1. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence Implementing NICE guidance February 2011 NICE clinical guideline 115

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.

3. What this presentation covers Definitions Epidemiology Background Scope Key priorities for implementation Principles of care Costs and savings Discussion Find out more

4. 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.

5. 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

6. 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.

7. 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.

8. 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.

9. 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. General principles for identification and assessment

10. 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. Assessment in specialist alcohol services

11. 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. General principles for all interventions: 1

12. 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. General principles for all interventions: 2

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

14. 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

15. 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. Community-based assisted withdrawal Inpatient and residential withdrawal Intensive community programmes after assisted withdrawal for severe dependence or mild to moderate dependence with complex needs

16. 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.

17. 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

18. 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.

19. 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.

20. Build a trusting relationship Provide information appropriate to the person’s understanding Work with and support families and carers. Principles of care

21. 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

22. 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?

23. 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

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26. 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: o significant psychiatric or physical comorbidities (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or o 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

27. 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

28. 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