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

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Presentation on theme: "Community Alcohol Detoxification Dr Merlin Willcox, Luther St Medical Centre, Oxford."— Presentation transcript:

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.”

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