“This guideline, one of the three clinical guidelines in the NICE series on alcohol-use disorders, provides an excellent review of current thinking on the assessment, treatment and management of harmful drinking and alcohol dependence. It is at once readable, practical, comprehensive and evidence- based, constituting one of the best formulas for delivering effective care and treatment that I have seen.” Thomas F. Babor, PhD, MPH, Professor and Chairman, Department of Community Medicine and Health Care, University of Connecticut School of Medicine This clinical guideline on alcohol-use disorders was commissioned by NICE and developed by the National Collaborating Centre for Mental Health, and sets out the evidence for the treatment and management of harmful drinking and alcohol dependence in adults and in young people aged 10 to 17 years. Harmful drinking leads to 2.5 million deaths annually and alcohol is the third leading risk factor globally for burden of illness. Alcohol-use disorders are an increasing problem in children and young people. Physical and psychiatric comorbidities add to the considerable burden that alcohol-use disorders can pose to the individual and to society. This guideline will enable healthcare professionals to recognise and manage these prevalent problems and offer effective treatments to their patients. This guideline reviews the evidence for the diagnosis and assessment of alcohol-use disorders, organisation and delivery of care, settings for assisted alcohol withdrawal, Alcohol-use psychological interventions, and pharmacological interventions for assisted D A withdrawal and relapse prevention. The guideline also includes health economic I L S modelling of pharmacological interventions as an adjunctive treatment for the C O prevention of relapse and a chapter on the experience of care. R O DISORDERs D H An accompanying CD contains further information about the evidence, including: E O • characteristics of included studies R L • profile tables that summarise both the quality of the evidence and the results S - U of the evidence synthesis S THE NICE GUIDELINE ON DIAGNOSIS, • all meta-analytical data presented as forest plots E • detailed information about how to use and interpret forest plots. ASSESSMENT AND MANAGEMENT OF HARMFUL DRINKING AND ALCOHOL NICE has also produced a clinical guideline on the diagnosis and management of DEPENDENCE alcohol-related physical complications and public health guidance on preventing the development of hazardous and harmful drinking. Cover photo: ©iStock Update information October 2022: We updated the recommendation about behavioural couples therapy to clarify that this is not suitable in cases of domestic abuse and to add a cross reference to the NICE technology appraisal guidance on nalmefene. We also updated information about off-label prescribing, and added cross references to legislation on controlled drugs and driving, to MHRA advice on addiction to benzodiazepines and codeine, and to NICE's guidelines on smoking, on antisocial personality disorder and on coexisting mental illness and substance misuse community health and social care services. March 2020: The recommendation to offer a carer's assessment has been updated to cross refer to NICE's guideline on supporting adult carers. August 2019: The title has been amended to: Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. The strikethrough text on page 21 has been changed to: The Department of Health and Social Care has introduced definitions that relate to different levels of drinking risk. One UK unit of alcohol is defined as 8 g (or 10 ml) of pure ethanol4. The last review of the Alcohol Guidelines made by the UK chief medical officers recommends to keep their risk from alcohol low, both men and women should not regularly drink more than 14 units of alcohol per week (UK chief medical officers, 2016)*. *UK chief medical officers (2016) Alcohol Guidelines Review - Report from the Guidelines Development Group to the UK chief medical officers. The term 'high-risk' has been inserted into recommendations 1.2.1.2, 1.2.2.2, 1.3.3.1 and 1.3.3.2 in relation to harmful drinking. October 2014: The wording of the final bullet in recommendation 5.31.1.5 (and 8.3.4.5) has been corrected to make it clear that inpatient or residential assisted withdrawal should be considered for people who regularly drink between 15 and 30 units (not between 15 and 20 units) of alcohol per day, if they also have the additional complicating features mentioned in the recommendation. The current recommendations can be seen in the short version of this guideline at www.nice.org.uk/guidance/CG115. ALCOHOL-USE DISORDERS DIAGNOSIS, ASSESSMENT AND MANAGEMENT OF HARMFUL DRINKING AND ALCOHOL DEPENDENCE National Clinical Practice Guideline 115 National Collaborating Centre for Mental Health commissioned by the National Institute for Health & Clinical Excellence published by The British Psychological Society and The Royal College of Psychiatrists © The British Psychological Society & The Royal College of Psychiatrists, 2011 The views presented in this book do not necessarily reflect those of the British Psychological Society, and the publishers are not responsible for any error of omission or fact. The British Psychological Society is a registered charity (no. 229642). All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN-: 978-1-904671-26-8 Printed in Great Britain by Stanley L. Hunt (Printers) Ltd. Additional material: data CD-Rom created by Pix18 (www.pix18.co.uk) developed by National Collaborating Centre for Mental Health The Royal College of Psychiatrists 4th Floor, Standon House 21 Mansell Street London E1 8AA www.nccmh.org.uk commissioned by National Institute for Health and Clinical Excellence MidCity Place, 71 High Holborn London WCIV 6NA www.nice.org.uk published by The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR www.bps.org.uk and The Royal College of Psychiatrists 17 Belgrave Square London SW1X 8PG www.rcpsych.ac.uk Contents CONTENTS GUIDELINE DEVELOPMENT GROUP MEMBERS 7 ACKNOWLEDGEMENTS 10 1 PREFACE 11 1.1 National clinical guidelines 11 1.2 The national alcohol dependence and harmful alcohol use guideline 14 2 ALCOHOL DEPENDENCE AND HARMFUL ALCOHOL USE 17 2.1 Introduction 17 2.2 Definitions 19 2.3 Epidemiology of alcohol 21 2.4 Aetiology 25 2.5 Course of harmful alcohol use and dependence 27 2.6 Pharmacology of alcohol 28 2.7 Identification and diagnosis 30 2.8 The role of treatment and management 31 2.9 Current care in the National Health Service 33 2.10 Service user organisations 34 2.11 Impact on families 34 2.12 Special populations 35 2.13 Economic impact 40 3 METHODS USED TO DEVELOP THIS GUIDELINE 41 3.1 Overview 41 3.2 The scope 41 3.3 The guideline development group 42 3.4 Review questions 44 3.5 Clinical evidence methods 46 3.6 Health economics methods 57 3.7 Stakeholder contributions 61 3.8 Validation of the guideline 62 4 EXPERIENCE OF CARE 63 4.1 Introduction 63 4.2 Review of the qualitative literature 63 4.3 From evidence to recommendations 80 4.4 Recommendations 81 3 Contents 5 ORGANISATION AND DELIVERY OF CARE 83 SECTION 1 – INTRODUCTION TO THE ORGANISATION AND DELIVERY OF CARE 83 5.1 Introduction 83 5.2 Organising principles of care 84 5.3 Services for people who misuse alcohol 86 SECTION 2 – EVALUATING THE ORGANISATION OF CARE FOR PEOPLE WHO MISUSE ALCOHOL 93 5.4 Review question 93 5.5 Introduction 93 5.6 Case management 94 5.7 Assertive community treatment 100 5.8 Stepped care 104 5.9 Clincial evidence summary 111 5.10 From evidence to recommendations 112 5.11 Recommendations 113 5.12 Research recommendation 114 SECTION 3 – THE ASSESSMENT OF HARMFUL DRINKING AND ALCOHOL DEPENDENCE 114 5.13 Introduction 114 5.14 Clincial questions 116 5.15 Aim of review of diagnostic and assessment tools for alcohol dependence and harmful alcohol use 116 5.16 Quantitative review of assessment tools 117 5.17 Narrative synthesis of assessment tools 119 5.18 The assessment of alcohol dependence 126 5.19 The assessment of problems associated with alcohol misuse 129 5.20 The assessment of motivation 130 5.21 Special populations – older people 132 5.22 Special populations – children and young people 132 5.23 The structure and content of the assessment interview 137 5.24 Framework for assessment of alcohol misuse 142 5.25 The framework for assessment of alcohol misuse 144 5.26 From evidence to recommendations 170 SECTION 4 – DETERMINING THE APPROPRIATE SETTING FOR THE DELIVERY OF EFFECTIVE CARE 175 5.27 Introduction 175 5.28 Review questions 177 5.29 Assisted alcohol withdrawal 177 5.30 Evaluating dosing regimes for assisted withdrawal 189 5.31 From evidence to recommendations: assisted withdrawal 204 5.32 Residential and community settings for the delivery of interventions for alcohol misuse 209 4 Contents 6 PSYCHOLOGICAL AND PSYCHOSOCIAL INTERVENTIONS 229 6.1 Introduction 229 6.2 Therapist factors 231 6.3 Matching effects/severity 235 6.4 Setting the context for 12-step facilitation and Alcoholics Anonymous 236 6.5 Review of psychological therapies 237 6.6 Outcomes 239 6.7 Motivational techniques 239 6.8 12-step facilitation 246 6.9 Cognitive behavioural therapy 255 6.10 Behavioural therapies (excluding contingency management) 269 6.11 Contingency management 275 6.12 Social network and environment-based therapies 285 6.13 Couples therapy 290 6.14 Counselling 303 6.15 Short-term psychodynamic therapy 309 6.16 Multi-modal treatment 312 6.17 Self-help-based treatment 315 6.18 Psychoeducational interventions 319 6.19 Mindfulness meditation 325 6.20 Clinical evidence summary 327 6.21 Health economic evidence 328 6.22 Special populations – children and young people 336 6.23 From evidence to recommendations 344 6.24 Recommendations 345 6.25 Acupuncture 349 6.26 Psychological interventions for carers 354 7 PHARMACOLOGICAL INTERVENTIONS 357 7.1 Introduction 357 7.2 Review of pharmacological interventions 362 7.3 Clinical review protocol for pharmacological interventions for relapse prevention 364 7.4 Acamprosate 364 7.5 Naltrexone 370 7.6 Acamprosate(cid:2)naltrexone (combined intervention) 380 7.7 Oral disulfiram 382 7.8 Meta-regression on baseline alcohol consumption and effectiveness 390 7.9 Predictors of efficacy 394 7.10 Health economic evidence 397 7.11 Economic model 402 7.12 Children and young people 415 7.13 Assessment, monitoring and side-effect profile 416 7.14 Review of other pharmacological interventions not licensed in the UK for relapse prevention 419 5 Contents 7.15 From evidence to recommendations 422 7.16 Pharmacotherapy for less severe dependence and non-dependent drinking 427 7.17 Comorbidities 429 7.18 Wernicke-Korsakoff syndrome 441 8 SUMMARY OF RECOMMENDATIONS 445 8.1 Principles of care 445 8.2 Identification and assessment 446 8.3 Interventions for alcohol misuse 449 8.4 Research recommendations 460 9 APPENDICES 464 10 REFERENCES 544 11 ABBREVIATIONS 603 6 Guideline Development Group members GUIDELINE DEVELOPMENT GROUP MEMBERS Professor Colin Drummond (Chair, Guideline Development Group) Professor of Addiction Psychiatry and Honorary Consultant Addiction Psychiatrist, National Addiction Centre, Institute of Psychiatry, King’s College London, and South London and Maudsley Foundation NHS Trust Professor Stephen Pilling (Facilitator, Guideline Development Group) Director, National Collaborating Centre for Mental Health Director, Centre for Outcomes Research and Effectiveness, University College London Mr Adrian Brown Alcohol Nurse Specialist, Addiction Services, Central and North West London NHS Foundation Trust, and St Mary’s Hospital, Imperial College Professor Alex Copello Professor of Addiction Research, University of Birmingham, and Consultant Clinical Psychologist, Addiction Services, Birmingham and Solihull Mental Health Foundation NHS Trust Dr Edward Day Senior Lecturer and Consultant in Addiction Psychiatry, University of Birmingham/Birmingham and Solihull Mental Health NHS Foundation Trust Mr John Dervan Lay member and retired Alcohol Treatment Agency CEO Mr Matthew Dyer Health Economist (2008 to 2010), National Collaborating Centre for Mental Health Ms Esther Flanagan Guideline Development Manager (2008 to 2010), National Collaborating Centre for Mental Health Ms Jan Fry Carer Representative and Voluntary Sector Consultant Mr Brendan Georgeson Treatment Coordinator, Walsingham House, Bristol 7 Guideline Development Group members Dr Eilish Gilvarry Consultant Psychiatrist (with specialist interest in adolescent addictions), and Assistant Medical Director, Northumberland, Tyne and Wear NHS Foundation Trust Ms Naomi Glover Research Assistant (from 2010), National Collaborating Centre for Mental Health Ms Jayne Gosnall Service User Representative, and Treasurer of Salford Drug and Alcohol Forum Dr Linda Harris Clinical Director, Wakefield Integrated Substance Misuse Services and Director, RCGP Substance Misuse Unit Dr John Lewis(Co-opted specialist paediatric adviser) Consultant Community Paediatrician, Royal Cornwall Hospitals Trust Professor Anne Lingford-Hughes Professor of Addiction Biology, Imperial College London and Honorary Consultant, Central North West London NHS Foundation Trust Dr Ifigeneia Mavranezouli Senior Health Economist, National Collaborating Centre for Mental Health Mr Trevor McCarthy Independent Addictions Consultant and Trainer Dr Marsha Morgan Reader in Medicine and Honorary Consultant Physician, University of London Medical School Mrs Stephanie Noble Registered Manager/Nursing Manager, Broadway Lodge Dr Suffiya Omarjee Health Economist (2008 to 2010), National Collaborating Centre for Mental Health Mr Tom Phillips Consultant Nurse in Addiction, Humber NHS Foundation Trust Dr Pamela Roberts Consultant Clinical and Forensic Psychologist, Cardiff Addictions Unit 8