Guidelines for the Treatment of Alcohol Problems (cid:3) (cid:43)(cid:89)(cid:77)(cid:72)(cid:73)(cid:80)(cid:77)(cid:82)(cid:73)(cid:87)(cid:3)(cid:74)(cid:83)(cid:86)(cid:3)(cid:88)(cid:76)(cid:73) (cid:56)(cid:86)(cid:73)(cid:69)(cid:88)(cid:81)(cid:73)(cid:82)(cid:88)(cid:3)(cid:83)(cid:74)(cid:3)(cid:37)(cid:80)(cid:71)(cid:83)(cid:76)(cid:83)(cid:80)(cid:3)(cid:52)(cid:86)(cid:83)(cid:70)(cid:80)(cid:73)(cid:81)(cid:87) (cid:3) Prepared for the Australian Government Department of Health and Ageing by Paul Haber, Nicholas Lintzeris, Elizabeth Proude and Olga Lopatko June 2009 (cid:43)(cid:89)(cid:77)(cid:72)(cid:73)(cid:80)(cid:77)(cid:82)(cid:73)(cid:87)(cid:3)(cid:74)(cid:83)(cid:86)(cid:3)(cid:88)(cid:76)(cid:73)(cid:3)(cid:56)(cid:86)(cid:73)(cid:69)(cid:88)(cid:81)(cid:73)(cid:82)(cid:88)(cid:3)(cid:83)(cid:74)(cid:3)(cid:37)(cid:80)(cid:71)(cid:83)(cid:76)(cid:83)(cid:80)(cid:3)(cid:52)(cid:86)(cid:83)(cid:70)(cid:80)(cid:73)(cid:81)(cid:87) Guidelines for the Treatment of Alcohol Problems ISBN: 1-74186-976-5 Online ISBN: 1-74186-977-3 Publications Number: P3 -5625 Copyright Statements: Paper-based publications © Commonwealth of Australia 2009 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca Internet sites © Commonwealth of Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to Commonwealth Copyright Administration, Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca ii Contents Acknowledgements vi Summary of recommendations vii 1. Introduction 1 Purpose of the guidelines 1 Structure of the guidelines 1 Evidence-based health care 3 Community and population approaches to alcohol problems 4 A note on terminology 4 2. Prevalence of alcohol consumption and related harms in Australia 7 Prevalence of alcohol use 7 Alcohol-related harm 8 3. Screening, assessment and treatment planning 13 Screening 13 Comprehensive clinical assessment 21 Treatment planning 32 4. Brief interventions 41 Who to target for brief interventions 41 How to deliver brief interventions 42 Who can deliver brief interventions? 43 Where should brief interventions be delivered? 43 Limitations of brief intervention 45 5. Alcohol withdrawal management 49 Alcohol withdrawal syndrome: Clinical presentation 49 Assessment and treatment matching 51 Supportive care 57 Medications for managing alcohol withdrawal 61 Treating severe withdrawal complications 68 Wernicke–Korsakoff’s syndrome 76 6. Psychosocial interventions for alcohol use disorders 81 Overview of psychosocial interventions 81 When to use psychosocial interventions 82 Choosing psychosocial interventions: a stepped care approach 82 Motivational interviewing 85 Cognitive behavioural interventions 86 Relapse prevention strategies 89 Residential rehabilitation programs 89 7. Pharmacotherapies for alcohol dependence 93 Naltrexone 93 Acamprosate 96 Combined acamprosate and naltrexone 98 Disulfiram 98 Other medications 101 Integration with psychosocial treatments 102 Increasing medication adherence 102 Selecting medications for individual patients 103 8. Self-help programs 107 Alcoholics Anonymous 107 SMART Recovery® 110 Self-help for families 111 iii (cid:43)(cid:89)(cid:77)(cid:72)(cid:73)(cid:80)(cid:77)(cid:82)(cid:73)(cid:87)(cid:3)(cid:74)(cid:83)(cid:86)(cid:3)(cid:88)(cid:76)(cid:73)(cid:3)(cid:56)(cid:86)(cid:73)(cid:69)(cid:88)(cid:81)(cid:73)(cid:82)(cid:88)(cid:3)(cid:83)(cid:74)(cid:3)(cid:37)(cid:80)(cid:71)(cid:83)(cid:76)(cid:83)(cid:80)(cid:3)(cid:52)(cid:86)(cid:83)(cid:70)(cid:80)(cid:73)(cid:81)(cid:87) 9. Specific populations 115 Adolescents and young people 115 Pregnant and breastfeeding women 121 Indigenous Australians and people from other cultures 130 Older people 135 Cognitively impaired patients 138 10. Comorbidities 145 Physical comorbidity 145 Co-occurring mental and alcohol-use disorders 147 Polydrug use and dependence 153 11. Aftercare and long-term follow-up 161 Aftercare 161 Working with the persistent problem drinker 161 Appendixes 165 Appendix 1 Screening and diagnostic instruments 167 Appendix 2 Diagnostic criteria for alcohol use disorders 195 Appendix 3 Withdrawal scales 197 Appendix 4 Alcohol and drug interactions 202 Appendix 5 Getting through alcohol withdrawal: A guide for patients and carers 205 Appendix 6 A guide for people with alcohol-related problems 208 Appendix 7 Disulfiram Agreement 213 Appendix 8 Treatment guidelines for mental disorders 214 Appendix 9 Standard drinks 215 Glossary 221 Acronyms 225 References 229 iv Tables and Figures Table 1.1: Categories of evidence and strength of recommendations 3 Table 3.1: AUDIT-C 17 Table 3.2: Matters to be covered in a comprehensive assessment 22 Table 3.3: How dependent on alcohol is your patient? 26 Table 3.4: Mental health assessment scales 29 Table 4.1: FLAGS brief intervention structure 42 Table 5.1: Signs and symptoms of alcohol withdrawal 49 Table 5.2: Characteristics of ambulatory, residential and inpatient hospital withdrawal settings 53 Table 5.3: Admission criteria for different withdrawal settings 54 Table 5.4: Example of symptom-triggered regimen 63 Table 5.5: Example of fixed-schedule regimen 64 Table 5.6: Post-ictal signs and symptoms: comparing epilepsy and alcohol withdrawal seizures 70 Table 5.7: DSM-IV-TR diagnostic criteria for substance withdrawal delirium 73 Table 8.1: The SMART Recovery® 4-Point Program™ 111 Table 10.1: Alcohol use and physical complications 146 Table 10.2: Clinical profile and treatment plans for withdrawal from alcohol and other drugs 158 Figure 2.1: Lifetime risk of death from alcohol-related injury per 100 male drinkers, by number of standard drinks per occasion and frequency of occasions 9 Figure 2.2: Lifetime risk of death from alcohol-related injury per 100 female drinkers, by number of standard drinks per occasion and frequency of occasions 9 Figure 3.1: Screening 20 Figure 3.2: Stepped care approach for delivering health care services 36 Figure 3.3: Assessment and treatment planning 38 Figure 5.1: Alcohol withdrawal syndrome progression 50 Figure 5.2: Selecting benzodiazepine regimens for alcohol withdrawal 65 Figure 6.1: Stepped care approach for delivering health care services 83 Figure 10.1: Level of care quadrants 148 v (cid:43)(cid:89)(cid:77)(cid:72)(cid:73)(cid:80)(cid:77)(cid:82)(cid:73)(cid:87)(cid:3)(cid:74)(cid:83)(cid:86)(cid:3)(cid:88)(cid:76)(cid:73)(cid:3)(cid:56)(cid:86)(cid:73)(cid:69)(cid:88)(cid:81)(cid:73)(cid:82)(cid:88)(cid:3)(cid:83)(cid:74)(cid:3)(cid:37)(cid:80)(cid:71)(cid:83)(cid:76)(cid:83)(cid:80)(cid:3)(cid:52)(cid:86)(cid:83)(cid:70)(cid:80)(cid:73)(cid:81)(cid:87) Acknowledgements A competitive tender from the Australian Government Department of Health and Ageing funded this project. The authors are grateful to Professor Richard Mattick for permission for unrestricted use of material from previous editions of these guidelines. Authors Chapter 1 Introduction Prof Paul Haber, A/Prof Nicholas Lintzeris Chapter 2 Prevalence of alcohol consumption and related harms Dr Elizabeth Proude in Australia Chapter 3 Screening, assessment and treatment planning Prof Paul Haber, A/Prof Nicholas Lintzeris Chapter 4 Brief interventions Dr Elizabeth Proude Chapter 5 Alcohol withdrawal management A/Prof Nicholas Lintzeris Chapter 6 Psychological interventions for alcohol use disorders Dr Claudia Sannibale, A/Prof Nicholas Lintzeris Chapter 7 Pharmacotherapies for alcohol dependence Dr Kirsten Morley, Prof Paul Haber, A/Prof Nicholas Lintzeris Chapter 8 Self-help programs Ms Genevieve Baijan Chapter 9 Specific populations Adolescents and young people Dr Yvonne Bonomo Pregnant and breastfeeding women Prof Charlotte de Crespigny Indigenous Australians and people from other cultures A/Prof Kate Conigrave, A/Prof Sawitri Assanangkornchai Older people Dr Celia Wilkinson, A/Prof Nicholas Lintzeris, Prof Paul Haber Cognitively impaired patients Dr Glenys Dore, A/Prof Stephen Bowden Chapter 10 Comorbidities Physical comorbidity Prof Bob Batey Co-occurring mental disorders Dr Andrew Baillie Polydrug use and dependence Dr Adam Winstock, A/Prof Nicholas Lintzeris Chapter 11 Aftercare and long-term follow-up A/Prof Nicholas Lintzeris, Prof Bob Batey Project Advisory Committee members who gave advice on the overall project, were consulted throughout, and reviewed the Guidelines: Professor Steven Allsop, Curtin University WA; Associate Professor Robert Ali, University of Adelaide; Professor Robert Batey, New South Wales Health; Dr Andrew Baillie, Macquarie University; Professor Margaret Hamilton, University of Melbourne; Dr Anthony Shakeshaft, NDARC, University of New South Wales; Associate Professor Kate Conigrave, Sydney South West Area Health Service; Professor John Saunders, University of Queensland; Ms Andrea Stone, RN, Sydney South West Area Health Service; Professor Nick Zwar, University of New South Wales. Guidelines Group members who provided advice on the content and format of the Guidelines, some of whom also reviewed chapters of both the Guidelines and the Review of the Evidence: Ms Genevieve Baijan, Dept of Psychology, University of Sydney; Dr Roger Brough, General Practitioner, Warrnambool, Victoria; Ms Rosalyn Burnett, Drug and Alcohol Nurses of Australia; Mr Steve Childs, Area Drug and Alcohol Service, North Sydney Central Coast Area Health; Professor Charlotte de Crespigny, University of Adelaide; Dr John Furler, Dept of General Practice, University of Melbourne; Dr Michael McDonough, Western Health Victoria; Dr Bridin Murnion, Sydney South West Area Health; Dr Claudia Sannibale, NDARC, University of New South Wales; Dr Hester Wilson, General Practitioner, Newtown, Sydney. Additional thanks to Dr Alan Gijsbers, Professor Jon Currie, Dr Phil Renner, Mr Paul Colwell, Dr Julie Erskine and all the other professionals who attended focus groups or took part in interviews, and to Annie Cooney for conducting the focus groups and interviews. Notwithstanding the support from many colleagues, the lead authors (Paul Haber, Nicholas Lintzeris, Elizabeth Proude and Olga Lopatko) accept final responsibility for the accuracy and content of this document. vi Summary of recommendations Screening Recommendation Strength of Level of evidence recommendation 3.1 Screening for risk levels of alcohol consumption and A Ia appropriate intervention systems should be widely implemented in general practice and emergency departments. 3.2 Screening for risk levels of alcohol consumption and D IV appropriate intervention systems should be widely implemented in hospitals. 3.3 Screening for risk levels of alcohol consumption and D IV appropriate intervention systems should be widely implemented in community health and welfare settings. 3.4 Screening for risk levels of alcohol consumption and D IV appropriate intervention systems should be widely implemented in high-risk workplaces. 3.5 Quantity–frequency estimates is the recommended way D IV to detect levels of consumption in excess of the NHMRC 2009 guidelines in the general population. 3.6 AUDIT is the most sensitive of the currently available A I screening tools and is recommended for use in the general population. 3.7 In pregnant women, quantity–frequency estimation is D IV recommended to detect any consumption of alcohol. T-ACE and TWEAK questionnaires may be used in this population to detect consumption at levels likely to place the foetus at significant risk of alcohol-related harm. 3.8 Direct measures of alcohol in breath and/or blood can D II be useful markers of recent use and in the assessment of intoxication. 3.9 Indirect biological markers (liver function tests or A Ia carbohydrate-deficient transferrin) should only be used as an adjunct to other screening measures as they have lower sensitivity and specificity in detecting at-risk people than structured questionnaire approaches (such as AUDIT). Comprehensive assessment Recommendation Strength of Level of evidence recommendation 3.10 Assessment should include patient interview, D IV structured questionnaires, physical examination, clinical investigations and collateral history. The length of the assessment should be balanced against the need to keep the patient in treatment and address immediate concerns. 3.11 A quantitative alcohol history should be recorded. A I 3.12 Motivation to change should be assessed through B II direct questioning, although expressed motivation has only a moderate impact on treatment outcome. 3.13 Assessment of the patient’s alcohol-related problems, S – diagnosis and severity of dependence should be recorded. 3.14 Assessment for alcohol-related physical health problems S – should be routinely conducted. A medical practitioner should assess patients at risk of physical health problems. vii (cid:43)(cid:89)(cid:77)(cid:72)(cid:73)(cid:80)(cid:77)(cid:82)(cid:73)(cid:87)(cid:3)(cid:74)(cid:83)(cid:86)(cid:3)(cid:88)(cid:76)(cid:73)(cid:3)(cid:56)(cid:86)(cid:73)(cid:69)(cid:88)(cid:81)(cid:73)(cid:82)(cid:88)(cid:3)(cid:83)(cid:74)(cid:3)(cid:37)(cid:80)(cid:71)(cid:83)(cid:76)(cid:83)(cid:80)(cid:3)(cid:52)(cid:86)(cid:83)(cid:70)(cid:80)(cid:73)(cid:81)(cid:87) Recommendation Strength of Level of evidence recommendation 3.15 Assessment for mental health problems, such as anxiety, S – depressive symptoms and suicidal risk, should be routine, including mental stage examination. Referral for further specialist assessment may be needed if significant mental problems are suspected. 3.16 Screening for cognitive dysfunction should be conducted if S – the clinician suspects the patient has cognitive impairment. Referral to a clinical psychologist or neuropsychologist for further testing may be appropriate. The need for formal cognitive assessment is generally deferred until the patient has achieved several weeks of abstinence. 3.17 Collateral reports should be incorporated in the S – assessment where inconsistencies appear likely, with the patient’s permission where possible, and subject to legal and ethical boundaries. 3.18 The social support for the patient should be assessed S – and this information should be incorporated into the management plan. 3.19 Clinicians should determine if the patient cares for S – any children under the age of 16, and act according to jurisdictional guidelines if there are any concerns about child welfare. 3.20 In the event of suspected or continuing concerns S – over safety of the patient or others, specialist consultation is advised. Assessment Recommendation Strength of Level of evidence recommendation 3.21 Assessment should lead to a clear, mutually acceptable D IV comprehensive treatment plan that structures specific interventions to meet the patient’s needs. 3.22 Patients should be involved in goal setting and A I treatment planning. 3.23 Treatment plans should be modified according to S – reassessment and response to interventions (stepped care approach). 3.24 Evidence-based treatment should be offered in a clinical S – setting with the appropriate resources based on the patient’s needs. 3.25 Alcohol dependence is a chronic and relapsing disorder S – such that long-term care is generally appropriate through self-help programs, primary care or other interventions that are acceptable to the patient. Brief interventions Recommendation Strength of Level of evidence recommendation 4.1 Brief interventions are effective in reducing alcohol use A Ia in people with risky pattern of alcohol use and in non- dependent drinkers experiencing alcohol-related harms and should be routinely offered to these populations. 4.2 Brief interventions are not recommended for people A Ib with more severe alcohol-related problems or alcohol dependence. 4.3 Brief interventions may consist of the five components of A Ia the FLAGS acronym: feedback, listening, advice, goals, and strategies (or equivalent). viii Recommendation Strength of Level of evidence recommendation 4.4 Brief advice may be sufficient for those drinking above S – NHMRC recommendations but not experiencing harm. 4.5 Brief interventions should be implemented in general A Ia practice and other primary care settings. 4.6 Brief interventions should be implemented in emergency A Ia departments and trauma centres. 4.7 Brief interventions should be implemented in general D IV hospital settings. 4.8 Brief interventions in community health and welfare D IV settings may be used, but should not be a sole intervention strategy. 4.9 Brief interventions in high-risk workplaces may be used, D IV but should not be a sole intervention strategy. Alcohol withdrawal: patient assessment and treatment planning Recommendation Strength of Level of evidence recommendation 5.1 The risk of severe alcohol withdrawal should be assessed B II based on current drinking patterns, past withdrawal experience, concomitant substance use, and concomitant medical or psychiatric conditions. 5.2 Successful completion of alcohol withdrawal does not A Ia prevent recurrent alcohol consumption and additional interventions are needed to achieve long-term reduction in alcohol consumption. 5.3 Realistic goals of clinicians, patients and their carers for D IV withdrawal services include: interrupting a pattern of heavy and regular alcohol use, alleviating withdrawal symptoms, preventing severe withdrawal complications, facilitating links to ongoing treatment for alcohol dependence, providing help with any other problems (such as accommodation, employment services). 5.4 Ambulatory withdrawal is appropriate for those with mild D IV to moderate predicted withdrawal severity, a safe ‘home’ environment and social supports, no history of severe withdrawal complications, and no severe concomitant medical, psychiatric or other substance use disorders. 5.5 Community residential withdrawal is appropriate for those D IV with predicted moderate to severe withdrawal, a history of severe withdrawal complications, withdrawing from multiple substances, no safe environment or social supports, repeated failed ambulatory withdrawal attempts, and with no severe medical or psychiatric comorbidity. 5.6 Inpatient hospital treatment is appropriate for those with S – severe withdrawal complications (such as delirium or seizures of unknown cause), and/or severe medical or psychiatric comorbidity. 5.7 Hospital addiction medicine consultation liaison services S – should be accessible in hospitals to aid assessment, management and discharge planning. ix