NICE clinical guidelines
Issued: February 2011
CG115

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg115

Introduction

This guideline makes recommendations on the diagnosis, assessment and management of harmful drinking and alcohol dependence in adults and in young people aged 10–17 years.

This is one of three pieces of NICE guidance addressing alcohol-related problems and should be read in conjunction with:

  • Alcohol-use disorders: preventing the development of hazardous and harmful drinking. NICE public health guidance 24 (2010). Public health guidance on the price, advertising and availability of alcohol, how best to detect alcohol misuse in and outside primary care, and brief interventions to manage it in these settings.

  • Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100 (2010). A clinical guideline covering acute unplanned alcohol withdrawal including delirium tremens, alcohol-related liver damage, alcohol-related pancreatitis and management of Wernicke's encephalopathy.

Harmful drinking is defined as a pattern of alcohol consumption causing health problems directly related to alcohol. This could include psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis. In the longer term, harmful drinkers may go on to develop high blood pressure, cirrhosis, heart disease and some types of cancer, such as mouth, liver, bowel or breast cancer.

Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences (for example, liver disease or depression caused by drinking). Alcohol dependence is also associated with increased criminal activity and domestic violence, and an increased rate of significant mental and physical disorders. Although alcohol dependence is defined in ICD-10 and DSM-IV in categorical terms for diagnostic and statistical purposes as being either present or absent, in reality dependence exists on a continuum of severity. However, it is helpful from a clinical perspective to subdivide dependence into categories of mild, moderate and severe. People with mild dependence (those scoring 15 or less on the Severity of Alcohol Dependence Questionnaire; SADQ) usually do not need assisted alcohol withdrawal. People with moderate dependence (with a SADQ score of between 15 and 30) usually need assisted alcohol withdrawal, which can typically be managed in a community setting unless there are other risks. People who are severely alcohol dependent (with a SADQ score of more than 30) will need assisted alcohol withdrawal, typically in an inpatient or residential setting. In this guideline these definitions of severity are used to guide selection of appropriate interventions.

For convenience this guideline refers to harmful drinking and alcohol dependence as 'alcohol misuse'. When recommendations apply to both people who are dependent on alcohol and harmful drinkers, the terms 'person who misuses alcohol' or 'service user' are used unless the recommendation is specifically referring to either people who are dependent on alcohol or who are harmful drinkers.

Alcohol dependence affects 4% of people aged between 16 and 65 in England (6% of men and 2% of women), and over 24% of the English population (33% of men and 16% of women) consume alcohol in a way that is potentially or actually harmful to their health or well-being. Alcohol misuse is also an increasing problem in children and young people, with over 24,000 treated in the NHS for alcohol-related problems in 2008 and 2009.

Comorbid mental health disorders commonly include depression, anxiety disorders and drug misuse, some of which may remit with abstinence from alcohol but others may persist and need specific treatment. Physical comorbidities are common, including gastrointestinal disorders (in particular liver disease) and neurological and cardiovascular disease. In some people these comorbidities may remit on stopping or reducing alcohol consumption, but many experience long-term consequences of alcohol misuse that may significantly shorten their life.

Of the 1 million people aged between 16 and 65 who are alcohol dependent in England, only about 6% per year receive treatment. Reasons for this include the often long period between developing alcohol dependence and seeking help, and the limited availability of specialist alcohol treatment services in some parts of England. Additionally, alcohol misuse is under-identified by health and social care professionals, leading to missed opportunities to provide effective interventions.

Diagnosis is made on the basis of the symptoms and consequences of alcohol misuse outlined above. Simple biological measures such as liver function tests are poor indicators of the presence of harmful or dependent drinking. Diagnosis and assessment of the severity of alcohol misuse is important because it points to the treatment interventions required. Acute withdrawal from alcohol in the absence of medical management can be hazardous in people with severe alcohol dependence, as it may lead to seizures, delirium tremens and, in some instances, death.

Current practice across the country is varied and access to a range of assisted withdrawal and treatment services varies as a consequence. Services for assisted alcohol withdrawal vary considerably in intensity and there is a lack of structured intensive community-based assisted withdrawal programmes. Similarly, there is limited access to psychological interventions such as cognitive behavioural therapies specifically focused on alcohol misuse. In addition, when the alcohol misuse has been effectively treated, many people continue to experience problems in accessing services for comorbid mental and physical health problems. Despite the publication of the Models of Care for Alcohol by the Department of Health in 2007 (National Treatment Agency, 2007), alcohol service structures are poorly developed, with care pathways often ill defined. In order to address this last point the three pieces of NICE guidance are integrated into a care pathway.

This guideline will assume that prescribers will use a drug's summary of product characteristics (SPC) to inform their decisions for individual service users.

In this guideline, drug names are marked with a footnote if they do not have a UK marketing authorisation for the indication in question at the time of publication. Prescribers should check each drug's SPC for current licensed indications.

At the time of publication, no drug recommended in this guideline has a UK marketing authorisation for use in children and young people under the age of 18. However, in 2000, the Royal College of Paediatrics and Child Health issued a policy statement on the use of unlicensed medicines, or the use of licensed medicines for unlicensed applications, in children and young people. This states that such use is necessary in paediatric practice and that doctors are legally allowed to prescribe unlicensed medicines where there are no suitable alternatives and where the use is justified by a responsible body of professional opinion.