Alcohol Dependence – Inpatient Management of Alcohol ... · Drug and Alcohol Project Limited...

1

Introduction

This guidance is intended for use throughout the NHS Fife - in Primary Care, Secondary Care and specialist services - to identify, assess and manage patients who misuse alcohol.

People who misuse alcohol may access:

Primary Care General Practice: for related conditions resulting from harmful or dependentdrinking.

Primary Care General Practice: for assessment and management of harmful or dependentdrinking.

Primary Care Specialist service: for assessment and management of harmful or dependentdrinking.

Secondary Care admission for planned inpatient detoxification.

Secondary Care Accident and Emergency: for related conditions resulting from harmful ordependent drinking.

Secondary Care admission for treatment of unrelated condition during which evidence of harmfulor dependent drinking emerges.

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Issued: February 2016 Review Date: February 2019 Prof. A. Baldacchino, Liz Hutchings, Addiction Services

Approved by NHS Fife ADTC on behalf of NHS Fife Date: February 2016

“Staff working in services provided and funded by the NHS who care for people who potentially misuse alcohol should be competent to identify harmful drinking and alcohol dependence. They should be competent to initially assess the need for an intervention or, if they are not competent, they should refer people who misuse alcohol to a service that can provide an assessment of need”

NICE clinical guideline 115 “Alcohol-use disorders”, Feb 2011

NHS Fife

Guidance for the Identification, Assessment and Management

of Harmful Drinking and Alcohol Dependence

2

Contents

Algorithm for screening, assessment and treatment of alcohol misuse ........................................... 3

Screening ......................................................................................................................................... 4

Assessment ..................................................................................................................................... 5

Controlled drinking ........................................................................................................................... 6

Community Based Detoxification ..................................................................................................... 7

Planned Inpatient Detoxification ....................................................................................................... 8

Unplanned Inpatient Management of Alcohol Withdrawal ................................................................ 9

Prophylaxis and Treatment of Wernicke’s Encephalopathy ........................................................... 10

Management of complex needs ..................................................................................................... 11

Psychological support .................................................................................................................... 12

Pharmacological Support ............................................................................................................... 13

Appendix 1 ALCOHOL CONSUMPTION CALCULATOR ............................................................ 15

Appendix 2 FAST ALCOHOL SCREENING TEST (FAST) .......................................................... 16

Appendix 3 Alcohol Use Disorders Identification Test (AUDIT) .................................................... 17

Appendix 4 Severity of Alcohol Dependence Questionnaire (SADQ) ........................................... 18

Appendix 5 Personal Drinking Questionnaire (SOCRATES) ........................................................ 19

Appendix 6 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) ....... 21

Appendix 7 Inpatient: Alcohol withdrawal observation chart (based on CIWA-Ar scale) .............. 22

Appendix 8 Inpatient symptom triggered chlordiazepoxide schedule. .......................................... 23

Appendix 9 Community detoxification fixed dose chlordiazepoxide schedule .............................. 24

Appendix 10 NHS Fife Addiction Services ..................................................................................... 25

References

1. NICE Guideline (CG115): Alcohol-use disorders: diagnosis, assessment and management ofharmful drinking and alcohol dependence. Available at http://www.nice.org.uk/guidance/CG115

2. NICE Guideline (CG 110): Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications. Available at https://www.nice.org.uk/Guidance/CG100

3. BAP Guidelines. Journal of Psycopharmacology 26(7) 899-952, 2012.

4. BNF 4.8 Substance dependence. Available at Substance dependence: BNF

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http://www.nice.org.uk/guidance/cg115

https://www.nice.org.uk/Guidance/CG100

https://www.medicinescomplete.com/mc/bnf/current/PHP78560-substance-dependence.htm?q=substance%20dependence&t=search&ss=text&p=1#_hit

3

Algorithm for screening, assessment and treatment of alcohol misuse

Controlled drinking

1. ALCOHOL consumption: 8 -15 units/day men 6 -10 units/day women

2. AUDIT score < 20

3. SADQ score <15

4. No physical withdrawalsymptoms

5. Requires psychosocialcounselling.

MODERATE DEPENDENCE with no complex needs

Community based detox.

1. ALCOHOL consumption: >15 units/day men

>10 units/day women

2. AUDIT SCORE ≥20

3. and/or SADQ 15 – 30

4. CIWA-Ar score 10 - 14

Manage withdrawal symptoms with

fixed dose schedule of

chlordiazepoxide for max. of 7 days.

Daily monitoring of Breath Alcohol

Concentration, withdrawal symptoms

and dosage adjustment

SEVERE DEPENDENCE and/or COMPLEX NEEDS

All patients asked about alcohol consumption and complete Fast Alcohol Screening Test.

Patient exceeds recommended drinking limits but scores < 3 with FAST

Patient exceeds recommended drinking limits and scores ≥ 3 with FAST

Planned inpatient detox.

1. ALCOHOL consumption: >15 units/day men

>10 units/day women 2. AUDIT SCORE ≥ 20

3. SADQ > 30

4. CIWA-Ar score ≥15

History of complicated withdrawal

and/or seizures

Previous failed community detoxes

Multiple substance use

High risk of self harm or suicide

Non-supportive home environment

see page 8 for full list

Manage withdrawal symptoms with

symptom-triggered chlordiazepoxide

schedule.

Further assessment to evaluate severity of dependence plus complexity of needs.

pattern of consumption (AUDIT) degree of dependency (SADQ) readiness to change (SOCRATES) withdrawal symptoms (CIWA-Ar) physical and/or mental co-morbidity cognitive function drug use

home environment risk of harm to self and others urgency of treatment

Physical examination and Biological Tests – Breath Alcohol Concentration, FBC (inc MCV), U&Es, LFTs (inc γGT), Glucose + drug screen

NO DEPENDENCE or

MILD DEPENDENCE

Deliver Alcohol Brief Intervention or

refer to ADAPT

VITAMIN SUPPLEMENTATION for WERNICKE’S ENCEPHALOPATHY

Detoxification may precipitate Wernicke’s encephalopathy. Those at risk should receive prophylactic dose and those with symptoms receive treatment dose of Pabrinex®

PROPHYLAXIS – patient with any of: history of alcohol misuse/ recent weight loss/vomiting/diarrhoea/malnutrition/ peripheral neuropathy/chronic ill-health.

ONE pair of Pabrinex IVHP or IMHP ONCE daily for 3 – 5 days

TREATMENT – patient with history of alcohol misuse and displaying any of symptoms of WE: confusion/ataxia/opthalmoplegia/nystagmus

TWO pairs of Pabrinex IVHP THREE times daily for 3 days

If response noted continue with ONE pair of Pabrinex IVHP or IMHP ONCE daily for 5 days

Small risk of anaphylaxis. Facilities to manage anaphylaxis must be available.

Continue with oral thiamine 100mg THREE times daily

Psychosocial counselling & relapse prevention

Behavioural Self Control Training,

Motivational Enhancement Training,

Family Therapy, Coping/Social Skills

Training are recommended counselling

options for the prevention of relapse.

Psychosocial counselling may be

supported by pharmacological

interventions: acamprosate, disulfirum,

naltrexone or baclofen as appropriate.

Alcohol dependent patients should be

encouraged to access mutual self-help

groups or 12 step facilitation such as

Smart Recovery and Alcoholics

Anonymous as they are beneficial in

relapse prevention.

4

Screening

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1. All patients should be asked how many units of alcohol they normally consume in a typical day

and week. (Alcohol Consumption Calculator) - appendix 1.

2. All patients should complete a Fast Alcohol Screening Test (FAST) – appendix 2.

Female patients consuming:

more than 2-3 units daily and/or

more than 6 units on one occasion but

scoring less than 3 with FAST

Alcohol Brief Intervention (ABI)*

Remind patient of recommended drinking limits

Facilitate calculation of consumption in units by providing unit calculator or referring to www.drinksmarter.org

Suggest ways of reducing alcohol intake.

Male patients consuming:

more than 3-4 units daily and/or

more than 8 units on one occasion but

scoring less than 3 with FAST

3. Female patients consuming more than 2-3 units daily or male patients consuming more than

3-4 units daily AND scoring 3 or more with FAST (defined as hazardous drinking) should

undergo further assessment.

NB. In settings where further assessment is inappropriate but the patient’s pattern of consumption and

FAST score indicates hazardous drinking, in addition to a brief intervention, the patient should be

advised to seek further information and assistance from their GP or:

Local Services

National Services

Drinkline 0800 731 4314

Alcohol Focuswww.alcohol-focus-scotland.org.uk

FASS – ADAPT RECOVERY SERVICES

01592 206200 01592 321321

www.fassaction.org.uk

Drug and Alcohol Project Limited

01333 422277

www.dapl.net

*Alcohol Brief Intervention

An alcohol brief intervention is a short evidence-based conversation with a patient/client about alcohol

consumption which is structured and non-confrontational and seeks to motivate and support the

person to think about and/or plan behaviour change.

Half-day and full day training courses are available in the Health Improvement Training Programme.

Contact: 01592 226488

http://www.drinksmarter.org/

http://www.alcohol-focus-scotland.org.uk/

http://www.fassaction.org.uk/

http://www.dapl.net/

https://intranet.fife.scot.nhs.uk/uploadfiles/publications/Health%20Improvement%20Training%20Programme%202015-2016.pdf

5

Assessment

Units/day AUDIT SADQ CIWA-Ar Treatment Option

Male Female

<15 <10 < 20 < 10 < 10

Counselling and relapse prevention ∙ no medication needed∙ provide information about alcohol services

8 -15 6 -10 < 20 < 15 < 10

Controlled drinking ∙ Psychosocial counselling∙ If nalmefene appropriate refer to NHS Fife Addiction Services

>15 > 10 ≥ 20 15 – 30 10 – 14

Community Based Detoxification ∙ Withdrawal symptoms controlled with chlordiazepoxide∙ Daily monitoring∙ Supportive home environment∙ Consider referral to NHS Fife Addiction Services

>15 > 10 ≥ 20 >30 ≥ 15

Planned Inpatient Detoxification ∙ History of complicated withdrawal and/or seizures∙ Previous failed community detoxes∙ Multiple substance use∙ At high risk of self harm or suicide∙ Acute physical or psychological illness∙ Non supportive home environment∙ Refer to NHS Fife Addiction Services

Patients drinking >21 units/week (male) or >14 units/week (female) and with a FAST score of ≥ 3 should be asked:

1. about historical and recent patterns of drinking using the Alcohol Use Disorders Identification Test(AUDIT) – appendix 3.

2. to establish degree of dependency by completing a Severity of Alcohol Dependence Questionnaire(SADQ) -appendix 4

3. about other medication and/or drugs misused (including over-the-counter medication)

4. about physical and/or mental co-morbidity

Assessment should also include:

5. Physical examination

6. Biological tests:

Breath - Breath Alcohol Concentration¹ (BAC)

Blood - Full Blood Count (including MCV), U & Es, LFTs (including γGT2) and glucose

7. Urine - Drug Screen

In order to inform treatment planning:

8. Cognitive function: for example Mini Mental State Examination (MMSE).

9. Psychological and social problems

10. Readiness and belief in ability to change by completing the Personal Drinking Questionnaire(SOCRATES) - appendix 5

11. Assessment of severity of alcohol withdrawal using the revised clinical institute withdrawalassessment for alcohol scale (CIWA-Ar) - appendix 7. This should be repeated throughoutdetoxification.

12. Home environment

¹ Contributes to screening, monitoring during detoxification and following progress thereafter 2 Of value when patients minimise their drinking and for monitoring progress in reducing drinking

6

Controlled drinking

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Alcohol consumption AUDIT score SADQ score CIWA-AR score

MEN 8 - 15 units/day WOMEN 6 - 10 units/day

< 20 < 15 <10

Controlled Drinking

For those unwilling or unable to become abstinent, reduced drinking may be an appropriateintermediate goal on the way to abstinence, although ideally clinical benefit should also be evident.

Controlled drinking should not be the first option for those who have lost control of their drinking(where drinking reduction may be hard to achieve) or those with physical illness where alcoholeven in small amounts is likely to be harmful.

For others with less adverse health consequences or not dependent, some drinking may beacceptable.

1. After initial assessment patient should record alcohol consumption for approximately 2weeks

2. Patients continuing to drink >7.5 units but <12.5 units daily (men) or >5 units but < 7.5 unitsdaily (women), without physical withdrawal symptoms and who do not require immediatedetoxification may be offered psychosocial intervention focused on treatment adherence andreducing alcoholic consumption in conjunction with nalmefene.

3. After 6 months of treatment the patient should be able to report a reduction of at least 50% inthe number of heavy drinking days¹ per month and a reduction of around 60% in the total

alcohol consumption² per month.

4. Online support such as www.reduceyourdrinking.co.uk may be a useful adjunct to conventionalpsychological support.

5. Nalmefene is in the Fife Formulary (section 4.10.1 Alcohol Dependence) approved for restricteduse by addiction services only.

6. For dose and other information see British National Formulary (BNF) and Summary of ProductCharacteristics (SPC)

1. “Heavy drinking day” defined as >7.5units/day (men) or >5units/day (women). WHO.2. “total alcohol consumption” defined as the mean daily alcohol consumption in grams/day over a month (28 days).WHO (8g of

alcohol is equivalent to 1 unit)

DAILY DRINKERS

Control may be achieved by setting targets to gradually reduce daily alcohol consumption using Behavioural Self-Control Training.

BINGE DRINKERS

Control may be achieved by using Motivational Enhancement Therapy to recognise and control triggers for binge.

http://www.reduceyourdrinking.co.uk/

http://www.fifeadtc.scot.nhs.uk/media/2174/chapter_4_cns_final_jan_13__last_amended_jan_16.pdf

https://www.medicinescomplete.com/mc/bnf/current/PHP33535-nalmefene.htm

https://www.medicines.org.uk/emc/medicine/27609/SPC/Selincro+18mg+film-coated+tablets/


7

Community Based Detoxification


MEN > 15 units/day WOMEN > 10 units/day

≥20 15 - 30 10 - 14

Preparation for detoxification - the following elements must be carried out:

Home visit to risk assess the suitability of environment

Meet with carer to assess support available and suitability for home detox

Education about the detoxification process and medication for patient and main carer

Plan for post detoxification relapse prevention including psychological support, discussion of

medication available and rehabilitation with referral to appropriate agency

Arrange for detoxification medication prescribing

Obtain informed consent for detoxification and associated medication

Detoxification

Start on a Monday or Tuesday to allow monitoring through the period of highest risk.

Treatment should not commence if the patient remains intoxicated.

A fixed dose chlordiazepoxide schedule should be used (Appendix 9).

There should be flexibility to allow for individual symptomatic response particularly in patients oflow body weight and older people.

Chlordiazepoxide is contraindicated in severe hepatic insufficiency. (See SPC)

Withdrawal symptoms should be monitored using CIWA-Ar twice on the first day and then asindicated. The second contact may be by telephone or second visit as appropriate.

Medication should be reviewed every 24 hours from Monday to Friday

Breathe Alcohol Concentration should be monitored at every visit – if patient has been drinkingstop chlordiazepoxide and review care plan

Consult medical staff urgently if any of the following emerge during detoxification failure to improve despite increased dosing hallucinations that fail to respond tochlordiazepoxide high level of disorientation suicidal ideation other new physical or mentalhealth concerns persistent vomiting.

The patient must be treated as a medical emergency and immediately be referred to A&E orthe Out-of Hours Service if suffering from: seizures chest pain signs of Wernicke’sEncephalopathy impaired level of consciousness active suicidal thoughts.

Relapse prevention

Relapse prevention work should be ongoing and may include individual work, group work, referral

to Alcoholics Anonymous and other appropriate agencies. See Psychological Support page 12

Medical adjuncts to relapse prevention should be considered. See Pharmacological Support page

13 & 14

VITAMIN SUPPLEMENTATION for Prevention and Treatment of Wernicke’s Encephalopathy

Detoxification may precipitate Wernicke’s encephalopathy. Those at risk should receive prophylactic dose and those with symptoms receive treatment dose Pabrinex® see page 7

DO NOT USE BENZODIAZEPINES AS ONGOING TREATMENT FOR ALCOHOL DEPENDENCE. USE FOR WITHDRAWAL ONLY.

A full assessment should be completed before detoxification is commenced. If this is not possible in primary care setting refer to specialist service - NHS Fife Addiction Services 01592 716446



http://www.medicines.org.uk/emc/medicine/26299#CONTRAINDICATIONS

8

Planned Inpatient Detoxification

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MEN > 15 units/day WOMEN > 10 units/day

≥20 > 30 ≥15

The following list is based on expert opinion and comprises validated and best practice contraindications to managing withdrawal at home.

Inpatient detoxification is advised if the patient:

is confused or has hallucinations

has a history of previously complicated withdrawal

has epilepsy or a history of fits

is undernourished

has severe vomiting or diarrhoea

is at risk of suicide

has severe dependence coupled with unwillingness to be seen daily

has previously failed community detoxes

has uncontrollable withdrawal symptoms

has an acute physical or psychiatric illness

has multiple substance misuse

has a home environment unsupportive of abstinence.

drinks over 30 units alcohol/day

score >30 on the SADQ

Treatment

1. Chlordiazepoxide is the preferred benzodiazepine for treatment of withdrawal symptoms.

2. Using a symptom triggered chlordiazepoxide schedule (appendix 8) for the first 24 hours is associatedwith significantly lower doses of benzodiazepines and a shorter duration of treatment without anincrease in the incidence of seizures or delirium tremens.

3. Observations (appendix 7) (i.e. withdrawal symptoms, blood pressure, heart rate and respiratory rate)should be carried out every 2 hours for the first 24 hours.

4. Use CIWA-Ar (appendix 6) to measure withdrawal symptoms,

5. If observations cannot be monitored at least every 2 hours then the Community detoxification fixeddose chlordiazepoxide schedule (appendix 9) must be used.

6. For information on treating patients with complex needs such as liver impairment, alcohol withdrawalseizures, delirium tremens, and patients dependent on benzodiazepines and alcohol see page 11

All patients requiring planned inpatient detoxification should be referred to the specialist service for a comprehensive assessment - NHS Fife Addiction Services 01592 716446



9

Unplanned Inpatient Management of Alcohol Withdrawal

MILD SYMPTOMS

Tense, irritable, poor concentration.

Review regularly if suspicion of withdrawal

6. ALCOHOL CONSUMPTION:<15 units/day men<10 units/day women

7. AUDIT score <20

8. SADQ score < 10

9. CIWA-Ar score <10

Encourage Fluids.

Continue to observe

IF NO IMPROVEMENT GO

TO AMBER ZONE

No medication required during admission or supplied on discharge

MODERATE/SEVERE SYMPTOMS

Tachycardia, systolic hypertension, nausea, vomiting, loss of appetite, retching, tremor, sweats, fever, insomnia, anxiety, headache, irritable, flu-like symptoms.

Abnormal LFT’s / raised MCV

5. ALCOHOL CONSUMPTION: >15 units/day men

>10 units/day women

6. AUDIT SCORE ≥20

7. and/or SADQ 15 – 30

8. CIWA-Ar score 10 - 14

Prescribe chlordiazepoxide according to symptoms.

Nursing observations and administration of chlordiazepoxide is every 2 hours for first 24 hours.

Dose dependent on CIWA-Ar score: CIWA-Ar 0 – 9 no treatment required CIWA-Ar 10-14 give 25mg CIWA-Ar 15 or more give 50mg

After 24 hours continue with fixed reduction schedule based on total dose of chlordiazepoxide given PRN in first 24 hours. Observations twice daily.

IF NO IMPROVEMENT GO TO RED ZONE

UNCONTROLLED SYMPTOMS

As for moderate/severe symptoms and in addition:

Confusion, disorientation, visual/auditory hallucinations, seizures, irrational thoughts/delusions, bizarre or aggressive or un-cooperative behaviour.

Offer brief intervention and self-help leaflet.

Provide information about alcohol services

Prescribe chlordiazepoxide starting with a dose of 50mg followed by a

further 2 doses at 1 hour intervals PRN

Nursing observations and administration of chlordiazepoxide is every 1 to 2 hours for first 24 hours. Further doses

dependent on CIWA-Ar score.

Consult with Critical Care Team before total dose exceeds 250mg in 24hours.

VITAMIN SUPPLEMENTATION ALL patients with alcohol dependency must be prescribed parenteral

Pabrinex®* for prophylaxis or treatment of Wernike’s Encepalopathy (WE)

PROPHYLAXIS – patient with history

of alcohol misuse

ONE pair of Pabrinex IVHP or IMHP ONCE daily for 3 – 5 days

TREATMENT – patient with history of

alcohol misuse and displaying symptoms of WE

TWO pairs of Pabrinex IVHP THREE times daily for 3 days

If response noted continue with ONE pair of Pabrinex IVHP or IMHP ONCE daily for 5 days

*Small risk of anaphylaxis. Facilities to manage anaphylaxis must be available.

Continue with oral thiamine 100mg THREE times daily on discharge

All patients asked about alcohol consumption and complete Fast Alcohol Screening Test.

Patient exceeds recommended drinking limits but

scores < 3 → Alcohol Brief Intervention (ABI)

Patient exceeds recommended drinking limits and

scores ≥ 3

5. ALCOHOL CONSUMPTION: >15 units/day men

>10 units/day women

6. AUDIT SCORE ≥ 20

7. SADQ > 30

8. CIWA-Ar score ≥15

Physical examination and Biological Tests – BAC¹, FBC (inc MCV), U&Es, LFTs (inc γGT), Glucose + drug screen

GREEN ZONE AMBER ZONE RED ZONE

1. Breath Alcohol Concentration

COMPLEX NEEDS Alcohol Withdrawal Seizures: add lorazepam 1-2 mg IV

Delirium Tremens: add lorazepam 1-2 mg oral/IM/IV and/or haloperidol 5mg oral or IM

(monitor ECG: QTc should be <440ms)

10

Patient with one or more of the following:

Malnourished Diarrhoea Vomiting Physical illness

Weight loss Decompensated liver disease

Prophylaxis and Treatment of Wernicke’s Encephalopathy

Patient with history of alcohol misuse and one or more of the following:

Acute confusion Opthalmoplegia/Nystagmus

Ataxia/unsteadiness Memory disturbance

Decreased consciousness Unconsciousness/coma

Unexplained hypotension with hypothermia

Administer TWO pairs of PABRINEX® IVHP* ampoules

THREE TIMES DAILY for 3 DAYS

No response after 72 hours:

Review diagnosis.

Consider augmentation with i.v. magnesium or

Discontinue supplementation unlesscomatose/unconscious

Response – continue with

ONE pair of PABRINEX® IVHP* ampoules

or ONE pair of PABRINEX® IMHP ampoules

ONCE DAILY for 5 DAYS or

for as long as improvement continues

Administer

ONE pair of PABRINEX® IMHP ampoules

or

ONE pair of PABRINEX® IVHP* ampoules

ONCE DAILY for 3 to 5 DAYS

Treatment of acute Wernicke’s Encephalopathy

Prophylaxis for Wernicke’s Encephalopathy

YES NO

Continue indefinitely with ORAL THIAMINE

100mg THREE times daily

N.B. There are TWO formulations of Pabrinex® injection, one for IV use and one for IM use.

THESE FORMULATIONS ARE NOT INTERCHANGEABLE:

PABRINEX® IVHP* = Pabrinex® intravenous high potency injection

PABRINEX® IMHP = Pabrinex® intramuscular high potency injection

ONE pair = ampoule No.1 plus ampoule No. 2

MHRA/CHM advice (September 2007) Although potentially serious allergic adverse reactions may rarely occur during, or shortly after, parenteral administration, the CHM has recommended that: 1. This should not preclude the use parenteral thiamine particularly in patients at risk of Wernicke-Korsakoff

syndrome where parenteral treatment with thiamine is essential.2. Intravenous administration should be by infusion over 30 minutes.3. Facilities for treating anaphylaxis should be available when parenteral thiamine is administered.

Wernicke’s Encephalopathy is an acute illness, precipitated by alcohol withdrawal, which is often under treated or missed. It should be suspected and treated in any patients undergoing alcohol detoxification who develop confusion, memory problems or difficulties with their gait or co-ordination.

Korsakoff’s psychosis is a preventable dementia, described as an amnesic syndrome with impaired recent memory, and relatively intact intellectual function. It occurs after one or more inadequately treated episodes of Wernicke’s encephalopathy.

All in-patients presenting in alcohol withdrawal should be considered at risk of developing Wernicke’s Encephalopathy

NO YES

*IV: Mix No.1 and No.2 ampoules with 100ml of normal saline or 5% glucose and infuse over 30 minutes

11

Management of complex needs

Patient with liver impairment

Longer acting benzodiazepines metabolised in the liver (e.g. chlordiazepoxide) are known toaccumulate but may be used with caution in the knowledge that a lower dose given lessfrequently will be required.

Metabolism of lorazepam is not impaired by liver disease and may be used in severe or acuteliver impairment. (approximate equivalent dose: chlordiazepoxide 25mg = lorazepam 1mg)

Lorazepam has a shorter half-life than chlordiazepoxide which may increase the seizure risk.

Liver function should be monitored during detoxification

Patient dependent on benzodiazepines and alcohol

Increased dose of benzodiazepine will be required for detoxification

Calculate initial daily dose based on requirement for alcohol withdrawal plus equivalentregularly used daily dose of benzodiazepine (up to a maximum daily dose of 30mg diazepam orequivalent)

Withdrawal is best managed with one benzodiazepine (diazepam or chlordiazepoxide) ratherthan multiple benzodiazepines.

Inpatient regimens should last for 2 – 3 weeks or longer, depending on severity of coexistingbenzodiazepine dependence.¹

Community based withdrawal should last for longer than 3 weeks and be tailored to patientssymptoms and discomfort.¹

1. See Guidance for benzodiazepine prescribing in benzodiazepine dependence at http://www.fifeadtc.scot.nhs.uk

Patient with Alcohol Withdrawal Seizures

Alcohol withdrawal seizures occur between 12 to 48 hours after significant reduction in alcohol

Adequate doses of chlordiazepoxide usually prevent withdrawal seizures.

For patients not taking chlordiazepoxide offer a fast-acting benzodiazepine, such as lorazepam,to reduce the likelihood of further seizures.

If the patient is already taking chlordiazepoxide as part of a withdrawal regimen give lorazepam

1-2mg IV in addition [unlicensed indication].

Repeat with a second dose after 15 minutes if required

Review chlordiazepoxide withdrawal regimen to prevent further seizures from occurring.

Patient with Delirium Tremens

Delirium Tremens can appear 24 – 72 hours after alcohol has stopped

Symptoms/signs differ from withdrawal symptoms in that there are signs of altered mentalstatus such as hallucinations, confusion, delusions, severe agitation.

Offer oral lorazepam 1-2 mg and/or haloperidol 5mg: if declined administer lorazepam 2mg IMand/or haloperidol 5mg IM. If no response after 1 hour repeat once.

ECG is mandatory before haloperidol use. If not possible or QTc >440ms monitor constantly

Maximum daily dose (oral and IM) for lorazepam 4mg and for haloperidol 15mg.

Dilute lorazepam for IM use with equal volume of water for injections or sodium chloride 0.9%.

If delirium tremens develops in a person during treatment for acute alcohol withdrawal withbenzodiazepines, review their withdrawal drug regimen.

n.b.

Lorazepam and haloperidol are used in UK clinical practice in the management of delirium tremens. At time of

writing they do not have UK marketing authorisation for this indication. Informed consent should be obtained and

documented. In addition the Summary of Product Characteristics advises:

Lorazepam –use in individuals with history of alcoholism should be avoided due to increased risk of dependence.

Haloperidol – caution is advised in patients suffering from conditions predisposing to convulsions, such as alcohol withdrawal.

For further advice contact - NHS Fife Addiction Services 01592 716446

http://www.fifeadtc.scot.nhs.uk/

12

Psychological support The following third sector agencies offer Fife wide support for alcohol dependant patients and their

families. Patients may be referred or self-refer. Contact the organisations for further information.

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Rehabilitation services

Family Support

Mutual aid groups

Psychosocial counselling

FASS offers a range of Motivational

Enhancement & Cognitive-Behavioural

counselling methods to individuals and

support for relatives and friends.

DAPL offers one to one counselling,

support, information and advice to

individuals and families across Fife.

“Self Management and Recovery Training” Helping people develop the tools and skills

they need to gain control over their addictive behaviours.

Alcoholics Anonymous

National 24-hour helpline 0845 769 7555

Local 24-hour helpline 0131 225 2727

www.aa-gb.org.uk/eastscotland/fife

AA is concerned with the personal recovery and continued sobriety of individual

alcoholics who turn to the Fellowship for help. There are more than 40 meetings in

16 different towns across Fife.

Fife Alcohol Support Service

17 Tolbooth St, KIRKCALDY KY1 1RW

01592 206200

www.fassaction.org.uk

Drug & Alcohol Project Limited

2 Parkdale, Park Drive Leven, KY8 5AO

01333 422277

www.dapl.net

Fife Intensive Rehabilitation & Substance Misuse Team

3 Fergus Place, KIRKCALDY KY1 1YA

01592 585960

www.firstforfife.co.uk

Meetings held across Fife: Phone 01333 422277 or

01592 585960 for details. www.smartrecovery.org

FIRST provides a Fife-wide rehabilitation service to individuals via one to one sessions, group work and

volunteer support

Al-Anon Family Groups provide support to anyone whose life is, or has been, affected

by someone else’s drinking. Groups currently meet in Cupar,

Dunfermline, Glenrothes and Kirkcaldy

Al-Anon

National helpline 020 7403 0888

www.al-anonuk.org.uk

Barnardo’s

Westbridge Mill, Bridge St, KIRKCALDY, KY1 1TE

01592 265294 www.barnardos.org.uk

A family intervention service for children affected by parental

substance use.

http://www.aa-gb.org.uk/eastscotland/fife

http://www.fassaction.org.uk/

http://www.dapl.net/

http://www.firstforfife.co.uk/

http://www.smartrecovery.org/

http://www.al-anonuk.org.uk/

http://www.barnardos.org.uk/

13

Pharmacological Support

Medication should be initiated and reviewed for up to 3 months by the specialist service.

Medication to support relapse prevention in abstinence should not be used without

psychological support.

Acamprosate

Acamprosate reduces the risk of relapse during the post-withdrawal period and is most valuablein the first few months after detoxification.

Generally well tolerated, it can be given safely to a wide number of patients with physical co-morbidity, but used with caution in those with severe liver or renal impairment (see SPC).

It should be initiated as soon as possible after detoxification although there is evidence to suggestthat starting during detoxification may provide an additional neuroprotective effect.¹

Efficacy should be assessed at monthly appointments for the first 6 months and, if effective,should be prescribed for at least 6, but preferably, 12 months.

Treatment may be continued longer term with regular reviews every six months.¹

Treatment should be stopped if drinking persists 4 to 6 weeks after starting the drug.

Treatment should not be stopped if there is a minor relapse.

1. Acamprosate does not have UK marketing authorisation for use during detoxification or for use longer than 12 months. Informedconsent should be obtained and documented.

Disulfiram

Disulfiram is used as a deterrent by triggering an unpleasant reaction if alcohol is consumed.Even small amounts of alcohol (in mouthwashes, medicines, and aftershave for example) mayprecipitate a reaction.

Caution should be exercised in the presence of renal failure, hepatic or respiratory disease,diabetes mellitus, hypothyroidism, cerebral damage and epilepsy. (see SPC)

Arrangements should be made to ensure consumption is witnessed (by spouse, friend,healthcare or support worker for example)

Efficacy should be assessed every 2 weeks for the first 2 months and then monthly for thefollowing 4 months.

Patients successfully maintaining abstinence should be continued for a minimum of 6 months butmay be continued longer-term with regular 6 monthly reviews.

Disulfiram should only be commenced when the patient has been alcohol free for at least 24hours and may have a residual effect lasting up to 7 days after the last dose.

Naltrexone

Naltrexone is thought to reduce a return to heavy drinking by reducing alcohol’s rewarding effectsand also the motivation to drink.

Contraindications include severe renal and/or hepatic impairment, acute hepatitis, opioiddependent patients and patients taking opioid containing medication (see SPC).

Naltrexone for relapse prevention should be commenced soon after stopping drinking.

The dosage regimen can be modified in order to improve compliance to a three times a weekdosing schedule as follows: 2 x 50mg tablets on Monday and on Wednesday and 3 x 50mgtablets on Friday.

Efficacy should be assessed at monthly appointments for the first 6 months and, if effective,should be prescribed for at least 6 – 12 months.

Treatment should be stopped if drinking persists 4 to 6 weeks after starting the drug.

Patients must be warned against concomitant use of opioid containing medication including over-the-counter medicines.

http://www.medicines.org.uk/emc/medicine/1042



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Baclofen

Baclofen has been shown to reduce alcohol craving and intake and enhance abstinence. Clinicaltrials have also shown baclofen to reduce anxiety levels in patients with alcohol relateddifficulties.²

Baclofen may be used in patients where significant liver impairment would contraindicate licensedmedication. Patient with impaired renal function however, should only use a low dose.

Baclofen should be used with caution in patients with severe psychiatric disorders, epilepsy,respiratory, hepatic or renal impairment, receiving antihypertensive therapy, suffering fromcerebrovascular accidents, or with a history of peptic ulceration (see SPC)

Baclofen is contraindicated in active peptic ulceration.

The recommended initial dose of 5mg three times daily should be titrated upwards slowly inincrements of 5 mg three times daily every three days in response to continued craving andmonitored side effects.

Studies have used doses of 10mg to 20mg three times daily.

Treatment should be continued for 6 months to 1 year

2. Baclofen is not licensed for use in alcohol dependency. Informed consent should be obtained and documented.

Nalmefene

Nalmefene should only be prescribed in conjunction with continuous psychosocialsupport focused on treatment adherence and reducing alcohol consumption.

Nalmefene reduces cravings in the alcohol-dependent drinker thus reducing alcohol consumption.

Nalmefene is licensed for patients:

continuing to exhibit a High Drinking Risk Level³ two weeks after initial assessment.

without physical withdrawal symptoms

who do not require immediate detoxification

Caution should be exercised in patients with current psychiatric comorbidity, history of seizuredisorders, mild or moderate hepatic and/or renal impairment (see SPC)

Contraindications include concomitant opioid analgesics, current or recent opioid addiction,severe hepatic and/or renal impairment, recent history of acute alcohol withdrawal syndrome.

The patient’s response to treatment should be evaluated on a regular (monthly) basis.

The greatest improvement is likely to be seen in the first 4 weeks of treatment.

Clinical data is available for a treatment period of between 6 and 12 months

Caution is advised if nalmefene is prescribed for more than 1 year.

Nalmefene is in the Fife Formulary approved for restricted use by addiction services only

3. WHO category defined as men drinking >7.5 but <12.5 units daily and women drinking >5 but < 7.5 units daily.

Medication to support controlled drinking should not be used without psychological support.



http://www.fifeadtc.scot.nhs.uk/media/2174/chapter_4_cns_final_jan_13__last_amended_jan_16.pdf

15

No. of drinks/day x units = daily units x days = weekly units

Can (500ml) 4% lager x 2 = x 7 =

Can (440ml) 4% lager x 1.7 = x 7 =

Can (440ml) strong 8.5% lager x 3.8 = x 7 =

Pint 4% lager x 2.3 = x 7 =

Pint 5% lager x 2.9 = x 7 =

Bottle (330ml) 5% lager x 1.7 = x 7 =

Bottle (3l) 7.5% cider x 22 = x 7 =

Bottle (1l) 7.5% cider x 7.5 = x 7 =

Pint 4.5% cider x 2.6 = x 7 =

Bottle (750ml) 12% [14%] wine x 9 [10.5] = x 7 =

Large glass (250ml) 12 [14%] wine x 3 [3.5] = x 7 =

Std glass (175ml) 12 [14%] wine x 2.1 [2.5]= x 7 =

Bottle (750ml) whisky/vodka/gin x 30 = x 7 =

Pub measure (25ml) spirit x 1 = x 7 =

Other drink

Total weekly units

1 pint of lager/beer

4% = 2.3 units of alcohol

Can (500ml) of lager/beer

4% = 2 units of alcohol

Can (440ml) of lager/beer


Can (440ml) of super strength lager/cider/beer 8.5% = 3.8 units of

alcohol

1 pint of lager/beer


Bottle (330ml) of Lager


Bottle (3litre) of cider

7.5% = 22.5 units of alcohol

Bottle (1litre) of cider


1 pint of Cider


Bottle (750ml) 12% wine


Bottle (750ml) 14% wine


Large glass (250ml) wine

12% = 3 units14% = 3.5 units

Bottle (750ml) of whisky/gin/vodka


Pub (25ml) measure whisky/gin/vodka

40% = 1 unit of alcohol

Standard glass (175ml) wine

12% = 2.1 units 14% = 2.5 units

Appendix 1 ALCOHOL CONSUMPTION CALCULATOR

16

Appendix 2 FAST ALCOHOL SCREENING TEST (FAST)

FAST questions Record the scores in the boxes on the right.

Score

Score

Score

Score

How often do you have:

6 or more units on one occasion? or 8 or more units on one occasion?

Never = 0 = 1 Monthly = 2 Weekly = 3 = 4

Question 1

Less than monthly

Daily or almost daily

If the response to this question is “never”, the person is at low risk for alcohol-related problems,

but bear in mind the drinking limits

If the response to this question is

“less than monthly” or “monthly” go on to ask

questions 2, 3 and 4

If the response to this question is

“weekly” or “daily or almost daily” the person is a risky

(hazardous), harmful or dependent drinker

How often during the last year have you been unable to remember what

happened the night before because you had been drinking?


Question 2

Less than monthly


How often during the last year have you failed to do what was normally

expected of you because you had been drinking?


Question 3

Less than monthly


In the last year has a relative, friend, doctor or health worker been

concerned about your drinking and suggested that you cut down?

No = 0 Yes, on one occasion = 2 Yes, on more than one occasion = 4

Question 4

Add up the scores to the above questions and record below. The minimum score is 0 and the maximum score is 16.

Total score: The score for hazardous drinking is 3 or more

Score

17

Appendix 3 Alcohol Use Disorders Identification Test (AUDIT)

1. How often do you have a drink containingalcohol?

0 Never 1 Monthly or less 2 2 to 4 times a month 3 2 to 3 times a week 4 4 or more times a week

2. How many drinks containing alcohol do youhave on a typical day when you are drinking?

0 1 or 2 1 3 or 4 2 5 or 6 3 7 to 9 4 10 or more

3. How often do you have six or more drinkson one occasion?

0 Never 1 Less than monthly 2 Monthly 3 Weekly 4 Daily or almost daily

4. How often during the last year have you foundthat you were not able to stop drinking onceyou had started?


5. How often during the last year have youfailed to do what was normally expectedfrom you because of drinking?


6. How often during the last year have you neededa first drink in the morning to get yourself goingafter a heavy drinking session?


7. How often during the last year have youhad a feeling of guilt or remorse afterdrinking?


8. How often during the last year have you beenunable to remember what happened the nightbefore because you had been drinking?


9. Have you or someone else been injured asa result of your drinking?

0 Never 2 Yes, but not in the last year 4 Yes, during the last year

10. Has a relative or friend or a doctor or anotherhealth worker been concerned about yourdrinking or suggested you cut down?

0 Never 2 Yes, but not in the last year 4 Yes, during the last year

Scoring and interpretation Total score

Between 8 and 15 – simple advice focused on the reduction of hazardous drinking

Between 16 and 19 – brief counselling and continued monitoring

Over 20 – further evaluation for alcohol dependence

Questions 4 to 6 – any points scored imply the presence or incipience of alcohol dependence.

Questions 7 to 10 – Any points scored indicate alcohol-related harm is being experienced.

The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care, 2nd

Edition. WHO 2001

18

Appendix 4 Severity of Alcohol Dependence Questionnaire (SADQ)

Name……………………………………………………….. Age………………………..

We would like you 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 other similar periods, and how often you experienced certain feelings.

Please answer every question by putting a tick in the appropriate column.

Almost never

Some- times

Often Nearly always

1. I wake up feeling sweaty 0 1 2 3

2. My hands shake first thing in the morning 0 1 2 3

3. My whole body shakes violently first thing in themorning, if I don’t have a drink 0 1 2 3

4. I wake up absolutely drenched in sweat 0 1 2 3

5. I dread waking up in the morning 0 1 2 3

6. I am frightened of meeting people first thing in themorning 0 1 2 3

7. I feel on the edge of despair when I wake up 0 1 2 3

8. I feel very frightened when I wake up 0 1 2 3

9. I like to have a morning drink 0 1 2 3

10. I always gulp down my morning drink as quickly aspossible 0 1 2 3

11. I drink in the morning to get rid of the shakes 0 1 2 3

12. I have a very strong craving for a drink when I wake up. 0 1 2 3

13. I drink more than ¼ bottle of spirits or 4 pints of beer or1 bottle of wine a day 0 1 2 3

14. I drink more than ½ bottle of spirits or 8 pints of beer or2 bottles of wine a day 0 1 2 3

15. I drink more than 1 bottle of spirits or 15 pints of beer or4 bottles of wine a day 0 1 2 3

16. I drink more than 2 bottles of spirits or 30 pints of beeror 8 bottles of wine a day 0 1 2 3

Imagine you have been completely off drink for a few weeks and then drink heavily for two days – how would you feel the morning after those two days?

Not at all

Slightly Moderately A lot

17. The morning after I would start to sweat 0 1 2 3

18. The morning after my hands would shake 0 1 2 3

19. The morning after my body would shake 0 1 2 3

20. The morning after I would be craving for a drink 0 1 2 3

TOTALS

Score maximum for questions 17 to 20 if patient has not been abstinent for a period of 2 weeks

Scores: 0-3 no dependence, 4-19 mild dependence, 20-30 moderate dependence,

31-44 severe dependence, 45+ very severe dependence

19

Appendix 5 Personal Drinking Questionnaire (SOCRATES) (The Stages of Change Readiness and Treatment Eagerness Scale)

Please read the following statements carefully. Each one describes a way that you might (or might not) feel about your drinking. For each statement circle one number from 1 to 5, to indicate how much you agree or disagree with it right now. Please circle one and only one number for every statement.

Strongly disagree

NO!

Disagree

no

Unsure

?

Agree

yes

Strongly agree

YES!

1. I really want to make changes to my drinking 1 2 3 4 5

2. Sometimes I wonder if I’m and alcoholic 1 2 3 4 5

3. If I don’t change my drinking soon, my problems are goingto get worse

1 2 3 4 5

4. I have already started making some changes in my drinking 1 2 3 4 5

5. I was drinking too much at one time, but I’ve managed tochange my drinking.

1 2 3 4 5

6. Sometimes I wonder if my drinking is hurting other people 1 2 3 4 5

7. I am a problem drinker 1 2 3 4 5

8. I’m not just thinking about changing my drinking, I’malready doing something about it.

1 2 3 4 5

9. I have already changed my drinking, and I am looking forways to keep from slipping back to my old pattern

1 2 3 4 5

10. I have serious problems with drinking 1 2 3 4 5

11. Sometimes I wonder if I am in control of my drinking 1 2 3 4 5

12. My drinking causes a lot of harm 1 2 3 4 5

13. I am actively doing things now to cut down or stop drinking 1 2 3 4 5

14. I want help to keep from going back to the drinkingproblems that I had before

1 2 3 4 5

15. O know that I have a drinking problem 1 2 3 4 5

16. There are times when I wonder if I drink too much 1 2 3 4 5

17. I am an alcoholic 1 2 3 4 5

18. I am working hard to change my drinking 1 2 3 4 5

19. I have made some changes in my drinking, and I want somehelp to keep from going back to the way I used to drink

1 2 3 4 5

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20

Personal Drinking Questionnaire Scoring Form

Transfer the client’s answers from questionnaire:

Recognition Ambivalence Taking Steps

1. ___________ 2. _________

3. ___________ 4. ___________

5. ___________

6. __________

7. ___________ 8. ___________

9. ___________

10. ___________ 11. __________

12. ___________ 13. ___________

14. ___________

15. ___________ 16. __________

17. ___________ 18. ___________

19. ___________

TOTALS

Possible range Recognition 7 - 35 Ambivalence 4 - 20 Taking Steps 8 - 40

PROFILE TABLE Decile scores

Recognition Ambivalence Taking Steps

90 very high 19-20 39-40

80 18 37-38

70 high 35 17 36

60 34 16 34-35

50 average 32-33 15 33

40 31 14 31-32

30 low 29-30 12-13 30

20 27-28 9-11 26-29

10 very low 7-26 4-8 8-25

Scores from table above

INTERPRETATION

Instructions:

1. From the scoring form above transfer the

total scores into the empty boxes at the

bottom of the profile table.

2. For each scale, CIRCLE the same value

above it to determine the decile range

3. This informs you if the client’s score is low,

average or high relative to people already

seeking treatment for alcohol problems.

RECOGNITION

High Scorer: Directly acknowledge they are

having problems related to theirdrinking.

Tend to express a desire forchange.

Perceive that harm will continueif they do not change

Low Scorer

Deny alcohol is causing aserious problem

Reject labels such as “problemdrinker” and “alcoholic”.

Do not express a desire tochange

AMBIVALENCE

High Scorer:

Uncertain and sometimeswonder if they are in control oftheir drinking, are drinking toomuch, hurting other peopleand/or are alcoholic

Are open to reflection and in thecontemplation stage of change.

Low Scorer with high recognition score:

“Know” their drinking is causingproblems

Low scorer with low recognition score:

“Know” that they do not have aproblem with alcohol

TAKING STEPS

High Scorer:

Report that they are makingpositive changes andexperiencing some success.

May need help to preventrelapse.

Likely to be successful

Low Scorer:

Report that they are notcurrently trying to changetheir drinking

Have not made any changesrecently

21

Appendix 6 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

NAUSEA AND VOMITING Ask “Do you feel sick to your stomach? Have you vomited? OBSERVATION

0 no nausea and no vomiting 1 mild nausea with no vomiting 2 3 4 Intermittent nausea with dry heaves 5 6 7 Constant nausea, frequent dry heaves & vomiting

TREMOR Arms extended and fingers spread apart. OBSERVATION

0 No tremor 1 Not visible, but can be felt fingertip to fingertip 2 3 4 Moderate, with patient’s arms extended 5 6 7 Severe, even with arms extended

ANXIETY Ask “Do you feel nervous?” OBSERVATION

0 No anxiety, at ease 1 Mildly anxious 2 3

4 Moderately anxious or guarded so anxiety inferred) 5 6

7 Equivalent to acute panic states seen in severe delirium or acute schizophrenic reactions

AGITATION OBSERVATION

0 Normal activity 1 Somewhat more than normal activity 2 3

4 Moderately fidgety and restless 5 6

7 Paces back and forth, or constantly thrashes about

PAROXYSMAL SWEATS OBSERVATION

0 No sweat visible 1 Barely perceptible sweating, palms moist 2 3 4 Beads of sweat obvious on forehead 5 6 7 Drenching sweats

ORIENTATION & CLOUDING OF SENSORIUM

Ask “What day is this? Where are you? Who am I?” Rate on scale 0 - 4

0 Oriented 1 Cannot do serial additions or is uncertain of the date 2 Disoriented to date by no more than 2 days 3 Disoriented to date by more than 2 days 4 Disoriented for place and / or person

TACTILE DISTURBANCES Ask “Have you any itching, pins

and needles, burning, numbness, or you do feel bugs crawling on or under your skin? OBSERVATION

0 none 1 very mild itching, pins & needles, burning or numbness 2 mild itching, pins & needles, burning or numbness 3 moderate itching, pins & needles, burning or numbness 4 moderate hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

VISUAL DISTURBANCES Ask “Does the light appear too

bright? Is its colour different to normal? Does it hurt your eyes? Are you seeing anything that is disturbing you or you know isn’t there?” 0 Not present 1 Very mild sensitivity 2 Mild sensitivity 3 Moderate sensitivity 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations

AUDITORY DISTURBANCES Ask “Are you more aware of

sounds? Are they harsh or startle you? Do you hear anything that disturbs you or you know is not there?

0 Not present 1 Very mild harshness or ability to startle 2 Mild harshness or ability to startle 3 Moderate harshness or ability to startle 4 Moderate hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations

HEADACHE, FULLNESS IN HEAD Ask “does your head feel

different? Does it feel like there is a band round your head?” (do not rate for dizziness or lightheadedness)

0 Not present 1 Very mild 2 Mild 3 Moderate 4 Moderately severe 5 Severe 6 Very severe 7 Extremely severe

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Patient:……………………………………………………………………Date:………………………Time:…………………

Pulse or heart rate taken for one whole minute…………………..Blood Pressure…………………………………...

22

Appendix 7 Inpatient: Alcohol withdrawal observation chart (based on CIWA-Ar scale)

Begin using this chart at first sign of withdrawal symptoms.

Name: (or affix label)

Date:

Time: (24 hour clock)

Blood Pressure

Heart Rate

Respiratory Rate (breaths per minute)

If below 10 inform medical team

Nausea/vomiting (0-7)

Tremor (0-7)

Anxiety (0-7)

Agitation (0-7)

Sweats (0-7)

Orientation (0-4)

Tactile disturbances(0-7)

Visual disturbances (0-7)

Auditory disturbances (0-7)

Headache (0-7)

Total CIWA-Ar Score (max 67)

Dose chlordiazepoxide (mg)

Total Dose Chlordiazepoxide in 24 hours = Consult with Critical Care Team before total dose exceeds 250mg in 24hours.

This acts as baseline dose – use to calculate 5 day (or longer if required) reducing regimen.

Guy’s and St Thomas’ NHS Foundation Trust DTC 10052a

CIWA-Ar 0-9 no dose CIWA-Ar 10-14 give 25mg

CIWA-Ar ≥ 15 give 50mg

23

Appendix 8 Inpatient symptom triggered chlordiazepoxide schedule.

The first 24 hours

1. An initial dose of chlordiazepoxide 25mg to 50mg is given according to the assessment ofwithdrawal signs and symptoms measured by the CIWA-Ar score (see appendix 6 and 7).

2. If withdrawal symptoms are mild an initial dose may not be necessary.

3. Observations should be repeated at least every two hours with subsequent doses ofchlordiazepoxide given when required and according to the CIWA-Ar score.

4. The cumulative dose administered during the initial 24 hour period (Day 1 total PRN dose – seetable below) is used to calculate the subsequent reducing regimen.

5. If the patient requires more than 250mg chlordiazepoxide in the first 24 hours consult with theCritical Care Team.

Days 2 to 6

6. After the initial 24 hour assessment period patients should be given chlordiazepoxide using afixed reducing schedule. Ideally no more chlordiazepoxide should be prescribed on a whenrequired basis.

7. Chlordiazepoxide is given in divided doses, four times daily, calculated according to the totaldose given in the first 24 hours.

8. Observations should be carried out twice daily.

Fixed reduction schedule from day 2

Day 1 total PRN dose

Day 2 (mg) Day 3 (mg) Day 4 (mg) Day 5* (mg)

8am 12pm 6pm 10pm 8am 12pm 6pm 10pm 8am 12pm 6pm 10pm 8am 12pm 6pm 10pm

250mg 50 50 50 50 40 40 40 40 25 25 25 25 15 15 15 15

225mg 45 45 45 45 35 35 35 35 25 25 25 25 15 10 10 15

200mg 40 40 40 40 30 30 30 30 20 20 20 20 10 10 10 10

175mg 35 35 35 35 25 25 25 25 20 20 20 20 10 10 10 10

150mg 30 30 30 30 20 20 20 20 15 15 15 15 10 5 5 10

125mg 25 25 25 25 20 20 20 20 15 10 10 15 10 5 5 10

100mg 20 20 20 20 15 15 15 15 10 10 10 10 5 5 5 5

75mg 15 15 15 15 10 10 10 10 5 5 5 5 5 5 5

50mg 10 10 10 10 5 5 5 5 5 5 5 5 5

25mg 5 5 5 5 5 5 5 5 5 5

*A longer detox may be required if at Day 5 the patient is on a total dose of 40mg or larger

Guy’s and St Thomas’ NHS Foundation Trust DTC Reference 10052a

CIWA-Ar 0 – 9 (or patient asleep)

no treatment necessary CIWA-Ar 10 – 14

give 25mg CIWA-Ar 15 or above

give 50mg

Each set of observations should consist of:

Assessment with the alcohol withdrawal scale (CIWA-Ar)

Taking BP

Taking pulse

Monitoring respiratory rateIf the patient is asleep they should not be woken up to be scored for observations. However, it should be recorded that they were asleep.

24

Appendix 9 Community detoxification fixed dose chlordiazepoxide schedule

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1. If fixed dose titrate initial dose according to the SADQ score and/or regular daily level ofalcohol consumption.

2. Clinical observations every 4 to 6 hours with CIWA-Ar score. If necessary an extra PRN doseof chlordiazepoxide may be prescribed.

Typical recent daily consumption

15 to 25 units 30 to 49 units 50 to 60 units

Severity of alcohol dependence

MODERATE SADQ score 15 to 30

SEVERE SADQ score 31 to 40

VERY SEVERE SADQ score 41 to 60

Starting dose of chlordiazepoxide

15mg to 25mg four times daily

30mg to 40mg four times daily

50mg four times daily

Day 1 (starting dose) 15mg q.d.s. 25mg q.d.s. 30mg q.d.s. 40mg q.d.s.* 50mg q.d.s.*

Day 2 10mg q.d.s. ¹ 20mg q.d.s. 25mg q.d.s. 35mg q.d.s. 45mg q.d.s.

Day 3 10mg t.d.s. ² 15mg q.d.s. 20 mg q.d.s. 30mg q.d.s. 40 mg q.d.s.

Day 4 5mg t.d.s. 10mg q.d.s. 15mg q.d.s. 25mg q.d.s. 35 mg q.d.s.

Day 5 5mg b.d. ³ 10mg t.d.s. 10mg q.d.s. 20mg q.d.s. 30mg q.d.s.

Day 6 5mg at night 5mg t.d.s. 10mg t.d.s. 15mg q.d.s. 25mg q.d.s.

Day 7 5mg b.d. 5mg t.d.s. 10mg q.d.s. 20mg q.d.s.

Day 8 5mg at night 5mg b.d. 10mg t.d.s. 15mg q.d.s.

Day 9 5mg at night 5mg t.d.s. 10mg q.d.s.

Day 10 5mg b.d. 10mg t.d.s.

Day 11 5mg at night 5mg t.d.s.

Day 12 5mg b.d.

Day 13 5mg at night

* Doses of chlordiazepoxide in excess of 30mg q.d.s should only be prescribed in cases where severewithdrawal symptoms are expected and the patient’s response to the treatment should always be regularly and closely monitored. Doses in excess of 40mg q.d.s. should only be prescribed where there is clear evidence of very severe alcohol dependence.

¹ FOUR times a day; ² THREE times a day;³ TWICE daily

DO NOT USE BENZODIAZEPINES AS ONGOING TREATMENT FOR ALCOHOL DEPENDENCE. USE FOR WITHDRAWAL ONLY

25

Appendix 10 NHS Fife Addiction Services

Agency Name NHS FIFE ADDICTION SERVICE

Contact Details: Addiction Services Ward 11, Cameron Hospital WINDYGATES KY8 5RR 01592 716446

Other locations across Fife Addiction Services Whyteman’s Brae KIRKCALDY 01592 716446

Addiction Services Lynebank Hospital DUNFERMLINE 01592 716466

Services offered NHS Fife Addiction Services offer a Fife wide service to individuals over the age of 16 years who experience drug and/or alcohol problems The service offers and provides:

Comprehensive assessment

A wide range of pharmacological treatments

Preparatory group work programme

A range of psychological therapies

Community and inpatient detoxification

Referral Criteria Individuals who are dependent on sedatives such as alcohol, opioidsand/or benzodiazepines and/or stimulants such as amphetamines.

Age 16 years and above

Resident in Fife

Referral routes Referral pathways into the service include:

Triage drop-in clinics (see Fife Direct)

Ongoing prescribing for individuals liberated from prison

Direct written referrals will only be accepted from consultant/GP if an individual cannot attend triage drop-in clinics due to physical or mental health reasons for example:

Acute episode of a mental illness such as bipolar disorder orschizophrenia

Insulin dependent diabetes

Malignancy

Complicated pregnancy

Individuals fleeing domestic violence.

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