AUD: diagnosis, assessment and management of harmful drinking and alcohol dependence

Citation

(2011), "AUD: diagnosis, assessment and management of harmful drinking and alcohol dependence", Advances in Dual Diagnosis, Vol. 4 No. 1. https://doi.org/10.1108/add.2011.54104aaa.006

AUD: diagnosis, assessment and management of harmful drinking and alcohol dependence

Article Type: News From: Advances in Dual Diagnosis, Volume 4, Issue 1

Recommendations are made in nine key areas: general principles of care, identification and assessment, assessment in specialist alcohol services, general principles for interventions, interventions for harmful drinking and mild dependence, interventions for moderate and severe alcohol dependence, assessment and interventions for assisted alcohol withdrawal, assessment and interventions for children and young people and interventions for conditions co-morbid with alcohol misuse.

The importance of staff competence is highlighted in relation to identification and assessment of harmful and dependent drinking, and delivery of interventions. It is also noted that staff should receive supervision from someone competent in the intervention and supervision.

AUDIT is again identified as the most appropriate tool to detect problem drinking. For those scoring 20 or more (i.e. dependent drinkers), it is recommended that the severity of dependence questionnaire (SADQ) (Stockwell et al., 1983) or the leeds dependence questionnaire (Raistrick et al., 1994) be completed. Scores on the SADQ indicate whether dependence is mild (<15), moderate (15-30) or severe (31+). The full NICE guideline includes summary flow charts for case identification and diagnosis and treatment of withdrawal based on these tools. Further tools that are recommended are the CIWA-AR Clinical Institute Withdrawal Assessment of Alcohol Scale (revised) (Sullivan et al., 1989), to assess the severity of withdrawal, and the alcohol problems questionnaire (Drummond, 1990) to assess the nature and extent of problems arising from alcohol misuse. The importance of assessing outcomes to routinely review treatment effectiveness is emphasised. AUDIT is identified as a suitable tool.

In relation to interventions, as well as general principles, such as taking a motivational approach, and providing information about community support networks and self-help groups (such as Alcoholics Anonymous and SMART Recovery), guidance to inform decisions about whether treatment should be provided in community or in-patient/residential settings is provided. Psychological interventions that are recommended include: cognitive behavioural therapies, behavioural therapies, social network and environment-based therapies.

Detailed guidance is provided on the assessment and delivery of assisted alcohol withdrawal and prescribing to support abstinence. A supplementary document provides examples of chlordiazepoxide dosing regimens.

Special considerations for children and young people are set out in a separate section.

In relation to the care and treatment of people that may have co-existing alcohol and mental health problems, it is noted that assessment of mental health problems should be integral to a comprehensive alcohol assessment. For people requiring assisted alcohol withdrawal “significant” psychiatric co-morbidity is identified as an indication that detoxification in an inpatient or residential, rather than community, setting is needed.

For people with co-morbid alcohol misuse and depression or anxiety the guidance recommends that alcohol misuse should be treated first as this can lead to a significant improvement in mental health problem. While, on one hand this recommendation is understandable, it may have unintended consequences. Particularly in the current climate, where many services are facing significant disinvestment, this recommendation may result in mental health teams excluding such people from services until they had addressed their alcohol problem. It will be essential that local care pathways are clarified to ensure that this does not happen.

If mental health symptoms persist when the person is abstinent treatment for the co-existing mental health disorder should be provided in line with the relevant NICE guidance: this may be delivered by the alcohol service or following onward referral. Again it will be important that local agreements have been made to ensure that such provision is available.

One positive note is that the guidance recommends that, although abstinence would be the most appropriate treatment goal for dependent drinkers who have significant psychiatric (or physical) co-morbidity, if the service user wants to work towards moderation rather than abstinence, treatment in specialist alcohol services should not be refused and a harm reduction approach should be considered.

For full details of all three pieces of guidance go the NICE web site www.nice.org.uk.

NICE produce several versions of their guidance: the full guideline, NICE guideline, quick reference guide and guidance for service users and carers. The full guidelines can be lengthy (AUD: diagnosis, assessment and management of harmful drinking and alcohol dependence is over 600 pages). However, it can be useful to “dip” into these. They include a wealth of information including a good introductory overview of the topic, the methods used to develop the guidance, the evidence that was reviewed and the recommendations themselves. An “experiences of care” chapter reviews relevant published literature and includes the accounts of service users and carers. As the name suggests, the “quick reference guides” provide an overview of the key recommendations.

In addition to the guidance implementation tools are available, such as slides that can be used for teaching, and AUDIT tools. The guidance and implementation tools can also be downloaded from the NICE web site. The links for the AUDs quick reference guides are included here.