COMMUNITY ALCOHOL WITHDRAWAL PRESCRIBING GUIDELINES MARCH 2020 This policy supersedes all previous policies for medically assisted community alcohol withdrawal Policy title Community alcohol withdrawal prescribing guidelines Policy PHA28 reference Policy category Clinical Relevant to Trust-wide – any services conducting medically assisted community alcohol withdrawal Date published Mar 2020 Implementation Mar 2020 date Date last Aug 2019 reviewed Next review Mar 2023 date Policy lead Bhaskar Punukollu, Consultant in Addiction Psychiatry Contact details Email: Telephone: 0203 317 6029 [email protected] .uk Accountable Vincent Kirchner, Medical Director director Approved by Substance misuse consultants meeting (Group): Approved by Drugs and Therapeutics Committee (Committee): Document Date Version Summary of amendments history 20.11.09 1 Original document 22.07.15 2 Original revised with minor amendments Aug 2018 3 No changes Mar 2020 4 Removal of vitamin B compound strong . Membership of the policy development/ Dr Bhaskar Punukollu review team Consultation Substance misuse consultants group Members of drugs and therapeutics committee DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. Community Alcohol Withdrawal Prescribing Guidelines: PHA28: Mar 2020 Contents Page 1 Introduction 1 2 Aims and objectives 1 3 Scope of the policy 2 4 Assessing suitability for community alcohol withdrawal 2 5 Information to be obtained prior to commencement of withdrawal 3 6 Procedure for medically assisted withdrawal 4-5 7 Medication interventions following successful withdrawal 6-7 8 Dissemination and implementation arrangements 7 9 Training requirements 7 10 Monitoring and audit arrangements 8 11 Review of the policy 8 12 References 8 13 Associated documents: Appendix 1: Contract and consent form for medically assisted 9 community alcohol withdrawal Appendix 2: Information sheet for clients on withdrawal process 10-11 Appendix 3: Severity of Alcohol Dependence Questionnaire (SADQ) 12-13 Appendix 4: Clinical Institute Withdrawal Assessment (CIWA-AR) 14-15 Appendix 5: Preparing for medically assisted community alcohol 1 6 withdrawal (client information sheet) Appendix 6: Pre-withdrawal checklist (key worker to complete) 17-18 Appendix 7: Template letter to GP to request blood results and physical 19 examination findings Community Alcohol Withdrawal Prescribing Guidelines: PHA28: Mar 2020 1. Introduction 1.1 Medically assisted community alcohol withdrawal is a process in which an individual’s physical and mental health are monitored whilst being provided medications and psychosocial support to relieve physical and psychological withdrawal symptoms, on cessation of the use of alcohol. 1.2 When undertaking assisted withdrawal, the patient is required to stop alcohol intake abruptly, and its effects are replaced by medication that has cross- tolerance. Then medication can be reduced at a rate that prevents withdrawal symptoms but without promoting over-sedation, and ultimately stopped altogether. The process involves providing a large enough initial dose to prevent severe withdrawal symptoms including seizures, delirium tremens, severe anxiety or autonomic instability, but to withdraw the medication before physical dependence on its effects begins. 1.3 The process should be conducted in a safe and structured manner so as to reduce the likelihood of potential adverse events. The structured approach will include careful assessment and discussion at the multi-disciplinary team meeting of a client’s suitability for a medically assisted alcohol detoxification. This discussion should take into account several factors including the client’s motivation to engage in a detoxification, current physical and mental health, social support, consideration of any absolute contraindications e.g. past history of seizures or delirium tremens, and the client’s future treatment plans/goals. There should be an after-care plan in place so that the client continues to be supported to remain alcohol-free in the period following detoxification and supported to develop skills needed to maintain long-term sobriety. 2. Aims and objectives 2.1 This policy will set out the procedure for carrying out a medically assisted community alcohol withdrawal safely. The policy draws on recent NICE guidance (CG115) on ‘Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence’. 2.2 This document aims to achieve the following objectives: 2.2.1 Make clear the inclusion and exclusion criteria for medically assisted community alcohol withdrawal. 2.2.2 Explain the roles and responsibilities of staff conducting medically assisted community alcohol withdrawal. 2.2.3 Set out a number of possible medically supervised detoxification regimens which can be used for the withdrawal process. 2.2.4 Describe the different types of medications that can be used following medically assisted alcohol withdrawal and explain how to prescribe these. 1 Community Alcohol Withdrawal Prescribing Guidelines: PHA28: Mar 2020 2.2.5 Provide a number of useful appendices including client information sheets, GP letter and well validated rating scales to measure severity of alcohol dependence and withdrawal symptoms. 3. Scope of the policy This policy is intended for staff working in Camden and Islington NHS Foundation Trust specialist substance misuse services and other trust sites where community alcohol detoxification may be undertaken. The policy does not apply to the management of in-patients admitted on mental health wards, however alcohol detoxification may be undertaken in inpatient mental health wards using the detoxification schedules listed in this policy and in consultation with specialist alcohol nurses at trust substance misuse services. 4. Assessing suitability for community alcohol withdrawal 4.1 For service users who typically drink over 15 units of alcohol per day, and/or who score 20 or more on the AUDIT, consider either: a) Assessment for and delivery of a community-based assisted withdrawal; or b) Assessment and management in specialist inpatient alcohol services if there are safety concerns about a community-based assisted withdrawal. 4.2 In the week prior to medically assisted alcohol withdrawal, use formal assessment tools to assess the nature and severity of alcohol misuse, including the: - Alcohol use disorders Identification Tool (AUDIT) for identification and as a routine outcome measure - Severity of Alcohol Dependence Questionnaire (SADQ) (Appendix 4) - Leeds Dependence Questionnaire (LDQ) to assess severity of dependence. 4.3 When assessing the severity of alcohol dependence and determining the need for assisted withdrawal, adjust the criteria for women, older people, children and young people, and people with established liver disease who may have problems with the metabolism of alcohol. 4.4 For service users having assisted withdrawal, particularly those who with severe (SADQ score over 30 or drinking over 50 units of alcohol per week) alcohol dependence use a formal measure of withdrawal symptoms such as the Clinical Institute Withdrawal Assessment Revised (CIWA-Ar) (see Appendix 4). Inclusion/Exclusion criteria: Outpatient versus Inpatient Medically Assisted Alcohol Withdrawal LEVEL OF DEPENDENCE INTERVENTION Mild to moderate dependence without Outpatient-based assisted withdrawal significant co morbidity. - Monitor client every other day. - Mild/moderate dependence + complex Outpatient- based assisted withdrawal needs / Severe dependence Monitor client daily. Drinking over 30 units/ day Inpatient or Residential Assisted 2 Community Alcohol Withdrawal Prescribing Guidelines: PHA28: Mar 2020 SADQ score > 30 Withdrawal Programme. A history of epilepsy, seizures or Lower threshold in vulnerable groups delirium tremens e.g. homeless and older people. 15-20 units/ day along with significant psychiatric or physical co morbidities, a significant learning disability or cognitive impairment. Concurrent benzodiazepine withdrawal. 5. Information to be obtained prior to commencement of medically assisted withdrawal 5.1 The key worker should meet the service user on two separate occasions to discuss the detoxification process and possible aftercare plans. The assessment may include a relative or spouse, who will be involved in providing support during the medically assisted withdrawal process. The following information should be presented by the key worker at the multidisciplinary team meeting before detoxification commences: • Eligibility criteria agreed by team, procedure explained to client by key worker and consent form signed by client. • Date for commencement and availability of staff (requires planning taking account of annual/ other leave). • Information from GP: List of medications, physical problems, allergies, blood test results (less than 6 months old), including liver function test (LFTs) results (ALT, AST, ALP, GGT, Total Bilirubin, Albumin, PT/INR) • Blood test results including LFTs must be seen by the doctor at least one week prior to commencement of medically assisted withdrawal. • Drink Diaries for a minimum of two weeks. • Baseline observations (pulse, BP, breath alcohol concentration (BAC). • Risk assessment and SADQ completed. • Aftercare plan agreed with client. 5.2 The service user must sign a contract agreeing to attend the clinic at a specified frequency, and to remain abstinent from alcohol and undergo breath alcohol testing and physical observations during the withdrawal