Download Alcohol Withdrawal – Inpatient Care

POLICY DOCUMENT
Document Title
POLICY AND PROTOCOL FOR THE
CLINICAL MANAGEMENT OF ALCOHOL
WITHDRAWL – IN PATIENT CARE
Reference Number
CG/inpatient alcohol withdrawal/11/14
Policy Type
Clinical Guideline
Electronic File/Location
N:\Pharmacy\NEPFT Policies, Procedures and Iconnect documents\Inpatient alcohol withdrawal 2014
Intranet Location
http://iconnect/policies/medicinesmanagement/prescribing-and-treatment-guidelines/
Status
Final
Version No/Date
Version 1 November 2014
Author(s) Responsible for
C. Carson – Operational Services Manager Substance
Writing and Monitoring
Misuse (West)
Approved By and Date
Implementation Date
Review Date
Medicines Management Group – November 2014
Clinical Governance Group
December 2014
December 2017
© North
Copyright
Essex Partnership University NHS
Foundation Trust (2014). All rights reserved. Not to
be reproduced in whole or in part without the
permission of the copyright owner.
All matters or concerns regarding fraud or corruption should be reported to: Chris Rising,
Senior Manager ([email protected] 07768 873701), Hannah Wenlock, LCFS Lead
([email protected] 07972 004257) Mark Trevallion, LCFS Lead
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0800 028 40 60 https://www.reportnhsfraud.nhs.uk/
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NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
Policy and Protocol for the Clinical
Management of Alcohol Withdrawal – In
Patient Care
Version: 1
Author: Cheryl Carson
Ratified/Approved by: Medicines Management Committee/Clinical
Governance Group
Effective from:
Review Date:
Targeted Audience: In Patient Care
Circulated to the following people for consultation: Dr B. Otun, Dr B. Sharma,
Dr H. Pal
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NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
CONTENTS
Section
Numbers
1
Subject
Purpose
Page
Number
4
2
Definitions
4
3
Intoxication
5
4
Clinical Management of Intoxication
6
5
Detoxification
7
6
Evaluation and Treatment of Alcohol Dependency
7
7
Medical Complications of Alcohol Withdrawal
8
8
Stabilisation
9
9
Chlordiazepoxide Regimes
10
10
Non Compliance with Treatment
11
11
Nursing Observations
11
12
Detoxification in older/physically frail Adults
12
13
Summary of Changes
12
APPENDICES
1
13
2
Clinical Institute Withdrawal Assessment Alcohol Revised
Scale (CIWA-Ar)
Severity of Alcohol Dependence Questionaire (SADQ-C) 1
3
What is Pabrinex?
18
4
Advice to Clients Withdrawing from Alcohol
19
5
CONSENT Forms For Pabrinex® And Chlordiazepoxide
20
6
Acute Alcohol Withdrawal Medicine Management
22
15
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Purpose
This policy governs the safe prescribing and management for patients with
Alcohol dependency problems who come under the care of acute psychiatric
services (NEPFT). This document is by no means exhaustive and does not
attempt to cover every eventuality. It is the duty of all employees to report
any unusual or unforeseen situations with regard to any procedure to their
line manager.
1.
Definitions
Unit of Alcohol
One "unit" in the UK usually means a beverage containing 8 g of ethanol, e.g.
a half pint of 3.5% beer or lager, or one 25 ml pub measure of spirits. A small
(125 ml) glass of average strength (12%) wine contains 1.5 units.
Hazardous Drinking
The term hazardous drinking is widely used. It is synonymous with "at-risk
drinking" and can be defined as the regular consumption of:

over 40 g of pure ethanol, (5 units) per day for men.
These figures derive from population studies showing the relationship of self
reported levels of drinking to risk of harm. It is arbitrary which point on the
risk curve is deemed to merit a warning. Other authorities have quoted
weekly recommended upper limits for alcohol consumption of 21 units per
week for men and 14 for women.
Consuming over 40 g/day alcohol on average doubles a man's risk for liver
disease, raised blood pressure, some cancers (for which smoking is a
confounding factor) and violent death (because some people who have this
average alcohol consumption drink heavily on some days).
The term hazardous drinking, is also used loosely to cover those who have
experienced minimal, as opposed to serious harm.
Harmful Drinking
Harmful drinking is defined in the International Classification of Diseases
(ICD-10) as a pattern of drinking that causes damage to physical (e.g. to the
liver) or mental health (e.g. episodes of depression secondary to heavy
consumption of alcohol).15 The diagnosis requires that actual damage should
have been caused to the mental or physical health of the user.
Alcohol Dependence
Alcohol dependence is defined as a cluster of physiological, behavioural, and
cognitive phenomena in which the use of alcohol takes on a much higher
priority for a given individual than other behaviours that previously had greater
value. A central characteristic is the desire (often strong, sometimes
perceived as overpowering) to drink alcohol. Return to drinking after a period
of abstinence is often associated with rapid reappearance of the features of
the syndrome (priming). A definitive diagnosis of dependence should usually
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be made only if three or more of the following have been present together at
some time during the previous year:






2.
a strong desire or sense of compulsion to take alcohol
difficulty in controlling drinking in terms of its onset, termination or level of
use
a physiological withdrawal state when drinking has ceased or been
reduced (e.g. tremor, sweating, rapid heart rate, anxiety, insomnia, or less
commonly seizures, disorientation or hallucinations) or drinking to relieve or avoid
withdrawal symptoms
evidence of tolerance, such that increased doses of alcohol are required in order to
achieve effects originally produced by lower doses (clear examples of this are
found in drinkers who may take daily doses sufficient to incapacitate or kill
non-tolerant users)
progressive neglect of alternative pleasures or interests because of drinking and
increased amount of time necessary to obtain or take alcohol or to recover from its
effects (salience of drinking)
persisting with alcohol use despite awareness of overtly harmful consequences,
such as harm to the liver, depressive mood states consequent to periods of
heavy drinking, or alcohol related impairment of cognitive functioning
Intoxication
Intoxication occurs when a person’s intake of alcohol exceeds their tolerance and
produces behavioural and/or physical change.
All staff must be able to correctly manage intoxication even when the intoxication
is not life threatening.
Any patient who is found to be intoxicated within the unit/ward, the following must
be adhered to:
General principles of managing intoxication
Maintenance of airways and breathing is of paramount importance to the
comatose patient.
Any person presenting as incoherent, disorientated or drowsy should be treated
as per head injury until proven otherwise.
Intoxicated patients must be kept under observation (level 2 as a minimum – 4 x
per hour) on the unit/ward until their intoxication diminishes.
A thorough physical and mental status examination by a nurse or doctor will
reveal the level of a patient’s intoxication to provide baseline information.
Assessing Intoxication






Take a comprehensive alcohol history
Observe vital signs – temperature, pulse, respirations and blood pressure.
Observe pupils, gait and for any ataxia.
Consider conditions other than intoxication (e.g.: head injury, CVA,
hypoglycaemia, psychosis, severe liver disease etc.)
Record all observations in the medical records.
Quantum 6 cup drug screen
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Signs of Mimicking or Masking Intoxication











Infections
Respiratory disease
Head injury, subdural haematoma
Acute psychosis
Diabetes, hypoglycaemia
Epilepsy (temporal lobe), post-ictal
Drug toxicity, e.g. phenytoin, digoxin
Meningitis
CVA or TIA
Withdrawal
Wernicke’s encephalopathy
If the assessment indicates intoxication






3.
Maintain vital signs
Continue to monitor the patients’ physical and mental state
Ensure that everyone on the unit/ward is aware of the patient’s status.
Airway maintenance is of the utmost importance
Place the client in the recovery position. Note: vomiting is likely to occur in the
grossly intoxicated patient – this can present a major problem in semi
conscious or unconscious patients.
If the patient vomits more than once, this may indicate a head injury or other
cause of serious illness. If the intoxicated patient vomits more than once and
is not completely coherent, then an ambulance should be called.
Clinical Management of Intoxication
Medication may not be necessary if:



4.
the patient reports consumption is less than 15 units/day in men and less
than 10units/day women and reports neither recent withdrawal symptoms
nor recent drinking to prevent withdrawal symptoms.
the patient has no withdrawal signs or symptoms; if a decision is made not
to prescribe, alcohol withdrawal monitoring should be undertaken twice
daily for three days to ensure that no symptoms emerge.
among periodic drinkers, whose last bout was less than one week long,
medication is seldom necessary unless drinking was extremely heavy
(over 20 units/day). Thiamine 200mg daily and Vitamin B Compound
Strong for a period of 28 days is still required
Detoxification
Detoxification refers to the planned withdrawal of alcohol. Alcohol withdrawal
carries risks and requires careful clinical management.
No service user can be discharged until an alcohol detoxification is complete.
CHLORDIAZEPOXIDE (LIBRIUM) is the preferred drug of choice to be
used in alcohol withdrawal regimes.
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5.
Evaluation and Treatment of Alcohol Dependency
Before any prescribing of medication the patient must have an assessment of
needs including a risk assessment (See Trust Risk Assessment Policy).
A full medical history must be taken as is the case with all clients this must
include details of their alcohol dependence including details of





What they drink?
When they last drank?
How much they drink daily?
Drinking patterns such as binges or daily?
Any health issues relating to alcohol dependence such as gastrointestinal
or Hepatic impairment
The patient must be seen by a nurse or doctor before any medication is
issued (either via a PGD or a prescription).
The patient must have had discussion with the doctor or nurse to discuss the
implications of chlordiazepoxide as a treatment, and the expectations for
treatment (Appendix 5). There needs to be documentary evidence of this in
the notes.
There needs to be a clear indication that the patient is dependent on alcohol
before treatment is commenced.
If the patient appears intoxicated or sedated, the first dose of
Chlordiazepoxide must be withheld until it is clinically safe to begin treatment.
An alcohol withdrawal scale (CIWA-Ar) and an SADQ must be completed on
all patients who are to be clinically assessed with possible alcohol
dependency problems (Appendices 1 and 2).
Cessation of drinking is unlikely to be complicated in milder dependence.
There should however be a lower threshold of prescribing, in part due to the
very limited access to alcohol, and also to the risks of self harm in
untreated/under treated withdrawal – if there are any withdrawals, then titrate
against withdrawal symptoms both up/down. Always prescribe if the patient
claims to be dependent, their history/evidence are believable, and there is
evidence of withdrawal.
6.
Medical Complications of Alcohol Withdrawal
Medical complications of Alcohol withdrawal are potentially life threatening
particularly if not optimally treated. Nursing observations should be
undertaken at least twice daily ( morning and evening) for these clients for at
least the first five days of their detoxification to identify at an early stage any
complications which may arise, particularly in respect of withdrawal fits and
delirium tremens.
Where there is a previous history of alcohol withdrawal fits, clients must be
prescribed sufficient chlordiazepoxide to ensure that this complication does
not occur. Delirium tremens are withdrawal symptoms complicated by
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disorientation, hallucinations, or delusions. Autonomic over-activity is a
potentially fatal aspect of this condition.
If a client does not require a formal alcohol detoxification, but has a recent
history of heavy drinking they should still receive the Thiamine 200mg daily
and Vitamin B Compound for a period of 28 days as a precautionary
measure.
Clients who undergo a detox also require vitamin supplementation; they
should be given Pabrinex (Appendix 4) .This is usually 3 days of vial pairs for
prophylaxis of the Wernike-Korsakoff syndrome. There is some doubt as to
the suitability of oral thiamine as a prophylactic treatment for WernickesKorsakoff syndrome due to limited oral absorption. It has also been shown to
have little or no effect on the CNS vitamin status whereas parenteral thiamine
replacement is rapidly effective in the treatment of Wernickes encephalopathy
and is an effective prophylactic treatment for high-risk clients. Pabrinex
should therefore be recommended for clients who present as being at high
risk of Wernicke’s –Korsakoff (NICE 100 2010). If clients present with
complicated alcohol withdrawal for example Delirium Tremens then one
should extend the Pabrinex treatment for 5 days
Anaphylaxis is a rare complication and is more likely to occur with IV use (see
Tab 18, in the Emergency Drugs Protocol). It is extremely rare after IM
administration and this should be considered the route of choice. It
should only be administered where suitable basic life support facilities and an
anaphylactic shock pack are available. Dosage should be 2 Pairs Pabrinex
ampoules IM (7mls injected very slowly into the gluteus maximus please
ensure the patient is lying down with their leg to be injected, slightly bent).
to be given daily for 3 days.
Should patients refuse IM treatment, they should then still be offered the oral
treatment – Vitamin B Compound, Strong.
All patients who undergo alcohol detoxification should routinely be prescribed
200mg of thiamine daily for a period of 28 days.
7.
Stabilisation
The client should remain on the unit/ward until the alcohol detoxification is
complete. It is important that these clients are monitored (using the CIWA-Ar
and risk assessed) for the first seven days of their management, as they may
suddenly deteriorate or may suffer withdrawal seizure. This means no leave
to be granted until day 7 or 8 of the detox.
In certain circumstances alcohol related withdrawal seizures have been
known to be near fatal or fatal.
An extended stay on the unit/ward is advised if the client:




has experienced confusion or hallucinations during the detoxification
has a history of previously complicated withdrawal
has epilepsy or a history of fits
is undernourished
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





has severe vomiting or diarrhoea (this should be controlled within 24
hours or patient transferred to hospital).
is at risk of suicide
has severe dependence coupled with unwillingness to be observed
daily
has uncontrollable withdrawal symptoms
has an acute physical or psychiatric illness
has multiple substance misuse
In the treatment of concurrent opiate and alcohol dependence, no reduction
in the opiate agonist should be attempted until the alcohol detoxification
is complete.
A baseline regime will be agreed by the doctor before commencement of
detoxification following the clinical assessment and SADQ and/or CIWA-Ar
scores.
8.
Chlordiazepoxide Regimes
UNITS OF ALCOHOL PER WEEK BASELINE REGIME
<150 UNITS
15mg tds decreasing to zero over 6
days
150-200 units per week
20mg tds decreasing to zero over 7
days
200-250 units per week
20mg qds decreasing to zero over 8
days
250-300 units per week
25mg qds decreasing to zero over 9
days
>300 units per week
30mg qds decreasing to zero over 10
days
Clients with a high level of dependency can be offered a higher level of
chlordiazepoxide to reduce the risk of withdrawal. Guidelines suggest
anything between 10-50mgs of chlordiazepoxide four times daily gradually
reducing over 7-10 days (www.bnf.org).
Clients who give a recent history of consuming 10-15 units of alcohol daily
MUST be given a stat dose of Chlordiazepoxide 20 mg as soon as possible
following assessment and as long as they aren’t intoxicated.
The time of administering the first dose must be recorded on the treatment
PMAC in order that the staff can then give the second dose after a minimum
3 hour interval.
If a client shows any signs of alcohol withdrawal during any 24 hour period it
would suggest that the dose of Chlordiazepoxide is insufficient. In this event,
revert to the level at which the withdrawal symptoms were controlled and
maintain for a further 2 days. The remainder of the regime should also be
extended, each dose being maintained for 2 or 3 days depending on the
severity of the symptoms.
All clients should be monitored and assessed at least twice daily for the first 5
days and longer if breakthrough withdrawal has been recorded using the
Clinical Indication of Withdrawal from Alcohol (CIWA-Ar).
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Where there is a previous history of alcohol withdrawal fits, clients must be
prescribed sufficient Chlordiazepoxide to ensure that this complication does
not occur. Delirium tremens are withdrawal symptoms complicated by
disorientation, hallucinations, or delusions. Autonomic over-activity is a
potentially fatal aspect of this condition.
All clients with a recent history of excessive alcohol consumption should have
routine blood tests to check liver function (LFTs), including GGTs and a full
blood count (FBC) – at assessment.
9.
Non-compliance with Treatment
If at any time a client does not wish to comply with any of the above advice,
after explaining the risks to the client, they should be asked to sign a
disclaimer to this effect – see Trust Discharge policy. If this happens please
make your local Community Drug and Alcohol Team aware as soon as
possible.
These clients should still be monitored and reviewed for the following three
days on the ward and offered the opportunity to re-commence prescribing if
withdrawal symptoms emerge.
10.
Routine Nursing Observations
TEMPRATURE, PULSE AND BLOOD PRESSURE to be recorded TWICE
DAILY for the first 5 days of detoxification
Observations should be performed as follows as a minimum:
DAYS 1 to 5
CLINICAL MONITORING REQUIREMENTS
Observations should be performed:
•
•
Immediately before the start of the detoxification
Six hourly throughout the detoxification until the CIWA-Ar score has
been < 9 for 24 hours

AND ADDITIONALLY at 1 hour after the last dose of chlordiazepoxide
administered
Each set of observations should include:
•
•
•
•
Alcohol withdrawal scale (CIWA-Ar)
Observation of level of consciousness and orientation.
Pulse, blood pressure and temperature
Observation for dehydration & marked tremor
DAY 6 onwards
Once or more daily, as indicated, by the results of clinical progress.
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Responsibilities
It is the duty of the Trust to amend and update this document in conjunction
with any other relevant authority.
Substitute medication such as chlordiazepoxide should not be prescribed in
isolation. A multidisciplinary approach to alcohol dependency treatment is
essential. If there are concerns or queries then advice should be sought from
the specialist Drug and Alcohol teams within the Trust as soon as is
practicably possible.
If the patient is a polydrug and alcohol user, joint clinical reviews should be
undertaken regularly. This includes drug screening on admission and if
necessary during the inpatient stay.
Thorough, clearly written or computer records of
must be kept.
prescribing/administration
Notes on the CIWA-Ar
This clinical tool assesses 10 common withdrawal signs. A score of 15
+
points means the patient may be at increased risk of alcohol
withdrawal effects
such as confusion or seizures.
11.
Detoxification in Older/Physically Frail Adults
Clinicians working with older/physically frail adults need to note that a
lower cut off CIWA-Ar score is advisable for older/physically frail adults, as a
score of more than 15 may mean a potential health crisis.
Older/physically frail adults do not always show withdrawal signs in the
same way that that younger adults do. For example, older/physically frail
adults may not demonstrate signs of anxiety, shakes, or sweating.
Alternatively, the signs may be confused with other medical conditions
such as that with older adults, such as Parkinson's disease. In other
cases, the person may have some degree of cognitive impairment and
may not be able to accurately tell you how she or he is feeling. For that
reason, monitoring vital signs before withdrawal (and having a baseline of
what is normal for this person) and during withdrawal can provide very
important information.
Older/physically frail adults also tend to be prescribed lots of
medications – of which some if not all have interactions with alcohol.
Physical dependency to alcohol is significantly lowered in older/physically
frail adults so it is possible that the same amount of alcohol can have a more
detrimental effect than it would on a younger person.
Older/physically frail adults are less tolerant to alcohol because of physical
changes including:

A fall in ratio of body water to fat - less water for the alcohol to be
diluted in
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


Decreased hepatic blood flow - liver will receive more damage
Inefficiency of liver enzymes - alcohol will not be broken down as
efficiently
Altered responsiveness of the brain - alcohol will have a faster
effect on the brain
It is generally expected that an older/physically frail adult’s alcohol
detox will take at least two or three days longer than normal.
12. Summary of Changes
Date
Page
Summary of Changes
Number(s)
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Appendix 1
Clinical Institute Withdrawal Assessment Alcohol Revised Scale (CIWA-Ar)
Tremor
Nausea & vomiting
Arms extended and fingers spread apart. Observation.
1. no tremor
2. not visible, but can be felt fingertip to fingertip
3.
4.
5. moderate, with patient’s arms extended
6.
7.
8. Severe, even with arms not extended
Ask “Do you feel sick to your stomach?
Have you vomited?” Observation.
1. no nausea and no vomiting
2. mild nausea with no vomiting 2
3.
4.
5. intermittent nausea with dry heaves
6.
7. constant nausea, frequent dry heaves and vomiting
Anxiety
Paroxysmal sweats
Ask “Do you feel nervous?” Observation.
1. no anxiety, at ease
2. mildly anxious
3.
4.
5. moderately anxious, or guarded, so anxiety is inferred
6.
7.
8. equivalent to acute panic states as seen in severe
delirium or acute schizophrenic reactions
Observation
1. no sweat visible
2. barely perceptible sweating, palms moist
3.
4.
5. beads of sweat obvious on forehead
6.
7.
8. drenching sweats
Tactile disturbances
Agitation
Ask “Have you any itching, pins and needles
sensations, any burning, any numbness or do you feel
bugs crawling on or under your skin?” Observation.
1. none
2. very mild itching, pins and needles, burning or
numbness
3. mild itching, pins and needles, burning or numbness
4. moderate itching, pins and needles, burning or
numbness
5. moderately severe hallucinations
6. severe hallucinations
7. extremely severe hallucinations
8. continuous hallucinations
Observation.
1. normal activity
2. somewhat more than normal activity
3.
4.
5. moderately fidgety and restless
6.
7.
8. paces back and forth during most of the interview, or
constantly thrashes about
Visual disturbances
Ask “Does the light appear to be too bright? Is its
colour different? Does it hurt your eyes? Are you
seeing anything that is disturbing you? Are you seeing
things you know are not there?” Observation.
1. not present
2. very mild sensitivity
3. mild sensitivity
4. moderate sensitivity
5. moderately severe hallucinations
6. severe hallucinations
7. extremely severe hallucinations
8. continuous hallucinations
Auditory disturbances
Ask “Are you more aware of sounds around you? Are
they harsh? Do they frighten you? Are you hearing
anything that is disturbing you? Are you hearing things
you know are not there?” Observation.
1. not present
2. very mild harshness or ability to frighten
3. mild harshness or ability to frighten
4. moderate harshness or ability to frighten
5. moderately severe hallucinations
6. severe hallucinations
7. extremely severe hallucinations
8. continuous hallucinations
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Orientation & clouding of sensorium
Headache, fullness in head
Ask “What day is this? Where are you? Who am I?”
1. orientated and can do serial additions
2. cannot do serial additions or is uncertain about the
date
3. disorientated for date by no more than 2 calendar
days
4. disorientated for date by more than 2 calendar days
5. disorientated for place and/or person
Ask “Does your head feel different? Does it feel like
there is a band around your head?” Do not rate for
dizziness or lightheadedness. Otherwise, rate severity.
1. not present
2. very mild
3. mild
4. moderate
5. moderately severe
6. severe
7. very severe
8. extremely severe
Cumulative Score
0-8
9-14
15-20
>20
No medication is necessary
Medication is optional for patients with a
score of 8–14
A score of 15 or over requires treatment with
medication
A score of over 20 poses a strong risk of
Delirium tremens
TOTAL CIWA-Ar SCORE
/67
(Max possible score is 67)
Date:
Time (24hr):
Rater's initials:
Score
0-8
9-14
15-20
>20
= Mild
= Moderate
= High
= Severe
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Appendix 2
SEVERITY OF ALCOHOL DEPENDENCE QUESTIONAIRE (SADQ-C) 1
NAME__________________________________________
AGE___________
No._______
DATE: __________
Please recall a typical period of heavy drinking in the last 6 months.
When was this? Month:………………………………. Year……………………………..
Please answer all the following questions about your drinking by ticking your most
appropriate response.
During that period of heavy drinking
ALMOST
NEVER
(0)
SOMETIMES
OFTEN
(1)
(2)
NEARLY
ALWAYS (3)
1. The day after drinking
alcohol, I woke up feeling
sweaty.
2. The day after drinking
alcohol, my hands shook
first thing in the morning.
3. The day after drinking
alcohol, my whole body
shook violently first thing in
the morning if I didn't have
a drink.
4. The day after drinking
alcohol, I woke up
absolutely drenched in
sweat.
5. The day after drinking
alcohol, I dread waking up
in the morning.
6. The day after drinking
alcohol, I was frightened of
meeting people first thing
in the morning.
7. The day after drinking
alcohol, I felt at the edge of
despair when I awoke.
8. The day after drinking
alcohol, I felt very
frightened when I awoke.
9. The day after drinking
alcohol, I liked to have an
alcoholic drink in the
morning.
10. The day after drinking
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Implementation Date: December 2014
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Page 15 of 22
NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
ALMOST
NEVER
(0)
SOMETIMES
OFTEN
(1)
(2)
NEARLY
ALWAYS (3)
alcohol, I always gulped
my first few alcoholic
drinks down as quickly as
possible.
12. The day after drinking
alcohol, I had a very strong
craving for a drink when I
awoke.
13. I drank more than a
quarter of a bottle of spirits
in a day (OR 1 bottle of
wine OR 7 beers).
14. I drank more than half
a bottle of spirits per day
(OR 2 bottles of wine OR
15 beers).
15. I drank more than one
bottle of spirits per day
(OR 4 bottles of wine OR
30 beers)
16. I drank more than two
bottles of spirits per day
(OR 8 bottles of wine OR
60 beers)
Imagine the following situation:
1. You have been completely off drink for a few weeks
2. You then drink very heavily for two days
How would you feel the morning after those two days of drinking?
NOT AT
ALL
(0)
SLIGHTLY MODERATELY
(1)
(2)
QUITE A
LOT
(3)
17. I would start to sweat.
18. My hands would shake.
19. My body would shake.
20. I would be craving for a
drink.
SCORE
CHECKED BY:
ALCOHOL DETOX PRESCRIBED: YES/NO
NOTES ON THE USE OF THE SADQ
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Review Date: December 2017
Page 16 of 22
NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
The Severity of Alcohol Dependence Questionnaire was developed by the Addiction
Research Unit at the Maudsley Hospital. It is a measure of the severity of dependence.
The SADQ questions cover the following aspects of dependency syndrome:





physical withdrawal symptoms
affective withdrawal symptoms
relief drinking
frequency of alcohol consumption
speed of onset of withdrawal symptoms
Scoring
Answers to each question are rated on a four-point scale:
Almost never - 0
Sometimes - 1
Often - 2
Nearly always - 3
A score of 31 or higher indicates "severe alcohol dependence".
A score of 16 -30 indicates "moderate dependence"
A score of below 16 usually indicates only a mild physical dependency.
A chlordiazepoxide detoxification regime is usually indicated for someone who scores 16 or
over.
It is essential to take account of the amount of alcohol that the patient reports drinking prior
to admission as well as the result of the SADQ.
There is no correlation between the SADQ and such parameters as the MCV or GGT.
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CG/inpatient alcohol withdrawal/11/14
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Review Date: December 2017
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NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
Appendix 3
WHAT IS PABRINEX®?
Pabrinex® is used for the prevention of nerve damage caused by alcohol misuse.
It is a medication that contains high potency Vitamin B1 and C amongst others.
People who have been using a lot of alcohol lose their body stores of B Vitamins and
this can lead to nerve damage in the body and brain. In particular this nerve damage
can lead to memory loss which can sometimes be very severe. Giving Pabrinex®
should prevent the development of nerve damage.
It is especially important to use it during detoxification from alcohol, as the actual
process of detoxification itself can sometimes lead to more vitamin loss than has
occurred through drinking.
Pabrinex® is given as an injection into your muscle – ideally on the first three days of
your detoxification. The injection may sting when it is given and for a few minutes
afterwards. Very occasionally giving Pabrinex® can lead to a serious allergic reaction.
For this reason you will be asked to stay under the observation of a nurse or doctor
for 15 minutes following your injection. If you do have a reaction a doctor will
immediately be available to treat you. If you have ever had a reaction to Pabrinex®
in the past you must tell the nurse and doctor and you will not be given
Pabrinex®.
CLIENT STATEMENT
I have had the above information explained and I have understood. I have had the
opportunity to ask the doctor any further questions and I consent to the use of
Pabrinex® during the first three days of my alcohol detoxification.
Signed……………………
Name…………… Date…………..
CLIENT REFUSAL
I have been given the above information on Pabrinex® but do not wish to
receive the Pabrinex® injections; however I am happy to receive the thiamine in
tablet form.
Signed…………………… Name……………. Date…………..
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CG/inpatient alcohol withdrawal/11/14
Implementation Date: December 2014
Review Date: December 2017
Page 18 of 22
NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
Appendix 4
Advice to Clients on withdrawing from alcohol
If you have been chemically dependent on alcohol, stopping drinking causes you to
get tense, edgy, perhaps shaky or sweaty, and unable to sleep. There can be
vomiting or diarrhoea. This “rebound” of the nervous system can be severe, and in
some cases severe withdrawal symptoms have been fatal. It is therefore essential
that you give an accurate description of how much alcohol you usually drink and
where possible the strength.
1. THE MEDICATION - you have been prescribed controls the symptoms
while the body adjusts to being without alcohol. This usually takes three
to seven days from the time of your last alcoholic drink. This is why the
dose starts high and then reduces.
2. IF YOU DON’T TAKE YOUR MEDICATION, your symptoms would be
worse in the first 48 hours. You will also be at risk of more serious
complications, such as delirium tremens and seizures or fits. Clients
who have been using a lot of alcohol lose their body store of B vitamins
and this can lead to nerve damage in the body and the brain. In
particular this nerve damage can lead to memory loss which can
sometimes be very severe.
3. WHEN YOU ARE WITHDRAWING FROM ALCOHOL - you may get
thirsty. Drink fruit juices and water but do not overdo it. You do not have
to “flush” alcohol out of the body. More than three litres of fluid could be
too much. Don’t drink more than three cups of coffee or five cups of tea.
These contain caffeine which disturbs sleep and causes nervousness.
4. AIM TO AVOID STRESS - during the daytime help yourself relax by
exercising or reading a book in stages or listening to music. You should
not do strenuous exercise near to bedtime, however mild stretching
exercises may help you to relax just before bed and exercise during the
day may be beneficial.
5. SLEEP - you may find that even with the medication, or as this is
reduced, your sleep is still disturbed. You need not worry about this lack of sleep does not seriously harm you. Your sleep pattern will return
to normal in a month or so. Take a bedtime snack and a hot milky drink.
The medication may make you drowsy. If you get drowsy, please tell
the Nurse.
6. MEALS - even when you are not hungry, try to eat small amounts
regularly. Your appetite will return.
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NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
Appendix 5
CONSENT FORM 1 OF 2 PABRINEX®
PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT
Patient’s full name
Date of Birth
� Male � Female
REMEDY number
NHS number
Responsible Health Professional
Job Title
Special Requirements (e.g. Other language/other communication method)
Name of Proposed procedure or course of treatment: PABRINEX®
This is a drug used for the prevention of nerve damage caused by alcohol misuse. It
contains a high potency vitamin B1 and C amongst others. People who have been
using a lot of alcohol lose their body stores of B vitamins and this can cause nerve
damage in the body/ brain. This can cause memory loss which can be severe.
Statement of health professional
I have explained the procedure to the patient. In particular, I have explained:
Pabrinex® should prevent the development of the nerve damage. It is especially
important to use this drug during detoxification as the process of detoxification itself can
sometimes lead to more vitamin loss than has already occurred through drinking.
Pabrinex® must be given as an injection into the buttock- ideally on the first 3 days of
the detoxification. The injection may sting when it is given and for a few minutes
afterwards. It can lead occasionally to a serious allergic reaction and for this reason
you will be under observation for 15 minutes following the injection so that immediate
treatment is available should you have a reaction.
If you have ever had a reaction to Pabrinex® in the past you must tell the nurse or
doctor and you will not be given Pabrinex®. The alternative will be to receive
Thiamine in tablet form.
The intended benefits: To prevent further nerve damage and prevent memory loss
Serious or frequently occurring risks: Severe allergic reaction – Pallor and limpness
- Anaphylaxis – upper airway obstruction, swelling, tightness of chest and difficulty in
breathing. Cardiovasular – drop in blood pressure and alteration in the heart rate,
tachycardia. Skin lesions and flushing, abdominal cramps, nausea and
vomiting.unconsiousness.
Any extra procedures which may become necessary during the procedure: Close
observation for 15 minutes psot the injection to ensure emergency treatment is
immediately available
� Other procedure (please specify)
I have also discussed what the procedure is likely to involve, the benefits and risks of
any available alternative treatments (including no treatment) and any particular
concerns of this patient.
� The following leaflet/ tape has been provided if applicable
Date
Signed
Name
(PRINT) Job title
Responsible Clinician’s Signature (if different from above)
Contact details (if patient wishes to discuss options later)
Statement of interpreter (where appropriate) I have interpreted the information above
to the patient to the best of my ability and in a way in which I believe s/he can
understand.
Signed
Date
Name (PRINT)
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Implementation Date: December 2014
Review Date: December 2017
Page 20 of 22
NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
APPENDIX 5
CONSENT FORM 2 OF 2 CHLORDIAZEPOXIDE
PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT
Patient’s full name
Date of Birth
� Male � Female
REMEDYnumber
NHS number
Responsible Health Professional
Job Title
Special Requirements (e.g. Other language/other communication method)
Name of Proposed procedure or course of treatment: Chlordiazepoxide
This is a medicine used to reduce and stop the symptoms of withdrawal from alcohol. This
prevents the brain from becoming over active when the alcohol consumption is stopped by
someone who is physically dependent upon alcohol.
Statement of health professional (to be filled in by health professional with appropriate
knowledge of proposed procedure, as specified in consent policy)
I have explained the procedure to the patient. In particular, I have explained:
The intended benefits: Sedation to prevent over activity of body functions such as brain,
heart and bowels
Serious or frequently occurring risks: Rapid pulse, raised blood pressure, and vomiting
Drowsiness and light headed the day after use, confusion and unsteadiness.
Any extra procedures which may become necessary during the procedure:
� Other procedure (please specify)
I have also discussed what the procedure is likely to involve, the benefits and risks of any
available alternative treatments (including no treatment) and any particular concerns of this
patient.
� The following leaflet/ tape has been provided
Signed
Date
Name
(PRINT)
Job title
Responsible Clinician’s Signature (if different from above)
Contact details (if patient wishes to discuss options later)
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way
in which I believe s/he can understand.
Signed
Date
Name (PRINT)
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Implementation Date: December 2014
Review Date: December 2017
Page 21 of 22
APPENDIX 6
ACUTE ALCOHOL WITHDRAWAL MEDICINE MANAGEMENT
TAKE AN ALCOHOL HISTORY
►Current daily intake (e.g.500ml of 8% lager is 4 units)
►Pattern of drinking/experience of withdrawals (e.g.morning sweats,
vomiting, DTs, fits, wernicke’s encephalopathy)
►Length of history
►Check bloods U&Es, Mg2+, PO4, FBC, LFTs, MCV, blood glucose,
clotting screen, folate/B12 , and blood pressure
EXHIBITING
WITHDRAWAL SYMPTOMS
NO
Monitor. Consider PRN
Chlordiazepoxide
PABRINEX IM 1 PAIR DAILY FOR 3-5 DAYS. Mix then
administer very slowly into gluteal muscle
Prescribe Thiamine 100mg 2 tabs OM
and Vit. B Co. Strong 1 tab OM
Consider anti-emetic Domperidone
WERNICKE’S
ENCEPHALO
PATHY
Confusion,
ophthalmople
gia, ataxia
Transfer to
acute Trust.
PABRINEX TDS
for as long as
improvement
occurs
SEVERE
Withdrawal
seizures, Delirium
tremens, confusion,
vivid
hallucinations/illusi
ons, marked
tremor
DIAZEPAM
RECTAL 10mg
PRN
CHLORDIAZEPOXIDE
REGIMEN 3
SEE ALCOHOL PROTOCOL http://iconnect/policies/medicinesmanagement/prescribing-and-treatment-guidelines/
DAY
REGIMEN 1
1
2
3
4
5
6
7
8
9
10
20
15
10
10
5
5
5
20
15
10
10
5
5
20
15
10
10
5
5
REGIMEN 2
20
15
10
10
5
5
5
5
See ANAPHYLAXIS protocol
30
25
20
15
10
10
5
5
30
25
20
15
10
10
5
30
25
20
15
10
10
5
REGIMEN 3
30
25
20
15
10
10
5
5
5
40
35
30
25
20
20
15
10
5
5
40
35
30
25
20
20
15
10
5
40
35
30
25
20
20
15
10
5
40
35
30
25
20
20
15
10
5
5
DISCUSS REFERRAL TO DRUG
AND ALCOHOL TEAM
PRN CHLORDIAZEPOXIDE UP TO
20mg QDS FOR 72HR
MODERATE
Withdrawal anxiety,
agitation, irritability,
tremors, sweating,
nausea/vomiting or
retching, insomnia
MILD
Alcohol intake
>units/day,
shakes, need for
morning drink
CHLORDIAZEPOXIDE
REGIMEN 2
CHLORDIAZEPOXIDE
REGIMEN 1
Cyrrhosis or alcoholic hepatitis,
elderly, liver failure, risk of
respiratory depression? Consider
Oxazepam instead of
Chlordiazepoxide
Pregnancy? CHECK! -Liaise
with obstetric team
PRN
CHLORDIAZEPOXIDE
AND MONITOR ONLY
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