Alcohol-use Disorders NICE Guidelines 2010

1. Alcohol-use DisordersNICE Guidelines 2010/11 Dr Fiona Carroll May 2011

2. NICE Guidance  Alcohol-use disorders; 1 Preventing the development of hazardous and harmful drinking (June 2010) 2 Diagnosis and clinical management of alcohol-related physical complications (June 2010) 3 Diagnosis, assessment and management of harmful drinking and alcohol dependence (Feb 2011)

3. 1 Preventing the development of hazardous and harmful drinking; Recommendations for Policy set minimum price per unit limit availability limit or ban advertising

4. Recommendations for Practice;Licensing Map local alcohol-related problems use map to guide licensing decisions devote resources to preventing inappropriate alcohol sales apply sanctions to businesses that break the law

5. Recommendations for Practice;Commissioners and NHS Managers Alcohol- use disorders prevention is a priority Undertake a local alcohol needs assessment include screening and brief interventions screening likely to trigger increase in referrals monitor interventions to ensure evidence- based and cost- effective nurse/ consultant to provide strategic direction supervision for those providing screening and brief intervention

6. Recommendations for practice;Supporting children and young people 10-15 years Ask children 10-15years about their drinking offer brief advice or refer on child /adolescent mental health services social services young peoples alcohol services

7. Recommendations for practice; Screening young people aged 16-17 yrs ask young people 16-17years about their drinking; accident/ minor injury GUM clinics/ emergency contraception crime self harm truant looked -after/ safeguarding agencies involved use AUDIT if appropriate offer brief intervention or refer on

8. Recommendations for Practice;Screening adults Ask all adults about their alcohol consumption new patient check/ screening /chronic disease review medication review/ sexual health /antenatal care /injuries target groups physical conditions eg hypertension/ GI and liver disorders mental health problems eg anxiety/ depression self -harm victims of assault/ domestic violence accidents/ trauma GUM clinic/ emergency contraception

9. Recommendations for Practice;Screening adults use AUDIT questionnaire self or guided biochemical measures not used for screening use to monitor adults drinking hazardous/ harmful amount of alcohol; offer brief intervention if unresponsive; referral for extended brief intervention specialist referral if dependent on alcohol

10. Definitions Harmful Drinking alcohol consumption that causes physical or mental damage Hazardous Drinking alcohol consumption that causes physical, mental or social harm (WHO)

11. Definitions Lower risk drinking Women; < 2-3 unites per day Men; < 3-4 unites per day Increasing risk drinking; regularly drinking Women; >2-3 units a day Men; >3-4 units a day Higher risk drinking; regularly drinking Women; >6 units per day or >35 units per week Men; >8 units per day or >50 units per week

12. Alcohol use disorders identification testAUDIT Please circle the answer that is correct for you 1. How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week >4 times a week 2. How many standard drinks containing alcohol do you have on a typical day when drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more 3. How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily 4. During the past year, how often have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily/ almost daily 5. During the past year, how often have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily

13. AUDIT 6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily 7. During the past year, how often have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily 8. During the past year, have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily 9. Have you or someone else been injured as a result of your drinking? No Yes, but not in the past year Yes, during the past year 10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down? No Yes, but not in the past year Yes, during the past year

14. AUDIT Score 0 – 7 Lower risk 8 – 15 Increasing risk 16 – 19 Higher risk 20+ Possible dependence

16. Structured Brief Advice Opportunistic With or without formal follow up Up to 10 minutes in duration With self-help materials Most effective for those drinking at increasing to higher risk levels Not designed to treat those with alcohol dependence

17. Structured Brief Advice- FRAMES Miller and Sanchez, 1993 Feedback: provide feedback on the patient's risk for alcohol problems Responsibility: highlight the individuals choice/ responsibility for change Advice: advise reduction or give explicit direction to change Menu: provide a variety of options for change Empathy: use a warm, reflective and understanding approach Self-efficacy: encourage optimism about changing behaviour

18. Structured Brief Advice Harm caused by current drinking benefits of reduction barriers to change practical strategies work towards a set of goals

19. 2 Diagnosis and clinical management of alcohol-related physical complications;Unplanned Acute alcohol withdrawal offer hospital admission if high risk of DTs/ seizures or <16 years consider hospital admission if vulnerable/ co-morbidity/ cognitive impairment do not admit if alcohol dependent and not vulnerable and not high risk of DTs/ seizures

20. Diagnosis and clinical management of alcohol-related physical complications;Unplanned Acute alcohol withdrawal If admitted use assessment scale and judgement Clinical Institute Withdrawal Assessment- Alcohol, revised CIWA-Ar use a symptom-triggered regimen benzodiazepine or carbemazepine clomethiazole- use caution/ inpatients only

21. Delirium tremens or seizures DTS; oral lorazepam parenteral lorazepam/ haloperidol/ olanzapine Seizures; lorazepam

22. Wernicke’s encephalopathy;Prevention Parental thiamine (then oral) malnourished/ risk of decompensated liver disease and attends A&E or admitted Oral thiamine to harmful/ dependent drinkers; malnourished/ risk of malnourishment decompensated liver disease in acute withdrawal before and during planned detox

23. Wernicke’s encephalopathy;Treatment Give parenteral thiamine if Wernicke’s suspected give for minimum 5 days oral thiamine follows parenteral give higher end of BNF doses Oral dose; 300mg daily IM dose; 250mg in 7mls (2 amps) Give 7mls bd for up to 7 days

24. Alcohol-related liver disease Exclude other causes liver problems in drinkers refer to specialist consider liver biopsy Refer patients with decompensated liver disease for consideration for liver transplant after best management and 3m abstinence

25. Management of acute alcohol- related hepatitis Diagnosis confirmed by specialist consider nutritional support assess severity- discriminant function consider liver biopsy corticosteroid treatment

26. Chronic Alcohol-related pancreatitis Diagnose with history/ CT/ biochemical tests steatorrheoa/ poor nutrition; offer enzyme supplements chronic pain; refer for specialist multidisciplinary assessment surgery (large duct/ obstructive) coeliac axis block /splanchnicectomy/ surgery (small duct/ non- obstructive)

27. 3 Diagnosis, assessment and management of harmful drinking and alcohol dependenceFebruary 2010 England; alcohol use increasing in children and young people >24% adults alcohol consumption is actually or potentially harmful 33% men, 16% women 4% alcohol dependent 6% men, 2% women

28. Alcohol dependence DSM-iv and ICD-10 term behavioural, cognitive and physiological factors craving for alcohol tolerance difficulty in controlling drinking continued drinking despite harm alcohol prioritised

29. Severity of alcohol dependence Questionnaire/ SADQ Developed at Maudsley Hospital, Addictions Research unit measures severity of dependence 20 questions, max score 60; physical symptoms relief drinking frequency of consumption speed of onset of withdrawal

30. Alcohol Dependence Mild; <15 SADQ moderate 15-30 SADQ severe >31 SADQ

31. Assessment Staff trained & competent to assess & treat use assessment tools Alcohol use disorders identification test, AUDIT Severity of alcohol dependence Questionnaire, SADQ Clinical Institute Withdrawal Assessment- Alcohol- revised, CIWA-Ar Alcohol Problems Questionnaire, APQ motivational intervention

32. Assessmentchildren/ young people 10-17yrs If alcohol associated problems Refer to Child and Adolescent mental health service

33. Assessment; AdultsSpecialist Alcohol Services AUDIT SADQ need for assisted withdrawal risk assessment co-morbidities agree goals of treatment; abstinence moderate drinking

34. Interventions for alcohol misuse Psychological interventions; evidence based treatment manual community support groups/ self-help eg AA homeless- consider residential treatment stop and review if no improvement or deterioration

35. Interventions for harmful drinking and mild alcohol dependence Psychological intervention Cognitive Behaviour Therapy social network therapy behavioural couples therapy 60mins per week for 12 weeks consider acamprosate/ naltrexone

36. Assisted Alcohol Withdrawal >15units per day and/ or >20 on AUDIT usually community based consider inpatient if; epilepsy/withdrawal seizures >30 units per day or SADQ >30 use alcohol and benzodiazepines vulnerable/ homeless /older offer drug regimen plus psychological intervention after

37. Drug regimens for assisted withdrawal Use chlordiazepoxide or diazepam use CIWA-Ar consider liver impairment- reduce dose/ lorazepam community setting titrate initial dose according to severity of dependence gradually reduce over 7-10 days monitor alternate days enlist family member for support/ monitoring avoid giving large amounts medication do not use clomethiazole/ heminevrin

38. Interventions for moderate and severe alcohol dependence after successful withdrawal Offer medication plus psychological therapy first line; Acamprosate/ Naltrexone second line; Disulfiram medical assessment/ C&E, LFT prior to starting

39. Acamprosate Start after assisted withdrawal 666mg tds if >60kg 666mg bd if <60kg 6m treatment monitor at least monthly stop if drinking 4-6weeks after starting

40. Naltrexone Not licensed for this indication start after assisted withdrawal start 25mg, maintenance dose 50mg per day 6m treatment monitor at least monthly interaction with opioid-based analgesics stop if drinking 4-6weeks after starting

41. Disulfiram Start >24hours after last alcohol 200mg per day monitor 2wkly for 2months, then monthly C&E and LFT prior to start check for contraindications; pregnancy/ mental illness/ stroke/ heart disease/ hypertension

42. Disulfiram Family member to oversee hidden sources of alcohol food/ perfume/ aerosol/ etc interaction with alcohol flushing/ nausea/ palpitations/ arrhythmia hypotension/ collapse rarely hepatotoxicity

43. Do not use; Gamma-hydroxybutyrate antidepressants alone ongoing benzodiazepines

44. Co-morbid conditions Smoking encourage stopping smoking Drug use actively treat drug and alcohol use depression/ anxiety treat alcohol misuse first if persist after 3-4 weeks abstinence, assess and treat according to NICE guidelines

45. Wernicke-Korsakoff syndrome Thiamine treatment mild cognitive impairment supported independent living moderate -severe impairment supported 24 hour care

46. Working with families and carers Involve family members/ carers give written information agree involvement with service user impact on children offer carer’s assessment guided self-help/ support groups family meeting