Karen Neoh

2.5 Management of Concurrent Clinical Problems Management of patients with pre-

existing drug dependence

2.14 Management of Emergencies in Palliative Medicine Recognition and management of alcohol

and drug withdrawal

2.15 Public Health Related to Palliative CareEffect of addictive and self harming behaviours on personal health, response to palliative intervention and symptom management

How big is the problem?NICE/LTHT guidance

Alcohol withdrawal Delirium tremens Wernicke’s encephalopathy

Assessment of alcohol intake (not just CAGE!)

UK - 24% of adults drink in a hazardous or harmful way

Highest in the North East, North West and Yorkshire and Humber

26–28% of men, 16–18% of women

Approximately 20% of patients admitted to hospital for illnesses unrelated to alcohol are drinking at potentially hazardous levels

Tremor Sweating Agitation Irritability Insomnia

Anorexia and nausea

Increased heart rate and BP

Fever Anxiety

The care of adults and young people (aged 10 years and older) who have any of the following physical health problems that are completely or partly caused by alcohol use:

▪Acute alcohol withdrawal▪ Lack of thiamine (Wernicke’s

encephalopathy)▪ Liver disease▪ Pancreatitis

Consider offering a benzodiazepine or carbamazepine

Clomethiazole may be offered as an alternative

Oral chlordiazepoxide is the preferred choice of benzodiazepine as it has long half life, low potency and lower potential for abuse than diazepam.

The dose should be tailored to each patient dependent upon severity of withdrawal symptoms.

BNF Fixed dose reducing regime in primary

care Symptom triggered flexible regime in

hospital or other settings usually followed by a 5 day reducing dose schedule

10-50mg QDS reducing over 5-7 days 10-40mg PRN for the first 2 days Max 250mg/day Gradually reduce over 7-10days

Day Morning Midday Early evening Night (Total)

1 30mg 30mg 30mg 30mg 120mg

2 30mg 30mg 30mg 90mg

3 30mg 30mg 60mg

4 30mg 30mg

5 20mg 20mg

6 10mg 10mg

Breakthrough symptoms: chlordiazepoxide 5 mg - 10mg prn

Chlordiazepoxide and diazepam should be avoided as these drugs are metabolised by the liver and can accumulate.

Lorazepam should be used as an alternative. 500 micrograms- 1mg orally every 6 hours to a maximum of 8mg/24 hours.

Contact liver team for advice.

Diazepam 10mg slow IV repeated after 4 hours if necessary

Lorazepam 1mg-2mg IV repeated after 6 hours if necessary

If IV access is a problem rectal diazepam (as solution, not suppositories), 500 micrograms/kg (up to a max of 30mg)

If PO/IV/PR not possible, IM but erratic absorption

If patient remains agitated contact senior member of team or liason psychiatry.

Unlicensed for alcohol withdrawal but can be used as an alternative if benzodiazepines are contraindicated or not tolerated

800mg PO in divided doses, reduce gradually over 5 days to 200mg OD

Usual treatment duration 7-10 days

Licensed for use in acute alcohol withdrawal, benzodiazepines are preferred. Inpatient setting and abstinent.

Dose 2-4 capsules, can be repeated after some hours. Each capsule 192mg.

Day 1: 9-12 capsules in 3-4 divided doses Day 2: 6-8 capsules in 3-4 divided doses Day 3: 4-6 capsules in 3-4 divided doses Gradually reduce over 4-6 days and

treatment not for more than 9 days

Heminevrin brand nameSedative/hypnoticUsed for agitation, restlessness,

short-term insomniaGood in the elderly as no hangover

but can lead to dependence Alcohol combined with clomethiazole,

particularly in alcoholics with cirrhosis, can lead to fatal respiratory depression even with short-term use

The symptoms/signs differ from usual withdrawal in that there are signs of altered mental status. Hallucinations (auditory, visual, or

olfactory) Confusion Delusions Severe agitation

Oral lorazepam first-line If symptoms persist/oral medication

declined, give parenteral lorazepam, haloperidol or olanzapine

If DT develops in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen

• Quick-acting benzodiazepine (lorazepam) to reduce the likelihood of further seizures

• If alcohol withdrawal seizures develop in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen

• Do not offer phenytoin to treat alcohol withdrawal seizures

• Offer thiamine to people at high risk of developing, or with suspected, Wernicke's encephalopathy.

• Offer prophylactic oral thiamine to harmful or dependent drinkers:• if they are malnourished or at risk of

malnourishment or• if they have decompensated liver disease

or• if they are in acute withdrawal or• before and during a planned medically

assisted alcohol withdrawal.

Mild deficiency 25-100mg OD POSevere deficiency 200-300mg/day

PO in divided doses

IV high potency 2-3 pairs daily for 2 days

If no response stop If improves IV/IM high potency 1 pair

daily for 5 days or as long as improvement continues

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.

A clinical guideline covering identification, assessment, pharmacological and psychological/psychosocial interventions, and the prevention and management of neuropsychiatric complications.

AUDIT – identification/outcome measure

SADQ (Severity of Alcohol Dependence Questionnaire )

or LDQ (Leeds Dependence Questionnaire) - severity of

dependence

CIWA (Clinical Institute Withdrawal Assessment) - severity of withdrawal

APQ (Alcohol Problems Questionnaire) for the nature and extent of the problems arising from alcohol misuse.

1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical

day when you are drinking?3. How often do you have six or more drinks on one occasion? 4. How often during the last year have you found that you almost

were not able to stop drinking daily once you had started?5. How often during the last year have you failed to do what was

normally expected of daily you because of drinking?6. How often during the last year have you needed a first drink in

the morning to get yourself going after a heavy drinking session?

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

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

10.Has a relative, friend, doctor, other health care worker been concerned about your drinking last year last year

• The AUDIT-C uses the first 3 questions only.

• Using a cutoff of ≥3, AUDIT-C identifies 90% of patients with active alcohol abuse or dependence and 98% of patients with heavy drinking

• A score of ≥3 on the AUDIT-C or a report of drinking 6 or more drinks on one occasion ever in the last year, should lead to a more detailed assessment of drinking problems (completion of the full questionnaire)

Thank you

publications.nice.org.uk/alcohol-use-disorders-diagnosis-and-clinical-management-of-alcohol-related-physical-complications-cg100/introduction

www.nice.org.uk/nicemedia/live/13337/53194/53194.pdf

LTHT. The management of alcohol withdrawal symptoms. Sarah Skitt (Lead medical Admissions Pharmacist) and Dr Michael Mansfield(Consultant Physician)

Joint Formulary Committee. British National Formulary. [64] ed. London: BMJ Group and Pharmaceutical Press; [2012]