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2 December 2020
Joshua Stapleton, clinical service lead for King’s College Hospital NHS Foundation Trust Alcohol Care Team, shares how the team have been helping to improve outcomes for patients.
The Alcohol Care Team (ACT) launched in October 2018 to ensure that alcohol and opioid-related referrals are directed to the most appropriate services. By engaging and reassuring people, and linking them into the right support structures, over the past two years the team has helped support hundreds of people on their journey to recovery. As a result, the team has also helped reduce admissions and length of stay for these patients, easing the strain put on emergency.
Over the past 12 months, there have been more than 2,200 ACT referrals. The team have put several measures in place to improve pathways of care for these patients, in mental health, acute care and community settings. We hear from Joshua on why these measures are so vital and how the team continue to improve outcomes for patients two years on.
Addressing mental health
People with mental health problems such as anxiety, depression, post-traumatic stress disorder, personality disorder and bipolar, are at increased risk of developing alcohol dependence. Alcohol dependence in turn is associated with the development of depression and anxiety. This can be a major barrier to accessing mental health treatment, even in crisis. Waiting lists or the requirement for abstinence to access mainstream psychological therapies can lead to a relapse in mental health, in turn triggering an alcohol relapse.
The World Health Organisation estimates that alcohol is responsible for one in five suicides worldwide. Alcohol dependence results in a nine-fold increased risk of suicide and even in the absence of alcohol dependence, people are six times more likely to attempt suicide on a heavy drinking day than a day without alcohol. Yet in many cases, patients who are seen following a suicide attempt associated with intoxication are less likely to be admitted to psychiatric hospital than those who are not alcohol dependent.
Additionally, ACT referral numbers increased rapidly to 10-20% higher than usual during the summer months this year, averaging 216 referrals a month between June and August. Patients have reported that the loss of structure and meaningful activity during the lockdown enforced in response to COVID-19, and the stress that comes with that, have precipitated relapse, or led to an escalation to alcohol dependence.
What the team are doing to help
A visit to the acute hospital has been described by patients with alcohol problems as a pivotal moment where they were finally put in touch with the specialist care they need. Treating withdrawal effectively and providing the necessary support means we can minimise psychological distress in this initial period.
In 2017 Public Health England produced guidelines that state the principle of 'no wrong door' - that a patient with comorbid mental health problems and addictions should receive assessment and appropriate treatment or onward care planning wherever they come for treatment, something our team fully supports.
We are working closely with the liaison psychiatry team to improve joint working around patients who present in suicidal crisis while intoxicated. We are also auditing our care, as part of our commitment to making sure this guidance is followed at King’s College Hospital NHS Foundation Trust. We have partnered with Dr Calcia, who is part of the Trust’s liaison psychiatry team, to audit our care against this standard and look to ways of improving the quality of crisis care.
Additionally, we have provided training in suicide risk assessment for the nurses in our team with a physical health background, and staff have had the opportunity to shadow the psychiatric liaison nurses to gain an understanding of crisis assessment and onward care planning. Senior members of the team also regularly attend the Southwark Dual Diagnosis Working Group to optimise joint working between community addictions services, community mental health services and our team.
Those patients presenting in psychiatric crisis or those who we become concerned about during admission, receive a psychiatric assessment from our supportive Liaison Psychiatry Team. In this group, we bring our perspective that most of our patients are not in psychiatric crisis; that while our patients are at increased risk of suicidality, crisis is still unusual, and most of our patients want desperately to live. It allows us to ask more nuanced questions that can help determine social factors which underly the patient’s desperation, and what interventions might be of most help.
Integrating acute care services
Data collected by our team shows that more than 80% of alcohol care patients also suffer from at least one chronic condition in addition to alcohol dependence. In fact, patients have a median of three chronic conditions, most commonly: hypertension, depression, and alcohol-related liver disease.
What the team are doing to help
Integrated care is essential for management of multi-morbidity, so our team have been focusing on developing a fully integrated liver service. We have introduced fibroScan screening for alcohol-related liver disease - a type of ultrasound which measures scarring in your liver due to liver disease. The team have scanned all patients admitted with an alcohol-related condition, and we have been able to help more than 200 patients.
Following these scans, we are able to refer patients with a fibrosis score indicating advanced fibrosis to the combined liver kidney clinic, jointly run by Dr Sapna Shah, consultant nephrologist at King's College Hospital NHS Foundation Trust and ACT consultant hepatologist, and Dr Nicola Kalk, ACT consultant addiction psychiatrist. Here we provide a comprehensive addictions assessment within the liver clinic and enhanced links with community addictions services. Where necessary, we can provide initial relapse prevention medication tailored to those with cirrhosis and psychiatric formulation.
We are looking at ways we can refine our alcohol-related liver disease pathway even further, so that an initial motivational intervention with a senior member of the team occurs while patients are in hospital, and additional interventions take place when patients are in clinic.
A major role for the team is also to increase skills relating to addiction in the acute hospital system. This year we have expanded our activities in training, welcoming three South London and Maudsley NHS Foundation Trust specialist registrars to spend part of their addiction’s placements or special interest sessions with us. We are also due to start welcoming nursing students to upskill in the new year.
Extending care beyond the hospital
Treatment and support to those battling addiction should not be limited to acute healthcare settings. It has been crucial to strengthen the foundations in place to support patients this year, including improvement to the alcohol treatment guidelines and collaboration with services within the local community.
Following the recent examination of whether vitamin D deficiency is a problem in our population, research has shown that that vitamin D deficiency may relate to proximal myopathy: a disease of the muscle that leads to both falls and fractures. We have found that two thirds of our patients had insufficient vitamin D and more than 50% had vitamin D deficiency, putting those with alcohol dependence at higher risk of repeat attendance due to injury.
The team also supports patients with opioid dependence and has found that the month following hospital discharge is associated with an 11-15 fold increased risk of overdose, and we are calling for improved measures beyond acute care services to minimise this risk.
What the team are doing to help
ACT has played a significant role in expanding the alcohol treatment guidelines, helping provide more detailed guidance on alcohol withdrawal in patients with liver disease and those suffering from alcohol withdrawal delirium.
The team has responded efficiently to the national prescribing policy changes made to opioid treatment and support measures during this COVID-19 pandemic. These changes have meant that patients have been given one-to-two weeks of methadone to take home, instead of a daily dose. We are currently exploring the possibility that ACT clinicians could train patients at risk of overdose and their loved ones to administer naloxone at home for prevention of opioid overdose and be given a supply before hospital discharge. At present this is provided by community addictions teams, needle exchanges and some pharmacies, but over half of our opioid using patients are not in touch with addictions services when we first meet them.
We have worked with local Alcoholics Anonymous (AA) representatives to facilitate hospital in-reach. AA volunteers come on a Tuesday evening to see patients on the wards, helping them to get access to local AA meetings that can support their recovery.
It has also been recommended that homeless patients be started on buprenorphine, because of its greater safety profile. ACT has been responsible for urgently re-writing the opioid substitution therapy guidelines in short order to reflect these changes.
We are seeking advice from pharmacies about whether people identified to have vitamin D deficiency alongside alcohol dependence could be considered sufficiently high risk to be included in the groups to receive blind prescribing.
Overall, the pandemic has provided an unexpectedly positive development in the way we communicate with our community addictions partners. Microsoft Teams has been more widely adopted so that we have a seamless, secure channel of communication to arrange appointments for patients accessing both acute and community services. We are currently exploring ways to provide a continued motivational intervention via telephone to enhance engagement with community services, and when COVID-19 restrictions lessen, we plan to recruit peer support workers to escort patients to their community appointments.
The significant amount of work done by the alcohol care team this year will make a huge difference to pathways of care for those battling opioid and alcohol dependency. These improvements are even more impressive when acknowledging that all but three members of the team were redeployed to alternative medical settings as a result of the COVID-19 pandemic.
