Dr Jack Leach explores current alcohol guidance and suggests ways in which primary care could play a vital role in the care and assessment of people with drink problems
NICE Clinical Guideline 115 on Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence has been awarded the NICE Accreditation Mark.
This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.
F ew people would question the high level of adverse health and social consequences associated with the excessive consumption of alcohol, and which are not restricted to dependent drinkers. Young and old people are particularly prone to consequences of intoxication resulting in injuries. Long-term drinking can lead to chronic diseases and alcohol dependence. Excessive drinking not only damages the health and social wellbeing of individuals, but also impacts on families, local communities (accidents and violence in public areas), and society (lost productivity, cost of managing the health, social, and legal complications).
There is no single cause of problem drinking; several causal factors have been identified, some of which interact in complex ways. These include genetic predisposition, personal characteristics, stress, life experiences, exposure to the drinking culture, and other environmental factors.1
Scale of the problem
Over 95% of the adult population in England drink, with the peak age for alcohol consumption being in the twenties.1 People who drink problematically when young are at much greater risk of problems at an older age.1 In those individuals who drink, it is estimated that:2
- 24% do so hazardously
- 8% do so harmfully
- 9% of men and 3% of women are dependent on alcohol.
Worldwide, alcohol contributes approximately 4% to the total disease burden and is the third leading cause of disability after smoking and hypertension.1 Three percent of all deaths in England are attributed to alcohol.1 Excessive drinking increases the age-adjusted risk of death by a factor of over four. The death rate from chronic liver disease is used as a measure of time trends of the consequences of problem drinking. For example, France had (and continues to have) a higher death rate from chronic liver disease, but has observed a fall over the last 20 years, with a similar decrease in its per capita alcohol consumption, but in England the death rate continues to rise.3
Hospital admissions from alcohol-related illness and injuries continue to rise in England. In the financial year 2010/2011 there were an estimated 1,168,300 admissions, and 15,500 people died from alcohol-related causes.4 Estimates suggest that overall, alcohol-related harm costs the NHS in England £3.5 billion annually.4
Reducing problem drinking and its consequences
There are two broad approaches to reducing problem drinking:
- public-health interventions
- clinical interventions.
Public health seeks to make social changes to the context of drinking by increasing the price of alcohol, reducing its availability, controlling drinking in public places, and changing drinking culture through education. The Government’s strategy focuses on public health interventions.5 International research has demonstrated that such approaches are effective.6
However, social policy and health education messages are complicated by increasing evidence that lower levels of drinking (i.e. less than 30 g [just under 4 UK units] of alcohol daily) are not associated with health complications and indeed may have a protective effect from ischaemic heart disease.7 Drinking above this level leads to an exponential increase in alcohol-related harm.
Clinical interventions focus on helping the problem drinker to reduce their consumption, and treating the associated physical and health complications. Unlike with smoking, considerable health benefits can result if the patient is able to reduce their alcohol intake, even if they are unable or unwilling to stop.
Studies of longer-term outcomes from alcohol dependence suggest that over a 10-year period, around 20% of dependent drinkers will have died (compared to 2%–3% of the general population). Of those still alive, one-third will:1
- continue to drink in the same way
- show some improvement
- will have a good outcome.
National policy and clinical guidance
Several pieces of guidance on alcohol-use disorders have been developed by the Government and NICE:
- The Government strategy on alcohol focuses on tackling the public disruption and violence of binge drinking5
- NICE Public Health Guidance 24 on Alcohol use disorders preventing harmful drinking (PH24):8
- analyses population versus individual approaches and finds that both can reduce the harmful effects of excessive alcohol
- assesses drinking trends and their implications for public health, and the influence of socio-economic factors and government policy
- NICE Clinical Guideline 100 on Alcohol use disorders; physical complications9 (CG100) is more relevant to hospital services—it examines the acute alcohol withdrawal states, consequences and treatment, and the assessment and treatment of alcohol-induced liver and pancreatic disease
- NICE Clinical Guideline 115 on Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (CG115) is particularly relevant to primary care (see below)1
- NICE Commissioning Guide 38 on Guidance to services for the identification and treatment of hazardous, harmful and alcohol dependence10 stresses the importance of commissioning for outcomes, and the value of the identification and treatment of alcohol problems
- NICE quality standard 11 on Alcohol dependence and harmful alcohol use (see www.nice.org.uk/guidance/QS11) sets out quality statements in this area11
- The NICE pathway on alcohol-use disorders12 (see pathways.nice.org.uk/pathways/alcohol-use-disorders) provides an overview of what the ideal treatment programme should include, supported by advice to commissioners.10
The available guidance is supported by the National Treatment Agency for Substance Misuse, Review of the effectiveness of treatment for alcohol problems13 and the findings of the study of Screening and Intervention Programme for Sensible drinking (SIPS) study.14 The latter is a research programme funded by the Department of Health that started in 2006 and reported its findings this year. These findings confirmed the value of screening tools and of brief interventions in primary care, which can be as effective as more intensive treatment.
Clinical Guideline 115
Clinical Guideline 115 examines the:1
- definition, identification, and diagnosis of harmful and dependent drinking
- effects on the individual, family (including children), and the community
- ways in which problem drinking should be defined, identified, and treated.
The recommendations from CG115 cover three areas:
- principles of care
- identification and assessment
Principles of care
Generally a good care experience is needed for patients to manage their alcohol-use disorder. The professionals involved in patient care should:1
- ensure a good relationship between the professional, patient and their family
- provide clear, factual, and personalised information
- work with and support the patient’s family and carers
- be aware of the potential impact of alcohol misuse within the family
(e.g. partner and children)
- comply with the requirements of the Children Act 1989 as amended.15
Identification and assessment
Assessment of alcohol-use disorders should involve validated assessment tools (e.g. Alcohol Use Disorders Identification Test,16 Severity of Alcohol Dependence Questionnaire17) and clinical interviews. It should cover assessment of physical and mental health, family and social circumstances, and a risk assessment of unplanned alcohol withdrawal, suicide and neglect, as well as risk from the patient to others.1
NICE CG115 recommends that care coordination forms part of routine care of all service users in specialist alcohol services. Case management to increase engagement should be considered for people who have moderate to severe alcohol dependence, who are considered at risk of dropping out of treatment, or who have a previous history of poor engagement. Structured-care coordination should be provided throughout the whole period of care, including aftercare. Case management should be delivered by staff experienced in alcohol problems. An individualised care plan should be developed and agreed with the patient, family and carers, based on a detailed assessment.1
Treatment for alcohol should address associated physical and mental health problems and include:1
- psychological and social support
- drug interventions.
Psychological interventions should be offered using motivation interviewing techniques, and should focus on:1
- aiding recognition of problems and relationships
- changing attitude
- supporting change
- reducing drinking
- promoting abstinence
- preventing relapse
- enabling the patient to access self-help and support groups such as Alcoholics Anonymous (AA) and other social programmes.
The person should also be given access to:
- assisted alcohol detoxification programmes
- relapse prevention support and medication (such as acamprosate and oral naltrexone).
Special consideration is given in CG115 to people with drink problems who:1
- have psychiatric illness
- misuse drugs
- are young (i.e. aged 10–17 years)
Role of primary care
Overall, primary care does not seem to perform well in the identification and treatment of problem drinkers. When problem drinking becomes apparent in a patient, many GPs merely direct them to specialist services. Often, professionals in primary care are not sufficiently skilled at dealing with problem drinkers, and they do not feel they have the time or effective interventions available to them. National reports, however, suggest that there is much that primary care could do to identify and treat problem drinkers.1,14
There are also certain organisational constraints. Although there is an enhanced service for general practices, this only offers a small renumeration. Identifying and treating alcohol problems is not currently part of the quality and outcomes framework.
Primary care can be effective at screening for alcohol problems by using rapid, well-validated screening questionnaires, and can provide brief interventions, either verbally or by using leaflets, which can make a significant difference for a substantial minority of people.14
Healthcare professionals in primary care are capable of identifying, assessing, and perhaps treating health complications of problem and dependent drinking: for example, gastrointestinal disease and nutritional deficiency, liver disease, neuromuscular disease, anxiety and mood disorders, all of which are common complications of prolonged and excessive drinking.
The GP and other primary care staff can work closely with an alcohol practitioner in a surgery or health-centre setting. With suitable training, such a service could offer a comprehensive range of treatments for dependent drinkers, including community detoxification, relapse prevention treatment (for harmful drinkers and dependent drinkers who are unable to stop), and an alcohol reduction programme; nalmefene,18 an opiate antagonist, has recently been licensed for this use.
An important dilemma remains: should all GPs know a little about, and be involved in assessing and treating patients with alcohol problems, or should the majority of them delegate to a smaller number of specially trained and experienced GPs? Arguing from the former point of view, problem drinking and health complications are common, and their identification, assessment, and treatment is no more complicated than many conditions that GPs deal with. However, from another perspective, the management of problem drinking is mostly about changing attitudes and behaviour (which takes time), and some of the treatments, such as community detoxification, may carry significant risk and therefore require considerable experience and judgment.
For many people in Britain, alcohol enhances their social life and causes few problems. For a significant minority, however, it cause social problems, illness, and premature death. A range of public health and clinical interventions have been shown to reduce the effects of harmful drinking; more effective identification and treatment of problem drinking improves outcomes.
NICE implementation tools
NICE has developed the following tools to support implementation of Clinical Guideline 115 (CG152) on Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. The tools are now available to download from the NICE website: www.nice.org.uk/CG115
NICE support for commissioners
Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline./
Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.
Guide for commissioners: alcohol services
This guide for commissioners provides support for the local implementation of NICE guidance through commissioning and is a resource to help commissioners, clinicians, and managers to commission evidence based and quality services across England.
NICE support for service improvement systems and audit
Audit support is developed to support the implementation of NICE guidance. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the recommendations of the guidance.
Electronic audit tool
Electronic audit tools are developed to assist organisations with clinical audit and to ensure that practice is in line with the NICE recommendations.
Baseline assessment tool
The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
NICE support for education and learning
The slides provide a framework for discussing the NICE guideline with a variety of audiences and can assist in local dissemination. This information does not supersede or replace the guidance itself.
This document provides examples of fixed-dose and symptom-triggered regimens for chlordiazepoxide dosing regimens for use in managing alcohol withdrawal.
Key to NICE implementation icons
NICE support for commissioners
- Support package for commissioners and others for quality standards
- NICE guide for commissioners
- NICE cost impact support for guidance (selection from national report/local template/costing statement, dependent on topic)
NICE support for service improvement systems and audit
- Forward planner
- 'How to' guides (generic advice on processes)
- Local government briefings (with Centre for Public Health Excellence)
- Baseline assessment tool for guidance
- Audit support including electronic data collection tools
- E-learning modules (commissioned)
NICE support for education and learning
- Clinical case scenarios
- Learning packages including slide sets
- Shared learning and other local best practice examples
- Excessive drinking is damaging to individuals, their families, and wider society
- Considerable benefits can be achieved by reducing alcohol intake, even if stopping is not possible
- The initial assessment should encompass physical and mental health,
family and social circumstances, and risk
- There needs to be a good relationship between healthcare professionals, the patient, and their family
- The impact of alcohol misuse on partners and family needs to be considered, and their involvement and cooperation sought
- Care coordination should be provided by specialist alcohol services throughout the entire period of care
- Case management should be provided by suitably experienced staff,
and an individual care plan agreed with the patient
- Treatment should address physical, psychological, and mental health aspects
- Primary care can offer effective screening questionnaires and brief verbal and/or written interventions.
- NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Clinical Guideline 115. London: NICE, 2011. Available at: www.nice.org.uk/cg115
- Office for National Statistics. Statistics on alcohol, England—2013. Available at: www.hscic.gov.uk/catalogue/PUB10932
- World Health Organization Regional Office for Europe website. European Information System on Alcohol and Health (EISAH).apps.who.int/gho/data/view.main-euro?showonly=GISAH (accessed 31 May 2013)
- NHS National Treatment Agency for Substance Misuse. Alcohol treatment in England 2011– 12. NHS, 2013. Available at: www.nta.nhs.uk/uploads/alcoholcommentary2013final.pdf
- The Stationery Office. The Government’s alcohol strategy. London: The Stationery Office, 2012. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/98121/alcohol-strategy.pdf
- Babor T, Caetano R, Casswell S et al. Alcohol: no ordinary commodity: research and public policy. 2nd edition. Oxford: Oxford University Press, 2010.
- Kannel W, Ellison R. Alcohol and coronary heart disease: the evidence for a protective effect. Clinica Chimica Acta 1996; 246 (1–2): 59–76.
- NICE. Alcohol-use disorders: preventing harmful drinking. Public Health Guidance 24. London: NICE, 2010.Available at: www.nice.org.uk/PH24
- NICE. Alcohol-use disorders: physical complications. Clinical Guideline 100. London: NICE, 2010. Available at: www.nice.org.uk/cg100
- NICE. Guidance to services for the identification and treatment of hazardous, harmful and alcohol dependence. Commissioning Guide 38. London: NICE, 2011. Available at: publications.nice.org.uk/services-for-the-identification-and-treatment-of-hazardous-drinking-harmful-drinking-and-alcohol-cmg38
- NICE website. Alcohol dependence and harmful alcohol use. Quality Standard 11. www.nice.org.uk/qs11 (accessed 2 June 2013).
- NICE Pathways website. Alcohol-use disorders pathway.pathways.nice.org.uk/pathways/alcohol-use-disorders (accessed 31 May 2013)
- Raistrick D, Healther N, Godfrey C. Review of the effectiveness of treatment for alcohol problems. London: National Treatment Agency for Substance Misuse, 2006. Available at: www.nta.nhs.uk/uploads/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf
- Kaner E, Bland M, Cassidy P et al. Effectiveness of screening and intervention programme for sensible drinking in primary care (SIPS trial): pragmatic cluster randomised controlled trial. BMJ 2013; 346: e8501.
- Children Act 1989 as amended. Available at www.legislation.gov.uk/ukpga/1989/41/contents (accessed 4 June 2013).
- Babor T, Higgins-Biddle J, Saunders J, Monteiro M. The alcohol use disorders identification test, guidelines for use in primary care. 2nd edition. Geneva: World Health Organization Department of Mental Health and Substance Dependence, 2001.
- Stockwell T, Hodgson R, Edwards G et al. The development of a questionnaire to measure severity of alcohol dependence. Br J Addiction 1979; 77: 79–87.
- Lundbeck Ltd. Nalmefene. Summary of product characteristics. June 2013. Available at: www.medicines.org.uk/emc/medicine/27609/SPC/ (accessed 4 June 2013). G