MEDICALLY ASSISTED COMMUNITY ALCOHOL WITHDRAWAL GUIDELINES SEPTEMBER 2015

Transcription

1 MEDICALLY ASSISTED COMMUNITY ALCOHOL WITHDRAWAL GUIDELINES SEPTEMBER 2015 This policy supersedes all previous policies for medically assisted community alcohol withdrawal

2 Policy title Guidelines for medically assisted community alcohol withdrawal Policy PHA28 reference Policy category Clinical Relevant to Trust-wide any services conducting medically assisted community alcohol withdrawal Date published Sept 2015 Implementation Sept 2015 date Date last July 2015 reviewed Next review July 2018 date Policy lead Bhaskar Punukollu, Consultant in Addiction Psychiatry Contact details Telephone: Accountable director Approved by (Group): Approved by (Committee): Document history Membership of the policy development/ review team Consultation Vincent Kirchner, Medical Director Substance Misuse Consultants Meeting Drugs and Therapeutics Committee Date Version Summary of amendments New Policy Revision with minor amendments Dr Bhaskar Punukollu Substance Misuse Consultants Group Members of drugs and therapeutics committee DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet.

3 Contents Page 1 Introduction 1 2 Aims and objectives 1 3 Scope of the policy 2 4 Assessing suitability for community alcohol withdrawal 2 5 Information to be obtained prior to commencement of withdrawal 3 6 Procedure for medically assisted withdrawal 4 7 Medication interventions following successful withdrawal 6 8 Dissemination and implementation arrangements 8 9 Training requirements 8 10 Monitoring and audit arrangements 8 11 Review of the policy 9 12 References 9 13 Associated documents: 9 Appendix 1: Contract and consent form for medically assisted community alcohol withdrawal 10 Appendix 2: Information sheet for clients on withdrawal process 11 Appendix 3: Severity of Alcohol Dependence Questionnaire (SADQ) 13 Appendix 4: Clinical Institute Withdrawal Assessment (CIWA-AR) 15 Appendix 5: Preparing for medically assisted community alcohol withdrawal (client information sheet) 17 Appendix 6: Pre-withdrawal checklist (key worker to complete) 18 Appendix 7: Template letter to GP to request blood results and physical examination findings 20

4 1. Introduction 1.1 Medically assisted community alcohol withdrawal is a process in which an individual s physical and mental health are monitored whilst being provided medications and psychosocial support to relieve physical and psychological withdrawal symptoms, on cessation of the use of alcohol. 1.2 When undertaking assisted withdrawal, the patient is required to stop alcohol intake abruptly, and its effects are replaced by medication that has crosstolerance. Then medication can be reduced at a rate that prevents withdrawal symptoms but without promoting over-sedation, and ultimately stopped altogether. The process involves providing a large enough initial dose to prevent severe withdrawal symptoms including seizures, delirium tremens, severe anxiety or autonomic instability, but to withdraw the medication before physical dependence on its effects begins. 1.3 The process should be conducted in a safe and structured manner so as to reduce the likelihood of potential adverse events. The structured approach will include careful assessment and discussion at the multi-disciplinary team meeting of a client s suitability for a medically assisted alcohol detoxification. This discussion should take into account several factors including the client s motivation to engage in a detoxification, current physical and mental health, social support, consideration of any absolute contraindications e.g. past history of seizures or delirium tremens, and the client s future treatment plans/goals. There should be an after-care plan in place so that the client continues to be supported to remain alcohol-free in the period following detoxification and supported to develop skills needed to maintain long-term sobriety. 2. Aims and objectives 2.1 This policy will set out the procedure for carrying out a medically assisted community alcohol withdrawal safely. The policy draws on recent NICE guidance (CG115) on Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. 2.2 This document aims to achieve the following objectives: Make clear the inclusion and exclusion criteria for medically assisted community alcohol withdrawal Explain the roles and responsibilities of staff conducting medically assisted community alcohol withdrawal Set out a number of possible medically supervised detoxification regimens which can be used for the withdrawal process Describe the different types of medications that can be used following medically assisted alcohol withdrawal and explain how to prescribe these. 1

5 2.2.5 Provide a number of useful appendices including client information sheets, GP letter and well validated rating scales to measure severity of alcohol dependence and withdrawal symptoms. 3. Scope of the policy This policy is intended for staff working in Camden and Islington NHS Foundation Trust specialist substance misuse services and other trust sites where community alcohol detoxification may be undertaken. The policy does not apply to the management of in-patients admitted on mental health wards, however alcohol detoxification may be undertaken in inpatient mental health wards using the detoxification schedules listed in this policy and in consultation with specialist alcohol nurses at trust substance misuse services. 4. Assessing suitability for community alcohol withdrawal 4.1 For service users who typically drink over 15 units of alcohol per day, and/or who score 20 or more on the AUDIT, consider either: a) Assessment for and delivery of a community-based assisted withdrawal; or b) Assessment and management in specialist inpatient alcohol services if there are safety concerns about a community-based assisted withdrawal. 4.2 In the week prior to medically assisted alcohol withdrawal, use formal assessment tools to assess the nature and severity of alcohol misuse, including the: - Alcohol use disorders Identification Tool (AUDIT) for identification and as a routine outcome measure - Severity of Alcohol Dependence Questionnaire (SADQ) (Appendix 4) - Leeds Dependence Questionnaire (LDQ) to assess severity of dependence. 4.3 When assessing the severity of alcohol dependence and determining the need for assisted withdrawal, adjust the criteria for women, older people, children and young people, and people with established liver disease who may have problems with the metabolism of alcohol. 4.4 For service users having assisted withdrawal, particularly those who with severe (SADQ score over 30 or drinking over 50 units of alcohol per week) alcohol dependence use a formal measure of withdrawal symptoms such as the Clinical Institute Withdrawal Assessment Revised (CIWA-Ar) (see Appendix 4). Inclusion/Exclusion criteria: Outpatient versus Inpatient Medically Assisted Alcohol Withdrawal LEVEL OF DEPENDENCE INTERVENTION Mild to moderate dependence without Outpatient-based assisted withdrawal significant co morbidity. - Monitor client every other day. - Mild/moderate dependence + complex Outpatient- based assisted withdrawal needs / Severe dependence Monitor client daily. Drinking over 30 units/ day Inpatient or Residential Assisted 2

6 SADQ score > 30 A history of epilepsy, seizures or delirium tremens units/ day along with significant psychiatric or physical co morbidities, a significant learning disability or cognitive impairment. Concurrent benzodiazepine withdrawal. Withdrawal Programme. Lower threshold in vulnerable groups e.g. homeless and older people. 5. Information to be obtained prior to commencement of medically assisted withdrawal 5.1 The key worker should meet the service user on two separate occasions to discuss the detoxification process and possible aftercare plans. The assessment may include a relative or spouse, who will be involved in providing support during the medically assisted withdrawal process. The following information should be presented by the key worker at the multidisciplinary team meeting before detoxification commences: Eligibility criteria agreed by team, procedure explained to client by key worker and consent form signed by client. Date for commencement and availability of staff (requires planning taking account of annual/ other leave). Information from GP: List of medications, physical problems, allergies, blood test results (less than 6 months old), including liver function test (LFTs) results (ALT, AST, ALP, GGT, Total Bilirubin, Albumin, PT/INR) Blood test results including LFTs must be seen by the doctor at least one week prior to commencement of medically assisted withdrawal. Drink Diaries for a minimum of two weeks. Baseline observations (pulse, BP, breath alcohol concentration (BAC). Risk assessment and SADQ completed. Aftercare plan agreed with client. 5.2 The service user must sign a contract agreeing to attend the clinic at a specified frequency, and to remain abstinent from alcohol and undergo breath alcohol testing and physical observations during the withdrawal process. The client must sign a consent form (appendix 1) and a post-withdrawal care plan that has been agreed with the key worker and discussed with the multi-disciplinary team beforehand. 5.3 If a service user plans to attend a day programme or residential rehabilitation centre, a visit to the centre should be made before the medically assisted withdrawal commences. The programme will need to provide approval and an agreement made for the client to attend before starting the medically assisted alcohol withdrawal. Attendance at Alcoholics Anonymous (AA) alone will not be adequate as a post-withdrawal care plan. If the post-withdrawal care plan includes placement in a residential rehabilitation centre or day programme requiring funding from social services or the primary care trust, a community care assessment (CCA) should be completed with a social worker before starting the withdrawal process. 3

7 5.4 If the post-withdrawal plan includes disulfiram or acamprosate prescribing (this should be discussed and agreed at the multi-disciplinary team meeting beforehand), an appointment should be arranged to see a psychiatrist to explain the medications available including their potential side effects and a decision made in agreement with the service user as to which (if any) to prescribe following medically assisted withdrawal. 6. Procedure for medically assisted alcohol withdrawal 6.1 Clients will see a doctor or a nurse prescriber on the Monday morning on commencement of community alcohol withdrawal. A key worker will review the client at an agreed frequency thereafter for the remainder of the withdrawal period. In the event of the client s allocated key worker being on leave, it will be their responsibility to arrange for another team member to see the client at an agreed frequency during the withdrawal process. As the alcohol service is closed on public holidays, take home medication will be prescribed for days when the service is shut. However for clients with severe dependence (SADQ score over 30 or drinking in excess of 50 units per week), medically assisted withdrawal should not take place on a week including a public holiday, so that the client will have the opportunity to come in to the service on a daily basis. 6.2 BAC readings during medically assisted alcohol withdrawal Breath alcohol concentration Zero on commencement and on each subsequent appointment during medically assisted withdrawal. Between zero and 0.5 on commencement of medically assisted withdrawal with objective evidence of withdrawal symptoms. Above zero on any day after the first day of medically assisted withdrawal. Treatment plan Start/ continue medically assisted withdrawal. Continue medically assisted withdrawal. Stop medically assisted withdrawal. 6.3 Individuals will be given FP10 prescriptions for their medications. The medication prescribed should be documented on the client s electronic patient record as well as on the FP10 prescription record sheet. Treatment contract and SADQ scores should also be documented on the electronic patient records. 6.4 Chlordiazepoxide will be used for medically assisted community alcohol withdrawal. The starting and subsequent day s dosing regimen will be decided on the basis of clinical assessment of the client. The starting and subsequent day s dosing will be determined by a number of factors including the client s SADQ score done prior to detoxification, clinical presentation (including BP, pulse, respiratory rate, breath alcohol concentration (BAC) and physical and mental state) and CIWA (clinical institute withdrawal assessment) scores. Vitamin replacement is essential as a preventative measure against the onset of Wernicke-Korsakoff syndrome. Vitamin B Co Strong two tablets daily and thiamine 100mg twice daily (both given orally) will be prescribed for a period of 28 days at the start of the detoxification. 4

8 6.5 When managing alcohol withdrawal in the community, avoid giving people who misuse alcohol large quantities of medication to take home to prevent overdose or diversion. Prescribe for installment dispensing, with no more than 2 days medication supplied at any time. For people with liver impairment, an inpatient detoxification using benzodiazepines with a shorter half-life (e.g. oxazepam) would be deemed most appropriate. When managing withdrawal from coexisting benzodiazepine and alcohol dependence increase the dose of benzodiazepine medication used for withdrawal. Calculate the initial daily dose based on the requirements for alcohol withdrawal plus the equivalent regularly used daily dose of benzodiazepine. This is best managed with one rather than multiple benzodiazepines. 6.6 Be aware that chlordiazepoxide doses may need to be reduced for children and young people, older people, and people with liver impairment. 6.7 Chlordiazepoxide reducing dose regimes based on SADQ scores on day 1 Daily Alcohol Consumption Severity of dependence Day 1 Day 2 Day 3 Day 4 Day units units units Mild/Moderate: SADQ Score <30 15mg 25mg qds qds 10mqd 20mg s qds 10mg 15mg tds qds 5mg tds 5mg bd 10mg tds 5mg nocte Severe: SADQ Score Very Severe: SADQ score mg 40mg qds 50mg qds qds 25mg 35mg qds 45mg qds qds 20mg 30mg qds 40mg qds qds 10mqds 15mg 25mg qds 35mg qds qds 10mqds 20mg qds 30mg qds Day 6 5mg tds 10mg 15mg qds 25mg qds tds Day 7 5mg bd 5mg tds 10mqds 20mg qds Day 8 5mg 5mg bd 10mg tds 15mg qds nocte Day 9 5mg 5mg tds 10mqds nocte Day 10 5mg bd 10mg tds Day 11 5mg nocte 5mg tds Day 12 Day 13 5mg bd 5mg nocte 6.8 Medication(s) for medically assisted community alcohol withdrawal will be provided using FP10 prescriptions. The prescription pad will be kept on site in a locked cupboard. The key will be kept in a locked safe on site. No medication for detoxifications will be kept on site. 5

9 6.9 In the unlikely event that a client presents in acute severe withdrawals or experiences seizures or other physical emergencies necessitating immediate medical attention, an ambulance should be called by dialling Medication interventions following successful withdrawal 7.1 After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention (e.g. cognitive behavioural therapy) focused specifically on alcohol misuse. 7.2 After a successful withdrawal for people with moderate and severe alcohol dependence consider offering disulfiram in combination with a psychological intervention to service users who: have a goal of abstinence but for whom acamprosate and oral naltrexone are not suitable, or prefer disulfiram and understand the relative risks of taking the drug. 7.3 Before starting treatment with acamprosate, oral naltrexone or disulfiram, conduct a comprehensive medical assessment (baseline urea and electrolytes and liver function tests including gamma glutamyl transferase [GGT]). In particular, consider any contraindications or cautions, and discuss these with the service user. For further information refer to the summary of product characteristics (SPC) site of the Medicines and Health Regulatory Authority (MHRA) Acamprosate If using acamprosate, start treatment as soon as possible after assisted withdrawal. Usually prescribe at a dose of 1998 mg (666 mg three times a day) unless the service user weighs less than 60 kg, and then a maximum of 1332 mg should be prescribed per day. Acamprosate should: usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it be stopped if drinking persists 4 6 weeks after starting the drug. Service users taking acamprosate should stay under supervision, at least monthly, for 6 months, and at reduced but regular intervals if the drug is continued after 6 months. Do not use blood tests routinely, but consider them to monitor for recovery of liver function and as a motivational aid for service users to show improvement. 7.5 Naltrexone If using oral naltrexone start treatment after assisted withdrawal. Start prescribing at a dose of 25 mg per day and aim for a maintenance dose of 50 mg per day. Draw the service user s attention to the information card that is issued with oral naltrexone about its impact on opioid-based analgesics. Oral naltrexone should: 6

10 usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it Be stopped if drinking persists 4 6 weeks after starting the drug. Service users taking oral naltrexone should stay under supervision, at least monthly, for 6 months, and at reduced but regular intervals if the drug is continued after 6 months. Do not use blood tests routinely, but consider them for older people, for people with obesity, for monitoring recovery of liver function and as a motivational aid for service users to show improvement. If the service user feels unwell advise them to stop the oral naltrexone immediately. 7.6 Disulfiram If using disulfiram, start treatment at least 24 hours after the last alcoholic drink consumed. Usually prescribe at a dose of 200 mg per day. For service users who continue to drink, if a dose of 200 mg (taken regularly for at least 1 week) does not cause a sufficiently unpleasant reaction to deter drinking, consider increasing the dose in consultation with the service user Before starting treatment with disulfiram, test liver function, urea and electrolytes to assess for liver or renal impairment. Check the SPC for warnings and contraindications in pregnancy and in the following conditions: a history of severe mental illness, stroke, heart disease or hypertension Make sure that service users taking disulfiram: stay under supervision, at least every 2 weeks for the first 2 months, then monthly for the following 4 months if possible, have a family member or carer, who is properly informed about the use of disulfiram, oversee the administration of the drug are medically monitored at least every 6 months after the initial 6 months of treatment and monitoring Warn service users taking disulfiram, and their families and carers, about: the interaction between disulfiram and alcohol (which may also be found in food, perfume, aerosol sprays and so on), the symptoms of which may include flushing, nausea, palpitations and, more seriously, arrhythmias, hypotension and collapse the rapid and unpredictable onset of the rare complication of hepatotoxicity; advise service users that if they feel unwell or develop a fever or jaundice that they should stop taking disulfiram and seek urgent medical attention. The above medication prescribing should be handed over to GPs in line with locally agreed pathways. The medications can be continued by GPs on repeat prescription after specialist prescribing ceases and for as long as is deemed necessary for the patient to remain on them. The specialist doctor should write to the GP and advise a period of time for which the medication(s) should be continued (usually for between 6-12 months, and disulfiram should be stopped if the client starts consuming alcohol at any point in time). Further detailed information about these drugs can be found in the Summary Product Characteristics (SPC) accessed on 7

11 8. Dissemination and implementation arrangements This policy will be circulated to all team members working in Camden Specialist Alcohol Treatment Service. The policy will also be circulated to other Camden substance misuse services and staff. Dr Bhaskar Punukollu can be contacted for clarification or support in relation to any aspect of this policy by on 9. Training requirements Implementation of this policy will be complemented by a training event for staff working in Camden Specialist Alcohol Service and the partner service CRI, in line with the trust s mandatory training policy and the learning and development guide. For training requirements please refer to the Trust s Mandatory Training Policy and Learning and Development Guide. 10. Monitoring and audit arrangements Regular audits will be conducted periodically to ensure that community alcohol withdrawals are being conducted in line with the policy. The audit will aim to ensure that appropriate assessment (including blood tests, liaison with GP and contract/ consent forms being signed) has been conducted prior to commencement of detoxification and that the detoxification process itself follows the guidelines in terms of medication prescribing both during and following successful completion of withdrawal. The results will be reported to the trust audit committee. Learning from the audit will be shared with staff at the service at local continuing professional development meetings. 8

12 Elements to be monitored Chlordiazepoxide prescribing is being done in line with the recommended procedures outlined in this policy (dosages based on SADQ and CIWA scores) Lead Nursing and medical team at CSATS How Trust will monitor compliance Carry out an audit of chlordiazepo xide prescribing. Frequency Annually Reporting Which committee or group will the monitoring report go to? Drugs and Therapeutics Group Acting on recommendati ons and Lead(s) Which committee or group will act on recommendatio ns? Drugs and Therapeutics Group / Pharmacists. Ensure that all Prescribers follow trust policy Immediate Change in practice and lessons to be shared How will changes be implemented and lessons learnt/ shared? Review of policy; implementation practices and procedures. Re- audit Give feedback to prescribers. Ensure that liver function test results are obtained prior to commencement of medically assisted withdrawal Nursing and medical team at alcohol services. Carry out an audit of blood test results. Annually Drugs and Therapeutics Group 11. Review of the policy The policy will be reviewed on or around May 4th 2018 (three years from the date of production of this policy). 12. References CG 115: Alcohol dependence and harmful use: NICE Guidance 28th Feb , 4, 6.4, 6.5 and 7 were excerpts from the NICE Guideline CG Associated documents There are no associated trust documents that this policy directly relates to. 9

13 Appendices Appendix 1 CONTRACT AND CONSENT FORM FOR MEDICALLY ASSISTED COMMUNITY ALCOHOL WITHDRAWAL The following stipulations have been designed to help you in the next couple of weeks, so that you have the best chance of giving up alcohol, as it is your wish. The programme requires that you be abstinent from alcohol and non-prescribed drugs. Thus, while on the programme you must not consume or possess any alcohol or drugs other than those prescribed by the doctor. During this time you will be asked to be breathalysed and you may be requested to supply a urine sample for drug screening. If either of these proves positive, you will not be able to continue with the programme. You may be able to join the programme again at a later date, but you should discuss first with your keyworker whether this is still the most appropriate option for you. In order to get the maximum benefit from the programme, you will need to give it your full priority. If you are working, it is strongly suggested that you arrange to take time off for an extended period, to give yourself space for the detox and recovery. You will be expected to stay the full duration of the sessions, for the whole programme, and to take all medication as prescribed by the doctor and detox nurse. Should you miss a session for whatever reason, you will not be able to continue with the programme. Aggressive, violent, abusive, racist or sexist language or behaviour can not be tolerated. If you demonstrate any of these you will be asked to leave the programme. Please sign below to confirm that the community alcohol detoxification programme has been explained to you, that you wish to go ahead with it and that you are happy with the conditions set above. Name Date Address Worker. 10

14 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal Appendix 2 INFORMATION SHEET Alcohol detoxification takes place at Camden Specialist Alcohol Treatment Service (CSATS) on the following mornings Monday am Consultant (doctor) clinic Tuesday, Wednesday From 9.30am with either key worker or doctor Friday From 9.30am with key worker == The programme is run by [Doctor name] [Nurse name] Points to Remember Your Safety During detoxification you may experience forgetfulness, irritability and poor coordination: be careful, therefore, when cooking, boiling water and doing other tasks that require care. It would be helpful for you to arrange to have a responsible person around during this time, to help you with these practicalities. Your Environment Try to arrange it so that your surroundings are as peaceful as possible. For this, it may be best to let those around you know that you will probably be feeling fragile for a few days. Also, it is advisable that you don t keep alcohol in your home. In the early stages of recovery you will be vulnerable, so avoid situations where alcohol is consumed or openly available. Your Time Most people find that if they keep busy, it helps them not to dwell on negative feelings. Give the coming week some consideration: don t leave things to chance. Your Diet Try to eat something even when you are not hungry. Eating little and often will help minimise craving. Drink plenty of fluids. CAMDEN & ISLINGON NHS TRUST Medically assisted community alcohol withdrawal programme * Specialist Alcohol Treatment Service Tel: You have made the very important decision to stop using alcohol and this programme has been put together to give you the best possible chance to achieve this goal. This leaflet will give you essential information about alcohol detoxification and inform you of what you can expect from us and what we expect from you. Please read it carefully and don t be afraid to ask questions 11

15 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal Withdrawal Symptoms Withdrawing from alcohol is often accompanied by some unpleasant experiences, such as shaking, anxiety, feeling jumpy and nervous, feeling irritable, sweating, nausea, racing thoughts and insomnia. These are withdrawal symptoms and with medication the worst aspects can be relieved. However, alcohol intoxication places a heavy burden on the body and consequently you should expect to experience some discomfort. On this programme, you will be prescribed a medication called chlordiazepoxide. This is usually quite safe, but can make people drowsy. Thus, during detoxification it is recommended that you refrain from driving, operating machinery or undertaking any tasks that require being alert. In addition, the medication is not safe when taken together with alcohol and thus if you resume drinking you must stop taking it at once. For some people withdrawal symptoms are more severe, including for example: Confusion Disorientation Blacking out Hallucinations Fits If you do experience any severe symptoms you will need to seek immediate assistance at the nearest Accident & Emergency Department. What you can expect from us When you start on this programme, you will be assessed by a doctor, who will prescribe the medication. A nurse will then monitor withdrawal closely, helping you to plan the week and to cope with these symptoms. What we expect from you The following stipulations have been designed to help you in the next couple of weeks, so that you have the best chance of giving up alcohol, as it is your wish. The programme requires that you be abstinent from alcohol and nonprescribed drugs. Thus, while on the programme you must not consume or possess any alcohol or drugs other than those prescribed by the doctor. You will be asked to be breathalysed and you may be requested to supply a urine sample for drug screening. If the breath alcohol reading is positive, you will not be able to continue with the programme. If your urine is positive for drug(s) that you have not told us about, the detoxification may need to stop. You may be able to join the programme again at a later date, but you should discuss first with your key worker whether this is still the most appropriate option for you. In order to get the maximum benefit from the programme, you will need to give it your full priority. If you are working, it is strongly suggested that you arrange to take time off for an extended period, to give yourself space for the detox and recovery. You will be expected to stay the full duration of the sessions, for the whole programme, and to take all medication as prescribed by the doctor and detox nurse. Should you miss a session for whatever reason, you will not be able to continue with the programme. Aggressive, violent, abusive racist or sexist language or behaviour cannot be tolerated. If you demonstrate any of these you will be asked to leave the programme. 12

16 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal Appendix 3 SEVERITY OF ALCOHOL DEPENDENCE QUESTIONNAIRE (SADQ) NAME: AGE: DATE: Recall a typical period of heavy drinking in the last 6 months. When was this? Month : Year : Answer all the following questions about your drinking by circling your most appropriate response. 1. The day after drinking alcohol, I woke up feeling sweaty 2. The day after drinking alcohol, my hands shook first thing in the morning. 3. The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn t have a drink. 4. The day after drinking alcohol, I woke up absolutely drenched in sweat. 5. The day after drinking alcohol, I dread waking up in the morning. 6. The day after drinking alcohol, I was frightened of meeting people first thing in the morning. 7. The day after drinking alcohol, I felt at the edge of despair when I awoke. 8. The day after drinking alcohol, I felt very frightened when I awoke. 9. The day after drinking alcohol, I liked to have an alcoholic drink in the morning. 10. The day after drinking alcohol, I always gulped my first few alcoholic drinks down as quickly as possible. 11. The day after drinking alcohol, I drank alcohol to get rid of the shakes. Not at all Slightly Moderately Quite a lot 13

17 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal 12. The day after drinking alcohol, I had a very strong craving for a drink when I awoke. 13. I drank more than a quarter of a bottle of spirits in a day (OR 1 bottle of wine OR 7 beers). 14. I drank more than half a bottle of spirits per day (OR 2 bottles of wine OR 15 beers). 15. I drank more than one bottle of spirits per day (OR 4 bottles of wine OR 30 beers). 16. I drank more than two bottles of spirits per day (OR 8 bottles of wine OR 60 beers). Imagine the following situation: 1. You have been completely off drink for a few weeks 2. You then drink very heavily for two days How would you feel the morning after those two days of drinking? 17. I would start to sweat. 18. My hands would shake. 19. My body would shake. 20. I would be craving for a drink. Answers to each question are rated on a four-point scale: Almost never = 0 Sometimes = 1 Often = 2 Nearly Always = 3 31 or higher = severe alcohol dependence = moderate dependence <16 = mild physical dependence 14

18 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal APPENDIX 4 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) Patient: Date: Time: (24 hour clock, midnight = 00:00) Pulse or heart rate, taken for one 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 and 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 not extended 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 sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation. 0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations 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 to you? Are you hearing things you know are not there?" Observation. 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations 15

19 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal ANXIETY -- Ask "Do you feel nervous?" Observation. 0 no anxiety, at ease 1 mild anxious moderately anxious, or guarded, so anxiety is inferred equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions AGITATION -- Observation. 0 normal activity 1 somewhat more than normal activity moderately fidgety and restless paces back and 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 to you? Are you seeing things you know are not there?" Observation. 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 around your head?" Do not rate for dizziness or light-headedness. Otherwise, rate severity. 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe ORIENTATION AND CLOUDING OF SENSORIUM -- Ask "What day is this? Where are you? Who am I?" 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date 2 disoriented for date by no more than 2 calendar days 3 disoriented for date by more than 2 calendar days 4 disoriented for place/or person Total CIWA-Ar Score Rater's Initials Maximum Possible Score 67 16

20 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal Appendix 5 PREPARING FOR MEDICALLY ASSISTED COMMUNITY ALCOHOL WITHDRAWAL Remember that you should allow 12 hours between finishing your last drink and starting to take your medication. This is to reduce the risk of the medication reacting with any alcohol that is still in your body. Try to gradually and gently reduce your alcohol consumption before the start of the detoxification, so the withdrawal symptoms will be less severe and the detoxification process will be shorter. Avoid the temptation to have a last fling, a heavy drinking binge just before you start the detoxification. This will make the withdrawal symptoms more intense and longer lasting. You will probably become dehydrated during detoxification so stock up with soft drinks such as fruit juice. Your appetite may be poor during detoxification, but it is still worth trying to eat a little, as small frequent meals will help minimise craving for alcohol. Most people find that if they keep busy or find something that they can get absorbed in, it helps them not to dwell on negative feelings. Start thinking about a few things you may do to keep yourself occupied. Examples may include: sorting out books or other possessions, writing letters, tidying out drawers, light gardening, etc. While it is good to keep busy, stress may increase craving. So, try to arrange your living space so that your surroundings are as peaceful as possible. If you are working, arrange with your employer and GP to take time off for an extended period, to give yourself space for the detoxification and recovery. During detoxification you may experience forgetfulness, irritability and poor coordination. It may be risky for you to perform tasks that require care, such as cooking, boiling water etc. Plan ahead so that you won t need to do any of these during the detoxification. Most people undergoing detoxification find that they need plenty of support from the people around them especially when they are craving for a drink. Try to arrange as much support as you can from family, friends, neighbours etc. Can your partner take time off work? If you live alone can someone stay with you for a few days? During the detoxification and in the early stages of recovery you will be quite vulnerable, so avoid situations where alcohol is consumed or openly available, and before the detoxification starts remove all the alcohol from your home. If anyone else in your home also drinks ask them if they will be prepared to stop drinking during the detoxification programme. After the detoxification you will remain vulnerable for a time, so make sure your after-detoxification plan is clear and definite. You may also want to consider attending Alcoholics Anonymous meetings. 17

21 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal Appendix 6 PRE-WITHDRAWAL CHECKLIST (TO BE COMPLETED BY KEY WORKER WITH SERVICE USER IN THE WEEK BEFORE MEDICALLY ASSISTED ALCOHOL WITHDRAWAL) Name: Key worker: Date: Pre-detoxification Facilitator: PRE-DETOXIFICATION CHECKLIST yes no 1. Breath Alcohol Level and SADQ? 2. Drinking diary completed? 2. Procedure explained (Information Leaflet)? 3. Planning satisfactory? 4. Contract and consent form signed? 5. Withdrawal symptoms discussed (checklist)? 6. Aftercare plan confirmed? PRE-ASSESSMENT FOR MEDICALLY ASSISTED ALCOHOL WITHDRAWAL General Presentation: Breath Alcohol Reading: SADQ score: Drinking Information: Day Units Total 18

22 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal Circumstances (any relevant changes to drinking, social, psychological, physical health in the past 7 days) Plan for next week (commencement of medically assisted alcohol withdrawal) (high risk situations, how to manage cravings, crisis plan, telephone help lines) Longer Term Plan (is aftercare in place?) Further Actions ======================================================= Signed 19

23 CSATS Guidelines for Medically Assisted Community Alcohol Withdrawal Appendix 7 TEMPLATE GP LETTER TO REQUEST BLOOD TEST RESULTS AND PHYSICAL FINDINGS Camden Specialist Alcohol Treatment Service (CSATS) 16a Cleveland Street, London, W1T 4HX Tel: Dear Dr Re: We plan to offer the above individual a community alcohol detoxification. I would be grateful if you could please send us the following information which will help inform our management plan. 1. A copy of recent blood test results (from within the last six months) including: LFTs (ALT, AST, ALP, GGT, Albumin, PT/INR and total bilirubin), FBC and U&Es If recent liver function test results are not available I would be grateful if you can arrange these. 2. A list of current medications being prescribed. 3. Details of any relevant physical health problems and investigations either completed or ongoing e.g. for HIV/ Hep C/ epilepsy or liver disease. Yours Sincerely, 20