How to manage harmful drinking
A guideline advises on diagnosing, assessing and managing harmful drinking and alcohol dependence in adults and young people
Harmful drinking and alcohol dependence are related to numerous health conditions and social problems (Rehm et al, 2009). One in 20 (4%) adults in England is alcohol dependent, with over one in four (26%) consuming alcohol in a way that is potentially or actually harmful (Drummond et al, 2005).
Alcohol misuse is also an increasing problem in children and young people, with more than 24,000 treated in the NHS for alcohol-related problems in 2008 (Fuller, 2009).
This February, the National Institute for Health and Clinical Excellence published its second clinical guideline on how the NHS should identify and treat alcohol misuse. This article summarises the most important recommendations that can be applied in non-specialist and specialist settings.
Implications for nursing practice
Nurses working in services funded by the NHS who care for people who potentially could misuse alcohol should be able to identify harmful drinking and alcohol dependence. They should be able to assess initially to see if any intervention is needed, or, if they are not competent to do this, should refer people who misuse alcohol to a service that can assess their need.
This initial assessment needs to consider the severity of alcohol dependence, risk of damage to health, extent of associated health and social problems and the need for assisted alcohol withdrawal.
The NICE clinical guideline recommends using formal assessment tools during this assessment. These include:
- Alcohol Use Disorders Identification Test (AUDIT) for identification of alcohol use (Babor et al, 2001);
- Clinical Institute Withdrawal Assessment of Alcohol Scale, revised for severity of withdrawal (Sullivan
- et al, 1989);
- Alcohol Problems Questionnaire for the nature and extent of the problems arising from alcohol misuse (Drummond, 1990).
Adult service users who score more than 15 on AUDIT at initial assessment in non-specialist settings or triage assessment in specialist alcohol services should be considered for a comprehensive assessment by specialist alcohol services.
Comorbid mental health problems and cognitive impairment are common in people who misuse alcohol and should be identified as part of the assessment.
Treatment goals depend on the level of severity of alcohol misuse and secondary problems.
All interventions for people who misuse alcohol should be delivered by competent, trained staff. Nurses should receive regular guidance from people who are competent in both intervention and supervision.
Harmful drinkers and people with mild alcohol dependence should be offered a psychological intervention, such as cognitive behavioural therapy, that focuses specifically on alcohol-related cognitions, behaviour, problems and social networks.
People who typically drink more than 15 units of alcohol per day and/or who score 20 or more on the AUDIT should be considered for an assisted alcohol reduction programme where medication can be administered according to a standard clinical protocol. Those who need assisted withdrawal should usually be offered a community-based programme.
Those with comorbid problems or who typically drink over 30 units of alcohol per day and/or have a score of more than 30 on the Severity of Alcohol Dependence Questionnaire should be considered for inpatient or residential assisted withdrawal. Criteria for access to inpatient care and medication doses may need to be lower for children and young people.
Children and young people aged 10-17 years who misuse alcohol, have limited comorbidities and good social support should be offered individual cognitive behavioural therapy. Those with significant comorbidities and/or limited social support should be offered multicomponent programmes, such as multidimensional family therapy.
This guideline emphasises the importance of identifying, assessing and diagnosing harmful drinking or alcohol dependence so evidence-based interventions can be delivered by trained and competent nurses. This will lead to improved outcomes. As frontline professionals, nurses have a vital role in this pathway of care. NT
The guideline, Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence, is available for download at www.nice.org.uk/CG115
Tom Phillips is consultant nurse in addiction, Humber Foundation Trust, CNO/NIHR, clinical doctoral research fellow with the Department of Addiction, Institute of Psychiatry, King’s College London, and a member of the NICE guideline development group
Babor T et al (2001) Brief Intervention for Hazardous and Harmful Drinking: a Manual for Use in Primary Care. Geneva: World Health Organization and Department of Mental Health and Substance Dependence. www.tinyurl.com/hazardous-harmful-drinking
Drummond C et al (2005) Alcohol Needs Assessment Research Project: the 2004 National Alcohol Needs Assessment for England. London: Department of Health.
Drummond DC (1990)The relationship between alcohol dependence and alcohol-related problems in a clinical population. British Journal of Addiction; 85: 3, 357-366.
Fuller E (2009) Smoking, Drinking and Drug Use Among Young People in England in 2008. London: National Centre for Social Research and National Foundation for Educational Research.
Rehm J et al (2009) Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. The Lancet; 27: 373, 2223-2233.
Sullivan JT et al (1989) Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale. British Journal of Addiction;11: 1353-1357.