Acute Alcohol Withdrawal Protocol Controlled document This document is uncontrolled when downloaded or printed Reference number Version 1 Author WHHT: C268 Dr Mohamed Shariff Date ratified August 2014 Committee/individual responsible Issue date August 2014 Review date August 2017 Target audience Key Words Previous Policy Name Gastroenterology Department Doctors and nurses of acute medical and surgical wards Alcohol, detoxification, detox, withdrawal, Chlordiazepoxide. N/A 1
Contribution List Key individuals involved in developing this version of the document Name Dr Mohamed Shariff Hayley Brookes Designation Consultant Gastroenterologist and Hepatologist, West Herts Hospitals NHS Trust Hospital Liaison Coordinator, Hertfordshire Drug and Alcohol Services, Spectrum Approved by Committee August 2014 (Gastroenterology Department Business meeting + awaiting Clinical Governance vember 2014) Change History Version Date Author Reason 2
CONTENTS Acute Alcohol Withdrawal Protocol... 1 Contribution List... 2 Introduction and Aim... 4 Withdrawal assessment and protocol... 5 Chlordiazepoxide prescribing regimen based on SADQ score and alcohol intake... 6 Severity of Alcohol Dependence Questionnaire (SADQ)... 7 CIWA-Ar Score Sheet... 8 References... 9 Equality Impact Assessment... 10 Policy and Procedure Sign-off Sheet... 11 Policy Ratification Form... 13 3
Introduction and Aim In the UK, it is estimated that 24% of adults drink in a hazardous or harmful way that may put them at risk of acute alcohol withdrawal, seizures or delirium tremens 1. Successful detoxification will reduce the risk of these complications, although prescription regimens are highly variable and do not always take into account the severity of alcohol withdrawal. Based on NICE guidance, these protocol guidelines were written 1. Patients with acute alcohol withdrawal of patients at risk of developing alcohol withdrawal seizures or delirium tremens, should be offered admission to hospital for medically assisted alcohol withdrawal 1. Withdrawal severity scoring tools, such as the Severity of Alcohol Dependence Questionnaire (SADQ) and Clinical Institute Withdrawal Assessment Alcohol revised (CIWA-Ar) score should be used to gauge the severity of withdrawal and treatment should be individualised 1,2,3. This allows an objective measure of severity of alcohol withdrawal to be recorded and an appropriate regimen prescribed. In the UK, benzodiazepines are the most commonly used medications for acute alcohol withdrawal. Chlordiezopoxide and diazepam have UK marketing authorisation for this indication 1. The recommended dose of chlordiazopoxide for acute alcohol withdrawal in moderate to severe dependence should be 10 to 50mg in four daily doses 4. The protocol herein reflects this. 4
Withdrawal assessment and protocol 1. Individualise the alcohol withdrawal regimen to the patient. 2. The SADQ should be used FIRST to determine the appropriate withdrawal regimen (see below). 3. With all scheduled regimens, as required chlordiazepoxide 10-20mg must be prescribed and administered as per clinical need. 4. Ensure that Pabrinex is prescribed and administered. One pair of Pabrinex IVHP ampoules IV TDS for at least 1 day for known or suspected chronic alcohol misuser. Two pairs of Pabrinex IVHP ampoules IV TDS for 3-7 days for patients displaying symptoms of Wernicke s Encephalopathy (WE). If Pabrinex is not available/cannot be administered, prescribe Thiamine 100mg TDS PO and Vitamin B compound strong 2 tablets TDS. 5. Review the drug chart and ensure that no other additional benzodiazepines are prescribed. 6. The modified CIWA-Ar score sheet should then be used twice daily (by nurses or doctors on ward rounds) to assess whether further as required chlordiazepoxide is required. 7. If, on day 5, the patient is still requiring as required doses of chlordiazepoxide, their regimen should be reviewed. 8. If the patient becomes drowsy then medical assistance should be requested and no further doses of chlordiazepoxide be given. 9. Please refer patient to the Substance Misuse Liaison Team at the earliest opportunity by calling 07881 335298 or 07881 335242. 5
Chlordiazepoxide prescribing regimen based on SADQ score and alcohol intake SADQ 10 SADQ 10-20 SADQ 20-30 SADQ >40 Alcohol units per day 10 units 10-20 units 20-30 units >40 units Day 1 10-20mg prn 20mg qds 30mg qds 40mg qds (chlordiazepoxide) Day 2 10-20mg prn 15mg qds 20mg qds 30mg qds Day 3 10-20mg prn 10mg qds 15mg qds 20mg qds Day 4-10mg bd 10mg qds 15mg qds Day 5 - Stop 10mg bd 10mg qds Day 6 - - Stop 10mg bd Day 7 - - - Stop + Chlordiazepoxide 10-20mg prn + Chlordiazepoxide 10-20mg prn 6
Patient Name: Ward: Hospital number NHS Number: Score 0 Date of birth: 1 2 3 Almost Never Sometimes Often Nearly Always 1) I wake up feeling sweaty. 2) My hands shake first thing in the morning. 3) My whole body shakes violently first thing in the morning if I don t have a drink. 4) I wake up absolutely drenched in sweat. 5) I dread waking up in the morning. 6) I am frightened of meeting people first thing in the morning. 7) I feel on the edge of despair when I wake up. 8) I feel very frightened when I wake up. 9) I like to have a morning drink. 10) I always gulp down my morning drink as quickly as possible. 11) I drink in the morning to get rid of the shakes. 12) I have a very strong craving for a drink when I wake up. 13) I drink more than ¼ bottle of spirits or 4 pints of beer /1 bottle of wine per day. 14) I drink more than ½ bottle of spirits or 8 pints of beer /2 bottles of wine per day. 15) I drink more than 1 bottle of spirits or 15 pints of beer /4 bottles of wine per day. 16) I drink more than 2 bottle of spirits or 30 pints of beer /8 bottles of wine per day. Severity of Alcohol Dependence Questionnaire (SADQ) You have been completely off drink for a few weeks and then drink very heavily for two 0 days. How would you feel the morning after those two days of drinking?*: t at all 17) I would start to sweat. 18) My hands would shake. 19) My body would shake. 20) I would be craving a drink. *If the patient has not been abstinent for a period of two weeks then score maximum for Q17-20. 1 Slightly 2 Moderately 3 A lot TOTAL SADQ SCORE= (Score 0-3= no dependence, 4-19= mild dependence, 20-30= moderate dependence, 31-44= severe dependence, 45+ = very severe dependence). 7
Patient Name: CIWA-Ar Score Sheet (Adapted from Sullivan et al, 1989) Hospital number NHS Number: 1. Perform twice daily to establish whether patient is receiving enough Chlordiazepoxide. Date of birth: 2. If patient appears over-sedated, call patient s team to assess if within working hours, Ward: Or, on call team if outside of working hours. Do not administer further Chlordiazepoxide before assessment. Is the patient A)Anxious B)Restless C)Aggressive Is the patient A)Shaky B)Sweating Is the patient experiencing hallucinations A)Auditory B)Visual Does the patient A)Feel sick B)Vomit Has the patient been sleeping well Time 10:00 18:00 10:00 18:00 10:00 18:00 10:00 18:00 10:00 18:00 Nursing/Doctor action taken Sign and Date Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 8
References 1. Alcohol-use Disorders: Diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100, June 2010. 2. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar).Br J Addict. 1989 v;84(11):1353-7. 3. Stockwell T, Hodgson R, Edwards G, Taylor C, Rankin H. The development of a questionnaire to measure severity of alcohol dependence. Br J Addict Alcohol Other Drugs. 1979 Mar;74(1):79-87. 4. British National Formulary, Edition 67, March 2014. 9
Equality Impact Assessment 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 N/A 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? N/A 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 10
Policy and Procedure Sign-off Sheet Policy Name and Number: Version Number and Date: : Service Location: PLEASE INSERT SERVICE LOCATION All staff members must sign to confirm they have read and understood this policy. Name Signature Name Signature 11
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Policy Ratification Form Name of Document: Alcohol Withdrawal Policy Ratification Date: Name of Persons Job Title Date Divisional Support (Direct Line Manager / Matron / Consultant / Divisional Manager) Consultation Process (list of stakeholders consulted / staff groups presented to) Endorsement By Panel/Group Name of Committee Chair of Committee Date Document Checklist Yes / 1. Style & Format Is the title clear and unambiguous? Is the font in Arial? Is the format for the front sheet as per Appendix 1 of the policy framework Has the Trust Logo been added to the Front sheet of the policy? Is it clear whether the document is a guideline, policy, protocol or standard operating procedure? 2. Rationale Are reasons for development of the document stated? 3. Content Is there an introduction? Is the objective of the document clear? Does the policy describe how it will be implemented? Are the statements clear and unambiguous? Are definitions included? Are the responsibilities of individuals outlined? 4. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are supporting documents referenced? 13
Document Checklist 5. Approval Does the document identify which committee/group will approve it? 6. Review Date Is the review date identified? Is the frequency of review identified? If so is it acceptable? 7. Process to Monitor Compliance and Effectiveness Are there measurable standards or Key Performance Indicators to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? Yes / Standard Equality Impact Assessment Tool Persons likely to be affected by policy change / Staff implementation Are there concerns that the proposed documentation / change could have an adverse impact on: Race. Ethnicity, National Origin, Culture, Heritage Religion, Faith, Philosophical Belief Gender, Marital Status, Pregnancy Physical or Learning Disabilities Mental Health Sexual Orientation / Gender Reassignment Age Homelessness, Gypsy / Travellers, Refugees / Asylum Seekers Please give details of any adverse impact identified: If adverse impacts are identified, are these considered justifiable? (Please give reasoning) There is unlikely to be an adverse impact on different minority groups Name of Person completing Ratification Form Job Title Date Ratification Group/Committee Chair Signature Date 14