DRAFT – for use in Alcohol Treatment PbR Pilot Programme
Alcohol Treatment PbR: Best Practice Packages of Care
Integrated care pathways and stepped care
Integrated care pathways (ICPs) have a function at both an individual and a
treatment system level. At the individual level the care plan should describe the
client’s personalised care pathway, designed to meet the assessed needs, the
planned interventions, and the agencies and staff intended to deliver them. The
pathway needs to be integrated in that it shows a logical progression of steps with
interventions being provided at the appropriate stages. For example, an alcohol
dependent client may initially require inpatient assisted alcohol withdrawal followed
by a structured psychosocial intervention in an alcohol day programme, followed by
specialised psychotherapy for post traumatic stress disorder, followed by vocational
services to support a return to work. This package of care may be delivered by one
agency or elements of care may be delivered by different agencies in different
locations with careful care co-ordination. The pathway needs to be integrated to
deliver maximum benefit and minimise the client’s premature disengagement.
Stepped care is described as having two defining characteristics the first concerns
the provision of the least restrictive and least costly intervention (including
assessments) that will be effective for an individual’s presenting problems, and the
second is concerned with building in a self-correcting mechanism. Escalating levels
of response to the complexity or severity of the disorder are often implicit in the
organisation and delivery of many healthcare interventions, but a stepped care
system is an explicit attempt to formalise the delivery and monitoring of patient flows
through the system. In establishing a stepped care approach, consideration should
not only be given to the degree of restrictiveness associated with a treatment, and its
costs and effectiveness, but also the likelihood of its uptake by a patient and the
likely impact that an unsuccessful intervention will have on the probability of other
interventions being taken up.
Elements of care packages
NICE Guidance has defined the packages of care or stages of care for those with
alcohol problems as:
 Assessment, engagement and motivational enhancement
 Care planning, care co-ordination and case management
 Withdrawal management
 Psychosocial interventions
 Pharmacotherapy
 Aftercare, reintegration and recovery
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Clusters and ‘Packages of Care’ to address needs
Care Cluster 1: Harmful drinking and mild dependence
•
•
•
•
•
•
Assessment / Engagement / Motivational enhancement: Use AUDIT,
SADQ/LDQ and units per day to determine level of dependence followed by
history taking and discussion about current circumstance to determine level of
risk and the presence of co-existing problems recorded by use of
HONOS/SARN. In-depth medical assessment will most likely not be
necessary. Deliver motivational enhancement as part of the assessment
stage to promote engagement and retention in treatment.
Care Planning / Care co-ordination and Case management: These
individuals should receive a care plan and at least monthly follow-up for 3
months.
Withdrawal management: Most likely, there will not be a need to provide
medical assistance, but if so, will probably be met through outpatient
management by a GP or local alcohol service.
Psychosocial interventions: Brief advice should be given and assessed for
effectiveness at key working sessions. If needed, a package of less intensive
brief CBT/MET based treatment lasting up to 4 sessions should be offered.
Pharmacotherapy: Prescribing for relapse prevention is not supported by
evidence for this group.
Aftercare / Reintegration / Recovery: Will depend on presenting need.
Encouragement should be given to engage in self-help groups such as AA or
SMART Recovery.
Care Cluster 2: Moderate dependence (without complex needs)
•
•
•
•
•
Assessment / Engagement / Motivational enhancement: Use AUDIT,
SADQ/LDQ and units per day to determine level of dependence followed by
history taking and discussion about current circumstance to determine level of
risk and the presence of co-existing problems recorded by use of
HONOS/SARN. Comprehensive assessment (including medical/psychiatric
assessment) will most likely be necessary. Deliver motivational enhancement
as part of the assessment stage to promote engagement and retention in
treatment.
Care Planning / Care co-ordination and Case management: These
individuals should receive a care plan and care co-ordination with at least
monthly follow-up for 6 months.
Withdrawal management: Most likely, withdrawal management can be met
through outpatient management. Post withdrawal assessment of mental
health issues and cognitive function should be carried out.
Psychosocial interventions: A package of less intensive CBT based
treatment lasting up to 4 sessions should be offered. If needed, a package of
12 weeks of CBT based treatment or a day treatment programme may be
required.
Pharmacotherapy: For relapse prevention, acamprosate or naltrexone (or
disulfiram if indicated) should be offered for up to one year. This should be
delivered in conjunction with psychosocial interventions in a comprehensive
package of care.
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•
Aftercare / Reintegration / Recovery: Encouragement should be given to
engage in self-help groups such as AA or SMART Recovery. Referral to
employment services, assistance with housing and benefits may be required.
Care Cluster 3: Severe dependence (without complex needs)
•
•
•
•
•
•
Assessment / Engagement / Motivational enhancement: Use AUDIT,
SADQ/LDQ and units per day to determine level of dependence followed by
history taking and discussion about current circumstance to determine level of
risk and the presence of co-existing problems recorded by use of
HONOS/SARN. Comprehensive assessment (including medical/psychiatric
assessment) will be necessary. Deliver motivational enhancement as part of
the assessment stage to promote engagement and retention in treatment.
Care Planning / Care co-ordination and Case management: These
individuals should receive a care plan and case management lasting at least
12 months with frequent appointments in first 3 months.
Withdrawal management: Most likely, withdrawal management will require
inpatient care. Post withdrawal assessment of mental health issues and
cognitive function should be carried out.
Psychosocial interventions: A package of 12 weeks of CBT based
treatment in the context of a day treatment programme lasting 8-12 weeks
should be offered. Residential rehabilitation of up to 12 weeks may be
required for those who do not benefit from outpatient treatments.
Pharmacotherapy: For relapse prevention, acamprosate or naltrexone (or
disulfiram if indicated) should be offered for up to one year. This should be
delivered in conjunction with psychosocial interventions in a comprehensive
package of care
Aftercare / Reintegration / Recovery: Encouragement should be given to
engage in self-help groups such as AA or SMART Recovery. Referral to
employment services, assistance with housing and benefits may be required.
Care Cluster 4: Moderate / Severe dependence with complex needs
(significant psychiatric or physical co-morbidities)
•
•
•
Assessment / Engagement / Motivational enhancement: Use AUDIT,
SADQ/LDQ and units per day to determine level of dependence followed by
history taking and discussion about current circumstance to determine level of
risk and the presence of co-existing problems recorded by use of
HONOS/SARN. Medical assessment will be necessary. Deliver motivational
enhancement as part of the assessment stage to promote engagement and
retention in treatment.
Care Planning / Care co-ordination and Case management: These
individuals should receive a care plan and case management to ensure
engagement in treatment lasting at least 12 months with frequent
appointments in the first 6 months.
Withdrawal management: Most likely, withdrawal management will require
inpatient care but upon assessment may be met through outpatient
management. Post withdrawal assessment of mental health issues and
cognitive function should be carried out.
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•
•
•
•
Psychosocial interventions: A package of 12 weeks of CBT based
treatment in the context of a day treatment programme lasting 8-12 weeks
should be offered. Residential rehabilitation of up to 12 weeks may be
required for those who do not benefit from outpatient treatments.
Pharmacotherapy: For relapse prevention, acamprosate or naltrexone (or
disulfiram if indicated) should be offered for up to one year. This should be
delivered in conjunction with psychosocial interventions in a comprehensive
package of care
Physical and Psychiatric co-morbidity: These should be managed
according to appropriate NICE guidelines after treating alcohol dependence.
Aftercare / Reintegration / Recovery: Encouragement should be given to
engage in self-help groups such as AA or SMART Recovery. Referral to
employment services, assistance with housing and benefits may be required.
Treatment elements are discussed further in Appendix A
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Appendix A
ASSESSMENT
The common aims for assessment of alcohol misuse are:
• establishing the presence of an alcohol use disorder
• the level of alcohol consumption
• determining whether the alcohol use disorder is best characterised as
harmful drinking or alcohol dependence
• establishing the presence of risks to self or others (for example, self-harm,
harm to other, medical/mental health emergencies, safeguarding children
issues)
• establishing the capacity to consent to treatment or onward referral
• experience and outcome of previous intervention(s)
• establishing the willingness to engage in further assessment and/or
treatment
• establishing the presence (but not necessarily diagnosing) of possible coexisting common problems features (for example, co-occurring substance
misuse, medical, mental health and social problems)
• determining the urgency of referral and/or an assessment for alcohol
withdrawal
As part of assessment, provide motivational interviewing to enhance engagement
and retention in treatment.
CARE PLANNING / CARE CO-ORDINATION AND CASE MANAGEMENT
Care planning and care co-ordination have several elements. The care co-ordinator
is responsible for:
 assessment of the individual client’s needs
 development of a care plan in collaboration with the client and relevant others
(including relatives and carers, other staff in specialist and generic agencies
involved in the client’s care)
 coordination of the delivery of interventions and services
 providing support to the client to assist in access to and engagement with
services and interventions.
Case management as an intervention to promote abstinence and reduce alcohol
consumption, as well as improving client engagement, treatment adherence and use
of aftercare services. Research has shown that case management is significantly
better in reducing lapse and days using alcohol than standard practice of care coordination.
The case manager will use psychological interventions such as motivational
interviewing to enhance the client’s readiness to engage with treatment and comply
with treatment goals. The case manager is also responsible for monitoring the
outcome of interventions and revising the care plan accordingly. Case management
is a skilled task that requires appropriately competent staff to deliver it effectively.
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WITHDRAWAL MANAGEMENT
Inpatient withdrawal management
In inpatient and residential settings, the service user is on-site for 24 hours a day for
the duration of assisted withdrawal. Inpatient and residential settings encompass a
spectrum of treatment intensity. At one end lie specialist units within either acute
medical or psychiatric hospitals, dedicated to the treatment of alcohol or drug
problems (known as ‘inpatient units’). Such units have specialist medical and nursing
input available 24 hours a day, and are staffed by a multidisciplinary team that may
also include psychologists, occupational therapists, social workers, counsellors, and
other staff specialising in debt, employment or housing issues. At the other end are
facilities usually known as ‘residential rehabilitation’ units, which are usually run by
the non-statutory sector and not sited within hospital premises. Although the goal of
such units is usually the provision of longer-term treatment (3 to 12 months) aimed at
enhancing the patient’s ability to live without using alcohol, increasingly they also
provide an initial period of assisted withdrawal. Such units may also have access to
medical and nursing input over the full 24-hour period, but this is usually at a lower
level of intensity and more likely to utilise non-specialist staff (for example, GPs).
Such units and may be staffed by both professionals and individuals in recovery. In
addition, a number of prisons may offer a high level of medical supervision including,
where necessary, admission to the hospital wing of the prison.
The evidence indicates that a community setting for assisted withdrawal is as
effective and safe for the majority of patients as an inpatient or residential assisted
withdrawal as long as the patient is without serious medical contraindications. It is
important to consider the following factors when determining whether a community or
residential/ inpatient assisted withdrawal is the most appropriate:
 severity of alcohol dependence
 a history of epilepsy or withdrawal-related seizures or DTs during previous
assisted withdrawals
 a significant psychiatric or physical co-morbidity (for example, chronic severe
depression, psychosis, malnutrition, congestive cardiac failure, unstable
angina, chronic liver disease)
 a significant learning disability
 significant cognitive impairment
 homelessness or inappropriate level of support at home
 pregnancy
 older age
Consider inpatient or residential assisted withdrawal if the 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:
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-
-
significant psychiatric or physical co-morbidities (for example, chronic
severe depression, psychosis, malnutrition, congestive cardiac failure,
unstable angina, chronic liver disease)
a significant learning disability or cognitive impairment.
Outpatient withdrawal management
In a community setting, a person undergoing assisted withdrawal lives in their own
accommodation throughout the treatment. A spectrum of treatment intensity is also
possible. Day hospital treatment (sometimes known as ‘partial hospitalisation’) may
involve the patient attending a treatment facility for up to 40 hours per week during
working hours, Monday to Friday, and returning home in the evening and weekends.
This facility may be located within an inpatient or residential rehabilitation unit, or
may be stand-alone. It is likely to be staffed by a multidisciplinary team, with input
from medical and nursing staff, psychologists, occupational therapists, social
workers, counsellors, and other staff specialising in debt, employment or housing
issues. Other community assisted withdrawals may invite the patient to attend for
appointments with a similar range of multidisciplinary staff, but at a much lower
frequency and intensity (for example, alternate days), or they may be provided by
GPs often with a special interest in treating alcohol-related problems. Alternatively,
staff may visit the patient in their own home to deliver interventions. Between these
two options are most intensive community-based options, where an increased
frequency of community visits and some limited use of office or team-based
treatment may form part of an intensive community programme.
Individuals should receive a re-assessment of mental health problems and cognitive
function on successful completion of any withdrawal regimen.
STRUCTURED PSYCHOSOCIAL INTERVENTIONS
Alcohol-focussed psychosocial interventions do not ignore issues of general
adjustment or exclude everything that is not related to drinking. However, the
alcohol-focussed perspective is most relevant to service users whose main
difficulties are judged to be consequences of excessive drinking or are exacerbated
by drinking and where it is considered that their more general life problems would
largely abate if drinking were stopped or brought under control.
Brief interventions
Brief interventions are carried out in generalist community settings and are delivered
by non-specialist personnel, such as general medical practitioners and other primary
health care staff, hospital physicians and nurses, social workers, probation officers
and other non-specialist professionals. They are directed at increasing and higherrisk drinkers or harmful drinkers who are not typically complaining about or seeking
help for an alcohol problem. These individual may have been identified by
opportunistic screening or some other identification process. Brief interventions can
themselves be subdivided into:

Simple Brief Interventions – structured advice taking no more than a
few minutes (sometimes also referred to as a minimal intervention).
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
Extended Brief Interventions / Brief Lifestyle Counselling – structured
interventions taking perhaps 20-30 minutes and may involving one or
more repeat sessions.1
The specific treatments detailed here come under the broad heading of cognitivebehavioural therapy (CBT) and have their foundations in social-cognitive learning
theory and experimental psychology. These are the treatments that tend to be best
supported by research evidence.
Brief or less intensive treatment2
The provision of less intensive forms of treatment is based on research showing that
they are no less effective than more intensive forms of treatment among the groups
of service users in which they have been compared. Less intensive treatments are
relatively brief and typically extend from 1-4 treatment sessions. Less intensive
treatments are:

delivered by specialist workers in alcohol treatment agencies or by
generalists who take a special interest in the treatment of alcohol
problems

mainly intended for moderately-dependent alcohol misusers, often as
the initial step in a stepped care programme in specialist services

also suitable for mildly dependent alcohol misusers or harmful drinkers
who have not benefited from a brief intervention and will accept referral
for relatively more intensive intervention.
An early form of less intensive treatment was the "basic treatment scheme" is
discussed by Edwards and Orford (1977) and consists of four elements:
(i)
a comprehensive assessment;
(ii)
a single, detailed counselling session for the service user and, when
the service user is in a close relationship, the partner;
(iii)
a follow-up system to check on progress;
(iv)
common reasons for going beyond the basic approach, e.g. a short
admission for detoxification, underlying or concomitant mental illness or
distress, physical illness, hostel care or other social provisions, or any
other reason for more extended treatment based on clinical judgement
(see Edwards and Orford3, p.347)
A condensed form of cognitive-behaviour therapy (three sessions) is especially
effective among female service users with a mild or moderate level of dependence 4
A single session of conjoint marital therapy is effective among socially stable
alcohol misusers with moderate dependence and alcohol problems and relatively
intact marriages.5
1
Raistrick, D., Heather, N. and Godfrey, C. (2006) Review of the effectiveness of treatment for alcohol problems.
National Treatment Agency for Substance Misuse.
2 Raistrick, D., Heather, N. and Godfrey, C. (2006) Review of the effectiveness of treatment for alcohol problems.
National Treatment Agency for Substance Misuse.
3 Edwards, G. & Orford, J. (1977). A plain treatment for alcoholism. Proceedings of the Royal Society of
Medicine, 70, 344–348.
4 Sanchez-Craig, M., Spivak, K. & Davila, R. (1991).Superior outcome of females over males after brief
treatment for the reduction of heavy drinking: Replication and report of therapist effects. British Journal of
Addiction, 86, 867–876.
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The most popular forms of less intensive treatment currently available are based on
the set of therapeutic principles and counselling techniques known as motivational
interviewing - MI (Miller & Rollnick, 1991; 2002). The evidence suggested good
effectiveness of MI-based interventions among a diverse range of groups, including
those with significant dependence seeking help for established alcohol problems. MIbased intervention is usually less intensive than other forms of psychosocial
interventions (see above), suggesting that it may be more cost-effective in some
instances).6
The treatments described in this section may be deployed in community outpatient
settings, day treatment programmes or in Tier 4 Residential Rehabilitation services.
Delivering these services in the community offers the service user the opportunity to
try out newly learned behaviour in the real environment and get immediate feedback
on performance. These treatments need to be delivered by appropriately trained
and competent staff and in accordance with the treatment manuals defining these
treatments.
When offered in an outpatient setting, these services could include:
 Cognitive behavioural therapies focused on alcohol-related problems
typically consisting of one 60-minute session per week for 12 weeks.
 Behavioural therapies focused on alcohol-related problems typically
consisting of one 60-minute session per week for 12 weeks.
 Social network and environment-based therapies focused on alcoholrelated 38 problems typically consisting of eight 50-minute sessions over
12 weeks.
 Behavioural couples therapy should be focused on alcohol-related
problems and their impact on relationships. It should aim for abstinence, or
a level of drinking predetermined and agreed by the therapist and the
service user to be reasonable and safe. It typically consists of one 60minute session per week for 12 weeks.
NB NICE guidelines suggest that both motivational techniques and twelve-step facilitation should be
seen as components of any effective psychosocial intervention delivered in alcohol services with the
assessment and enhancing of motivation forming a key element of the assessment process.
Alcohol day treatment programmes
Alcohol day treatment programmes are an intensive setting to offer a range of
structured psychosocial interventions (as described below) and support with daily
living skills. These programmes are often provided over several weeks with the
patient attending daily for at least 3 to 4 days of the week and engaged in activities
for at least 3 to 4 hours a day.
Alcohol specialist residential rehabilitation services
Alcohol residential rehabilitation can offer a range of interventions including assisted
withdrawal or provide an intensive supportive setting to deliver structured psycho5
Zweben, A., Pearlman, S. & Li, S. (1988). A comparison of brief advice and conjoint therapy in the treatment of
alcohol abuse: The results of the Marital System study. British Journal of Addiction, 83, 899-916.
6 Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change, (2nd edition). New
York: Guilford Press.
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social interventions as described above. These are often offered over several weeks
while the patient lives in residence with the service provider.
PHARMACOTHERAPY
Pharmacotherapy is recognised as an adjunct to psychosocial treatment to provide
an optimum treatment package to improve physical and mental health. All
medications should be used as an adjunct to psychosocial treatment and not
prescribed in isolation.
After a successful withdrawal for people with moderate and severe alcohol
dependence, consideration should be given to offering acamprosate or oral
naltrexone in combination with an individual psychological interventions.
Pharmacotherapies are generally targeted at a narrow spectrum of symptoms or
psychological problems such as cravings and the prevention of relapse. They are
delivered in conjunction with psychosocial interventions and can be a useful adjunct
to the treatment package.
These pharmacotherapies consist of:
 relapse prevention medications
i.
sensitising agents
ii.
anti craving agents
 nutritional supplements (prophylaxis for wernicke’s emcephalopathy)
AFTERCARE / REINTEGRATION / RECOVERY
In the later stages of treatment the focus will be more on reintegration into society
and restoration of normal function, including establishing a healthy lifestyle, finding
stable housing, re-entering employment, re-establishing contact with their families,
and forming appropriate and fulfilling relationships 7. All of these factors are
important in promoting longer term stable recovery.
Currently, the National Alcohol Treatment Monitoring System (NATMS) collects data
from treatment providers for these treatment modalities:
 Inpatient Treatment (Medically managed care)
o Inpatient detoxification within a hospital setting
 Residential Rehabilitation (setting for Psychosocial Interventions)
o Residential rehabilitation programmes outside hospital
 Community Prescribing (Medically managed care)
o Outpatient detoxification
o Pharmacotherapy to enhance treatment
 Structured Psychosocial Interventions
o Less intensive or brief treatments
o Evidenced based packages of therapy
 Structured Day Programme (setting for Psychosocial Interventions)
o Therapy programme with daily or frequent attendance
7
National Treatment Agency for Substance Misuse (2006) Models of Residential Rehabilitation for Drug and
Alcohol Misusers. London: NTA.
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

Other Structured Treatment
o Case management
o Key working
Brief Interventions
o Simple brief advice
o Brief lifestyle counselling
Table 1 details which Care Cluster might be best served by which elements of
treatment.
Table 1: Treatment Interventions & Care Clusters
Treatment
Harmful & Moderate
Severe
Intervention
Mild
Dependence
Dependence
Dependence
Inpatient
Withdrawal
+++
Management
Residential
++
Rehabilitation
Community
++
+++
Prescribing
Day Treatment
++
+++
Programme
Psychosocial
++
+++
+++
Intervention
Moderate /
Severe +
complex needs
Other
++
++
+++
Interventions
Brief
+++
++
Interventions
+++ Care Cluster treatment service best designed to address
++
Care Cluster treatment service may be needed to address
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+++
+++
++
+++
+++
+++
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