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Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
1: Overview of alcohol detoxification programmes in CIOS
The following chart shows the different services available to CIOS residents that, following
full assessment, are deemed as requiring a structured detoxification from alcohol use.
‘Home and Dry’
Community Specialist Alcohol Detox or St Petrocs Alcohol Detox
Community Hospital Alcohol Detox
Residential Alcohol Detox (Boswyns or Broadreach)
RCHT acute admission in-patient alcohol stabilisation
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There are clear eligibility and exclusion criteria for each service. Clients should be able to access the
type of detoxification service that best meets their needs and level of dependency.
Access to each service is through an agreed protocol and assessment procedure.
Having a range of detox options allows for cost-effective treatment based on levels of need.
Client choice may be a factor in deciding which detox should be accessed but this should not
compromise patient safety or put staff in a position where they have to manage patients that their
particular detox is not designed to care for.
Preparation and Aftercare Support
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For a patient to benefit most from a detox it should be viewed as a planned intervention and subject
to care co-ordination and recovery care planning processes.
Preparation processes include use of the relevant assessment tool, care plan, risk assessment,
contingency plan and aftercare plan.
Quality of referrals to detoxification services must include the above and offer comprehensive and
relevant information for the detoxification service to assess suitability.
Robust and comprehensive multi-agency assessment & preparation needs will precede any detox
including the planning of post detox support and aftercare.
An acute admission to RCHT that leads to an alcohol stabilisation will be overseen by the Specialist
Alcohol Nurse and continuation of care post discharge planned and arranged in conjunction with the
appropriate agency.
If a patient remains ambivalent about the need for a detox or resolving their alcohol dependency it
may be appropriate to delay detoxification and continue to explore their problems.
Repeated unsupported and unplanned detoxes may be harmful to the patient (kindling), and as such
all care provided to clients in treatment should seek to prevent this occurring.
However, supported detoxes should be carefully planned and appropriate for the client. Through
assessment a health professional must be assured that motivation and circumstances are conducive
to detoxification.
Should a client fail to complete a planned detox, the Key-Worker will explore the circumstances to try
and avoid the same problem(s) occurring with subsequent detox attempts.
Post detox support, as a part of a plan of care, will maximise the benefit for the patient and reduce
the risk of a subsequent relapse.
1 Alcohol detoxification services in Cornwall
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
Capacity
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The capacity for each type of detox in Cornwall clearly needs to match the number of patients who
need it, and will be defined annually in the alcohol needs assessment.
Each detox should be as accessible and available as possible in terms of geography and waiting times
but there will inevitably be a balance to be achieved for more specialist detoxes.
2 Alcohol detoxification services in Cornwall
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
Alcohol Detox Services available in CIOS
‘Home and Dry’
Delivered through Addaction and GP practices contracted under an LES
A supported community detox for the least complex of patients with alcohol dependency. It is provided in
General Practice with the patient attending the surgery on a daily basis for monitoring by the Practice Nurse
during the course of the detox, typically for 5 days. It is dependent on the patient having a responsible carer
who can support them throughout the course of detox including the management of their withdrawal
medication.
The detox is provided through a practice team including the Addaction worker, GP and Practice Nurse all of
whom will have received training to provide Home & Dry.
Chlordiazepoxide is the withdrawal medication used in dosing regimens chosen according to patient
presentation, suitable for those with a SADQ of <30.
59% of GP practices have been trained to provide this detox options. Practices will offer this service to
patient’s of other practices where this service is not available.
Cornwall Drug & Alcohol Team Community Detox
Delivered by CDAT nurses in conjunction with a consultant psychiatrist
A supported community detox for patients who can be managed in the community whilst remaining in their
own accommodation with care provided by a Community Detox Nurse. Contraindications to this detox are
similar to those for Home & Dry but as support is offered in the patient’s own home then it is suitable for
patients who are unable to attend their GP surgery. Also the skills of the Community Detox Nurse allow more
flexibility to support patients with mental health and other substance misuse problems. Diazepam ‘symptom
triggered therapy’ is the withdrawal medication used and can usually be managed over 24-48hrs.
St Petrocs Alcohol Detox for homeless people
Delivered by Addaction, CDAT and Health for the Homeless PHC service
This is provided to patients who are homeless and without a responsible carer to support them through a
detox. After being assessed for their suitability the detox is planned with a ‘detox’ bed secured at St Petrocs for
a 6 week period. This allows a secure and safe setting for the detox itself (supervised by a Community Detox
Nurse with on-call support from Health for Homeless clinicians) as well as a stable environment for aftercare
support/PODS.
Care is delivered by collaboration between the Health for the Homeless service, an Addaction-CADA Support
Worker, a Community Detox Nurse and St Petrocs. Prescriptions are supplied from Health for the Homeless
GPs or the CDAT Consultant.
Community Hospital Alcohol Detox
Delivered by Addaction, GP practices contracted under an LES & PHC community Hospital
services.
An inpatient detox delivered in a local Community Hospital (currently St Ives, Helston, Bodmin) for patients
who are not suitable for a Home and Dry or Community Specialist Detox because of their home circumstances
or a lack of a responsible carer. It can also cater for patients who have physical problems that would make a
community detox unsafe. It is also suitable for those on ORT who are stable on their medication. This may also
be a good option for those who have previously been unsuccessful in attempted home detoxes.
Assessment & preparation is provided by the patients Addaction Key-Worker, and a CHAD LES GP (who also
has input into the local Community Hospital). The detox takes place in a booked Community Hospital bed,
typically over a 5-7 day period with monitoring and support during the detox coming from trained Community
Hospital Nursing staff. Diazepam ‘symptom triggered therapy’ is the withdrawal medication tailored using
CIWA-Ar scoring with the majority of dosing taking place in the 1st 24-48hrs.
3 Alcohol detoxification services in Cornwall
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
Residential Detox (Boswyns or Broadreach)
Residential detoxes are for patients who are not suitable for community detox. These may include patients
who have specific complicating problems including those with concomitant substance misuse who want to
stabilise or detox their drug problem as well as detox from alcohol. They may also be suitable for patients who
need to progress to secondary rehabilitation and support as part of their recovery. Currently options include
Broadreach, in Devon, and Boswyns, in Cornwall. These residential units may be particularly suitable for those
with mental health problems, learning disability problems or couples who both require detox/stabilisation.
Service User Profile
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Aged 18y - 65yrs
Drug / alcohol users already engaged in Tier 3 community-based treatment
Those needing short-term, intensive assessment, treatment, or care, which cannot be carried out
effectively in a community setting.
Those requiring access to a short-term specialist residential setting, at a time of crisis, in order to
reduce associated risks, and stay in (T3) treatment.
Those requiring a short period in a managed environment to stabilise their drug use, with particular
reference to chaotic illicit use “on top” of an established substitute prescription.
Those requiring titration onto a substitute prescription within a residential setting.
All forms of drug use including poly-drug use will be included
Interventions Offered
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Stabilisation on substitution opioids
Withdrawal from substitution opioids
Supported withdrawal from sedatives (including alcohol) using benzodiazepines
Withdrawal from opioids using non-opioid medication
Opioid relapse prevention with naltrexone
Symptomatic treatment for stimulant withdrawal
In-patient assessment
(a combination of any of the above)
RCHT Acute Admission Inpatient Stabilisation
For those patients who have to be admitted without planning to the acute hospital because of another
condition (e.g. medical or surgical emergency) and who are at risk of going into alcohol withdrawal., care is
coordinated by the specialist alcohol nurse based at Treliske Hospital in Truro and covering the other RCHT
sites.
Chlordiazepoxide ‘symptom triggered therapy’ according to the patient’s CIWA-Ar score is the withdrawal
/stabilisation medication.
The specialist alcohol nurse will assess the patient’s needs, work with hospital staff to determine prescribing
regimes and liaise regarding discharge and onward referral to specialist community agencies.
Reasons to Delay any alcohol detox
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If a patient develops any acute illness/infection prior to detox consider delaying the
detox until the patient is recovered.
Patient has unresolved ambivalence about their alcohol intake and the need for a
Detox
Kindling (needs explanation)
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Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
Part 2: Contra-indications & cautions
HOME & DRY ALCOHOL DETOX
Contraindications
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Significant cardiac problem (e.g. unstable ischaemic heart disease or arrhythmia)
Liver failure with decompensation
Severely undernourished
Has severe vomiting or diarrhoea
History of epilepsy or status epilepticus or fits during a supported/supervised
detoxification
History of Wernicke’s Encephalopathy or Delirium Tremens
Is confused or has hallucinations
Active severe mental illness
Is at significant risk of suicide
Severe personality disorder
History of violence during alcohol detoxification
Has chaotic other substance misuse
Under 16 years of age
SADQ score of more than 40
Has a home environment unsupportive of abstinence
Absence of a carer who would accompany the patient to surgery appointments
during the detox
Has severe dependence coupled with unwillingness to be seen daily
Unable to travel to the surgery
Cautions
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If the patient has a history of significant complications during a previous
supported/supervised withdrawal the circumstances need to be examined carefully
before.
Benzodiazepine dependency - an assessment of risk before a decision is taken to
proceed with detox.
16 to 18 years of age – decision based on individual presentation and assessment.
5 Alcohol detoxification services in Cornwall
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
COMMUNITY SPECIALIST ALCOHOL DETOX
Contraindications
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Significant cardiac problem (e.g. unstable ischaemic heart disease or arrhythmia)
Liver failure with decompensation
Severely undernourished
Has severe vomiting or diarrhoea
History of epilepsy or status epilepticus or fits during a supported/supervised
detoxification
History of Wernicke’s Encephalopathy or Delirium Tremens
Is confused or has hallucinations
Is at significant risk of suicide
History of violence during alcohol detoxification
Has a home environment unsupportive of abstinence
Under 18 years of age
Cautions
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If the patient has a history of significant complications during a previous
supported/supervised withdrawal the circumstances need to be examined carefully
before commencement
Repeated detoxifications, assess with care.
Active severe mental illness
Severe personality disorder
Assess carefully other chaotic substance misuse
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Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
ST PETROCS/ HEALTH FOR THE HOMELESS DETOX
Contraindications
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Significant cardiac problem (e.g. unstable ischaemic heart disease or arrhythmia)
Liver failure with decompensation
Severely undernourished
Has severe vomiting or diarrhoea
History of epilepsy or status epilepticus or fits during a supported/supervised
detoxification
History of Wernicke’s Encephalopathy or Delirium Tremens
Is confused or has hallucinations
Active severe mental illness
Is at significant risk of suicide
Severe personality disorder
History of violence during alcohol detoxification
Has chaotic other substance misuse
Under 18 years of age
Cautions
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If the patient has a history of significant complications during a previous
supported/supervised withdrawal the circumstances need to be examined carefully
before commencement.
Unknown previous health history.
7 Alcohol detoxification services in Cornwall
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
COMMUNITY HOSPITAL ALCOHOL DETOX
Contraindications
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Liver failure with decompensation
Active neuropathy/neurology (Wernicke’s encephalopathy)
Severe cardiac problems
History of uncontrolled status epilepticus or delirium tremens
History of violence during alcohol detoxification
Violence in clinical settings
SADQ > 55
Under the age of 16 years
Cautions
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Poor nutrition - ensure Pabrinex course before admission
Benzodiazepine dependency-assessment of risk before referral
Epilepsy-controlled & without history of status
History of violence &/or deliberate self harm
Significant mental illness, impulsivity, masked anxiety, psychosis
Careful assessment of co-existent drug dependency
Behavioural problems that may impact on safety of others in ward settings.
For patients aged between 16 and 18 years the Primary Care Trust (which manages
Community Hospital beds) requires a risk assessment to ensure suitability.
8 Alcohol detoxification services in Cornwall
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
RESIDENTIAL ALCOHOL DETOX
Boswyns and Broadreach
Contra-indications
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Drug/alcohol users whose treatment needs can be met within a community setting.
Drug/alcohol users with serious mental health problems, who require
hospitalisation, or containment under the Mental Health Act
People with severe cognitive deficits / encephalopathy related to alcohol
dependency
People with acute clinical symptoms of severe liver disease, e.g. Jaundice/Ascites
where hospital admission may be advisable
Severe uncontrolled cardiac problems
Cautions
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Aged under 18 years or over 65 years will need careful consideration
People with a history of violence, arson, or schedule 1 offences will need careful
assessment & consideration.
Acute glaucoma
People with evidence of severe malnutrition (BMI<18)
9 Alcohol detoxification services in Cornwall
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
Care
Co-ordn
CONDITION
Alcohol
Key
SPECIFIC CONDITIONS FOR DETOX:
10 Alcohol detoxification services in Cornwall
POSSIBLE SOLUTION
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
Worker
 Active severe and enduring mental
illness
 Contraindications to a Community
Specialist or Home & Dry detox but
fear/anxiety/phobia about being in a
hospital setting or institution
 Learning Disability
 Young person (16-18yrs) without
support
CMHT
CDAT
CDAT or
Addaction or
CMHT
CDAT or
Addaction
Learning
Disability
CDAT or
Addaction
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Longreach/Bodmin CHAD
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Community Specialist with extra
support for physical problems
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Detox venue based upon patient
assessment with appropriate LD
specialist support
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Community detox with care
support/ foster care for the
duration of the detox
CDAT or
Addaction
CDAT or
Addaction
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CHAD (needs initial risk
assessment)
 Young person under the age of 16yrs
YZUP
YZUP
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Out-of-county
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 Chaotic polydrug use
CDAT
CDAT
Simultaneous drug and alcohol
detox (Broadreach or Boswyns)
CMHT (Eating
Disorders)
CDAT
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Boswyns
CMHT or
CDAT
CDAT
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Detox venue based on individual
patient risk assessment
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CDAT
CDAT or
Addaction
Any of the detox options may be
appropriate based on individual
patient assessment
 Eating disorder and significantly
underweight
 History of violence or severe
personality disorder
 Drug dependency and stable on
substitute medication
11 Alcohol detoxification services in Cornwall
Alcohol Detoxification Services in CIOS – a Stepped Approach
November, 2011
SPECIFIC CONDITIONS FOR DETOX (contd):
CONDITION
Care
Co-ordn
Alcohol
Key
Worker
POSSIBLE SOLUTION
 Sensory impairment e.g. deafness,
blindness, speech
Addaction or
CDAT
Addaction or
CDAT
 All options with consideration
of suitability of environment
of detox
 Bariatric
Addaction or
CDAT
Addaction or
CDAT
 All options with consideration
of suitability of environment
of detox
 Pregnancy
Addaction or
CDAT
Addaction or
CDAT
 All options with caution
12 Alcohol detoxification services in Cornwall