Last month's research roundup provided you with an overview of articles looking at the many and varied uses of botulinum toxin. The articles reviewed looked at the prescribing in glabellar lines, the use in overactive bladder conditions and in the management of hyperhidrosis (Robertson, 2022). This month, we will review three articles all with a relationship to prescribing in alcohol dependence. The first article looks at prescribing for alcohol detoxification while the second focuses on withdrawal syndromes. The final article looks at medication factors and patient characteristics in people admitted to hospital with an alcohol-related condition.
Quality improvement within a mental health setting: alcohol detoxification
This first article, published in the Irish Medical Journal in January 2022 (Doody et all, 2022), presents the findings of a clinical audit on alcohol detoxification within the National Institute of Health and Care Excellence (NICE) guidelines (NICE, 2010). It comprised a retrospective patient chart review for patients admitted during a pre-defined six-month period in 2016-2017 for prescription of an alcohol detoxification schedule and who met the study inclusion criteria within a single mental health service. This service comprised two hospitals with 293 beds and specialist units including the addiction services centre. Three cycles of the audit were completed with the first cycle being part of a larger international audit, Prescribing Observatory for Mental Health, UK (POMH-UK). The audit was to determine adherence to the guidelines around diagnosis and management of physical complications in alcohol-use disorders. The rationale for this was to improve and maintain rates of successful detoxification with minimal complications as an alcohol-use disorder is associated with increased morbidity and mortality. Outcome measures used were derived from the gold standard guidelines and included a thorough alcohol history, documentation of physical examination, monitoring of vital signs and investigation of liver function. Further recommendations included screening for Wernicke's encephalopathy and monitoring of breath alcohol levels as well as documentation of chlordiazepoxide and thiamine prescription regimes.
Within the 6-month period, 1143 patients were included in the POMH-UK study and 63 of those from this one mental health service audit. With regard to the alcohol history, the single mental health service showed better adherence to the NICE recommendations that the POMH-UK study in four key areas. These were estimated daily units (92% v 77%), prior detoxification (92% v 73%), duration of misuse (79% v 48%) and misuse identified date (60% v 53%). The second and third cycles of audit in the single service showed consistent improvement across three of the areas but with a drop in the third cycle for misuse identified date. The review of physical examination and investigations data showed a similar response with the single mental health service outperforming the POMH-UK in seven measures reported. Most notably the POMH-UK only reported 48-59% for signs of encephalopathy with the single service showing 85-92%. With the prescription of chlordiazepoxide and thiamine, the POMH-UK showed rates of 92% with the single service showing at 100%. The authors conclude that the results of this audit reveal that compliance to NICE recommended standards within this mental health service exceeded that of the benchmark POMH-UK data. They suggest that the effectiveness of electronic patient records in improving adherence to guidelines is evident. They also show by using repeat cycles of audit that areas of low achievement can be targeted and improved upon or that good adherence can be maintained to the recommendations.
Clinical management of alcohol withdrawal syndrome
This clinical review published in the Journal of Addiction in March 2022 sought to discuss key elements of medically assisted withdrawal from alcohol from the clinical management perspective (Day and Daly, 2022). Factors and barriers to completion of a detoxification programme as well as pharmacological management are well explored in this review regarding withdrawal syndrome. This review is in a narrative format and is directed at prescribers working in specialist addition units where planned, medically assisted alcohol withdrawal programmes are implemented as part of the patient treatment and recovery plan. The authors give a good overview of withdrawal states and characteristics including pathophysiological changes before outlining the objectives of clinical management of withdrawal from alcohol dependence. The fact that up to half of the individuals with a history of long-term, heavy alcohol consumption will experience alcohol withdrawal syndrome when consumption is significantly decreased or stopped is a driver to explore this area. It is known that severe alcohol withdrawal can be life-threatening and by acknowledging this and medically managing detoxification, serious outcomes can be minimised. Within the withdrawal syndrome, symptoms such as delirium tremens and seizures should be aimed at preventing these or managing them early if they occur. They suggest that best practice involves daily monitoring by a specialist for any signs and symptoms and in community settings the prescribing is often done by the GP, with the primary medications being benzodiazepines. They report on studies that suggest that community-based programmes with this in place have a higher completion and safety rate compared to hospital-based treatments, however, higher-risk withdrawal patients are better managed in an inpatient setting.
The suggested withdrawal timeframe is between three and 10 days with the crucial period for symptom development in the first 48-72 hours. Prescribing in this period helps prevent or minimise effects with chlordiazepoxide being the commonest benzodiazepine used. Dose regimes can be simple, fixed-dose reducing or a more complex symptom-triggered mechanism of prescribing may need to be used. This is why specialist monitoring is so vital as it may need to be reactive.
The authors suggest that the optimum prescribing input should maximise the controlled withdrawal from alcohol, reducing the risk of complications and prevent long-term damage and prevent relapse.
Medications and patient factors associated with increased readmission for alcohol-related diagnoses
This original research article, published in February 2022 aimed to investigate medication factors and patient characteristics which could be seen to be associated with readmission events after a hospital stay for an alcohol-related or induced reason (Osborne et al, 2022). The research team identified participants using electronic patient record systems for the period from September 2016 to August 2019 in a single medical centre in Rochester, Minnesota. Inclusion criteria were aged over 18 and admitted to hospital between the inclusion dates for an alcohol-related diagnosis as defined by ICD10 criteria (World Health Organization, 2019). Exclusion criteria were direct mental health reasons admission and admissions requiring intensive or hospice care, and any patient who died during the admission. The research's primary outcome of interest was to identify medications and patient factors that could be associated with readmission within 30 days of the alcohol-related episode. The secondary outcome of interest was to review multiple readmissions within 1 year. The patient characteristics of interest were numerous but included age, patient-reported gender, BMI, race, psychiatric history, marital status, alcohol withdrawal severity score (CIWA) and medication exposure. The medication included approved drugs for alcohol use disorder such as benzodiazepines.
In total 932 patients met the criteria to be included in the study having had a readmission. The median age was 52.6 years and the majority were caucasian and identified as male. The median length of stay for the initial admission due to alcohol-related factors was 3.1 days and 8.3% (77) of these patients were admitted for intensive care. The patient factors identified that were significantly associated with readmission were younger, had a higher severity of withdrawal score, had a history of psychiatric illness and had more alcohol-related admission in the past. From a prescription drug perspective, increased risk of admission was seen with benzodiazepines and barbiturates but not with gabapentin. The authors conclude that their findings confirm the information in current literature that specific patient factors can have a significant effect on readmissions.
Conclusion
Prescribing in the field of alcohol and substance misuse is a complex and often lengthy process whether this be for detoxification or prescribing around the alcohol misuse and its resultant issues. Guidelines are useful in supporting.
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