INPATIENT ALCOHOL WITHDRAWAL PRESCRIBING GUIDELINES MAY 2018

Transcription

1 INPATIENT ALCOHOL WITHDRAWAL PRESCRIBING GUIDELINES MAY 2018

2 Policy title Inpatient alcohol withdrawal Prescribing Guidelines Policy PHA28B reference Policy category Clinical Relevant to Trust-wide any services conducting medically assisted inpatient alcohol withdrawal Date published May 2018 Implementation July 2018 date Date last May 2018 reviewed Next review May 2020 date Policy lead Lucy Reeves, Chief Pharmacist Contact details Telephone: Accountable director Approved by: Vincent Kirchner, Medical Director Drugs and Therapeutics Committee Ratified by: Document history Quality Committee Date Version Summary of amendments May Original document Membership of the policy development/ review team Consultation Audrey Coker, Lead Pharmacist for Clinical Services Dr John Dunn, Lead Consultant, Dr Bhaskar Punukollu, Lead Consultant, Simon Peel, Lead Nurse for Medicines Management, Ruari McCallion, SMS Service Manager 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 1 4 The Alcohol Withdrawal Syndrome 2 5 Assessing suitability for inpatient alcohol withdrawal 2 6 Information to be obtained prior to commencement of withdrawal 3 7 Procedure for medically assisted withdrawal 4 8 Remedies for somatic complaints during assisted alcohol withdrawal 9 9 Medication interventions following successful withdrawal 9 10 Medicines not recommended Discharge Dissemination and implementation arrangements Training requirements Monitoring and audit arrangements Review of the policy References Associated documents: 14 Appendix 1: Severity of Alcohol Dependence Questionnaire (SADQ) 15 Appendix 2: Clinical Institute Withdrawal Assessment (CIWA-AR) 17 Appendix 3: Alcohol units calculating units 19 Appendix 4: Abbreviations 19

4 1. Introduction 1.1 Medically assisted inpatient alcohol withdrawal is a process in which an individual s physical and mental health is monitored whilst being provided with medicines and psychosocial support to relieve physical and psychological withdrawal symptoms, on alcohol cessation When undertaking assisted withdrawal, the patient is required to stop alcohol intake abruptly, and its effects are replaced by medication that has cross-tolerance in a safe and structured manner. 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 The assessment of the patient should take into account the patient s motivation to engage in a detoxification, current physical and mental health, the environment, social support, consideration of any absolute contraindications e.g. past history of seizures or delirium tremens, and the patient s future treatment plans/goals. There should be an after-care plan in place so that the patient continues to be supported to remain alcoholfree in the period following detoxification and supported to develop skills needed to maintain long-term sobriety Aims and objectives 2.1 This policy will set out the procedure for carrying out a medically assisted inpatient alcohol withdrawal safely. The policy draws from the NICE guidance: Assisted Alcohol Withdrawal Pathway This document aims to achieve the following objectives 1 : Outline the assessments required prior to conducting a medically assisted inpatient alcohol withdrawal The medical complications which may occur Set out a number of possible medically supervised detoxification regimens which can be used for the withdrawal process Describe the different types of medicines that can be used following medically assisted alcohol withdrawal and explain how to prescribe these Provide appendices, including 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 where inpatient alcohol detoxification may be undertaken. 1

5 4. The Alcohol Withdrawal Syndrome Table 1: Symptoms of alcohol withdrawal 3 Malaise Hypertension Headache Tremor Sweating Arrhythmias Minor hallucinations Tachycardia Insomnia Convulsions Parasthesiae Agitation Nausea, vomiting Hepatic dysfunction Suicidal ideation Symptoms are seen within hours (typically 3-12 hours) of the last drink. Symptoms commonly peak at hours and usually lasting 5 14 days 3. Alcohol related seizures This includes epileptiform seizures that usually occur within 12 to 18 hours of alcohol cessation 3. Fits are rare beyond 48 hours following alcohol cessation 4. Long-acting benzodiazepines significantly reduce seizures and are therefore recommended for medically assisted withdrawal in those with a previous history of seizures 3. Delirium Tremens (DTs) Onset of DTs is 3-4 days 3, following alcohol cessation and represents a medical emergency 3. Risk factors are a long history of dependence, severe dependence, previous admissions / assisted withdrawals, older age and a history of delirium tremens or alcohol related seizures 3. Table 2: Characteristic symptoms of DTs 3 Severe tremor Vivid hallucinations including paranoid delusions Tachycardia. Sweating Insomnia Clouding consciousness Confusion Agitation Fever Hypertension 5. Assessing suitability for inpatient alcohol withdrawal 5.1 On admission to hospital, prior to medically assisted alcohol withdrawal, formal assessment tools must be used to assess the nature and severity of alcohol misuse, including the: - AUDIT tool (see the physical health screening tool in Care Notes) to initially identify dependent drinkers. There is a Trust an online training package for this tool. - Severity of Alcohol Dependence Questionnaire (SADQ) (Appendix 1) - Clinical institute withdrawal Assessment revised (CIWA-Ar) (Appendix 2) 5.2 Once patients are identified as dependent drinker (via the AUDIT tool), then the SADQ should be done to identify the level of severity of their dependence (mild/ moderate/ severe) which can in turn be used to decide the detox regimen. 2

6 Table 3: Inclusion/Exclusion criteria: Outpatient versus Inpatient Medically Assisted Alcohol Withdrawal 2,3 LEVEL OF DEPENDENCE INTERVENTION Mild dependence. (SADQ< 15 or CIWA-AR<10) Moderate dependence (SADQ 15-30, CIWA- Ar </= 15) Severe dependence Regularly drinking over 30 units/ day SADQ score > 30, CIWA-Ar >15 or CIWA-Ar >10 plus co-morbid alcohol related medical problems. A history of seizures, experience of withdrawal related seizures or delirium tremens. Regularly drink between 15-30units of alcohol per day and have significant mental illness (e.g. chronic severe depression, psychosis) or physical co morbidities (malnutrition, congestive cardiac failure, unstable angina, chronic liver disease), a significant learning disability or cognitive impairment. Concurrent withdrawal from alcohol and benzodiazepine. Pregnant women History of failed community detoxifications 6.0 Information to be obtained prior to commencement of medically assisted withdrawal 6.1 The doctor should meet the patient to discuss the detoxification process and aftercare plans. The following information should be assessed by the doctor before detoxification commences: On admission, medicine reconciliations, including allergies should be undertaken. Previous reactions to Pabrinex or Parentrovite must be particularly noted. History of alcohol use, including daily consumption and recent patterns of drinking History of previous episodes of alcohol withdrawal Time of most recent drink Other drug (illicit or prescribed) use Co-existing medical and mental health problems Physical examination including cognitive function Blood tests on admission or if refused a blood test less than 6 months old 2, including FBC, Us and Es, liver function test (LFTs) results (ALT, AST, ALP, GGT, Total Bilirubin, Albumin, PT/INR) and urinary drug screen 3. Baseline observations (pulse, BP, breath alcohol concentration (BAC) 1 (taken at least twenty minutes after the last drink). If admitted an inpatient assisted withdrawal programme will be required. An initial AUDIT should be undertaken to initially identify dependent drinkers. Severity of dependence (SADQ) and of withdrawal symptoms (CIWA-Ar) rating scales should be used as outlined below 3. 3

7 7.0 Procedure for medically assisted alcohol withdrawal 7.1 Pharmacologically assisted withdrawal is likely to be needed when there is regular consumption of > 15 units/day, AUDIT score >20 or a CIWA-Ar score >15 3. Table 4: BAC Readings during medically assisted withdrawal and action taken Breath alcohol concentration Treatment plan Zero on commencement and on each day Start/ continue medically assisted during medically assisted withdrawal. withdrawal. Between zero and 0.5 on commencement of Continue medically assisted medically assisted withdrawal with objective withdrawal. evidence of withdrawal symptoms. Above zero on any day after the first day of Stop medically assisted withdrawal. medically assisted withdrawal. Modified from the Trust Guidelines for Medically Assisted Community Alcohol Withdrawal 7.2 Note withdrawals can start even with a high BAC and the patient smelling strongly of alcohol if medical team think the patient is displaying symptoms of withdrawal. This risk of seizures if the detoxification is not started should be considered. 7.3 There are two types of assisted withdrawal regimens: fixed dose reduction or variable dose reduction. For variable dose reduction, staff must have specialist skills For fixed dose regimens, patients should be started on a dose of benzodiazepine selected after an assessment of the severity of alcohol dependence (clinical history, number of units per drinking day and SADQ score) 3. The dose of the benzodiazepine should be reduced over 5-10 days 3. See table 6. Alcohol withdrawal symptoms should be monitored using a validated instrument e.g. CIWA-Ar Patients with more severe alcohol dependence 2 (e.g. SADQ score > 30 or a CIWA-Ar >15) or those undergoing a symptom triggered regimen 1 should have a formal measure of withdrawal symptoms. 7.6 A CIWA-Ar scale is not appropriate if the patient is confused, cannot speak English or unable to communicate effectively. For these patients, a fixed schedule reducing regimen should be used. It may be necessary to chart PRN chlordiazepoxide for the 24 hours in case of breakthrough symptoms. If PRN doses are used, a review of the fixed dose regimen is needed after 24 hours and increased. 7.7 Table 5: Formulary Medicines 2,3 Medicine Comments Benzodiazepines Chlordiazepoxide (NICE) Chlordiazepoxide has a lower for alcohol abuse potential 3. withdrawal (AW) Diazepam (NICE) Lorazepam (NICE) For clinically significant liver Medicines withdrawal after Oxazepam Acamprosate (NICE) Naltrexone (NICE) Disulfiram (NICE) impairment. Off-label. Contra-indicated if taking opioid medication Potential interaction with alcohol from other products. 4

8 Vitamin supplementation Pabrinex IM High Potency All inpatients receiving alcohol detoxification. Risk of anaphylaxis: 1 per 5million pairs Thiamine tablets Fixed dose regimen Table 6: Chlordiazepoxide reducing dose regimens based on SADQ scores on day 1 5 Daily Alcohol units units units Consumption Severity of dependence Mild/Moderate: SADQ Score <30 Severe: SADQ Score Very Severe: SADQ score Day 1 15mg 25mg 30mg 40mg qds 50mg qds qds qds qds Day 2 10mqds 20mg 25mg 35mg qds 45mg qds qds qds Day 3 10mg 15mg 20mg 30mg qds 40mg qds tds qds qds Day 4 5mg tds 10mqds 15mg 25mg qds 35mg qds qds Day 5 5mg bd 10mg 10mqds 20mg qds 30mg qds tds Day 6 5mg 5mg tds 10mg 15mg qds 25mg qds nocte 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 5mg bd Day 13 5mg nocte SADQ = Severity of Alcohol Dependence Questionnaire a) Doses of chlordiazepoxide in excess of 30 mg four times a day should be prescribed only in severe alcohol dependence The patient s response to treatment should always be regularly and closely monitored. b) Doses in excess of 40 mg four times a day should be prescribed only if there is clear evidence of very severe alcohol dependence. Such doses are rarely necessary in women and never in older people or if there is liver impairment. Reproduced from the NICE guidance 100 and 115. Alcohol use disorders: sample chlordiazepoxide dosing regimens for use in managing alcohol withdrawal. February Pharmacotherapy should be delivered with the dose tailored to the patient s requirements. To individualise treatment, several factors have to be taken into account, including: the severity of dependence (history and assessment tools e.g. SADQ) the severity of the current withdrawal episode the patient s physical status / other medication being take 6. For example, a young male patient with a high alcohol intake, a history of withdrawal seizures and normal liver function will likely require higher doses of pharmacotherapy 5

9 than a small older female patient with cirrhosis who develops mild withdrawal on the background of a moderate alcohol intake Omitting doses If patient is asleep or appears over-sedated omit prescribed dose and then review when next dose due. Beware risk of respiratory depression (see 7.18 (monitoring guidance)). Consider re-using a breathalyser if there is any suspicion of alcohol consumption on ward Be aware that chlordiazepoxide doses may need to be reduced for older people 3. Patients with clinically significant liver impairment should receive lorazepam 2,3 or oxazepam 3 may be prescribed. Lorazepam and oxazepam are not licensed for the management of alcohol withdrawal. Benzodiazepines should be avoided in severe liver impairment 5. Oxazepam may also be useful in patients with chronic respiratory disease Dose equivalences: chlordiazepoxide 25mg = diazepam 10mg = oxazepam 25-30mg = lorazepam 1mg Note benzodiazepines with shorter half-lives may increase seizure risk 3. For patients with a previous history of seizures, longer acting benzodiazepines e.g. chlordiazepoxide should be used Symptom-triggered regimen This approach may be useful for:- For mild dependence, or where the extent of dependence is unclear. Where a patient is still under the influence of alcohol at the point of assessment i.e. withdrawal symptoms have not started yet. Where the patient is already taking regular benzodiazepines 12. If the patient is pregnant 6 If staff are confident about assessing the severity of alcohol withdrawal and dosing appropriately 7. On days 1-4, chlordiazepoxide 20-30mg hourly as required based on symptoms (including pulse rate greater than 90 beats per minute, diastolic blood pressure greater than 90mmHg or severity of withdrawal signs and symptoms The patient should be regularly assessed or monitored using clinical experience or a formal measure of withdrawal symptoms (e.g. the CIWA-Ar). Chlordiazepoxide is provided if the patient needs it and treatment is withheld if there are no symptoms of withdrawal A CIWA-Ar score >15 during assisted withdrawal suggests the regimen is inadequate and further intervention is required If the patient suffered hallucinations, an increased dose of benzodiazepine e.g. chlordiazepoxide should be administered according to clinical judgement 3. Mild perceptual disturbances usually respond to chlordiazepoxide. If there is no response, oral or intramuscular haloperidol may be used. Note haloperidol can reduce seizure threshold and also cause dystonic reactions 3. 6

10 7.15 Liver impairment Benzodiazepine dose equivalences: Chlordiazepoxide 25mg = Diazepam 10mg = Oxazepam 25-30mg = Lorazepam 1mg 3 Dosing regimens of shorter acting benzodiazepines in liver impairment. A withdrawal scale should be used as a marker for optimal dosing. Oxazepam 40mg four times a day and gradually reduced. Some people may only be able to tolerate lower doses 3.Doses above 120mg per day are above licensed dosage limits 9. Lorazepam 500micrograms to 1mg 6 hours (maximum 4mg in 24 hours) is an alternative to chlordiazepoxide in severe liver disease 10. The dose should be gradually reduced. Note higher doses are above licensed dosage limits Elderly There should be a lower threshold for inpatient medically-assisted alcohol withdrawal for elderly people. Benzodiazepines remain the treatment of choice, but lower doses may be required and in some cases, shorter-acting benzodiazepines Pregnancy For alcohol-dependent pregnant women who have withdrawal symptoms, treatment of detoxification should be offered. The timing of the detoxification in relation to the trimester of the pregnancy should be risk assessed against continued alcohol consumption and risks to foetus. Benzodiazepines have been associated with unconfirmed reports of teratogenicity 3. Chlordiazepoxide has been suggested as being unlikely to pose a substantial risk, however dose dependent malformations have been observed 3. One method is a closely monitored symptom triggered one at the lowest possible dose for the minimum possible time 6. No relapse prevention medication has been evaluated in pregnancy 3. Pabrinex IM high potency injection has not been reported to have clinically adverse effects at recommended doses 11. If the patient presents late in pregnancy, the obstetric team should be informed Breastfeeding Benzodiazepines with a long-half-life e.g. diazepam and chloridiazepoxide should be avoided in breastfeeding 3. There have no adverse effects have been reported with Pabrinex IMHP at recommended doses when used as clinically indicated Co-existing benzodiazepine and alcohol dependence When managing withdrawal from co-existing benzodiazepine and alcohol dependence, the dose of the benzodiazepine medication used for withdrawal should be increased. This is best managed with one benzodiazepine (e.g. chlordiazepoxide) rather than multiple benzodiazepines 1. Calculate the initial daily dose based on the requirements for alcohol withdrawal plus the equivalent regularly used daily dose of benzodiazepine. The withdrawal regimens should last 2-3 weeks or longer depending on the severity of co-existing benzodiazepine dependence Monitoring Observations to be carried out 1,5 :- - applying the alcohol withdrawal scale (CIWA-Ar) - taking BP, pulse, oximetry and monitoring respiratory rate The frequency of observations should be documented 7 by the medical team.

11 Signs of toxic side effects of benzodiazepines include respiratory depression and reduced GCS 1. The emergency bag contains flumazenil Seizures In the unlikely event that a patient presents in acute severe withdrawals or experiences seizures or other physical emergencies necessitating immediate medical attention, an ambulance should be called by dialling 999. The emergency bag contains diazepam 10mg rectal tubes and buccal midazolam. See the advice cards contained in the bag for directions for use Vitamin replacement Vitamin replacement is essential as a preventative measure against the onset of Wernicke s Encephalopathy (WE). If untreated, WE progresses to Korsakoff s syndrome. WE is a progressive neurological condition caused by thiamine deficiency. WE can occur in those who consume a large amount of alcohol, have a restricted diet and alcohol related reduced absorption of thiamine 3. All inpatients should be given parenteral thiamine as prophylaxis 3. If there has been a previous documented allergic reaction, then oral thiamine 100mg three times a day should be commenced. If Wernicke s encephalopathy is suspected, the patient should be transferred to medical unit for Pabrinex IV 3. Prevention dose of Pabrinex IMHP, one ampoule pair (7mls) daily for five days followed by oral vitamins: Thiamine 1,8 100mg three times a day 10 for as long as diet is inadequate or alcohol consumption is resumed 3. Advise GP of treatment duration of thiamine supplementation. The risk of anaphylaxis in general is very low (1 per 5 million pairs of ampoules of Pabrinex) and this alone should not preclude the use of parenteral thiamine in patients where this route of administration is required 3. Facilities for treating anaphylaxis should be available at any site where parenteral thiamine is to be administered 3. An emergency bag containing Emerade 1 in 1000 (1mg/ml) must be available. The UK Resuscitation Council states that staff administering parenteral medication should be trained in the assessment and management of anaphylaxis. All staff should receive training in immediate life support annually, which includes the treatment of anaphylaxis. Staff should follow existing trust protocols for this. There is no requirement that medical staff should be present whilst Pabrinex is administered 1. 8

12 Site of administration: The contents of one ampoule number 1 and one ampoule number 2 of Pabrinex Intramuscular High Potency (total 7 ml) are drawn up into a syringe to mix them just before use, then injected slowly high into the gluteal muscle, 5cm below the iliac crest 11.The appropriate site for this type of administration is the gluteus medious (part of the ventro gluteal muscle). The Z-track injection technique should be used. This site is used to lower the risk of hitting the sciatic nerve and the superior gluteal arteries 1. The Z - tracking method involves pulling the underlying skin down wards or on to one side of the injection site, inserting the needle at a right angle to the skin, which moves the subcutaneous and cutaneous muscle tissues by approximately 1-2 cm. The injection is given and the needle withdrawn, whilst releasing and retracting the skin at the same time. This manoeuvre seals of the puncture tract at the junction at each tissue layer 1. Refer to the Trust Safer Use of Injectable Medicines policy. Aftercare Observe for anaphylactic- type reaction for 30 mins. If repeatedly injecting, vary sites as much as possible and avoid previous sites by 2.5cm. Ice can be used to numb the injection site, or lower pain if appropriate for patient comfort TABLE 7: REMEDIES FOR SOMATIC COMPLAINTS DURING ASSISTED ALCOHOL WITHDRAWAL 3 Symptom Dehydration Pain Nausea and vomiting Diarrhoea Skin itching Insomnia Suggested treatment Ensure adequate fluid intake in order to maintain hydration and electrolyte balance. Dehydration can precipitate life-threatening cardiac arrhythmia. Paracetamol Metoclopromide 10mg or prochlorperazine 5mg every four to six hours Loperamide Occurs commonly and not only in individuals with alcoholic liver disease: antihistamines Zopiclone mg nocte prn (specialist opinion) 9.0 Medication interventions following successful withdrawal 9.1 For people with moderate to severe dependence, the post-withdrawal plan may include disulfiram or acamprosate and a psychological intervention (this should be discussed and agreed at a ward round). An alternative is naltrexone. Naltrexone does not have licence in the treatment of moderate to severe alcohol dependence and informed consent should be sought and documented 3. The medicines should be discussed with the patient, including potential benefits and side effects. If disulfiram is considered, patients should: 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 medicine. 9.2 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 patient 1. The initiation of 9

13 naltrexone is restricted to Substance Misuse services because of the risk of reversing the effect of all opiod medication, including painkillers and causing precipitated withdrawals. For further information refer to the summary of product characteristics (SPC) site of the Medicines and Health Regulatory Authority (MHRA) Acamprosate If using acamprosate, treatment should be started as soon as possible after assisted withdrawal. Dose regimen (18-65years): Less than 60kg: 666mg in the morning and 333mg at noon and at night 2,14. 60kg or more: 666mg three times a day 2,14. Acamprosate should not be used in older people as per product licence 14. Acamprosate should: usually be prescribed for up to 6 months, or longer for those benefiting from the medicine who want to continue with it 2,14. be stopped if drinking persists 4 6 weeks after starting the medicine 2,14. Patients taking acamprosate should stay under supervision, at least monthly, for 6 months, and at reduced, but regular intervals if the medicine is continued after 6 months. Blood tests should not be routinely carried out, but consider them to monitor for recovery of liver function and as a motivational aid for patients to show improvement 2. Acamprosate is contraindicated in lactating women and patients with a serum creatinine of >120 micromol/l 14. Acamprosate must only be used during pregnancy after a careful benefit/risk assessment, when the patient cannot abstain from drinking alcohol without being treated with acamprosate and when there is consequently a risk of foetotoxicity or teratogenicity due to alcohol Naltrexone An opiate urine drug screen (UDS) should be done before starting naltrexone. Prior to initiation of naltrexone, the medical team should consult the consultant of the borough alcohol service because of the risk of reversing the effect of all opiod medication, including painkillers and causing precipitated withdrawals. The dose schedule is:- Initial dose: 25 mg per day and aim for a maintenance dose of 50 mg per day. The patient s should be advised about the information in the card that is issued with oral naltrexone about its impact on opioid-based analgesics. Oral naltrexone should: usually be prescribed for up to 6 months, or longer for those benefiting from the medicine who want to continue with it. be stopped if drinking persists 4 6 weeks after starting the medicine 1. Patient s taking oral naltrexone should stay under supervision, at least monthly, for 6 months, and at reduced but regular intervals if the medicine is continued after 6 months. Blood tests should not be routinely carried out, but consider them for older people, for people with obesity, for monitoring recovery of liver function and as a motivational aid for patients to show improvement. Patients should be advised to stop oral naltrexone immediately if they feel unwell 1. Liver function test abnormalities have been reported in obese and elderly patients taking naltrexone who have no history of drug abuse. Liver function tests should be carried out both before and during treatment 15. Naltrexone is contraindicated in patients with acute hepatitis, liver failure, renal failure, patients prescribed opiod containing medicines or have a positive urine drug screen for opiods 15. Naltrexone is contra-indicated in patients who 10

14 are prescribed opioid medication for chronic pain or addiction as the Naltrexone will stop the opioids from working and put the patient into an acute opiate withdrawal state. Naltrexone should only be given to pregnant women the potential benefits outweigh and the possible risk. Breast feeding is not recommended during naltrexone treatment Disulfiram If using disulfiram, treatment should be started at least 24 hours after the last alcoholic drink consumed. Initial dose: 200 mg per day. For patients 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 after discussion with the patients 1. Disulfiram can be prescribed for elderly people Before starting treatment with disulfiram, test liver function, urea and electrolytes to assess for liver or renal impairment Make sure patients taking disulfiram: stay under supervision, at least every 2 weeks for the first 2 months, then monthly for the following 4 months. if possible on discharge, have a family member or carer, who is properly informed about the use of disulfiram, oversee the administration of the medicine. are medically monitored at least every 6 months after the initial 6 months of treatment and monitoring Warn patients taking disulfiram, and their families and carers, about: the interaction between disulfiram and alcohol (which may also be found in food, perfume, and aerosol sprays, 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 patients that if they feel unwell or develop a fever or jaundice that they should stop taking disulfiram and seek urgent medical attention Disulfiram is contraindicated in the presence of heart failure, coronary artery disease, previous history of cerebrovascular accident, hypertension, severe personality disorder, suicidal risk, psychosis or consumption of alcohol Disulfiram in the first trimester of pregnancy is not advised. Disulfiram should not be used in breastfeeding especially where there is a possibility of interaction with medicines that the baby may be taking Medicines that are not recommended 10.1 Antidepressants, GHB should not be used in the treatment of alcohol misuse and benzodiazepines should not be used long-term Clomethiazole is not included in this guidance. The NICE guidance advises clomethiazole is used with caution Discharge 11.1 Patients must not be discharged on chlordiazepoxide unless the crisis team or assertive outreach team is in daily contact The GP should be advised to prescribe:- 11

15 Thiamine 100mg TDS for as long as diet is inadequate or alcohol consumption is resumed The GP should be advised if a medication intervention (acamprosate, disulfiram or naltrexone) has been agreed with the patient The medical team must write to the GP and advise a period of time for which the medicines should be continued and disulfiram should be stopped if the patient starts consuming alcohol at any point in time). Further detailed information about these medicines can be found in the Summary Product Characteristics (SPC) accessed on For information and support following discharge from hospital, ensure that patients and relatives are signposted to local NHS services. First point of contact for substances in Camden is the Margarete Centre scds@candi.nhs.uk First point of contact for Alcohol in Camden is: Integrated Camden Alcohol Service (ICAS) for Alcohol camden.referrals@cgl.org.uk First point of contact for all substances in Islington is: IDASS Idass.referrals@nhs.net Information regarding all services available in both boroughs on the intranet here: Dissemination and implementation arrangements This policy will be circulated to all team members working in the Acute Service line. The policy will also be circulated to Acute Service Line staff. 13. Training requirements Implementation of this policy will be complemented by a training event for staff working in the Acute Service Line, 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 14. Monitoring and audit arrangements Regular audits will be conducted periodically to ensure that inpatient alcohol withdrawals are being conducted in line with the policy. The audit will aim to ensure that appropriate assessment (including blood tests) 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. 12

16 Element to be monitored See list of NHSLA minimum requirements if relevant Chlordiazepoxide prescribing is being done in line with the recommended procedures outlined in this policy (dosages based on SADQ and CIWA scores) Ensure that liver function test results are obtained prior to commencement of medically assisted withdrawal Lead Nursing and medical team Nursing and medical team in the Acute Service Line. How Trust will monitor compliance Carry out an audit of chlordiazepoxide prescribing. Carry out an audit of blood test results. 15. Review of the policy Frequency Annually Annually Reporting arrangemen ts Which committee or group will the monitoring report go to? Drugs and Therapeutics Committee Drugs and Therapeutics Committee Acting on recommendation s and Lead(s) Which committee or group will act on recommendations? Drugs and Therapeutics Committee / 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. The policy will be reviewed on or around January 2020 (two years from the date of production of this policy). 16. References 1. Camden and Islington NHS Foundation Trust. Guidelines for medically assisted community alcohol withdrawal. July NICE guidance (2017). Assisted alcohol withdrawal pathway. )(online). Available: Ewigjqn42_bYAhUkh6YKHSSABJkQFggnMAA&url=https%3A%2F%2Fpathways.nic e.org.uk%2fpathways%2falcohol-use-disorders%2fassisted-alcoholwithdrawal.pdf&usg=aovvaw1pcadpz30kk5frorh5niwy (accessed 26th January 2018). 3. Taylor D. Paton C., Kapur S. Editors. The South London and Maudsley NHS Foundation Trust. Oxleas NHS Foundation Trust. Prescribing Guidelines. 12 th Edition. Chichester. Wiley Blackwell G. Brathen at al. Alcohol - related seizures. European Handbook of Neurological Management: Volume 1, 2nd Edition 5. NICE guidance. Alcohol use disorders: sample chlordiazepoxide dosing regimens for use in managing alcohol withdrawal. February Western and Health and Social Care Trust. Management and Treatment Guidelines For Acute Alcohol Withdrawal Policy Cambridgeshire and Peterborough NHS Foundation Trust. Alcohol Detoxification (Inpatient) Prescribing Guidelines. August NICE. Alcohol-use disorders: diagnosis and management of physical complications. June 2010, updated )(online). Available: (accessed 26th January 2018). 9. BNF: Southern Health NHS Foundation Trust. Alcohol Withdrawal Guidelines. SH CP 197. Version 1. 13

17 11. Kyowa Kirn Ltd. The Specification of Product Characteristics: Pabrinex Intramuscular High Potency (December 2017)(online). Available: (accessed 26th January 2018). 12. NICE 192. Antenatal and postnatal mental health: clinical management and service guidance. December )(online). Available: ct=8&ved=0ahukewjw4sco3pbyahvbmywkhcvjducqfggymae&url=https%3a%2 F%2Fwww.nice.org.uk%2Fguidance%2Fcg192%2Fresources%2Fantenatal-and- postnatal-mental-health-clinical-management-and-service-guidance-pdf &usg=AOvVaw2xXK9ESuDE92ocxC5vBX86 (accessed 26th January 2018). 13. Ankur Sachdeva et al. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond, 14. Merck. The Specification of Product Characteristics: Campral EC (March 2015)(online). Available: (accessed 26th January 2018). 15. Bristol Myers Squibb Pharmaceutical Ltd. The specification of Product Characteristics. Nalorex (February 2014) (online). Available: (accessed 26th January 2018). 16. Guy s and St Thomas s NHS Foundation Trust. Clinical Guideline (1) The detection of alcohol misusers attending hospital 2. The management of alcohol withdrawal syndrome (AWS) 3. The management of Wernicke s Encephalopathy (WE). June Actavis UK Ltd. The Specification of Product Characteristics: Disulfiram (30 th December 2011)(online). Available: (accessed 26th January 2018). 17. Associated documents Camden and Islington NHS Foundation Trust. Guidelines for medically assisted community alcohol withdrawal. July Pabrinex Prescribing Protocol July

18 Trust Guidelines for Medically Assisted Inpatient Alcohol Withdrawal Appendix 1: 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. 12. The day after drinking alcohol, I had Not at all Slightly Moderately Quite a lot 15

19 Trust Guidelines for Medically Assisted Inpatient Alcohol Withdrawal 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 (Reproduced from the Trust Guidelines for Medically Assisted Community Alcohol Withdrawal). 16

20 Trust Guidelines for Medically Assisted Inpatient Alcohol Withdrawal APPENDIX 2 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 17

21 Trust Guidelines for Medically Assisted Inpatient 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 Scores Total CIWA-Ar Score </=10 mild withdrawal (does not need additional medication Rater's Initials </=15 moderate withdrawal Maximum Possible Score severe withdrawal (Reproduced from the Trust Guidelines for Medically Assisted Community Alcohol Withdrawal and the Maudsley Prescribing Guidelines). 18

22 Trust Guidelines for Medically Assisted Inpatient Alcohol Withdrawal Appendix 3: Alcohol units calculating units Type of drink ABV No. of units Pint of lager (568ml) regular 3.6% 2 Pint of lager (568ml) special brew 9% 5.1 Pint of ale (568ml) special brew 4.5% 2.6 Pint of ale (568ml) strong brew 8.5% 4.8 Pint of cider (568ml) regular 5% 2.8 Pint of cider (568ml) strong 7.5% 4.3 Single 25ml shot of spirits* 40% 1 Bottle of spirits (700ml) 40% 28 Alcopop (275ml) 5.5% 1.5 Large glass of wine (250ml) 12% 3 Small glass of wine (125ml) 12% 1.5 Bottle of wine 12% 9 *Gin, rum, vodka, whiskey, tequila, sambuca Appendix 4: Abbreviations SADQ (Severity of alcohol dependence questionnaire): a short-self-administered 20 item questionnaire designed by the WHO to measure severity of dependence on alcohol. BAC blood alcohol concentration CIWAS: Clinical Institute Withdrawal Assessment for Alcohol. 19