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

Key recommendations

Identification and assessment in all settings

• Staff working in services provided and funded by the NHS who care for people who potentially misuse alcohol should be competent to identify harmful drinking and alcohol dependence. They should be competent to initially assess the need for an intervention or, if they are not competent, they should refer people who misuse alcohol to a service that can provide an assessment of need.

Assessment in specialist alcohol services

• Consider a comprehensive assessment for all adults referred to specialist services who score more than 15 on the Alcohol Use Disorders Identification Test (AUDIT). A comprehensive assessment should assess multiple areas of need, be structured in a clinical interview, use relevant and validated clinical tools (see 1.2.1.4), and cover the following areas:
• alcohol use, including:
  • consumption: historical and recent patterns of drinking (using, for example, a retrospective drinking diary), and if possible, additional information (for example, from a family member or carer)
  • dependence (using, for example, SADQ or Leeds Dependence Questionnaire [LDQ])
  • alcohol-related problems (using, for example, Alcohol Problems Questionnaire [APQ])
  • other drug misuse, including over-the-counter medication
  • physical health problems
  • psychological and social problems
  • cognitive function (using, for example, the Mini-Mental State Examination [MMSE])
  • readiness and belief in ability to change.

General principles for all interventions

• 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.
  • 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, which should guide the structure and duration of the intervention. Staff should consider using competence frameworks developed from the relevant treatment manuals and for all interventions should:
• receive regular supervision from individuals competent in both the intervention and supervision
• routinely use outcome measurements to make sure that the person who misuses alcohol is involved in reviewing the effectiveness of treatment
• engage in monitoring and evaluation of treatment adherence and practice competence, for example, by using video and audio tapes and external audit and scrutiny if appropriate.

Interventions for harmful drinking and mild alcohol dependence

• For harmful drinkers and people with mild alcohol dependence, offer a psychological intervention (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol-related cognitions, behaviour, problems and 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.

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 (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol misuse.

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 (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy) 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 as this may lead to significant improvement in the depression and anxiety. If depression or anxiety continues after 3 to 4 weeks of abstinence from alcohol, undertake an assessment of the depression or anxiety and consider referral and treatment in line with the relevant NICE guideline for the particular disorder.