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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
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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
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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.
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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
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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.
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 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.
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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
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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.
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 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.
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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-
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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.