This impressive assessment of what evaluation research means for alcohol dependence treatment in Britain is distinguished by reviews of the latest literature on the sub-topics it covers; in some cases these starkly reveal the inadequacies of the evidence base.
Summary This summary is based on the quick reference guide associated with the guidance.
Noting that current practice across the country is varied, leading to variation in access to assisted withdrawal and treatment services, this guideline makes recommendations on the diagnosis, assessment and management of harmful drinking and alcohol dependence in adults and young people aged 1017.
Treatment and care should take into account peoples individual needs and preferences. Good communication is essential, supported by evidence-based information, to allow people to reach informed decisions about their care. If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. If caring for young people in transition between paediatric and adult services, refer to Transition: getting it right for young people.
Key priorities for implementation
Identification and assessment in all settings
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.
Assessment in specialist alcohol services
Consider a comprehensive assessment for all adults referred to specialist services who score more than 15 on the Alcohol Use Disorders Identification Test (AUDIT). A comprehensive assessment should assess multiple areas of need, be structured in a clinical interview, use relevant and validated clinical tools, 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, the Severity of Alcohol Dependence Questionnaire (SADQ) or the Leeds Dependence Questionnaire (LDQ); alcohol-related problems, using, for example, the Alcohol Problems Questionnaire (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.
General principles for all interventions
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, living alone or with very little contact with family or friends; or
complex physical or psychiatric comorbidities; or
not responded to initial community-based interventions.
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 in 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.
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 alcohol-related cognitions, behaviour, problems and social networks.
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.
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 therapy, behavioural therapy or social network and environment-based therapy) focused specifically on alcohol misuse.
Assessment and interventions for children and young people who misuse alcohol
For children and young people aged 1017 years who misuse alcohol offer:
individual cognitive-behavioural therapy for those with limited comorbidities and good social support;
multi-component 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.
Interventions for conditions comorbid with alcohol misuse
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 these continue after three to four weeks of abstinence from alcohol, undertake an assessment of the depression or anxiety and consider referral and treatment in line with the relevant NICE guideline for the particular disorder.
[UK] National Collaborating Centre for Mental Health.
[UK] National Institute for Health and Clinical Excellence, 2011.