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South Staffordshire and Shropshire Healthcare NHS Foundation Trust – Community Alcohol Assisted Recovery . APPENDIX 1 to GP Alcohol LES 2015/16 in Cambridgeshire Policy Document Version Control Document Type and Title: Alcohol Assisted Recovery Pathway and Guidance Document – Inclusion Substance Misuse Services Authorised Document Folder: New or Replacing: Document Reference: Version No. Implementation Date: Author: Catherine Larkin Approving body: Approval Date: March 2013, reviewed by Dr Brinksman August 2014 Ratifying body: Ratified Date: Committee, Group or Individual Monitoring the Document: Review Date: Inclusion Alcohol Assisted recovery August 2016 1 Community Alcohol Assisted Recovery Policy Introduction This guidance policy is to advise practitioners and clinical services in delivering effective and safe alcohol interventions. It is based on the NICE alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence 2011 (clinical guideline 115) and RCGP management of alcohol problems in primary care (2010). Alcohol dependence affects 4% of people aged between 16 and 65 in England (6% of men and 2% of women), and over 24% of the English population (33% of men and 16% of women) consume alcohol in a way that is potentially or actually harmful to their health or well-being. Inclusion Alcohol Assisted recovery Alcohol misuse is also an increasing problem in children and young people, with over 24,000 treated in the NHS for alcohol-related problems in 2008 and 2009. Co morbid mental health disorders commonly include depression, anxiety disorders and drug misuse, some of which may remit with abstinence from alcohol but others may persist and need specific treatment. Physical co morbidities are common, including gastrointestinal disorders (in particular liver disease) and neurological and cardiovascular disease. In some people these co morbidities may remit on stopping or reducing alcohol consumption, but many experience long-term 2 consequences of alcohol misuse that may significantly shorten their life. The UK recommended drinking limits for men is: No more than 3-4 units per day. At least 2 days with no alcohol per week. No more than 7 units on one drinking occasion. The UK recommended drinking limits for adult women is: No more than 2-3 units per day. At least 2 days of no alcohol per week. No more than 5 units on one drinking day. Community Alcohol Assisted Recovery Policy Drinking Levels for men per week 0-21 units 22-49 units More than 49 Drinking Levels for women per week 0-14 15-28 More than 28 Risk Green Amber Red Green Amber Red Brief Interventions Brief interventions are acknowledged as an effective part of the treatment of alcohol use disorder. Whilst they are primarily aimed at those increasing and higher risk [or harmful and hazardous, or WHO level as appropriate] they are Inclusion Alcohol Assisted recovery endorsed by NICE as there is strong evidence to suggest that they reduce alcohol consumption among a substantial minority of problem drinkers (Raistrick 2006, Miller 2004 and Hester 1995). Problem drinkers have been shown to reduce their consumption by as much as 20% after a brief intervention. Assessment of alcohol risk using a validated screening tool is the first step and this should then naturally lead into the delivery of a brief intervention. The 4 principles of Brief Interventions are: identification of excessive drinking, linking this to the patient’s health or social difficulties, discussing what changes the patient can make and how these will benefit the 3 patient and finally set goals for change and arrange a follow up appointment. Medically Assisted Withdrawal Assisted Alcohol Detoxification should form part of a wider care plan (Raistrick 2006, DOH 2006, Alcohol Harm reduction strategy 2004). The patients care plan should outline the responsibilities of the different professional and agencies involved in the patient’s treatment. Psychosocial and pharmacological interventions should be used in combination to improve treatment outcomes (Raistrick). Community Alcohol Assisted Recovery Policy All patients undergoing community based medically assisted alcohol withdrawal should receive time limited structured psychosocial interventions alongside pharmacotherapy. NICE endorsed treatments include motivational interviewing, cognitive behavioural therapy, social behaviour and network therapy, behavioural therapies and behavioural couples’s therapy. Treatment and care should take into account people's needs and preferences. Service users should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Inclusion Alcohol Assisted recovery Who doesn’t need a Medically Assisted Withdrawal? Generally less than 15 units per day (M) or 10 units a day (F). No recent withdrawal symptoms. No drinking to prevent withdrawal. Occasional binge drinking lasting less than a week. SADQ (Severity of Alcohol Dependence Questionnaire) score of 4 or below. Patients falling into these categories should be managed using psychosocial interventions. 4 For patients who are identified as high risk on assessment or who are at risk of developing, alcohol withdrawal seizures, Wernicke’s Encephalopathy or delirium tremens, offer admission to hospital or specialist inpatient facilities for medically assisted alcohol withdrawal. For Patients who are alcohol dependant but not admitted to hospital, offer advice to avoid a sudden large reduction in alcohol intake and information about treatment options. Community Alcohol Assisted Recovery Policy Who is not suitable for a medically assisted alcohol withdrawal? Assessing suitability for community based medical withdrawal should include the careful risk assessment of potential physical and mental health problems across 3 main categories Manifestation of withdrawal Pre-existing conditions Supervision and support Manifestation of withdrawal Should a previous history of the below conditions be established, community based withdrawal should only be considered in exceptional circumstances. This should be discussed with a Inclusion Alcohol Assisted recovery senior clinician and clearly documented. History of seizures. History of delirium. Severe mental distress/anxiety. Elderly and debilitated Hypertension Coronary heart disease Significant liver impairment Diabetes Mental Health Support and Supervision Pre-existing conditions With the exception of pregnancy, the below factors should not be considered as absolute contraindications to community based withdrawal, however they increase risk. As a rule of thumb, the more of these that apply the less suitable the patient is likely to be. PREGNANCY Depressant drugs Poly drug use Polypharmacy 5 The below factors should be considered as likely reasons for community based withdrawal not being appropriate. Lack of appropriate support from a carer/relative/friend (first 3 days = 24hr support as a minimum). Lack of a carer/relative/friend willing to supervise medication. Childcare difficulties. Unsuitable accommodation. Community Alcohol Assisted Recovery Policy If community detoxification is considered inappropriate due to any of the above, then a referral for inpatient medical assisted withdrawal should be made. During any wait for inpatient admission, work should continue to be done in preparing the patient for their detoxification. Preparation Preparation needs to involve the patient, carers/relatives/friends, recovery worker, nurse and/or clinician. Determine readiness for detoxification. Discuss coping strategies for dealing with withdrawal symptoms. Revisiting learning points from previous treatment episodes. Inclusion Alcohol Assisted recovery Indentify a support person and plan their role Describe programme and treatment options. Identify a post detoxification plan. Attend the pre detoxification group. Involve recovery champions/peer mentors where appropriate. Clinical Preparation The Medic, Non-Medical Prescriber and Recovery Detoxification Nurse must ensure a robust clinical assessment is carried out. The following should be included: Summary of preparation. Celebrate success. Assess risk. 6 Baseline of vital signs. Baseline blood tests – FBC, LFTs, U & Es. Discuss prescribing options. Detail the care plan. After care arrangements. Ensure GP is informed and kept up to date. Screening Tools Validated screening tools should be used for screening all those who present with symptoms relating to excessive alcohol use, specific diseases known to have a correlation with alcohol consumption or where the results of blood tests are known to be associated with problematic alcohol use. Community Alcohol Assisted Recovery Policy The Alcohol Use Disorder Identification Test (AUDIT) was implemented by the World Health Organisation to identify problem drinking. It consists of 10 questions around alcohol consumption, harmful alcohol use and possible alcohol dependence. The AUDIT screen should be done on all patients entering treatment at the point of referral. Alcohol dependence can be assessed by use of the Severity of Alcohol Dependence Questionnaire (SADQ). It is important to establish that the patient is dependent on alcohol and the severity thereof before commencing a medically assisted alcohol detoxification. Inclusion Alcohol Assisted recovery Alcohol withdrawal can be assessed by using the Clinical Institute Withdrawal Assessment tool (CIWA). CIWA can also be used to monitor and adjust the dosage of depressant drugs in an inpatient setting. Using it in the community may inform the need to discuss PRN withdrawal medication with the prescriber. Alcohol dependence is characterised by craving, tolerance, preoccupation with alcohol and continued drinking in spite of harmful consequences for example, liver disease or depression caused by drinking (International Classification of Diseases, ICD). Alcohol use disorder is also associated with increased criminal activity and domestic violence, and an increased rate of significant mental and physical disorders. 7 In reality, dependence exists on a continuum of severity. However, it is helpful from a clinical perspective to subdivide dependence into categories of mild, moderate and severe. People with MILD dependence (those scoring 15 or less on the SADQ) usually do not need medically assisted alcohol withdrawal. Those with MODERATE dependence (SADQ score 15 30) usually need medically assisted alcohol withdrawal, which can typically be managed in a community setting unless there are other risks. Community Alcohol Assisted Recovery Policy Those who are SEVERELY alcohol dependent (SADQ score more than 30) will need medically assisted alcohol withdrawal, typically in an inpatient setting. Give Benzodiazepines for 7-10 days and do not reintroduce upon completion of detoxification. There is no evidence to suggest that low dose Benzodiazepines will prevent relapse. Medication First choice – Chlordiazepoxide. Never use Chlormethiazole (Clomethiazole) in the community setting! Slow onset of action. Examples of a Chlordiazepoxide or Diazepam community detoxification regime are detailed below. Daily doses should be given in three to four divided doses. Chlordiazepoxide Day Diazepam Total Day Total Daily Daily dose Dose 1 120mg 1 40mg 2 100mg 2 35mg 3 80mg 3 30mg 4 60mg 4 20mg 5 40mg 5 15mg 6 20mg 6 10mg 7 10mg 7 5 mg (RCGP Substance Misuse) Less potential for abuse. Second line – Diazepam. Faster onset of action. Higher risk of diversion. Consider Oxazepam in elderly patients. Inclusion Alcohol Assisted recovery Community Detoxification 8 Community Alcohol Assisted Recovery Policy Detoxification – Adjusted doses for Chlordiazepoxide depending on SADQ score. SADQ SADQ SADQ SADQ 30 25 20 15 Day 30mg 25mg 20mg 15mg 1 QDS QDS QDS QDS Day 25mg 20mg 15mg 10mg 2 QDS QDS QDS QDS Day 20mg 15mg 10mg 10mg 3 QDS QDS QDS TDS Day 15mg 10mg 10mg 5mg 4 QDS QDS TDS TDS Day 10mg 10mg 5mg 5mg 5 QDS TDS TDS BD Day 10mg 5mg 5mg 5mg 6 TDS TDS BD OD Day 5mg 5mg 5mg 7 TDS BD OD Day 5mg 5mg 8 BD OD Day 5mg 9 OD (RCGP Substance Misuse) Inclusion Alcohol Assisted recovery Note: For equivalent doses of Diazepam divide by 3. Vitamins Prescribing vitamins, particularly Thiamine, reduces the risk of Wernicke’s Encephalopathy and Vitamin B deficiency related diseases. Alcohol detoxification puts considerable stress on already depleted stores of B Vitamins. Prescribe Thiamine 50100mg four times a day. Give Vitamin B Co strong tables as well, 1-2 tablets four times a day. Consider indefinite oral prescribing in dependent drinkers. Thiamine and Vitamin B should always be prescribed during community detoxification. If oral, this should be for at least two weeks before detox is due to 9 start. A parenteral preparation, Pabrinex, is available and should be given intramuscularly if the patient is thought to be at high risk of possible Wernicke’s Encephalopathy. Monitoring Regular monitoring should be in place throughout the withdrawal and this includes daily contact with a health care professional. It should include: General condition, tremor, sweating. Blood pressure and pulse. Reports from carers/relatives/friends. Breathalyse. Community Alcohol Assisted Recovery Policy Assessment of effectiveness of prescribed medication to try and prevent under or over dosing (consider CIWA). If any of the following symptoms are reported then refer for emergency admission: Seizure. Severe depression/suicidal ideation. Suspected Wernicke’s. Uncontrollable vomiting. Confusion, hallucinations, delirium. CIWA should be used to assess physical symptoms. Inclusion Alcohol Assisted recovery Risks Aftercare Grand mal seizure – alcohol withdrawal can lead to grand mal fits, occasionally fatal. Delirium tremens – alcohol withdrawal can lead to delirium tremens (DTs). 10% of these can be fatal. Overdose – taking Benzodiazepines and alcohol in large doses can be fatal. Kindling – grand mal fits in withdrawal can cause ‘kindling’ effect, in which alcohol withdrawals are more readily complicated by fitting in future. 10 Structured support for individuals. Psychosocial interventions are always a crucial part of relapse prevention. Pharmacotherapy may be useful to maintain abstinence. Family/Carer/Relative/ Friend support and involvement. Managing post-detox symptoms. Self help or mutual aid e.g. Alcoholics Anonymous (AA). Community Alcohol Assisted Recovery Policy Medication for relapse prevention. Disulfiram (Antabuse) Generally well tolerated however side effects may include drowsiness, fatigue, abdominal pain, nausea and diarrhoea. Sensitising provides negative reinforcement. Severe aversive reaction after any alcohol: flushing, palpitations, hypotension, vomiting, headache. Daily dose 200mg. Evidence for efficacy only if supervised. Only initiate by a specialist which would include a GP with Special Interest. Do no prescribe in pregnancy, liver and renal Inclusion Alcohol Assisted recovery impairment, history of severe mental illness, cerebrovascular or cardiovascular disease including hypertension. Acamprosate Prescribed for anti craving. 333mg, take two tabs TDS. (reduce if weight is less than 60kg - max 4 tablets). Up to 12 months treatment. Few side effects but possible diarrhoea, pruritus, rash. Don’t prescribe in pregnancy, breastfeeding, renal insufficiency and severe hepatic failure. 11 Naltrexone Prescribed for anti- craving (not licensed). Well tolerated but side effects may include nausea, headache, abdominal pain, reduced appetite and tiredness. Opioid antagonist – cannot be used in people taking opioid agonist analgesia. 25mg (half tablet) a day for first week. If well tolerated then 50mg a day. Community Alcohol Assisted Recovery Policy Nalmefene Opioid antagonist. Prescribed for anti-craving alongside psychosocial interventions. Indicated for those who have a high drinking risk level (DRL) but don’t require immediate detox. Longer half life. Only initiate in those who continue to have high DRL 2 weeks following initial assessment. Antidepressants Severe depression or that persisting for more than 2 weeks may need SSRI treatment ( e.g. Citalopram). Inclusion Alcohol Assisted recovery After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering Acamprosate or oral Naltrexone in combination with psychological interventions focused on alcohol misuse (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies). Interventions for harmful drinking and mild alcohol dependence. For harmful drinkers and people with mild alcohol dependence, offer psychological interventions such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies focused specifically on alcohol- 12 related cognitions, behaviour, problems and social networks. Where possible encourage families and carers to be involved in the treatment and care of people who misuse alcohol to help support and maintain positive change.