Alcohol Detoxification Services in CIOS a Stepped Approach

Alcohol Detoxification Services in CIOS – a Stepped Approach

Revision May 2013

Authors: Angela Andrews (DAAT) and Jenny Teagle (Addaction),

Introduction

The majority of people with an alcohol problem that is uncomplicated by serious illness or social chaos receive treatment through community services. This treatment encompasses harm reduction, education and ultimately detoxification.

There is much work that can be done to help clients reduce their drinking and many will be able to self detox whilst being supported by a recovery coordinator. Detoxification should not take place in isolation and should be part of a planned episode of treatment with an emphasis put on preparation for detox and post detox provision of support, (Rehabilitation, PODs).

The purpose of detoxification is to minimise the severity of withdrawal symptoms that occur when alcohol consumption is abruptly stopped or markedly reduced and thereby to achieve an alcohol free state with maximum safety and minimum discomfort to the client.

Clients, friends, relatives and on occasion doctors when faced with the magnitude of alcohol related harm can become so desperate that they see detox as the only answer. Detox may provide respite and be a caring intervention but it does not have a long term significant effect on long term drinking behaviour.

Robust assessment encompassing all aspects of a client’s life with proper planning for detox and aftercare are vital if there is to be sustained change and abstinence following detox.

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’ / St Petrocs Alcohol Detox (Health for the Homeless)
Community Hospital Alcohol Detox (CHAD)
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 of dependency.
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 will explore the circumstances to try and avoid the same problem(s) occurring with subsequent detox attempts.
Post detox support, as a part 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, working to Cornwall Council contracts

A supported community detox for the least complex of patients with alcohol dependency. It is provided in General Practice with the patient attending their surgery three times a week for monitoring by the Practice Nurse during the course of the week long detox. A key requirement is that the patient has a responsible carer (relative, friend or Addaction volunteer) who can support them throughout the course of detox and assist in the management of their detox medication.

The detox is delivered in accordance with the Integrated Care Pathway ‘Home & Dry, March 2011’. The joint working arrangement involves a Carer, an Addaction worker, GP and Practice Nurse all of whom will have received training to provide Home & Dry detoxs.

Chlordiazepoxide is the withdrawal medication used in dosing regimens chosen according to patient presentation as assessed by the GP overseeing the detox.

This detox is suitable for those with a SADQ of <40, and without complex physical or mental health conditions.

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

St Petrocs Alcohol Detox for homeless people

Delivered by Addaction in conjunction with the ‘Health for the Homeless’ GP service and St Petrocs.

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 by one of the Health for the Homeless (HfH) GPs, the detox is planned with a bed secured at St Petrocs for a 6 week period. The HfH Gps will provide the prescribed medication which is a Chlordiapepoxide regime based on the one used in the ‘Home & Dry Detox ICP’. This arrangement ensures a secure and safe setting for the detox itself (supervised by an Addaction worker with on-call support from Health for Homeless clinicians).

Petrocs.

Community Hospital Alcohol Detox (CHAD)

Delivered by collaboration between Addaction, those GP practices contracted by Cornwall Council & Peninsula Community Healthcare Community Hospital services.

CHAD is an inpatient detox delivered in a local Community Hospital (currently St Ives, Helston, Bodmin, St Marys) for patients who are not suitable for a Home and Dry Detox because of their home circumstances or a lack of a responsible carer.

Patients undergoing this detox must have a SADQ of >50. There is a list of cautions and contra-indications within the Integrated Care pathway (CHAD ICP, August 2012).

CHAD is suitable for patients who have physical or mild mental health problems that would make a community detox unsafe. It may (subject to medical assessment by the responsible GP, and agreement by the Community Hospital nursing staff) be suitable for those on opiate substitute medication who are stable.

CHAD may also be a good option for those who have previously been unsuccessful in attempting a home detox.

Assessment, referral & preparation is provided by an Addaction Worker. The GP who is undertaking the CHAD medical assessment (who also has input into the local Community Hospital) then decides on the patient’s suitability and books a bed at the appropriate community hospital. The detox takes place in a Community Hospital, typically over a 5-7 day period with monitoring and support during the detox delivered by trained Community Hospital nursing staff. Diazepam ‘symptom triggered therapy’ is the withdrawal medication given using CIWA scoring with the majority of dosing taking place in the 1st 24-48hrs.

Residential Detox (Boswyns or Broadreach)

Residential detoxes are for those 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 in addition to detoxing from alcohol. Residential detox may also be the most suitable option for patients who need to progress to secondary rehabilitation and support as part of their recovery, and be particularly suitable for those with mental health problems.

Currently options include Boswyns in Cornwall, or Broadreach in Devon.

Service User Profile

Aged 18 - 65yrs
Drug and/or alcohol users already engaged in structured 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 treatment.
Those requiring an alcohol detox in conjunction with titration onto a substitute prescription within a residential setting.

Alcohol Interventions Offered

Supported withdrawal from alcohol using benzodiazepines, according to medical assessment.

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 Treliske Hospital in Truro and covering the other RCHT sites.

Chlordiazepoxide ‘symptom triggered therapy’ is the stabilisation regime used according to the patient’s CIWA score.

The specialist alcohol nurse will assess the patient’s needs on admission and work with hospital staff to determine prescribing regimes. On discharge the specialist nurse will liaise regarding onward referral and further intervention from Addaction.

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.
If a patient has unresolved ambivalence about their alcohol intake and the need for a detox then these issues must be addressed prior to admission.
If a patient has a history of repeated unsupervised self detox that have been unsuccessful preparation for detox must carefully planned (Risk of kindling)

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.

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.

COMMUNITY HOSPITAL 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 (which manages Community Hospital beds) requires a risk assessment to ensure suitability.

RESIDENTIAL ALCOHOL DETOX

Boswyns and Broadreach

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 with acute 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 WITH OPTIONS FOR DETOX:

CONDITION / Care
Co-ordn / Alcohol
Key Worker / POSSIBLE SOLUTION
Active severe and enduring mental illness / CMHT / ADDACTION / Boswyns/Longreach/Bodmin CHAD
Contraindications to a Home & Dry detox but fear/anxiety/phobia about being in a hospital setting / Addaction or CMHT / Addaction / Boswyns or careful supervision by keyworker to achieve self detox.
Learning Disability / Learning Disability / Addaction / Detox venue based upon patient assessment with appropriate LD specialist support
Young person (16-18yrs) without support / YZUP/ Addaction / YZUP/Addaction / Home & Dry 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 / Addaction / Addaction / Simultaneous drug and alcohol detox (Broadreach or Boswyns)
Eating disorder and significantly underweight / CMHT (Eating Disorders) / Addaction / Boswyns
History of violence or severe personality disorder / CMHT / Addaction / Detox venue based on careful individual patient risk assessment and liaison with chosen venue.
Drug dependency and stable on substitute medication / Addaction / Addaction / Any of the detox options may be appropriate based on individual patient assessment and liaiason with chosen venue.
CONDITION / Care
Co-ordn / Alcohol
Key Worker / POSSIBLE SOLUTION
Sensory impairment e.g. deafness, blindness, speech / Addaction / Addaction / All options with consideration of suitability of environment of detox,
Bariatric / Addaction / Addaction / All options with consideration of suitability of environment of detox
Pregnancy / Addaction/Specialist midwifery service / Addaction / All options with caution

SPECIFIC CONDITIONS FOR DETOX (contd):

1 Alcohol detoxification services in Cornwall