Treatment Pathways

Step Pathway Details
Step 1 – Triage
    • Referral: Referrals can be taken online, by phone, via family or other professionals, or self-referred.
    • Triage Assessment: Complete Timeline up to AUDIT. (For alcohol: If AUDIT score ≤15, follow one pathway; if AUDIT score ≥16, follow an alternate route.)
    • Case Record: A summary case record is completed by the Single Point of Contact worker via a central form (see current guidance on Summary Case Records).
    • Identification: At triage, for alcohol cases: complete 12 alcohol physical health questions; if criteria (e.g. no pregnancy, no CJIT involvement, no relapse prevention medication requests) are met, STOP PATHWAY and REFER TO A Better Life (ABL).
Twelve Questions to Ask about Alcohol-Related Physical Ill Health

These 12 questions are designed for the generic worker to ask when discussing alcohol-related physical health. They aim to raise awareness of the potential risks of alcohol to one’s health. Please ensure you ask for permission before proceeding and encourage the individual to seek medical advice (e.g. contact their GP or NHS 111) if any issues arise.

1. Do you ever experience a painful feeling of heaviness or tightness in your chest?

This question explores whether there have been any symptoms of a heart attack. If the individual answers “yes,” ask when they last experienced the pain and its duration. If the symptoms are active, advise immediate medical attention – call 999 for an ambulance.

2. Have you coughed or noticed blood in your vomit?

This question is aimed at identifying gastrointestinal issues such as a Mallory-Weiss tear. Bright red blood or a “coffee grounds” appearance in vomit may indicate a serious problem. If the response is positive, advise the person to seek medical attention promptly.

3. Have you ever noticed or has someone commented that the whites of your eyes or your skin have turned yellow?

This question is designed to detect signs of alcoholic liver disease, such as alcoholic hepatitis. A change in colour can be a potentially life-threatening indicator. Advise immediate medical attention if this symptom is present.

4. Have you passed any blood from your back passage?

This question helps identify bleeding issues that may result from ulceration or oesophageal varices. Ask about the colour and consistency of the blood. Bright red or tar-like (black) blood should prompt medical evaluation.

5. Do you have a sensation of numbness or pins and needles in your feet or hands?

This question aims to detect peripheral neuropathy, which can cause pain, loss of sensation, and muscle control issues. If symptoms are present, consider advising a healthcare review.

6. Have you had a history of head injuries (including non-alcohol related and as a child)?

A history of head injuries may predispose individuals to alcohol-related brain injury or increase the risk of seizures during withdrawal. Ask for details of any past injuries and associated symptoms.

7. Have you lost or gained weight unexpectedly recently?

Unexplained weight changes can signal liver disease (such as ascites) or muscle degeneration. If significant changes are noted, advise the individual to seek medical evaluation.

8. Have you noticed that you bruise more easily than normal?

Easily bruising may indicate impaired liver function and reduced production of clotting factors. A positive response should lead to further medical inquiry.

9. Do you experience or have you experienced a severe, dull pain around the top of your stomach that develops suddenly?

This question aims to detect acute pancreatitis. Since pain may be referred to other areas, clarify the location and severity. Advise immediate medical attention if symptoms are acute.

10. Have you or a relative/carer expressed concerns about your memory?

This question addresses potential cognitive impairment from alcohol. Memory issues may indicate effects on the brain and warrant further evaluation by a healthcare professional.

11. Are you pregnant or thinking about becoming pregnant?

The safest approach during pregnancy is to abstain from alcohol to minimise risks to the unborn baby. Advise seeking medical advice and support if the individual is pregnant or planning pregnancy.

12. When was the last time you had your blood pressure checked or had a blood test?

This question opens up discussion about recent health monitoring. If the individual has not had recent blood tests (e.g. within the last 3 months), encourage them to consult a healthcare professional for further tests.
Step 2 – Personalised Assessment
  • Assessment: Complete a personalised assessment and offer naloxone and BBV screening where appropriate.
  • Consent Forms: Completed consent forms should be sent to your locality administrator as separate files in one email.
  • Medical Assessment: Recovery workers offer a medical assessment as soon as practically possible, with appropriate harm reduction interventions (e.g. Nottinghamshire YouTube harm reduction content, Breaking Free Online workshops).
Step 3 – Offer of Appropriate Support
    • Medical/Healthcare Assessment: For non-opiate cases, this may not be required; for alcohol cases, complete a medical assessment and offer medically assisted treatment promptly.
    • Induction Contact: The recovery coordinator should offer weekly face-to-face contacts during induction (e.g. 4 weeks for physeptone, 2 weeks for Espranor) with a titration checklist completed during each contact.
Titration Checklist

As a minimum, the following information should be determined at the review. Please then email the information to the prescriber for consideration and to make a decision as to whether a change in the treatment plan is to be made.

Regular check-ins: Regular check-ins during the titration period are essential.

  • Drug screen result:
  • Self-declared use of any drugs in the last 7 days:
  • Self-declared use of any alcohol in the last 7 days:
  • Contact with pharmacist: Any missed collections?
  • Other medicines: Are they taking any other medicines at the moment (if so, which ones)?
  • Side effects: Are they experiencing any side effects (especially sedation)? If yes, please give details.
  • General appearance: How do they appear today?
  • Other relevant information:
  • Next clinical review: Has the next clinical review been booked?

Note: Ensure to email the Script Department to post out future scripts once the patient is on the optimal dose.

    • Follow-Up: Arrange the next medical appointment during induction, in line with medic direction, no later than 6 months after.
    • Alcohol Pathway: For cases with alcohol and an AUDIT score ≤15 (and meeting other criteria), refer to the dedicated Alcohol pathway for further advice.
Alcohol Pathway (SADQ Guidance)

This pathway outlines when to refer clients for a nurse assessment or medical review based on their Severity of Alcohol Dependence Questionnaire (SADQ) score and presenting concerns.

  • SADQ <16 (Requesting Relapse Prevention Medication):
    • If there has been no nurse assessment in the last 3 months, refer to your locality nurse for observations and GP summary. Discuss blood test results and next steps.
    • If no immediate medical concerns are identified, no new nurse assessment may be required.
  • SADQ 16+ (No Major Concerns):
    • If the client declines a nurse assessment, inform the locality nurse.
    • If no urgent medical issues are flagged, the assessment can be conducted over the phone, then followed up with blood tests if indicated.
  • SADQ 16+ (Multiple Health Conditions):
    • Refer to the nurse, highlighting any significant health concerns or high-risk factors.
    • If SADQ is 40+ (indicating higher severity), mark as high priority for nurse assessment.
  • SADQ 16+ (Not Dependently Drinking, e.g., Binging):
    • No nurse assessment required unless otherwise indicated.
    • Prescribing decisions may be carried out directly by the medic or nurses as needed.
Step 4 – Ongoing Case Management
  • Post-Induction Contact: Arrange contact every 4 to 6 weeks to review the service user’s situation. Record telephone check-ins as recovery worker contacts.
  • Every 12 Weeks: Conduct a full risk review, complete the treatment outcome profile/combined review form, review the dispensing regime, and discuss naloxone.
  • 6-Monthly: Schedule medic reviews (unless specified otherwise by the prescribing medic).
  • 12-Monthly: Review the safe storage offer, update the Blood Borne Virus (BBV) offer, ensure an up-to-date GP summary, consider a home visit, and update consent forms.
  • Additional Considerations: Needle exchange services remain available; BBV screening is open to anyone who may require it. Some individuals may require more frequent support based on their risk and individual needs.
  • Dual Dependencies: For cases with dual dependencies (e.g. alcohol and opiate), arrange a nursing review prior to the medical assessment.