1. Detox workshop Susanna Lawrence October 2011

2. Aim and objectives  Create consistent, evidence based process for opiate, alcohol and benzodiazepine detoxes across Leeds  Informing SMHS detox team  Aligning LCDP partners  Role in supporting/disseminating to full team

3. Guidelines  RCGP, NICE, DH guidelines  SMHS guidelines on website: –Community alcohol detoxification –Community opiate detoxification –Benzodiazepine prescribing –Lofexidine monitoring –Chlordiazepoxide monitoring –Naltrexone

4. Selection  Recovery Road Map –Alcohol stage 4b –Benzodiazepines stage 4d –Opiates stage 7  3 way agreement – client, RC, prescriber

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10. Logistics  Dedicated detox appts  3/5 alcohol/opiate detoxes per fortnight  4 week process  All 7 appts to be booked at commencement (3,2,1,1)  Appts to be booked by SMHS admin  Spare appts to be released one wk before

11. Alcohol detox Benzodiazepine detox Opiate detox

12. Questions Joanna Bloggs is on OST M60mls, has stopped using heroin, but is drinking 2-3 litres 9% cider daily  What RRM stage is Joanna?  What is his treatment goal?  What options at this point?  Who should be involved?  What needs to happen before starting detox?  Where do you enter data on S1?

13. Alcohol Detox  RRM Stage 4b  Residential, community detox, rehab  SystmOne: –Link on Portal front page to community alcohol detox (page 4 of template)  Detox preparation: –ADS worker –RC –Reduction to 20units/day or less

14. Treatment Goals  Abstinence –Realistic goal to be abstinent from all drugs (inc prescribed)/high risk alcohol within 6 months  Maintenance –Maintained on OST, no illicit drug (or high risk alcohol use) on top  Harm Reduction –Maintained on OST, reduced illicit drug (or alcohol) use on top

16. Community Alcohol Detox clinical considerations 1  NICE guidance February 2011  Prevent recurrent detoxes – adequate preparation  Self reduce to <20u/day  Manage prescribed diazepam  Data entry through alcohol template  Thiamine/(vitamin B strong not required)  (im thiamine for inpt settings only)

17. Alcohol detox – Clinical considerations 2 Chlordiazepoxide (or diazepam)  Dose max 120 (160) mg daily  Titrate against symptoms/standard regime  4-10 days duration  Attend daily for first 5 days  Stop if alcohol restarts

18. Community alcohol detox clinical considerations 3 Week 1  Prescriber appts days 1 3 5  RC appts days 2 4  Withdrawal symptoms checklist  On each attendance –CIWA/withdrawal symptoms checklist –Pulse and BP –alcometer

19. Alcohol detox Benzodiazepine detox Opiate detox

20. Questions Joanna Bloggs is still on OST M60mls and illicit benzos (nitrazepam and diazepam). Successfully completed alcohol detox 4 weeks ago.  What RRM stage?  What is her treatment goal?  What options are open to her?  What is a likely 6 month plan?  Who should be involved?  Where do you enter data?  When does a benzo detox start?

21. Benzodiazepine Reduction/Detox  RRM Stage 4d  SystmOne: –Link on Portal front page to benzodiazepine detox (under construction)  Regular (not detox) appointments  Protocol due for review Jan 2012

22. Treatment Goals  Abstinence –Realistic goal to be abstinent from all drugs (inc prescribed)/high risk alcohol within 6 months  Maintenance –Maintained on OST, no illicit drug (or high risk alcohol use) on top  Harm Reduction –Maintained on OST, reduced illicit drug (or alcohol) use on top

24. Benzodiazepine reduction/detox clinical considerations 1 Preconditions to initiating prescribing:  Committed to eventual abstinence  Self reduced to 30mg or less  No illicit opiate/stimulant/alcohol use  Clear UTs (2)  No concerns re diversion  Guideline to be reviewed shortly

25. Benzodiazepine reduction/detox clinical considerations 2  Convert to diazepam  Blue script  Daily pickup  Agree reduction (2-5mg per fortnight)

26. Benzodiazepine reduction/detox clinical considerations 3 Small number of clients may benefit from benzodiazepine maintenance:  Recent alcohol detox  improved stability on OST

27. Alcohol detox Benzodiazepine detox Opiate detox

28. Questions Joanna has successfully detoxed from alcohol and benzos, and reduced to M40. She has a new partner and wants to be out of treatment in 6m.  What RRM stage?  What treatment goal?  What options are open to her?  Who should be involved?

29. Community Opiate Detox  RRM Stage 7  Residential or community detox?  SystemOne: –Link on Portal front page to opiate detox  Needs to involve: –Family and friends –Recovery groups, SMART, NA –RC –prescriber

30. Treatment Goals  Abstinence –Realistic goal to be abstinent from all drugs (including prescribed)/high risk alcohol within 6 months  Maintenance –Maintained on OST, no illicit drug (or high risk alcohol use) on top  Harm Reduction –Maintained on OST, reduced illicit drug (or alcohol) use on top

32. Which detox (programme)? Which detox (medication)?  Programme: –SCOD, –standalone opiate detox –(preparation phase)  Medication: –Buprenorphine detox –Methadone detox –Lofexidine/symptomatic detox

33. Which detox programme? SCOD:  12 week programme  4 weeks preparation  4 weeks pharmacological detox  4 weeks structured aftercare  RC appt at least 1x week  Structured planned daily activity  Suitable for clients  First attending CDTS  Previous failed detoxes  Needing additional support/motivation

34. Which detox programme? 2 Standalone community opiate detox  2-4 appts/wk (RC/Prescriber)  Duration 2-4 weeks.  Suitable for clients who  Are motivated  Are prepared  Have stable social circumstances  Have adequate support in place  Clients entering service on small amounts of heroin

37. Community Opiate Detox Clinical considerations 1  Destabilising process – consider supervised consumption/more frequent pickups  Both programmes – adequate detox preparation  Detox booklet

38. Opiate Detox Medication Options  Buprenorphine  Methadone  Lofexidine  Above plus symptomatic: –Mebeverine/hyoscine –Paracetamol/ibuprofen (oral or gel) –Metoclopramide/prochlorperazine –Loperamide –Diazepam/zopiclone

39. Buprenorphine detox  From buprenorphine or methadone  Methadone/Buprenorphine crossover or buprenorphine reduction  Detox 4mg to zero 7 days  4mg, 2mg, 2mg, 1.6mg, 1.2mg, 0.8mg, 0.4mg, 0.  Naltrexone from day 6 post detox

40. Methadone detox  Straight reduction to zero or transfer to buprenorphine (avoids prolonged withdrawal symptoms).  Reduction from 20mls to zero always uncomfortable, encourage completion within 14 days  Symptomatic treatment needed  Withdrawal symptoms peak 2-4 days AFTER reduction to zero.  Prescribe for withdrawal symptoms further 14 days  Naltrexone after 10 days.

41. Lofexidine Detox  Can use alongside low dose meth/bup  Timetable to coincide with peak withdrawal symptoms  Daily BP for first 3-5 days  Dose according to response  May need symptomatic rx in addition  Use lofexidine treatment agreement and medication chart on template.

42. Opiate detox – data  Opiate detox commenced –Final 4 weeks of prescribing  Opiate detox successfully completed –At final prescription appointment.  Opiate detox not successful  On Portal and on opiate detox page.

43. Relapse Prevention  What problems do you anticipate for the client?  How would you help her address them?

44. Naltrexone  Most suitable if someone to support compliance  LFTs before starting  Test dose 25mg on site  6/10 days after opiates.  Clear UT  Guideline on Portal

45. Discussion  Whats gone well in a recent client who has detoxed?  What’s gone badly in a recent client who has had an unsuccessful detox?  How can you transfer this into standard practice?

46. Learning  What have I learned about –Opiate detox –Alcohol detox –Benzodiazepine detox? –Templates/systmOne  What do I forget to do on S1?  What will I do differently?