The majority of people who are dependent on alcohol are not currently being treated, partly because health and social care professionals are failing to identify those in need and assisted withdrawal treatments are inadequate. In response, the National Institute for Health and Care Excellence (NICE) has published guidance today (23 February) which outlines how the NHS should diagnose, assess and treat the condition.

Although over one million people in England are dependent on alcohol, only around 6% of these currently receive treatment^[1]. This means that every year there are over 940,000 people who are either not seeking help, do not have access to the relevant services, or whose symptoms are not being appropriately identified by healthcare professionals.

This is the first time that NICE has published guidance for the NHS to help address these serious variations in clinical practice. The guideline calls for all relevant health and social care professionals to be able to identify patients who could be misusing alcohol through clinical interviews and internationally recognised assessment tools, such as the AUDIT and SADQ^[2]. These will help healthcare professionals to make accurate diagnoses and measure the severity of their patients' dependence, on which their subsequent treatment options will be based.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE said: “People who suffer from alcohol dependence often face much stigma and discrimination in their day to day lives which can act as a barrier to them seeking help. Our guideline calls for all healthcare professionals who come into contact with these people to be appropriately trained to identify those in need and be able to offer them help in a trusting, supportive and non-judgemental environment.

“Improvements must be made across the NHS so that more people can be correctly diagnosed, assessed and treated for their dependence and harmful drinking patterns. Our clinical guideline outlines the most effective ways that the NHS can do this, based on the available evidence and expert feedback.”

Alcohol dependence is characterised by a craving for, tolerance of, and preoccupation with alcohol and continued drinking, despite the physical and mental harm that it can cause. Harmful drinking is defined as drinking over the recommended weekly amount and experiencing health problems directly related to alcohol. This could include psychological problems such as depression and anxiety, or physical illness such as high blood pressure, acute pancreatitis, liver cirrhosis, heart disease and several cancers.

Other key recommendations from NICE include:

• Harmful drinkers and people who are mildly dependent (e.g. those who score 15 or less on the SADQ) should be offered psychological interventions, such as cognitive behavioural therapy, behavioural couples therapy or social network and environment-based therapies.
• People who drink more than 15 units a day or who score 20 or more on the AUDIT should be offered a structured assisted withdrawal programme. This can be offered in a community-based setting, unless there are safety concerns; e.g. if the person drinks more than 30 units a day, scores more than 30 on the SADQ, has a history of epilepsy, withdrawal-related seizures, delirium tremens or previous withdrawal attempts, is homeless, or needs concurrent assisted withdrawal from benzodiazepines. In these circumstances, people should be offered an inpatient or residential assisted withdrawal programme. People who drink 15-20 units of alcohol a day and have significant mental or physical problems (e.g. depression or psychosis) or a significant learning disability or cognitive impairment, should also be offered inpatient or residential assisted withdrawal.
• After completing a successful alcohol withdrawal programme, healthcare professionals should consider offering people who were moderately or severely dependent, acamprosate or oral naltrexone. This should be offered alongside an individual psychological intervention which specifically focuses on alcohol misuse.
• Health and social care professionals should seek to treat a person's alcohol misuse before treating any coexisting mental health conditions, e.g. depression or anxiety. This is because symptoms can often improve once alcohol misuse has been effectively treated. However, if a person with a mental health condition hasn't experienced significant improvements after abstaining from alcohol for around 3-4 weeks, then the health and social care professionals should consider referring them for specific treatment of this.

Dr Linda Harris, GP and Guideline Developer said: “For far too long, poor recognition of alcohol misuse has been a major barrier to effective treatment. The guideline calls for GPs and other frontline healthcare professionals to be competent enough to identify those who may be drinking harmful amounts or who may be alcohol dependent, so that everyone in need can receive appropriate treatment. The use of structured clinical interviews and internationally recognised assessment tools like the AUDIT can greatly support this.”

Professor Colin Drummond, Professor of Addiction Psychiatry and Chair of the Guideline Development Group said: “The clinical guideline from NICE has been developed following a detailed systematic review of research on the full range of alcohol treatments to date. The evidence shows that alcohol treatment can be both effective and cost effective. However the effectiveness of these are crucially dependent upon people who misuse alcohol having better access to evidence-based interventions, which are delivered by appropriately trained and skilled staff.

“With problems relating to alcohol consumption increasing steeply in the UK, I hope that this guideline provides a much needed impetus to making effective treatments more available to those who need them.”

Download PDF version

[1] Drummond DC, Oyefeso N, Phillips T, Cheeta S, Deluca P, Perryman K, et al. (2005) Alcohol needs assessment research project: the 2004 national alcohol needs assessment for England. London: Department of Health.

[2] See the Notes to Editors.

Notes to Editors

About the clinical guideline

1. For further information about NICE clinical guideline 115 on “Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence” visit: www.nice.org.uk/CG115.

2. The Alcohol Use Disorders Identification Test (AUDIT) is a ten-question assessment developed by the World Health Organization and used by healthcare professionals to help determine if a person is drinking hazardous or harmful amounts of alcohol or if they could be alcohol dependent.

3. The Severity of Alcohol Dependence Questionnaire (SADQ) is a twenty-item clinical screening tool developed by King's College London and used by specialist healthcare professionals to measure the severity of a person's alcohol dependence.

4. The clinical guideline was developed for NICE by the National Collaborating Centre for Mental Health. For further information about the NCCMH visit www.nccmh.org.uk/.

5. This clinical guideline on “Alcohol dependence” complements two existing pieces of NICE guidance, published last year:

a. “Alcohol-use disorders: preventing the development of harmful and hazardous drinking - public health guidance on the price, marketing and availability of alcohol, how best to detect alcohol misuse in and outside of primary care, and brief interventions to manage it in these settings.” For more information visit: www.nice.org.uk/PH24.

b. “Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications - a clinical guideline covering acute alcohol withdrawal (including delirium tremens), alcohol-related liver damage, alcohol-related pancreatitis and Wernicke's encephalopathy”. For more information visit: www.nice.org.uk/CG100.

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS

3. NICE produces standards for patient care:

• quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
• Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.