Guideline update - NICE alcohol use disorders

The guideline

NICE. Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE 2011; CG115

The key points at a glance

Choose a screening tool that can pick up harmful drinking as well as dependence.
The AUDIT-C and FAST tools are recommended in the guidance, but CAGE is not.
The SADQ tool can be used to assess severity.
In patients with depression or anxiety, any alcohol misuse should be addressed first.
Hazardous and harmful drinking should be initially addressed with brief advice or extended brief interventions.
An alcohol-focused psychological intervention such as CBT should be offered to those with mild alcohol dependence.
Those with moderate or severe alcohol dependence should be considered for specialist assessment.
Assisted withdrawal should be considered for anyone who is classified as alcohol-dependent.

Almost 90% of the population regularly drink alcohol, and although most drink sensibly much of the alcohol drunk in the UK is consumed by a minority who have become dependent.

Clinically-defined alcohol dependence affects 4% of 16- to 65-year-olds in England and is a bigger problem in men (6%) than in women (2%). 1 But more than 26% of all adults (38% of men and 16% of women) drink alcohol in a way that is harmful or potentially harmful to their health or wellbeing. ¹

The extent of the problem is one worry, but the extent of under-treatment is another – only 6% of people who are alcohol-dependent receive treatment.¹

This article will outline the recommendations in the latest NICE guidance on alcohol use disorders.² This is the third and final piece of NICE guidance on alcohol-related problems. The other two were published in 2010 and some of the points discussed below refer to these. NICE has brought together the recommendations from the three pieces of guidance into an integrated care pathway, which is available from pulsetoday.co.uk/tools-and-resources.

The two earlier guidelines covered:

how the development of hazardous and harmful drinking might be prevented³
the diagnosis and clinical management of alcohol-related physical complications.⁴

One of the major barriers to improving the detection and management of alcohol use disorders is that alcohol misuse services are currently fragmented and both patients and healthcare professionals are unclear how to access them.

This article will focus on the NICE recommendations most relevant to primary care that relate to identification and initial assessment of alcohol misuse, assessment of severity and interventions for depression and anxiety associated with alcohol misuse. It will also briefly outline the recommendations on interventions for particular patient groups. The guideline refers to harmful drinking and alcohol dependence as alcohol misuse and this article will use the same terminology.

Use AUDIT tool to screen

Firstly, it is worth distinguishing between hazardous drinking, harmful drinking and alcohol dependence.

Hazardous drinking is a pattern of alcohol consumption that increases someone's risk of harm.
Harmful drinking is a pattern of alcohol consumption that is causing mental or physical damage.
Alcohol dependence is characterised by withdrawal, craving, impaired control and tolerance of alcohol and is associated with a higher rate of mental and physical illness than harmful drinkers, as well as a wide range of social problems.

The key to identifying alcohol misuse in primary care is the use of validated screening questionnaires. We should be using one of these tools routinely in newly registered patients and in the management of any patient in whom we suspect alcohol misuse.

We should be particularly aware of those at increased risk of alcohol-related harm, including:

patients who are known to have other drug problems
patients we suspect of being at risk of self-harm
patients who repeatedly suffer accidents or minor trauma, including domestic abuse
patients known to be involved in crime or antisocial behaviour.

NICE recommends the Alcohol Use Disorders Identification Test (AUDIT) tool and the guideline is based around its use. AUDIT was devised by the World Health Organisation and is a 10-question test that has been shown to effectively identify alcohol misuse and classify it into three groups, based on the final score:

AUDIT score 8–15 is classified as hazardous drinking (which is likely to be eventually harmful)
AUDIT score 16–19 is classified as harmful drinking
AUDIT score 20 and above is classified as alcohol dependence.

However, it can be impractical to use the full AUDIT as a routine screening tool in general practice and the guidance does recommend the use of a shorter screening tool ‘if time is limited'.

Some shorter tools, such as FAST and the Paddington Alcohol Test, were developed for use in A&E settings but there are two shortened versions of AUDIT that might be more suitable for use in primary care. AUDIT-PC is a five-question version while AUDIT-C (see opposite) contains only the first three questions.⁵

A total AUDIT-C score of five or more should prompt the GP to ask the patient to complete the full AUDIT tool.

The brief alcohol screening tool probably most familiar to GPs – CAGE – is not one of those recommended in the guideline. CAGE identifies patients with alcohol dependence at any time in their lives, but is not good at identifying those with hazardous or harmful drinking.⁶

It is these patients who could benefit from brief counselling about their drinking, so it is vital that a primary care screening tool picks them up.

CAGE is not included in the current alcohol-related risk reduction scheme DES either, which uses both AUDIT-C and FAST as screening tools, with a fuller assessment through AUDIT for patients who screen positive.

Question	Score
Question	0	1	2	3	4
How often do you have a drink containing alcohol?	Never	Monthly or less	2-4 times per month	2-3 times per week	4+ times per week
How many unit of alcohol do you drink on a typical day when you are drinking?	1-2	3-4	5-6	7-9	10+
How often have you had ?6 units if female or ?8 if male on a single occasion in the last year?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily

Advice on when to use assisted alcohol withdrawal

Although alcohol dependence is defined in both ICD-10 and DSM-IV as being either present or absent, we know dependence actually exists on a continuum of severity.

So it is helpful from a clinical perspective to subdivide dependence into mild, moderate and severe, and the NICE guidance uses these categories to recommend whether treatment should involve assisted alcohol withdrawal.

The Severity of Alcohol Dependence Questionnaire (SADQ) contains 20 questions designed to assess the potential for withdrawal symptoms.

A SADQ score of 15 or less corresponds to mild dependence and these people will not usually need assisted alcohol withdrawal.
A SADQ score between 15 and 30 denotes moderate dependence, which will usually need assisted alcohol withdrawal, probably in a community setting unless there are other risks.
A SADQ score of more than 30 suggests severe alcohol dependence and these people will need assisted withdrawal, typically in an inpatient or residential setting.

Treat alcohol misuse first

In patients who misuse alcohol and have comorbid depression or anxiety disorders, it's important to treat the alcohol misuse first as this may lead to significant improvement in the depression and anxiety.

If depression or anxiety continues after three to four weeks of abstinence from alcohol, then the problem should be reassessed and managed in line with the relevant guideline.

Clearer guidance on managing specific patient groups

Interventions for hazardous and harmful drinking

The NICE integrated care pathway recommends offering a session of structured brief advice on alcohol for these patients.

If this cannot be given immediately, offer an appointment as soon as possible, taking around 15 minutes to:

cover the potential harm caused by their level of drinking and reasons for change, including benefits to health and wellbeing
outline the practical strategies to help reduce alcohol consumption, but also discuss barriers to change
develop a set of goals.

If on follow-up this has been ineffective, NICE recommends patients should then be offered an extended brief intervention of motivational interviewing or motivational enhancement lasting 20-30 minutes from someone trained in these techniques, depending on local availability.

Where necessary, up to four additional sessions or referral to a specialist alcohol treatment service should be offered.

Interventions for mild alcohol dependence

Offer a psychological intervention such as cognitive behavioural therapy that focuses specifically on alcohol-related cognitions, behaviour, problems and social networks.

If service users have not responded to psychological interventions alone, or specifically request a pharmacological intervention, consider also offering acamprosate or oral naltrexone – although the latter is an unlicensed indication.

Interventions for moderate and severe alcohol dependence

These patients should be considered for specialist assessment. Assisted withdrawal should be considered for anyone who is classified as alcohol-dependent, consisting of a fixed-dose pharmacological regimen plus psychological support.

Preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam).

Mild and moderate dependence can often be managed at home after risk assessment by the community alcohol service. Administration should follow appropriate training in alcohol withdrawal.

Inpatient detoxification should be considered in:

those with severe dependence
those with mild to moderate dependence with complex needs
those with previous withdrawal-related seizures or psychiatric, cognitive or physical comorbidities
children and young people aged 10-17.

After a successful withdrawal for a patient with moderate or severe alcohol dependence, acamprosate or oral naltrexone should be considered.

Dr Jane Marshall is a GP in Birmingham who works in a local alcohol misuse service

References

1 Drummond D, Oyefeso N, Phillips T et al. Alcohol needs assessment research project: the 2004 national alcohol needs assessment for England. Department of Health, 2005. dh.gov.uk

2 NICE. Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence CG115. NICE, February 2011

3 NICE. Alcohol use disorders: preventing the development of hazardous and harmful drinking PH24. NICE, May 2010

4 NICE. Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications. CG100. NICE, June 2010

5 Aertgeerts B, Buntix F, Ansoms S et al. Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. Brit J Gen Pract 2001;51:206-17

6 Bradley K, Bush K, McDonell M et al. Screening for problem drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med 1998;13:379-88