Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 5 March 2012

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents

UK national guidance on alcohol prevention, treatment and brief interventions

All five entries document the interlocking network of medical and public health guidance on responding to alcohol-related problems recently published by the UK National Institute for Health and Clinical Excellence (NICE). The bulletin collects together new analyses of the latest guidance and updated analyses of earlier guidance.

UK clinical guidance on treating dependent drinkers ...

UK clinical guidance on treating acute alcohol withdrawal ...

UK guidance on commissioning services for problem drinkers ...

UK health quality standards on identifying and caring for problem drinkers ...

UK public health guidance on preventing problem drinking ...


Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.

National Collaborating Centre for Mental Health.
National Institute for Health and Clinical Excellence, 2011.
Unable to obtain a copy by clicking title? Try this alternative source.

This impressive assessment of what evaluation research means for alcohol dependence treatment in Britain is distinguished by reviews of the latest literature on the sub-topics it covers; in some cases these starkly reveal the inadequacies of the evidence base.

Summary This summary is based on the quick reference guide associated with the guidance.

Noting that current practice across the country is varied, leading to variation in access to assisted withdrawal and treatment services, this guideline makes recommendations on the diagnosis, assessment and management of harmful drinking A pattern of alcohol consumption causing health problems directly related to alcohol, including psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis. and alcohol dependence Characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences. in adults and young people At the time of publication, no drug recommended in this guideline has a UK marketing authorisation for use in 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 use is justified by a responsible body of professional opinion. aged 10–17.

Person-centred care

Treatment and care should take into account people's individual needs and preferences. Good communication is essential, supported by evidence-based information, to allow people to reach informed decisions about their care. If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. If caring for young people in transition between paediatric and adult services, refer to Transition: getting it right for young people.

Key priorities for implementation

Identification and assessment in all settings

Staff working in services provided and funded by the NHS who care for people who potentially misuse alcohol should be competent to identify harmful drinking and alcohol dependence. They should be competent to initially assess the need for an intervention or, if they are not competent, they should refer people who misuse alcohol to a service that can provide an assessment of need.

Assessment in specialist alcohol services

Consider a comprehensive assessment for all adults referred to specialist services who score more than 15 on the Alcohol Use Disorders Identification Test (AUDIT). A comprehensive assessment should assess multiple areas of need, be structured in a clinical interview, use relevant and validated clinical tools, and cover the following areas:
• alcohol use, including: consumption – historical and recent patterns of drinking (using, for example, a retrospective drinking diary), and if possible, additional information (for example, from a family member or carer); dependence, using, for example, the Severity of Alcohol Dependence Questionnaire (SADQ) or the Leeds Dependence Questionnaire (LDQ); alcohol-related problems, using, for example, the Alcohol Problems Questionnaire (APQ);
• other drug misuse, including over-the-counter medication;
• physical health problems;
• psychological and social problems;
• cognitive function, using, for example, the Mini-Mental State Examination (MMSE);
• readiness and belief in ability to change.

General principles for all interventions

Consider offering interventions to promote abstinence and prevent relapse as part of an intensive structured community-based intervention for people with moderate and severe alcohol dependence who have:
• very limited social support, for example, living alone or with very little contact with family or friends; or
• complex physical or psychiatric comorbidities; or
• not responded to initial community-based interventions.

All interventions for people who misuse alcohol should be delivered by appropriately trained and competent staff. Pharmacological interventions 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. should be administered by specialist and competent staff. Psychological interventions should be based on a relevant evidence-based treatment manual, which should guide the structure and duration of the intervention. Staff should consider using competence frameworks developed from the relevant treatment manuals and for all interventions should:
• receive regular supervision from individuals competent in both the intervention and in supervision;
• routinely use outcome measurements to make sure that the person who misuses alcohol is involved in reviewing the effectiveness of treatment;
• engage in monitoring and evaluation of treatment adherence and practice competence, for example, by using video and audio tapes and external audit and scrutiny if appropriate.

Interventions for harmful drinking and mild alcohol dependence

For harmful A pattern of alcohol consumption causing health problems directly related to alcohol, including psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis. drinkers and people with mild alcohol dependence, A score of 15 or less on the Severity of Alcohol Dependence Questionnaire (SADQ). offer a psychological intervention (such as cognitive-behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol-related cognitions, behaviour, problems and social networks.

Assessment for assisted alcohol withdrawal

For service users These is a question over whether this guideline should be reduced to 10 units for women. See the comments below from Drug and Alcohol Findings. who typically drink over 15 units A UK unit is 8gm alcohol. of alcohol per day and/or who score 20 or more on the AUDIT, consider offering:
• an assessment for and delivery of a community-based assisted withdrawal; or
• assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal.

Interventions for moderate and severe alcohol dependence

After a successful withdrawal for people with moderate A score of 15–30 on the Severity of Alcohol Dependence Questionnaire (SADQ). and severe A score of 31 or more on the Severity of Alcohol Dependence Questionnaire (SADQ). alcohol dependence, consider offering acamprosate or oral naltrexone At the time of publication (February 2011), oral naltrexone did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. in combination with an individual psychological intervention (cognitive-behavioural therapy, behavioural therapy or social network and environment-based therapy) focused specifically on alcohol misuse.

Assessment and interventions for children and young people who misuse alcohol

For children and young people aged 10–17 years who misuse alcohol offer:
• individual cognitive-behavioural therapy for those with limited comorbidities and good social support;
• multi-component programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy) for those with significant comorbidities and/or limited social support.

Interventions for conditions comorbid with alcohol misuse

For people who misuse alcohol and have comorbid depression or anxiety disorders, treat the alcohol misuse first as this may lead to significant improvement in the depression and anxiety. If these continue after three to four weeks of abstinence from alcohol, undertake an assessment of the depression or anxiety and consider referral and treatment in line with the relevant NICE guideline Depression: the treatment and management of depression in adults NICE clinical guideline 90 (2009), available from www.nice.org.uk/guidance/CG90; and Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care, NICE clinical guideline 113 (2011), available from www.nice.org.uk/guidance/CG113. for the particular disorder.

2013 update

An update on the evidence released in January 2013 which does not replace current guidance was also considered not to justify any changes to this guidance. Generally the new reviews and studies identified in the update were consistent with the research reviewed for the original document and with the original practice recommendations based on that research.


Findings logo commentary This report offers a thoroughly researched, root and branch re-assessment of what evaluation research means for alcohol dependence treatment in the British context. It is distinguished by the many fresh searches for and reviews of the literature on the sub-topics it covers, including where appropriate meta-analytic A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. syntheses of the findings in to single, easily understood metric. Thoughtful narrative reviews explain the contexts of the studies and an expert and experienced group sifted and adapted the findings to British caseloads, services and resources. Limits imposed on the report by the available research ( below) detract from its ability to advance practice, but not from an impressive attempt to offer comprehensive, coherent, evidence-informed guidance based on the research to hand.

Research lacking in some areas

Despite the fresh searches, the main limitation faced by the report's authors was that in some cases the evidence remained very thin, leaving the guidance largely devoid of an evidential basis for what are presumed to be crucial treatment strategies. Among these were using research-validated assessment tools as opposed to a more ad-hoc approach, whether it is important to offer a coherent, case managed programme or whether patients do as well using a 'pick and mix' or 'take what's available' approach, and whether offering the least intensive intervention first ('stepped care') risks demoralising failure or is a cost- and trouble-saving strategy with no major downsides. In these situations, the expert group which drafted the guidance had to rely substantially on experience and common sense – in other words, continuation of the 'way we do things now' – rather than research-based advancements.

For example, in respect of the crucial case management function intended to knit together assessment, planning, coordination and monitoring of care and treatment, just three studies met the most stringent methodological criteria (randomised trials with a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group), were concerned with drinkers, and provided the required outcome data. Another important and common approach to care planning is to offer the least restrictive and least costly intervention first and move up the scale if that fails – so called 'stepped care' – yet the report found that "none of [the potentially relevant] studies delivered a form of stepped care that was fully consistent with the definition of a stepped care approach adopted for this guideline". Assessment is clearly a critical stage, determining what services the client will be offered and at what intensity, yet at just six suitable studies, the evidence base for adults was too thin to permit use of the most appropriate statistical methods to judge what works best.

Interpreting the research

On other issues the expert group was vulnerable to seeing what researchers have chosen to study for research purposes as the way practitioners should do things. This happens because the researchers' choices gather an evidence base around them which is not gathered by more rarely researched approaches such as routine medical management or the exercise of clinical judgement. Examples below.

In particular, researchers like to standardise the interventions they research so that they know what causes the impacts they observe, and so that other researchers can replicate or extend their findings. The key way this is done is to manualise the intervention and ensure that highly trained interventionists stick to the manual. Manualised interventions then gather an evidence base around them, and practitioners are persuaded that this is how they should work in routine practice – a process reflected in the guideline's belief that "Psychological interventions should be based on a relevant evidence-based treatment manual, which should guide the structure and duration of the intervention". Yet it has recently become clear that for motivational interviewing, one of the most influential counselling styles in Britain, insisting that a manual guide the structure and duration of the intervention actually reduces its effectiveness (1 2 3).

Similarly, the report's stipulations about session numbers and durations of certain psychological therapies seem to reflect the fact that researchers have to package their interventions in order to standardise them, limit costs, and have a set end date from which the follow-up period can begin. Twelve weeks is the commonest compromise between a manageable research intervention and one which lasts long enough to possibly have the desired impacts. As a result, 12-week treatments have collected an evidence base around them, reflected in the report's recommendations for the main psychological therapies it advocates. Yet there is no reason to believe that because 12 weeks is convenient for researchers, it is also the way patients should be treated. For example, a reanalysis of the US alcohol treatment trial Project MATCH showed that patients who did not return for a single therapy session did almost as well as those who went through all 12 sessions of the project's two most extensive therapies. Across the entire study, nearly all the improvement there was going to be in drinking had occurred by week one, before most of the treatment had been delivered.

Other issues

Among the important messages from the featured report not in the Key implications summarised above are that therapeutic staff should aim to build a trusting relationship with their clients and work in a supportive, empathic and non-judgmental manner, taking in to account that stigma and discrimination are often associated with drink problems and lead clients to understate these problems. Discussions should, the report says, take place in settings in which confidentiality, privacy and dignity are respected.

On one issue this NICE report seems clearly at variance with the relevant NHS Clinical Knowledge Summary provided on behalf of NICE by the Sowerby Centre for Health Informatics at Newcastle. Rather than a blanket recommendation that adults who typically drink over 15 units A UK unit is 8gm alcohol. of alcohol a day should be considered for assisted withdrawal, this summary amends that guideline downwards "Assisted withdrawal may not be necessary in people with mild dependence. The decision to use assisted withdrawal should be made with the person, bearing in mind that treatment may reduce unpleasant symptoms and increase the chances of success. Drug treatment may not be necessary if:
The person reports drinking less than 15 units (men) or 10 units (women) per day, and does not need to drink to avoid withdrawal symptoms ..."
for women to 10 units.

Related guidance

Other related NICE guidance documents are listed below.

Alcohol-use disorders: preventing the development of hazardous and harmful drinking Prevention guidelines which prioritised population-wide changes like price rises and outlet restrictions which affect everyone, independent of the choices they make.

Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications Clinical guidelines on the medical care of people suffering acute alcohol withdrawal or alcohol-related lack of thiamine, liver disease, or inflammation of the pancreas.

Alcohol dependence and harmful alcohol use quality standard Concise statement of 13 practices which constitute high quality health care for problem drinkers and good practice in identifying and advising hazardous drinkers. The standards may be used to assess and reward providers and health service commissioning authorities.

Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults Guidance for commissioners on how to organise and procure alcohol treatment and brief intervention services in an area which implement related national clinical guidance and satisfy policy requirements.

For the nearest Scottish equivalent to the featured document see these guidelines developed for the Scottish Intercollegiate Guidelines Network.

Thanks for their comments on this entry in draft to Mary Longley and to Brian Kidd of Tayside Primary Care Trust. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 11 February 2013. First uploaded 05 June 2011

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MATRIX CELL 2016 Alcohol Matrix cell C2: Management/supervision; Generic and cross-cutting issues

MATRIX CELL 2014 Drug Matrix cell C2: Management/supervision; Generic and cross-cutting issues

REVIEW 2011 Evidence-based therapy relationships: research conclusions and clinical practices

MATRIX CELL 2014 Drug Matrix cell E2: Treatment systems; Generic and cross-cutting issues

MATRIX CELL 2013 Alcohol Matrix cell D2: Organisational functioning; Generic and cross-cutting issues

DOCUMENT 2013 Delivering recovery. Independent expert review of opioid replacement therapies in Scotland

MATRIX CELL 2014 Drug Matrix cell D2: Organisational functioning: Generic and cross-cutting issues

REVIEW 2012 BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

STUDY 2009 Therapist behavior as a predictor of black and white caregiver responsiveness in multisystemic therapy

STUDY 2005 'Real-world' studies show that medications do suppress heavy drinking





Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications.

National Clinical Guidelines Centre
Royal College of Physicians, 2010.

Clinical guidance developed for the National Institute for Health and Clinical Excellence (NICE) on the medical care of patients suffering acute alcohol withdrawal or alcohol-related lack of thiamine, liver disease, or inflammation of the pancreas.

Summary The featured document is clinical guidance funded by the UK National Institute for Health and Clinical Excellence (NICE) on the medical care of people aged 10 or over suffering acute alcohol withdrawal or alcohol-related lack of thiamine, liver disease, or inflammation of the pancreas.

The next sections of this entry summarise only the findings and recommendations in relation to alcohol withdrawal, focusing on those possibly of general interest. The guidelines focused on what from the point of view of the health service provider is an unplanned withdrawal – a patient presenting with symptoms These may include any combination of generalized hyperactivity, anxiety, tremor, sweating, nausea, retching, tachycardia, hypertension and mild pyrexia. Seizures may occur in the first 12 to 48 hours and only rarely after this. Auditory and visual hallucinations may develop. Delirium tremens (DTs) occurs uncommonly and is characterised by coarse tremor, agitation, fever, tachycardia, profound confusion, delusions and hallucinations. Hyperpyrexia, ketoacidosis, and profound circulatory collapse may develop. which can occur when patients who are physically dependent on alcohol abruptly stop drinking or substantially cut down. Planned withdrawal as part of a treatment programme for alcohol dependence is dealt with in Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.

Main findings on alcohol withdrawal

The experts who developed the guidance noted there was no reliable evidence that repeated unplanned medically assisted withdrawals from alcohol caused harm – the so-called 'kindling' effect. Though not disproved, there was not enough clinical evidence in favour of the hypothesis to support a recommendation.

No studies evaluated hospital admission for unplanned withdrawal versus planned withdrawal. Nevertheless, opinion based on experience within the expert group was that unplanned withdrawal in isolation is rarely an effective long-term treatment for alcohol dependence. Patients were likely to get better long-term benefits by undergoing a planned withdrawal through addiction services, with relevant and appropriate follow-up. The risks of sudden withdrawal from alcohol should be made clear to patients and advice should be given about how best to engage with the most appropriate local addiction services. Advice about reducing and stopping drinking was outside the scope of this guidance, but if the patient does not require admission, will usually involve drinking and then slowly reducing consumption or undergoing a planned medically assisted withdrawal of alcohol.

The consensus was that individuals may need admission due to the severity or predicted severity of the syndrome. More specifically, if a person presents following or in a withdrawal seizure or delirium tremens they should be admitted for medical care. In addition the evidence was examined to identify which factors confer a high risk of the withdrawal episode progressing to either seizure or delirium tremens. These were a history of alcohol withdrawal seizures or DTs, and signs and symptoms of autonomic over-activity with blood ethanol concentration greater than 100mg/100ml.

As to what medically assisted withdrawal should consist of, the experts assessed the evidence on the safety and efficacy of various Chlordiazepoxide, alprazolam, oxazepam, clobazam, lorazepam. benzodiazepines and of clomethiazole or carbamazepine as ways of controlling withdrawal symptoms. They found benzodiazepines to be more effective than placebo for the prevention of alcohol withdrawal seizures, but no other significant differences within and across the agents considered. In particular, there was no evidence to support the widely held view that clomethiazole is less safe than the other agents, although there was concern about use of this agent outside a closely monitored inpatient setting. If patients are discharged form hospital to finish their withdrawal in the community, it is very important to coordinate care with the care giver in the community.

There are three ways of administering these medications. Fixed dose regimens start with a standard dose which is then reduced over the next several days. Symptom-triggered regimens tailor treatment to the severity of withdrawal signs and symptoms which are regularly assessed and monitored. Pharmacotherapy is provided if the patient needs it and treatment is withheld if there are no symptoms of withdrawal. Front-loaded regimens provide a large dose of long-acting pharmacotherapy at the start and then 'as required'. There was insufficient evidence on front-loading. Compared to fixed dose regimens, symptom-triggered dosing involves significantly lower doses of benzodiazepines over a shorter period without an increase in the incidence of seizures or delirium tremens or in the severity of withdrawal symptoms. However, most studies were of mainly men admitted to specialist addiction services; only one was set in a general medical ward. Also, symptom-triggered dosing requires patients to be closely monitored and health care workers with the specialist clinical knowledge needed to identify signs and symptoms that imply a change in severity of withdrawal. In the experience of the expert group, acquiring the required skills was not a major task.

Another issue addressed by the guidance was the identification of patients at risk of or actually experiencing alcohol withdrawal. One study confirmed the experts' experience that late recognition of withdrawal leads to a more severe syndrome and a greater risk of alcohol withdrawal complications. The implication is that hazardous and harmful drinkers should be assessed for dependence (and therefore risk of withdrawal) as soon as possible. Patients in alcohol withdrawal should be assessed by an appropriately skilled health worker for the severity of their symptoms and the need for pharmacotherapy.

Selected recommendations

For people in acute alcohol withdrawal with, or who are assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, offer admission to hospital for medically assisted alcohol withdrawal.

For young people under 16 years who are in acute alcohol withdrawal, offer admission to hospital for physical and psychosocial assessment, in addition to medically assisted alcohol withdrawal.

For certain vulnerable people who are in acute alcohol withdrawal (for example, those who are frail, have cognitive impairment or multiple comorbidities, lack social support, have learning difficulties or are 16 or 17 years), consider a lower threshold for admission to hospital for medically assisted alcohol withdrawal.

For people who are alcohol dependent but not admitted to hospital, offer advice to avoid a sudden reduction in alcohol intake and information about how to contact local alcohol support services.

Offer pharmacotherapy to treat the symptoms of acute alcohol withdrawal. Consider a benzodiazepine or carbamazepine. Clomethiazole may be offered as an alternative, but should be used with caution, in inpatient settings only and according to the summary of product characteristics.

Offer information about how to contact local alcohol support services to people who are being treated for acute alcohol withdrawal.

Follow a symptom-triggered dosing regimen for drug treatment for people in acute alcohol withdrawal who are in hospital or in other settings where 24-hour assessment and monitoring are available.

Healthcare professionals who care for people in acute alcohol withdrawal should be skilled in the assessment and monitoring of withdrawal symptoms and signs.

People in acute alcohol withdrawal should be assessed immediately on admission to hospital by a healthcare professional skilled in the management of alcohol withdrawal.


Findings logo commentary Other related NICE guidance documents are listed below.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence Assessment of what evaluation research means for alcohol dependence treatment in Britain, featuring reviews of the literature on the topics it covers.

Alcohol-use disorders: preventing the development of hazardous and harmful drinking Prevention guidelines which prioritised population-wide changes like price rises and outlet restrictions which affect everyone, independent of the choices they make.

Alcohol dependence and harmful alcohol use quality standard Concise statement of 13 practices which constitute high quality health care for problem drinkers and good practice in identifying and advising hazardous drinkers. The standards may be used to assess and reward providers and health service commissioning authorities.

Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults Guidance for commissioners on how to organise and procure alcohol treatment and brief intervention services in an area which implement related national clinical guidance and satisfy policy requirements.

Last revised 03 March 2012

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DOCUMENT 2015 Alcohol-use disorders

REVIEW 2008 Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates

DOCUMENT 2009 Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence

REVIEW 2011 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

REVIEW 2012 BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

STUDY 2010 An open trial of gabapentin in acute alcohol withdrawal using an oral loading protocol

REVIEW 2010 Gamma-hydroxybutyrate (GHB) for treatment of alcohol withdrawal and prevention of relapses

REVIEW 2009 Pharmacotherapies for the treatment of opioid dependence: efficacy, cost-effectiveness and implementation guidelines

STUDY 2015 High-dose baclofen for the treatment of alcohol dependence (BACLAD study): A randomized, placebo-controlled trial

MATRIX CELL 2014 Alcohol Matrix cell E3: Treatment systems; Medical treatment





Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults.

National Institute for Health and Clinical Excellence.
National Institute for Health and Clinical Excellence, 2011.

From the UK health service standard-setting agency, guidance for commissioners on how to organise and procure alcohol treatment and brief intervention services in an area which implement related national clinical guidance and satisfy policy requirements.

Summary This guidance from the UK National Institute for Health and Clinical Excellence (NICE) aims to support commissioners in England to in their attempts to provide services for the identification and care of hazardous, harmful and dependent drinkers which implement other relevant NICE guidance on alcohol, and to commission high quality services that meet the quality standard on alcohol dependence and harmful alcohol use. Essentially it extracts the messages for commissioners from related NICE and other official guidance and distils these in to a single document to guide the organisation and procurement of treatment and brief intervention services in an area which embody those messages. In doing so it offers reasons for organisations responsible for spending health service resources to devote these to services for drinkers.

The guide highlights the benefits of commissioning for outcomes – principally reducing consumption, alcohol-related hospital admissions and alcohol-related mortality by improving access to evidence-based interventions that promote recovery.

It is estimated that only a small proportion of the £2.7 billion annual expenditure on alcohol-related harm is spent on identifying and treating alcohol misuse. NICE guidance advocates an invest-to-save approach by prioritising the prevention of alcohol-use disorders. This commissioning guide sets out a whole system approach to commissioning integrated alcohol services across the whole spectrum of care, from preventing harmful drinking through opportunistic screening and brief interventions, to specialist treatment programmes for children, young people and adults, and their families or carers.

The guide describes the following service components required to deliver a high quality service:
• opportunistic screening and brief interventions for adults who are hazardous and harmful drinkers;
• diagnosis, assessment and management of harmful drinking and alcohol dependence in adults, in specialist services;
• services for children and young people who are vulnerable to alcohol-related harm;
• whole system commissioning of high quality alcohol services.

Each section offers examples of service models, including case studies and ideas for using Quality, Innovation, Productivity and Prevention (QIPP) and Commissioning for Quality and Innovation (CQUIN) to drive improvements to alcohol services. There is also an outline service specification to assist commissioners when tendering or contract managing alcohol services.

The benchmark section contains further information to help commissioners to assess levels of alcohol dependence and hazardous and harmful drinking in their population. A population benchmark has been provided for the number of people in England aged 16 or above who are hazardous, harmful or dependent drinkers.

The guide contains a commissioning and benchmarking tool that can be used to calculate the costs of increasing access to opportunistic screening and brief interventions and to specialist alcohol treatment for adults. Providing evidence-based packages of care using the stepped-care model may reduce the unit cost of treatment per person by offering the least intensive, most cost effective intervention that is appropriate. Whole system commissioning may generate savings by reducing alcohol-related harm and alcohol-attributable hospital admissions


Findings logo commentary Other related NICE guidance documents are listed below.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence Assessment of what evaluation research means for alcohol dependence treatment in Britain, featuring reviews of the literature on the topics it covers.

Alcohol-use disorders: preventing the development of hazardous and harmful drinking Prevention guidelines which prioritised population-wide changes like price rises and outlet restrictions which affect everyone, independent of the choices they make.

Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications Clinical guidelines on the medical care of people suffering acute alcohol withdrawal or alcohol-related lack of thiamine, liver disease, or inflammation of the pancreas.

Alcohol dependence and harmful alcohol use quality standard Concise statement of 13 practices which constitute high quality health care for problem drinkers and good practice in identifying and advising hazardous drinkers. The standards may be used to assess and reward providers and health service commissioning authorities.

Last revised 03 March 2012. First uploaded

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DOCUMENT 2011 Alcohol dependence and harmful alcohol use quality standard

REVIEW 2010 Alcohol-use disorders: Preventing the development of hazardous and harmful drinking

STUDY 2008 Reducing alcohol harm: health services in England for alcohol misuse

STUDY 2011 Reducing the impact of alcohol-related harm to Londoners – how well are we doing?

STUDY 2011 An evaluation to assess the implementation of NHS delivered alcohol brief interventions: final report

STUDY 2011 Supporting partnerships to reduce alcohol harm: key findings, recommendations and case studies from the Alcohol Harm Reduction National Support Team

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2012 Alcohol screening and brief intervention in emergency departments

STUDY 2013 Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial

STUDY 2012 The forgotten carers: support for adult family members affected by a relative's drug problems





Alcohol dependence and harmful alcohol use quality standard.

National Institute for Health and Clinical Excellence.
National Institute for Health and Clinical Excellence, 2011.

From the UK health service standard-setting agency, a concise statement of 13 practices which constitute high quality health care for problem drinkers and good practice in identifying and advising hazardous drinkers - standards which may be used to assess and reward providers and health service commissioning authorities.

Summary Quality standards set by expert groups convened by the UK National Institute for Health and Clinical Excellence (NICE) are intended to represent concise aspirational, but achievable, markers of high-quality, cost-effective patient care, derived from the best available evidence. They will be used to assess the performance of health services and will inform associated payment mechanisms and incentive schemes.

The featured set of standards cover the care in all NHS-funded settings of people aged 10 or older dependent on alcohol or drinking in a harmful way. They also include opportunistic screening and brief interventions for hazardous and harmful drinkers and address the prevention and management of Wernicke's encephalopathy, A brain and nervous system disorder caused by a lack of thiamine (vitamin B1). but not the management of other disorders associated with drinking. Also available is an associated guide for commissioners of services.

The standards

Below verbatim are the agreed quality standards sometimes with explanatory notes drawn from the standards. The meaning, assessment and practice implications of each is expanded on in the source documents.

1 Health and social care staff receive alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol.

2 Health and social care staff opportunistically 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.
carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice.

3 People 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). who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and are able to access 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. specialist alcohol treatment.

4 People accessing specialist alcohol services receive assessments and interventions delivered by appropriately 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. trained and competent specialist staff.

5 Adults accessing specialist alcohol services for alcohol misuse receive a comprehensive assessment that includes the use of validated measures.

6 Children and young people accessing specialist services for alcohol use receive a comprehensive assessment that includes the use of validated measures.

7 Families and carers of people who misuse alcohol have their own needs 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 ... 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). identified, including those associated with risk of harm, and are offered information and support.

8 People needing medically assisted alcohol withdrawal are offered treatment within the setting most appropriate 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 ... 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 20 units of alcohol per day and have significant psychiatric or physical comorbidities ... 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 ... 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.
to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.

9 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.

10 People with suspected, or at high risk of developing, Wernicke's encephalopathy are offered thiamine in accordance with NICE guidance.

11 Adults who misuse alcohol are offered evidence-based psychological interventions, 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. and those with alcohol dependence that is moderate or severe can in addition access relapse prevention medication 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. in accordance with NICE guidance.

12 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 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 ... programme of care including family or systems therapy.

13 People receiving specialist treatment for alcohol misuse have regular treatment outcome reviews, which are used to plan subsequent care.


Findings logo commentary Other related NICE guidance documents are listed below.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence Assessment of what evaluation research means for alcohol dependence treatment in Britain, featuring reviews of the literature on the topics it covers.

Alcohol-use disorders: preventing the development of hazardous and harmful drinking Prevention guidelines which prioritised population-wide changes like price rises and outlet restrictions which affect everyone, independent of the choices they make.

Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications Clinical guidelines on the medical care of people suffering acute alcohol withdrawal or alcohol-related lack of thiamine, liver disease, or inflammation of the pancreas.

Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults Guidance for commissioners on how to organise and procure alcohol treatment and brief intervention services in an area which implement related national clinical guidance and satisfy policy requirements.

Last revised 02 March 2012. First uploaded

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DOCUMENT 2011 Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults

REVIEW 2010 Alcohol-use disorders: Preventing the development of hazardous and harmful drinking

STUDY 2011 An evaluation to assess the implementation of NHS delivered alcohol brief interventions: final report

STUDY 2008 Reducing alcohol harm: health services in England for alcohol misuse

STUDY 2011 Supporting partnerships to reduce alcohol harm: key findings, recommendations and case studies from the Alcohol Harm Reduction National Support Team

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Alcohol-use disorders: Preventing the development of hazardous and harmful drinking.

National Institute for Health and Clinical Excellence
National Institute for Health and Clinical Excellence, 2010.
Unable to obtain a copy by clicking title? Try this alternative source.

In these UK national prevention guidelines, experts prioritised population-wide changes like price rises and outlet restrictions which affect everyone, independent of the choices they make. But in England government prefers to target what they see as the troublesome minority, not the responsible majority.

Summary The UK Department of Health asked the National Institute for Health and Clinical Excellence (NICE) to produce public health guidance on the prevention and early identification of alcohol-use disorders 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. among adults and adolescents. The guidance is for government, industry and commerce, the NHS and all those whose actions affect the population’s attitude to – and use of – alcohol. This includes commissioners, managers and practitioners working in local authorities, education and the wider public, private, voluntary and community sectors.

When writing the recommendations, the Programme Development Group considered evidence of effectiveness (including cost-effectiveness), fieldwork data and comments from stakeholders and experts.

Population versus individual approach

A combination of interventions are needed to reduce alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. – to the benefit of society as a whole.

Population-level approaches are important because they can help reduce the aggregate level of alcohol consumed and therefore lower the whole population’s risk of alcohol-related harm. Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. They can help:
• those who are not in regular contact with the relevant services;
• those who have been specifically advised to reduce their alcohol intake, by creating an environment that supports lower-risk Regularly consuming 21 UK units (8g alcohol per unit) per week or less (adult men) or 14 units per week or less (adult women). drinking.

They can also help prevent people from drinking harmful A pattern of alcohol consumption that is causing mental or physical damage. or hazardous 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. amounts in the first place.

Interventions aimed at individuals can help make people aware of the potential risks they are taking (or harm they may be doing) at an early stage. This is important, as they are most likely to change their behaviour if it is tackled early. In addition, an early intervention could prevent extensive damage.

This NICE guidance provides authoritative recommendations, based on a robust analysis of the evidence, which support current government activities. The recommendations could form part of a national framework for action. National-level action to reduce the population’s alcohol consumption requires coordinated government policy. It also needs government, industry and key non-governmental organisations to work together.

Policy and practice

This guidance makes the case that alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. is a major public health problem. On the basis of the best available evidence, it also identifies the policy options that are most likely to be successful in combating such harm. Policy recommendations (recommendations 1 to 3) are based on extensive and consistent evidence which suggests that the issues identified deserve close attention. This evidence also suggests that policy change is likely to be a more effective – and more cost-effective – way of reducing alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. among the population than actions undertaken by local health professionals. Practice recommendations (4 to 12) support, complement – and are reinforced by – these policy options. They include screening For the purposes of this guidance, 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. and brief interventions. This can comprise 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.

RECOMMENDATIONS FOR POLICY

The Chief Medical Officer should coordinate the alcohol harm-reduction strategy for England across government, supported by the Department of Health.

The following departments and national agencies should also be involved:
• Advertising Standards Authority;
• Department for Business, Innovation and Skills;
• Department for Children, Schools and Families;
• Department for Culture, Media and Sport;
• Department for Environment, Food and Rural Affairs;
• Department of Communities and Local Government;
• HM Treasury;
• Home Office;
• Ministry of Justice;
• National Treatment Agency;
Ofcom;
• Office of Fair Trading.

Organisations that should be consulted include:
• advertisers;
• alcohol producers;
• national non-governmental organisations (for example, Alcohol Concern and the Royal Medical Colleges);
• off- and on-sale retailers.

Recommendation 1: price

Making alcohol less affordable is the most effective way of reducing alcohol-related harm. Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. The current excise duty varies for different alcoholic products (for historical reasons and under EU legislation). This means that the duty does not always relate directly to the amount of alcohol in the product. In addition, an increase in the duty levied does not necessarily translate into a price increase as retailers or producers may absorb the cost. There is extensive international and national evidence (within the published literature and from economic analyses) to justify reviewing policies on pricing to reduce the affordability of alcohol.

What action could be taken?

Consider introducing a minimum price per unit. A UK unit is 8g alcohol. Set the level by taking into account the health and social costs of alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. and its impact on alcohol consumption. Consider initiating a review of the excise duty regime with fellow EU member states. The aim would be to obtain a pan-EU agreement on harmonisation which links alcohol duty to the strength of each product.

Regularly review the minimum price per unit A UK unit is 8g alcohol. and alcohol duties to ensure alcohol does not become more affordable over time.

Recommendation 2: availability

International evidence suggests that making it less easy to buy alcohol, by reducing the number of outlets selling it in a given area and the days and hours when it can be sold, is another effective way of reducing alcohol-related harm. Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. In Scotland, protection of the public’s health is among the objectives of licensing decisions.

What action could be taken?

Consider revising legislation on licensing to ensure:
• protection of the public’s health is one of its objectives;
• health bodies are responsible authorities; Responsible authorities have to be notified of all licence variations and new applications and can make representations regarding them. The Licensing Act 2003 lists responsible authorities. They include the police, environmental health and child protection services, fire and rescue and trading standards.
• licensing departments can take into account the links between the availability of alcohol and alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. when considering a licence application (that is, they can take into account the number of alcohol outlets in a given area and times when it is on sale and the potential links to local crime and disorder and alcohol-related illnesses and deaths);
• immediate sanctions can be imposed on any premises in breach of their licence, following review proceedings.

Consider reducing personal import allowances to support the introduction of a minimum price per unit A UK unit is 8g alcohol. of alcohol.

Recommendation 3: marketing

There is evidence that alcohol advertising does affect children and young people. It shows that exposure to alcohol advertising is associated with the onset of drinking among young people and increased consumption among those who already drink. All of the evidence suggests that children and young people should be protected as much as is possible by strengthening the current regulations.

What action could be taken?

Ensure children and young people’s exposure to alcohol advertising is as low as possible by considering a review of the current advertising codes. This review would ensure:
• the limits set by the Advertising Standards Authority for the proportion of the audience under age 18 are appropriate;
• where alcohol advertising is permitted there is adequate protection for children and young people;
• all alcohol marketing, particularly when it involves new media (for example, web-based channels and mobile phones) and product placement, is covered by a stringent regulatory system which includes ongoing monitoring of practice.

Ofcom, the Advertising Standards Authority and the government should keep the current regulatory structure under review.

Assess the potential costs and benefits of a complete alcohol advertising ban to protect children and young people from exposure to alcohol marketing.

RECOMMENDATIONS FOR PRACTICE

Recommendation 4: licensing

Who is the target population?

Alcohol licence-holders and designated supervisors of licensed premises.

Who should take action?

• Local authorities;
• Trading standards officers;
• The police;
• Magistrates;
• Revenue and customs.

What action should they take?

Use local crime and related trauma data to map the extent of alcohol-related problems before developing or reviewing a licensing policy. If an area is ‘saturated’ 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. with licensed premises and the evidence suggests that additional premises may affect the licensing objectives, adopt a ‘cumulative impact’ policy. If necessary, limit the number of new licensed premises in a given area.

Ensure sufficient resources are available to prevent under-age sales, sales to people who are intoxicated, proxy sales (that is, illegal purchases for someone who is under-age or intoxicated), non-compliance with any other alcohol licence condition and illegal imports of alcohol.

Work in partnership with the appropriate authorities to identify and take action against premises that regularly sell alcohol to people who are under-age, intoxicated or making illegal purchases for others.

Undertake test purchases (using ‘mystery’ shoppers) to ensure compliance with the law on under-age sales. Test purchases should also be used to identify and take action against premises where sales are made to people who are intoxicated or to those illegally purchasing alcohol for others.

Ensure sanctions are fully applied to businesses that break the law on under-age sales, sales to those who are intoxicated and proxy purchases. This includes fixed penalty and closure notices (the latter should be applied to establishments that persistently sell alcohol to children and young people).

Recommendation 5: resources for screening and brief interventions

Who is the target population?

Professionals who have contact with those aged 16 and over.

Who should take action?

• Chief executives of NHS and local authorities;
• Commissioners of NHS healthcare services;
• Commissioners from multi-agency joint commissioning groups;
• Managers of NHS-commissioned services.

What action should they take?

Chief executives of NHS and local authorities should prioritise alcohol-use disorder 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. prevention as an ‘invest to save’ measure.

Commissioners should ensure a local joint alcohol needs assessment is carried out in accordance with World class commissioning and Signs for improvement. They should also ensure locally defined integrated care pathways for alcohol treatment are reviewed.

Commissioners should ensure their plans include screening For the purposes of this guidance, 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. and brief interventions This can comprise 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. for people at risk of an alcohol-related problem – hazardous 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. drinkers – and those whose health is being damaged by alcohol – harmful A pattern of alcohol consumption that is causing mental or physical damage. drinkers. This includes people from disadvantaged groups.

Commissioners should make provision for the likely increase in the number of referrals to services providing tier two, three and four structured alcohol treatments as a result of screening. For the purposes of this guidance, 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. These services should be properly resourced to support the stepped care approach recommended in Models of care for alcohol misusers.

Commissioners should ensure at least one in seven dependent drinkers can get treatment locally, in line with Signs for improvement.

Commissioners should include formal evaluation within the commissioning framework so that alcohol interventions and treatment are routinely evaluated and followed up. The aim is to ensure adherence to evidence-based practice and to ensure interventions are cost effective.

Managers of NHS-commissioned services must ensure an appropriately trained nurse or medical consultant, with dedicated time, is available to provide strategic direction, governance structures and clinical supervision to alcohol specialist nurses and care givers.

Managers of NHS-commissioned services must ensure community and voluntary sector providers have an appropriately trained professional who can provide strategic direction, governance structures and supervision to those providing screening For the purposes of this guidance, 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. and brief interventions. This can comprise 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.

Managers of NHS-commissioned services must ensure staff have enough time and resources to carry out screening For the purposes of this guidance, 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. and brief intervention This can comprise 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. work effectively. Staff should have access to recognised, evidence-based packs. These should include: a short guide on how to deliver a brief intervention, This can comprise 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. a validated screening For the purposes of this guidance, 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. questionnaire, a visual presentation (to compare the person’s drinking levels with the average), practical advice on how to reduce alcohol consumption, a self-help leaflet and possibly a poster for display in waiting rooms.

Managers of NHS-commissioned services must ensure staff are trained to provide alcohol screening For the purposes of this guidance, 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. and structured brief advice. A brief intervention that takes only a few minutes to deliver. If there is local demand, staff should also be trained to deliver extended brief interventions. 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’.

Recommendation 6: supporting children and young people aged 10 to 15 years

Who is the target population?

Children and young people aged 10 to 15 years who are thought to be at risk from their use of alcohol.

Who should take action?

Any professional with a safeguarding responsibility for children and young people and who regularly comes into contact with this age group.

What action should they take?

Use professional judgement to routinely assess the ability of these children and young people to consent to alcohol-related interventions and treatment. Some will require parental or carer involvement.

Obtain a detailed history of their alcohol use (for example, using the Common Assessment Framework as a guide). Include background factors such as family problems and instances of child abuse or under-achievement at school.

Use professional judgement to decide on the appropriate course of action. In some cases, it may be sufficient to empathise and give an opinion about the significance of their drinking and other related issues that may arise. In other cases, more intensive counselling and support may be needed.

If there is a reason to believe that there is a significant risk of alcohol-related harm, Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. consider referral to child and adolescent mental health services, social care or to young people’s alcohol services for treatment, as appropriate and available.

Ensure discussions are sensitive to the child or young person’s age and their ability to understand what is involved, their emotional maturity, culture, faith and beliefs. The discussions (and tools used) should also take into account their particular needs (health and social) and be appropriate to the setting.

Recommendation 7: screening young people aged 16 and 17 years

Who is the target population?

Young people aged 16 and 17 years who are thought to be at risk from their use of alcohol.

Who should take action?

Health and social care, criminal justice and community and voluntary professionals in both NHS and non-NHS settings who regularly come into contact with this group.

What action should they take?

Complete a validated alcohol screening For the purposes of this guidance, 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. questionnaire with these young people. Alternatively, if they are judged to be competent enough, ask them to fill one in themselves. In most cases, AUDIT should be used. If time is limited, use an abbreviated version (such as AUDIT-C, AUDIT-PC, CRAFFT, SASQ or FAST). Screening tools should be appropriate to the setting. For instance, in an emergency department, FAST or the Paddington Alcohol Test (PAT) would be most appropriate.

Focus on key groups that may be at an increased risk of alcohol-related harm. Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. This includes those:
• who have had an accident or a minor injury;
• who regularly attend genito-urinary medicine (GUM) clinics or repeatedly seek emergency contraception;
• involved in crime or other antisocial behaviour;
• who truant on a regular basis;
• at risk of self-harm;
• who are looked after;
• involved with child safeguarding agencies.

When broaching the subject of alcohol and screening, For the purposes of this guidance, 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. ensure discussions are sensitive to the young person’s age and their ability to understand what is involved, their emotional maturity, culture, faith and beliefs. The discussions should also take into account their particular needs (health and social) and be appropriate to the setting.

Routinely assess the young person’s ability to consent to alcohol-related interventions and treatment. If there is doubt, encourage them to consider involving their parents in any alcohol counselling they receive.

Recommendation 8: extended brief interventions with young people aged 16 and 17 years

Who is the target population?

Young people aged 16 and 17 years who have been identified via screening For the purposes of this guidance, 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. as drinking hazardously 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. or harmfully. A pattern of alcohol consumption that is causing mental or physical damage.

Who should take action?

Health and social care, criminal justice and community and voluntary sector professionals in both NHS and non-NHS settings who regularly come into contact with this group.

What action should they take?

Ask the young person’s permission to arrange an extended brief intervention 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. for them.

Appropriately trained staff should offer the young person an extended brief intervention. 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’.

Provide information on local specialist addiction services to those who do not respond well to discussion but who want further help. Refer them to these services if this is what they want. Referral must be made to services that deal with young people.

Give those who are actively seeking treatment for an alcohol problem a physical and mental assessment and offer, or refer them for, appropriate treatment and care.

Recommendation 9: screening adults

Who is the target population?

Adults.

Who should take action?

Health and social care, criminal justice and community and voluntary sector professionals in both NHS and non-NHS settings who regularly come into contact with people who may be at risk of harm from the amount of alcohol they drink.

What action should they take?

NHS professionals should routinely carry out alcohol screening For the purposes of this guidance, 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. as an integral part of practice. For instance, discussions should take place during new patient registrations, when screening for other conditions and when managing chronic disease or carrying out a medicine review. These discussions should also take place when promoting sexual health, when seeing someone for an antenatal appointment and when treating minor injuries.

Where screening For the purposes of this guidance, 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. everyone is not feasible or practicable, NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and those with an alcohol-related condition. This includes people:
• with relevant physical conditions (such as hypertension and gastrointestinal or liver disorders);
• with relevant mental health problems (such as anxiety, depression or other mood disorders);
• who have been assaulted;
• at risk of self-harm;
• who regularly experience accidents or minor traumas;
• who regularly attend GUM clinics or repeatedly seek emergency contraception.

Non-NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and people who have alcohol-related problems. For example, this could 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.

When broaching the subject of alcohol and screening, For the purposes of this guidance, 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. ensure the discussions are sensitive to people’s culture and faith and tailored to their needs.

Complete a validated alcohol questionnaire with the adults being screened. For the purposes of this guidance, 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. Alternatively, if they are competent enough, ask them to fill one in themselves. Use AUDIT to decide whether to offer them a brief intervention This can comprise 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. (and, if so, what type) or whether to make a referral. If time is limited, use an abbreviated version (such as AUDIT-C, AUDIT-PC, SASQ or FAST). Screening tools should be appropriate to the setting. For instance, in an emergency department FAST or PAT would be most appropriate.

Do not offer simple brief advice to anyone who may be dependent on alcohol. Instead, refer them for specialist treatment (see recommendation 12). If someone is reluctant to accept a referral, offer an extended brief intervention 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. (see recommendation 11).

Use professional judgement as to whether to revise the AUDIT scores downwards when screening:
• women, including those who are, or are planning to become, pregnant;
• younger people (under the age of 18);
• people aged 65 and over;
• people from some black and minority ethnic groups.
If in doubt, consult relevant specialists. Work on the basis that offering an intervention is less likely to cause harm than failing to act where there are concerns.

Consult relevant specialists 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.

Biochemical measures including of blood alcohol concentration should not be used as a matter of routine to screen For the purposes of this guidance, 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. someone to see if they are drinking hazardously 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. or harmfully. A pattern of alcohol consumption that is causing mental or physical damage. Biochemical measures may be used to assess the severity and progress of an established alcohol-related problem, or as part of a hospital assessment, including assessments carried out in emergency departments.

Recommendation 10: brief advice for adults

Who is the target population?

Adults who have been identified via screening For the purposes of this guidance, 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. as drinking a hazardous 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. or harmful A pattern of alcohol consumption that is causing mental or physical damage. amount of alcohol and who are attending NHS or NHS-commissioned services or services offered by other public institutions.

Who should take action?

Professionals who have received the necessary training and work in:
• primary healthcare;
• emergency departments;
• other healthcare services (hospital wards, outpatient departments, occupational health, sexual health, needle and syringe exchange programmes, pharmacies, dental surgeries, antenatal clinics and those commissioned from the voluntary, community and private sectors);
• the criminal justice system;
• social services;
• higher education;
• other public services.

What action should they take?

Offer a session of structured brief advice A brief intervention that takes only a few minutes to deliver. on alcohol. If this cannot be offered immediately, offer an appointment as soon as possible thereafter.

Use a recognised, evidence-based resource that is based on FRAMES 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). principles. It should take 5–15 minutes and should:
• cover the potential harm caused by their level of drinking and reasons for changing the behaviour, including the health and wellbeing benefits;
• cover the barriers to change;
• outline practical strategies to help reduce alcohol consumption, to address the ‘menu’ component of the FRAMES 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). model;
• lead to a set of goals.

Where there is an ongoing relationship with the patient or client, routinely monitor their progress in reducing their alcohol consumption to a low-risk level. Where required, offer an additional session of structured brief advice. A brief intervention that takes only a few minutes to deliver. or, if there has been no response, offer an extended brief intervention. 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’.

Recommendation 11: extended brief interventions for adults

Who is the target population?

Adults who have not responded to structured brief advice. A brief intervention that takes only a few minutes to deliver. on alcohol and require an extended brief intervention 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. or would benefit from this for other reasons.

Who should take action?

NHS and other professionals in the public, private, community and voluntary sectors who are in contact with adults and have received training in extended brief intervention 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. techniques.

What action should they take?

Offer an extended brief intervention 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. to help people address their alcohol use. This could take the form of motivational interviewing or motivational-enhancement therapy. Sessions should last from 20 to 30 minutes. They should aim to help people to reduce the amount they drink to low risk levels, reduce risk-taking behaviour as a result of drinking, or to consider abstinence.

Follow up and assess people who have received an extended brief intervention. 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. Where necessary, offer up to four additional sessions or referral to a specialist alcohol treatment service (see recommendation 12).

Recommendation 12: referral

Who is the target population?

Those aged 16 years and over who attend NHS or other public services and may be alcohol-dependent. (For those under 16 see recommendation 6.)

Who should take action?

NHS and other professionals in the public, private, community and voluntary sectors who have contact with anyone aged 16 and over.

What action should they take?

Consider making a referral for specialist treatment if one or more of the following has occurred. They:
• show signs of moderate or severe alcohol dependence; 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.
• have failed to benefit from structured brief advice A brief intervention that takes only a few minutes to deliver. and an extended brief intervention 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. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. and wish to receive further help for an alcohol problem;
• show signs of severe alcohol-related impairment or have a related co-morbid condition (for example, liver disease or alcohol-related mental health problems).

An update on the evidence behind the report was published in March 2014. None of the new findings were considered to possibly requires changes to the original guidance. Among these, new studies on alcohol pricing were considered to strengthen the original recommendations and in particular the call for a minimum unit price. Similarly considered strengthened were calls for controls on availability and in particular restricting the concentration of alcohol outlets and controlling marketing. Evidence from the SIPS studies in England on primary care screening and brief interventions was considered unlikely to have an impact on the original recommendations.


Findings logo commentary The expert group responsible for the featured report were all in a position to be well aware of the dangers of drinking and/or involved in initiatives to curtail these, and their remit was to recommend ways to cut the risks. There were no alcohol industry representatives or ‘ordinary’ members of the (overwhelmingly) drinking public. The report which emerged focused almost entirely on dangers; the only benefit acknowledged was a possible reduction in the risk of some cardiovascular diseases among certain sections of the population; overall, the verdict was that “drinking alcohol is never without risk”.

Most eggs in pricing and availability baskets

When it came to how to reduce the risks, their report firmly prioritised national policy initiatives to tighten the alcohol availability environment in ways which affect the entire population, independent of each individual’s choices. Most importantly of all, alcohol would become less affordable (by setting a minimum price per unit A UK unit is 8g alcohol. of alcohol), but it would also become less available in other ways (by reducing the number of outlets and times they can sell) and less visible and visibly acceptable (through the implementation of stringent controls on marketing, particularly of the kind which might influence young people).

Such actions are thought “likely to be a more effective – and more cost-effective – way of reducing alcohol-related harm among the population than actions undertaken by local health professionals”. The expected impact was to cut average consumption across the nation and with it the population’s risk of alcohol-related harm. Benefits will it was thought be experienced across the board. Even dependent drinkers are expected to cut back and/or become fewer. This will happen because the average level of drinking across a population is linked to the extent of excessive drinking. As the former recedes, so too will the latter, cutting the tally of people with severe alcohol-related problems. This new environment is expected to be more conducive to individual-level interventions, helping tip the balance towards moderation in the way individuals respond to advice to cut back, brief interventions, and treatment.

These lines of argument are plausible and backed by considerable evidence, though little which directly tests the underlying assumptions. More below.

In the British context, the reliability of the links between average consumption and the prevalence of excessive drinking and harm seem challenged by experience from 1990 to 2010, when a drop in average consumption was paired with a rise in heavy episodic drinking. Rather than the two varying together, it has been argued that there was a “polarisation of the distribution of consumption ... heavy drinkers drink even higher volumes whilst moderate drinkers appear to have decreased their average intake”. In turn it was argued, this partly explains why the expected co-variation of average consumption and harm failed to materialise. Instead there was a “continuing increase in alcohol related morbidity and mortality, despite a recent downturn in population level consumption”.

While this calls in to question the presumed impact of availability restrictions on excessive drinking, it by no means invalidates it. What caused recent per capita drinking reductions is unclear, but it was certainly not explicit policies to cut availability. It could be that a reduction caused by such policies would reduce excessive drinking and related harm. This was the conclusion of research led by the author responsible for the questioning observations referred to above, though largely on the basis of studies which related harm to each individual’s intake, rather than the average across a society. Also, health gains among moderate drinkers of the kind associated with slightly lowering consumption (such as a gradual cumulative impact on chronic diseases) take years or decades to become apparent, while some associated with fewer heavy drinkers (such as reduced accidents and injuries) are immediate or more rapid. Given these time scales, it could be that the recent reduction in average consumption in Britain really will be associated with the expected improvement in health across the population.

Support for the report’s priorities comes from two recent reviews. One judged there was strong evidence that raising alcohol taxes reduced both excessive alcohol consumption and related harms, though it relied primarily on North American studies; even within Europe, a given consumption change has impacts which differ greatly across nations. Another gap in the analysis was that it was unable to explicitly account for the potential impact of drinkers switching to other beverages. The second review focused on tax and price impacts on health. It found a weak but statistically significant link between higher prices and taxes and better health, mortality and other health and social improvements, which was probably due to higher prices curbing consumption. However, all but one study fell short of assessing the impact on all deaths from whatever cause; the others may have missed some impacts positive or negative. The exception which did assess overall mortality found this weakly related to US state alcohol taxes, such that higher taxes were associated with fewer deaths, but the link was not strong enough to eliminate the possibility According to the conventional criterion of a less than a 1 in 20 chance that the findings were due to chance. that it was due to chance rather than to a real causal effect.

Screening: not universal but still important

Mass screening in GPs’ surgeries, accident and emergency departments, hospitals and elsewhere was recently seen as a feasible and effective way to reduce the public health burden of drinking which exceeds national ‘safe drinking’ guidelines. Now the ambition in England and Scotland has been scaled back to screening new patients and/or those thought possibly at risk, diluting the hoped-for public health benefits of a mass programme. This change is reflected in the featured report, which without being entirely explicit, encourages screening to take place only in circumstances where both patient and doctor might feel it was ‘natural’ and justified to ask about a patient’s drinking. The evidence appendix cautions that, “Clinical consultations for non-alcohol-related medical problems can be an inappropriate time to discuss alcohol use, given that users are focused on the condition for which they are seeking advice”, and recognises the greater acceptability of discussing drinking “in a context that is related to the purpose of the visit (such as lifestyle assessment or chronic condition monitoring)”. Quality standards developed by NICE and based partly on the featured report are however explicit that the expectation is that staff will screen “opportunistically”, meaning as the opportunity presents itself, which is in turn expected to be in certain types The standards say that 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.
of medical encounters but not others.

Even in this less ambitious form, screening remains important. Diligently implementing it in the recommended circumstances and for the recommended patients (which include new patient registrations and medicine reviews) could cumulate over the years to a high-coverage programme, and minor gains per individual can sum to appreciable public health gains.

Whether this will happen depends on how widely screening and brief interventions are implemented and how effective they are. On both counts the SIPS studies in England give little reassurance. A report has been published on the primary care findings and informal reports were made available on the study’s emergency department and probation trials. NICE’s update report considered these findings unlikely to have an impact on the original recommendations, but this itself seems unlikely.

In all the SIPS studies it seems that a year later the proportion of risky drinkers had fallen by about a sixth, and whatever the intervention, it made no substantial difference. Most basic was a simple warning that the patient or offender was drinking “above safe levels, which may be harmful to you” plus advice to read the alcohol information and advice booklet handed to the client. Supplementing this with an individualised brief intervention based on relatively sophisticated counselling techniques and scientific understandings made no difference, seemingly undermining the featured report’s specification that brief interventions should use a recognised, evidence-based resource based on FRAMES 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). principles. In SIPS too, even among what should have been the most promising settings, numbers screened also seem to have been small and achieving them often required specialist support – a finding which might shake confidence in whether such initiatives can affect population-wide health unless backed by sufficiently persuasive carrots and/or sticks to encourage widespread and effective implementation.

One in seven?

NICE’s report follows its predecessors in stipulating that provision be made for at least one in seven dependent drinkers to be treated in each local area. This Findings analysis reveals that this proportion is based on assumptions and findings of questionable relevance to the UK, and that depending on how you define treatment need, treatment services in England may be capturing numbers equivalent to an abysmal 7% of harmful drinkers ranging up to a creditable 40% or more of those also at least moderately dependent. The conclusion is that while we may suspect that in 2012/13 capturing 110,000 of England’s problem drinkers in treatment was not enough, there is no clear way to determine whether this was the case.

Policy plusses and minuses

For more see these hot topics on pricing policy, on controlling alcohol-related disorder including licensing law and allied developments, and on brief interventions.

In 2011 the UK government’s Home Office hedged its bets on the key tactic recommended in the featured report – an across-the-board and appreciable price rise – judging that “on balance” the evidence “suggests” that increasing the price of alcohol “may” reduce alcohol-related harms. It also pointed out that there were other influences on consumption and harm which operate at the level of the individual or of drinking cultures and environments rather than national taxation and availability restrictions.

So far it is these more restricted levers which the UK government prefers to rely on most, applying them to what is perceived as particularly troublesome drinkers/drinking patterns (especially young ‘binge’ drinkers), while avoiding population-wide measures of the kind advocated by NICE and other public health and alcohol experts. The following year, the 2012 alcohol strategy’s commitment to a minimum per unit price for England was abandoned on the grounds that it might penalise responsible drinkers. However, the Scottish government is pressing ahead with legislation which may yet be derailed by arguments that minimum pricing contravenes UK devolution and/or European Union free trade laws. Despite this being introduced seemingly successfully in Scotland, elsewhere in the UK it was a similar story with respect to the now abandoned proposal to ban off-licence promotions offering discounts contingent on buying several drinks at once.

Outside Scotland, the major pricing initiative is a ‘below-cost’ price ban to be implemented subject to parliamentary approval by April 2014. It will affect very few promotions and is intended to target ‘problem’ drinkers, on whom it is projected to have little impact. Additionally, Public Health Responsibility Deal agreements with the alcohol industry loosely commit them to implement guidelines on issues such as under-age sales, responsible marketing, and labelling.

Some of what the featured report wanted on licensing law has been implemented, but not in England and Wales making health impact a relevant issue in licensing decisions, seen as a key change by campaigners for more health-oriented alcohol policies. In Scotland prevention of health harm has for several years been among the objectives which must be considered while making licensing decisions. However, in what may prove a step in this direction, as called for by the featured report, from 2012 licensing authorities in England and Wales have themselves been ‘responsible authorities’ under licensing law, meaning they can initiate action for example to oppose new licences or review an existing licence.

For the great majority of drinkers in England and Wales, little will change as a result of these initiatives and nor will their drinking change, unless they choose to make these changes in response to other influences.

Action on brief interventions in England includes an expectation that Directors of Public Health will include these among attempts to address the population-wide determinants of ill health. As yet no decision has been made to incorporate alcohol screening and brief intervention in to the national quality framework for primary care, a major national practice driver. However, screening remains among the practices commissioners must offer to incentivize through cash rewards. From April 2013 this work was also incorporated in the NHS Health Check for older adults.

Scottish national policy is more prescriptive, prioritising screening and brief intervention, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions supported by dedicated funding. The target was exceeded and has been extended to later years. An evaluation found that “healthcare staff saw the delivery of [alcohol brief interventions] as a worthwhile activity for NHS staff”, but of the three settings, only primary care practices really accepted the challenge. Even there it seems most risky drinkers were not screened and the quality of the work was unclear; emergency departments and ante-natal clinics accounted for few patients.

Related guidance

Other related NICE guidance documents are listed below.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence Assessment of what evaluation research means for alcohol dependence treatment in Britain, featuring reviews of the literature on the topics it covers.

Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications Clinical guidelines on the medical care of people suffering acute alcohol withdrawal or alcohol-related lack of thiamine, liver disease, or inflammation of the pancreas.

Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults Guidance for commissioners on how to organise and procure alcohol treatment and brief intervention services in an area which implement related national clinical guidance and satisfy policy requirements.

Alcohol dependence and harmful alcohol use quality standard Concise statement of 13 practices which constitute high quality health care for problem drinkers and good practice in identifying and advising hazardous drinkers. The standards may be used to assess and reward providers and health service commissioning authorities.

Thanks for their comments on the original entry to Iain MacAllister of the Health Analytical Services Division of the Scottish Government and Eileen Kaner of the Institute of Health and Society at Newcastle University who chaired the expert group behind the report. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 12 March 2014. First uploaded 05 November 2010

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