Transcript Services at Luther Street Medical Centre

Community Alcohol Detoxification
Dr Merlin Willcox,
Luther St Medical Centre,
Oxford
Luther St Medical Centre
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523 patients registered
252 (48%) have past or present problem of
alcohol dependence
28/68 women (41%)
224/455 men (49%)
Plan
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Case Study
Background and evidence
Luther St Protocol
Audit of our patients
Patient information leaflet
Case Study
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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
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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
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Developed over 25 years
Pre-detox assessment
Decision to initiate community detox
Detox regimen
Follow-up
Our basic philosophy
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Open door to anyone
Careful pre-detox assessment
Careful risk management
Close supervision
Clear boundaries
Pre-detox assessment: history
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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
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Signs of Wernicke’s encephalopathy (WE):
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Balance difficulties
Confusion
Eye signs: (only present in 30%)
Signs of alcohol-related nerve damage:
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“Pins & needles”, or loss of vibration sense
Balance problems, low BP
Memory problems
Pre-detox investigations
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Breath Alcohol Concentrations
Urine drug screen – is alcohol the main
problem?
Bloods:
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Liver function, Kidney function, random glucose
Full Blood Count, coagulation,
(Blood Borne Virus screening if risk factors)
Pre-detox plans
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Liaise with other services
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Street services / accommodation providers
Drug services if patient is on script
Mental health services if appropriate
Daily team meetings
Pre-detox treatment
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If history of fitting, anticonvulsant for at least 2
days before starting detox:
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usually carbamazepine 200mg MR bd
Valproate if patient is on methadone
Vitamins
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i-m Pabrinex
Oral Thiamine
The detox begins…
The detox procedure
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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 restarts
Patients who should NOT be
detoxed in the community:
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Lack of appropriate accommodation
Delerium tremens
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Day 1: anxiety, tremor, sweating, fast pulse
Days 2-4: confusion, hallucinations, delusions
Days 1-10: fits
Wernicke’s = alcohol + 1 or more of
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Ataxia (not due to intoxication)
Confusion, memory disturbance, coma (acute,
not due to intoxication)
Eye signs
Detoxification protocol: Key points
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Pre-detox assessment is very
important
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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
breathalyser
Eve Gibb
Luther St Detox Audit
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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
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Adverse events occurred in 2 (5%)
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1 fit (admitted)
1 Wernicke’s encephalopathy (refused admission)
Significant events
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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
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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%
Dry at 10 weeks
24%
Drinking by 2 weeks
18%
Lost to follow-up
8%
Drinking by 10
weeks
11%
Suicide
3%
Drinking by 4 weeks
18%
Not suitable for community detox
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Patient not coming to be seen or unreliable
Severe liver impairment
Benzo addiction
Andy, a homeless man.
“You’re never a failure
until you stop trying.”