NICE guidelines - New guideline on treating alcohol-dependent patients

This NICE guideline outlines diagnosis and treatment. By Dr Linda Harris

Patient with ascites and hernia caused by cirrhosis, a complication of long-term alcohol misuse (Photograph: SPL)
Patient with ascites and hernia caused by cirrhosis, a complication of long-term alcohol misuse (Photograph: SPL)

There is no doubt that specialist alcohol care can pull patients back from the brink of the most devastating consequences of alcohol misuse, especially alcohol-related liver disease, give them back their self respect and restore them to their families and communities.

Primary care professionals working with specialist community alcohol services are the cornerstone of this response.

The NICE clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence has been written for healthcare 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 NICE guideline contains 94 recommendations about how care can be improved but nine key recommendations have been identified as having the greatest impact on care and are therefore prioritised for implementation.

This is the first time that NICE has published guidance specifically on diagnosing alcohol dependence, as well as how these patients should be treated, based on the severity of their condition. It has been based on the best available evidence and expert opinion.

Harmful drinking
Harmful drinking is defined as a pattern of alcohol consumption causing health problems, such as psychological problems, alcohol-related accidents or physical illness, such as acute pancreatitis. In the longer term, harmful drinkers may go on to develop hypertension, cirrhosis, heart disease and cancer.

Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking despite harmful consequences.

Why is this guideline important?
It is estimated that 24 per cent of the adult population in England consumes alcohol in a potentially harmful manner1 and 4 per cent of adults are alcohol dependent.2

Alcohol-related hospital admissions increased by 85 per cent between 2002/3 and 2008/93 and the current trends show admissions to be rising at 11 per cent per year.

Of the one million people aged between 16 and 65 who are alcohol dependent in England, only about 6 per cent per year receive treatment. Reasons for this include the often long period between developing alcohol dependence and seeking help, the limited availability of specialist alcohol treatment services in parts of England and the under-identification of alcohol misuse by health and social care professionals.

Prompt diagnosis and assessment of the severity of alcohol misuse is vital in identifying the treatment interventions required. Acute withdrawal from alcohol in the absence of medical management can be hazardous, as it may lead to seizures, delirium tremens and death.

Services for assisted alcohol withdrawal and treatment vary across the UK and there is a lack of intensive community-based withdrawal programmes. Similarly, there is limited access to psychological interventions, such as cognitive behavioural therapies specifically focused on alcohol misuse.

In addition, when the alcohol misuse has been effectively treated, many patients continue to experience problems in accessing services for comorbid mental and physical health problems.

Key recommendations
When working with alcohol misusers, it is vital to build a trusting relationship, be empathic and non-judgmental. Stigma and social isolation are often a part of the presentation and it is vital that wherever possible families and carers are involved in care plans.

The guideline acknowledges the need for professionals to be able to identify harmful drinking and dependence. Most GPs have the skills to assess the need for an intervention, however some professionals lack competence and confidence to provide structured community-based interventions.

In these cases, NICE recommends referral to a service that can provide a comprehensive assessment of need.

The guideline encourages doctors to subdivide dependence into categories of mild, moderate and severe and to use validated screening questionnaires to select the most appropriate intervention.

Screening tools highlighted in the guidance include the alcohol use disorders identification test,4 severity of alcohol disorders questionnaire (SADQ)5 and the Leeds dependence questionnaire.6 These tools are used to determine whether or not the patient requires assisted withdrawal (see box).

Assessment for assisted withdrawal
  • Patients with mild dependence (scoring 15 or less on the SADQ) usually do not need assisted alcohol withdrawal.
  • Patients with moderate dependence (SADQ score of 15 to 30) usually need assisted alcohol withdrawal, which can typically be managed in a community setting unless there are other risks.
  • Patients who are severely alcohol dependent (SADQ score of 31 or more) will need assisted alcohol withdrawal, typically in an inpatient or residential setting.

The recommended treatment regimes suitable in community and residential/inpatient settings are outlined in the guideline and there is information about what interventions support patients to maintain their abstinence, including a combination of pharmacological and psychosocial interventions.

First-line pharmacological therapies recommended to promote abstinence include acamprosate and naltrexone but always in combination with psychosocial interventions that focus specifically on alcohol-related cognition, behaviour, problems and social networks.

For patients who lack social support, have complex physical and psychiatric comorbidities or have failed to respond to initial community-based interventions, the guideline recommends offering interventions to promote abstinence and prevent relapse as part of an intensive community-based intervention encouraging the use of motivational techniques to support patients to achieve general health goals.

People who are homeless should enter residential rehabilitation for a minimum of three months.

Summary
The availability of enhanced services in primary care needs to be improved in order to detect alcohol-related harm at an early stage. This should be supported, where necessary, by an alcohol specialist worker.

The NICE guideline outlines the responsibilities of healthcare professionals to examine current practice at a local level and identify which local professionals are competent to identify harmful drinking and alcohol dependence, what training is needed and which formal assessment tools are currently used.

  • Dr Harris is a GP in West Yorkshire, the clinical director, Wakefield Integrated Substance Misuse Services and a member of the NICE alcohol guideline development group

References
1. McManus S, Meltzer H, Brugha T et al. NHS Information Centre for Health and Social Care, Leeds, 2009.

2. Drummond DC, Oyefeso, N, Phillips T et al. Department of Health, London, 2005.

3. North West Public Health Observatory (2010). www.nwph.net/alcohol/lape/

4. Babor TF, Higgins-Biddle JC, Saunders JB et al. Department of Mental Health and Substance Dependence, WHO.

5. Stockwell T, Murphy D, Hodgson R. Br J Addict 1983; 78: 45-156.

6. Raistrick D, Bradshaw J, Tober G et al. Addiction 1994; 89: 563-72.

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