1. Community Alcohol Detoxification Dr Merlin Willcox, Luther St Medical Centre, Oxford

3. 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%)

4. Plan Case Study Background and evidence Luther St Protocol Audit of our patients Patient information leaflet

5. 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?

6. 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.

7. Luther St Detox protocol Developed over 25 years Pre-detox assessment Decision to initiate community detox Detox regimen Follow-up

8. Our basic philosophy Open door to anyone Careful pre-detox assessment Careful risk management Close supervision Clear boundaries

9. 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

10. 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

11. 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)

12. Pre-detox plans Liaise with other services – Street services / accommodation providers – Drug services if patient is on script – Mental health services if appropriate

13. Daily team meetings

14. 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

15. The detox begins…

16. 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

17. 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

18. 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 breathalyser Eve Gibb

19. 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

20. Adverse events Adverse events occurred in 2 (5%) – 1 fit (admitted) – 1 Wernicke’s encephalopathy (refused admission)

21. 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.

22. 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

23. Detox outcomes - 2009

24. Not suitable for community detox Patient not coming to be seen or unreliable Severe liver impairment Benzo addiction

27. Andy, a homeless man. “You’re never a failure until you stop trying.”