MANAGEMENT AND DETOXIFICATION FOR GAMMA- HYDROXYBUTYRATE (GHB) AND GAMMA-BUTARYL LACTONE (GBL) GUIDELINES SEPTEMBER 2017

Transcription

1 MANAGEMENT AND DETOXIFICATION FOR GAMMA- HYDROXYBUTYRATE (GHB) AND GAMMA-BUTARYL LACTONE (GBL) GUIDELINES SEPTEMBER 2017

2 Policy title Management and Detoxification for GHB and GBL Policy PHA61 reference Policy category Clinical Relevant to Medical Staff, n-medical prescribers and all staff involved in Substance Misuse Services Date published September 2017 Implementation September 2017 date Date last New Guidelines reviewed Next review September 2019 date Policy lead Dr Sarah Minot, Consultant in Addiction Psychiatry Contact details Telephone: Accountable director Dr Vincent Kirchner, Medical Director Approved by (Group): Drug & Therapeutics committee 9 August 2017 Approved by (Committee): Quality Committee 19 September 2017 Document history Date Version Summary of amendments Sept New guidelines Membership of the policy development/ review team Dr Sarah Minot, Consultant in Addiction Psychiatry Consultation Substance Misuse Services Consultant Group DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. 1 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

3 Contents Page 1 Introduction 3 2 Aims and Objectives 3 3 Scope of the Policy 3 4 Background Information 4 5 Licensed usage of GHB, GBL and 1,4-BD 4 6 Effects of GHB, GBL and 1,4-BD 4 7 Withdrawal Symptoms 5 8 Management of GHB and GBL principals including C&I in-patient setting 6 9 GHB / GBL Detoxification Prescribing Protocol 7 10 Additional Support Dissemination and Implementation Arrangements Training requirements Monitoring and audit arrangements Review of the policy References Associated Documents 11 Appendix 1: Equality Impact Assessment Tool 12 Appendix 2: Contract and Consent Form for Medically Assisted Community GHB / GBL Withdrawal 13 Appendix 3: GHB / GBL Reduction Diary Sheet 14 Appendix 4: Accident and Emergency Letter 15 Appendix 5: Information on GHB / GBL for Professionals 16 Appendix 6: Information on GHB / GBL Detoxifications for Clients 17 Appendix 7: Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-AR) 19 2 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

4 1. Introduction These guidelines have been produced primarily in response to changes in drug usage amongst the clients who present for assessment and treatment within community substance misuse services. Camden and Islington NHS Foundation Trust has now established a specialist party drug clinic and all SMS have noticed an increase in clients presenting to services who are using gamma-hydroxybutyrate (GHB) and gamma-butaryl lactone (GBL). 2. Aims and objectives The main aim of this guidance is to provide clear guidance about the withdrawal effects of GHB and GBL and their management. To provide guidance to clinicians who are planning reduction plans and the medical detoxification for GHB and GBL. To provide guidance on administering medication and monitoring of clients undergoing a detox from GHB and GBL. To provide information about the potential dangers of clients suddenly stopping GHB and GBL. 3. Scope These guidelines will be mostly applicable to community substance misuse services which are provided by the Trust i.e. in Camden, Islington, and Kingston. It may also be relevant to other services within Camden and Islington NHS Foundation Trust as clients using GHB and GBL may also present to other services and who are admitted to the in-patient wards. It would be recommended that detoxifications for GHB and GBL are carried out in discussion with specialist substance misuse services. 3 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

5 4. Background Information Gamma butyrolactone (GBL) and 1,4-butanediol (1,4-BD) are precursors of Gamma-hydroxy butyric acid (GHB). GBL and / or 1,4-BD are quickly converted to GHB when they are ingested. GHB and GBL can cause feeling of euphoria, reduce inhibitions and cause sleepiness. The effects start about 10 minutes to an hour and can last up to 7 hours. GHB, GBL and 1,4-BD are clear, odourless, oily liquids with a salty taste that resembles stale water or burnt plastic (1). They are sold in liquid form in small bottles. GHB can also be found in powder form (2) e.g. capsules or tablets as it can form salts. These are usually dissolved in water or mixed with sweetened drinks to hide their salty taste (1,2). In 2003, GHB was classified as a Class C drug under the Misuse of Drugs Act It was then found that users were switching to GBL and 1,4-BD and so in 2009, GBL and 1,4-BD were also classified as Class C drugs under the Misuse of Drugs Act It is against the law to possess them or sell them for human consumption. 5. Licensed Usage of GHB, GBL and 1,4-BD GHB is licensed in Europe as an anaesthetic agent. In the UK is in authorized medicine, sodium oxybate for the treatment of narcolepsy with cataplexy (under specialist supervision). GBL and 1,4-BD also have legal uses and are available to licensed buyers. They are used in solvents such as paint stripper, nail varnish removal and stain removers. 6. Effects of GHB, GBL and 1,4-BD GBL and 1,4-BD are inactive and are metabolised into GHB shortly after entering the body. GHB occurs naturally in the central nervous system. It is metabolised in the body into GABA which acts on the GABAa receptor causing similar effects to benzodiazepines. 4 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

6 GHB and GBL have euphoric effects and can lead to increased confidence and reduced inhibition at low levels. At higher dosages they can cause sedation. The dose response curve is steep and so users can experience toxicity leading to nystagmus, aggression, urinary incontinence and nausea. Users of GHB, GBL and 1,4-BD use a pipette to measure out small doses. Effects include the following: Euphoria Decreased inhibitions Reduced anxiety Loss of motor control Emotional warmth Increased libido Sleepiness Confusion / disorientation Loss of coordination and balance Reduced consciousness Memory problems Respiratory depression Overdose headache; nausea and vomiting; hallucinations; seizures Loss of consciousness, coma and even death 7. Withdrawal Symptoms When GHB and GBL usage increases the frequency of dosing becomes very regular with users having to use every few hours. GHB users can develop physiological dependency when they are using 1-2 mls of GHB/GBL every 1-2 hours; this includes waking during the night to take further doses. It is estimated that users can develop dependency after using x3-4 per day for 2-3 months (2). Withdrawal from GHB can last around 9 days (3). Stopping GHB leads to a rapid onset of withdrawal symptoms which are similar to the withdrawal effects of alcohol or benzodiazepines. 5 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

7 Withdrawal symptoms are as follows: Tachycardia Insomnia Anxiety / restlessness Confusion Delirium Nausea Vomiting Tremor Hallucinations Hypertension Diaphoresis Less common symptoms may include seizures, rhabdomyolysis and possibly death. GHB withdrawal is a medical emergency. 8. Management of GHB and GBL Withdrawal principles of gradual reduction and detoxifications As stated earlier withdrawal is a medical emergency and as such must be managed very carefully. It is advised to have a clear acute pathway for each particular substance misuse service to their local general hospital. There should have been liaison with the relevant hospital specialists, in particular the AED and anaesthetic departments before detoxifications are agreed. If problems should arise during the detox the client will need to go urgently to hospital and they should be issued with the Accident and Emergency letter (Appendix 4) and the Information on GHB / GBL for professionals (Appendix 5). The scope of this guidance is for planned gradual reductions and / or planned community detoxification of clients with GHB / GBL dependency. The treatment protocol is for clients who are presenting in the absence of delirium. It should be noted that if clients are not suitable for gradual reduction plans or community detoxifications they may need to referred for in-patient detox and rehabilitation each service should follow their own policies and procedures for Tier 4 applications. It may be possible for a client to follow a gradual reduction plan. Clients should be advised to stay on a consistent dose that they can tolerate for a few days, taking this dosage at the same time each hour. When clients have been able to 6 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

8 do this for a few days they can then start to reduce the dosage by one-tenth of an ml each day, i.e. 2.0ml on Monday; then 1.9ml on Tuesday; then 1.8ml on Wednesday, etc. Once the client is down to 0.1ml they will be able to stop GBL without experiencing withdrawals symptoms. Clients should be informed that they may still feel uncomfortable and that it will take time for them to be able to adjust to life without GHB / GBL (see refer to Reduction Diary in Appendix 3). Where delirium is present clients should be admitted to a general hospital as a matter of urgency and may need very high dosages of diazepam up to 200mg in the first 24 hours. In essence where clients are using high dosages of GHB or GBL; are using GHB > 6 times every day; have a history of severe withdrawal symptoms are also dependent on other drugs (including alcohol or benzodiazepines) they would not be suitable for a community detox please refer to indications for in-patient detoxes. Where the client presents without delirium the following protocol can be used i.e. using diazepam and baclofen. tes for in-patient Camden and Islington Staff In the Camden and Islington in-patient ward setting management of clients presenting with GHB / GBL dependency and withdrawal should be managed very carefully. There should be a low threshold for liasing and transferring patients to local general hospitals. In this group of patients who are acutely mentally unwell it would be unsafe to carry out a GHB / GBL detox within the psychiatric inpatient setting. 9. GHB / GBL Detoxification Prescribing Protocol Inclusion Criteria Objective evidence of dependency on GHB / GBL Motivation to achieve abstinence Stable accommodation and 24 hour support during the detoxification Willingness to agree to the boundaries of the service and the treatment plan including daily reviews if clients don t adhere to these boundaries and continue to use illicit / non-prescribed substances after the detoxification has started the detox will be stopped Clients will need to be accompanied to and from their planned appointments during the detox period It should it stressed that clients shouldn t drive or operate machinery during the detox period 7 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

9 Exclusive Criteria Polysubstance misuse History / current physical health problems including hepatic and renal disorders Pregnant or breastfeeding women Indications for in-patient detoxification Using >30g GHB per day Using >15g GBL per day Using GHB >6 times per day History of severe withdrawal symptoms Currently dependent on other drugs, especially alcohol and / or benzodiazepines Assessment A full psychiatric history should be taken to include the following: Quantity / frequency / duration of GHB / GBL usage Any periods of abstinence Previous withdrawal symptoms including severity i.e. any seizures Medical history Mental health history Medications including allergies Other illicit substance usage Social support Motivation levels Physical examination Detoxification Plan The onset of withdrawal symptoms can range from 30 minutes to a few hours. It is important to prevent the development of withdrawal delirium rather than waiting for the full symptoms of withdrawal to start. Please note that the withdrawal medication regimen below is a standard regimen and depending on the amount of GBH / GBL the length of the regimen may be altered. 8 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

10 Prior to the commencement of a GHB / GBL detoxification clients should sign the contract and consent form (Appendix 2). They should also be issued with the information sheet for clients undergoing a GHB / GBL detox (Appendix 6). Table 1 GHB / GBL Withdrawal Medication Regimen Day of Treatment Time of observation and treatment (T1 is 1 hour after last time of usage; T2 is 2 hours after last time of usage; etc.) 1 T1 observations, diazepam 10-20mg (10mg standard dosage, 20mg if agitated) 2 Take observations as in Day 1 3 Take observations as in Day 1 4 Take observations as in Day 1 5 Take observations as in Day 1 6 Take observations as in Day 1 7 Take observations as in Day 1 8 Take observations as in Day 1 9 Take observations as in Day 1 10 Take observations as in Day 1 T2 observations, diazepam 10-20mg, baclofen 10mg T4 observations, diazepam 10mg PRN (if symptomatic) Please issue diazepam 3x10mg to be taken PRN at T6, T8 and T14 (if symptomatic) and 2x10mg baclofen to be taken at T8 and T14 Observations (temperature, pulse, blood pressure, mental state examination, alcohol withdrawal scales) to be taken at T1, T2, T4. Generally maximum dosage on Day 1 is diazepam 100mg and baclofen 30mg Diazepam 10-20mg qds Baclofen 10mg tds Diazepam 10-20mg tds Baclofen 10mg tds Diazepam 10-20mg tds Baclofen 10mg tds Diazepam 5-10mg tds Baclofen 10mg tds Diazepam 5-10mg bd Baclofen 10mg bd Diazepam 5-10mg od Baclofen 10mg od Diazepam 5-10mg od Diazepam 5-10mg od Diazepam 5-10mg od 9 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

11 There is no GHB / GBL withdrawal scale but as the withdrawals are similar to alcohol withdrawals in the early stages then the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-AR) can be used (please see Appendix 7). In severe withdrawals urgent transfer to hospital will be necessary. However the following medications may be useful. Table 2 Adjunctive Medications Diarrhoea Nausea and Vomiting Pain Loperamide (4mg initially followed by 2mg after each loose stool [max 16mg daily]) Domperidone 10mg tablets, maximum 30mg in 24 hours Paracetamol 500mg-1g qds 10. Additional Support It should be remembered that the above treatment is the pharmacological treatment for the withdrawal symptoms but as with all substance misuse treatment there is the need for psychosocial interventions. As part of an individual s treatment plan there will be psychosocial support in the form of motivational interviewing, the use of individual and group sessions, mutual aid organisations and relapse prevention work. Clients need to be made aware of the risk of decreased tolerance following a detoxification and a careful aftercare plan is critical. As part of the aftercare clients need to be made aware of relapse triggers and cues for relapse. Referrals may also need to be made to other services to support with underlying or additional needs. Clients need to be informed that following GHB / GBL usage clients can experience insomnia, anxiety and loss of appetite for weeks to months following the detox. 11. Dissemination and implementation arrangements This policy will be circulated to all team members working in Camden and Islington NHS Foundation Trust Substance Misuse Services. Dr Sarah Minot can be contacted for clarification or support in relations to any aspect of this policy by on sarah.minot@candi.nhs.uk. 10 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

12 12. Training requirements Implementation of this policy will be complemented by a discussion within the Substance Misuse Consultant group and the education programme of improving skills for NPS which is currently being undertaken within the division. 13. Monitoring and audit arrangements Regular audits will be conducted periodically to ensure that the detox policy is being adhered to. The audit will aim to ensure that appropriate assessment has been conducted prior to the commencement of GHB / GBL detoxification and that the process itself follows the guidelines. The results will be reported to the Trust audit committee. Learning from the audit will be shared with staff at the service at local CPD meetings. 14. Review of the policy The policy will be reviewed on or around April 2019 (two years from the date of production of this policy) 15. References 1) GBL Pre-review report WHO June ) Wood DM, Brailsford AD, Dargan Pl. Acute toxicity and withdrawal syndromes related to gammahydroxybutyrate (GHB) and its analogues gammabutyrolactone (GBL) and 1,4-butanediol (1,4-BD). Drug Test Anal 2011; 6 May Epub ahead of print [DOI /dta.292] 3) McDonough M, Kennedy N, Glasper A, Bearn J. Clinical features and management of gammahydroxybutyrate (GHB) withdrawal: a review. Drug Alcohol Depend. 2004: 75: Associated documents There are no associated Trust documents that this policy directly relates to. 11 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

13 Appendix 1 Equality Impact Assessment Tool Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A N/A N/A 12 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

14 Appendix 2 CONTRACT AND CONSENT FORM FOR MEDICALLY ASSISTED COMMUNITY SMS GBL / GHB 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 GBL / GHB, as it is your wish. The programme requires that you be abstinent from GBL / GHB, 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. During this time you may 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 GHB / GBL 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. 13 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

15 Appendix 3 GBL REDUCTION DIARY SHEET First STABILISE on a dose, take it at REGULAR time intervals. A different bedtime dose may be necessary Second REDUCE the dose, start with a dose that works and stick to it for day 1, reduce by 0.1ml every day Time of Day Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 14 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

16 Appendix 4 ACCIDENT AND EMERGENCY LETTER Dear Doctors The below client is undertaking a GBL/GHB DETOXIFICATION PATIENT NAME: D.O.B: STARTING DATE OF MEDICAL DETOXIFICATION: CURRENT MEDICATION: Drug Dose Frequency Last Taken Diazepam Baclofen Other Other For information regarding the clinic management of the patient please contact Dr. at.. on (please insert name of doctor and service) 15 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

17 Appendix 5 INFORMATION ON GHB / GBL FOR PROFESSIONALS Known as G it is a clear, odourless, oily liquid which is sold in liquid form or GHB can found in powder form which is dissolved in water or mixed with drinks to hide their salty taste. Users will then take small amounts 1-2 mls using a pipette in increasing frequently as dependency increases. Users can have to use every 1-2 hours throughout the day and night. Dependency on GHB / GBL can develop after daily usage for several months. Stopping GHB leads to a very rapid onset of withdrawal symptoms which are similar to the withdrawals effects of alcohol and / or benzodiazepines. GHB / GBL withdrawals are a very serious and potential fatal condition and needs to be treated rapid and often involves admission to Intensive Care Units. The withdrawal symptoms may include: Tachycardia Insomnia Anxiety / restlessness Confusion Delirium Nausea Vomiting Tremor Hallucinations Hypertension Diaphoresis Seizures Treatment of GHB / GBL withdrawals includes the use of high dosage benzodiazepines about 100mg diazepam in the first 24 hours. Research has also shown that baclofen may be helpful in the management of withdrawal symptoms; further studies are continuing to fully explore the benefits of baclofen. Generally baclofen 10mng tds is given to patients and this dosage is gradually reduced after the few 5 days. 16 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

18 Appendix 6 INFORMATION ON GHB / GBL DETOXIFICATION FOR CLIENTS You have made the very important decision to stop using GHB / GBL, 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 GHB / GBL 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 Withdrawal Symptoms Withdrawing from GHB / GBL 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, GHB / GBL 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 diazepam and baclofen. 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 GHB / GBL, as it is your wish. The programme requires that you be abstinent from GHB / GBL, alcohol and nonprescribed drugs. Thus, while on the programme you must not consume or possess any GHB / GBL, alcohol or drugs other than those prescribed by the doctor. 17 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

19 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 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. 18 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

20 Appendix 7 Clinical Institute Withdrawal Assessment for Alcohol Scale CIWA-AR Auditory (hearing) 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? Observations 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 Visual (sight) Disturbances Ask Does the light appear to be too bright? Is it s colour different? Does it hurt your eyes? Are you seeing anything that s disturbing you? Are you seeing anything that you know is not there? Observations 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 Tremor Arms extended and fingers spread wide apart Observations 0 not present 1 not visible, but can be felt fingertip to fingertip 4 moderate, with patients arms extended 7 severe, even with arms not extended Paroxysmal sweats Observations 0 no sweat visible 1 barely perceptible sweating, palms moist 4 beads of sweat obvious on forehead 7 drenching sweats Anxiety Ask Do you feel nervous? Observations 0 no anxiety, at ease 1 mildly anxious 4 moderately anxious or guarded, so anxiety is suggested 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic states 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 lightheadedness. Otherwise, rate severity 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe Nausea and Vomiting Ask do you feel sick to your stomach? Have you vomited? Observations 0 no nausea with no vomiting 1 mild nausea with no vomiting 4 intermittent nausea with dry heaves 7 constant nausea, frequent dry heaves and vomiting Orientation and clouding of Sensorium Ask What day is this? Where are you? Who am I 0 orientated and can do serial addictions 1 cannot do serial addictions or it uncertain about date 2 disorientated for date by no more than 2 calendar date 3 disorientated for date by more than 2 calendar date 4 disorientated for place or person Agitation Observations 0 normal activity 1 somewhat more than normal activity 4 moderately fidgety and restless 7 paces back and forth during interview, or constantly thrashes about Tactile (touch) 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 Date: Time: 24 hour clock Respiratory Rate: if < 10rpm inform medical team Auditory disturbances (0-7) Visual disturbances (0-7) Tremor (0-7) Nausea/vomiting (0-7) Sweats (0-7) Orientation (0-4) Anxiety (0-7) Agitation (0-7) Headache (0-7) Tactile disturbances (0-7) Total Score (MAX 67) Rater s initials: 19 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017