Alcohol Withdrawal Inpatient Care

POLICY DOCUMENT

POLICY AND PROTOCOL FOR THE Document Title CLINICAL MANAGEMENT OF ALCOHOL WITHDRAWL – IN PATIENT CARE

Reference Number CG/inpatient alcohol withdrawal/11/14

Policy Type Clinical Guideline

N:\Pharmacy\NEPFT Policies, Procedures and I-connect Electronic File/Location documents\Inpatient alcohol withdrawal 2014

http://iconnect/policies/medicines- Intranet Location management/prescribing-and-treatment-guidelines/

Status Final

Version No/Date Version 1 November 2014

Author(s) Responsible for C. Carson – Operational Services Manager Substance Writing and Monitoring Misuse (West)

Medicines Management Group – November 2014 Approved By and Date Clinical Governance Group

December 2014 Implementation Date

Review Date December 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/

http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 1 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

Policy and Protocol for the Clinical Management of Alcohol Withdrawal – In Patient Care

Version: 1 Author: Cheryl Carson Ratified/Approved by: Medicines Management Committee/Clinical Governance Group Effective from: Review Date: Targeted Audience: In Patient Care Circulated to the following people for consultation: Dr B. Otun, Dr B. Sharma, Dr H. Pal

CONTENTS

Section Subject Page Numbers Number 1 Purpose 4

2 Definitions 4

3 Intoxication 5

4 Clinical Management of Intoxication 6

5 Detoxification 7

6 Evaluation and Treatment of Alcohol Dependency 7

7 Medical Complications of Alcohol Withdrawal 8

8 Stabilisation 9

9 Chlordiazepoxide Regimes 10

10 Non Compliance with Treatment 11

11 Nursing Observations 11

12 Detoxification in older/physically frail Adults 12

13 Summary of Changes 12

APPENDICES

1 Clinical Institute Withdrawal Assessment Alcohol Revised 13 Scale (CIWA-Ar) 2 Severity of Alcohol Dependence Questionaire (SADQ-C) 1 15

3 What is Pabrinex? 18

4 Advice to Clients Withdrawing from Alcohol 19

5 CONSENT Forms For Pabrinex® And Chlordiazepoxide 20

6 Acute Alcohol Withdrawal Medicine Management 22

Purpose

This policy governs the safe prescribing and management for patients with Alcohol dependency problems who come under the care of acute psychiatric services (NEPFT). This document is by no means exhaustive and does not attempt to cover every eventuality. It is the duty of all employees to report any unusual or unforeseen situations with regard to any procedure to their line manager.

1. Definitions

Unit of Alcohol One "unit" in the UK usually means a beverage containing 8 g of ethanol, e.g. a half pint of 3.5% beer or lager, or one 25 ml pub measure of spirits. A small (125 ml) glass of average strength (12%) wine contains 1.5 units.

Hazardous Drinking The term hazardous drinking is widely used. It is synonymous with "at-risk drinking" and can be defined as the regular consumption of:

 over 40 g of pure ethanol, (5 units) per day for men.

These figures derive from population studies showing the relationship of self reported levels of drinking to risk of harm. It is arbitrary which point on the risk curve is deemed to merit a warning. Other authorities have quoted weekly recommended upper limits for alcohol consumption of 21 units per week for men and 14 for women.

Consuming over 40 g/day alcohol on average doubles a man's risk for liver disease, raised blood pressure, some cancers (for which smoking is a confounding factor) and violent death (because some people who have this average alcohol consumption drink heavily on some days).

The term hazardous drinking, is also used loosely to cover those who have experienced minimal, as opposed to serious harm.

Harmful Drinking Harmful drinking is defined in the International Classification of Diseases (ICD-10) as a pattern of drinking that causes damage to physical (e.g. to the liver) or mental health (e.g. episodes of depression secondary to heavy consumption of alcohol).15 The diagnosis requires that actual damage should have been caused to the mental or physical health of the user.

Alcohol Dependence Alcohol dependence is defined as a cluster of physiological, behavioural, and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that previously had greater value. A central characteristic is the desire (often strong, sometimes perceived as overpowering) to drink alcohol. Return to drinking after a period of abstinence is often associated with rapid reappearance of the features of the syndrome (priming). A definitive diagnosis of dependence should usually http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 4 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

be made only if three or more of the following have been present together at some time during the previous year:

 a strong desire or sense of compulsion to take alcohol  difficulty in controlling drinking in terms of its onset, termination or level of use  a physiological withdrawal state when drinking has ceased or been reduced (e.g. tremor, sweating, rapid heart rate, anxiety, insomnia, or less commonly seizures, disorientation or hallucinations) or drinking to relieve or avoid withdrawal symptoms  evidence of tolerance, such that increased doses of alcohol are required in order to achieve effects originally produced by lower doses (clear examples of this are found in drinkers who may take daily doses sufficient to incapacitate or kill non-tolerant users)  progressive neglect of alternative pleasures or interests because of drinking and increased amount of time necessary to obtain or take alcohol or to recover from its effects (salience of drinking)  persisting with alcohol use despite awareness of overtly harmful consequences, such as harm to the liver, depressive mood states consequent to periods of heavy drinking, or alcohol related impairment of cognitive functioning

2. Intoxication Intoxication occurs when a person’s intake of alcohol exceeds their tolerance and produces behavioural and/or physical change.

All staff must be able to correctly manage intoxication even when the intoxication is not life threatening.

Any patient who is found to be intoxicated within the unit/ward, the following must be adhered to:

General principles of managing intoxication Maintenance of airways and breathing is of paramount importance to the comatose patient.

Any person presenting as incoherent, disorientated or drowsy should be treated as per head injury until proven otherwise.

Intoxicated patients must be kept under observation (level 2 as a minimum – 4 x per hour) on the unit/ward until their intoxication diminishes.

A thorough physical and mental status examination by a nurse or doctor will reveal the level of a patient’s intoxication to provide baseline information. Assessing Intoxication

 Take a comprehensive alcohol history  Observe vital signs – temperature, pulse, respirations and blood pressure.  Observe pupils, gait and for any ataxia.  Consider conditions other than intoxication (e.g.: head injury, CVA, hypoglycaemia, psychosis, severe liver disease etc.)  Record all observations in the medical records.  Quantum 6 cup drug screen

Signs of Mimicking or Masking Intoxication

 Infections  Respiratory disease  Head injury, subdural haematoma  Acute psychosis  Diabetes, hypoglycaemia  Epilepsy (temporal lobe), post-ictal  Drug toxicity, e.g. phenytoin, digoxin  Meningitis  CVA or TIA  Withdrawal  Wernicke’s encephalopathy

If the assessment indicates intoxication

 Maintain vital signs  Continue to monitor the patients’ physical and mental state  Ensure that everyone on the unit/ward is aware of the patient’s status.  Airway maintenance is of the utmost importance  Place the client in the recovery position. Note: vomiting is likely to occur in the grossly intoxicated patient – this can present a major problem in semi conscious or unconscious patients.  If the patient vomits more than once, this may indicate a head injury or other cause of serious illness. If the intoxicated patient vomits more than once and is not completely coherent, then an ambulance should be called.

3. Clinical Management of Intoxication

Medication may not be necessary if:

 the patient reports consumption is less than 15 units/day in men and less than 10units/day women and reports neither recent withdrawal symptoms nor recent drinking to prevent withdrawal symptoms.  the patient has no withdrawal signs or symptoms; if a decision is made not to prescribe, alcohol withdrawal monitoring should be undertaken twice daily for three days to ensure that no symptoms emerge.  among periodic drinkers, whose last bout was less than one week long, medication is seldom necessary unless drinking was extremely heavy (over 20 units/day). Thiamine 200mg daily and Vitamin B Compound Strong for a period of 28 days is still required

4. Detoxification

Detoxification refers to the planned withdrawal of alcohol. Alcohol withdrawal carries risks and requires careful clinical management. No service user can be discharged until an alcohol detoxification is complete.

CHLORDIAZEPOXIDE (LIBRIUM) is the preferred drug of choice to be used in alcohol withdrawal regimes. http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 6 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

5. Evaluation and Treatment of Alcohol Dependency

Before any prescribing of medication the patient must have an assessment of needs including a risk assessment (See Trust Risk Assessment Policy).

A full medical history must be taken as is the case with all clients this must include details of their alcohol dependence including details of

 What they drink?  When they last drank?  How much they drink daily?  Drinking patterns such as binges or daily?  Any health issues relating to alcohol dependence such as gastrointestinal or Hepatic impairment

The patient must be seen by a nurse or doctor before any medication is issued (either via a PGD or a prescription).

The patient must have had discussion with the doctor or nurse to discuss the implications of chlordiazepoxide as a treatment, and the expectations for treatment (Appendix 5). There needs to be documentary evidence of this in the notes.

There needs to be a clear indication that the patient is dependent on alcohol before treatment is commenced.

If the patient appears intoxicated or sedated, the first dose of Chlordiazepoxide must be withheld until it is clinically safe to begin treatment.

An alcohol withdrawal scale (CIWA-Ar) and an SADQ must be completed on all patients who are to be clinically assessed with possible alcohol dependency problems (Appendices 1 and 2).

Cessation of drinking is unlikely to be complicated in milder dependence. There should however be a lower threshold of prescribing, in part due to the very limited access to alcohol, and also to the risks of self harm in untreated/under treated withdrawal – if there are any withdrawals, then titrate against withdrawal symptoms both up/down. Always prescribe if the patient claims to be dependent, their history/evidence are believable, and there is evidence of withdrawal.

6. Medical Complications of Alcohol Withdrawal

Medical complications of Alcohol withdrawal are potentially life threatening particularly if not optimally treated. Nursing observations should be undertaken at least twice daily ( morning and evening) for these clients for at least the first five days of their detoxification to identify at an early stage any complications which may arise, particularly in respect of withdrawal fits and delirium tremens.

Where there is a previous history of alcohol withdrawal fits, clients must be prescribed sufficient chlordiazepoxide to ensure that this complication does not occur. Delirium tremens are withdrawal symptoms complicated by http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 7 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

disorientation, hallucinations, or delusions. Autonomic over-activity is a potentially fatal aspect of this condition.

If a client does not require a formal alcohol detoxification, but has a recent history of heavy drinking they should still receive the Thiamine 200mg daily and Vitamin B Compound for a period of 28 days as a precautionary measure.

Clients who undergo a detox also require vitamin supplementation; they should be given Pabrinex (Appendix 4) .This is usually 3 days of vial pairs for prophylaxis of the Wernike-Korsakoff syndrome. There is some doubt as to the suitability of oral thiamine as a prophylactic treatment for Wernickes- Korsakoff syndrome due to limited oral absorption. It has also been shown to have little or no effect on the CNS vitamin status whereas parenteral thiamine replacement is rapidly effective in the treatment of Wernickes encephalopathy and is an effective prophylactic treatment for high-risk clients. Pabrinex should therefore be recommended for clients who present as being at high risk of Wernicke’s –Korsakoff (NICE 100 2010). If clients present with complicated alcohol withdrawal for example Delirium Tremens then one should extend the Pabrinex treatment for 5 days

Anaphylaxis is a rare complication and is more likely to occur with IV use (see Tab 18, in the Emergency Drugs Protocol). It is extremely rare after IM administration and this should be considered the route of choice. It should only be administered where suitable basic life support facilities and an anaphylactic shock pack are available. Dosage should be 2 Pairs Pabrinex ampoules IM (7mls injected very slowly into the gluteus maximus please ensure the patient is lying down with their leg to be injected, slightly bent). to be given daily for 3 days.

Should patients refuse IM treatment, they should then still be offered the oral treatment – Vitamin B Compound, Strong.

All patients who undergo alcohol detoxification should routinely be prescribed 200mg of thiamine daily for a period of 28 days.

7. Stabilisation

The client should remain on the unit/ward until the alcohol detoxification is complete. It is important that these clients are monitored (using the CIWA-Ar and risk assessed) for the first seven days of their management, as they may suddenly deteriorate or may suffer withdrawal seizure. This means no leave to be granted until day 7 or 8 of the detox.

In certain circumstances alcohol related withdrawal seizures have been known to be near fatal or fatal.

An extended stay on the unit/ward is advised if the client:

 has experienced confusion or hallucinations during the detoxification  has a history of previously complicated withdrawal  has epilepsy or a history of fits  is undernourished http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 8 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

 has severe vomiting or diarrhoea (this should be controlled within 24 hours or patient transferred to hospital).  is at risk of suicide  has severe dependence coupled with unwillingness to be observed daily  has uncontrollable withdrawal symptoms  has an acute physical or psychiatric illness  has multiple substance misuse

In the treatment of concurrent opiate and alcohol dependence, no reduction in the opiate agonist should be attempted until the alcohol detoxification is complete.

A baseline regime will be agreed by the doctor before commencement of detoxification following the clinical assessment and SADQ and/or CIWA-Ar scores.

8. Chlordiazepoxide Regimes

UNITS OF ALCOHOL PER WEEK BASELINE REGIME <150 UNITS 15mg tds decreasing to zero over 6 days 150-200 units per week 20mg tds decreasing to zero over 7 days 200-250 units per week 20mg qds decreasing to zero over 8 days 250-300 units per week 25mg qds decreasing to zero over 9 days >300 units per week 30mg qds decreasing to zero over 10 days

Clients with a high level of dependency can be offered a higher level of chlordiazepoxide to reduce the risk of withdrawal. Guidelines suggest anything between 10-50mgs of chlordiazepoxide four times daily gradually reducing over 7-10 days (www.bnf.org).

Clients who give a recent history of consuming 10-15 units of alcohol daily MUST be given a stat dose of Chlordiazepoxide 20 mg as soon as possible following assessment and as long as they aren’t intoxicated.

The time of administering the first dose must be recorded on the treatment PMAC in order that the staff can then give the second dose after a minimum 3 hour interval.

If a client shows any signs of alcohol withdrawal during any 24 hour period it would suggest that the dose of Chlordiazepoxide is insufficient. In this event, revert to the level at which the withdrawal symptoms were controlled and maintain for a further 2 days. The remainder of the regime should also be extended, each dose being maintained for 2 or 3 days depending on the severity of the symptoms.

All clients should be monitored and assessed at least twice daily for the first 5 days and longer if breakthrough withdrawal has been recorded using the Clinical Indication of Withdrawal from Alcohol (CIWA-Ar). http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 9 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

Where there is a previous history of alcohol withdrawal fits, clients must be prescribed sufficient Chlordiazepoxide to ensure that this complication does not occur. Delirium tremens are withdrawal symptoms complicated by disorientation, hallucinations, or delusions. Autonomic over-activity is a potentially fatal aspect of this condition.

All clients with a recent history of excessive alcohol consumption should have routine blood tests to check liver function (LFTs), including GGTs and a full blood count (FBC) – at assessment.

9. Non-compliance with Treatment

If at any time a client does not wish to comply with any of the above advice, after explaining the risks to the client, they should be asked to sign a disclaimer to this effect – see Trust Discharge policy. If this happens please make your local Community Drug and Alcohol Team aware as soon as possible.

These clients should still be monitored and reviewed for the following three days on the ward and offered the opportunity to re-commence prescribing if withdrawal symptoms emerge.

10. Routine Nursing Observations

TEMPRATURE, PULSE AND BLOOD PRESSURE to be recorded TWICE DAILY for the first 5 days of detoxification

Observations should be performed as follows as a minimum:

DAYS 1 to 5

CLINICAL MONITORING REQUIREMENTS

Observations should be performed:

• Immediately before the start of the detoxification • Six hourly throughout the detoxification until the CIWA-Ar score has been < 9 for 24 hours  AND ADDITIONALLY at 1 hour after the last dose of chlordiazepoxide administered

Each set of observations should include:

• Alcohol withdrawal scale (CIWA-Ar) • Observation of level of consciousness and orientation. • Pulse, blood pressure and temperature • Observation for dehydration & marked tremor

DAY 6 onwards

Once or more daily, as indicated, by the results of clinical progress. http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 10 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

Responsibilities It is the duty of the Trust to amend and update this document in conjunction with any other relevant authority.

Substitute medication such as chlordiazepoxide should not be prescribed in isolation. A multidisciplinary approach to alcohol dependency treatment is essential. If there are concerns or queries then advice should be sought from the specialist Drug and Alcohol teams within the Trust as soon as is practicably possible.

If the patient is a polydrug and alcohol user, joint clinical reviews should be undertaken regularly. This includes drug screening on admission and if necessary during the inpatient stay.

Thorough, clearly written or computer records of prescribing/administration must be kept.

Notes on the CIWA-Ar

This clinical tool assesses 10 common withdrawal signs. A score of 15 + points means the patient may be at increased risk of alcohol withdrawal effects such as confusion or seizures.

11. Detoxification in Older/Physically Frail Adults

Clinicians working with older/physically frail adults need to note that a lower cut off CIWA-Ar score is advisable for older/physically frail adults, as a score of more than 15 may mean a potential health crisis.

Older/physically frail adults do not always show withdrawal signs in the same way that that younger adults do. For example, older/physically frail adults may not demonstrate signs of anxiety, shakes, or sweating. Alternatively, the signs may be confused with other medical conditions such as that with older adults, such as Parkinson's disease. In other cases, the person may have some degree of cognitive impairment and may not be able to accurately tell you how she or he is feeling. For that reason, monitoring vital signs before withdrawal (and having a baseline of what is normal for this person) and during withdrawal can provide very important information.

Older/physically frail adults also tend to be prescribed lots of medications – of which some if not all have interactions with alcohol.

Physical dependency to alcohol is significantly lowered in older/physically frail adults so it is possible that the same amount of alcohol can have a more detrimental effect than it would on a younger person.

Older/physically frail adults are less tolerant to alcohol because of physical changes including:

 A fall in ratio of body water to fat - less water for the alcohol to be diluted in http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 11 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

 Decreased hepatic blood flow - liver will receive more damage  Inefficiency of liver enzymes - alcohol will not be broken down as efficiently  Altered responsiveness of the brain - alcohol will have a faster effect on the brain

It is generally expected that an older/physically frail adult’s alcohol detox will take at least two or three days longer than normal.

12. Summary of Changes

Page Date Summary of Changes Number(s)

http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 12 of 22 Appendix 1 Clinical Institute Withdrawal Assessment Alcohol Revised Scale (CIWA-Ar)

Tremor Nausea & vomiting Arms extended and fingers spread apart. Observation. Ask “Do you feel sick to your stomach? 1. no tremor Have you vomited?” Observation. 2. not visible, but can be felt fingertip to fingertip 1. no nausea and no vomiting 3. 2. mild nausea with no vomiting 2 4. 3. 5. moderate, with patient’s arms extended 4. 6. 5. intermittent nausea with dry heaves 7. 6. 8. Severe, even with arms not extended 7. constant nausea, frequent dry heaves and vomiting Anxiety Paroxysmal sweats Ask “Do you feel nervous?” Observation. Observation 1. no anxiety, at ease 1. no sweat visible 2. mildly anxious 2. barely perceptible sweating, palms moist 3. 3. 4. 4. 5. moderately anxious, or guarded, so anxiety is inferred 5. beads of sweat obvious on forehead 6. 6. 7. 7. 8. equivalent to acute panic states as seen in severe 8. drenching sweats delirium or acute schizophrenic reactions Tactile disturbances Agitation Ask “Have you any itching, pins and needles Observation. sensations, any burning, any numbness or do you feel 1. normal activity bugs crawling on or under your skin?” Observation. 2. somewhat more than normal activity 1. none 3. 2. very mild itching, pins and needles, burning or 4. numbness 5. moderately fidgety and restless 3. mild itching, pins and needles, burning or numbness 6. 4. moderate itching, pins and needles, burning or 7. numbness 8. paces back and forth during most of the interview, or 5. moderately severe hallucinations constantly thrashes about 6. severe hallucinations 7. extremely severe hallucinations 8. continuous hallucinations Visual disturbances Auditory disturbances Ask “Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you Ask “Are you more aware of sounds around you? Are seeing anything that is disturbing you? Are you seeing they harsh? Do they frighten you? Are you hearing things you know are not there?” Observation. anything that is disturbing you? Are you hearing things 1. not present you know are not there?” Observation. 2. very mild sensitivity 1. not present 3. mild sensitivity 2. very mild harshness or ability to frighten 4. moderate sensitivity 3. mild harshness or ability to frighten 5. moderately severe hallucinations 4. moderate harshness or ability to frighten 6. severe hallucinations 5. moderately severe hallucinations 7. extremely severe hallucinations 6. severe hallucinations 8. continuous hallucinations 7. extremely severe hallucinations 8. continuous hallucinations

Orientation & clouding of sensorium Headache, fullness in head Ask “What day is this? Where are you? Who am I?” Ask “Does your head feel different? Does it feel like 1. orientated and can do serial additions there is a band around your head?” Do not rate for 2. cannot do serial additions or is uncertain about the dizziness or lightheadedness. Otherwise, rate severity. date 1. not present 3. disorientated for date by no more than 2 calendar 2. very mild days 3. mild 4. disorientated for date by more than 2 calendar days 4. moderate 5. disorientated for place and/or person 5. moderately severe 6. severe 7. very severe 8. extremely severe

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)

Time (24hr):

Rater's initials:

0-8 = Mild 9-14 = Moderate 15-20 = High >20 = Severe

Appendix 2

SEVERITY OF ALCOHOL DEPENDENCE QUESTIONAIRE (SADQ-C) 1

NAME______

AGE______No.______DATE: ______

Please recall a typical period of heavy drinking in the last 6 months.

When was this? Month:………………………………. Year……………………………..

Please answer all the following questions about your drinking by ticking your most appropriate response.

During that period of heavy drinking

ALMOST SOMETIMES OFTEN NEARLY NEVER ALWAYS (3) (0) (1) (2) 1. The day after drinking alcohol, I woke up feeling sweaty. 2. The day after drinking alcohol, my hands shook first thing in the morning. 3. The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn't have a drink. 4. The day after drinking alcohol, I woke up absolutely drenched in sweat. 5. The day after drinking alcohol, I dread waking up in the morning. 6. The day after drinking alcohol, I was frightened of meeting people first thing in the morning. 7. The day after drinking alcohol, I felt at the edge of despair when I awoke. 8. The day after drinking alcohol, I felt very frightened when I awoke. 9. The day after drinking alcohol, I liked to have an alcoholic drink in the morning. 10. The day after drinking http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 15 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

ALMOST SOMETIMES OFTEN NEARLY NEVER ALWAYS (3) (0) (1) (2) alcohol, I always gulped my first few alcoholic drinks down as quickly as possible. 12. The day after drinking alcohol, I had a very strong craving for a drink when I awoke. 13. I drank more than a quarter of a bottle of spirits in a day (OR 1 bottle of wine OR 7 beers). 14. I drank more than half a bottle of spirits per day (OR 2 bottles of wine OR 15 beers). 15. I drank more than one bottle of spirits per day (OR 4 bottles of wine OR 30 beers) 16. I drank more than two bottles of spirits per day (OR 8 bottles of wine OR 60 beers)

Imagine the following situation:

1. You have been completely off drink for a few weeks

2. You then drink very heavily for two days How would you feel the morning after those two days of drinking?

NOT AT SLIGHTLY MODERATELY QUITE A ALL LOT (0) (1) (2) (3) 17. I would start to sweat. 18. My hands would shake. 19. My body would shake. 20. I would be craving for a drink.

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:

 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.

Appendix 3

WHAT IS PABRINEX®?

Pabrinex® is used for the prevention of nerve damage caused by alcohol misuse.

It is a medication that contains high potency Vitamin B1 and C amongst others.

People who have been using a lot of alcohol lose their body stores of B Vitamins and this can lead to nerve damage in the body and brain. In particular this nerve damage can lead to memory loss which can sometimes be very severe. Giving Pabrinex® should prevent the development of nerve damage.

It is especially important to use it during detoxification from alcohol, as the actual process of detoxification itself can sometimes lead to more vitamin loss than has occurred through drinking.

Pabrinex® is given as an injection into your muscle – ideally on the first three days of your detoxification. The injection may sting when it is given and for a few minutes afterwards. Very occasionally giving Pabrinex® can lead to a serious allergic reaction. For this reason you will be asked to stay under the observation of a nurse or doctor for 15 minutes following your injection. If you do have a reaction a doctor will immediately be available to treat you. If you have ever had a reaction to Pabrinex® in the past you must tell the nurse and doctor and you will not be given Pabrinex®.

CLIENT STATEMENT

I have had the above information explained and I have understood. I have had the opportunity to ask the doctor any further questions and I consent to the use of Pabrinex® during the first three days of my alcohol detoxification.

Signed…………………… Name…………… Date…………..

CLIENT REFUSAL

I have been given the above information on Pabrinex® but do not wish to receive the Pabrinex® injections; however I am happy to receive the thiamine in tablet form.

Signed…………………… Name……………. Date…………..

Appendix 4

Advice to Clients on withdrawing from alcohol

If you have been chemically dependent on alcohol, stopping drinking causes you to get tense, edgy, perhaps shaky or sweaty, and unable to sleep. There can be vomiting or diarrhoea. This “rebound” of the nervous system can be severe, and in some cases severe withdrawal symptoms have been fatal. It is therefore essential that you give an accurate description of how much alcohol you usually drink and where possible the strength.

1. THE MEDICATION - you have been prescribed controls the symptoms while the body adjusts to being without alcohol. This usually takes three to seven days from the time of your last alcoholic drink. This is why the dose starts high and then reduces. 2. IF YOU DON’T TAKE YOUR MEDICATION, your symptoms would be worse in the first 48 hours. You will also be at risk of more serious complications, such as delirium tremens and seizures or fits. Clients who have been using a lot of alcohol lose their body store of B vitamins and this can lead to nerve damage in the body and the brain. In particular this nerve damage can lead to memory loss which can sometimes be very severe. 3. WHEN YOU ARE WITHDRAWING FROM ALCOHOL - you may get thirsty. Drink fruit juices and water but do not overdo it. You do not have to “flush” alcohol out of the body. More than three litres of fluid could be too much. Don’t drink more than three cups of coffee or five cups of tea. These contain caffeine which disturbs sleep and causes nervousness. 4. AIM TO AVOID STRESS - during the daytime help yourself relax by exercising or reading a book in stages or listening to music. You should not do strenuous exercise near to bedtime, however mild stretching exercises may help you to relax just before bed and exercise during the day may be beneficial. 5. SLEEP - you may find that even with the medication, or as this is reduced, your sleep is still disturbed. You need not worry about this - lack of sleep does not seriously harm you. Your sleep pattern will return to normal in a month or so. Take a bedtime snack and a hot milky drink. The medication may make you drowsy. If you get drowsy, please tell the Nurse. 6. MEALS - even when you are not hungry, try to eat small amounts regularly. Your appetite will return.

Appendix 5 CONSENT FORM 1 OF 2 PABRINEX® PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT Patient’s full name Date of Birth � Male � Female REMEDY number NHS number Responsible Health Professional Job Title Special Requirements (e.g. Other language/other communication method) Name of Proposed procedure or course of treatment: PABRINEX® This is a drug used for the prevention of nerve damage caused by alcohol misuse. It contains a high potency vitamin B1 and C amongst others. People who have been using a lot of alcohol lose their body stores of B vitamins and this can cause nerve damage in the body/ brain. This can cause memory loss which can be severe. Statement of health professional I have explained the procedure to the patient. In particular, I have explained: Pabrinex® should prevent the development of the nerve damage. It is especially important to use this drug during detoxification as the process of detoxification itself can sometimes lead to more vitamin loss than has already occurred through drinking. Pabrinex® must be given as an injection into the buttock- ideally on the first 3 days of the detoxification. The injection may sting when it is given and for a few minutes afterwards. It can lead occasionally to a serious allergic reaction and for this reason you will be under observation for 15 minutes following the injection so that immediate treatment is available should you have a reaction. If you have ever had a reaction to Pabrinex® in the past you must tell the nurse or doctor and you will not be given Pabrinex®. The alternative will be to receive Thiamine in tablet form. The intended benefits: To prevent further nerve damage and prevent memory loss Serious or frequently occurring risks: Severe allergic reaction – Pallor and limpness - Anaphylaxis – upper airway obstruction, swelling, tightness of chest and difficulty in breathing. Cardiovasular – drop in blood pressure and alteration in the heart rate, tachycardia. Skin lesions and flushing, abdominal cramps, nausea and vomiting.unconsiousness. Any extra procedures which may become necessary during the procedure: Close observation for 15 minutes psot the injection to ensure emergency treatment is immediately available � Other procedure (please specify) I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. � The following leaflet/ tape has been provided if applicable Date Signed Name (PRINT) Job title Responsible Clinician’s Signature (if different from above) Contact details (if patient wishes to discuss options later) Statement of interpreter (where appropriate) I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand. Signed Date Name (PRINT) APPENDIX 5 CONSENT FORM 2 OF 2 CHLORDIAZEPOXIDE http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 20 of 22 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT Patient’s full name Date of Birth � Male � Female REMEDYnumber NHS number Responsible Health Professional Job Title Special Requirements (e.g. Other language/other communication method) Name of Proposed procedure or course of treatment: Chlordiazepoxide This is a medicine used to reduce and stop the symptoms of withdrawal from alcohol. This prevents the brain from becoming over active when the alcohol consumption is stopped by someone who is physically dependent upon alcohol.

Statement of health professional (to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in consent policy) I have explained the procedure to the patient. In particular, I have explained: The intended benefits: Sedation to prevent over activity of body functions such as brain, heart and bowels Serious or frequently occurring risks: Rapid pulse, raised blood pressure, and vomiting Drowsiness and light headed the day after use, confusion and unsteadiness. Any extra procedures which may become necessary during the procedure: � Other procedure (please specify) I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. � The following leaflet/ tape has been provided Signed Date Name (PRINT) Job title Responsible Clinician’s Signature (if different from above) Contact details (if patient wishes to discuss options later) Statement of interpreter (where appropriate) I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand. Signed Date Name (PRINT)

http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ CG/inpatient alcohol withdrawal/11/14 Implementation Date: December 2014 Review Date: December 2017 Page 21 of 22 APPENDIX 6 ACUTE ALCOHOL WITHDRAWAL MEDICINE MANAGEMENT TAKE AN ALCOHOL HISTORY SEE ALCOHOL PROTOCOL ►Current daily intake (e.g.500ml of 8% lager is 4 units) http://iconnect/policies/medicines-management/prescribing-and-treatment-guidelines/ ►Pattern of drinking/experience of withdrawals (e.g.morning sweats, vomiting, DTs, fits, wernicke’s encephalopathy) DAY ►Length of history REGIMEN 1REGIMEN 2REGIMEN ►Check bloods U&Es, Mg2+, PO4, FBC, LFTs, MCV, blood glucose, 3120202020303030304040404021515151525252525353 clotting screen, folate/B12 , and blood pressure 5353531010101020202020303030304101010101515151 5252525255555510101010202020206555510101010202 EXHIBITING WITHDRAWAL NO Monitor. Consider PRN 020207555555151515158555101010109555551055 SYMPTOMS Chlordiazepoxide

PABRINEX IM 1 PAIR DAILY FOR 3-5 DAYS. Mix then administer very slowly into gluteal muscle

Prescribe Thiamine 100mg 2 tabs OM and Vit. B Co. Strong 1 tab OM See ANAPHYLAXIS protocol Consider anti-emetic Domperidone DISCUSS REFERRAL TO DRUG AND ALCOHOL TEAM

WERNICKE’S SEVERE PRN CHLORDIAZEPOXIDE UP TO ENCEPHALOP Withdrawal 20mg QDS FOR 72HR ATHY seizures, Delirium Cyrrhosis or alcoholic hepatitis, Confusion, tremens, confusion, elderly, liver failure, risk of ophthalmopleg vivid MODERATE MILD respiratory depression? Consider ia, ataxia hallucinations/illusio Withdrawal anxiety, Alcohol intake Oxazepam instead of ns, marked tremor agitation, irritability, >units/day, Chlordiazepoxide tremors, sweating, shakes, need for nausea/vomiting or morning drink DIAZEPAM retching, insomnia Pregnancy? CHECK! -Liaise Transfer to RECTAL 10mg with obstetric team acute Trust. PRN

PABRINEX TDS for as long as improvement CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE PRN occurs REGIMEN 3 REGIMEN 2 REGIMEN 1 CHLORDIAZEPOXIDE AND MONITOR ONLYPage 22 of 22