Alcohol Issues in the Acute General Hospital Setting

Alcohol Issues in the Acute General Hospital Setting (Guidelines and Management) This procedural document supersedes: PAT/T 25 version 2 - Guidelines for the Management of Alcohol Issues in the Acute General Hospital Setting Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours. Author/reviewer: (this version) Date written/revised: April 2014 Approved by: Date of approval: 22 October 2014 Date issued: 29 October 2014 Next review date: April 2017 Target audience: Shane Peagram Drug & Alcohol Liaison Nurse Specialist Policy Approval and Compliance Group Trust-wide Page 1 of 41

Amendment Form Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same. Version Date Issued Brief Summary of Changes Author Version 3 29 October 2014 Revised layout to all sections to make the policy more user friendly. S Peagram Section 8 now includes a greater choice of drug regimens in keeping with NICE guidance. Section 9 clear guidance on discharge arrangements for patients undergoing detox across a wide range of scenarios. Version 2 January 2010 Section 1 - Background information updated to include current national, regional and local strategies Section 2 - Reference made to the new Trust alcohol screening and care pathway [Appendix 1 and 2] Section 4 - Throughout the general management there are various aspects of treatment and prescribing amendments as advised by Lee Wilson - Consultant Pharmacist. Included in this edition are notes regarding rapid tranquillisation; [supported by Shane Peagram Drug & Alcohol Liaison Nurse Specialist DR1] also added is Nutritional Management of Alcoholic Liver Disease [submitted by Vera Todorovic - Consultant Dietitian] Revised reference Revised Appendices V Wood Version 1 June 2006 New Document V Wood Page 2 of 41

Contents Section 1 INTRODUCTION 6 2 PURPOSE 6 3 DUTIES and RESPONSIBILITIES 6 3.1 Working with people who misuse alcohol 6 3.2 Doctors Responsibilities 7 3.3 Prescribers Responsibilities 7 3.4 DANS Responsibilities 7 3.5 Nurses Responsibilities 7 3.6 Patient Responsibilities 7 4 BACKGROUND 8 4.1 Current Advised Drinking Limits 8 4.2 Risk of Harm from Excess Alcohol 8 4.3 Binge Drinking 9 4.4 Dependent Drinking 9 5 SCREENING 10 5.1 FAST 10 5.2 A&E screening 10 5.3 Combined Risk Assessment Screening 11 5.4 Specialist Screening 11 6 ASSESSMENT 13 6.1 General Principles 13 6.2 Triage Assessment 13 6.3 Comprehensive Assessment 13 6.4 Examination 14 6.5 Investigations 14 Page No. 6.6 Observations 15 Page 3 of 41

Section PAT/T 25 v.3 7 ALCOHOL WITHDRAWAL SYNDROME 16 7.1 Set 1: Uncomplicated Withdrawal 16 7.2 Set 2: Hallucinations 16 7.3 Set 3: Seizures 17 7.4 Set 4: Delirium Tremens 17 7.5 Risk Factors for complex withdrawal 17 7.6 Protracted withdrawal 18 8 DETOXIFICATION REGIMENS 18 8.1 Low dose fixed regimen Moderate Dependency 19 8.2 High dose fixed regimen Severe Dependency 19 8.3 Very high dose fixed regimen Very Severe Dependency 20 8.4 Symptom triggered regimen 20 8.5 JAC Electronic prescribing 21 8.6 Delirium Tremens 21 8.7 Hallucination 22 8.8 Seizure 23 8.9 Liver Disease 23 8.10 Nursing Management 24 9 DISCHARGE PLANNING 25 9.1 Self discharge 25 9.2 Non compliance 25 9.3 Declines detox 26 9.4 Detox completed Medically Fit 26 9.5 Incomplete Detox Medically Fit 26 9.6 Maximum take home doses 27 10 WERNICKE S ENCEPHALOPATHY 28 10.1 Background 28 10.2 Diagnosis 28 Page No. 10.3 Treatment 29 Page 4 of 41

Section PAT/T 25 v.3 11 TRAINING/SUPPORT 30 12 MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT 30 13 DEFINITIONS 30 14 EQUALITY IMPACT ASSESSMENT 31 15 ASSOCIATED TRUST PROCEDURAL DOCUMENTS 31 16 REFERENCES 31 Page No. Appendices: Appendix 1 COMBINED RISK SCREENING AND ASSESSMENT DOCUMENT (FAST) 33 Appendix 2 CIWA-AR 35 Appendix 3 AUDIT 36 Appendix 4 SADQ 37 Appendix 5 FAST ED 38 Appendix 6 EQUALITY IMPACT ASSESSMENT SCREENING FORM 41 Page 5 of 41

1. INTRODUCTION These guidelines are intended for both medical and nursing staff, to act as a resource in the screening of patients to identify risk of harm from alcohol AND the treatment of alcohol dependency through medically managed withdrawal. The main source of evidence used within these guidelines is taken from NICE (2010) CG100 Alcohol Use Disorders Diagnosis and clinical management of alcohol related physical complications. NICE (2011) CG115 Alcohol Use Disorders Diagnosis, assessment and management of harmful drinking and alcohol dependence. And should be read in conjunction with NICE (2010) PHG24 Alcohol Use Disorders preventing the development of hazardous and harmful drinking. 2. PURPOSE The purpose of these guidelines is to offer a comprehensive structure to our approach to alcohol within the context of the Government s Alcohol Strategy s aims of: Ensuring everyone is aware of the risks of excessive alcohol consumption and can make informed choices about responsible drinking. Recognising that some people will need support to change their behaviour and ensuring that this is available, particularly for the most vulnerable in our communities. This strategy signals a radical change in the approach and seeks to turn the tide against irresponsible drinking. Such change will not be achieved overnight. HMSO (2012). 3. DUTIES AND RESPONSIBILITIES 3.1 Working with people who misuse alcohol Build a trusting relationship and work in a supportive, empathic and non-judgemental manner. Take into account that stigma and discrimination are often associated with alcohol misuse and that those presenting to services may minimise their alcohol problem. Hold discussions in settings in which confidentiality, privacy and dignity are respected. Provide information appropriate to the individual s level of understanding about the nature and treatment of alcohol misuse to support their choice from a range of evidence based treatments. Make sure that comprehensive written information is available in an appropriate language or in an accessible format. Avoid clinical language without explanation. Provide independent interpreters if needed. Page 6 of 41

3.2 Doctors responsibilities The Doctor responsible for the patient will ensure a triage assessment [Sec 6.2], of alcohol intake including the risk of alcohol withdrawal syndrome and Wernicke s encephalopathy [Sec 10], is undertaken upon admission to hospital and where necessary immediate treatment initiated. [Sec 8] A risk assessment is also required as part of discharge planning. [Sec 9] 3.3 Prescribers responsibilities The prescriber will ensure a triage assessment [Sec 6.2] of alcohol intake, including the risk of alcohol withdrawal syndrome and Wernicke s encephalopathy [Sec 10], is undertaken prior to prescribing. In the case of non medical prescribers, prescribing will only take place where the prescriber is feels competent to do so. [Sec 8] Prescribers must ensure an adequate risk assessment is carried out as part of discharge planning process. [Sec 9] 3.4 DANS responsibilities The Drug and Alcohol Liaison Nurse Specialist (DANS) will ensure a comprehensive assessment of alcohol intake [Sec 6.3] including risk of dependence, severity of dependence, risk of Wernicke s encephalopathy [Sec 10], social support networks, motivation to change and safe discharge plan are undertaken. [Sec 9] 3.5 Nurses responsibilities The nursing staff is responsible for screening patients for risk of harm from alcohol intake as part of the Combined Risk Screening and Assessment Document for all inpatients. [APPENDIX 1] For patients requiring detoxification nursing staff are expected to complete the required physical observations at the frequency dictated by the clinical assessment tool CIWA-AR [APPENDIX 2]. 3.6 Patients responsibilities The patient is expected to engage with the screening and assessment process providing a true and honest account of their alcohol intake in order to ensure safe and appropriate treatment. For patients requiring detoxification there is an expectation that they remain drug and alcohol free throughout in order to ensure safe treatment. Page 7 of 41

Where there is reason to believe patients are non compliant with the detoxification and the patient is medically fit and has capacity the patient will be discharged without take home medication. 4. BACKGROUND The risk of harm from alcohol increases the more you drink, AND the more often you drink. By helping people to understand the risk of harm associated with their alcohol intake we enable them to make better informed lifestyle choices. 4.1 Current Advised Drinking Limits Daily units Weekly units Days Off per week Men 3 4 21 2 Women 2 3 14 2 Adults are advised not to exceed daily drinking limits on any given day and not to exceed weekly totals. In order to reduce the risk of harm from alcohol further they are advised to have a minimum of 2 (non consecutive) alcohol free days per week. 4.2 Risk of Harm from Excess Alcohol The level of risk is linked to the total alcohol intake and can be assessed by calculating the total number of units of alcohol consumed per week. In the UK 1 unit alcohol = 8g (10mls) Ethanol. Total units = vol mls / 1000 x ABV % Risk Level Men Women Common effects Low Risk (Sensible) (Safe) <21 units / week <14 units / week Increased relaxation Reduced risk heart disease Sociability Increasing Risk (Hazardous) Higher Risk (Harmful) 22-49 units / week 15-35 units / week Less energy Depression / stress Insomnia Risk of injury High blood pressure 50+ units / week 36+ units / week All of the above and Memory loss Liver disease Cancer Alcohol dependence Avoid terms such as Social, Heavy or Excessive to describe alcohol intake Page 8 of 41

Alcohol Dependency or Alcohol Dependent are preferred to Alcoholic, known alcoholic or Addict. Screening tools such as AUDIT [APPENDIX 3], FAST [APPENDIX 1] and SADQ [APPENDIX 4] are useful to aid the assessment process. [Sec 6] 4.3 Binge Drinking A person is said to be Binge Drinking when they have consumed more than twice the guidance amounts in any one session. E.g. Women - 6 units / day Men 8 units / day Binge drinking is essentially drinking too much alcohol over a short period of time and it typically leads to drunkenness. It has immediate and short-term risks to the drinker and to those around them. People who become drunk are much more likely to be involved in an accident or assault, be charged with a criminal offence, contract a sexually transmitted disease and, for women, are more likely to have an unplanned pregnancy. Regular and repeated Binge drinking is associated with an increased Risk of Harm from alcohol. Binge drinkers may also be at risk of dependency, where the binge episodes extend for periods of several days OR weeks. 4.4 Dependent Drinking In England, 4% of people between 16 and 65 are dependent on alcohol (6% men 2% women) Alcohol Dependence: characterised by craving, tolerance, a preoccupation with alcohol in spite of harmful consequences, physical withdrawal syndrome. While most patients who experience alcohol dependency are aware of their condition and will inform medical staff others might not be or are in denial. The use of assessment tools such as the SADQ can aid diagnosis and highlight risk of complication. [APPENDIX 4] Mild alcohol dependence: a score of 15 or less on SADQ. Moderate alcohol dependence: a score of 15 30 on SADQ. Severe alcohol dependence: a score of 30 40 on SADQ. Very severe alcohol dependence: a score of 40-60 on SADQ Page 9 of 41

5. SCREENING Screening is a systematic process of identifying people whose alcohol consumption places them at increased risk of physical, psychological or social problems and who would benefit from a preventative intervention. Questionnaire based screening is accurate, minimally intrusive and has been found to be acceptable to recipients. (Wallace 2001) While screening will inevitably highlight people who are physically dependent on alcohol these patients are not the reason why we screen. Screening aims to identify the non dependent drinkers whose current lifestyle of frequent exposure to alcohol significantly increases their risk of chronic illness i.e. heart disease, liver disease and cancer. For this reason NICE PHG 24 2010 requires that ; All NHS professionals should routinely carry out screening as an integral part of practice 5.1 FAST NICE recommends the use of a validated alcohol questionnaire such as AUDIT, FAST or PAT. Across the Trust the FAST [APPENDIX 1] has been chosen, as the preferred tool for screening as it is: Reliable identifies 930 per thousand Quick as little as 12 seconds Terminated after one question for 60% patients Cost effective - 1669 per 50,000 screens by an E Grade equivalent nurse Acceptable to patients 77% would take literature, 46% would welcome further discussion. Already in use as part of Combined Risk Assessment (AERC Alcohol Education Research council) The FAST is for use within the Accident & Emergency Department [APPENDIX 5] and is included within the Combined Risk Screening and Assessment Document for all inpatients. [APPENDIX 1] 5.2 A&E Screening The FAST [APPENDIX 5] has been adapted for use in the Emergency Department where it is used as a targeted assessment tool for patients presenting with one or more of the top ten conditions linked to increased alcohol intake. Patients who test positive are given feedback about their level of risk of harm from their lifestyle and offered supporting literature and / or a referral to specialist community alcohol services. Where patients present to A&E with a condition not included in the top ten screening is not required. Page 10 of 41

5.3 Combined Risk Assessment Screening All inpatients are required to have a Combined Risk Screening and Assessment completed within 24hrs of admission to a ward (WPR 23084), contained within this is an Alcohol Screening with FAST. [APPENDIX 1] Patients who test positive for risk of harm from alcohol using FAST are offered the opportunity to see a specialist alcohol health worker. 5.4 Specialist Screening Where a patient has screened positive for FAST and is referred to the Drug and Alcohol Specialist Nurse (DANS) an initial triage assessment will take place [sec 6.2] and where the patients condition allows it a comprehensive alcohol assessment will be undertaken [sec 6.3] Included within the DANS comprehensive assessment is the use the AUDIT Screening Tool [APPENDIX 3] to identify the patients Risk of Dependency. An AUDIT score of >20 indicates possible dependence and an additional SADQ Screening [APPENDIX 4] to establish Severity of Dependence is required. The results of the AUDIT and SADQ combined with the detailed alcohol history will guide the clinicians in deciding which if any detox regimen is required. [sec 8] Page 11 of 41

Page 12 of 41 PAT/T 25 v.3

6. ASSESSMENT 6.1 General Principles On admission to an acute hospital patients may be unwell with an array of complex and pressing physical health problems. These problems can be exacerbated by the onset of physical withdrawal from alcohol. It is therefore necessary to include an alcohol risk assessment (triage assessment) as early as possible in the patient admission process. The extent of the assessment should be sufficient to identify immediate risks without impeding the broader patient assessment. 6.2 Triage Assessment A triage assessment must be completed during medical clerking or on testing FAST Positive [5.1] during the completion of the nursing Combined Risk Screening and Assessment [APPENDIX 1]. The triage assessment should consider Pattern and severity of alcohol misuse and severity of dependence. The need for urgent treatment including assisted withdrawal Any associated risks to self or others The presence of any co-morbidity or other factors that may need further specialist assessments or intervention. The Triage assessment agrees the initial plan, taking into account the service user s preferences and outcomes of any previous treatments. [NTA, 2005] 6.3 Comprehensive Assessment A comprehensive assessment should assess multiple areas of need, be structured in a clinical interview, use relevant and validated clinical tools, and cover the following areas: alcohol consumption, dependence and alcohol-related problems co-existing health conditions, including co-existing drug and mental health problems cognitive functioning risk of harm to self and others urgency for treatment motivation and readiness to change socio-demographic data family relationships, social functioning The Drug and Alcohol nurse specialist will undertake the comprehensive assessment. Any child protection issues that might arise during the assessment must be address following the appropriate local Area Child Protect Committee guidelines. Page 13 of 41

6.4 Examination Patients who misuse alcohol may appear to be sober and unexceptional upon attendance. They might not yet display signs of withdrawal [Sec 7] or may have symptoms overlooked during an incurrent illness, [DTB, 1991]. There are number of specific physical signs when present are highly suggestive of liver disease as a result of alcohol abuse and should be specifically sought and recorded if this diagnosis is being considered. : Spider naevi Telangiectasia Facial mooning Parotid enlargement Palmer erythema Dupuytren s contracture Gynaecomastia 6.5 Investigations Patients who present acutely with decompensated liver disease, and who drink alcohol at a potentially harmful level, should not be assumed to have alcohol-related liver disease. A full assessment to exclude all other potential causes of liver disease should be performed as soon as possible after admission to hospital. Consent must be obtained prior to further investigation. Laboratory Investigations Haemoglobin Urea & Electrolytes, Creatinine Liver function tests, GGT Glucose Magnesium levels Assessment of liver disease Non invasive Liver Screen Abdominal ultrasound TABLE 1 - LABORATORY MARKERS THAT INDICATE ALCOHOL EXCESS [RCP, 2001] Blood and breath alcohol A raised blood or breath alcohol is firm evidence of recent alcohol consumption. However alcohol is metabolised rapidly and absence of alcohol indicates only that alcohol has not been consumed in the past few hours. Erythrocyte Mean Corpuscular Volume [MCV] MCV is raised in many chronic heavy drinkers but may also be raised for other reasons. Gamma glutamyl trasferase [GGT] GGT is a liver enzyme raised in a high proportion of chronic heavy drinkers but returns to normal levels after about 5 week s abstinence. It may also be raised in non-alcoholic liver disease an in patients taking enzyme-inducing drugs. Page 14 of 41

Aspartate amino transferase [AST] The liver enzyme AST is raise after heavy binge drinking but returns to normal within 48 hours. It may also be raised for other reasons. Carbohydrate deficient transferrin [CDT] CDT is raised in some heavy drinkers. It is more specific than AST,GGT, or MCV [Stribler, 1991] Conclusion Whilst laboratory markers may provide corroboratory evidence of hazardous drinking in patients where this is suspected, none are sensitive or specific enough to be used in isolation, nor can they distinguish hazardous drinkers from alcohol-dependant patients. The results need to be supported by an assessment of the patient s alcohol history. 6.6 Nursing Observations In the general hospital, setting alcohol withdrawal is usually accompanied by a serious acute illness, signs and symptoms may not be obvious, assessment may be difficult, and yet the consequences of inadequate or excessive treatment are likely to be much more serious. Repeated nursing observations using valid assessment tools are invaluable in identifying subtle changes in the patient s condition, allowing earlier intervention and management. CIWA-Ar An adaptation of the Addiction Research Foundation Clinical Institute s Withdrawal Assessment for Alcohol, Revised [CIWA-Ar] tool has been formatted for use in acute hospital settings. [APPENDIX 2] The CIWA-Ar tool must be initiated for all patients where alcohol withdrawal is present or suspected. The CIWA-Ar is repeated 4hrly initially and the subsequent frequency is dictated by the total score. Less than 10 repeat 4 hourly for 24 hrs More than 10 repeat 2 hourly More than 15 repeat 1 hourly STOP once score less than 10 for 24hrs At each assessment interval there is an opportunity to give additional medication in response to developing symptoms. The CIWA-Ar score can be used to determine when to initiate treatment for patients where alcohol abuse is suspected but not established. Page 15 of 41

Score 15 or more on two occasions Score 20 or more on one occasion. 7. ALCOHOL WITHDRAWAL SYNDROME Alcohol withdrawal syndrome occurs when people who are physically dependent upon alcohol stop drinking or rapidly reduce their alcohol consumption. Not all drinkers will experience withdrawal and those that do will present with a wide range of symptoms described across 4 sets [Hall, 1997, Rubino, 1992, Turner, 1989] AUDIT score of 20+ indicates possible dependency [APPENDIX 3] SADQ scores indicate the severity of that Dependency [APPENDIX 4] 15 25 Units / day 30 49 units / day 50 60 units / day SADQ 15 25 SADQ 30 40 SADQ 40 60 Moderate Dependency Severe Dependency Very Severe Dependency 7.1 Set 1: Uncomplicated Withdrawal Occurring within hours [typically 6-8 hours] of last drink and may develop before the blood alcohol level has fallen to zero. Peaking at 10-30 hours Subsiding by 40 to 50 hours [Adinoff 1988, DTB,1991, Hall,1997, Morgan, 1998] Characteristic tremor, starting in the hands but progressing to the head and trunk as severity worsens. Anxiety, restlessness, irritability, depression, insomnia and tiredness Anorexia, nausea, and weakness. Confusion Signs and symptoms of autonomic arousal Sweating Tachycardia [100+bpm] Raised BP Fever [37-38 C] Hyperreflexia 7.2 Set 2: Hallucinosis Onset in the majority of cases is within 24 hours of last drink Stopping within another 24-48 hours [Turner,1998] Both auditory [frequently accusatory or derogatory voices] and visual [bugs crawling on the bed, for example] hallucinations occur in otherwise clear sensorium. This is unlike delirium tremens where sensorium is diffused and impaired. [Chick, 2000, Rubino,1992, Turner, 1998] Page 16 of 41

7.3 Set 3: Seizures Can occur at 6 to 48 hours of alcohol cessation are more likely if there is a previous history of withdrawal fits or epilepsy. Rare beyond 48 hours following cessation. [Morgan, 1998] They are characterised by major motor seizures that occur during withdrawal in patient who normally have no seizures and have normal EEGs. Fits tend to be single, generalised (if focal, suspect head injury) and may occur in bouts. 30% of cases are followed by DTs. 7.4 Set 4: Delirium Tremens Onset of DTs is 2 to 5 days [most commonly at 2 to 3 days] following cessation and represents a medical emergency. [Adinoff,1988, Erwin, 1998, CRAG 1994, Morgan, 1998, Rubino,1992] Delirium tremens is the most severe manifestation of alcohol withdrawal. DTs occur in only about 5% of patients undergoing alcohol withdrawal but account for the highest morbidity and mortality. DT s usually occur in heavy drinkers who have minimised their consumption or withdrawn unexpectedly, been inadequately treated during withdrawal. Patients consuming more than 16 units per day (½ to a bottle of spirits per day or equivalent) are particularly at risk. In addition to the classical symptoms of withdrawal the characteristic symptoms of DT s are: Agitation, apprehension, confusion, disorientation in time and place, visual and auditory hallucinations, insomnia, nausea, vomiting, motor inco-ordination and paranoid ideation may be present. Fever is common. Poor concentration, intermittent disorientation and agitation may continue for 1-2 weeks before recovery. 7.5 Risk Factors for Complex Withdrawal There is a risk of progression to severe / complex withdrawal and delirium tremens when the patient with mild symptoms also have associated risk factors [DBT, 1991, CRAG, 1994, RCP, 2001] Concomitant use of other psychotropic drugs, high levels of anxiety, other psychiatric disorders. Page 17 of 41

Poor physical health, hypoglycaemia, hypokalaemia [with respiratory alkalosis, hypocalcaemia] Fever, sweating, insomnia, tachycardia Poor nutritional state 7.6 Protracted Withdrawal Although not an official diagnosis protracted withdrawal has been noted in many alcohol dependant patients. This disorder is characterised by irritability, emotional liability, insomnia and anxiety that persist for weeks to months after alcohol withdrawal. It is due to the residual effects of alcohol on the central nervous system and generally clears spontaneously after prolonged abstinence. [Armstong, 2002] 8. DETOXIFICATION REGIMENS Withdrawal from alcohol can develop 6-8 hours following cessation of drinking or upon significant dose reduction in active drinkers resulting in autonomic arousal. In order to safely manage the autonomic arousal associated with acute alcohol withdrawal treatment with an appropriate Benzodiazepine is required. The mainstay of treatment is Chlordiazepoxide. It is slowly absorbed, has a long half-life and low potency. Adequate and timely dosing with Chlordiazepoxide usually prevents complications such as withdrawal seizures. The choice of detox regime should be based on the patients reported level of alcohol consumption and severity of dependence. Clinical tools such as AUDIT, SADQ and CIWA-AR inform the decision making process. Nutritional support with parenteral Pabrinex 2 x pairs TDS is also required to prevent Wernickes Encephalopathy. The patients Liver Function and Renal output need to be taken into account to avoid potential over sedation through accumulation. Patients with grossly deranged Liver Function Tests / Decompensation should receive treatment with Lorazepam at equivalent dosage [sec 8.9]. Page 18 of 41

8.1 Low Dose Fixed Regimen - Moderate Dependency NOT SUITABLE FOR PATIENTS WITH ACUTE HEPATIC IMPAIRMENT or DECOMPENSATED ALCOHOL RELATED LIVER DISEASE see [sec8.9]. For individuals displaying or reporting the need to relief drink to prevent physical withdrawal from alcohol who drink 15 20 units / day or SADQ 15-25 daily OR who are frail. Day 1 Chlordiazepoxide 20mg QDS Pabrinex 2 x pair TDS Day 2 Chlordiazepoxide 20mg QDS Pabrinex 2 x pair TDS Day 3 Chlordiazepoxide 15mg QDS Pabrinex 2 x pair TDS Day 4 Chlordiazepoxide 10mg QDS Pabrinex 1 x pair OD* Day 5 Chlordiazepoxide 10mg BD Pabrinex 1 x pair OD* Day 6 Chlordiazepoxide 10mg OD Pabrinex 1 x pair OD* PRN Chlordiazepoxide 20mg Nursing staff able to administer Max 240mg Chlordiazepoxide (Routine + PRN) in 24hrs. *IV Pabrinex can be discontinued Oral Thiamine initiated where there is no evidence of or increased risk factors for Wernickes Encephalopathy. 8.2 High Dose Fixed Regimen Severe Dependency NOT SUITABLE FOR PATIENTS WITH ACUTE HEPATIC IMPAIRMENT or DECOMPENSATED ALCOHOL RELATED LIVER DISEASE see [sec8.9] For individuals displaying or reporting the need to relief drink to prevent physical withdrawal from alcohol who drink 30 49 units / day or SADQ 30-40 daily. Day 1 Chlordiazepoxide 30mg QDS Pabrinex 2 x pairs TDS Day 2 Chlordiazepoxide 30mg QDS Pabrinex 2 x pairs TDS Day 3 Chlordiazepoxide 25mg QDS Pabrinex 2 x pairs TDS Day 4 Chlordiazepoxide 20mg QDS Pabrinex 1 x pair OD* Day 5 Chlordiazepoxide 15mg QDS Pabrinex 1 x pair OD* Day 6 Chlordiazepoxide 10mg QDS Pabrinex 1 x pair OD* Day 7 Chlordiazepoxide 10mg BD Pabrinex 1 x pair OD* Day 8 Chlordiazepoxide 10mg OD Pabrinex 1 x pair OD* PRN Chlordiazepoxide 30mg Nursing staff able to administer Max 240mg Chlordiazepoxide (Routine + PRN) in 24hrs. *IV Pabrinex can be discontinued Oral Thiamine initiated where there is no evidence of or increased risk factors for Wernickes Encephalopathy. Page 19 of 41

8.3 Very High Dose Fixed Regimen Very Severe Dependency NOT SUITABLE FOR PATIENTS WITH ACUTE HEPATIC IMPAIRMENT or DECOMPENSATED ALCOHOL RELATED LIVER DISEASE see [sec8.9] For individuals displaying or reporting the need to relief drink to prevent physical withdrawal from alcohol who drink 50 60+ units / day or SADQ 40-60 daily. Day 1 Chlordiazepoxide 45mg QDS Pabrinex 2 x pairs TDS Day 2 Chlordiazepoxide 40mg QDS Pabrinex 2 x pairs TDS Day 3 Chlordiazepoxide 35mg QDS Pabrinex 2 x pairs TDS Day 4 Chlordiazepoxide 30mg QDS Pabrinex 1 x pair OD* Day 5 Chlordiazepoxide 25mg QDS Pabrinex 1 x pair OD* Day 6 Chlordiazepoxide 20mg QDS Pabrinex 1 x pair OD* Day 7 Chlordiazepoxide 15mg QDS Pabrinex 1 x pair OD* Day 8 Chlordiazepoxide 10mg QDS Pabrinex 1 x pair OD* Day 9 Chlordiazepoxide 10mg BD Pabrinex 1 x pair OD* Day 10 Chlordiazepoxide 10mg OD Pabrinex 1 x pair OD* PRN Chlordiazepoxide 30mg Nursing staff able to administer Max 240mg Chlordiazepoxide (Routine + PRN) in 24hrs. *IV Pabrinex can be discontinued Oral Thiamine initiated where there is no evidence of or increased risk factors for Wernickes Encephalopathy 8.4 Symptom-Triggered Regimen (Chlordiazepoxide) NOT SUITABLE FOR PATIENTS WITH ACUTE HEPATIC IMPAIRMENT or DECOMPENSATED ALCOHOL RELATED LIVER DISEASE see [sec8.9] Symptom-triggered (PRN ONLY) regimens present a particular challenge on our busy general hospital wards and where possible the appropriate fixed dosing regimens should be used to prevent unwanted escalation of withdrawal symptoms. Symptom-triggered regimens should therefore only be considered where there is a need to monitor the patient s underlying physical health concerns very closely e.g. reduced renal function. Chlordiazepoxide 20mg 30mg PRN max 240mg / 24hrs (or an equivalent dose of alternative Benzodiazepine) should be adequate in most cases. Nutritional support to prevent Wernicke s Encephalopathy with Pabrinex 2 x pair TDS 72hrs is also required. Nursing Staff to complete CIWA-AR, Assessment and Measurement of Alcohol Withdrawal tool to determine the severity of withdrawal symptoms, frequency of observations and need for PRN medication. [APPENDIX 2] Page 20 of 41

8.5 Jac Electronic Prescribing In order to optimise patient care and minimise the risks associated with inadequate prescribing there are two fixed dosing alcohol detox regimens available to prescribers using JAC. Selecting ALCOHOL as the drug to be prescribed, a choice of three detox regimens is offered: LOW DOSE SADQ 15-25 HIGH DOSE SADQ 30-49 VERY HIGH DOSE SADQ 40-60 By selecting the preferred regimen and clicking YES on the following confirmation screens the appropriate fixed dose reducing regimen of Chlordiazepoxide, PRN Chlordiazepoxide and Pabrinex is rapidly prescribed. No fixed dose reducing regimen for Lorazepam is available. For patients with impaired hepatic or renal function individualised regimes at equivalent doses will be required. [sec 8.9] 8.6 Delirium Tremens Management of Delirium Tremens requires specialist intervention including the administration of IV Benzodiazepines, advice from DANS or senior members of the medical team is advised. The most complex form of acute alcohol withdrawal, occurring in about 5% of cases, Delirium Tremens and recurrent alcohol withdrawal seizures are medical emergencies and treatment is administered in the patient s best interest to prevent rapid deterioration. Attention should be paid to the Mental Capacity Act 2005 policy PAT/PA 19 and Restrictive Practice Policy PAT/PS 15. The purpose of treatment is to make the patient calm and relaxed, over sedation or flattening the patient should be avoided. The drug recommendations listed are for adult patients with Deilrium Tremens, the BNF does not provide alternative regimens, in the elderly or patients with hepatic or renal impairment dose titration should be made in response to clinical symptoms. Oral Lorazepam as the first-line treatment 1 2 mg in response to CIWAR-AR. If symptoms persist or oral medication is declined, consider parenteral Benzodiazepines. Titrate IV / IM Lorazepam up to 0.5 to 1mgs every thirty minutes in response to CIWAR-AR Page 21 of 41

Titrate IV Diazepam emulsion 5-10 mgs every 30 60 minutes [should be given at a rate of not more than 5mgs per minute into a large vein]. Try to avoid IM administration due to unpredictable absorption. Baseline physical observations prior to IV drug administration to be repeated every 15 mins for the first hour and half hourly for the next four hours. PAT/PS 15 Restrictive Practice Policy. Nursing staff to complete CIWA-AR scores and repeat observations as directed If using more than one type of Benzodiazepine, approximate equivalent doses are as follows: Chlordiazepoxide 15mg, Diazepam 5mg, Lorazepam 500mcg Nitrazepam 5mg Temazepam 10mg WARNING: Up to 50% of patients with DTs have a secondary infection, gastro-intestinal bleeding or evidence of trauma especially head injury. These conditions must be actively excluded or treated if present. RAPID TRANQUILLISATION should not be regarded as a primary treatment technique, intervention should be reasonable and proportionate to the identified risk. Rapid tranquillisation or urgent sedation should only be used in situations requiring the rapid control of agitation, aggression or excitement in adult s psychiatric / acute hospital inpatients where de-escalation techniques alone have not proved sufficient. Suggested further reading: NICE (2005) VIOLENCE: The short-term management of disturbed / violent behaviour in psychiatric in-patient settings and emergency departments. Clinical Guideline 25 8.7 Hallucination Auditory, visual or tactile hallucinations can develop within 24 hours and can last for a further 24 48 hours. They can occur in patients with an otherwise clear sensorium. Severe psychotic symptoms may be managed by the addition of Haloperidol 1 to 5mgs 2-3 times a day. Adequate treatment with benzodiazepines to manage the underlying withdrawal is the priority. Page 22 of 41

8.8 Seizures Seizures can occur 6 48 hours after alcohol cessation. Patients with a history of seizure are more likely if there is a history of previous withdrawal seizure or epilepsy. Alcohol withdrawal seizures are usually self-limiting; however if a patient develops prolonged or recurrent seizures, intravenous Lorazepam [2mgs] is effective in terminating seizures and preventing re-occurrence, and may be less of a respiratory depressant than diazepam. Some units advocate Carbimazepine [100mg 200mg twice daily] loading in patients with untreated epilepsy:- those with a history of more than 2 seizures during previous withdrawal episodes previous seizures despite adequate diazepam loading. Those who have a seizure for the first time should be investigated to rule out an organic disease or structural legion [Maudsley, 2005]:- subdural etc. require a CT scan - brain rule out head injury - subdural haemorrhage even if the patient is known to have alcohol withdrawal seizures There is little or no evidence to support conventional anti-epileptics in either the treatment of prophylaxis of alcohol withdrawal seizures. [Maudsely, 2005]. 8.9 Liver Disease For patients with grossly deranged Liver Function suggestive of acute alcoholic hepatitis or decompensated alcohol related liver disease first line treatment with Chlordiazepoxide is not recommended due to impaired metabolism and accumulation. Lorazepam is the preferred Benzodiazepine and should be prescribed at an equivalent dose to Chlordiazepoxide Lorazepam 1mg = Chlordiazepoxide 30mg Where there is evidence of hepatic encephalopathy symptom triggered dosing with Lorazepam is favoured over fixed dosing regimens. When treatment with regular Lorazepam has been insufficient to control severe alcohol withdrawal symptoms, use of symptom triggered dosing of Chlordiazepoxide is required. Please read pharmokinetics information provided. DANS and Gastroenterology advice must be sought. Page 23 of 41

Drug Pharmokinetics Lorazepam is rapidly absorbed after oral administration, with mean peak plasma concentrations of free Lorazepam at 2 hours (range between 1-6 hours). Following intravenous administration, peak plasma levels are reached within minutes, whereas following administration by the intramuscular route, peak plasma levels occur between 60 to 90 minutes. After sublingual administration, peak plasma levels occur at 60 minutes. By the intramuscular route, the absorption half-life values of Lorazepam average 12 and 19 minutes, whereas by the oral route, there is an additional lag period averaging 15 and 17 minutes. Bioavailability was shown to be identical by all routes of administration. Lorazepam is rapidly conjugated to a glucuronide which has no demonstrable psychopharmacological activity and is excreted mainly in the urine. Very small amounts of other metabolites and their conjugates have been isolated from urine and plasma. Serum half-life of Lorazepam ranges between 12 to 15 hours, while that of the conjugate varied between 16 to 20 hours. Most of the drug (88%) is excreted in the urine, with 75% excreted as the glucuronide. At the clinically relevant concentrations, approximately 85% of Lorazepam is bound to plasma proteins. (Pfizer) Chlordiazepoxide is well absorbed with peak blood levels being achieved one or two hours after administration. Rate of absorption is age-related and tends to be delayed in the elderly. After absorption it is highly bound to plasma proteins. Serum half life Chlordiazepoxide is 6-30 hours. Steady state levels are usually reached within 3 days. Chlordiazepoxide is extensively metabolised in the liver by hepatic microsomal enzymes and exhibits capacity limited, protein binding sensitive, hepatic clearance. Pharmacologically active metabolites of Chlordiazepoxide include desmethylchlordiazepoxide, demoxepam, desmethyldiazepam and oxazepam. The active metabolite desmethylchlordiazepoxide has an accumulation half-life of 10-18 hours and Demoxepam has an accumulation half-life of approximately 21-78 hours. Steady state levels of these active metabolites are reached after 10-15 days with metabolite concentrations which are similar to those of the parent drug. 8.10 Nursing Management The safe management of acute withdrawal is best achieved through proactive rather than reactive management. Steps such as; early identification through screening and triage assessment Close monitoring of physical observations using CIWAr tool Appropriate use of routine and as required medication Can prevent the escalation of simple withdrawal to complex withdrawal. The following general measures should be put in place [Ghodse, 2002]: Ensure adequate levels of medical and nursing staff Treat the patient in a well lit area away from other patients Keep external stimuli, especially noise, to a minimum Use a friendly, understanding but firm approach Be aware of the possibility of withdrawal fits Page 24 of 41

Where a patient presents with challenging behaviour i.e. delirium and this represents a risk to the patient or others it may be necessary to intervene in order to maintain patient safety. Measures to maintain patient safety such as physical or chemical restraint should be at a level proportionate to the level of risk in keeping with PAT/PS 15 Restrictive Practice Policy: Clinical holding, restraint and restriction. 9. DISCHARGE PLANNING The decision when to discharge patients receiving alcohol detoxification is one that requires careful consideration. Discharge planning should adhere to the Trust guidelines contained within PAT/PA 3 - Discharge of Patients from Hospital Policy. There are several common scenarios which might arise. 9.1 Self Discharge Where a patient wishes to self discharge their Mental Capacity, as per the Mental Capacity Act 2005 Policy for Staff (PAT/PA 19) must be established. Patients experiencing complex alcohol withdrawal such as delirium, hallucination or delusions, Wernicke s Encephalopathy, MAY lack capacity and MAY require intervention to maintain their safety and wellbeing. Alternatively, patients experiencing uncomplicated withdrawal symptoms such as tremors, sweats, pyrexia, tachycardia (albeit intensely) MAY their retain capacity. Where patients are deemed to have capacity and wish to self discharge WPR10390A release from responsibility for discharge must be completed. No Take home medication for detoxification is to be issued. 9.2 Non Compliance with Detox Despite their good intentions and our best efforts some patients will continue to drink alcohol whilst receiving alcohol detox. This represents a significant risk due to the mixing of Benzodiazepines and alcohol. if MEDICALLY FIT and patient safe to do so: Assess patient capacity, document accordingly Ensure no complex symptoms present i.e. seizure, delirium Inform patient that combining alcohol with detox medication is harmful and could result in death. Document accordingly. Discharge without Take Home Detox medications Page 25 of 41

Document patient given advice to seek planned treatment from local Community Alcohol Team Document patient given advice that - acute withdrawal MAY occur and COULD result in seizure IF alcohol ceased abruptly, continue drinking alcohol AND reduce intake slowly. Where the patient is MEDICALLY UNFIT for discharge: Assess capacity, document accordingly. Inform patient that combining alcohol with detox medication is harmful and could result in death. Document accordingly. Discontinue routine dosing of detox medication. Continue PRN only symptomatic relief of withdrawal symptoms in response to CIWA score. Continue routine vitamin supplementation i.e. Pabrinex / oral Thiamine 9.3 Patient Declines Detox Opportunity Sometimes patients are admitted to hospital who are physically dependent on alcohol and experience withdrawal symptoms whilst with us, BUT do not want to stop drinking upon discharge. IF medically fit AND safe to do so Assess capacity, document accordingly. Ensure no complex symptoms present i.e. seizure, delirium Discharge without Take Home Detox medications Document patient given advice to seek planned treatment from local Community Alcohol Team Document patient given advice that acute withdrawal MAY occur and COULD result in seizure IF alcohol ceased abruptly, continue drinking alcohol AND reduce intake slowly. Explain benefits and offer oral Thiamine 9.4 Detox Completed Medically Fit Prescription for 28 days oral Thiamine Advice / Referral regarding local community alcohol services Liaison with existing community services i.e. Drug and Alcohol, Community Mental Health Team. 9.5 Incomplete Detox Medically Fit Where possible the opportunity to fully complete detox in hospital should be provided, however, for some patients the opportunity to complete detox at home is possible with careful planning and consideration. Page 26 of 41

Where local pathways exist these should be adhered to: Bassetlaw Drug & Alcohol Service A protocol for Completion of Hospital Initiated Alcohol Detoxification Where there are no local pathways in place i.e. Doncaster OR the patient declines input from the community alcohol team for a continuation of detox, discharge can still take place with take home detox medication providing a RISK ASSESSMENT has been completed. The Risk Assessment should consider the following: Suitable Simple withdrawal tremors, sweats Asymptomatic receiving routine meds Supported non drinking family members, spouse Mental health stable,non suicidal Non drug user, ex drug user, stable community drug treatment Planning abstinence choosing to be alcohol free Absence Neurological symptoms completed initial Pabrinex 2 x pairs TDS for 72hrs Contra-indication Complex withdrawal delirium, hallucination, paranoid delusions Symptomatic requiring PRN in past 24hrs Unsupported living alone, NFA Mental health unstable, Suicidal, admitted with overdose Chaotic Drug use heroin, methadone, benzodiazepines Controlled drinking risk mixing alcohol and medication Neurological Symptoms Seizures (whilst receiving Detox), Wernicke s Encephalopathy NOTE There is no given Day or Dose at which discharge becomes possible, each case is different and the decision to discharge should be a purely clinical one and not be driven by external factors such as demand for beds. Where Community Mental Health or Drug services are involved liaison with the patients named worker is advised. 9.6 Maximum Take Home Doses Clear instructions of day / dose and timing medications should be clearly documented in the Medication Changes section of the Discharge Letter to assist the patient. For suitable, well supported patients engaged with Community Alcohol Services Chlordiazepoxide 15mg QDS (0800/1200/1800/2200hr) Chlordiazepoxide 10mg QDS (0800/1200/1800/2200hr) Chlordiazepoxide 10mg BD (0800/1800hr) Chlordiazepoxide 10 OD (0800hr) Page 27 of 41

For suitable patients not engaged with Community Alcohol Services Chlordiazepoxide 10mg QDS (0800/1200/1800/2200hr) Chlordiazepoxide 10mg BD (0800/1800hr) Chlordiazepoxide 10 OD (0800hr) No PRN doses to be given as Take home. The decision to discharge with medication exceeding the above guidelines should only be taken following a joint review by the responsible Consultant and DANS.C 10. WERNICKE S ENCEPHALOPATHY An acute life-threatening neurological syndrome consisting of confusion, apathy, dullness, delirium, palsies of the ocular muscles, nystagmus, disturbances in equilibrium, and ataxia. Its most common cause in industrialized countries is thiamine deficiency associated with alcoholism. If not treated immediately with thiamine, the patient is likely to progress to an amnesic state and may even die. 10.1 Background Thiamine plays a role in metabolizing glucose to produce energy for the brain. An absence of thiamine therefore results in an inadequate supply of energy to the brain, particularly the hypothalamus and mammillary bodies. Heavy alcohol use increases the demand for and interferes with the metabolism of thiamine, so even in cases where patients are eating a balanced diet while drinking heavily, the metabolic problem persists because most of the thiamine is not absorbed. 10.2 Diagnosis A diagnosis of Wernicke s encephalopathy can be difficult to establish as the triad of classic symptoms is seldom present; Signs Incidence Mental changes 82% Ataxia 23% Eye signs 29% Classic Triad 10% Page 28 of 41

A high index of suspicion is therefore needed and diagnosis should be based on the presence of any one of following signs [Chick 2000, Cook 2000, Morgan 1998]. Acute confusion Decreases consciousness level including unconsciousness/coma Memory disturbance Ataxia/unsteadiness Ophthalmoplegia Nystagmus Unexplained hypotension with hypothermia Mental changes such as confusion, drowsiness, obtundation (slowness of response), pre-coma and coma maybe the only signs of Wernicke s encephalopathy [Cook, 1998]. These mental changes are non-specific and may be attributed to head injury, intoxication or alcohol withdrawal resulting in a missed diagnosis of Wernicke s. 10.3 Treatment Parenteral thiamine (Pabrinex) followed by oral thiamine should be given to harmful or dependent drinkers: AND If they are malnourished or at risk of malnourishment OR If they have decompensated liver disease Attend an emergency department OR Are admitted to hospital with an acute illness or injury SYMPTOMATIC WERNICKE S IV Pabrinex 2 x ampoule pairs TDS for 5 days AND continue until there is no further improvement in clinical symptoms HIGH RISK OF / ASYMPTOMATIC WERNICKE S IV Pabrinex 2 x ampoule pairs TDS for 3 days followed by 1 x ampoule pair daily for a further 5 days Offer prophylactic oral thiamine to harmful or dependent drinkers: If they are malnourished or at risk of malnourishment OR If they have decompensated liver disease OR If they are in acute alcohol withdrawal OR Before and during a planned medically assisted alcohol withdrawal Thiamine 100mg TDS NICE (2014) Page 29 of 41

Note Oral treatment alone does not create sufficiently high concentrations of Thiamine within the blood stream to bring about passive diffusion and is therefore ineffective at preventing harm to patients who are at HIGH RISK of developing Wernicke s. 11. TRAINING/ SUPPORT DANS service to provide ongoing education and training via: Rolling Preceptorship package Rolling CQC package DANS update days Individual ward teaching sessions 1:1 support Student shadowing 12. MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT What is being Monitored Who will carry out the Monitoring How often How Reviewed/ Where Reported to FAST ED completion ED sister annual Emergency care governance group FAST combined risk assessment Ward sisters / DANS annual Emergency care governance group CIWAR completion Ward sisters / DANS annual Emergency care governance group Detox regimen choices DANS annual Emergency care governance group Discharge planning DANS annual Emergency care governance group 13. DEFINITIONS ABV% - Alcohol By Volume AUDIT Alcohol Use Disorders Identification Test BD Twice daily CG Clinical Guideline CIWA-AR Clinical Institute Withdrawal Assessment Alcohol Revised DANS Drug and Alcohol Nurse Specialist DTs Delirium Tremens FAST Fast Alcohol Screening Test FAST ED Fast Alcohol Screening Test Emergency Department IPOC Integrated Pathway of Care Page 30 of 41

NICE National Institute for Clinical Excellence NTA National Treatment Agency OD Once daily PAT Paddington Alcohol Test PHG Public Health Guideline PRN As the occasion arises SADQ Severity of Alcohol Dependence Questionnaire TDS Three times daily QDS Four times daily 14. EQUALITY IMPACT ASSESSMENT An Equality Impact Assessment (EIA) has been conducted on this procedural document in line with the principles of the Equality Analysis Policy (CORP/EMP 27) and the Fair Treatment for All Policy (CORP/EMP 4). The purpose of the EIA is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified. [APPENDIX 6] 15. ASSOCIATED TRUST PROCEDURAL DOCUMENTS Discharge of Patients from Hospital Policy PAT/PA 3 Equality Analysis Policy CORP/EMP 27 Mental Capacity Act 2005 Policy and Guidance - PAT/PA 19 Privacy and Dignity Policy - PAT/PA 28 Restrictive Practice Policy: Clinical holding, restraint and restriction PAT/PS 15 16. REFERENCES Adinoff B [1988] et al. Medical toxicology; 3: 172-196 Armstong D, Phillips T, [2002] Management of Patients with Alcohol Problems on a Psychiatric Ward, Hull & East Riding Community NHS Trust. Chick J [2000]. Hosp Pharm; 7: 251 254 Cook, CCH et al [1998] Alcohol Alcohol, 33(4): 317-336 Cook, CCH et al, [2000] Alcohol Alcohol, 35[Supplement 1]: 19-20 CRAG/SCOTMEG [1991] Working Group on Mental Illness. The Management of Alcohol Withdrawal & delirium tremens: A good practice statement. Final Report. London: HMSO, 1994 Page 31 of 41

Department of Health, (2005) National Treatment Agency for Substance Misuse Models of care for alcohol misusers. Consultation document. London Department of Health, NICE (2005) VIOLENCE: The short-term management of disturbed / violent behaviour in psychiatric in-patient settings and emergency departments. Clinical Guideline 25 Drug and Therapeutics Bulletin, [1991], 29(18): 69-71 Erwin WE et al, [1998], 91(5): 425-432 Ghodse, H. (Ed) (1998). Department of Psychiatry of Addictive Behaviour: Handbook. London University. Hall W et al. [1997], Lancet, 349: 1897-1900 HMSO (2012) The Government s Alcohol Strategy NICE (2010) CG100 Alcohol Use Disorders Diagnosis and clinical management of alcohol related physical complications NICE (2010) PHG24 Alcohol Use Disorders preventing the development of hazardous and harmful drinking NICE (2011) CG115 Alcohol Use Disorders Diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE (2014) NICE Pathways Wernicke s encephalopathy and Wernicke-Korsakoff syndrome. Maudsley, [2005] Prescribing Guidelines, Martin Dunitz, London Morgan, MY et al editors. [1998] Alcohol and Health. Medical Council on Alcoholism London. Royal College of Physicians (2001) A Report of the Working Party of the Royal College of Physicians: Alcohol can the NHS afford it? Health Development Agency. London. Rubino, FA. [1992] Psychiatry Clinical, North America, 15(2): 359-372 Stribler H. (1991), Carbohydrate-deficient transferrin in serum: a new marker of potentially harmful alcohol consumption reviewed. Clinical Chemistry. 37: 2029-37 Turner A et al [1989] J General Intern Medicine, 4: 423-444 Wallace P (2001) Patients with alcohol problems simple questioning is the key to effective identification and management. British journal of General Practice 51: 172-3 Page 32 of 41

APPENDIX 1 COMBINED RISK SCREENING AND ASSESSMENT DOCUMENT (FAST) Page 33 of 41

Page 34 of 41 PAT/T 25 v.3

APPENDIX 2 CIWA-AR Page 35 of 41

APPENDIX 3 - AUDIT SCORING SYSTEM AUDIT 0 1 2 3 4 Your Score How often do you have a drink containing alcohol? Never Monthly or less 2-4 times per month 2-4 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year, have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year, have you failed to do what was normally expected from you because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year, have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year, have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily Have you or somebody else been injured as a result of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in the last year Yes, during the last year SCORING SYSTEM 0-7 LOWER RISK, 8 15 INCREASING RISK, 16 19 HIGHER RISK, 20+ POSSIBLE DEPENDENCE Your Total Score Page 36 of 41

APPENDIX 4 - SADQ The following questions cover a wide range of topics to do with drinking. Please read each one carefully and answer without thinking too much about the exact meaning. Answer all questions in relation to your recent drinking Question 0 Never Do you find it difficult getting the thought of alcohol out of your mind? Is getting drunk more important than your next meal? Do you plan your day so you know you will be able to drink? Do you start drinking in the morning and continue drinking right through the afternoon into the evening? Do you drink as much as you can without considering what you have to do the next day? Knowing that many of your problems may be caused by alcohol, do you still drink too much? Do you find that once you have had one drink you have to have another? Do you need an alcoholic drink to get yourself going in the morning? Do you notice a definite tremor in your hands in the morning? When you have been drinking, do you go out of your way to avoid people? Do you see things and later realise they were not real? Do you find that you have gaps in your memory or are unable to remember recent events? Do you vomit following a drinking session? Do you deliberately control your drinking by giving up for days or weeks at a time? 1 Sometimes 3 Often 4 Nearly always Scoring Scores below 15 indicates Mild Dependency 15-30 indicates Moderate Dependency 30-40 indicates Severe Dependency 40-60 indicates Very Severe Dependency DISCHARGE PLANNI Page 37 of 41

APPENDIX 5 FAST ED Page 38 of 41

Page 39 of 41 PAT/T 25 v.3

ISCHG Page 40 of 41