North Yorkshire Horizons Medically Assisted Withdrawal & Step down to primary care

Pathway GPs and Pharmacies Group Work Mutual Aid SPOC Triage Group Work Mutual Aid Next Steps Community Groups & Activities Volunteers Treatment Dentists, housing services, mental health teams etc. Recovery & Mentoring

Recovery and Mentoring SPOC (Referral, enquires, information and guidance) Triage Assertive engagement with the service Recovery support during treatment Post treatment Recovery support Community groups & Activities Volunteers Sustainable Recovery Community

Treatment Comprehensive Assessment Shared Care Clinical Interventions – Prescribing / Detox / BBV PSI support to achieve treatment goals 1-1 appointments Group work – including criminal justice (DRR/ATR) 3 Way Review Meetings / Co-ordination Shared Care Family Co-ordinator – Safeguarding Lead Harm Reduction Whole Family Approach

Detox Community Detoxes Appropriately prepared for and managed Opiate or Alcohol Community Detoxes Appropriately prepared for and managed Follow up prescribing if required Naltrexone Disulfiram Acamprosate

Residential or Community Residential should be reserved for those with severe enduring psychiatric co-morbidity or significant social instability Use chordiazepoxide (typically 20mg qds) Or diazepam 15mg bd Do prescribe thiamine Avoid regular repeat detoxifications as some evidence for “kindling effect” – i.e. Increased risk of withdrawal seizures Seizures most common in first 24 hours

Relapse Prevention Medication Options for Alcohol Dependence Disulfiram (antabuse) Acamprosate (campral) Naltrexone (Adepend, Nalorex, Opizone)

Key Outcomes Abstinence Drinking frequency measures (e.g. number of days drinking in the past month) Quantity of alcohol consumption measures (e.g. drinks per drinking day [DDD]) Number retained in treatment, aftercare attendance, engagement in aftercare Relapse, lapse (time to, or severity of)

Disulfiram Works by negative reinforcement, i.e. nausea and vomiting and feeling unwell if drinking alcohol when taking the medication Dose one 200mg tablet per day but can increase to 500mg Comprehensive holistic assessment – social, physical, occupational, psychological/ psychiatric Avoid use (contraindicated) in heart disease, hypertension, psychosis, personality disorder, suicide risk

Acamprosate Gamma-aminobutyric acid analogue Dose dependent upon weight - > 60kg 666mg (two tablets) three times a day; < 60kg 666mg breakfast , 333mg lunch and 333mg at night. Only contraindication is allergy to the drug Can get gastrointestinal side effects – nausea, vomiting, diarrhoea, flatulence Also side effects of rash, itching, impotence

Naltrexone Opioid antagonist to prevent relapse in formerly alcohol dependent patients Dose half a 50mg tablet taken on first day increased to one 50mg tablet daily if tolerated Contraindications: opioid dependence Can get side effects – significant ones include chest pain, impotence, delayed ejaculation, mood swings, retention of urine.

Moving patients on – NYH responsibilities 1. Handover guidelines is in accordance with NICE Guidance CCG115 – issue discharge letter if GP signed up to deliver service 2. Prescribing regimens Acamprosate: 1998mg per day (666mg x three times daily) unless weight <60kg, then maximum 1332mg per day Naltrexone: 25mg per day, aim for maintenance dose of 50mg per day Disulfiram: 200mg per day 3. Monitoring - Fortnightly + PSI - Stop if evidence of relapse - Educate and coach patient and carers re contraindications, rare complications and management of expectations NICE CCG 115 (refer to section 1.3.6) recommends that adults with moderate and severe alcohol dependence are offered acamprosate or oral naltrexone in combination with an individual psychological intervention focussed on alcohol misuse following a successful assisted alcohol withdrawal programme. Disulfiram is only recommended in the same circumstances if:  The service user has a goal of abstinence but the aforementioned medications are not suitable;  The service user prefers disulfiram and understands the relative risks. Usually prescribed for up to 6 months in total, and only longer if service user benefiting and wants to continue, following medical assessment. Patients eligible only if transferred from North Yorkshire Horizons via Appendix A.

Moving patients on – GP responsibilities 1. Receive and review transfer communication (discharge letter) from NYH and ensure transfer follow up appointment with patient in surgery. This will include summary comprehensive medical assessment including baseline urea and electrolytes and liver function tests including gamma glutamyl transferase. 2. Instigate monthly repeat appointments for ALL pharmacotherapies to ensure safe and effective monitoring 3. Use BRENDA model as one way of framing the review conversation/PSI 4. No need for blood tests in first 12 weeks unless physical deterioration, naltrexone in older /obese patients

Monitoring Monthly clinical review Naltrexone – three monthly liver function tests Disulfiram – six monthly liver function tests Acamprosate – No routine blood testing recommended, but may want to repeat liver function tests regularly to monitor recovery Where prescribing beyond 6 months a detailed clinical review is required, identifying the clinical indication for continued prescribing and the future management plan

BRENDA B Biopyschosocial evaluation – holistic assessment R Report to patient – brief feedback to patient during appointment following holistic assessment (strengths based) E Empathy – development of positive therapeutic relationship with patient N Address Needs D Direct Advice – brief advice following 4 steps above directly to patient during appointment A Assess patient reaction - to direct advice and address and compliance or reaction concerns during appointment

Outcomes - Disulfiram Compared to naltrexone longer time to relapse and longer time to relapse into heavy drinking; statistically significant reduction in days abstinent Evidence only of moderate quality, therefore more research needed Counselling+ led to no added treatment effect The British Psychological Society and The Royal College of Psychiatrists. (2011). Alcohol Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence

Outcomes - Acamprosate Compared to placebo - small but statistically significant increase in numbers achieving abstinence Effect most pronounced at six months but effect lasted up to two years Reduced proportion relapsing into heavy drinking Treatment with acamprosate, in conjunction with psychosocial support, significantly increases the proportion of alcohol-dependent patients who remained completely abstinent from alcohol at 6 months…36.1% compared to 23.4% of those receiving placebo A reduction in the risk of any drinking to 86% of the placebo rate and an increase in the number of abstinent days by approximately three per month The British Psychological Society and The Royal College of Psychiatrists. (2011). Alcohol Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence

Outcomes - Naltrexone Statistically significant reduction in relapse to heavy drinking ie 83% of placebo rate 4% reduction in number of drinking days 3% reduction in the number of heavy drinking days Reduction in the amount of alcohol consumed, on drinking days, by about 11g The British Psychological Society and The Royal College of Psychiatrists. (2011). Alcohol Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence

Outcomes - Combination Acamprosate and Naltrexone Naltrexone/acamprosate combination was no more effective than mono acamprosate or naltrexone therapy in reducing time to or severity of relapse The British Psychological Society and The Royal College of Psychiatrists. (2011). Alcohol Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence

Psychological Interventions Therapeutic alliance crucial – better predictor than technique in determining outcomes Confrontational approach increases alcohol intake Role of ‘homework’ important Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) – CBT, MET, TSF – only severity of psychiatric illness predicted drinking at one year Confirmed by UKATT – i.e. SBNT vs MET no statistically significant difference. Also long term outcomes not studied

What is a positive therapeutic alliance Supportive, facilitative Non-confrontational Engaging of outside resources Goal orientated Realistic

info@NYHorizons.org.uk 01723 330730