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Formulary and Prescribing Guidelines

SECTION 10: MANAGEMENT OF , AND

BENZODIAZEPINE DEPENDENCE

10. Treatment of dependence

10.1 Introduction

One unit of alcohol () is equivalent to 8 grams of ethanol. Calculating units of alcohol follows the formula; Number of units = Volume (in litres) x Strength ABV () and invaluable when estimating levels of dependence and planning treatment for medically assisted .

Following alcohol consumption, it takes between 10 and 100 minutes for alcohol to reach peak levels. One unit of alcohol increases the Blood Alcohol Concentration by 15-30 mg/dl. Alcohol’s rate of elimination follows zero-order kinetics (around one unit per hour).

10.2 Management of acute alcohol withdrawal and Wernicke’s encephalopathy

The management of acute alcohol withdrawal and Wernicke’s encephalopathy (WE) should be considered together. Only 10% of patients with WE experience the classic tetrad of symptoms (i.e. , ophthalmoplegia, and ) and therefore all patients being treated for acute alcohol withdrawal should also be treated for WE1.

10.2.1 Acute alcohol withdrawal syndrome Following periods of excessive alcohol consumption, a drop in blood-alcohol concentration may precipitate withdrawal syndrome. The first symptoms of alcohol withdrawal usually appear within hours (5-8) of the last intake of alcohol and peak over 24-48 hours. The alcohol withdrawal syndrome may be a continuum from simple with relatively mild signs/symptoms through to hallucinations, or the life threatening tremens. It is important to remember that all have the additional risk of lowering the threshold, which is a particular concern in alcohol withdrawal1.

Signs and symptoms of alcohol withdrawal Symptoms may be seen within hours of the last drink and may develop before the blood alcohol level has fallen to zero. Symptoms outlined below may vary in severity, commonly peaking at 10 to 30 hours and usually subsiding by 40 to 50 hours.

Common features of alcohol withdrawal include:  Tremor of hands, tongue, eyelids  , , diarrhoea  Fever, sweating, flushing  , agitation,  Fleeting hallucinations   Convulsions

Less common features include:  Hypertension   Paraesthesia  Suicidal ideation 2

For Approval by Medicines Management Group November 2016 10. Treatment of dependence

Delirium Tremens (DTs) DTs occur in about 5% of individuals during alcohol withdrawal but account for the highest level of morbidity and mortality1. Onset of symptoms usually occurs 2–3 days following cessation or reduction in alcohol consumption and this represents a medical emergency. Prevention and treatment is through prompt diagnosis, admission and the administration of high dose ().

DTs are fatal in 15-20% of inappropriately managed cases, usually due to respiratory and cardiovascular collapse or cardiac arrhythmias. Patients most at risk are those with tachycardia, a high fever (> 39.9C/ 104F), dehydration with an associated illness (pneumonia/pancreatitis), general debility or where the diagnosis is delayed. Appropriate management reduces mortality to about 1%.

Patients suspected of having or Wernicke’s syndrome should be transferred to an acute medical hospital. wards do not have the facilities for administering IV fluids and these conditions are also often associated with inter-current illnesses such as electrolyte imbalances and chest infections.

Common features of delirium tremens include:  Severe tremor  Systolic hypertension  Tachycardia: > 100/min  Fever, with or without infection: temp > 38.3C/ 101F  Sometimes convulsions  Severe hallucinations which often evoke extreme fear (usually visual but may be tactile or auditory)  Clouding of consciousness  Confusion, disorientation  Agitation, violent behaviour  Delusions  Delirium  Insomnia

Place of Detoxification Community Detoxification There should be suitable support and monitoring at home, preferably by a close relative. Treatment should be discussed with both the patient and supporting individual. If the patient resumes drinking during the detoxification, the process should be stopped and inpatient detoxification should be considered as the next option. If features of DTs/seizures present, emergency medical treatment should be sought.

When conducting community-based assisted withdrawal programmes, a fixed- dose regimen should be used. 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.

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence

When managing alcohol withdrawal in the community, avoid giving people who misuse alcohol large quantities of medication to take home to prevent overdose or diversion. Prescribe for instalment dispensing, with no more than 2 days’ medication supplied at any time. Do not offer for community- based assisted withdrawal because of the risk of overdose and misuse.

Inpatient Detoxification An inpatient or residential assisted withdrawal should be considered if a service user meets one or more of the following criteria:

 drinking over 30 units of alcohol per day  have a score of more than 30 on the SADQ (Appendix 1)  have a history of , or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes  need concurrent withdrawal from alcohol and benzodiazepines

The presence of significant psychiatric or physical comorbidities (for example, chronic severe depression, , , congestive cardiac failure, unstable angina, chronic disease) or a significant learning disability or cognitive impairment should warrant inpatient detoxification even at lower levels of alcohol use (between 15 and 20 units of alcohol per day). A lower threshold for inpatient or residential assisted withdrawal should also be considered for vulnerable groups, for example; homeless and older adults.

Fixed-dose or symptom-triggered medication regimens can be used in assisted withdrawal programmes in inpatient or residential settings. A symptom-triggered approach involves tailoring the 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. 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 (Appendix 2). In a fixed- dose regimen, one should titrate the initial dose of medication to the severity of 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. There should be adequate supervision if high doses are administered. A gradual reduction of the dose of the over seven to ten days is advised to avoid alcohol withdrawal recurring.

Benzodiazepine doses may need to be reduced for children and young people, older people and people with liver impairment

Choice of Benzodiazepine Chlordiazepoxide has a lower potential of abuse than and is therefore the benzodiazepine of choice for the management of alcohol withdrawal. Intravenous diazepam or has a more rapid onset of effect so may be preferred where urgent control is required. Oral equivalences for common benzodiazepines can be found in the most current edition of the BNF.

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence

Algorithm for management of acute alcohol withdrawal symptoms1 (See also, the algorithm for the Management of Wernicke’s encephalopathy, 10.1.2 if necessary)

Levels of dependence can be estimated according to the daily units of alcohol used and the scores in the Severity of Alcohol Dependence Questionnaire (SADQ).10, (Appendix 1)

People with mild dependence usually do not need assisted alcohol withdrawal. People with moderate dependence (with a SADQ score of between 20 and 30) usually need assisted alcohol withdrawal, which can typically be managed in community setting unless there are other risks. People who are severely alcohol dependent (with a SADQ score of more than 30) will need assisted alcohol withdrawal, typically in an inpatient or residential setting. Readers are also referred to WHO AUDIT11 for further guidance.

Severity Number of SADQ Chlordiazepoxide units/day score (estimated starting dose)

Moderate 15 - 30 20- 30 15 – 30 mg QDS

Severe 30 - 40 31 – 44 30 – 40 mg QDS

Very severe 40 - 60 >45 > 40 mg QDS

Mild dependence Requires small doses of chlordiazepoxide or may even be managed without medication.

Moderate dependence 15-30 units/day A typical regime might be 15-30mg QDS, reducing gradually over 5-7 days. Note that 5-7 days treatment is adequate and longer treatment is rarely helpful or necessary. The table below is an example of an outpatient regime.

Day Dose A client may be on the same dose for a day or two depending on clinical need, presentation and therapeutic 1 20mg QDS response. In cases of more severe objective withdrawal 2 15mg QDS up to 20mg PRN (split across the doses if needed) can be given in the first 48 hours if required. 3 10mg QDS 4 10mg BD 100mg TDS and Vitamin B Co strong tablets (2 5 10mg OD tablets three times daily) may be prescribed for the prevention of WE.

Severe dependence > 30 units/day (inpatient) Severely dependent patients should get 7-10 days treatment with the flexibility of ‘as required’ medication for the first 2 days. If symptoms are controlled within the first 2 days it will be easier to implement the reducing regime. Patients who have DTs, head injury or cognitive impairment may need lengthier withdrawal regimes. Intensive daily monitoring is advised for the first 3 days. The intention of flexible dosing is to titrate dosage against symptoms.

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence

The following are examples of a fixed-dose regimen for severe (7-10 days) and very severe dependence (9 -14 days)

Severe Very Severe Day Dose Day Dose

1 30mg QDS 1 40mg QDS + 40mg PRN divided

2 25mg QDS 2 40mg QDS 3 20mg QDS 3 35mg QDS 4 15 mg QDS 4 30mg QDS

5 10mg QDS 5 25mg QDS

6 10mg TDS 6 20mg QDS 7 10 mg BD 7 15mg QDS 8 10 mg OD 8 10mg QDS 9 10 mg TDS

10 10mg BD

11 10mg OD

Options that may be considered in difficult to manage cases  Doses of chlordiazepoxide >300mg per day may be given only after consultant review. (Monitor ECG, blood pressure, pulse oximetry (<90%), respiratory rate (<10/min) and temperature when giving high dose benzodiazepines)

 Many mental health units use PR diazepam for seizure control. If IV diazepam (or IV fluids) are necessary the patient needs to be in an acute medical hospital.

 If delirium tremens develops in a patient during treatment for acute alcohol withdrawal, review drug regimen. In people with delirium tremens, oral lorazepam should be offered as a first line treatment. If symptoms persist or oral medication is declined, give IM lorazepam, haloperidol or and exclude comorbid acute medical conditions. Care must be taken if using IM lorazepam and olanzapine. ONE hour must be left between doses of the two

 In individuals with alcohol withdrawal seizures, consider offering a quick- acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures. (inpatient setting only, see also SPC) may also be considered. Staff in the inpatient setting should be familiar with administration of rectal diazepam should a withdrawal seizure occur.

 If benzodiazepines are used for people with liver impairment, consider one requiring limited liver (for example, lorazepam); start with a reduced dose and monitor liver function carefully. Avoid using benzodiazepines for people with severe liver impairment. is another option. 6

For Approval by Medicines Management Group November 2016 10. Treatment of dependence

 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 benzodiazepine. 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.

 Consider an (caution required due to lowered seizure threshold) in a patient with delirium who is distressed or considered a risk to themselves or others and if verbal and non-verbal de-escalation techniques are ineffective. This should normally be for a short-term only (usually for 1 week or less). Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson’s disease or with Lewy bodies (DLB). Patients with DLB (more common in men) may be extremely sensitive to antipsychotics, which may result in a sudden onset of EPSEs, profound confusion and deterioration, and can lead to . Do not use . Usual choice is haloperidol PO 5mg TDS or IM equivalent. Maximum 12mg IM or 20mg PO in 24 hours (consider lower doses in the elderly). The recommended starting dose for haloperidol in most liver units, (i.e. in patients with underlying liver disease) is 1.5 – 2mg TDS, although treatment with benzodiazepines should be the priority.

 Monitor closely blood pressure and heart rate. Diastolic blood pressure and/or heart rate above 100 may indicate the need to administer higher doses of benzodiazepines.

 Beta-blockers may be helpful where there is sympathetic over activity. Consider atenolol 50mg daily.

 Avoid carbohydrate loads where possible (e.g. IV Dextrose) in chronic alcohol abusers as this will deplete thiamine reserves and may precipitate Wernicke’s encephalopathy. Always administer parenteral Pabrinex before administering glucose in all patients with altered mental state

 Always consider the risk of re-feeding syndrome and monitor appropriately (see relevant chapter in eating Disorders section)

 Carefully monitor for electrolyte imbalances and especially for potassium, , phosphate and magnesium levels. Consider an ECG and early referral to a medical ward when significant abnormalities are detected.

 Carry out a medication review for people taking multiple drugs, taking into account both the type and number of .

 The FDA has warned of a serious risk of death when benzodiazepines are used in combination with Opioid analgesic or cough preparations.14

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence

10.2.2 Wernicke’s Encephalopathy4 Wernicke’s encephalopathy (WE) occurs in approximately 12.5% of alcohol misusers and is fatal in approximately 17% of untreated cases. Permanent brain damage (Korsakoff’s psychosis) occurs in approximately 85% of inappropriately managed survivors, 25% of whom require long-term institutionalisation. WE and Korsakoff’s psychosis can be prevented through the identification of those at risk, and the administration of parenteral B vitamins. Failure to treat WE may constitute negligence. Damages of £500,000 and more have been awarded to cover long- term care costs in patients who have developed Korsakoff’s psychosis as a result of inappropriate management of WE. Patients suspected of having Delirium Tremens or Wernicke’s syndrome should be transferred to an acute medical hospital. Mental Health wards do not have facilities for administering IV fluids and these conditions are also often associated with inter-current illness such as electrolyte imbalance and chest infection.

Algorithm for the management of Wernicke’s encephalopathy4

Known/suspected chronic alcohol misuser

Any ONE or more from: (the classic triad of symptoms only occur in 10% of patients) - ataxia - and - confusion - ophthalmoplegia and or nystagmus - memory disturbances - or unconsciousness

NO YES

Prophylactic treatment of Presumptive diagnosis of Wernicke’s encephalopathy Wernicke’s encephalopathy

Give Pabrinex IV, TWO pairs of ampoules Give Pabrinex IM or IV, ONE THREE times a day for TWO to THREE pair of ampoules ONCE a day days, then ONE pair daily for THREE to for THREE to FIVE days. FIVE days, or until improvement of clinical symptoms stops.

Prescribe oral B vitamins (even if parenteral vitamins refused): Thiamine (100mg TDS) and Vitamin B compound strong (TWO tablets three times daily). Review oral prescription after SIX weeks.

Intramuscular Administration of Pabrinex The contents of one ampoule number 1 and one ampoule number 2 of Pabrinex Intramuscular High (total 7ml) are drawn up into a syringe to mix them

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence

just before use, then injected slowly high into the gluteal muscle, 5cm below the iliac crest.IM administration is therefore only suitable for prophylactic treatment.

There is a small risk of anaphylaxis when Pabrinex is administered. Facilities to manage anaphylaxis must be available. The incidence of anaphylactic reactions to IM Pabrinex is estimated to be 1 in 5 million pairs of ampoules. Given the nature of Wernicke’s encephalopathy, the benefit to risk ratio favours parenteral thiamine and fears about using it should not result in inappropriate use of oral thiamine.

10.2.3 Observations Each set of observations should consist of:

 BP  Pulse  Respiratory rate  Applying the CIWA-Ar alcohol withdrawal scale (if appropriate see Appendix 2)

If the patient is asleep, they should not be woken for observations. However, it should be recorded that they were asleep.

Nutritional support and close monitoring of fluid balance are important. Nutrition is especially important within a few hours following parenteral thiamine administration (i.e. Pabrinex).

Urea and electrolytes (including magnesium) should be regularly checked.

The first 24 hours Observations should be carried out at least four times daily during the first 24 hours. This is also to determine the dose of chlordiazepoxide that should be administered. In complicated patients (e.g. those with DTs), consider monitoring and dosing at this frequency beyond the first 24 hours.

Contact the prescriber if tachycardia or hypertensive.

Days 2 to 6 Observations should be carried out TWICE daily from days 2 to 6. This may be more frequent if any complications are seen. These observations are solely for the purpose of monitoring the patient and not for the administration of chlordiazepoxide. The patient should be on a set reducing regime from Day 2.

10.2.4 Drugs for maintaining Abstinence3,4 After a successful withdrawal of people with moderate and severe alcohol dependence, consider offering , or oral in combination with an individual psychological intervention (cognitive behavioural , behavioural therapies or social network and environment-based therapies) focused specifically on alcohol misuse

Behavioural couple’s should be offered to service users who have a regular partner and whose partner is willing to participate in treatment. Before starting treatment with acamprosate, oral naltrexone or disulfiram, conduct a

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence comprehensive medical assessment (baseline urea and electrolytes and liver function tests including gamma glutamyl transferase [GGT]). In particular, consider any contraindications or cautions (see the SPC), and discuss these with the service user.

Acamprosate Acamprosate has been shown to increase abstinence rates in people receiving treatment for alcohol dependence by 10-20% (40% at best). Evidence suggests the intended actions of acamprosate are maintained over 1 year but not beyond. It should be initiated as soon as possible after abstinence has been achieved and should be maintained if the patient relapses. Contraindications include severe renal or hepatic failure so functions tests should be performed prior to initiation. Avoid in those who are pregnant or . Refer to BNF/SPC for full details

Acamprosate is usually prescribed at a dose of 1998mg (666mg three times a day) unless the service user weighs less than 60 kg, and then a maximum of 1332mg should be prescribed per day.

Acamprosate should usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it. It should be stopped if drinking persists 4–6 weeks after starting the drug.

Service users taking acamprosate should stay under supervision, at least monthly, for 6 months, and at reduced but regular intervals if the drug is continued after 6 months.

Do not use blood tests routinely, but consider them to monitor for recovery of liver function and as a motivational aid for service users to show improvement.

Disulfiram

Disulfiram inhibits aldehyde dehydrogenase, leading to an acetaldehyde (ethanol) accumulation after drinking alcohol which can cause unpleasant physical effects. Continued drinking can lead to arrhythmias, hypotension and collapse. Disulfiram appears to reduce the number of drinking days but not to increase abstinence. Supervised consumption may improve efficacy. Contra-indications for using disulfiram include cardiac failure, coronary artery disease, and history of cerebrovascular accident, hypertension, psychosis, severe and risk. Disulfiram should not be continued for more than six months without a review. Refer to BNF/SPC for full details.

After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering disulfiram in combination with a psychological intervention to service users who have a goal of abstinence but for whom acamprosate and oral naltrexone are not suitable, or prefer disulfiram and understand the relative risks of taking the drug

If using disulfiram, start treatment at least 24 hours after the last consumed. Usually prescribe at a dose of 200 mg per day. For service users who continue to drink, if a dose of 200 mg (taken regularly for at least 1 week) does not cause a sufficiently unpleasant reaction to deter drinking, consider increasing the dose in consultation with the service user.

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence

Before starting treatment with disulfiram, test liver function, urea and electrolytes to assess for liver or renal impairment. Check the SPC for warnings and contraindications in .

Make sure that service users taking disulfiram stay under supervision, at least every 2 weeks for the first 2 months, then monthly for the following 4 months. If possible, they should have a family member or carer, who is properly informed about the use of disulfiram, oversee the administration of the drug. Service users on disulfiram should be medically monitored at least every 6 months after the initial 6 months of treatment and monitoring.

Warn service users taking disulfiram, and their families and carers, about:  The interaction between disulfiram and alcohol (which may also be found in food, perfume, mouthwash etc.), the symptoms of which may include flushing, nausea, and, more seriously, arrhythmias, hypotension and collapse.

 The rapid and unpredictable onset of the rare of ; advise service users that if they feel unwell or develop a fever or jaundice that they should stop taking disulfiram and seek urgent medical attention.

Naltrexone Naltrexone is a non-selective and has UK marketing authorisation for treatment of alcohol dependence Naltrexone is thought to reduce pleasurable effects of alcohol due to its propensity to block the release of endogenous and reduce dopaminergic activity. Thus naltrexone reduces alcohol’s rewarding effects and motivation to drink or “cravings”. Naltrexone is shown to reduce the number of drinking days and the amount of alcohol consumed in those who are still drinking or have just relapsed. Naltrexone should not be stopped if drinking resumes unless drinking persists for longer than 4-6 weeks. It should not be started in patients known or suspected of being dependent on including , or and analgesia such as tramadol, or other containing agents. Naltrexone will precipitate acute opiate withdrawal in these patients.

It is usually prescribed after alcohol detoxification .though patients who are less dependent or drinking harmfully also benefit. Start prescribing at a dose of 25 mg per day and aim for a maintenance dose of 50 mg per day. It can also be prescribed on an as needed basis to reduce heavy drinking in those patients who do not require immediate detoxification. LFTs should be monitored monthly with this administration. Draw the service user’s attention to the information card that is issued with oral naltrexone about its impact on opioid-based analgesics.

Oral naltrexone should usually be prescribed for up to 6 months or longer for those benefiting from the drug who wish to continue with it. It should be stopped if drinking persists 4–6 weeks after starting the drug.

Service users taking oral naltrexone should stay under supervision, at least monthly for 6 months and at reduced but regular intervals if the drug is continued after 6 months. Do not use blood tests routinely, but consider them for older people, for people with obesity, for monitoring recovery of liver function and as a motivational aid for service users to show improvement. If the service user feels unwell advise them to stop the oral naltrexone immediately. 11

For Approval by Medicines Management Group November 2016 10. Treatment of dependence

Nalmefene

Nalmefene is an opioid antagonist with a different pharmacological profile to naltrexone at the three opioid receptor subtypes. Nalmefene exhibits antagonist activity at the mu and delta opioid receptors, and partial activity at the kappa opioid receptors. Nalmefene has a marketing authorisation in the UK for 'the reduction of alcohol consumption in adult patients with alcohol dependence who have a high drinking risk level without physical withdrawal symptoms and who do not require immediate detoxification'. It may have a better safety profile than Naltrexone with less risk of liver .

Nalmefene is recommended within its marketing authorisation, as an option for reducing alcohol consumption, for people with a milder form of alcohol dependence:

who have a high drinking risk level (between 5-10 units/daily for women and 7- 12units/daily for men). be) without physical withdrawal Symptoms and therefore do not require alcohol detoxification.

The marketing authorisation states that nalmefene should: only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption and be initiated only in patients who continue to have a high drinking risk level 2 weeks after initial assessment. It therefore should not be prescribed for inpatients. Any prescribing by trust community teams should be in consultation with CDAS.

Other medications: Benzodiazepines should only be used for managing alcohol withdrawal and not as ongoing treatment for alcohol dependence.

Do not use (including selective reuptake inhibitors [SSRIs]) routinely for the treatment of alcohol misuse alone.

Do not use gammahydroxybutyrate (GHB / ) for the treatment of alcohol misuse.

10.2.5 Acute Injury(AKI) Patients who misuse drugs and alcohol are at risk of AKI via a number of mechanisms including: dehydration due to , muscle breakdown from immobilisation, thrombosis (especially for intravenous drug misuse), amyloidosis from “skin popping” and the direct effects of drugs. For further information refer to Guidance for Mental Health Professionals on the management of Acute Kidney Injury

10.2.6 National Services The DVLA must be informed about all patients with any form of alcohol problems Alcoholics Anonymous (Available 10am to 10pm, 7 days a week) Tel: 0845 769 7555 www.alcoholics-anonymous.org.uk

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence

Drinkline (Available 24 hours a day, 7 days a week) Tel 0800 917 8282

10.3 Approved drugs for the treatment of opioid dependence

Drug2 Formulations2 Methadone 1mg/ml Sugar Solution 1mg/ml Sugar Free Solution Buprenorphine S/L tabs 0.4mg, 2mg, 8mg Buprenorphine + (Suboxone) S/L tabs (2mg + 0.5mg), (8mg + 2mg)

10.4 NICE Clinical Guidelines

NICE TA114, January 2007. Methadone and Buprenorphine for the management of opioid dependence5

Methadone and buprenorphine using flexible dosing regimens are recommended as options for maintenance therapy in the management of opioid dependence. Methadone should never be prescribed to a patient without first consulting the Community Drug Team for on-going care. It is not necessary to prescribe out of hours. If absolutely necessary, small doses of codeine or can be used. Titration (initiation) of methadone must only be performed in conjunction with specialists. Remember is NOT a life-threatening condition, opioid toxicity can be fatal.

The decision of which drug to prescribe should be made on a case by case basis, taking into account a number of factors. These include history of opioid dependence, commitment to a particular long-term management strategy, an estimate of the risks and benefits of each treatment made by the responsible clinician in consultation with the patient, physical health status, motivation and whether the patient is pregnant or breastfeeding. If both drugs are equally suitable, methadone may be preferred if the client agrees.

Methadone particulars2,3 Methadone is a synthetic opioid receptor agonist with pharmacological activity similar to that of . The ‘British national formulary’ (BNF) states that methadone should be used in opioid dependence at an initial dose of 10–40mg daily, which is increased by up to 10mg daily (with a maximum weekly increase of 30mg) until no signs of withdrawal or intoxication are seen. The usual maintenance dose range is 60–120mg daily.

Methadone is available as an oral solution (1mg/ml), an oral concentrate (10mg/ml), tablets or injectable ampoules. Only oral formulations of methadone are considered in this guidance. Administering methadone orally avoids the risks associated with injecting. Methadone has a long elimination half-life (usually 20–37 hours), which allows for a once- daily dosing schedule. Methadone appears to have no serious long-term side effects associated with chronic administration. In people stabilised on a methadone maintenance regimen, the drug does not have the pronounced effects seen with shorter-acting opioids.

Methadone is metabolised primarily by CYP3A4, but also by CYP2D. In addition, methadone induces its’ own metabolism. Some drugs, including , phenytoin,

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence and some antiviral drugs used in the treatment of HIV infection, speed up the metabolism of methadone from the body (enzyme inducers). Other drugs, such as , , , may have the opposite effect on methadone metabolism (enzyme inhibitors). Knowledge of these interactions usually enables the appropriate adjustment of methadone dose for effective treatment. For full details of side effects, contraindications and drug interactions, see the SPC.

Initiation of treatment with methadone presents a potential risk of respiratory depression and should be undertaken with care. Interactions between methadone and other respiratory such as alcohol, benzodiazepines and the newer non- benzodiazepine (Z-drugs), other or antidepressants may also induce serious respiratory depression.

Clients should be advised as follows:

 MOST OCCUR BY MIXING METHADONE & OTHER SEDATIVES (e.g. alcohol, benzodiazepines, antidepressants). Do not mix drugs  Overdoses are most common after a period of not using opiates (opiate naive), so use less than you normally would. You can always use more if not strong enough  Be careful when using a drug for the first time. If you do not know how a new drug will work for you, use small amounts and do not mix with other drugs

There is a risk of death early in methadone treatment as a result of excessive initial doses, failing to recognise cumulative effects, giving methadone to people with impaired liver function (due to chronic ) or failing to inform patients of the dangers of overdose if they are using other drugs at the same time. The relatively slow onset of action and long half-life means methadone overdose and toxic effects may become life threatening several hours after a dose is taken.

During the initiation phase, the methadone dose should be adjusted carefully in order to eliminate drug craving and prevent withdrawal while avoiding the risk of intoxication or overdose. This process needs to be monitored by a doctor or trained nurse, and may require regular visits by the patient to a community prescribing centre. Initially patients may need to be seen at least fortnightly, but when they are stable, the frequency of assessment can be reduced.

Methadone is considered to increase the QT interval. In 2006 the MHRA recommended that patients on methadone and with additional risk factors for QT prolongation (heart or liver disease, electrolyte imbalances, treatment with CYP3A4 inhibitors or other medicines causing QT prolongation) should be closely monitored. Similarly, any patient requiring more than 100 mg of methadone should be monitored for evidence of increased QTc

Buprenorphine particulars2,3 Buprenorphine is chemically distinct from methadone. Buprenorphine has a higher affinity for opioid receptors and this reduces the impact of additional illicit diamorphine (including heroin) or other opiate use by preventing these drugs from binding to the opioid receptors. The long half-life and high affinity of buprenorphine for opioid receptors means that it has a prolonged duration of action at higher doses which can allow alternate-day dosing regimens. Buprenorphine also has a relatively good safety profile. Even higher than normal therapeutic doses rarely result in clinically significant respiratory depression because of its partial agonist activity at the opioid receptor involved with respiratory function. Due to its high receptor binding affinity, it is more difficult to displace

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For Approval by Medicines Management Group November 2016 10. Treatment of dependence buprenorphine from receptor binding sites using opiate antagonists (e.g. naloxone) in comparison with other opiate such as methadone. The safety of buprenorphine mixed with high doses of other drugs such as alcohol or benzodiazepines remains unclear. Starting buprenorphine treatment in opioid-dependent clients may precipitate symptoms of withdrawal because buprenorphine displaces any residual opiate agonists from the opiate receptor sites. For full details of side effects and contraindications, see the SPC. Buprenorphine has abuse potential as tablets can be crushed before being injected. The introduction of buprenorphine and naloxone (Suboxone) may reduce this potential.

Methadone and buprenorphine should ideally be administered daily under supervision, for at least the first 3months of treatment. Supervision should be relaxed only when the patient’s compliance is assured and illicit substance use has stopped. Both drugs should be given as part of a programme of supportive care.

Opioid dependent patients may have co-morbid psychiatric conditions. A thorough psychiatric assessment should be carried out before starting substitution therapy. Some patients may develop psychosis, depressive or anxiety symptoms during the withdrawal phase and therefore they should be carefully monitored.

NICE TA115, January. 2007. Naltrexone for the management of opioid dependence6

Naltrexone is recommended as a treatment option in detoxified formerly opioid-dependent people who are highly motivated to remain in an abstinence programme. Naltrexone should only be administered under adequate supervision to people who have been fully informed of the potential adverse effects of treatment. It should be given as part of a programme of supportive care. The effectiveness of naltrexone in preventing opioid misuse in people being treated should be reviewed regularly. Discontinuation of naltrexone treatment should be considered if there is evidence of such misuse.

Naltrexone Naltrexone is an opioid antagonist with a high affinity for opioid receptors. It competitively displaces opioid agonists, blocking the euphoric and other effects of opioids minimising the positive rewards associated with their use. It is postulated that Naltrexone reduces the pleasurable effects of alcohol by blocking the effects of opioids released by alcohol that enhance release in the mesolimbic system.

NICE CG52, July 2007. Drug misuse – opioid detoxification7

Methadone or buprenorphine should be offered as the first-line treatment in opioid detoxification. When deciding between these medications, healthcare professionals should take into account:

 Whether the service user is receiving maintenance treatment with methadone or buprenorphine; if so, opioid detoxification should normally be started with the same medication  The preference of the service user.

Lofexidine may be considered for people:

 Who have made an informed and clinically appropriate decision not to use methadone or buprenorphine for detoxification

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 Who have made an informed and clinically appropriate decision to detoxify within a short time period  With mild or uncertain dependence (including young people).

Clonidine should not be used routinely in opioid detoxification.

Dihydrocodeine should not be used routinely in opioid detoxification

Dosage and duration of detoxification When determining the starting dose, duration and regimen (for example, linear or stepped) of opioid detoxification, healthcare professionals, in discussion with the service user should take into account the:

 Severity of dependence (particular caution should be exercised where there is uncertainty about dependence)  Stability of the service user (including polydrug and alcohol use, and comorbid mental health problems)  Pharmacology of the chosen detoxification medication and any adjunctive medication  Setting in which detoxification is conducted.

The duration of opioid detoxification should normally be up to 4 weeks in an inpatient/residential setting and up to 12 weeks in a community setting.

Ultra-rapid, rapid or accelerated detoxification SEPT does not undertake Ultra-rapid, rapid or accelerated detoxification Ultra-rapid and rapid detoxification using precipitated withdrawal should not be routinely offered. This is because of the complex adjunctive medication and the high level of nursing and medical supervision required. Accelerated detoxification, using opioid antagonists at lower doses to shorten detoxification, should not be routinely offered. This is because of the increased severity of withdrawal symptoms and the risks associated with the increased use of adjunctive medications.

Adjunctive medications When prescribing adjunctive medications during opioid detoxification, healthcare professionals should:

 Only use them when clinically indicated, such as when agitation, nausea, insomnia, pain and/or diarrhoea are present  Use the minimum effective dosage and number of drugs needed to manage symptoms  Be alert to the risks of adjunctive medications, as well as interactions between them and with the opioid agonist.

Monitoring of detoxification medication Healthcare professionals should be aware that medications used in opioid detoxification are open to risks of misuse and diversion in all settings (including prisons), and should consider:

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 Monitoring of medication concordance  Methods of limiting the risk of diversion where necessary, including supervised consumption.

10.5 Opioid Detoxification for General Inpatient

The following opioid detoxification algorithms are for patients who present for general medical hospital treatment. Methadone should never be prescribed to a patient without first consulting the Community Drug Team. It is not necessary to prescribe out of hours. Opioid withdrawal is not a life-threatening condition, opioid toxicity is.

Patient claiming or known to be dependent on

morphine, heroin or other opioids

Is the patient on a supervised methadone program? Yes

Call Community Drug Team Contact Community Drug to confirm dose of Team for further advice No methadone

Yes No Dose Is patien pregnant? confirmed Dose confirmed No Yes

Prescribe Buprenorphine s/l tabs Prescribe methadone. as follows: Ensure today’s dose not Day 1 4 mg already consumed in Day 2 8 mg community *produced Day 3 8 mg In consultation with Dr Luty, Day 4 6 mg Consultant in addictions Day 5 4 mg Day 6 2 mg Day 7 0.8mg NB: Do not supply methadone as a TTA. Patient to resume usual methadone program on discharge unless If patient is discharged prior to completing CDAS confirms hospital is to programme, buprenorphine should not be supply. prescribed as a TTA. Refer to community services 10.6 Methadone and Buprenorphine prescribing guidelines

The guidelines are primarily for use by the Community Drug and Alcohol Services and GPs working with them.

Goals and Objectives of Substitute Prescribing Treatment The goals of substitute prescribing are to reduce the health, social, economic and legal consequences of illegal opiate use to the individual and the community.

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The objectives of substitute prescribing are:

 To reduce illegal use of opiates  To reduce other drug use  To improve the health of the client  To help reduce the spread of infectious diseases associated with illegal opiate use, especially HIV, Hep B and Hep C  To reduce death associated with illegal opiate use  To reduce crime associated with illegal opiate use  To facilitate an improvement in social functioning  To make the environment a safer place to live in

Substitute Prescribing Treatment Approaches The Community Drug & Alcohol Service (CDAS) is committed to providing a range of interventions that are flexible enough to meet the needs of clients and to respond to changes during the treatment course.

Short and long-term goals, which are constructed around a hierarchy of drug misuse behaviour change are the main factors which influence substitute-prescribing treatment. The ultimate aim, where possible, is to stop addiction to opiates.

Substitute prescribing treatment approaches are therefore individually tailored to meet a client’s severity of dependence and other related problems or difficulties (health, social, legal and economic).

Although substitute prescribing is a major element of treatment, it is just one component that should be used in conjunction with other care planned approaches that include counselling, other psychotherapeutic interventions and other services linked within the care planning approach.

Screening of Clients for Substitute Prescribing Treatment Screening is the initial stage where the member of the team determines whether a client is eligible and suitable for substitute prescribing treatment and allows the client to make an informed decision whether or not to accept treatment. The screening process is designed to speed up admissions into treatment and to prevent unsuitable clients being held on long waiting lists

Written screening procedure should include the following areas:

OPIATE DEPENDENCY – It should be determined that a person is opiate dependant, taking into account the actual drug of misuse, amount and frequency. Failure to provide a urine sample automatically disqualifies the client from admission to the program.

SUITABILITY FOR SUBSTITUTE PRESCRIBING TREATMENT – A clinical judgment should be made that substitute-prescribing treatment is indicated. Substitute prescribing is the treatment of choice for opiate dependency and should not be given to non-opiate dependent individuals. Poly-drug users, who are misusing a range of drugs and are opiate dependent, should be considered for substitute prescribing treatment with a view to controlling the opiate dependency.

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DOUBLE SCRIPTING – The GPs should be informed to check that the individual is not receiving substitute prescribing elsewhere.

PREVIOUS TREATMENT - Any previous treatment for drug dependency should be investigated, including reason for discharge.

INFORMED CONSENT – Client must fully understand and agree to the treatment offered.

AGE – The person must be old enough to give informed consent; if under the age of 16 years, consent from Parents or Legal Guardian is required. (See Policy on Working with Young People)

COMPLICATING FACTORS such as mental illness, HIV/ AIDS, pregnancy, hepatitis are not contra-indications to substitute prescribing treatment, but will require additional and/or specific management.

Prescribing agreement Initially all clients will be given a substitute prescription on a daily dispensing basis with supervision until after the first review (usually after three months).

Clients will be informed that the safety and security of substitute prescribing is their sole responsibility and that under no circumstances will repeat prescription(s) be issued.

A prescription sheet will only be given to the client and not a Third Party unless an agreement exists with the clients regular pharmacy where scripts may be posted or delivered.

If a client does not collect his/her prescription sheet on the day it is due, the pharmacist should be informed to dispense only the remaining dosage. The Client must be informed of this.

A joint working agreement should be agreed upon and all clients should be registered with a GP.

Prescribing for pregnant service users If a pregnant opiate user is seeking substitute prescribing, all attempts should be made to find a prescriber as soon as practicable.

The initial screening should focus on immediate needs so that clients can be admitted onto the program as quickly as possible. In the first trimester clients are at risk of spontaneous and should be titrated with adequate doses as quickly as possible to prevent withdrawal. Dose changes can be made in the second trimester when the pregnancy is more stable. In the third trimester due to increase surface area, increased levels of hormones and foetal demands, doses may need to be increased to prevent withdrawal symptoms which may precipitate premature labour.

If a client is already taking buprenorphine they can continue to do so following informed consent and advice that the safety of buprenorphine in pregnancy has not been demonstrated. There is more experience on the safety of methadone in pregnancy.

All staff to read this in conjunction with policy on ‘Working with Pregnant Women who Misuse Drugs’.

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Urine/saliva screening All clients are required to undergo a urine /saliva screen for opiates prior to admission to a substitute prescribing treatment program and/or at regular intervals.

Urine/ for illegal drugs is one method of monitoring client’s treatment progress. Testing is useful to detect whether unsanctioned opiate use is occurring or whether the prescribed substitute prescription is being taken or diverted. Positive tests may also signal low and/or ineffective substitute prescribing dose levels.

Apart from the initial urine/saliva screening for admission to treatment, tests are only useful when conducted randomly and checked to ensure that client urine has not be substituted. Significant treatment decisions should not be based solely on urine/saliva testing and never on the basis of just one positive result. Clients should be tested randomly unless there are strong arguments for more regular testing. Absence of the substitute prescribed after random testing will also result in exclusion from the program.

Clients rights and staff responsibilities All clients should receive professional and courteous care and be treated with dignity and respect. Clients have the right to leave treatment at any time and to be detoxified from substitute prescribing or other drugs within the program. Staff are obliged to advise clients of the advantages and disadvantages of withdrawing from substitute prescribing or other drug treatment.

Clients have the right to have details of their treatment kept confidential in accordance with Professional Code of Conduct and Health Service arrangements. Clients have the right to be informed about the medical implications of taking substitute prescribing or other prescribed drugs. All clients have the right to participate in the process of devising their own treatment plans and setting both short and long goals. Clients should have access to the CDAS Complaints Procedure.

Disqualification from the programme If a client misses three consecutive appointments arranged with his/her counsellor or the medical officer then the client will be disqualified from the programme and a rapid withdrawal will be offered unless a valid reason is provided.

Physical abuse or threat/actual assault on CDAS personnel or anyone attending CDAS premises may result in disqualification from the programme.

Where a client makes discriminating remarks to CDAS personnel or others attending premises on the grounds of racial origin, sexuality or gender then the client may be dismissed from treatment.

Wilful damage to property belonging to the service or premises occupied by the Service may also result in dismissal from the programme.

A negative urine/saliva test for substitute prescribing substance disqualifies the client from the programme.

The principles underlying treatment for drug misuse and dependence in the UK can be found in the “Orange” Guidelines (Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive)

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(http://www.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf)

10.7 Treatment of benzodiazepine dependence

 Confirm that benzodiazepine dependence is present – patient should have at least one benzodiazepine positive urine drug screen within the last few weeks and be in receipt of long-term prescription for benzodiazepine (at least 3 months for established dependence)  Prescribing should be for a short time and with a clear goal in mind  Benzodiazepines need to be taken daily (rather than binge consumption).  Only prescribe one Benzodiazepine at a time. If using more than one Benzodiazepine change to one preparation.  Convert all Benzodiazepines to Diazepam (because of longer ½ life, and wider range of tablet strengths for small dose increments). Benzodiazepine conversion equivalents: Diazepam 5mg = Chlordiazepoxide 15 mg = Lorazepam 0.5–1 mg = 5 mg = oxazepam 15 mg = 10 mg (BNF 70)  Aim for lowest dose possible. Very rarely should dose exceed Diazepam 30 mg (or equivalent) daily  The patient should not be intoxicated, ‘stoned’ or drowsy during the day.  If insomnia continues to be a problem, use a non-Benzodiazepine for a short period (up to 2 weeks)  The Ashton manual9 is a useful reference source  Reduce the daily dose by 1/10-1/8 dose every 2 weeks or 2 mg every 2 weeks  If prescriptions have been lost or the drugs have been used before the next is due they should not be repeated.  Prescription from multiple sources can be problematic. There should be in place an agreement with primary care colleagues about which service will be the sole prescriber and will be monitoring progression of the reduction programme

Signs and symptoms of Benzodiazepine withdrawal8 Symptoms Signs Increased psychomotor activity, agitation, muscular Anxiety, depression, , incoherent weakness, tremulousness, hyperpyrexia, diaphoresis, thoughts, hostility, grandiosity, disorientation, delirium, convulsions, elevated blood pressure, pulse and tactile, auditory and visual hallucinations, temperature, tremor of eyelids, tongue and hands suicidal thoughts

Example: Switching from to diazepam

Clonazepam (Intermediate acting) Diazepam (Long acting) 0.5mg 5mg 1mg 10mg 8mg 80mg

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Maudsley Guidelines  1-2 mg clonazepam = 10mg diazepam

National Prescribing Services Limited (www.nps.org)  0.5mg clonazepam = 5mg diazepam  Go for 1mg clonazepam = 10mg diazepam  Switch intermediate acting clonazepam to long acting diazepam. This will provoke less severe withdrawal.  Half lives of benzodiazepines vary greatly  Degree of sedation induced also varies  Variability in half life and sedation makes it difficult to determine exact equivalents  Exclude hepatic dysfunction as diazepam may accumulate to toxic levels. Diazepam substitution may not be appropriate in this group of patients

Dose reduction (suggested taper schedule)  Convert clonazepam to diazepam  8mg clonazepam = 80mg diazepam  Reduce by 10mg every 1-2 weeks, down to a daily dose of 50mg  Reduce by 5mg every 1-2 weeks, to a daily dose of 30mg  Reduce by 2mg every 1-2 weeks, to a daily dose of 20mg  Reduce by 1mg every 1-2 weeks, until stopped

Caution  If withdrawal symptoms re-emerge, the dose may be held at a plateau for 1-2 weeks or even increased for a few days before the reduction regime is resumed.

References

1. South London & Maudsley NHS Foundation Trust Prescribing Guidelines 12th edition, Wiley Blackwell 2015 2. BNF 70 th current edition, Sep 2015 3. Summary of Product Characteristics for Individual Drugs [accessed Dec 2015] http://www.medicines.org.uk/EMC/ 4. South Essex Partnership NHS trust prescribing guidelines, 2010, section 10.1.2 5. NICE TA114, January 2007: Methadone and Buprenorphine for the management of opioid dependence 6. NICE TA115, January 2007: Naltrexone for the management of opioid dependence 7. NICE CG52, July 2007: Drug Misuse – opioid detoxification 8. Miller, N.S and Gold, M.S; Management of Withdrawal Syndromes and Relapse Prevention in Drug and Alcohol Dependence, American family physician, July 2008 9. Ashton Manual: Benzodiazepines, how they work and how to withdraw http://www.benzo.org.uk/manual/contents.htm 10. Severity of alcohol dependence questionnaire http://www.alcohollearningcentre.org.uk/Topics/Latest/Resource/?cid=4615 11. The alcohol use disorders identification test, WHO, 2001 http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf 22

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12. NICE CG115, February 2011: Alcohol use disorders 13. NICE TA 325 November 2014: Nalmefene for reducing alcohol consumption for people with alcohol dependence. 14. http://www.fda.gov/Drugs/DrugSafety/default.htm Accessed September 2016

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Appendix 1

SEVERITY OF ALCOHOL DEPENDENCE QUESTIONNAIRE (Stockwell et al, 1979)

We would like to recall a recent month when you were drinking in a way, which for you was fairly typical of a heavy drinking period. Please fill in the month and the year: -

MONTH: ………………………………………YEAR: ......

We want to know more about your drinking during this time and how often you experienced certain feelings. Please put a tick to show how frequently each of the following statements applied to you during this typical period of drinking.

Score 0 1 2 3 Almost Some- Often Nearly Never times Always 1) I wake up feeling sweaty 2) My hands shaking first thing in the morning 3) My whole body shakes violently first thing in the morning, if I don’t have a drink 4) I wake up absolutely drenched in sweat 5) I dread waking up in the morning 6) I am frightened of meeting people first 7) I feel on the edge of despair when I wake up 8) I feel very frightened when I wake up 9) I like to have a morning drink 10) I always gulp down my morning drink as quickly as possible 11) I drink in the morning to get rid of the shakes 12) I have a very strong craving for a drink when I wake up 13) I drink more than 1/4 bottle of spirits or 4 pints /1 bottle per day 14) I drink more than 1/2 bottle of spirits or 8 pints beer/2 bottles wine per day 15) I drink more than 1 bottle of spirits or 15 pints beer/4 bottles of wine per day 16) I drink more than 2 bottles of spirits or 30 pints beer/8 bottles wine per day

10. Treatment of dependence

Imagine the following situation:

You have been completely off drink for a few weeks and you then drink very heavily for two days

HOW WOULD YOU FEEL THE MORNING AFTER THOSE TWO DAYS OF DRINKING?

Score 0 1 2 3 Almost Some- Often Nearly Never times Always 17) I would start to sweat 18) My hands would shake 19) My body would shake 20) I would be craving a drink Totals SEVERITY OF ALCOHOL DEPENDENCE QUOTIENT

Re: Questions 17 – 20

(If the patient has not been abstinent for a period of two weeks then score maximum for Q17–20)

TOTAL SADQ SCORE =

(Score 0-3 no dependence, 4-19 mild dependence, 20-30 moderate dependence, 31-44+ severe dependence, 45+ very severe dependence)

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Appendix 2

Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-Ar)

Nausea/Vomiting – Rate on scale 0 – 7 – have patient extend arms & spread fingers. Rate on 0 – None scale 0 - 7 1 – Mild nausea with no vomiting 0 – No tremor 2 1 – Not viable, but can be felt fingertip to fingertip 3 2 4 – Intermittent nausea 3 5 4 – Moderate, with patient’s arms extended 6 5 7 – Constant nausea and frequent dry heaves and vomiting 6 7 – severe, even w/arms not extended

Anxiety – Rate on scale 0 – 7 Agitation - Rate on scale 0 – 7 0 – no anxiety, patient at ease 0 – normal activity 1 – mildly anxious 1 – somewhat normal activity 2 2 3 3 4 – moderately anxious or guarded, so anxiety is inferred 4 – moderately fidgety and restless 5 5 6 6 7 – equivalent to acute states seen in severe delirium or 7 – paces back and forth, or constantly thrashes about acute reactions

Paroxysmal Sweats – Rate on Scale 0 – 7 Orientation and clouding of sensorium – Ask, “What day is this? 0 – no sweats Where are you? Who am I?” Rate scale 0 – 4 1 – barely perceptible sweating, palms moist 0 – Orientated 2 1 – cannot do serial additions or is uncertain about date 3 2 – disorientated to date by no more than 2 calendar days 4 – beads of sweat obvious on forehead 3 – disorientated to date by more than 2 calendar days 5 4 – disoriented to place and/or person 6 7 – drenching sweats

Tactile disturbances – Ask, “Have you experienced any itching, Auditory Disturbances – Ask “Are you more aware of sounds pins & needles sensation, burning or numbness, or a feeling of around you? Are they harsh? Do they startle you? Do you hear bugs crawling on or under your skin?” anything that disturbs you or that you know isn’t there?” 0 – none 0 – not present 1 – very mild itching, pins & needles, burning, or numbness 1 – Very mild harshness or ability to startle 2 – mild itching, pins & needles, burning, or numbness 2 – mild harshness or ability to startle 3 – moderate itching, pins & needles, burning, or numbness 3 – moderate harshness or ability to startle 4 – moderate hallucinations 4 – moderate hallucinations 5 – severe hallucinations 5 – severe hallucinations 6 – extremely severe hallucinations 6 – extremely severe hallucinations 7 – continuous hallucinations 7 – continuous hallucinations

Visual disturbances – Ask “Does the light appear to be too – Ask, “Does your head feel different than usual? bright? Is its colour different than normal? Does it hurt your Does it feel like there is a band around your head?” Do not rate eyes? Are you seeing anything that disturbs you or that you know or light headiness. isn’t there?” 0 – not present 0 – not present 1 – very mild 1 – very mild sensitivity 2 – mild 2 – mild sensitivity 3 – moderate 3 – moderate sensitivity 4 – moderately severe 4 – moderate hallucinations 5 – severe 5 – severe hallucinations 6 – very severe 6 – extremely severe hallucinations 7 – extremely severe 7 – continuous hallucinations

Procedure: 1. Assess and rate of each of the 10 criteria of the CIWA scale. Each criterion is rated on a scale from 0 to 7, except for “Orientation and clouding of sensorium” which is rated on scale 0 to 4. Add up the scores for all ten criteria. This is the total CIWA-Ar score for the patient at that time. Prophylactic medication should be started for any patient with a total CIWA-Ar score of 8 or greater (i.e. Start on withdrawal medication). If started on scheduled medication, additional PRN medication should be given for a total CIWA-Ar score of 15 or greater. 2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment Sheet. 3. The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal.

10. Treatment of dependence

Assessment Protocol Date a. Vitals, Assessment Now. b. If initial score ≥ 8 repeat q1h x 8hrs, then if Time stable q2h x 8 hrs, then if stable q4h.

c. If initial score < 8, assess q4h x 72 hrs. If Pulse score < 8 for 72 hours, d/c assessment. If score ≥ 8 at any time, go to (b) above. RR d. If indicated, (see indications below) O sat administer pm medications as ordered and 2 record on MAR and below. BP

Assess and rate each of the following (CIWA-Ar Scale): Refer to reverse for details instructions in use of the CIWA-Ar scale. Nausea/vomiting (0 – 7) 0 – none, 1 – mild nausea no vomiting; 4 – intermittent nausea; 7 – constant nausea, frequent dry heaves and vomiting Tremors (0 – 7) 0 – no tremor, 1 – not viable but can be felt; 4 – moderate w/arms ex tended, 7 – severe even w/arms not extended Anxiety (0 – 7) 0 – none, at ease; 1 – mildly anxious; 4 – moderately anxious or guarded; 7 – equivalent to acute panic state Agitation (0 – 7) 0 – normal activity; 1 – somewhat normal activity; 4 – moderately fidgety/restless; 7 – paces or continuously thrashes about Paroxysmal Sweats (0 – 7) 0 – no sweats; 1 – barely perceptible sweating, palms moist; 4 – heads of sweat obvious to forehead; 7 – drenching sweat Orientation (0 – 4) 0 – orientated; 1 – uncertain about date; 2 – disorientated to date by no more than 2 days; 3 – disorientated by > 2 days; 4 – disorientated to place and/or person Tactile Disturbances (0 – 7) 0 – none; 1 – very mild , P&N, numbness; 2 – mild itch, P&N, burning, numbness; 3 – moderate itch, P&N, burning, numbness; 4 – moderate hallucinations; 5 –severe hallucinations; 6 – extremely severe hallucinations; 7 – continuous hallucinations Auditory Disturbances (0 – 7) 0 – not present; 1 – very middle harshness/ability to startle; 2 – mild harshness/ability to startle; 3 – moderate harshness/ ability to startle; 4 – moderate hallucinations; 5 severe hallucinations; 6 – extremely severe hallucinations; 7 – continuous hallucinations Visual Disturbances (0 – 7) 0 – not present; 1 – very mild sensitivity, 2 – mild sensitivity; 3 – moderate sensitivity; 4 – moderate hallucinations; 5 – severe hallucinations; 6 – extremely severe hallucinations; 7 – continuous hallucinations Headache (0 -7) 0 – not present; 1 – very mild; 2 – mild; 3 – moderate; 4 – moderately severe; 5 – severe; 6 – very severe; 7 – extremely severe Total CIWA-Ar score: Scale for Scoring: Indication for PRN medication: Total Score:= a. Total CIWA- AR score 8 or higher if ordered PRN only (Symptom triggered method) 0 – 9: absent or minimal withdrawal b. Total CIWA-Ar score 15 or higher if on Scheduled medication. (Scheduled + pm 10 – 19: mild to moderate withdrawal method) more than 20: severe withdrawal Assessment of response (CIWA-Ar score 30-60 minutes after medication administered) Assessor initials Patient Identification (Addressograph)

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