Prescribing for substance misuse: alcohol detoxification. Clinical background

Transcription

1 Prescribing for substance misuse: alcohol detoxification POMH-UK Quality Improvement Programme. Topic 14a: baseline Clinical background The Royal College of Psychiatrists. For further information please contact pomh-uk@rcpsych.ac.uk

2 Clinical background Alcohol use disorders span a wide spectrum of severity from hazardous and harmful drinking through to severe and complex alcohol dependence and place a considerable cost burden on the NHS. Alcohol is now the third leading cause of disability in Europe and is the leading preventable cause of morbidity and mortality in working age adults. Alcohol related hospital admissions in England have doubled to 1.2 million in the last 9 years. Alcohol dependence affects 4% of the adult population in England (6% of men and 2% of women), which represents approximately 1.6 million adults. Alcohol dependence leads on average to 25 years of life lost. Patients with alcohol dependence are often admitted to acute and mental health hospitals with alcohol related disorders as a primary or, more commonly, a secondary reason for admission. One study in South London found that 50% of mental health inpatients had an alcohol use disorder, and 24% were alcohol dependent, primarily those with depressive or personality disorders and this was accompanied by a considerably increased risk of suicidality. Such admissions present opportunities for intervention and treatment for alcohol dependence, and this means that all mental health staff need to be competent in diagnosis and management of alcohol withdrawal and alcohol related complications. Recent NICE guidelines set out a series of recommendation for best practice in diagnosis, assessment and management of harmful drinking and alcohol dependence and related complications (NICE, 2010; 2011a). Subsequently NICE quality standards set out a series of benchmarks against which current practice can be compared (NICE, 2011b). However, in spite of this guidance alcohol use disorders remain under-diagnosed in acute and mental health care leading to sub-optimal clinical management. Acute alcohol withdrawal, if untreated or sub-optimally managed, can be a life threatening condition with a risk of grand mal seizures, delirium tremens, and in extreme cases, preventable deaths. Also in the absence of adequate prophylaxis with thiamine, there is a risk of a rare but serious complication of Wernicke s encephalopathy, which can lead to permanent brain damage in the form of Korsakoff syndrome. Adequate management of alcohol withdrawal requires clinicians to be competent in diagnosis of alcohol dependence and the alcohol withdrawal syndrome, prescribing of medications, and monitoring of response to treatment. Once alcohol withdrawal has been completed, there is an opportunity to prevent relapse through advice and counselling, medication prescribing and referral to specialist alcohol services. The NICE guidelines set out evidence-based methods for clinical management during alcohol withdrawal and beyond. This national audit of the management of alcohol withdrawal for mental health inpatients examines all aspects of clinical assessment and management against NICE guidelines and quality standards. It is intended that this first national audit of alcohol withdrawal will provide a benchmark against which a national quality improvement programme can be developed. Further reading NICE (2010) Alcohol-Use Disorders: Diagnosis and Clinical Management of Alcohol- Related Physical Complications. Clinical Guideline 100. London: NICE. 2

3 NICE (2011a) Alcohol-Use Disorders: Diagnosis, assessment and Management of Harmful Drinking and Alcohol Dependence. Clinical Guideline 115. London: NICE. NICE (2011b) Alcohol Dependence and Harmful Alcohol Use Quality Standard. Quality Standard 11. London NICE. Schuckit, MA (2009) Alcohol-use disorders. Lancet, 373(9662),

4 Audit standards and treatment targets The audit standards shown below were derived from the NICE clinical guidelines on alcohol-use disorders (NICE CG100, 2010 and CG115, 2011). Clinical practice standards for the audit 1. The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission 2. Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission 3. Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG115, ) 4. Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012) 5. Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal These audit standards were agreed by expert advisors to POMH-UK, and have been primarily extrapolated from relevant recommendations in the NICE guidelines referenced above. In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers. Treatment targets 1. Breath alcohol should be measured as part of the initial assessment for alcohol detoxification (derived from NICE CG 115, recommendation ). 2. Following alcohol detoxification, initiation of relapse prevention medication should be considered (NICE CG 115, ). 3. After alcohol detoxification, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, and , and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3). Benchmarked data on Trust performance are presented for treatment target 1 as this directly relates to prescribing practice for alcohol detoxification. Data for treatment targets 2 and 3 are only presented at national level. 4

5 Method The Prescribing Observatory for Mental Health (POMH-UK) invited all National Health Service (NHS) Trusts and other healthcare organisations (hereafter referred as Trusts) in the United Kingdom providing specialist mental health services to participate in a baseline audit as part of a QIP on prescribing for alcohol detoxification. All Trusts and clinical teams were self-selected in that they chose to participate. All participating Trusts are listed in alphabetical order in Error! Reference source not found.. Subjects and settings Each Trust was invited to include as many clinical teams as they wished. Each participating team was asked to collect data from the clinical records of patients on their case load who had been admitted to an adult psychiatric ward for alcohol detoxification in the past year from the time of data collection (March 2014). Data collection A copy of the data collection form can be found in Error! Reference source not found. Submission of data Each Trust was allocated an identifying (code) number that was known only to the Trust and POMH-UK. Trusts were asked to allocate codes to participating services and eligible patients and, if they wished, individual consultants. The key to these codes is held by the Trust and is not known to POMH-UK. Data coded in this way were entered onto an internet-based form and submitted to POMH-UK via a secure website. Data cleaning Data were cleaned to correct instances of obvious data entry error. Details of corrections are held on file by POMH-UK; please contact pomh-uk@rcpsych.ac.uk if you wish to examine these. Data analysis The data were analysed and results presented at three levels, as described on the previous page. Data were collected, stored and analysed using SNAP (electronic survey software) and IBM SPSS statistics. All figures presented are rounded to zero decimal places for clarity of presentation. Therefore, the total percentages for some charts or graphs may not add up to 100%. The abbreviation TNS on some charts refers to the combined data set of the total national sample. The local POMH-UK lead for each participating Trust has been sent an Excel dataset containing their Trust s data. This allows Trusts to conduct further analyses on their own data should they wish. 5

6 References Lingford-Hughes, Anne R., et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Psychopharmacology 26.7 (2012): National Institute for Health and Clinical Excellence. Alcohol dependence and harmful alcohol use quality standard. NICE quality standards QS11, Quality statement 3: Referral to specialist alcohol services. National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115, National Institute for Health and Clinical Excellence. Diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100, Saunders, J.B., Aasland, O.G., Babor, T.F., de la Fuente, J.R. & Grant, M. (1993). Development of the Alcohol Use Disorders Screening Test (AUDIT). WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Addiction 88, Stockwell, T., Murphy, D. & Hodgson, R. (1983). The severity of alcohol dependence questionnaire: Its use, reliability and validity. British Journal of Addiction, 78(2), Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84: ,