NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
POLICY DOCUMENT
Document Title / Policy For the Clinical Management of Alcohol Withdrawal
Reference Number / CG/HMP Alcohol Withdrawal/03/15
Policy Type / ClinicalGuideline
Electronic File/Location / N:\Pharmacy\Intranet
Intranet Location /
Status / Final
Version Number/Date / Version 1 / March 2015
Author(s) Responsible for Writing and Monitoring / Head of Essex STaRS
IDTS Clinical Nurse Manager
Charge Nurse
Responsible Director / Director of Operations & Nursing
Approved By / Medicines Management Group
Approval Date / March 2015
Implementation Date / April 2015
Review Date / April 2018
Copyright / © North Essex Partnership University NHS Foundation Trust (2015). All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner.
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Policy for the Clinical Management of Alcohol Withdrawal

IDTS HMP Chelmsford

Version: 01

Author: Cheryl Carson andIan Melia

Ratified/Approved by: Medicines Management Committee/Clinical Governance Group

Effective from: April 2015

Review Date: April 2018

Targeted Audience: Healthcare, Inside Out, Governors, Prison Officers, Inreach

Circulated to the following people for consultation:

Governor HMP Chelmsford

Contents

Section / Topic / Page Number
1 / Purpose / 4
2 / Definitions / 4
3 / Detoxification / 5
4 / Responsibilities / 6
5 / Evaluation and Treatment of Alcohol Dependency / 6
6 / Medical Complications of Alcohol Withdrawal / 7
7 / Acamprosate Calcium / 8
8 / Stabilisation / 9
9 / Intoxication / 9
10 / Clinical Management / 11
11 / Chlordiazepoxide Regimes / 11
12 / Non-compliance with Treatment / 12
13 / Summary of Changes / 13

Appendices

1 / Advice to clients on withdrawing from alcohol / 14
2 / Routine Nursing Observations / 15
3 / What is Pabrinex®? / 16
4 / Signs and Symptoms of Anaphylaxis / 17
5 /

Client Consent to Chlordiazepoxide for Alcohol Detoxification

/ 18
6 / HMP Chelmsford Detoxification Disclaimer / 19
7 / Alcohol Withdrawal Scale Template and Alcohol Withdrawal Record / 20
8 / Fact Sheets / 24

Policy For the Clinical Management of Alcohol Withdrawal

1. Purpose

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

2. Definitions

2.1.Unit of Alcohol

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

2.2. Hazardous Drinking

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

Over 40g of pure ethanol (5 units) per day formen

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

iii. Consuming over the equivalent of 40gof pure ethanol (Alcohol) per day on average doubles a man's risk for liverdisease, raised blood pressure, some cancers (for which smoking is a confounding factor) and violent death (because some people who have this average alcohol consumption drink heavily on some days).

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

2.3. Harmful Drinking

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

2.4. Alcohol Dependence

Alcohol dependence is defined as a cluster of physiological, behavioural, and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that previously had greater value. A central characteristic is the desire (often strong, sometimes perceived as overpowering) to drink alcohol. Return to drinking after a period of abstinence is often associated with rapid reappearance of the features of the syndrome (priming). A definitive diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:

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

3. Detoxification

3.1. Detoxification refers to the planned withdrawal of alcohol. Alcohol withdrawal carries risks and requires careful clinical management.

3.2. Chelmsford is a local prison and therefore will receive prisoners directly from the courts and those transferred from other establishments. Chelmsford must ensure that if a prisoner is transferredto them during an alcohol detox, that the regime is continued to its completion. No prisoners can be transferred out of Chelmsford until an alcohol detoxification is complete unless this is in order to transfer the prisoner into the High Secure Estate.

3.3. CHLORDIAZEPOXIDE (LIBRIUM) is the preferred drug of choice to be used in alcoholwithdrawal regimes. However patients can be prescribed benzodiazepine as a reducing regime if they are currently prescribed this medication or using benzodiazepine illicitly.

4. Responsibilities

4.1. It is the duty of the IDTS Clinical NurseManager and the IDTS Team of HMP/YOI Chelmsford to amend and update this document in conjunction with any other relevant authority.

4.2. It is the duty of the IDTS Clinical NurseManager and the IDTS Team of HMP/YOI Chelmsford to ensure client consent is obtained and signed (Appendix 5).

4.3. Substitute medication such as Chlordiazepoxide should not be prescribed in isolation. A multidisciplinary approach to alcohol dependency treatment is essential.

4.4. Prescribing is the particular responsibility of the professional signing the prescription. The responsibility cannot be delegated.

4.5. The registered professional who administers the medication under supervised conditions has a responsibility to ensure that the correct patient receives the correct dose and that appropriate efforts are taken to ensure that the drug is used appropriately and not diverted onto the illegal market.

4.6. If the patient is a polydrug and alcohol user, joint clinical reviews should be undertaken regularly, at least every three monthsWhere needs are complex or the drug use is unstable then reviews should be undertaken more often.

4.7. Thorough, clearly written or computer records of prescribing interventions must be kept.

5. Evaluation and Treatment of Alcohol Dependency

5.1. Before any prescribing of medication the patient must have anassessment of needs.

5.2. A full medical history must be taken as is the case with all prisoners this must include details of their alcohol dependenceusing the Alcohol Assessment Form,

Including details of

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

5.3. The patient must be seen by the IDTSNurse or Doctor/Independent Non-medical Prescriber (IP) before any medication is issued.

5.4. The patient must have had discussion with the Doctor/IP or IDTS Nurse to discuss the implications of Chlordiazepoxide as a treatment, and the expectations for treatment. There needs to be documentary evidence of this in the patient notes.

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

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

5.7. An alcohol withdrawal scale(Appendix 7) must be completed on all patients who are to be clinically assessed with possible alcohol dependency problems.

5.8. Cessation of drinking is unlikely to be complicated in milder dependence. There should however be a lower threshold of prescribingin prison, in part due to the very limited access toalcohol, and also to the risks of self-harm in untreated/under treated withdrawal – if there is any withdrawals then titrate against withdrawal symptoms both up/down. Always prescribe if the prisoner claims to be dependent, this should be based on a comprehensive history and evidence is believable, and where clinical presentation demonstrates there is evidence of withdrawal.

6. Medical Complications of Alcohol Withdrawal

6.1. Medical complications of Alcohol withdrawal are potentially lifethreatening. Nursing observations (Appendix 2) should be undertaken twice daily for these clients for at least the first five days of their detoxification to identify at an early stage any complications which may arise, particularly in respect of withdrawal fits and delirium tremens.

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

6.3. If a client does not require a formal alcohol detoxification, but has a recent history of heavy drinking they should still receive the Thiamine 100mg BD and Vitamin B Compound for a period of 28 days as a precautionary measure.

6.4. Clients who have a chronic alcohol problem should be given Pabrinex®IM Appendix 3).There is some doubt as to the suitability of oral thiamine as a prophylactic treatment for Wernicke’sEncephalopathyand Korsakoff Psychosis due to limited oral absorption. It has also been shown to have little or no effect on the CNS vitamin status whereas parenteral thiamine replacement is rapidly effective in the treatment of Wernicke’sEncephalopathy and is an effective prophylactic treatment for high-risk clients. Pabrinex® should therefore be recommended for clients who present as being at high risk of Wernicke’s –Korsakoff (NICE 100 2010)

6.5. Anaphylaxis is a rare complication and is more likely to occur with IV use (Appendix 4). It is extremely rare after IM administration and this should be considered the route of choice.It should only be administered where suitable basic life support facilities and an anaphylactic shock pack are available. Dosage should be 1 Pair of Pabrinex® ampoules IM to be given daily for 3 days or 5 days which will be determined upon presentation.

Should patients refuse IM treatment, they should then still be offered the oral treatment.

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

7. Acamprosate Calcium

7.1. Acamprosate is recommended in a review of the effectiveness of treatment for alcohol problems by the NTA 2006. NICE alcohol use disorder: Diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE Clinical Practice Guideline 115 Feb 2011) recommend the use of Acamprosate as first line treatment after successful withdrawal from alcohol (Recommendation 7.15.1.1)

7.2. Contraindications:

  • Established hypersensitivity to Acamprosate.
  • Renal Insufficiency (creatinine >120mmol/l)
  • Severe hepatic failure (Childs-Pugh classification C)

7.3. Dosage Regime

  • Oral Administration
  • Preparations available Acamprosate calcium 333mg, enteric coated tablets (Campral EC®)
  • Adult >60kg: 666mg (2 tablets) three times daily (TDS)
  • Adult <60kg: 666mg mane, 333mg midday and 333mg evening
  • Acamprosate taken with food reduces its bioavailability.
  • Titration is not required.
  • Adjunctive psychosocial intervention recommended
  • Treatment should be continued for 6 to 12 months

7.4. If the patient agrees to Acamprosate then treatment should be initiated as soon as day 2 of his detoxification.

8. Stabilisation

8.1. The client should remain on the IDTS Wing until the alcohol detoxification is complete. It is important that these clients are monitored for the first seven days of their management, as they may suddenly physically deteriorate or may suffer an epileptic seizure.

8.2. An extended stay on the IDTS Wing is advised if the client:

  • has experienced confusion or hallucinations during the detoxification
  • has a history of previously complicated withdrawal
  • has epilepsy or a history of fits
  • is undernourished (could move to second stage if otherwise stable)
  • has severe vomiting or diarrhoea (this should be controlled within 24 hours or patient transferred to hospital).
  • is at risk of suicide
  • has severe dependence coupled with unwillingness to be observed daily
  • has uncontrollable withdrawal symptoms
  • has an acute physical or psychiatric illness
  • has multiple substance misuseproblems

8.3. In the treatment of concurrent opiate and alcohol dependence, no reductionin the opiate agonist should be attempted until the alcohol detoxificationis complete.

8.4. In accordance with DoH Guidelines (1999) detoxification for concurrent ‘significant polydrug’ use or ‘benzodiazepine use’ should be undertaken in the IDTS stabilisation wing. All clients undergoing alcohol detoxification must therefore remain on the IDTS stabilisation wing until their alcohol detoxification is complete. (If a patient refuses location on the stabilisation unit treatment cannot be refused, but he must sign a disclaimer which should detail the risks of not being properly observed and supported).

9. Intoxication

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

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

9.3. Any prisoner who is found to be intoxicated within the establishment, the following must be adhered to:

9.4. General principles of managing intoxication

  • Maintenance of airways and breathing is of paramount importance to the comatose patient.
  • Any person presenting as incoherent, disorientated or drowsy should be treated as per head injury until proven otherwise.
  • Intoxicated patients must be kept under observation on the healthcare wing until their intoxication diminishes.
  • A thorough physical and mental status examination by a nurse or doctor will reveal the level of a patient’s intoxication to provide baseline information.

9.5. Assessing Intoxication

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

9.6. Signs of Mimicking or Masking Intoxication

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

9.7. If the Assessment Indicates Intoxication

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

10. Clinical Management

10.1. Medication may not be necessary if:

  • the patient reports consumption is less than 15 units/day in men and reports neither recent withdrawal symptoms nor recent drinking to prevent withdrawal symptoms (however please see notes above re prescribing in prison)
  • the patient has no withdrawal signs or symptoms; if a decision is made not to prescribe alcohol withdrawal then monitoring can be undertakentwice daily for three days to ensure that no symptoms emerge.
  • among periodic drinkers, whose last bout was less than one week long, medication is seldom necessary unless drinking was extremely heavy (over 20 units/day). Thiamine 100mg BD and Vitamin B Compound for a period of 28 days is still required

10.2. A baseline regime will be agreed by the doctor before commencement of detoxification according to the above criteria and the clinical triage and theAlcohol Withdrawal Scale and RecordChecklist (Appendix 7). The advice to clients on withdrawing from alcohol information sheet should be given to the client (Appendix 1).

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

11.1. Clients with a high level of dependency can be offered a higher level of Chlordiazepoxide to reduce the risk of withdrawal. Guidelines suggest anything between 10-50mgs of ChlordiazepoxideQDS gradually reducing over 7-10days. (BNF 2010).

11.2. Clients who give a recent history of consuming 10-15 units of alcohol daily MUST be given a stat dose of Chlordiazepoxide 20mg as soon as possible after arriving in reception, in line with PSO 3550.

11.3. The time of administering the first dose must be recorded ontoSystmOne® in order that the late duty staff can then give the second dose after a minimum 3hour interval.

11.4. Although clients will be urine tested for other drugs upon admission to the IDTS wing, their alcohol detoxification medication must NOT be withheld pending the result and must be given as prescribed.

11.5. If a client shows any signs of alcohol withdrawal during any 24 hour period