1. The introduction of a routine offer of relapse prevention pharmacotherapy following successful alcohol withdrawal: A quality improvement project in a 20 bed acute male inner city psychiatric ward
Dr Emmert Roberts, Dr Claire Hennigan, Dr Arnaldo Felix de Carvalho and Dr Luiz Dratcu South London and the Maudsley Mental Health Trust
Introduction
Abstract
Introduction
Background
Results and Conclusions
Introduction
Problem: Whilst physical health CQUIN targets in inpatient psychiatric units promote monitoring of lipids, weight, blood pressure and diabetic screening no current policy suggests a similarly structured approach to monitoring alcohol intake or interventions following alcohol withdrawal.
Background: NICE guideline CG115 for alcohol use disorders recommends that, following successful withdrawal for people with moderate and severe alcohol dependence, clinicians should consider offering relapse prevention pharmacotherapy namely acamprosate, naltrexone or disulfiram in combination with a psychological intervention.
Baseline Measurement: All patients admitted to John Dickson Ward, Maudsley Hospital, London from February 2016 until August 2016 were screened to assess the number of patients eligible for consideration of relapse prevention pharmacotherapy. Of 83 patients admitted, 9 were eligible for relapse prevention pharmacotherapy. No patients were prescribed medication nor was their any documentation surrounding discussion of relapse prevention pharmacotherapy.
Design and Strategy: We implemented a universal clinical discussion, provision of patient information leaflets and if clinically appropriate prescription of relapse prevention pharmacotherapy to all inpatients completing self or pharmacologically assisted alcohol withdrawal.
Results: As of January 2017, Seven patients were eligible for relapse prevention pharmacotherapy. All eligible patients had a clinical discussion and PILs provided. One started naltrexone, six started acamprosate, and zero commenced disulfiram. On review of there notes four remained abstinent from alcohol as of 6 months from baseline measurement.
Conclusions: Implementation resulted in an increase in prescriptions from 0% to 100%, and an increase from 11% to 57% in the number of patients able to be identified from electronic health records as maintaining abstinence from alcohol at 6 months from baseline measurement
NICE guideline CG115 for alcohol use disorders recommends that, following successful withdrawal for people with moderate and severe alcohol dependence, clinicians should consider offering relapse prevention pharmacotherapy, namely acamprosate, naltrexone or disulfiram, in combination with a psychological intervention.2
Current evidence suggests that these interventions are under utilised by clinicians due to a variety of factors including lack of familiarity with their use and perceived lack of efficacy.3
Number of patients admitted from Aug 2016 – Jan 2016 81
Number of patients eligible for consideration of relapse prevention pharmacotherapy 7
Number of patients eligible for consideration of pharmacotherapy with documented discussion around pharmacotherapy
7/7
Number of patients eligible for consideration of pharmacotherapy prescribed pharmacotherapy
Number of patients prescribed acamprosate
6/7
Number of patients prescribed naltrexone
1/7
Number of patients prescribed disulfiram
0/7
Number of patients eligible for consideration of pharmacotherapy able to be identified as abstinent from alcohol from electronic health record as of Jan 2016
4/7
Introduction
Baseline Measurement
Number of patients admitted from Feb – Aug 2016 83
Number of patients admitted from Feb – Aug 2016 eligible for consideration of relapse prevention pharmacotherapy 9
Number of patients eligible for consideration of pharmacotherapy with documented discussion around pharmacotherapy
0/9
Number of patients eligible for consideration of pharmacotherapy prescribed pharmacotherapy
Number of patients eligible for consideration of pharmacotherapy able to be identified as abstinent from alcohol from electronic health record as of August 2016
1/9
Difference in number of patients prescribed pharmacotherapy
+ 7
Difference in number of patients abstinent from alcohol at 6 months from baseline measurement
+ 3
Implementation of a universal clinical discussion with those patients identified as eligible for consideration of relapse prevention pharmacotherapy resulted in an increase in prescriptions from 0% to 100%, and an increase from 11% to 57% in the number of patients able to be identified from electronic health records as maintaining abstinence from alcohol at 6 months from baseline measurement. it is unlikely these prescriptions would have been initiated without this intervention.
Universal offer of a clinical discussion of pharmacotherapy shall continue on the ward, and is expanding to other wards within the hospital. The next stage of the project is to disseminate this information to other wards within the trust to increase clinician familiarity with these medications and widen the knowledge of their clinical utility.
Introduction
Design and Strategy
Yes No
Assess patient’s level of alcohol intake and assess for features of moderate or severe dependence syndrome
If the patient has capacity to consent to treatment, initiate clinical discussion around risks, benefits and most appropriate relapse prevention pharmacotherapy from acamporsate, naltrexone and disulfiram.
Offer PIL.
Document on ePJS
If clinically appropriate and consenting prescribe and monitor relapse prevention pharmacotherapy in addition to provision of psychological support.
Ensure adequate response on discharge and communicate with subsequent prescriber with regards monitoring requirements.
Consider pharmacologically assisted inpatient alcohol detoxification if clinically appropriate
Identify if patient has recently completed self or pharmacologically assisted alcohol withdrawal
Introduction
Problem
Alcohol misuse is ranked third as the leading global disease risk factor after hypertension and tobacco smoking worldwide.1 Whilst physical health Commissioning for QUality and Innovation (CQUIN) targets in psychiatric hospitals encourage monitoring of cardiovascular and metabolic risk factors including serum lipids, patient weight, smoking status, baseline electrocardiogram and diabetic screening no current policy suggests a similarly structured approach to monitoring of alcohol intake or associated interventions following successful withdrawal.
Introduction
References
Lim S, Vos T, Flaxman A et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study. Lancet. 2010; 380:2224–2260.
Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Clinical guideline [CG115] Published date: February 2011
Jung YC and Namkoong K. Pharmacotherapy for Alcohol Dependence: Anticraving Medications for Relapse Prevention. Yonsei Med J. 2006; 47(2):167–178.
Identify if patient completes pharmacologically assisted alcohol withdrawal
Acknowledgements: The authors have no competing interests to disclose