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Detoxing drinkers in a methadone prescribing service

Jeff Fernandez
RGN MSc MPhil
Alcohol Lead Nurse for Primary Care Islington Primary Care Trust

This article examines how patients with drug and alcohol problems can reduce their drinking, with a guide to medication in line with the author's experiences at a treatment centre in North London

Drug treatment centres recognise alcohol as being an important risk factor in patients' health. It is something to take into consideration when someone has hepatitis C as it can lead to hepatic cancer, particularly with opiates or methadone.
Treatment for hepatitis C is also not given unless alcohol is consumed in a controlled fashion or the patient is ‘dry'.
Drinking in a dependent pattern will not always result in starting substitute methadone treatment.1 In the National Treatment Outcomes Research Study (NTORS), published in 2001, it was found that 24% of patients receiving treatment were alcohol dependent. Other studies have shown that one third of patients are drinking at high levels and often dependently.2 So what do treatment services do with this population?

The National Treatment Agency for Drug Misuse ‘orange guidelines' (2007) state that patients who are on methadone are often very difficult to manage and retain in treatment; but interventions should be offered for patients who show alcohol-dependent patterns.3 This can often be through the use of psychological interventions or prescribing interventions, such as benzodiazepine detoxification programmes and the prescribing of acamprosate and disulfiram post detoxification. Using a breathlyser can help reduce alcohol consumption.
There is little evidence that it does, but it can make the dispensing of methadone safer.

Offering a benzodiazepine detoxification regime is useful for patients and is often what patients request themselves. However, some patients who are more stable on their prescribed methadone and have a longer history of being stable are more successful in being alcohol free.

There are two types of detoxification: community detoxification and inpatient detoxification. The inpatient detoxification regime entails a five-to-10-day admission into a specialist centre for patients who present with a profile that is clinically risky; for example, poly-drug use with mental health problems. The community detoxification is for patients who have a minimal risk profile, but often this excludes patients with alcohol and substance misuse. However, there is a place for community detoxification in the field of substance misuse.

First, it is important to explain the process and clinical guideline for an alcohol detoxification regime. This is illustrated in more detail in the appendix. The clinical guideline was developed by the nurse consultant in NHS Islington who is also an independent prescriber. It was developed from the Clinical Knowledge Summaries (see Resources) where the nurse consultant also acts as a peer reviewer for the field of drugs and alcohol.

The assessment is conducted by the MAP comprehensive assessment, which asks questions on alcohol and poly-drug use and route of administration. This also asks for blood-borne virus status as hepatitis C and alcohol are an important risk to recognise. Therefore, the assessment would identify dependent drinking and also drug use. Important questions to ask in the assessment process include the folllowing.

History of fits or epilepsy
Alcohol withdrawal fits are often common in this client group but there needs to be a rationale for considering a community detoxification for a patient who suffers from regular fits, whether or not they are due to alcohol withdrawal. There is a risk that even on benzodiazepine if the dose is not adequate an alcohol fit could occur.

History of previous treatment for alcohol
The answer to this question informs the clinician about the patient's progress through detoxification regimes they may have had in the past. Usually, the more detoxification a patient has had the more likely they are to complete the detox successfully with the potential of ‘dry' time afterwards.

History of any mental health issues that could compromise the detox regime
It is important to assess mental stability, as anything that could lead to a period of instability would make adherence to the detoxification regime very difficult, with a risk of overdose if the supervision is not daily. If anyone with an active mental health problem is referred for an inpatient detoxification as the community detoxification would not provide enough supervision for this intervention.

Recent liver function tests
If a patient has liver damage and their gamma glutamyl transpeptidase (GGTs) are above 1,000, an inpatient detoxification regime should be sought as the dose and reaction to a benzodiazepine detoxification needs constant monitoring.
This looks at the suitability of a patient for a community detoxification regime. If there are needs that arise that would warrant specialist care, an inpatient detoxification centre would need to be considered.

Criteria for a community detox
Criteria for inclusion
Assessment carried out.
Stable living environment, with social support.
Patient agrees to attend after care session with the specialist nurse and day care from outside agencies, such as CASA, as part of recovery.
Absence of severe physical health problems.
Absence of severe mental health problems.

Criteria for exclusion
Severe physical health problems.
Severe mental health problems.
Unstable living environment, eg, homeless.
No additional support (unless daily ARP attendance).
A high number of previous failed community detoxes with no change in environmental factors.
Evidence of poly-drug use and chaotic lifestyle.
Evidence of DTs and/or withdrawal fits in the past.

Medication
The drug of choice is chlordiazepoxide in 5 mg caps for greater flexibility. The prescribing regime is flexible but recommended range of dose and duration is as follows:
Men - 10-30 mg QDS in a reducing dose over
five days
Women - 10-20 mg QDS in a reducing dose over five days.
Towards the end of the detox it is possible to reduce the daily frequency of medication, for example, to tds/bd/nocte.
In some instances it may be necessary to continue the medication for another two to three days, especially for night restlessness. The prescription for medication will normally be given on a daily basis.  
Vitamin B1 100 mg bd and vitamin B compound can be further prescribed if necessary by the independent prescriber.
Night sedation may be appropriate for two weeks only and can be negotiated.

ISIS drugs project
Methodology
This was an evaluation of a new approach to make alcohol detoxification regimes more available to patients who presented to a substance misuse centre. The main rationale was to offer detoxification to new patients who presented to the ISIS Islington drugs service an alcohol on the MAP assessment, but also to take referrals for an alcohol detoxification from other agencies dealing with substance misuse.

The ISIS drugs project was an open access drug service that assessed and processed drug users for treatment and if the patient had complex needs would sign post to the appropriate service.

The theoretical background of the approach was inductive as there is little to no research in the field of detoxing patients who are in methadone treatment with a prescribing service. It was also from a case notes review of all the alcohol detoxes conducted in the six-month period of March to August in 2009. Informal qualitative interviews where also conducted on all the patients in this study. The data collected from the interviews where analysed through coding common themes and phrases that emerged from the interviews. But presented here is a typical case study were a period of ‘dry' time was achieved.
In the six-month period there were 15 alcohol detoxifications offered to patients attending the ISIS drug project in Islington. Within this number, 10 were referred from the primary care drugs service for an alcohol detox and this cohort of clients is analysed in the results with a more thorough typical case study illustrating what characteristics make a successful outcome for a patient to achieve some ‘dry' time.

Case study
The man described here is a typical case as discussed in the previous section. His name has been changed to protect his identity. Chris, 44, has lived in Islington since he was a child. He has been in treatment for drug dependency since the year 2000 when he admitted to himself with a heroin problem. He was at a specialist service for drugs initially and was transferred to shared care when he was seen as more stable on his dose of methadone (opiate substitute) and is seen in primary care by a specialist drugs nurse and the GP.
He has been drinking dependently for the last seven years and feels his alcohol grew into a dependent pattern gradually. He has been drinking dependently which is every day for the last two years and wants to stop.

One assessment he had been drinking around 10-15 units a day and was on 70 mg of methadone and had no use on top of this (he was not using any other drug on top of his prescription). He described himself as a stable patient apart from his alcohol. He had previously conducted an inpatient detox from alcohol and had stayed ‘dry' for two weeks. He had some insight into how a detoxification regime off alcohol would work. He also knew how easy it was to relapse, and seemed to be aware of the problems and triggers he would need to deal with when attempting to stay ‘dry'. He was offered disulfiram post detoxification and this is something he had never been offered before, and that he felt would be useful.

Outcome
Chris was given a standard chlordiazepoxide detoxification regime in line with the Islington guidelines. He completed this regime successfully and then started on disulfiram 200 mg a day. He was given a fortnight's supply and was reviewed by the specialist nurse after two weeks. He was ‘dry' when assessed at the two-week period and was prescribed another two weeks. He was seen at the four-week period and was still ‘dry'. He stopped taking the disulfiram tablets on the fourth week and managed to stay dry for another two weeks. He is now awaiting another alcohol detoxification with the view to extend the length of time he is on disulfiram for at least three months.

Conclusion
There have been 15 alcohol detoxification regimes conducted by the specialist nurse in people who are prescribed methadone and have alcohol dependency in Islington. The referrals can come from anywhere, but most are from primary care and patients prescribed by the specialist service.

The case study above illustrates the outcomes for all primary care referrals as this cohort of patients were able to stay ‘dry' with disulfiram for longer. Referrals from patients at the specialist service did not stay dry post detoxification, despite the prescribing of disulfiram. The longest ‘dry' time for patients from other referral sources was two weeks. This could be argued as a useful respite for patients, but note has to be taken not to prescribe too many detoxifications in primary care as this can cause the ‘kindling effect' - where repeated episodes of detoxification can make the problem worse.3

The primary care patients differed on presentation to the other referral sources due to:
Length of treatment history. Primary care patients had a longer history of treatment than other patients at ISIS referred for an alcohol detoxification.
Engagement. The primary care patients were better engaged in services and more exposure to health care than  other ISIS referrals.
Stabilty. The primary care patients were more stable overall in their drug use and had miminal use on top of their methadone doses as opposed to the ISIS patients.

All the above factors are now noted in local services as being useful criteria to look at suitability for alcohol detoxification regimes in drug services and primary care.

Primary care services and those services attached to the ethos can prescribe community detoxification regimes to methadone-dependent patients with good outcomes and at least a break from their alcohol-dependent pattern.

References

  1. National Treatment Agency for Drug Misuse. Reducing Drug-related Deaths: Guidance for Drug Treatment Providers. London: NTA; 2004.
  2. Gossop M, Marsden J, Stewart D. NTORS after five years (National Treatment Outcome Research Study): Changes in substance use, health and criminal behaviour in the five years after intake. London: DH; 2001.
  3. Department of Health. Drug Misuse and Dependence: UK guidelines on Clinical Management (Orange Guidelines). London: DH; 2007.

Resources
NHS Clinical Knowledge Summaries
W: www.cks.nhs.uk

National Treatment Agency for Substance Misuse
W: www.nta.nhs.uk

Islington PCT
W: www.islingtonpct.nhs.uk