Alcohol-use disorders: physical complications

1. Alcohol-use disorders: physical complications Implementing NICE guidance 2nd. Edition – August 2011 NICE clinical guideline 100

2. Directly related NICE guidance • This guideline is one of three pieces of NICE guidance addressing alcohol-use disorders. The others are: • Preventing hazardous and harmful drinking (PH24) • Dependence and harmful alcohol use (CG115) • The term alcohol-use disorders encompasses physical, mental and behavioural conditions associated with alcohol use.

3. NICE Pathway • The NICE Alcohol pathway shows recommendations on: • key areas in the investigation and management of alcohol-related physical complications. • the diagnosis, assessment and management of harmful drinking and alcohol dependence • prevention and early identification of alcohol-use disorders, including interventions in schools to prevent and reduce alcohol use among children and young people Click here to go to NICE Pathways website

5. What this presentation covers • Background • Scope • Recommendations • Costs and savings Discussion • NHS Evidence • Find out more • NICE alcohol quality standard

6. Background • In the UK, it is estimated that 24% of adults drink in a hazardous or harmful way. • Continued hazardous and harmful drinking can result in alcohol dependence and damage to almost every organ or system of the body. • This clinical guideline aims to ensure that patients with alcohol-related complications receive the best possible clinical care.

7. Scope • This guideline covers key areas in the investigation and management of alcohol-related physical complications in adults and young people (10 years and older) as follows: • acute alcohol withdrawal • Wernicke’s encephalopathy • liver damage • acute and chronic pancreatitis. • It does not specifically look at: • women who are pregnant • children younger than 10 years • people with physical or mental health conditions caused by alcohol use, other than those listed above.

8. Definitions • Acute alcohol withdrawal • Alcohol dependence • Coeliac axis block • Decompensated liver disease • Harmful drinking • Hazardous drinking • Medically assisted alcohol withdrawal • Medicines licensing

9. Recommendations Key themes for recommendations: • Acute alcohol withdrawal • Delirium tremens, alcohol withdrawal seizures and Wernicke’s encephalopathy • Alcohol-related liver disease • Alcohol-related pancreatitis

10. Acute alcohol withdrawal: 1 For people in acute alcohol withdrawal with, or who are assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, offer admission to hospital for medically assisted alcohol withdrawal.

11. Acute alcohol withdrawal: 2 Healthcare professionals who care for people in acute alcohol withdrawal should be skilled in the assessment and monitoring of withdrawal symptoms and signs.

12. Acute alcohol withdrawal: 3 • Follow a symptom-triggered regimen for drug treatment for people in acute alcohol withdrawal who are: • in hospital or • in other settings where 24-hour assessment and monitoring are available.

13. Specific circumstances: 1 • Delirium tremens • Offer lorazepam* or alternative • Review withdrawal drug regimen • Alcohol withdrawal seizures • Offer a quick-acting benzodiazepine • Do not offer phenytoin • Review withdrawal drug regimen

14. Specific circumstances: 2 • Wernicke’s encephalopathy • Offer thiamine (oral and/or parenteral) to people at high risk of developing, or with suspected, Wernicke’s encephalopathy.

15. Alcohol-related liver disease • Refer patients with decompensated liver disease to be considered for assessment for liver transplantation if they: • still have decompensated liver disease after best management and 3 months’ abstinence from alcohol and • are otherwise suitable candidates for liver transplantation.

16. Alcohol-related pancreatitis Refer people with pain from chronic alcohol-related pancreatitis to a specialist centre for multidisciplinary assessment.

17. Supporting QIPP • Symptom-triggered dosing for the inpatient management of acute alcohol withdrawal is likely to reduce the patients length of stay. • Do not offer phenytoin to treat alcohol withdrawal seizures. • Do not give prophylactic antibiotics to people with mild acute alcohol-related pancreatitis, unless otherwise indicated. • Do not prescribe pancreatic enzyme supplements to people with chronic alcohol-related pancreatitis if pain is their only symptom.

18. Costs and savings per 250,000 population Costs correct at June 2010. Costs not updated for 2nd. edition

19. Discussion • How can we move from fixed dosing to symptom-triggered treatment? How will the additional patient monitoring be done? What staff training needs are there to deliver this recommendation? • How will these recommendations affect the attainment of A&E targets? What can be done to ensure we continue to meet A&E targets? • Is there a role for specialist alcohol liaison workers or a specialist doctor or nurse who is available 24 hours a day? Do we have these in our organisation? If so how can we use them?

20. NHS Evidence Visit NHS Evidence for the best available evidence on all aspects of harmful alcohol use Click here to go to the NHS Evidence website

21. Find out more • Visit www.nice.org.uk/guidance/CG100 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing report and template • audit support • baseline assessment tool

22. NICE Quality Standard Alcohol dependence and harmful alcohol use August 2011

23. Quality Standards • A quality standard is a set of specific, concise statements that: • act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention • are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources • are produced collaboratively with the NHS and social care, along with their partners and service users

24. Alcohol Quality Standard • This Quality Standard covers the care of people aged 10 years and over with alcohol dependence and people drinking in a harmful way in all NHS and social care-funded settings • It also includes identification and brief interventions for hazardous drinkers • The Quality Standard consists of 13 quality statements.

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