Alcohol Detoxification Services in CIOS – a Stepped Approach

November, 2011

1: Overview of alcohol detoxification programmes in CIOS

The following chart shows the different services available to CIOS residents that, following full assessment, are deemed as requiring a structured detoxification from alcohol use.

‘Home and Dry’
Community Specialist Alcohol Detoxor St Petrocs Alcohol Detox
CommunityHospital Alcohol Detox
Residential Alcohol Detox (Boswyns or Broadreach)
RCHT acute admission in-patient alcohol stabilisation
  • There are clear eligibility and exclusion criteria for each service. Clients should be able to access the type of detoxification service that best meets their needs and level ofdependency.
  • Access to each service is through an agreed protocol and assessment procedure.
  • Having a range of detox options allows for cost-effective treatment based on levels of need.
  • Client choice may be a factor in deciding which detox should be accessed but this should not compromise patient safety or put staff in a position where they have to manage patients that their particular detox is not designed to care for.

Preparation and Aftercare Support

  • For a patient to benefit most from a detox it should be viewed as a planned intervention and subject to care co-ordination and recovery care planning processes.
  • Preparation processes include use of the relevant assessment tool, care plan, risk assessment, contingency plan and aftercare plan.
  • Quality of referrals to detoxification services must include the above and offer comprehensive and relevant information for the detoxification service to assess suitability.
  • Robust and comprehensive multi-agency assessment & preparation needs will precede any detox including the planning of post detox support and aftercare.
  • An acute admission to RCHT that leads to an alcohol stabilisation will be overseen by the Specialist Alcohol Nurse and continuation of care post discharge planned and arranged in conjunction with the appropriate agency.
  • If a patient remains ambivalent about the need for a detox or resolving their alcohol dependency it may be appropriate to delay detoxification and continue to explore their problems.
  • Repeated unsupported and unplanned detoxes may be harmful to the patient (kindling), and as such all care provided to clients in treatment should seek to prevent this occurring.
  • However, supported detoxes should be carefully planned and appropriate for the client. Through assessment a health professional must be assured that motivation and circumstances are conducive to detoxification.
  • Should a client fail to complete a planned detox, the Key-Worker willexplore the circumstances to try and avoid the same problem(s) occurring with subsequent detox attempts.
  • Post detox support, as apart of a plan of care, will maximise the benefit for the patient and reduce the risk of a subsequent relapse.

Capacity

  • The capacity for each type of detox in Cornwall clearly needs to match the number of patients who need it, and will be defined annually in the alcohol needs assessment.
  • Each detox should be as accessible and available as possible in terms of geography and waiting times but there will inevitably be a balance to be achieved for more specialist detoxes.

Alcohol Detox Services available in CIOS

‘Home and Dry’

Delivered through Addaction and GP practices contracted under an LES

A supported community detox for the least complex of patients with alcohol dependency. It is provided in General Practice with the patient attending the surgery on a daily basis for monitoringby the Practice Nurse during the course of the detox, typically for 5 days. It is dependent on the patient having a responsible carer who can support them throughout the course of detox including the management of their withdrawal medication.

The detox is provided through a practice team including the Addaction worker, GP and Practice Nurse all of whom will have received training to provide Home & Dry.

Chlordiazepoxide is the withdrawal medication used in dosing regimens chosen according to patient presentation, suitable for those with a SADQ of30.

59% of GP practices have been trained to provide this detox options. Practices will offer this service to patient’s of other practices where this service is not available.

Cornwall Drug & Alcohol Team Community Detox

Delivered by CDAT nurses in conjunction with a consultant psychiatrist

A supported community detox for patients who can be managed in the community whilst remaining in their own accommodation with care provided by a Community Detox Nurse. Contraindications to this detox are similar to those for Home & Dry but as support is offered in the patient’s own home then it is suitable for patients who are unable to attend their GP surgery. Also the skills of the Community Detox Nurse allow more flexibility to support patients with mental health and other substance misuse problems. Diazepam ‘symptom triggered therapy’ is the withdrawal medication used and can usually be managed over 24-48hrs.

St Petrocs Alcohol Detox for homeless people

Delivered by Addaction, CDAT and Health for the Homeless PHC service

This is provided to patients who are homeless and without a responsible carer to support them through a detox. After being assessed for their suitability the detox is planned with a ‘detox’ bed secured at St Petrocs for a 6 week period. This allows a secure and safe setting for the detox itself (supervised by a Community Detox Nurse with on-call support from Health for Homeless clinicians) as well as a stable environment for aftercare support/PODS.

Care is delivered by collaboration between the Health for the Homeless service, an Addaction-CADA Support Worker, a Community Detox Nurse and St Petrocs. Prescriptions are supplied from Health for the Homeless GPs or the CDAT Consultant.

CommunityHospital Alcohol Detox

Delivered by Addaction, GP practices contracted under an LES & PHCcommunityHospital services.

An inpatient detox delivered in a local CommunityHospital (currently St Ives, Helston, Bodmin) for patients who are not suitable for a Home and Dry or Community Specialist Detox because of their home circumstances or a lack of a responsible carer. It can also cater for patients who have physical problems that would make a community detox unsafe. It is also suitable for those on ORT who are stable on their medication. This may alsobe a good option for those who have previously been unsuccessful in attempted home detoxes.

Assessment & preparation is provided by the patients Addaction Key-Worker,and a CHAD LES GP (who also has input into the local CommunityHospital). The detox takes place in a booked CommunityHospital bed, typically over a 5-7 day period with monitoring and support during the detox coming from trained Community Hospital Nursing staff. Diazepam ‘symptom triggered therapy’ is the withdrawal medication tailored using CIWA-Ar scoring with the majority of dosing taking place in the 1st 24-48hrs.

Residential Detox (Boswyns or Broadreach)

Residential detoxes are for patients who are not suitable for community detox. These may include patients who have specific complicating problems including those with concomitant substance misuse who want to stabilise or detox their drug problem as well as detox from alcohol. They may also be suitable for patients who need to progress to secondary rehabilitation and support as part of their recovery. Currently options include Broadreach, in Devon,and Boswyns, in Cornwall. These residential units may be particularly suitable for those with mental health problems, learning disability problems or couples who both require detox/stabilisation.

Service User Profile

  • Aged 18y - 65yrs
  • Drug / alcohol users already engaged in Tier 3 community-based treatment
  • Those needing short-term, intensive assessment, treatment, or care, which cannot be carried out effectively in a community setting.
  • Those requiring access to a short-term specialist residential setting, at a time of crisis, in order to reduce associated risks, and stay in (T3) treatment.
  • Those requiring a short period in a managed environment to stabilise their drug use, with particular reference to chaotic illicit use “on top” of an established substitute prescription.
  • Those requiring titration onto a substitute prescription within a residential setting.
  • All forms of drug use including poly-drug use will be included

Interventions Offered

  • Stabilisation on substitution opioids
  • Withdrawal from substitution opioids
  • Supported withdrawal from sedatives (including alcohol) using benzodiazepines
  • Withdrawal from opioids using non-opioid medication
  • Opioid relapse prevention with naltrexone
  • Symptomatic treatment for stimulant withdrawal
  • In-patient assessment
  • (a combination of any of the above)

RCHT Acute Admission Inpatient Stabilisation

For those patients who have to be admitted without planning to the acute hospital because of another condition (e.g. medical or surgical emergency) and who are at risk of going into alcohol withdrawal., care is coordinated by the specialist alcohol nurse based at TreliskeHospital in Truro and covering the other RCHT sites.

Chlordiazepoxide ‘symptom triggered therapy’ according to the patient’s CIWA-Ar score is the withdrawal /stabilisation medication.

The specialist alcohol nurse will assess the patient’s needs, work with hospital staff to determine prescribing regimes and liaise regarding discharge and onward referral to specialist community agencies.

Reasons to Delay any alcohol detox

  • If a patient develops any acute illness/infection prior to detox consider delaying the detox until the patient is recovered.
  • Patient has unresolved ambivalence about their alcohol intake and the need for a Detox
  • Kindling (needs explanation)

Part 2: Contra-indications & cautions

HOME & DRY ALCOHOL DETOX

Contraindications

  • Significant cardiac problem (e.g. unstable ischaemic heart disease or arrhythmia)
  • Liver failure with decompensation
  • Severely undernourished
  • Has severe vomiting or diarrhoea
  • History of epilepsy or status epilepticus or fits during a supported/supervised detoxification
  • History of Wernicke’s Encephalopathy or Delirium Tremens
  • Is confused or has hallucinations
  • Active severe mental illness
  • Is at significant risk of suicide
  • Severe personality disorder
  • History of violence during alcohol detoxification
  • Has chaotic other substance misuse
  • Under 16 years of age
  • SADQ score of more than 40
  • Has a home environment unsupportive of abstinence
  • Absence of a carer who would accompany the patient to surgery appointments during the detox
  • Has severe dependence coupled with unwillingness to be seen daily
  • Unable to travel to the surgery

Cautions

  • If the patient has a history of significant complications during a previous supported/supervised withdrawal the circumstances need to be examined carefully before.
  • Benzodiazepine dependency - an assessment of risk before a decision is taken to proceed with detox.
  • 16 to 18 years of age – decision based on individual presentation and assessment.

COMMUNITY SPECIALIST ALCOHOL DETOX

Contraindications

  • Significant cardiac problem (e.g. unstable ischaemic heart disease or arrhythmia)
  • Liver failure with decompensation
  • Severely undernourished
  • Has severe vomiting or diarrhoea
  • History of epilepsy or status epilepticus or fits during a supported/supervised detoxification
  • History of Wernicke’s Encephalopathy or Delirium Tremens
  • Is confused or has hallucinations
  • Is at significant risk of suicide
  • History of violence during alcohol detoxification
  • Has a home environment unsupportive of abstinence
  • Under 18 years of age

Cautions

  • If the patient has a history of significant complications during a previous supported/supervised withdrawal the circumstances need to be examined carefully before commencement
  • Repeated detoxifications, assess with care.
  • Active severe mental illness
  • Severe personality disorder
  • Assess carefully other chaotic substance misuse

ST PETROCS/ HEALTH FOR THE HOMELESS DETOX

Contraindications

  • Significant cardiac problem (e.g. unstable ischaemic heart disease or arrhythmia)
  • Liver failure with decompensation
  • Severely undernourished
  • Has severe vomiting or diarrhoea
  • History of epilepsy or status epilepticus or fits during a supported/supervised detoxification
  • History of Wernicke’s Encephalopathy or Delirium Tremens
  • Is confused or has hallucinations
  • Active severe mental illness
  • Is at significant risk of suicide
  • Severe personality disorder
  • History of violence during alcohol detoxification
  • Has chaotic other substance misuse
  • Under 18 years of age

Cautions

  • If the patient has a history of significant complications during a previous supported/supervised withdrawal the circumstances need to be examined carefully before commencement.
  • Unknown previous health history.

COMMUNITYHOSPITAL ALCOHOL DETOX

Contraindications

  • Liver failure with decompensation
  • Active neuropathy/neurology (Wernicke’s encephalopathy)
  • Severe cardiac problems
  • History of uncontrolled status epilepticus or delirium tremens
  • History of violence during alcohol detoxification
  • Violence in clinical settings
  • SADQ > 55
  • Under the age of 16 years

Cautions

  • Poor nutrition - ensure Pabrinex course before admission
  • Benzodiazepine dependency-assessment of risk before referral
  • Epilepsy-controlled & without history of status
  • History of violence &/or deliberate self harm
  • Significant mental illness, impulsivity, masked anxiety, psychosis
  • Careful assessment of co-existent drug dependency
  • Behavioural problems that may impact on safety of others in ward settings.
  • For patients aged between 16 and 18 years the Primary Care Trust (whichmanagesCommunityHospital beds) requires a risk assessment to ensure suitability.

RESIDENTIAL ALCOHOL DETOX

Boswyns andBroadreach

Contra-indications

  • Drug/alcohol users whose treatment needs can be met within a community setting.
  • Drug/alcohol users with serious mental health problems, who require hospitalisation, or containment under the Mental Health Act
  • People with severe cognitive deficits / encephalopathy related to alcohol dependency
  • People withacute clinical symptoms of severe liver disease, e.g. Jaundice/Ascites where hospital admission may be advisable
  • Severe uncontrolled cardiac problems

Cautions

  • Aged under 18 years or over 65 years will need careful consideration
  • People with a history of violence, arson, or schedule 1 offences will need careful assessment & consideration.
  • Acute glaucoma
  • People with evidence of severe malnutrition (BMI<18)

SPECIFIC CONDITIONS FOR DETOX:

CONDITION / Care
Co-ordn / Alcohol
Key Worker / POSSIBLE SOLUTION
Active severe and enduring mental illness / CMHT / CDAT / Longreach/BodminCHAD
Contraindications to a Community Specialist or Home & Dry detox but fear/anxiety/phobia about being in a hospital setting or institution / CDAT or Addaction or CMHT / CDAT or Addaction / Community Specialist with extra support for physical problems
Learning Disability / Learning Disability / CDAT or Addaction / Detox venue based upon patient assessment with appropriate LD specialist support
Young person (16-18yrs) without support / CDAT or Addaction / CDAT or Addaction / Community detox with care support/ foster care for the duration of the detox
CHAD (needs initial risk assessment)
Young person under the age of 16yrs / YZUP / YZUP / Out-of-county
Chaotic polydrug use / CDAT / CDAT / Simultaneous drug and alcohol detox (Broadreach or Boswyns)
Eating disorder and significantly underweight / CMHT (Eating Disorders) / CDAT / Boswyns
History of violence or severe personality disorder / CMHT or CDAT / CDAT / Detox venue based on individual patient risk assessment
Drug dependency and stable on substitute medication / CDAT / CDAT or Addaction / Any of the detox options may be appropriate based on individual patient assessment
CONDITION / Care
Co-ordn / Alcohol
Key Worker / POSSIBLE SOLUTION
Sensory impairment e.g. deafness, blindness, speech / Addaction or CDAT / Addaction or CDAT / All options with consideration of suitability of environment of detox
Bariatric / Addaction or CDAT / Addaction or CDAT / All options with consideration of suitability of environment of detox
Pregnancy / Addaction or CDAT / Addaction or CDAT / All options with caution

SPECIFIC CONDITIONS FOR DETOX (contd):

1 Alcohol detoxification services in Cornwall