POLICY DOCUMENT
Policy and Protocol for Medically Assisted Alcohol Document Title Withdrawal - Community
Reference Number CG/community alcohol withdrawal/11/14
Policy Type Clinical Guideline
Electronic File/Location N:\Pharmacy\Internet
http://intranep/TeamCentre/pharm/PublishedDocuments Intranet Location /Forms/Prescribing.aspx
Status Draft
Version No/Date 1 / November 2014
Author(s) Responsible for C. Carson – Operational Services Manager Substance Writing and Monitoring Misuse (West)
Approved By and Date Medicines Management Group Nov 2014
Nov 2014 Implementation Date
Review Date Nov 2017
© North Essex Partnership University NHS Foundation Trust (2014). All rights reserved. Not to Copyright 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 ([email protected] 07800 718680) OR the National Fraud and Corruption Line 0800 028 40 60 https://www.reportnhsfraud.nhs.uk/
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Policy and Protocol for Medically Assisted Alcohol Withdrawal - Community
Version: 1 Author: Cheryl Carson Ratified/Approved by: Medicines Management Committee/Clinical Governance Group Effective from: Review Date: Targeted Audience: Community Substance Misuse Specialist Teams Circulated to the following people for consultation: Dr B. Otun, Dr B. Sharma, Dr H. Pal
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CONTENTS
Section Topic Page Number 1.0 Purpose 4 2.0 Introduction 4 3.0 Medication 4 4.0 Monitoring Requirements 5 5.0 Characteristics Of Staff Authorised To Take 7 Responsibility For The Supply Or Administration Of Medicines Under The Policy 6.0 Description Of Treatment Available Under The 7 Policy 7.0 Example Protocol For Community Alcohol 7 Detoxification With Chlordiazepoxide 8.0 Clinical Monitoring Requirements 7 9.0 Adjunctive Medication 8 10.0 Managing Adverse Outcomes 10 11.0 References 11 12.0 Summary Of Changes 11
APPENDICES APPENDIX 2 Confidentiality And Information Sharing Policy, And Comprehensive 12 Assessment APPENDIX 3 Physical Examination 41 APPENDIX 4 Contract/Consent For Alcohol Home Detoxification 44 Appendix 5 Medically Assisted Withdrawal From Alcohol Detoxification Pack 45
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1.0 PURPOSE
This policy is intended for use by NEP community drug and alcohol services only as part of a planned medically assisted alcohol withdrawal intervention. Other NEP services, which may have clients who are alcohol dependant, should refer to their local community drug and alcohol service prior to undertaking a community medically assisted alcohol withdrawal. Stand-alone medically assisted alcohol withdrawal is rarely recommended without adequate aftercare in situ
2.0 INTRODUCTION
Detoxification is only indicated in those who experience physical withdrawal symptoms such as shakes, sweats, panic, anxiety or withdrawal fits after a period of abstinence (e.g. overnight), or in those that drink to avoid such symptoms. As a rule of thumb, medication may not be required for women who drink less than 12 units per day, or men who drink less than 16 units per day. The final decision will be based on the elicitation of a history of alcohol withdrawal symptoms. No patient should ever be advised to stop drinking immediately due to the potentially life threatening complications of Delirium Tremens, seizures and Wernicke's Encephalopathy. Patients who do not require a detoxification can be advised to slowly reduce their daily intake of alcohol over a period of days or weeks, as can patients who are physically dependent but cannot or will not access detoxification.
3.0 MEDICATION
The drug of choice for control of withdrawal is chlordiazepoxide (Librium). Oxazepam may be the drug of choice for alcohol detoxification in patients with hepatic insufficiency, as it is not metabolised by the liver. Diazepam should be avoided where possible in the treatment of addictive disorders due to its greater addictive potential as compared to chlordiazepoxide. A course of parenteral thiamine (Pabrinex) should be given over the first several days of detoxification as prophylaxis against the development of Wernicke's Encephalopathy and chronic memory deficits. Wernicke's-type brain damage is highly prevalent in alcoholics as are associated memory deficits which cause permanent disability. The process of detoxification is liable to precipitate acute loss of thiamine (vitamin B1) stores in patients who are already chronically thiamine deficient. The acute effects are often subclinical, but it is likely that many chronic memory problems in alcoholic patients are the direct result of episodes of withdrawal whether this is medically assisted or not. Oral thiamine preparations may be poorly absorbed in the alcoholic patient; administration by the intramuscular or intravenous route is essential for effectiveness. The administration of glucose for the treatment of hypoglycaemia may exacerbate the acute loss of thiamine even further in the detoxifying alcoholic, and it is essential that parenteral thiamine is administered before the glucose load. Due to the small risk of anaphylaxis associated with parenteral thiamine administration, this should only be given where medication for treatment of anaphylaxis is available on-site. A presumptive diagnosis of Wernicke's Encephalopathy should be made if any of the following supervene during detoxification: ataxia, confusion, memory disturbance, hypothermia, hypotension, opthalmoplegia or nystagmus, coma/ unconsciousness. This represents a medical emergency and should result in immediate transfer to hospital, and treatment with high dose Pabrinex.
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Chlordiazepoxide - fixed-schedule regimes: For the mildly dependent alcoholic (SADQ* 10-20): 20mg qds tapered to zero over 5 to7 days. For the moderately dependent alcoholic (SADQ 20-30): 30mg qds tapered to zero over 7 days. For the severely dependent alcoholic (SADQ > 30): 40 to 50mg qds tapered to zero over 10 days.
The effect of dosages will vary from individual to individual due to physiological variations in metabolism and the effect of liver disease and cognitive deficits on sensitivity to medication. Regular monitoring by a nurse from the specialist team will allow adjustment of dosage as necessary. Patients that appear over-sedated should be advised to omit a dose of medication. Patients whose CIWA-Ar (see appendix 1) scores are consistently less than ten after the third day of detoxification should have their dosage schedule reviewed with a view to a more rapid completion of detoxification.
Pabrinex injections: One pair IM ampoules daily for the first 3 days of treatment as prophylaxis - this should be administered in the GP's surgery (with their agreement and consent) or specialist team base if the detoxification is taking place in the community, due to the unlikely eventuality of anaphylaxis occurring following IM injection. Qualified nurses from the specialist services (Substance Misuse) will administer the injections. A doctor must be present on site whilst the injections are administered. Other medication: For fits: diazepam 10mg PR or IV followed by transfer to A&E (unless on medical ward). For insomnia: zopiclone 7.5mg prn for a maximum of four weeks. General Care. Clients undergoing detoxification require lots of fluid with sugary fluids available in case of hypoglycaemia and light regular meals despite feeling anorexic. Caffeine intake should be cut down to 4-5 cups of tea or coffee a day. Agitation can be reduced if there is a quiet and ordered environment.
4.0 MONITORING REQUIREMENTS
Each set of observations should include:
Alcometer reading. Alcohol withdrawal scale (CIWA-Ar see appendix 1). Observation of level of consciousness and orientation. Pulse, blood pressure and temperature Observation for nystagmus & opthalmoplegia & ataxia. Observation for dehydration & marked tremor. With fixed-dose regimes used in community detoxification observations should be performed:
Immediately before the start of the detoxification. Twice daily on days one to five.
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As indicated thereafter. In the presence of a positive alcometer reading, chlordiazepoxide should only be commenced if withdrawal symptoms are significant (i.e. CIWA-Ar of more than 15). Patients should always be requested to have their last alcoholic drink on the night before detoxification is due to commence. If the detoxification is occurring at home, then a nurse from the local specialist substance misuse team will act as the observer, and arrange with the GP for the administration of Pabrinex in the surgery on days one to three of detoxification, and for the dispensing of chlordiazepoxide. In addition, home detoxification should only be commenced if there is a supportive spouse, family member or friend who is willing to remain continuously with the client for a minimum of 72 hours, and for the majority of the rest of the week.
CLINICAL CONDITION TO WHICH THE POLICY APPLIES
Medication as described in this policy is for use in planned community alcohol detoxification of patients who are under the care of the specialist team consultant. The inclusion criteria are a diagnosis of alcohol dependence syndrome and a pre-detoxification assessment (see appendix 2) which supports the indication of community alcohol detoxification on clinical grounds.
Exclusion criteria for treatment under the protocol are:
A: Chlordiazepoxide specific exclusion criteria
• A history of respiratory depression or acute pulmonary insufficiency. • Severe hepatic impairment. • Sleep apnoea syndrome. • Myasthenia Gravis. • Concurrent pregnancy or breast feeding. • Concomitant prescription of medication other than described in this policy. • Concomitant use of illicit substances or any CNS depressant drug (including alcohol) during detoxification.
B: General exclusion criteria
• Inadequate degree of social support (a responsible adult will need to be present on a 24 hour basis with the client for the duration of the detoxification). • A history of repeated failure to complete community detoxification. • Severe concurrent medical or psychiatric illness, or potential for detoxification-induced relapse of such illness. • A history of Delirium Tremens or alcohol withdrawal fits. • Concurrent suicidal risk. • Cognitive deficits.
The consultant should be contacted to advise on an appropriate alcohol detoxification regime if any of these exclusion criteria are present. Patients will be fully assessed by their key-worker/care coordinator in the Community Drug and Alcohol Team (CDAT) before community detoxification. Patients not wishing to receive chlordiazepoxide, or other medications named in this policy, will be offered alternative means of
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5.0 CHARACTERISTICS OF STAFF AUTHORISED TO TAKE RESPONSIBILITY FOR THE SUPPLY OR ADMINISTRATION OF MEDICINES UNDER THE POLICY
• A qualified medical doctor will be required to prescribe all medication as described in this policy. • A registered nurse or associate practitioner will be required to monitor and advise the patient and carer regarding the correct use of medication according to the terms of the policy . The patient will be responsible for their medication, and for following advice given. The consultant should be contacted in case of patients refusing to comply with care as stated in the policy after detoxification has commenced.
6.0 DESCRIPTION OF TREATMENT AVAILABLE UNDER THE POLICY
• Chlordiazepoxide. • Metoclopramide. • Zopiclone. • Diazepam. • Pabrinex. • Acamprosate. • Disulfiram. DETOXIFICATION PROTOCOLS AND WITHDRAWAL SCALES 7.0 EXAMPLE PROTOCOL FOR COMMUNITY ALCOHOL DETOXIFICATION WITH CHLORDIAZEPOXIDE X10 PAPER WORK REQUIREMENTS
Before detoxification
• Patients should have received a full assessment at CDAT, including a risk assessment. • A CDAT detoxification assessment (comprehensive substance misuse assessment and medical physical assessment, and contract must be completed (see appendix 2 &3).
During detoxification
• CDAT community alcohol detoxification pack must be completed (see appendix 4).
After detoxification
• Outcome monitoring sections of detoxification assessment package must be completed.
8.0 CLINICAL MONITORING REQUIREMENTS
• A responsible adult must be living with the patient for the duration of the detoxification. This person must be educated by the detoxification nurse or associate practitioner as to means of accessing help in the case of acute deterioration of the patient’s clinical state, both within and out of working hours. • Detoxification should always be commenced on a Monday morning. • The patient should be visited by the CDAT detoxification nurse or associate practitioner on a twice daily basis for the first five days of detoxification. A once daily visit will be sufficient in most cases on days 8 and onwards. http://intranep/TeamCentre/pharm/PublishedDocuments/Forms/Prescribing.aspx CG/community alcohol withdrawal/11/14 Approved date: Nov 2014 Review date Nov 2017 Page 8 of 58
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• The CDAT consultant should be informed of the patient’s clinical presentation on a Friday as a routine, and at any other time there is concern. In cases where there is marked concern on a Friday, following discussion with the consultant, arrangements will be made either for admission to hospital, or for home visits by a CDAT staff member to occur over the weekend.
• Each set of observations should include:
• Alcohol withdrawal scale (CIWA-Ar**). • Alcometer reading. • Observation of level of consciousness and orientation. • Pulse, blood pressure and temperature. • Observation for nystagmus & opthalmoplegia & ataxia. • Observation for dehydration & marked tremor.
• Observations should be performed as follows: Day 1, 2 & 3
AM: For one hour following Pabrinex injection (continuous observation). PM: 4 to 5 hours later.
Days 4 & 5 AM: At some point in the morning. PM: 4 to 5 hours later.
Days 8 onwards Once or more daily as indicated by clinical progress. ** The CIWA-Ar should be completed as if the observation was occurring immediately before the most recently taken dose of chlordiazepoxide. N.B. The client’s key-worker should visit the client at home on at least one occasion during the detoxification.
9.0 ADJUNCTIVE MEDICATION
Pabrinex.
One pair of IM High Potency ampoules of Pabrinex should be given IM on each of the first three days of detoxification. Pabrinex injections should be administered by the CDAT detox nurse in the patient’s GP’s surgery, with prior agreement of the GP, or at the CDAT base. The only contraindication to administration of Pabrinex is a past history of severe allergic reaction to Pabrinex.
As Required Medication to alleviate specific withdrawal symptoms
Medication to prevent relapse.
Acamprosate:
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This will be commenced as a routine on day 2 of all alcohol detoxes, as long as the patient has given informed consent for this. Dosage will be 666mg tds, unless weight is less than 60kg in which case the dose will be 666mg mane and 333mg bd.
Disulfiram: This will be commenced only if specifically identified as appropriate by the consultant during the detoxification assessment process. DETOXIFICATION PROTOCOLS AND WITHDRAWAL SCALES Commencing detoxification. If the alcometer reading is positive, then the first dose of chlordiazepoxide on the first day of detoxification should only be taken if the CIWA-Ar is > 15.
Altering the baseline regime during detoxification. i) Over-medication.
If the patient appears over-sedated on a particular regime, or if the sedation scale reads 13 or below, then the next dose of chlordiazepoxide should be omitted. If the CIWA-Ar remains below 9 for both readings on a single day, then the planned regular dosage for the following day should be replaced by that of the day after. This will have the effect of shortening the duration of detoxification by one day. For example, if the CIWA-Ar is 8 on both of Tuesday’s readings, then the schedule planned for Thursday should be administered on Wednesday, the schedule planned for Friday should be administered on Thursday etc.etc. ii) Under-medication.
If the CIWA-Ar is > 15, then the next dose of chlordiazepoxide given should be 50% greater than the planned dose (up to a maximum of 60mg in a single dose). If the CIWA-Ar is > 29, then the next dose of chlordiazepoxide should be 100% greater than the planned dose (up to a maximum of 60mg in a single dose). If the CIWA-Ar is > 39, the consultant should be contacted to discuss the case, or if he is unavailable, the client should be taken to A&E for assessment. If the CIWA-Ar remains >15 for both readings on a single day then the planned dosage for the following day should be replaced by that of the day on which the readings took place. This will have the effect of lengthening the duration of detoxification by one day. For example, if the CIWA-Ar is 16 on both of Tuesday’s readings, then the schedule for Tuesday should be administered on Wednesday, the schedule planned for Wednesday should be administered on Thursday etc. iii) Drinking during detoxification.
If the alcometer reads positive during detoxification, then the next dose of chlordiazepoxide should only be given if the CIWA-Ar is > 15. If the client drinks on 2 concurrent days during detoxification, then the detoxification should cease. In such a case, the client should be advised to continue drinking at a level of approximately 75% of their regular consumption in the week immediately preceding detoxification, and then to cut down slowly over a period of several weeks.
X10
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10.0 MANAGING ADVERSE OUTCOMES
Managing confusion and disorientation (delirium).
Confusion and disorientation can occur during detoxification as a result of several different complications of alcohol dependency. The differential diagnosis includes:
• Severe alcohol intoxication. • Delirium tremens (severe alcohol withdrawal). • Alcohol withdrawal seizure (ictal/post-ictal). • Wernicke’s Encephalopathy. • Hepatic encephalopathy. • Head injury. • Hypoglycaemia.
All of these conditions are potentially life-threatening and the occurrence of acute confusion in the detoxifying alcoholic should be treated as a medical emergency. The CDAT nurse should arrange for immediate transfer of the patient to A&E.
Wernickes Encephalopathy. A presumptive diagnosis of Wernicke’s encephalopathy should be made if any of the following supervene during detoxification: ataxia, confusion, memory disturbance, hypothermia and hypotension, opthalmoplegia or nystagmus, coma/unconsciousness.
Hepatic Encephalopathy. Hepatic encephalopathy occurs in the context of hepatic failure. As such, if this is the cause of the confusional state there will usually be evidence of liver failure evident on examination. Findings in liver failure may include liver palms, spider naevi, gynaecomastia, jaundice, ascites, oedema, cyanosis, clubbing, hepatic foetor. Blood tests may demonstrate grossly elevated liver enzymes, reduced albumin and clotting abnormalities.
The acute onset of hepatic encephalopathy is otherwise hard to differentiate from the other causes of acute confusion, although the presence of a coarse flapping tremor which occurs when the arms are outstretched and the wrists extended is indicative, although not pathognomic.
Delirium Tremens. Delirium Tremens is merely an especially severe alcohol withdrawal syndrome. However, it is also potentially fatal, and should be managed as such. The classical triad of symptoms include confusion, vivid hallucinations and illusions affecting any sensory modality and marked tremor. Prodromal symptoms include insomnia, tremulousness and fear. Onset may also be preceded by withdrawal convulsions.
Head injury. Acute extradural haematoma and chronic subdural haematoma are both more commonly occurring in alcohol dependency and both lead to the development of acute confusion which is then likely to progress to coma and death if untreated.
Acute extradural haematoma.
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The usual history is of recent head injury, with a lucid interval of some hours, followed by the development of headache and drowsiness, followed by development of signs of acutely increased intracranial pressure; the latter include raised blood pressure, bradycardia (50-60bpm), slow & deep respiration, seizures, progressing to coma and fixed, dilated pupils. The bradycardia may be replaced by a tachycardia when approaching the terminal phase.
Chronic subdural haematoma. The usual history is one of signs of chronically raised intracranial pressure which slowly increase in severity. The original head injury may have occurred weeks or months ago and have seemed trivial – as such there is often no recollection of the injury. Early signs are headache which is worse in the morning, throbbing in character and accentuated by exertion and vomiting which usually occurs at the peak of the headache. This progresses in due course to confusion, papilloedema, and false localising signs such as 6th nerve palsies, 3rd nerve palsies and extensor plantar responses.
11.0 REFERENCES
Arnedt, TJ., Conroy, DA., Brower, KJ, (2007). Treatment Options for Sleep Disturbances During Alcohol Recovery http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936493/
NICE (2010) Alcohol Disorders: Preventing the Development of Hazardous and Harmful Drinking. NICE clinical guideline 100. London: National Institute for Health and Clinical Excellence.
NICE (2011) Alcohol-use Disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115. London: National Institute for Health and Clinical Excellence.
GREAT BRITAIN. Department of Health, NATIONAL TREATMENT AGENCY FOR SUBSTANCE MISUSE. (2006) Great Britain. Department of Health London
Trathen, B et al. (2008) Guidelines for the Best Practice Treatment of Substance Misuse.
12.0 Summary of Changes Page Date Summary of Changes Number(s) November All First version 2014
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Appendix 2
Confidentiality and Information Sharing Policy This is a confidential multi-disciplinary service intended to help and support you and our policy on confidentiality is to work within the current legal frameworks. It may be helpful to share information with others to fully understand your current situation and to meet your needs. We will only share information which is relevant to your to your health and care needs. We will always respect the confidentiality of any information shared with agencies. As part of the EDAP we are required to enter data on a number of systems to record how many people are entering into treatment and what care is being offered to them. This data will not be used to identify you as an individual. Below is a list of agencies/partners who we share information with to ensure you receive the best possible care. Agency Agree to Client Comments share Signature GP
Health and Social Care services
Other treatment providers
Housing Services
Education, Training and Employment
Legal Representatives
NDTMS and local EDAP partner database/s
Criminal Justice Services
Other/s (please state)
However, whilst you can speak to the worker in confidence, he/she may be obliged to break the confidentiality of this agreement for any of the reasons stated below and notify any relevant agencies accordingly. 1) if he/she suspects there is any neglect or mistreatment of children 2) if he/she suspects that you would seriously harm yourself or cause serious harm to others 3) if you disclose details of a serious crime committed or intending to commit 4) if you disclose anything which is a risk to the safety and security within these premises 5) If there is any evidence of trafficking on these premises
We always aim to offer you the best service possible, if however you wish to make a complaint please ask any member of staff for more details
I………………………………..agree with and understand this policy regarding confidentiality and data sharing. (To be signed by client)
Client unable to sign consent form but indicates agreement Yes
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Print name…………………………………Signature…….……………………….Date……………………(Client)
Print name…………………………………Signature……………………………..Date……………………(Worker)
Current Data/Registration - To be sent to the Information Department
Confidentiality has been explained to the client and signed for by the client. Yes
Confidentiality has been explained to the client agreed and not signed for by the client. Yes
(if initial details taken face to face client must sign confidentiality, if initial details taken via phone the worker must ensure confidentiality is explained and signed for when triage takes place/is completed
By (state workers name, please print)…………………………………………………………………………………………
PLEASE NOTE! ALL FIELDS ARE MANDATORY AND FAILURE TO COMPLETE MAY CAUSE DELAY FOR THE CLIENT Referral Source (as per current NDTMS dataset codes):
Referral Date/Time: Duty Worker Name: (PRINT)
Person Referred: Mr Mrs Miss Ms
Date of Birth: Other (please state):
Surname: Marital Status:
Forenames: Gender: Male Female Address: Next of Kin: (name):
Relationship to You:
Contact Details:
National Insurance Post Code: Number (if known): Contact Details and Telephone Numbers which can be used to contact you on and e-mail address if applicable. Please state if messages can be left on this number or text message sent etc.
Ethnicity of Service User: White British Bangladeshi White Irish Any other Asian Background Any other White Background Black Caribbean White and Black Caribbean Black African White and Black African Any other Black Background White and Black Asian Chinese Any other Mixed Background Any other Ethnic Group Indian Unknown Pakistani Not stated
Nationality (please state):
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Communication issues: (state) Requires advocate and/or Is Client able to read and/or (document format) interpreter: write? (give details) e.g. large print/Braille/language Yes No (if yes state issues which) Preferred Language:
General Practitioner: Other Professional Contact/Agencies: name, address and telephone number, if not name, address and telephone number registered give advice on becoming registered and detail below
Reason for referral – Current Substance Misuse Overview and current circumstances/issues
Prompts:
Child Care Issues
Pregnancy
Criminal Justice
Mental Health Issues
Housing Status
Safeguarding (child protection)
Vulnerable Adults (specifically Learning Difficulties)
Employment/education etc
Alcohol use
Drug use
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Does the client consider themselves to have a disability Disability – Yes/no – provide details.
Is client registered disabled?
Outcome and Overview of Referral:
Triage Assessment Appointment Details: (if client is on any medication remind them to bring details of this to the assessment – not the actual medications)
Date:
Time: place:
Assessment booked with (state name) at (state location):
Previously Treated for Substance Misuse: Yes No
By Whom: (state dates, agency and area)
Dates: Agency/area:
Dates: Agency/area:
Dates: Agency/area:
Key Points (please include any identified risks)
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Is person referred aware of referral to this service? Yes No
If not aware please specify further details
Signature: ………………………………………… Designation: ……………………………………………..
Print Name: ………………………………………. Date: ……………………………………………………..
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Comprehensive Assessment / All boxes to be COMPLETED. Sign confidentiality forms if previous details not taken in person
Confidentiality has been explained to the client and signed for by the client if not previously done.
Yes……Worker Name………………………………….Worker Signature………………………Date…………………..
Location of assessment: (State premises)
Date assessment started: ______Date assessment finished: ______
Signature: ______Name of Assessor: ______
Health & Social Function: (what is daily life like)
Details of problems/needs as described by person: Current alcohol/drug use e.g. quantities/units
Affects relationships?
Effects on day-to-day functioning?
How Service User perceives the connection between substance misuse & psychological health?
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Substance Misuse / Use of alcohol and non-prescribed drugs Substance Misuse: in the last 28 days: Route: Amount: Substance Preference Age of If main substance has not been and days used in past first use: used in the last 28 days, state Past 28 day 1 = Inject, 28 days: when it was last used: 2 = Sniff, 1 = Main Substance, frequency 3 = 2 = Second Substance Smoke, 3 = Third Substance 4 = etc Oral, 5 = Other pref Number of days used out of 28 Heroin Injecting Status:
Methadone Has client ever injected Other Opiate Yes No Barbiturate Ever shared any equipment? Benzodiazepine Yes No Amphetamine Currently injecting (most days) Cocaine Powder Yes No Crack Cocaine Injected in the last 28 days? If not LSD most days Yes No Cannabis Previously injected (but not in last Solvent 28 days) Yes No Alcohol (state how long ago)
Ecstasy Age of first injecting………………. Methamphetamine Has the client previously Ketamine received Specialist Substance Mephedrone Misuse Treatment? Yes No Tobacco
Other drug - Further information can be added to the following details below section also: State name of drug, please include legal highs.
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Substance Misuse history: Prompts. Previous history, including previous engagement with drug/alcohol services?
Occasional/habitual, include quantities? How much spent per day/week? Loss of memory/control? Use alone? Safe use? I.e. sharing needles
If smoking drugs state how (pipes, bongs etc)
At what age did this become a problem for you
Alcohol consumption
Typical amount of units consumed on a drinking day in last 28 days? (use calculation below)
How long has client consumed at this level?
How much does the client’s drinking cost per week? (Approximately)
How many hours after waking does the client usually have their first drink?
At what age did your drinking become a problem for you…………………………………………………………….
Does client experience withdrawals on alcohol free days? Yes No
If yes, which of the following symptoms does the client experience? (please tick all that apply)
Tremor/shakes Sensory disturbance (e.g. visual/auditory) Sweats Epileptic form fits/seizures Nausea Blackouts Agitation/anxiety
Does client have any peripheral neuritis symptoms or diagnosis? Yes No http://intranep/TeamCentre/pharm/PublishedDocuments/Forms/Prescribing.aspx CG/community alcohol withdrawal/11/14 Approved date: Nov 2014 Review date Nov 2017 Page 21 of 58
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Details of symptoms and details of any diagnosis in comments box
Other physical problems including gastric and liver conditions (detail in comments box) Yes No
Comments re answers above and/or prompts: Prompts Blood Forms? Or has the client had a recent test
Out-patients appt?
Where does client do his/her drinking?
With whom does the client drink?
When did the client view their drinking as being a problem
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Continuation Page regarding substance use and/or alcohol consumption (please use if required and state page number that you are continuing from)
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Health & Social Function / Cultural, Pastoral and Spiritual needs: Special diet? Religion: Yes No Needs related to customs or Other cultural issues relevant to presentation and notes re observances? prompts: Yes No Other cultural needs? Yes No If Yes specify in text box (left)
Health & Social Function / Carer’s Needs: Prompts
Describe carer’s (including young Is there a Carer for you? Yes No carers) situation and needs Are you a carer? Yes No Carer’s assessment to action Assessment Offered: Yes No (Action – please state which assessment is offered) (CPA Form 17 & 18)
Client welfare workers Assessment Date / details / additional information:
Potential referrals to:- Social care Benefits
Family support
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Health & Social Function: Prompts
Details of dependent / Parental Status:- non- dependent children How many children under 18yrs of age, living with Client:- Are any school age
children attending school Please circle number 1 2 3 4 5
Name (s) DOB (s): Ages Status of children if not living with client, 1) fostered, adopted, with partner etc 2)
Formally consider 3) safeguarding if 4) Vulnerable persons in the home? 5) children and young people Significant others Marital relationships Is service user in a
Client / Partner Pregnant? Yes No relationship? (if partner is pregnant ask if substance misuse referral is appropriate) Any stresses/difficulties? Referral taken: Yes No Not required Difficult (state why) relationships/stresses Level of support needed
Antenatal Care in place for client or partner? If not action, & advise accordingly.
If the client has children that do not live with them please include details in notes section including who the children live with, if the client has any care responsibility and/or contact.
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Notes re prompts
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Employment Status: Prompts
e.g. pensioner, housewife/husband or Regular employment: Yes No disabled
Average number of hours worked per week……………. Is the client an ex armed forces/service man/woman Unemployed: Yes No
Student: Yes No
Economically inactive*: Yes No
How do you spend your day? Additional Comments: (see prompts) Employment situation (length, permanent, part-time) Occupation / work history Difficulties in work Is help required to regain or maintain employment? Courses Leisure Networks Service User’s aspirations for work, leisure and networks
Consider client welfare worker
Does the client have training/educational needs: Yes: No: Involvement of others
Referred On?
Numeracy / Literacy Skills? Comments:- Interested in voluntary work?
Life Skills
Client Welfare
Aspirations
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Financial Status: (Cross Reference with TOPs) Prompts
What is your main source/sources of income? Budgeting? Are you managing bills?
Legitimate paid work Funding habit? How do you pay for Benefits your drugs? Selling Drugs Shoplifting Burglary Handling Stolen Goods Are you dealing/trading Fraud Auto Crime B Begging St Street Robbery Other (details below) Income
Benefits, pensions, are you aware of
entitlements
Is client a Sex Worker? Yes No
If Yes, Selling sex on the street? Yes No
Selling sex from premises? Yes No Advice / Information re: BBV services re sex worker question
Indicate if client refused to answer?
Financial Status (Debt Problems) Safety information?
Advice / Information
CAB, etc.
Job Centre Plus
In house welfare services Details of current benefits
Comments/additional info re prompts
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Accommodation Need: Prompts
Please indicate current housing situation:- Referral to Housing Support? NFA Living on Streets Refer to homeless housing centre? Use night Hostels Housing situation – type of If “yes” how many nights per week …………… Housing, tenure etc. Sleep on a difference friends floor each night Housing history – frequent
moves/difficulties Staying with friends/family as a short term guest Night winter shelter Problems with accommodation Direct Access short say hostel Need for adaptation? Short term B&B or other hotel Squatting Is help required?
Is support required to maintain
a tenancy? Local Auth (LA) Registered Social Landlord (RSL) Rented
Private Rented Is client living alone? Approved premises If client is living with someone Supported Housing / Hostel please state who in comments Traveller
Own Property Settled with Friends or Family
Comments:
Criminal Justice History: Prompts Previous Conviction: Yes No Sentence details? Cautions (incl. Conditional Cautions)? Details Community Orders? DRR/ATRs
Prison Sentences? previous convictions, index offence, details of whether victim known, dates, sentence
How Service User perceives connections between their CJH & Current circumstances
Current Legal Situation: Pending? Details: Have they got any court dates coming up?
DRR/ATRs
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Probation? Police? Solicitor?
Family History - Substance Misuse: Prompts
Substance Misuse Yes No Mother, Father, siblings, extended family etc
Dual Diagnosis Yes No
Alcohol Yes No
Comments:
Psychological Health: Prompts
Anxiety Dual Diagnosis Yes No (currently in contact with Mental Health services if so Depression provide detail) Mood swings
History of contact with mental
health services?
History of non-compliance with treatment?
Describe mood swings e.g. extremes of ‘highs’ or ‘lows’. Describe depressive mood and Comments re prompts ideation e.g. guilt feelings, low self- esteem, suicidal thoughts.
Any previous suicide attempts
Describe any problem with anxiety or fear e.g. panic attacks, undue fear of everyday things or events Has the client reduced their involvement in everyday activities or interests? Has their appetite decreased? Difficulties sleeping? Describe any difficulties with
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Concentration? Referral on required?
Does client believe they have a mental health issue?
Current Medication: Prompts Name Dose Source taken for Does the client experience any side effects?
Regular medication
Contraception
Over the Counter or prescribed?
Who is prescribing?
Does the client purchase any medication/remedies via the internet?
Detail medications, dosage, frequency etc.,
Notes Does client purchase prescription drugs via a dealer?
Does the client take medication belonging to a friend or relative?
Significant Life Events: Prompts This can include triggers which brought the client into this treatment episode Including any relevant to current state
Involvement with other authorities: e.g. Social Services, Probation, Police
Divorce, Marriage
Domestic Violence
Assault, Robbery, Abuse
Childhood abuse
Birth/Loss of children
Employment / Redundancy
Housing loss
Physical Health Problems
Bereavement
Post traumatic stress
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General Health Care Assessment: Prompts Section 1 – Sexuality: Significant illnesses? Heterosexual Homosexual Bi-sexual Smear status in Women, 25 – 65yrs Other Not stated olds?
STIs (GUM)
Sexual Health/History: Treatment of any of these conditions?
Current use of or need for
contraception?
Comments: Referred on?
Liaison if necessary
General Health Care Assessment: Prompts Section 2 – Dental Health & Diet: Significant illnesses?
Treatment of any of these conditions?
Are client registered with a Dental
Practice? (refer)
Discuss balanced diet?
Comments: Eating disorders (past or current)
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General Health Care Assessment: Section 3 – BBV: Prompts Hepatitis C: Significant illnesses? 1. Have you been tested for Hep C? Yes No
Treatment of any of 2. If so when, (if exact date unknown please put year): ………………. these conditions? If already tested what was the result? ……………….
Signpost and refer to
3. Would you like a Hep C Test? Yes No Not Appropriate Services, i.e.: GUM Clinic, or local 4. If not appropriate state why Already tested provision, providing Already diagnosed these services?
Already in treatment
Hepatitis B:
1. Have you had a Hep B Vaccination Yes No
If YES, did you complete the course/post course blood test & when? (state details below)
2. Have you been tested for Hep B? Yes No
If so when, (if exact date unknown please put year): ………………...
If already tested what was the result …………………
3. Would you like a Hep B Test? Yes No Not appropriate If no to completing all doses and post course blood test refer onwards 4. If not appropriate state why Already tested
Already diagnosed
Already in treatment
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HIV:
1. Have you been tested for HIV? Yes No
2. When, (if exact date unknown please put year): ..………………..
3. Would you like a HIV Test? Yes No
If already tested please circle result…..POSITIVE.….NEGATIVE..…DECLINED TO COMMENT
Comments - If referred on where to Referred on Yes No
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General Health Care Assessment: Prompts
Section 4 - Risky behaviours:
History of overdose Yes No Were overdose episodes considered (if yes please give detail can include drugs, alcohol medication etc) by the client to be accidental or
intentional?
Significant illnesses?
Treatment of any of these conditions?
Overdose advice & information? History of associated injecting problems?
Overview of injecting sites Cellulites, ulcer, abscess?
Septicaemia, endocarditis?
Deep Vain Thrombosis, Pulmonary Embolism
Treatment of any of these conditions?
Please indicate area’s of concern?
Front Back
Comments: Actions taken?
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Overall Summary of Assessment Prompts
Biological Psychological Social
Criminal Justice
For NHS Services – on completing please sign, print name and date
Has an advocate been offered? Yes No
Has a Carers Assessment been offered? Yes No
Has a Direct Payment been discussed / offered? Yes No
Has the client made an Advanced Directive? Yes No
Would the client like assistance to make an Advanced Directive? Yes No
Does the client require an Independent Mental Capacity Advocate? Yes No
Has Family Group Conferencing been offered? (only available in Yes No Essex Local Authority)
Signature Print Name Date
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Interim Care Plan Prompt
Specialist prescribing
Range of Prescribing interventions
(N.I.C.E.)
Structured psychosocial interventions – CBT, Coping skills training, relapse prevention, MI, contingency
management (the modality start date
is the date of the first formal and time limited appt)
Other structured drug treatment
(regular one-to-one sessions with Keyworker)
Harm reduction activities as integrated to care planned treatment BBVs and sexual health
Residential / home detox
Access for rehabilitation via CC Grant
Needs to be completed at assessment
Appointments for treatment added Clients signature
Referred on information
Client’s Signature: ………………………. Date: ……………………..
Worker’s Signature: ……………………… Date: ……………………..
Worker Name (print)……………………… Date……………………….
Copy offered: Yes No
Copy taken by client Yes No
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Signature: ...... Designation: ......
Print Name: ...... Date: ......
Extension Page 1 – this page is to continue any section where space does not allow for full details to be included, or to complete BTEI-ITEP map or Genogram.
If using this as an extension page please state page number, section title, date and your name (print and sign for each extension section) E
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Signature: ...... Designation: ......
Print Name: ...... Date: ......
Extension Page 1 – this page is to continue any section where space does not allow for full details to be included, or to complete BTEI-ITEP map or Genogram.
If using this as an extension page please state page number, section title, date and your name (print and sign for each extension section) E
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Signature: ...... Designation: ......
Print Name: ...... Date: ......
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Appendix 3
PHYSICAL EXAMINATION General Health NAME DOB
DATE NDTMS NUMBER
GENERAL OBSERVATIONS
Jaundice: Needle marks: Angular stomatitis: Spider Naevi:
Gynaecomastia: Teeth: Lacrimation: Conjunctival infusion:
Sweating: Variceal markers: Peripheral circulation:
SYSTEMS REVIEW CARDIOVASCULAR SYSTEM
Pulse: BP: Heart Sounds: Murmurs:
RESPIRATORY SYSTEM
Air entry: Breath sounds: Chest expansion:
ABDOMEN
Consistency: Organomegaly:
Ascites: Tenderness:
Bowel sounds:
CENTRAL NERVOUS SYSTEM:
Gait: Tremor: Coordination:
Cranial nerves:
Any other comments:
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MOTOR SYSTEM:
Right: Left:
Tone:
Upper limb: Lower limb:
Power:
Upper limb: Lower limb:
Reflexes:
Biceps:
Triceps:
Knee:
Ankle:
Plantar:
Sensory system:
Cerebellar signs:
Investigations:
BBV’s:
ECG:
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Name DOB Date NDTMS Number
MENTAL STATE EXAMINATION
FORENSIC HISTORY (Current legal status/pending cases/convictions)
MENTAL STATE Appearance and behaviour:
Speech:
Mood:
Thought: (form/content/suicide/homicide)
Perception:
Cognition function:
Orientation:
Attention and concentration:
Immediate and 5 minute recall:
Long term memory:
Insight:
Mental health problems:
Addiction problems:
Motivation:
Any other comments:
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Appendix 4
Contract/consent for ALCOHOL HOME DETOXIFICATION
Please sign and date this form as a statement that you agree to undergo detoxification at home and will comply with the following conditions
That you will not drink alcohol during the agreed periods of detoxification and will comply with regular breath-analyser recording by CDAT staff.
That you will take the medication prescribed and agreed by your GP/CDAT, and as indicated by staff.
Should you test positive for alcohol that you allow CDAT staff to remove any remaining medication.
That you will allow CDAT staff to visit your home daily as arranged to supervise and monitor the detoxification, check your progress and carry out baseline observations e.g.BP as required
That you agree to have blood tests to check your physical condition as required.
If you are a driver As you are in need of alcohol detoxification, it is your legal responsibility to inform the DVLA of your situation.
...... Signature of Client Signature of key-worker
Date: ...... Date: ......
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Appendix 5
Medically Assisted Withdrawal from Alcohol Detoxification Pack
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Surname Date of birth Forename Reference no
CDAT COMMUNITY ALCOHOL DETOXIFICATION
Client name Client age/DOB CDAT Care Co-ordinator/Keyworker CDAT Detox Nurse General Practitioner Name Client’s Postcode
Detoxification commence on Detoxification ceased on
MCV
GGT
BP Lying Standing
Contents:
Medication charts Summary monitoring charts CIWA-Ar Sedation scales
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Surname Date of birth Forename Reference no
CHLORDIAZEPOXIDE REGIME
DAY 1 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig:
DAY 2 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig: ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
DAY 3 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig: ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
DAY 4 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig:
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ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
Surname Date of birth Forename Reference no
DAY 5 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig: ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
DAY 6 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig: ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
DAY 7 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig: ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
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DAY 8 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig: ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
Surname Date of birth Forename Reference no
DAY 9 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig: ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
DAY 10 CHLORDIAZEPOXIDE Dose Date : Mg Dr Sig. Morning Time: Noon Dose: Date of sig Evening CIWA: Night Sig: ACAMPROSATE Date :
Morning Time: Afternoon Dose: Night Sig:
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Surname Date of birth Forename Reference no
AS REQUIRED MEDICINES (ONLY IF REQUIRED)
Dr Sig. ZOPICLONE Day 7.5 mg Date NOCTE Date of Morning (at night) for sig sleeplessness Lunch Evening Bedtime
Dr Sig. METOCLOPRAMIDE Day 10 mg tds orally as required Date Date of Morning sig Lunch Evening Bedtime
Dr Sig. DIAZEPAM Day 10 mg PR for Date FITS Date of Morning sig Lunch Evening Bedtime
Dr Sig. CHLORDIAZEPOXIDE Day PO 5 mg-30mg qds if Date Date of Undermedication Morning sig (as directed in protocol). Lunch Evening Bedtime
ONCE ONLY MEDICATION
Date to Drug Dose Route Dr Sig Given by Date Time be given PABRINEX 1 + 1 IM PABRINEX 1 + 1 IM PABRINEX 1 + 1 IM
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Surname Date of birth Forename Reference no
OBSERVATIONS & SCALES OBSERVATIONS
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Surname Date of birth Forename Reference no
Detox Day 1 Day 2 Day 3 Day 4 Day 5 Start Date Date RESPIRATORY Time RATE 30-25 (breaths per minute) 24-20 19-15 14-10 <10 PULSE >180 (beats per minute) 180 160 140 130 120 110 100 90 80 80 70 60 50 40 30 <30 BLOOD >240 PRESSURE 240 (MM HG) 230 220 200 180 180 170 160 150 140 130 120 110 100 80 80 70 60 60 <60 TEMPERATURE C
ALCOMETER
COMMENTS
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Surname Date of birth Forename Reference no
CIWA-Ar
NAUSEA & VOMITTING – Ask “Do you feel sick to your AUDITORY DISTURBANCES – Ask “Are you more aware of stomach? Have you vomited?” sounds around you? Are they harsh? Do they frighten you? Observation. Are you hearing anything that is disturbing you? Are you 0 no nausea and no vomiting hearing things you know are not there?” 1 mild nausea with no vomiting Observation> 2 0 not present 3 3 1 very mild harshness or ability to frighten 4 intermittent nausea with dry heaves 2 mild harshness or ability to frighten 5 5 3 moderate harshness or ability to frighten 6 6 4 moderately severe hallucinations 7 constant nausea, frequent dry heaves and vomiting 5 severe hallucinations 6 extremely severe hallucinations TREMOR – Arms extended and fingers spread apart. 7 continuous hallucinations Observation. 0 no tremor VISUAL DISTURBANCES – Ask “does the light appear to be 1 not visible, but can be felt fingertip to fingertip too bright? Is its colour different? Does it hurt your eyes? 2 2 Are you seeing anything that is disturbing you? Are you 3 3 seeing things you know are not there?” 4 moderate, with patient’s arms extended Observation. 5 5 0 not present 6 6 1 very mild sensitivity 7 Severe, even with arms not extended 2 mild sensitivity 3 moderate sensitivity PAROXYSMAL SWEATS 4 moderately severe hallucinations Observation. 5 severe hallucinations 0 no sweat visible. 6 extremely severe hallucinations 1 barely perceptible sweating, palms moist 7 continuous hallucinations 2 2 3 3 HEADACHE, FULLNESS IN HEAD – Ask “Does your head feel 4 beads of sweat obvious on forehead different? Does it feel like there is a band around your 5 head?” Do not rate for dizziness or light-headedness. 6 6 Otherwise, rate severity. 7 drenching sweat 0 not present 1 very mild ANXIETY – Ask “Do you feel nervous?” 2 mild Observation. 3 moderate 0 no anxiety, at ease 4 moderately sever 1 mildly anxious 5 severe 2 2 6 very severe 3 3 7 extremely severe 4 moderately anxious, or guarded, so anxiety is inferred 5 5 ORIENTATION 7 CLOUDING OF SENSORIUM – Ask “What 6 6 day is this? Where are you? Who am I ?” 7 equivalent to acute panic states as seen in severe delirium 0 orientated and can do serial additions or acute schizophrenic reactions 1 cannot do serial additions or is uncertain about the date 2 disorientated for date by no more than 2 calendar days AGITATION 3 disorientated for date by more than 2 calendar days Observation. 4 disorientated for place and/or person 0 normal activity 1 somewhat more than normal activity 2 2 3 3 4 moderately fidgety and restless 5 5 6 6 7 paces back and forth during most of the interview, or constantly thrashes about
TACTILE DISTURBANCES – Ask “Have you any itching, pins TOTAL CIWA-Ar SCORE and needles sensations, any burning, any numbness or do you feel bugs crawling on or under your skin?” (Max possible score is 67) Observation. 0 none 1 very mild itching, pins and needles, burning or numbness DATE: http://intranep/TeamCentre/pharm/PublishedDocuments/Forms/Prescribing.aspx CG/community alcohol withdrawal/11/14 Approved date: Nov 2014 Review date Nov 2017 Page 52 of 58
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2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations TIME: (24hr) 6 extremely severe hallucinations 7 continuous hallucinations Rater’s initials:______
CUMULATIVE SCORE 0-8 No medication is necessary 9-14 Medication is optional for patients with a score of 8– 14 15-20 A score of 15 or over requires treatment with medication >20 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:
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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 circling your most appropriate response.
During that period of heavy drinking 1. The day after drinking alcohol, I woke up feeling sweaty. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
2. The day after drinking alcohol, my hands shook first thing in the morning. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
3. The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn't have a drink. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
4. The day after drinking alcohol, I woke up absolutely drenched in sweat. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
5. The day after drinking alcohol, I dread waking up in the morning. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
6. The day after drinking alcohol, I was frightened of meeting people first thing in the morning. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
7. The day after drinking alcohol, I felt at the edge of despair when I awoke. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
8. The day after drinking alcohol, I felt very frightened when I awoke. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
9. The day after drinking alcohol, I liked to have an alcoholic drink in the morning. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
10. The day after drinking alcohol, I always gulped my first few alcoholic drinks down as quickly as possible. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
11. The day after drinking alcohol, I drank more alcohol to get rid of the shakes. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS
1 Stockwell, T., Sitharan, T., McGrath, D. & Lang, (1994). The measurement of alcohol dependence and impaired control in community samples. Addiction, 89, 167-174.
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12. The day after drinking alcohol, I had a very strong craving for a drink when I awoke. ALMOST NEVER SOMETIMES OFTEN ALMOST ALWAYS
13. I drank more than a quarter of a bottle of spirits in a day (OR 1 bottle of wine OR 7 beers). ALMOST NEVER SOMETIMES OFTEN ALMOST ALWAYS
14. I drank more than half a bottle of spirits per day (OR 2 bottles of wine OR 15 beers). ALMOST NEVER SOMETIMES OFTEN ALMOST ALWAYS
15. I drank more than one bottle of spirits per day (OR 4 bottles of wine OR 30 beers). ALMOST NEVER SOMETIMES OFTEN ALMOST ALWAYS
16. I drank more than two bottles of spirits per day (OR 8 bottles of wine OR 60 beers) ALMOST NEVER SOMETIMES OFTEN ALMOST ALWAYS
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?
17. I would start to sweat. NOT AT ALL SLIGHTLY MODERATELY QUITE A LOT
18. My hands would shake. NOT AT ALL SLIGHTLY MODERATELY QUITE A LOT
19. My body would shake. NOT AT ALL SLIGHTLY MODERATELY QUITE A LOT
20. I would be craving for a drink. NOT AT ALL SLIGHTLY MODERATELY QUITE A LOT
SCORE
CHECKED BY:
ALCOHOL DETOX PRESCRIBED: YES/NO
NOTES ON THE USE OF THE SADQ 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: http://intranep/TeamCentre/pharm/PublishedDocuments/Forms/Prescribing.aspx CG/community alcohol withdrawal/11/14 Approved date: Nov 2014 Review date Nov 2017 Page 55 of 58
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· 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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Advice to Patients 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.
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.
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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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