Alcohol Detoxification (Inpatient) Prescribing Guidelines Author: Sponsor/Executive: Responsible committee: Consultation & Approval: (Committee/Groups which signed off the procedure, including date) This document replaces: Consultant Psychiatrist; Pharmacist Team Manager Medical Director Medicines Management Group Medicines Management Group Clinical Governance and Patient Safety Group August 2016 CCS NHS Trust Policy for Delegation of insulin Administration to Assistant Practitioners and/or Healthcare Assistants for Adults with Diabetes; Review Date; October 2015 Date ratified: April 2016 Date issued: April 2016 Review date: July 2019 Version: Document Number: Purpose of Procedure: If developed in partnership with another agency, ratification details of the relevant agency V2 G5 To guide prescribers in the management of inpatients with acute alcohol withdrawal, including planned alcohol detoxes. N/A Signed on behalf of the Trust:.. Aidan Thomas, Chief Executive Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs, CB21 5EF Phone: 01223 726789
Version Control Sheet Version Date Author Comments 1.0 November 2011 1.1 March 2015 1.2 March 2016 Zahoor Syed; Sara Williamson Sara Williamson Sue Coaker First version of the guideline developed Reviewed, no changes required. Amendments in line with action plan from POMH audit Topic 14a Prescribing for substance misuse: Alcohol detoxification and current practice within CPFT 2
Contents Section Page 1 Introduction.. 4 2 Purpose 4 3 Scope 4 4 Duties and responsibilities 4 5 Aims of treatment 5 6 Admissions tests and assessment 5 7 Acute alcohol withdrawal. 5 8 Wernicke s encephalopathy. 8 9 Discharge planning 8 10 Training and education.. 9 11 Monitoring compliance... 9 12 Links to other documents.. 9 13 References. 9 Appendix 1. 10 3
1 Introduction 1.1 In alcohol-dependent individuals, abruptly stopping drinking can precipitate an alcohol withdrawal syndrome: this may occur if people are admitted suddenly to hospital and their alcohol dependence has not been previously recognized. Planned alcohol detoxification may also form part of the treatment plan for an in-patient admission. 2 Purpose 2.1 To guide prescribers in the management of in-patients with acute alcohol withdrawal, including planned alcohol detoxes. 3 Scope 3.2 These guidelines apply to all in-patient wards for Adults, Older People, Children and Learning Disability services within Cambridgeshire and Peterborough NHS Foundation Trust (hereafter referred to as the Trust or CPFT ) 4 Duties and responsibilities 4.1 Medical Director The Medical Director has delegated responsibility to ensure that appropriate arrangements and guidelines are in place within the Trust in respect of the appropriate use of this policy. 4.2 Chief Pharmacist The Chief Pharmacist has primary responsibility for the development, implementation, monitoring and review of this guidance document. 4.3 Medicines Management Group The Medicines Management Group has overarching responsibility for the development, implementation, monitoring and review of this policy. The Group reports into the Quality, Safety and Governance Committee, which is responsible for the formal approval of medicines management documents that guide practice (DtGP). 4.4 Team managers Team managers must ensure that members of their team are aware of this policy and fulfill the requirements within it. 4.5 All staff Each individual member of staff, particularly doctors, non-medical prescribers, pharmacists and qualified nursing staff are responsible for ensuring that they are aware of this policy and fulfill the requirements within it if relevant to their practice. 4
5 Aims of treatment To control symptoms of acute alcohol withdrawal o Benzodiazepines (usually chlordiazepoxide) To recognize, prevent and treat Wernicke s encephalopathy o Vitamin B supplements (parenteral and oral) The approach to prescribing in in-patient detoxifications should be flexible and will depend on the individual. All in-patient detoxifications run for a maximum of 10 days. Withdrawal should be assessed and the regime reviewed daily. Biochemical abnormalities such as hypokalaemia, hypophosphataemia and hypomagnesaemia are common. These should be monitored and corrected. 6 Admission tests and assessment Blood tests on admission should include LFT, GGT, renal function, blood glucose, cell counts and coagulation Full alcohol history should be taken as soon as feasible after admission. This should include daily intake in units (see appendix 1), patterns of drinking, type of drink used and length of dependence The patient should complete a severity of alcohol dependence questionnaire (SADQ) on admission to help determine the severity of alcohol dependence and aid clinicians in assessing the amount of benzodiazepine required to manage withdrawal symptoms Patients admitted for alcohol detox or those admitted for other reasons with co-morbid alcohol use and therefore needing a detox should be routinely breathalysed on admission and randomly breathalysed after return from any leave 7 Acute alcohol withdrawal 7.1 Symptoms of alcohol withdrawal Symptoms of alcohol withdrawal occur in about 40% of dependent drinkers, and usually begin within 24 hours of the last intake of alcohol. They include: Restlessness Tremor Sweating Anxiety Nausea/vomiting Loss of appetite Insomnia Tachycardia Systolic hypertension Alcohol-withdrawal seizures usually occur within 12-48 hours of alcohol cessation, and may develop before the blood alcohol level has fallen to zero. Patients who experience seizures while detoxifying will need full medical assessment and may need on-going medical in-patient treatment. 5
Delirium tremens (DTs) is a toxic confusional state that occurs in about 5% of patients but accounts for the highest morbidity and mortality. Onset of DTs is typically 2-3 days after cessation, and represents a medical emergency. In DTs there may be: Confusion and disorientation Hallucinations (visual and auditory) Delusions Agitation Fever in addition to the general symptoms of alcohol withdrawal above. Rating scales can be used to assess the severity of symptoms and to guide the need for additional Chlordiazepoxide. The Clinical Institute Withdrawal Assessment of Alcohol Scale Revised (CIWA-Ar) is used within CPFT. It is an extensive scale that is completed by an experienced rater 7.2 Benzodiazepine regimes The benzodiazepine of choice for uncomplicated withdrawal is chlordiazepoxide, as it has low potential for dependence. However its long half-life may lead to accumulation in older patients, or those with impaired liver function. In these circumstances a shorter-acting benzodiazepine, such as oxazepam, may be prescribed instead. The dose regime will depend on the extent of alcohol dependence (history, number of units a day) and the severity of alcohol withdrawal symptoms. 7.2.1 Mild dependence Symptoms may be managed without medication, or by following a symptomdriven approach (see section 7.2.4). 7.2.2 Moderate dependence This will require a regular chlordiazepoxide regimen, e.g. 0800 1200 1800 2200 prn Day 1 20mg 20mg 20mg 20mg 10-20mg Day 2 20mg 10mg 10mg 20mg Day 3 10mg 10mg 10mg 10mg Day 4 10mg 5mg 5mg 10mg Day 5 5mg 5mg 5mg 5mg Day 6 5mg 5mg Day 7 5mg (max 40mg in 24 hours) 6
7.2.3 Severe dependence This will require larger doses of chlordiazepoxide, e.g. 0800 1200 1800 2200 prn Day 1 40mg 40mg 40mg 40mg 10-20mg Day 2 40mg 30mg 30mg 40mg Day 3 30mg 30mg 30mg 30mg Day 4 30mg 20mg 20mg 30mg Day 5 20mg 20mg 20mg 20mg Day 6 20mg 10mg 10mg 20mg Day 7 10mg 10mg 10mg 10mg Day 8 10mg 5mg 5mg 10mg Day 9 5mg 5mg 5mg 5mg Day 10 5mg 5mg Doses should not exceed 200mg/day (including prn) without previous agreement of the consultant. (max 40mg in 24 hours) 7.2.4 Symptom-driven detox This approach may be useful 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. (It is recognized that patients attending for planned detox may drink immediately before admission). Where the patient is already taking regular benzodiazepines. Where staff are confident about assessing the severity of alcohol withdrawal and dosing appropriately. Chlordiazepoxide should be prescribed to be given prn as withdrawal symptoms manifest: e.g. 10-40mg initially then 10-20mg prn. The total dose should be monitored for 24 hours, and used to create a reducing regime if necessary (over 5-10 days depending on severity). 7.3 Other medications for management of withdrawal symptoms Paracetamol 1g QDS for pain Cyclizine 50mg TDS for nausea Diazepam 10mg PR max 30mg for seizures Zopiclone 7.5 15mg for insomnia 7
8 Wernicke s encephalopathy Wernicke s encephalopathy is a relatively common condition. It is caused by acute thiamine deficiency. Signs of Wernicke s encephalopathy Ataxia Ophthalmoplegia Loss of memory Confusion High risk signs for development of Wernicke s encephalopathy Hypotension Hypothermia Hypoglycaemia Malnourishment 8.1 Prophylaxis with thiamine Absorption of thiamine is poor by the oral route, so high-potency I/M vitamin B complex (Pabrinex) should be used for rapid thiamine supplementation. This should be prescribed for all patients undergoing in-patient detoxification (unless their alcohol dependence is mild, and they are well-nourished and healthy prior to admission). Refusal of treatment or contraindication to treatment should be documented in the progress notes. Pabrinex I/M 1 pair of ampoules daily for 3 days Followed by oral: Thiamine 100mg three times a day Vitamin B Co Strong 2 twice daily continued for 2 weeks (prescribe supply for discharge if needed). 8.2 Treatment of Wernicke s encephalopathy If the patient develops signs of Wernicke s encephalopathy, the dose should be increased to Pabrinex I/M 2 pairs of ampoules three times a day and consideration given to referral for in-patient medical management. 9 Discharge planning If the referral agency request a relapse prevention treatment after alcohol detox this should be initiated if appropriate before discharge and documented in the progress notes. For an unplanned detox the patient should be referred to a specialist alcohol service if not previously known Follow up arrangements for all patients should be clearly documented in the progress notes. 8
10 Training and education 10.1 Training needs will be identified through the supervision process. Additional training should be undertaken in the following circumstances: After any change to the policy, including addition of new drugs to the policy After a long period of leave from work, for example, study sabbaticals, extended maternity leave After a change in personal circumstances, for example, a change in job resulting in a transfer between specialties If identified as required, through annual appraisals or objective setting process. 11 Monitoring compliance 11.1 Compliance with this policy will be monitored by the Chief Pharmacist using a risk-based approach and as agreed by the Medicines Management Group. Exceptions will be reported through the MMC to the Clinical Governance and Patient Safety Group as required. 12 Links to other documents This policy should be read in conjunction with Medicines Policy 13 References Alcohol-use disorders diagnosis and clinical management of alcohol-related physical complications (CG100, 2010). London: National Institute for Health and Clinical Excellence. Available from www.nice.org.uk Maudsley Prescribing Guidelines, 12th edition (2015). London: Informa Healthcare 9
Appendix 1 Alcohol history - calculating units Using units is a simpler way of representing a drink's alcohol content, which is usually expressed by the standard measure ABV, which stands for alcohol by volume. ABV is a measure of the amount of pure alcohol as a percentage of the total volume of liquid in a drink. You can find the ABV on the labels of cans and bottles, sometimes written as "vol" or "alcohol volume". For example, wine that says "12% ABV" or "alcohol volume 12%" means that 12% of the volume of that drink is pure alcohol. You can work out how many units there are in any drink by multiplying the total volume of a drink (in ml) by its ABV (which is measured as a percentage) and dividing the result by 1,000. Strength (ABV) x Volume (ml) 1,000 = units. Thus 1 litre of 1% alcohol= 1 unit For example, to work out the number of units in a pint (568ml) of strong lager (ABV 5.2%): 5.2 (%) x 568 (ml) 1,000 = 2.95 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) regular 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 (750ml) 12% 9 *Gin, rum, vodka, whisky, tequila, sambuca http://www.nhs.uk/tools/pages/alcohol-unit-calculator.aspx 10