Practice Guidelines

Diagnosis, assessment, and management of harmful drinking and alcohol dependence: summary of NICE guidance

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d700 (Published 23 February 2011) Cite this as: BMJ 2011;342:d700
  1. Stephen Pilling, director 12,
  2. Amina Yesufu-Udechuku, systematic reviewer2,
  3. Clare Taylor, editor3,
  4. Colin Drummond, professor of addiction psychiatry, honorary consultant addiction psychiatrist4
  5. on behalf of the Guideline Development Group
  1. 1Centre for Outcomes Research and Effectiveness, University College London, London WC1E 7HB, UK
  2. 2National Collaborating Centre for Mental Health, University College London
  3. 3National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E1 8AA, UK
  4. 4National Addiction Centre, Institute of Psychiatry, King’s College London, and South London and Maudsley Foundation NHS Trust, London SE5 8AF
  1. Correspondence to: S Pilling s.pilling{at}ucl.ac.uk

Alcohol dependence affects 4% of people aged between 16 and 65 years in England (6% of men and 2% of women),1 and over 26% of all adults (38% of men and 16% of women) consume alcohol in a way that is potentially or actually harmful to their health or wellbeing. Yet currently only 6% of people who are alcohol dependent receive treatment.1 Alcohol dependence is characterised by withdrawal, craving, impaired control, and tolerance of alcohol and is associated with a higher rate of mental and physical illness and a wide range of social problems. Harmful drinking is a pattern of alcohol consumption that can lead to psychological problems such as depression, accidents, injuries, and physical health problems such as pancreatitis. Alcohol misuse is also an increasing problem in children and young people, with over 24 000 treated in the NHS for alcohol related problems in 2008 and 2009.2 Hospital admissions related to alcohol consumption increased by 81% between 2003 and 2009.3 Harmful drinking and alcohol dependence therefore represent a considerable burden to individuals, their families, and wider society.

This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the diagnosis, assessment, and management of harmful drinking and alcohol dependence.4

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Identification and initial assessment

  • Staff working in services provided and funded by the NHS should be competent to identify harmful drinking and alcohol dependence and to initially assess the need for an intervention; if they are not competent, they should refer people who misuse alcohol to a service that can provide such an assessment. [Based on high quality observational studies and the experience and opinion of the Guideline Development Group (GDG)] Validated tools such as the alcohol use disorders identification test (AUDIT) (figure) are effective in identifying harmful drinking and alcohol dependence in non-specialist settings such as primary care and acute hospitals. [Based on high quality validation studies]

Figure1

Alcohol use disorders identification test (AUDIT), self report version,5 with interpretation guidance based on the current NICE guideline on diagnosing, assessing, and managing harmful drinking and alcohol dependence4 and on NICE’s public health guideline on preventing the development of hazardous and harmful drinking.6 An interview version of the AUDIT is also available

  • Consider a comprehensive assessment for all adults referred to specialist alcohol services who score more than 15 on the identification test (figure)5 This should assess multiple areas of need, be structured in a clinical interview, and cover:

    • -Alcohol use, including consumption and patterns of drinking; severity of dependence (using the severity of alcohol dependence questionnaire (SADQ)7 or Leeds dependence questionnaire (LDQ)8); and alcohol related problems (using the alcohol problems questionnaire (APQ)9)

    • -Misuse of other drugs, including over the counter medication

    • -Physical health problems

    • -Psychological and social problems

    • -Cognitive function (using, for example, the mini-mental state examination10)

    • -Readiness and belief in ability to change.

[Based on high quality observational and validation studies and the experience and opinion of the GDG]

All interventions for harmful drinking and alcohol dependence

  • All interventions for harmful drinking and alcohol dependence should be delivered by appropriately trained and competent staff. Drug interventions should be administered by specialist and competent staff. Base psychological interventions on a relevant evidence based treatment manual, which should guide the structure and duration of the intervention. [Based on high and moderate quality randomised controlled trials]

  • Carry out a motivational intervention as part of the initial assessment to help engage the person in treatment from first contact. The intervention should include helping people to recognise problems related to drinking and resolve ambivalence; encouraging positive change; and adopting a persuasive and supportive rather than argumentative and confrontational position. [Based on high and moderate quality randomised controlled trials]

  • For all interventions, staff should:

    • -Receive regular supervision from individuals competent in both the intervention and supervision

    • -Routinely use outcome measurements to ensure that the person who misuses alcohol is involved in reviewing the effectiveness of their treatment

    • -Monitor and evaluate the person’s adherence to the treatment and their own practice competence—for example, by using videotapes and audiotapes and external audit.

[Based on high quality observational evidence and the experience and opinion of the GDG]

Psychological interventions for harmful drinking and mild alcohol dependence

  • For harmful drinkers and people with mild alcohol dependence, offer a psychological intervention (such as cognitive behavioural therapies, behavioural therapies, or social network and environment based therapies) focused specifically on cognitions, behaviour, problems, and social networks that are related to alcohol. [Based on high and moderate quality randomised controlled trials]

Assessment for assisted alcohol withdrawal

  • For those who typically drink over 15 units of alcohol a day and/or score 20 or more on the identification test,5 consider offering:

    • -Assessment for and delivery of a community based assisted withdrawal, or

    • -Assessment and management in inpatient care if you have safety concerns (see below) about a community based assisted withdrawal. [Based on high quality observational studies and the experience and opinion of the GDG]

  • Consider inpatient or residential assisted withdrawal if the person meets one or more of the following criteria:

    • -Drinks over 30 units of alcohol a day

    • -Has a score of more than 30 on the severity of alcohol dependence questionnaire7

    • -Has a history of epilepsy or of withdrawal related seizures or delirium tremens during previous assisted withdrawal programmes

    • -Needs concurrent withdrawal from alcohol and benzodiazepines

    • -Regularly drinks 15-20 units of alcohol a day and has psychiatric or physical comorbidities (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or a learning disability or cognitive impairment.

[Based on high quality observational studies and the experience and opinion of the GDG]

Interventions for moderate and severe alcohol dependence

  • After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies, or social network and environment based therapies) that focuses specifically on alcohol misuse. [Based on high quality randomised controlled trials] At the time of publication (mid-February 2011), oral naltrexone did not have UK marketing authorisation for this indication. Obtain and document informed consent before prescribing.

  • Consider offering interventions to promote abstinence and prevent relapse as part of an intensive and structured community based intervention for people with moderate and severe alcohol dependence who have:

    • -Very limited social support (for example, they are living alone or have very little contact with family or friends)

    • -Complex physical or psychiatric comorbidities

    • -Not responded to initial community based interventions to promote abstinence or moderate drinking. [Based on high quality observational evidence and the experience and opinion of the GDG]

Interventions for children and young people aged 10-17 years who misuse alcohol

  • For those with limited comorbidities and good social support, offer individual cognitive behavioural therapy.

  • For those with significant comorbidities and/or limited social support, offer multicomponent programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy, or multisystemic therapy) .

[Based on moderate quality randomised controlled trials and the experience and opinion of the GDG]

Interventions for depression or anxiety disorders in alcohol misuse

  • Treat the alcohol misuse first as this may lead to improvement in the depression or anxiety. If depression or anxiety continues after three to four weeks of abstinence from alcohol, assess the depression or anxiety and consider referral and treatment in line with the relevant NICE guideline for the particular disorder.11 12 13 14

[Based on the experience and opinion of the GDG]

Overcoming barriers

Poor recognition of alcohol misuse is a major barrier to effective treatment1 and requires a service-wide approach to improve case identification. Current service delivery is also fragmented, with access pathways to services unclear to both patients and professionals. To clarify care pathways and properly implement this and other NICE guidance that relates to alcohol use5 15 NICE is currently developing an integrated care pathway for the three pieces of guidance.

Limited availability of specialist alcohol services also hinders effective guideline implementation—for example, there is a lack of skilled staff to deliver evidence based psychological interventions and support intensive community based assisted withdrawal, and limited prescribing of cost effective medication such as acamprosate and oral naltrexone to prevent relapse in moderate to severely dependent drinkers. Guideline recommendations on these interventions will need to be supported by effective commissioning.

In addition, safe and effective assisted alcohol withdrawal may require prescription outside the limits of the British National Formulary, and the guideline offers clear advice on dose regimens to support this.

Further information on the guidance

Current practice in England and Wales is inconsistent, with very variable access to and provision of assisted alcohol withdrawal and treatment services for harmful drinking and alcohol dependence.16 Many people are neither identified nor effectively treated, and even where treatment is offered, coordination of services across the various sectors is poor and can lead to substandard or inconsistent care. In addition, after effective treatment of dependence or harmful drinking, many people continue to have problems in accessing services for comorbid mental and physical health problems.16 The guideline offers advice on the assessment of comorbid disorders, the nature and sequencing of appropriate treatments, and the appropriate referral pathways for their treatment. In particular, the guideline notes that although anxiety and depressive symptoms may often remit once the alcohol misuse has been effectively treated and therefore should not be the focus of initial treatment, some people may continue to experience such symptoms after resolution of their alcohol misuse and therefore should be offered further assessment and treatment.

Methods

This guideline was developed by the National Collaborating Centre for Mental Health using NICE guideline methodology.17 The guideline review process involved comprehensive and systematic literature searches to identify relevant evidence for the clinical and economic reviews, with critical appraisal of the quality of the identified evidence. A multidisciplinary guideline development group of healthcare professionals and patient and carer representatives was convened to review the evidence and develop the subsequent recommendations. The guideline then went through an external consultation with stakeholders. The Guideline Development Group considered the stakeholders’ comments, reanalysed the data where necessary, and modified the guideline as appropriate.

NICE has produced four different versions of each guideline: a full version; a quick reference guide (which combines both guidelines); a version known as the “NICE guideline” that summarises the recommendations; and a version for patients, carers, and the public. All these versions are available from the NICE website. Further updates of the guideline will be produced as part of NICE’s guideline development programme.

Future research
  • Compare the effectiveness of contingency management (an incentives programme) with standard care in reducing alcohol consumption

  • Ascertain the methods that are most effective in assessing and diagnosing the presence and severity of harmful drinking and alcohol dependence in children and young people

  • Compare the effectiveness of acupuncture with standard care in reducing alcohol consumption

  • Identify those with moderate and severe alcohol dependence for whom an assertive community treatment is a clinical and cost effective intervention compared with standard care. (Assertive community treatment comprises long term contact with a mental health team responsible for all aspects of a person’s care and providing an intensive and coordinated approach)

  • For people with moderate and severe alcohol dependence and comorbid problems, compare the clinical and cost effectiveness of an intensive residential rehabilitation programme with intensive community based care

  • Ascertain which medication is most likely to improve adherence, promote abstinence, and prevent relapse for people with alcohol dependence

Notes

Cite this as: BMJ 2011;342:d700

Footnotes

  • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

  • Contributors: All authors drafted and reviewed the summary. SP is the guarantor.

  • Funding: The National Collaborating Centre for Mental Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: SP, AY-U, and CT had support from the National Collaborating Centre for Mental Health (NCCMH) for the submitted work; SP, AY-U, and CT have been employed by the NCCMH in the previous 3 years; SP receives funding from NICE to support guideline development at the NCCMH; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References