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

2. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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)

10. 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

11. 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

12. 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.

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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