blood - Full Blood Count (including MCV), U & Es, LFTs (including γgt 2 ) and glucose In order to inform treatment planning: 8. Cognitive function: for example Mini Mental State Examination (MMSE). 9. Psychological and social problems 10. Readiness and belief in ability to change by completing the Personal Drinking Questionnaire (SOCRATES) - appendix Assessment of severity of withdrawal using the revised clinical institute withdrawal assessment for scale (CIWA-Ar) - appendix 7. This should be repeated throughout detoxification. 12. Home environment ¹ Contributes to screening, monitoring during detoxification and following progress thereafter 2 Of value when patients minimise their drinking and for monitoring progress in reducing drinking Male Units/day Female AUDIT SADQ CIWA-Ar Treatment Option <15 <10 < 20 < 10 < < 20 < 15 < 10 >15 > >15 > >30 15 Counselling and relapse prevention no medication needed provide information about services Controlled drinking Psychosocial counselling If nalmefene appropriate refer to NHS Fife Addiction Services Community Based Detoxification Withdrawal symptoms controlled with chlordiazepoxide Daily monitoring Supportive home environment Consider referral to NHS Fife Addiction Services Planned Inpatient Detoxification History of complicated withdrawal and/or seizures Previous failed community detoxes Multiple substance use At high risk of self harm or suicide Acute physical or psychological illness Non supportive home environment Refer to NHS Fife Addiction Services 5

6 Controlled drinking Alcohol consumption AUDIT score SADQ score CIWA-AR score MEN WOMEN 8-15 units/day 6-10 units/day < 20 < 15 <10 Controlled Drinking For those unwilling or unable to become abstinent, reduced drinking may be an appropriate intermediate goal on the way to abstinence, although ideally clinical benefit should also be evident. DAILY DRINKERS Control may be achieved by setting targets to gradually reduce daily consumption using Behavioural Self-Control Training. BINGE DRINKERS Control may be achieved by using Motivational Enhancement Therapy to recognise and control triggers for binge. Controlled drinking should not be the first option for those who have lost control of their drinking (where drinking reduction may be hard to achieve) or those with physical illness where even in small amounts is likely to be harmful. For others with less adverse health consequences or not dependent, some drinking may be acceptable. 1. After initial assessment patient should record consumption for approximately 2 weeks 2. Patients continuing to drink >7.5 units but <12.5 units daily (men) or >5 units but < 7.5 units daily (women), without physical withdrawal symptoms and who do not require immediate detoxification may be offered psychosocial intervention focused on treatment adherence and reducing ic consumption in conjunction with nalmefene. 3. After 6 months of treatment the patient should be able to report a reduction of at least 50% in the number of heavy drinking days¹ per month and a reduction of around 60% in the total consumption² per month. 4. Online support such as may be a useful adjunct to conventional psychological support. 5. Nalmefene is in the Fife Formulary (section Alcohol Dependence) approved for restricted use by addiction services only. 6. For dose and other information see British National Formulary (BNF) and Summary of Product Characteristics (SPC) 1. Heavy drinking day defined as >7.5units/day (men) or >5units/day (women). WHO. 2. total consumption defined as the mean daily consumption in grams/day over a month (28 days).who (8g of is equivalent to 1 unit) Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 6

7 Community Based Detoxification A full assessment should be completed before detoxification is commenced. If this is not possible in primary care setting refer to specialist service - NHS Fife Addiction Services Alcohol consumption AUDIT score SADQ score CIWA-AR score MEN > 15 units/day WOMEN > 10 units/day Preparation for detoxification - the following elements must be carried out: Home visit to risk assess the suitability of environment Meet with carer to assess support available and suitability for home detox Education about the detoxification process and medication for patient and main carer Plan for post detoxification relapse prevention including psychological support, discussion of medication available and rehabilitation with referral to appropriate agency Arrange for detoxification medication prescribing Obtain informed consent for detoxification and associated medication Detoxification Start on a Monday or Tuesday to allow monitoring through the period of highest risk. Treatment should not commence if the patient remains intoxicated. A fixed dose chlordiazepoxide schedule should be used (Appendix 9). There should be flexibility to allow for individual symptomatic response particularly in patients of low body weight and older people. Chlordiazepoxide is contraindicated in severe hepatic insufficiency. (See SPC) Withdrawal symptoms should be monitored using CIWA-Ar twice on the first day and then as indicated. The second contact may be by telephone or second visit as appropriate. Medication should be reviewed every 24 hours from Monday to Friday Breathe Alcohol Concentration should be monitored at every visit if patient has been drinking stop chlordiazepoxide and review care plan Consult medical staff urgently if any of the following emerge during detoxification failure to improve despite increased dosing hallucinations that fail to respond to chlordiazepoxide high level of disorientation suicidal ideation other new physical or mental health concerns persistent vomiting. The patient must be treated as a medical emergency and immediately be referred to A&E or the Out-of Hours Service if suffering from: seizures chest pain signs of Wernicke s Encephalopathy impaired level of consciousness active suicidal thoughts. VITAMIN SUPPLEMENTATION for Prevention and Treatment of Wernicke s Encephalopathy Detoxification may precipitate Wernicke s encephalopathy. Those at risk should receive prophylactic dose and those with symptoms receive treatment dose Pabrinex see page 10 7 DO NOT USE BENZODIAZEPINES AS ONGOING TREATMENT FOR ALCOHOL DEPENDENCE. USE FOR WITHDRAWAL ONLY. Relapse prevention Relapse prevention work should be ongoing and may include individual work, group work, referral to Alcoholics Anonymous and other appropriate agencies. See Psychological Support page 12 Medical adjuncts to relapse prevention should be considered. See Pharmacological Support page 13 & 14 7

8 Planned Inpatient Detoxification All patients requiring planned inpatient detoxification should be referred to the specialist service for a comprehensive assessment - NHS Fife Addiction Services Alcohol consumption AUDIT score SADQ score CIWA-AR score MEN > 15 units/day WOMEN > 10 units/day 20 > The following list is based on expert opinion and comprises validated and best practice contraindications to managing withdrawal at home. Inpatient detoxification is advised if the patient: is confused or has hallucinations has a history of previously complicated withdrawal has epilepsy or a history of fits is undernourished has severe vomiting or diarrhoea is at risk of suicide has severe dependence coupled with unwillingness to be seen daily has previously failed community detoxes has uncontrollable withdrawal symptoms has an acute physical or psychiatric illness has multiple substance misuse has a home environment unsupportive of abstinence. drinks over 30 units /day score >30 on the SADQ Treatment 1. Chlordiazepoxide is the preferred benzodiazepine for treatment of withdrawal symptoms. 2. Using a symptom triggered chlordiazepoxide schedule (appendix 8) for the first 24 hours is associated with significantly lower doses of benzodiazepines and a shorter duration of treatment without an increase in the incidence of seizures or delirium tremens. 3. Observations (appendix 7) (i.e. withdrawal symptoms, blood pressure, heart rate and respiratory rate) should be carried out every 2 hours for the first 24 hours. 4. Use CIWA-Ar (appendix 6) to measure withdrawal symptoms, 5. If observations cannot be monitored at least every 2 hours then the Community detoxification fixed dose chlordiazepoxide schedule (appendix 9) must be used. 6. For information on treating patients with complex needs such as liver impairment, withdrawal seizures, delirium tremens, and patients dependent on benzodiazepines and see page 11 VITAMIN SUPPLEMENTATION for Prevention and Treatment of Wernicke s Encephalopathy Detoxification may precipitate Wernicke s encephalopathy. Those at risk should receive prophylactic dose and those with symptoms receive treatment dose Pabrinex see page 10 Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 8

9 Unplanned Inpatient Management of Alcohol Withdrawal All patients asked about consumption and complete Fast Alcohol Screening Test. Patient exceeds recommended drinking limits but scores < 3 Alcohol Brief Intervention (ABI) Patient exceeds recommended drinking limits and scores 3 Physical examination and Biological Tests BAC¹, FBC (inc MCV), U&Es, LFTs (inc γgt), Glucose + drug screen GREEN ZONE AMBER ZONE RED ZONE 6. ALCOHOL CONSUMPTION: <15 units/day men <10 units/day women 7. AUDIT score <20 8. SADQ score < CIWA-Ar score <10 5. ALCOHOL CONSUMPTION: >15 units/day men >10 units/day women 6. AUDIT SCORE and/or SADQ CIWA-Ar score ALCOHOL CONSUMPTION: >15 units/day men >10 units/day women 6. AUDIT SCORE SADQ > CIWA-Ar score 15 MILD SYMPTOMS Tense, irritable, poor concentration. Review regularly if suspicion of withdrawal MODERATE/SEVERE SYMPTOMS Tachycardia, systolic hypertension, nausea, vomiting, loss of appetite, retching, tremor, sweats, fever, insomnia, anxiety, headache, irritable, flu-like symptoms. Abnormal LFT s / raised MCV UNCONTROLLED SYMPTOMS As for moderate/severe symptoms and in addition: Confusion, disorientation, visual/auditory hallucinations, seizures, irrational thoughts/delusions, bizarre or aggressive or un-cooperative behaviour. Encourage Fluids. Continue to observe IF NO IMPROVEMENT GO TO AMBER ZONE No medication required during admission or supplied on discharge Prescribe chlordiazepoxide according to symptoms. Nursing observations and administration of chlordiazepoxide is every 2 hours for first 24 hours. Dose dependent on CIWA-Ar score: CIWA-Ar 0 9 no treatment required CIWA-Ar give 25mg CIWA-Ar 15 or more give 50mg After 24 hours continue with fixed reduction schedule based on total dose of chlordiazepoxide given PRN in first 24 hours. Observations twice daily. IF NO IMPROVEMENT GO TO RED ZONE Prescribe chlordiazepoxide starting with a dose of 50mg followed by a further 2 doses at 1 hour intervals PRN Nursing observations and administration of chlordiazepoxide is every 1 to 2 hours for first 24 hours. Further doses dependent on CIWA-Ar score. Consult with Critical Care Team before total dose exceeds 250mg in 24hours. COMPLEX NEEDS Alcohol Withdrawal Seizures: add lorazepam 1-2 mg IV Delirium Tremens: add lorazepam 1-2 mg oral/im/iv and/or haloperidol 5mg oral or IM (monitor ECG: QTc should be <440ms) Offer brief intervention and self-help leaflet. Provide information about services VITAMIN SUPPLEMENTATION ALL patients with dependency must be prescribed parenteral Pabrinex * for prophylaxis or treatment of Wernike s Encepalopathy (WE) PROPHYLAXIS patient with history of misuse ONE pair of Pabrinex IVHP or IMHP ONCE daily for 3 5 days 1. Breath Alcohol Concentration TREATMENT patient with history of misuse and displaying symptoms of WE TWO pairs of Pabrinex IVHP THREE times daily for 3 days If response noted continue with ONE pair of Pabrinex IVHP or IMHP ONCE daily for 5 days *Small risk of anaphylaxis. Facilities to manage anaphylaxis must be available. Continue with oral thiamine 100mg THREE times daily on discharge 9

10 Prophylaxis and Treatment of Wernicke s Encephalopathy Wernicke s Encephalopathy is an acute illness, precipitated by withdrawal, which is often under treated or missed. It should be suspected and treated in any patients undergoing 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. All in-patients presenting in withdrawal should be considered at risk of developing Wernicke s Encephalopathy Patient with history of misuse and one or more of the following: Acute confusion Opthalmoplegia/Nystagmus Ataxia/unsteadiness Memory disturbance Decreased consciousness Unconsciousness/coma Unexplained hypotension with hypothermia NO Patient with one or more of the following: Malnourished Diarrhoea Vomiting Physical illness Weight loss Decompensated liver disease YES Prophylaxis for Wernicke s Encephalopathy Administer ONE pair of PABRINEX IMHP ampoules or ONE pair of PABRINEX IVHP* ampoules ONCE DAILY for 3 to 5 DAYS Continue indefinitely with ORAL THIAMINE 100mg THREE times daily NO YES Treatment of acute Wernicke s Encephalopathy Administer TWO pairs of PABRINEX IVHP* ampoules THREE TIMES DAILY for 3 DAYS No response after 72 hours: Review diagnosis. Consider augmentation with i.v. magnesium or Discontinue supplementation unless comatose/unconscious Response continue with ONE pair of PABRINEX IVHP* ampoules or ONE pair of PABRINEX IMHP ampoules ONCE DAILY for 5 DAYS or for as long as improvement continues N.B. There are TWO formulations of Pabrinex injection, one for IV use and one for IM use. THESE FORMULATIONS ARE NOT INTERCHANGEABLE: PABRINEX IVHP* = Pabrinex intravenous high potency injection PABRINEX IMHP = Pabrinex intramuscular high potency injection ONE pair = ampoule No.1 plus ampoule No. 2 *IV: Mix No.1 and No.2 ampoules with 100ml of normal saline or 5% glucose and infuse over 30 minutes MHRA/CHM advice (September 2007) Although potentially serious allergic adverse reactions may rarely occur during, or shortly after, parenteral administration, the CHM has recommended that: 1. This should not preclude the use parenteral thiamine particularly in patients at risk of Wernicke-Korsakoff syndrome where parenteral treatment with thiamine is essential. 2. Intravenous administration should be by infusion over 30 minutes. 3. Facilities for treating anaphylaxis should be available when parenteral thiamine is administered. 10

11 Management of complex needs Patient with liver impairment Longer acting benzodiazepines metabolised in the liver (e.g. chlordiazepoxide) are known to accumulate but may be used with caution in the knowledge that a lower dose given less frequently will be required. Metabolism of lorazepam is not impaired by liver disease and may be used in severe or acute liver impairment. (approximate equivalent dose: chlordiazepoxide 25mg = lorazepam 1mg) Lorazepam has a shorter half-life than chlordiazepoxide which may increase the seizure risk. Liver function should be monitored during detoxification Patient dependent on benzodiazepines and Increased dose of benzodiazepine will be required for detoxification Calculate initial daily dose based on requirement for withdrawal plus equivalent regularly used daily dose of benzodiazepine (up to a maximum daily dose of 30mg diazepam or equivalent) Withdrawal is best managed with one benzodiazepine (diazepam or chlordiazepoxide) rather than multiple benzodiazepines. Inpatient regimens should last for 2 3 weeks or longer, depending on severity of coexisting benzodiazepine dependence.¹ Community based withdrawal should last for longer than 3 weeks and be tailored to patients symptoms and discomfort.¹ 1. See Guidance for benzodiazepine prescribing in benzodiazepine dependence at Patient with Alcohol Withdrawal Seizures Alcohol withdrawal seizures occur between 12 to 48 hours after significant reduction in Adequate doses of chlordiazepoxide usually prevent withdrawal seizures. For patients not taking chlordiazepoxide offer a fast-acting benzodiazepine, such as lorazepam, to reduce the likelihood of further seizures. If the patient is already taking chlordiazepoxide as part of a withdrawal regimen give lorazepam 1-2mg IV in addition [unlicensed indication]. Repeat with a second dose after 15 minutes if required Review chlordiazepoxide withdrawal regimen to prevent further seizures from occurring. Patient with Delirium Tremens Delirium Tremens can appear hours after has stopped Symptoms/signs differ from withdrawal symptoms in that there are signs of altered mental status such as hallucinations, confusion, delusions, severe agitation. Offer oral lorazepam 1-2 mg and/or haloperidol 5mg: if declined administer lorazepam 2mg IM and/or haloperidol 5mg IM. If no response after 1 hour repeat once. ECG is mandatory before haloperidol use. If not possible or QTc >440ms monitor constantly Maximum daily dose (oral and IM) for lorazepam 4mg and for haloperidol 15mg. Dilute lorazepam for IM use with equal volume of water for injections or sodium chloride 0.9%. If delirium tremens develops in a person during treatment for acute withdrawal with benzodiazepines, review their withdrawal drug regimen. n.b. Lorazepam and haloperidol are used in UK clinical practice in the management of delirium tremens. At time of writing they do not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. In addition the Summary of Product Characteristics advises: Lorazepam use in individuals with history of ism should be avoided due to increased risk of dependence. Haloperidol caution is advised in patients suffering from conditions predisposing to convulsions, such as withdrawal. For further advice contact - NHS Fife Addiction Services

12 Psychological support The following third sector agencies offer Fife wide support for dependant patients and their families. Patients may be referred or self-refer. Contact the organisations for further information. Psychosocial counselling Fife Alcohol Support Service 17 Tolbooth St, KIRKCALDY FASS offers a range of Motivational Enhancement & Cognitive-Behavioural counselling methods to individuals and support for relatives and friends. Drug & Alcohol Project Limited 2 Parkdale, Park Drive Leven, KY8 5AO DAPL offers one to one counselling, support, information and advice to individuals and families across Fife. Rehabilitation services Fife Intensive Rehabilitation & Substance Misuse Team 3 Fergus Place, KIRKCALDY KY1 1YA FIRST provides a Fife-wide rehabilitation service to individuals via one to one sessions, group work and volunteer support Mutual aid groups Alcoholics Anonymous National 24-hour helpline Local 24-hour helpline AA is concerned with the personal recovery and continued sobriety of individual ics who turn to the Fellowship for help. There are more than 40 meetings in 16 different towns across Fife. Meetings held across Fife: Phone or for details. Self Management and Recovery Training Helping people develop the tools and skills they need to gain control over their addictive behaviours. Family Support Barnardo s Westbridge Mill, Bridge St, KIRKCALDY, KY1 1TE A family intervention service for children affected by parental substance use. Al-Anon National helpline Al-Anon Family Groups provide support to anyone whose life is, or has been, affected by someone else s drinking. Groups currently meet in Cupar, Dunfermline, Glenrothes and Kirkcaldy Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 12

13 Pharmacological Support Medication should be initiated and reviewed for up to 3 months by the specialist service. Medication to support relapse prevention in abstinence should not be used without psychological support. Acamprosate Acamprosate reduces the risk of relapse during the post-withdrawal period and is most valuable in the first few months after detoxification. Generally well tolerated, it can be given safely to a wide number of patients with physical comorbidity, but used with caution in those with severe liver or renal impairment (see SPC). It should be initiated as soon as possible after detoxification although there is evidence to suggest that starting during detoxification may provide an additional neuroprotective effect.¹ Efficacy should be assessed at monthly appointments for the first 6 months and, if effective, should be prescribed for at least 6, but preferably, 12 months. Treatment may be continued longer term with regular reviews every six months.¹ Treatment should be stopped if drinking persists 4 to 6 weeks after starting the drug. Treatment should not be stopped if there is a minor relapse. 1. Acamprosate does not have UK marketing authorisation for use during detoxification or for use longer than 12 months. Informed consent should be obtained and documented. Naltrexone Naltrexone is thought to reduce a return to heavy drinking by reducing s rewarding effects and also the motivation to drink. Contraindications include severe renal and/or hepatic impairment, acute hepatitis, opioid dependent patients and patients taking opioid containing medication (see SPC). Naltrexone for relapse prevention should be commenced soon after stopping drinking. The dosage regimen can be modified in order to improve compliance to a three times a week dosing schedule as follows: 2 x 50mg tablets on Monday and on Wednesday and 3 x 50mg tablets on Friday. Efficacy should be assessed at monthly appointments for the first 6 months and, if effective, should be prescribed for at least 6 12 months. Treatment should be stopped if drinking persists 4 to 6 weeks after starting the drug. Patients must be warned against concomitant use of opioid containing medication including overthe-counter medicines. Disulfiram Disulfiram is used as a deterrent by triggering an unpleasant reaction if is consumed. Even small amounts of (in mouthwashes, medicines, and aftershave for example) may precipitate a reaction. Caution should be exercised in the presence of renal failure, hepatic or respiratory disease, diabetes mellitus, hypothyroidism, cerebral damage and epilepsy. (see SPC) Arrangements should be made to ensure consumption is witnessed (by spouse, friend, healthcare or support worker for example) Efficacy should be assessed every 2 weeks for the first 2 months and then monthly for the following 4 months. Patients successfully maintaining abstinence should be continued for a minimum of 6 months but may be continued longer-term with regular 6 monthly reviews. Disulfiram should only be commenced when the patient has been free for at least 24 hours and may have a residual effect lasting up to 7 days after the last dose. 13

14 Baclofen Baclofen has been shown to reduce craving and intake and enhance abstinence. Clinical trials have also shown baclofen to reduce anxiety levels in patients with related difficulties.² Baclofen may be used in patients where significant liver impairment would contraindicate licensed medication. Patient with impaired renal function however, should only use a low dose. Baclofen should be used with caution in patients with severe psychiatric disorders, epilepsy, respiratory, hepatic or renal impairment, receiving antihypertensive therapy, suffering from cerebrovascular accidents, or with a history of peptic ulceration (see SPC) Baclofen is contraindicated in active peptic ulceration. The recommended initial dose of 5mg three times daily should be titrated upwards slowly in increments of 5 mg three times daily every three days in response to continued craving and monitored side effects. Studies have used doses of 10mg to 20mg three times daily. Treatment should be continued for 6 months to 1 year 2. Baclofen is not licensed for use in dependency. Informed consent should be obtained and documented. Medication to support controlled drinking should not be used without psychological support. Nalmefene Nalmefene should only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing consumption. Nalmefene reduces cravings in the -dependent drinker thus reducing consumption. Nalmefene is licensed for patients: continuing to exhibit a High Drinking Risk Level³ two weeks after initial assessment. without physical withdrawal symptoms who do not require immediate detoxification Caution should be exercised in patients with current psychiatric comorbidity, history of seizure disorders, mild or moderate hepatic and/or renal impairment (see SPC) Contraindications include concomitant opioid analgesics, current or recent opioid addiction, severe hepatic and/or renal impairment, recent history of acute withdrawal syndrome. The patient s response to treatment should be evaluated on a regular (monthly) basis. The greatest improvement is likely to be seen in the first 4 weeks of treatment. Clinical data is available for a treatment period of between 6 and 12 months Caution is advised if nalmefene is prescribed for more than 1 year. Nalmefene is in the Fife Formulary approved for restricted use by addiction services only 3. WHO category defined as men drinking >7.5 but <12.5 units daily and women drinking >5 but < 7.5 units daily. Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 14

15 Appendix 1 ALCOHOL CONSUMPTION CALCULATOR Can (500ml) of lager/beer 4% = 2 units of 1 pint of lager/beer 4% = 2.3 units of Bottle (3litre) of cider 7.5% = 22.5 units of Bottle (750ml) 12% wine 12% = 9 units of Bottle (750ml) of whisky/gin/vodka 40% = 30 units of Can (440ml) of lager/beer 4% = 1.7 units of 1 pint of lager/beer 5% = 2.9 units of Bottle (1litre) of cider 7.5% = 7.5 units of Bottle (750ml) 14% wine 14% = 10.5 units of Pub (25ml) measure whisky/gin/vodka 40% = 1 unit of Can (440ml) of super strength lager/cider/beer 8.5% = 3.8 units of Bottle (330ml) of Lager 5% = 1.7 units of 1 pint of Cider 4.5% = 2.6 units of Large glass (250ml) wine 12% = 3 units 14% = 3.5 units Standard glass (175ml) wine 12% = 2.1 units 14% = 2.5 units No. of drinks/day x units = daily units x days = weekly units Can (500ml) 4% lager x 2 = x 7 = Can (440ml) 4% lager x 1.7 = x 7 = Can (440ml) strong 8.5% lager x 3.8 = x 7 = Pint 4% lager x 2.3 = x 7 = Pint 5% lager x 2.9 = x 7 = Bottle (330ml) 5% lager x 1.7 = x 7 = Bottle (3l) 7.5% cider x 22 = x 7 = Bottle (1l) 7.5% cider x 7.5 = x 7 = Pint 4.5% cider x 2.6 = x 7 = Bottle (750ml) 12% [14%] wine x 9 [10.5] = x 7 = Large glass (250ml) 12 [14%] wine x 3 [3.5] = x 7 = Std glass (175ml) 12 [14%] wine x 2.1 [2.5]= x 7 = Bottle (750ml) whisky/vodka/gin x 30 = x 7 = Pub measure (25ml) spirit x 1 = x 7 = Other drink Total weekly units 15

16 Appendix 2 FAST ALCOHOL SCREENING TEST (FAST) FAST questions Record the scores in the boxes on the right. Question 1 How often do you have: 6 or more units on one occasion? or 8 or more units on one occasion? Less than Daily or Never = 0 = 1 Monthly = 2 Weekly = 3 = 4 monthly almost daily Score Score If the response to this question is never, the person is at low risk for -related problems, but bear in mind the drinking limits If the response to this question is less than monthly or monthly go on to ask questions 2, 3 and 4 If the response to this question is weekly or daily or almost daily the person is a risky (hazardous), harmful or dependent drinker Question 2 How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never = 0 Less than = 1 Monthly = 2 Weekly = 3 Daily or = 4 monthly almost daily Score Question 3 How often during the last year have you failed to do what was normally expected of you because you had been drinking? Never = 0 Less than = 1 Monthly = 2 Weekly = 3 Daily or = 4 monthly almost daily Score Question 4 In the last year has a relative, friend, doctor or health worker been concerned about your drinking and suggested that you cut down? Score No = 0 Yes, on one occasion = 2 Yes, on more than one occasion = 4 Add up the scores to the above questions and record below. The minimum score is 0 and the maximum score is 16. Total score: The score for hazardous drinking is 3 or more 16

17 Appendix 3 1. How often do you have a drink containing? Alcohol Use Disorders Identification Test (AUDIT) 2. How many drinks containing do you have on a typical day when you are drinking? 0 Never 1 Monthly or less 2 2 to 4 times a month 3 2 to 3 times a week 4 4 or more times a week 3. How often do you have six or more drinks on one occasion? 0 Never 1 Less than monthly 2 Monthly 3 Weekly 4 Daily or almost daily 5. How often during the last year have you failed to do what was normally expected from you because of drinking? 0 Never 1 Less than monthly 2 Monthly 3 Weekly 4 Daily or almost daily 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 0 Never 1 Less than monthly 2 Monthly 3 Weekly 4 Daily or almost daily 9. Have you or someone else been injured as a result of your drinking? 0 Never 2 Yes, but not in the last year 4 Yes, during the last year Scoring and interpretation 0 1 or or or to or more 4. How often during the last year have you found that you were not able to stop drinking once you had started? 0 Never 1 Less than monthly 2 Monthly 3 Weekly 4 Daily or almost daily 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 0 Never 1 Less than monthly 2 Monthly 3 Weekly 4 Daily or almost daily 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? 0 Never 1 Less than monthly 2 Monthly 3 Weekly 4 Daily or almost daily 10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? 0 Never 2 Yes, but not in the last year 4 Yes, during the last year Total score Between 8 and 15 simple advice focused on the reduction of hazardous drinking Between 16 and 19 brief counselling and continued monitoring Over 20 further evaluation for dependence Questions 4 to 6 any points scored imply the presence or incipience of dependence. Questions 7 to 10 Any points scored indicate -related harm is being experienced. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care, 2 nd Edition. WHO

18 Appendix 4 Severity of Alcohol Dependence Questionnaire (SADQ) Name.. Age.. We would like you to recall a recent month when you were drinking in a way which, for you, was fairly typical of a heavy drinking period. Please fill in the month and the year: Month. Year.. We want to know more about your drinking during this time, and other similar periods, and how often you experienced certain feelings. Please answer every question by putting a tick in the appropriate column. Almost never Sometimes Often 1. I wake up feeling sweaty Nearly always 2. My hands shake first thing in the morning My whole body shakes violently first thing in the morning, if I don t have a drink I wake up absolutely drenched in sweat I dread waking up in the morning I am frightened of meeting people first thing in the morning I feel on the edge of despair when I wake up I feel very frightened when I wake up I like to have a morning drink I always gulp down my morning drink as quickly as possible I drink in the morning to get rid of the shakes I have a very strong craving for a drink when I wake up I drink more than ¼ bottle of spirits or 4 pints of beer or 1 bottle of wine a day I drink more than ½ bottle of spirits or 8 pints of beer or 2 bottles of wine a day I drink more than 1 bottle of spirits or 15 pints of beer or 4 bottles of wine a day I drink more than 2 bottles of spirits or 30 pints of beer or 8 bottles of wine a day Imagine you have been completely off drink for a few weeks and then drink heavily for two days how would you feel the morning after those two days? Not at all Slightly Moderately A lot 17. The morning after I would start to sweat The morning after my hands would shake The morning after my body would shake The morning after I would be craving for a drink TOTALS Score maximum for questions 17 to 20 if patient has not been abstinent for a period of 2 weeks Scores: 0-3 no dependence, 4-19 mild dependence, moderate dependence, severe dependence, 45+ very severe dependence 18

19 Appendix 5 Personal Drinking Questionnaire (SOCRATES) (The Stages of Change Readiness and Treatment Eagerness Scale) Please read the following statements carefully. Each one describes a way that you might (or might not) feel about your drinking. For each statement circle one number from 1 to 5, to indicate how much you agree or disagree with it right now. Please circle one and only one number for every statement. Strongly disagree NO! Disagree Unsure Agree Strongly agree YES! no? yes 1. I really want to make changes to my drinking Sometimes I wonder if I m and ic If I don t change my drinking soon, my problems are going to get worse I have already started making some changes in my drinking I was drinking too much at one time, but I ve managed to change my drinking Sometimes I wonder if my drinking is hurting other people I am a problem drinker I m not just thinking about changing my drinking, I m already doing something about it. 9. I have already changed my drinking, and I am looking for ways to keep from slipping back to my old pattern I have serious problems with drinking Sometimes I wonder if I am in control of my drinking My drinking causes a lot of harm I am actively doing things now to cut down or stop drinking I want help to keep from going back to the drinking problems that I had before O know that I have a drinking problem There are times when I wonder if I drink too much I am an ic I am working hard to change my drinking I have made some changes in my drinking, and I want some help to keep from going back to the way I used to drink Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 19

20 Personal Drinking Questionnaire Scoring Form Transfer the client s answers from questionnaire: TOTALS Recognition Ambivalence Taking Steps Possible range Recognition 7-35 Ambivalence 4-20 Taking Steps 8-40 PROFILE TABLE Instructions: 2. From the scoring form above transfer the total scores into the empty boxes at the bottom of the profile table. 3. For each scale, CIRCLE the same value above it to determine the decile range 4. This informs you if the client s score is low, average or high relative to people already seeking treatment for problems. Decile scores Recognition Ambivalence Taking Steps 90 very high high average low very low Scores from table above INTERPRETATION RECOGNITION High Scorer: Directly acknowledge they are having problems related to their drinking. Tend to express a desire for change. Perceive that harm will continue if they do not change Low Scorer Deny is causing a serious problem Reject labels such as problem drinker and ic. Do not express a desire to change AMBIVALENCE High Scorer: Uncertain and sometimes wonder if they are in control of their drinking, are drinking too much, hurting other people and/or are ic Are open to reflection and in the contemplation stage of change. Low Scorer with high recognition score: Know their drinking is causing problems Low scorer with low recognition score: Know that they do not have a problem with TAKING STEPS High Scorer: Report that they are making positive changes and experiencing some success. May need help to prevent relapse. Likely to be successful Low Scorer: Report that they are not currently trying to change their drinking Have not made any changes recently 20

21 Appendix 6 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) Patient: Date: Time: Pulse or heart rate taken for one whole minute..blood Pressure... NAUSEA AND VOMITING Ask Do you feel sick to your stomach? Have you vomited? OBSERVATION 0 no nausea and no vomiting 1 mild nausea with no vomiting Intermittent nausea with dry heaves Constant nausea, frequent dry heaves & vomiting TREMOR Arms extended and fingers spread apart. OBSERVATION 0 No tremor 1 Not visible, but can be felt fingertip to fingertip Moderate, with patient s arms extended Severe, even with arms extended ANXIETY Ask Do you feel nervous? OBSERVATION AGITATION OBSERVATION 0 No anxiety, at ease 1 Mildly anxious Moderately anxious or guarded so anxiety inferred) Equivalent to acute panic states seen in severe delirium or acute schizophrenic reactions PAROXYSMAL SWEATS OBSERVATION 0 No sweat visible 1 Barely perceptible sweating, palms moist Beads of sweat obvious on forehead Drenching sweats TACTILE DISTURBANCES Ask Have you any itching, pins and needles, burning, numbness, or you do feel bugs crawling on or under your skin? OBSERVATION 0 none 1 very mild itching, pins & needles, burning or numbness 2 mild itching, pins & needles, burning or numbness 3 moderate itching, pins & needles, burning or numbness 4 moderate hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations AUDITORY DISTURBANCES Ask Are you more aware of sounds? Are they harsh or startle you? Do you hear anything that disturbs you or you know is not there? 0 Not present 1 Very mild harshness or ability to startle 2 Mild harshness or ability to startle 3 Moderate harshness or ability to startle 4 Moderate hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations 0 Normal activity 1 Somewhat more than normal activity Moderately fidgety and restless Paces back and forth, or constantly thrashes about ORIENTATION & CLOUDING OF SENSORIUM Ask What day is this? Where are you? Who am I? Rate on scale Oriented 1 Cannot do serial additions or is uncertain of the date 2 Disoriented to date by no more than 2 days 3 Disoriented to date by more than 2 days 4 Disoriented for place and / or person VISUAL DISTURBANCES Ask Does the light appear too bright? Is its colour different to normal? Does it hurt your eyes? Are you seeing anything that is disturbing you or you know isn t there? 0 Not present 1 Very mild sensitivity 2 Mild sensitivity 3 Moderate sensitivity 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations HEADACHE, FULLNESS IN HEAD Ask does your head feel different? Does it feel like there is a band round your head? (do not rate for dizziness or lightheadedness) 0 Not present 1 Very mild 2 Mild 3 Moderate 4 Moderately severe 5 Severe 6 Very severe 7 Extremely severe Prof. A. Baldacchino, Liz Hutchings, Addiction Services Issued: February 2016 Review Date: February 2019 Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016 [Alt+ to go back] 21

22 Appendix 7 Inpatient: Alcohol withdrawal observation chart (based on CIWA-Ar scale) Begin using this chart at first sign of withdrawal symptoms. Name: (or affix label) Date: Time: (24 hour clock) Blood Pressure Heart Rate Respiratory Rate (breaths per minute) If below 10 inform medical team Nausea/vomiting (0-7) Tremor (0-7) Anxiety (0-7) Agitation (0-7) Sweats (0-7) Orientation (0-4) Tactile disturbances(0-7) Visual disturbances (0-7) Auditory disturbances (0-7) Headache (0-7) Total CIWA-Ar Score (max 67) Dose chlordiazepoxide (mg) CIWA-Ar 0-9 no dose CIWA-Ar give 25mg CIWA-Ar 15 give 50mg Guy s and St Thomas NHS Foundation Trust DTC 10052a Total Dose Chlordiazepoxide in 24 hours = Consult with Critical Care Team before total dose exceeds 250mg in 24hours. This acts as baseline dose use to calculate 5 day (or longer if required) reducing regimen. 22