and alcohol dependence Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence This slide set was updated in August 2011 to include the NICE quality standard. ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on Alcohol- use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. This guideline has been written for health and social care professionals who have direct contact with, and make decisions concerning, the care of young people and adults with alcohol dependence or harmful alcohol use. The guideline is available in a number of formats, including a NICE version and quick reference guide. As the presenter, you should have access to the NICE version and should be familiar with its content. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details. You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. Slide 17 presents an algorithm containing hyperlinks to allow you to show additional details of the contents of the information boxes. Use these hyperlinks during your presentation. In order to guarantee effective use of the hyperlinks you must ensure you are clicking exactly on the hyperlink (wait for the mouse arrow to turn to a hand). Once you have viewed all of the hyperlinks on slide 17, click on the screen away from the algorithm and you will be taken to the next slide where the presentation will continue as normal DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Implementing NICE guidance 2nd. Edition - August 2011 NICE clinical guideline 115

Directly related NICE guidance This guideline is one of three pieces of NICE guidance addressing alcohol-use disorders. The others are: Preventing hazardous and harmful drinking (PH24) Diagnosis and clinical management of physical complications (CG 100) The term alcohol-use disorders encompasses physical, mental and behavioural conditions associated with alcohol use. NOTES FOR PRESENTERS: This guideline is one of three pieces of NICE guidance addressing alcohol-use disorders. Alcohol-use disorders: preventing the development of hazardous and harmful drinking. NICE public health guidance 24 (2010) This focuses on the prevention of alcohol-use disorders in people 10 years and older, covering: interventions affecting the price, advertising and availability of alcohol; how to detect alcohol misuse both in and outside primary care; and brief interventions to manage alcohol misuse in these settings. Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100 (2010). This is a clinical guideline covering acute unplanned alcohol withdrawal including delirium tremens, alcohol-related liver damage, alcohol-related pancreatitis and management of Wernicke’s encephalopathy. The term alcohol-use disorders encompasses physical, mental and behavioural conditions associated with alcohol use. Health problems can be related to heavy alcohol use over a relatively short period of time (for example, intoxication) or to the long-term use of alcohol (for example, cirrhosis of the liver). NICE published a quality standard for Alcohol dependence and harmful alcohol use in August 2011 and this should be referred to alongside the guideline. Full details available at: http://www.nice.org.uk/guidance/qualitystandards/alcoholdependence/home.jsp

Click here to go to NICE Pathways website The NICE Alcohol pathway shows recommendations on: the diagnosis, assessment and management of harmful drinking and alcohol dependence key areas in the investigation and management of alcohol-related physical complications. prevention and early identification of alcohol-use disorders, including interventions in schools to prevent and reduce alcohol use among children and young people NOTES FOR PRESENTERS: Key points to raise - This pathway covers all NICE guidance on Alcohol and not just CG115 If you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE Pathways website. The front page includes a two minute video giving an overview of the features and content within the site, as well as the list of topics covered. NICE Pathways: guidance at your fingertips Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended. Click here to go to NICE Pathways website

NOTES FOR PRESENTERS: The NICE pathway can be found at http://pathways.nice.org.uk/pathways/alcohol-use-disorders (note – no “www.”)

What this presentation covers Definitions Epidemiology Background Scope Key priorities for implementation Principles of care Costs and savings Discussion NHS Evidence Find out more NICE alcohol quality standard NOTES FOR PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then present the key priorities for implementation. The NICE guideline contains nine key priorities for implementation, which you can find on pages 5 and 6 of your quick reference guide. This section also contains the care pathway for assisted withdrawal. This will be followed by recommendations about principles of care. Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Following this we will look at further information about the support provided by NICE. Finally, we will end the presentation on this guideline by looking at the NICE alcohol dependence and harmful alcohol use quality standard which was published in June 2011.

Definitions Harmful drinking is a pattern of alcohol consumption causing mental and physical health problems directly related to alcohol Alcohol dependence is characterised by continued drinking despite harmful consequences Mild dependence = Severity of Alcohol Dependence Questionnaire (SADQ) score 15 or less Moderate dependence = SADQ score of 15–30 Severe dependence = SADQ score of 31 or more. NOTES FOR PRESENTERS: Key points to raise: Harmful drinking is defined as a pattern of alcohol consumption causing health problems directly related to alcohol. This could include psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis. In the longer term, harmful drinkers may go on to develop high blood pressure, cirrhosis, heart disease and some types of cancer, such as mouth, liver, bowel or breast cancer. Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking despite harmful consequences (for example, liver disease or depression caused by drinking). Alcohol dependence is also associated with increased criminal activity and domestic violence, and an increased rate of significant mental and physical disorders. Although alcohol dependence is defined in ICD-10 and DSM-IV in categorical terms for diagnostic and statistical purposes as being either present or absent, in reality dependence exists on a continuum of severity. It is helpful from a clinical perspective to subdivide dependence into categories of mild, moderate and severe. People with mild dependence (those scoring 15 or less on the Severity of Alcohol Dependence Questionnaire; SADQ) usually do not need assisted alcohol withdrawal. People with moderate dependence (with a SADQ score of between 15 and 30) usually need assisted alcohol withdrawal, which can typically be managed in a community setting unless there are other risks. People who are severely alcohol dependent (with a SADQ score of 31 or more) will need assisted alcohol withdrawal, typically in an inpatient or residential setting. In this guideline these definitions of severity are used to guide selection of appropriate interventions. For convenience this guideline refers to harmful drinking and alcohol dependence as ‘alcohol misuse’. When recommendations apply to both people who are dependent on alcohol and harmful drinkers, the terms ‘person who misuses alcohol’ or ‘service user’ are used unless the recommendation is specifically referring to either people who are dependent on alcohol or who are harmful drinkers.

Epidemiology Weekly alcohol consumption of more than 50 units (men) or more than 35 units (women) by age (years) and gender – Great Britain, 2009 Y = Percentage of population X = Age in years NOTES FOR PRESENTERS: Key points to raise: 24% of the adult population in England, including 33% of men and 16% of women, consumes alcohol in a way that is potentially or actually harmful to their health or well being (Defined as scoring 8 or more on the Alcohol Use Disorders Identification Test AUDIT) (McManus et al. 2009). 4% of adults in England are alcohol dependent (6% men; 2% women) (Defined as scoring 16 or more on the AUDIT) (Drummond et al. 2005). Alcohol related hospital admissions increased by 85% between 2002–03 and 2008–09, accounting for 945,000 admissions with a primary or secondary diagnosis wholly or partly related to alcohol in 2006–07, 7% of all hospital admissions (North West Public Health Observatory 2010). Additional information To clarify the terms used in association with alcohol consumption and its risks, the Department of Health now recommends the use of terms: lower risk, increasing risk and higher risk because these are more readily understood by the general public and reflect the level of risk incurred by drinkers as their consumption increases. These terms differ from the categories of alcohol dependence identified on the previous slide. Alcohol dependence is a type of drinking that develops in regular excessive drinkers, mainly in those drinking at higher risk levels (Department of Health’s Learning Centre. E-learning for primary care, 2009. Available at www.alcohollearningcentre.org.uk/alcoholeLearning/learning/IBA/Module1_v2/D/ALC_Session/443/tab_580.html). For more information about the terms lower risk, increasing risk and higher risk, visit the alcohol learning centre www.alcohollearningcentre.org.uk References Drummond DC, Oyefes, N, Phillips T et al. (2005) Alcohol needs assessment research project: the 2004 national alcohol needs assessment for England. Department of Health, London McManus S, Meltzer H, Brugha T et al. (2009) Adult psychiatric morbidity in England, 2007: results of a household survey. NHS Information Centre for Health and Social Care, Leeds North West Public Health Observatory (2010) Local alcohol profiles for England. www.nwph.net/alcohol/lape/ (accessed 5 October 2010) Source: General Lifestyle Survey, Office for National Statistics

Background Current practice and service provision across the country is varied Only 6% per year of people aged 16–65 years who are alcohol dependent receive treatment Comorbid mental and physical disorders are common. NOTES FOR PRESENTERS: Key points to raise: Comorbid mental disorders commonly include depression, anxiety disorders and drug misuse. Physical comorbidities, which are common, include gastrointestinal disorders and neurological and cardiovascular disease. Many people experience long-term consequences of alcohol misuse that may significantly shorten their life even when alcohol consumption has stopped or reduced. Of the 1 million people aged between 16 and 65 who are alcohol dependent in England, only about 6% per year receive treatment. Reasons for this include the often long period between developing alcohol dependence and seeking help, limited availability of specialist alcohol treatment services in some parts of England and under-identification of alcohol misuse by health and social care professionals. Diagnosis and assessment of the severity of alcohol misuse is important because it points to the treatment interventions required. Acute withdrawal from alcohol in the absence of medical management can be hazardous in people with severe alcohol dependence, as it may lead to seizures, delirium tremens and, in some instances, death. Current practice and service provision across the country is varied and access to a range of assisted withdrawal and treatment services and psychological interventions varies as a consequence. In addition, when the alcohol misuse has been effectively treated, many people continue to experience problems in accessing services for comorbid mental and physical health problems. Alcohol service structures are poorly developed, with care pathways often ill defined.

Scope Diagnosis, assessment and management of harmful drinking and alcohol dependence in young people and adults Does not cover children younger than 10 years or pregnant women. NOTES FOR PRESENTERS: Key points to raise: Groups that are covered a) Young people (10 years and older) and adults with a diagnosis of alcohol dependence or harmful alcohol use. Groups that are not covered a) Children younger than 10 years. b) Pregnant women. Additional information: This guideline will assume that prescribers will use a drug’s summary of product characteristics (SPC) to inform their decisions for individual service users. At the time of publication (February 2011), oral naltrexone, acamprosate and benzodiazepines, which are recommended in this guideline did not have UK marketing authorisation for all the indications, doses or age groups stated in the recommendations. If the drug does not have UK marketing authorisation for a particular use, informed consent should be obtained and documented.

Key priorities for implementation Identification and assessment in all settings Assessment in specialist alcohol services General principles for all interventions Interventions for harmful drinking and mild alcohol dependence Assessment for assisted alcohol withdrawal Interventions for moderate and severe alcohol dependence Assessment and interventions for children and young people who misuse alcohol Interventions for conditions comorbid with alcohol misuse. NOTES FOR PRESENTERS: The NICE guideline contains 94 recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into eight areas of key priority and within these are nine recommendations that we will consider.

General principles for identification and assessment Staff working in services caring for people who potentially misuse alcohol should be competent: to identify harmful drinking and alcohol dependence 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 assess need. NOTES FOR PRESENTERS: Key points to raise: Staff working in services provided and funded by the NHS who care for people who potentially misuse alcohol should be competent to identify harmful drinking and alcohol dependence. They should be competent to initially assess the need for an intervention or, if they are not competent, they should refer people who misuse alcohol to a service that can provide an assessment of need. [1.2.1.2] Related recommendations: Make sure that assessment of risk is part of any assessment, that it informs the development of the overall care plan, and that it covers risk to self (including unplanned withdrawal, suicidality and neglect) and risk to others. [1.2.1.1] When conducting an initial assessment, as well as assessing alcohol misuse, the severity of dependence and risk, consider the: extent of any associated health and social problems need for assisted alcohol withdrawal. [1.2.1.3] Use formal assessment tools to assess the nature and severity of alcohol misuse, including the: Alcohol Use Disorders Identification Test (AUDIT) for identification and as a routine outcome measure Severity of Alcohol Dependence Questionnaire (SADQ) or Leeds Dependence Questionnaire (LDQ) for severity of dependence Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) for severity of withdrawal Alcohol Problems Questionnaire (APQ) for the nature and extent of the problems arising from alcohol misuse. [1.2.1.4] When assessing the severity of alcohol dependence and determining the need for assisted withdrawal, adjust the criteria for women, older people, children and young people, and people with established liver disease who may have problems with the metabolism of alcohol (see guideline section 1.3.7 for details on the assessment of children and young people). [1.2.1.5] Staff responsible for assessing and managing assisted alcohol withdrawal (see guideline section 1.3.4) should be competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms and the use of drug regimens appropriate to the settings (for example, inpatient or community) in which the withdrawal is managed. [1.2.1.6]

Assessment in specialist alcohol services Consider a comprehensive assessment for all adults referred to specialist alcohol services who score more than 15 on the AUDIT. A comprehensive assessment should: assess multiple areas of need be structured in a clinical review use validated clinical tools cover alcohol use, other drug misuse, physical health problems, psychological and social problems, cognitive function and readiness and belief in ability to change. NOTES FOR PRESENTERS: Recommendation in full: Consider a comprehensive assessment for all adults referred to specialist alcohol services who score more than 15 on the AUDIT. A comprehensive assessment should assess multiple areas of need, be structured in a clinical interview, use relevant and validated clinical tools (see 1.2.1.4 in the notes of slide 9), and cover the following areas: alcohol use, including: consumption: historical and recent patterns of drinking (using, for example, a retrospective drinking diary), and if possible, additional information (for example, from a family member or carer) dependence (using, for example, SADQ or LDQ) alcohol-related problems (using, for example, APQ) other drug misuse, including over-the-counter medication physical health problems psychological and social problems cognitive function (using, for example, the Mini-Mental State Examination [MMSE]) readiness and belief in ability to change. [1.2.2.6] Additional information: The use of individual assessment tools alone does not constitute a comprehensive assessment. The evidence suggested that, in addition to a past and recent history of drinking, the associated physical and mental health problems and the impact on health and social and economic problems and the family (including children) should also be assessed. See the notes of slide 9, recommendation 1.2.1.5, for details of when to adjust the assessment criteria for certain groups. Further related recommendations concerning assessment in specialist alcohol services: comprehensive assessment (pages 10 and 11 of the quick reference guide) treatment goals (page 9 of the quick reference guide) brief triage assessment (page 9 of the quick reference guide).

General principles for all interventions: 1 Consider offering interventions to promote abstinence and prevent relapse as part of an intensive 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) or complex physical or psychiatric comorbidities or not responded to initial community-based interventions. NOTES FOR PRESENTERS: Key points to raise: Recommendation 1.3.1.3 is shown in full on the slide. For people who do not responded to initial community-based interventions (bullet 3) see recommendation 1.3.1.2 below for further information Related recommendations: For all people who misuse alcohol, offer interventions to promote abstinence or moderate drinking as appropriate (see recommendations 1.2.2.1–1.2.2.4 in the NICE guideline) and prevent relapse, in community-based settings. [1.3.1.2] For all people who misuse alcohol, carry out a motivational intervention as part of the initial assessment. The intervention should contain the key elements of motivational interviewing including: helping people to recognise problems or potential problems related to their drinking helping to resolve ambivalence and encourage positive change and belief in the ability to change adopting a persuasive and supportive rather than an argumentative and confrontational position. [1.3.1.1] For people with alcohol dependence who are homeless, consider offering residential rehabilitation for a maximum of 3 months. Help the service user find stable accommodation before discharge. [1.3.1.4] Additional information: The group of experts who reviewed the evidence for this guideline identified that community settings are at least as effective as residential units and less costly in providing effective treatment for alcohol misuse. The evidence did not show any additional benefit of residential-based interventions.

General principles for all interventions: 2 All interventions for people who misuse alcohol should be delivered by appropriately trained and competent staff Pharmacological interventions should be administered by specialist and competent staff Psychological interventions should be based on a relevant evidence-based treatment manual Staff should consider using competence frameworks developed from the relevant treatment manuals. NOTES FOR PRESENTERS: Recommendation in full: All interventions for people who misuse alcohol should be delivered by appropriately trained and competent staff. Pharmacological interventions should be administered by specialist and competent staff. Psychological interventions should be based on a relevant evidence-based treatment manual, which should guide the structure and duration of the intervention. Staff should consider using competence frameworks developed from the relevant treatment manuals and for all interventions should: receive regular supervision from individuals competent in both the intervention and supervision routinely use outcome measurements to make sure that the person who misuses alcohol is involved in reviewing the effectiveness of treatment engage in monitoring and evaluation of treatment adherence and practice competence, for example, by using video and audio tapes and external audit and scrutiny if appropriate. [1.3.1.5] Please note: if a drug is used at a dose that does not have UK marketing authorisation, informed consent should be obtained and documented. Related recommendations: All interventions for people who misuse alcohol should be the subject of routine outcome monitoring. This should be used to inform decisions about continuation of both psychological and pharmacological treatments. If there are signs of deterioration or no indications of improvement, consider stopping the current treatment and review the care plan. [1.3.1.6] For all people seeking help for alcohol misuse: give information on the value and availability of community support networks and self-help groups (for example, Alcoholics Anonymous or SMART Recovery) and help them to participate in community support networks and self-help groups by encouraging them to go to meetings and arranging support so that they can attend. [1.3.1.7] Additional information Care coordination is routine coordination of the care of a person who misuses alcohol. Case management is more intensive, concerned with delivering all aspects of care, including assessment, treatment, monitoring and follow-up (see page 13 of the quick reference guide).

Interventions for harmful drinking and mild alcohol dependence Offer a psychological intervention focused specifically on: alcohol-related cognitions behaviour problems social networks. NOTES FOR PRESENTERS: Key points to raise: 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 alcohol-related cognitions, behaviour, problems and social networks.[1.3.3.1] Related recommendations: For harmful drinkers and people with mild alcohol dependence who have a regular partner who is willing to participate in treatment, offer behavioural couples therapy. [1.3.3.2] For harmful drinkers and people with mild alcohol dependence who have not responded to psychological interventions alone, or who have specifically requested a pharmacological intervention, 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) or behavioural couples therapy. [1.3.3.3] (see section 1.3.6 in the NICE guideline for pharmacological interventions or slide 17 for more information). Additional information: The guideline makes further detailed recommendation about delivering psychological interventions. See pages 13 and 14 of the quick reference guide for more information.

Assessment for assisted alcohol withdrawal For service users who typically drink over 15 units of alcohol per day and/or who score 20 or more on the AUDIT, consider offering: an assessment for and delivery of a community-based assisted withdrawal, or assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal. NOTES FOR PRESENTERS: Recommendation 1.3.4.1 is shown in full on the slide. See recommendation 1.3.4.5 below for more information about safety concerns. Related recommendations: Service users who need assisted withdrawal should usually be offered a community-based programme, which should vary in intensity according to the severity of the dependence, available social support and the presence of comorbidities. For people with mild to moderate dependence, offer an outpatient-based withdrawal programme in which contact between staff and the service user averages 2–4 meetings per week over a 3-week period. For people with mild to moderate dependence and complex needs (for example, psychiatric comorbidity, poor social support or homelessness), or severe dependence, offer an intensive community programme following assisted withdrawal in which the service user may attend a day programme lasting between 4 and 7 days per week over a 3-week period. [1.3.4.2] Consider inpatient or residential assisted withdrawal if a service user meets one or more of the following criteria. They: drink over 30 units of alcohol per day have a score of more than 30 on the SADQ have a history of epilepsy, or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes need concurrent withdrawal from alcohol and benzodiazepines regularly drink between 15 and 20 units of alcohol per day and have: significant psychiatric or physical comorbidities (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or a significant learning disability or cognitive impairment. [1.3.4.5] Consider a lower threshold for inpatient or residential assisted withdrawal in: homeless people, older people. [1.3.4.6] Additional information See page 15 of the quick reference guide for details of outpatient based and intensive community withdrawal programmes See slide 16 or page 16 of the quick reference guide for the drug regimens recommended for assisted alcohol withdrawal. See slide 15 for the algorithm describing assisted alcohol withdrawal. See the notes of slide 9 recommendation 1.2.1.5 for adjusting assessment criteria.

Assisted alcohol withdrawal Person who drinks > 15 units alcohol per day or scores > 20 on AUDIT Assessment Consider offering: – assessment for and delivery of a community-based assisted withdrawal, or – assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal. Inpatient and residential withdrawal Community-based assisted withdrawal NOTES FOR PRESENTERS: Key points to raise: See page 15 of the quick reference guide for more information about outpatient based community withdrawal programmes and intensive community withdrawal programmes. See slide 18 and see page 16 of the quick reference guide for more information about recommended drug regimes for assisted withdrawal programmes. See slide 26 for details of the Sample chlordiazepoxide dosing regimens implementation tool which provides examples of fixed-dose and symptom-triggered regimens for chlordiazepoxide dosing in alcohol withdrawal. The evidence indicated that a community setting for assisted withdrawal is as clinically effective and safe for the majority of patients as an inpatient or residential setting and it is also likely to be more cost effective. The group of experts who developed this guideline identified that symptom-triggered assisted withdrawal was practical only in those inpatient settings that had 24-hour medical monitoring and high levels of specially trained staff. Therefore, the preferred method for assisted withdrawal was a fixed-dose regimen for community and residential settings. Intensive community programmes after assisted withdrawal for severe dependence or mild to moderate dependence with complex needs

Drug regimens for assisted withdrawal When conducting community-based assisted withdrawal programmes, use fixed-dose medication regimens and monitor the service user every other day Fixed-dose or symptom-triggered medication regimens can be used in assisted withdrawal programmes in inpatient or residential settings Prescribe and administer medication for assisted withdrawal within a standard clinical protocol. NOTES FOR PRESENTERS: Key points to raise: Recommendations in this section are not key priorities for implementation but have been included because they are an important component of care for people withdrawing from alcohol. Recommendations in full: When conducting community-based assisted withdrawal programmes, use fixed-dose medication regimens. [1.3.5.1] In a community-based assisted withdrawal programme, monitor the service user every other day during assisted withdrawal. A family member or carer should preferably oversee the administration of medication. Adjust the dose if severe withdrawal symptoms or over-sedation occur. [1.3.5.6] Fixed-dose or symptom-triggered medication regimens can be used in assisted withdrawal programmes in inpatient or residential settings. If a symptom-triggered regimen is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely. [1.3.5.2] Prescribe and administer medication for assisted withdrawal within a standard clinical protocol. The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam). [1.3.5.3] Related recommendations: See recommendations 1.3.5.4–1.3.5.12 in the NICE guideline, or pages 16 and 17 of the quick reference guide which cover the factors to be considered when prescribing drug regimens for assisted withdrawal. Additional information: A fixed-dose regimen involves starting treatment with a standard dose, not defined by the level of alcohol withdrawal, and reducing the dose to zero over 7–10 days according to a standard protocol. A symptom-triggered approach involves tailoring the drug regimen according to the severity of withdrawal and any complications. The service user is monitored on a regular basis and pharmacotherapy only continues as long as the service user is showing withdrawal symptoms. The Sample chlordiazepoxide dosing regimens implementation tool provides examples of fixed-dose and symptom-triggered regimens for chlordiazepoxide dosing in alcohol withdrawal

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. NOTES FOR PRESENTERS: Key points to raise: 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) focused specifically on alcohol misuse. [1.3.6.1] See section 1.3.3 of the NICE guideline or slide 13 ‘Interventions for harmful drinking and mild alcohol dependence’ for further details. Related recommendations: After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone in combination with behavioural couples therapy to service users who have a regular partner and whose partner is willing to participate in treatment (see section 1.3.3 of the NICE guideline). [1.3.6.2] After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering disulfiram in combination with a psychological intervention to service users who: have a goal of abstinence but for whom acamprosate and oral naltrexone are not suitable, or prefer disulfiram and understand the relative risks of taking the drug (see recommendation 1.3.6.12 in the NICE guideline). [1.3.6.3] Please note: all prescribers should consult the SPC for a full description of the contraindications and the special considerations of the use of disulfiram. See pages 18 and 19 of the quick reference guide for further information about pharmacological interventions or recommendations 1.3.6.4–1.3.6.15 in the NICE guideline for detailed recommendations concerning delivering pharmacological interventions (acamprosate, naltrexone, disulfiram), and drugs not to be routinely used for the treatment of alcohol misuse.

Assessment and interventions for children and young people who misuse alcohol For children and young people aged 10–17 years who misuse alcohol offer: individual cognitive behavioural therapy for those with limited comorbidities and good social support multicomponent programmes for those with significant comorbidities and/or limited social support. NOTES FOR PRESENTERS: Recommendation in full: For children and young people aged 10–17 years who misuse alcohol offer: individual cognitive behavioural therapy for those with limited comorbidities and good social support multicomponent programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy) for those with significant comorbidities and/or limited social support. [1.3.7.8] Related recommendations Further recommendations concerning special considerations for children and young people who misuse alcohol fall into the following sections: assessment and referral of children and young people (recommendations 1.3.7.1–1.3.7.4) assisted withdrawal in children and young people (recommendation 1.3.7.5–1.3.7.6) promoting abstinence and preventing relapse in children and young people (recommendations 1.3.7.7–1.3.7.9) delivering psychological and psychosocial interventions for children and young people (recommendation 1.3.7.10–1.3.7.13). See pages 20 and 21 of the quick reference guide for more information. Additional information: In developing the recommendations concerning withdrawal, the experts who developed this guideline acknowledged the uncertainty about the severity of withdrawal symptoms and the potential negative consequences of withdrawal for children and young people. They therefore felt that there should be a lower threshold in the admission criteria for children and young people who misuse alcohol than for adults, and that specialist advice should be made available to healthcare professionals.

Interventions for conditions comorbid with alcohol misuse For people who misuse alcohol and have comorbid depression or anxiety disorders, treat the alcohol misuse first If depression or anxiety continues after 3 to 4 weeks of abstinence from alcohol, assess the depression or anxiety and consider referral and treatment. NOTES FOR PRESENTERS: For people who misuse alcohol and have comorbid depression or anxiety disorders, treat the alcohol misuse first as this may lead to significant improvement in the depression and anxiety. If depression or anxiety continues after 3 to 4 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.[1.3.8.1] Related recommendations: Refer people who misuse alcohol and have a significant comorbid mental disorder, and those assessed to be at high risk of suicide, to a psychiatrist to make sure that effective assessment, treatment and risk-management plans are in place. [1.3.8.2] For the treatment of comorbid mental health disorders refer to the relevant NICE guideline for the particular disorder, and: for alcohol misuse comorbid with opioid misuse actively treat both conditions; take into account the increased risk of mortality with taking alcohol and opioids together for alcohol misuse comorbid with stimulant, cannabis or benzodiazepine misuse actively treat both conditions. Service users who have been dependent on alcohol will need to be abstinent, or have very significantly reduced their drinking, to benefit from psychological interventions for comorbid mental health disorders. [1.3.8.3] For comorbid alcohol and nicotine dependence, encourage service users to stop smoking and refer to ‘Brief interventions and referral for smoking cessation in primary care and other settings’ (NICE public health guidance 1).[1.3.8.4] For recommendation concerning Wernicke-Korsakoff syndrome see recommendations 1.3.8.5 and 1.3.8.6 in the NICE guideline (page 22 of the quick reference guide). Additional information: Relevant NICE guidelines: Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. NICE clinical guideline 113 (2011). [Updated from 2007 guideline] Depression: the treatment and management of depression in adults. NICE clinical guideline 90 (2009). Drug misuse: opioid detoxification, NICE clinical guideline 52 (2007). Drug misuse: psychosocial interventions, NICE clinical guideline 51 (2007).

Principles of care Build a trusting relationship Provide information appropriate to the person’s understanding Work with and support families and carers. NOTES FOR PRESENTERS: Key points to raise: Recommendations in this section are not key priorities for implementation but are included because they are important principles of care for people who misuse alcohol. When working with people who misuse alcohol: build a trusting relationship and work in a supportive, empathic and non‑judgmental manner take into account that stigma and discrimination is often associated with alcohol misuse and that minimising the problem may be part of the service user’s presentation make sure that discussions take place in settings in which confidentiality, privacy and dignity are respected. [1.1.1.1] provide information appropriate to their level of understanding about the nature and treatment of alcohol misuse to support choice from a range of evidence-based treatments avoid clinical language without explanation make sure that comprehensive written information is available in an appropriate language or, for those who cannot use written text, in an accessible format provide independent interpreters (that is, someone who is not known to the service user) if needed. [1.1.1.2] Encourage families and carers to be involved in the treatment and care of people who misuse alcohol to help support and maintain positive change. [1.1.2.1] Related recommendations: See page 23 of the quick reference guide for further information concerning working with and supporting families and carers (recommendations 1.1.2.2–1.1.2.5). Additional information: The positive aspects and benefits of a therapeutic relationship both in a treatment setting and in assessment procedures were cited frequently.

Costs and savings per 100,000 population Recommendation Costs (£ per year) Offering psychological interventions to harmful drinkers and people with mild alcohol dependence 1,800 For people with mild to moderate dependence and complex needs, or severe dependence, offering an intensive community programme following assisted withdrawal –23,400 Offering acamprosate or oral naltrexone in combination with an individual psychological intervention after a successful withdrawal for people with moderate and severe alcohol dependence 3000 Estimated net saving of implementation –18,600 ADAPTING THIS SLIDE FOR LOCAL USE: We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues. NOTES FOR PRESENTERS: NICE has worked closely with people within and outside the NHS to look at the major costs and savings related to implementing this guideline. The estimated national annual cost arising from implementing ‘Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence’ (NICE clinical guideline 115) is a net saving of £9.3 million. NICE has produced a costing report that provides detailed estimates of the national costs and savings associated with implementing this guideline. NICE has also developed a costing template to calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table. The additional cost of offering psychological interventions to harmful drinkers and people with mild alcohol dependence are offset to a large extent by potential savings due to a decrease in the number of harmful drinkers becoming dependent on alcohol and people with mild alcohol dependence developing moderate or severe dependence. Similarly, the additional costs incurred by offering acamprosate or oral naltrexone after a successful withdrawal are offset by reduced relapse rates after withdrawal and corresponding cost savings. The relatively large savings as a result of offering an intensive community programme following assisted withdrawal are due to the large cost differential between residential rehabilitation and intensive community programmes (estimated at around £9696 and £1906 per person respectively). For further information please refer to the costing template and costing report for this guideline on the NICE website. Costs correct at Feb. 2011. Costs not updated for 2nd.edition

Discussion How can we ensure that health and social care professionals in our organisation are competent to identify harmful drinking and alcohol dependence? What training do staff need to enable them to assess the need for interventions in people who are drinking harmfully or who are alcohol dependent? Which formal assessment tools do we use to assess the nature and severity of the alcohol misuse and are these included in the guidance? If not, how can we change to a recommended tool? NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

Click here to go to the NHS Evidence website Visit NHS Evidence for the best available evidence on all aspects of harmful alcohol use Click here to go to the NHS Evidence website NOTES FOR PRESENTERS: If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website topic page for Alcohol. For the home page go to www.evidence.nhs.uk

Find out more Visit www.nice.org.uk/guidance/CG115 for: the guideline the quick reference guide ‘Understanding NICE guidance’ costing report and template audit support baseline assessment tool sample chlordiazepoxide dosing regimens NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. The NICE guideline – all the recommendations. A quick reference guide – a summary of the recommendations for healthcare professionals. ‘Understanding NICE guidance’ – information for patients and carers. The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk and quote reference numbers N2440 (quick reference guide) and/or N2441 (‘Understanding NICE guidance’). NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved. Audit support – for monitoring local practice. Baseline assessment tool - to help identify which areas of practice may need more support, decide on clinical audit topics and prioritise implementation activities. Sample chlordiazepoxide dosing regimens - this document provides examples of fixed-dose and symptom-triggered regimens for chlordiazepoxide dosing in alcohol withdrawal

Alcohol dependence and harmful alcohol use NICE quality standard Alcohol dependence and harmful alcohol use August 2011

Quality standards A quality standard is a set of specific, concise statements that: act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources are produced collaboratively with the NHS and social care, along with their partners and service users NOTES FOR PRESENTERS: Key points to raise: There are two components to a quality standard. These are qualitative statements and quantitative measures. Quality standards also include audience descriptors, definitions and data sources which support the statement measures. Qualitative statements are descriptive statements of the key infrastructure and clinical requirements for high quality care, as well as the desirable or expected outcomes. Commissioners will be interested in quality standards as markers of high quality care and patients and the public will see clear statements of what they can expect to receive from high quality services.

Alcohol quality standard This quality standard covers the care of people aged 10 years and over with alcohol dependence and people drinking in a harmful way in all NHS and social care-funded settings It also includes identification and brief interventions for hazardous drinkers The quality standard consists of 14 quality statements NOTES FOR PRESENTERS: This quality standard covers the care of people aged 10 years and over with alcohol dependence and people drinking in a harmful way in all NHS and social care-funded settings. It also includes identification and brief interventions for hazardous drinkers. It does not cover the management of physical and mental health disorders comorbid with alcohol use. This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for harmful drinkers and people with alcohol dependence in the following ways: Preventing people from dying prematurely. Enhancing quality of life for people with long-term conditions. Ensuring that people have a positive experience of care. Treating and caring for people in a safe environment and protecting them from avoidable harm.

What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form. If you are experiencing problems accessing or using this tool, please email implementation@nice.org.uk NOTES FOR PRESENTERS: Additional information: The final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice - your opinion would be appreciated. To open the links in this slide set right click over the link and choose ‘open link’ To open the links in this slide set right click over the link and choose ‘open link’

End of slide show The following slides contain the boxes referred to in the algorithm If you used the hyperlinks in the algorithm you would have viewed the slides beyond this point The notes section of these box slides contain the recommendations in full where appropriate

Inpatient and residential withdrawal Consider inpatient or residential assisted withdrawal if a service user meets one or more of the following criteria. They: drink over 30 units of alcohol per day have a score of more than 30 on the SADQ have a history of epilepsy or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes need concurrent withdrawal from alcohol and benzodiazepines regularly drink between 15 and 20 units of alcohol per day and have: significant psychiatric or physical comorbidities (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or a significant learning disability or cognitive impairment. Consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups for example homeless and older people. See page 20 of the quick reference guide for special considerations for children and young people. Click here to return to main assisted alcohol withdrawal pathway

Intensive community programmes after assisted withdrawal for severe dependence or mild to moderate dependence with complex needs Offer an intensive community programme in which the service user may attend a day programme lasting between 4 and 7 days per week over a 3-week period. Intensive community programmes should consist of a drug regimen (see page 16 of the quick reference guide) supported by psychological interventions including individual treatments (see page 17 of the quick reference guide), group treatments, psychoeducational interventions, help to attend self-help groups, family and carer support and involvement, and case management (see page 13 of the quick reference guide). Click here to return to main assisted alcohol withdrawal pathway

Community-based assisted withdrawal Service users who need assisted withdrawal should usually be offered a community-based programme – vary in intensity according to the severity of the dependence, available social support and comorbidities. Offer an outpatient based programme for people with mild to moderate dependence in which contact between staff and the service user averages 2–4 meetings per week over the first week. Outpatient-based community assisted withdrawal programmes should consist of a drug regimen (see page 16 of the quick reference guide) and psychosocial support including motivational interviewing. Click here to return to main assisted alcohol withdrawal pathway