By Lilian Anekwe
GPs should assess all patients for harmful drinking levels and offer ‘brief’ 45-minute interventions to patients who they identify with moderate dependence, according to new advice from NICE.
The new guideline is the first NICE has published on the diagnosis and treatment of patients who misuse alcohol and the institute says it will help address ‘serious variations in clinical practice.’
But the recommendations were met with scepticism from GPs, including the GP who worked on the NICE guideline development group, who admitted that its implementation could be hamstrung by GPs’ inability to refer to ‘patchy’ specialist services.
Although over one million people in England are dependent on alcohol, only around 6% currently receive treatment.
The new guideline calls for GPs to assess patients for harmful drinking levels – defined as drinking over the recommended weekly amount and experiencing health problems directly related to alcohol – and patients in ‘key condition areas’, using the alcohol use disorders identification test AUDIT.
People who drink more than 15 units of alcohol a day or who score 20 or more on AUDIT should be offered a structured assisted withdrawal programme. This can be offered in a community-based setting.
Patients who drink more than 30 units a day, score more than 30 on the severity of alcohol dependence questionnaire, or in whom GPs have other safety concerns should be offered an inpatient or residential assisted withdrawal programme.
After completing a successful alcohol withdrawal programme, GPs should consider offering people who were moderately or severely dependent, acamprosate or oral naltrexone alongside an individual psychological intervention which specifically focuses on alcohol misuse.
Dr Linda Harris, a GP and director of the RCGP substance misuse unit said: ‘The screening tools are not new but there’s been a patchiness to how they have been implemented, because of paucity of resources.
‘There are key condition areas, and in these patients should trigger the opportunities for GPs to think “Is this person’s drinking becoming hazardous?” and open up a dialogue. GPs can do quite a lot within their general practice and many patients feel that is valuable and beneficial.’
Dr Harris said there is ‘strong evidence’ that structured, brief interventions can help people to get their drinking levels under control.
‘For people with moderate dependence, GPs can offer brief advice and structured brief interventions of around 45 minutes. This can take the form of written information, advice on basic strategies to modify drinking and information on the risks and consequences of hazardous drinking.
‘For GPs who don’t have the confidence or competence, they can refer to specialist services, and one hopes the services are available. But provision on the ground at the moment is very patchy. Where there is investment outcomes are better but it’s not consistent across the country.
‘GPs commissioners are being asked to deliver on outcomes and admissions for alcohol-related disease. There’s a responsibility for the field and the GP community to tackle this, it’s not something GPs can ignore.’
But Dr Jane Kidd, a GP in Newcastle-upon-Tyne with an interest in drug and alcohol abuse said though she was fortunate to have access to specialist services, her experiences of brief interventions were ‘very time-consuming’.
‘You start asking questions and it opens up all sorts of things that it can be difficult to deal with in one consultation, and we often had to make double consultations.
‘It’s very time-consuming going through and explaining to people what units are and what level of drinking is safe, and people completely underestimate their intake.’
Key areas where GPs should consider harmful or hazardous drinking
• People with coexisting mental and physical health problems
• Depression and anxiety
• Patients who make repeat requests for sick notes and time off work
• Patients who have experienced significant recent life events, e.g. bereavement or break-up with partner
• Regular presenters with upper gastrointestinal problems and abdominal pain
• Coronary heart disease, hypertension, stroke and diabetes
Source: NICE guidance on alcohol-use disorders, published 23 February 2011