Looking for some advice from anyone with experience of setting up local alcohol detox protocols based around primary care.

In a nutshell our local area has a high historical reliance on inpatient detox in our GP led community hospital. Often patients are admitted in crisis situations... are detoxed for a week then come back again some time down the line (often within a few months) requesting detox again.

I am keen to rationalise the service, and prevent what i see as an abuse of health care resources (not to mention the negative effects on the potential for bringing about change in the patients lives as they become so medically dependent!)

Obviously the SIGN guideline gives a good starting point, but I would be grateful if anyone has any useful info/links to research that points to the appropriate use of expensive in-patient resources/ the negative effects of hospitalisation/ any evidence that crisis detoxification is inappropriate. Basically, it seems obvious to me - but could do with some hard evidence to back up any proposed changes that i might put forward.

There also seem to be issues with some switched on patients gaming the system to some extent - claiming to have haematemesis for example when no objective evidence for this can be found whilst they are admitted... giving them an easy route to inpatient detoxification. Do any of you have experience of sticking to a strict early discharge policy with these patients before they have been weaned off the drink... if so how do you manage the risk? Similar problems occur with people claiming that they will kill themselves if they arent admitted as an emergency for detox (the old issue of CPN's not wanting to assess drunk patients... but someone having to take on the responsibility for sending these people home.) Other than the obvious 'do a risk assessment on each situation as it arises' does anyone have experience of adopting a hard line in these situations? Any experience of the legal ramifications of things gone wrong?

Sorry for all the questions - cheers for any help you can provide.

Interesting article in the Sunday Times magazine, see below. Food for thought.
http://www.timesonline.co.uk/tol/life_and_style/health/article4861010.ece

Thanks for that link.. it is food for thought indeed.

Personally i never give patients a bunch of librium and tell them to detox themselves - I am far too concerned about the possible sequelae of trying to do this at home unsupervised. The authors disparaging remarks about community nurses supervising detoxes are inappropriate - they do a great job in my experience and undoubtedly make the whole process a lot safer.

Our local problem isn't that we don't have enough resources for helping alcoholics who want to detox to do so. It's that it is often being done in what i view as being a negative fashion - i.e. in crisis situations, with a reliance on in-patient detoxes that patently dont lead to long term change.

Hi Doc
I've read your post several times and struggled with how to respond. The situation you describe seems so inherently wrong on both clinical and psychological grounds, as well as being bad use of healthcare resources, that I certainly agree with you it needs changing!
I think there are three sorts of evidence that you could use to back this up
1. kindling - it is thought that the threshold for fitting in withdrawal goes down the more times you have withdrawal fits.
2. Wernicke's - detoxing someone in a crisis gives you very little time for thiamine loading pre-detox with the risk of precipitating Wernickes encephalopathy
3. Self-efficacy is enhanced by achievement, reduced by failure - there is a body of psychology literature on the subject.

You could also mention, along with SIGN, that the approved stepped care aproach as cited in MoCAM would suggest that the expensive inpatient detox should be reserved for those who truly need it on clinical or social grounds.

But having won the argument you still have to win the war - I sense there will be a great deal of cultural resistance to overcome here.

Thanks susi. Some good points there which I might well be able to use.

The MoCAM information was also something i wasn't aware of - thanks for pointing me in the right direction.