Alcohol-use disorders:
diagnosis, assessment and
management of harmful drinking
and alcohol dependence
Implementing NICE guidance
February 2011
NICE clinical guideline 115
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)
• Diagnosis and clinical management of physical
complications (CG 100)
The term alcohol-use disorders encompasses
physical, mental and behavioural conditions
associated with alcohol use.
What this presentation covers
Definitions
Epidemiology
Background
Scope
Key priorities for implementation
Principles of care
Costs and savings
Discussion
Find out more
Definitions
• Harmful drinking is a pattern of alcohol consumption
causing mental and physical health problems directly
related to alcohol
• Alcohol dependence is characterised by continued
drinking despite harmful consequences
• Mild dependence = Severity of Alcohol Dependence
Questionnaire (SADQ) score 15 or less
• Moderate dependence = SADQ score of 15–30
• Severe dependence = SADQ score of 31 or more.
Epidemiology
Weekly alcohol consumption of more than 50 units (men) or more than
35 units (women) by age (years) and gender – Great Britain, 2009
Y = Percentage of
population
X = Age in years
Source: General Lifestyle Survey, Office for National Statistics
Background
• Current practice and service provision
across the country is varied
• Only 6% per year of people aged 16–65 years who are
alcohol dependent receive treatment
• Comorbid mental and physical disorders are common.
Scope
• Diagnosis, assessment and management of harmful
drinking and alcohol dependence in young people and
adults
• Does not cover children younger than 10 years or
pregnant women.
Key priorities for implementation
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Identification and assessment in all settings
Assessment in specialist alcohol services
General principles for all interventions
Interventions for harmful drinking and mild alcohol
dependence
Assessment for assisted alcohol withdrawal
Interventions for moderate and severe alcohol
dependence
Assessment and interventions for children and young
people who misuse alcohol
Interventions for conditions comorbid
with alcohol misuse.
General principles for
identification and assessment
Staff working in services caring for people who
potentially misuse alcohol should be competent:
• to identify harmful drinking and alcohol dependence
• to initially assess the need for an intervention
If they are not competent they should refer people who
misuse alcohol to a service that can assess need.
Assessment in specialist
alcohol services
Consider a comprehensive assessment for all adults
referred to specialist alcohol services who score more than
15 on the AUDIT. A comprehensive assessment should:
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assess multiple areas of need
be structured in a clinical review
use validated clinical tools
cover alcohol use, other drug misuse, physical health
problems, psychological and social problems,
cognitive function and readiness and
belief in ability to change.
General principles for all
interventions: 1
Consider offering interventions to promote abstinence and
prevent relapse as part of an intensive structured
community-based intervention for people with moderate
and severe alcohol dependence who have:
• very limited social support (for example, they are
living alone or have very little contact with family or
friends) or
• complex physical or psychiatric comorbidities or
• not responded to initial community-based
interventions.
General principles for all
interventions: 2
• All interventions for people who misuse alcohol should be
delivered by appropriately trained and competent staff
• Pharmacological interventions should be administered by
specialist and competent staff
• Psychological interventions should be based on a
relevant evidence-based treatment manual
• Staff should consider using competence frameworks
developed from the relevant treatment manuals.
Interventions for harmful drinking
and mild alcohol dependence
Offer a psychological intervention focused specifically
on:
• alcohol-related cognitions
• behaviour
• problems
• social networks.
Assessment for assisted
alcohol withdrawal
For service users who typically drink over 15 units of
alcohol per day and/or who score 20 or more on the
AUDIT, consider offering:
• an assessment for and delivery of a community-based
assisted withdrawal, or
• assessment and management in specialist alcohol
services if there are safety concerns about a
community-based assisted withdrawal.
Assisted alcohol withdrawal
Person who drinks > 15 units alcohol per day or scores > 20
on AUDIT
Assessment
 Consider offering:
– assessment for and delivery of a community-based assisted withdrawal, or
– assessment and management in specialist alcohol services if there are safety
concerns about a community-based assisted withdrawal.
Community-based assisted
withdrawal
Inpatient and residential
withdrawal
Intensive community
programmes after
assisted withdrawal for
severe dependence or
mild to moderate
dependence with
complex needs
Drug regimens for
assisted withdrawal
• When conducting community-based assisted
withdrawal programmes, use fixed-dose medication
regimens and monitor the service user every other day
• Fixed-dose or symptom-triggered medication regimens
can be used in assisted withdrawal programmes in
inpatient or residential settings
• Prescribe and administer medication for assisted
withdrawal within a standard clinical protocol.
Interventions for moderate and
severe alcohol dependence
After a successful withdrawal for people with moderate
and severe alcohol dependence, consider offering:
• acamprosate
• or oral naltrexone
in combination with an individual psychological
intervention.
Assessment and interventions
for children and young people
who misuse alcohol
For children and young people
aged 10–17 years who misuse
alcohol offer:
• individual cognitive behavioural
therapy for those with limited
comorbidities and good social
support
• multicomponent programmes
for those with significant
comorbidities and/or limited
social support.
Interventions for conditions
comorbid with alcohol misuse
• For people who misuse alcohol and have comorbid
depression or anxiety disorders, treat the alcohol
misuse first
• If depression or anxiety continues after 3 to 4 weeks of
abstinence from alcohol, assess the depression or
anxiety and consider referral and treatment.
Principles of care
• Build a trusting
relationship
• Provide information
appropriate to the
person’s understanding
• Work with and support
families and carers.
Costs and savings
per 100,000 population
Recommendation
Costs
(£ per year)
Offering psychological interventions to harmful drinkers and
people with mild alcohol dependence
1,800
For people with mild to moderate dependence and complex
needs, or severe dependence, offering an intensive
community programme following assisted withdrawal
–23,400
Offering acamprosate or oral naltrexone in combination with
an individual psychological intervention after a successful
withdrawal for people with moderate and severe alcohol
dependence
Estimated net saving of implementation
3000
–18,600
Discussion
• How can we ensure that health and social care
professionals in our organisation are competent to
identify harmful drinking and alcohol dependence?
• What training do staff need to enable them to assess
the need for interventions in people who are drinking
harmfully or who are alcohol dependent?
• Which formal assessment tools do we use to assess
the nature and severity of the alcohol misuse and are
these included in the guidance? If not, how can we
change to a recommended tool?
Find out more
Visit www.nice.org.uk/guidance/CG115 for:
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the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
audit support
baseline assessment tool
sample chlordiazepoxide dosing regimens
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Inpatient and residential withdrawal
 Consider inpatient or residential assisted withdrawal if a service user meets
one or more of the following criteria. They:
• drink over 30 units of alcohol per day
• have a score of more than 30 on the SADQ
• have a history of epilepsy or experience of withdrawal-related seizures or
•delirium tremens during previous assisted withdrawal programmes
• need concurrent withdrawal from alcohol and benzodiazepines
• regularly drink between 15 and 20 units of alcohol per day and have:
o significant psychiatric or physical comorbidities (for example, chronic
severe depression, psychosis, malnutrition, congestive cardiac failure,
unstable angina, chronic liver disease) or
o a significant learning disability or cognitive impairment.
 Consider a lower threshold for inpatient or residential assisted withdrawal in
vulnerable groups for example homeless and older people.
 See page 20 of the quick reference guide for special considerations for children
and young people.
Click here to return to main assisted alcohol withdrawal pathway
Intensive community programmes after assisted withdrawal for
severe dependence or mild to moderate dependence with
complex needs
 Offer an intensive community programme in which the service user may attend
a day programme lasting between 4 and 7 days per week over a 3-week period.
 Intensive community programmes should consist of a drug regimen (see page
16 of the quick reference guide) supported by psychological interventions
including individual treatments (see page 17 of the quick reference guide), group
treatments, psychoeducational interventions, help to attend self-help groups,
family and carer support and involvement, and case management (see page 13
of the quick reference guide).
Click here to return to main assisted alcohol withdrawal pathway
Community-based assisted withdrawal
 Service users who need assisted withdrawal should usually be offered a
community-based programme – vary in intensity according to the severity of
the dependence, available social support and comorbidities.
 Offer an outpatient based programme for people with mild to moderate
dependence in which contact between staff and the service user averages 2–4
meetings per week over the first week.
 Outpatient-based community assisted withdrawal programmes should consist
of a drug regimen (see page 16 of the quick reference guide) and psychosocial
support including motivational interviewing.
Click here to return to main assisted alcohol withdrawal pathway