Alcohol dependence and harmful alcohol use

543 Pages·2010·3.72 MB·English

by  Esther Flanagan

DRAFT FOR CONSULTATION MAY 2010

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Alcohol use disorders: diagnosis,
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assessment and management of
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harmful drinking and alcohol
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dependence
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Full guideline draft for consultation
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June 2010
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Alcohol use disorders: harmful drinking and alcohol dependence 1
DRAFT FOR CONSULTATION MAY 2010
Contents
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3 Guideline Development Group members ........................................................................ 6
4 1 Preface ................................................................................................................................. 9
5 1.1 National guideline.................................................................................................... 9
6 1.2 The national alcohol dependence and harmful alcohol use guideline ..................... 12
7 2. Alcohol dependence and harmful alcohol use ...................................................... 14
8 2.1 Introduction ........................................................................................................... 14
9 2.2 Definitions ............................................................................................................. 15
10 2.3 Epidemiology of alcohol .......................................................................................... 17
11 2.4 Aetiology ................................................................................................................ 20
12 2.5 Course of harmful alcohol use and dependence ...................................................... 22
13 2.6 Pharmacology of alcohol ......................................................................................... 23
14 2.7 Identification and diagnosis ................................................................................... 24
15 2.8 The role of treatment and management ................................................................. 25
16 2.9 Current care in the NHS ....................................................................................... 27
17 2.10 Service user organisations ..................................................................................... 28
18 2.11 Impact on families .................................................................................................. 28
19 2.12 Economic impact .................................................................................................... 29
20 3. Methods used to develop this guideline ................................................................ 31
21 3.1 Overview ................................................................................................................ 31
22 3.2 The scope ................................................................................................................ 31
23 4. Experience of care ....................................................................................................... 51
24 4.1 Introduction ........................................................................................................... 51
25 4.2 Personal accounts—alcohol dependence and harmful alcohol use ......................... 51
26 4.3 Personal accounts—carers ..................................................................................... 58
27 4.4 Review of the qualitative literature ........................................................................ 65
28 4.5 Qualitative analysis – people with parents who have alcohol problems ................ 81
29 4.6 From evidence to recommendations ....................................................................... 90
30 5. The organisation and delivery of care for people who misuse alcohol ............ 94
31 5.1 Introduction ........................................................................................................... 94
32 5.2 Organising principles of care ................................................................................. 95
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DRAFT FOR CONSULTATION MAY 2010
1 5.3 Services for people who misuse alcohol .................................................................. 96
2 5.4 Clinical question .................................................................................................. 104
3 5.5 Introduction ......................................................................................................... 104
4 5.6 Case management ................................................................................................ 104
5 5.7 Assertive community treatment .......................................................................... 109
6 5.8 Stepped care ......................................................................................................... 113
7 5.9 From evidence to recommendations ..................................................................... 119
8 5.10 Recommendations ................................................................................................ 120
9 5.11 Research recommendation .................................................................................... 120
10 5.12 Introduction ......................................................................................................... 122
11 5.13 Clinical questions ................................................................................................. 123
12 5.14 Aim of review of diagnostic and assessment tools for alcohol dependence and
13 harmful alcohol use ........................................................................................................... 123
14 5.15 Quantitative review of assessment tools .............................................................. 124
15 5.16 Narrative synthesis of assessment tools ............................................................... 125
16 5.17 Assessment of alcohol dependence - review of included assessment tools ............ 127
17 5.18 The assessment of problems associated with alcohol misuse ................................ 130
18 5.19 The assessment of motivation .............................................................................. 135
19 5.20 The structure and content of the assessment interview ....................................... 137
20 5.21 The framework for assessment of alcohol misuse ................................................. 146
21 5.22 From evidence to recommendations ..................................................................... 167
22 5.23 Introduction ......................................................................................................... 173
23 5.24 Clinical questions ................................................................................................. 174
24 5.25 Assisted withdrawal ............................................................................................. 175
25 5.26 Evaluating dosing regimes for assisted withdrawal ............................................ 185
26 5.27 From evidence to recommendations: assisted withdrawal ................................... 194
27 5.28 Residential and community settings for the delivery of interventions for alcohol
28 misuse 198
29 6. Psychological and psychosocial interventions in the treatment and
30 management of alcohol misuse ....................................................................................... 214
31 6.1 Introduction ......................................................................................................... 214
32 6.2 Therapist factors ................................................................................................... 216
33 6.3 Matching effects/severity ..................................................................................... 219
34 6.4 Setting the context for TSF and AA .................................................................... 221
35 6.5 Review of psychological therapies ........................................................................ 221
36 6.6 Outcomes ............................................................................................................. 223
37 6.7 Motivational Techniques ..................................................................................... 224
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DRAFT FOR CONSULTATION MAY 2010
1 6.8 Twelve-Step Facilitation (TSF) ............................................................................ 231
2 6.9 Cognitive Behavioural Therapy ........................................................................... 237
3 6.10 Behavioural Therapies (excluding contingency management) ............................ 250
4 6.11 Contingency Management ................................................................................... 260
5 6.12 Social Network and Environment Based Therapies ............................................. 265
6 6.13 Couples Therapy .................................................................................................. 270
7 6.14 Counselling .......................................................................................................... 277
8 6.15 Psychodynamic Therapy ...................................................................................... 282
9 6.16 Multi-Modal Treatment ...................................................................................... 285
10 6.17 Self-help based treatment ..................................................................................... 287
11 6.18 Psychoeducational Interventions ......................................................................... 290
12 6.19 Mindfulness Meditation ...................................................................................... 295
13 6.20 Clinical evidence summary .................................................................................. 298
14 6.21 Health economic evidence .................................................................................... 299
15 6.22 Acupuncture ........................................................................................................ 308
16 6.23 Psychological interventions for carers ................................................................. 313
17 6.24 Children and young people .................................................................................. 316
18 6.25 The assessment of harmful alcohol use and dependence in children and young
19 people 318
20 6.26 Treatment interventions to reduce harmful drinking, promote abstinence and
21 prevent relapse in children and young people with harmful drinking and alcohol
22 dependence ........................................................................................................................ 325
23 7. Pharmacological interventions for treatment and management of alcohol
24 misuse .................................................................................................................................. 338
25 7.1 Introduction ......................................................................................................... 338
26 7.2 Review of pharmacological interventions ............................................................ 343
27 7.3 Meta-regression on baseline alcohol consumption and effectiveness ................... 368
28 7.4 Predictors of efficacy ............................................................................................ 373
29 7.5 Assessment, monitoring and side effect profile .................................................... 376
30 7.6 Health economic evidence .................................................................................... 379
31 7.7 Economic model ................................................................................................... 383
32 7.8 Other pharmacological interventions .................................................................. 396
33 7.9 Pharmacotherapy for less severely dependent and non-dependent drinkers ........ 399
34 7.10 Comorbidities ....................................................................................................... 400
35 7.11 Wernicke-Korsakoff Syndrome ............................................................................. 410
36 8. Appendices................................................................................................................. 414
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DRAFT FOR CONSULTATION MAY 2010
1 Appendix 1: Scope for the development of the clinical guideline ........................... 416
2 Appendix 2: Declarations of interests by GDG members ......................................... 421
3 Appendix 3: Special advisors to the Guideline Development Group ..................... 429
4 Appendix 4: Stakeholders who responded to early requests for evidence ............ 430
5 Appendix 5: Stakeholders and experts who submitted comments in response to the
6 consultation draft of the guideline ................................................................................ 431
7 Appendix 6: Researchers contacted to request information about studies ............ 432
8 Appendix 7: Clinical questions ....................................................................................... 433
9 Appendix 8: Review protocols ........................................................................................ 435
10 Appendix 9: Search strategies for the identification of clinical studies ................. 438
11 Appendix 10: Clinical study data extraction form ....................................................... 444
12 Appendix 11: Quality checklists for clinical studies and reviews ........................... 445
13 Appendix 12: Search strategies for the identification of health economics evidence
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15 Appendix 13: Quality checklists for economic studies .............................................. 462
16 Appendix 14: Data extraction form for economic studies .......................................... 465
17 Appendix 15. Network meta-analysis for the economic model ................................ 469
18 9. References .................................................................................................................. 475
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DRAFT FOR CONSULTATION MAY 2010
Guideline Development Group members
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2 Professor Colin Drummond (Chair, Guideline Development Group)
3 Professor of Addiction Psychiatry, Institute of Psychiatry, King’s College London
4 Professor Stephen Pilling
5 Director, National Collaborating Centre for Mental Health; Director, Centre for
6 Outcomes Research and Effectiveness, University College London.
7 Mr Adrian Brown
8 Alcohol Nurse Specialist, St Mary’s Hospital, Imperial College
9 Professor Alex Copello
10 Professor of Addiction Research, University of Birmingham
11 Dr Edward Day
12 Senior Lecturer and Consultant in Addiction Psychiatry, University of Birmingham
13 Mr John Dervan
14 Lay member and Retired Alcohol Treatment Agency CEO
15 Mr Matthew Dyer
16 Health Economist, National Collaborating Centre for Mental Health
17 Ms Esther Flanagan
18 Guideline Development Manager, National Collaborating Centre for Mental Health
19 Ms Jan Fry
20 Carer Representative and voluntary sector consultant
21 Mr Brendan Georgeson
22 Treatment Coordinator, Walsingham House, Bristol
23 Dr Eilish Gilvarry
24 Consultant Director in Addictions, and Assistant Medical Director, Northumberland,
25 Tyne & Wear NHS Trust
26 Ms Jayne Gosnall
27 Service User Representative and Treasurer of Salford Drug and Alcohol Forum
Alcohol use disorders: harmful drinking and alcohol dependence 6
DRAFT FOR CONSULTATION MAY 2010
1 Dr Linda Harris
2 Clinical Director Integrated Substance Misuse Services and Director RCGP substance
3 misuse unit
4 Professor Anne Lingford-Hughes
5 Professor of Addiction Biology, Imperial College London, Hon Consultant, Central
6 North West London NHS Foundation Trust.
7 Dr Ifigeneia Mavranezouli
8 Senior Health Economist, National Collaborating Centre for Mental Health
9 Mr Trevor McCarthy
10 Independent Consultant
11 Dr Marsha Morgan
12 Reader in Medicine and Honorary Consultant Physician, University of London
13 Medical School
14 Mrs Stephanie Noble
15 Registered Manager/Nursing Manager, Broadway Lodge
16 Dr Suffiya Omarjee
17 Health Economist, National Collaborating Centre for Mental Health
18 Mr Tom Phillips
19 Consultant Nurse in Addiction, Humber NHS Foundation Trust
20 Dr Pamela Roberts
21 Consultant Clinical and Forensic Psychologist, Cardiff Addictions Unit
22 Mr Rob Saunders
23 Research Assistant, National Collaborating Centre for Mental Health
24 Ms Laura Shields
25 Research Assistant, National Collaborating Centre for Mental Health
26 Dr Julia Sinclair
27 Senior Lecturer in Psychiatry, University of Southampton
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DRAFT FOR CONSULTATION MAY 2010
1 Ms Sarah Stockton
2 Senior Information Scientist, National Collaborating Centre for Mental Health
3 Dr Clare Taylor
4 Senior Editor, National Collaborating Centre for Mental Health
5 Dr Amina Yesufu -Udechuku
6 Systematic Reviewer, National Collaborating Centre for Mental Health
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Alcohol use disorders: harmful drinking and alcohol dependence 8
DRAFT FOR CONSULTATION MAY 2010
1 Preface
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2 This guideline is one of three pieces of NICE guidance addressing alcohol-use
3 disorders. The present guideline addresses the management of alcohol dependence
4 and harmful alcohol use in people 10 years and older including: assessment,
5 pharmacological interventions, psychological and psychosocial interventions, and
6 settings of assisted withdrawal and rehabilitation. The two other NICE guidelines
7 address: 1) The prevention of alcohol-use disorders in people 10 years and older,
8 which is public health guidance on the price of alcohol, advertising and availability
9 of alcohol, how best to detect alcohol misuse both in and outside primary care and
10 brief interventions to manage alcohol misuse in these settings (NICE, 2010a), and 2)
11 The assessment and clinical management in people 10 years and older of acute
12 alcohol withdrawal, including delirium tremens, liver damage, acute and chronic
13 pancreatitis and the management of Wernicke’s encephalopathy (NICE, 2010b).
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15 This guideline will sometimes use the term alcohol misuse, which will encompass
16 both people with alcohol dependence and harmful alcohol use.
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18 The guideline recommendations have been developed by a multidisciplinary team of
19 healthcare professionals, lay member, service user and carer representatives, and
20 guideline methodologists, after careful consideration of the best available evidence. It
21 is intended that the guideline will be useful to clinicians and service commissioners
22 in providing and planning high-quality care for people who misuse alcohol while
23 also emphasising the importance of the experience of care for them and their carers.
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25 Although the evidence base is expanding, there are also a number of gaps in the
26 literature. The guideline makes a number of research recommendations specifically
27 to address gaps in the evidence base. In the meantime, it is hoped that the guideline
28 will assist clinicians, people who misuse alcohol and their carers by identifying the
29 merits of particular treatment approaches where the evidence from research and
30 clinical experience exists.
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32 1.1 National guideline
33 1.1.1 What are clinical practice guidelines?
34 Clinical practice guidelines are ‘systematically developed statements that assist
35 clinicians and patients in making decisions about appropriate treatment for specific
36 conditions’ (Mann, 1996). They are derived from the best available research evidence,
37 using predetermined and systematic methods to identify and evaluate the evidence
38 relating to the specific condition in question. Where evidence is lacking, the
39 guidelines incorporate statements and recommendations based upon the consensus
40 statements developed by the Guideline Development Group (GDG).
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42 Clinical guidelines are intended to improve the process and outcomes of healthcare
43 in a number of different ways. They can:
44 • provide up-to-date evidence-based recommendations for the management of
45 conditions and disorders by healthcare professionals
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DRAFT FOR CONSULTATION MAY 2010
1 • be used as the basis to set standards to assess the practice of healthcare
2 professionals
3 • form the basis for education and training of healthcare professionals
4 • assist people with alcohol dependence and harmful alcohol use and their carers in
5 making informed decisions about their treatment and care
6 • improve communication between healthcare professionals, people with alcohol
7 dependence and harmful alcohol use and their carers
8 • help identify priority areas for further research.
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10 1.1.2 Uses and limitations of clinical guidelines
11 Guidelines are not a substitute for professional knowledge and clinical judgement.
12 They can be limited in their usefulness and applicability by a number of different
13 factors: the availability of high-quality research evidence, the quality of the
14 methodology used in the development of the guideline, the generalisability of
15 research findings and the uniqueness of individuals who misuse alcohol.
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17 Although the quality of research in this field is variable, the methodology used here
18 reflects current international understanding on the appropriate practice for guideline
19 development (AGREE: Appraisal of Guidelines for Research and Evaluation
20 Instrument; www.agreecollaboration.org), ensuring the collection and selection of
21 the best research evidence available and the systematic generation of treatment
22 recommendations applicable to the majority of people with these disorders and
23 situations. However, there will always be some people and situations for which
24 clinical guideline recommendations are not readily applicable. This guideline does
25 not, therefore, override the individual responsibility of healthcare professionals to
26 make appropriate decisions in the circumstances of the individual, in consultation
27 with the person with alcohol dependence and harmful alcohol use or their carer.
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29 In addition to the clinical evidence, cost-effectiveness information, where available, is
30 taken into account in the generation of statements and recommendations of the
31 clinical guidelines. While national guidelines are concerned with clinical and cost
32 effectiveness, issues of affordability and implementation costs are to be determined
33 by the National Health Service (NHS).
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35 In using guidelines, it is important to remember that the absence of empirical
36 evidence for the effectiveness of a particular intervention is not the same as evidence
37 for ineffectiveness. In addition, of particular relevance in mental health, evidence-
38 based treatments are often delivered within the context of an overall treatment
39 programme including a range of activities, the purpose of which may be to help
40 engage the person and to provide an appropriate context for the delivery of specific
41 interventions. It is important to maintain and enhance the service context in which
42 these interventions are delivered; otherwise the specific benefits of effective
43 interventions will be lost. Indeed, the importance of organising care in order to
44 support and encourage a good therapeutic relationship is at times as important as the
45 specific treatments offered.
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