Post-its from Practice:
The poor state of in-patient alcohol detoxification (May 2007)
A few weeks ago I had to admit John as an emergency to an acute medical bed. John who was in his early 50's and had suffered a haematemesis (vomiting of fresh blood). He was seriously unwell on admission and although improving remains very poorly.
John first came to see me about 8 weeks ago. He informed me that after 7 years of being abstinent from alcohol he had relapsed about 8 months ago. He was drinking at least a bottle of vodka a day as well as several (4-6) cans of 9% lager (about 53 units/day). On examination he was already showing signs of liver damage and his liver function results were seriously alarming. He had managed to gain 7 years of sobriety following an in-patient detoxification and he pleaded with me to arrange the same again. He declined individual and group counselling and he explained that AA hadn't worked for him. He knew it was in-patient detox that would work for him. He also knew that he had no chance doing it in the community.
I agreed and said I would do my best but had to explain to him that "urgent" and "detox" weren't two words that go together in our area (and I know that it is far worse in other areas). On his next visit we completed the forms, faxed them off and got him on the urgent waiting-list. His date to for admission was 4 days after he presented as an emergency.
What I can't say for certain is whether John could have avoided this life threatening episode, if I had been able to get him a bed when he first presented. What I do know is that his chances of good recovery would have improved dramatically.
Where I work I am more fortunate than many of my colleagues who have no access to specialist in-patient detoxification beds. The service available to us did try to get John in as an emergency but because of funding and waiting lists the first available bed was given to him several weeks after he first asked for it. Dr Ed Day in his "In-patient drug treatment survey" in December 2004 found that 41% of detoxifications were for alcohol, only 29% of all of detoxifications were provided in specialist units, there were not enough beds, there was no consensus on management and there were poor links to aftercare.
I would suggest that, as with John, alcohol detoxification is often an emergency and we should be able to treat it as such. Additionally John was extremely motivated and personally I worry when motivation is almost used as a weapon to exclude people from services.
Perhaps we need to rethink our supply and entrance criteria for detoxification both for alcohol and other drugs? The NTA said that access to in-patient detoxification should be within 4 weeks for 2002/03 and 2 weeks from 2003/04 onwards (Ref 1) - are we even close to achieving this? Plus I would have preferred to admit John as an emergency on the same or next day of presenting - do you agree?
1. NTA In-patient drug (and alcohol) misuse treatment March 2003