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These are the paths in the Alcohol-use disorders pathway:
Alcohol-use disorders
About
What is covered
This pathway covers prevention, diagnosis and management of alcohol-related disorders, including hazardous and harmful drinking, alcohol dependence and the physical complications of alcohol use in adults and children and young people aged under 18 years in educational institutions.
Hazardous drinking, harmful drinking and alcohol dependence cause many mental and physical health problems, and social problems. In England, 4% of people aged between 16 and 65 are dependent on alcohol (6% of men and 2% of women). More than 24% of the English population (33% of men and 16% of women) consume alcohol in a way that is potentially or actually harmful to their health or wellbeing. Alcohol-use disorders are also an increasing problem in children and young people. This pathway includes NICE recommendations on:
- prevention and early identification of alcohol-use disorders, including interventions in schools to prevent and reduce alcohol use among children and young people
- the diagnosis, assessment and management of harmful drinking and alcohol dependence
- key areas in the investigation and management of alcohol-related physical complications.
Align actions to prevent harmful drinking with strategies to prevent obesity at a community level to ensure a coherent, integrated approach (see the obesity: working with local communities pathway).
Updates
Updates to this pathway
21 July 2015 Living-donor liver transplantation (NICE interventional procedures guidance 194) removed from referral for consideration of transplantation and replaced with a link to liver transplantation nodes in the liver cancers and liver conditions pathways.
24 March 2015 Rifaximin for preventing episodes of overt hepatic encephalopathy (NICE technology appraisal guidance 337) added to management of alcohol-related liver disease and its complications and alcohol: preventing harmful alcohol use in the community (NICE quality standard 83) added to this pathway.
25 November 2014 Nalmefene for reducing alcohol consumption in people with alcohol dependence (NICE technology appraisal guidance 325) added to interventions for harmful drinking and mild alcohol dependence.
21 October 2014 Correction made to inpatient and residential withdrawal to make it clear that inpatient or residential assisted withdrawal should be considered for people who regularly drink between 15 and 30 units (not between 15 and 20 units) of alcohol per day, if they also have the additional complicating features mentioned in the recommendation.
22 August 2014 Minor maintenance updates.
23 June 2014 Minor maintenance updates.
25 February 2014 Minor maintenance updates.
21 January 2014 Minor maintenance updates.
17 October 2013 Minor maintenance updates.
25 June 2013 SonoVue for contrast-enhanced ultrasound imaging of the liver (NICE diagnostics guidance 5) added to diagnostics and procedures for alcohol-related liver disease and its complications.
4 January 2013 Minor maintenance updates.
4 December 2012 Minor maintenance updates.
28 November 2012 Information about obesity prevention added to introduction.
19 June 2012 Information about oesophageal varices added to diagnostics and procedures for alcohol-related liver disease and its complications.
14 May 2012 Effective interventions library information added to school-based information and advice and brief advice for adults attending a service
25 October 2011 Minor maintenance updates.
31 August 2011 Quality standard for alcohol dependence and harmful alcohol use added.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.
Short Text
What is covered
This pathway covers prevention, diagnosis and management of alcohol-related disorders, including hazardous and harmful drinking, alcohol dependence and the physical complications of alcohol use in adults and children and young people aged under 18 years in educational institutions.
Hazardous drinking, harmful drinking and alcohol dependence cause many mental and physical health problems, and social problems. In England, 4% of people aged between 16 and 65 are dependent on alcohol (6% of men and 2% of women). More than 24% of the English population (33% of men and 16% of women) consume alcohol in a way that is potentially or actually harmful to their health or wellbeing. Alcohol-use disorders are also an increasing problem in children and young people. This pathway includes NICE recommendations on:
- prevention and early identification of alcohol-use disorders, including interventions in schools to prevent and reduce alcohol use among children and young people
- the diagnosis, assessment and management of harmful drinking and alcohol dependence
- key areas in the investigation and management of alcohol-related physical complications.
Align actions to prevent harmful drinking with strategies to prevent obesity at a community level to ensure a coherent, integrated approach (see the obesity: working with local communities pathway).
Updates
Updates to this pathway
21 July 2015 Living-donor liver transplantation (NICE interventional procedures guidance 194) removed from referral for consideration of transplantation and replaced with a link to liver transplantation nodes in the liver cancers and liver conditions pathways.
24 March 2015 Rifaximin for preventing episodes of overt hepatic encephalopathy (NICE technology appraisal guidance 337) added to management of alcohol-related liver disease and its complications and alcohol: preventing harmful alcohol use in the community (NICE quality standard 83) added to this pathway.
25 November 2014 Nalmefene for reducing alcohol consumption in people with alcohol dependence (NICE technology appraisal guidance 325) added to interventions for harmful drinking and mild alcohol dependence.
21 October 2014 Correction made to inpatient and residential withdrawal to make it clear that inpatient or residential assisted withdrawal should be considered for people who regularly drink between 15 and 30 units (not between 15 and 20 units) of alcohol per day, if they also have the additional complicating features mentioned in the recommendation.
22 August 2014 Minor maintenance updates.
23 June 2014 Minor maintenance updates.
25 February 2014 Minor maintenance updates.
21 January 2014 Minor maintenance updates.
17 October 2013 Minor maintenance updates.
25 June 2013 SonoVue for contrast-enhanced ultrasound imaging of the liver (NICE diagnostics guidance 5) added to diagnostics and procedures for alcohol-related liver disease and its complications.
4 January 2013 Minor maintenance updates.
4 December 2012 Minor maintenance updates.
28 November 2012 Information about obesity prevention added to introduction.
19 June 2012 Information about oesophageal varices added to diagnostics and procedures for alcohol-related liver disease and its complications.
14 May 2012 Effective interventions library information added to school-based information and advice and brief advice for adults attending a service
25 October 2011 Minor maintenance updates.
31 August 2011 Quality standard for alcohol dependence and harmful alcohol use added.
Sources
NICE guidance
The NICE guidance that was used to create the pathway.
Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) NICE guideline CG115
Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications (2010) NICE guideline CG100
Alcohol-use disorders: preventing the development of hazardous and harmful drinking (2010) NICE guideline PH24
Interventions in schools to prevent and reduce alcohol use among children and young people (2007) NICE guideline PH7
Rifaximin for preventing episodes of overt hepatic encephalopathy (2015) NICE technology appraisal guidance 337
Nalmefene for reducing alcohol consumption in people with alcohol dependence (2014) NICE technology appraisal guidance 325
Subcutaneous implantation of a battery-powered catheter drainage system for managing refractory and recurrent ascites (2014) NICE interventional procedure guidance 479
Extracorporeal albumin dialysis for acute liver failure (2009) NICE interventional procedure guidance 316
SonoVue (sulphur hexafluoride microbubbles) – contrast agent for contrast-enhanced ultrasound imaging of the liver (2012) NICE diagnostics guidance 5
Quality standards
Alcohol dependence and harmful alcohol use quality standard
These quality statements are taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Alcohol: preventing harmful alcohol use in the community
These quality statements are taken from the alcohol: preventing harmful alcohol use in the community. The quality standard defines clinical best practice in alcohol: preventing harmful alcohol use in the community and should be read in full.
Quality statements
Opportunistic screening and brief interventions
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
Health and social care staff opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice.
Quality measure
Structure:
a) Evidence of local arrangements to ensure that healthcare staff opportunistically carry out screening and brief interventions for hazardous and harmful drinking on a routine basis.
b) Evidence of local arrangements to ensure that social care staff opportunistically carry out screening with people who may be at an increased risk of harm from alcohol and people who have alcohol-related problems, and deliver brief interventions for hazardous and harmful drinking.
c) Evidence of local arrangements within the commissioning framework to ensure that brief interventions are reviewed to ensure effective practice.
Process:
a) Proportion of people aged 16 years and over in the locally defined target population who receive alcohol screening.
Numerator – the number of people in the denominator receiving alcohol screening.
Denominator – the number of people aged 16 years and over in the locally defined target population for alcohol screening.
b) Proportion of people aged 18 and older identified as hazardous or harmful drinkers who receive structured brief advice.
Numerator – the number of people in the denominator receiving structured brief advice.
Denominator – the number of people aged 18 and older identified as hazardous or harmful drinkers.
c) Proportion of people aged 16 or 17 identified as hazardous or harmful drinkers and people aged 18 and older not responding to structured brief advice for hazardous or harmful drinking, who receive an extended brief intervention.
Numerator – the number of people in the denominator receiving an extended brief intervention.
Denominator – the number of people aged 16 or 17 identified as hazardous or harmful drinkers and people aged 18 and older not responding to structured brief advice for hazardous or harmful drinking.
Outcome:
Decrease in the quantity and frequency of alcohol consumption in the locally defined target population.
Description of what the quality statement means for each audience
Service providers ensure that healthcare staff opportunistically carry out alcohol screening and brief interventions for hazardous and harmful drinking on a routine basis, and that social care staff opportunistically carry out alcohol screening with people who may be at an increased risk of harm from alcohol and deliver brief interventions for hazardous and harmful drinking.
Healthcare professionals ensure they opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice and on a routine basis.
Social care professionals ensure they opportunistically carry out screening for people who may be at an increased risk of harm from alcohol and deliver brief interventions for hazardous and harmful drinking.
Commissioners ensure they commission services that opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice, and develop commissioning frameworks that review this practice to ensure effectiveness.
People aged 16 and over are asked questions about their drinking during contact with health and social care professionals, and may be offered some brief advice about what this means or a longer session to help reduce their drinking.
Source clinical guideline references
NICE public health guidance 24 recommendations 5, 7 and 9.
Data source
Structure: a), b) and c) Local data collection.
Process:
a) GP practices delivering the current Directed Enhanced Service (DES) specification for the Alcohol-related risk reduction scheme, England are required to send to commissioners an audit of:
- Number of newly-registered patients aged 16 and over within the financial year who have had the shortened standard test (FAST or AUDIT-C – both abbreviated versions of the alcohol use disorders identification test [AUDIT]).
- Number of newly-registered patients aged 16 and over who have screened positive using a short test during the financial year, who then undergo a fuller assessment using a validated tool (for example, AUDIT) to determine increasing risk, higher risk, or probable alcohol dependence.
The current National patient survey of PCTs collects the following data:
- Whether people have been asked by someone at their GP practice/health centre in the last 12 months about how much alcohol they drink.
And data on respondents' discussions with their GP, someone else at the surgery, another doctor or any other medical professional is available from the Omnibus ONS drinking survey.
Contained within NICE public health guidance 24: audit support criteria 1, 4a, 4b and 5.
b) The DES requires participating GP practices to audit the number of newly-registered patients who have been identified as drinking at increasing risk or higher risk levels who have during that period received a brief intervention to help them reduce their alcohol-related risk. Contained within NICE public health guidance 24: audit support criterion 6.
c) Local data collection. Contained within NICE public health guidance 24: audit support criteria 3 and 8.
Outcome:
Data on prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.
Definitions
The following definitions are adapted from NICE public health guidance 24.
'Screening' involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. The term is not used here to refer to national screening programmes such as those recommended by the UK National Screening Committee (UK NSC). Screening should be carried out with a validated alcohol questionnaire (such as the AUDIT).
'Brief intervention' comprises either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists.
Screening and extended brief interventions are recommended in people aged 16 or 17 years. Screening and structured brief advice are recommended as the first step in people aged 18 years and older. For those who do not respond to structured brief advice, an extended brief intervention is recommended.
For the purposes of this statement, health and social care staff are defined as any professional working in any health or social care setting, including those working in criminal justice, prison, community or voluntary sector settings who regularly come into contact with people at risk of harm from the amount of alcohol they drink.
NHS professionals should consider discussing alcohol consumption during new patient registrations at a GP practice, when screening for other conditions, and when managing chronic disease or carrying out a medicine review. Discussions should also take place when promoting sexual health, when seeing someone for an antenatal appointment and when treating minor injuries.
Social care professionals should focus on people who may be at an increased risk of harm and people who have alcohol-related problems. People who may be at an increased risk of harm from alcohol include those:
- at risk of self-harm
- involved in crime or other antisocial behaviour
- who have been assaulted
- at risk of domestic abuse
- whose children are involved with child safeguarding agencies
- with drug problems.
Figure 5 in the full version of clinical guideline 115 provides a care pathway for case identification and possible diagnosis for adults, including criteria for brief interventions, extended brief interventions, and specialist referral.
Equality and diversity considerations
Lower screening thresholds may be needed when assessing older and younger people. In addition, by recommending that those aged 16 and 17 receive extended brief interventions (rather than structured brief advice) it may reduce the number of opportunities to receive an intervention, as extended brief interventions may be less readily available. Lower screening thresholds should also be considered for women and some black and minority ethnic groups too.
Discussions broaching the subject of alcohol and screening should be sensitive to people's culture and faith, and tailored to their needs. Discussions with young people should be sensitive to the person's age, their ability to understand what is involved and their emotional maturity. Relevant specialists should be consulted when it is not appropriate to use an English language-based screening questionnaire, for example when dealing with people whose first language is not English or who have a learning disability.
Referral to specialist alcohol services
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
People who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and are able to access specialist alcohol treatment.
Quality measure
Structure:
a) Evidence of local arrangements to ensure effective identification of people who may benefit from specialist assessment or treatment for alcohol misuse.
b) Evidence of the use of a local referral pathway in accordance with NICE public health guidance 24 and NICE clinical guideline 115 to ensure that people who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services.
c) Evidence of a local needs assessment highlighting gaps in and barriers to accessing specialist alcohol treatment as well as prevalence of alcohol misuse. Estimated burden of alcohol misuse and uptake of specialist treatment should be broken down by key equality groups such as women, people from minority ethnic groups, people who are homeless and people in different age groups.
d) Evidence of audit of waiting times in specialist alcohol services from initial referral to assessment, assessment to treatment start, and total waiting time from referral to starting treatment.
Process:
Proportion of people meeting NICE guidance criteria for referral to specialist alcohol services who are referred to specialist alcohol services.
Numerator – the number of people in the denominator referred to specialist alcohol services.
Denominator – the number of people meeting NICE guidance criteria for referral to specialist alcohol services.
Outcome:
a) Proportion of people in the local population estimated to be dependent on alcohol who access specialist alcohol services.
Numerator – the number of people in the denominator accessing specialist alcohol services.
Denominator – the number of people in the local population estimated to be dependent on alcohol.
NICE public health guidance 24 recommends that commissioners should ensure at least one in seven dependent drinkers can get treatment locally.
b) Decrease in the quantity and frequency of alcohol consumption in people who misuse alcohol.
Description of what the quality statement means for each audience
Service providers ensure that access pathways are implemented for referring to specialist alcohol services and that appropriate arrangements are in place for self-referral for people who may benefit from specialist assessment or treatment for alcohol misuse.
Health and social care professionals ensure they are aware of local access pathways and offer referral to specialist alcohol services to people who may benefit from specialist assessment or treatment for alcohol misuse.
Commissioners ensure they commission services that implement effective access pathways to specialist alcohol services and commission specialist alcohol services with capacity for at least one in seven of the estimated dependent drinking population to access treatment.
People who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and are able to access specialist alcohol treatment.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.2.1.2 and 1.3.4.1 (key priorities for implementation) and NICE public health guidance 24 recommendations 5, 8, 9, 11 and 12.
Data source
Structure:
a), b), c) Local data collection.
d) Local data collection. The National Alcohol Treatment Monitoring System (NATMS) collects data on people presenting for structured treatment in specialist alcohol services; 'date referred to modality', 'date of first appointment offered for modality' and 'triage date' are collected. 'Modality start date' records when the person actually starts a treatment modality.
Process:
GP practices delivering the Directed Enhanced Service (DES) specification for the Alcohol-related risk reduction scheme, England are required to send to commissioners an audit of:
- Number of newly registered patients scoring 20 or more on the full ten-question alcohol-use disorders identification test (AUDIT) questionnaire who have been referred for specialist advice for dependent drinking during that period.
The National Alcohol Treatment Monitoring System (NATMS) collects data on referral routes into specialist alcohol services for people who present for structured specialist treatment, that is, those who complete a structured treatment assessment.
Outcome:
a) Data on prevalence of alcohol misuse in adults is available from the NHS Adult Psychiatric Morbidity Survey in England. The NATMS collects data on people receiving structured alcohol treatment, but does not differentiate between harmful drinkers and people with alcohol dependence.
b) Local data collection. Data on prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.
Definitions
See quality statement 2 on opportunistic screening and brief interventions for a definition of brief interventions.
NICE public health guidance 24 recommends that referral for specialist treatment is considered for people aged 16 years and older if they:
- show signs of moderate or severe alcohol dependence or
- fail to benefit from structured brief advice and an extended brief intervention and desire to receive further help for an alcohol problem or
- show signs of severe alcohol-related impairment or related comorbid condition (for example, liver disease or alcohol-related mental health problems).
Referral for young people aged 16 or 17 years must be to services that deal with young people.
NICE clinical guideline 115 recommends that people should be referred to specialist services for assessment of need where staff making the referral are not competent themselves to identify harmful drinking or alcohol dependence. It also recommends that service users who typically drink over 15 units of alcohol per day and/or who score 20 or more on the AUDIT should be considered for assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal.
Figure 5 in the full version of clinical guideline 115 provides a care pathway for case identification and possible diagnosis for adults, including referral to specialist assessment.
Access to specialist alcohol services for those who might benefit from specialist treatment requires a responsive treatment system. A responsive treatment system is a pathway that ensures appropriate case identification and subsequent referral to specialist services, which respond appropriately to referrals and provide ease of access to treatment. Treatment access should include appropriate arrangements for self-referral.
People who are likely to benefit from specialist alcohol treatment who accept a referral to specialist alcohol services should expect the service to make contact with them as soon as possible. During any period of waiting, the service user remains under the care of the referrer (for example, their GP), who should continue monitoring and address any urgent needs as appropriate.
Equality and diversity considerations
This statement promotes equality by ensuring that all people who may benefit from specialist alcohol services are offered a referral and can access specialist alcohol services for assessment and treatment.
Currently, some equality groups may be under-referred, such as older adults (due to a lack of clinical suspicion or misdiagnosis) and young adults presenting at emergency departments or in primary care.
Homeless people can have difficulty accessing appointment-only services, women can regard services less suited to their needs in terms of children and childcare, and people from minority ethnic groups may find a lack of ethno-cultural peers and staff a barrier to treatment access. There is a risk that people who are housebound (which may include a large number of older people) currently wait longer to access specialist treatment.
Outreach and assertive engagement techniques should be considered with some of these groups who may otherwise find it difficult to engage in treatment.
Trained and competent specialist staff
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
People accessing specialist alcohol services receive assessments and interventions delivered by appropriately trained and competent specialist staff.
Quality measure
Structure:
a) Evidence of local implementation of current guidance from the Royal College of Psychiatrists and Royal College of General Practitioners on training and competence for doctors working in substance misuse.
b) Evidence of local arrangements to ensure that all staff carrying out initial assessments in specialist alcohol services are trained in the key elements of motivational interviewing.
c) Evidence of local arrangements to ensure that care coordination with other agencies (for example, housing, employment and social care) is delivered by appropriately trained and competent staff working in specialist alcohol services.
d) Evidence of local arrangements to ensure the use of competence frameworks developed from relevant treatment manuals that guide the structure and duration of psychological interventions for people who misuse alcohol.
e) Evidence of local arrangements to ensure that staff responsible for assessing and managing assisted alcohol withdrawal are trained and competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms, and the use of drug regimens appropriate to the setting in which the withdrawal is managed.
f) Evidence of local arrangements to ensure that staff working in specialist alcohol services receive appropriate monitoring and supervision.
Process:
Proportion of staff carrying out assessments or delivering interventions in specialist alcohol services who are Drugs and Alcohol National Occupational Standards (DANOS) compliant.
Numerator – the number of people in the denominator who are DANOS compliant.
Denominator – the number of staff carrying out assessments or delivering interventions in specialist alcohol services.
Outcome:
Decrease in the quantity and frequency of alcohol consumption in people who misuse alcohol.
Description of what the quality statement means for each audience
Service providers ensure that specialist staff carrying out assessments or delivering interventions for alcohol misuse are appropriately trained and competent in accordance with current national guidance.
Health and social care professionals carrying out assessments or delivering interventions for alcohol misuse as part of specialist alcohol treatment ensure they are aware of current national guidance, participate in appropriate training, and engage in evaluation and supervision of their practice.
Commissioners ensure they commission specialist alcohol services with an adequate specialist workforce in accordance with current national guidance and where staff training and competence are monitored and maintained.
People accessing specialist alcohol services are assessed by and receive treatment from appropriately trained and competent specialist staff.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.2.1.6, 1.3.1.1, 1.3.1.5 (key priority for implementation) and 1.3.2.1.
Data source
Structure:
a) to f) Local data collection.
Process:
Local data collection.
Outcome:
Local data collection. Data on the prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.
Definitions
At the time of publication (June 2011), current national guidance on a specialist workforce includes:
- NICE clinical guideline 115
- Royal College of Psychiatrists and Royal College of GPs: Roles and responsibilities of doctors in the provision of treatment for drug and alcohol misusers guidance
- Drug and Alcohol National Occupational Standards (DANOS).
DANOS should be considered a minimum requirement for practitioners in specialist alcohol services. In addition, relevant specialists will be required for some assessments and interventions, such as mental health assessments and delivery of cognitive behavioural therapy.
The level and type of training or specialism required will vary across different stages of the treatment system. Exact workforce composition and planning should be determined locally in accordance with local need. Provision for ongoing monitoring and evaluation of practice competence, for example, by using video and audio tapes and external audit and scrutiny, should be assured.
Assessment in specialist alcohol services – adults
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
Adults accessing specialist alcohol services for alcohol misuse receive a comprehensive assessment that includes the use of validated measures.
Quality measure
Structure:
a) Evidence of local arrangements to ensure that adults accessing specialist alcohol services for alcohol misuse receive a comprehensive assessment that includes the use of validated measures.
b) Evidence of local arrangements to ensure the use of a standardised comprehensive assessment form for adults accessing specialist alcohol services.
c) Evidence of regular local audit of case files for adults in specialist alcohol services to ensure adherence to all assessment domains.
d) Evidence of local arrangements in specialist alcohol services for effective coordination with other agencies relevant to adult service users.
Process:
a) Proportion of adults accessing specialist alcohol services for alcohol misuse who receive a comprehensive assessment.
Numerator – the number of people in the denominator receiving a comprehensive assessment.
Denominator – the number of adults accessing specialist alcohol services for alcohol misuse.
b) Proportion of adults accessing specialist alcohol services for alcohol misuse who are assessed using appropriate and validated measures for each applicable assessment domain.
Numerator – the number of people in the denominator assessed using appropriate and validated measures for each applicable assessment domain.
Denominator – the number of adults accessing specialist alcohol services for alcohol misuse.
Description of what the quality statement means for each audience
Service providers ensure they implement validated measures for assessing adults accessing specialist alcohol services for alcohol misuse, and provide a standardised assessment form to ensure that all components of a comprehensive assessment are completed for every person.
Health and social care professionals ensure they complete all components of a comprehensive assessment including the use of validated measures, for adults accessing specialist alcohol services for alcohol misuse.
Commissioners ensure they commission specialist alcohol services that use validated measures for assessing adults accessing specialist treatment for alcohol misuse, and ensure that all components of a comprehensive assessment are completed for every person.
Adults accessing specialist alcohol services for alcohol misuse receive a full assessment of the different areas in which they might need help.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.2.1.4, 1.2.1.5, 1.2.2.5, 1.2.2.6 (key priority for implementation), 1.2.2.7 and 1.3.2.3.
Data sources
Structure:
a), b), c) and d) Local data collection.
Process:
a) The National Alcohol Treatment Monitoring System (NATMS) collects data on people presenting for structured treatment in specialist alcohol services; 'triage date' is collected, which is the date that triage/initial assessment took place (this is not necessarily a comprehensive assessment). It also collects data at the start of treatment for the numbers of drinking days in the last 28 days (self-report) and typical numbers of units consumed in an average drinking day. Full assessment requirements contained within NICE clinical guideline 115: audit support criteria 2 and 3.
b) Local data collection. Contained within NICE clinical guideline 115: audit support criterion 1.
Definitions
NICE clinical guideline 115 recommends the following validated assessment tools to assess the nature and severity of alcohol misuse:
- Alcohol Use Disorders Identification Test (AUDIT) for identification and as a routine (drinking) outcome measure
- Severity of Alcohol Dependence Questionnaire (SADQ) or Leeds Dependence Questionnaire (LDQ) for severity of dependence
- Alcohol Problems Questionnaire (APQ) for the nature and extent of the problems arising from alcohol misuse.
The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) may be used to assess the severity of alcohol withdrawal.
NICE clinical guideline 115 recommends considering a comprehensive assessment for all adults referred to specialist 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, 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 (including housing)
- cognitive function (using, for example, the Mini-Mental State Examination [MMSE])
- readiness and belief in ability to change.
Comorbid mental health problems should also be assessed as part of any comprehensive assessment, because many comorbid problems (though not all) will improve with treatment for alcohol misuse.
Any initial assessment, which may take place as a triage or as part of the comprehensive assessment, should also assess:
- the pattern and severity of alcohol misuse (using AUDIT) and severity of dependence (using SADQ)
- the need for urgent treatment including assisted withdrawal
- any associated risk to self or risk to others
- the presence of any comorbdities or other factors that may need further specialist assessment or intervention.
Equality and diversity considerations
When assessing the severity of alcohol dependence and determining the need for assisted withdrawal, the criteria should be adjusted for women, older people and younger people.
All assessments should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People who need a comprehensive assessment should have access to an interpreter or advocate if needed.
Assessment in specialist services – children and young people
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
Children and young people accessing specialist services for alcohol use receive a comprehensive assessment that includes the use of validated measures.
Quality measure
Structure:
a) Evidence of local arrangements to ensure that children and young people accessing specialist services for alcohol use receive a comprehensive assessment that includes the use of validated measures.
b) Evidence of local arrangements to ensure the use of a standardised comprehensive assessment form in specialist services accessed by children and young people for alcohol use.
c) Evidence of regular local audit of case files for children and young people in specialist services accessed by children and young people for alcohol use, to ensure adherence to all assessment domains.
d) Evidence of local arrangements in specialist services for effective coordination with other relevant agencies for children and young people at risk of harm from alcohol use.
Process:
a) Proportion of children and young people accessing specialist services for alcohol misuse who receive a comprehensive assessment.
Numerator – the number of people in the denominator receiving a comprehensive assessment.
Denominator – the number of children and young people accessing specialist services for alcohol use.
b) Proportion of children and young people accessing specialist services for alcohol use who are assessed using appropriate and validated measures for each applicable assessment domain.
Numerator – the number of people in the denominator assessed using appropriate and validated measures for each applicable assessment domain.
Denominator – the number of children and young people accessing specialist services for alcohol use.
Description of what the quality statement means for each audience
Service providers ensure they implement validated measures for assessing children and young people who access specialist services for alcohol use and ensure that all components of a comprehensive assessment are completed for every person.
Health and social care professionals ensure they carry out a comprehensive assessment of multiple areas of need using a validated measure such as the Adolescent Diagnostic Interview (ADI) or the Teen Addiction Severity Index (T-ASI) for children and young people accessing specialist services for alcohol use.
Commissioners ensure they commission specialist services for children and young people at risk of harm from alcohol use that use validated measures for assessment and ensure that all components of a comprehensive assessment are completed for every person.
Children and young people attending specialist services for alcohol problems receive a full assessment of different areas in which they may need help.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.3.7.1, 1.3.7.2, 1.3.7.3 and 1.3.7.4 and NICE public health guidance 24 recommendation 6.
Data source
Structure:
a), b), c) and d) Local data collection.
Process:
Local data collection. The National Drug Treatment Monitoring System (NDTMS) collects data on young people (lower age limit 9 years old) presenting to specialist young people's drug and alcohol services; 'triage date' is collected, which is the date that triage/initial assessment took place (this is not necessarily a comprehensive assessment). Also collects data at treatment start on the numbers of drinking days in the last 28 days (self-report) and typical numbers of numbers of units consumed in an average drinking day. Contained within NICE clinical guideline 115: audit support criterion 15.
Definitions
NICE clinical guideline 115 recommends that a comprehensive assessment for children and young people (supported if possible by additional information from a parent or carer) should assess multiple areas of need, be structured around a clinical interview using a validated clinical tool (such as the ADI or T-ASI), and cover the following areas:
- consumption, dependence features and patterns of drinking
- comorbid substance misuse (consumption and dependence features) and associated problems
- mental and physical health problems
- peer relationships and social and family functioning
- developmental and cognitive needs, and educational attainment and attendance
- history of abuse and trauma
- risk to self and others
- readiness to change and belief in the ability to change
- obtaining consent to treatment
- developing a care plan and risk management plan.
NICE clinical guideline 115 recommends that comprehensive assessments for children and young people are carried out in child and adolescent mental health services (CAMHS). NICE public health guidance 24 recommends that, for children aged 10–15 years, if there is a reason to believe that there is a significant risk of alcohol-related harm, referral to either CAMHS, social care or to young people's alcohol services for treatment, should be considered.
Any initial assessment of children and young people where alcohol misuse is identified as a potential problem, which may or may not form part of the comprehensive assessment, should assess:
- the duration and severity of the alcohol misuse (the standard adult threshold on the AUDIT for referral and intervention should be lowered for young people aged 10–16 years because of the more harmful effects of a given level of alcohol consumption in this population)
- any associated health and social problems
- the potential need for assisted withdrawal.
NICE public health guidance 24 recommends that, for children aged 10–15 years, a detailed history of their alcohol use (for example, using the Common Assessment Framework as a guide) should be obtained. Background factors such as family problems and instances of child abuse or under-achievement at school should also be included.
Equality and diversity considerations
All assessments should be age-appropriate and accessible to children and young people with additional needs such as physical, sensory or learning disabilities, and to children and young people who do not speak or read English. Children and young people needing a comprehensive assessment should have access to an interpreter or advocate if needed.
This statement applies to people aged 10–17 years only, which is appropriate given the different needs of children and young people compared to adults who misuse alcohol.
Families and carers
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
Families and carers of people who misuse alcohol have their own needs identified, including those associated with risk of harm, and are offered information and support.
Quality measure
Structure:
a) Evidence of local arrangements to ensure that local services use promotional materials to encourage families and carers of people who misuse alcohol to access information and support.
b) Evidence of local arrangements to ensure that families and carers of people who misuse alcohol are offered written and verbal information on alcohol misuse and its management, including how families and carers can support the person who misuses alcohol.
c) Evidence of local arrangements to ensure those at risk of harm, including alcohol-related domestic violence, are offered information, advice and referral to other services where appropriate.
d) Evidence of local arrangements to ensure that services are compliant with current national guidance on safeguarding children.
e) Evidence of local arrangements to ensure that carers' assessments are offered to eligible carers of people who misuse alcohol.
f) Evidence of local arrangements to ensure provision of guided self-help for families and carers of people who misuse alcohol, including facilitating contact with support groups.
g) Evidence of local arrangements to ensure provision of family meetings for families and carers with significant problems, typically consisting of at least five weekly sessions providing information, identifying sources of stress and exploring coping behaviours.
Process:
a) Proportion of identified family members and carers (if not family) of people who misuse alcohol who receive appropriate written and verbal information.
Numerator – the number of people in the denominator receiving appropriate written and verbal information.
Denominator – the number of identified family members and carers (if not family) of people who misuse alcohol.
b) Proportion of identified family members and carers (if not family) of people who misuse alcohol who receive guided self-help and information about support groups.
Numerator – the number of people in the denominator receiving guided self-help and information about support groups.
Denominator – the number of identified family members and carers (if not family) of people who misuse alcohol.
c) Proportion of family members and carers (if not family) of people who misuse alcohol not benefiting from guided self-help and/or support groups who attend a family meeting(s).
Numerator – the number of people in the denominator attending a family meeting(s).
Denominator – the number of family members and carers (if not family) of people who misuse alcohol not benefiting from guided self-help and/or support groups.
Description of what the quality statement means for each audience
Service providers ensure they provide and promote a range of services to support families and carers of people who misuse alcohol, and implement guidance and procedures to safeguard those at risk of harm.
Health and social care professionals ensure they follow local policies for supporting families and carers of people who misuse alcohol including carrying out carers' assessments, identifying and safeguarding those at risk of harm, and promoting and delivering support groups and family meetings.
Commissioners ensure they commission services that provide and promote a range of services to support families and carers of people who misuse alcohol, and implement guidance to safeguard those at risk of harm.
Families and carers of people who misuse alcohol have the opportunity to discuss their own needs, and can access information and support.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.1.2.2, 1.1.2.3, 1.1.2.4 and 1.1.2.5.
Data source
Structure:
a), b) and c) Local data collection.
d) The National Alcohol Treatment Monitoring System (NATMS) collects data on the parental status of people receiving structured alcohol treatment as well as pregnancy and whether the person receiving specialist treatment lives with children.
e), f) and g) Local data collection.
Process:
a), b) and c) Local data collection. See also data source for structure measure d).
Definitions
The definition of 'families' is broad and may include any relationship where regular care or contact occurs.
NICE clinical guideline 115 recommends that families and carers involved in supporting a person who misuses alcohol should have the opportunity to discuss concerns about the impact of alcohol misuse on themselves and other family members, and:
- receive written and verbal information on alcohol misuse and its management, including how families or carers can support the service user
- are offered a carer's assessment where necessary
- have the opportunity, along with the service user, to negotiate about their involvement in the service user's care and the sharing of information; the healthcare professional should make sure the service user's, family's and carer's right to confidentiality is respected
- are offered guided self-help, typically consisting of a single session, with the provision of written materials
- receive information about, and have contact facilitated with, support groups (such as self-help groups specifically focused on addressing the needs of families and carers).
If the families and carers of people who misuse alcohol have not benefited, or are not likely to benefit, from guided self-help and/or support groups and continue to have significant problems, consideration should be given to offering them individual family meetings that:
- provide information and education about alcohol misuse
- help to identify sources of stress related to alcohol misuse
- explore and promote effective coping behaviours
- usually consist of at least five weekly sessions.
All staff in contact with parents who misuse alcohol and who have care of or regular contact with their children, should take account of the impact of the parent's drinking on the parent–child relationship and the child's development, education, mental and physical health, own alcohol use, safety, and social network and be aware of and comply with the requirements of the Children Act (2004).
Equality and diversity considerations
Discussions with families and carers of people who misuse alcohol should be individualised and culturally sensitive.
Medically assisted alcohol withdrawal – setting
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
People needing medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
Quality measure
Structure:
a) Evidence of local arrangements to ensure that people who need medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
b) Evidence of local commissioning arrangements for provision of community-based medically assisted alcohol withdrawal in accordance with local need.
c) Evidence of local commissioning arrangements for provision of residential and inpatient medically assisted alcohol withdrawal, including provision for children and young people, and people with highly complex needs such as those at high risk of severe alcohol withdrawal syndromes, and/or with severe physical or psychiatric comorbidity.
d) Evidence of local arrangements to ensure that people in vulnerable groups who are in acute alcohol withdrawal are considered for admission to hospital for medically assisted withdrawal.
Process:
a) Proportion of adults needing medically assisted alcohol withdrawal not requiring an inpatient or residential setting, who complete a successful community-based withdrawal.
Numerator – the number of people in the denominator completing a successful community-based medically assisted alcohol withdrawal.
Denominator – the number of adults needing medically assisted alcohol withdrawal not requiring an inpatient or residential setting.
b) Proportion of people needing medically assisted alcohol withdrawal meeting criteria for inpatient or residential care who complete a successful withdrawal in an inpatient or residential setting.
Numerator – the number of people in the denominator completing successful medically assisted alcohol withdrawal in an inpatient or residential setting.
Denominator – the number of people needing medically assisted alcohol withdrawal meeting criteria for inpatient or residential care.
c) Proportion of people in defined groups in acute alcohol withdrawal who are admitted to hospital for medically assisted withdrawal.
Numerator – the number of people in the denominator admitted to hospital for medically assisted withdrawal.
Denominator – the number of people in defined groups in acute alcohol withdrawal.
Outcome:
a) Proportion of people undergoing medically assisted alcohol withdrawal (planned or unplanned) who complete withdrawal successfully and without complications.
Numerator – the number of people in the denominator completing medically assisted withdrawal successfully and without complications.
Denominator – the number of people undergoing medically assisted alcohol withdrawal (planned or unplanned).
b) Decrease in quantity and frequency of alcohol consumption in people needing medically assisted alcohol withdrawal.
Description of what the quality statement means for each audience
Service providers ensure that people needing medically assisted alcohol withdrawal are referred to and treated in the setting (community, residential or inpatient) most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
Healthcare professionals ensure they care for people needing medically assisted alcohol withdrawal in the setting (community, residential or inpatient) most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
Commissioners ensure they commission services with adequate residential, inpatient and community-based capacity to enable their local population needing medically assisted alcohol withdrawal to be treated within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
People needing medically assisted alcohol withdrawal are cared for in the place most appropriate to their needs, for example, this may be at home, in a clinic or in hospital.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.3.4.2, 1.3.4.5, 1.3.4.6 and 1.3.7.5.
NICE clinical guideline 100 recommendations 1.1.1.1 (key priority for implementation) 1.1.1.2 and 1.1.1.3.
Data source
Structure:
a), b), c) and d) Local data collection.
Process:
a) Local data collection for denominator. The National Alcohol Treatment Monitoring System (NATMS) collects intervention type for people who present to specialist alcohol services and then start structured treatment. 'Alcohol – community prescribing interventions' is one of the interventions that can be recorded.
b) Local data collection for denominator. The NATMS collects data on the number of people receiving inpatient treatment for alcohol misuse (adults) and whether a person is in a substance misuse treatment specific residential placement (children and young people). The offer of inpatient or residential withdrawal (rather than programme completion) is contained within NICE clinical guideline 115: audit support criteria 5 and 16.
c) Local data collection. The International statistical classification of diseases and related health problems (ICD-10) code for alcohol withdrawal state with delirium is F10.4. Contained within NICE clinical guideline 100: audit support criteria 1 and 2.
The NHS Information Centre statistics on alcohol in England reports on items prescribed for the treatment of alcohol dependence, including the setting in which they are prescribed.
Outcome:
a) Local data collection. The International statistical classification of diseases and related health problems (ICD-10) code for alcohol withdrawal state with delirium is F10.4.
b) Local data collection. Data on prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.
Definitions
NICE clinical guideline 115 recommends the following:
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 assisted withdrawal programme in which contact between staff and the service user averages 2–4 meetings per week over the first week.
- 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.
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 30 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.
Also consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups, for example, homeless and older people.
Offer inpatient care to children and young people aged 10–17 years who need assisted withdrawal.
NICE clinical guideline 100 recommends that people in acute withdrawal with, or assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, should be offered admission to hospital for medically assisted alcohol withdrawal. A lower threshold for admission to hospital for medically assisted withdrawal should also be considered in certain vulnerable people, for example people who:
- are frail
- have cognitive impairment
- have multiple comorbidities
- lack social support
- have learning difficulties
- are 16 or 17 years.
Young people under 16 years who are in acute alcohol withdrawal should be offered admission to hospital for physical and psychosocial assessment, in addition to medically assisted alcohol withdrawal.
Equality and diversity considerations
A lower threshold for inpatient assisted withdrawal, whether planned or unplanned, should be considered for people who are homeless, older people and children and young people, to ensure their safety.
Medically assisted alcohol withdrawal – drug regimens
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
People needing medically assisted alcohol withdrawal receive medication using drug regimens appropriate to the setting in which the withdrawal is managed in accordance with NICE guidance.
Quality measure
Structure:
Evidence of local arrangements to ensure that people undergoing medically assisted alcohol withdrawal are prescribed medication that is administered using drug regimens in accordance with NICE clinical guideline 115 and NICE clinical guideline 100.
Process:
a) Proportion of people undergoing planned medically assisted alcohol withdrawal who receive medication using drug regimens in accordance with NICE clinical guideline 115.
Numerator – the number of people in the denominator receiving medication using drug regimens in accordance with NICE clinical guideline 115.
Denominator – the number of people undergoing medically assisted alcohol withdrawal.
b) Proportion of people in acute (unplanned) alcohol withdrawal who receive medication using drug regimens in accordance with NICE clinical guideline 100.
Numerator – the number of people in the denominator receiving medication using drug regimens in accordance with NICE clinical guideline 100.
Denominator – the number of people in acute (unplanned) alcohol withdrawal.
Outcome:
Proportion of people undergoing medically assisted alcohol withdrawal (planned or unplanned) who complete withdrawal successfully and without complications.
Numerator – the number of people in the denominator completing medically assisted withdrawal successfully and without complications.
Denominator – the number of people undergoing medically assisted alcohol withdrawal (planned or unplanned).
Description of what the quality statement means for each audience
Service providers ensure that people undergoing planned medically assisted alcohol withdrawal are prescribed medication that is administered using drug regimens in accordance with NICE clinical guideline 115 and people in acute (unplanned) withdrawal are prescribed medication that is administered using drug regimens in accordance with NICE clinical guideline 100.
Healthcare professionals caring for people undergoing planned medically assisted alcohol withdrawal ensure they use drug regimens in accordance with NICE clinical guideline 115 and, for people in acute (unplanned) withdrawal, use drug regimens in accordance with NICE clinical guideline 100.
Commissioners ensure they commission services for planned medically assisted alcohol withdrawal that use drug regimens in accordance with NICE clinical guideline 115 and for people in acute (unplanned) withdrawal, that use drug regimens in accordance with NICE clinical guideline 100.
People undergoing medically assisted alcohol withdrawal are given medication in a manner (frequency and amount) determined by the place where withdrawal is carried out.
Source clinical guideline references
NICE clinical guideline 115 section 1.3.5, recommendation 1.3.7.6 and NICE clinical guideline 100 recommendations 1.1.3.1 and 1.1.3.4.
Data source
Structure:
Local data collection.
Process:
a) Local data collection. Prescription of clomethiazole (which should not be offered for community-based withdrawal) is contained within NICE clinical guideline 115: audit support criterion 7.
b) Local data collection. Contained within NICE clinical guideline 100: audit support criteria 3 and 4.
The NHS Information Centre statistics on alcohol in England reports on items prescribed for the treatment of alcohol dependence, including the setting in which they are prescribed.
Outcome:
Local data collection. The International statistical classification of diseases and related health problems (ICD-10) code for alcohol withdrawal state with delirium is F10.4.
Definitions
All prescribing for medically assisted alcohol withdrawal should be carried out in accordance with NICE clinical guideline 115 section 1.3.5, recommendation 1.3.7.6 and NICE clinical guideline 100 recommendations 1.1.3.1 and 1.1.3.4 on drug regimens for assisted withdrawal.
Prescribers should use each drug's summary of product characteristics (SPC) with regard to current licensed indications, contraindications and special considerations to inform their decision about a person they are prescribing for. If a drug is used at a dose or for an application that does not have UK marketing authorisation, informed consent should be obtained and documented.
Wernicke's encephalopathy
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
People with suspected, or at high risk of developing, Wernicke's encephalopathy are offered thiamine in accordance with NICE guidance.
Quality measure
Structure:
Evidence of local arrangements to ensure that people with suspected, or at high risk of developing, Wernicke's encephalopathy are offered thiamine in accordance with NICE clinical guideline 115 and NICE clinical guideline 100.
Process:
a) Proportion of people misusing alcohol, meeting NICE guidance criteria for prophylactic oral thiamine, who receive oral thiamine.
Numerator – the number of people in the denominator receiving prophylactic oral thiamine.
Denominator – the number of people misusing alcohol, meeting NICE guidance criteria for prophylactic oral thiamine.
b) Proportion of people misusing alcohol, meeting NICE guidance criteria for parenteral thiamine followed by oral thiamine, who receive parenteral thiamine followed by oral thiamine.
Numerator – the number of people in the denominator receiving parenteral thiamine followed by oral thiamine.
Denominator – the number of people misusing alcohol, meeting NICE guidance criteria for parenteral thiamine followed by oral thiamine.
Outcome:
Proportion of people misusing alcohol who have Wernicke's encephalopathy or Wernicke-Korsakoff syndrome.
Numerator – the number of people in the denominator with Wernicke's encephalopathy or Wernicke-Korsakoff syndrome.
Denominator – the number of people misusing alcohol.
Description of what the quality statement means for each audience
Service providers ensure that systems are in place to provide thiamine in accordance with NICE guidance to people with suspected, or at high risk of developing, Wernicke's encephalopathy.
Healthcare professionals ensure they offer thiamine in accordance with NICE guidance to people with suspected, or at high risk of developing, Wernicke's encephalopathy.
Commissioners ensure they commission services that provide thiamine in accordance with NICE guidance for people with suspected, or at high risk of developing, Wernicke's encephalopathy.
People with suspected, or at high risk of developing, Wernicke's encephalopathy, which is a condition that affects the brain and nervous system, and is caused by a lack of thiamine (also called vitamin B1) in the body, are offered thiamine (either as tablets or as an injection followed by tablets, depending on the situation) to help prevent the condition developing or getting worse.
Source clinical guideline references
NICE clinical guideline 115 recommendation 1.3.8.5 and NICE clinical guideline 100 recommendations 1.2.1.1, 1.2.1.2, 1.2.1.3 and 1.2.1.4.
Data source
Structure:
Local data collection.
Process:
a) Local data collection.
b) Local data collection. The International statistical classification of diseases and related health problems (ICD-10) code for Wernicke's encephalopathy is E51.2 and alcohol amnesic syndrome is F10.6.
Outcome:
See process b) data source for information relevant to the numerator. Data on the prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.
Definitions
NICE clinical guideline 100 recommends that thiamine is offered to people at high risk of developing, or with suspected, Wernicke's encephalopathy. Thiamine should be given in doses toward the upper end of the 'British national formulary' (BNF) range.
Prophylactic oral thiamine should be offered to harmful or dependent drinkers:
- if they are malnourished or at risk of malnourishment or
- if they have decompensated liver disease or
- if they are in acute withdrawal or
- before and during a planned medically assisted alcohol withdrawal.
Parenteral thiamine followed by oral thiamine should be offered to people with suspected Wernicke's encephalopathy and harmful or dependent drinkers if they:
- are malnourished or at risk of malnourishment or
- have decompensated liver disease and in addition
- attend an emergency department or
- are admitted to hospital with an acute illness or injury.
In addition, NICE clinical guideline 115 recommends offering parenteral thiamine followed by oral thiamine to people entering planned assisted alcohol withdrawal in specialist inpatient alcohol services or prison settings who are malnourished, at risk of malnourishment or have decompensated liver disease.
Equality and diversity considerations
This statement applies only to groups at high risk of developing Wernicke's encephalopathy. People with alcohol dependence who are homeless are likely to be included in this group.
Psychological interventions and relapse prevention medication for adults
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
Adults who misuse alcohol are offered evidence-based psychological interventions, and those with alcohol dependence that is moderate or severe can in addition access relapse prevention medication in accordance with NICE guidance.
Quality measure
Structure:
a) Evidence of local arrangements to ensure that adults who misuse alcohol are offered evidence-based psychological interventions appropriate to their circumstances, in accordance with NICE clinical guideline 115.
b) Evidence of local formal evaluation of psychological interventions within the commissioning framework, including routine review and follow-up, to ensure adherence to evidence based practice.
c) Evidence of local arrangements to ensure that people with moderate or severe alcohol dependence are considered for relapse prevention medication after a successful medically assisted withdrawal.
Process:
a) Proportion of adults accessing specialist services for alcohol misuse who receive evidence-based psychological interventions in accordance with NICE clinical guideline 115.
Numerator – the number of adults in the denominator receiving evidence-based psychological interventions in accordance with NICE clinical guideline 115.
Denominator – the number of adults accessing specialist services for alcohol misuse.
b) Proportion of adults with moderate or severe alcohol dependence completing a successful medically assisted withdrawal who receive relapse prevention medication.
Numerator – the number of adults in the denominator receiving relapse prevention medication.
Denominator – the number of adults with moderate or severe alcohol dependence completing a successful medically assisted withdrawal.
Outcome:
a) Decrease in the quantity and frequency of alcohol consumption in people who misuse alcohol.
b) Reduction in the rates of relapse to heavy drinking.
Description of what the quality statement means for each audience
Service providers ensure provision of evidence-based psychological interventions in accordance with NICE clinical guideline 115, and ensure that relapse prevention medication is offered to those with moderate or severe alcohol dependence following a successful withdrawal.
Healthcare professionals use competence frameworks developed from relevant treatment manuals to ensure they offer and deliver evidence-based psychological interventions to adults misusing alcohol and consider relapse prevention medication for those with moderate or severe alcohol dependence following a successful withdrawal.
Commissioners ensure they commission services that provide evidence-based psychological interventions in accordance with NICE clinical guideline 115, which are offered to adults accessing specialist treatment for alcohol misuse, and that relapse prevention medication is offered to those with moderate or severe alcohol dependence following a successful withdrawal.
Adults who misuse alcohol are offered psychological treatment, and those with moderate or severe alcohol dependence may also receive medication to help them stay alcohol-free following a successful withdrawal from alcohol.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.3.1.5 (key priority for implementation), 1.3.3.1 (key priority for implementation) 1.3.3.2–1.3.3.7, 1.3.4.4, 1.3.6.1 (key priority for implementation), 1.3.6.2 and 1.3.6.3.
Data source
Structure:
a), b) and c) Local data collection.
Process:
a) Local data collection. The National Alcohol Treatment Monitoring System (NATMS) collects data on intervention type for people in structured specialist treatment. 'Alcohol – structured psychosocial interventions' can be recorded although the details of the intervention cannot be specified. Contained within NICE clinical guideline 115: audit support criterion 4.
b) Local data collection. The NHS Information Centre statistics on alcohol in England reports on items prescribed for the treatment of alcohol dependence, including relapse prevention medication.
Outcome:
a) Local data collection. Data on the prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.
b) Local data collection of relapse rates. See also data source for process b).
Definitions
NICE clinical guideline 115 defines moderate dependence as an SADQ score of between 15 and 30 and a need for assisted alcohol withdrawal, which can typically be managed in a community setting unless there are other risks. Severe alcohol dependence is defined as an SADQ score of more than 30 and a need for assisted alcohol withdrawal, typically in an inpatient or residential setting.
NICE clinical guideline 115 recommends the following psychological interventions for harmful drinkers and people with alcohol dependence:
- behavioural couples therapy where people have a regular partner who is willing to participate in treatment
- cognitive behavioural therapies
- behavioural therapies
- social network and environment-based therapies.
Recommendations 1.3.3.4–1.3.3.7 provide guidance on the duration and frequency of these psychological interventions.
In addition, acamprosate or oral naltrexone in combination with a psychological intervention should be considered for people with moderate and severe alcohol dependence following successful withdrawal. Disulfiram may be considered if acamprosate and oral naltrexone are not suitable for clinical reasons or if it is the informed service user's choice.
Acamprosate and oral naltrexone may also be considered 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.
All prescribing should be carried out in accordance with NICE clinical guideline 115. Prescribers should use each drug's summary of product characteristics (SPC) with regard to current licensed indications, contraindications and special considerations to inform their decision about a person they are prescribing for. If a drug is used at a dose or for an application that does not have UK marketing authorisation, informed consent should be obtained and documented.
Equality and diversity considerations
This statement promotes equality of access to evidence-based psychological interventions as well as relapse prevention medication for those most likely to benefit.
Specialist interventions for children and young people
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
Children and young people accessing specialist services for alcohol use are offered individual cognitive behavioural therapy, or if they have significant comorbidities or limited social support, a multicomponent programme of care including family or systems therapy.
Quality measure
Structure:
Evidence of local provision in specialist services of individual cognitive behavioural therapy and multicomponent programmes of care tailored to children and young people accessing these services for alcohol use, which may include multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy.
Process:
a) Proportion of children and young people with limited comorbidities and good social support accessing specialist services for alcohol use who receive individual cognitive behavioural therapy.
Numerator – the number of people in the denominator receiving individual cognitive behavioural therapy.
Denominator – the number of children and young people with limited comorbidities and good social support accessing specialist services for alcohol use.
b) Proportion of children and young people with significant comorbidities and/or limited social support accessing specialist services for alcohol use who receive a multicomponent treatment programme of care including family or systems therapy.
Numerator – the number of people in the denominator receiving a multicomponent treatment programme of care including family or systems therapy.
Denominator – the number of children and young people with significant comorbidities or limited social support accessing specialist services for alcohol use.
Outcome:
Decrease in quantity and frequency of alcohol consumption in children and young people with identified alcohol-related problems.
Description of what the quality statement means for each audience
Service providers ensure that systems are in place to provide children and young people accessing specialist services for alcohol use with individual cognitive behavioural therapy or, for those with significant comorbidities or limited social support, multicomponent programmes of care including family or systems therapy.
Health and social care professionals ensure they support children and young people accessing specialist services for alcohol use to receive individual cognitive behavioural therapy or, for those with significant comorbidities or limited social support, a multicomponent programme of care including family or systems therapy.
Commissioners ensure they commission specialist services with provision specifically for children and young people at risk of harm from alcohol use, with adequate provision of individual cognitive behavioural therapy or, for those with significant comorbidities or limited social support, multicomponent programmes of care including family or systems therapy.
Children and young people receiving specialist support for alcohol use are offered a psychological treatment called cognitive behavioural therapy (or CBT for short) or, if they have other health or family problems, they are offered different types of help including psychological treatment that involves their family and other people in their life.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.3.7.8 (key priority for implementation), 1.3.7.10, 1.3.7.11, 1.3.7.12 and 1.3.7.13.
Data source
Structure:
Local data collection.
Process:
a) and b) Local data collection. The National Drug Treatment Monitoring System (NDTMS) collects data on intervention type for young people (lower age limit 9 years old) starting treatment in specialist young people's drug and alcohol services. There are a number of intervention types that can be recorded, including 'Psychosocial – cognitive behavioural therapy' and 'Psychosocial – family work', although the nature of these is not specified and they are not currently reported by primary substance (that is, alcohol or drugs).
Outcome:
Local data collection. From 2011–12 the NDTMS will start to record the frequency of drinking days at treatment start and at treatment exit (for planned exits only) if alcohol is the young person's main 'drug' of choice. The NHS Information Centre conducts an annual survey 'Smoking, drinking and drug use among young people in England'.
Definitions
Multicomponent treatment programmes may include multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy. NICE clinical guideline 115 makes recommendations about the content, structure and duration of these therapies in recommendations 1.3.7.10, 1.3.7.11, 1.3.7.12 and 1.3.7.13.
Equality and diversity considerations
This statement applies to people aged 10–17 years only, which is appropriate given the different needs of children and young people compared with adults who misuse alcohol. In general the range of specialist services for younger people is less comprehensive than for adults. This statement therefore promotes equality in providing interventions suited to the needs of children and young people.
Outcomes monitoring
This quality statement is taken from the alcohol dependence and harmful alcohol use quality standard. The quality standard defines clinical best practice in the care of people (aged 10 and above) drinking in a harmful way and those with alcohol dependence and should be read in full.
Quality statement
People receiving specialist treatment for alcohol misuse have regular treatment outcome reviews, which are used to plan subsequent care.
Quality measure
Structure:
a) Evidence of local implementation of the Alcohol Use Disorders Test (AUDIT) and the Alcohol Problems Questionnaire (APQ) for outcome monitoring in specialist alcohol services.
b) Evidence of local arrangements to ensure that interventions for people receiving specialist treatment for alcohol misuse are the subject of routine outcome monitoring.
c) Evidence of regular local audit of case files in specialist alcohol services to ensure that people receiving treatment for alcohol misuse have an individualised care plan that is frequently reviewed and revised based on treatment outcomes.
Process: Proportion of people receiving specialist treatment for alcohol misuse who have a current individualised care plan.
Numerator – the number of people in the denominator with a current individualised care plan.
Denominator – the number of people receiving specialist treatment for alcohol misuse.
Outcome: Proportion of people accessing specialist alcohol services who achieve their treatment goals.
Numerator – the number of people in the denominator achieving their treatment goals.
Denominator – the number of people accessing specialist alcohol services.
Description of what the quality statement means for each audience
Service providers ensure systems are in place for the regular review of treatment outcomes in people receiving specialist treatment for alcohol misuse, and for individualised care plans to be based on outcome reviews.
Health and social care professionals ensure they regularly review treatment outcomes in people receiving specialist treatment for alcohol misuse, and maintain care plans to be individualised and current based on outcome reviews.
Commissioners ensure they commission specialist alcohol services that review regularly treatment outcomes in people receiving specialist treatment for alcohol misuse, and maintain care plans to be individualised and current based on outcome reviews.
People receiving specialist treatment for alcohol misuse have their treatment reviewed regularly and have the opportunity to be involved in planning further care, based on these reviews.
Source clinical guideline references
NICE clinical guideline 115 recommendations 1.2.1.4, 1.3.1.5 (key priority for implementation), 1.3.1.6 and 1.3.2.3.
Data source
Structure:
a), b) and c) Local data collection.
Process:
Local data collection for the numerator. The National Alcohol Treatment Monitoring System (NATMS) collects data on the number of people receiving specialist alcohol treatment.
Outcome:
Local data for detail on achievement of specific treatment goals. The NATMS collects data on the number of people receiving specialist alcohol treatment and discharge status.
Definitions
NICE clinical guideline 115 recommends that all interventions for people who misuse alcohol should be the subject of routine outcome monitoring and that this be used to inform decisions about continuation of both psychological and pharmacological treatments. If there are signs of deterioration or no indications of improvement, consideration should be given to stopping the current treatment and the care plan reviewed.
The AUDIT tool may be used as a routine outcome measure for drinking-related outcomes and the APQ may be used for monitoring changes in alcohol-related problems.
Alcohol education
This quality statement is taken from the alcohol: preventing harmful alcohol use in the community quality standard. The quality standard defines clinical best practice in alcohol: preventing harmful alcohol use in the community and should be read in full.
Quality statement
Schools and colleges include alcohol education in the curriculum.
Rationale
Schools and colleges have an important role to play in helping children and young people to understand the harmful consequences of alcohol and in combating harmful drinking. Alcohol education should be used to increase knowledge about alcohol use and its effects. Learning and teaching about alcohol should be contextualised as part of promoting positive messages and values about keeping healthy and safe. Teachers and children and young people should be able to have open discussions about alcohol in the context of wider social norms, since one way information giving is not as effective in engaging children and young people in the topic and in affecting attitudes, values and behaviour.
Quality measures
Structure
Evidence that schools and colleges include alcohol education the curriculum.
Data source: Local data collection. Ofsted inspection reports contain information on the achievement of pupils, quality of teaching, behaviour and safety of pupils and leadership and management for all schools and colleges.
Outcome
Rates of absence from school or college related to alcohol.
Data source: Local data collection.
What the quality statement means for head teachers, school governors, staff and local authorities
Head teachers and school governors include alcohol education in the curriculum. Although alcohol education is not a statutory part of the curriculum, quality statements describe best practice that goes beyond minimum statutory requirements and can be used to help organisations improve quality.
Staff who have the trust and respect of the children and young people in the school or college deliver alcohol education as part of the curriculum. Staff should have received appropriate training and be able to provide accurate information using appropriate techniques.
Local authorities advocate that schools and colleges in their area include alcohol education in the curriculum. Public health teams can offer help with education and training of staff and provide schools and colleges with information and materials for teaching.
What the quality statement means for children and young people
Children and young people in schools and colleges learn about keeping healthy and safe, and about alcohol use and its effects. This is done by giving them the chance to talk about the issues involved. This should help them to develop the knowledge, attitudes and skills needed to support their health and wellbeing.
Source guidance
- School-based interventions on alcohol (NICE guideline PH7), recommendation 1
Definitions of terms used in this quality statement
Schools and colleges
Schools and colleges comprise state-sector, special and independent primary and secondary schools and colleges, including:
- free schools
- academies and city technology colleges
- pupil referral units, secure training and local authority secure units
- further education colleges and sixth form colleges.
[Adapted from School-based interventions on alcohol (NICE guideline PH7)]
Alcohol education
Specific time should be allocated within the school curriculum to help children and young people to develop the knowledge, attitudes and skills needed to support their own health and wellbeing. Alcohol education should be tailored for different age groups and take different learning needs into account (based, for example, on individual, social and environmental factors). It should aim to encourage children not to drink, delay the age at which young people start drinking and reduce the harm it can cause among those who do drink. Alcohol education programmes should:
- increase knowledge of the potential damage alcohol use can cause – physically, mentally and socially (including the legal consequences)
- provide the opportunity to explore attitudes to – and perceptions of – alcohol use
- help develop decision-making, assertiveness, coping and verbal and non verbal skills
- help develop self-esteem
- increase awareness of how the media, advertisements, role models and the views of parents, peers and society can influence alcohol consumption.
[School-based interventions on alcohol (NICE guideline PH7)]
Equality and diversity considerations
It is important to take individual, social, cultural, economic and religious factors into account when delivering alcohol education, and to tailor it to the needs of the children and young people. Groups that may be at increased risk of under age drinking and alcohol abuse, such as lesbian, gay, bisexual and transgender (LGBT) young people, should be considered.
Alcohol education
This quality statement is taken from the alcohol: preventing harmful alcohol use in the community quality standard. The quality standard defines clinical best practice in alcohol: preventing harmful alcohol use in the community and should be read in full.
Quality statement
Schools and colleges include alcohol education in the curriculum.
Rationale
Schools and colleges have an important role to play in helping children and young people to understand the harmful consequences of alcohol and in combating harmful drinking. Alcohol education should be used to increase knowledge about alcohol use and its effects. Learning and teaching about alcohol should be contextualised as part of promoting positive messages and values about keeping healthy and safe. Teachers and children and young people should be able to have open discussions about alcohol in the context of wider social norms, since one way information giving is not as effective in engaging children and young people in the topic and in affecting attitudes, values and behaviour.
Quality measures
Structure
Evidence that schools and colleges include alcohol education the curriculum.
Data source: Local data collection. Ofsted inspection reports contain information on the achievement of pupils, quality of teaching, behaviour and safety of pupils and leadership and management for all schools and colleges.
Outcome
Rates of absence from school or college related to alcohol.
Data source: Local data collection.
What the quality statement means for head teachers, school governors, staff and local authorities
Head teachers and school governors include alcohol education in the curriculum. Although alcohol education is not a statutory part of the curriculum, quality statements describe best practice that goes beyond minimum statutory requirements and can be used to help organisations improve quality.
Staff who have the trust and respect of the children and young people in the school or college deliver alcohol education as part of the curriculum. Staff should have received appropriate training and be able to provide accurate information using appropriate techniques.
Local authorities advocate that schools and colleges in their area include alcohol education in the curriculum. Public health teams can offer help with education and training of staff and provide schools and colleges with information and materials for teaching.
What the quality statement means for children and young people
Children and young people in schools and colleges learn about keeping healthy and safe, and about alcohol use and its effects. This is done by giving them the chance to talk about the issues involved. This should help them to develop the knowledge, attitudes and skills needed to support their health and wellbeing.
Source guidance
- School-based interventions on alcohol (NICE guideline PH7), recommendation 1
Definitions of terms used in this quality statement
Schools and colleges
Schools and colleges comprise state-sector, special and independent primary and secondary schools and colleges, including:
- free schools
- academies and city technology colleges
- pupil referral units, secure training and local authority secure units
- further education colleges and sixth form colleges.
[Adapted from School-based interventions on alcohol (NICE guideline PH7)]
Alcohol education
Specific time should be allocated within the school curriculum to help children and young people to develop the knowledge, attitudes and skills needed to support their own health and wellbeing. Alcohol education should be tailored for different age groups and take different learning needs into account (based, for example, on individual, social and environmental factors). It should aim to encourage children not to drink, delay the age at which young people start drinking and reduce the harm it can cause among those who do drink. Alcohol education programmes should:
- increase knowledge of the potential damage alcohol use can cause – physically, mentally and socially (including the legal consequences)
- provide the opportunity to explore attitudes to – and perceptions of – alcohol use
- help develop decision-making, assertiveness, coping and verbal and non verbal skills
- help develop self-esteem
- increase awareness of how the media, advertisements, role models and the views of parents, peers and society can influence alcohol consumption.
[School-based interventions on alcohol (NICE guideline PH7)]
Equality and diversity considerations
It is important to take individual, social, cultural, economic and religious factors into account when delivering alcohol education, and to tailor it to the needs of the children and young people. Groups that may be at increased risk of under age drinking and alcohol abuse, such as lesbian, gay, bisexual and transgender (LGBT) young people, should be considered.
Schools and colleges involve parents, carers, children and young people
This quality statement is taken from the alcohol: preventing harmful alcohol use in the community quality standard. The quality standard defines clinical best practice in alcohol: preventing harmful alcohol use in the community and should be read in full.
Quality statement
Schools and colleges involve parents, carers, children and young people in initiatives to reduce alcohol use.
Rationale
A school or college's approach to alcohol in the context of the curriculum and its policies, values and environment is more effective if parents, carers, children and young people are involved. This means that children and young people's views are considered and that parents and carers are included in discussions and decisions in an effort to ensure consistent messages about alcohol outside school or college.
Quality measures
Structure
Evidence that schools and colleges involve parents, carers, children and young people in initiatives to reduce alcohol use.
Data source: Local data collection. Ofsted inspection reports contain information on the achievement of pupils, quality of teaching, behaviour and safety of pupils and leadership and management for all schools and colleges.
What the quality statement means for head teachers and school governors
Head teachers and school governors ensure that they consult and involve parents, carers, children and young people in discussions and decisions about, as well as in the implementation of, initiatives to reduce alcohol use. Although alcohol education is not a statutory part of the curriculum, quality statements describe best practice that goes beyond minimum statutory requirements and can be used to help organisations improve quality.
What the quality statement means for parents, carers, children and young people
Parents and carers have the chance to be involved in discussions and decisions about ideas and plans that schools and colleges have for reducing alcohol use, and in putting these ideas into practice. This means that parents and carers know about the plans and can support them at home if they choose to.
Children and young people are involved in discussions and decisions about ideas and plans at their school or college for reducing alcohol use. They are also involved in putting these ideas into practice. This means that they will know what is planned and are more likely to back the plans.
Source guidance
- School-based interventions on alcohol (NICE guideline PH7), recommendation 3
Definitions of terms used in this quality statement
Involve parents, carers, children and young people
This might include consulting parents, carers, children and young people about initiatives to reduce alcohol use, gathering their opinions through discussions and involving them in decisions about, and in the implementation of, initiatives. [Adapted from School-based interventions on alcohol (NICE guideline PH7)]
Initiatives to reduce alcohol use
Initiatives to reduce alcohol use might include alcohol education programmes and using a 'whole school' approach. A 'whole school' approach should cover policy development, the school environment and the professional development of (and support for) staff. [School-based interventions on alcohol (NICE guideline PH7)]
Effective interventions library
Effective interventions library
Interventions in schools
The interventions listed below are part of NICE's effective interventions library on public health. The evidence on these interventions was used to develop the recommendations in this pathway. All interventions listed have been identified and appraised using NICE public health methods and processes.
When reading the data, bear in mind that it has been interpreted in a review process, discussed by committee and considered in relation to a range of populations and different experiences in order to develop recommendations. In general, data on interventions is often limited: population studies are expensive to run; follow-up is generally short; studies may have been poorly conducted; reporting is variable and often poor. However, even when effects seem to be small, there can be enormous benefits when an intervention is applied across the whole population.
Where possible, the NICE analysts have calculated a measure of effectiveness from the original studies. These cases are marked 'i' (implied by the data).
School-based programmes
Key elements of the intervention
School-based alcohol education programmes.
Source guidance
Recommendation 1 from School-based interventions on alcohol (NICE public health guidance 7).
Effectiveness
For more details of the evidence below, see the NICE review of effectiveness and cost effectiveness.
Botvin et al (1995a), USA
Polydrug use study. Data extracted for alcohol only
Study design 6-year longitudinal RCT, site control, repeated measures
Final sample size 2752
Outcome Self-reported weekly and monthly alcohol use.
Measures of effect Mean differences (SE).
- Monthly alcohol use: intervention plus 0.58 (0.03), reduced intervention 0.54p≤0.05 (0.03), information-only control 0.60 (0.02)
- Weekly alcohol use: intervention plus 0.24p<0.01 (0.02), reduced intervention 0.20 (0.02), information-only control 0.29 (0.02)
Botvin et al. (1995b), USA
Poly-substance study; alcohol data extracted only.
Study design RCT, site control, repeated measures, 3-year follow up
Final sample size 456
Outcomes Drinking frequency, amount and incidences of drunkenness for two intervention groups (generic skills training and culturally focussed interventions)
Measure of effect Mean differences (SE); p values reported <0.01. Insufficient data to calculate ES, NNT and SD
Current drinking
- Drinking frequency: generic life skills 1.94, culturally focussed 1.61, control 2.25
- Drinking amount: generic 1.65, culturally focussed 1.42, control 1.85
- Incidences of drunkenness: generic 1.40, culturally focussed 1.25, control 1.64
Future drinking
- Intention to drink wine or beer: generic 2.06, culturally focussed 1.77, control 2.33
- Intention to drink liquor: generic 1.32, culturally focussed 1.25, control 1.56
Botvin et al. (2001b), USA
Poly-substance use study; data extracted for alcohol (binge drinking) only.
Study design RCT, site control, repeated measures, 2-year follow up
Final sample size 2982
Outcome Proportion of binge drinkers who had received the intervention compared with control group at two follow-up assessments
Measure of effect
- At 1 year: OR 0.41 (95% CI 0.18–0.93)
- At 2 years: OR 0.40 (95% CI 0.22–0.74)
McBride et al. (2004)
Measures of effect
Alcohol consumption The intervention group consumed significantly less alcohol than the control group at the 8-month follow-up (31.4% difference) and the 20-month follow-up (31.7% difference). Non-parametric tests showed that intervention students consumed alcohol significantly less often than comparison students at the first and second follow-ups (p=0.03 and p<0.0001, respectively). Intervention students consumed significantly less alcohol per occasions at the second follow-up (p=0.01).
Knowledge The intervention group had significantly greater alcohol-related knowledge at 8-month follow-up. This significant difference was maintained at 20 months; however at the 32-month follow-up, the difference between the mean knowledge scores had converged (4.5% difference).
Cuijpers et al. (2002), Netherlands
Poly-substance use study; data extracted for alcohol only.
Study design Quasi-experimental, site control, repeated measures, 3-year follow up
Final sample size 1405
Outcome Self-reported alcohol use and knowledge about alcohol
Measure of effect Mean (SE)
Alcohol use
- At 1 year: intervention 0.328, control 0.428 (p<0.05), NNT 10 (i)
- At 2 years: intervention 0.566, control 0.654 (p<0.01), NNT 11(i)
- At 3 years: intervention 0.738, control 0.805 (p<0.01) NNT 14(i)
Increased knowledge
- At 2 years: intervention 3.81 (1.30), control 3.31 (1.36) (p<0.01), ES 0.19 (i), NNT 2 (i)
- At 3 years: intervention 4.12 (1.23), control 3.68 (1.31) (p<0.01), ES 0.17 (i), NNT 2 (i)
Costs
Cost effectiveness
There is inconsistent and insufficient published evidence to determine the cost effectiveness of school-based interventions that aim to prevent or reduce alcohol use in young people under 18 years old. For more details, see the NICE review of effectiveness and cost effectiveness.
Resource impact
If implemented as part of the UK national curriculum, no additional costs are anticipated. See the NICE costing report.
Factors to take account of
School-based interventions on alcohol summarises the factors NICE's committee considered when developing the recommendations on alcohol education programmes in schools. See paragraphs 3.7, 3.8 and 3.10–16.
Impact on health inequalities
NICE's committeeFrom School-based interventions on alcohol noted that: 'While some individuals may be more vulnerable than others, it is inappropriate only to focus on those individuals. Children and young people from all backgrounds – and in all types of school – may drink harmful amounts of alcohol.'
The samples represented a diverse population, including BME groups and areas of deprivation.
Education and community activities
Key elements of the intervention
School-based education and advice integrated with community activities.
Source guidance
Recommendation 1 from School-based interventions on alcohol (NICE public health guidance 7).
Effectiveness
For more details of the evidence below, see the NICE review of effectiveness and cost effectiveness.
Schinke et al. (2000), USA
Poly-substance use study of native American young people; data extracted for alcohol only
Study design RCT, site control, repeated measures, 3.5 years
Final sample size 1268
Outcome self-reported alcohol consumption over time
Measures of effect
Skills vs control F(2,1186)=7.63, p<0.01
Intervention | Percentage drinking > 4 drinks a week | ||
|---|---|---|---|
Baseline | 30 months | 42 months | |
Skills only | 9.13 | 15.89 | 22.87 |
Skills and community activities | 8.94 | 17.18 | 25.44 |
Control | 8.72 | 19.06 | 30.17 |
Costs
Cost effectiveness
There is inconsistent and insufficient published evidence to determine the cost effectiveness of school-based interventions that aim to prevent or reduce alcohol use in young people under 18 years old. For more details, see the NICE review of effectiveness and cost effectiveness.
Resource impact
If schools-based interventions are implemented as part of the UK national curriculum, no additional costs are anticipated. See the NICE costing report.
Factors to take account of
School-based interventions on alcohol summarises the factors NICE's committee considered when developing the recommendations on alcohol education programmes in schools. See paragraphs 3.10–12 , 3.15 and 3.16.
Impact on health inequalities
NICE's committeeFrom School-based interventions on alcohol noted that: 'While some individuals may be more vulnerable than others, it is inappropriate only to focus on those individuals. Children and young people from all backgrounds – and in all types of school – may drink harmful amounts of alcohol.
Due to the limitations of the evidence, it was not possible to determine the differential effectiveness of the interventions in relation to disadvantaged and minority groups. In addition, it was not possible to determine what impact the recommendations may have on health inequalities.'
Schinke et al. (2000) may have some relevance to UK health inequalities.
Education and family activities
Key elements of the intervention
School-based education and advice integrated with family initiatives
Source guidance
Recommendation 1 from School-based interventions on alcohol (NICE public health guidance 7).
Effectiveness
For more details of the evidence below, see the NICE review of effectiveness and cost effectiveness.
Eddy (2000), USA
Measure of effect Young people in the control group were 1.49 times more likely to report patterned alcohol use (alcohol use at least once every 2 or 3 months) than those in the intervention group.
Hawkins (1999), USA
Study design RCT
Outcome Significant differences between control and intervention group for heavy alcohol use in the past year (drunk alcohol 10 or more times)
Measure of effect 25% of controls compared with 15.4% of full intervention participants reported heavy drinking in the past year (p=0.04)
Foxcroft et al. (2002), USA
Study design RCT
Outcome Self-reported use of alcohol without permission
Measure of effect 4 years later, % of sample who reported:
Authors state it would be inappropriate to calculate ES.
Costs
Cost effectiveness
There is inconsistent and insufficient published evidence to determine the cost effectiveness of school-based interventions that aim to prevent or reduce alcohol use in young people under 18 years old. For more details, see the NICE review of effectiveness and cost effectiveness.
Resource impact
If implemented as part of the UK national curriculum, no additional costs are anticipated. See the NICE costing report.
Factors to take account of
School-based interventions on alcohol summarises the factors NICE's committee considered when developing the recommendations on alcohol education programmes in schools. See paragraphs 3.7, 3.8. 3.10–16.
Impact on health inequalities
NICE's committeeFrom School-based interventions on alcohol noted that: 'While some individuals may be more vulnerable than others, it is inappropriate only to focus on those individuals. Children and young people from all backgrounds – and in all types of school – may drink harmful amounts of alcohol.
Due to the limitations of the evidence, it was not possible to determine the differential effectiveness of the interventions in relation to disadvantaged and minority groups. In addition, it was not possible to determine what impact the recommendations may have on health inequalities.'
Brief interventions for adults
The interventions listed below are part of NICE's effective interventions library on public health. The evidence on these interventions was used to develop the recommendations in this pathway. All interventions listed have been identified and appraised using NICE public health methods and processes.
When reading the data, bear in mind that it has been interpreted in a review process, discussed by committee and considered in relation to a range of populations and different experiences in order to develop recommendations. In general, data on interventions is often limited: population studies are expensive to run; follow-up is generally short; studies may have been poorly conducted; reporting is variable and often poor. However, even when effects seem to be small, there can be enormous benefits when an intervention is applied across the whole population.
Where possible, the NICE analysts have calculated a measure of effectiveness from the original studies. These cases are marked 'i' (implied by the data).
Brief interventions
Key elements of the intervention
Brief interventions for adults.
Source guidance
Recommendation 10 from Alcohol-use disorders - preventing harmful drinking (NICE public health guidance 24).
Effectiveness
For more details of the evidence below, see the NICE evidence review on screening and brief interventions.
Ashenden et al. (1997), international
Study design Systematic review
Final sample size Pooled studies, 4/6 from the UK, age range 17–69 years
Outcome Alcohol consumption, weekly amount and heavy drinking
Measures of effect
- Weekly amount: men, reduction of 10.1 standard drinks (p<0.001); women, reduction of 5.2 drinks (p<0.05)
- Heavy drinking (difference in proportion of people drinking heavily in intervention group vs control groups): men, 18.2% (p<0.001); women, 18.5% (p<0.05)
Ballesteros et al. (2004a), international
Study design Meta-analysis
Final sample size 4353, age range 18–70 years
Outcome Alcohol consumption.
Measure of effect Random effects model OR 1.55 (95% CI 1.27–1.90), RD 0.11 (95% CI 0.06–0.16), NNT 10 (95% CI 7–17).
Similar results were obtained when two influential studies were removed (fixed effect model OR 1.57, 95% CI 1.32–1.87; RD 0.11, 95% CI 0.07–0.15; NNT 9, 95% CI 7–15).
Bertolet et al. (2005), international
Study design Meta-analysis
Outcome Weekly alcohol consumption
Measure of effect Of 17 trials of brief interventions for drinkers in primary care, 8 reported statistically significant effects of brief interventions. No studies reported negative effects of brief interventions. Overall pooled effect size of trials: net reduction of 50g of ethanol (approximately 5 drinks) per week (95%CI –65 to –34) (based on follow-up observations without adjustment for drop-out). Net reduction of 50g/week corresponds to relative mean reduction of 15% in consumption for the brief intervention group (relative mean reduction 34%), compared with control group (relative mean reduction 19%).
Kaner et al. (2007), international
Study design Meta-analysis of 22 RCTs
Final sample size 7619
Outcome Weekly alcohol consumption
Measure of effect Participants receiving brief intervention had lower alcohol consumption than the control group after follow-up of 1 year or longer (mean difference -38 g/week, 95% CI –54 to –23), although there was substantial heterogeneity between trials (I2 57%). Sub-group analysis (8 studies, 2307 participants) confirmed the benefit of brief intervention in men (mean difference –57 g/week, 95% CI –89 to –25, I2 = 56%), but not in women (mean difference –10 g/week, 95% CI –48 to 29, I2 45%). Meta-regression showed little evidence of a greater reduction in alcohol consumption with longer treatment exposure or among trials that were less clinically representative. Extended intervention was associated with a non-significantly greater reduction in alcohol consumption than brief intervention (mean difference –28, 95%CI –62 to 6 g/week, I2 0%)
Poikolainen (1999), international
Study design Meta-analysis
Outcome Weekly alcohol consumption
Measure of effect For very brief interventions, the change in alcohol consumption was not significant among men or among women. For extended brief interventions, the pooled effect estimate of change in alcohol intake was –51 g per week (95% CI –74 to –29) among women. Among men the estimate was of similar magnitude, but significant lack of statistical homogeneity implied that the summary estimate was not meaningful. Significant statistical heterogeneity was observed when data on very brief interventions among men and women were pooled.
Whitlock et al. (2004), international
Study design Meta-analysis
Outcome Weekly alcohol consumption
Measure of effect Among 12 studies synthesised, 6–12 months after good-quality, brief, multicontact behavioural counseling interventions (up to 15 minutes of initial contact and at least 1 follow-up), the average number of drinks per week fell by 13% to 34% more for participants than for controls, and the proportion of participants drinking at moderate or safe levels was 10% to 19% greater than for controls. One study reported maintenance of improved drinking patterns for 48 months.
D'Onofrio and Degutis (2002), international
Measure of effect Of 41 studies on screening and brief intervention for alcohol problems in an emergency department, 32 demonstrated a positive effect of the intervention.
Havard et al. (2008), international
Study design Meta-analysis of 13 studies
Outcome Alcohol consumption
Measure of effect Interventions did not significantly reduce subsequent alcohol consumption, but were associated with approximately half the odds of experiencing an alcohol-related injury (OR 0.59, 95% CI 0.42–0.84). Methodological quality was reasonable, except for poor reporting of effect-size information and inconsistent selection of outcome measures.
Nilsen et al. (2008), international
Study design 14 studies on brief interventions for injured patients in emergency departments
Outcomes Alcohol consumption, risky drinking practices, alcohol-related negative consequences, and injury frequency
Measure of effect Of the 12 studies that compared pre- and post-intervention results, 11 found a significant effect on at least some of the outcomes. More intensive interventions tended to yield better results. In five studies there were no significant differences between the compared treatment conditions.
Emmen et al. (2004), international
Outcomes Weekly alcohol consumption, alcohol-related harm, gamma-glutamyltransferase levels
Measure of effect Of the eight studies summarised:
- only 1 trial showed statistically significant reduction in alcohol consumption: -309 g/week (95%CI –470 to –148)
- 4 trials reported reductions in alcohol-related problems
- 2 trials showed statistically significant reductions in levels of gamma-glutamyltransferase
Webb et al. (2009), international
Measure of effect Four RCTs reported on workplace interventions. Although all had methodological problems, three reported statistically significant differences in measures such as reduced alcohol consumption, binge drinking and alcohol problems. All had methodological problems
Kahan et al. (1995), international
Study design Meta-analysis of 22 RCTs
Final sample size 7619
Outcome Alcohol consumption
Measure of effect Of 43 studies, the four with the highest validity scores showed that men in the intervention groups reduced their weekly alcohol consumption by five to seven standard drinks more than the men in the control groups. Results for women were inconsistent. There was no convincing evidence of decline in alcohol-related morbidity among men or women.
Ballesteros et al. (2004b), international
Measure of effect Seven studies on brief interventions for hazardous drinkers delivered in primary care. Standardised ESs for the reduction of alcohol consumption were similar in men (d –0.25; 95% CI –0.34 to –0.17) and women (d –0.26; 95% CI –0.38 to –0.13). ORs for the frequency of people who drank below harmful levels were also similar (four studies; OR for men 2.32; 95% CI 1.78–2.93; OR for women 2.31; 95% CI 1.60–3.17).
Costs
Resource impact
For more details, see the NICE costing report.
It may be possible to provide brief advice at little or no extra cost as it is anticipated that the advice would be given on an opportunistic basis.
The cost of a practice nurse providing 5 minutes of brief advice is estimated at £11.50 (including materials), the cost of a GP is estimated at £23.85.
This report does not quantify the savings associated with providing brief advice to people identified through screening, but these could also be significant.
Factors to take account of
Alcohol-use disorders - preventing harmful drinking summarises the factors NICE's committee considered when developing the recommendations on brief interventions. See paragraphs 3.49–55, 3.58 and 3.59.
Structured brief advice
Key elements of the intervention
Structured brief advice for adults.
Source guidance
Recommendation 11 from Alcohol-use disorders - preventing harmful drinking (NICE public health guidance 24).
Effectiveness
For more details of the evidence below, see the NICE evidence review on screening and brief interventions.
Kaner et al. (2007)
Study design Meta-analysis of 22 RCTs
Final sample size 7619
Outcome Weekly alcohol consumption
Measure of effect Participants receiving brief intervention had lower alcohol consumption than the control group after 1 year or longer (mean difference –38 g/week, 95% CI –54 to –23), although there was substantial heterogeneity between trials (I2 = 57%).
Sub-group analysis (8 studies, 2307 participants) confirmed the benefit of brief intervention in men (mean difference –57 g/week, 95% CI –89 to –25, I2 56%), but not in women (mean difference –10 g/week, 95% CI: –48 to 29, I2 45%).
Extended intervention was associated with a non-significantly greater reduction in alcohol consumption than brief intervention (mean difference –28, 95%CI –62 to 6 g/week, I2 0%)
Ballesteros et al. (2004a), international
Study design Meta-analysis of 13 studies
Measure of effect No clear evidence of a dose-effect relationship. Brief interventions outperformed minimal interventions and usual care (random effects model OR 1.55, 95% CI 1.27–1.90; RD 0.11, 95% CI 0.06–0.16; NNT 10, 95% CI 7–17).
The heterogeneity between individual estimates was accounted for by the type of hazardous drinkers (heavy versus moderate) and by the characteristics of the included individuals (treatment seekers versus nontreatment seekers).
Costs
Resource impact
For more details, see the NICE costing report.
It may be possible to provide brief advice at little or no extra cost as it is anticipated that the advice would be given on an opportunistic basis.
The cost of a practice nurse providing 5 minutes of brief advice is estimated at £11.50 (including materials), the cost of a GP is estimated at £23.85.
This report does not quantify the savings associated with providing brief advice to people identified through screening, but these could also be significant.
Factors to take account of
Alcohol-use disorders - preventing harmful drinking summarises the factors NICE's committee considered when developing the recommendations on brief interventions. See paragraph 3.58.
Successful effective interventions library details
Implementation
Commissioning
These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
Education and learning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Pathway information
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.
Supporting information
Cognitive behavioural therapies
Focus: alcohol-related problems.
Length and frequency: usually one 60-minute session per week for 12 weeks.
Behavioural therapies
Focus: alcohol-related problems.
Length and frequency: usually one 60-minute session per week for 12 weeks.
Behavioural couples therapy
Focus: alcohol-related problems and their impact on relationships.
Aim: abstinence, or a level of drinking predetermined and agreed by the therapist and the service user to be reasonable and safe.
Length and frequency: usually one 60-minute session per week for 12 weeks.
Acamprosate
Start treatment:
As soon as possible after assisted withdrawal.
Dosage:
Usually 1998 mg (666 mg three times a day) unless the service user weighs less than 60 kg, and then a maximum of 1332 mg per day.
Usual duration of treatment:
Up to 6 months, longer for those benefiting from the drug who want to continue with itAt the time this pathway was created (May 2011), acamprosate did not have UK marketing authorisation for use longer than 12 months. Informed consent should be obtained and documented..
Supervision:
At least monthly, for 6 months, and at reduced but regular intervals if continued after this. Do not use blood tests routinely, but consider them to monitor for recovery of liver function and as a motivational aid for service users to show improvement.
Important information:
Stop treatment if drinking persists 4–6 weeks after starting the drug.
Oral naltrexone
Start treatment:
After assisted withdrawal.
Dosage:
Initially 25 mg per day, aiming for a maintenance dose of 50 mg per dayAt the time this pathway was created (May 2011), oral naltrexone did not have UK marketing authorisation for this indication or at this dosage. Informed consent should be obtained and documented..
Usual duration of treatment:
Up to 6 months, or longer for those benefiting from the drug who want to continue with it.
Supervision:
At least monthly, for 6 months, and at reduced but regular intervals if continued after this. Do not use blood tests routinely, but consider them for older people, for people with obesity, for monitoring recovery of liver function and as a motivational aid for service users to show improvement.
Important information:
Draw the service user's attention to the information card that is issued with oral naltrexone about its impact on opioid-based analgesics.
Stop treatment if drinking persists 4–6 weeks after starting the drug.
If the service user feels unwell advise them to stop the oral naltrexone immediately.
Disulfiram
Start treatment:
At least 24 hours after the last alcoholic drink consumed.
Dosage:
Usually 200 mg per day.
For people who continue to drink, if 200 mg taken regularly for at least 1 week does not cause a sufficiently unpleasant reaction to deter drinking, consider increasing the dosage in consultation with the person.
Supervision:
At least every 2 weeks for the first 2 months, then monthly for the following 4 months.
Service users should be medically monitored at least every 6 months after the initial 6 months of treatment and monitoring.
Important information:
Before starting treatment with disulfiram, test liver function, urea and electrolytes to assess for liver or renal impairment.
Check the SPC for warnings and contraindications in pregnancy and in the following conditions: a history of severe mental illness, stroke, heart disease or hypertension.
If possible, a family member or carer, who is properly informed about the use of disulfiram, should oversee administration of the drug.
Warn service users taking disulfiram, and their families or carers, about:
- the interaction between disulfiram and alcohol (which may also be found in food, perfume, aerosol sprays and so on), the symptoms of which may include flushing, nausea, palpitations, and, more seriously, arrhythmias, hypotension, and collapse.
- the rapid and unpredictable onset of the rare complication of hepatotoxicity; advise service users that if they feel unwell or develop a fever or jaundice that they should stop taking disulfiram and seek urgent medical attention.
Acute alcohol withdrawal
Benzodiazepines are used in UK clinical practice in the management of alcohol-related withdrawal symptoms. Diazepam and chlordiazepoxide have UK marketing authorisation for the management of acute alcohol withdrawal symptoms. However, at the time this pathway was created (May 2011), alprazolam, clobazam and lorazepam did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. In addition, the SPC for alprazolam advises that benzodiazepines should be used with extreme caution in patients with a history of alcohol abuse. The SPC for clobazam states that it must not be used in patients with any history of alcohol dependence (due to increased risk of dependence). The SPC for lorazepam advises that use in individuals with a history of alcoholism should be avoided (due to increased risk of dependence).
Carbamazepine is used in UK clinical practice in the management of alcohol-related withdrawal symptoms. At the time this pathway was created (May 2011), carbamazepine did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented.
Clomethiazole has UK marketing authorisation for the treatment of alcohol withdrawal symptoms where close hospital supervision is also provided. However, at the time this pathway was created (May 2011), the SPC advises caution in prescribing clomethiazole for individuals known to be addiction-prone and to outpatient alcoholics. It also advises against prescribing to patients who continue to drink or abuse alcohol. Alcohol combined with clomethiazole, particularly in alcoholics with cirrhosis, can lead to fatal respiratory depression even with short-term use. Clomethiazole should only be used in hospital under close supervision or, in exceptional circumstances, on an outpatient basis by specialist units when the daily dosage must be monitored closely.
Delirium tremens
Lorazepam is used in UK clinical practice in the management of delirium tremens. At the time this pathway was created (May 2011), lorazepam did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. In addition, the SPC advises that use in individuals with a history of alcoholism should be avoided (due to increased risk of dependence).
Haloperidol is used in UK clinical practice in the management of delirium tremens. At the time this pathway was created (May 2011), haloperidol did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. In addition, the SPC advises caution in patients suffering from conditions predisposing to convulsions, such as alcohol withdrawal.
Olanzapine is used in UK clinical practice in the management of delirium tremens. At the time this pathway was created (May 2011), olanzapine did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. In addition, the SPC advises that the safety and efficacy of intramuscular olanzapine has not been evaluated in patients with alcohol intoxication.
Alcohol withdrawal seizures
Lorazepam is used in UK clinical practice in the management of alcohol withdrawal seizures. At the time this pathway was created (May 2011), lorazepam did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. In addition, the SPC advises that use in individuals with a history of alcoholism should be avoided (due to increased risk of dependence).
At the time this pathway was created, no drugs recommended for the treatment of harmful drinking or alcohol dependence had a UK marketing authorisation for use in children and young people under the age of 18. However, in 2000, the Royal College of Paediatrics and Child Health issued a policy statement on the use of unlicensed medicines, or the use of licensed medicines for unlicensed applications, in children and young people. This states that such use is necessary in paediatric practice and that doctors are legally allowed to prescribe unlicensed medicines where there are no suitable alternatives and where the use is justified by a responsible body of professional opinion.
Glossary
The physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time.
A cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. For further information please refer to: 'Diagnostic and statistical manual of mental disorders' (DSM-IV) (American Psychiatric Association 2000) and 'International statistical classification of diseases and related health problems – 10th revision' (ICD-10) (World Health Organization 2007).
Used in this pathway to refer to harmful drinking and alcohol dependence.
Confidence interval. There is always some uncertainty in research. This is because a small group of people is studied to predict the effects of an intervention on the wider population. The confidence interval is a way of expressing how certain we are about the findings from a study, using statistics. It gives a range of results that is likely to include the 'true' value for the population.
The CI is usually stated as '95% CI', which means that the range of values has a 95 in a 100 chance of including the 'true' value. For example, a study may state that 'based on our sample findings, we are 95% certain that the 'true' population blood pressure is not higher than 150 and not lower than 110'. In such a case the 95% CI would be 110 to 150.
A wide confidence interval indicates a lack of certainty about the true effect of the test or treatment – often because a small group of patients has been studied. A narrow confidence interval indicates a more precise estimate (for example, if a large number of patients have been studied).
Alcohol-use disorders cover a wide range of mental health problems as recognised within the international disease classification systems (ICD-10, DSM-IV). These include hazardous and harmful drinking and alcohol dependence. See 'Harmful' and 'Hazardous' drinking and 'Alcohol dependence'.
Alcohol Problems Questionnaire
AUDIT is an alcohol screening test designed to see if people are drinking harmful or hazardous amounts of alcohol. It can also be used to identify people who warrant further diagnostic tests for alcohol dependence.
Effect size. A measure that shows the magnitude of the outcome in one group compared with that in a control group.
For example, if the absolute risk reduction is shown to be 5% and it is the outcome of interest, the effect size is 5%.
The effect size is usually tested, using statistics, to find out how likely it is that the effect is a result of the treatment and has not just happened by chance (that is, to see if it is statistically significant).
This can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention – see also below). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists.
The Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA–Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of the alcohol withdrawal syndrome, and to monitor and medicate patients throughout withdrawal.
NICE analysts have calculated this figure using data from the original study.
Pain relief by nerve block of the coeliac plexus.
Incremental cost effectiveness ratio. A measure of the cost effectiveness of a treatment or health intervention. It estimates how much more the benefits of a certain treatment cost, compared with other treatments or health interventions.
Liver disease complicated by the development of jaundice, ascites, bruising or abnormal bleeding and/or hepatic encephalopathy.
Number needed to treat. The average number of people who need to receive an intervention to get a positive outcome. For example, if the NNT is four, then 4 people would have to receive the intervention to ensure one of them gets better. The closer the NNT is to one, the better the intervention. However, as with most data, caution is needed when considering whether results apply to populations beyond the sample described in the original study.
This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change.
Odds ratio. Odds are a way to represent how likely it is that something will happen (the probability). An odds ratio compares the probability of something in one group with the probability of the same thing in another.
An odds ratio of 1 between two groups would show that the probability of the event (for example a person developing a disease, or an intervention working) is the same for both.
Sometimes probability can be compared across more than two groups – in this case, one of the groups is chosen as the 'reference category', and the odds ratio is calculated for each group compared with the reference category. For example, to compare the risk of dying from lung cancer for non-smokers, occasional smokers and regular smokers, non-smokers could be used as the reference category. Odds ratios would be worked out for occasional smokers compared with non-smokers and for regular smokers compared with non-smokers.
FRAMES is an acronym summarising the components of a brief intervention. Feedback (on the client's risk of having alcohol problems), responsibility (change is the client's responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change).
A pattern of alcohol consumption that is causing mental or physical damage.
A pattern of alcohol consumption that increases someone's risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. The term is currently used by WHO to describe this pattern of alcohol consumption. It is not a diagnostic term.
Quality-adjusted life year. A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health.
QALYS are calculated by estimating the years of life remaining for a person following a particular treatment or intervention and weighting each year with a quality of life score (on a zero to one scale). It is often measured in terms of the person's ability to perform the activities of daily life, freedom from pain and mental disturbance.
Leeds Dependence Questionnaire
Randomised controlled trial. A study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or intervention. One group (the experimental group) receives the intervention being tested, the other (the comparison or control group) receives an alternative intervention, a dummy intervention (placebo) or no intervention at all. The groups are followed up to see how effective the experimental intervention was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias.
The term 'looked after' has a specific legal meaning. It refers to children and young people who are provided with accommodation on a voluntary basis for more than 24 hours. This compares with the term 'in care' which refers to those who are compulsorily removed from home and placed in care under a court order.
Regularly consuming 21 units per week or less (adult men) or 14 units per week or less (adult women). It is also known as 'sensible' or 'responsible' drinking.
Standard deviation. A measure used to summarise numerical data and describe how 'spread out' a set of measures (or 'values') are from the average. For example, the average height of a group of schoolchildren can be calculated using the total of all their heights added together and then divided by the number of schoolchildren in the group. Standard deviation measures the 'spread' of those heights. So, in the example it tells you whether all those in the group were about the same height or whether some were very tall and some were short.
The deliberate withdrawal from alcohol by a dependent drinker under the supervision of medical staff. Prescribed medication may be needed to relieve the symptoms. It can be carried out at home, in the community or in a hospital or other inpatient facility.
A score of 15 or less on the Severity of Alcohol Dependence Questionnaire (SADQ).
Mini-Mental State Examination
A score of 15–30 on the Severity of Alcohol Dependence Questionnaire (SADQ).
Severity of Alcohol Dependence Questionnaire
In relation to licensed premises, this describes a specific geographical area where there are already a lot of premises selling alcohol – and where the awarding of any new licences to sell alcohol may contribute to an increase in alcohol-related disorder.
For the purposes of this pathway, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. The term is not used here to refer to national screening programmes such as those recommended by the UK National Screening Committee (UK NSC).
A score of 31 or more on the Severity of Alcohol Dependence Questionnaire (SADQ).
Summary of product characteristics
Surgical division of the splanchnic nerves and coeliac ganglion.
A brief intervention that takes only a few minutes to deliver.
A programme designed to reduce alcohol consumption or any related problems. It could involve a combination of counselling and medicinal solutions.
In the UK, alcoholic drinks are measured in units. Each unit corresponds to approximately 8 g or 10 ml of ethanol. The same volume of similar types of alcohol (for example, 2 pints of lager) can comprise a different number of units depending on the drink's strength (that is, its percentage concentration of alcohol).
For the purposes of this pathway, schools include: state-sector, special and independent primary and secondary schools; city technology colleges, academies and grammar schools; pupil referral units, secure training and local authority secure units; and further education colleges.
Paths in this pathway
- Prevention strategies and policy for alcohol-use disorders
- Prevention and screening for alcohol-use disorders
- Brief interventions for alcohol-use disorders
- Assessment for harmful drinking and alcohol dependence
- Interventions for harmful drinking and alcohol dependence
- Assisted alcohol withdrawal
- Special considerations for children and young people with alcohol-use disorders
- Interventions for conditions comorbid with alcohol-use disorders
- Acute alcohol withdrawal
- Wernicke’s encephalopathy and Wernicke-Korsakoff syndrome
- Alcohol-related liver disease
- Alcohol-related pancreatitis
Pathway created: May 2011 Last updated: July 2015
© NICE 2015