12. Specialist inpatient medically assisted withdrawal
The core specialist competencies and systems needed to provide specialist inpatient medically assisted withdrawal for people with severe dependence or complex needs. The chapter distinguishes between specialist inpatient withdrawal units and residential withdrawal settings.
Specialist inpatient medically assisted withdrawal units provide medically assisted withdrawal to people with severe dependence or complex needs. They require specific specialist competencies and systems to do this.
Every local treatment system should have a pathway so that people with the highest levels of need can access specialist inpatient medically assisted withdrawal. People should be able to access it easily and without any unnecessary delays.
Specialist inpatient medically assisted withdrawal units should have a thorough admissions process to assess whether the unit can safely manage the withdrawal process for each patient.
Each patient should have a multi-agency treatment and recovery plan that includes plans for ongoing treatment and recovery support after discharge.
Core elements of specialist inpatient withdrawal include specialist competencies and systems including:
- a skilled multidisciplinary team led by an addiction specialist, normally a consultant addiction psychiatrist
- medical and nursing staff with a range of specialist competencies
- ability to identify and manage severe withdrawal complications including seizures, delirium tremens and Wernicke’s encephalopathy
- ability to assess and manage complex co-occurring physical health, mental health, additional drug use conditions, alcohol related brain damage and other complexities
- ability to implement relevant legislation and statutory guidance for safeguarding, mental capacity and mental health
- tailored psychosocial interventions and pharmacological interventions
- staffing arrangements that offer out of hours cover that are adequate for the safe running of the unit and the number of patients they treat
- an extensive range of referral pathways, including a rapid pathway to acute hospital care
- multi-agency working partnerships with community alcohol treatment services, health, social care, criminal justice and community agencies
Residential settings providing medically assisted withdrawal that do not have the core elements in place (as outlined in this chapter) do not have the appropriate capacity to manage people with more severe withdrawal complications or complex co-occurring conditions. These settings are suitable for people with alcohol dependence who would otherwise meet the criteria for community based medically assisted withdrawal but are lacking adequate social support.
This chapter describes the core elements of specialist inpatient medically assisted withdrawal, usually referred to as specialist inpatient detoxification units. You should read this chapter alongside:
- chapter 10 on pharmacological interventions
- chapter 11 on community based medically assisted withdrawal
- chapter 16 on alcohol care in acute hospitals
Medically assisted withdrawal occurs in several different inpatient, community healthcare and other residential settings, in both a planned way and as part of unscheduled care. Settings include the following.
12.3.1 Community-based medically assisted withdrawal
Community-based medically assisted withdrawal is usually provided by the community alcohol treatment service but may be provided in other community settings, such as primary care or by a community mental health team.
You can read about community based medically assisted withdrawal in chapter 11.
12.3.2 Residential settings
Medically assisted withdrawal is provided by some residential treatment services and in some supported housing settings. See section 12.6 below for further definition and distinction between residential medically assisted withdrawal settings and specialist inpatient medically assisted withdrawal units.
12.3.3 Specialist inpatient medically assisted withdrawal units
Specialist inpatient medically assisted withdrawal units are set up to provide medically assisted withdrawal to people with severe dependence or complex co-occurring conditions, including physical health, mental health, additional drug comorbidities and other complexities. These services require specialist competencies and systems tailored to manage people with complex needs. They are the subject of this chapter and described in detail below.
12.3.4 Acute hospital settings
People may be provided with medically assisted withdrawal in an acute general hospital setting following an admission for acute alcohol withdrawal, or admission for other reasons. In some areas, planned specialist inpatient medically assisted withdrawal is provided within an acute hospital as part of a planned local pathway. Hospital alcohol care teams provide additional specialist expertise where these exist.
You can read about medically assisted withdrawal in acute hospital settings in chapter 16.
12.3.5 Mental health hospital settings
People may be provided with medically assisted withdrawal in an inpatient mental health hospital setting following admission.
You can read about medically assisted withdrawal in inpatient mental health settings in chapter 18 on people with co-occurring mental health conditions.
12.3.6 Prison settings
People may be provided with medically assisted withdrawal if they enter the prison system while experiencing alcohol dependence.
You can read about medically assisted withdrawal in criminal justice settings in chapter 17.
Clinicians should base decisions on whether to refer people for specialist inpatient medically assisted withdrawal on individual clinical assessment. But they should normally consider specialist inpatient withdrawal for people who meet one or more of the criteria below, weighing up the risks and benefits of that setting for the person.
These criteria are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) and clinical consensus from the guidelines development group.
12.4.1 Criteria for considering inpatient medically assisted withdrawal
You should consider inpatient medically assisted withdrawal for people who meet one of more of the following criteria.
People who drink over 30 units of alcohol per day or have a score of more than 30 on the Severity of Alcohol Dependence Questionnaire (indicating severe dependence). People with severe dependence should normally be considered for inpatient medically assisted withdrawal, but if they do not have any complex needs or significant comorbidities, it can be appropriate to offer them a community based medically assisted withdrawal. Any decision to do this should be based on individual assessment by a clinician with appropriate training and expertise in managing withdrawal for people with severe alcohol dependence and comorbidities.
People who have a history of seizures, or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes.
People who are assessed as at high risk of Wernicke’s encephalopathy (WE). Based on individual assessment, it may be possible to offer them medically assisted withdrawal in the community if intramuscular thiamine is available on site and there is a sufficiently skilled, trained and resourced team to administer it. Clinicians should follow guidance in section 10.4.3 on WE and medically assisted withdrawal.
People who have a co-occurring substance use problem. This includes harmful or dependent use of drugs (illicit, prescribed, or over the counter medication) which requires management. They may need concurrent medically assisted withdrawal from alcohol and one or more substances.
People who have a severe mental health condition (for example, untreated psychosis, severe depression, or suicidal ideation) that makes medically assisted withdrawal in a community or residential setting potentially unsafe.
People who have a significant physical health condition (for example, chronic liver disease, malnutrition, congestive cardiac failure, unstable angina or chronic lung disease) that makes medically assisted withdrawal in a community or residential setting potentially unsafe.
People who have a significant learning disability or cognitive impairment.
Pregnant women and other people who are pregnant.
12.4.2 Considerations for vulnerable groups
Clinicians should consider a lower threshold for referring vulnerable groups and people who are frail to specialist inpatient medically assisted withdrawal. This includes:
- people experiencing homelessness
- older people
- children and young people
- people with established liver disease
People in each of these groups are very likely to require closer monitoring (for safety reasons) than can be provided in a community medically assisted withdrawal.
Also, people experiencing homelessness are unlikely to have a sufficiently safe and stable home environment to manage community-based medically assisted withdrawal.
Access to specialist inpatient medically assisted withdrawal is an essential part of any local alcohol treatment system. Every local area should have a pathway so that people with the highest levels of need can access appropriate treatment, including accessing specialist inpatient services.
If a local area does not have access to specialist inpatient medically assisted withdrawal unit as described in this chapter, there should be an alternative pathway so people with complex physical and mental health conditions can access the care they need. For example, a local agreement between commissioners and services that people with high risks spend at least 48 hours on a medical ward or medical assessment unit to stabilise their condition, before going on to complete medically assisted withdrawal in an appropriate specialist setting.
Commissioners and services should work to reduce any barriers that prevent people having rapid access to specialist inpatient medically assisted withdrawal such as prolonged funding processes or standard requirements. Clinicians should determine the urgency of need for rapid access for each individual.
Practitioners in community alcohol treatment services (and other referrers) should consider a person’s need for specialist inpatient medically assisted withdrawal at their first assessment. Where clinical assessment identifies a need for specialist inpatient medically assisted withdrawal, they should refer the person without any unnecessary delays.
A period of preparation work before a person enters specialist inpatient medically assisted withdrawal may be useful. However, it is not helpful to have a standard requirement that people should attend a fixed number of groups or sessions to prepare them for specialist inpatient medically assisted withdrawal. This is because it could exclude people whose lives are particularly complex and who often face the highest risk. People with the highest levels of need may not be able to comply with requirements to attend a fixed number of meetings.
It is important that people being referred to specialist inpatient medically assisted withdrawal know what to expect from this treatment. Practitioners also need to make sure that the person already has in place an aftercare and contingency plan for after they are discharged. But these processes should not cause unnecessary delays in referring them to treatment.
12.6.1 Background
In 2006, the Specialist Clinical Addiction Network consensus project published ‘Inpatient treatment of drug and alcohol misusers in the National Health Service’. This report distinguished between different levels of clinical input and supervision offered by inpatient or residential units providing medically assisted withdrawal. It introduced the terms ‘medically managed’ and ‘medically monitored’ to describe these different kinds of provision, which are still used in the treatment sector.
However, there is now some confusion and a lack of shared understanding about the kind of units that the 2 terms ‘medically managed’ and ‘medically monitored’ refer to. For this reason, the alcohol guidelines development group has not used these terms. Instead, this chapter introduces the terms ‘specialist inpatient medically assisted withdrawal’ and ‘residential medically assisted withdrawal’. The chapter goes on to distinguish between these different settings and gives a detailed description of the core elements that units need to provide ‘specialist inpatient medically assisted withdrawal’ from alcohol. These units were formerly referred to as ‘medically managed’ inpatient settings. The core elements of specialist medically assisted withdrawal units described below are based on clinical consensus of the alcohol guidelines development group.
12.6.2 Residential medically assisted withdrawal settings
Residential settings providing medically assisted withdrawal that do not have the core elements in place (as outlined in section 12.7 below) do not have the appropriate capacity to manage people with more severe withdrawal complications or complex co-morbidities. These guidelines refer to those services as residential medically assisted withdrawal settings.
Residential medically assisted withdrawal settings are suitable for people with alcohol dependence who would otherwise meet the criteria for undergoing a community based medically assisted withdrawal but are lacking adequate social support. Residential medically assisted withdrawal settings are important and provide a supportive environment for managing people with limited psychosocial support. They also support people who would benefit from an environment free from alcohol or drug using networks while going through medically assisted withdrawal.
Residential medically assisted withdrawal settings were formerly referred to as ‘medically monitored’ settings. These settings need to ensure that they meet the criteria and follow the guidance for a community medically assisted withdrawal set out in chapter 11 on community medically assisted withdrawal. There is no further information about residential medically assisted withdrawal settings in this chapter.
12.6.3 Defining specialist inpatient medically assisted withdrawal units
Specialist inpatient medically assisted withdrawal units are services that are staffed with appropriately trained specialist medical and nursing staff. These appropriately trained staff are able to manage people with more severe withdrawals and the associated complex physical and mental health conditions they can experience. The provision can be in the NHS, non-statutory or the private sector and may be in specialist units, which also provide stabilisation and management of withdrawal from other substances.
Within this group of specialist inpatient medically assisted withdrawal units there is wide variability in the workforce and the complexity of medically assisted withdrawal that they can manage. The guidance in section 12.7 below describes core elements of service provision for all specialist inpatient medically assisted withdrawal units. Specialist inpatient units can provide additional elements beyond these core elements if suitably staffed and equipped. Examples of additional elements that could enhance service provision are also included below.
All units should operate with a comprehensive quality assurance framework. They should assure themselves that staff have the appropriate competencies, and the unit has the appropriate facilities, systems, and protocols to meet the needs of their patients. All units need to have pathways to acute or mental health hospitals to meet the needs of patients if required.
12.7.1 A skilled and competent workforce
Core elements
All specialist inpatient medically assisted withdrawal units should have a workforce with relevant skills and competence. Core elements of a skilled and competent workforce include the following.
An addiction specialist leading the service. In most cases, this will be a consultant addiction psychiatrist or a specialist with a similar standard of training and expertise and acknowledged on the appropriate specialist register of the General Medical Council. The role of addiction specialist doctors in drug and alcohol services provides guidance on required competencies.
Registered nurses and doctors with different competencies, including registered mental health nurses, registered general nurses and doctors on the specialist register.
Staff with competencies in assessment for inpatient specialist medically assisted withdrawal and in comprehensive assessment of patient needs.
All clinical staff are competent in providing evidence-based medically assisted withdrawal, including identifying and managing severe complications. This should be in line with NICE CG115 and NICE clinical guideline Alcohol-use disorders: diagnosis and management of physical complications (CG100).
A team with several specific physical health and mental health competencies. This should include competencies to assess and manage a patient’s complex physical health, mental health, concurrent drug use, and other complexities described in section 12.7.2 below.
Competence in the team to manage alcohol medically assisted withdrawal for pregnant patients, except where they have complex co-occurring conditions (see section 10.6.4 in chapter 10, for guidance on medically assisted withdrawal during pregnancy). In Scotland, pregnant patients are generally admitted to the maternity hospital for medically assisted withdrawal, under the care of multidisciplinary specialist antenatal substance use teams.
Competence in the team to provide a therapeutic environment and psychosocial interventions appropriate to the patients’ stage of their treatment journey.
All staff undertake regular supervision and training to develop and maintain their competencies in line with clinical governance requirements. There should be mechanisms in place to monitor and ensure revalidation takes place for staff who are required to do so.
Access to or support from additional specialist staff including from:
- pharmacy
- psychotherapy or psychology
- other specialist services, for example physiotherapy and occupational therapy
People with lived experience of alcohol dependence are involved in service provision. This could include paid employees, volunteers or peer mentors. People with lived experience should also receive appropriate training, supervision and support.
Nursing competencies
All units should assure themselves that there are adequate numbers of nursing staff at a suitable grade to manage the service safely. All units require specific nursing competencies, which include the following.
On every shift, the team should include at least one registered mental health nurse (RMN) or one registered general nurse with appropriate additional skills in the management of complex alcohol withdrawals. These nurses should have a minimum of 6 months’ experience in a specialist inpatient medically assisted withdrawal unit. Larger services will require more staff in their teams and possibly more than one RMN, depending on need.
An adequate number of registered nurses and healthcare assistants to staff the unit safely, depending on its size. Staff should be competent to use evidence-based assessment tools, risk management formulation and care plans.
Registered nurses with enhanced skills and experience of assessing and managing complex medically assisted withdrawal, complex physical health, mental health and drug use conditions and other complexities as described in section 12.7.2 below.
Registered nurses who are competent in using patient group directions.
Registered nurses who are competent in undertaking electrocardiograms (ECGs).
Registered nurses who are competent in undertaking relevant nursing tasks such as:
- administering parenteral thiamine
- dressing wounds
- performing venepuncture
- giving advice on blood-borne virus testing and vaccination
- managing medications such as possible side effects, concordance (reaching an agreement with the patient about prescribing and administering their medicines), and interactions
Additional elements that can enhance service provision
Some units have staff with relevant additional skills and competencies who can enhance service provision. Examples include:
- nurses trained in administering intravenous (IV) medication
- nurses trained to cannulate
- nurses trained as non-medical prescribers
- staff are able to manage patients with neurocognitive deficits, such as patients with alcohol related brain damage (ARBD) who need regular medication reviews to avoid over medication, falls and confusion
- specialist psychology provision, including neuropsychology for patients with ARBD dedicated to the unit
- a social worker dedicated to the unit
- specialist pharmacy provision dedicated to the unit
- allied health professionals dedicated to the unit, such as physiotherapists, dieticians, occupational therapists and speech and language therapists
12.7.2 Managing patients with complex needs
Core elements of managing complex needs that all specialist inpatient medically assisted withdrawal units should provide are set out below.
Admission and assessment
All specialist inpatient units should have a thorough admissions process where referrers are required to provide clinical information, including medical history and the results of physical examinations and tests, for each person they refer. An appropriately trained clinician from the specialist inpatient unit should screen the information on each new referral to assess whether the unit can safely manage the withdrawal process.
On accepting the patient into the unit, the team should further assess their physical, psychological, forensic and social needs, including any experience of domestic abuse. The clinicians responsible for screening and assessment should ask the referrer and the patient’s GP for any additional relevant information on their needs and any risks. They should also develop a personalised care plan, which includes post-discharge planning. In specific cases, a member of the team may need to meet the referrer and the patient before their admission to the unit to discuss expectations of treatment and work together on a care plan.
Multi-agency working and pathways
All specialist inpatient medically assisted withdrawal units should have working relationships with other relevant health, social care and criminal justice services to support people with complex or multiple support needs. All units should work with the relevant community alcohol treatment service (or other referrer) and the patient’s GP before and during treatment. Referrers and other relevant services should contribute to care planning, including discharge and contingency planning where appropriate. Patients will sometimes come from different local areas to the specialist inpatient unit and the community alcohol treatment services can offer relationships with and referrals to local services.
Identifying and managing severe alcohol withdrawal complications
All specialist inpatient medically assisted withdrawal units should identify and immediately manage severe alcohol withdrawal complications. These complications can include delirium tremens and seizures.
Core elements
Core elements of identifying and managing severe alcohol withdrawal complications include the following.
Staff competent to use recognised alcohol withdrawal scales to inform prescribing, for example the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar), and recognised early warning scales, for example the Royal College of Physicians’ National Early Warning Score 2 (NEWS 2).
Staff competent in assessing and identifying the onset of severe withdrawal complications and intervening to prevent their escalation.
Skilled nurses competent in managing severe withdrawal complications, including delirium tremens, seizures and overdose.
The unit has procedures for escalating medication regimens when severe withdrawal complications occur.
The unit has developed treatment protocols and guidelines for recognising and immediately managing severe alcohol withdrawal complications.
The unit has an agreed pathway to acute physical and mental health hospital care where needed.
Additional elements that can enhance service provision
Some units with suitably trained and experienced medical and nursing staff and appropriate facilities may be able to treat acute and severe complications of withdrawal without transferring patients to an acute setting. Those units should have clear criteria for escalating care to safely manage and treat severe withdrawal complications. Where units are able to offer this, the person can receive tailored care in a specialist setting throughout the process of medically assisted withdrawal.
You can read more about identifying and treating severe withdrawal complications in sections 10.4.1 to 10.4.3 of chapter 10 on pharmacological interventions and in section 16.9 in chapter 16 on alcohol care in acute hospitals.
Assessing and managing Wernicke’s encephalopathy
All specialist inpatient units should be able to assess patients at risk of WE and those with incipient WE and manage this appropriately.
Core elements
Core elements of assessing and managing Wernicke’s encephalopathy include the following.
Staff competent to identify patients at risk of developing WE
Staff competent to treat patients at risk of WE with intramuscular thiamine.
The unit has an established pathway for patients with incipient WE so that they can access treatment immediately. There is also an established pathway to an acute hospital.
The unit has an agreed treatment pathway for patients with established Wernicke-Korsakoff syndrome.
Additional elements that can enhance service provision
Some units have specialist clinical competencies and facilities to provide high dose intravenous thiamine in patients with suspected or confirmed WE. This is so patients can be treated in the unit and not transferred to an acute setting.
You can read more guidance on WE in section 10.4.3 of chapter 10 on pharmacological interventions and in section 16.9.4 in chapter 16 on alcohol care in acute hospitals.
Assessing and managing complex physical health conditions
All specialist inpatient medically assisted withdrawal units should be able to assess and manage a patient’s complex physical health conditions. This includes alcohol-related conditions, such as liver disease, as well as more common physical health conditions unrelated to alcohol.
Core elements
Core elements of assessing and managing complex physical health conditions include team competencies and arrangements in the following areas.
Staff are able to assess patients using early warning scales such as the NEWS 2. As a minimum this needs to be completed 6 times during the first 72 hours of admission. There should also be procedures in place for escalating any concerns about the patient’s condition and managing them if they start deteriorating.
Staff are able to assess and manage pregnant patients for specialist inpatient alcohol treatment. In Scotland, pregnant patients are generally admitted to the maternity hospital for medically assisted withdrawal, under the care of multidisciplinary specialist antenatal substance use teams.
Staff are able to assess and manage patients for medical emergencies. The team should include nurses qualified to provide immediate life support (ILS) and basic life support (BLS). Other competencies include assessing and managing patients for anaphylaxis, overdose and naloxone prescribing.
Staff are able to assess and manage patients for common medical conditions, for example diabetes, myopathy, balance, falls and mobility issues.
Staff are able to undertake investigations, such as blood tests, ECGs, venous thromboembolism risk, and can understand the laboratory results and act on those results.
Staff are able to assess and manage malnourished patients.
Staff are able to identify and manage patients with alcohol-related liver disease.
Staff are able to provide smoking cessation interventions and manage chronic obstructive pulmonary disease.
The unit has pathways into relevant local primary and secondary care services, and social care services, and staff are aware of these pathways.
The unit has an agreed pathway for transferring patients to an acute hospital in an emergency.
It’s important to note that the list above contains a combination of competencies that the team needs to have (as a team, not necessarily for every staff member in the team) and relevant arrangements they need to have in place, such as appropriate procedures and equipment. This applies to the core elements set out in the following sections as well.
Additional elements that can enhance service provision
Some units have additional staff competencies and facilities for assessing and managing complex physical health conditions. These could include the following.
Appropriately trained staff with higher level physical health skills, including GPs and physicians, able to assess and provide initial treatment for a range of alcohol-related physical health conditions.
Staff with experience in using vitamin K for clotting disorders.
Staff who are able to assess and manage specialist alcohol treatment for pregnant women and other people who are pregnant and have other complex co-occurring conditions, such as severe mental health conditions.
Some units have access to urgent laboratory results and integrated record systems.
Some units can offer virtual ward rounds with primary and secondary care services as an expansion of multidisciplinary team working.
Assessing and managing mental health conditions
All specialist inpatient medically assisted withdrawal units should be able to provide assessment and management of mental health conditions. Mental health problems may manifest during medically assisted withdrawal or may be part of an ongoing co-occurring mental health condition. These could include common mental health conditions, such as depression and anxiety, and severe mental health conditions, such as psychosis.
Core elements
Core elements of assessing and managing mental health conditions include team competencies and arrangements in the following areas.
Staff are able to carry out a mental health assessment, risk formulation and assessment and manage mental health conditions.
Staff are able to apply the appropriate legal framework to assess mental capacity and manage issues where people lack the relevant capacity (see annex 1 for relevant national legislation and guidance).
Staff have knowledge and experience of the Mental Health Act, Mental Capacity Act (including the Deprivation of Liberty Safeguards), or equivalent legislation in the devolved nations. They should also understand how these apply to patients undergoing medically assisted withdrawal (see annex 1 for relevant national legislation and guidance).
The unit has robust risk management plans and safeguarding procedures in place to either implement these legal frameworks or urgently transfer the patient to the appropriate facility.
The unit has clearly established pathways to inpatient and community mental health services.
The team provides trauma-informed care, recognising that many patients will have experienced trauma. The unit has developed pathways for ongoing management of trauma-related mental health difficulties both during and after medically assisted withdrawal.
You can read more about trauma-informed care in section 2.2.8 of chapter 2 on the principles of care.
Additional elements that can enhance service provision
Where units have the appropriate quality governance frameworks, facilities and staff competencies they may be able to provide one or both of the following elements.
Staff manage severe acute behavioural disturbances associated with imminent risk to self and others, for example through using the Mental Health Act or equivalent national legislation, rapid tranquillisation and seclusion, as appropriate (see annex 1 for information on national legislation and guidance).
Staff with appropriate approval in the team are able to assess and apply the Mental Health Act and manage patients detained under the act or other equivalent national legislation.
Medically assisted withdrawal in patients with co-occurring substance use
All units should have competencies to manage medically assisted withdrawal from alcohol in patients who are using a range of licit and illicit drugs, including opiates, stimulants or sedatives, in addition to alcohol. Some patients will continue to be prescribed medication (for example, methadone or benzodiazepines) during the medically assisted withdrawal, while some patients will require medically assisted withdrawal from additional substances as well as alcohol.
Core elements
Core elements of managing patients with co-occurring drug use include the following.
Staff competence within the team to understand and assess the importance of co-occurring substance use and how this may affect the medically assisted withdrawal from alcohol.
The unit has appropriate protocols and procedures for managing a range of complex medically assisted withdrawal often required in this group. For example, this could include patients who are also using benzodiazepines, GBL, new psychoactive substances, crack cocaine or methadone.
Additional elements that can enhance service provision
Some units will have the necessary staff competence and arrangements in place to manage more complex medically assisted withdrawal from alcohol and one or more substances at the same time.
You can read more about medically assisted withdrawal from alcohol for people who have co-occurring drug use, including co-occurring benzodiazepine dependence, in section 10.6.1 of chapter 10 on pharmacological interventions. You can read guidance on drug use and dependence, including medically assisted withdrawal, in Drug misuse and dependence: UK guidelines on clinical management.
Alcohol related brain damage
All specialist medically assisted withdrawal units should have competencies and procedures to identify possible ARBD and develop assessment and referral protocols for ongoing management.
Core elements
Core elements of managing patients with alcohol related brain damage include the following.
Competence within the team and procedures to complete routine psychometric screening for possible ARBD using a validated tool, such as the Addenbrooke’s Cognitive Examination - III (available through the NHS Scotland Addenbrookes Cognitive Examination page). The team may also use the ‘Montreal Cognitive Assessment’, available on the MoCA Cognition website (the test is copyrighted and requires registration and payment).
The unit has established pathways for referring patients for a specialist neurological assessment and treatment where ARBD is suspected or indicated following screening.
Staff have knowledge and expertise in applying the Mental Capacity Act or equivalent national legislation in relation to patients with ARBD.
Staff tailor communication and psychosocial interventions to the needs of people with ARBD (see chapter 20 on alcohol related brain damage for guidance on tailoring communication and interventions).
The unit has a multidisciplinary approach to discharge planning.
Additional elements that can enhance service provision
Some units have access to a full multidisciplinary team during the admission to assess the ongoing treatment requirements for patients with ARBD and help refer them into appropriate therapeutic settings. The team can include input from neuropsychology, social work, physiotherapy and occupational therapy.
You can find guidance on ARBD in chapter 20.
12.7.3 Safeguarding
Core elements
All specialist inpatient medically assisted withdrawal units should comply with national safeguarding legislation and statutory guidance. You can find information on safeguarding legislation and statutory guidance for each of the UK nations in annex 1.
Core elements of this provision include the following.
The unit has organisational safeguarding procedures and governance structures in place. It complies with relevant national legislation on child and adult safeguarding.
All staff trained in child and adult safeguarding and able to make a safeguarding referral.
The unit has mechanisms to involve patients’ family, partner or appropriate friends in safeguarding risk assessment, care planning and treatment decisions.
All staff trained to make routine enquires on domestic abuse and respond appropriately to current risks.
Additional elements that can enhance service provision
Additional elements that can enhance service provision include some units having access to dedicated social workers.
12.7.4 Psychosocial interventions
Core elements
All specialist inpatient medically assisted withdrawal units should provide therapeutic support based on the principles of care set out in chapter 2. Core elements of therapeutic support include the following.
The unit’s ethos and approach of staff towards patients is non-judgmental, empathic and non-stigmatising.
Staff provide culturally competent care.
The service and staff provide a trauma-informed approach to care. This includes helping people to manage distressing thoughts and feelings that might become apparent during the medically assisted withdrawal process. And where appropriate, assessing the person for any ongoing trauma-focused treatment they may need.
Individual and group psychosocial interventions are available, and staff are proactive in encouraging patients to engage in psychosocial support based on individual assessment.
The service offers psychosocial interventions including:
- motivational interventions
- psychoeducational interventions providing information on alcohol dependence and basic harm reduction advice (see chapter 8 on harm reduction)
- relapse prevention support and recovery planning for patients after discharge
Staff help patients to access mutual aid groups (such as Alcoholics Anonymous and SMART Recovery programmes) or peer support groups that may run in the unit and promote their value as part of a recovery support plan (see chapter section 5.5.4 of chapter 5 on facilitating access to mutual aid and peer support and chapter 6 on recovery support services).
Staff identify mental health conditions and provide support and information for ongoing management of these conditions through national and local pathways to psychological therapy services, and bereavement services.
Staff provide information and support for families, partners or supporting friends.
Additional elements that can enhance service provision could include
Additional elements that can enhance service provision could include some units having:
- 7-day availability of a therapeutic support service
- initial psychological support based on evidence-based approaches, such as cognitive behavioural therapy for common mental health conditions, including post-traumatic stress disorder
- mindfulness-based relapse prevention
- family interventions delivered by a family therapist, such as initial assessment and referral for ongoing support
- couples-based interventions delivered by a couples or family therapist, such as initial assessment and referral for ongoing support
You can find detailed guidance on psychosocial interventions in chapter 5.
12.7.5 Pharmacological interventions for relapse prevention
Core elements
All clinicians in specialist inpatient medically assisted withdrawal units should be competent to provide pharmacological interventions for relapse prevention, including prescribing acamprosate, naltrexone and disulfiram.
Additional elements that can enhance service provision
Experienced specialist clinicians may also prescribe baclofen and other novel medications based on clinical assessment. This should be done in consultation and with agreement of clinicians continuing the care plan after discharge.
You can find guidance on pharmacological interventions for relapse prevention in section 10.5 of chapter 10 on pharmacological interventions.
12.7.6 Out of hours cover
Core elements
All specialist inpatient medically assisted withdrawal units should have arrangements for out of hours cover and make sure that these are adequate for the safe running of the unit and the number of patients they treat. Core elements of this provision will include:
- at least one registered ILS trained nurse and one other appropriately trained member of staff (larger units require additional staff)
- 24-hour in-person clinical cover for acute assessment and management of withdrawals
- out of hours on call cover arrangements that can:
- provide access to medications
- arrange for replacement staff to respond to any staff shortages
- respond to medical emergencies and overall be able to manage acute withdrawals
- respond to safeguarding concerns and incidents affecting the safe running of the unit
- have a duty doctor, consultant psychiatrist or senior clinical manager available on call to support these arrangements
Additional elements that can enhance service provision
Additional elements that can enhance service provision include some units having access to on-call pharmacist provision.
12.7.7 Referral pathways
Services have two-way referral pathways, and they communicate effectively with these other relevant services to provide comprehensive assessment, care and discharge planning for their patients. All units should be able to confidentially share patient information appropriately across systems. Pathways should include:
- GP and wider primary care, including community pharmacy
- secondary care and acute hospitals
- primary, secondary and crisis mental health services
- safeguarding and social care services
- community alcohol treatment services and residential treatment services
- psychological services
- neuropsychology services and memory clinics
- housing and homelessness services
- criminal justice services
- community services, such as domestic abuse services
- lived experience recovery organisations and mutual aid groups
- support organisations for family members and carers