Sammi: Good evening everybody and welcome to this evening’s A Practical Guide to Alcohol Home Detox for GPs webinar. My name is Samantha and I am your host for this evening. Before we jump in, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present.
Alright, so in saying that I would like to introduce our presenters for this evening.
We are joined by Dr Chris Davis and Dr Tim Senior. Chris is a full time GP and a director of East Sydney Doctors in Darlinghurst. He was a clinical lead in substance misuse and alcohol and a partner in a large inner-city London practice for many years before immigrating to Sydney in 2014. Whilst working at Kildare Road Medical Centre in Blacktown, Chris designed the Clean Slate Clinic, a GP-led alcohol management and home detox service, the only one of its kind in Australia. So, welcome Chris.
And we are joined by our facilitator this evening, Tim. Tim is a GP at Thurawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, and a Senior Lecturer in General Practice and Indigenous Health at UWS. So welcome, Chris and Tim and thank you for joining us this evening.
Alrighty, so I will hand over to our facilitator, Tim now to take us through the learning outcomes for this evening and then we will hand over to Chris to kick off the presentation.
Tim: Thank you very much, Sammi and good evening everyone. It turns out we have just discovered Chris and I are from very close together in the North West of England, so you are in the hands of North Western England people tonight. I hope that is not a disadvantage. These are the learning outcomes which is the education-speak for what we hope to get out of the webinar tonight. So by the end of this online activity, you should be able to assess patients who are using alcohol to determine their level of dependency and their suitability for GP-led home withdrawal management or detox. You should be able to explain the components of structured home detox, including urine drug screens, appropriate medication provision, breathalyser tests and withdrawal scales and you should be able to conduct a post-detox review, develop an effective recovery plan including anti-craving medication and list ongoing support resources. So to take us through all of that, I will let Chris start off with the first slide.
Chris: That is great, thanks very much, Tim. And thank you to the College for allowing me to really share what has become my passion and by far and away the most rewarding thing that I have ever done in medicine which is to help people who have got into trouble with their drinking through a detox and through into their recovery. It is the most satisfying thing I have ever done and I really encourage people to give it a go and hopefully after this you will feel a bit more comfortable in doing so.
I would start by introducing really the scale of the problem and I think it is down-played, certainly we know that 15 Australians die every single day from alcohol misuse and it is the most dangerous addictive drug across the entire planet. We are all aware of the ice epidemic and the media certainly has been talking about the ice epidemic. I have a lot of patients who using this drug. But to put it into context in 2014 I sat on an ice taskforce and we discussed ED presentations and intoxications in ED and during that year there were nearly 3,000 presentations due to ice. But the same number, the same number of ED presentations or the equivalent number of alcohol presentations I should say, was 13,000. And that number has been stable for many years. Almost five million Australians, that is nearly half the country aged 14 and over have been a victim of an alcohol related incident in 2013 and nearly two million of these were physical abuse. And Australians themselves are not fully aware of the dangers of alcohol in that in the 2019 FARE study that has just been released only 41% of Australians were aware that alcohol was related to an increased stroke risk. 29% were aware that it increased their risk of mouth and throat cancers. And only 16% of Australians were aware that high alcohol intake was associated with an increased risk of breast cancer. In fact just four standard drinks per day can double your risk of breast cancer. And the answers to these questions have been consistently low since the question was first asked in 2011. So we still have some way to go in educating our patients.
So, I guess a quick introduction to my story was that I became interested in substance abuse and alcohol when I was doing a health promotion radio program for Prison FM radio station in Brixton Prison for the inmates. And I also got an interest in HIV and sexual health and I thought that is what I was coming on to talk about, but all they wanted to know about were drugs and alcohol and mainly how to get drugs into the prison. So, I went on and did a diploma in substance misuse and became a methadone prescriber, but quickly realised in my general practice what I was seeing was not really substance misuse, but the effects of alcohol. People with insomnia, with depression, anxiety, high blood pressure even, who would really benefit from reducing their alcohol intake and at the time there were some, they were known as Fresh Start Clinics in my borough which were mainly nurse-led, but a GP and nurse-led alcohol detox service for the mild to moderate alcohol drinkers. So when I immigrated to Australia four or five years ago, I realised that the same problems existed here that for our heavy drinkers, the complex poly-drug use, dual diagnosis drinkers, there were really good pathways into specialist services for inpatient detox. But for the single mum of three who had a job who was maybe drinking a bottle of wine a night and has tried to stop on her own but cannot, there were no real services for her. And I guess it is that sort of patient which I designed the Clean Slate Clinic around.
So what is it? It is a GP-led primary care alcohol management clinic. I guess the main thing that it offers is the home detox service. But it is much more than that and hopefully as we go through, the learning outcomes fit nicely into the three stages that I see alcohol detox lying in, the preparing the patient for this long-term behavioural change, the safe withdrawal of alcohol and then a structured recovery plan. And I will take you through those as we go along. I audited the results of the Clean Slate Clinic the first year I did it in Blacktown and as you can see, it is a really successful model and that is well-evidenced in the literature. We know that community detox is safe, it is successful, the patients really like it and it is between 10 and 20 times cheaper. The other beautiful thing about a GP doing this is that any chronic diseases and indeed alcohol dependence should be viewed as a chronic disease which is what we are the specialists in dealing with. Any mental health issues, any chronic diseases can all be managed in the same place and by the same doctor and the relationships you build with your patients really are quite special when you go on the journey with them. So, yes, the results are very favourable to inpatient detox, although they are comparing different types of patients. And even those who did not reduce their alcohol dependence, because of the relationship you build with them, they stayed engaged with the clinic in the main.
So that brings us to the first learning outcome which we said is assessment which is true, but when I am talking to patients and talk about the assessment process it is really getting them prepared. And patients come to you in crisis, very keen to start, they do not want to drink ever again and you need to sort of put the brakes on them a little bit. But I will come on to that a bit as we go.
I have to talk about motivational interviewing. The first time you meet someone, it is essential that you make a good impression, but there is no judgment there, that they do not feel judged with their drinking. Because indeed they face stigma even asking for help. Society is not good at helping you know, people who want to put down their drinking. So they are already feeling stigmatised by making the appointment and making the appointment is a massive step. So you need to be very welcoming and show no judgment when they arrive. There is a fantastic document called Language Matters by NADA which really talks about the language we should and should not be using. I never use the word, when I say never, I try to never use the word “alcoholic” or even “alcoholism”. So I tend to stick to someone who is drinking alcohol or who is not. They are alcohol-free. Trying to stop using the word “sober” which is particularly difficult, but certainly things like “clean”, you know “being on the wagon” or “off the wagon”. Again these are terms associated with failing or succeeding rather than someone who is drinking or not drinking as part of their journey. Really listen to the patient and what do they want, you might think that they can never drink again given their story, but that might not be even on their radar so you have got to listen to what their goals are and aim towards them. I concentrate on the huge positives. I did a talk for the community in Blacktown and said you know, if there was a pill that could help you lose weight, put more money in your pocket, increase your libido, improve your sleep, put your hand up who would take that pill? And really, the benefits of giving up alcohol are untold, especially for those heavy drinkers. And as the GP you have the privilege of seeing the benefits that they gain. They bounce in after a detox looking brighter. Some people will give you a hug. If people are a little bit ambivalent, I might ask them the mark out of 10 question, you know, give me a mark out of 10 how ready you are to make this change and if it is an eight, why only an eight? How can we get you to a 10? The magic wand question is also you know a good tool to use.
So they have arrived, we have used all our motivational interviewing skills to enthuse them and feel comfortable in the room and really, I think that is the main thing to get out of your first appointment to be honest. I always make it a long consult if possible, 30 minutes and really that rapport is essential. I really want them to come back and see me again. I do take a history and a risk assessment. I make sure that I feel that they are safe leaving the room and I will touch on substance misuse history and alcohol history. I will talk about mental health, physical health, if they have got children in the home that might be in any immediate danger. But I do not dwell on this too much. I have got it down pat a little bit now, but if I am running late I do not worry if I have forgotten to ask if they have had a seizure, because I will give them as assessment pack and again I will come on to that in a second. I also give them a planning sheet, so a written down plan of what is going to happen when they leave my room, what they need to do when they leave my room. Because again, I do not want to overload them with information and often they are just feeling grateful that they have made it and survived it and then I make sure that before they leave my room, I book them a long appointment with my nurse for the next week, a half hour appointment and another 30 minute appointment with me in the coming week.
So, this is what I have written here, I have put this onto an A4 piece of paper and I always get a blood test unless they have brought some blood results in with them. I get them to start some thiamine. Generally if they are a heavy drinker and I am thinking they are going to need a detox, I give them high dose oral thiamine 200 mg three times a day. It is water soluble. You cannot really sort of wee out any excess. You cannot really give them too much. They are not likely to take it three times a day. If they do, then that is great. I only use B vitamin injections generally if I feel like I have to rush through a detox, or I do not feel they have got enough thiamine on board. In the NHS it was compulsory, but here they are about $100 for the three injections, so I do not feel I can force that on people. So long as they have had thiamine high dose for two weeks before the detox, then I am happy that is enough.
I get them to keep a drink diary. I give them a paper drink diary and I will show you what that looks like and that is my preferred drink diary. And these are well-evidenced, brilliant tools for raising someone’s consciousness and awareness, not only about how much they are drinking but to get them to start thinking about the reasons why they are drinking. There are phone Apps. There is Drink Coach for iPhone which is really good and there is AlcoDroid for android if people prefer to use phone Apps. I will give them my assessment pack and I will talk about that in a second. And that assessment pack really covers all of the questions that I may or may not have asked or had a chance to ask in that first appointment. I give them a resource list. I have really got a large resource list since I have been doing this for so long. I really recommend a TED lecture that is in my resource list which is at the end of this talk by Judson Brewer about breaking bad habits. It is really good for them to watch that early on in the process. The Daybreak App is excellent. This Naked Mind is a book I recommend by Annie Grace, and that is a really good website. I have a book list and a podcast list and I will give them that list when I feel it is appropriate for them. You know, depending on what modality is going to work for them.
Now what is really difficult is advising them to keep on drinking or reduce by a small amount by 10% only until I see them again in a week’s time and this is often met with horror by my patients who have never been told to keep on drinking by a doctor before. But there is good reason for that. I mean, again this is flexible advice and if I have a binge drinker or if I have someone who has not had a drink for a week, then I will not tell them to restart their drinking. But if they have come to you and they have been drinking heavily daily, then it is important that they keep on drinking and do not go cold turkey because of that risk of seizure. So to cover myself, unless I am very happy they, you know, they are not going to go into withdrawals, I will tell them to keep drinking until they can see me next week. And that is actually a really powerful thing to do, to drink when you do not want to drink whilst being mindful, is a powerful thing, and you really want them to be very ready for the next part which is the detox. And this sort of period of consciousness raising is really important for their state of mind.
That is what my drink diary looks like. It is quite simple.
Tim: We have just got a couple of questions as well come through. Just asking about the role of the nurse in the review appointment, what sort of thing they are doing?
Chris: Yes, absolutely. So, I will take you through what my assessment pack is and then, so at the end of the first appointment, I give them this assessment pack. I will talk you through this and then I will explain what the nurse does at the second appointment. The assessment pack is like a sort of 13-14 page document that I have really streamlined from the initial document that I stole from the NHS which took an hour and a half to go through. It had a full risk assessment in it, and I have really streamlined it so that the patient can take it away and fill it out at home and bring it back in. So, it covers the important things like child protection and medical history, all those things that I have listed there. There is an ICD-10 tick box. Now, that is six tick boxes and, because if the patient is alcohol-dependent, if you assess them as alcohol-dependent, they then become eligible for a 721, 723, 2715. So a mental health care plan and a physical chronic disease management plan. But as I said at the beginning, this is a chronic disease and I have cleared this with Medicare. So again to cover myself when it comes to doing a management plan, I have included an audit questionnaire, an SADQ questionnaire which is a severity of alcohol dependence questionnaire. That again helps me work out what their level of withdrawals might look like. I will talk a bit more about that as we go. And in the ICD-10 tick box, they tick a box, the six components to that are whether they feel like they have impaired control of their drinking. The second one is craving or a compulsion to drink. The third one is drinking taking over their lives. The fourth one is a tolerance to alcohol. So they are needing more alcohol for the same effect. The fifth one is withdrawal symptoms when they stop. And the sixth one is persistent use despite knowing it is harming you. Because patients will often ask me, am I an alcoholic, doctor? I immediately tell them that I do not use that word. But that obviously alcohol is causing them some problems. But, yes I guess the assessment pack will answer the question as to whether they are dependent or not if I had not worked that out already from the first meeting. There is also a K10 and a suicide risk assessment.
So when the patient comes to the second appointment, they will see my nurse first. The nurse will go through the assessment pack with them, make sure they have completed every question, because this information is really important for my safety, for my risk assessment. And so then I know as I go through the detox process, if I have got any questions, if I have forgotten whether they have had a seizure or whether they are using drugs, it is all in one place. My nurse will also do some obs, blood pressure, height and weight. Things that I will not have time to do in the first instance. So I know when I get to see them in the second appointment, all of this information is ready and it really makes, it is much more streamlined. Because I have got all this information in place, when I see them again I can use this information if it is appropriate to formulate a 721 and a mental health care plan. It might not all happen in that appointment, but I have got the K10, I have got all the information I need to formulate those plans in conjunction with the patient and with their consent. And this second appointment is where we do all of the planning, all of the planning of the next step which is either the detox or if they do not need a detox, say they have already stopped drinking, or they just want to cut down, or they are not dependent upon alcohol, then at this point I would just do a brief or an extended intervention.
Queensland University have just released these insight guides which I highly recommend, fantastic brief intervention tools, not just for alcohol, but also for marijuana, for ice, crystal meth and for opioids. And there is one for benzodiazepines as well. Great tools. And there is really good evidence to show that if you hand someone a brief intervention tool, it really does make a difference. They did a SIPS trial in England before I left which proves that just giving someone a leaflet in the Emergency Department about alcohol, a brief intervention leaflet, that people then did change their behaviours. And again, when I am doing the brief intervention, remember the motivational interviewing, we talk about their goals. I have a pacing skills hand out to talk about how they can just cut down safely. Drinking water between each drink, drinking lower alcohol drinks, avoiding rounds, having exit plans, having a wing person with them, always trying to get two dry days in a week. Find out what their goals are and really make them make their own rules, make their own goals. Try not to force goals on somebody else. So if their goal is to do Dry July, or if it is just to have two dry days in the week, then really support them with that. And book in a review. So, they then become accountable to yourself and to them. And that gives them a better chance of sticking to what their individualised goals are.
Tim: And just before we move on to detoxification, I have just got a couple of probably simple questions. Just to specify, what are the blood tests that are involved that you mentioned earlier?
Chris: So, really, if I know nothing about the patient I do a full raft. I do liver, kidneys, full blood count. I do iron studies. I do lipid screen to see if they have high triglycerides. I do calcium, magnesium, phosphate, because you can have low magnesium. I think that is it. I have a little clean slate, you know, template for that, so it just uploads my blood test form. And they do that at the first appointment hopefully so that comes back to me for the second.
Tim: And there is someone else asking specifically about if you have had much success with the Hello Sunday Morning App?
Chris: Yes I know the Hello Sunday Morning team quite well now. The Daybreak App. Yes, I have. I always recommend it. It is free now for clients in Australia and you would be surprised who gets it, who enjoys it. I have had people in their 70’s who have formed friendships from the Daybreak App, and certainly it is very good for young people. It is great because it is a support group in your pocket. So if you are having a craving at three in the morning, or you know, if you are struggling, you can go on the App and it is really supportive. So look, it is free. It is not for everyone but I think it is a fantastic tool to use and it is definitely something that I recommend to all my clients. Apart from those that do not have mobile phones and there are some.
Tim: Excellent. Let us move on to detoxification.
Chris: So if the brief intervention was not enough, these are people who really want to stop drinking or we have decided that they are dependent through their assessment pack, no matter what their individual goal is, so a lot of people will say I want to go back to controlled drinking. I want to be able to have a glass of wine with my husband or my wife on a Friday. I want to be able to have a drink at a wedding. If that is their goal, or if they say I never want to drink again, or if they say, whatever their goal is, three months, six months, a year, I always recommend a break. So a break from alcohol is the best way to get to whatever your goal is. Ideally, you know, it depends, again I try and sus out the patient but if we can get to three months that is when real behaviour change can start to make. If we just do a month, people tend to white knuckle ride that first month and then reward themselves with a drink on the 32nd day. And we need to detox them safely. So if they are dependent upon alcohol, if they are drinking heavily daily and they score, or if they score highly on the SADQ score, then we need to do a detox.
This is how we do it. I mean, I cannot emphasise enough how important it is that you feel comfortable and safe before you start to go on and go and detox somebody. It is a dangerous thing to do potentially. I must have detoxed over 200 patients and no one has ever had a seizure through any of my detoxes, but obviously that is the worry. We can reduce this by doing the assessment and the blood test and making sure they have their Valium on board, but it is always a risk. And to minimise that risk, and certainly if you are starting out or have not done detoxes before, I would have very, very strict boundaries on who you would detox and what that looks like. As you get more confident, you can be a bit more flexible and I have broken my own rules at times. But you know, only I have certainly not done anything I have felt uncomfortable doing and I have put extra safety nets in place if I have had to break these rules. So I would certainly start with the mild to moderate dependence, so your bottle of wine maybe two bottles of wine a night, but no more than that. So less than 20 standard drinks I would stick to. If they are drinking more than that, then maybe you want to try and help them reduce for a period until they are less than 20 or you might want to refer them to specialist services. And if you ever do refer people into specialist services, let that client know, that patient know that you are still there for them no matter what. That they can come out of their detox and come back to you. I have never detoxed anybody at home with a history of withdrawal seizure. That is a real no. They need inpatient care.
I insist on a support person. Certainly for the high risk three days. And the support person really is there to hold their hand. They are there for you, in case the patient does have a seizure. So they are your safety net. But really, you are giving somebody often a high dose of a sedative medication, so they cannot drive. They may feel woozy, they may fall or cut themselves or burn themselves on the kettle. So they need someone there to support them through that. Or indeed, you might under-dose them so they might be under-sedated so they might be very, very anxious. They might have strong cravings. They might have a desire to drink or to go to the bottle-o. Again, the support person can talk them down for that.
A safe environment is essential if they are in a household where there is lots of drinking going on or if they are indeed homeless. Then we need to find them a safe environment to do this detox from. And again, often lack of a support person and a lack of a safe environment are the commonest reasons I refer people into inpatient care. And then again, no complexity, no complex comorbidity, that should say.
There is not that much comorbidity that we cannot deal with as GPs, so you know, certainly if someone has cirrhosis, end-stage liver failure, if they are pregnant, if they have a concurrent dependency on another drug. So drug use itself is okay, but if they are dependent upon ice or certainly benzodiazepines are a big no-no, then you really need to defer to the Drug and Alcohol Services. So long as alcohol is the main drug of dependency and the others are bit players, I ask them to stop using them in the run-up to the detox and generally that is okay.
So, once we have decided we need to do a detox at this planning appointment, I will get them in at least one more time before I do the detox. So you are really looking at a two week minimum lead time from the moment you meet a person to the moment you detox them. And in that planning appointment, again you want to check that they are ready. Check that they are motivated. And I have got some motivation tools that I use, I think I talk about that a little bit later about coping skills, plan, pros and cons list. You know I have asked them who they are going to tell that they are going through this. The more people that they can tell and be honest about the better. I check that they have got a support person, their environment is safe. I talk about any high-risk events that are coming up on the horizon, if they have got a wedding that week or a you know, a work do or a party that they cannot get out of, and if they do, then we plan around that, and ideally to avoid it completely.
The coping skills plan. Yes, sorry that is the pros and cons list. So write down a list of all the things you really like about drinking and a list of all the things you do not like about drinking. And hopefully the cons list is much longer than the pros list by this point. If it is just a list of pros and one column, they are probably not ready to give up. Again, that coping skill plan is really thinking about what they are going to do with their time instead of drinking. What are they going to do when they are feeling stressed. What are we going to do at weekends, and really planning for this change. I will discuss the blood results prior to detox and yes, often I quite like it if there is some mild abnormality in their bloods. If their MCV is a bit up or their liver functions are abnormal and you can use this as a motivation tool and it is lovely to see all these things normalise in the weeks afterwards. Certainly blood pressure always comes down. In the audit I did, on average their systolic blood pressure dropped by 16 or 17 millimetres of mercury which beats any blood pressure pill on the market.
We go through the assessment pack, drink diaries, and prior to detox, I would hope that they would have a GPMP and a mental health care plan, and that we will have linked them into a psychologist. I have got some really good addiction psychologists who I have got a good relationship with now. They are often malnourished so a dietician can be important. Exercise is an essential part of their recovery. I cannot sort of you know, cannot describe how important exercise can be to somebody – obviously not everyone is capable of all types of exercise, but I have got a really good exercise physiologist that I refer everybody to.
I try to link them into other local services and it is really worth knowing what services are in your area. AA certainly has its place. Smart Recoveries is great. I did have my own Clean Slate support group in Blacktown. Kildare Road were really supportive of everything I did and indeed covered my hour to run a support group and that gives you a fantastic insight into your patients. I mean, you really get to know them well when they share in a meeting.
And then you book the detox in. That takes a bit of time, but I do do it myself. So, that looks like a single appointment with the nurse on day one. So, it starts on a Monday always if possible. So that gives you the longest period of time seeing them. So on day one you book an appointment with the nurse first and then an appointment with yourself. And you do that for Monday, Tuesday, Wednesday, Thursday and Friday. Now, not everyone works all those days. I happen to. In Blacktown I only worked Monday to Thursday and I think four days is just about enough. But you really need that daily review. And you could work in conjunction with a colleague at the practice, so one could see the client Monday, Tuesday, Wednesday and then another one Thursday and Friday. But the daily review is really important.
So, this is what day one looks like. So it is usually a Monday. They will come in, having their last drink on a Sunday. Try and get them to have that drink early in the evening. And hopefully by this time they have cut down a little bit. So their withdrawals are not too uncomfortable for them. So then my nurse will run a urine drug screen. We do this on day one only. I do not do that again. And the main reason I do that is to check that there are no benzodiazepines in their system. And it is surprising what that urine drug screen can show you. I did have one mother of three recently divorced who denied any drug use and her urine drug screen came up positive for marijuana, opioids, benzodiazepines and amphetamines. So my nurse came through all panicked and I said well we certainly cannot be detoxing her today. But as it turned out, she had had a Panadeine Extra for her back. She had taken 2 mg Valium because she was meeting the in-laws. She had had a spliff when she met the in-laws and she was on Duromine for something which it is not licensed for. But at least she had a good reason for all of these, for why it was flashing up positive. We still did manage to start her detox that day. The nurse will breathalyse the patient. I used to be very strict on saying that the breathalyser had to come back zero on day one before I would hand out Valium, but as I have spoken to a few of my addiction specialist colleagues and they are less insistent on that on day one. But certainly it needs to be less than 0.1 and if they do blow slightly positive on day one, I do get them to go away, have a coffee and some breakfast and come back to make sure that the breathalyser reading is at least coming down. And I like it to be sort of you know, less than 0.05 really before I am comfortable giving them the Valium and I might say look, here is your Valium but do not take it for another hour or two. Every day they have the CIWA score which is the Clinical Institute Withdrawal Chart for alcohol. It is slightly better than the AWS which is more hospital focussed. I do some observations or the nurses do observations. On day one, I will hand out some support information for the patient and ideally their support person is with them on day one. That does not always happen. I do have an information pack which includes what to do if they have a seizure to give to that support person, and I give some information to the patient talking about what they might expect through the week.
Tim: We have got a question about the support person, whether you screen them in advance, like to see whether they understand their role and who the support person is?
Chris: Yes. I really, I really love it if I can do that. That is ideal. I cannot always. The support person cannot always come in with the patient. I have sometimes called them on the phone. So, yes that is ideal. And it makes me feel a lot safer if I have met the support person before. I did detox a 22-year-old girl who said she was going to stay with her mum and I did not ask too many questions about the mum, and when she turned up on day one, the mum was drunk. And the mum had driven her in. And I had to ask, I did not breathalyse mum but I asked her not to drive her daughter home. I was tempted to start them both on a detox, but that was not the idea. So yes, absolutely. So the handout for the supporter is quite nice and they have their own questions. I like to also sign post the supporter to services like Al-Anon or Family Drug Support and make sure that support person has the right support too, because families are terribly affected by this. So yes, I love it when I can meet the support person. Does that answer the question?
Tim: Yes. Thank you.
Chris: So I get the patient to sign a contract which looks like this. And really again, it is to cover myself, this. And the main reason I have this is that they understand that, I have it written down and they sign that they are not going to drive whilst they are on one of my Valium scripts. So if they do, if something does go wrong and they crash, you know at least I am covered legally. But it is an important point, absolutely. So again, to look through that and sign it. So then, using, I have put together a diazepam dosing document. I wrote an article for Australian Prescriber Magazine and put it in there and it is one that I loosely follow, that I sort of put together from a few different guidelines. And so, I will give them a medication chart which is really, again, I have got that on another slide. So I give them this medication chart and I will write in each of those boxes the dose that I think they should take, for example 10 mg four times a day is a common starting dose and I will also give them two extras to take home as well, so if they are feeling anxious or they wake up in the middle of the night feeling anxious, or if they are anxious indeed before they come and see me in the morning, they have got some extras. And I explain to them that this, what diazepam is for, is to stop seizures, so stop cravings and to prevent withdrawals, to help their anxiety. And I ask them to write down how much they take and at what time they take it. And the beauty of this model is that you can be really flexible. There are some people say, you know 10 tds and then 5 tds and then none, or you know, but because you are seeing them every day, and going on this journey with them you can really tailor the dose to what they are doing that day. And you know, that makes it much easier. Sorry, just looking back.
The other thing that I do on day one is give them an ADIS card. I am in New South Wales, I am not sure if they work outside of New South Wales, but it is the Alcohol and Drug Information and Support Service I think. It is run out of St. Vincent’s Hospital and it is a 24/7, it is a fantastic service, 24/7 counselling and information and advice. So, if they cannot phone me, if I have gone home for the day and it is nine o’clock at night, and they are panicking or they have got a craving or they have lost the Valium, they can call ADIS for advice. So then, I will quickly show you the diazepam dosing guidelines. So, I use how much they have been drinking, the SADQ score which is in their assessment pack and their CIWA score as well, I also use which is their withdrawal scale score. And I put those sorts of figures together and come up with a dosage of diazepam. I do not tend to look at this anymore because I have been doing this for so long. But that is just a rough guide. I have written hospital guideline in here. The Australian Prescriber would not let me put 20 mg of Valium qds in the paper and I have used 20 mg four times a day on occasion for the riskier patients. But again, and certainly when you are starting out, you should not really be seeing those patients but I guess the point is you can use what you think you need to keep that patient safe.
So that was the first day of the detox. The rest of it is much easier. So it is a 15 minute appointment with the nurse where she will breathalyse them. She will do the withdrawal scale and a blood pressure and a pulse. Then they will come through to me. I will ask them how they were. I will go through their medication chart and I will dose them again for day two. I use Oxazepam if there is any sense of any liver failure because that is not oxidised in the liver and it is a bit safer to use. But again, I have only used that a handful of times because if they have got liver issues or if it is complicated then they may well have needed an inpatient detox. I check that they are taking their thiamine throughout the detox. And again, I have five appointments which is a great amount of time to really make sure that their recovery plan is there. I ask them of any fears that they might have about group sessions or talk them through the Daybreak App, maybe suggest a few more books or podcasts now I have got to know them. And then on the Friday will give them some Valium. So basically the alcohol is out of your system after four days. With hospital detox it is four days generally. And that is because they are in a safe environment. But if I stop the detox after four days, I would then be asking them to be on their own at the weekend without any Valium and so I always give them, I continue the detox over the weekend so if on a Saturday night they want to go to the pub because they have to and they do not want to drink, then they can take a Valium instead if that makes sense. So they have got some Valium just to keep them going over the weekend. And then I book in a post-detox review on the Monday.
So, that brings us to the third part of the process which is the recovery. So, the Monday after detox they are generally already feeling a lot better. Now, people’s journeys are different and what happens in those first few weeks of recovery is quite an individual experience. I have had patients who are completely euphoric, whose lives have changed. Who bounce into the room and you know, they are the ones that give you a hug and you do not see them again after a month until they then relapse six months later. But you also get people who are hugely emotional. Very, very tearful. It can be a real rollercoaster ride. So close support in this early recovery phase is really important. Some people’s sleep improves very quickly. For some people it takes weeks. And people are often expecting miracles, you know, they say I have not had a drink for a week so why am I still anxious, why am I still depressed? So, close review is really important. Anyway, sorry I digress.
On that Monday, I will do a final breathalyser, make sure they have not drank over the weekend, and again it is quite nice for the patient to see that negative breathalyser number, the CIWA score and I will remark on how good their blood pressure now is. Certainly there is no more Valium. You do not get Valium after the Monday and I will explain the reasons for that to the patient. We need to build up better coping mechanisms for craving. I talk about craving management through the process if they are having cravings. And the craving sort of management tools I use are visualisation, so you visualise the craving as a wave that you surf to the shore and then once that craving has past, and all cravings eventually do pass, you get a bit of a boost from that. Or we talk about the three D’s, which is now sort of increased to five D’s. So the first D is to delay. The sort of new D’s which have been introduced to me are to: Deep breathe, Drink water and then after you have Delayed that initial desire to drink, you Distract yourself. So we talk about, and we will have this written down in out coping skills planner, we talk about going for a walk or calling a friend or going on the Daybreak App, whatever it might be, and then the final one is to Decide to really go back to reasons why you have decided to make this change, looking at the cons list from the pros and cons list we have done.
On this day, I generally start anti-craving medication. I will come on to that in the next slide, but I always recommend anti-craving medication. You have got a few different options and I will start that on the Monday. And again, that is a bit of a carrot, that since I am taking away the Valium, here is another medication which might help.
I talked about the active aftercare. I will see them weekly and again this is always case dependent. Some people travel from quite a distance to come and see me and cannot see me weekly. Some people will see me daily that second week if they really need to. But ideally you would see them weekly for the first few weeks and then once their aftercare is in place, they have got a good relationship with a psychologist or they are going to AA, then you can reduce the frequency of GP visits. Certainly if they have had abnormal bloods at the beginning which they often do, or their blood pressure has not recovered, then you want to keep an eye on those. I have put 1, 3, 6 and 12 months, just that is because that is the timings I had for my audit. But obviously if someone’s bloods are completely normal before detox you do not really have to check them after detox, unless you have started them on anti-craving medication which again I will talk about.
So my go-to anti-craving medication is naltrexone or Revia. It is on PBS. It is a once daily medication. It is an opioid agonist, so it blocks the opioid receptors in the brain and they are the receptors that will flash when you walk past the off-licence or there is a trigger that can cause a craving. So it really does work at dampening cravings, for most people, obviously not for everybody. It also has a nice secondary effect that if you do lapse and have a drink, the naltrexone takes a lot of the pleasure out of that drink, so you are much less likely to go on to have a full relapse. The important thing is that therefore, because of its mechanism of action, it blocks all opioid analgesics as well. So every patient I start on naltrexone gets an alert card to keep in their wallet which you can get from the people who make it. I cannot remember who make it now, but if you just phone them up they put it in the post. So everyone gets an alert card. And I get them to write a disclaimer that they cannot take opioid analgesics. If they need surgery or if they are in a car accident, I had one patient who broke his arm and he gave the ambos his alert card which was great. Then on the alert card it gives you alternative pain killers that you can use. If you do have surgery, you just need to stop the naltrexone two days before and then you can go on and use the opioid analgesics as normal.
Campral. I used to use it a lot in the NHS. I use it much less now, but partly because it is a high pill burden. You need two pills three times a day unless you are less than 60 kg, and then it is two and one and one. I tend to use it now only in conjunction with naltrexone. So if naltrexone, if they are getting breakthrough cravings with naltrexone now I might add in Campral as an extra. It is pretty safe. They do not tend to have side effects with that. You can get side effects with naltrexone. Not commonly, most people do not get side effects with naltrexone. If they are going to, they will get some nausea and I minimise the nausea by asking them to cut their first naltrexone pill in half and then it just goes on to one a day. Headache and sleep disturbance are common-ish side effects. You can just get them to reduce the naltrexone to half or indeed you know, stop it.
Antabuse I do not often use. It is quite counter intuitive to give an alcohol dependent person a drug which might kill them if they drink on it. So you really have to cherry pick your patient. It is a private script so it is much more expensive. You can pay sort of anywhere between $70 to $120 for a month’s supply. I get them to sign a full disclaimer that they really do understand what they are letting themselves in for, that they have got to avoid anything with alcohol in. Unfortunately they cannot do wine tasting. They cannot have food with alcohol in. I tell them to avoid alcohol gel washes on their hands because that can cause a rash. And really, there is only good evidence for Antabuse working if it is supervised for the first few months. So they need daily pickup at the chemist or if you have got a reliable support person, they need to be you know, the support person has to give it to them every day. There is an Antabuse clinic at the Langton Centre in St. Vincent’s where I work locally, and that way they can get the Antabuse for free. But they have to go there every day. I guess that is gold standard.
Baclofen I have never used. There is a lady called Amanda in Perth who really likes baclofen for her street drinking population. So, it is pretty good for people who really have no intention of wanting to stop drinking at all, like her regular attendees at the ED department. It is used quite widely in France as well. But there are side effects with it. You get very tired so you might not be able to drive with it. You need to use quite high doses, so you have got to slowly titrate the dose which can be again limiting because of the lethargy, and then you cannot just stop it, unlike Campral and naltrexone and Antabuse which you can just stop dead. You really need to withdrawal slowly from baclofen. There has also been baclofen overdoses, so I leave that in the hands of the specialists. There are other drugs sort of on the horizon. I am doing a research project of naltrexone versus topiramate so that looks like a decent option for the future. But again, not on PBS just yet.
So, it has all gone well. You have not seen them for a couple of months and they come back and they have started drinking again. And that is obviously very common. Because this is a chronic relapsing, remitting disease. Again, because we have got this real open non-judgmental relationship with our patients, I have already said you know, that I do not want them to drink but if they do I really want them to come in and talk to me about it. And that we can turn that into a real positive learning tool. You know, so we can reflect on what led them to that drink, how it made them feel and what we can do to prevent that from happening again. So lapses can be real positive experiences. So the lapse is a drink or a drinking episode. Full relapse really means they are back to square one, that they are now dependent on alcohol again. And again, they are back to see you which is fantastic. So, they are still engaged which is brilliant, and keeping the patient engaged has to be a real important goal. I aim not to do a home detox within six months of the last, or the first. There is something called a kindling effect which is not well understood, but the more detoxes a person has, the riskier they become and their long term outcomes are worse. So, if they have come back after a couple of months, I would maybe try considering maybe a specialist referral, ambivalence counselling, just try and work out what went wrong. What had we not put in place the first time? Most of the time, it is because of lack of after care. We have either rushed the detox or we did not prepare well enough or we have not got good after care in place. And again, we can use this as a learning experience. The other thing to really think about if people are not doing well is, is there something we have missed? Is there a dual diagnosis that we did not quite pick up the first time around? Is there an acquired brain injury? Again that has been shown to increase your risk of addictive behaviours, ADHD, PTSD, certainly anxiety and depression are common. And this is when I would start an SSRI. I would never start, I know I never say never, but I would not start an SSRI before detox or even shortly after detox if I can help it because it takes weeks for sleep patterns and mood to settle down, and you do not want to confuse the issue by starting an SSRI if you do not have to, because then it is difficult to pick out what is a side effect of the SSRI, what is a normal part of their recovery and especially if you are starting on naltrexone or Campral which drug is causing the side effect. So I tend to follow them more closely and start an SSRI a few weeks in. Often patients are already on an SSRI.
Tim: We have just got a question. A couple of people are asking how long people use naltrexone or acamprosate?
Chris: Sure. I have got one patient who is has been on naltrexone for nearly two years. That is probably a little too long, but he is so happy with his new life, he just does not want to change anything and I do not see a great reason to stop it for him. So the PBS will give you two months straight up and that is quite a nice length of time you know to review your patient. So you know, again it depends on the patient’s goal. It depends on how they are going with the naltrexone. So there is no set length I guess is the answer to that question. And it is the same with Campral. People tend to stop using Campral a bit quicker just because it is six pills a day. So if they are going well, you know I do not see reason to stop. Patients will often ask me that question and I will often say a year, because if I can get them sober for a year – sorry I should not use that word – if I can get them alcohol-free for a year, then we have done really well. And that is a way of sort of introducing a year as a goal to them. But yes, no set length.
Yes, so for your frequent relapser, or your frequent lapser may be it is time to consider a rehab unit. And again, that is not for every patient, but I also do one session a week in a residential drug and alcohol unit, William Booth House, and it is a fantastic service for the right person.
So, there are some common pitfalls I thought I would mention. The first one is the emergency detox and I alluded to this at the beginning. You will have really well-meaning patients who are desperate to stop who you have never met before. They will come in and they will be in withdrawals. They will not have had a drink for two days and they are like, I need Valium, doctor. And you have really got to resist this. This is a planned detox service. GPs cannot do emergency detoxes. We are not set up for it. And neither are the private units that you pay thousands of dollars to go in. They will not do an emergency detox, so why should we? And it is not safe. If a patient really needs an emergency detox, they have to go to ED. To tell this sort of person that they need to keep on drinking for a short period of time is a hard sell, and patients can sometimes get frustrated or angry with you, so you have really got to sell it to them as a chronic disease. You know, if someone comes in with an HbA1c of 10, you do not start them on three oral medications and insulin on that day. You know, this really is a chronic disease and we need to look at the long term goals. Emergency detoxes have a massive, massively high relapse rate. So I would really encourage you to never be tempted to do this.
The lack of support person. Again, that does happen and if you cannot convince someone to go into inpatient units for this reason, then you can safety net. Again I would try and get them to reduce their alcohol down to as low a level as possible and again I would put as many safety nets in as you can think of. I have had patients come and see me four times a day for the first few days since they live around the corner. I can get patients to pick up their diazepam from the chemist four times a day, but again do not detox someone without a support person unless you feel very safe in doing that. You have patients who cannot take time off work. Again, this is something that I commonly encounter and I really again try and encourage them to take this really seriously and I sign them off work. I always sign someone off work with a medical certificate. I mean this is a medical procedure that they need time off work for, and certainly if they are an Uber driver or working on a building site, then you know, there is no choice. But I have office workers who just say that this is impossible. Again, I would insist that they tell somebody at work. It does not have to be a boss, but a colleague at work that they are going through a detox. Again, I would try and limit, reduce their alcohol intake. I might see them before work and then after work, but again I really encourage them to have that week off if possible.
Again we have got the three key learning points which we will come to at the end. Sorry, right at the end. But there are a few things that I guess I just wanted to reiterate. That the thiamine is really important. If you do nothing else with your patients, give them a brief interventional form and start them on thiamine and you have done them the world of good. Then rush into detox which we have just talked about. The support person again is really important. They do need that daily review. Try not to send someone home on a Friday with a packet of Valium and say you will see them on Monday, because their Valium and alcohol is a fatal mix. So they need that daily review. And again, I recommend naltrexone first for maintaining abstinence.
This is a reference and resource list. I am more than happy for everyone to have a copy of these slides of course. That first top one is the article I wrote a few months ago. That is the FARE data. That is last years. There is the Language Matters by NADA. I really recommend you print that out and distribute it amongst all of your staff. It really is a fantastic document of non-stigmatising language. That is the link for the Insight brief interventions. Please look at that. I think they are brilliant tool kits. I have seen quite a few brief intervention toolkits down the years and this is by far the best. And as I say, it is for alcohol, benzodiazepines, cannabis, ice and opioids. There is the TED talk which is great. A couple of drink diary Apps. That is the baclofen website but yes again, only if you are really interested. There is the ADIS phone number. Again, what we are blessed with is, sorry I am just keeping to the bottom, but the DASAS service, again is fantastic. This the Drug and Alcohol Specialist Advisory Service which is manned by addiction specialists. You might have to wait for the next day to get advice, but I will always call DASAS if I have got a patient that I feel uncomfortable with and record their advice in the patient’s notes which just gives you a little bit of extra cover. But there is always someone on the end of the phone for you. So again, do not feel like you are alone.
Yes, thanks so much for joining me. I do not expect anyone can go away and set up a Clean Slate clinic after listening to an hour long webinar. But the Royal College of GPs has just won a large national drug and alcohol education grant from the Commonwealth Government, and myself and Tim are both sitting on that panel trying to work out the best way to spend that money. But it will be available next year and there will be a range of alcohol modules including alcohol detox within this grant and the guidelines and the education package will be promoted to all College members in October 2019. If anyone really does want to set up a Clean Slate clinic in their practice, again I am happy to give you more information if you email me. If you would like me to come to your practice and spend a day with you helping you to streamline things, train your receptionists and nurses up, I have set this up in quite a few practices now. I can give you access to all of the paperwork that I use. Then please just contact me.
Thank you very much for joining me.
Tim: Thank you very much indeed. That was an excellent session. I think this is a whole of practice thing, not just us as individuals. There are the learning outcomes again. I think we have hopefully covered all of those off for you. You will get an evaluation so you get to assess how well we achieved those learning activities. Thank you very much to Chris for an excellent presentation tonight, and thank you to Sammi for running the technology behind us. There were a few questions that came through that we have not had a chance to get to and we will try and get to those by email afterwards as well. And the presentation and a recording will be available in the near future of tonight’s webinar. So, thank you very much indeed and have a great rest of the evening.
Sammi: That is great, thanks Tim and thanks again Chris for tonight’s presentation and thanks to everyone that joined us online. We hope you enjoyed the presentation and we hope you enjoy the rest of your evening.