SUBSTANCE MISUSE FACT SHEETS d R a e d e a c n a T s s t A 2 h p l W W a w S a c a r s w a e a s t r o D V a e o l b s x h x . e e e e o l c o e e w e a 0 x h a s i r

n s l u

c a i c 1 M 3 2 c n p u u t p e e a s r i o c z c m r o

r g h h p k o l t t i o e t e e t t d o e l i . . . l o v s s e r n r u e t y e h

h i h e i

v e k e n e a a c

c c o x r s a g a d e u e

a i p c

h h a c n r w i d t e o t d a c e C c a d u i i s t t i e t D E R n b m o t t l h r e

a m o t a n t h f o e s

d t o

h

i n n o

y o l i r i o w i n a n i t e o q e

a a n v l t s . e n . t n s e

c o L s n

r c l g , e e b e t e n t

x

t S l

. p e n , d p o c s d e e d n t u o p ; e s a

a

k s h

a o

n

o

e U

n e a i

y h u h o t i f r d n d w p p t c t

p c d y i l v c e

r E t e d r . a r p e l r o

e u n

m

e g i

c a n e r e i r g t v

e i t r n s k

c o D e m

s

o

r r e o e t n s s i m c i i

e o e e g x r x s n e

t f e r r u w e o i n t i b n t i r e d t A h r p p n f o u

l n n u e x s n d . c

d r

c t

i l a a s

d v a i s f s h r l w g u b u T e i i o o

i e n f i t r

o i n e e e

g

d e

e t i t

n

l o e i a n r t h

h w t a 4 o o

t f a h c

d

m e r i g n l a i n R c i c n

l s t h

a

t

e s u g o n c d

i e t o d m i 6 e i h c f a m s f a e ( h a n t v . n h s t a m r d e h s s k . n t

n

3 e n

t

s m

s v n t

n k a

t h a e A H n a e e a f o i w i u e

f s i

w i e w I e N n

o s t

7 a s h

h c e e n v i n e o a f

o n l o t a o w

r t

s f n t

t s e m n

l e o c a

h . t o t c t h r

s t i s e

i o e g l s i h d 5

f c f e t s p t

. a f e s

t y

e w o r

t l c o

u

f a

b n

. m a a

I

y h

H

h

r r a )

h l o u

o e a o a i c i l p r

p a m p h r n H w t . h y t e m e o u y s e n p d ?

l i e i

o o i p n u c w d l e n s r N H h l d p l i p r d

i s n

p e g a

d n o c m o n

m l y h c

i u

n

i f s s i e l

e r d c s g

e s e t h s e r

n l b o s n o i a a k e

g a

l r

o a i a e i y s t v a o y o s n t y a

a a p

s

e

k c a G a l c s h c a d u e r l h e h t l w i a

e r

c e

o m p n o t s

n p i n i

d e n a a

o f d e t s i o e e n 3 t s d

m

d o a i i n r i n a

t p i t o i i d u e

n n a v t e t d a e r r

d . d

n n

h f c n r

p h 0 e

k

s A l o d i n i i o t l d h d

i r l r d d

e g

a

n o a b i g i w

e t e m a i d a r

a t h e w k e

t % a

O i & m t

1 u s m

t i r f m

o e t t

o s g e o n e o p p s c e s

y d h n w u e s s h e y a

e i e w E t . E i

e t

x t t v f

o d t C

r s k l m p

s t

m 0 p

e t p u o e n b a o l s a a o N e

i f

i h n i n i

U e

h i . a o t h n e n

w e e

l t s n

? m a l u c s f a u d t w o c y n h r

s f o d t

T a s h d

n a

A y e

f u g c r l v a e e

t h i

e d s h l t a r t a o f

s o o a

a

e n r r l

s d T i p w

t d d r

c e a

u I t o o a s r h

e l e y e h a . e a e i s r s a t i d

l s f n i i i d p o T v t t r

e d l r t v l c m l o s t m n e l d w

d t h o

i t n i

e w a C i h e e

u e t m o o t t n s t p

n u h a

o a i

c B t n h g r

l u d o i w e a t

r E a a a a r e s c e u

n e t s a g a a g r e d s t x a d a y i o

a e e e c a t

l

t

d l e

O

o s n m

f

e s t n a l s r

i n r i

f a , d

u t i e s p

m w o n

l n

o G t d r i

f

o h c e e s t s i d

o s

a . o e g l i n

e d i h l s n y a

n

m i p t

n t o

l c t e r c f e u f y e y f o b o m P l y

n l l i

h

e M c

t r i

,

. e t p w r a a o o e w l a t m e p

v : d

t O o m i s c i

c s b A c r i r e l o i e g e

s i h

e r r n o u o t n c

i w p

s u o t

t o b t e u l e n i

s u n g o

a a

m e i s n i p e o g t d a i n i e g d d d f o l l d n a t l n E R r

t d h o o e r n t t b l e s l

o d b a m o r l o t i a u

r

k . ,

c

e m n i

i s r e

a

u v c t d h

t

n o u l a l d n r c H h a

n n e i a a p i c i r e o y y h

t , r a . Y l S s m e n n

n a

l i

s m e

e o

o t t x s n h l g m . e e d

c s s b m

l a h

p n n a e c o o g o w

e k H n

i

o

t

o a e e a g e t a B o y a n o w

’

s

o h

n r

i

a i t i t t h p o a k

e t n e l w h t n n m d t .

s l P h u h I e o

a r o

y a c l e a f

l y m n h t

d o h i

t

n g

l s o a c o i i

o I s c i n c o s t p a t s n d a e s . o

l i k i i i r s

t l u h a h a t

e m

I m o n g c r e n o h p

f o t r n i o n a n g

i e r

d n n e e e a s s h - f l l

– , t . . p t

e i a l 1 e a a n n l y A d t t A l l l l S 3 a l 3 l l l l l l N l l l l l ( W l l l l p c d A a d

h C i

o l s i u n . . c e r a l l e L r c g

0 1 h c c i s o g o t p p n

n H T T A I H A A o u o n o o t n y m t “ v n e P O D u F M C P D N a A U L o m m d C n a r u e k h r i h e g a r n n y y h s

c h o a i l e n a e s t u p o e a c c e d n o o a i e i t r c n i r n

i r o i p p o C B e i x o i s o s t O c o n t m o r o a

a h u l t r f s h t t t p u a o n s c d & l o i b d d t i , i i o

i d t r l k e e s r p

a m o a s v n l l g e t a p e l

e c t e i y

a t s

s e h o

y e

e e a

o w e e

s u B

l

m r r t e i e w a e r o H u g i e n l p d t o c e r

d l h

e o r

- i x i r t o s t e c n l l b n

r r o

s t y

n

d o o o w

a r e f t m c i

i e a e p t

f e f i

r d e i

i m v o m l o i n n t e l c s i

e a l e

t o o

s t a i f o d r o n n e k

a n c c l O h r h m a m r r

e y h i h o a

c d n e l r f f w u

r o i p t

a p m a t t r

o , e c

s h a s l o s e

d p m h f c l m y t d o r h u 2 e e e i h s s o l n

r i o b i , c r

n s n o i a L

a r o a

r c 0 ) h o e

w c d

v a t l d r x s i r d n n u n e e p e

t a h s i

a s s v

d 0

a r i h o l l s l a n e o y c i s p i t

o r u

e p e

c o

w h l

e a 8 n t o a a y n w

o

r i s p

t a l ” p

a r m o o n r W i )

u

c s c t

e y n

e o a c l

a . l t n d w o r d a f f w e a c r d a

r r

o h m a

r i s

o

n r w l a p i i t o l

e f n e d o t r n

s o l

e t e u r t i u

h o a o a o

r

h

a h n

e i t m i s i s c e b i h m I i p

g d

a i m n l s n i o o o t s r

l f n y e

n e j

a l n e p u o o h o e e k

e a T r o u u

g l k n s a s c i d a n c n i i , n t r u w n i a a l t c f d

l e r e n r r n i

t n a

o a r

a l j h

w n d H e t p y r a r a e c s

o r n v i o e k g e l n g t

p i c t y o a

g i n

e e l o r s e n o h c p i a ( r g e r i c

h d

o a d w n l l l l l l l s n e d r

o

j D

f

r c s

i o g r l s n c u f

a

t c p

e b c . g e i

r s u o e e b n o a i g s h m o o o h

s o s d i n h

u l f r v i D H S N D H S a d r n r l R i e e r s . e

e y r i o c l n

n p e g

c c

e c b b n w s e

l f w a

k i

, t s m y a

i i e a c

l n a a n o c t h a s e y g e s r i h s n i

d e

s r i A p l u e

l e r w z c i a n o a n e c u l n l e g

r e d i

f

h

o s t r c i w u a r a u n e i r a

a e c p s o i r

b g i n

c k d a n

s . i i t o s W

i n a b s r l c e t i t r t u r w c n n i h m a c s

a

e

e e u r t

i i h e t t s h i n g a e s p i o h n i n m o . c c n c

b h

h n

e

s

n s

t a d s a g o a t a w u r

d a y o f i P g l g m o a a o A e e

s t t i u o

s s r r f t a l m p

s a l a a

a t c s c h r l f d a e

h r s i d i

i l e v i e p m c t c y o e t c i o t n e y L o w a o s i u e b a i i e a

e c a s i e s i e o t n t d n

. n

e

z e t i o e s : a

e t t n a

d s s w a o n e g c f

a u e s c

n

r y l s n a k r o i t

r u d p

l

u

d n

r

o i m ( i s t o e l o s s c t l n d e y v s

l l s l

o e

i

w

f o e c o a m t i o t

p s i k p

e

n d a s

o h w c r

r

i w o i

n l , t u e

n u o t a i

s u a d e i o t r n b w

h a h a o e a s d r c o c r r a n y m

m t e a

s

d l

o r e i h a i r a

n , a t w d o t

y o d

u

?

t

t l i s o o h i i b b g d c n a f r n e n h m u e

r i y a o c y i e s r g n e a r l y n n i l a i : t h

i a

n

h n ) t n n n i g , d o a l r o a g e g o k e e s f l l , SUBSTANCE MISUSE FACT SHEETS CATEGORY III – ALCOHOL WITHDRAWAL

l Fear of being “found out” such as medical students, doctors l Withdrawal seizures: seizures occur within 48 hours of or other allied professions whereby the risk of detection alcohol cessation and occur either as a single generalized has an impact on the individual’s job. tonic-clonic seizure or as a brief episode of multiple l A lack of knowledge by the practitioner making the seizures. assessment, and the issue of alcohol not being identified l Delirium tremens: hyperadrenergic state, disorientation, when assessing the presenting problem. tremors, diaphoresis, impaired attention/consciousness, 4.0 Assessment and visual and auditory hallucinations. This usually occurs 24 to 72 hours after alcohol cessation. Delirium tremens is As part of routine assessment, it is useful to use screening tools the most severe form of withdrawal and occurs in 5 to 20% such as the AUDIT questionnaires, Alcohol Use Disorders of patients experiencing detoxification and a third of Identification Test (AUDIT and AUDIT C), FAST, or CAGE. patients experiencing withdrawal seizures. It can be fatal For a more detailed assessment tool, the Severity of Alcohol in about 5% patients if not treated or not treated promptly. Dependence Questionnaire (SADQ) is a useful tool. The SADQ It is a medical emergency. is a short, self-administered, 20-item questionnaire designed by the World Health Organisation to measure severity of In Duncan’s situation, it will be important to build up a dependence on alcohol. chronological picture of his drinking habits over the years. Alcohol withdrawal syndrome refers to symptoms and signs that He may find this difficult to recall as it is unlikely he has had to occur in a person who has been drinking excessively every day, think about it before if he has not been asked any questions. and who stops drinking abruptly or significantly reduces their With his permission it may be useful to involve his girlfriend in consumption. building up a picture. Alcohol detoxification is the management of alcohol withdrawal When taking a general history including concurrent physical with medication. and psychiatric illness always enquire about alcohol use, The mechanism underpinning alcohol withdrawal is the drinking history, recent levels of consumption and consumption neuroadaptation to continued excessive alcohol consumption patterns. Be aware of common conditions associated with leading to tolerance to the effects of alcohol. excessive alcohol use and ask about previous episodes of Cessation (or reduction) of consumption following this alcohol withdrawal especially identifying episodes of seizures neuroadaptation leads to a hyper-aroused state with associated or delirium. Assessing the severity of alcohol withdrawal and the symptomatology (see below). early identification of severe complications is a key task for The symptoms and signs of alcohol withdrawal will usually clinicians. commence 6-24 hours after the last drink (Muncie et al, 2013). Investigations should include Liver function tests, (LFT), with The symptoms will tend to peak at 48-72 hours, and occur particular reference to Gamma Glutamyl Transferase (GGT), primarily in the central nervous system, but in severe cases the magnesium (e.g. low); Full blood count (FBC), with particular symptoms may persist for several days or weeks. The severity of reference to Mean Cell Volume (MCV), clotting; All may be withdrawal can vary from mild symptoms such insomnia, normal in a heavy drinker. Also test for any thiamine deficiency. nightmares, nausea and anxiety to severe and life-threatening Factors suggesting high risk of withdrawal include previous or symptoms such as delirium, hallucinations, autonomic instability current severe withdrawal; withdrawal with high alcohol level and seizures. (use Breathalyzer if available); pyrexia; tachycardia; significant Alcohol withdrawal syndrome, patients must exhibit at least two physical illness (e.g. infection, diabetes); concurrent use of of the following symptoms include: benzodiazepines, possibly other psychoactive drugs (e.g. l increased hand tremor opiates/stimulants). l insomnia 5.0 Treatment l nausea or vomiting Complications of alcohol withdrawal must be identified early l transient hallucinations (auditory, visual or tactile) and managed appropriately. It is important to consider the most l psychomotor agitation appropriate setting for managing alcohol withdrawal. This will l anxiety often depend upon a number of factors, including supportive l tonic-clonic seizures, and family members, carer or friend, home environment, and l autonomic instability previous history of withdrawal in any setting. The severity of symptoms is dictated by a number of factors, the If the patient has severe withdrawal, has comorbidities, has an most important of which are the degree of alcohol intake, length unstable home situation, is a polydrug user, has had previous of time the individual has been using alcohol, and previous admissions for treatment of withdrawal, admission to a hospital history of alcohol withdrawal (Bayard et al (2004) . Other for detoxification is the appropriate option. If the patient has diagnoses are: family/carers at home, and there are mild symptoms, with no significant medical problems, this may be undertaken in the l Alcohol hallucinosis: patients have transient visual, community with full supervision from a community alcohol auditory, or tactile hallucinations, but are otherwise clear. team.

2 SUBSTANCE MISUSE FACT SHEETS CATEGORY III – ALCOHOL WITHDRAWAL

1. Delirium Tremens (DTs) – the most severe complication of practice to enhance the identification of severe withdrawals and alcohol withdrawal and characterised by fluctuating confusion, the onset of complications and assist in titrating detoxification severe tremor, autonomic features and visual (and auditory) medication doses. The CIWA-Ar scale can measure 10 symptoms. hallucinations. It is uncommon (<5% of those in withdrawal), Scores of less than 10 indicate minimal to mild withdrawal. but, untreated, carries a high mortality. The peak onset is 48-72 Scores of 10 to 15 indicate moderate withdrawal (marked hours after cessation of drinking, and symptoms can persist for autonomic arousal); and scores of 15 or more indicate severe several days or weeks. A suggested regime for treatment is withdrawal (impending delirium tremens) outlined below: http://www.chce.research.va.gov/apps/PAWS/pdfs/ciwa-ar.pdf IM/IV Pabrinex 2 pairs tds for 3-5 days. Locally agreed policies and procedures in relation to the Haloperidol 0.5-5mg prn for disturbed behaviour and may management of alcohol withdrawal must be observed. Severity require parenteral benzodiazepines. can vary from mild tremor (often no medication needed) to life threatening delirium (medication obligatory).The treatment of 2. Alcohol withdrawal seizures – Generalized tonic-clonic choice in moderate to severe alcohol withdrawal is a long acting (convulsive) seizures (isolated, multiple, or rarely status benzodiazepines (e.g. chlordiazepoxide, diazepam). epilepticus) peak at 48 hours post-cessation. Seizures occur in 1-15% of alcohol withdrawals (increased risk if a previous history Diazepam of withdrawal seizures, or co-morbid epilepsy). Day 1 20mg diazepam qds (if high risk, start here) Treatment: increase benzodiazepine dose and initiate/continue anticonvulsants. Day 2-3 15mg qds 15mg tds Alcohol withdrawal Scales (e.g. CIWA-Ar, Clinical Institute Day 4-5 10mgs qds 10mg tds (in community, usually Withdrawal Assessment of Alcohol Scale, Revised, an alcohol start here) withdrawal scale reporting template) may be used in clinical Day 6-9 5mg qds tds bd nocte, then STOP

Suggested protocol for titrated fixed-dose chlordiazepoxide for treatment of alcohol withdrawal (Ghodse et al., 1998; South West London and St George’s Mental Health NHS Trust, 2010) as cited in NICE 2011 Typical recent daily 15-20 units 30-49 units 50-60 units consumption Severity of alcohol Moderate SADQ score Severe SADQ score Very severe SADQ score dependence 15-25 30-40 40-60 Starting dose of 15-25mgs qds 30-40mgs qds 50mg qds chlordiazepoxide

Day 1 (starting dose) 15 qds 25 qds 30 qds 40 qds* 50 qds* Day 2 10 qds 20 qds 25 qds 35 qds 45 qds Day 3 10 tds 15 qds 20 qds 30 qds 40 qds Day 4 5 tds 10 qds 15 qds 25 qds 35 qds Day 5 5 bd 10 tds 10 qds 20 qds 30 qds Day 6 5 nocte 5 tds 10 tds 15 qds 25 qds Day 7 5 bd 5 tds 10 qds 20 qds Day 8 5 nocte 5 bd 10 tds 10 qds Day 9 5 nocte 5 tds 10 qds Day 10 5 bd 10tds Day 11 5 nocte 5 tds Day 12 5 bd Day 13 5 nocte

Note. * Doses of chlordiazepoxide in excess of 30 mg q.d.s. should only be prescribed in cases where severe withdrawal symptoms are Key: expected and the patient’s response to the treatment should always – Qds = Quater die sumendus: four times a day be regularly and closely monitored. Doses in excess of 40 mg q.d.s. should only be prescribed where there is clear evidence of very severe – Tds = ter die sumendum: three times a day alcohol dependence. – Bd = bis die: twice a day Such doses are rarely necessary in women and never in the elderly or – Nocte: at night where there is severe liver impairment. 3 SUBSTANCE MISUSE FACT SHEETS CATEGORY III – ALCOHOL WITHDRAWAL

Symptom triggered medication can be used according to 6.0 Referral/networks/services withdrawal assessment rating scales, potentially with closer There are a range of services to support people with problems titration of dose against symptoms and shorter periods of with alcohol both during and after detoxification. It is important detoxification. Appropriate medication may be used for nausea to encourage patients to make contact with services at the diarrhoea, heartburn and itching. earliest opportunity and it is helpful for staff to assist where Vitamin deficiency (Thiamine B1) is common and can cause possible, by making appointments or providing patients with serious problems on withdrawal. contact numbers and addresses of local services, such as self Wernicke’s encephalopathy: confusion with or without ataxia help groups and specialist services. and ophthalmoplegia. Untreated, the mortality can rise to 20% Alcoholic anonymous (AA): Alcoholics Anonymous is a and survivors may develop Korsakoff syndrome with profound fellowship of men and women who share their experience, short term memory deficits. All patients require oral thiamine strength and hope with each other that they may solve their 200mg bd and vitamin B Co Strong 2 tabs bd. Also, see local common problem and help others to recover from alcoholism. protocols regarding vitamin prophylaxis and treatment. AA run groups across the whole country, patients can call the Hospitalised patients should normally be treated with National Helpline 084 5 76 9 7555 or visit the website parenteral thiamine. [email protected] Treatment for alcohol detoxification can be managed in a http://www.alcoholics-anonymous.org.uk/ hospital setting, prison or in the community. Patients with severe Al-Anon: Al-Anon Family Groups provide support to anyone alcohol dependence and a history of severe and life threatening whose life is, or has been, affected by someone else’s drinking, withdrawal symptoms are more appropriately treatment in an regardless of whether that person is still drinking or not. in-patient setting. www.al-anonuk.org.uk/ Psychosocial interventions and support. Alateen: Alateen is for teenage relatives and friends of Alcohol detoxification should not be viewed as a standalone alcoholics. Alateen is part of Al-Anon. For Alateen meetings, episode of treatment as there is strong evidence for the use of phone the General Service Office on 020 7407 0215 or visit the psychosocial interventions improving treatment outcomes from website www.al-anonuk.org.uk/alateen alcohol detoxification. Alcohol Nurse Specialists have an 7.0 References and useful resources important role in all aspects of alcohol treatment, including screening, identification of at risk patients, brief interventions Bayard, M, McIntyre J, & Hill KR, Woodside J (2004). ‘Alcohol withdrawal syndrome’. American Family Physician 69 (6): 1443–50. and motivational enhancement programmes. They can improve Brathen G.E. et al (2005) EFNS guideline on diagnosis and management of management by preparation and assessment of suitability and alcohol related seizures: report of an EFNS task force. European Journal of promote engagement with alcohol services in the community Neurology, 12 (8): 575-581 for aftercare. Crome, I. B & Bloor, R (2008) Alcohol problems, in Essential Psychiatry, ed Robin Murray et al, Cambridge University Press. Drummond C, Ghodse H, & Chengappa S. (2007). Use of investigations in the In Duncan’s case it would be appropriate to liaise with the diagnosis and management of alcohol use disorders. In Clinical Topics in alcohol liaison nurse in the hospital to arrange a community Addiction ed. E Day. London: Royal College of Psychiatrists. detoxification for Barry within the community in conjunction Edwards G, Marshall J, Cook C.(2003). The treatment of drinking problems :a guide for the helping professions 4th ed. Cambridge: Cambridge University with his GP as he has a supportive girlfriend who is able to Press take time off work in the week he commences the Findings (2013) Alcohol Matrix cell A3: Interventions; Medical treatment detoxification regime. However, if he is unable to manage, he http://findings.org.uk/count/downloads/download.php?file=Matrix/Alcohol/A can be admitted to hospital. See section above regarding 3.htm Hall, W & Zador D (1997) The alcohol withdrawal syndrome, The Lancet; vol 349, factors to consider in relation to whether a community or June 28 inpatient detoxification would be appropriate. Hughes, J.R 2009). ‘Alcohol withdrawal seizures’. Epilepsy Behav 15 (2): 92–7 Muncie HL, Jr; Yasinian, Y; Oge', L (2013). ‘Outpatient management of alcohol withdrawal syndrome. American family physician 88 (9): 589–95. NICE (2011) Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE clinical guideline, CG115) http://guidance.nice.org.uk/CG115 Sech G, & Serra A. (2007) Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis management: The Lancet Neurology , 6(5) 442-455.

July 2014

4