Evidence

2019 surveillance of alcohol-use disorders (NICE guidelines PH24 and CG115)

Overview of 2019 surveillance methods

Overview of 2019 surveillance methods

NICE's surveillance team checked whether recommendations in the following guidelines remain up to date:

The surveillance process consisted of:

  • Feedback from topic experts via a questionnaire.

  • A search for new or updated Cochrane reviews and national policy.

  • Consideration of evidence from previous surveillance.

  • Examining related NICE guidance and quality standards and NIHR signals.

  • A search for ongoing research.

  • Examining the NICE event tracker for relevant ongoing and published events.

  • Literature searches to identify relevant evidence.

  • Assessing the new evidence against current recommendations to determine whether or not to update sections of the guideline, or the whole guideline.

  • Consulting on the proposal with stakeholders.

  • Considering comments received during consultation and making any necessary changes to the proposal.

For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Evidence considered in surveillance

Search and selection strategy

We searched for new evidence related to the whole guideline for alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115), and for recommendations 4 to 12 within alcohol-use disorders: prevention (NICE guideline PH24). Recommendations 1 to 3 within NICE's guideline on alcohol-use disorders: prevention were excluded from the 2019 surveillance review as they are national policy recommendations, which are not within NICE's current remit.

NICE is currently developing a guideline on behaviour change: digital and mobile health interventions which will cover digital interventions for hazardous drinking and, as such, digital interventions are not part of the scope of the current surveillance review of NICE's guideline on alcohol-use disorders: prevention. Digital interventions for harmful drinking are within scope of the current surveillance review for the NICE guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence as they will not be covered by the in-development guideline on behaviour change.

Searches were conducted between 10 November 2014 to 14 August 2018 for NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, and between 5 July 2013 to 7 September 2018 for NICE's guideline on alcohol-use disorders: prevention, which reflected previous surveillance cut-off periods, and the dates when searches were conducted. However, both searches provided studies that were relevant to both guidelines.

Alcohol-use disorders: prevention (NICE guideline PH24)

We found 85 studies in a search for observational, experimental and systematic reviews for recommendation 4 on licensing, and a search for randomised controlled trials and systematic reviews for recommendations 5 to 11.

We also included:

  • 1 study, which was not identified via literature searches, from a total of 11 studies identified by topic experts

  • 15 studies identified by searches conducted in previous surveillance in 2014, including those from comments received during consultation on the previous surveillance review in 2014.

From all sources, we considered 101 studies to be relevant to the guideline.

See appendix A1: summary of evidence from surveillance for details of all evidence considered, and references.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115)

We found 79 studies in a search for randomised controlled trials and systematic reviews.

There were also 94 studies identified by searches conducted in previous surveillance in 2013 and 2015.

From all sources, we considered 173 studies to be relevant to the guideline.

See appendix A2: summary of evidence from surveillance for details of all evidence considered, and references.

Selecting relevant studies

Studies were selected in line with the standard surveillance methods, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual. However, due to the amount of research available in relation to brief advice for adults (recommendation 10 in NICE's guideline on alcohol-use disorders: prevention), only systematic reviews were included in the 2019 evidence summary, and randomised controlled trials (RCT) were summarised briefly apart from RCTs that were not covered by systematic reviews, which were included.

Ongoing research

We checked for relevant ongoing research; of the ongoing studies identified, 2 were assessed as having the potential to change recommendations. Therefore, we plan to regularly check whether these studies have published results and evaluate the impact of the results on current recommendations as quickly as possible. These studies are:

Intelligence gathered during surveillance

Views of topic experts

We considered the views of Public Health England (PHE) and topic experts who were recruited to the NICE Centre for Guidelines Expert Advisors Panel to represent their specialty. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to the guidelines.

We sent questionnaires to 21 topic experts. The experts completing the questionnaires included representation from PHE, academics with a specialist interest in alcohol and substance misuse, commissioners of drug and alcohol services, and medical professionals involved in treating alcohol misuse.

Alcohol-use disorders: prevention (NICE guideline PH24)

All experts who completed the questionnaire in relation to this guideline felt that it required updating. The main issues raised were changes to how alcohol services are commissioned and delivered, new evidence on brief advice, and a potential overlap between recommendations 6 and 7 in this guideline and recommendations 1.3.7.1 to 1.3.7.4 in NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Further clarity was sought from experts on the potential overlap between guideline recommendations. The views, whilst mixed, seemed to indicate that, on balance, the recommendations complemented each another, with this guideline focussing on prevention, and the other one focussing on treatment.

Digital interventions were also raised as a potential update area by topic experts. However, NICE is currently developing a guideline on behaviour change: digital and mobile health interventions which will cover digital interventions for hazardous drinking and, as such, digital interventions were not part of the surveillance review for this guideline.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115)

All experts who completed the questionnaire in relation to this guideline felt that it required updating. The main issues raised were changes to how alcohol services are commissioned and delivered and new evidence on pharmacotherapies for withdrawal and relapse prevention. Comments were also made on a lack of resources affecting implementation of recommendations and the delivery of services, such as the provision of psychological services, as well as comments that some drugs have become licensed for alcohol dependence.

Uptake of the guideline

There was no implementation information available on the uptake of these guidelines in practice.

Other sources of information

We considered all other correspondence received since the guideline was published. These included external communications from healthcare professionals and external organisations received before and during this surveillance review.

Views of stakeholders

Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance proposal was to update NICE's guideline on alcohol-use disorders: prevention and not update NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, we consulted with stakeholders.

Overall, 6 stakeholders commented on NICE's guideline on alcohol-use disorders: prevention and 5 stakeholders commented on NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Stakeholders included PHE, NHS England, professional bodies and charities.

Alcohol-use disorders: prevention (NICE guideline PH24)

Overall 4 out of 6 stakeholders agreed with the proposal to update defined sections of the guideline. Comments made included:

  • Support for the need to offer brief advice in settings only where there is evidence that they are effective and cost-effective.

  • The need to provide additional support to groups who are underserved or for whom there are barriers in accessing services. A reference to the LGB&T briefing on Alcohol identification and brief advice, which provides information on how brief advice may be made more accessible to LGBT people. This briefing will be passed onto the NICE team planning the update of this guideline.

See appendix B1 for full details of stakeholders' comments and our responses.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115)

Overall 4 out of 5 stakeholders agreed with the proposal to not update the guideline and 1 stakeholder did not provide any comment. Comments made included:

  • We received a proposal to revise recommendation 1.2.2.8 where it suggests access to treatment of mental health disorders that persist beyond 3 to 4 weeks after abstinence, as this stands in the way of immediate treatment. The committee who developed the guideline noted that for many people, symptoms of, for example, depression and anxiety may reduce following 3 to 4 weeks of abstinence from alcohol. The committee felt it is therefore often not appropriate or necessary to instigate treatment for the disorder at the point of the initial assessment. They also noted that careful monitoring and reassessment of mental health symptoms following abstinence are an important part of the assessment procedure. We found no new evidence to change this recommendation and professionals are anticipated to safeguard individuals and take appropriate action if they are concerned about co-morbid mental health conditions. The committee felt it is therefore often not appropriate or necessary to instigate treatment for the disorder at the point of the initial assessment.

  • We received a proposal to amend recommendation 1.3.3.2 to clarify that behavioural couples' therapy should not be used where domestic violence is a current concern in the relationship. See editorial amendments for details of how this will impact recommendation 1.3.3.2.

  • A stakeholder had a concern that updating the NICE guideline on alcohol-use disorders: prevention could impact upon this guideline and that all links should be appropriately updated. During the update of NICE's guideline on alcohol-use disorders: prevention we will check and update cross-references to this guideline as needed.

See appendix B2 for full details of stakeholders' comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Equalities

During stakeholder consultation it was highlighted that LGBT people need greater attention when planning and delivering alcohol services as they are more likely to misuse alcohol than the general population but may face barriers in accessing services. A reference to the LGB&T briefing on Alcohol identification and brief advice was provided, which includes information on how brief advice may be made more accessible to LGBT people. This equalities issue will be considered during the development of the update.

Editorial amendments

During surveillance of the guidelines, we identified the following points that should be amended.

Alcohol-use disorders: prevention (NICE guideline PH24)

Recommendation 5 will be amended to refresh out of date links to 'World class commissioning' and 'Signs for improvement'. The recommendation will state: 'Commissioners should ensure a local joint alcohol needs assessment is carried out in accordance with the Alcohol, drugs and tobacco: commissioning support pack and the Local alcohol services and systems improvement tool.

Recommendation 7 will be amended to add: 'Use professional judgement as to whether to revise the AUDIT scores downwards when screening people under the age of 18'.

Recommendation 9 will be amended to remove the second sub-bullet point on younger people (under the age of 18) in relation to: 'Use professional judgement as to whether to revise the AUDIT scores downwards when screening'.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115)

Recommendation 1.3.3.2 will be amended to say: 'Offer behavioural couples' therapy for harmful drinkers and people with mild alcohol dependence who have a regular partner who is willing to participate in treatment, unless there are indicators that the person is currently experiencing, or is a current perpetrator of, domestic abuse'.

Recommendation 1.3.3.2 will be amended to include the following cross reference: 'For advice on the use of nalmefene for alcohol dependence see NICE's technology appraisal guidance on nalmefene for reducing alcohol consumption in people with alcohol dependence'.

Recommendation 1.3.5.3 will be amended to add: 'Prescribers should be aware of the following legislation and advise patients accordingly: Drugs and driving: blood concentration limits to be set for certain controlled drugs in a new legal offence (2014)'.

Recommendation 1.3.5.11 will be amended to add: 'Prescribers should also see Addiction to benzodiazepines and codeine (July 2011)'.

Recommendation 1.3.8.4 will be amended with a cross reference to NICE's guideline on stop smoking interventions and services, which has since replaced NICE's guideline on smoking: brief interventions and referrals, which was published in 2006.

Footnotes 1, 5 and 16 will be amended to the new standard wording for unlicensed medicines: 'The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information'.

Footnotes 2 and 7 will be amended to reflect changes in licensing: 'Oral naltrexone is licensed for alcohol dependence. See the summary of product characteristics. Prescribers should follow the safety advice around opioids'.

Footnotes 12 and 13 will be amended to the new standard wording for unlicensed medicines: 'The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Prescribers should check the licensing status of benzodiazepines in this age group'.

Footnote 17 will be amended to include NICE's guideline on antisocial personality disorder: prevention and management. It will also be amended to say: 'Also see NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services'.

Overall decision

After considering all evidence and other intelligence and the impact on current recommendations, we decided to update the guideline on alcohol-use disorders: prevention (NICE guideline PH24). The update will focus on screening children and young people aged 10 to 15 years, and 16 and 17 years (recommendations 6 and 7), and brief advice and extended brief advice in adults in various settings and populations (recommendations 10 and 11).

We decided not to update the guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115) as the new evidence was not deemed sufficient at this point in time to change recommendations.

ISBN: 978-1-4731-3461-4


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