HMP Policy for the Management of Alcohol Withdrawal



NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUSTPOLICY DOCUMENTDocument TitlePolicy For the Clinical Management of Alcohol WithdrawalReference NumberCG/HMP Alcohol Withdrawal/03/15Policy TypeClinical GuidelineElectronic File/LocationN:\Pharmacy\Intranet Intranet Location StatusFinalVersion Number/DateVersion 1 / March 2015Author(s) Responsible for Writing and MonitoringHead of Essex STaRSIDTS Clinical Nurse Manager Charge NurseResponsible DirectorDirector of Operations & NursingApproved By Medicines Management Group Approval DateMarch 2015Implementation DateApril 2015Review DateApril 2018Copyright? North Essex Partnership University NHS Foundation Trust (2015). All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner.All matters or concerns regarding fraud or corruption should be reported to: Chris Rising, Senior Manager (Chris.Rising@bakertilly.co.uk 07768 873701), Hannah Wenlock, LCFS Lead (Hannah.Wenlock@bakertilly.co.uk 07972 004257) Mark Trevallion, LCFS Lead (Mark.Trevallion@bakertilly.co.uk 07800 718680) OR the National Fraud and Corruption Line 0800 028 40 60 for the Clinical Management of Alcohol WithdrawalIDTS HMP ChelmsfordVersion: 01Author: Cheryl Carson and Ian MeliaRatified/Approved by: Medicines Management Committee/Clinical Governance GroupEffective from: April 2015Review Date: April 2018Targeted Audience: Healthcare, Inside Out, Governors, Prison Officers, InreachCirculated to the following people for consultation:Governor HMP ChelmsfordContentsSectionTopicPage Number1Purpose42Definitions43Detoxification54Responsibilities65Evaluation and Treatment of Alcohol Dependency 66Medical Complications of Alcohol Withdrawal77Acamprosate Calcium88Stabilisation99Intoxication910Clinical Management1111Chlordiazepoxide Regimes1112Non-compliance with Treatment1213Summary of Changes13Appendices1Advice to clients on withdrawing from alcohol142Routine Nursing Observations153What is Pabrinex??164Signs and Symptoms of Anaphylaxis175Client Consent to Chlordiazepoxide for Alcohol Detoxification186HMP Chelmsford Detoxification Disclaimer197Alcohol Withdrawal Scale Template and Alcohol Withdrawal Record208Fact Sheets24Policy For the Clinical Management of Alcohol Withdrawal1. Purpose1.1. This policy governs the safe prescribing and management for patients with Alcohol dependency problems who come under the care of HMP/YOI Chelmsford. This document is by no means exhaustive and does not attempt to cover every eventuality. It is the duty of all employees to report any unusual or unforeseen situations with regard to any procedure to their line manager.2. Definitions2.1. Unit of AlcoholOne "unit" in the UK usually means a beverage containing 8 g of ethanol, e.g. a half pint of 3.5% beer or lager, or one 25 ml pub measure of spirits. A small (125 ml) glass of average strength (12%) wine contains 1.5 units.2.2. Hazardous Drinkingi. The term hazardous drinking is widely used. It is synonymous with "at-risk drinking" and can be defined as the regular consumption of:Over 40g of pure ethanol (5 units) per day for menii. These figures derive from population studies showing the relationship of self-reported levels of drinking to risk of harm. It is arbitrary at which point on the risk curve is deemed to merit a warning. Other authorities have quoted weekly recommended upper limits for alcohol consumption of 21 units per week for men.iii. Consuming over the equivalent of 40g of pure ethanol (Alcohol) per day on average doubles a man's risk for liver disease, raised blood pressure, some cancers (for which smoking is a confounding factor) and violent death (because some people who have this average alcohol consumption drink heavily on some days).iv. The term hazardous drinking is also used loosely to cover those who have experienced minimal as opposed to serious harm2.3. Harmful DrinkingHarmful drinking is defined in the International Classification of Diseases (ICD-10) as a pattern of drinking that causes damage to physical (e.g. to the liver) or mental health (e.g. episodes of depression secondary to heavy consumption of alcohol).15 The diagnosis requires that actual damage should have been caused to the mental or physical health of the user.2.4. Alcohol DependenceAlcohol dependence is defined as a cluster of physiological, behavioural, and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that previously had greater value. A central characteristic is the desire (often strong, sometimes perceived as overpowering) to drink alcohol. Return to drinking after a period of abstinence is often associated with rapid reappearance of the features of the syndrome (priming). A definitive diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:a strong desire or sense of compulsion to take alcoholdifficulty in controlling drinking in terms of its onset, termination or level of use a physiological withdrawal state when drinking has ceased or been reduced (e.g. tremor, sweating, rapid heart rate, anxiety, insomnia, or less commonly seizures, disorientation or hallucinations) or drinking to relieve or avoid withdrawal symptomsevidence of tolerance, such that increased doses of alcohol are required in order to achieve effects originally produced by lower doses (clear examples of this are found in drinkers who may take daily doses sufficient to incapacitate or kill non-tolerant users)progressive neglect of alternative pleasures or interests because of drinking and increased amount of time necessary to obtain or take alcohol or to recover from its effects (salience of drinking)persisting with alcohol use despite awareness of overtly harmful consequences, such as harm to the liver, depressive mood states consequent to periods of heavy drinking, or alcohol related impairment of cognitive functioning3. Detoxification3.1. Detoxification refers to the planned withdrawal of alcohol. Alcohol withdrawal carries risks and requires careful clinical management.3.2. Chelmsford is a local prison and therefore will receive prisoners directly from the courts and those transferred from other establishments. Chelmsford must ensure that if a prisoner is transferred to them during an alcohol detox, that the regime is continued to its completion. No prisoners can be transferred out of Chelmsford until an alcohol detoxification is complete unless this is in order to transfer the prisoner into the High Secure Estate.3.3. CHLORDIAZEPOXIDE (LIBRIUM) is the preferred drug of choice to be used in alcohol withdrawal regimes. However patients can be prescribed benzodiazepine as a reducing regime if they are currently prescribed this medication or using benzodiazepine illicitly.4. Responsibilities4.1. It is the duty of the IDTS Clinical Nurse Manager and the IDTS Team of HMP/YOI Chelmsford to amend and update this document in conjunction with any other relevant authority. 4.2. It is the duty of the IDTS Clinical Nurse Manager and the IDTS Team of HMP/YOI Chelmsford to ensure client consent is obtained and signed (Appendix 5). 4.3. Substitute medication such as Chlordiazepoxide should not be prescribed in isolation. A multidisciplinary approach to alcohol dependency treatment is essential.4.4. Prescribing is the particular responsibility of the professional signing the prescription. The responsibility cannot be delegated.4.5. The registered professional who administers the medication under supervised conditions has a responsibility to ensure that the correct patient receives the correct dose and that appropriate efforts are taken to ensure that the drug is used appropriately and not diverted onto the illegal market. 4.6. If the patient is a polydrug and alcohol user, joint clinical reviews should be undertaken regularly, at least every three months Where needs are complex or the drug use is unstable then reviews should be undertaken more often.4.7. Thorough, clearly written or computer records of prescribing interventions must be kept.5. Evaluation and Treatment of Alcohol Dependency 5.1. Before any prescribing of medication the patient must have an assessment of needs. 5.2. A full medical history must be taken as is the case with all prisoners this must include details of their alcohol dependence using the Alcohol Assessment Form, Including details ofWhat they drink? When they last drank? How much they drink daily? Drinking patterns such as binges or daily?Any health issues relating to alcohol dependence such as gastrointestinal or hepatic impairment 5.3. The patient must be seen by the IDTS Nurse or Doctor/Independent Non-medical Prescriber (IP) before any medication is issued.5.4. The patient must have had discussion with the Doctor/IP or IDTS Nurse to discuss the implications of Chlordiazepoxide as a treatment, and the expectations for treatment. There needs to be documentary evidence of this in the patient notes.5.5. There needs to be a clear indication that the patient is dependent on alcohol before treatment is commenced.5.6. If the prisoner appears intoxicated or sedated, the first dose of Chlordiazepoxide must be withheld until it is clinically safe to begin treatment. 5.7. An alcohol withdrawal scale(Appendix 7) must be completed on all patients who are to be clinically assessed with possible alcohol dependency problems.5.8. Cessation of drinking is unlikely to be complicated in milder dependence. There should however be a lower threshold of prescribing in prison, in part due to the very limited access to alcohol, and also to the risks of self-harm in untreated/under treated withdrawal – if there is any withdrawals then titrate against withdrawal symptoms both up/down. Always prescribe if the prisoner claims to be dependent, this should be based on a comprehensive history and evidence is believable, and where clinical presentation demonstrates there is evidence of withdrawal.6. Medical Complications of Alcohol Withdrawal6.1. Medical complications of Alcohol withdrawal are potentially life threatening. Nursing observations (Appendix 2) should be undertaken twice daily for these clients for at least the first five days of their detoxification to identify at an early stage any complications which may arise, particularly in respect of withdrawal fits and delirium tremens.6.2. Where there is a previous history of alcohol withdrawal fits, clients must be prescribed sufficient Chlordiazepoxide to ensure that this complication does not occur. Delirium tremens are withdrawal symptoms complicated by disorientation, hallucinations, or delusions. Autonomic over-activity is a potentially fatal aspect of this condition.6.3. If a client does not require a formal alcohol detoxification, but has a recent history of heavy drinking they should still receive the Thiamine 100mg BD and Vitamin B Compound for a period of 28 days as a precautionary measure. 6.4. Clients who have a chronic alcohol problem should be given Pabrinex? IM Appendix 3). There is some doubt as to the suitability of oral thiamine as a prophylactic treatment for Wernicke’s Encephalopathy and Korsakoff Psychosis due to limited oral absorption. It has also been shown to have little or no effect on the CNS vitamin status whereas parenteral thiamine replacement is rapidly effective in the treatment of Wernicke’s Encephalopathy and is an effective prophylactic treatment for high-risk clients. Pabrinex? should therefore be recommended for clients who present as being at high risk of Wernicke’s – Korsakoff (NICE 100 2010) 6.5. Anaphylaxis is a rare complication and is more likely to occur with IV use (Appendix 4). It is extremely rare after IM administration and this should be considered the route of choice. It should only be administered where suitable basic life support facilities and an anaphylactic shock pack are available. Dosage should be 1 Pair of Pabrinex? ampoules IM to be given daily for 3 days or 5 days which will be determined upon presentation.Should patients refuse IM treatment, they should then still be offered the oral treatment. 6.6. All patients who undergo alcohol detoxification should routinely be prescribed 200mg of Thiamine daily for a period of 28 days.7. Acamprosate Calcium7.1. Acamprosate is recommended in a review of the effectiveness of treatment for alcohol problems by the NTA 2006. NICE alcohol use disorder: Diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE Clinical Practice Guideline 115 Feb 2011) recommend the use of Acamprosate as first line treatment after successful withdrawal from alcohol (Recommendation 7.15.1.1)7.2. Contraindications: Established hypersensitivity to Acamprosate.Renal Insufficiency (creatinine >120mmol/l)Severe hepatic failure (Childs-Pugh classification C)7.3. Dosage RegimeOral AdministrationPreparations available Acamprosate calcium 333mg, enteric coated tablets (Campral EC?)Adult >60kg: 666mg (2 tablets) three times daily (TDS)Adult <60kg: 666mg mane, 333mg midday and 333mg eveningAcamprosate taken with food reduces its bioavailability.Titration is not required.Adjunctive psychosocial intervention recommendedTreatment should be continued for 6 to 12 months7.4. If the patient agrees to Acamprosate then treatment should be initiated as soon as day 2 of his detoxification. 8. Stabilisation8.1. The client should remain on the IDTS Wing until the alcohol detoxification is complete. It is important that these clients are monitored for the first seven days of their management, as they may suddenly physically deteriorate or may suffer an epileptic seizure.8.2. An extended stay on the IDTS Wing is advised if the client:has experienced confusion or hallucinations during the detoxification has a history of previously complicated withdrawal has epilepsy or a history of fitsis undernourished (could move to second stage if otherwise stable)has severe vomiting or diarrhoea (this should be controlled within 24 hours or patient transferred to hospital). is at risk of suicide has severe dependence coupled with unwillingness to be observed daily has uncontrollable withdrawal symptoms has an acute physical or psychiatric illness has multiple substance misuse problems8.3. In the treatment of concurrent opiate and alcohol dependence, no reduction in the opiate agonist should be attempted until the alcohol detoxification is complete.8.4. In accordance with DoH Guidelines (1999) detoxification for concurrent ‘significant polydrug’ use or ‘benzodiazepine use’ should be undertaken in the IDTS stabilisation wing. All clients undergoing alcohol detoxification must therefore remain on the IDTS stabilisation wing until their alcohol detoxification is complete. (If a patient refuses location on the stabilisation unit treatment cannot be refused, but he must sign a disclaimer which should detail the risks of not being properly observed and supported).9. Intoxication9.1. Intoxication occurs when a person’s intake of alcohol exceeds their tolerance and produces behavioural and/or physical change.9.2. All staff must be able to correctly manage intoxication even when the intoxication is not life threatening.9.3. Any prisoner who is found to be intoxicated within the establishment, the following must be adhered to:9.4. General principles of managing intoxicationMaintenance of airways and breathing is of paramount importance to the comatose patient.Any person presenting as incoherent, disorientated or drowsy should be treated as per head injury until proven otherwise.Intoxicated patients must be kept under observation on the healthcare wing until their intoxication diminishes.A thorough physical and mental status examination by a nurse or doctor will reveal the level of a patient’s intoxication to provide baseline information.9.5. Assessing IntoxicationTake a comprehensive alcohol historyObserve vital signs – temperature, pulse, respirations and blood pressure.Observe pupils, gait and for any ataxia.Consider conditions other than intoxication (e.g.: head injury, CVA, hypoglycaemia, psychosis, severe liver disease etc.)Record all observations in the medical records.9.6. Signs of Mimicking or Masking IntoxicationInfectionsRespiratory diseaseHead injury, subdural haematomaAcute psychosisDiabetes, hypoglycaemiaEpilepsy (temporal lobe), post-ictalDrug toxicity, e.g. phenytoin, digoxinMeningitisCVA or TIAWithdrawalWernicke’s encephalopathy9.7. If the Assessment Indicates IntoxicationMaintain vital signsContinue to monitor the patients’ physical and mental stateEnsure that everyone on the wing is aware of the patient’s status either on the IDTS Wing or in the Healthcare dept.Airway maintenance is of the utmost importancePlace the client in the recovery position. Note: vomiting is likely to occur in the grossly intoxicated patient – this can present a major problem in semi-conscious or unconscious patients.If the prisoner vomits more than once, this may indicate a head injury or other cause of serious illness. If the intoxicated prisoner vomits more than once and is not completely coherent, then an ambulance should be called as per prison policy.10. Clinical Management10.1. Medication may not be necessary if:the patient reports consumption is less than 15 units/day in men and reports neither recent withdrawal symptoms nor recent drinking to prevent withdrawal symptoms (however please see notes above re prescribing in prison) the patient has no withdrawal signs or symptoms; if a decision is made not to prescribe alcohol withdrawal then monitoring can be undertaken twice daily for three days to ensure that no symptoms emerge. among periodic drinkers, whose last bout was less than one week long, medication is seldom necessary unless drinking was extremely heavy (over 20 units/day). Thiamine 100mg BD and Vitamin B Compound for a period of 28 days is still required10.2. A baseline regime will be agreed by the doctor before commencement of detoxification according to the above criteria and the clinical triage and the Alcohol Withdrawal Scale and Record Checklist (Appendix 7). The advice to clients on withdrawing from alcohol information sheet should be given to the client (Appendix 1). 11. CHLORDIAZEPOXIDE REGIMESUNITS OF ALCOHOL PER WEEKBASELINE REGIME<150 UNITS15mg tds decreasing to zero over 6 days150-200 units per week20mg tds decreasing to zero over 7 days200-250 units per week20mg qds decreasing to zero over 8 days250-300 units per week25mg qds decreasing to zero over 9 days>300 units per week30mg qds decreasing to zero over 10 days11.1. Clients with a high level of dependency can be offered a higher level of Chlordiazepoxide to reduce the risk of withdrawal. Guidelines suggest anything between 10-50mgs of Chlordiazepoxide QDS gradually reducing over 7-10days. (BNF 2010).11.2. Clients who give a recent history of consuming 10-15 units of alcohol daily MUST be given a stat dose of Chlordiazepoxide 20mg as soon as possible after arriving in reception, in line with PSO 3550.11.3. The time of administering the first dose must be recorded onto SystmOne? in order that the late duty staff can then give the second dose after a minimum 3 hour interval.11.4. Although clients will be urine tested for other drugs upon admission to the IDTS wing, their alcohol detoxification medication must NOT be withheld pending the result and must be given as prescribed.11.5. If a client shows any signs of alcohol withdrawal during any 24 hour period it would suggest that the dose of Chlordiazepoxide is insufficient. In this event, revert to the level at which the withdrawal symptoms were controlled and maintain for a further 2 days. The remainder of the regime should also be extended, each dose being maintained for 2 or 3 days depending on the severity of the symptoms. 11.6. All clients should be monitored and assessed at least twice daily for the first 5 days and longer if breakthrough withdrawal has been recorded using the Clinical Indication of Withdrawal from Alcohol (Appendix 7). 11.7. If Clients attend court during alcohol detoxification then arrangements must be made for their noon Chlordiazepoxide medication to accompany them to court. The pm dose will then be given as soon as the prisoner returns from court.11.7. Where there is a previous history of alcohol withdrawal fits, clients must be prescribed sufficient Chlordiazepoxide to ensure that this complication does not occur. Delirium tremens are withdrawal symptoms complicated by disorientation, hallucinations, or delusions. Autonomic over-activity is a potentially fatal aspect of this condition.11.8. All clients with a recent history of excessive alcohol consumption should have routine blood tests to check liver function (LFTs), including GGTs and a full blood count (FBC).12. Non-compliance with Treatment12.1. If at any time a client does not wish to comply with any of the above advice, after explaining the risks to the client, they should be asked to sign a disclaimer to this effect (Appendix 9). 12.2 These clients should still be monitored and reviewed for the following three days, and offered the opportunity to re-commence prescribing if withdrawal symptoms emerge.13 SUMMARY OF CHANGESDatePage Number(s)Summary of ChangesMarch 2015First versionAppendix 1Advice to clients on withdrawing from alcoholIf you have been chemically dependent on alcohol, stopping drinking causes you to get tense, edgy, perhaps shaky or sweaty, and unable to sleep. There can be vomiting or diarrhoea. This “rebound” of the nervous system can be severe, and in some cases severe withdrawal symptoms have been fatal. It is therefore essential that you give an accurate description of how much alcohol you usually drink and where possible the strength. THE MEDICATION - you have been prescribed controls the symptoms while the body adjusts to being without alcohol. This usually takes three to seven days from the time of your last alcoholic drink. This is why the dose starts high and then reduces.IF YOU DON’T TAKE YOUR MEDICATION, your symptoms would be worse in the first 48 hours. You will also be at risk of more serious complications, such as delirium tremens and seizures or fits. Clients who have been using a lot of alcohol lose their body store of B vitamins and this can lead to nerve damage in the body and the brain. In particular this nerve damage can lead to memory loss which can sometimes be very severe.WHEN YOU ARE WITHDRAWING FROM ALCOHOL - you may get thirsty. Drink fruit juices and water but do not overdo it. You do not have to “flush” alcohol out of the body. More than three litres of fluid could be too much. Don’t drink more than three cups of coffee or five cups of tea. These contain caffeine which disturbs sleep and causes nervousness. AIM TO AVOID STRESS - during the daytime help yourself relax by exercising or reading a book in stages or listening to music. You should not do strenuous exercise near to bedtime, however mild stretching exercises may help you to relax just before bed and exercise during the day may be beneficial. We will ensure that you have access to the gym, library and music players (where possible). SLEEP - you may find that even with the medication, or as this is reduced, your sleep is still disturbed. You need not worry about this - lack of sleep does not seriously harm you. Your sleep pattern will return to normal in a month or so. Take a bedtime snack and a hot milky drink both of which will be provided for the first fourteen days ONLY. After this you can buy similar products from the canteen. The medication may make you drowsy. If you get drowsy, please tell the Prison Custody Officer or the Nurse. MEALS - even when you are not hungry, try to eat small amounts regularly. Your appetite will return. Appendix 2ROUTINE NURSING OBSERVATIONSTemperature, Pulse And Blood Pressure to be recorded TWICE DAILY for the first 5 days of detoxificationObservations should be performed as follows as a minimum:DAYS 1 to 5 CLINICAL MONITORING REQUIREMENTSObservations should be performed:? Immediately before the start of the detoxification? Twice daily throughout the detoxification for the first 5 days? Increase observations dependent on severity of the withdrawal symptoms ? AND ADDITIONALLY at 1 hour after the last dose of Chlordiazepoxide administered? Record all the observations on the client’s electronic notes (SystmOne) Each set of observations should include:? Alcohol withdrawal scale (CIWA-Ar)? Observation of level of consciousness and orientation.? Pulse, blood pressure and temperature? Observation for dehydration & marked tremorDAY 6 onwardsOnce or more daily observations as indicated by the results of clinical progressDay 9Once the alcohol detoxification is complete the IDTS Client will have a 9 Day review and members of the Inside Out Team (WDP) will be invited. The purpose of this review is to document progress with the Inside Out Team, establish further identified needs in order to signpost to appropriate agencies, and to ensure clinical stability in order for the individual to be relocated within the Prison establishment. Appendix 3WHAT IS PABRINEX??Pabrinex? is used for the prevention of nerve damage caused by alcohol misuse.It is a medication that contains high potency Vitamin B1 and C amongst others.People who have been using a lot of alcohol lose their body stores of B Vitamins and this can lead to nerve damage in the body and brain. In particular this nerve damage can lead to memory loss which can sometimes be very severe. Giving Pabrinex? should prevent the development of nerve damage.It is especially important to use it during detoxification from alcohol, as the actual process of detoxification itself can sometimes lead to more vitamin loss than has occurred through drinking.Pabrinex? is given as an injection into your muscle – ideally on the first three or five days of your detoxification depending on presentation. The injection may sting when it is given and for a few minutes afterwards. Very occasionally giving Pabrinex? can lead to a serious allergic reaction. For this reason you will be asked to stay under the observation of a nurse or doctor or IP for 15 minutes following your injection. If you do have a reaction the nurse or doctor will immediately be available to treat you. If you have ever had a reaction to Pabrinex? in the past you must tell the nurse or doctor and you will not be given Pabrinex?.CLIENT STATEMENTI have had the above information explained and I have understood. I have had the opportunity to ask the nurse or doctor or IP any further questions and I consent to the use of Pabrinex? during the first three days of my alcohol detoxification.Signed…………………… Name…………… Date…………..CLIENT REFUSALI have been given the above information on Pabrinex? but do not wish to receive the Pabrinex? injections; however I am happy to receive the Thiamine in tablet form.Signed…………………… Name……………. Date…………..Appendix 4 Signs and Symptoms of AnaphylaxisPallor, limpnessUpper airway obstruction – swelling of throat and mouth, difficulty in swallowing, speaking and breathingLower airway obstruction – feeling of tightness in chest, difficulty in breathing, audible wheeze from bronchospasmCardiovascular – alteration in heart rate, drop in blood pressure (hypotension) in association with tachycardia; sever brachycardiaSkin – rapid development of urticarial lesions, intensely itchy welts anywhere on body, generalised flushing of skinGeneral symptoms – abdominal cramps, nausea and vomiting, sudden feeling of weakness, sense of impending doom, collapse and unconsciousness.Appendix 5HMP/YOI ChelmsfordClient Consent to Chlordiazepoxide for Alcohol DetoxificationWhat is Chlordiazepoxide?Chlordiazepoxide (Librium?) is a medicine used to reduce and stop the symptoms of withdrawal from alcohol. When one is physically dependent on alcohol, the brain becomes overactive when alcohol is suddenly stopped. This can cause parts of the body to become overactive, such as the heart and bowels leading to a rapid pulse, raised blood pressure and vomiting. Chlordiazepoxide works by sedating the brain and preventing this over activity occurring.All medicines can sometimes produce side effects and chlordiazepoxide is no exception. Possible side effects include: drowsiness and light headedness the day after use, confusion and unsteadiness on the feet. If you have any of the following conditions you should avoid using chlordiazepoxide:Lung DiseaseLiver and Kidney FailureMyasthenia GravisPorphyriaSleep apnoea syndromeThe detoxification will take between 7 and 10 days.CLIENT STATEMENTI the client have read the above information; I have had the opportunity to ask the doctor/IP/nurse any further questions in order for me to understand the prescribed treatment in full. I consent to the use of Chlordiazepoxide (Librium?) during my detoxification. Signed…………………… PRINT Name………………………….. Date……………………IDTS NURSE /DOCTOR/IP STATEMENTSigned…………………….Name…………………………... Date…………………….Appendix 6HMP ChelmsfordDETOXIFICATION DISCLAIMER I refuse to comply with the chlordiazepoxide treatment against medical advice; the risks of my actions have been fully explained to me. PRINT NAME..................................................................................................SIGNED..........................................................PRISON NUMBER...................WITNESSED.............................................................PRINT NAME……………………………………..DATE...................................... Appendix 7Alcohol Withdrawal Scale Template:Name:Prison No.Address:Date of Birth:Telephone:Mobile Tel:------------------------------------------------------------------------------------------------------------------Done byName: Date:Alcohol Screen: Only needs completing on AssessmentALCOHOL WITHDRAWAL RECORDHow often do you have a drink containing alcohol?NA ? Never (0) ? Monthly or less (1)? 2-4 times per month (2)? 2-3 times per week (3)? 4+ times per week (4)How many drinks containing alcohol do you have on a typical day, when you are drinking? ? N/A ? 1-2 (0) ? 3 or 4 (1)? 5 or 6 (2) ? 7,8,or 9 (3)? 10 or more (4)How often have you had 6 or more drinks on a single occasion in the last year?? N/A ? Never (0) ? Less than monthly (1)? Monthly (2) ? Weekly (3)? Daily or almost daily (4)How often during the past year have you found that you were not able to stop drinking once you had started?? N/A ? Never (0) ? Less than monthly (1)? Monthly (2) ? Weekly (3)? Daily or almost daily (4)How often during the past year have you failed to do what was normally expected from you because of drinking?? N/A ? Never (0) ? Less than monthly (1)? Monthly (2) ? Weekly (3)? Daily or almost daily (4)How often during the last 6 months, have you needed a drink within an hour of waking?? N/A ? Never (0) ? Less than monthly (1)? Monthly (2) ? Weekly (3)? Daily or almost daily (4)How often during the last year have you been unable to remember what happened the night before, because you had been drinking?? N/A ? Never (0) ? Less than monthly (1)? Monthly (2) ? Weekly (3)? Daily or almost daily (4)How often during the last year have you had a feeling of guilt or remorse after drinking?? N/A ? Never (0) ? Less than monthly (1)? Monthly (2) ? Weekly (3)? Daily or almost daily (4)Have you or someone else been injured as a result of your drinking?? N/A ? Never (0) ? Yes but not in the last year (1)? Yes, in the last year (4)Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down>? N/A ? Never (0) ? Yes but not in the last year (1)? Yes, in the last year (4)Alcohol Screen – AUDIT COMPLETEDALCOHOL SCORES0-7Alcohol EducationZONE I8-15Simple AdviceZONE II16-19Simple advice plus brief counselling and continued monitoringZONE III20-40Referral to Specialist for diagnostic Evaluation and TreatmentZone IVALCOHOL WITHDRAWAL RECORDNAUSEA and VOMITING – Ask ‘Do you feel sick your stomach? Have you vomited?’ - ObservationNA ? No Nausea and no Vomiting (0)? Mild nausea with no vomiting (1)? Intermittent nausea with dry heaves (4)? Constant nausea, frequent dry heaves and vomiting (7)TREMOR – Arms extended and fingers spread apart. Observation. ? N/A ? No Tremor (0) ? Not visible, but can be felt fingertip to fingertip (1)? Moderate with patient’s arms extended (4) ? Severe, even with arms, not extended (7)PAROXYSMAL SWEATS - Observation? N/A ? No sweat visible (0) ? Barely perceptible sweating, palms moist (1)? Beads of sweat obvious on forehead(4)? Drenching sweats (7)ANXIETY – Ask ‘Do you feel nervous?’Observation? N/A ? No anxiety, at ease (0) ? Mildly anxious(1)? Moderately anxious, or guarded, so anxiety is inferred (4) ? ? Equivalent reactions to acute panic states as seen in severe delirium or acute schizophrenic (7)AGITATION - Observation? N/A ? Normal Activity (0) ? Somewhat more than normal activity (1)? Moderately fidgety and restless (4)? Paces back and forth during most of the interview, or constantly thrashes out (7)TACTILE DISTURBANCES – Ask ‘Have you any itching, pins and needles sensations, burning sensations, numbness or do you feel bugs crawling on or under your skin?’ Observation? N/A ? None (0) ? Very mild itching, pins and needles, burning or numbness (1)? Mild itching, pins and needles, burning or numbness (2)? Moderate itching, pins and needles, burning or numbness (3)? Moderately severe hallucinations(4)? Severe Hallucinations (5)? Extreme severe hallucinations (6)? Continuous hallucinations(7)AUDITORY DISTURBANCES – Ask ‘Are you more aware of sounds around you? Are they harsh?, Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?’. Observation? N/A ? Not present (0) ? Very mild harshness or ability to frighten (1)? Mild harshness or ability to frighten (2) ? Moderate harshness or ability to frighten (3)? Moderately severe hallucinations (4)? Severe hallucinations (5)? Extremely severe hallucinations (6)? Continuous severe hallucinations (7)VISUAL DISTURBANCES – Ask ‘Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?’ Observation.? N/A ? Not present (0) ? Very mild sensitivity (1)? Mild Sensitivity (2) ? Moderate sensitivity(3)? Moderately severe hallucinations (4)? Severe hallucinations (5) ? Extremely severe hallucinations (6)? Continuous hallucinations (7)HEADACHE, FULLNESS IN HEAD – Ask ‘Does your head feel different? Does it feel as if there is a band around your head?’ Do not rate for dizziness or light-headedness. Otherwise rate severity.? N/A ? Not present (0) ? Very mild (1)? Mild (2) ? Moderate (3) ? Moderately severe (4)? Severe (5) ? Very severe (6) ? Extremely severe (7)ORIENTATION AND CLOUDING OF SENSORIUM – Ask ‘What day is this? Where are you? Who am I?’? N/A ? Oriented and can do serial additions (0)? Cannot do serial additions or is uncertain about date (1)? Disoriented for date by no more than 2 calendar days (2)? Disoriented for date by more than 2 calendar days (3)? Disoriented for place and/or person (4)Alcohol Screen – AUDIT COMPLETEDDD/MM/CCYYSCORESSEVERITYSCOREMild SeverityLess than 10Moderate Severity10-20SevereOver 20Appendix 8 Fact Sheets ................
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