1. This presentation uses information freely available from: NICE Guidance CG115 2 nd. Edition - August 2011 CG115 Alcohol dependence and harmful alcohol use: slide seCG115 Alcohol dependence and harmful alcohol use: slide set Glen Hanson (2004) Psychology of Addiction http://ebookpp.com/gl/glen-hanson-ppt.html CPCAB TC L4 Addictions Presentation Unit 6 2.1, 2.2, 2.4

2. 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. (DSM-IV) definition of substance abuse is at least one of the following four criteria. Continued use despite social or interpersonal problems. Repeated use resulting in failure to fulfill obligations at work, school, or home. Repeated use resulting in physically hazardous situations. Use resulting in legal problems.

3. 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.

4. Epidemiology Weekly alcohol consumption of more than 50 units (men) or more than 35 units (women) by age (years) and gender – Great Britain, 2009 Source: General Lifestyle Survey, Office for National Statistics Y = Percentage of population X = Age in years

5. Perspectives on Addiction Biological / Neurotransmitters The chemical that moves between nerve cells to transmit messages. If the message is blocked or replaced there will be a change to the physiological system and this in turn will effect mood behaviour and cognition. Dopamine is the most commonly associated neurotransmitter with addiction. Dopamine is similar to adrenaline in that it affects brain processes that control movement, emotional response, and ability to experience pleasure and pain.

6. Perspectives on Addiction Cocaine and other drugs of abuse can alter dopamine function Some drugs are known as dopamine agonists. These drugs bind to dopamine receptors in place of dopamine & directly stimulate those receptors. Drugs such as cocaine and amphetamine produce their effects by changing the flow of neurotransmitters. These drugs are defined as indirect acting because they depend on the activity of neurons.

7. Perspectives on Addiction In contrast, some drugs bypass neurotransmitters altogether and act directly on receptors. Such drugs are direct acting. However, some drugs increase dopamine by preventing dopamine reuptake, leaving more dopamine in the synapse. An example is the widely abused stimulant drug, cocaine. Another is methylphenidate, used therapeutically to treat childhood hyperkinesis (ADHD) and symptoms of schizophrenia.

8. Perspectives on Addiction Scientists will never find just one single addiction gene. Susceptibility to addiction is the result of many interacting genes "Just because you are prone to addiction doesn't mean you're going to become addicted. It just means you've got to be careful." Glen Hanson (2004) http://ebookpp.com/gl/glen-hanson-ppt.html

9. Cognitive explanations of addictive behaviour. Faulty Thinking Example= Gambling “I will win, I can control the odds, if I use my lucky numbers I'll be rich one day.” Irrational biases Overestimate the extent to which they can predict or influence the outcomes. This also leads to a under estimation of how much has been lost/won. See Griffiths (1994) Gamblers irrational cognitive biases.

10. Treatment 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 Co-morbid mental and physical disorders are common. 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.

11. All adults referred to specialist alcohol services who score more than 15 on the AUDIT. Should have a comprehensive assessment to: 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. Assessment in specialist alcohol services

12. Offer a psychological intervention focused specifically on: alcohol-related cognitions behaviour problems social networks. Interventions for harmful drinking and mild alcohol dependence

13. 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. Assessment for assisted alcohol withdrawal

14. 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. Interventions for moderate and severe alcohol dependence

15. 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.

16. 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.

17. Costs and savings per 100,000 population Recommendation Costs (£ per year) Offering psychological interventions to harmful drinkers and people with mild alcohol dependence1,800 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 Costs correct at Feb. 2011. Costs not updated for 2 nd.edition

18. Find out more Visit www.nice.org.uk/guidance/CG115 for:www.nice.org.uk/guidance/CG115 the guideline the quick reference guide ‘Understanding NICE guidance’ costing report and template audit support baseline assessment tool sample chlordiazepoxide dosing regimens