MANAGEMENT AND DETOXIFICATION FOR GAMMA- … and... · GBL and 1,4-BD also have legal uses and are available to licensed buyers. ... body into GABA which acts on the GABAa receptor

MANAGEMENT AND DETOXIFICATION FOR GAMMA- HYDROXYBUTYRATE (GHB) AND GAMMA-BUTARYL

LACTONE (GBL) GUIDELINES

SEPTEMBER 2017

1 MANAGEMENT AND DETOXIFICATION FOR GHB AND GBL GUIDELINES: PHA61: SEPT 2017

Policy title Management and Detoxification for GHB and GBL

Policy reference

PHA61

Policy category Clinical

Relevant to Medical Staff, Non-medical prescribers and all staff involved in Substance Misuse Services

Date published September 2017

Implementation date

September 2017

Date last reviewed

New Guidelines

Next review date

September 2019

Policy lead Dr Sarah Minot, Consultant in Addiction Psychiatry

Contact details Email: [email protected] Telephone: 020 3317 7900

Accountable director

Dr Vincent Kirchner, Medical Director

Approved by (Group):

Drug & Therapeutics committee 9 August 2017

Approved by (Committee):

Quality Committee 19 September 2017

Document history

Date Version Summary of amendments

Sept 2017 1 New guidelines

Membership of the policy development/ review team

Dr Sarah Minot, Consultant in Addiction Psychiatry

Consultation

Substance Misuse Services Consultant Group

DO NOT AMEND THIS DOCUMENT

Further copies of this document can be found on the Foundation Trust intranet.


Contents Page

1 Introduction 3

2 Aims and Objectives 3

3 Scope of the Policy 3

4 Background Information 4

5 Licensed usage of GHB, GBL and 1,4-BD 4

6 Effects of GHB, GBL and 1,4-BD 4

7 Withdrawal Symptoms 5

8 Management of GHB and GBL – principals including C&I in-patient

setting

6

9 GHB / GBL Detoxification Prescribing Protocol 7

10 Additional Support 10

11 Dissemination and Implementation Arrangements 10

12 Training requirements 11

13 Monitoring and audit arrangements 11

14 Review of the policy 11

15 References 11

16 Associated Documents 11

Appendix 1: Equality Impact Assessment Tool 12

Appendix 2: Contract and Consent Form for Medically Assisted

Community GHB / GBL Withdrawal

13

Appendix 3: GHB / GBL Reduction Diary Sheet 14

Appendix 4: Accident and Emergency Letter 15

Appendix 5: Information on GHB / GBL for Professionals 16

Appendix 6: Information on GHB / GBL Detoxifications for Clients 17

Appendix 7: Clinical Institute Withdrawal Assessment for Alcohol

Scale (CIWA-AR) 19


1. Introduction

These guidelines have been produced primarily in response to changes in drug usage amongst the clients who present for assessment and treatment within community substance misuse services.

Camden and Islington NHS Foundation Trust has now established a specialist “party drug” clinic and all SMS have noticed an increase in clients presenting to services who are using gamma-hydroxybutyrate (GHB) and gamma-butaryl lactone (GBL).

2. Aims and objectives

The main aim of this guidance is to provide clear guidance about the withdrawal effects of GHB and GBL and their management.

To provide guidance to clinicians who are planning reduction plans and the medical detoxification for GHB and GBL.

To provide guidance on administering medication and monitoring of clients undergoing a detox from GHB and GBL.

To provide information about the potential dangers of clients suddenly stopping GHB and GBL.

3. Scope

These guidelines will be mostly applicable to community substance misuse services which are provided by the Trust i.e. in Camden, Islington, and Kingston.

It may also be relevant to other services within Camden and Islington NHS Foundation Trust as clients using GHB and GBL may also present to other services and who are admitted to the in-patient wards. It would be recommended that detoxifications for GHB and GBL are carried out in discussion with specialist substance misuse services.


4. Background Information

Gamma butyrolactone (GBL) and 1,4-butanediol (1,4-BD) are precursors of

Gamma-hydroxy butyric acid (GHB). GBL and / or 1,4-BD are quickly converted

to GHB when they are ingested.

GHB and GBL can cause feeling of euphoria, reduce inhibitions and cause

sleepiness. The effects start about 10 minutes to an hour and can last up to 7

hours.

GHB, GBL and 1,4-BD are clear, odourless, oily liquids with a salty taste that

resembles stale water or burnt plastic (1). They are sold in liquid form in small

bottles. GHB can also be found in powder form (2) e.g. capsules or tablets as it

can form salts. These are usually dissolved in water or mixed with sweetened

drinks to hide their salty taste (1,2).

In 2003, GHB was classified as a Class C drug under the Misuse of Drugs Act

1971. It was then found that users were switching to GBL and 1,4-BD and so in

2009, GBL and 1,4-BD were also classified as Class C drugs under the Misuse of

Drugs Act 1971. It is against the law to possess them or sell them for human

consumption.

5. Licensed Usage of GHB, GBL and 1,4-BD

GHB is licensed in Europe as an anaesthetic agent. In the UK is in authorized

medicine, sodium oxybate for the treatment of narcolepsy with cataplexy (under

specialist supervision).

GBL and 1,4-BD also have legal uses and are available to licensed buyers.

They are used in solvents such as paint stripper, nail varnish removal and stain

removers.

6. Effects of GHB, GBL and 1,4-BD

GBL and 1,4-BD are inactive and are metabolised into GHB shortly after entering the body.

GHB occurs naturally in the central nervous system. It is metabolised in the body into GABA which acts on the GABAa receptor causing similar effects to benzodiazepines.


GHB and GBL have euphoric effects and can lead to increased confidence and reduced inhibition at low levels. At higher dosages they can cause sedation. The dose response curve is steep and so users can experience toxicity – leading to nystagmus, aggression, urinary incontinence and nausea.

Users of GHB, GBL and 1,4-BD use a pipette to measure out small doses.

Effects include the following:

Euphoria

Decreased inhibitions

Reduced anxiety

Loss of motor control

Emotional warmth

Increased libido

Sleepiness

Confusion / disorientation

Loss of coordination and balance

Reduced consciousness

Memory problems

Respiratory depression

Overdose – headache; nausea and vomiting; hallucinations; seizures

Loss of consciousness, coma and even death

7. Withdrawal Symptoms

When GHB and GBL usage increases the frequency of dosing becomes very

regular with users having to use every few hours. GHB users can develop

physiological dependency when they are using 1-2 mls of GHB/GBL every 1-2

hours; this includes waking during the night to take further doses.

It is estimated that users can develop dependency after using x3-4 per day for 2-

3 months (2). Withdrawal from GHB can last around 9 days (3).

Stopping GHB leads to a rapid onset of withdrawal symptoms which are similar

to the withdrawal effects of alcohol or benzodiazepines.


Withdrawal symptoms are as follows:

Tachycardia

Insomnia

Anxiety / restlessness

Confusion

Delirium

Nausea

Vomiting

Tremor

Hallucinations

Hypertension

Diaphoresis

Less common symptoms may include – seizures, rhabdomyolysis and possibly

death.

GHB withdrawal is a medical emergency.

8. Management of GHB and GBL Withdrawal – principles of gradual reduction

and detoxifications

As stated earlier withdrawal is a medical emergency and as such must be managed very carefully. It is advised to have a clear acute pathway for each particular substance misuse service to their local general hospital. There should have been liaison with the relevant hospital specialists, in particular the AED and anaesthetic departments before detoxifications are agreed. If problems should arise during the detox the client will need to go urgently to hospital and they should be issued with the Accident and Emergency letter (Appendix 4) and the Information on GHB / GBL for professionals (Appendix 5).

The scope of this guidance is for planned gradual reductions and / or planned community detoxification of clients with GHB / GBL dependency. The treatment protocol is for clients who are presenting in the absence of delirium.

It should be noted that if clients are not suitable for gradual reduction plans or community detoxifications they may need to referred for in-patient detox and rehabilitation – each service should follow their own policies and procedures for Tier 4 applications.

It may be possible for a client to follow a gradual reduction plan. Clients should be advised to stay on a consistent dose that they can tolerate for a few days, taking this dosage at the same time each hour. When clients have been able to


do this for a few days they can then start to reduce the dosage by one-tenth of an ml each day, i.e. 2.0ml on Monday; then 1.9ml on Tuesday; then 1.8ml on Wednesday, etc. Once the client is down to 0.1ml they will be able to stop GBL without experiencing withdrawals symptoms. Clients should be informed that they may still feel uncomfortable and that it will take time for them to be able to adjust to life without GHB / GBL (see refer to Reduction Diary in Appendix 3).

Where delirium is present clients should be admitted to a general hospital as a matter of urgency and may need very high dosages of diazepam – up to 200mg in the first 24 hours. In essence where clients are using high dosages of GHB or GBL; are using GHB > 6 times every day; have a history of severe withdrawal symptoms are also dependent on other drugs (including alcohol or benzodiazepines) they would not be suitable for a community detox – please refer to indications for in-patient detoxes.

Where the client presents without delirium the following protocol can be used i.e. using diazepam and baclofen.

Notes for in-patient Camden and Islington Staff

In the Camden and Islington in-patient ward setting management of clients presenting with GHB / GBL dependency and withdrawal should be managed very carefully. There should be a low threshold for liasing and transferring patients to local general hospitals. In this group of patients who are acutely mentally unwell it would be unsafe to carry out a GHB / GBL detox within the psychiatric in-patient setting.

9. GHB / GBL Detoxification Prescribing Protocol

Inclusion Criteria

Objective evidence of dependency on GHB / GBL

Motivation to achieve abstinence

Stable accommodation and 24 hour support during the detoxification

Willingness to agree to the boundaries of the service and the treatment plan including daily reviews – if clients don‟t adhere to these boundaries and continue to use illicit / non-prescribed substances after the detoxification has started the detox will be stopped

Clients will need to be accompanied to and from their planned appointments during the detox period

It should it stressed that clients shouldn‟t drive or operate machinery during the detox period


Exclusive Criteria

Polysubstance misuse

History / current physical health problems including hepatic and renal disorders

Pregnant or breastfeeding women

Indications for in-patient detoxification

Using >30g GHB per day

Using >15g GBL per day

Using GHB >6 times per day

History of severe withdrawal symptoms

Currently dependent on other drugs, especially alcohol and / or benzodiazepines

Assessment

A full psychiatric history should be taken to include the following:

Quantity / frequency / duration of GHB / GBL usage

Any periods of abstinence

Previous withdrawal symptoms including severity i.e. any seizures

Medical history

Mental health history

Medications including allergies

Other illicit substance usage

Social support

Motivation levels

Physical examination

Detoxification Plan

The onset of withdrawal symptoms can range from 30 minutes to a few hours. It is

important to prevent the development of withdrawal delirium rather than waiting for

the full symptoms of withdrawal to start. Please note that the withdrawal medication

regimen below is a standard regimen and depending on the amount of GBH / GBL

the length of the regimen may be altered.


Prior to the commencement of a GHB / GBL detoxification clients should sign the

contract and consent form (Appendix 2). They should also be issued with the

information sheet for clients undergoing a GHB / GBL detox (Appendix 6).

Table 1 – GHB / GBL Withdrawal Medication Regimen

Day of Treatment Time of observation and treatment

(T1 is 1 hour after last time of usage; T2 is 2 hours after last time of usage; etc.)

1 T1 observations, diazepam 10-20mg (10mg standard dosage, 20mg if agitated)

T2 observations, diazepam 10-20mg, baclofen 10mg

T4 observations, diazepam 10mg PRN (if symptomatic)

Please issue diazepam 3x10mg to be taken PRN at T6, T8 and T14 (if symptomatic) and 2x10mg baclofen to be taken at T8 and T14

Observations (temperature, pulse, blood pressure, mental state examination, alcohol withdrawal scales) to be taken at T1, T2, T4.

Generally maximum dosage on Day 1 is diazepam 100mg and baclofen 30mg

2 Take observations as in Day 1

Diazepam 10-20mg qds

Baclofen 10mg tds


Diazepam 10-20mg tds

Baclofen 10mg tds


Diazepam 10-20mg tds

Baclofen 10mg tds


Diazepam 5-10mg tds

Baclofen 10mg tds


Diazepam 5-10mg bd

Baclofen 10mg bd


Diazepam 5-10mg od

Baclofen 10mg od


Diazepam 5-10mg od


Diazepam 5-10mg od


Diazepam 5-10mg od


There is no GHB / GBL withdrawal scale but as the withdrawals are similar to alcohol withdrawals in the early stages then the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-AR) can be used (please see Appendix 7).

In severe withdrawals urgent transfer to hospital will be necessary. However the following medications may be useful.

Table 2 – Adjunctive Medications

Diarrhoea Loperamide (4mg initially followed by 2mg after each loose stool [max 16mg daily])

Nausea and Vomiting Domperidone 10mg tablets, maximum 30mg in 24 hours

Pain Paracetamol 500mg-1g qds

10. Additional Support

It should be remembered that the above treatment is the pharmacological treatment for the withdrawal symptoms but as with all substance misuse treatment there is the need for psychosocial interventions.

As part of an individual‟s treatment plan there will be psychosocial support in the form of motivational interviewing, the use of individual and group sessions, mutual aid organisations and relapse prevention work. Clients need to be made aware of the risk of decreased tolerance following a detoxification and a careful aftercare plan is critical. As part of the aftercare clients need to be made aware of relapse triggers and cues for relapse.

Referrals may also need to be made to other services to support with underlying or additional needs. Clients need to be informed that following GHB / GBL usage clients can experience insomnia, anxiety and loss of appetite for weeks to months following the detox.

11. Dissemination and implementation arrangements

This policy will be circulated to all team members working in Camden and Islington NHS Foundation Trust Substance Misuse Services. Dr Sarah Minot can be contacted for clarification or support in relations to any aspect of this policy by email on [email protected].


12. Training requirements

Implementation of this policy will be complemented by a discussion within the Substance Misuse Consultant group and the education programme of improving skills for NPS which is currently being undertaken within the division.

13. Monitoring and audit arrangements

Regular audits will be conducted periodically to ensure that the detox policy is being adhered to. The audit will aim to ensure that appropriate assessment has been conducted prior to the commencement of GHB / GBL detoxification and that the process itself follows the guidelines. The results will be reported to the Trust audit committee. Learning from the audit will be shared with staff at the service at local CPD meetings.

14. Review of the policy

The policy will be reviewed on or around April 2019 (two years from the date of production of this policy)

15. References

1) GBL Pre-review report WHO June 2012

2) Wood DM, Brailsford AD, Dargan Pl. Acute toxicity and withdrawal syndromes

related to gammahydroxybutyrate (GHB) and its analogues gamma-

butyrolactone (GBL) and 1,4-butanediol (1,4-BD). Drug Test Anal 2011; 6 May

Epub ahead of print [DOI 10.1002/dta.292]

3) McDonough M, Kennedy N, Glasper A, Bearn J. Clinical features and

management of gammahydroxybutyrate (GHB) withdrawal: a review. Drug

Alcohol Depend. 2004: 75: 3-9

16. Associated documents

There are no associated Trust documents that this policy directly relates to.


Appendix 1

Equality Impact Assessment Tool

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers) No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A


Appendix 2 CONTRACT AND CONSENT FORM FOR MEDICALLY ASSISTED COMMUNITY SMS GBL / GHB WITHDRAWAL

The following stipulations have been designed to help you in the next couple of weeks, so that you have the best chance of giving up GBL / GHB, as it is your wish.

The programme requires that you be abstinent from GBL / GHB, alcohol and non-prescribed drugs. Thus, while on the programme you must not consume or possess any alcohol or drugs other than those prescribed by the doctor. During this time you may be breathalysed and you may be requested to supply a urine sample for drug screening. If either of these proves positive, you will not be able to continue with the programme. You may be able to join the programme again at a later date, but you should discuss first with your keyworker whether this is still the most appropriate option for you.

In order to get the maximum benefit from the programme, you will need to give it your full priority. If you are working, it is strongly suggested that you arrange to take time off for an extended period, to give yourself space for the detox and recovery.

You will be expected to stay the full duration of the sessions, for the whole programme, and to take all medication as prescribed by the doctor and detox nurse. Should you miss a session for whatever reason, you will not be able to continue with the programme.

Aggressive, violent, abusive, racist or sexist language or behaviour can not be tolerated. If you demonstrate any of these you will be asked to leave the programme.

Please sign below to confirm that the community GHB / GBL detoxification programme has been explained to you, that you wish to go ahead with it and that you are happy with the conditions set above. Name …………………………………… Date …………………………………… Address …………………………………… Worker …………………………………….


Appendix 3 GBL REDUCTION DIARY SHEET

First STABILISE on a dose, take it at REGULAR time intervals. A different bedtime dose may be necessary Second REDUCE the dose, start with a dose that works and stick to it for day 1, reduce by 0.1ml every day Time of Day

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8


Appendix 4 ACCIDENT AND EMERGENCY LETTER

Dear Doctors The below client is undertaking a GBL/GHB DETOXIFICATION PATIENT NAME: D.O.B: STARTING DATE OF MEDICAL DETOXIFICATION: CURRENT MEDICATION:

Drug Dose Frequency Last Taken

Diazepam

Baclofen

Other

Other

For information regarding the clinic management of the patient please contact Dr ………………………. at …………………….. on (please insert name of doctor and service)


Appendix 5 INFORMATION ON GHB / GBL FOR PROFESSIONALS

Known as „G‟ it is a clear, odourless, oily liquid which is sold in liquid form or GHB can found in powder form which is dissolved in water or mixed with drinks to hide their salty taste. Users will then take small amounts – 1-2 mls using a pipette in increasing frequently as dependency increases. Users can have to use every 1-2 hours throughout the day and night. Dependency on GHB / GBL can develop after daily usage for several months. Stopping GHB leads to a very rapid onset of withdrawal symptoms which are similar to the withdrawals effects of alcohol and / or benzodiazepines. GHB / GBL withdrawals are a very serious and potential fatal condition and needs to be treated rapid and often involves admission to Intensive Care Units. The withdrawal symptoms may include: Tachycardia Insomnia Anxiety / restlessness Confusion Delirium Nausea Vomiting Tremor Hallucinations Hypertension Diaphoresis Seizures Treatment of GHB / GBL withdrawals includes the use of high dosage benzodiazepines – about 100mg diazepam in the first 24 hours. Research has also shown that baclofen may be helpful in the management of withdrawal symptoms; further studies are continuing to fully explore the benefits of baclofen. Generally baclofen 10mng tds is given to patients and this dosage is gradually reduced after the few 5 days.


Appendix 6 INFORMATION ON GHB / GBL DETOXIFICATION FOR CLIENTS You have made the very important decision to stop using GHB / GBL, this programme has been put together to give you the best possible chance to achieve this goal. This leaflet will give you essential information about GHB / GBL detoxification and inform you of what you can expect from us and what we expect from you. Please read it carefully and don‟t be afraid to ask questions

Withdrawal Symptoms Withdrawing from GHB / GBL is often accompanied by some unpleasant experiences, such as shaking, anxiety, feeling jumpy and nervous, feeling irritable, sweating, nausea, racing thoughts and insomnia. These are withdrawal symptoms and with medication the worst aspects can be relieved. However, GHB / GBL intoxication places a heavy burden on the body and consequently you should expect to experience some discomfort. On this programme, you will be prescribed a medication called diazepam and baclofen. This is usually quite safe, but can make people drowsy. Thus, during detoxification it is recommended that you refrain from driving, operating machinery or undertaking any tasks that require being alert. In addition, the medication is not safe when taken together with alcohol and thus if you resume drinking you must stop taking it at once. For some people withdrawal symptoms are more severe, including for example:

Confusion

Disorientation

Blacking out

Hallucinations

Fits

If you do experience any severe symptoms you will need to seek immediate assistance at the nearest Accident & Emergency Department.

What you can expect from us When you start on this programme, you will be assessed by a doctor, who will prescribe the medication. A nurse will then monitor withdrawal closely, helping you to plan the week and to cope with these symptoms.

What we expect from you The following stipulations have been designed to help you in the next couple of weeks, so that you have the best chance of giving up GHB / GBL, as it is your wish.

The programme requires that you be abstinent from GHB / GBL, alcohol and non-prescribed drugs. Thus, while on the programme you must not consume or possess any GHB / GBL, alcohol or drugs other than those prescribed by the doctor.


You will be asked to be breathalysed and you may be requested to supply a urine sample for drug screening. If the breath alcohol reading is positive, you will not be able to continue with the programme. If your urine is positive for drug(s) that you have not told us about, the detoxification may need to stop. You may be able to join the programme again at a later date, but you should discuss first with your key worker whether this is still the most appropriate option for you.

In order to get the maximum benefit from the programme, you will need to give it your full priority. If you are working, it is strongly suggested that you arrange to take time off for an extended period, to give yourself space for the detox and recovery.

You will be expected to stay the full duration of the sessions, for the whole programme, and to take all medication as prescribed by the doctor and detox nurse. Should you miss a session for whatever reason, you will not be able to continue with the programme.

Aggressive, violent, abusive racist or sexist language or behaviour cannot be tolerated. If you demonstrate any of these you will be asked to leave the programme

Points to Remember Your Safety During detoxification you may experience forgetfulness, irritability and poor coordination: be careful, therefore, when cooking, boiling water and doing other tasks that require care. It would be helpful for you to arrange to have a responsible person around during this time, to help you with these practicalities. Your Environment Try to arrange it so that your surroundings are as peaceful as possible. For this, it may be best to let those around you know that you will probably be feeling fragile for a few days. Also, it is advisable that you don‟t keep alcohol in your home. In the early stages of recovery you will be vulnerable, so avoid situations where alcohol is consumed or openly available. Your Time Most people find that if they keep busy, it helps them not to dwell on negative feelings. Give the coming week some consideration: don‟t leave things to chance. Your Diet Try to eat something even when you are not hungry. Eating little and often will help minimise craving. Drink plenty of fluids.


Appendix 7 Clinical Institute Withdrawal Assessment for Alcohol Scale – CIWA-AR Auditory (hearing) Disturbances Ask “are you more aware of sounds around you? Are they harsh? Do they frighten you Are you hearing anything that is disturbing you? Are you hearing things you know are not there?” Observations 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

Visual (sight) Disturbances Ask “Does the light appear to be too bright? Is it‟s colour different? Does it hurt your eyes? Are you seeing anything that‟s disturbing you? Are you seeing anything that you know is not there?” Observations 0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

Tremor Arms extended and fingers spread wide apart Observations 0 not present 1 not visible, but can be felt fingertip to fingertip 4 moderate, with patients‟ arms extended 7 severe, even with arms not extended

Nausea and Vomiting Ask “do you feel sick to your stomach? Have you vomited?” Observations 0 no nausea with no vomiting 1 mild nausea with no vomiting 4 intermittent nausea with dry heaves 7 constant nausea, frequent dry heaves and vomiting

Paroxysmal sweats Observations 0 no sweat visible 1 barely perceptible sweating, palms moist 4 beads of sweat obvious on forehead 7 drenching sweats

Orientation and clouding of Sensorium Ask “What day is this? Where are you? Who am I” 0 orientated and can do serial addictions 1 cannot do serial addictions or it uncertain about date 2 disorientated for date by no more than 2 calendar date 3 disorientated for date by more than 2 calendar date 4 disorientated for place or person

Anxiety Ask “Do you feel nervous?” Observations 0 no anxiety, at ease 1 mildly anxious 4 moderately anxious or guarded, so anxiety is suggested 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic states

Agitation Observations 0 normal activity 1 somewhat more than normal activity 4 moderately fidgety and restless 7 paces back and forth during interview, or constantly thrashes about

Headache, Fullness in Head Ask “Does your head feel different? Does it feel like there is a band around your head? Do not rate for dizziness or light-headedness.” Otherwise, rate severity 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe

Tactile (touch) Disturbances Ask “Have you any itching, pins and needles sensations, any burning, any numbness or do you feel bugs crawling on or under your skin?” Observation 0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

Date:

Time: 24 hour clock

Respiratory Rate: if < 10rpm inform medical team

Auditory disturbances (0-7)

Visual disturbances (0-7)

Tremor (0-7)

Nausea/vomiting (0-7)

Sweats (0-7)

Orientation (0-4)

Anxiety (0-7)

Agitation (0-7)

Headache (0-7)

Tactile disturbances (0-7)

Total Score (MAX 67)

Rater’s initials: