Download Alcohol Detox - Camden GP website

SPECIFICATION FOR THE
LOCAL COMMISSIONED SERVICE
FOR THE
MANAGEMENT
OF
ALCOHOL MISUSE
Date: March 2015
1
1. Introduction
Alcohol misuse is a major public health problem in Camden with high rates of
hospital admission and mortality related to alcohol.
Camden has around 12,000 higher risk drinkers who are drinking above
recommended limits, of whom around 4,000 have developed a dependency. The
impact is considerable: higher than average rates of alcohol related crimes, rates of
mortality from chronic liver disease that are nearly double the regional average, and
alcohol related hospital admissions are nearly one third higher. Addressing alcohol
misuse is one of the key priorities for Camden Health and Wellbeing Board, Camden
Clinical Commissioning Group (CCCG) and Community Safety Partnerships.
Interventions that are known to be effective in reducing alcohol misuse include:
1) Targeted screening of at-risk groups using a standard screening tool to identify
alcohol misuse
2) Brief interventions for hazardous and harmful drinkers
3) Specialist alcohol treatment and support for dependent drinkers
This Local Commissioned Service (LCS) will support these interventions in Camden
GP Practices with input from the Camden Integrated Alcohol Service.
This specification is based on the following clinical guidance from the National
Institute of Clinical Excellence (NICE):
 CG115 – Alcohol use and disorders: diagnosis, assessment and
management of harmful drinking and alcohol dependence (2011)
The Camden Alcohol LCS is specifically for the delivery of home detoxification
intervention. Screening, brief interventions and extended brief interventions are
commissioned nationally by NHS England through a Direct Enhanced Service (DES)
scheme.
Definitions
Hazardous Drinking: Drink over sensible limits but have not yet sustained adverse
health outcomes
Harmful Drinking: Drink over sensible limits and have begun to experience adverse
health outcomes
Dependent Drinking: Increased drive to use alcohol. More severe dependence is
associated with physical withdrawal symptoms.
2. Eligibility
Assisted alcohol withdrawal can be considered for people who typically drink 15 units
of alcohol per day and / or who score 20 or more on the AUDIT.
Where there are safety concerns, the community based assisted withdrawal should
be managed through a specialist alcohol service, and patients should be supported
to access these services. This includes patients with moderate dependence and
2
complex needs, or severe dependence, where the assisted withdrawal should be
offered alongside an intensive community programme.
Please see Appendix 1 and also NICE CG 115, sections 1.3.4 and 1.3.7 for exclusion
criteria for community based referral.
3. Service specification
3.1 Delivery of Home Detox Intervention
Requirements
People needing medically assisted alcohol withdrawal should be offered treatment
within the setting most appropriate to their age, the severity of alcohol dependence,
their social support and the presence of any physical or psychiatric co-morbidities.
The assisted withdrawal should be usually offered as part of a community-based
programme which should vary in intensity according to the severity of dependence,
available social support and the present of co-morbidities. The assisted withdrawal
programme should consist of a drug regime (see Appendix 1) and psychosocial
support, including motivational interviewing.
Camden Integrated Alcohol Service is able to provide GPs additional support in
delivering motivational interventions and psychosocial support to patients who are
going through assisted withdrawal programmes.
Effective and reliable “Triage Assessment” should have already been carried out to
ensure only appropriate patients receive this treatment. The assessment will cover at
minimum:
 Risk plan (including risk to self and risk to others)
 Extend of any associated health problems
 Needs for assisted withdrawal
 Interventions required
Please refer to NICE CG115, 1.2 ‘Identification and assessment’.
The medically assisted alcohol withdrawal in primary care should take place as part
of an overall integrated service offer for people who misuse alcohol. Patients who
present to medically assisted withdrawal in primary care should be offered referral to
specialist services for relapse prevention and recovery support. Where patients
refuse this type of referral, at minimum they should be encouraged to engage with
local mutual aid support groups (AA, NA) as part of the relapse prevention plan.
Further information is provided in Appendix 1.
Competency for Home Detox Intervention
All interventions for people who misuse alcohol should be delivered by appropriately
trained and competent staff. Pharmacological interventions should be administered
by a specialist and competent staff. Staff who deliver interventions should:

receive regular supervision from individuals competent in both the
intervention and supervision provided through the specialist alcohol treatment
3


services (this can be delivered as part of the team discussion regarding the
detoxification request).
routinely use outcome measurements to make sure that person who misuses
alcohol is involved in reviewing the effectiveness of treatment (the specialist
alcohol service will lead on the development of these)
engage in monitoring and evaluation of treatment adherence and practice
competence. This could be e.g. using available data on engagement with
treatment and also repeat requests for assisted withdrawal interventions, as
well as improvements in general physical and mental health.
The clinical lead is expected to have acquired and be able to demonstrate the clinical
competencies to deliver the service and to assess the training needs of themselves
and other staff involved.
Basic training in contraindications and prescribing, plus motivational interviewing
techniques, relapse prevention and management, and appropriate referral decisions
through approved training will be required.
GPs should work with a named advisor from Camden Integrated Alcohol Service.
Practices will need to demonstrate that they are competent in line with The Drug and
Alcohol National Occupational Standards (DANOS) to provide the home
detoxification service (either alone or in partnership with Camden Integrated Alcohol
Service).
Payment is a fixed IoS per patient per year
1. Delivery by competent staff member £200
Monitoring
There is currently ongoing collaboration with Camden Clinical Commissioning Group
(CCG) Contracts and Performance and Camden Public Health regarding the
monitoring. Practices are to be advised of the quality monitoring for Home Detox
Interventions.
Read codes

9NJz: - In house alcohol detoxification
and any of the following:


8HkG - Referral to specialist alcohol treatment service
8IAJ - Declined referral to specialist alcohol treatment service
‘Specialist Alcohol Treatment Service’ refers mainly to the Camden Integrated
Alcohol Service, including Assertive Outreach Team. This service provides
interventions ranging from brief interventions to relapse prevention, as well as
specialist clinical interventions. The service also provides access to peer led
interventions, and referral to peer led interventions through the specialist alcohol
team will be considered as a relevant onward referral. Other treatment providers can
be considered, including
Data Collection
4
Performance data will be collated quarterly via EMIS Payment will be made based on
the above read codes.
Practices will be advised on their progress at the end of each quarter through a
feedback report containing the alcohol misuse balanced scorecard results. Practices
will be expected to take appropriate action for the following quarterly monitoring and
show improvement, where appropriate.
4. Payment for the Management of Alcohol Misusers LCS
Payment
Practices will be paid £200 per patient for completion of a home detox intervention.
Once per year per patient.
This is capped at a total maximum expenditure of £11,000 across Camden.
5
Appendix 1 Home Detox
Mild/moderate dependence is psychological dependence with an increased drive
to use alcohol and difficulty in controlling its use. More severe dependence is
usually associated with physical withdrawal upon cessation. Detoxification is only
suitable for those seeking abstinence and should be seen as the first step
towards achieving this.1 Detoxification should be used alongside psychosocial
therapies in the context of a structured care plan.2
Medication may not be necessary if:
 The patient reports consumption is less than 15 units a day (men) or 10
units a day (women) and report neither recent withdrawal symptoms nor
recent drinking to prevent withdrawal symptoms
 The patient has no alcohol on breath test and no withdrawal symptoms 1
Community detoxification is an effective and safe treatment for patients with mild
to moderate withdrawal symptoms.
Inpatient detoxification is advised if:
 Is confused/has hallucinations
 Has a history of previously complicated withdrawal
 Has epilepsy/history of fits
 In undernourished
 Has severe vomiting/diarrhoea
 Is at risk of suicide
 Has severe dependence coupled with unwillingness to be seen daily
 Has previous failed home-assisted withdrawal
 Has uncontrollable withdrawal symptoms
 Has an acute physical/psychiatric illness
 Has multiple substance misuse
 Has an unsupportive home environment for abstinence 1
Three types of pharmacotherapy:
 Medications for treatment of withdrawal symptoms
 Medications to promote abstinence or prevent relapse
 Nutritional supplements (e.g. vitamin supplements)
Home detox should be provided according to the protocol and include:
Confirm level and recency of drinking and review contraindications
Confirm understanding and agreement to the terms and conditions before
prescribing commences (i.e. goal is abstinence, drinking must cease when
medication starts, social support is in place and significant other(s) have
received instruction, what to do if there are any untoward events /
emergencies).
 Ensure referral to post-detox psycho-social intervention is in place, with no or
very short waiting time.
 Prescription of a reducing regime of chlordiazepoxide over 3 – 7 days plus
vitamin supplementation
 Daily review by GP/PN or nurse from specialist service to assess withdrawal
and monitor for complications


1
2
SIGN, 2003
MoCAM, 2006
6



Follow-up and review: Prescription medications to prevent relapse
acamprosate or disulfiram).
Reassurance & discussion of depression. (If necessary) prescription of antidepressants at one month.
Ensure engagement with psycho-social support.
Drug regimens for assisted withdrawal (NICE CG115)
When conducting community-based assisted withdrawal programmes, use fixeddose medication regimens3.
Fixed-dose or symptom-triggered medication regimens4 can be used in assisted
withdrawal programmes in inpatient or residential settings. If a symptom-triggered
regimen is used, all staff should be competent in monitoring symptoms effectively
and the unit should have sufficient resources to allow them to do so frequently and
safely.
Prescribe and administer medication for assisted withdrawal within a standard clinical
protocol. The preferred medication for assisted withdrawal is a benzodiazepine
(chlordiazepoxide or diazepam).
In a fixed-dose regimen, titrate the initial dose of medication to the severity of alcohol
dependence and/or regular daily level of alcohol consumption. In severe alcohol
dependence higher doses will be required to adequately control withdrawal and
should be prescribed according to the SPC. Make sure there is adequate supervision
if high doses are administered. Gradually reduce the dose of the benzodiazepine
over 7–10 days to avoid alcohol withdrawal recurring.
When managing alcohol withdrawal in the community, avoid giving people who
misuse alcohol large quantities of medication to take home to prevent overdose or
diversion5. Prescribe for instalment dispensing, with no more than 2 days' medication
supplied at any time.
In a community-based assisted withdrawal programme, monitor the service user
every other day during assisted withdrawal. A family member or carer should
preferably oversee the administration of medication. Adjust the dose if severe
withdrawal symptoms or over-sedation occur.
Do not offer clomethiazole for community-based assisted withdrawal because of the
risk of overdose and misuse.
For service users having assisted withdrawal, particularly those who are more
severely alcohol dependent or those undergoing a symptom-triggered regimen,
consider using a formal measure of withdrawal symptoms such as the CIWA-Ar.
3
A fixed-dose regimen involves starting treatment with a standard dose, not defined by the
level of alcohol withdrawal, and reducing the dose to zero over 7–10 days according to a
standard protocol.
4
A symptom-triggered approach involves tailoring the drug regimen according to the severity
of withdrawal and any complications. The service user is monitored on a regular basis and
pharmacotherapy only continues as long as the service user is showing withdrawal
symptoms.
5
When the drug is being taken by someone other than for whom it was prescribed
7
If benzodiazepines are used for people with liver impairment, consider one requiring
limited liver metabolism (for example, lorazepam); start with a reduced dose and
monitor liver function carefully. Avoid using benzodiazepines for people with severe
liver impairment.
When managing withdrawal from co-existing benzodiazepine and alcohol
dependence increase the dose of benzodiazepine medication used for withdrawal.
Calculate the initial daily dose based on the requirements for alcohol withdrawal plus
the equivalent regularly used daily dose of benzodiazepine6. This is best managed
with one benzodiazepine (chlordiazepoxide or diazepam) rather than multiple
benzodiazepines. Inpatient withdrawal regimens should last for 2–3 weeks or longer,
depending on the severity of co-existing benzodiazepine dependence. When
withdrawal is managed in the community, and/or where there is a high level of
benzodiazepine dependence, the regimen should last for longer than 3 weeks,
tailored to the service user's symptoms and discomfort.
For managing unplanned acute alcohol withdrawal and complications including
delirium tremens and withdrawal-related seizures, refer to NICE clinical guideline 100
6
At the time of publication of NICE CG115 (February 2011), benzodiazepines did not have
UK marketing authorisation for this indication or for use in children and young people under
18. Informed consent should be obtained and documented. This should be done in line with
normal standards of care for patients who may lack capacity (or see NHS Wales) or in line
with normal standards in emergency care.
8