Downloaded from http://jramc.bmj.com/ on August 18, 2017 - Published by group.bmj.com
Review
A proposed model for community-assisted alcohol withdrawal in primary care in the UK Armed Forces Nicholas H Faerestrand, R H Coetzee Department of Community Mental Health, Portsmouth, UK Correspondence to Surg Cdr Rikus H Coetzee, Department of Community Mental Health, Sunny Walk PP6, Her Majesty’s Naval Base Portsmouth, PO1 3LT, UK; [email protected] Received 29 December 2013 Revised 29 January 2014 Accepted 22 March 2014 Published Online First 23 April 2014
ABSTRACT Alcohol misuse and related morbidity continues to represent a challenge to the both the National Health Service (NHS) and the Defence Medical Services (DMS). A significant part of the management of patients who misuse alcohol involves planned assisted withdrawal for dependent drinkers. Traditionally, assisted alcohol withdrawal has been conducted in an in-patient setting owing to the perceived risks of carrying out this treatment. Current evidence shows that community-based approaches offer a safe and effective alternative to the traditional inpatient model with significant cost savings. This article proposes a model for community-assisted alcohol withdrawal (CAAW) for use within the DMS. It considers current guidelines and models already in operation within the NHS, offering evaluation and adjustments to fit the requirements that are applicable to the UK Armed Forces medical environment.
INTRODUCTION Alcohol misuse and related morbidity continues to represent a challenge to both the National Health Service (NHS) and the Defence Medical Services (DMS). In recent years, the DMS has treated 77 patients for assisted alcohol withdrawal in an in-patient setting (38 patients in 2011 and 39 patients in 2012). The average length of stay for this process in 2011 was 9 days and 10 days in 2012.1 It is known that alcohol withdrawal carries risks and requires careful clinical management.2 The perceived risks of detoxification have traditionally meant that this was conducted in an in-patient setting by secondary care providers. This model has since been challenged by delivery centred in the community, known as community-assisted alcohol withdrawal (CAAW). Evidence has shown that not only is CAAW as clinically effective and safe as in-patient detoxification,3–5 it also conforms better to the needs of the client6 and may offer significant cost savings.7 8 Furthermore, CAAW has been well supported by the National Treatment Agency for Substance Misuse (NTA), which evaluates the effectiveness of alcohol treatments.3
AIMS OF CAAW
To cite: Faerestrand NH, Coetzee RH. J R Army Med Corps 2015;161:308–314. 308
The main aim of CAAW is to prevent unpleasant, and potentially serious, withdrawal symptoms as a result of alcohol-stimulated gamma-aminobutyric acid (GABA) potentiation being interrupted. This leads to the dominance of excitatory glutamine transmission that has been upregulated and opposed by the alcohol effects on the GABA inhibitory system. CAAW is normally offered to the following patient groups:
Key messages ▸ Community-assisted alcohol withdrawal (CAAW) is a safe and effective alternative to inpatient detoxification. ▸ CAAW can readily be conducted within Primary Care in the UK Armed Forces. ▸ CAAW offers superior patient acceptability and cost savings.
▸ Problem alcohol use where the patient shows signs of dependence and withdrawal symptoms. ▸ All patients with a confirmed diagnosis of alcohol dependence. ▸ In both groups, the patient must be assessed clinically as motivated to embark on a period of abstinence. CAAW is achieved mainly by pharmacological means and only has a routine indication for use in dependent drinkers. CAAW also aims to prevent two associated syndromes related closely to detoxification, namely, delirium tremens and Wernicke– Korsakoff syndrome. The clinical features of these syndromes are detailed in Table 1. The complications of detoxification raise some patient safety concerns; however, the evidence shows that they are rare and most patients do not experience serious complications during withdrawal and do not require medication.3 9 The use of exclusion criteria based on the recognition of high-risk patients helps to ensure the prevention of these rare but serious complications. The evidence base supporting these exclusion criteria already exists to provide a framework for a DMS CAAW model.3 These criteria were further adapted by a Royal Navy Specialist Group convened to investigate CAAW in the Royal Navy and adapted to meet the needs of the DMS population (Box 1). In assessing the safety of CAAW in the UK Armed Forces, other factors may also be important. First, the studies upon which the NTA based their guidance were conducted in the general population using samples likely to contain older individuals with a more prolonged period of dependence, malnutrition and systemic complications than are found in the UK Armed Forces. In service it is unlikely that individuals would be so severely dependent as to render CAAW unsafe, as severely dependent individuals would be likely to function poorly and would have thus been identified as having a problem by their chain of command, potentially as a result of disciplinary
Faerestrand NH, Coetzee RH. J R Army Med Corps 2015;161:308–314. doi:10.1136/jramc-2013-000244
Downloaded from http://jramc.bmj.com/ on August 18, 2017 - Published by group.bmj.com
Review Table 1 Symptoms and complications of detoxification due to alcohol withdrawal Alcohol-related withdrawal symptoms
Delirium tremens
Wernicke–Korsakoff syndrome
▸ Agitation and physical restlessness frequently associated with emotions of anxiety and fear ▸ Insomnia ▸ Tremor ▸ Ataxia ▸ Perspiration ▸ Flushing or pallor ▸ Dilated pupils ▸ Nausea and vomiting ▸ Transient hallucinations and illusions in full consciousness
▸ Disorientation (usually losing orientation to time, then place and lastly person) ▸ Fluctuation in consciousness levels ▸ Marked reversal of day/night wake cycles ▸ Hallucinations (mostly visual, but also auditory and tactile) ▸ Seizures, sometimes progressing to status epilepticus ▸ Stupor, coma and death
▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸
problems or through routine interaction with the medical system. They would also be of a younger age and physically more robust due to the physical requirements of military service. Therefore, it seems reasonable to view the Armed Forces population as being lower risk than the general population in terms of the likelihood of serious complications during withdrawal, provided that the exclusion criteria are adhered to. Therefore, it is likely that the NTA’s view that most dependent drinkers can be safely withdrawn from alcohol in the community applies even more firmly to the UK Armed Forces.
Box 1 Adapted exclusion criteria for Defence Medical Services model of community-assisted alcohol withdrawal (CAAW) ▸ The presence of neurological disorder ( previous CVA, history of epilepsy or withdrawal fits, Wernicke’s encephalopathy, recent significant head injury with loss of consciousness, cognitive impairment, history or signs of delirium). ▸ Major psychiatric disorder (severe anxiety and depression, psychotic illness, suicidal intent). ▸ Major systemic complications (hepatitis, significant liver damage—not just raised gamma-glutamyl transpeptidase (GGT), significant haematemesis, infections particularly if pyrexia above 38.5°C). ▸ Moderate-to-severe malnutrition or dehydration. ▸ History of high-dose poly-drug abuse. If current low-dose comorbid substance abuse, please seek advice from a psychiatrist. ▸ Severe dependence (greater than 30 units of alcohol per day). ▸ Two or more failed attempts at CAAW in the last 6 months. ▸ Highly unstable social environment (homeless, living alone, little support). ▸ Score of 30 or more on the Severity of Alcohol Dependence Scale (SADQ). ▸ Although not an absolute contraindication, the resources of the medical centre undertaking the CAAW must be considered. For instance, if it is small and in an isolated location, or staffed by a junior doctor or one with limited knowledge of the military system (eg, a short-term locum), then these may sway the decision towards in-patient treatment. Alternatively, the patient can be transferred to a larger facility temporarily for the community intervention to be undertaken there.
Nystagmus Lateral rectus palsy Paralysis of conjugate gaze Ataxia Peripheral neuropathy Retinal haemorrhages Delirium Enduring cognitive impairment after acute phase ▸ Amnesia ▸ Confabulation
PHARMACOLOGICAL ASPECTS OF CAAW Cessation of drinking is unlikely to be complicated in milder dependence, and these patients usually do not need pharmacological assistance. This can be defined as consumption reported as
Review
A proposed model for community-assisted alcohol withdrawal in primary care in the UK Armed Forces Nicholas H Faerestrand, R H Coetzee Department of Community Mental Health, Portsmouth, UK Correspondence to Surg Cdr Rikus H Coetzee, Department of Community Mental Health, Sunny Walk PP6, Her Majesty’s Naval Base Portsmouth, PO1 3LT, UK; [email protected] Received 29 December 2013 Revised 29 January 2014 Accepted 22 March 2014 Published Online First 23 April 2014
ABSTRACT Alcohol misuse and related morbidity continues to represent a challenge to the both the National Health Service (NHS) and the Defence Medical Services (DMS). A significant part of the management of patients who misuse alcohol involves planned assisted withdrawal for dependent drinkers. Traditionally, assisted alcohol withdrawal has been conducted in an in-patient setting owing to the perceived risks of carrying out this treatment. Current evidence shows that community-based approaches offer a safe and effective alternative to the traditional inpatient model with significant cost savings. This article proposes a model for community-assisted alcohol withdrawal (CAAW) for use within the DMS. It considers current guidelines and models already in operation within the NHS, offering evaluation and adjustments to fit the requirements that are applicable to the UK Armed Forces medical environment.
INTRODUCTION Alcohol misuse and related morbidity continues to represent a challenge to both the National Health Service (NHS) and the Defence Medical Services (DMS). In recent years, the DMS has treated 77 patients for assisted alcohol withdrawal in an in-patient setting (38 patients in 2011 and 39 patients in 2012). The average length of stay for this process in 2011 was 9 days and 10 days in 2012.1 It is known that alcohol withdrawal carries risks and requires careful clinical management.2 The perceived risks of detoxification have traditionally meant that this was conducted in an in-patient setting by secondary care providers. This model has since been challenged by delivery centred in the community, known as community-assisted alcohol withdrawal (CAAW). Evidence has shown that not only is CAAW as clinically effective and safe as in-patient detoxification,3–5 it also conforms better to the needs of the client6 and may offer significant cost savings.7 8 Furthermore, CAAW has been well supported by the National Treatment Agency for Substance Misuse (NTA), which evaluates the effectiveness of alcohol treatments.3
AIMS OF CAAW
To cite: Faerestrand NH, Coetzee RH. J R Army Med Corps 2015;161:308–314. 308
The main aim of CAAW is to prevent unpleasant, and potentially serious, withdrawal symptoms as a result of alcohol-stimulated gamma-aminobutyric acid (GABA) potentiation being interrupted. This leads to the dominance of excitatory glutamine transmission that has been upregulated and opposed by the alcohol effects on the GABA inhibitory system. CAAW is normally offered to the following patient groups:
Key messages ▸ Community-assisted alcohol withdrawal (CAAW) is a safe and effective alternative to inpatient detoxification. ▸ CAAW can readily be conducted within Primary Care in the UK Armed Forces. ▸ CAAW offers superior patient acceptability and cost savings.
▸ Problem alcohol use where the patient shows signs of dependence and withdrawal symptoms. ▸ All patients with a confirmed diagnosis of alcohol dependence. ▸ In both groups, the patient must be assessed clinically as motivated to embark on a period of abstinence. CAAW is achieved mainly by pharmacological means and only has a routine indication for use in dependent drinkers. CAAW also aims to prevent two associated syndromes related closely to detoxification, namely, delirium tremens and Wernicke– Korsakoff syndrome. The clinical features of these syndromes are detailed in Table 1. The complications of detoxification raise some patient safety concerns; however, the evidence shows that they are rare and most patients do not experience serious complications during withdrawal and do not require medication.3 9 The use of exclusion criteria based on the recognition of high-risk patients helps to ensure the prevention of these rare but serious complications. The evidence base supporting these exclusion criteria already exists to provide a framework for a DMS CAAW model.3 These criteria were further adapted by a Royal Navy Specialist Group convened to investigate CAAW in the Royal Navy and adapted to meet the needs of the DMS population (Box 1). In assessing the safety of CAAW in the UK Armed Forces, other factors may also be important. First, the studies upon which the NTA based their guidance were conducted in the general population using samples likely to contain older individuals with a more prolonged period of dependence, malnutrition and systemic complications than are found in the UK Armed Forces. In service it is unlikely that individuals would be so severely dependent as to render CAAW unsafe, as severely dependent individuals would be likely to function poorly and would have thus been identified as having a problem by their chain of command, potentially as a result of disciplinary
Faerestrand NH, Coetzee RH. J R Army Med Corps 2015;161:308–314. doi:10.1136/jramc-2013-000244
Downloaded from http://jramc.bmj.com/ on August 18, 2017 - Published by group.bmj.com
Review Table 1 Symptoms and complications of detoxification due to alcohol withdrawal Alcohol-related withdrawal symptoms
Delirium tremens
Wernicke–Korsakoff syndrome
▸ Agitation and physical restlessness frequently associated with emotions of anxiety and fear ▸ Insomnia ▸ Tremor ▸ Ataxia ▸ Perspiration ▸ Flushing or pallor ▸ Dilated pupils ▸ Nausea and vomiting ▸ Transient hallucinations and illusions in full consciousness
▸ Disorientation (usually losing orientation to time, then place and lastly person) ▸ Fluctuation in consciousness levels ▸ Marked reversal of day/night wake cycles ▸ Hallucinations (mostly visual, but also auditory and tactile) ▸ Seizures, sometimes progressing to status epilepticus ▸ Stupor, coma and death
▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸
problems or through routine interaction with the medical system. They would also be of a younger age and physically more robust due to the physical requirements of military service. Therefore, it seems reasonable to view the Armed Forces population as being lower risk than the general population in terms of the likelihood of serious complications during withdrawal, provided that the exclusion criteria are adhered to. Therefore, it is likely that the NTA’s view that most dependent drinkers can be safely withdrawn from alcohol in the community applies even more firmly to the UK Armed Forces.
Box 1 Adapted exclusion criteria for Defence Medical Services model of community-assisted alcohol withdrawal (CAAW) ▸ The presence of neurological disorder ( previous CVA, history of epilepsy or withdrawal fits, Wernicke’s encephalopathy, recent significant head injury with loss of consciousness, cognitive impairment, history or signs of delirium). ▸ Major psychiatric disorder (severe anxiety and depression, psychotic illness, suicidal intent). ▸ Major systemic complications (hepatitis, significant liver damage—not just raised gamma-glutamyl transpeptidase (GGT), significant haematemesis, infections particularly if pyrexia above 38.5°C). ▸ Moderate-to-severe malnutrition or dehydration. ▸ History of high-dose poly-drug abuse. If current low-dose comorbid substance abuse, please seek advice from a psychiatrist. ▸ Severe dependence (greater than 30 units of alcohol per day). ▸ Two or more failed attempts at CAAW in the last 6 months. ▸ Highly unstable social environment (homeless, living alone, little support). ▸ Score of 30 or more on the Severity of Alcohol Dependence Scale (SADQ). ▸ Although not an absolute contraindication, the resources of the medical centre undertaking the CAAW must be considered. For instance, if it is small and in an isolated location, or staffed by a junior doctor or one with limited knowledge of the military system (eg, a short-term locum), then these may sway the decision towards in-patient treatment. Alternatively, the patient can be transferred to a larger facility temporarily for the community intervention to be undertaken there.
Nystagmus Lateral rectus palsy Paralysis of conjugate gaze Ataxia Peripheral neuropathy Retinal haemorrhages Delirium Enduring cognitive impairment after acute phase ▸ Amnesia ▸ Confabulation
PHARMACOLOGICAL ASPECTS OF CAAW Cessation of drinking is unlikely to be complicated in milder dependence, and these patients usually do not need pharmacological assistance. This can be defined as consumption reported as
