WIXLIB

Queensland Alcohol and Drug Withdrawal Clinical Practice Guidelines1. Introduction1.2Dependence, toleranceand withdrawalWithdrawal occurs in alcohol and drugdependent people who stop or considerablyreduce their drug use. The diagnosis ofdependence is generally required in orderto understand and manage drug withdrawal.1.2.1 ICD-10 definitionsThe International Classification of Diseases,10th Revision (ICD-10) contains the followingdefinitions:Dependence syndrome1.2.2 DSM-IV definitionsThe Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition (DSM-IV) contains thefollowing definitions:Substance dependenceSubstance dependence is a maladaptive patternof substance use, leading to clinically significantimpairment or distress, as manifested by 3 ormore of the following occurring at any time in thesame 12-month period: tolerance, as defined by either of thefollowing:– a need for markedly increased amounts ofthe substance to achieve intoxication or thedesired effectThis syndrome is a cluster of behavioural,cognitive and physiological phenomena thatdevelop after repeated substance use and thattypically include a strong desire to take thedrug, difficulties in controlling its use, persistingin its use despite harmful consequences, ahigher priority given to drug use than to otheractivities and obligations, increased toleranceand, sometimes, a physical withdrawal state. withdrawal, as manifested by either ofthe following:The dependence syndrome may be present fora specific psychoactive substance (e.g. tobacco,alcohol or diazepam), for a class of substances(e.g. opioid drugs), or for a wider range ofpharmacologically different psychoactivesubstances. the substance is often taken in largeramounts or over a longer period than wasintendedWithdrawal stateA withdrawal state is a group of symptomsof variable clustering and severity occurringon absolute or relative withdrawal of apsychoactive substance after persistent useof that substance. The onset and courseof the withdrawal state are time-limitedand are related to the type of psychoactivesubstance and dose being used immediatelybefore cessation or reduction of use.– markedly diminished effect with continueduse of the same amount of the substance– the characteristic withdrawal syndromefor the substance– the same (or a closely related) substanceis taken to relieve or avoid withdrawalsymptoms there is a persistent desire or unsuccessfulefforts to cut down or control substance use a great deal of time is spent in activitiesnecessary to obtain the substance, use thesubstance or recover from its effects important social, occupational or recreationalactivities are given up or reduced because ofsubstance use the substance use is continued despiteknowledge of having a persistent or recurrentphysical or psychological problem that islikely to have been caused or exacerbated bythe substance.Queensland Health5

Queensland Alcohol and Drug Withdrawal Clinical Practice Guidelines2. G eneral principlesof withdrawal management2.General principles of withdrawal managementKey points Withdrawal management provides an opportunity for engagement, planning and coordination ofpost-withdrawal care. Patients may present for elective withdrawal, present when already in withdrawal (crisispresentation), or commence withdrawal incidentally when in treatment for another condition. A comprehensive assessment is the first step in managing the withdrawal process. It will definethe risks that will confront the patient by identifying alcohol, drug use and health issues for thepatient and it will also identify specific needs that may interfere with successfully completingwithdrawal. For each drug (prescribed or not) an accurate consumption history should record: the quantity,frequency, duration and pattern of use; time and amount of last use; route of administration;recent pattern leading up to this presentation; and average daily consumption. For prescribedmedications, also record the prescribed dose and prescribing doctor. Try to match the patient with the withdrawal treatment approach that maximises patient safetyand provides the most effective and most resource-efficient options for their management. If possible, formalise a treatment agreement with the patient. The agreement may be verbal orwritten. It should not be used against the patient in a punitive manner. Frequent observations of the patient are the mainstay of management. Assessment of clinicalfeatures, explanation, reassurance and repeated encouragement are provided at these times. Medication is used in withdrawal to provide symptomatic relief, to treat complications andcoexisting conditions, and to reduce the intensity of withdrawal. The aim of supportive care is to minimise environmental stimuli that may exacerbate withdrawalsymptoms and to enhance the patient’s ability to complete withdrawal successfully. Develop strategies to help the patient cope with the period after withdrawal, particularly if thepatient required withdrawal management in hospital. Strategies for discharge should encourageharm reduction and referral to appropriate agencies. The withdrawal state from some drugs may be complicated by seizures that may belife-threatening.6Queensland Health

Queensland Alcohol and Drug Withdrawal Clinical Practice Guidelines2. General principlesof withdrawal management2.1Rationale and underlyingprinciples for withdrawalmanagementWhen a person is dependent on a drug,withdrawal of the drug carries risks of physicalharm, psychological trauma and (rarely) death.The aim of withdrawal management is tominimise the risks associated with withdrawal.The rationale of withdrawal management isto provide the appropriate level of supportso that withdrawal can be completed safely,which then allows the individual to determinehis or her optimal ongoing managementstrategy. An understanding of the pharmacologyand physiology of withdrawal allows theuse of appropriate medications to modifythe withdrawal process, making it safer andmore tolerable.Underlying principles: While withdrawal management may be anopportunity to initiate lasting abstinence, theprimary goal is patient safety, not long-termabstinence. Withdrawal management services shouldnot be withheld from people because ofdoubts about their commitment to long-termabstinence. Supportive care and patient choice are crucialto success. Supportive care should includeattention to the patient’s environment,the transfer of information, reassurance,attention to anxiety, and assistance with thedevelopment of coping skills. The syndrome of withdrawal should bemonitored clinically and appropriate careshould be provided. This can range fromcounselling and support to the use of specificmedications to ameliorate symptoms ofwithdrawal. Planning and coordinating post-withdrawalcare is an integral part of treatment.2.2Presentation forwithdrawal managementPatients present for withdrawal managementwith a mixture of attitudes and emotions. Somepresent in crisis. They may be suspicious ofpeople in positions of authority as a result ofprevious experiences in a variety of settings,including the healthcare system. The initialassessment is an important opportunityto begin building an effective therapeuticrelationship with the patient. Be non-judgmental, empathetic andrespectful. Listen and clearly elucidate the patient’s needs. Encourage the patient to actively participatein treatment decisions from the outset. Communicate clearly, and allow time for thepatient to understand what assistance isbeing offered and the reasons for it.It is common for drug-dependent people to present in astate of intoxication (which can complicate assessmentand management of withdrawal) or overdose, which canbe life-threatening. Both intoxication and overdose mayrequire acute medical care.See Appendix B for guidelines on assessmentand management of intoxication and overdose.2.2.1 Elective presentationsThe objective in managing patients seekingelective withdrawal management is to balancethe need for safety with patient choice anddesirable outcomes.In order of priority, this requires: identifying withdrawal risks assessing psychosocial factors matching safety requirements andpsychosocial factors to the treatment setting.Queensland Health7

Queensland Alcohol and Drug Withdrawal Clinical Practice Guidelines2. General principlesof withdrawal management2.2.2 Crisis presentations2.2.4 Information about withdrawal service(presenting in withdrawal)Alcohol Drug Information Service (ADIS)Crisis presentations generally involve peoplewho are already in withdrawal. The patient maypresent to a variety of settings (e.g. emergencydepartment, drug and alcohol unit, psychiatricservice, correctional service, emergencyaccommodation centre, general practitioner or ahospital ward).ADIS is a 24-hour, 7-day phone service forpeople seeking information or assistance withdrug or alcohol issues. The telephone linealso provides assessment, referral and briefcounselling.The critical issues are: prompt identification of the withdrawalAlcohol Drug Information Service (ADIS)Phone: 1800 177 83324-hour, 7-day phone service minimising the risk of complications managing withdrawal symptoms stabilising medical and psychiatricconditions.2.2.3 Unplanned withdrawalSome people in the care of a clinician forreasons other than withdrawal managementmay begin to undergo withdrawal. These peoplemay be receiving acute care in a hospital orbeing assisted with psychiatric, medical orsurgical problems in other settings.Assessment for unplanned withdrawal is similarto that for crisis presentations.Early detection of withdrawal and preventingthe risks associated with withdrawal are the keyconsiderations.The key to effective management iscoordinating withdrawal and other clinical care.Withdrawal may increase the expected hospitallength of stay of the patient or require theirtransfer to a more suitable setting.2.3Assessment forwithdrawal management2.3.1 Primary aims of assessmentAssessment is the first step in managing drugand alcohol withdrawal. The primary aims are to: predict the risks that will confront the patientbecause of withdrawal identify the specific needs of the patientto enhance the likelihood of completingwithdrawal (i.e. to match treatment to patientneeds) begin building a therapeutic relationship withthe patient.Clinicians should: take care to ensure that personal values andstereotypes do not interfere with effectiveassessment of the patient explain the purpose of each element of theassessment process to the patient seek the active involvement of the patient inplanning treatment.2.3.2 Key elements in assessmentComponents of a comprehensive assessment are: full drug consumption history identifying risks associated with polydrug use8Queensland Health

Queensland Alcohol and Drug Withdrawal Clinical Practice Guidelines2. General principlesof withdrawal management identifying history of withdrawal and anyassociated complications Ascertain how much was consumedat that time. medical and psychiatric history Enquire back through that day: ‘What aboutduring the day?’ physical examination mental state examination appropriate laboratory investigations psychosocial assessment to identifyexpectations, supports, barriers andpreferences that may influence withdrawalmanagement formulating a management plan.Psychosocial assessment can be deferred if thepatient is unwell, but it will help to plan futurecare and determine treatment options.Note: In some circumstances, the advice orassistance of a drug and alcohol specialist –or other specialist – may be required.2.3.3 Full consumption historyObtain a description of the patient’sconsumption over a typical week or month,as there is a degree of correlation betweenthe quantity consumed and the severity ofwithdrawal. Link consumption to activities: ‘What wereyou doing during the day?’ Then, for example:‘How much did you drink or use when youwent to your friend’s house?’ Examine consumption through each day forthe past week. Then ask if that was a typical week’s pattern.If not, ask specifically how it differed (i.e. howmuch more or less of each drug than usual). Recording a complete consumption history isnot always practical because of the context ofthe presentation, including the physical andmental state of the person in withdrawal. A common drug combination that should benoted is alcohol and benzodiazepines. Thesedrugs produce cross-tolerance and regularuse of both can make withdrawal moresevere and protracted.Recording consumption historyAn accurate consumption history should recordfor each drug (whether prescribed or not):First, obtain a general history of alcohol anddrug use, then attempt to identify daily patternsof alcohol and drug consumption from aretrospective consumption history. quantity, frequency, duration of use andpattern of useMost people, with or without alcohol anddrug problems, are likely to underestimate orestimate inaccurately how much they use ifasked the question: ‘On average, how much doyou use a day or a week?’ recent pattern leading up to this presentationTaking a retrospective consumption history time and amount of last use route of administration average daily consumption periods and longest period of abstinence.For prescribed medications, also record thepre

of clinicians to manage drug and alcohol dependent people who are experiencing withdrawal: 1. Specialist withdrawal services that treat individuals on an outpatient and inpatient basis for alcohol and drug withdrawal 2. Hospitals, nursing homes, and other acute facilities that admit patient