Welcome to the Australian Prescriber Podcast. I'm Ashlea Broomfield, your host for this episode, and it's a pleasure to be speaking to Dr Chris Davis who's a GP in Darlinghurst with an interest in alcohol.
Hi. How’re you going?
Good. How are you?
Really well thanks.
So, Chris you've written an article for this edition of Australian Prescriber on allowing patients to have a home detox from alcohol, and that can be a little bit tricky in general practice in terms of picking the right patient and getting the right systems happening. So, could you talk a little bit about what's important to do before you start somebody on home detox programs?
Yeah absolutely. I guess it's important to say that the vast majority of dependent drinkers can actually be detoxed safely in their own home, but it does take a lot of planning to ensure that it is safe because there are inherent dangers with alcohol withdrawal, those of seizures and delirium, but with good planning and assessment in the vast majority of cases it's a safe process to undertake. I see a home detox in three main stages. The first one is when they approach you for help with their drinking and it's really important that you engage them at this stage because it's a wonderful thing that they're trying to do a real positive lifestyle change so being very encouraging and using motivational interviewing techniques to keep them engaged at this point is really important. To then get them ready for the change so making sure their mindset is in the right place and I do this by utilising online resources like This Naked Mind is great. The Daybreak phone app is fantastic. I get them to keep drink diaries to increase their awareness around their drinking and how the drinking is actually affecting them. You know the good and the bad. I use this first sort of part of it to get them to be curious about their habit about what makes them drink and sort of ensure that they're ready to go through a detox.
So what kind of patients would you say are not suitable for home detox? How would you kind of say this person is probably a risk of not being able to complete a home detox?
You can do quite a lot of work with someone before their detox and really the main reason I can't detox somebody at home is that they don't have a support person to be there for those sort of risky first three to four days of the detox so it is important that they have someone who's there with them most of the time. I have detoxed hundreds of people at home and I've never had anyone have a seizure or go into the DTs and that's because they're well assessed and generally the mild to moderate end of the spectrum but it's nice to know that they're supported by a family or a friend. The other things that would prevent me from doing a home detox would be someone who has a history of seizures especially withdrawal seizures, someone who has complex medical history, but someone who really has end-stage liver failure, history of epilepsy, someone who is actively suicidal or has uncontrolled mental health issues, and these are really the people who definitely need specialist support. They also need the support of a good GP however. So you might not be able to detox them at home on your own but you can certainly be there to help in their recovery from alcohol.
And so what kind of assessment tools and planning do you do to ensure that you're able to safely detox patients at home?
So in my assessment pack I have an AUDIT questionnaire which is the screening tool to see if there is any alcohol dependence. I also use the SADQ – the severity of alcohol dependence questionnaire – and that gives me an idea of how severe their withdrawals are when they don't drink and the severity of their dependence. I also use a K10 and I do a suicide, quite an in-depth risk assessment. I also ask general questions like do they have a history of withdrawal seizures, did they use other drugs? I put that all in the pack in case I forgot to ask.
And so when you talk about the AUDIT are you talking about the AUDIT-C?
And once you've decided that somebody's suitable for the home detox program, how do you ensure that your staff are kind of on board in terms of the process?
Absolutely, it's really important that everyone knows what you're doing. You certainly need help from a practice nurse who you've been able to talk through the process, but once the structure is in place and it really is a simple structure the home detox is really easy, so on day one, and the patient's well prepared, they've been having their thiamine, they've done their drink diaries, they're mentally ready, they've seen your alcohol counsellor perhaps, they might have gone to an AA meeting, you've met with their support person and day one of detox comes, they would have had their last drink on the Sunday night early on, around eight o'clock, and they come and see you Monday morning and they see your nurse first and the nurse will do a breathalyser and blood pressure and then I'll administer a CIWA [Clinical Institute Withdrawal Assessment] score which is a withdrawal assessment questionnaire which is better used in the community than the hospital ones. And from those scores you can then use the prescribing guideline to determine how much Valium they're going to use for that day. So then they come through to the GP who has this information already from the nurse, so the hard works already been done by your nurse. I assess them, talk them through what that day is going to look like. I have a handout just to explain what to expect when they go home, what to do in the case of a seizure. I used to give them a prescription. Now I have a locked drawer with Valium that I sign out with the nurse and I give them a day's worth of Valium with a medication chart advising them when they should take their Valium. That's flexible and I just get them to write down how much they've taken and when they've taken it, to bring through to me the next day. On day one I get them to do a urine drug screen as well and that's really to make sure there's no benzos in their system already.
And is that a spot urine drug screen that you do?
Absolutely just a spot urine drug screen. And then every day, they come in every morning, they see my nurse first, they get breathalysed, I do the withdrawal questionnaire, and we check their blood pressure and gradually wean them off the Valium over the week. So you really need a consistent GP to be there for the first four days ideally. I mean you could share it with a colleague but you need a practice nurse 15-minute appointment and a GP 15-minute appointment Monday to Thursday. That's how I work it. I then see them the following Monday to do a post-detox review. I generally give them some Valium to deal with cravings over that risky first weekend off the booze, and then on the post-detox interview we talk about anti-craving medications, generally naltrexone is my go-to but I also have used Campral [Acamprosate] and Antabuse [disulfiram] for highly motivated patients as well.
And are these patients typically already enrolled in a support program such as Alcoholics Anonymous or linked in with a drug and alcohol counsellor or do you do that with them once you finish the detox?
Generally I'm often the first port of call for people who haven't asked for help before, that people feel stigmatised by approaching AA, or going to specialist drug and alcohol units where they may find themselves in a room with people who are waiting for their methadone dose, and drinkers don't see themselves in the same community as drug users. So being a GP gives you a huge advantage in that it's completely confidential and they could just be coming in for a skin check. Sometimes they may have tried before themselves, they may have been through services, they may know about AA, but certainly that's part of my work up is to make sure that they have as much wraparound support as possible.
So you were talking a little bit before about this assessment tool kit that you have. Where are these kits available from, and where can GPs find them from to help assist them and their staff?
In the article that I've written for Australian Prescriber the three main questionnaires that I use there are links in the article to those questionnaires and they're readily available online.
I wouldn't recommend any GP goes ahead and does a home alcohol detox unless they feel comfortable doing it because there are those risks of seizure. However any GP can do this with just a little bit of training and a little bit of structure. There's a fantastic article in the AFP by Associate Professor Apo Demirkol in 2011. It quite neatly explains the process. They can have a look at my article but then there's also the NICE guidelines, and the New South Wales Drug and Alcohol Withdrawal guidelines are all very clear and certainly what I do is really just follow the guidelines.
Excellent. So how much does a breathalyser cost and where do you get a breathalyser from?
That’s a good question. We got ours online I think we got one that the police use so we knew we were going to have a lot of use out of it so I think we paid maybe three or four hundred dollars for ours, but you can get them much cheaper.
And you have to get it validated every year?
Yeah, we get it validated every year just like every other part of doctors’ agreement.
What I would really want to get across is how amazing it is and how satisfying it is to be able to help someone through a home detox, to see someone come to you when something has gone wrong in their life and probably alcohol being either a cause or a symptom of that, so they’ve often lost their job or their wife, they've lost their driving license, they've ended up in hospital or in court, something pretty bad has happened and they come to you for help, and to be able to say I can help you and things will get better with conviction is amazing. And you get to meet their families, you go on the journey with them, you see them every day through the detox, and then when you see the patient after detox you know their whole life has changed and it is a real privilege to be able to help patients go through that. It really is the most satisfying thing, the most incredible thing that I have done in medicine, and I really wish more GPs would get involved because there's a massive need for it and it is hugely satisfying.
You've definitely inspired me.
Well that’s good.
So unfortunately that's all the time we've got for this episode. Thanks for joining us today.
Yeah thanks very much.
The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicinewWise.