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Alcohol-Use Disorders Guideline at a Glance (Nursing Practice Guideline)

Alcohol-Use Disorders Guideline at a Glance (Nursing Practice Guideline) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines




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Guideline Title: Alcohol-Use Disorders: diagnosis, assessment and management of harmful
drinking and alcohol dependence

Effective Date: November 2014
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council

I. Guideline Overview

This content is extracted from the adopted source document: National Institutes for Health and
Clinical Excellence (NICE). (2011). Alcohol use disorders: Diagnosis, assessment, and
management of harmful drinking and alcohol dependence (National Clinical Practice Guideline
115). Leicester & London, UK: The British Psychological Society & The Royal College of
Psychiatrists. Please refer to the source guideline for complete information.
Population
Groups that will be covered
• Young people (10 years and older) and adults with a diagnosis of alcohol dependence
or harmful alcohol use.
Groups that will not be covered
• Children younger than 10 years.
• Pregnant women.

The present guideline addresses the management of alcohol dependence and harmful alcohol
use in people aged 10 years and older, including assessment, pharmacological interventions,
psychological and psychosocial interventions, and settings of assisted withdrawal and
rehabilitation.

Specific aims of this guideline

The guideline makes recommendations for the treatment and management of alcohol
dependence and harmful alcohol use. It aims to:
• improve access and engagement with treatment and services for people who misuse
alcohol
• evaluate the role of specific psychological, psychosocial and pharmacological
• interventions in the treatment of alcohol dependence and harmful alcohol use
• evaluate the role of psychological and psychosocial interventions in combination with
pharmacological interventions in the treatment of alcohol dependence and harmful
alcohol use
• integrate the above to provide best-practice advice on the care of individuals
throughout the course of their alcohol dependence and harmful alcohol use
• promote the implementation of best clinical practice through the development of
recommendations tailored to the requirements of the NHS in England and Wales.

Clinical Questions Considered

1. For people who misuse alcohol, what are their experiences of having problems with alcohol, of
access to services and of treatment?
2. For families and carers of people who misuse alcohol, what are their experiences of caring for
people with an alcohol problem and what support is available for families and carers?
3. In adults with alcohol misuse, what is the clinical efficacy, cost effectiveness, and safety of,
and patient satisfaction associated with different systems for the organization of care?
4. What are the most effective (a) diagnostic and (b) assessment tools for alcohol dependence
and harmful alcohol use?

University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance



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5. What are the most effective ways of monitoring clinical progress in alcohol dependence and
harmful alcohol use?
6. To answer questions 4 and 5, what are the advantages, disadvantages, and clinical utility of:
• the structure of the overall clinical assessment
• biological measures
• psychological/behavioural measures
• neuropsychiatric measures (including cognitive impairment)
• physical assessment?
7. In adults in planned alcohol withdrawal, what is the clinical efficacy, cost effectiveness, safety
of, and patient satisfaction associated with:
• preparatory work before withdrawal
• different drug regimens the setting (that is, community, residential or inpatient)?
8. In adults in planned alcohol withdrawal what factors influence the choice of setting in terms of
clinical and cost effectiveness including:
• severity of the alcohol disorder
• physical comorbidities
• psychological comorbidities
• social factors.
9. In adults with harmful or dependent alcohol use what are the preferred structures for and
components of community-based and residential specialist alcohol services to promote long-
term clinical and cost-effective outcomes?
10. For people with alcohol dependence or who are harmful drinkers, is psychological treatment x
when compared with y, more clinically and cost effective and does this depend on:
• presence of comorbidities
• subtypes (matching effects)
• therapist-related factors (quality, therapeutic alliance, competence, training, and so
on).
11. What are the most effective (a) diagnostic and (b) assessment tools for alcohol dependence
and harmful alcohol use in children and young people (aged 10–18 years)?
12. What are the most effective ways of monitoring clinical progress in alcohol dependence and
harmful alcohol use in children and young people (aged 10–18 years)?
13. For children and young people with alcohol dependence or harmful alcohol use is treatment x
when compared with y more clinically and cost effective and does this depend on the presence
of comorbidities?
14. For people with alcohol dependence or harmful alcohol use, what pharmacological
interventions are more clinically and cost effective? In addition:
• What are the impacts of severity and comorbities on outcomes?
• When should pharmacological treatments be initiated and for what duration should they be
prescribed?
II. Practice Recommendations
PRINCIPLES OF CARE
Building a trusting relationship and providing information
When working with people who misuse alcohol:
• build a trusting relationship and work in a supportive, empathic and non-judgmental
manner
• take into account that stigma and discrimination are often associated with alcohol misuse
and that minimising the problem may be part of the service user’s presentation
• make sure that discussions take place in settings in which confidentiality, privacy and
dignity are respected.
When working with people who misuse alcohol:
• provide information appropriate to their level of understanding about the nature and
treatment of alcohol misuse to support choice from a range of evidence-based treatments

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• avoid clinical language without explanation
• make sure that comprehensive written information is available in an appropriate language
or, for those who cannot use written text, in an accessible format
• provide independent interpreters (that is, someone who is not known to the service user)
if needed.
Working with and supporting families and carers
• Encourage families and carers to be involved in the treatment and care of people who
misuse alcohol to help support and maintain positive change.
• When families and carers are involved in supporting a person who misuses alcohol, discuss
concerns about the impact of alcohol misuse on themselves and other family members,
and:
o provide written and verbal information on alcohol misuse and its management,
including how families and carers can support the service user
o offer a carer’s assessment where necessary
o negotiate with the service user and their family or carer about the family or carer’s
involvement in their care and the sharing of information; make sure the service
user’s, family’s and carer’s right to confidentiality is respected.
• When the needs of families and carers of people who misuse alcohol have been identified:
o offer guided self-help, usually consisting of a single session, with the provision of
written materials
o provide information about, and facilitate contact with, support groups (such as
self-help groups specifically focused on addressing the needs of families and
carers).
IDENTIFICATION AND ASSESSMENT
General principles
• Make sure that assessment of risk is part of any assessment, that it informs the
development of the overall care plan, and that it covers risk to self (including unplanned
withdrawal, suicidality and neglect) and risk to others.
• When conducting an initial assessment, as well as assessing alcohol misuse, the severity
of dependence and risk, consider the:
o extent of any associated health and social problems
o need for assisted alcohol withdrawal.
• Use formal assessment tools to assess the nature and severity of alcohol misuse, including
the:
o AUDIT for identification and as a routine outcome measure
o CIWA-Ar for severity of withdrawal
• Staff responsible for assessing and managing assisted alcohol withdrawal (see Section
8.3.4) should be competent in the diagnosis and assessment of alcohol dependence and
withdrawal symptoms and the use of drug regimens appropriate to the settings (for
example, inpatient or community) in which the withdrawal is managed.
Assessment in specialist alcohol services
Brief triage assessment
All adults who misuse alcohol who are referred to specialist alcohol services should have a
brief triage assessment to assess:
• the pattern and severity of the alcohol misuse (using AUDIT) and severity of
dependence (using SADQ)
• the need for urgent treatment including assisted withdrawal
• any associated risks to self or others

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• the presence of any comorbidities or other factors that may need further specialist
assessment or intervention.
Agree the initial treatment plan, taking into account the service user’s preferences and
outcomes of any previous treatment.
Comprehensive assessment
Consider a comprehensive assessment for all adults referred to specialist alcohol services who
score more than 15 on the AUDIT.
Consider blood tests to help identify physical health needs, but do not use blood tests
routinely for the identification and diagnosis of alcohol-use disorders.
INTERVENTIONS FOR ALCOHOL MISUSE
General principles for all interventions
For all people who misuse alcohol, carry out a motivational intervention as part of the initial
assessment. The intervention should contain the key elements of motivational interviewing
including:
• helping people to recognise problems or potential problems related to their drinking
• helping to resolve ambivalence and encourage positive change and belief in the ability
to change adopting a persuasive and supportive rather than an argumentative and
confrontational position.
For all people who misuse alcohol, offer interventions to promote abstinence or moderate
drinking as appropriate (see 8.2.2.1–8.2.2.4) and prevent relapse, in community-based
settings.
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 staff62. Psychological interventions should be based on a relevant evidence-based
treatment manual, which should guide the structure and duration of the intervention.
For all people seeking help for alcohol misuse:
• give information on the value and availability of community support networks and self-
help groups (for example, Alcoholics Anonymous or SMART Recovery) and
• help them to participate in community support networks and self-help groups by
encouraging them to go to meetings and arranging support so that they can attend.
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.
Consider inpatient or residential assisted withdrawal if a service user meets one or more of the
following criteria. They:
• drink over 30 units of alcohol per day
• have a score of more than 30 on the SADQ
• have a history of epilepsy, or experience of withdrawal-related seizures or delirium
tremens during previous assisted withdrawal programmes
• need concurrent withdrawal from alcohol and benzodiazepines
• regularly drink between 15 and 20 units of alcohol per day and have:
o significant psychiatric or physical comorbidities (for example, chronic severe
depression, psychosis, malnutrition, congestive cardiac failure, unstable
angina, chronic liver disease) or

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o a significant learning disability or cognitive impairment.
Consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable
groups, for example, homeless and older people.
Drug regimens for assisted withdrawal
Fixed-dose or symptom-triggered medication regimens
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can be used in assisted withdrawal
programmes in inpatient or residential settings. If a symptom-triggered regimen is used, all
staff should be competent in monitoring symptoms effectively and the unit should have
sufficient resources to allow them to do so frequently and safely.
Prescribe and administer medication for assisted withdrawal within a standard clinical protocol.
The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or
diazepam).
For service users having assisted withdrawal, particularly those who are more severely alcohol
dependent or those undergoing a symptom-triggered regimen, consider using a formal
measure of withdrawal symptoms such as the CIWA-Ar.
Be aware that benzodiazepine doses may need to be reduced for children and young people69,
older people, and people with liver impairment (see 8.3.5.10).
Special considerations for children and young people who misuse alcohol
Assessment and referral of children and young people
If alcohol misuse is identified as a potential problem, with potential physical, psychological,
educational or social consequences, in children and young people aged 10–17 years, conduct
an initial brief assessment to assess:
• the duration and severity of the alcohol misuse (the standard adult threshold on the
AUDIT for referral and intervention should be lowered for young people aged 10–16
years because of the more harmful effects of a given level of alcohol consumption in
this population)
• any associated health and social problems
• the potential need for assisted withdrawal.
A comprehensive assessment for children and young people (supported if possible by
additional information from a parent or carer) should assess multiple areas of need, be
structured around a clinical interview using a validated clinical tool (such as the Adolescent
Diagnostic Interview [ADI] or the Teen Addiction Severity Index [T-ASI]), and cover the
following areas:
• consumption, dependence features and patterns of drinking
• comorbid substance misuse (consumption and dependence features) and associated
problems
• mental and physical health problems
• peer relationships and social and family functioning
• developmental and cognitive needs, and educational attainment and attendance
• history of abuse and trauma
• risk to self and others
• readiness to change and belief in the ability to change
• obtaining consent to treatment
• developing a care plan and risk management plan.

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Promoting abstinence and preventing relapse in children and young people
For all children and young people aged 10–17 years who misuse alcohol, the goal of treatment
should usually be abstinence in the first instance.
Interventions for conditions comorbid with alcohol misuse
Refer people who misuse alcohol and have a significant comorbid mental health disorder, and
those assessed to be at high risk of suicide, to a psychiatrist to make sure that effective
assessment, treatment and risk-management plans are in place.
Wernicke-Korsakoff syndrome
Follow the recommendations in NICE Clinical Guideline 100
83
on thiamine for people at high
risk of developing, or with suspected, Wernicke’s encephalopathy. In addition, offer parenteral
thiamine followed by oral thiamine to prevent Wernicke-Korsakoff syndrome in people who are
entering planned assisted alcohol withdrawal in specialist inpatient alcohol services or prison
settings and who are malnourished or at risk of malnourishment (for example, people who are
homeless) or have decompensated liver disease.
II. Pertinent Resources
A. Policies and Protocols
• Policy 2.18, Oxygen Therapy
• Policy 4.38, Release of Alcohol and Other Drug Abuse Patient Information
• Policy 6.10, Seizure, Care of Patient with or at Risk for
• Policy 7.55 Professional Boundaries and Therapeutic Relationships within UW Health
• Policy 2.4.6, Protective Custody, Emergency and Involuntary Commitment for Persons
Intoxicated and Incapacitated by Alcohol
• Policy 8.38, UWHC Adult Sedation Policy
• Policy 8.56, Pediatric Sedation Policy
• Policy 2.4.1, Suicide Assessment and Prevention
• Policy 2.4.2, Restraint and Seclusion
• Policy 13.23, Application of Physical Restraint
• Policy 14.40,Constant Observation
B. Patient Education Resources
• HFFY, Alcohol and Drug Abuse: A Guide to Community Services (#4611)
• HFFY, Alcohol Withdrawal (#5219)
• HFFY, Alcohol Use and Abuse after Spinal Cord Injury (#5404)
• HFFY, Post Acute Withdrawal Syndrome (PAWS) (#7228)
C. Clinical Tools
• Alcohol Withdrawal Syndrome: Suggested Criteria for Nursing to Consider
Recommending Transfer from General Care to Higher Level of Care to the Team
• AFCH Adolescent Alcohol Related Issues (ARI) Algorithm Triggered Management
• Assessment of Alcohol Withdrawal: The revised clinical institute withdrawal
assessment for alcohol scale (CIWA-Ar) (pdf)
• CIWA Accordion Report available in Patient Summary
• CIWA Video- Used with permission from the Mayo Clinic. Reproduction is not allowed.
• UWHC Form, Alcohol withdrawal “Suggested Dosing for Alcohol Withdrawal
Management”
• UWHC Form, IP - Alcohol Withdrawal - Adult - Supplemental [3538] (pdf)
• UWHC Form, Flow Sheet Alcohol Withdrawal Assessment (CIWA-Ar) (#SR300885)
IV. References
See full guideline document for list of references.

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V. Strengths of Recommendations
Synthesising the Evidence
Meta-Analysis
Where possible, meta-analysis was used to synthesise the evidence using Review Manager. If
necessary, reanalyses of the data or sub-analyses were used to answer review questions not
addressed in the original studies or reviews.
Presenting the data to the Guideline Development Group
Evidence profile tables
A GRADE
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evidence profile was used to summarise both the quality of the evidence and the results
of the evidence synthesis (see Table 4 for an example of an evidence profile). The GRADE approach
is based on a sequential assessment of the quality of evidence followed by judgement about the
balance between desirable and undesirable effects and subsequent decision about the strength of a
recommendation. For each outcome, quality may be reduced depending on the following factors:
• study design (randomised trial, observational study, or any other evidence)
• limitations (based on the quality of individual studies)
• inconsistency (see Section 3.5.3 for how consistency was assessed)
• indirectness (that is, how closely the outcome measures, interventions and participants
match those of interest)
• imprecision (based on the CI around the effect size).
For observational studies the quality may be increased if there is a large effect, plausible
confounding would have changed the effect, or there is evidence of a dose–response gradient
(details would be provided under the other considerations column). Each evidence profile also
included a summary of the findings: number of patients included in each group, an estimate of the
magnitude of the effect and the overall quality of the evidence for each outcome.
Forming the clinical summaries and recommendations
Once the GRADE evidence profiles relating to a particular review question were completed,
summary evidence tables were developed (these tables are presented in the evidence chapters).
Finally, the systematic reviewer in conjunction with the topic group lead produced a clinical
evidence summary. After the GRADE profiles and clinical summaries were presented to the GDG,
the associated recommendations were drafted. In making recommendations, the GDG took into
account the trade-off between the benefits and downsides of treatment as well as other important
factors, such as economic considerations, social value judgements
8
, the requirements to prevent
discrimination and to promote equality
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, and the group’s awareness of practical issues (Eccles et
al., 1998; NICE, 2009a).