Community Alcohol Detoxification Dr Merlin Willcox, Luther St Medical Centre, Oxford
Luther St Medical Centre
523 patients registered 252 (48%) have past or present problem of
alcohol dependence 28/68 women (41%) 224/455 men (49%)
Plan
Case Study Background and evidence Luther St Protocol Audit of our patients Patient information leaflet
Case Study
Martin is a 38 year old man whom you have seen drinking on the street for a long time.
He has now decided he wants to stop drinking and asks for your help.
He has a history of seizures. Would you organise an alcohol detox for
him, and if so what would you do?
Background
Randomised study in 50 heavily alcohol dependent patients in Oxford, comparing inpatient detox with detox in a dry hostel
Detox in hostel was preferred by patients, cheaper, offered earlier appointments, and was equally safe.
Haigh & Hibbert, 1990. Where and when to detoxify single homeless drinkers. BMJ 301:848-9.
Luther St Detox protocol
Developed over 25 years Pre-detox assessment Decision to initiate community detox Detox regimen Follow-up
Our basic philosophy
Open door to anyone Careful pre-detox assessment Careful risk management Close supervision Clear boundaries
Pre-detox assessment: history
Drinking pattern – what, when, where, with whom, units?
History of detox – have you been dry before? When? How did you get dry? What worked?
Withdrawal symptoms? Drug use – illegal and prescribed. Compliance? Social circumstances – where living, what plans? Risk assessment: living in isolated place, history of fits,
overdose risk? Nutrition assessment
Pre-detox examination
Signs of Wernicke’s encephalopathy (WE): – Balance difficulties – Confusion– Eye signs: (only present in 30%)
Signs of alcohol-related nerve damage: – “Pins & needles”, or loss of vibration sense– Balance problems, low BP– Memory problems
Pre-detox investigations
Breath Alcohol Concentrations Urine drug screen – is alcohol the main
problem? Bloods:
– Liver function, Kidney function, random glucose – Full Blood Count, coagulation, – (Blood Borne Virus screening if risk factors)
Pre-detox plans
Liaise with other services– Street services / accommodation providers– Drug services if patient is on script– Mental health services if appropriate
Pre-detox treatment
If history of fitting, anticonvulsant for at least 2 days before starting detox:– usually carbamazepine 200mg MR bd– Valproate if patient is on methadone
Vitamins– i-m Pabrinex– Oral Thiamine
The detox procedure
Patient must arrive with BAC <0.30mg/l and withdrawing
Chlordiazepoxide 4x daily (reducing course), e.g. 40mg-30mg-20mg-10mg (over 2 weeks)
Pabrinex 1 pair daily i-m for 3 days or thiamine 50mg 4x daily + Forceval 1x daily Daily follow-up, BAC, observe first dose and
prescription Clear boundaries – stop immediately if drinking re-
starts
Patients who should NOT be detoxed in the community:
Lack of appropriate accommodation Delerium tremens
– Day 1: anxiety, tremor, sweating, fast pulse– Days 2-4: confusion, hallucinations, delusions– Days 1-10: fits
Wernicke’s = alcohol + 1 or more of– Ataxia (not due to intoxication)– Confusion, memory disturbance, coma (acute,
not due to intoxication)– Eye signs
Detoxification protocol: Key points
Pre-detox assessment is very important
– to assess and manage risk (e.g. fitting, nutrition etc)
– To plan detox Detoxes start on Mon-Weds
ONLY Reducing course of librium
over 1-2 weeks Daily supervision and
breathalyserEve Gibb
Luther St Detox Audit
One year of detoxes (Jan-Dec 2009) 38 detoxes on 33 patients 3 patients had 2 detoxes, 1 had 3 33 given chlordiazepoxide, 1 given diazepam Average duration of CDZ = 7 days 31 (82%) successfully completed the detox
Adverse events
Adverse events occurred in 2 (5%)– 1 fit (admitted)– 1 Wernicke’s encephalopathy (refused admission)
Significant events
Lack of supervision over bank holiday weekends (2) Some locums unaware of pre-detox protocols: patient
told they would get detox, but then when come in have not had proper work-up
Wrong dose of carbamazepine prescribed by locum – patient admitted with ? Worsening Wernickes and CBZ toxicity
Prescription error – 90 CDZ issued by locum over weekend instead of 9 – but 74 tabs retrieved from patient.
Monitoring and safety
See 1-2x daily initially, then daily until end of detox
Reduce dose if signs of drowsiness Monitor methadone Never start on Thursday or Friday
Detox outcomes - 2009
Drinking before end of detox
18%
Drinking by 2 weeks18%
Drinking by 4 weeks18%
Suicide3%
Drinking by 10 weeks11%
Lost to follow-up8%
Dry at 10 weeks24%
Not suitable for community detox
Patient not coming to be seen or unreliable Severe liver impairment Benzo addiction