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Alcohol-use Disorders Full Guideline

Alcohol-use Disorders Full Guideline - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines, Related


Alcohol-use
DISORDERs
THE NICE GUIDELINE ON DIAGNOSIS,
ASSESSMENT AND MANAGEMENT OF
HARMFUL DRINKING AND ALCOHOL
DEPENDENCE

ALCOHOL-USE
DISORDERS
DIAGNOSIS, ASSESSMENT
AND MANAGEMENT OF
HARMFUL DRINKING AND
ALCOHOL DEPENDENCE
National Clinical Practice Guideline 115
National Collaborating Centre for Mental Health
commissioned by the
National Institute for Health &
Clinical Excellence
published by
The British Psychological Society and The Royal College of
Psychiatrists

© The British Psychological Society
& The Royal College of Psychiatrists, 2011
The views presented in this book do not necessarily reflect those of the British
Psychological Society, and the publishers are not responsible for any error of
omission or fact. The British Psychological Society is a registered charity
(no. 229642).
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from
the publishers. Enquiries in this regard should be directed to the British
Psychological Society.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from
the British Library.
ISBN-: 978-1-904671-26-8
Printed in Great Britain by Stanley L. Hunt (Printers) Ltd.
Additional material: data CD-Rom created by Pix18
(www.pix18.co.uk)
developed by National Collaborating Centre for Mental Health
The Royal College of Psychiatrists
4th Floor, Standon House
21 Mansell Street
London
E1 8AA
www.nccmh.org.uk
commissioned by National Institute for Health and Clinical Excellence
MidCity Place, 71 High Holborn
London
WCIV 6NA
www.nice.org.uk
published by The British Psychological Society
St Andrews House
48 Princess Road East
Leicester
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www.bps.org.uk
and
The Royal College of Psychiatrists
17 Belgrave Square
London
SW1X 8PG
www.rcpsych.ac.uk

CONTENTS
GUIDELINE DEVELOPMENT GROUP MEMBERS 7
ACKNOWLEDGEMENTS 10
1 PREFACE 11
1.1 National clinical guidelines 11
1.2 The national alcohol dependence and harmful alcohol
use guideline 14
2 ALCOHOL DEPENDENCE AND HARMFUL ALCOHOL USE 17
2.1 Introduction 17
2.2 Definitions 19
2.3 Epidemiology of alcohol 21
2.4 Aetiology 25
2.5 Course of harmful alcohol use and dependence 27
2.6 Pharmacology of alcohol 28
2.7 Identification and diagnosis 30
2.8 The role of treatment and management 31
2.9 Current care in the National Health Service 33
2.10 Service user organisations 34
2.11 Impact on families 34
2.12 Special populations 35
2.13 Economic impact 40
3 METHODS USED TO DEVELOP THIS GUIDELINE 41
3.1 Overview 41
3.2 The scope 41
3.3 The guideline development group 42
3.4 Review questions 44
3.5 Clinical evidence methods 46
3.6 Health economics methods 57
3.7 Stakeholder contributions 61
3.8 Validation of the guideline 62
4 EXPERIENCE OF CARE 63
4.1 Introduction 63
4.2 Review of the qualitative literature 63
4.3 From evidence to recommendations 80
4.4 Recommendations 81
Contents
3

5 ORGANISATION AND DELIVERY OF CARE 83
SECTION 1 – INTRODUCTION TO THE ORGANISATION AND
DELIVERY OF CARE 83
5.1 Introduction 83
5.2 Organising principles of care 84
5.3 Services for people who misuse alcohol 86
SECTION 2 – EVALUATING THE ORGANISATION OF CARE
FOR PEOPLE WHO MISUSE ALCOHOL 93
5.4 Review question 93
5.5 Introduction 93
5.6 Case management 94
5.7 Assertive community treatment 100
5.8 Stepped care 104
5.9 Clincial evidence summary 111
5.10 From evidence to recommendations 112
5.11 Recommendations 113
5.12 Research recommendation 114
SECTION 3 – THE ASSESSMENT OF HARMFUL DRINKING
AND ALCOHOL DEPENDENCE 114
5.13 Introduction 114
5.14 Clincial questions 116
5.15 Aim of review of diagnostic and assessment tools for alcohol
dependence and harmful alcohol use 116
5.16 Quantitative review of assessment tools 117
5.17 Narrative synthesis of assessment tools 119
5.18 The assessment of alcohol dependence 126
5.19 The assessment of problems associated with alcohol misuse 129
5.20 The assessment of motivation 130
5.21 Special populations – older people 132
5.22 Special populations – children and young people 132
5.23 The structure and content of the assessment interview 137
5.24 Framework for assessment of alcohol misuse 142
5.25 The framework for assessment of alcohol misuse 144
5.26 From evidence to recommendations 170
SECTION 4 – DETERMINING THE APPROPRIATE SETTING
FOR THE DELIVERY OF EFFECTIVE CARE 175
5.27 Introduction 175
5.28 Review questions 177
5.29 Assisted alcohol withdrawal 177
5.30 Evaluating dosing regimes for assisted withdrawal 189
5.31 From evidence to recommendations: assisted withdrawal 204
5.32 Residential and community settings for the delivery of
interventions for alcohol misuse 209
Contents
4

6 PSYCHOLOGICAL AND PSYCHOSOCIAL INTERVENTIONS 229
6.1 Introduction 229
6.2 Therapist factors 231
6.3 Matching effects/severity 235
6.4 Setting the context for 12-step facilitation and Alcoholics
Anonymous 236
6.5 Review of psychological therapies 237
6.6 Outcomes 239
6.7 Motivational techniques 239
6.8 12-step facilitation 246
6.9 Cognitive behavioural therapy 255
6.10 Behavioural therapies (excluding contingency management) 269
6.11 Contingency management 275
6.12 Social network and environment-based therapies 285
6.13 Couples therapy 290
6.14 Counselling 303
6.15 Short-term psychodynamic therapy 309
6.16 Multi-modal treatment 312
6.17 Self-help-based treatment 315
6.18 Psychoeducational interventions 319
6.19 Mindfulness meditation 325
6.20 Clinical evidence summary 327
6.21 Health economic evidence 328
6.22 Special populations – children and young people 336
6.23 From evidence to recommendations 344
6.24 Recommendations 345
6.25 Acupuncture 349
6.26 Psychological interventions for carers 354
7 PHARMACOLOGICAL INTERVENTIONS 357
7.1 Introduction 357
7.2 Review of pharmacological interventions 362
7.3 Clinical review protocol for pharmacological interventions
for relapse prevention 364
7.4 Acamprosate 364
7.5 Naltrexone 370
7.6 Acamprosate � naltrexone (combined intervention) 380
7.7 Oral disulfiram 382
7.8 Meta-regression on baseline alcohol consumption and effectiveness 390
7.9 Predictors of efficacy 394
7.10 Health economic evidence 397
7.11 Economic model 402
7.12 Children and young people 415
7.13 Assessment, monitoring and side-effect profile 416
7.14 Review of other pharmacological interventions not licensed
in the UK for relapse prevention 419
Contents
5

7.15 From evidence to recommendations 422
7.16 Pharmacotherapy for less severe dependence and
non-dependent drinking 427
7.17 Comorbidities 429
7.18 Wernicke-Korsakoff syndrome 441
8 SUMMARY OF RECOMMENDATIONS 445
8.1 Principles of care 445
8.2 Identification and assessment 446
8.3 Interventions for alcohol misuse 449
8.4 Research recommendations 460
9 APPENDICES 464
10 REFERENCES 544
11 ABBREVIATIONS 603
Contents
6

GUIDELINE DEVELOPMENT GROUP MEMBERS
Professor Colin Drummond (Chair, Guideline Development Group)
Professor of Addiction Psychiatry and Honorary Consultant Addiction Psychiatrist,
National Addiction Centre, Institute of Psychiatry, King’s College London, and
South London and Maudsley Foundation NHS Trust
Professor Stephen Pilling (Facilitator, Guideline Development Group)
Director, National Collaborating Centre for Mental Health
Director, Centre for Outcomes Research and Effectiveness, University College
London
Mr Adrian Brown
Alcohol Nurse Specialist, Addiction Services, Central and North West London NHS
Foundation Trust, and St Mary’s Hospital, Imperial College
Professor Alex Copello
Professor of Addiction Research, University of Birmingham, and
Consultant Clinical Psychologist, Addiction Services, Birmingham and Solihull
Mental Health Foundation NHS Trust
Dr Edward Day
Senior Lecturer and Consultant in Addiction Psychiatry, University of
Birmingham/Birmingham and Solihull Mental Health NHS Foundation Trust
Mr John Dervan
Lay member and retired Alcohol Treatment Agency CEO
Mr Matthew Dyer
Health Economist (2008 to 2010), National Collaborating Centre for Mental Health
Ms Esther Flanagan
Guideline Development Manager (2008 to 2010), National Collaborating Centre
for Mental Health
Ms Jan Fry
Carer Representative and Voluntary Sector Consultant
Mr Brendan Georgeson
Treatment Coordinator, Walsingham House, Bristol
Guideline Development Group members
7

Dr Eilish Gilvarry
Consultant Psychiatrist (with specialist interest in adolescent addictions), and
Assistant Medical Director, Northumberland, Tyne and Wear NHS Foundation Trust
Ms Naomi Glover
Research Assistant (from 2010), National Collaborating Centre for Mental Health
Ms Jayne Gosnall
Service User Representative, and Treasurer of Salford Drug and Alcohol Forum
Dr Linda Harris
Clinical Director, Wakefield Integrated Substance Misuse Services and Director,
RCGP Substance Misuse Unit
Dr John Lewis (Co-opted specialist paediatric adviser)
Consultant Community Paediatrician, Royal Cornwall Hospitals Trust
Professor Anne Lingford-Hughes
Professor of Addiction Biology, Imperial College London and Honorary Consultant,
Central North West London NHS Foundation Trust
Dr Ifigeneia Mavranezouli
Senior Health Economist, National Collaborating Centre for Mental Health
Mr Trevor McCarthy
Independent Addictions Consultant and Trainer
Dr Marsha Morgan
Reader in Medicine and Honorary Consultant Physician, University of London
Medical School
Mrs Stephanie Noble
Registered Manager/Nursing Manager, Broadway Lodge
Dr Suffiya Omarjee
Health Economist (2008 to 2010), National Collaborating Centre for Mental Health
Mr Tom Phillips
Consultant Nurse in Addiction, Humber NHS Foundation Trust
Dr Pamela Roberts
Consultant Clinical and Forensic Psychologist, Cardiff Addictions Unit
Guideline Development Group members
8

Mrs Kate Satrettin
Guideline Development Manager (from 2010), National Collaborating Centre for
Mental Health
Mr Rob Saunders
Research Assistant (2008 to 2010), National Collaborating Centre for Mental Health
Ms Laura Shields
Research Assistant (2009 to 2010), National Collaborating Centre for Mental Health
Dr Julia Sinclair
Senior Lecturer in Psychiatry, University of Southampton and Honorary Consultant
in Addiction Psychiatry, Hampshire Partnership NHS Foundation Trust
Ms Sarah Stockton
Senior Information Scientist, National Collaborating Centre for Mental Health
Dr Clare Taylor
Senior Editor, National Collaborating Centre for Mental Health
Dr Amina Yesufu-Udechuku
Systematic Reviewer, National Collaborating Centre for Mental Health
Guideline Development Group members
9

ACKNOWLEDGEMENTS
The Guideline Development Group would like to thank the following:
Editorial assistance
Ms Nuala Ernest, Assistant Editor, National Collaborating Centre for Mental Health
Acknowledgements
10

1 PREFACE
This guideline is one of three pieces of the National Institute for Health and Clinical
Excellence’s (NICE) guidance developed to advise on alcohol-use disorders. The
present guideline addresses the management of alcohol dependence and harmful
alcohol use in people aged 10 years and older, including assessment, pharmacolog-
ical interventions, psychological and psychosocial interventions, and settings of
assisted withdrawal and rehabilitation. The two other NICE guidelines address:
(1) the prevention of alcohol-use disorders in people aged 10 years and older, which
is public health guidance on the price of alcohol, advertising and availability of
alcohol, how best to detect alcohol misuse both in and out of primary care and brief
interventions to manage alcohol misuse in these settings (NICE, 2010a); and (2) the
assessment and clinical management in people aged 10 years and older of acute
alcohol withdrawal, including delirium tremens (DTs), liver damage, acute and
chronic pancreatitis, and the management of Wernicke’s encephalopathy (WE)
(NICE, 2010b).
This guideline will sometimes use the term alcohol misuse, which will encompass
both people with alcohol dependence and harmful alcohol use.
The guideline recommendations have been developed by a multidisciplinary team
of healthcare professionals, a lay member, service users and carer representatives, and
guideline methodologists after careful consideration of the best available evidence. It
is intended that the guideline will be useful to clinicians and service commissioners
in providing and planning high-quality care for people who misuse alcohol while also
emphasising the importance of the experience of care for them and their carers (see
Appendix 1 for more details on the scope of the guideline).
Although the evidence base is rapidly expanding there are a number of gaps and
future revisions of this guideline will incorporate new scientific evidence as it devel-
ops. The guideline makes a number of research recommendations specifically to
address gaps in the evidence base. In the meantime, it is hoped that the guideline will
assist clinicians, people who misuse alcohol and their carers by identifying the merits
of particular treatment approaches where the evidence from research and clinical
experience exists.
1.1 NATIONAL CLINICAL GUIDELINES
1.1.1 What are clinical guidelines?
Clinical guidelines are ‘systematically developed statements that assist clinicians and
service users in making decisions about appropriate treatment for specific conditions’
(Mann, 1996). They are derived from the best available research evidence, using prede-
termined and systematic methods to identify and evaluate the evidence relating to the
Preface
11

Preface
12
specific condition in question. Where evidence is lacking, the guidelines incorporate
statements and recommendations based upon the consensus statements developed by
the Guideline Development Group (GDG).
Clinical guidelines are intended to improve the process and outcomes of health-
care in a number of different ways. They can:
� provide up-to-date evidence-based recommendations for the management of
conditions and disorders by healthcare professionals
� be used as the basis to set standards to assess the practice of healthcare professionals
� form the basis for education and training of healthcare professionals
� assist service users and their carers in making informed decisions about their treat-
ment and care
� improve communication between healthcare professionals, service users and their
carers
� help identify priority areas for further research.
1.1.2 Uses and limitations of clinical guidelines
Guidelines are not a substitute for professional knowledge and clinical judgement.
They can be limited in their usefulness and applicability by a number of different
factors: the availability of high-quality research evidence, the quality of the method-
ology used in the development of the guideline, the generalisability of research find-
ings and the uniqueness of individuals.
Although the quality of research in this field is variable, the methodology used
here reflects current international understanding on the appropriate practice for
guideline development (Appraisal of Guidelines for Research and Evaluation
Instrument [AGREE]; www.agreetrust.org; AGREE Collaboration, 2003), ensuring
the collection and selection of the best research evidence available, and the system-
atic generation of treatment recommendations applicable to the majority of people
who misuse alcohol. However, there will always be some people and situations for
which clinical guideline recommendations are not readily applicable. This guide-
line does not, therefore, override the individual responsibility of healthcare profes-
sionals to make appropriate decisions in the circumstances of the individual, in
consultation with the person with alcohol dependence and harmful alcohol use or
their carer.
In addition to the clinical evidence, cost-effectiveness information, where avail-
able, is taken into account in the generation of statements and recommendations of
the clinical guidelines. While national guidelines are concerned with clinical and cost
effectiveness, issues of affordability and implementation costs are to be determined
by the National Health Service (NHS).
In using guidelines, it is important to remember that the absence of empirical
evidence for the effectiveness of a particular intervention is not the same as evidence
for ineffectiveness. In addition, and of particular relevance in mental health, evidence-
based treatments are often delivered within the context of an overall treatment
programme including a range of activities, the purpose of which may be to help

engage the person and provide an appropriate context for the delivery of specific
interventions. It is important to maintain and enhance the service context in which
these interventions are delivered; otherwise the specific benefits of effective interven-
tions will be lost. Indeed, the importance of organising care in order to support and
encourage a good therapeutic relationship is at times as important as the specific treat-
ments offered.
1.1.3 Why develop national guidelines?
NICE was established as a Special Health Authority for England and Wales in 1999,
with a remit to provide a single source of authoritative and reliable guidance for serv-
ice users, professionals and the public. NICE guidance aims to improve standards of
care, diminish unacceptable variations in the provision and quality of care across the
NHS, and ensure that the health service is patient centred. All guidance is developed
in a transparent and collaborative manner, using the best available evidence and
involving all relevant stakeholders.
NICE generates guidance in a number of different ways, three of which are
relevant here. First, national guidance is produced by the Technology Appraisal
Committee to give robust advice about a particular treatment, intervention, proce-
dure or other health technology. Second, NICE commissions public health inter-
vention guidance focused on types of activity (interventions) that help to reduce
people’s risk of developing a disease or condition or help to promote or maintain
a healthy lifestyle. Third, NICE commissions the production of national clinical
practice guidelines focused upon the overall treatment and management of a
specific condition. To enable this latter development, NICE has established four
National Collaborating Centres in conjunction with a range of professional organ-
isations involved in healthcare.
1.1.4 The National Collaborating Centre for Mental Health
This guideline has been commissioned by NICE and developed within the National
Collaborating Centre for Mental Health (NCCMH). The NCCMH is a collaboration
of the professional organisations involved in the field of mental health, national ser
-
vice user and carer organisations, a number of academic institutions and NICE. The
NCCMH is funded by NICE and is led by a partnership between the Royal College
of Psychiatrists and the British Psychological Society’s Centre for Outcomes
Research and Effectiveness, based at University College London.
1.1.5 From national clinical guidelines to local protocols
Once a national guideline has been published and disseminated, local healthcare
groups will be expected to produce a plan and identify resources for implementation,
Preface
13

along with appropriate timetables. Subsequently, a multidisciplinary group involving
commissioners of healthcare, primary care and specialist mental health professionals,
service users and carers should undertake the translation of the implementation plan
into local protocols taking into account both the recommendations set out in this
guideline and the priorities set in the National Service Framework for Mental Health
(Department of Health, 1999) and related documentation. The nature and pace of the
local plan will reflect local healthcare needs and the nature of existing services; full
implementation may take considerable time, especially where substantial training
needs are identified.
1.1.6 Auditing the implementation of clinical guidelines
This guideline identifies key areas of clinical practice and service delivery for local
and national audit. Although the generation of audit standards is an important and
necessary step in the implementation of this guidance, a more broadly-based imple-
mentation strategy will be developed. Nevertheless, it should be noted that the Care
Quality Commission will monitor the extent to which Primary Care Trusts, trusts
responsible for mental health and social care, and Health Authorities have imple-
mented these guidelines.
1.2 THE NATIONAL ALCOHOL DEPENDENCE AND HARMFUL
ALCOHOL USE GUIDELINE
1.2.1 Who has developed this guideline?
The GDG was convened by the NCCMH and supported by funding from NICE. The
GDG included alcohol misusers and carers, and professionals from psychiatry, clini-
cal psychology, general practice, nursing and psychiatric pharmacy.
Staff from the NCCMH provided leadership and support throughout the process
of guideline development, undertaking systematic searches, information retrieval,
appraisal and systematic review of the evidence. Members of the GDG received train-
ing in the process of guideline development from NCCMH staff, and the service users
and carers received training and support from the NICE Patient and Public
Involvement Programme. The NICE Guidelines Technical Advisor provided advice
and assistance regarding aspects of the guideline development process.
All GDG members made formal declarations of interest at the outset, which were
updated at every GDG meeting. The GDG met a total of 12 times throughout the
process of guideline development. It met as a whole, but key topics were led by a
national expert in the relevant topic. The GDG was supported by the NCCMH tech-
nical team, with additional expert advice from special advisors where needed. The
group oversaw the production and synthesis of research evidence before presentation.
All statements and recommendations in this guideline have been generated and
agreed by the whole GDG.
Preface
14

1.2.2 For whom is this guideline intended?
This guideline is relevant for adults and young people with alcohol dependence and
harmful alcohol use as the primary diagnosis, and covers the care provided by
primary, community, secondary, tertiary and other healthcare professionals who have
direct contact with, and make decisions concerning the care of, adults and young
people with alcohol dependence and harmful alcohol use.
The guideline will also be relevant to the work, but will not specifically cover the
practice, of those in:
� occupational health services
� social services
� forensic services
� the independent sector.
The experience of alcohol misuse can affect the whole family and often the
community. The guideline recognises the role of both in the treatment and support of
people with alcohol dependence and harmful alcohol use.
1.2.3 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.
1.2.4 The structure of this guideline
The guideline is divided into chapters, each covering a set of related topics. The first
three chapters provide a summary of the clinical practice and research recommenda-
tions, and a general introduction to guidelines and to the methods used to develop them.
Chapter 4 provides the evidence for the experience of care of individuals who misuse
alcohol and their carers. Chapters 5 to 7 provide the evidence that underpins the recom-
mendations about the treatment and management of alcohol misuse.
Each evidence chapter begins with a general introduction to the topic that sets the
recommendations in context. Depending on the nature of the evidence, narrative
Preface
15

reviews or meta-analyses were conducted, and the structure of the chapters varies
accordingly. Where appropriate, details about current practice, the evidence base and
any research limitations are provided. Where meta-analyses were conducted, infor-
mation is given about both the interventions included and the studies considered for
review. Clinical summaries are then used to summarise the evidence presented.
Health economic evidence is then presented (where appropriate), followed by a
section (from evidence to recommendations) that draws together the clinical and
health economic evidence, and provides a rationale for the recommendations. On the
CD-ROM, full details about the included studies can be found in Appendix 16. Where
meta-analyses were conducted, the data are presented using forest plots in Appendix
17 (see Table 1 for details).
Preface
16
Clinical study characteristics tables Appendix 16
Clinical evidence forest plots Appendix 17
GRADE evidence profiles Appendix 18
Evidence tables for economic studies Appendix 19
Table 1: Appendices on CD-ROM

2 ALCOHOL DEPENDENCE AND HARMFUL
ALCOHOL USE
2.1 INTRODUCTION
This guideline is concerned with the identification, assessment and management of
alcohol dependence and harmful alcohol use
1
in people aged 10 years and older. In
2008, alcoholic beverages were consumed by 87% of the population in England,
which is equivalent to 36 million people (adults aged 16 years or over) (Fuller, 2009).
Drinking alcohol is widely socially accepted and associated with relaxation and
pleasure, and some people drink alcohol without experiencing harmful effects.
However, a growing number of people experience physical, social and psychological
harmful effects of alcohol. Twenty-four per cent
2
of the adult population in England,
including 33% of men and 16% of women, consumes alcohol in a way that is poten-
tially or actually harmful to their health or well-being (McManus et al., 2009). Four
per cent of adults in England are alcohol dependent
3
(6% men; 2% women), which
involves a significant degree of addiction to alcohol, making it difficult for them to
reduce their drinking or abstain despite increasingly serious harm (Drummond et al.,
2005). Alcohol dependence and harmful alcohol use are recognised as mental health
disorders by the World Health Organization (WHO, 1992; see Section 2.2). Although
not an official diagnostic term, ‘alcohol misuse’ will be used as a collective term to
encompass alcohol dependence and harmful alcohol use throughout this guideline.
The physical harm related to alcohol is a consequence of its toxic and depend-
ence-producing properties. Ethanol (or ethyl alcohol) in alcoholic beverages is
produced by the fermentation of sugar by yeast. It is a small molecule that is rapidly
absorbed in the gut and is distributed to, and has effects in, every part of the body.
Most organs in the body can be affected by the toxic effects of alcohol, resulting in
more than 60 different diseases. The risks of developing these diseases are related to
the amount of alcohol consumed over time, with different diseases having different
levels of risk. For example, the risk of developing breast cancer increases in a linear
way, in which even small amounts of alcohol increase risk. With alcoholic liver
disease the risk is curvilinear, with harm increasing more steeply with increasing
alcohol consumption. In the case of cardiovascular disease a modest beneficial effect
has been reported with moderate amounts of alcohol, although recent research
Alcohol dependence and harmful alcohol use
17
1
Several terms including ‘alcoholism’, ‘alcohol addiction’, ‘alcohol abuse’ and ‘problem drinking’ have
been used in the past to describe disorders related to alcohol consumption. However, ‘alcohol dependence’
and ‘harmful alcohol use’ are used throughout this guideline to be consistent with WHO’s International
Classification of Mental Disorders, 10th Revision (WHO, 1992).
2
Defined as scoring 8 or more on the Alcohol Use Disorders Identification Test (AUDIT).
3
Defined as scoring 16 or more on the AUDIT.

Alcohol dependence and harmful alcohol use
18
suggests this effect may have been overestimated (Ofori-Adjei et al., 2007). During
pregnancy alcohol can cause harm to the foetus, which can cause prematurity, still-
birth and the developmental disorder fetal alcohol syndrome.
Alcohol is rapidly absorbed in the gut and reaches the brain soon after drinking.
This quickly leads to changes in coordination that increase the risk of accidents and
injuries, particularly when driving a vehicle or operating machinery, and when
combined with other sedative drugs (for example, benzodiazepines). Its adverse
effects on mood and judgement can increase the risk of violence and violent crime.
Heavy chronic alcohol consumption increases the risk of mental health disorders
including depression, anxiety, psychosis, impairments of memory and learning, alco-
hol dependence and an increased risk of suicide. Both acute and chronic heavy drink-
ing can contribute to a wide range of social problems including domestic violence and
marital breakdown, child abuse and neglect, absenteeism and job loss (Drummond,
1990; Head et al., 2002; Velleman & Orford, 1999).
The physical harm related to alcohol has been increasing in the UK in the past
three decades. Deaths from alcoholic liver disease have doubled since 1980 (Leon &
McCambridge, 2006) compared with a decrease in many other European countries.
Alcohol related hospital admissions increased by 85% between 2002/03 and 2008/09,
accounting for 945,000 admissions with a primary or secondary diagnosis wholly or
partly related to alcohol in 2006/07 and comprising 7% of all hospital admissions
(North West Public Health Observatory, 2010).
Alcohol is a psychoactive substance with properties known to cause dependence
(or addiction). If compared within the framework of the 1971 Convention on
Psychotropic Substances, alcohol would qualify as a dependence-producing
substance warranting international control (United Nations, 1977; Ofori-Adjei et al.,
2007). Alcohol shares some of its dependence-producing mechanisms with other
psychoactive addictive drugs. Although a smaller proportion of the population who
consume alcohol become dependent than is the case with some illegal drugs such as
cocaine, it is nevertheless a significant problem due to much the larger number of
people who consume alcohol (Kandel et al., 1997).
Alcohol presents particularly serious consequences in young people due to a
higher level of vulnerability to the adverse effects of alcohol (see Section 2.12 on
special populations).
Heavy drinking in adolescence can affect brain development and has a higher
risk of organ damage in the developing body (Zeigler et al., 2005). Alcohol
consumption before the age of 13 years, for example, is associated with a four-fold
increased risk of alcohol dependence in adulthood (Dawson et al., 2008; Hingson &
Zha, 2009).
Other groups who are also at higher risk of alcohol-related harm include: the
elderly, those with pre-existing illnesses or who are taking a range of medicines that
interact with alcohol, and the socially disadvantaged (Marmot et al., 2010; O’Connell
et al., 2003). A given amount of alcohol will also be more harmful in women
compared with men due to differences in body mass and composition, hence the
government’s recommended sensible-drinking guidelines are lower for women than

men. Nevertheless, or perhaps as a consequence, women tend to seek help for alcohol
misuse earlier in their drinking career than do men (Schuckit, 2009).
2.2 DEFINITIONS
The definition of harmful alcohol use in this guideline is that of WHOs International
Classification of Diseases, 10th Revision (The ICD–10 Classification of Mental and
Behavioural Disorders) (ICD–10; WHO, 1992):
a pattern of psychoactive substance use that is causing damage to health. The
damage may be physical (e.g. hepatitis) or mental (e.g. depressive episodes
secondary to heavy alcohol intake). Harmful use commonly, but not invariably,
has adverse social consequences; social consequences in themselves, however,
are not sufficient to justify a diagnosis of harmful use.
The term was introduced in ICD–10 and replaced ‘non-dependent use’ as a diag-
nostic term. The closest equivalent in other diagnostic systems (for example, the
Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
Association [APA, 1994], currently in its fourth edition [DSM–IV]) is ‘alcohol
abuse’, which usually includes social consequences.
The term ‘hazardous use’ appeared in the draft version of ICD–10 to indicate a
pattern of substance use that increases the risk of harmful consequences for the user.
This is not a current diagnostic term within ICD–10. Nevertheless it continues to be
used by WHO in its public health programme (WHO, 2010a and 2010b).
In ICD–10 the ‘dependence syndrome’ is defined as:
a cluster of behavioural, cognitive, and physiological phenomena that develop
after repeated substance use and that typically include a strong desire to take
the drug, difficulties in controlling its use, persisting in its use despite harm-
ful consequences, a higher priority given to drug use than to other activities
and obligations, increased tolerance, and sometimes a physical withdrawal
state.
In more common language and in earlier disease-classification systems this has
been referred to as ‘alcoholism’. However, the term ‘alcohol dependence’ is preferred
because it is more precise, and more reliably defined and measured using the criteria
of ICD–10 (Text Box 1).
Alcohol dependence is also a category of mental disorder in DSM–IV (APA,
1994), although the criteria are slightly different from those used by ICD–10. For
example a strong desire or compulsion to use substances is not included in DSM–IV,
whereas more criteria relate to harmful consequences of use. It should be noted that
DSM is currently under revision, but the final version of DSM–V will not be
published until 2013 (APA, 2010).
Alcohol dependence and harmful alcohol use
19

Although alcohol dependence is defined in ICD–10 and DSM–IV in categorical
terms for diagnostic and statistical purposes as being either present or absent, in real-
ity dependence exists on a continuum of severity. Therefore, it is helpful from a clin-
ical perspective to subdivide dependence into categories of mild, moderate and
severe. People with mild dependence (those scoring 15 or less on the Severity of
Alcohol Dependence Questionnaire [SADQ]) usually do not need assisted alcohol
withdrawal. People with moderate dependence (with an SADQ score of between 15
and 30) usually need assisted alcohol withdrawal, which can typically be managed in
a community setting unless there are other risks. People who are severely alcohol
Alcohol dependence and harmful alcohol use
20
A definite diagnosis of dependence should usually be made only if three or more
of the following have been present together at some time during the previous year:
(a) a strong desire or sense of compulsion to take the substance;
(b) difficulties in controlling substance-taking behaviour in terms of its onset,
termination, or levels of use;
(c) a physiological withdrawal state when substance use has ceased or been
reduced, as evidenced by: the characteristic withdrawal syndrome for the
substance; or use of the same (or a closely related) substance with the intention
of relieving or avoiding withdrawal symptoms;
(d) evidence of tolerance, such that increased doses of the psychoactive substances
are required in order to achieve effects originally produced by lower doses (clear
examples of this are found in alcohol- and opiate-dependent individuals who may
take daily doses sufficient to incapacitate or kill non-tolerant users);
(e) progressive neglect of alternative pleasures or interests because of psycho-
active substance use, increased amount of time necessary to obtain or take the
substance or to recover from its effects;
(f) persisting with substance use despite clear evidence of overtly harmful conse-
quences, such as harm to the liver through excessive drinking, depressive mood
states consequent to periods of heavy substance use, or drug-related impairment
of cognitive functioning; efforts should be made to determine that the user was
actually, or could be expected to be, aware of the nature and extent of the harm.
Narrowing of the personal repertoire of patterns of psychoactive substance use
has also been described as a characteristic feature (for example, a tendency to
drink alcoholic drinks in the same way on weekdays and weekends, regardless
of social constraints that determine appropriate drinking behaviour).
It is an essential characteristic of the dependence syndrome that either psycho-
active substance taking or a desire to take a particular substance should be pres-
ent; the subjective awareness of compulsion to use drugs is most commonly seen
during attempts to stop or control substance use.
Text Box 1: ICD–10 diagnostic guidelines for the dependence syndrome
(WHO, 1992)

dependent (with an SADQ score of 31 or more) will need assisted alcohol withdrawal,
typically in an inpatient or residential setting. In this guideline these definitions of
severity are used to guide the selection of appropriate interventions.
2.3 EPIDEMIOLOGY OF ALCOHOL
2.3.1 Prevalence
Alcohol was consumed by 87% of the UK population in the past year (Fuller, 2009).
Amongst those who are current abstainers, some have never consumed alcohol for
religious, cultural or other reasons, and some have consumed alcohol but not in the
past year. This latter group includes people who have been harmful drinkers or alcohol
dependent in the past and who have stopped because of experiencing the harmful
effects of alcohol.
Amongst those who currently consume alcohol there is a wide spectrum of alcohol
consumption, from the majority who are moderate drinkers through to a smaller
number of people who regularly consume a litre of spirits per day or more and who
will typically be severely alcohol dependent. However, it is important to note that most
of the alcohol consumed by the population is drunk by a minority of heavy drinkers.
The Department of Health has introduced definitions that relate to different levels
of drinking risk. One UK unit of alcohol is defined as 8 g (or 10 ml) of pure ethanol.
4
The Department of Health recommends that adult men should not regularly drink
more than four units of alcohol per day and women no more than three units
(Department of Health, 1995). This definition implies the need for alcohol free or
lower alcohol consumption days. Below this level alcohol consumption is regarded a
‘low risk’ in terms of health or social harms. The government’s advice on alcohol in
pregnancy is to abstain (Department of Health, 2008a). The Royal College of
Psychiatrists’ advice is to drink less than 21 units of alcohol per week in men and 14
units in women, which is consistent with government advice if alcohol-free days are
included in the weekly drinking pattern (Royal College of Psychiatrists, 1986). Those
people who drink above these levels but have not yet experienced alcohol-related
harm are regarded as hazardous drinkers: that is, their drinking is at a level which
increases the risk of harm in the future. These recommendations are based on longi-
tudinal research on the impact of different levels of alcohol consumption on mortal-
ity. Above 50 units of alcohol per day in men and 35 units in women is regarded as
‘definitely harmful’ (Royal College of Psychiatrists, 1986). Those drinking more than
eight units per day in men and six units in women are regarded by the government as
‘binge drinkers’ (Prime Minister’s Strategy Unit, 2004). Again these definitions are
based on longitudinal research on the effects of alcohol consumption on adverse
consequences including accidents, injuries and other forms of harm.
Alcohol dependence and harmful alcohol use
21
4
The UK unit definition differs from definitions of standard drinks in some other countries. For example,
a UK unit contains two thirds of the quantity of ethanol that a US ‘standard drink’ has.

Most of the data on the English population’s drinking patterns comes from the
General Household Survey, the Health Survey for England and the Psychiatric
Morbidity Survey (Craig et al., 2009; McManus et al., 2009; Robinson & Bulger,
2010). In terms of hazardous drinking, in 2008, 21% of adult men were drinking
between 22 and 50 units per week, and 15% of adult women were drinking between
15 and 35 units; a further 7% of men and 5% of women were harmful drinkers, drink-
ing above 50 and 35 units per week, respectively. In addition, 21% of adult men and
14% of women met the government’s criteria for binge drinking. There were regional
variations in the prevalence of these drinking patterns. Hazardous drinking among
men varied from 24% in the West Midlands to 32% in Yorkshire and Humber, and in
women from 15% in the East of England to 25% in the North East. Harmful drinking
in men varied from 5% in the East Midlands to 11% in Yorkshire and Humber, and in
women from 2% in the East of England to 7% in Yorkshire and Humber. Binge drink-
ing among men varied from 19% in the West Midlands to 29% in Yorkshire and
Humber and among women from 11% in East of England to 21% in Yorkshire and
Humber (Robinson & Bulger, 2010).
There is a lack of reliable data on the prevalence of alcohol dependence because
UK general-population surveys do not include questionnaires that provide an ICD–10
diagnosis of alcohol dependence (for example, the WHO Composite International
Diagnostic Interview [CIDI]). Instead the most reliable estimate of alcohol depend-
ence comes from the Psychiatric Morbidity Survey, which used a WHO measure of
alcohol-use disorders: the Alcohol Use Disorders Identification Test (AUDIT; Babor
et al., 2001). A score of 16 or more on this questionnaire is indicative of possible alco-
hol dependence (Drummond et al., 2005). The Alcohol Needs Assessment Research
Project (ANARP) in England found the prevalence of alcohol dependence to be
4% in 16- to 64-year-old adults: 6% of men and 2% of women (Drummond et al.,
2005). This equates to a population of 1.1 million people in England with alcohol
dependence in 2000. This population increased to 1.6 million in 2007 (McManus
et al., 2009). There was considerable regional variation in the prevalence of alcohol
dependence, from 2% in the East Midlands to 5% in the North West. The prevalence
of hazardous and harmful drinking and dependence is highest in 16- to 24-year-olds
and decreases steadily with age. Hazardous and harmful drinking is 1.6 times greater
in the white population than in the black and minority ethnic population. However,
alcohol dependence is approximately equally prevalent in these two populations (see
Section 2.12 on special populations).
Whilst the government and Royal Colleges’ definitions of harmful drinking and
risk levels of alcohol consumption provide useful benchmarks to estimate the preva-
lence of alcohol-use disorders in the general population and monitor trends over time,
they have a number of limitations. This is particularly apparent when examining an
individual’s risk of alcohol-related harm at a given level of alcohol consumption.
According to WHO, alcohol is implicated as a risk factor in over 60 health dis-
orders including high blood pressure, stroke, coronary heart disease, liver cirrhosis
and various cancers. The extent to which these disorders are attributable to alcohol
varies. This is known as the alcohol-attributable fraction (AAF). The AAF for alco-
holic liver disease and alcohol poisoning is 1 (or 100% alcohol attributable) (WHO,
Alcohol dependence and harmful alcohol use
22

2000). For other diseases such as cancer and heart disease the AAF is less than 1 (that
is, partly attributable to alcohol) or 0 (that is, not attributable to alcohol). Further, the
AAF varies with age and gender. Also, as noted earlier, the risk with increasing levels
of alcohol consumption is different for different health disorders. Risk of a given level
of alcohol consumption is also related to gender, body weight, nutritional status,
concurrent use of a range of medications, mental health status, contextual factors and
social deprivation, amongst other factors. Therefore it is impossible to define a level
at which alcohol is universally without risk of harm.
2.3.2 Mental health
Alcohol is strongly associated with a wide range of mental health problems.
Depression, anxiety, drug misuse, nicotine dependence and self-harm are commonly
associated with excessive alcohol consumption. Up to 41% of suicides are attributa-
ble to alcohol and 23% of people who engage in deliberate self-harm are alcohol
dependent (Demirbas et al., 2003; Merrill et al., 1992). Amongst adults admitted to
inpatient mental health services, hazardous and harmful alcohol use increased the risk
of a suicidal presentation by a factor of three, and alcohol dependence increased the
risk by a factor of eight (McCloud et al., 2004). In the same study 49% of patients
admitted were hazardous and harmful drinkers, including 53% of men and 44% of
women, and 22% of the total population were alcohol dependent (Barnaby et al.,
2003). These prevalence rates are considerably higher than the general population,
particularly in women.
A UK study found 26% of community mental health team patients were
hazardous or harmful drinkers and 9% were alcohol dependent (Weaver et al., 2003).
In the same study examining patients attending specialist alcohol treatment services,
overall 85% had a psychiatric disorder in addition to alcohol dependence. Eighty-one
per cent had an affective and/or anxiety disorder (severe depression, 34%; mild
depression, 47%; anxiety, 32%), 53% had a personality disorder and 19% had a
psychotic disorder.
2.3.3 Social problems
Alcohol is implicated in relationship breakdown, domestic violence and poor parent-
ing, including child neglect and abuse. It is estimated that over 1 million children are
affected by parental alcohol misuse and up to 60% of child protection cases involve
alcohol (Prime Minister’s Strategy Unit, 2003). Alcohol also contributes to unsafe sex
and unplanned pregnancy, financial problems and homelessness. Up to half of home-
less people are alcohol dependent (Gill et al., 1996).
In terms of productivity, alcohol contributes to absenteeism, accidents in the
workplace and decline in work performance. Up to 17 million working days are lost
annually in the UK due to alcohol-related absences and 58,000 working years are lost
annually due to premature deaths related to alcohol (Leontaridi, 2003). Alcohol
Alcohol dependence and harmful alcohol use
23

misuse can also lead to job loss and over 38,000 people of working age in England
were claiming Incapacity Benefit with a diagnosis of ‘alcoholism’ – nearly 2% of all
claimants (Deacon et al., 2007).
2.3.4 Criminality
There were 986,000 violent incidents in England and Wales in 2009/10 where the
victim believed the offender to be under the influence of alcohol, accounting for 50%
of all violent crimes (Flatley et al., 2010). Nearly half of all offences of criminal
damage are alcohol related and alcohol is implicated in domestic violence, sexual
assaults, burglary, theft, robbery and murder (Prime Minister’s Strategy Unit, 2003).
In 2008, it was estimated that 13,020 reported road casualties (6% of all road casual-
ties) occurred when someone was driving whilst over the legal alcohol limit. The
provisional number of people estimated to have been killed in drink-driving accidents
was 430 in 2008 (17% of all road fatalities) (Department of Transport, 2009).
Approximately two thirds of male prisoners and over one third of female prison-
ers are hazardous or harmful drinkers, and up to 70% of probation clients are
hazardous or harmful drinkers (Singleton et al., 1998).
2.3.5 Public health impact
WHO has estimated the global burden of disease due to alcohol using AAFs, as
described above, and found that alcohol accounts for 4% of all disease burden world-
wide (Rehm et al., 2004). Alcohol is the third leading cause of disability in the devel-
oped world after smoking and hypertension. Using the same methodology, nearly
15,000 deaths in England are caused by alcohol per annum – 3% of all deaths (Jones
et al., 2008). Men had more than double the risk of alcohol attributable deaths
compared with women, and deaths of 16- to 24–year-olds are 20 times more likely to
be the result of alcohol compared with deaths of those aged 75 years and over (23%
of all deaths in 16- to 24-year-olds), mostly due to acute effects of alcohol: intentional
self-harm and road traffic accidents. In those over 35 years old, alcohol-related deaths
are more commonly due to chronic physical illness from alcohol, for example alco-
holic liver disease, malignant cancers of the oesophagus and breast, and hypertension.
The health consequences of alcohol, including deaths from alcoholic liver
disease, have been increasing in the UK compared with a reduction in many other
European countries (Leon & McCambridge, 2006). Further, the age at which deaths
from alcoholic liver disease occur has been falling in the UK, which is partly attrib-
utable to increasing alcohol consumption in young people (Office for National
Statistics, 2003).
Alcohol-related hospital admissions increased by 85% between 2002/03 and
2008/09. For conditions directly attributable to alcohol, admissions increased by 81%
between 2002/03 and 2008/09. In 2008/09, there were 945,000 hospital admissions in
England where alcohol was either a primary or secondary diagnosis (North West
Alcohol dependence and harmful alcohol use
24

Public Health Observatory, 2010). Alcohol related admissions increase steeply with
age, peaking in the 60- to 64-year-old age group (Deacon et al., 2007).
Data on alcohol-related attendances at accident and emergency departments are not
routinely collected nationally in England. However, a 24-hour weekend survey of 36
accident and emergency departments found that 40% of attendances were alcohol
related and at peak times (midnight to 5 a.m. at weekends) this rises to 70%
(Drummond et al., 2005). Harmful and dependent drinkers are much more likely to be
frequent accident and emergency department attenders, attending on average five times
per annum. Between 20 and 30% of medical admissions, and one third of primary care
attendances, are alcohol related (Coulton et al., 2006; Kouimtsidis et al., 2003; Royal
College of Physicians, 2001). Further, people who are alcohol dependent are twice as
likely as moderate drinkers to visit their general practitioner (GP) (Fuller et al., 2009).
2.4 AETIOLOGY
There is no single factor that accounts for the variation in individual risk of develop-
ing alcohol-use disorders. The evidence suggests that harmful alcohol use and alco-
hol dependence have a wide range of causal factors, some of which interact with each
other to increase risk.
2.4.1 Family history
It is well established that alcohol dependence runs in families. In general, offspring of
parents with alcohol dependence are four times more likely to develop alcohol depend-
ence. Evidence from genetic studies, particularly those in twins, has clearly demon-
strated a genetic component to the risk of alcohol dependence. A meta-analysis of 9,897
twin pairs from Australian and US studies found the heritability of alcohol dependence
to be in excess of 50% (Goldman et al., 2005). However, a meta-analysis of 50 family,
twin and adoption studies showed the heritability of alcohol misuse to be at most 30 to
36% (Walters, 2002). Whatever the true heritability, these studies indicate that genetic
factors may explain only part of the aetiology of alcohol dependence. The remaining
variation is accounted for by environmental factors and their interaction with genetic
factors. While no single gene for alcohol dependence has so far been identified, a range
of genes that determine brain function have been implicated (Agrawal et al., 2008).
2.4.2 Psychological factors
There is good evidence that a range of psychological factors contribute to the risk of
developing alcohol-use disorders. Various learning theories have provided evidence
of an important role of learning in alcohol dependence. Conditioning theories provide
an explanation for the development of alcohol dependence. Alcohol, being a
psychoactive drug, has reinforcing properties, for example through its pleasurable
Alcohol dependence and harmful alcohol use
25

effects and its ability to relieve negative mood states such as anxiety. Conditioning
can also explain why people become particularly sensitive to stimuli or cues associ-
ated with alcohol consumption, for example the sight and smell of a favourite drink,
such that these cues can trigger craving for and continued use of alcohol, including
relapse after a period of abstinence (Drummond et al., 1990).
Social learning theory also provides some explanations of increased risk of exces-
sive drinking and the development of alcohol dependence. People can learn from
families and peer groups through a process of modelling patterns of drinking and
expectancies (beliefs) about the effects of alcohol. Teenagers with higher positive
expectancies (for example, that drinking is pleasurable and desirable) are more likely
to start drinking at an earlier age and to drink more heavily (Christiansen et al., 1989;
Dunn & Goldman, 1998).
2.4.3 Personality factors
The idea that a particular ‘addictive personality’ leads to the development of alcohol
dependence is popular with some addiction counsellors, but does not have strong
support from research. Often with patients in treatment for alcohol dependence, it is
difficult to disentangle the effects of alcohol on the expression of personality and
behaviour from those personality factors that preceded alcohol dependence.
Nevertheless, people who are alcohol dependent have a 21-fold higher risk of also
having antisocial personality disorder (ASPD; Regier et al., 1990), and people with
ASPD have a higher risk of severe alcohol dependence (Goldstein et al., 2007).
Recent evidence points to the importance of disinhibition traits, such as novelty and
sensation seeking, and poor impulse control, as factors related to increased risk of
both alcohol and drug dependence, which may have a basis in abnormal brain func-
tion in the pre-frontal cortex (Dick et al., 2007; Kalivas & Volkow, 2005).
2.4.4 Psychiatric comorbidity
As noted earlier, people who are alcohol dependent have higher rates of comorbidity
with other psychiatric disorders, particularly depression, anxiety, post-traumatic
stress disorder (PTSD), psychosis and drug misuse, than people in the general popu-
lation. Alcohol can, temporarily at least, reduce the symptoms of anxiety and depres-
sion, leading to the theory that alcohol use in this situation is a form of
‘self-medication’. This theory, however, lacks clear experimental support, and the
longer-term effects of alcohol worsen these disorders.
2.4.5 Stress, adverse life events and abuse
There is clear evidence that adverse life events can trigger excessive drinking and may
predispose to the development of alcohol dependence. This is particularly apparent in
Alcohol dependence and harmful alcohol use
26

alcohol dependence developing later in life following, for example, a bereavement or
job loss. Stressful life situations or events can also trigger heavy drinking. People who
are alcohol dependent also report much higher levels of childhood abuse and neglect,
particularly sexual abuse. One UK study found 54% of female and 24% of male alco-
hol dependent patients identified themselves as victims of sexual abuse, mostly before
the age of 16 years (Moncrieff et al., 1996). Further, they were more likely to have a
family history of alcohol misuse, and began drinking and developed alcohol depend-
ence earlier than those without such a history.
2.4.6 Other environmental and cultural factors
There is a wide range of other environmental factors that predispose to the deve-
lopment of alcohol-use disorders (Cook, 1994). These include the affordability and
availability of alcohol, high consumption rates in the general population, occupational
risk factors (such as working in the alcohol or hospitality industries), social pressure
to drink, and religious- and culturally-related attitudes towards alcohol.
2.5 COURSE OF HARMFUL ALCOHOL USE AND DEPENDENCE
Harmful alcohol use and dependence are relatively uncommon before the age of
15 years, but increase steeply to reach a peak in the early 20s, this being the period
when alcohol use-disorders are most likely to begin. One US general population study
found the prevalence of alcohol dependence to be 2% in 12- to 17-year-olds, rising to
12% in 18- to 20–year-olds (Grant et al., 2004a). Thereafter, the prevalence of alco-
hol-use disorders declines steadily with age. The same US study found the prevalence
of dependence was 4% in 30- to 34-year-olds and 1.5% in 50- to 54-year-olds. A simi-
lar UK study found the prevalence of alcohol dependence to be 6% in 16- to 19-year-
olds, 8.2% in 20- to 24–year-olds, 3.6% in 30- to 34-year-olds and 2.3% in 50- to
54–year-olds (Drummond et al., 2005). Therefore, it is clear that there is substantial
remission from alcohol-use disorders over time. Much of this remission takes place
without contact with alcohol treatment services (Dawson et al., 2005a).
However, it is also known that people who develop alcohol dependence at a
younger age tend to have a more chronic course (Dawson et al., 2008). Further, while
a large proportion of those who meet the criteria for alcohol dependence in their 20s
will remit over the following two decades, those who remain alcohol dependent in
their 40s will tend to have a more chronic course. This is the typical age group of
people entering specialist alcohol treatment. Most studies examining the outcome of
people attending alcohol treatment find that 70 to 80% will relapse in the year follow-
ing treatment, with the highest rate of relapse taking place in the first 3 months after
completing treatment (Hunt et al., 1971; Raistrick et al., 2006). Those who remain
abstinent from alcohol for the first year after treatment have a relatively low risk of
relapse thereafter (Schuckit, 2009). Factors associated with a worse outcome include
having less social stability and support (for example, those without jobs, families or
Alcohol dependence and harmful alcohol use
27

stable housing), lacking a social network of non-drinkers, a family history of alcohol
dependence, psychiatric comorbidity, multiple previous treatment episodes and
history of disengagement from treatment.
In contrast with the relatively positive prognosis in younger people who are alco-
hol dependent in the general population, the longer term prognosis of alcohol
dependence for people entering specialist treatment is comparatively poor. Over a
10-year period about one third have continuing alcohol problems, a third show some
improvement and a third have a good outcome (either abstinence or moderate drink-
ing) (Edwards et al., 1988). The mortality rate is high in this population, nearly four
times the age-adjusted rate for people without alcohol dependence. Those who are
more severely alcohol dependent are less likely to achieve lasting stable moderate
drinking and have a higher mortality than those who are less dependent (Marshall
et al., 1994). It is important to note that most of the excess mortality is largely
accounted for by lung cancer and heart disease, which are strongly related to contin-
ued tobacco smoking.
2.6 PHARMACOLOGY OF ALCOHOL
Following ingestion, alcohol is rapidly absorbed by the gut and enters the blood-
stream with a peak in blood alcohol concentration after 30 to 60 minutes. Alcohol is
then distributed around every part of the body. It readily crosses the blood–brain
barrier to enter the brain where it causes subjective or psychoactive and behavioural
effects, and, following high levels of chronic alcohol intake, it can cause cognitive
impairment and brain damage.
Alcohol is excreted in urine, sweat and breath, but the main method of elimina-
tion from the body is by metabolism in the liver where it is converted to acetaldehyde
and acetate. These metabolites are then excreted from the body, primarily in urine.
The rate at which alcohol is metabolised and the extent to which an individual is
affected by a given dose of alcohol is highly variable from one individual to another.
These individual differences affect drinking behaviour and the potential for alcohol-
related harm and alcohol dependence. Also, the effects of alcohol vary in the same
individual over time depending on several factors including whether food has been
consumed, rate of drinking, nutritional status, environmental context and concurrent
use of other psychoactive drugs. Therefore, it is very difficult to predict the effects of
a given amount of alcohol both between individuals and within individuals over time.
For instance, the impact on the liver varies clinically so that some experience liver
failure early on in their drinking career, whilst in others drinking heavily liver func-
tion is relatively normal.
Alcohol is a toxic substance and its toxicity is related to the quantity and duration
of alcohol consumption. It can have toxic effects on every organ in the body. In the
brain, in a single drinking episode, increasing levels of alcohol lead initially to stim-
ulation (experienced as pleasure), excitement and talkativeness. At increasing concen-
trations alcohol causes sedation leading to sensations of relaxation, then later to
slurred speech, unsteadiness, loss of coordination, incontinence, coma and ultimately
Alcohol dependence and harmful alcohol use
28

death through alcohol poisoning, due to the sedation of the vital brain functions on
breathing and circulation.
The dependence-producing properties of alcohol have been studied extensively in
the last 20 years. Alcohol affects a wide range of neurotransmitter systems in the
brain, leading to the features of alcohol dependence. The main neurotransmitter
systems affected by alcohol are gamma-aminobutyric acid (GABA), glutamate,
dopamine and opioid (Nutt, 1999). The action of alcohol on GABA is similar to the
effects of other sedatives such as benzodiazepines and is responsible for alcohol’s
sedating and anxiolytic properties (Krystal et al., 2006). Glutamate is a major neuro-
transmitter responsible for brain stimulation, and alcohol affects glutamate through its
inhibitory action on N-methyl D-aspartate (NMDA)-type glutamate receptors,
producing amnesia (for example, blackouts) and sedation (Krystal et al., 1999).
Chronic alcohol consumption leads to the development of tolerance through a
process of neuroadaptation: receptors in the brain gradually adapt to the effects of
alcohol, to compensate for stimulation or sedation. This is experienced by the indi-
vidual as the same amount of alcohol having less effect over time. This can lead to an
individual increasing alcohol consumption to achieve the desired psychoactive
effects. The key neurotransmitters involved in tolerance are GABA and glutamate,
with chronic alcohol intake associated with reduced GABA inhibitory function and
increased NMDA-glutamatergic activity (Krystal et al., 2003 and 2006). This
GABA–glutamate imbalance is acceptable in the presence of alcohol, which increases
GABA and reduces NMDA-glutamate activity. However, when the alcohol-dependent
individual stops drinking, the imbalance between these neurotransmitter systems
results in the brain becoming overactive after a few hours leading to unpleasant with-
drawal symptoms such as anxiety, sweating, craving, seizures and hallucinations. This
can be life threatening in severe cases and requires urgent medical treatment. Repeated
withdrawal is also thought to underlie the toxic effect of alcohol on neurons, leading
to cognitive impairment and brain damage (Loeber et al., 2009). The effects of alco-
hol withdrawal can take up to between 3 months and 1 year to fully recover from
(referred to as the protracted withdrawal syndrome). Even then, the brain remains
abnormally sensitive to alcohol and, when drinking is resumed, tolerance and with-
drawal can return within a few days (known as reinstatement) (Edwards & Gross,
1976). This makes it extremely difficult for a person who has developed alcohol
dependence to return to sustained moderate drinking.
The brain’s endogenous opioid system is also affected by alcohol (Oswald &
Wand, 2004). Alcohol stimulates endogenous opioids, which are thought to be related
to the pleasurable, reinforcing effects of alcohol. Opioids in turn stimulate the
dopamine system in the brain, which is thought to be responsible for appetite for a
range of appetitive behaviours including regulation of appetite for food, sex and
psychoactive drugs. The dopamine system is also activated by stimulant drugs such
as amphetamines and cocaine, and it is through this process that the individual seeks
more drugs or alcohol (Everitt et al., 2008; Robinson & Berridge, 2008). There is
evidence that drugs which block the opioid neurotransmitters, such as naltrexone, can
reduce the reinforcing or pleasurable properties of alcohol and so reduce relapse in
alcohol-dependent patients (Anton, 2008).
Alcohol dependence and harmful alcohol use
29

2.7 IDENTIFICATION AND DIAGNOSIS
People with alcohol-use disorders commonly present to health, social and criminal
justice agencies, often with problems associated with their alcohol use, but they less
often seek help for the alcohol problem itself. Further, alcohol-use disorders are
seldom identified by health and social care professionals. One recent study found that
UK GPs routinely identify only a small proportion of people with alcohol-use disor-
ders who present to primary care (less than 2% of hazardous or harmful drinkers and
less than 5% of alcohol-dependent drinkers) (Cheeta et al., 2008). This has important
implications for the prevention and treatment of alcohol-use disorders. Failure to
identify alcohol-use disorders means that many people do not get access to alcohol
interventions until the problems are more chronic and difficult to treat. Further, fail-
ure to address an underlying alcohol problem may undermine the effectiveness of
treatment for the presenting health problem (for example, depression or high blood
pressure).
Screening and brief intervention delivered by a non-specialist practitioner is a cost-
effective approach for hazardous and harmful drinkers (NICE, 2010a). However, for
people who are alcohol dependent, brief interventions are less effective and referral
to a specialist service is likely to be necessary (Moyer et al., 2002). It is important,
therefore, that health and social care professionals are able to identify and appropri-
ately refer harmful drinkers who do not respond to brief interventions, and those who
are alcohol dependent, to appropriate specialist services. In acute hospitals, psychia-
try liaison teams or specialist addiction liaison psychiatry staff can provide a useful
in-reach service including the provision of staff training in alcohol identification and
brief interventions, advice on management of alcohol withdrawal and referral to
specialist alcohol services in the community (Moriarty et al., 2010). Addiction
psychiatrists also have an important role in liaison with general psychiatrists in the
optimal management of people with alcohol and mental health comorbidity (Boland
et al., 2008).
Around one third of people presenting to specialist alcohol services in England are
self-referred and approximately one third are referred by non-specialist health or
social care professionals (Drummond et al., 2005). The majority of the remainder are
referred by other specialist addiction services or criminal justice services. At the point
of entry to treatment it is essential that patients are appropriately diagnosed and
assessed in order to decide on the most appropriate treatment and management, assess
the level of risk, such as self-harm and risk to others, and identify co-occurring prob-
lems that may need particular attention, for example psychiatric comorbidity, physi-
cal illness, problems with housing, vulnerability and pregnancy (National Treatment
Agency for Substance Misuse, 2006). Therefore assessment should not be narrowly
focused on alcohol consumption, but should include all areas of physical, psycholog-
ical and social functioning.
Because alcohol dependence is associated with a higher level of problems and a
more chronic course, and requires a higher level of medical and psychiatric interven-
tion, it is essential that practitioners in specialist alcohol services are able to appro-
priately diagnose and assess alcohol dependence.
Alcohol dependence and harmful alcohol use
30

2.8 THE ROLE OF TREATMENT AND MANAGEMENT
As noted above, many people will recover from alcohol-use disorders without
specialist treatment and many will reduce their alcohol intake following a change in
circumstances, such as parenthood, marriage or taking on a responsible job.
Hazardous and harmful drinkers may respond to a brief intervention provided in
primary care without requiring access to specialist treatment (NICE, 2010a). For
others, their alcohol problems are overcome with the help of a mutual aid organisa-
tion, such as Alcoholics Anonymous (AA; see Section 2.10). Nevertheless, many will
require access to specialist treatment by virtue of having more severe or chronic alco-
hol problems, or a higher level of complications of their drinking (for example, social
isolation, psychiatric comorbidity and severe alcohol withdrawal).
The primary role of specialist treatment is to assist the individual to reduce or stop
drinking alcohol in a safe manner (National Treatment Agency for Substance Misuse,
2006). At the initial stages of engagement with specialist services, service users may
be ambivalent about changing their drinking behaviour or dealing with their prob-
lems. At this stage, work on enhancing the service user’s motivation towards making
changes and engagement with treatment will be particularly important.
For most people who are alcohol dependent the most appropriate goal in terms of
alcohol consumption should be to aim for complete abstinence. With an increasing
level of alcohol dependence a return to moderate or ‘controlled’ drinking becomes
increasingly difficult (Edwards & Gross, 1976; Schuckit, 2009). Further, for people
with significant psychiatric or physical comorbidity (for example, depressive disorder
or alcoholic liver disease), abstinence is the appropriate goal. However, hazardous
and harmful drinkers, and those with a low level of alcohol dependence, may be able
to achieve a goal of moderate alcohol consumption (Raistrick et al., 2006). Where a
client has a goal of moderation but the clinician believes there are considerable risks
in doing so, the clinician should provide strong advice that abstinence is most appro-
priate but should not deny the client treatment if the advice is unheeded (Raistrick
et al., 2006).
For people who are alcohol dependent, the next stage of treatment may require
medically-assisted alcohol withdrawal, if necessary with medication to control the
symptoms and complications of withdrawal. For people with severe alcohol depend-
ence and/or significant physical or psychiatric comorbidity, this may require assisted
alcohol withdrawal in an inpatient or residential setting, such as a specialist NHS
inpatient addiction treatment unit (Specialist Clinical Addiction Network, 2006). For
the majority, however, alcohol withdrawal can be managed in the community either
as part of shared care with the patient’s GP or in an outpatient or home-based
assisted alcohol withdrawal programme, with appropriate professional and family
support (Raistrick et al., 2006). Treatment of alcohol withdrawal is, however, only
the beginning of rehabilitation and, for many, a necessary precursor to a longer-term
treatment process. Withdrawal management should therefore not be seen as a stand-
alone treatment.
People who are alcohol dependent and who have recently stopped drinking are
vulnerable to relapse, and often have many unresolved co-occurring problems that
Alcohol dependence and harmful alcohol use
31

predispose to relapse (for example, psychiatric comorbidity and social problems)
(Marlatt & Gordon, 1985). In this phase, the primary role of treatment is the preven-
tion of relapse. This should include interventions aimed primarily at the drinking
behaviour, including psychosocial and pharmacological interventions, and interven-
tions aimed at dealing with co-occurring problems. Interventions aimed at preventing
relapse include individual therapy (for example, motivational enhancement therapy
[MET], cognitive behavioural therapy [CBT]), group and family based therapies,
community-based and residential rehabilitation programmes, medications to attenuate
drinking or promote abstinence (for example, naltrexone, acamprosate or disulfiram) and
interventions promoting social support and integration (for example, social behaviour
and network therapy [SBNT] or 12-step facilitation [TSF]) (Raistrick et al., 2006).
Although psychiatric comorbidity is common in people seeking help for alcohol-
use disorders, this will usually resolve within a few weeks of abstinence from alco-
hol without formal psychiatric intervention (Petrakis et al., 2002). However, a
proportion of people with psychiatric comorbidity, usually those in whom the mental
disorder preceded alcohol dependence, will require psychosocial or pharmacological
interventions specifically for the comorbidity following assisted withdrawal. Self-harm
and suicide are relatively common in people who are alcohol dependent (Sher, 2006).
Therefore, treatment staff need to be trained to identify, monitor and if necessary treat
or refer to an appropriate mental health specialist those patients with comorbidity
which persists beyond the withdrawal period, and/or are at risk of self-harm or
suicide. Patients with complex psychological issues related to trauma, sexual abuse or
bereavement will require specific interventions delivered by appropriately trained
personnel (Raistrick et al., 2006).
Often, people who are alcohol dependent (particularly in the immediate post-with-
drawal period) find it difficult to cope with typical life challenges such as managing
their finances or dealing with relationships. They will therefore require additional
support directed at these areas of social functioning. Specific social problems such as
homelessness, isolation, marital breakdown, child care issues including parenting
problems, child abuse and neglect will require referral to, and liaison with, appropri-
ate social care services (National Treatment Agency for Substance Misuse, 2006). A
proportion of service users entering specialist treatment are involved with the crimi-
nal justice system and some may be entering treatment as a condition of a court order.
Therefore, appropriate liaison with criminal justice services is essential for this group.
People who are alcohol dependent are often unable to take care of their health
during drinking periods and are at high risk of developing a wide range of health
problems because of their drinking (Rehm et al., 2003). Treatment staff therefore
need to be able to identify and assess physical health consequences of alcohol use,
and refer patients to appropriate medical services.
In the later stages of treatment, the focus will be more on reintegration into soci-
ety and restoration of normal function, including establishing a healthy lifestyle, find-
ing stable housing, re-entering employment, re-establishing contact with their
families, and forming appropriate and fulfilling relationships (National Treatment
Agency for Substance Misuse, 2006). All of these factors are important in promoting
longer term stable recovery.
Alcohol dependence and harmful alcohol use
32

2.9 CURRENT CARE IN THE NATIONAL HEALTH SERVICE
A recent alcohol needs assessment in England identified nearly 700 agencies
providing specialist alcohol treatment, with an estimated workforce of 4,250 and an
annual spend of between £186 million and £217 million (Drummond et al., 2005;
National Audit Office, 2008). The majority of agencies (70%) were community
based and the remainder were residential, including inpatient units in the NHS, and
residential rehabilitation programmes mainly provided by the non-statutory or
private sector. Overall, approximately half of all alcohol services are provided by
the non-statutory sector but are typically funded by the NHS or local authorities.
Approximately one third of specialist alcohol services exclusively provide treatment
for people with alcohol problems, but the majority (58%) provide services for both
drug and alcohol misuse.
In terms of services provided by community specialist agencies, the majority
(63%) provide structured psychological interventions either on an individual basis or
as part of a structured community programme (Drummond et al., 2005). There is
considerable variation in the availability and access to specialist alcohol services both
in community settings and in inpatient settings where provision of specialist psychi-
atric liaison services with responsibility for alcohol misuse is also very variable. Only
30% provide some form of assisted alcohol-withdrawal programme, and less than
20% provide medications for relapse prevention. Of the residential programmes, 45%
provide inpatient medically-assisted alcohol withdrawal and 60% provide residential
rehabilitation with some overlap between the two treatment modalities. The alcohol
withdrawal programmes are typically of 2 to 3 weeks duration and the rehabilitation
programmes are typically of 3 to 6 months duration.
It is estimated that approximately 63,000 people entered specialist treatment for
alcohol-use disorders in 2003–04 (Drummond et al., 2005). The recently estab-
lished National Alcohol Treatment Monitoring System (NATMS) reported 104,000
people entering 1,464 agencies in 2008–09, of whom 70,000 were new presenta-
tions (National Treatment Agency, 2009a). However, it is not possible to identify
what proportion of services is being provided by primary care under the enhanced
care provision as opposed to specialist alcohol agencies.
The 2004 ANARP found that only one out of 18 people who were alcohol depend-
ent in the general population accessed treatment per annum. Access varied consider-
ably from one in 12 in the North West to one in 102 in the North East of England
(Drummond et al., 2005).
Although not directly comparable because of different methodology, a low level
of access to treatment is regarded as one in ten (Rush, 1990). A recent Scottish
national alcohol needs-assessment using the same methods as ANARP found treat-
ment access to be higher than in England, with one in 12 accessing treatment per
annum. This level of access may have improved in England since 2004 based on the
NATMS data. However, the National Audit Office (2008) reported that the spending
on specialist alcohol services by Primary Care Trusts was not based on a clear under-
standing of the level of need in different parts of England. There is therefore some
further progress needed to make alcohol treatment accessible throughout England.
Alcohol dependence and harmful alcohol use
33

2.10 SERVICE USER ORGANISATIONS
There are several organisations available in England to provide mutual aid for service
users and their families. The largest and longest established such organisation is
Alcoholics Anonymous. Founded in the US in the 1930s, AA is based on a ‘12-step’
programme, and the ‘12 traditions’ of AA. The programme includes acceptance that one
is powerless over alcohol, acceptance of the role of a higher power and the role of the
support of other members. AA is self-financing and the seventh tradition is that AA
groups should decline outside contributions. In 2010, AA membership worldwide was
reported as nearly 2 million (Alcoholics Anonymous, 2010). While AA might not suit all
people who misuse alcohol, its advantages include its wide availability and open access.
Allied to AA are Al-anon and Alateen, jointly known as Al-anon Family Groups.
Al-anon uses the same 12 steps as AA with some modifications and is focused on
meeting the needs of friends and family members of alcoholics. Again, meetings are
widely available and provide helpful support beyond what can be provided by special-
ist treatment services.
Another organisation developing England is Self-Management and Recovery
Training (SMART). Its development is being supported by Alcohol Concern, a lead-
ing UK alcohol charity, and the Department of Health. SMART is another mutual aid
organisation but is based more on cognitive behavioural principles and provides an
alternative or adjunct to AA.
5
2.11 IMPACT ON FAMILIES
The adverse effects of alcohol dependence on family members are considerable.
Marriages where one or both partners have an alcohol problem are twice as likely to
end in divorce as those in which alcohol is not a problem. Nearly a million children
live with one or more parents who misuse alcohol and 6% of adults report having
grown up in such a family. Alcohol is implicated in a high proportion of cases of child
neglect and abuse, and heavy drinking was identified as a factor in 50% of child
protection cases (Orford et al., 2005).
Partners of people with harmful alcohol use and dependence experience higher
rates of domestic violence than where alcohol misuse is not a feature. Some 70% of
men who assault their partners do so under the influence of alcohol (Murphy et al,
2005). Family members of people who are alcohol dependent have high rates of
psychiatric morbidity, and growing up with someone who misuses alcohol increases
the likelihood of teenagers taking up alcohol early and developing alcohol problems
themselves (Latendresse et al., 2010).
All of this points to the importance of addressing the needs of family members of
people who misuse alcohol. This includes the need for specialist treatment services to
assess the impact of the individual’s drinking on family members and the need to
ensure the safety of children living with people who misuse alcohol.
Alcohol dependence and harmful alcohol use
34
5
See www.smartrecovery.org.

2.12 SPECIAL POPULATIONS
There are several special populations which require separate consideration because
they have particular needs that are often not well met by mainstream services, or
require particular considerations in commissioning or delivering care, or who require
modification of general treatment guidelines. This section provides an overview of
the issues for each special population. Specific guidance applying to special popula-
tions will be referred to in the appropriate section in subsequent chapters.
2.12.1 Children and young people
While drinking and alcohol-use disorders are relatively rare under the age of 10 years,
the prevalence increases steeply from the teens to peak in the early 20s. The UK has
the highest rate of underage drinking in Western Europe (Hibell et al., 2009). This is
of particular concern because alcohol presents particularly serious consequences in
young people due to a higher level of vulnerability to the adverse effects of alcohol.
Heavy drinking in adolescence can affect brain development and has a higher risk of
organ damage in the developing body (Brown et al., 2008).
The number of adolescents consuming alcohol has shown a reduction from 60 to
65% between 1988 and 1998 to 54% in 2007, but the amount consumed by those
drinking doubled over the same period to 12.7 units per week (Fuller, 2008). Regular
alcohol consumption in adolescence is associated with increased accidents, risky
behaviour (including unprotected sex, antisocial behaviour and violence) and
decreased family, social and educational functioning. There is evidence of an associ-
ation between hazardous alcohol consumption in adolescence and increased level of
alcohol dependence in early and later adulthood (Hingson et al., 2006). For example,
alcohol consumption before the age of 13 years is associated with a four-fold
increased risk of alcohol dependence in adulthood. Adolescents with early signs of
alcohol misuse who are not seeking treatment are a critical group to target interven-
tions towards. Adolescent alcohol-related attendances at accident and emergency
departments saw a tenfold increase in the UK since 1990 and a recent audit estimates
that 65,000 alcohol-related adolescent attendances occur annually.
Comorbid psychiatric disorders are considered to be ‘the rule, not the exception’
for young people with alcohol-use disorders (Perepletchikova et al., 2008). Data from
the US National Comorbidity study demonstrated that the majority of lifetime disor-
ders in their sample were comorbid disorders (Kessler et al., 1996). This common
occurrence of alcohol-use disorders and other substance-use disorders along with
other psychiatric disorders notes the importance of a comprehensive assessment and
management of all disorders. Disruptive behaviour disorders are the most common
comorbid psychiatric disorders among young people with substance-use disorders.
Those with conduct disorder and substance-use disorders are more difficult to treat,
have a higher treatment dropout rate and have a worse prognosis. This strong associ-
ation between conduct disorder and substance-use disorders is considered to be recip-
rocal, with each exacerbating the expression of the other. Conduct disorder usually
Alcohol dependence and harmful alcohol use
35

precedes or coincides with the onset of substance-use disorders, with conduct disor-
der severity found to predict substance-use severity. Significantly higher rates of
attention deficit hyperactivity disorder (ADHD) have been reported in young people
with substance-use disorders; data from untreated adults with ADHD indicate a
higher risk of developing substance-use disorders and at an earlier age compared with
treated controls as well as a more prolonged course of substance-use disorders.
However, those young people with ADHD and co-occurring conduct or bipolar disor-
ders are at highest risk of development of substance-use disorders.
High rates of depression and anxiety have been reported in adolescents with alcohol-
use disorders, with increased rates of suicidality. Among clinical populations for alcohol-
use disorders there was an increased rate of anxiety symptoms and disorder, PTSD and
social phobias (Clark et al., 1997a and 1997b). For young people the presentation may
be different because dependence is not common, with binge drinking being the pattern
seen more often, frequently alongside polydrug use. Criminality and offending behaviour
are often closely related to alcohol misuse in children and adolescents. Liaison with
criminal justice services is necessary to ensure that appropriate co-ordination of care and
effective communication and information-sharing protocols are in place.
In addition to the problems presented by comorbid disorders, the concept of depend-
ence and criteria for diagnosis (DSM–IV or ICD–10) has limitations when applied to
adolescents because of the low prevalence of withdrawal symptoms and the low speci-
ficity of tolerance in this age group (Chung et al., 2001). The adolescent therefore may
continue drinking despite problems, which manifest as difficulties with school atten-
dance, co-morbid behavioural difficulties, peer affiliation and arguments at home.
As has been noted previously, relationships with parents, carers and the children
in their care are often damaged by alcohol misuse (Copello et al., 2005). The preva-
lence of alcohol-use disorders in the victims and perpetrators of domestic violence
provides an important rationale for the exploration of these issues. Sexual abuse has
been found to be prevalent in alcohol dependent drinkers seeking treatment and may
be a particular concern with young people with alcohol misuse problems (Moncrieff
et al., 1996). For young people, both their own alcohol misuse and that of their
parents or carers may be a safeguarding concern. The Children Act 2004 places a
statutory duty on services providing assessments to make arrangements to ensure that
their functions are discharged with regard to the need to safeguard and promote the
welfare of children. Services that are involved with those who misuse alcohol fit into
a wider context of safeguarding young people from harm and need to work to ensure
that the rights of children, young people and their parents are respected. Local proto-
cols between alcohol treatment services and local safeguarding and family services
determine the specific actions to be taken (Department for Children, Schools and
Families, National Treatment Agency & Department of Health, 2009).
2.12.2 Current service provision for children and young people
In the UK, most treatment is community based and provided as part of a range of serv-
ices and models. These can be services provided by child and adolescent mental health
Alcohol dependence and harmful alcohol use
36

services (CAMHS) in Tier 2 and Tier 3 services, specific CAMHS addiction services
and other commissioned specialist services that are formed by a range of practitioners
(generally Tier 2 and Tier 3 collaborating from the youth offending teams, looked-after
teams and voluntary sector). Much of the focus is on engagement, health promotion and
retention in services. In addition, in the UK, services that offer treatment tend to priori-
tise drug misuse such as opiate or cannabis misuse and not alcohol. Given the comor-
bidity noted above, many adolescents having treatment for alcohol-use disorders are
often seen in specialist services, such as Youth Offending Teams, or specialist services
for young people with conduct disorders, such as the newly-developed multisystemic
therapy teams (Department of Health, 2007), although identification and treatment of
their dependence and/or harmful use may not be fully explored. In the US, adolescents
with substance-use disorders receive treatment in a variety of settings including
community, residential and criminal justice settings, and home-based treatment.
However, there is little research evaluating the differences between these settings. As a
consequence there is little clear evidence to determine the most appropriate treatment
environments. The American Academy of Child and Adolescent Psychiatry (2005)
recommend that factors affecting the choice of setting should include: the need to
provide a safe environment; motivation of the adolescent and his/her family to cooper-
ate with treatment; the need for structure and limit-setting; the presence of additional
medical or psychiatric conditions and the associated risks; the availability of specific
types of treatment settings for adolescents; preferences for treatment in a particular
setting; and treatment failure in a less restrictive/intensive setting in the past.
2.12.3 Older people
The prevalence of alcohol-use disorders declines with increasing age, but the rate of
detection by health professionals may be underestimated in older people because of a lack
of clinical suspicion or misdiagnosis (O’Connell et al., 2003). Nevertheless, the propor-
tion of older people drinking above the government’s recommended levels has recently
been increasing in the UK. The proportion of men aged 65 to 74 years who drank more
than four units per day in the past week increased from 18 to 30% between 1998 and 2008
(Fuller et al., 2009). In women of the same age, the increase in drinking more than three
units per day was from 6 to 14%. Also, as noted earlier, alcohol-related admissions to
hospital increase steeply with age although the prevalence of heavy drinking is lower in
this group. This may partly reflect the cumulative effects of lifetime alcohol consumption
as well as the general increasing risk of hospital admission with advancing age.
Further, it is important to note that due to age-related changes in metabolism,
intercurrent ill health, changing life circumstances and interactions with medications,
sensible drinking guidelines for younger adults may not be applicable to older people
(Reid & Anderson, 1997). Equivalent levels of alcohol consumption will give rise to
a higher blood alcohol concentration in older people compared with younger people
(Reid & Anderson, 1997). The US National Institute of Alcohol Abuse and
Alcoholism (NIAAA) has therefore recommended people over the age of 65 years
should drink no more than one drink (1.5 UK units) per day and no more than seven
Alcohol dependence and harmful alcohol use
37

drinks (10.5 UK units) per week. There are no similar recommendations for older people
in the UK. A related issue is that standard alcohol screening tools such as the AUDIT
may require a lower threshold to be applied in older people (O’Connell et al., 2003).
Older people are at least as likely as younger people to benefit from alcohol treatment
(Curtis et al., 1989). Clinicians therefore need to be vigilant to identify and treat older
people who misuse alcohol. As older people are more likely to have comorbid physical
and mental health problems and be socially isolated, a lower threshold for admission for
assisted alcohol withdrawal may be required (Dar, 2006). Further, in view of changes in
metabolism, potential drug interactions and physical comorbidity, dosages for medica-
tions to treat alcohol withdrawal and prevent relapse may need to be reduced in older
people (Dar, 2006). These issues are dealt with in more detail in the relevant chapters.
2.12.4 Homeless people
There is a high prevalence of alcohol misuse (as well as mental and physical health,
and social problems) amongst people who are homeless. The prevalence of alcohol-
use disorders in this population has been reported to be between 38 and 50% in the
UK (Gill et al., 1996; Harrison & Luck, 1997). In the US, studies of this population
typically report prevalence rates of 20 to 45%, depending on sampling methods and
definitions (Institute of Medicine, 1988).
Homeless people who misuse alcohol have particular difficulties in engaging main-
stream alcohol services, often due to difficulties in attending planned appointments.
Homelessness is associated with a poorer clinical outcome, although this may also
be due to the higher levels of comorbidity and social isolation in this population rather
than the homelessness per se. Hence services need to be tailored to maximise engage-
ment with this population.
This has led to the development of specific alcohol services for homeless drinkers,
including assertive outreach and ‘wet’ hostels. In wet hostels, residents are able to
continue drinking, but do so in an environment that aims to minimise the harm associated
with drinking and address other issues including homelessness (Institute of Medicine,
1988; Harrison & Luck, 1997). Such hostels tend to be located in urban centres where
there is a higher concentration of homeless drinkers. Assertive outreach and ‘crisis’
centres have been developed to attract homeless people who misuse alcohol into treat-
ment (Freimanis, 1993). Further, a lower threshold for admission for assisted alcohol
withdrawal and residential rehabilitation will often be required with this population.
2.12.5 People from ethnic minority groups
It is often asserted that people from ethnic minority groups are under-represented
in specialist alcohol treatment services (Harrison & Luck, 1997). The reality is that
the situation is likely to be more complex and depends on which specific ethnic
group and the prevalence of alcohol misuse in that group (Drummond, 2009). Based
on the Psychiatric Morbidity Survey, the ANARP study found that people from
Alcohol dependence and harmful alcohol use
38

ethnic minority groups as a whole had a lower prevalence of hazardous and harmful
drinking compared with the white population (ratio of 1:1.7) whereas alcohol depend-
ence was approximately equal in prevalence (ratio of 1:1.1) (Drummond et al., 2005).
However this study was unable to compare different ethnic minority groups.
Nevertheless, because people from ethnic minority groups have approximately the
same prevalence of alcohol dependence as the white population, if access to treatment
is equal one would expect the population in treatment to have approximately the same
proportion of people for ethnic minorities. The ethnic minority population in England
was 13% in the 2001 census. The NATMS found that in 2008–09 the proportion of
people from ethnic minorities with alcohol dependence is 9%, suggesting some
under-representation (National Treatment Agency and Department of Health, 2010).
However, it is not clear what proportion of NATMS attenders were hazardous/harm-
ful or dependent drinkers, which may account for the difference in proportions.
Adelstein and colleagues (1984) found that cirrhosis mortality rates are higher
than the national average for men from the Asian subcontinent and Ireland, but lower
than average for men of African–Caribbean origin. Cirrhosis mortality was lower in
Asian and African–Caribbean women but higher in Irish women. However, because
there were few total deaths in ethnic minority groups this may lead to large errors in
estimating prevalence in this population. Studies in England have tended to find over-
representation of Indian-, Scottish- and Irish-born people and under-representation in
those of African–Caribbean or Pakistani origin (Harrison & Luck, 1997). This may
partly be due to differences in prevalence rates of alcohol misuse, but differences in
culturally-related beliefs and help-seeking as well as availability of interpreters or
treatment personnel from appropriate ethnic minority groups may also account for
some of these differences (Drummond, 2009). There are relatively few specific
specialist alcohol services for people from ethnic minority groups, although some
examples of good practice exist (Harrison & Luck, 1997).
2.12.6 Women
Thom and Green (1996) identified three main factors that may account for a historical
under-representation of women in specialist alcohol services. Women tend to perceive
their problems differently from men, with a greater tendency not to identify themselves
as ‘alcoholic’. They are more likely to experience stigma in relation to their drinking
than men and have concerns about their children being taken into care. Also, women
regard the services as less suited to their needs than men do. Few services tend to
provide childcare facilities or women-only services. Nevertheless, more women are
now accessing treatment. The ANARP study found that, taking account of the lower
prevalence of alcohol dependence in women compared with men (ratio of 1:3), they
were 1.6 times more likely to access treatment (Drummond et al., 2005). Women are
also more likely to seek help for alcohol misuse than men in the US (Schuckit, 2009).
This may indicate that some of the barriers identified by Thom and Green (1996) may
have been overcome. However, services need to be sensitive to the particular needs of
women. There is also a need to develop services for pregnant women. This is the subject
of a separate NICE guideline on complex pregnancies (NICE, 2010c).
Alcohol dependence and harmful alcohol use
39

2.13 ECONOMIC IMPACT
Alcohol misuse and the related problems present a considerable cost to society.
Estimates of the economic costs attempt to assess in monetary terms the damage that
results from the misuse of alcohol. These costs include expenditures on alcohol-
related problems and opportunities that are lost because of alcohol (NIAAA, 1991).
Many challenges exist in estimating the costs required for cost-of-illness studies
in health; there are two such challenges that are particularly relevant to alcohol
misuse. First, researchers attempt to identify costs that are caused by and not merely
associated with alcohol misuse, yet it is often hard to establish causation (Cook, 1990;
NIAAA, 1991). Second, many costs resulting from alcohol misuse cannot be meas-
ured directly. This is especially true of costs that involve placing a value on lost
productivity. Researchers use mathematical and statistical methods to estimate such
costs, yet recognise that this is imprecise. Moreover, costs of pain and suffering of
both people who misuse alcohol and people affected by them cannot be estimated in
a reliable way, and are therefore not considered in most cost studies. These challenges
highlight the fact that although the economic cost of alcohol misuse can be estimated,
it cannot be measured precisely. Nevertheless, estimates of the cost provide an idea
of the dimensions of the problem and the breakdown of costs suggests which cate-
gories are most costly (NIAAA, 1991).
The first category of costs is that of treating the medical consequences of alcohol
misuse and treating alcohol misuse. The second category of health-related costs
includes losses in productivity by workers who misuse alcohol. The third category of
health-related costs is the loss to society because of premature deaths due to alcohol
misuse. In addition to the health-related costs of alcohol misuse are costs involving the
criminal justice system, social care, property losses from alcohol-related motor vehi-
cle crashes and fires, and lost productivity of the victims of alcohol-related crime and
individuals imprisoned as a consequence of alcohol-related crime (NIAAA, 1991).
The UK Cabinet Office recently estimated that the cost of alcohol to society was
£25.1 billion per annum (Department of Health, 2007). A recent report by the
Department of Health estimated an annual cost of £2.7 billion attributable to alcohol
harm to the NHS in England (Department of Health, 2008a). Hospital inpatient and
day visits accounted for 44% of these total costs, whilst accident and emergency
department visits and ambulance services accounted for 38%. However, crime and
disorder costs amount to £7.3 billion per annum, including costs for policing, drink
driving, courts and the criminal justice system, and costs to services both in anticipa-
tion and in dealing with the consequences of alcohol-related crime (Prime Minister’s
Strategy Unit, 2003). The estimated costs in the workplace amount to some £6.4
billion through lost productivity, absenteeism, alcohol-related sickness and premature
deaths (Prime Minister’s Strategy Unit, 2003).
For the European Union, the US and Canada, social costs of alcohol were esti-
mated to be around �270 billion (2003 prices; Anderson and Baumberg, 2005),
US$185 billion (1998 prices; WHO, 2004), and CA$14.6 billion (2002 prices; Rehm
et al., 2006), respectively.
Alcohol dependence and harmful alcohol use
40

3 METHODS USED TO DEVELOP THIS
GUIDELINE
3.1 OVERVIEW
The development of this guideline drew upon methods outlined by NICE (further
information is available in The Guidelines Manual; NICE, 2009a). A team of health
professionals, lay representatives and technical experts known as the Guideline
Development Group (GDG), with support from the NCCMH staff, undertook the
development of a patient-centred, evidence-based guideline. There are six basic steps
in the process of developing a guideline:
� Define the scope, which sets the parameters of the guideline and provides a focus
and steer for the development work.
� Define review questions considered important for practitioners and service users.
� Develop criteria for evidence searching and search for evidence.
� Design validated protocols for systematic review and apply to evidence recovered
by search.
� Synthesise and (meta-) analyse data retrieved, guided by the review questions, and
produce Grading of Recommendations: Assessment, Development and Evaluation
(GRADE) evidence profiles and summaries.
� Answer review questions with evidence-based recommendations for clinical practice.
The clinical practice recommendations made by the GDG are therefore derived
from the most up-to-date and robust evidence base for the clinical and cost effective-
ness of the treatments and services used in the treatment and management of alcohol
dependence and harmful alcohol use. In addition, to ensure a service user and carer
focus, the concerns of service users and carers regarding health and social care have
been highlighted and addressed by recommendations agreed by the whole GDG.
3.2 THE SCOPE
Guideline topics are selected by the Department of Health and the Welsh Assembly
Government, which identify the main areas to be covered by the guideline in a specific
remit (see The Guidelines Manual [NICE, 2009a] for further information). The NCCMH
developed a scope for the guideline based on the remit. The purpose of the scope is to:
� provide an overview of what the guideline will include and exclude
� identify the key aspects of care that must be included
� set the boundaries of the development work and provide a clear framework to
enable work to stay within the priorities agreed by NICE and the National
Collaborating Centre, and the remit from the Department of Health/Welsh
Assembly Government
Methods used to develop this guideline
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Methods used to develop this guideline
42
� inform the development of the review questions and search strategy
� inform professionals and the public about expected content of the guideline
� keep the guideline to a reasonable size to ensure that its development can be
carried out within the allocated period.
An initial draft of the scope was sent to registered stakeholders who had agreed to
attend a scoping workshop. The workshop was used to:
� obtain feedback on the selected key clinical issues
� identify which patient or population subgroups should be specified (if any)
� seek views on the composition of the GDG
� encourage applications for GDG membership.
The draft scope was subject to consultation with registered stakeholders over a
4-week period. During the consultation period, the scope was posted on the NICE
website (www.nice.org.uk). Comments were invited from stakeholder organisations
and the Guideline Review Panel (GRP). Further information about the GRP can also
be found on the NICE website. The NCCMH and NICE reviewed the scope in light
of comments received, and the revised scope was signed off by the GRP.
3.3 THE GUIDELINE DEVELOPMENT GROUP
The GDG consisted of: professionals in psychiatry, clinical psychology, nursing,
social work, and general practice; academic experts in psychiatry and psychology;
and service user, lay member and carer representatives. The guideline development
process was supported by staff from the NCCMH, who undertook the clinical and
health economic literature searches, reviewed and presented the evidence to the GDG,
managed the process and contributed to drafting the guideline.
3.3.1 Guideline Development Group meetings
Twelve GDG meetings were held between March 2009 and September 2010. During
each day-long GDG meeting, in a plenary session, review questions and clinical and
economic evidence were reviewed and assessed, and recommendations formulated.
At each meeting, all GDG members declared any potential conflicts of interest, and
service user and carer concerns were routinely discussed as part of a standing agenda.
3.3.2 Topic groups
The GDG divided its workload along clinically relevant lines to simplify the guide-
line development process, and GDG members formed smaller topic groups to under-
take guideline work in that area of clinical practice. Topic group membership was
decided after a discussion between all GDG members, and each topic group was
chaired by a GDG member with expert knowledge of the topic area (one of the health-
care professionals). Topic Group 1 covered questions relating to pharmacological

intervention. Topic Group 2 covered psychological and psychosocial interventions.
Topic Group 3 covered assessment of alcohol misuse, Topic Group 4 covered service
user and carer experiences of care, and Topic Group 5 covered delivery settings for
treatment. These groups were designed to efficiently manage the large volume of
evidence appraisal prior to presenting it to the GDG as a whole. Topic groups refined
the review questions and the clinical definitions of treatment interventions, reviewed
and prepared the evidence with the systematic reviewer before presenting it to the
GDG as a whole, and helped the GDG to identify further expertise in the topic. Topic
group leaders reported the status of the group’s work as part of the standing agenda.
They also introduced and led the GDG discussion of the evidence review for that
topic and assisted the GDG Chair in drafting the section of the guideline relevant to
the work of each topic group. All statements and recommendations in this guideline
have been agreed by the whole GDG.
3.3.3 Service users and carers
Individuals with direct experience of services gave an integral service-user focus to
the GDG and the guideline. The GDG included service user, carer and lay member
representatives who contributed as full GDG members to writing the review ques-
tions, helping to ensure that the evidence addressed their views and preferences, high-
lighting sensitive issues and terminology relevant to the guideline, and bringing
service-user research to the attention of the GDG. In drafting the guideline, they
contributed to writing Chapter 4 and identified recommendations from the service
user and carer perspective.
3.3.4 Special advisors
Special advisors, who had specific expertise in one or more aspects of treatment and
management relevant to the guideline, assisted the GDG, commenting on specific
aspects of the developing guideline and making presentations to the GDG. Appendix
3 lists those who agreed to act as special advisors.
3.3.5 National and international experts
National and international experts in the area under review were identified through
the literature search and through the experience of the GDG members. These experts
were contacted to recommend unpublished or soon-to-be published studies to ensure
that up-to-date evidence was included in the development of the guideline. They
informed the group about completed trials at the pre-publication stage, systematic
reviews in the process of being published, studies relating to the cost effectiveness of
treatment, and trial data if the GDG could be provided with full access to the
complete trial report. Appendix 6 lists researchers who were contacted.
Methods used to develop this guideline
43

3.3.6 Integration of other guidelines on alcohol-use disorders
In addition to this guideline, there are two other pieces of NICE guidance addressing
alcohol-use disorders outlined in Chapter 1. During development, steering group
meetings were held in which representatives from the three development groups met
to discuss any issues, such as overlapping areas of review work and integration of the
guidelines.
3.4 REVIEW QUESTIONS
Review (clinical) questions were used to guide the identification and interrogation of
the evidence base relevant to the topic of the guideline. The draft review questions
were discussed by the GDG at the first few meetings and amended as necessary.
Where appropriate, the questions were refined once the evidence had been searched
and, where necessary, subquestions were generated. Questions submitted by stake-
holders were also discussed by the GDG and the rationale for not including any ques-
tions was recorded in the minutes. The final list of review questions can be found in
Appendix 7.
For questions about interventions, the Patient, Intervention, Comparison and
Outcome (PICO) framework was used (see Table 2).
Questions relating to assessment and diagnosis do not involve an intervention
designed to treat a particular condition, therefore the PICO framework was not used.
Rather, the questions were designed to identify key issues specifically relevant to
diagnostic tests, for example their accuracy, reliability and safety.
Methods used to develop this guideline
44
Patients/population Which patients or population of patients are we interested
in? How can they be best described? Are there subgroups
that need to be considered?
Intervention Which intervention, treatment or approach should be used?
Comparison What is/are the main alternative/s to compare with the
intervention?
Outcome What is really important for the patient? Which outcomes
should be considered: intermediate or short-term meas-
ures; mortality; morbidity and treatment complications;
rates of relapse; late morbidity and readmission; return to
work, physical and social functioning and other measures
such as quality of life; general health status?
Table 2: Features of a well-formulated question on effectiveness
intervention – the PICO guide

In some situations, the prognosis of a particular condition is of fundamental
importance, over and above its general significance in relation to specific interven-
tions. Areas where this is particularly likely to occur relate to assessment of
risk, for example in terms of behaviour modification or screening and early inter-
vention. In addition, review questions related to issues of service delivery are
occasionally specified in the remit from the Department of Health/Welsh
Assembly Government. In these cases, appropriate review questions were devel-
oped to be clear and concise.
To help facilitate the literature review, a note was made of the best study design
type to answer each question. There are four main types of review question of rele-
vance to NICE guidelines. These are listed in Table 3. For each type of question the
best primary study design varies, where ‘best’ is interpreted as ‘least likely to give
misleading answers to the question’.
However, in all cases a well-conducted systematic review (of the appropriate type
of study) is likely to yield a better answer than a single study.
Deciding on the best design type to answer a specific review question does
not mean that studies of different design types addressing the same question were
discarded.
The GDG classified each review question into one of three groups: (1) questions
concerning good practice; (2) questions likely to have little or no directly relevant
evidence; and (3) questions likely to have a good evidence base. Questions concern-
ing good practice were answered by the GDG using informal consensus. For ques-
tions that were unlikely to have a good evidence base, a brief descriptive review was
initially undertaken and then the GDG used informal consensus to reach a decision
(see Section 3.5.7). For questions with a good evidence base, the review process
followed the methods outlined in Section 3.5.1.
Methods used to develop this guideline
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Type of question Best primary study design
Effectiveness or other Randomised controlled trial (RCT); other
impact of an intervention studies that may be considered in the absence of
RCTs are the following: internally/externally
controlled before-and-after trial, interrupted
time-series
Accuracy of information Comparing the information against a valid gold
(for example, risk factor, standard in a randomised trial or inception
test, prediction rule) cohort study
Rates (of disease, patient Prospective cohort, registry, cross-sectional study
experience, rare side effects)
Table 3: Best study design to answer each type of question

3.5 CLINICAL EVIDENCE METHODS
The aim of the clinical evidence review was to systematically identify and synthesise
relevant evidence from the literature to answer the specific review questions devel-
oped by the GDG. Thus, clinical practice recommendations are evidence-based where
possible and, if evidence is not available, informal consensus methods are used (see
Section 3.5.7) and the need for future research is specified.
3.5.1 The search process
Scoping searches
A broad preliminary search of the literature was undertaken in September 2008 to
obtain an overview of the issues likely to be covered by the scope and to help define
key areas. Searches were restricted to clinical guidelines, health technology assess-
ment (HTA) reports, key systematic reviews and RCTs, and conducted in the follow-
ing databases and websites:
� British Medical Journal Clinical Evidence
� Canadian Medical Association (CMA) Infobase (Canadian guidelines)
� Clinical Policy and Practice Program of the New South Wales Department of
Health (Australia)
� Clinical Practice Guidelines (Australian Guidelines)
� Cochrane Central Register of Controlled Trials (CENTRAL)
� Cochrane Database of Abstracts of Reviews of Effects (DARE)
� Cochrane Database of Systematic Reviews (CDSR)
� Excerpta Medica Database (EMBASE)
� Guidelines International Network (G-I-N)
� Health Evidence Bulletin Wales
� Health Management Information Consortium (HMIC)
� HTA database (technology assessments)
� Medical Literature Analysis and Retrieval System Online (MEDLINE)/MEDLINE
in Process
� National Health and Medical Research Council (NHMRC)
� National Library for Health (NLH) Guidelines Finder
� New Zealand Guidelines Group
� NHS Centre for Reviews and Dissemination (CRD)
� OmniMedicalSearch
� Scottish Intercollegiate Guidelines Network (SIGN)
� Turning Research Into Practice (TRIP)
� US Agency for Healthcare Research and Quality (AHRQ)
� Websites of NICE and the National Institute for Health Research (NIHR) HTA
Programme for guidelines and HTAs in development.
Existing NICE guidelines were updated where necessary. Other relevant guide-
lines were assessed for quality using the AGREE instrument (AGREE Collaboration,
2003). The evidence base underlying high-quality existing guidelines was utilised and
Methods used to develop this guideline
46

updated as appropriate. Further information about this process can be found in The
Guidelines Manual (NICE, 2009a).
Systematic literature searches
After the scope was finalised, a systematic search strategy was developed to locate all
the relevant evidence. The balance between sensitivity (the power to identify all stud-
ies on a particular topic) and specificity (the ability to exclude irrelevant studies from
the results) was carefully considered, and a decision made to utilise a broad approach
to searching, to maximise the retrieval of evidence to all parts of the guideline.
Searches were restricted to: systematic reviews, meta-analyses, RCTs, observational
studies, quasi-experimental studies and qualitative research. Searches were conducted
in the following databases:
� Allied and Complementary Medicine Database (AMED)
� Cumulative Index to Nursing and Allied Health Literature (CINAHL)
� EMBASE
� MEDLINE/MEDLINE In-Process
� Psychological Information Database (PsycINFO)
� DARE
� CDSR
� CENTRAL
� HTA database.
For standard mainstream bibliographic databases (AMED, CINAHL, EMBASE,
MEDLINE and PsycINFO), search terms for alcohol dependence and harmful alco-
hol use were combined with study design filters for systematic reviews, RCTs and
qualitative research. For searches generated in databases with collections of study
designs at their focus (DARE, CDSR, CENTRAL and HTA), search terms for alco-
hol dependence and harmful alcohol use were used without a filter. The sensitivity of
this approach was aimed at minimising the risk of overlooking relevant publications,
due to inaccurate or incomplete indexing of records, as well as potential weaknesses
resulting from more focused search strategies (for example, for interventions).
For focused searches, terms for case management and assertive community treat-
ment (ACT) were combined with terms for alcohol dependence and harmful alcohol
use, and filters for observational and quasi-experimental studies.
Reference manager
Citations from each search were downloaded into Reference Manager (a software
product for managing references and formatting bibliographies) and duplicates
removed. Records were then screened against the inclusion criteria of the reviews
before being quality appraised (see Section 3.5.2). To keep the process both replica-
ble and transparent, the unfiltered search results were saved and retained for future
potential re-analysis.
Search filters
The search filters for systematic reviews and RCTs are adaptations of filters designed
by the CRD and the Health Information Research Unit of McMaster University,
Methods used to develop this guideline
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Ontario. The qualitative, observational and quasi-experimental filters were developed
in-house. Each filter comprised index terms relating to the study type(s) and associ-
ated text words for the methodological description of the design(s).
Date and language restrictions
Date restrictions were not applied, except for searches of systematic reviews, which
were limited to research published from 1993 onwards. Systematic database searches
were initially conducted in June 2008 up to the most recent searchable date. Search
updates were generated on a 6-monthly basis, with the final re-runs carried out in
March 2010 ahead of the guideline consultation. After this point, studies were only
included if they were judged by the GDG to be exceptional (for example, if the
evidence was likely to change a recommendation).
Post-guideline searching: following the draft guideline consultation, searches for
observational and quasi-experimental studies were conducted for case management
and ACT.
Although no language restrictions were applied at the searching stage, foreign
language papers were not requested or reviewed unless they were of particular impor-
tance to a review question.
Other search methods
Other search methods involved: (1) scanning the reference lists of all eligible
publications (systematic reviews, stakeholder evidence and included studies) for
more published reports and citations of unpublished research; (2) sending lists of
studies meeting the inclusion criteria to subject experts (identified through
searches and the GDG) and asking them to check the lists for completeness, and
to provide information of any published or unpublished research for consideration
(see Appendix 3); (3) checking the tables of contents of key journals for studies
that might have been missed by the database and reference list searches; (4) track-
ing key papers in the Science Citation Index (prospectively) over time for further
useful references.
Full details of the search strategies and filters used for the systematic review of
clinical evidence are provided in Appendix 9.
Study selection and quality assessment
All primary-level studies included after the first scan of citations were acquired in
full and re-evaluated for eligibility at the time when they were being entered into
the study information database. More specific eligibility criteria were developed
for each review question and are described in the relevant clinical evidence chap-
ters. Eligible systematic reviews and primary-level studies were critically
appraised for methodological quality (see Appendix 11 for methodology check-
lists). The eligibility of each study was confirmed by at least one member of the
appropriate topic group.
For some review questions, it was necessary to prioritise the evidence with respect
to the UK context (that is, external validity). To make this process explicit, the topic
groups took into account the following factors when assessing the evidence:
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� participant factors (for example, gender, age and ethnicity)
� provider factors (for example, model fidelity, the conditions under which the inter-
vention was performed and the availability of experienced staff to undertake the
procedure)
� cultural factors (for example, differences in standard care and the welfare system).
It was the responsibility of each topic group to decide which prioritisation factors
were relevant to each review question in light of the UK context. Any issues and
discussions within topic groups were brought back to the wider GDG for further
consideration.
Unpublished evidence
The GDG used a number of criteria when deciding whether or not to accept unpub-
lished data. First, the evidence must have been accompanied by a trial report contain-
ing sufficient detail to properly assess the quality of the data. Second, the evidence
must have been submitted with the understanding that data from the study and a
summary of the study’s characteristics would be published in the full guideline.
Therefore, the GDG did not accept evidence submitted as commercial in confidence.
However, the GDG recognised that unpublished evidence submitted by investigators
might later be retracted by those investigators if the inclusion of such data would
jeopardise publication of their research.
3.5.2 Data extraction
Study characteristics and outcome data were extracted from all eligible studies that met
the minimum quality criteria using a Microsoft Word-based form (see Appendix 11).
In most circumstances, for a given outcome (continuous and dichotomous), where
more than 50% of the number randomised to any group were lost to follow-up, the data
were excluded from the analysis (except for the outcome ‘leaving the study early’, in
which case the denominator was the number randomised). Where possible, dichotomous
efficacy outcomes were calculated on an intention-to-treat basis (that is, a ‘once-
randomised-always-analyse’ basis). Where there was good evidence that those partici-
pants who ceased to engage in the study were likely to have an unfavourable outcome,
early withdrawals were included in both the numerator and denominator. Adverse effects
were entered into Review Manager, as reported by the study authors, because it is usually
not possible to determine whether early withdrawals have had an unfavourable outcome.
Where there was limited data for a particular review, the 50% rule was not applied. In
these circumstances the evidence was downgraded due to the risk of bias.
Where some of the studies failed to report standard deviations (for a continuous
outcome) and where an estimate of the variance could not be computed from other
reported data or obtained from the study author, the following approach was taken.
6
Methods used to develop this guideline
49
6
Based on the approach suggested by Furukawa and colleagues (2006).

When the number of studies with missing standard deviations was less than one
third and when the total number of studies was at least ten, the pooled standard devi-
ation was imputed (calculated from all the other studies in the same meta-analysis
that used the same version of the outcome measure). In this case, the appropriateness
of the imputation was made by comparing the standardised mean differences (SMDs)
of those trials that had reported standard deviations against the hypothetical SMDs of
the same trials based on the imputed standard deviations. If they converged, the meta-
analytical results were considered to be reliable.
When the conditions above could not be met, standard deviations were taken from
another related systematic review (if available). In this case, the results were consid-
ered to be less reliable.
The meta-analysis of survival data, such as time to any drinking episode, was
based on log hazard ratios and standard errors. Since individual patient data were not
available in included studies, hazard ratios and standard errors calculated from a Cox
proportional hazard model were extracted. Where necessary, standard errors were
calculated from confidence intervals (CIs) or p-value according to standard formulae
(see Cochrane Handbook for Systematic Reviews of Interventions, 5.0.2, Higgins
et al., 2009). Data were summarised using the generic inverse variance method, using
Review Manager.
Consultation with another reviewer or members of the GDG was used to over-
come difficulties with coding. Data from studies included in existing systematic
reviews were extracted independently by one reviewer and cross-checked with the
existing data set. Where possible, two independent reviewers extracted data from
new studies. Where double data extraction was not possible, data extracted by one
reviewer was checked by the second reviewer. Disagreements were resolved through
discussion. Where consensus could not be reached, a third reviewer or GDG
members resolved the disagreement. Masked assessment (that is, blind to the jour-
nal from which the article comes, the authors, the institution and the magnitude of
the effect) was not used since it is unclear that doing so reduces bias (Berlin, 2001;
Jadad et al., 1996).
3.5.3 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.
Dichotomous outcomes were analysed as relative risks (RR) with the associated
95% CI (for an example, see Figure 1). A relative risk (also called a risk ratio) is the
ratio of the treatment event rate to the control event rate. An RR of 1 indicates no
difference between treatment and control. In Figure 1, the overall RR of 0.73 indi-
cates that the event rate (that is, non-remission rate) associated with intervention A is
about three quarters of that with the control intervention or, in other words, the RR
reduction is 27%.
Methods used to develop this guideline
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The CI shows a range of values within which we are 95% confident that the true
effect will lie. If the effect size has a CI that does not cross the ‘line of no effect’, then
the effect is commonly interpreted as being statistically significant.
Continuous outcomes were analysed using the SMD because different measures
were used in different studies to estimate the same underlying effect (for an example
see Figure 2). If reported by study authors, intention-to-treat data using a valid
method for imputation of missing data were preferred over data only from people who
completed the study.
The number needed to treat for benefit (NNTB) or the number needed to treat for
harm (NNTH) was reported for each outcome where the baseline risk (that is, the
control group event rate) was similar across studies. In addition, numbers needed to
treat (NNTs) calculated at follow-up were only reported where the length of follow-up
was similar across studies. When the length of follow-up or baseline risk varies (espe-
cially with low risk), the NNT is a poor summary of the treatment effect (Deeks, 2002).
Heterogeneity
To check for consistency of effects among studies, both the I
2
statistic and the chi-
squared test of heterogeneity as well as a visual inspection of the forest plots were
used. The I
2
statistic describes the proportion of total variation in study estimates that
is due to heterogeneity (Higgins & Thompson, 2002). The I
2
statistic was interpreted
in the following way based on Higgins and Green (2009):
Methods used to develop this guideline
51
Review: NCCMH clinical guideline review (example)
Comparison: 01 Intervention A compared with a control group
Outcome: 01 Number of people who did not show remission
Study Intervention A Control RR (fixed) Weight RR (fixed)
or sub-category n/N n/N 95% CI % 95% CI
01 Intervention A versus control
GRIFFITHS1994 13/23 27/28 38.79 0.59 [0.41, 0.84]
LEE1986 11/15 14/15 22.30 0.79 [0.56, 1.10]
TREASURE1994 21/28 24/27 38.92 0.84 [0.66, 1.09]
Subtotal (95% CI) 45/66 65/70 100.00 0.73 [0.61, 0.88]
Test for heterogeneity: Chi² = 2.83, df = 2 (P = 0.24), I² = 29.3%
Test for overall effect: Z = 3.37 (P = 0.0007)
0.2 0.5 1 2 5
Favours intervention Favours control
Figure 1: Example of a forest plot displaying dichotomous data
Review: NCCMH clinical guideline review (example)
Comparison: 01 Intervention A compared with a control group
Outcome: 03 Mean frequency (endpoint)
Study Intervention A Control SMD (fixed) Weight SMD (fixed)
or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI
01 Intervention A versus control
FREEMAN1988 32 1.30(3.40) 20 3.70(3.60) 25.91 -0.68 [-1.25, -0.10]
GRIFFITHS1994 20 1.25(1.45) 22 4.14(2.21) 17.83 -1.50 [-2.20, -0.81]
LEE1986 14 3.70(4.00) 14 10.10(17.50) 15.08 -0.49 [-1.24, 0.26]
TREASURE1994 28 44.23(27.04) 24 61.40(24.97) 27.28 -0.65 [-1.21, -0.09]
WOLF1992 15 5.30(5.10) 11 7.10(4.60) 13.90 -0.36 [-1.14, 0.43]
Subtotal (95% CI) 109 91 100.00 -0.74 [-1.04, -0.45]
Test for heterogeneity: Chi² = 6.13, df = 4 (P = 0.19), I² = 34.8%
Test for overall effect: Z = 4.98 (P < 0.00001)
–4 –2 0 2 4
Favours intervention Favours control
Figure 2: Example of a forest plot displaying continuous data

� 0 to 40%: might not be important
� 30 to 60%: may represent moderate heterogeneity
� 50 to 90%: may represent substantial heterogeneity
� 75 to 100%: considerable heterogeneity.
Two factors were used to make a judgement about importance of the observed value
of I
2
: first, the magnitude and direction of effects, and second, the strength of evidence
for heterogeneity (for example, p-value from the chi-squared test, or a CI for I
2
).
Publication bias
Where there was sufficient data, we intended to use funnel plots to explore the possi-
bility of publication bias. Asymmetry of the plot would be taken to indicate possible
publication bias and investigated further. However, due to a paucity of data, funnel
plots could not be used.
Where necessary, an estimate of the proportion of eligible data that were missing
(because some studies did not include all relevant outcomes) was calculated for each
analysis.
3.5.4 Summary statistics used to evaluate assessment instruments
The main outcomes that need to be extracted from diagnostic accuracy studies are
sensitivity, specificity, positive predictive validity and negative predictive validity.
These are discussed in detail below. Negative likelihood ratios, positive likelihood
ratios and area under the curve will also be briefly described. In addition, definitions
of relevant validation and reliability assessment strategies will be provided below.
The sensitivity of an instrument refers to the proportion of those with the condi-
tion who test positive. An instrument that detects a low percentage of cases will not
be very helpful in determining the numbers of patients who should receive a known
effective treatment because many individuals who should receive the treatment will
not do so. This would make for poor planning, and underestimate the prevalence of
the disorder and the costs of treatments to the community. As the sensitivity of an
instrument increases, the number of false negatives it detects will decrease.
The specificity of an instrument refers to the proportion of those without the
condition who test negative. This is important so that well individuals are not given
treatments they do not need. As the specificity of an instrument increases, the number
of false positives will decrease.
To illustrate this: from a population in which the point prevalence rate of alcohol
dependence is 10% (that is, 10% of the population has alcohol dependence at any one
time), 1000 people are given a test that has 90% sensitivity and 85% specificity. It is
known that 100 people in this population have alcohol dependence, but the test
detects only 90 (true positives), leaving ten undetected (false negatives). It is also
known that 900 people do not have alcohol dependence and the test correctly identi-
fies 765 of these (true negatives), but classifies 135 incorrectly as having alcohol
dependence (false positives). The positive predictive value of the test (the number
correctly identified as having alcohol dependence as a proportion of positive tests) is
Methods used to develop this guideline
52

40% (90/90 � 135) and the negative predictive value (the number correctly identified
as not having alcohol dependence as a proportion of negative tests) is 98%
(765/765 � 10). Therefore, in this example a positive test result is correct in only
40% of cases whilst a negative result can be relied upon in 98% of cases.
The example above illustrates some of the main differences between positive
predictive values and negative predictive values in comparison with sensitivity and
specificity. For both positive predictive values and negative predictive values, preva-
lence explicitly forms part of their calculation (see Altman & Bland, 1994a). When
the prevalence of a disorder is low in a population this is generally associated with a
higher negative predictive value and a lower positive predictive value. Therefore,
although these statistics are concerned with issues probably more directly applicable
to clinical practice (for example, the probability that a person with a positive test
result actually has alcohol dependence), they are largely dependent on the character-
istics of the populations sampled and cannot be universally applied (Altman & Bland,
1994a).
In contrast, sensitivity and specificity do not theoretically depend on prevalence
(Altman & Bland, 1994b). For example, sensitivity is concerned with the perform-
ance of an identification test conditional on a person having depression. Therefore the
higher false positives often associated with samples of low prevalence will not affect
such estimates. The advantage of this approach is that sensitivity and specificity can
be applied across populations (Altman & Bland, 1994b). However, the main disad-
vantage is that clinicians tend to find such estimates more difficult to interpret.
Criterion validity (or predictive validity) is evaluated when the purpose is to use
an instrument to estimate some important form of behaviour that is external to the
measuring instrument itself, the latter being referred to as the criterion (Nunnally,
1978). Criterion validity evaluates how well scores on a measure relate to real-world
behaviours such as motivation for treatment and long-term treatment outcomes. The
degree of correspondence between the test and the criterion is estimated by the size
of their correlation.
Construct validity refers to the experimental demonstration that a test is measur-
ing the construct it was intended to measure. Relationships among items, domains
and concepts conform to a priori hypotheses concerning logical relationships that
should exist with other measures or characteristics of patients and patient groups
(Brown, 1996).
Content validity is derived from the degree to which a test is a representative
sample of the content of whatever objectives or specifications the test was originally
designed to measure (Brown, 1996).
Inter-rater reliability refers to the degree to which observers, or raters, are consis-
tent in their scoring on a measurement scale. Internal reliability gives an indication of
how much homogeneity or consensus there is amongst the raters (Allen, 2003).
Test–retest reliability is determined by administering the measurement instrument
two or more times to each subject. If the correlation between scores is high, the meas-
urement instrument can be said to have good test–retest reliability. This is desirable
when measuring constructs that are not expected to change over time, for example
family history of alcoholism, age of onset of problem drinking and general expectancies
Methods used to develop this guideline
53

of alcohol effects. In contrast, when measuring more transient constructs such as
cravings and treatment motivation, the test–retest reliability would be expected to be
lower (Allen, 2003).
Internal consistency is a measure based on the correlation between different items
within the scale itself. For instruments designed to measure a single phenomenon, these
correlation coefficients should be high (Allen, 2003).
3.5.5 Presenting the data to the Guideline Development Group
Study characteristics tables and, where appropriate, forest plots generated with
Review Manager were presented to the GDG.
Where meta-analysis was not appropriate and/or possible, the reported results
from each primary-level study were included in the study characteristics table (and,
where appropriate, in a narrative review).
Evidence profile tables
A GRADE
7
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.
3.5.6 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
Methods used to develop this guideline
54
7
For further information about GRADE, see www.gradeworkinggroup.org.

Methods used to develop this guideline
55
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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 judge-
ments
8
, the requirements to prevent discrimination and to promote equality
9
, and the
group’s awareness of practical issues (Eccles et al., 1998; NICE, 2009a).
3.5.7 Method used to answer a review question in the absence of
appropriately designed, high-quality research
In the absence of appropriately designed, high-quality research, or where the GDG
were of the opinion (on the basis of previous searches or their knowledge of the liter-
ature) that there were unlikely to be such evidence, an informal consensus process was
adopted. This process focused on those questions that the GDG considered a priority.
Informal consensus
The starting point for the process of informal consensus was that a member of the
topic group identified, with help from the systematic reviewer, a narrative review that
most directly addressed the review question. Where this was not possible, a brief
review of the recent literature was initiated.
This existing narrative review or new review was used as a basis for beginning an
iterative process to identify lower levels of evidence relevant to the review question and
to lead to written statements for the guideline. The process involved a number of steps:
1. A description of what was known about the issues concerning the review question
was written by one of the topic group members.
2. Evidence from the existing review or new review was then presented in narrative
form to the GDG and further comments were sought about the evidence and its
perceived relevance to the review question.
3. Based on the feedback from the GDG, additional information was sought and
added to the information collected. This may include studies that did not directly
address the review question but were thought to contain relevant data.
4. If, during the course of preparing the report, a significant body of primary-level
studies (of appropriate design to answer the question) were identified, a full
systematic review was done.
5. At this time, subject possibly to further reviews of the evidence, a series of state-
ments that directly addressed the review question were developed.
Methods used to develop this guideline
56
8
See NICE (2008b).
9
See NICE’s equality scheme: www.nice.org.uk/aboutnice/howwework/NICEEqualityScheme.jsp.

6. Following this, on occasions and as deemed appropriate by the development
group, the report was then sent to appointed experts outside of the GDG for peer
review and comment. The information from this process was then fed back to the
GDG for further discussion of the statements.
7. Recommendations were then developed and could also be sent for further external
peer review.
8. After this final stage of comment, the statements and recommendations were
again reviewed and agreed upon by the GDG.
3.6 HEALTH ECONOMICS METHODS
The aim of health economics was to contribute to the guideline’s development by
providing evidence on the cost effectiveness of interventions for alcohol misuse
covered in the guideline. This was achieved by:
� a systematic literature review of existing economic evidence
� decision-analytic economic modelling.
Systematic reviews of economic literature were conducted in all areas covered in
the guideline. Economic modelling was undertaken in areas with likely major
resource implications, where the current extent of uncertainty over cost effectiveness
was significant and economic analysis was expected to reduce this uncertainty, in
accordance with The Guidelines Manual (NICE, 2009a). Prioritisation of areas for
economic modelling was a joint decision between the health economist and the GDG.
The rationale for prioritising review questions for economic modelling was set out in
an economic plan agreed between NICE, the GDG, the health economist and the
other members of the technical team. The following economic questions were
selected as key issues that were addressed by economic modelling:
1. What is the preferred method of medically-assisted withdrawal, in terms of clini-
cal and cost effectiveness (taking into consideration the benefits/adverse effects)
and for which people and in which setting (taking into account the nature of inter-
vention in each setting)?
– Community (taking into account levels of supervision: structured versus
unstructured day programme)
– Residential
– Inpatient: mental health or acute hospital
– Prisons.
2. For people who are alcohol dependent or harmful drinkers, which pharmacologi-
cal interventions aimed at attenuation of drinking/maintenance of abstinence are
clinically and cost-effective?
3. For people who are alcohol dependent or harmful drinkers, which psychological
and psychosocial interventions aimed at attenuation of drinking/maintenance of
abstinence are clinically and cost-effective?
4. For people who are alcohol dependent or harmful drinkers, which combination of
psychological/psychosocial and pharmacological interventions aimed at attenua-
tion of drinking/maintenance of abstinence are clinically and cost-effective?
Methods used to develop this guideline
57

In addition, literature on the health-related quality of life of people with alcohol-
use disorders was systematically searched to identify studies reporting appropriate
utility scores that could be utilised in a cost-utility analysis.
The rest of this section describes the methods adopted in the systematic literature
review of economic studies. Methods employed in economic modelling are described
in the respective sections of the guideline.
3.6.1 Literature search strategy for economic evidence
Scoping searches
A broad preliminary search of the literature was undertaken in September 2008 to
obtain an overview of the issues likely to be covered by the scope and help define key
areas. Searches were restricted to economic studies and HTA reports, and conducted
in the following databases:
� EMBASE
� MEDLINE/MEDLINE In-Process
� HTA database (technology assessments)
� NHS Economic Evaluation Database (NHS EED).
Systematic literature searches
After the scope was finalised, a systematic search strategy was developed to locate all
the relevant evidence. The balance between sensitivity (the power to identify all stud-
ies on a particular topic) and specificity (the ability to exclude irrelevant studies from
the results) was carefully considered, and a decision made to utilise a broad approach
to searching to maximise retrieval of evidence to all parts of the guideline. Searches
were restricted to economic studies and HTA reports, and conducted in the following
databases:
� CINAHL
� EconLit
� EMBASE
� MEDLINE/MEDLINE In-Process
� PsycINFO
� HTA database (technology assessments)
� NHS EED.
Any relevant economic evidence arising from the clinical scoping searches was
also made available to the health economist during the same period.
For standard mainstream bibliographic databases (CINAHL, EMBASE,
MEDLINE and PsycINFO), search terms on alcohol dependence and harmful alcohol
use were combined with a search filter for health economic studies. For searches
generated in topic-specific databases (HTA, NHS EED), search terms on alcohol
dependence and harmful alcohol use were used without a filter. The sensitivity of this
approach was aimed at minimising the risk of overlooking relevant publications, due to
inaccurate or incomplete indexing of records on the databases, as well as potential weak-
nesses resulting from more focused search strategies (for example, for interventions).
Methods used to develop this guideline
58

Reference manager
Citations from each search were downloaded into Reference Manager and duplicates
removed. Records were then screened against the inclusion criteria of the reviews
before being quality appraised. To keep the process both replicable and transparent,
the unfiltered search results were saved and retained for future potential re-analysis.
Search filters
The search filter for health economics is an adaptation of a filter designed by the
CRD. The filter comprises a combination of controlled vocabulary and free-text
retrieval methods.
Date and language restrictions
All of the searches were restricted to research published from 1993 onwards.
Systematic database searches were initially conducted in June 2008 up to the most
recent searchable date. Search updates were generated on a 6-monthly basis, with the
final re-runs carried out in March 2010 ahead of the guideline consultation. After this
point, studies were included only if they were judged by the GDG to be exceptional
(for example, if the evidence was likely to change a recommendation).
Although no language restrictions were applied at the searching stage, foreign
language papers were not requested or reviewed unless they were of particular impor-
tance to an area under review.
Other search methods
Other search methods involved scanning the reference lists of all eligible publications
(systematic reviews, stakeholder evidence and included studies from the economic
and clinical reviews) to identify further studies for consideration.
Full details of the search strategies and filter used for the systematic review of
health economic evidence are provided in Appendix 12.
3.6.2 Inclusion criteria for economic studies
The following methods were applied to select studies identified by the economic
searches for further consideration:
� No restriction was placed on language or publication status of the papers.
� Studies published from 1998 onwards that reported data from financial year
1997–98 onwards were included. This date restriction was imposed in order to
obtain data relevant to current healthcare settings and costs.
� Only studies from Organisation for Economic Co-operation and Development
member-countries were included, because the aim of the review was to identify
economic information transferable to the UK context.
� Selection criteria based on types of clinical conditions and patients as well as
interventions assessed were identical to the clinical literature review.
� Studies were included provided that sufficient details regarding methods and
results were available to enable the methodological quality of the study to be
Methods used to develop this guideline
59

assessed, and provided that the study’s data and results were extractable. Poster
presentations of abstracts were excluded; however, they were included if they
reported utility data required for a cost-utility analysis when no other data were
available.
� Full economic evaluations that compared two or more relevant options and
considered both costs and consequences (that is, cost-consequence analysis, cost
effectiveness analysis, cost-utility analysis or cost-benefit analysis) as well as cost
analyses that compared only costs between two or more interventions were
included in the review.
� Economic studies were included if they used clinical effectiveness data from an
RCT, a prospective cohort study, or a systematic review and meta-analysis of clin-
ical studies. Studies that had a mirror-image or other retrospective design were
excluded from the review.
� Studies were included only if the examined interventions were clearly described.
This involved the dosage and route of administration and the duration of treatment
in the case of pharmacological therapies, and the types of health professionals
involved, as well as the frequency and duration of treatment in the case of psycho-
logical interventions. Evaluations in which medications were treated as a class
were excluded from further consideration.
� Studies that adopted a very narrow perspective, ignoring major categories of costs
to the NHS, were excluded; for example, studies that estimated exclusively drug
acquisition costs or hospitalisation costs were considered non-informative to the
guideline development process.
3.6.3 Applicability and quality criteria for economic studies
All economic papers eligible for inclusion were appraised for their applicability and
quality using the methodology checklist for economic evaluations recommended by
NICE (NICE, 2009a), which is shown in Appendix 13 of this guideline. The method-
ology checklist for economic evaluations was also applied to the economic models
developed specifically for this guideline. All studies that fully or partially met the
applicability and quality criteria described in the methodology checklist were consid-
ered during the guideline development process, along with the results of the economic
modelling conducted specifically for this guideline.
3.6.4 Presentation of economic evidence
The economic evidence considered in the guideline is provided in the respective
evidence chapters, following presentation of the relevant clinical evidence. The refer-
ences to included studies and to those that were potentially relevant but did not meet
the inclusion criteria can be found in Appendix 19, as well as the evidence tables with
the characteristics and results of economic studies included in the review. Methods
and results of economic modelling undertaken alongside the guideline development
Methods used to develop this guideline
60

process are presented in the relevant evidence chapters. Characteristics and results of
all economic studies considered during the guideline development process (including
modelling studies conducted for this guideline) are summarised in economic evidence
profiles accompanying respective GRADE clinical evidence profiles in Appendix 18.
3.6.5 Results of the systematic search of economic literature
Publications that were clearly not relevant to the topic (that is, economic issues and infor-
mation on health-related quality of life in harmful drinkers and people with alcohol
dependency) were excluded at the sifting stage first. The abstracts of all potentially rele-
vant publications were then assessed against the inclusion criteria for economic evalua-
tions by the health economist. Full texts of the studies potentially meeting the inclusion
criteria (including those for which eligibility was not clear from the abstract) were
obtained. Studies that did not meet the inclusion criteria, were duplicates, were second-
ary publications of one study, or had been updated in more recent publications were
subsequently excluded. Economic evaluations eligible for inclusion were then appraised
for their applicability and quality using the methodology checklist for economic evalua-
tions. Finally, economic studies that fully or partially met the applicability and quality
criteria were considered at formulation of the guideline recommendations.
3.7 STAKEHOLDER CONTRIBUTIONS
Professionals, service users and companies have contributed to and commented on
the guideline at key stages in its development. Stakeholders for this guideline include:
� service user and carer stakeholders: the national service-user and carer organisa-
tions that represent people whose care is described in this guideline
� professional stakeholders: the national organisations that represent healthcare
professionals who are providing services to service users
� commercial stakeholders: the companies that manufacture medicines used in the
treatment of alcohol dependence and harmful alcohol use
� primary care trusts
� Department of Health and Welsh Assembly Government.
NICE clinical guidelines are produced for the NHS in England and Wales, so a
‘national’ organisation is defined as one that represents England and/or Wales, or has
a commercial interest in England and/or Wales.
Stakeholders have been involved in the guideline’s development at the following
points:
� commenting on the initial scope of the guideline and attending a briefing meeting
held by NICE
� contributing possible review questions and lists of evidence to the GDG during the
initial scoping phase of the guideline
� commenting on the draft of the guideline
� highlighting factual errors in the pre-publication check.
Methods used to develop this guideline
61

3.8 VALIDATION OF THE GUIDELINE
Registered stakeholders had an opportunity to comment on the draft guideline, which
was posted on the NICE website during the consultation period. Following the
consultation, all comments from stakeholders and others were responded to, and the
guideline updated as appropriate. The GRP also reviewed the guideline and checked
that stakeholders’ comments had been addressed.
Following the consultation period, the GDG finalised the recommendations and
the NCCMH produced the final documents. These were then submitted to NICE for
the pre-publication check where stakeholders were given the opportunity to highlight
factual errors. Any errors are corrected by the NCCMH, then the guideline is formally
approved by NICE and issued as guidance to the NHS in England and Wales.
Methods used to develop this guideline
62

4 EXPERIENCE OF CARE
4.1 INTRODUCTION
This chapter provides an overview of the experience of people who misuse alcohol
and their families/carers in the form of a review of the qualitative literature. As part
of the process of drafting this chapter, the GDG and review team elicited personal
accounts from people who misuse alcohol and their family/carers. The personal
accounts that were received from service users were from people who had experi-
enced long-standing (almost life-long) problems with alcohol and identified them-
selves as ‘alcoholic’. For this reason, the GDG judged that it could not include them
in this chapter because they did not illustrate the breadth of experience covered by this
guideline, which ranges from occasional harmful drinking to mild, moderate and
severe dependence. (The personal accounts that were received and the methods used
to elicit them can be found in Appendix 14.)
As the guideline also aims to address support needs for families/carers, a thematic
analysis was conducted using transcripts from people with parents who misuse alco-
hol. These were accessed from the National Association for Children of Alcoholics
(NACOA) website (www.nacoa.org.uk). NACOA provides information and support
to people (whether still in childhood or in adulthood) of parents who misuse alcohol
and the website includes personal experiences from such people in narrative form.
However, there were some limitations to the thematic analysis. Because the review
team relied only on transcripts submitted to NACOA, information on other issues that
could be particularly pertinent for children with parents who misuse alcohol may not
have been identified. Moreover, people who have visited the NACOA website to
submit their accounts may over-represent a help-seeking population. Finally, while
some accounts are based on experiences that occurred recently, others occurred a long
time ago; therefore there may be differences in attitudes, information and services
available. For these reasons this analysis was not included in Chapter 4, but it can be
found in Appendix 14.
4.2 REVIEW OF THE QUALITATIVE LITERATURE
4.2.1 Introduction
A systematic search for published reviews of relevant qualitative studies of people
who misuse alcohol was undertaken. The aim of the review was to explore the
experience of care for people who misuse alcohol and their families and carers in
terms of the broad topics of receiving a diagnosis, accessing services and having
treatment.
Experience of care
63

Experience of care
64
4.2.2 Review questions
For people who misuse alcohol, what are their experiences of having problems with
alcohol, of access to services and of treatment?
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 fami-
lies and carers?
4.2.3 Evidence search
Reviews were sought of qualitative studies that used relevant first-hand experiences
of people who misuse alcohol and their families/carers. For more information about
the databases searched, see Table 5.
4.2.4 Studies considered
Based on the advice of the GDG, this review was focused on qualitative research only
because it was felt to be most appropriate to answer questions about the experience of
care of those with alcohol dependence or alcohol misuse. Because good quality qualita-
tive research exists within the literature, quantitative and survey studies were excluded.
The search found 32 qualitative studies which met the inclusion criteria (Aira
et al., 2003; Allen et al., 2005; Bacchus, 1999; Beich et al., 2002; Burman, 1997;
Copeland, 1997; Dyson, 2007; Gance-Cleveland, 2004; Hartney et al., 2003; Hyams
et al., 1996; Jethwa, 2009
10
; Kaner et al., 2006; Lock, 2004; Lock et al., 2002;
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO
Date searched Database inception to March 2010
Study design Systematic reviews and narratives of qualitative stud-
ies, qualitative studies
Population People who are alcohol dependent or harmful drinkers,
families and carers, staff who work in alcohol services
Outcomes None specified - any narrative description of service
user/carer experience of alcohol misuse
Table 5: Databases searched and inclusion/exclusion criteria for
clinical evidence
10
It should be noted that the qualitative patient interviews from the Jethwa (2009) study were not published
with the paper, but were received from a member of the GDG. The review team received written permis-
sion from the author to use the interviews to identify any themes relevant to this section.

Mohatt et al., 2007; Morjaria & Orford, 2002; Murray, 1998; Nelson-Zlupko et al.,
1996; Nielsen, 2003; Orford et al., 1998a and 1998b; Orford et al., 2002; Orford
et al., 2006a and 2006b; Rolfe et al., 2005; Rolfe et al., 2009; Smith, 2004;
Vandermause, 2007; Vandermause & Wood, 2009; Vandevelde et al., 2003; Vargas &
Luis, 2008; Yeh et al., 2009).
Thirty-four studies considered for the review did not meet the inclusion criteria.
The most common reasons for exclusion were: alcohol was not the primary substance
used; or there was not a high enough percentage of people who were alcohol depend-
ent or reaching harmful levels of alcohol consumption; or the studies were quantitative
or surveys.
Further information about both included and excluded studies can be found in
Appendix 16a. The included studies have been categorised under six main headings:
experience of alcohol misuse, access and engagement, experience of assessment and
treatment for alcohol misuse, experience of recovery, and carer experiences and staff
experiences.
4.2.5 Experience of alcohol misuse
One of the main themes that emerged under the heading of ‘experience of alcohol
misuse’ was reasons for discontinuation of drinking. There were seven studies
(Burman, 1997; Hartney et al., 2003; Jethwa, 2009; Mohatt et al., 2007; Nielsen,
2003; Rolfe et al., 2005; Yeh et al., 2009) that looked at people’s motivation for stop-
ping drinking in populations of people who drank heavily and were untreated. All
studies mentioned that a significant motivation to discontinue drinking stemmed from
external factors such as relationships, employment and education. Responsibility for
others was a particular catalyst in maintaining motivation to stop drinking (for exam-
ple, having a child, loss of a family member, or divorce/separation from a partner).
Rolfe and colleagues (2005) found that participants specified three key reasons for
decreasing alcohol consumption. The first was ‘needing to’ decrease their alcohol
consumption to minimise harm, once there was a realisation that alcohol was having a
direct negative impact on their emotional and physical well-being. Both Rolfe and
colleagues (2005) and Burman (1997) reported that the onset of physical problems was
a significant motivation to stop drinking: ‘You need that scare to do it … you don’t pack
it in until you’ve had that scare and reached rock bottom’. The second reason was
‘having to’ decrease alcohol consumption due to work or relationship factors. The third
was ‘being able to cut down’, which referred to no longer feeling the need or desire to
consume alcohol and was typically inspired by a positive or negative change in a
specific area of their life (for example, medical treatment or change in employment).
In the qualitative component of their study, Hartney and colleagues (2003) found that
most participants did not have a sense of being unable to stop drinking alcohol, and issues
such as relationships or driving a car would be prioritised over continuing to drink. This
furthers the idea that, for untreated heavy drinkers, triggers and cues for alcohol consump-
tion are largely socially determined. Another interesting finding was the conscious
process that many participants went through in order to find moderation strategies to
Experience of care
65

apply to their alcohol consumption. This was largely based around an observation of their
own drinking in relation to other people’s drinking levels, and disconnecting themselves
from a drinking ‘taboo’ or what they considered to be ‘dependence’, including conceal-
ing evidence of alcohol consumption or the effects of physical withdrawal.
Nielsen (2003) found that participants in Denmark used different ways to narra-
tively describe and contextualise their drinking behaviour. Several participants cate-
gorised their alcohol consumption as ‘cultural drinking’, where alcohol was used in a
social and cultural context. Cultural drinking is a way of normalising alcohol
consumption within a social environment (such as drinking at a party). Moreover,
participants in this study distinguished their own heavy alcohol consumption from
what they perceived as ‘real alcoholics’, who appeared to be more out of control:
‘Real alcoholics are drinking in the streets’.
Other patterns of drinking included symptomatic drinking, where patients drink as a
reaction to external influences (for example, workload or relationship difficulties) or
internal influences (for example, mental health problems). Cultural drinkers were found
to use therapy and treatment more for information and feedback, rather than for the help-
fulness of their therapists. Cultural drinkers tended to rely on their own willpower to cut
back on their drinking. Conversely, those who were symptomatic drinkers used alcohol
more as a way to solve problems and were more reliant and engaged in their treatment
sessions with their therapists. Lastly, the Nielsen (2003) study highlights the process of
heavy drinking and the ‘turning point’ that many harmful and dependent drinkers expe-
rience once the realisation is made that their alcohol consumption needs to change and
treatment is needed. This turning point is in line with what Burman (1997) and Mohatt
and colleagues (2007) found as well, in that participants typically experience an accumu-
lation of negative alcohol-related events, and this prompts the decision to give up drink-
ing. A period of reflection regarding their alcohol misuse may follow, and a key event
often precipitates the motivation to stop drinking, and leads to a turning point.
Recently, Jethwa (2009) interviewed people who were alcohol dependent and
found that six of the ten participants interviewed started drinking in response to a
stressful life event (for example, depression, bereavement, or breakdown of a relation-
ship). Other common reasons included familial history of drinking, being lured in by
social networks, or just liking the taste of alcohol. Interestingly, once the decision was
made to quit drinking, nearly all of the participants did not find it difficult once this
‘turning point’ was reached.
Yeh and colleagues (2009) conducted a study to look into the process of abstinence
for alcohol-dependent people in Taiwan and discuss their challenges in abstaining from
alcohol. Based on previous theories and the interviews, Yeh and colleagues (2009)
identified a cycle of dependence, comprising the stages of indulgence, ambivalence
and attempt (the IAA cycle). In the first stage of indulgence, alcohol-dependent people
feel a loss of control over their alcohol consumption and to overcome unpleasant phys-
ical or mental states they consume more alcohol, exacerbating their dependence:
When I had physical problems and saw the doctor, they never got better. But I felt
good when I had a drink. I started relying on alcohol and started wanting to
drink all the time. Drinking would help me feel better.
Experience of care
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In the ambivalent stage, people want to seek help but the will to drink is stronger than
to remain abstinent. In the attempt phase, people try to remain abstinent but, due to a lack
of coping strategies in situations that trigger alcohol consumption, many relapse.
Dyson (2007) found that recovery from alcohol dependence arose from a culmi-
nation or combination of consequences, coupled with the realisation that life was
unbearable as it was:
My real recovery began when I admitted that my life had become unmanageable
and that I could not control the drink. I experienced a deep change in thinking –
sobriety had to be the most important thing in my life.
Several participants pointed out that their decision to pursue recovery and absti-
nence had to be made on their own and could not be made or influenced much by
others: ‘It was something I had to do on my own and I had to do it for me, not for
anyone else’. Evidently this personal decision has important implications for the
carers around them. The key to begin recovery appears to be the individual’s willing-
ness and readiness to stop drinking (Dyson, 2007).
An earlier study by Orford and colleagues (1998) looked at social support in
coping with alcohol and drug problems at home, using a cross-cultural comparison
between Mexican and English families. The main cross-cultural differences were that
positive social support for Mexican relatives stemmed mostly from family, whereas
English relatives mentioned self-help sources, professionals and friends in addition to
family. The accounts from the participants mentioned family and friend support as
more unsupportive or more negative for the English families. Conversely, the
Mexican families often mentioned their family and neighbours as significant contrib-
utors of support. The researchers explored the participant’s perceptions of the positive
and negative drawbacks to their heavy drinking. The negative aspects included
increased vulnerability to arguments and fights, and the unpleasant physical effects of
drinking (such as waking up tired, stomach upsets and headaches). Many participants
mentioned the adverse effects alcohol had had on their physical and mental health.
Interestingly, several participants mentioned drinking in order to cope with difficult
life events, but masked this association between coping and alcohol by terming it as
being ‘relaxed’. Many submerged the notion of coping by using the fact that alcohol
helped them relax in distressing situations. Thus, the long-term psychological and
short-term physical consequences were noted as the principle drawbacks of harmful
alcohol consumption, whereas coping, and feelings of being carefree and relaxed,
seem to constitute the positive aspects of drinking.
4.2.6 Access and engagement
In the review of the qualitative literature, several themes emerged under the broad
heading of ‘access and engagement’ to services for alcohol misuse, including factors
that may act as barriers to accessing treatment services such as external and internal
stigma, ethnicity and gender. This review also identified ‘reasons for seeking help’ as
Experience of care
67

a theme emerging from the included studies. There were eight studies from which
themes of access and engagement emerged (Copeland, 1997; Dyson, 2007; Lock,
2004; Nelson-Zlupko et al., 1996; Orford et al., 2006; Rolfe et al., 2009;
Vandermause & Wood, 2009; Vandevelde et al., 2003; Vargas & Luis, 2008).
Stigma
Dyson (2007) found that all participants used strategies to hide their alcohol dependence,
including covering up the extent of their alcohol consumption. This was primarily due to
the fear of being judged or stigmatised: ‘I knew that I was ill but was too worried about
how other people would react. I felt I would be judged’. All participants in the study had
some contact with healthcare professionals in an attempt to control or reduce their drink-
ing. GPs were described as being particularly helpful and supportive, and nurses and
other healthcare workers as less understanding and more dismissive, especially those in
accident and emergency departments; this contrasts with another study (Lock, 2004),
where people who misuse alcohol found primary care nurses to be helpful. Social stigma
can also occur from groups in the community. For example, Morjaria and Orford (2002)
highlight in their study that South Asian men in the UK often perceive that members of
their religious community could influence their desire to consume alcohol, and further-
more, once religious leaders in the community expressed disapproval of alcohol
consumption, there was more encouragement towards being abstinent from alcohol.
Ethnicity
Vandevelde and colleagues’ (2003) study of treatment for substance misuse looked at
cultural responsiveness from professionals and clients’ perspectives in Belgium.
People from minority groups found it difficult to openly discuss their emotional prob-
lems due to cultural factors, such as cultural honour and respect. Participants stressed
the absence of ethno-cultural peers in substance misuse treatment facilities, and how
this made it hard to maintain the motivation to complete treatment. Although this
study had a focus on substance misuse (that is, both drugs and alcohol), it is impor-
tant to note its generalisability to alcohol services and treatment.
Gender
Vandermause and Wood (2009) and Nelson-Zlupko and colleagues (1996) both
looked at experiences and interactions of women with healthcare practitioners in the
US. Many women described waiting until their symptoms were severe before they
would seek out healthcare services:
… it’s hard for me to go in … and it’s not someplace that I want to be, especially
when I know that I have to be there. I know that I’m ill, I don’t want to admit it…
I have to get my temperature taken and my blood pressure and they gotta look at
my eyes and my ears … find out what it is that I’ve got from somebody else shar-
ing a bottle you know.
Once the women sought help from a healthcare professional, several felt angry
and frustrated after repeated clinic visits resulted in being turned away, treated poorly,
Experience of care
68

or silenced by comments from healthcare professionals. Some women would go in
needing to be treated for a physical health problem and the practitioner would address
the alcohol problem while ignoring the primary physical complaint.
Conversely, other women were satisfied about how they were treated in interac-
tions with their practitioners, which influenced perceptions of the healthcare services,
seeking out treatment and feeling comfortable about disclosing their alcohol use:
I was confused and angry, and the doctor made me feel comfortable, even though
I was very very ill … he let me know that I was an individual person but I had a
problem that could be arrested. He was very compassionate very empathetic with
me and told me the medical facts about what was happening to me, why I was the
way I was and he told me a little bit about treatment, what it would do … so I
was able to relax enough and stop and listen rather than become defensive …
When women specifically sought treatment for their alcohol use, the authors
suggested that there was a crucial need for healthcare practitioners to make the patient
feel comfortable and acknowledge their alcohol problem in addition to addressing any
other physical health problems.
Nelson-Zlupko and colleagues (1996) found that individual counselling might be
important in determining whether a woman is retained or drops out of treatment. Many
women felt that what they wanted from treatment was someone to ‘be there for them’ and
lend support. A therapist’s ability to treat their patients with dignity, respect and genuine
concern was evaluated as more important than individual therapist characteristics (such
as ethnicity or age). Some women mentioned that good counsellors were those who:
… view you as a person and a woman, not just an addict. They see you have a lot
of needs and they try to come up with some kind of a plan.
Both Nelson-Zlupko and colleagues (1996), and Copeland (1997), highlighted
that childcare was a particular need for women because it was not widely available in
treatment. When childcare was available, this was perceived to be among one of the
most helpful services in improving attendance and use of treatment and drug/alcohol
services. In addition, women felt strongly about the availability and structure of
outpatient services offered and felt there should be more flexible outpatient
programmes taking place, for example, in the evenings or at weekends.
Copeland’s (1997) Australian study was of women who self-managed change in
their alcohol dependence and the barriers that they faced in accessing treatment. One
of the central themes of the study was the social stigma that women felt as being drug
or alcohol dependent. Seventy-eight per cent of participants felt that women were
more ‘looked down upon’ as a result of their drinking and the additional burden of an
alcohol or drug problem only increased the stigma. Some women reported that the
feeling of being stigmatised impacted on their willingness to seek treatment:
There is the whole societal thing that women shouldn’t show themselves to be so
out of control … that stigma thing was part of the reason for not seeking treatment.
Experience of care
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In line with this, Rolfe and colleagues (2009) interviewed women in the UK
about their own perceptions of their heavy alcohol consumption and its relation to a
wider social perspective. Many women claimed that stigma was a major obstacle to
accessing treatment services and that, while men did carry stigma as heavy drinkers,
there was an additional stigma for women due to the way a ‘heavy drinking woman’
was perceived within society. The interviews emphasised that women need to
perform a ‘balancing act’ to avoid being stigmatised as a ‘manly’ woman or as some-
one with alcohol dependence. These discourses are important in understanding the
perception of gender differences in heavy alcohol consumption and ways in which
stigma can affect women, and their ability and willingness to seek treatment for their
alcohol use.
Reasons for seeking help
A study conducted by Orford and colleagues (2006b) investigated the reasons for
entering alcohol treatment in the UK. The study was based on pre-treatment inter-
views from participants who were about to commence the UK Alcohol Treatment
Trial (UKATT) and receive either MET or social network behavioural therapy
(SNBT) for alcohol dependence or harmful alcohol use. Reasons for entering alcohol
treatment included the realisation of worsening problems and accumulating multiple
problems relating to alcohol use, which had a negative impact on both family
members and the participants’ health. Participants were also interviewed about
reasons for seeking professional treatment as opposed to unaided or mutual self-help.
Common reasons for seeking formal help included such help being suggested by
primary care workers, a strong belief in the medical model and in counselling or
psychological therapy, or feelings of helplessness.
Accessing help: reasons and preferences
Lock (2004) conducted a focus group study with patients registered with general prac-
tices in England. Participants were classified as ‘sensible’ or ‘heavy/binge drinkers’.
Participants responded positively to advice delivered in an appropriate context and by
a healthcare professional with whom they had developed a rapport. Overall, the GP
was deemed to be the preferred healthcare professional with whom to discuss alcohol
issues and deliver brief alcohol interventions. Practice nurses were also preferred due
to the perception that they were more understanding and more approachable than other
healthcare workers. Most said they would rather go straight to their GP with any
concern about alcohol, either because the GP had a sense of the patient’s history, had
known them for a long time or because they were traditionally whom the person would
go to see. It was assumed that the GP would have the training and experience to deal
with the problem, and refer to a specialist if necessary. Alcohol workers were
perceived by many as the person to go to with more severe alcohol misuse because
they were experts, but this also carried the stigma of being perceived to have a severe
alcohol problem. Seeing a counsellor was also perceived as negative in some ways, as
there would be a stigma surrounding mental health problems and going to therapy.
Experience of care
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4.2.7 Experience of assessment and treatment for alcohol misuse
In the review of the qualitative literature, several themes emerged under the broad
heading of ‘experience of treatment for alcohol misuse’, including experience of
assessment (pre-treatment), assisted withdrawal, other treatments (such as psycho-
logical interventions) and treatment setting (inpatient). In this review of assess-
ment and treatment, there were six studies included (Allen et al., 2005; Bacchus,
1999; Dyson, 2007; Hyams et al., 1996; Orford et al., 2006a; Smith, 2004).
Experience of assessment (pre-treatment)
Hyams and colleagues (1996) interviewed service users about their experience and
satisfaction with the assessment interview prior to engagement in alcohol treatment.
The study had both a quantitative and qualitative aspect to it. The qualitative compo-
nent assessed the best and worst aspects of the assessment interview. Thirty-three of
the 131 participants said that the therapeutic relationship with the interviewer was
most beneficial (as assessed by ‘The interviewer’s understanding of the real me’,
‘Friendliness of the interviewer’ and ‘A feeling of genuine care about my problems’).
Twenty participants appreciated the ability to talk generally and therapeutically to the
interviewer about their problems. Eight participants reported that the assessment
interview provided them with a sense of increased awareness about their alcohol use
and its impact on their lives: ‘I found insight into why I drink …’ Others found that
the assessment interview was crucial in taking the first step into treatment: ‘Glad that
I did attend the interview’ and ‘Given me some hope’.
Although participants identified few drawbacks regarding the interview, they did
cite general nervousness particularly about starting the interview. Some criticised the
interviewer for not giving enough feedback or not having enough time to talk. Several
participants felt that it was distressing to have to reveal so much information about
their drinking problems and to come to a state of painful awareness about their prob-
lem. This study is noteworthy because it highlights the importance of a thorough
assessment prior to entering alcohol treatment that allows participants to speak freely
to an accepting, empathetic interviewer and that, if a positive experience for the serv-
ice user, will increase engagement and motivation to change in subsequent alcohol
treatment programmes.
In line with these findings, Orford and colleagues (2006a) found that a compre-
hensive pre-treatment assessment was perceived by participants to have motiva-
tional and self-realising aspects to it. Many participants expressed that this
assessment was influential in increasing motivation to undergo their alcohol
treatment.
Experience of assisted withdrawal
Two studies, Allen and colleagues (2005) and Smith (2004), captured the patient
experience of medically-assisted withdrawal programmes for alcohol misuse in both
the UK and Australia. Both studies found that participants expressed fears about the
Experience of care
71

future and a hesitation about coping with life events that had previously been associ-
ated with alcohol consumption:
I feel safe in the environment but I don’t feel safe with my thoughts at the moment
because I can’t use alcohol or any drug to cope with it …
The most common themes emerged around fears regarding social environment,
the physical effects of withdrawal and medication prescribed during detoxification.
Participants discussed fears about returning to their homes after detoxification and
how to lead a life without alcohol:
When you’ve done the first few days [of detoxification], you get your head back
together and start to think, How am I going to be able to cope outside? You know
you’ve got to leave here sometime, so how am I going to cope?
Participants also expressed significant concerns about the effects of medication,
although there were also a number of positive experiences of medication which were
referred to but were not described in detail. Some participants feared that their
medication would be addictive:
I didn’t want another problem of having to get off something as well as the booze.
I was worried that I could get addicted to the tablets as well and then start crav-
ing for those.
Nearly all participants were apprehensive about the transmission of information
about medication between the staff and themselves; they felt they had inadequate
information about what medication they were taking, why they were taking it and the
effects it may have on them:
I didn’t know what they were, what they were going to do to me … they didn’t tell
me why I was taking them.
It is clear from this study that providing adequate information about assisted with-
drawal and medication procedures needs to be ensured in alcohol services.
A significant proportion of participants also expressed fears about the physical
effects of withdrawal, and any pain and/or distress that may be a side effect of the
detoxification programme. Those who had had previous medically-assisted with-
drawals prior to this study seemed to have the greatest fears. Lastly, participants
discussed fears about their future and were concerned about their ability to cope once
completing the detoxification programme. These fears mostly stemmed from difficult
interpersonal situations and coping strategies:
I’m worried about having too much time on my hands; the day goes so much
quicker with a few drinks inside you.
Experience of care
72

In both studies, participants expressed a lack of confidence and an inability to
resist temptation; they also felt that they were not being accepted back into their orig-
inal social networks where heavy drinking was perceived as the norm. Additionally,
fears about the future were related to a feeling that the hospital setting was too far
removed from real life:
It’s nice and safe in here. You are secure in here. But it’s not real life is it? And
it tells you nothing about how you are going to cope when you are back in the
same old situations with the same old problems.
Participants in the Smith (2004) study also articulated feelings of being out of
control during their admission to treatment. These feelings of distress revolved
around the difficulty to alter their alcohol consumption, and stick to a reduced
consumption level or abstinence:
You get well physically and you start thinking clearly … you start telling yourself
you’re over it … you might maintain some kind of normal drinking activity for a
short period of time. I just believe that I can’t keep doing it. I don’t want to.
With each medically-assisted withdrawal, the goal of abstinence seemed more
distant – the thought of this was anxiety-provoking for many participants because
they felt they would be unable to maintain abstinence in the future. After medically-
assisted withdrawal, they would have to return to a life where all their personal,
professional and relationship difficulties still existed but were previously associated
with alcohol.
Conversely, there were positive feelings about treatment because most felt they
had taken steps to bring about positive changes in their lives by seeking treatment.
The facility enabled participants to have respite from their lives as well as social and
emotional support from other participants in the programme. The authors suggested
that nurses could assist participants in reducing negative feelings (such as shame) by
closely observing behaviour and being more sensitive and empathetic to service
users’ feelings, thereby strengthening therapeutic communication between staff and
patients.
Experience of psychological treatment
Orford and colleagues (2005 and 2008) carried out a content analysis of service users’
perspectives on change during a psychological intervention for their alcohol depend-
ence in UKATT. Participants highlighted that psychological treatment had helped
them to think differently, for example about fearing the future and focusing on the
downside of drinking. Others talked of adopting a more positive outlook or more
alcohol-focused thinking (for example, paying attention to the physical consequences
such as liver disease or brain damage). Several participants mentioned that, ‘the ques-
tions, the talking, being honest, being open – that was positive [of treatment]’. Other
factors to which change was attributed to were awareness of the consequences of
drinking and feeling comfortable talking about their alcohol consumption.
Experience of care
73

Experience of support from family and voluntary organisations
Orford and colleagues (2005) also found that the influence of family and friends
helped in promoting change in alcohol consumption. Treatment seemed to assist
participants in finding non-drinking-related activities and friends, and seeking out
more support from their social networks to deal with problematic situations involv-
ing alcohol. Supportive networks provided by AA and the 12-step programme facil-
itated recovery for participants in the Dyson (2007) study as well, because they were
able to be with others who genuinely understood their experiences and fostered a
sense of acceptance: ‘Here was a bunch of people who really understood where I was
coming from’.
Experience of treatment setting – inpatient
Bacchus (1999) carried out a study about opinions on inpatient treatment for drug and
alcohol dependence. Over one third of participants reported that they would have
preferred to enter treatment sooner because there was an urgent need to maintain
treatment motivation and receive acute medical care:
When you make that decision to ask for help, you need it straight away. If you
have to wait a long time to get in you just lose your motivation and you might
just give up.
Participants also felt frustrated about the lack of communication and liaison from
the referring agency during the waiting period. The structured individual and group
counselling treatment programme was seen as a generally effective way of improving
self-confidence and self-esteem. Educational group discussions about substance use
and risks were particularly positively regarded. Recreational groups (for example, art
therapy, exercise and cookery) also proved to be beneficial in terms of engaging in
other non-drinking-related activities. One of the most positive aspects of treatment
noted by participants was the quality of the therapeutic relationships. Staff attitudes,
support, and being non-judgemental and empathetic were all mentioned as crucial
components of a positive experience in treatment. Sixty-two per cent of patients had
made prior arrangements with staff for aftercare treatment and expressed satisfaction
with the arrangements. The only exception was that patients wished for more detailed
information about the next phase of their treatment.
4.2.8 Experience of recovery
Four studies (Burman, 1997; Mohatt et al., 2007; Morjaria & Orford, 2002; Yeh et al.,
2009) looked at the experience and process of recovery for people who misuse alco-
hol. All studies with the exception of Yeh and colleagues (2009) looked at recovery
from the standpoint of drinkers who were untreated. Nearly all the studies highlighted
the importance of utilising active coping and moderation strategies in order to stop
consuming alcohol, and a number of the studies touch on the importance of positive
social support networks, faith and self-help groups.
Experience of care
74

Morjaria and Orford (2002) examined the role of religion and spirituality in
promoting recovery from drinking problems, specifically in AA programmes and in
South Asian men. Both South Asian men and men in AA began recovery once there
was a feeling of hitting ‘rock bottom’ or of reaching a turning point where they felt
their drinking must stop. Both groups drew on faith to help promote recovery, but the
South Asian men already had a developed faith from which to draw upon, whereas
the men in AA had to come to accept a set of beliefs or value system and develop reli-
gious faith to help promote abstinence.
In terms of self-recovery strategies, participants in Burman (1997), Mohatt and
colleagues (2007) and Yeh and colleagues (2009) often utilised recovery strategies
that mirrored those in formal treatment, consisting of drawing on social support
networks and avoiding alcohol and alcohol-related situations. Seeing another person
giving up alcohol also helped to promote abstinence and motivation, again high-
lighting the necessity of positive support networks. Another stage of sobriety for
participants in Mohatt’s study (2007) involved a more gradual acceptance of their
vulnerability towards consuming alcohol and continuing to strategise and resist the
urge to drink. Additional coping strategies outlined by Burman (1997) were: setting
a time limit for recovery; discussing their goals and plans with others to help keep
them on track; and keeping reminders of negative experiences to help prevent
further relapse.
Similar to those in formal treatment programmes, once in the midst of self-recov-
ery, participants reported a number of positive changes since abstaining (for example,
increased energy and memory, self-awareness and empowerment), and more external
benefits including regaining trust from their social networks and reintegrating into
society. Negative consequences of abstinence included edginess and physical side
effects, family problems, struggles with craving and a loss of a specific social circle
or group previously related to alcohol.
Taken together, the self-recovery studies highlight the process of abstinence for
alcoholics, stressing that the path is not straightforward, and assistance from self-help
groups and social support networks are crucial to help ensure a better recovery.
4.2.9 Carer experiences
Four studies (Gance-Cleveland, 2004; Murray, 1998; Orford et al., 1998a; Orford et
al., 2002) were found that could be categorised under the heading ‘carer experiences’.
Orford and colleagues (1998) conducted cross-sectional interview and question-
naire studies with a series of family members in two sociocultural groups, in Mexico
City and in the west of England. They found that there were three approaches to inter-
acting with their family members who misuse alcohol: (1) tolerating; (2) engaging;
and (3) withdrawing. In the first approach, the carer would tolerate inaction and
support the person in a passive way. Some carers mentioned taking the ‘engaging’
position with their family members in an attempt to change unacceptable and exces-
sive substance use. Some forms of engagement were more controlling and emotional
in nature; others more assertive and supportive. Lastly, some carers mentioned
Experience of care
75

emotionally and physically withdrawing from their family members with an alcohol
problem (for example, asking their alcohol-using family member to leave the house).
This was seen as a way to detach oneself from the alcohol problem of their family
member. One form of coping that carers also mentioned was that one needs to enforce
supportive and assertive coping:
You need to be very strong, to be there and talk to him but still stick to your own
values and beliefs in life.
There was significant overlap between the coping strategies outlined by both
families from England and from Mexico. Families in both countries used assertive
and supportive ways of coping with their family member’s alcohol problem, either
through direct confrontation, financial or emotional sacrifice. Thus, even given a
different sociocultural context, there are several common ways for carers to cope and
interact with a family member with an alcohol problem.
Orford and colleagues (2002) interviewed the close relatives of untreated heavy
drinkers. Most relatives recognised the positive aspects of their family member
consuming alcohol (for example, social benefits) and reported a few drawbacks to
drinking. Many family members contrasted their family member’s current problem
with how their problem used to be. Other family members used controlling tactics
(for example, checking bottles) as a way to monitor their family members, while
others tried to be tolerant and accepting of their family member’s drinking behaviour.
There are two qualitative studies that have looked at the perspectives and experi-
ences of people whose parents misuse alcohol. Murray (1998) conducted a qualitative
analysis of five in-depth accounts of adolescents with parents who misuse alcohol and
found four main themes: (1) ‘The nightmare’, which includes betrayal (abuse/aban-
donment), over-responsibility, shame, fear, anger, lack of trust and the need to escape;
(2) ‘The lost dream’, which consists of loss of identity and childhood (lack of parent-
ing, comparing oneself with others, unrealistic expectations); (3) ‘The dichotomies’,
which is the struggle between dichotomies, for example, love and hate (towards
parents), fear and hope (towards the future) and denial and reality; (4) ‘The awaken-
ing’, which is gaining an understanding of the problem, realising alcohol is not an
answer (possibly through their own experiences), realising they were not to blame and
regaining a sense of self.
Another qualitative study (Gance-Cleveland, 2004) investigated the benefit of a
school-based support group for children with parents who misuse alcohol and found
that the group helped them to identify commonalities with each other, feel that they
were understood, support and challenge each other, and share coping strategies. The
children who took part also felt that the group was a trusted and safe place in which
they could reveal secrets and feel less isolated and lonely, that it enabled them to be
more aware of the impact of addiction on family dynamics and helped them
increase resilience and do better at school (Gance-Cleveland, 2004). In conclusion,
talking to others (especially with those who have had similar experiences) was
found to be helpful in terms of coping, making friendships and understanding more
about alcohol misuse.
Experience of care
76

4.2.10 Staff experiences
There were six studies (Aira et al., 2003; Beich et al., 2002; Kaner et al., 2006; Lock
et al., 2002; Vandermause, 2007; Vandevelde et al., 2003, Vargas & Luis, 2008) look-
ing at the experience of staff who work with people who misuse alcohol. There were
several themes emerging from staff experiences, the first being hesitancy in deliver-
ing brief interventions to people who misuse alcohol. Staff implementing the WHO
screening and brief intervention programme in Denmark found that it was difficult to
establish a rapport with patients who screened positive for alcohol misuse and ensure
adherence with the intervention (Beich et al., 2002). In England, primary care practi-
tioners had little confidence in their ability to deliver brief interventions and override
negative reactions from patients (Lock et al., 2002). Furthermore, because alcohol
misuse can be a sensitive and emotional topic, a significant proportion of the staff in
the studies expressed a lack of confidence about their ability to counsel patients effec-
tively on lifestyle issues (Aira et al., 2003; Beich et al., 2002; Lock et al., 2002):
The patient does not bring it up and obviously is hiding it … [Alcohol] is a more
awkward issue; which of course must be brought up…
Approaching emotional problems related to substance misuse through the medical
dimension might facilitate the treatment of minority groups, because it was perceived
that emotional problems were more often expressed somatically (Vandevelde et al.,
2003).
A positive experience with a service user involved an assessment using effective
diagnostic tools where staff were able to employ an indirect, non-confrontational
approach and service users were able to discuss their problems and tell their story at
their own pace (Vandermause, 2007).
Both Beich and colleagues (2002) and Lock and colleagues (2002) highlighted
that brief interventions and confronting service users regarding their alcohol
consumption was important; there were, however, a number of significant barriers to
delivering these interventions effectively (for example, the fear of eliciting negative
reactions from their patients). Staff interviewed in the Vandermause (2007) qualita-
tive study also found that staff had concerns about defining alcohol as problematic for
their patients.
Aira and colleagues (2003) found that staff were not ready to routinely inquire
about alcohol consumption in their consultations, unless an alcohol problem was
specifically indicated (for example, the service user was experiencing sleeplessness,
high blood pressure or dyspepsia). Even when they were aware of alcohol misuse in
advance, staff still had significant difficulty in finding the ideal opportunity to raise
the issue with their patients. If they did not know in advance about a drinking prob-
lem, they did not raise the issue.
Kaner and colleagues (2006) looked at GPs’ own drinking behaviour in relation
to recognising alcohol-related risks and problems in their patients. The interviews
indicated that GPs’ perceived their own drinking behaviour in two ways. Some GPs
drew on their own drinking behaviour when talking to patients because it could be
Experience of care
77

seen as an opportunity to enable patients to gain insight into alcohol issues, facilitate
discussion and incorporate empathy into the interaction. Other GPs separated their
own drinking behaviour from that of ‘others’, thereby only recognising at-risk behav-
iours in patients who were least like them.
Vargas and Luis (2008) interviewed nurses from public district health units in
Brazil and discovered that despite alcoholism being perceived as a disease by most
of the nurses, the patients who misuse alcohol who seek treatment are still stigma-
tised:
We generally think the alcohol addict is a bum, an irresponsible person, we give
them all of these attributes and it doesn’t occur to you that [he/she] is sick.
Furthermore, the nurses interviewed seemed to express little hope and optimism
for their patients because they believed that after being assisted and detoxified, they
would relapse and continue drinking:
… he comes here looking for care, takes some glucose and some medications,
and as soon as he is discharged he goes back to the ... drink.
This study highlights the extent of external stigma that those who misuse alcohol
can face within the healthcare setting, and how it could prevent positive change due
to an apprehension about continually accessing services or seeking help.
All six studies made recommendations for improving staff experience when
engaging with people who misuse alcohol, with an emphasis on training, communi-
cation skills and engaging patients about alcohol consumption, combined with a flex-
ible approach to enhance dialogue and interaction. However, although many
healthcare professionals received training about delivering brief interventions, many
lacked the confidence to do so and questioned their ability to motivate their patients
to reduce their alcohol consumption. Staff also frequently cited a lack of guidance
concerning alcohol consumption and health. Clear health messages, better prepara-
tion and training, and more support were cited as recommendations for future
programmes. As many healthcare professionals found screening for excessive alcohol
use created more problems than it solved, perhaps improving screening procedures
could improve the experience of staff delivering these interventions.
4.2.11 Summary of the literature
The evidence from the qualitative literature provides some important insights into the
experience of people who misuse alcohol, their carers and staff. Problematic alcohol
consumption appears to stem from a range of environmental and social factors,
including using alcohol to cope with stressful life events, having family members
with alcohol or drug problems and/or social situations that encourage the consump-
tion of alcohol. A cycle of dependence then begins wherein the person goes through
stages of indulgence in, ambivalence towards and attempts to abstain from alcohol
Experience of care
78

(Yeh et al., 2009), resulting in a loss of control over their alcohol consumption. This
leads to the consumption of more alcohol to counteract unpleasant physical or mental
states. As the alcohol consumption becomes harmful, there seems to be an accumula-
tion of negative alcohol-related events. These can become the catalyst for change in
the person’s life, when the person realises that their alcohol problem requires further
assistance and/or treatment. This readiness or willingness to change needs to be deter-
mined by the person who misuses alcohol, sometimes with support and insight from
their social networks – readiness to change cannot be imposed externally. These
differing patterns of alcohol consumption and reasons for deciding to engage in treat-
ment or change one’s behaviour mean that treatment services need to understand an
individual’s reasons for drinking and how this may influence treatment.
With regard to access and engagement in treatment, once people who misuse alco-
hol had made the conscious decision to abstain from or reduce their drinking, they
were more willing to access treatment, although external factors and the motivational
skills of healthcare professional may also play a part. Barriers to treatment included
internal and external stigma, an apprehension towards discussing alcohol-related
issues with healthcare professionals, and a fear of treatment and the unpleasant effects
of stopping drinking. As a group, women felt that they faced additional barriers to
treatment in the form of more social stigma, and the need for childcare while seeking
and undergoing treatment. In addition, women felt that they received less support
from treatment providers, and would benefit from a more empathetic and therapeutic
approach. The studies focusing on women and alcohol problems emphasise that a
non-judgemental atmosphere in primary care is necessary in order to foster openness
and willingness to change with regard to their alcohol problems.
In one study looking at the impact of ethnicity and culture on access to treatment,
participants from an ethnic minority report having mostly positive experiences with
healthcare practitioners, but improvements could be made to the system in the form
of more ethno-cultural peers and increased awareness of culture and how it shapes
alcohol consumption and misuse.
The literature strongly suggests that assessments that incorporate motivational
cues are crucial in ensuring and promoting readiness to change early on in the treat-
ment process. Having open and friendly interviewers conducting the assessments also
seems to have an effect on increasing disclosure of information and the person’s will-
ingness to enter into subsequent alcohol treatment.
Although there were some positive experiences of medication, the qualitative
literature highlights consistent fears surrounding assisted withdrawal and the unpleas-
ant effects one may experience while in treatment. Many participants across studies
fear the future and not being able to adopt appropriate coping strategies that will assist
in preventing relapse once they return to their familiar social milieu. More informa-
tion from staff in alcohol services may be beneficial in alleviating patient’s fears
about treatment.
Psychological treatment was seen to facilitate insight into one’s drinking behav-
iour and understand the downsides of drinking. Talking with a therapist honestly and
openly about alcohol helped in alleviating fears about the future and developing
coping strategies. Within a residential treatment programme setting, a therapeutic
Experience of care
79

ethos and a strong therapeutic relationship were regarded as the most positive aspects
of alcohol treatment.
Active coping and moderation strategies, self-help groups, rehabilitation
programmes and aftercare programmes were found to be helpful in preventing relapse
post-treatment, and social support networks may serve as an additional motivation to
change and can help promote long-term recovery. It should be noted that these find-
ings were from studies of untreated drinkers, so this should be interpreted with
caution if generalising to a population formally in treatment. Emphasis on a therapeu-
tic relationship between healthcare practitioners and patients and good communica-
tion seem integral to promoting recovery. Social support, empathic feedback, and
adequate information provision also facilitate the recovery process.
Family and friends can have an important role in supporting a person with an alco-
hol problem to promote and maintain change, but to do this they require information
and support from healthcare professionals. But the strain on carers can be challeng-
ing and they may require a carer’s assessment.
From a staff perspective, the qualitative studies suggest that many staff in
primary care have feelings of inadequacy when delivering interventions for alcohol
misuse and lack the training they need to work confidently in this area. An improve-
ment in staff training is required to facilitate access and engagement in treatment for
people with alcohol problems. When interventions were successfully delivered,
assessment and diagnostic tools were seen as crucial. In addition, thorough assess-
ment and diagnostic tools may aid in the process of assessing and treating patients
with alcohol-use disorders.
Even if they were aware of a problem, many healthcare professionals felt they had
inadequate training, lack of resources, or were unable to carry out motivational tech-
niques themselves. More training about harmful drinking populations and associated
interventions, as well as more awareness about how to interact with these populations
from a primary care perspective, should be considered.
4.3 FROM EVIDENCE TO RECOMMENDATIONS
In reviewing the qualitative literature, the GDG were able to make a number of
recommendations addressing experience of care. However, it should be noted that
some of the evidence reviewed in this chapter contributed to the formulation of
recommendations in other chapters, in particular Chapter 5.
Stigma was a prevalent theme in the literature review. It was experienced both
externally (mostly from healthcare professionals) and internally; internal stigma
could result in concealment of the person’s alcohol problem from others due to fear
or shame, therefore healthcare professionals should take this into account when
working with people who misuse alcohol and ensure that the setting is conducive
to full disclosure of the person’s problems. The positive aspects and benefits of a
therapeutic relationship both in a treatment setting and in assessment procedures
were cited frequently. This highlights the need for healthcare professionals to
interact with people who misuse alcohol in an encouraging and non-judgemental
Experience of care
80

manner. A number of studies also focused on the importance of good information
about alcohol misuse and about its treatment (particularly assisted withdrawal), and
the GDG makes a detailed recommendation about provision of comprehensive and
accessible information.
The GDG also makes a number of recommendations regarding working with
families and carers. Given the challenges of caring for someone with an alcohol prob-
lem, as described in the review of the literature, more information and support should
be available to carers and there should be an emphasis on including them in the treat-
ment process, if this is appropriate and the service user agrees. Furthermore, with the
understanding of how important positive social support networks are in maintaining
positive change, helping carers supporting their supportive role is crucial so as to
promote change.
Children of parents who have alcohol problems will have specific needs that
should be recognised. They may struggle to form stable relationships and their educa-
tion and own mental health may be affected. More opportunities to support those who
have parents with alcohol problems, as well as finding ways for them to talk about
their emotions, would be beneficial and may help prevent the child or young person
developing their own alcohol problems later in life.
4.4 RECOMMENDATIONS
Building a trusting relationship and providing information
4.4.1.1 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 confidential-
ity, privacy and dignity are respected.
4.4.1.2 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
� 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
4.4.1.3 Encourage families and carers to be involved in the treatment and care of
people who misuse alcohol to help support and maintain positive change.
Experience of care
81

4.4.1.4 When families and carers are involved in supporting a person who misuses
alcohol, discuss concerns about the impact of alcohol misuse on them-
selves and other family members, and:
� provide written and verbal information on alcohol misuse and its
management, including how families and carers can support the serv-
ice user
� offer a carer’s assessment where necessary
� negotiate with the service user and their family or carer about the
family or carer’s involvement in their care and the sharing of informa-
tion; make sure the service user’s, family’s and carer’s right to confi-
dentiality is respected.
4.4.1.5 All staff in contact with parents who misuse alcohol and who have care of
or regular contact with their children, should:
� take account of the impact of the parent’s drinking on the parent-child
relationship and the child’s development, education, mental and phys-
ical health, own alcohol use, safety and social network
� be aware of and comply with the requirements of the Children Act
(2004).
Experience of care
82

5 ORGANISATION AND DELIVERY OF CARE
SECTION 1 – INTRODUCTION TO THE
ORGANISATION AND DELIVERY OF CARE
5.1 INTRODUCTION
This chapter provides an overview of the types of services available for people who
misuse alcohol and how they are currently organised, and reviews the evidence to
guide future development and improvements in service provision. The key concepts
underpinning service organisation and delivery will be explained and their nature and
role will be defined. These concepts will build on existing guidance in the field,
notably Models of Care for Alcohol Misusers (MoCAM) developed by the National
Treatment Agency and the Department of Health (Department of Health, 2006b) and
the Review of the Effectiveness of Treatment for Alcohol Problems (Raistrick et al.,
2006). Where relevant, parallel guidance from NICE on alcohol services will be
referred to, in particular the NICE guideline on prevention and early detection (NICE,
2010a) and the NICE guideline on management of alcohol-related physical complica-
tions (NICE, 2010b). Because this guideline was the last in the suite of NICE guide-
lines on alcohol misuse to be developed, this chapter aims to integrate and provide an
overview of how the various guidelines are related in order to support the development
of a comprehensive pathway for the care and treatment of alcohol misuse.
In Chapter 2 it was highlighted that alcohol service commissioning and provision
across England is variable and in some cases poorly integrated (National Audit
Office, 2008). Hence the availability of alcohol services and the extent to which they
meet the needs of people who misuse alcohol vary across England (Drummond et al.,
2005). The GDG also took the view that there is a lack of clarity in the field about
which kinds of alcohol services are most beneficial for which people – for example,
who should be treated in a community setting compared with a residential setting,
what constitutes an adequate assessment of individual’s presenting needs and how an
individual’s care can be most appropriately coordinated. These are all key questions
that need to be addressed. This lack of clarity has resulted in diverse commissioning
and provision of alcohol services.
This chapter will also highlight that the provision of care for people who misuse
alcohol is not solely the responsibility of the agencies and staff who specialise in alco-
hol treatment. Staff across a wide range of health, social care and criminal justice
services who are not exclusively working with people who misuse alcohol but regu-
larly come into contact with them in the course of providing other services also have
a crucial role to play in helping people to access appropriate care. In some cases, staff
Organisation and delivery of care
83

Organisation and delivery of care
84
that are not alcohol treatment specialists (most notably those working in primary
care) will have a role in delivering key elements of an integrated care pathway for this
population.
The chapter begins by describing the organising principles of care for people who
misuse alcohol, followed by a description of the different types of services and how
they are currently organised; where relevant, existing definitions and frameworks
will be referred to. The principles and methods of care delivery, including assessment,
care coordination, integrated care pathways and stepped care, will then be reviewed.
Evidence on case management, stepped care, ACT, assessment, assisted alcohol with-
drawal and care delivered in residential versus community settings will also be
reviewed. The chapter will conclude with a description of the main care pathways
stemming from the findings of the evidence review.
5.2 ORGANISING PRINCIPLES OF CARE
The introductory chapter highlighted the diverse range and severity of alcohol misuse
that exist in the general population, from hazardous and harmful drinking through to
alcohol dependence of varying degrees of severity. Alcohol misuse is associated with
a wide range of physical, psychological and social problems, some of which are a
direct consequence of drinking and others are incidental, but often highly relevant, in
planning and delivering individual care. For example, a harmful alcohol user who is
homeless and suffering from mental health problems may have more significant care
needs than a more severely dependent drinker who has stable accommodation and
employment and no psychiatric comorbidity.
It was also noted in Chapter 2 that in many cases alcohol misuse remits without
any form of formal intervention or contact with the health or social care system, let
alone specialist alcohol treatment. Studies of what has been referred to as ‘sponta-
neous remission’ from alcohol misuse find that this is often attributed, by individuals,
to both positive and negative life events, such as getting married, taking on childcare
responsibilities, or experiencing a negative consequence of drinking such as being
arrested, having an accident or experiencing alcoholic hepatitis. It therefore follows
that not everyone in the general population who meets the criteria for a diagnosis of
an alcohol-use disorder requires specialist treatment. Often a brief intervention from
a GP, for example, may be sufficient to help an individual reduce their drinking to a
less harmful level (see NICE guideline on prevention and early detection; NICE,
2010a).
Nevertheless, the level of alcohol consumption, and the severity of alcohol
dependence and alcohol-related problems, are positively correlated such that people
with more severe alcohol dependence usually have more severe problems and greater
care needs (Wu & Ringwalt, 2004). Also, a proportion of people will require profes-
sional intervention to achieve sufficient change in their drinking behaviour, or to
shorten the course of their alcohol-use disorder.
A useful framework for this spectrum of need and the intensity of professional
responses was provided by Raistrick and colleagues (2006), adapted from work

originally developed the US Institute of Medicine (2003) (Figure 3). Whilst the authors
noted that alcohol problems exist on a continuum of severity rather than in categories,
and that an individual can move between categories over time, the framework provides
a useful general principle that people with more severe problems generally require
more intensive and specialised interventions. While matching people who misuse alco-
hol to different treatment intensities based on the severity of their problems has some
empirical support (Mattson et al., 1994) this has not generally been borne out in stud-
ies designed specifically to test matching hypotheses (Drummond et al., 2009). This
issue will be explored in more detail throughout this guideline.
Figure 3 is a schematic representation of the population of England, with the spec-
trum of alcohol problems experienced by the population and their relative prevalence
shown along the upper side of the figure. Responses to these problems are shown
along the lower side. The dotted lines suggest that primary prevention, simple brief
intervention, extended brief intervention and less-intensive treatment may have
effects beyond their main target area. Although the figure is not drawn to scale, the
prevalence in the population of each of the categories of alcohol problem is approxi-
mated by the area of the triangle occupied; most people have no alcohol problems, a
very large number show risky consumption but no current problems, many have risky
consumption and less serious alcohol problems, some have moderate dependence and
problems and a few have severe dependence or complicated alcohol problems.
Organisation and delivery of care
85
Alcohol problemsNone
Hazardous drinking
Harmful drinking
Moderately dependent
drinking
Severely dependent
drinking
More intensive
specialist treatment
Less intensive treatment in
generalist or specialist settings
Extended brief interventions in generalist settings
Simple brief interventions in generalist settings
Public health programmes – primary prevention
Figure 3: A spectrum of responses to alcohol problems. Reproduced
from a review of the effectiveness of treatment for alcohol problems
(Raistrick et al., 2006)

5.3 SERVICES FOR PEOPLE WHO MISUSE ALCOHOL
5.3.1 Introduction
The provision of alcohol services in England, from the Second World War until around
the 1970s, was driven by a view of alcoholism as an all-or-nothing disease state, affect-
ing a relatively small proportion of the population and requiring intensive, specialist
treatment with the goal of complete abstinence from alcohol, often provided in inpatient
specialist units closely affiliated with the AA fellowship (Drummond et al., 2009).
From the 1970s, there came greater recognition of a wider spectrum of alcohol misuse
that could respond to less intensive interventions as well as the development of public
health approaches to alcohol misuse. This, combined with evidence from randomised
trials which questioned the value of inpatient treatment, led to a shift towards more
community-based care and early brief interventions provided by GPs. Many of the large,
regional, inpatient alcohol units in England subsequently closed and many of the NHS
staff moved to work in newly created community alcohol teams, along with growth in
community-based non-statutory alcohol counselling services. The current service provi-
sion in England with its patchwork of brief alcohol interventions provided by GPs, NHS
and non-statutory specialist community alcohol services, some remaining NHS inpa-
tient units providing mainly assisted alcohol withdrawal, and a declining number of
residential alcohol rehabilitation agencies, mostly in the non-statutory or private sectors,
are a legacy of this gradual and incomplete shift towards community-based care.
5.3.2 Classification of interventions and services
Services and interventions for alcohol misuse can be classified in several different ways.
Models of Care for the Treatment of Drug Misusers (National Treatment Agency for
Substance Misuse, 2002 and 2006b) and MoCAM (Department of Health, 2006a)
describe individual interventions as belonging to different tiers, within a four-tier frame-
work. As noted in MoCAM this has been widely interpreted in the field as individual
agencies rather than interventions belonging to tiers, which has had unintended conse-
quences. Interventions are individual elements of care (for example, a brief intervention,
assisted alcohol withdrawal or CBT) which, when combined, comprise a programme of
care for the individual. These interventions can, and often are, delivered by a range of
both generic (for example, GPs, physicians in acute hospitals or prison healthcare staff)
and alcohol-specialist staff working in a wide range of agencies (for example, NHS,
non-statutory, criminal justice and social care). So the tier to which an intervention
belongs is determined by its nature and intensity, rather than the agency delivering it.
5.3.3 Alcohol interventions
Within MoCAM, Tier 1 interventions include identification of alcohol misuse; provi-
sion of information on sensible drinking; simple brief interventions to reduce alcohol
Organisation and delivery of care
86

related harm; and referral of those with alcohol dependence or harm for more inten-
sive interventions. These can be delivered by a wide range of staff in a various
settings, including accident and emergency departments, primary care, acute hospi-
tals, mental health services, criminal justice services and social services.
Tier 2 interventions include open-access facilities and outreach that provide:
alcohol-specific advice, information and support; extended brief interventions; and
triage assessment and referral of those with more serious alcohol-related problems
for ‘care planned’ treatment. Care-planned treatment refers to the process of plan-
ning and reviewing care within the context of structured alcohol treatment, and
this is located within Tier 3. If staff have the appropriate competencies to deliver
Tier 2 interventions, these can be delivered by the same range of agencies as Tier
1 interventions.
Tier 3 interventions include the provision of community-based specialist alcohol-
misuse assessment, and alcohol treatment that is coordinated and planned (see
below). These include comprehensive assessment, structured psychological interven-
tions or pharmacological interventions which aim to prevent relapse, community-
based assisted alcohol withdrawal, day programmes and specialist alcohol liaison
provided to for example, acute hospitals by specialist staff. Tier 3 interventions
are usually provided by staff working in specialist alcohol treatment agencies both
NHS and non-statutory (although the latter are often funded by the NHS to provide
these interventions). Important exceptions to this are GPs who may provide more
specialised interventions within a Direct Enhanced Services contract (NHS
Employers, 2008). Interventions provided by GPs often involve assisted alcohol with-
drawal in the community or prescribing medication for relapse prevention. As with
interventions in other tiers, staff need to have the relevant competence to be able to
provide them safely and effectively.
Tier 4 interventions include the provision of residential, specialised alcohol treat-
ments that are planned and coordinated, to ensure continuity of care and aftercare.
These interventions include comprehensive assessment, inpatient assisted alcohol
withdrawal and structured psychosocial interventions provided in a residential
setting, including residential rehabilitation. ‘Wet’ hostels also fit within this tier,
although they operate more on a ‘harm reduction’ than an abstinence-oriented model
of care. Tier 4 interventions are usually provided by specialist alcohol inpatient or
residential rehabilitation units. However, assisted alcohol withdrawal is often
provided in other residential settings, including acute hospitals, mental health inpa-
tient services, police custody and prisons, delivered by medical and other staff whose
primary role is not specialist alcohol treatment.
5.3.4 Agencies
A diverse range of health, social care and criminal justice agencies provide alcohol
interventions. These agencies can be classified into specialist alcohol treatment
agencies, whose primary role it is to provide interventions for people who misuse
alcohol, and generic agencies, which are not primarily focused on alcohol treatment
Organisation and delivery of care
87

(National Treatment Agency for Substance Misuse, 2006). In practice the majority
of specialist alcohol agencies also provide treatment for people who misuse drugs,
or both drugs and alcohol. Specialist alcohol treatment agencies are provided by
NHS trusts (usually mental health NHS trusts), non-statutory agencies and the
private sector, with considerable overlap in the range of interventions provided
across the different sectors. However, many of these agencies are funded by the
NHS. Some agencies provide both community-based and residential interventions,
whereas others primarily deliver interventions in one setting. For example, special-
ist NHS alcohol treatment services often have a community alcohol (or drug and
alcohol) team linked to a specialist inpatient alcohol treatment unit in the same local-
ity, with some staff working in both settings. Some non-statutory agencies exclu-
sively provide residential rehabilitation with a regional or national catchment area,
or community-based day programmes with a smaller local catchment area. There is
considerable diversity in the nature of provision across agencies and different parts
of the country, in part reflecting differences in commissioning patterns (Drummond
et al., 2005)
A national survey of alcohol treatment agencies in England, conducted in 2005 as
part of the ANARP (Drummond et al., 2005), identified 696 agencies providing
specialist alcohol interventions. Nearly 69% of alcohol agencies were community
based and 31% were residential services. One third were primarily alcohol services
and 58% were combined drug and alcohol services. Over half of all agencies were
non-statutory, one-third statutory (NHS) and 8% private sector. Interventions
provided by these agencies were classified according to MoCAM criteria.
Community agencies most commonly provided advice, briefer treatments and struc-
tured psychological interventions. Residential agencies most commonly provided
residential rehabilitation and inpatient treatment, including assisted withdrawal.
Overall, 45% of community agencies and 46% of residential agencies provided
assisted alcohol withdrawal. Residential agencies reported greater severity of alcohol
misuse in their client group, with 91% of clients said to be alcohol dependent
compared with 71% of community agency clients (Drummond et al., 2005). The esti-
mated annual spend on specialist alcohol treatment in England was £217 million and
the estimated number of whole time equivalent staff working in this field was 4,250
(Drummond et al., 2005).
The American Society of Addiction Medicine (ASAM) has developed criteria to
define different types of services, some of which are partly relevant to the UK. Some
aspects of their classification are helpful in understanding the terminology used later
in this chapter in the evidence review and the GDG recommendations.
ASAM defines four levels of care (Mee-Lee et al., 2001) (see Text Box 2). Level
I outpatient treatment involves regular scheduled sessions at a specialist treatment
centre, whereas Level II refers to more intensive outpatient treatment/partial hospital-
isation. Both fit within Tier 3 community-based interventions in the MoCAM frame-
work, but they offer a different intensity of intervention. Level II is closest to what
has been described in England as an intensive day programme, although the typical
programme in England does not offer a 7 days per week service. The Level I care is
the more typical provision in England.
Organisation and delivery of care
88

ASAM Levels III and IV both fit within MoCAM Tier 4 interventions. Level III is
residential (medically monitored) treatment which is closest to residential rehabilitation
in England and provides medical cover, often by local GPs who are not necessarily
specialists in alcohol treatment. Level IV is medically managed intensive inpatient treat-
ment which is closest to NHS provided inpatient treatment and is usually led by special-
ist addiction psychiatrists in England.
Organisation and delivery of care
89
Level I – Outpatient treatment
Treatment provided in regularly scheduled sessions at a treatment centre,
designed to help the individual achieve changes in their alcohol use and physi-
cal, psychological and social functioning
Level II – Intensive outpatient treatment/partial hospitalisation
An organised outpatient service that delivers treatment services during the day,
before or after work or school, in the evenings or on weekends. Such treatment
may include medical and psychiatric assessment and treatment, medication,
psychological interventions, and educational, housing and employment support.
Level III – Residential (medically-monitored) treatment
Organised services staffed by designated addiction treatment and mental health
personnel who provide a planned regimen of care in a 24-hour live-in setting.
Such services adhere to defined sets of policies and procedures. They are housed
in, or affiliated with, permanent facilities where patients can reside safely. They
are staffed 24 hours a day. They all serve individuals who need safe and stable
living environments in order to develop their recovery skills. Such living
environments may be housed in the same facility where treatment services are
provided or they may be in a separate facility affiliated with the treatment
provider
Level IV – Medically-managed intensive inpatient treatment
Provide a planned regimen of 24-hour medically directed evaluation, care and
treatment of mental and substance-related disorders in an acute care inpatient
setting. They are staffed by designated addiction specialist doctors, including
psychiatrists, as well as other mental-health and specialist addiction clinicians.
Such services are delivered under a defined set of policies and procedures and
have permanent facilities that include inpatient beds. They provide care to
patients whose mental and substance-related problems are so severe that they
require primary biomedical, psychiatric and nursing care. Treatment is provided
24 hours a day, and the full resources of a general acute care hospital or psychi-
atric hospital are available. The treatment is specific to mental and substance-
related disorders – however, the skills of the interdisciplinary team and the
availability of support services allow the conjoint treatment of any co-occurring
biomedical conditions that need to be addressed.
Text Box 2: Levels of care for addiction treatment (Mee-Lee et al., 2001)

In England, generic agencies providing interventions for people who misuse
alcohol are also diverse. Important among these are general NHS services and crim-
inal justice agencies. Within the NHS, GPs frequently come into contact with people
who misuse alcohol and have an important role to play in providing Tier 1 interven-
tions, including early identification, advice, brief intervention and referral of patients
to specialist alcohol agencies. Some primary care staff, including GPs, practice
nurses and counsellors, also provide more complex alcohol interventions
including assisted alcohol withdrawal, and psychological and pharmacological inter-
ventions. Sometimes this is provided in a collaborative shared care arrangement with
a specialist alcohol treatment agency in liaison with specialist addiction psychiatrists
and nurses. Some GPs also provide medical support to residential non-statutory
agencies such as assisted alcohol withdrawal.
In relation to the criminal justice system, forensic medical examiners are often
called upon to provide assessment and management of detainees in police custody
who misuse alcohol. This often includes the management of acute conditions, such as
severe alcohol intoxication or alcohol withdrawal. Prison health services also have a
key role in the assessment and management of prisoners who misuse alcohol, includ-
ing assessment and management of assisted alcohol withdrawal.
In acute hospitals a wide range of healthcare professionals come into contact
with people who misuse alcohol. In particular, staff in accident and emergency
departments often encounter patients with alcohol-related presentations, such as
accidents and injuries sustained whilst intoxicated with alcohol, and can play an
important role in early identification and intervention. Alcohol-misusing patients
admitted to acute hospitals, either in an emergency or for elective treatment, pres-
ent an opportunity for early identification and intervention. Some acute hospitals
will have specialist alcohol liaison teams, often led by addiction psychiatrists or
nurses, who support the acute care staff and provide staff training, assessment,
intervention and referral to specialist alcohol agencies. Accident and emergency
department staff also encounter patients presenting in acute unplanned alcohol
withdrawal (NICE, 2010b) and some of these patients will require assisted alcohol
withdrawal.
Alcohol misuse is common in clients attending mental health services, particu-
larly among the severely mentally ill (Weaver et al., 2003), but seldom identified by
mental health staff (Barnaby et al., 2003). This represents an important missed oppor-
tunity to provide early alcohol intervention or referral to specialist services. Also,
mental health clients attending both inpatient and community mental health services
will often require assisted alcohol withdrawal. Given the wide range of physical co-
morbidities associated with alcohol use, there are also potential benefits from improv-
ing generic staff competencies in a wider range of healthcare settings. Staff working
in these generic settings need to be competent to identify, assess and manage the
complications of alcohol misuse. Some mental health trusts have an addiction liaison
service provided by specialist addiction psychiatrists and nurses in a model similar to
that described above for acute hospitals.
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5.3.5 Coordination and organisation of care
From the foregoing, it is apparent that the range of interventions and the agencies that
provide them are highly complex and diverse, with considerable geographic variation.
This diversity presents challenges both for the person who misuses alcohol and at a
treatment system level. For the person entering treatment for the first time, the array
of interventions, agencies and staff can be bewildering. Service users, therefore, need
considerable help in orientation and understanding what is available to them and what
services they might require. Also, the alcohol interventions that an individual requires
may be provided by several different agencies in the course of an episode of care, as
well as needing care from a range of generic agencies for physical, psychological or
social problems. As clients move between different agencies there is considerable
potential for premature disengagement. There is therefore the care of an individual
client’s needs to be planned and coordinated.
5.3.6 Care coordination
Several terms have been used to describe the coordination of care within specialist
alcohol services, including case management, keyworking, care coordination, care
planning and assertive outreach. In MoCAM (Department of Health, 2006a) there is
an expectation that all cases would be care coordinated. These include harmful
drinkers who respond to a brief intervention but do not usually require more intensive
form of care coordination such as case management. More severely dependent
drinkers with complex mental or physical comorbidities or social needs usually
require considerable case management due to the complex nature of their problems
and/or the wide range of agencies involved. Some studies reviewed in this chapter
include more assertive approaches in supporting clients, including ACT.
In this guideline, two terms are mainly used: care coordination and case manage-
ment. Care coordination describes the coordination of an individual’s care whilst in a
treatment episode. It is limited in its responsibilities and may involve little or no direct
contact with the patient, but rather the focus is on assuring all agreed elements of the
care package are linked together and communicated in a clear and effective manner.
Case management, as defined in this guideline, is a more substantial endeavour and has
several elements. The individual case manager is responsible for assessment of the
individual client’s needs, development of a care plan in collaboration with the client
and relevant others (including relatives and carers, other staff in specialist and generic
agencies involved in the client’s care), coordination of the delivery of interventions and
services, providing support to the client to assist in access to and engagement with
services and interventions. The case manager will often use psychological interven-
tions such as motivational interviewing to enhance the client’s readiness to engage
with treatment. The case manager is also responsible for monitoring the outcome of
interventions and revising the care plan accordingly. Case management is a skilled task
Organisation and delivery of care
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which requires appropriately competent clinical staff to deliver it effectively. Further,
to discharge this function effectively, case managers need to limit the number of clients
they can support at any one time. Case management is a Tier 3/4 intervention within
MoCAM and should begin with a comprehensive specialist clinical assessment.
5.3.7 Integrated care pathways and stepped care
An integrated care pathway ‘describes the nature and anticipated course of treatment
for a particular client and a predetermined plan of treatment’ (National Treatment
Agency, 2002). Integrated care pathways have a function at both an individual and a
treatment system level. At the individual level the care plan should describe the
client’s personalised care pathway, designed to meet the assessed needs, the planned
interventions, and the agencies and staff intended to deliver them. The pathway needs
to be integrated so that it shows a logical progression of steps with interventions being
provided at the appropriate stages. For example, an alcohol-dependent client may
initially require inpatient assisted alcohol withdrawal followed by a structured
psychosocial intervention in an alcohol day programme, followed by specialised
psychotherapy for PTSD, followed by vocational services to support a return to work.
Each of these elements of care may be delivered by different agencies in different
locations, and the pathway needs to be integrated to deliver maximum benefit and
minimise the client’s premature disengagement.
Stepped care is a method of organising and providing services in the most cost effi-
cient way to meet individual needs (Sobell & Sobell, 2000). Two defining characteris-
tics are common to all stepped-care systems (Davison, 2000). The first concerns the
provision of the least restrictive and least costly intervention (including assessments)
that will be effective for an individual’s presenting problems, and the second is
concerned with building in a self-correcting mechanism. Escalating levels of response
to the complexity or severity of the disorder are often implicit in the organisation and
delivery of many healthcare interventions, but a stepped-care system is an explicit
attempt to formalise the delivery and monitoring of patient flow through the system.
In establishing a stepped-care approach, consideration should not only be given to the
degree of restrictiveness associated with a treatment, and its costs and effectiveness,
but also the likelihood of its uptake by a patient and the likely impact that an unsuc-
cessful intervention will have on the probability of other interventions being taken up.
Within this approach people who misuse alcohol are initially offered the least
intensive intervention that is acceptable and most likely to be effective for them,
followed by increasingly intensive interventions for those not responding to the less
intensive interventions. A stepped-care algorithm effectively describes an integrated
care pathway that accommodates individual needs and responses to interventions
(Drummond et al., 2009). This approach has gained increasing currency in other
mental health disorders, including depression (NICE, 2009b). The stepped-care
approach has also been supported by recent guidance from the National Treatment
Agency and the Department of Health (National Treatment Agency for Substance
Misuse, 2002; Raistrick et al., 2006). The evidence for stepped care for alcohol
misuse is reviewed later in this chapter.
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5.3.8 Relationship of this guidance to other NICE guidelines
This guideline is focused on the identification, assessment and management of harm-
ful alcohol use and alcohol dependence (alcohol misuse). The NICE guideline on
prevention and early detection (NICE, 2010a) is concerned with a range of preventive
strategies for alcohol-use disorders. This includes alcohol screening and brief inter-
vention, which is not only a Tier 1 alcohol intervention but also potentially acts as a
gateway to other more intensive interventions for alcohol misuse. The NICE guide-
line on management of alcohol-related physical complications (NICE, 2010b) is
focused on the management of a wide range of physical consequences of alcohol
misuse. These include the management of assisted alcohol withdrawal in acute hospi-
tal settings, which are Tier 4 interventions. However, the guideline is restricted to the
management of unplanned assisted alcohol withdrawal – that is, in circumstances
where a patient presents to hospital already in a state of alcohol withdrawal. This
guideline is concerned with a much wider range of potential scenarios where people
who misuse alcohol may require assisted alcohol withdrawal, including where
assisted withdrawal is provided in a planned way as part of an integrated programme
of alcohol specialist care, and where people are identified as being at risk of develop-
ing alcohol withdrawal in acute hospitals or prison settings and therefore require
planned assisted alcohol withdrawal.
SECTION 2 – EVALUATING THE ORGANISATION OF CARE
FOR PEOPLE WHO MISUSE ALCOHOL
5.4 REVIEW QUESTION
In adults with alcohol misuse, what is the clinical efficacy, cost-effectiveness, safety of
and patient satisfaction associated with different systems for the organisation of care?
5.5 INTRODUCTION
This section presents reviews of the evidence for case management, ACT and stepped
care. The reviews and evidence summaries are presented separately, but a combined
section on evidence into recommendation is presented at the end of this section along
with the recommendations developed by the GDG. In reviewing the evidence for the
effectiveness of different service delivery models, the GDG initially decided to focus
on RCTs. The use of this type of study design to evaluate service-level interventions
gives rise to a number of problems, including the definition of the interventions, the
specification of the comparator and the interpretation of results of trials of complex
healthcare interventions across different healthcare systems (Campbell et al., 2007).
As demonstrated in the section below, the use of RCTs was further complicated by
Organisation and delivery of care
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the limited number of studies identified. This led the GDG to include a range of
observational studies in a review of the service delivery models, both to increase the
available evidence base and also because some observational studies may provide
richer data on what services do, how they do it, and how they differ from alternative
types of service and the standard care they hope to replace. Given the nature of the
studies identified, a narrative synthesis of observational and RCT studies that were
relevant to the review question but could not be meta-analysed was conducted after
the review of RCTs.
5.6 CASE MANAGEMENT
5.6.1 Introduction
For the purposes of the guideline, case management is defined as the bringing
together of the assessment, planning, coordination and monitoring of care under one
umbrella. In a number of cases all four of these activities will be undertaken by one
individual, but in other cases some of the above functions will be undertaken by other
team members or health professionals and coordinated by one individual. In some
case management interventions the case manager adopts largely a brokerage role,
while at other times they take on an active and direct clinical role. Where the case
manager takes on an active clinical role using a specific intervention (for example,
CBT), such interventions were excluded from the case management review and
included in another relevant review within this guideline. Case management may also
vary in its duration and intensity. For the purposes of this guideline, the GDG took the
view that the intervention should be of sufficient duration to allow for all four func-
tions to be undertaken.
5.6.2 Clinical review protocol
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Table 6.
5.6.3 Studies considered
11
The review team conducted a new systematic search for RCTs and systematic reviews
that assessed the benefits and downsides of case management and related health
economic evidence.
Organisation and delivery of care
94
11
Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
tal letters (primary author and date of study publication, except where a study is in press or only submit-
ted for publication, then a date is not used).

Five trials (three RCTs and two observational studies) relating to clinical evidence
met the eligibility criteria set by the GDG, providing data on 1,261 participants. Of
these trials, all five were published in peer-reviewed journals between 1983 and 1999.
In addition, 13 studies were excluded from the analysis. The most common reason for
exclusion was no usable outcome data, or the intervention was aimed at a primarily
drug misusing population rather than alcohol misuse. Summary study characteristics
of the included studies are presented in Table 7. (further information about both
included and excluded studies can be found in Appendix 16b).
Case management versus treatment as usual
There were three RCTs and two observational studies involving comparisons of case
management and treatment as usual (AHLES1983; CONRAD1998; COX1998;
MCLELLAN1999; PATTERSON1997). AHLES1983 compared case management
with treatment as usual (standard aftercare arrangements), where the importance of
attending aftercare was emphasised but not enforced. Patients were scheduled for one
aftercare session at discharge and aftercare consisted of individual problem-oriented
counselling. COX1998 compared case management with treatment as usual (there was
no further description of treatment as usual). CONRAD1998 compared two types of
residential inpatient care; the experimental group was case managed, whereas the
control group participated in the residential care programme without case management.
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Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane
Library
Date searched Systematic reviews from 1993 to March 2010; RCTs
from database inception to March 2010; observational
and quasi-experimental studies from database inception to
October 2010
Study design Systematic reviews, RCTs, observational studies, quasi-
experimental studies
Patient population Alcohol dependence or harmful drinking
Interventions Case management versus other treatment
Case management versus treatment as usual (TAU)
Outcomes Aftercare attendance; engagement in aftercare; abstinence;
drinking frequency measures (for example, number of
days drinking in the past month); quantity of alcohol
consumption measures (for example, drinks per drinking
day [DDD]); number retained in treatment; relapse; lapse
Table 6: Databases searched and inclusion/exclusion criteria for
clinical evidence

Two observational were also included in the review. PATTERSON1997 compared
the addition of a community psychiatric nurse (CPN) to aftercare with standard hospi-
tal care. Standard hospital care consisted of an offer of review appointments every 6
weeks following discharge. Lastly, MCLELLAN1999 compared case management
with treatment as usual (no case management). In the standard-care condition, partici-
pants received group abstinence-oriented outpatient drug-misuse counselling twice
weekly. In the case management condition, participants received a clinical case
manager to provide support for housing, medical care, legal advice and parenting
classes in addition to the drug counselling programme. For a graphical representation
of the data, these two studies were inputted into the forest plots for comparison with
the results of the RCTs; however, it should be noted that the outcomes and data were
not pooled with the data found in the RCTs.
Organisation and delivery of care
96
Case management versus TAU
Total number of trials (total 5 RCTs (N = 1262)
number of participants)
Study ID (1) AHLES1983
(2) COX1998
(3) CONRAD1998
(4) MCLELLAN1999 (observational)
(5) PATTERSON1997 (observational)
Baseline severity (mean (1) 80% admitted to levels of drinking within
[standard deviation; SD]) the abusive range
(2) Days of drinking (any alcohol use) in last
30 days:
Case management: 23.6 (9.2)
Control: 23 8 (9.1)
(3) Days of alcohol use in past 30 days (mean):
18.4 for control group; 19.0 for experimental group
(4) Whole sample on average reported 13.4 years
of problem alcohol use (12.1)
(5) Daily alcohol (units) (mean [SD])
CPN aftercare: 39.4 (18.3)
Standard aftercare: 42.9 (16.6)
Length of follow-up (1) 6- and 12-month
(2) Assessed in 6-month intervals up to 2-year
follow-up
(3) 3, 6 and 9 months during enrolment and 12, 18
and 24 months after completion of treatment.
(4) 6-month
(5) Assessed at 1, 2, 3, 4 and 5 years post-treatment
Table 7: Study information table for trials of case management

5.6.4 Clinical evidence for case management
Evidence from the important outcomes and overall quality of evidence are presented
in Table 7 and Table 8. The associated forest plots can be found in Appendix 17a.
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Outcome or subgroup K Total N Statistics Effect (95% CI) Quality of
the evidence
(GRADE)
Lapse (non-abstinence)
At 6-month follow-up 1 36 RR (M-H, Random, 0.27 (0.11,0.65) ����
95% CI) MODERATE
At 12-month follow-up 1 36 RR (M-H, Random, 0.75 (0.52,1.08) ����
(RCT) 95% CI) MODERATE
At 2-year follow-up 1 122 RR (M-H, Random, 0.88 (0.69,1.12) ����
(non-RCT) 95% CI) VERY LOW
At 3-year follow-up 1 122 RR (M-H, Random, 0.68 (0.53,0.85) ����
95% CI) VERY LOW
At 4-year follow-up 1 122 RR (M-H, Random, 0.57 (0.45,0.73) ����
95% CI) VERY LOW
At 5-year follow-up 1 122 RR (M-H, Random, 0.49 (0.37,0.63) ����
95% CI) VERY LOW
Drinking frequency
Mean days of alcohol 1 537 SMD (IV, Random, −0.07 (−0.25,0.11) ����
intoxication (non-RCT) 95% CI) LOW
Days any alcohol use 2 551 SMD (IV, Random, −0.10 (−0.40,0.20) ����
at 6-month follow-up 95% CI) HIGH
Days using alcohol 1 193 SMD (IV, Random, −0.34 (−0.63,-0.05) ����
since last interview at 95% CI) HIGH
6-month follow-up
Days drinking any 1 358 SMD (IV, Random, −0.13 (−0.34,0.08) ����
alcohol in last 30 days 95% CI) HIGH
at 9-month follow-up
Days drinking any 1 193 SMD (IV, Random, −0.21 (−0.49,0.08) ����
alcohol in last 30 days 95% CI) HIGH
at 12-month follow-up
Days using any alcohol 1 193 SMD (IV, Random, −0.30 (−0.59,−0.01) ����
since last interview at 95% CI) HIGH
12-month follow-up
Days drinking any 1 193 SMD (IV, Random, −0.33 (−0.62,−0.05) ����
alcohol in last 30 days 95% CI) HIGH
at 18-month follow-up
Days using alcohol 1 193 SMD (IV, Random, −0.49 (−0.78,−0.20) ����
since last interview at 95% CI) HIGH
18-month follow-up
Table 8: Case management versus TAU
Note. M-H = Mantel-Haenszel estimate; IV = inverse variance.

5.6.5 Evidence summary
Case management versus treatment as usual
There was a significant difference in lapse (non-abstinence) at 6-month follow-up, in
favour of case management, with a small effect size; however, this effect was not
significant at 12-month follow-up. There was a significant difference favouring case
management found at 3-, 4- and 5-year follow-up, with the largest effect size occur-
ring at 3-year follow-up and decreasing to a moderate effect size at 4- and 5-year
follow-up, respectively. It is important to note that these results are based on one
observational study (PATTERSON1997).
On measures of drinking frequency, when considering the number of days drink-
ing any alcohol (in the last 30 days) or mean days of intoxication, there were no
significant differences between case management or treatment as usual at either 6-, 9-
or 12-month follow-up. Interestingly, there was a significant effect observed at 18-
month follow-up in favour of case management (small effect size) based on the results
of one study (COX1998).
When considering the number of days using alcohol since the last interview
(COX1998), there was a significant difference observed, favouring case management
over treatment as usual at all follow-up points (small to moderate effect sizes): 6-, 12-
and 18-month follow-up.
Based on the GRADE methodology outlined in Chapter 3, the quality of this
evidence is moderate, therefore further research is likely to have an important impact
on the confidence in the estimate of the effect (see Table 8).
Due to the heterogeneous nature of studies within case management, it was not
possible to combine the outcome data provided across studies. As a result, there are a
number of RCTs which add value to the meta-analysis presented. For the purpose of
this guideline and to obtain a better overview of the available literature, four RCTs
(Chutuape et al., 2001; Gilbert, 1988; Krupski et al., 2009; Sannibale et al., 2003;
Stout et al., 1999), which met methodological criteria but did not have outcomes that
could be used in meta-analyses for this review, are described below.
Gilbert (1988) conducted an RCT comparing case management, a home visit and
treatment as usual for those with alcohol dependence. After receiving inpatient or
outpatient treatment, patients were scheduled to be assigned a case manager or have a
home visit, which consisted of appointments scheduled not at the hospital but at a
convenient location for the patient. Patients in the home visit condition were contacted
with follow-up letters to reschedule aftercare appointments. In the traditional treatment
(treatment as usual), no active attempts were made to improve attendance at aftercare
appointments. On appointment keeping measures, results from an analysis of variance
(ANOVA) revealed a significant group by time interaction F = 4.56 (6,240), p �0.01,
and post-hoc Tukey’s Honestly Significant Difference (HSD) test revealed significant
differences between home visit and case manager groups at 6- (p �0.05), 9- and 12-
month follow-up (p�0.01). Both active treatment groups showed a decline in appoint-
ment keeping rates after the therapists stopped making active attempts to encourage the
patient to attend therapy. On drinking outcomes, there were no significant differences
between groups at any follow-up point.
Organisation and delivery of care
98

Stout and colleagues (1999) conducted an RCT comparing case monitoring versus
treatment as usual for those with alcohol dependence. The results indicated a signifi-
cant difference on percentage of days heavy drinking at 3-year follow-up, where the
frequency of heavy drinking was twice as high in the controls as in the case moni-
tored participants. In addition, survival analysis indicated that case monitoring was
significantly better at prolonging time to lapse and relapse (p = 0.05), as well as in
reducing the severity of the relapse. There was no significant difference between the
two groups for time to first heavy drinking day (p = 0.1). It should be noted that 66%
of this sample had a comorbid Axis 1 diagnosis.
Chutuape and colleagues (2001) looked at the transition from an assisted-with-
drawal programme to aftercare. Participants were randomly assigned to one of three
conditions: incentive and escort to aftercare; incentive only; or standard treatment.
Standard treatment participants only received referral instructions and were told to go
to aftercare following discharge. Results from a logistic regression analysis indicated
that aftercare contact rates differed significantly by referral condition (p = 0.001).
Post hoc tests indicated that participants in the escort and incentive and incentive only
conditions completed intake at aftercare more (p �0.05) than those receiving stan-
dard treatment.
When comparing a structured aftercare programme with an unstructured aftercare
programme, Sannibale and colleagues (2003) found that structured programmes had
a fourfold increase in aftercare attendance (odds ratio [OR] 4.3, 95% CI 1.7 to 11.2)
and a reduced rate of uncontrolled substance use at follow-up (OR 0.3, 95% CI 0.1 to
0.9). Furthermore, participants in either aftercare condition relapsed later than those
who attended no aftercare programme; however, this significant difference did not
emerge for time to lapse.
More recently, Krupski and colleagues (2009) evaluated the impact of recovery
support services (including case management) provided through an access to recov-
ery programme in the US for clients undergoing substance-misuse treatment.
Standard treatment consisted of ‘chemical dependency treatment’. The comparison
group was a multi-modal programme entitled Access to Recovery (ATR), which
included a case management component. They found that in comparison with stan-
dard care the ATR programme was associated with increased length of stay in treat-
ment and completion of treatment (42.5 days longer). Further, multivariate survival
analysis indicated the risk of ending treatment was significantly lower (hazard
ratio = 0.58, p �0.05) among the ATR clients.
5.6.6 Special populations
No studies that evaluated the efficacy of case management for children and young
people or older people and met inclusion criteria were identified.
5.6.7 Health economic evidence
No studies were identified in the systematic literature review that considered the cost
effectiveness of case management in the treatment of alcohol misuse. Details on the
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methods used for the systematic review of the health economic literature for this
guideline are described in Chapter 3.
5.7 ASSERTIVE COMMUNITY TREATMENT
5.7.1 Introduction
ACT is a method of delivering treatment and care which was originally developed for
people with serious mental illness in the community (Thompson et al., 1990). The inten-
tion is to prevent or reduce admission to hospital. The model of care has been defined
and validated, based upon the consensus of an international panel of experts (McGrew
et al., 1994; McGrew & Bond, 1995). Over time, the focus has shifted to provide for
effective support in the community to those with severe, long-term mental illness who
may previously have spent many years as hospital inpatients. ACT now aims to support
continued engagement with services, reduce the extent (and cost) of hospital admissions
and improve outcomes (particularly quality of life and social functioning).
The evidence for effectiveness in the international literature is strong for severe
mental illness (Marshall & Lockwood, 2002), although this may in part be due to the
comparator used (essentially poor quality standard care). For example, ACT has been
shown to be effective in the US (Marshall & Lockwood, 2002), but less so in the UK
where standard care is of a better quality (Killaspy et al., 2006). There is little evidence
for the effectiveness of ACT in alcohol disorders and the evidence from the field of dual
diagnosis (psychosis and substance misuse) is currently rather weak (NICE, 2011a).
5.7.2 Clinical review protocol
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Table 9.
5.7.3 Studies considered
12
For the purposes of this guideline the GDG adopted the definition of ACT used by
Marshall and Lockwood (2002), which identified the following key elements:
� care is provided by a multidisciplinary team (usually involving a psychiatrist with
dedicated sessions)
� care is exclusively provided for a defined group of people (those with severe and
chronic problem)
Organisation and delivery of care
100
12
Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
tal letters (primary author and date of study publication, except where a study is in press or only submit-
ted for publication, then a date is not used).

� team members share responsibility for clients, so that several members may work
with the same client, and members do not have individual caseloads (unlike case
management)
� the team attempts to provide all psychiatric and social care for each service user,
rather than making referrals to other agencies
� care is provided at home or in the workplace, as far as possible
� treatment and care are offered assertively to individuals who are uncooperative or
reluctant (‘assertive outreach’)
� medication concordance is emphasised.
The review team conducted a new systematic search for RCTs and systematic
reviews that assessed the benefits and downsides of ACT methods.
Four trials relating to clinical evidence met the eligibility criteria set by the GDG,
providing data on 706 participants. Of these, none were unpublished and three were
published in peer-reviewed journals between 1991 and 2008. In addition, two studies
were excluded. The most common reason for exclusion was due to a comorbid sample
population of psychosis (where this was the primary diagnosis) and alcohol depend-
ence/misuse. Summary study characteristics of the included studies are presented
Table 10 (further information about both included and excluded studies can be found
in Appendix 16b).
A meta-analysis was not performed as there was only one non-randomised study
which concerned people who misuse alcohol as the primary group (Passetti et al.,
2008). The three RCTs, Bond and McDonel (1991), Drake and colleagues (1998) and
Essock and colleagues (2006), include populations with co-existing and primary
Organisation and delivery of care
101
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane
Library
Date searched Systematic reviews from 1993 to March 2010; RCTs
from database inception to March 2010; observational
and quasi-experimental studies from database inception to
October 2010.
Study design Systematic reviews, RCTs, observational studies,
quasi-experimental studies
Patient population Diagnosed with an alcohol-use disorder (alcohol
dependence) or alcohol misuse
Interventions ACT versus other active interventions
ACT versus TAU
Outcomes None specified
Table 9: Databases searched and inclusion/exclusion criteria for
clinical evidence

Organisation and delivery of care
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diagnosis psychosis and substance misuse, and thus have been covered in another
NICE guideline on psychosis and substance misuse (NICE, 2011a). It is important to
note that in the Bond and McDonel (1991) study, 70% had a primary diagnosis of
schizophrenia or schizoaffective disorder and 61% reported their primary substance
misuse problem was with alcohol. Conversely, in the Essock and colleagues’ (2006)
study, 76% had a primary diagnosis of schizophrenia or schizoaffective disorder, and
74% misused alcohol while 81% used other substances. In the Drake and colleagues’
(1998) study, 53.4% had a primary diagnosis of schizophrenia, 22.4% of schizoaffec-
tive disorder, 24.2% of bipolar and 72.6% of the sample misused alcohol. No differ-
ences were reported in any of the three trials on relapse outcomes, and there were no
significant differences reported on hospitalisation or relapse rates in the Essock and
colleagues’ (2006) or Drake and colleagues’ (1998) trials, both comparing ACT with
case management. In the Bond and McDonel (1991) trial, there were significant
differences in treatment engagement and completion of assessment, but no significant
differences between groups on drinking outcomes.
5.7.4 Evidence summary
Passetti and colleagues (2008) conducted a parallel cohort trial comparing a flexible
access clinic (based on ACT principles) with a usual care clinic. Treatment as usual
(usual care clinic) consisted of two specialist alcohol community nurses and social
workers. Medical cover was provided by a consultant, an associate specialist and a
junior doctor. Care coordinators had a relatively large caseload and there was limited
integration of health and social care staff, along with less community-based assess-
ments and case discussions. The trial found that participants in the flexible access
clinic were significantly more likely to complete withdrawal (Pearson’s Chi square
test, �
2
= 4.43 p = 0.05) and enter an aftercare programme earlier (Student’s t-test,
t = 2.61, p = 0.02). No significant difference between the two groups was found on
completion of assessment and drinking outcomes were not measured.
5.7.5 Special populations
No studies evaluating the efficacy of ACT for children and young people or older
people which met inclusion criteria could be identified.
5.7.6 Health economic evidence
No studies were identified in the systematic literature review that considered the cost
effectiveness of ACT for alcohol misuse. Details on the methods used for the system-
atic review of the health economic literature for this guideline are described in
Chapter 3.
Organisation and delivery of care
103

5.8 STEPPED CARE
5.8.1 Introduction
The stepped-care approach to care is based on two key principles (Davison, 2000;
Sobell & Sobell, 2000):
� The provision of the least restrictive and least costly intervention that will be
effective for a person’s presenting problems.
� The use of a self-correcting mechanism which is designed to ensure that if an indi-
vidual does not benefit from an initial intervention, a system of monitoring is in
place to identify a more appropriate and intensive intervention is provided.
Stepped-care models, which have their origins in the treatment of tobacco addic-
tion (Sobell & Sobell, 2000), provide for escalating levels of response to the comp
-
lexity or severity of the disorder and are an explicit attempt to formalise the delivery
and monitoring of patient flow through the system. In establishing a stepped-care
approach, consideration should be given not only to the degree of restrictiveness asso-
ciated with a treatment, and its costs and effectiveness, but also to the likelihood of
its uptake by a patient and the likely impact that an unsuccessful intervention will
have on the probability of other interventions being taken up. Despite the origins in
the field of addiction, stepped-care systems have not been the subject of much formal
evaluation in the area.
A review by Bower and Gilbody (2005) of the evidence for the use of stepped care
in the provision of psychological therapies generally was unable to identify a signif-
icant body of evidence. However, they set out three assumptions on which they argued
a stepped-care framework should be built and which should be considered in any
evaluation of stepped care. These assumptions concern the equivalence of clinical
outcomes (between minimal and more intensive interventions, at least for some
patients), the efficient use of resources (including healthcare resources outside the
immediate provision of stepped care) and the acceptability of low-intensity interven-
tions (to both patients and professionals). They reviewed the existing evidence for
stepped care against these three assumptions and found some evidence to suggest that
stepped care may be a clinically and cost-effective system for the delivery of psycho-
logical therapies, but no evidence that strongly supported the overall effectiveness of
the model.
In the field of alcohol misuse there are well-developed brief interventions which
are suitable for use in a stepped-care system (see NICE, 2010a, for a comprehensive
review) such as brief motivational interventions, but other low-intensity interven-
tions that are less dependent on the availability of professional staff and focus on
patient-initiated approaches to treatment are also available and include self-help
materials such as books and computer programmes (Bennet-Levey et al., 2010). In
addition, many alcohol treatment services already operate forms of stepped care and
they are implicit in current national policy guidance (MoCAM; Department of
Health, 2006a) but as yet there has been little formal evaluation or systematic review
of the area.
Organisation and delivery of care
104

Definition
For the purposes of this review, stepped care is defined as a system for the organisa-
tion and delivery of care to people with harmful or dependent drinking which:
a) provides to the majority, if not all harmful or dependent drinkers, the least restric-
tive and least costly brief interventions that will be effective for a person’s present-
ing problems
b) has a system of built-in monitoring that ensures that those who have not benefited
from the initial intervention will be identified
c) has the referral systems and capacity to ensure that more intensive interventions
are provided to those who have not benefited from a low intensity intervention.
5.8.2 Clinical review protocol
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Table 11 (further information about the
search for health economic evidence can be found in Chapter 3).
5.8.3 Studies considered
13
The review team conducted a new systematic search for RCTs and systematic reviews
that assessed the efficacy of stepped-care approaches.
Three trials relating to clinical evidence that potentially met the eligibility crite-
ria set by the GDG were found, providing data on 496 participants. These trials
Organisation and delivery of care
105
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO,
Cochrane Library
Date searched Systematic reviews from 1993 to March 2010. All
other searches from database inception to March 2010
Study design Systematic reviews, RCTs
Patient population Those with alcohol dependence or alcohol misuse
Interventions Stepped-care approach versus TAU
Outcomes Any drinking outcome; engagement or attendance in
aftercare sessions or programmes
Table 11: Databases searched and inclusion/exclusion criteria for
clinical evidence
13
Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
tal letters (primary author and date of study publication, except where a study is in press or only submit-
ted for publication, then a date is not used).

Organisation and delivery of care
106
(Bischof et al., 2008; Breslin et al., 1999; Drummond et al., 2009) were published in
peer-reviewed journals between 1999 and 2009. The trials are listed below in Table
12 and the outcomes of the studies are described in the text below. The GDG consid-
ered these studies very carefully and concluded that, despite the claims of individual
studies (for example, labelling the intervention as stepped care), none of these stud-
ies delivered a form of stepped care that was fully consistent with the definition of a
stepped-care approach adopted for this guideline.
5.8.4 Evidence summary
Breslin and colleagues (1997) evaluated the contribution of pre- and within treatment
predictors with 212 ‘problem drinkers’ who initially completed a brief cognitive behav-
ioural motivational outpatient intervention. The analyses revealed that in the absence of
the ability to systematically monitor within treatment drinking outcomes and goals,
therapist prognosis ratings can be used in making stepped-care treatment decisions.
These prognosis ratings improve predictions of outcomes even after pre-treatment char-
acteristics are controlled. In a later study, Breslin and colleagues (1999) evaluated a
stepped-care model (but which the GDG considered might be more accurately
described as an evaluation of sequenced as opposed to stepped care
14
) for harmful
drinkers, with the initial treatment consisting of four sessions of motivationally-based
outpatient treatment. The design split participants into treatment responders and non-
responders, with treatment non-responders defined as those having consumed more
than 12 drinks per week between assessment and the third session of the intervention.
There was also a third group of non-responders who did not respond to initial treatment,
but received a supplemental intervention consisting of post-treatment progress reports.
A repeated measures ANOVA indicated a significant effect of time for percent days
abstinent (PDA), F (2,116) = 35.89, p �0.0001, for all groups) and for DDD, F
(2,115) = 26.91, p �0.0001. F results from follow-up contracts revealed that those who
received a supplemental intervention showed no additional improvements on drinking
outcome measures in comparison with those who did not receive a supplemental inter-
vention (no significant differences on PDA or DDD). Furthermore, treatment respon-
ders and non-responders sought additional help at the same rate. It should be noted that
this intervention was aimed at problem drinkers and not at severely dependent drinkers.
Furthermore, it is possible that the lack of effect in this study was due to the ‘intensity’
of the ‘stepped’ intervention, as it only consisted of a progress report. It is possible
that confidence in the effect could be increased if the supplemental intervention
provided to treatment non-responders from the initial intervention was more intensive
and alcohol-focused.
Bischof and colleagues (2008) compared two types of ‘stepped-care’ interven-
tions (but which the GDG consider to be a comparison of two different models of
14
‘Stepped care’ is a system for the organisation of care in which the least intrusive and most effective
intervention is offered first. ‘Sequenced care’ refers to a process of care where intervention often of equiv-
alent intensity is offered in sequence if there is no response to the first intervention.

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Organisation and delivery of care
107

Organisation and delivery of care
108
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Organisation and delivery of care
109

brief interventions) with a control group. The ‘stepped-care’ group received a comput-
erised feedback programme after assessment and a maximum of three brief counselling
sessions delivered by telephone, lasting 30 to 40 minutes each. The counselling was
delivered based on the success of the previous intervention, the computerised feedback
programme. If a participant reported a reduction of alcohol consumption, the interven-
tion was discontinued. Those in the full-care group received a fixed number of four tele-
phone-based brief counselling sessions at 30 minutes each in addition to the
computerised feedback system. The control group received a booklet on health behav-
iour. An OLS regression analysis indicated that there was no significant difference over-
all, in terms of efficacy of the intervention (R
2
change = 0.006, p = 0.124). A significant
difference was found for at risk/alcohol misuse at 12-month follow-up (R
2
change = 0.039, p = 0.036), but not for alcohol dependence (R
2
change = 0.002,
p = 0.511) or heavy episodic driving (R
2
change = 0.000, p = 0.923). Thus stepped-care
and full-care groups did not differ on drinking outcomes, but when compared with the
control group the intervention showed small to medium effect size for at-risk drinkers
only. It should be noted that this intervention does not fit with the definition of stepped
care used for this guideline because the approach employed in this study represents more
intensive levels of the same interventions rather than ‘stepped’-up care if the participant
does not respond to the initial intervention.
More recently, Drummond and colleagues (2009) conducted an RCT pilot study
to evaluate a stepped-care intervention in primary care primarily for hazardous and
harmful drinkers (and, in the view of the GDG, not a stepped-care model with much
relevance to the population which is the focus of this guideline), compared with a
minimal intervention. Participants received either a three-stage stepped-care interven-
tion or 5 minutes of brief advice delivered by a practice nurse. Participants in the
stepped-care intervention received a single session of behaviour change counselling
(delivered by a practice nurse), four 50-minute sessions of MET provided by an alco-
hol counsellor and, lastly, referral to a community alcohol treatment agency. At
6-month follow-up, there was a reduction on drinking outcome measures in both
groups and a slight trend favouring the stepped-care intervention for total alcohol
consumed (adjusted mean difference = 145.6, 95% CI, −101.7 to 392.9, effect size
difference = 0.23) and drinks per drinking day (adjusted mean difference = 1.1, 95%
CI, −0.9 to 3.1, effect size difference = 0.27). These differences were not significant.
5.8.5 Special populations
No studies evaluating the efficacy of a stepped-care approach for children and young
people or older people which met inclusion criteria were identified.
5.8.6 Health economic evidence
The study by Drummond and colleagues (2009) included a cost-effectiveness analysis of
a stepped-care alcohol intervention compared with minimal intervention in the primary
care setting. The study population consisted of UK males with a diagnosis of an alcohol-
use disorder and follow-up was 6 months post-randomisation. The primary outcome
Organisation and delivery of care
110

measure used in the economic analysis was the quality-adjusted life year (QALY), esti-
mated from European Quality of Life – 5 Dimensions (EQ-5D) utility scores obtained
from the study participants. A societal perspective was adopted for the analysis which
included costs relating to staff training, specific psychological interventions, and other
healthcare, social care and criminal justice services. In the intervention group, mean total
treatment costs were £216 at baseline and total mean service costs were £2,534 at follow-
up, compared with £20 and £12,637 in the control group. These differences in 6-month
follow-up costs were largely explained by criminal justice services utilisation in the
control group (£8,000 versus £0). At 6 months, the intervention group gained a mean
0.3849 QALYs compared with 0.3876 in the control group. Therefore the control group
was both more costly and more effective in comparison with the intervention group,
although the difference in both costs and QALYs were not statistically significant. The
authors did not present the incremental cost-effectiveness ratio (ICER) for the control
group versus the intervention group but calculated that, at a UK cost-effectiveness thresh-
old range of between £20,000 to £30,000 per QALY, stepped care had a 98% probabil-
ity of being the most cost-effective option. The results from this study are directly
applicable to UK clinical practice and the primary outcome measure ensures compara-
bility across healthcare interventions. However, potential limitations include the small
sample size which limits the ability to detect statistically significant differences in costs
and outcomes, and the short time horizon of the study. In addition, no sensitivity analy-
ses were carried out to test the robustness of the cost-effectiveness results.
5.8.7 Health economics summary
Only one study was identified that considered the cost-effectiveness of a stepped-care
approach to the management of alcohol-use disorders (Drummond et al., 2009). The
initial results of this short-term pilot study suggest that stepped care may offer signif-
icant cost savings without any significant impact on health outcomes over 6 months.
However, the GDG expressed the opinion that the study described a stepped-care
model that was not of much relevance to the population that is the focus of this guide-
line. In addition, longer term trial based evidence is required to confirm the cost-
effectiveness of stepped care beyond 6 months.
5.9 CLINCIAL EVIDENCE SUMMARY
The five studies (three RCTs and two observational) reviewed for case management
indicate that when case management is compared with standard treatment it is signif-
icantly better in reducing lapse and days using alcohol. All other outcomes assessing
drinking frequency and measures of abstinence did not reach significance. The five
studies reviewed narratively to support the results of the meta-analysis all found
significant improvements in favour of case management on aftercare attendance,
those attending intake sessions and completion of treatment. Only one of these addi-
tional studies (Stout et al., 1999) reported a significant difference on any drinking
outcome, lapse and relapse in favour of case management. The overall quality of the
Organisation and delivery of care
111

evidence is moderate, therefore more studies would help increase confidence in the
estimate of the effect of case management.
One observational study assessing ACT methods versus standard care found that
ACT improved rates of completion and attendance in medically-assisted withdrawal
and aftercare programmes.
Four studies assessing stepped-care methods found that there may be a small
effect in favour of stepped care for hazardous drinkers. There were no significant
differences found on alcohol outcomes for more harmful and dependent drinkers,
which are the population covered by this guideline.
5.10 FROM EVIDENCE TO RECOMMENDATIONS
5.10.1 Case management
The GDG reviewed the evidence for the clinical efficacy of case management as an inter-
vention to promote abstinence and reduce alcohol consumption, as well as improving
client engagement, treatment adherence and use of aftercare services. Evidence from
randomised trials and observational studies indicates that when case management is
compared with standard treatment, case management had significant benefit over treat-
ment as usual for certain drinking-related outcomes (for example, lapse and
frequency/quantity of alcohol use), and outcomes evaluating engagement and completion
of treatment and aftercare. It must be noted, however, that the overall quality of the
evidence base was limited because the results of the meta-analysis had to be supported by
additional evidence that could not be included in meta-analyses. In terms of aftercare, the
components of aftercare and outcome measures vary widely across studies. There are
many ways of motivating a patient to engage in aftercare programmes and of structuring
an aftercare programme in an attempt to retain the patient. These include the use of incen-
tives, having help to access aftercare sessions, being prompted and contacted by an after-
care therapist, and having structured aftercare programmes. The GDG considered case
management to be an effective but relatively intensive intervention for people who misuse
alcohol. The GDG felt, therefore, that case management should be targeted at those with
moderate and severe dependence, and in particular those who have a history of difficulty
in engaging with services. The GDG were also aware that care coordination is part of
routine care (see the introduction to this chapter) in all specialist alcohol services, but
were concerned that if the focus of case management were only on the severely alcohol
dependent that, as a consequence, the coordination of care for harmful alcohol misuse and
those with mild alcohol dependence would be at risk of being neglected. This was a
particular concern, given the considerable number of agencies involved in the delivery of
alcohol misuse services. To address this issue, the GDG made a recommendation for the
delivery of care coordination for those with harmful alcohol misuse and mild dependence.
5.10.2 Assertive community treatment
Although assertive community interventions have been reviewed in another NICE
guideline under development for the treatment of individuals with a diagnosis of
Organisation and delivery of care
112

psychosis and a history of substance misuse (NICE, 2011a), the narrative review of
these studies in this guideline identified a very limited evidence base. In this review,
one trial assessing ACT versus standard care suggested that assertive methods may be
beneficial in improving rates of completion and attendance in medically-assisted
withdrawal and aftercare programmes. On the basis of this single trial, there is insuf-
ficient evidence to support any clinical recommendation. However, the GDG did
develop a research recommendation because it considered that the ACT might have
value in ensuring more effective care and treatment for severely alcohol dependent
people who have significant problems in engaging with services.
5.10.3 Stepped care
None of the studies reviewed directly addressed stepped care either as defined in the
guideline or for the populations covered by this guideline. The GDG therefore has no
recommendations that might suggest changes to or developments of the current, well-
established system for stepped care that structures the provision of alcohol misuse
services in the NHS and related services.
5.11 RECOMMENDATIONS
Care coordination and case management
5.11.1.1 Care coordination should be part of the routine care of all service users in
specialist alcohol services and should:
� be provided throughout the whole period of care, including aftercare
� be delivered by appropriately trained and competent staff working in
specialist alcohol services
� include the coordination of assessment, interventions and monitoring
of progress, and coordination with other agencies.
5.11.1.2 Consider case management to increase engagement in treatment for people
who have moderate to severe alcohol dependence and who are considered
at risk of dropping out of treatment or who have a previous history of poor
engagement. If case management is provided it should be throughout the
whole period of care, including aftercare.
5.11.1.3 Case management should be delivered in the context of Tier 3 interven-
tions
15
by staff who take responsibility for the overall coordination of care
and should include:
� a comprehensive assessment of needs
� development of an individualised care plan in collaboration with the
service user and relevant others (including families and carers and
other staff involved in the service user’s care)
Organisation and delivery of care
113
15
See Figure 4.

� coordination of the care plan to deliver a seamless multiagency and
integrated care pathway and maximisation of engagement, including
the use of motivational interviewing approaches
� monitoring of the impact of interventions and revision of the care plan
when necessary.
5.12 RESEARCH RECOMMENDATION
5.12.1.1 For which service users who are moderately and severely dependent on
alcohol is an assertive community treatment model a clinically- and cost-
effective intervention compared with standard care?
This question should be answered using a randomised controlled design in which
participants are stratified for severity and complexity of presenting problems. It should
report short- and medium-term outcomes (including cost-effectiveness outcomes) of at
least 18 months’ duration. Particular attention should be paid to the reproducibility of
the treatment model and training and supervision of those providing the intervention
to ensure that the results are robust and generalisable. The outcomes chosen should
reflect both observer and service user-rated assessments of improvement (including
personal and social functioning) and the acceptability of the intervention. The study
needs to be large enough to determine the presence or absence of clinically important
effects, and mediators and moderators of response should be investigated.
Why this is important
Many people, in particular those with severe problems and complex comorbidities, do
not benefit from treatment and/or lose contact with services. This leads to poor outcomes
and is wasteful of resources. Assertive community treatment models have been shown to
be effective in retaining people in treatment in those with serious mental illness who
misuse alcohol and drugs, but the evidence for an impact on outcomes is not proven. A
number of small pilot studies suggest that an assertive community approach can bring
benefit in both service retention and clinical outcomes in alcohol misuse. Given the high
morbidity and mortality associated with chronic severe alcohol dependence the results of
this study will have important implications for the structure and provision of alcohol
services in the NHS.
SECTION 3 – THE ASSESSMENT OF HARMFUL DRINKING
AND ALCOHOL DEPENDENCE
5.13 INTRODUCTION
The purpose of this section is to identify best practice in the diagnosis and assessment of
alcohol misuse across a range of clinical settings; NHS provided and funded services,
Organisation and delivery of care
114

including primary care and non-statutory alcohol services. Previous reviews of assess-
ment procedures (for example, Allen & Wilson, 2003; Raistrick et al., 2006) have
outlined the role of clinical interview procedures, identification questionnaires and inves-
tigations in developing an assessment of needs. To obtain a comprehensive overview of
the range and variety of assessment procedures, this chapter should be read in conjunc-
tion with the reviews and recommendations on identification and assessment contained
in two other NICE guidelines on alcohol misuse (NICE, 2010a and 2010b).
A key aim of the assessment process should be to elicit information regarding the
relevant characteristics of alcohol misuse as outlined in the current diagnostic systems
for alcohol-use disorders; that is, the ICD–10 (WHO, 1992) and the DSM–IV (APA,
1994). Although diagnosis is an important aspect of most assessments, the focus of
assessment should not only be on diagnosis and alcohol consumption but should also
consider physical, psychological and social functioning. The range and comprehensive-
ness of any assessment will vary depending on the setting in which it is undertaken and
the particular purpose of the assessment, but in all cases the central aim is to identify a
client’s need for treatment and care. The comprehensiveness of the assessment should
be linked to the intended outcomes (for example, onward referral of an individual or
offering treatment interventions). The range and depth of the components of assessment
should reflect the complexity of tasks to be addressed and the expertise required to carry
out the assessment. Crucial to the effective delivery of any assessment process is the
competence of the staff who are delivering it, including the ability to conduct an assess-
ment, interpret the findings of the assessment and use these finding to support the devel-
opment of appropriate care plans and, where necessary, risk management plans.
Current practice in the assessment of alcohol misuse is very varied across England
and Wales, including the range of assessments in specialist alcohol services
(MoCAM; Department of Health, 2006a). To some extent this reflects the different
aims and objectives of the services (including specialist alcohol services) in which
assessments are undertaken, but it also reflects the lack of clear guidance and subse-
quent agreement on what constitutes the most appropriate assessment methods for
particular settings (MoCAM; Department of Health, 2006a). Given the high preva-
lence of alcohol misuse and comorbidity with a wide range of other physical and
mental disorders, effective diagnosis and assessment can have major implications for
the nature of any treatment provided and the likely outcome of that treatment. In an
attempt to address some of these concerns the National Treatment Agency (NTA)
developed MoCAM, which outlined a four-tiered conceptual framework for treatment
and describes three levels of assessment that should be considered in different clini-
cal settings: a screening assessment, a triage assessment and a comprehensive assess-
ment. However, the extent to which this framework has led to improvements in the
nature and quality of assessments provided remains unclear (but it has been more
influential in determining the structure of services). The importance of MoCAM for
this chapter (and for the guideline in general) is that it provides a conceptual framework
in which to place the recommendations on assessment and which also link with the
recommendation on assessment in the other NICE guidelines on alcohol (NICE, 2010a
and 2010b). With this in mind, the GDG decided to develop a set of recommendations
for assessment that supported the development of clinical care pathways to promote
Organisation and delivery of care
115

access to effective care, where possible integrating with the existing service structure.
Where this is not possible, the GDG has developed recommendations which suggest
changes in existing service structures.
5.14 CLINICAL QUESTIONS
The clinical questions that the GDG addressed and from which the literature searches
were developed were:
a) What are the most effective (i) diagnostic and (ii) assessment tools for alcohol
dependence and harmful alcohol use?
b) What are the most effective ways of monitoring clinical progress in alcohol
dependence and harmful alcohol use?
c) To answer these questions, 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?
5.15 AIM OF REVIEW OF DIAGNOSTIC AND ASSESSMENT TOOLS
FOR ALCOHOL DEPENDENCE AND HARMFUL ALCOHOL USE
5.15.1 Introduction
This review aims to identify the most appropriate tools for assessing the presence of
alcohol dependence or harmful drinking, the severity of dependence, alcohol consump-
tion/frequency of use, motivation and readiness to change, alcohol withdrawal, and
alcohol-related problems in adults. (The issue of assessment in special populations is
dealt with in Sections 5.21 and 5.22.) The GDG were also tasked with identifying all
the potential components of a clinical assessment (and their respective places in the care
pathway) that would facilitate the most effective delivery of any assessment. This
section sets out the criteria for a quantitative analysis of the assessment tools included
in the review, and the subsequent synthesis of the characteristics and psychometric
properties of the tools. Please note, the GDG was not tasked with evaluating assessment
tools used for the screening of alcohol dependence and harmful alcohol use because this
is outside the scope of the guideline. See the NICE public health guideline (NICE,
2010a) for a review of screening tools.
5.15.2 Clinical review protocol
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Table 13.
Organisation and delivery of care
116

5.16 QUANTITATIVE REVIEW OF ASSESSMENT TOOLS
5.16.1 Aim of a quantitative review of assessment tools
The initial aim of this review was to assess the pooled diagnostic accuracy of the
assessment tools using meta-analytic receiver operating characteristic (ROC) curve
analyses. ROC analyses would therefore provide the pooled sensitivity and speci-
ficity of each assessment tool, and give an indication of positive predictive value and
negative predictive value. For a definition and explanation of these terms, see
Chapter 3.
Organisation and delivery of care
117
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane
Library Library
Date searched Systematic reviews from 1993 to March 2010. All other
searches from database inception to March 2010
Study design Systematic reviews; RCTs
Patient population Adults (over 18 years old)
At least 80% of the sample meet the criteria for alcohol
dependence or harmful alcohol use (clinical diagnosis
or drinking �30 drinks per week)
Assessment domains Dependence (and severity of dependence); consump-
tion/frequency; alcohol withdrawal; motivation and
readiness to change; physical, psychological and social
problems; clinical interview; physical examination;
blood, breath and urine testing
Outcomes Critical outcomes for quantitative review: sensitivity,
specificity, area under the curve, positive predictive
value, negative predictive value
For quantitative meta-analyses calculating the diagnos-
tic accuracy of an assessment tool, raw data (true posi-
tive, true negative, false positive, false negative) is
needed. See methods, Chapter 3, for a definition of
these terms
Table 13: Clinical review protocol for the evaluation of tools for assessing
alcohol dependence and harmful alcohol use

5.16.2 Evaluating assessment tools for use in a review to assess
diagnostic accuracy
The review team conducted a systematic review of studies that assessed the psycho-
metric properties of all alcohol-related assessment tools. From these, references
were excluded by reading the title and/or abstract. At this stage of the sifting process,
studies were excluded if they did not address the diagnostic accuracy of an assess-
ment tools and hence were not relevant for this section of the review. Further, the
focus of this review was on assessment and not screening or case identification
(latter issues are covered in the NICE guideline on preventing hazardous and harm-
ful drinking [NICE, 2010a]). Therefore, tools developed solely for those purposes
were excluded from the review. The remaining references were assessed for eligibil-
ity for use in meta-analyses on the basis of the full text using certain inclusion crite-
ria and papers excluded if they did not meet those criteria. The inclusion criteria
were as follows:
� The study meets basic guideline inclusion criteria (see Chapter 3).
� The population being assessed in the study reflects the scope of this guideline (see
Table 13).
� Extractable data is available to perform pooled sensitivity and specificity analyses
(see methods Chapter 3).
� The assessment tool is tested against a validated gold-standard diagnostic instru-
ment (for example, DSM–IV, ICD–10, CIDI) (APA, 1994; WHO, 1992).
5.16.3 Outcome of study search for quantitative review
Following the sifting process as outlined above, 33 studies assessing the diagnostic
accuracy of a wide range of assessment tools were identified for possible inclusion in
meta-analyses. Twenty-seven studies were excluded and could not be used for a
quantitative review. The main reason for this was that the population being assessed
were outside the scope of this guideline (for example, pregnant women, hazardous
drinkers, or less than 80% of the sample were alcohol dependent or harmful drinkers).
Studies were further excluded because they did not report sensitivity and specificity
data in an extractable format.
After all exclusion criteria were applied, there were only six studies remaining
which could have been used for a quantitative review. This number of studies was
insufficient to perform an unbiased and comprehensive diagnostic accuracy meta-
analyses of all the assessment tools identified in the review for alcohol misuse.
Although there were a wide range of tools initially identified for the meta-analyses,
most studies did not provide appropriate psychometric information and the majority
of studies reported the results of their own sensitivity and specificity analyses. As
outlined above, the actual number of participants identified as true positive, true nega-
tive, false positive, false negative (see Chapter 3 for definition) is needed to run
pooled sensitivity and specificity analyses.
Organisation and delivery of care
118

In view of the limitations of the data, it was decided by the GDG that a narrative
synthesis of assessment tools should be undertaken. Therefore, all papers were recon-
sidered for use in a narrative review.
5.17 NARRATIVE SYNTHESIS OF ASSESSMENT TOOLS
5.17.1 Aim of narrative synthesis
The main aim of the narrative synthesis was to identify tools that could inform clini-
cal decision-making and treatment planning in the following areas: the assessment of
alcohol dependence; the severity of alcohol dependence and the associated harms;
and motivation for change. This guideline did not aim to review assessment tools to
aid in the measurement of alcohol withdrawal because these tools have already been
reviewed in the accompanying NICE guideline on the management of alcohol-related
physical complications (NICE, 2010b), which recommends the use of the Clinical
Institute Withdrawal Assessment for Alcohol scale, revised, (CIWA-Ar) (Sullivan
et al., 1989). To facilitate understanding and use of the CIWA-Ar, its characteristics
can be seen in Table 14 and Table 15.
5.17.2 Evaluating assessment tools for use in a narrative synthesis
The inclusion and exclusion criteria of the initial sifting process were reapplied to the
available literature and involved identifying assessment tools that were applicable to
the population of interest in this guideline. The literature was evaluated for a number
of important study characteristics, and assessment tools/literature were excluded on
this basis. First, the patient population was required to meet inclusion criteria for
alcohol misuse, that is harmful or dependent drinkers. Further, the psychometric data
for the study was required to adequately distinguish between alcohol misuse and
substance misuse in an adult dual-diagnosed sample. The context in which the tool is
used was also evaluated, that is, to ascertain if the tool is used for opportunistic
screening in non-treatment seeking populations (see the NICE [2010a] guideline on
preventing hazardous and harmful drinking) or can be used for assessment of depend-
ence and outcome monitoring in a treatment-seeking population.
The second stage of the review was to identify tools for a narrative that could be
recommended for use in assessing alcohol misuse in a clinical setting. In the absence
of a formal quantitative review, the decision to include assessment tools in a narrative
synthesis was made using the three criteria outlined below. These criteria were devel-
oped and agreed by the GDG, and informed by the NIAAA guide for assessing alco-
hol misuse (Allen & Wilson, 2003).
Clinical utility
This criterion required the primary use of the assessment tool to be feasible and
implementable in a routine clinical care. The tool should contribute to the identifica-
tion of treatment needs and therefore be useful for treatment planning.
Organisation and delivery of care
119

Organisation and delivery of care
120
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Organisation and delivery of care
121

Psychometric data
Reported findings for sensitivity, specificity, area under the curve, positive predictive
value, negative predictive value, reliability and validity of the assessment tools were
considered. Although sensitivity and specificity are important outcomes in deciding
on the usefulness of an assessment tool, particularly for diagnostic purposes, for other
clinical purposes reliability and validity are also important. See Chapter 3 for a
description of diagnostic test accuracy terms. The tool should be applicable to a UK
population, for example by being validated in either a UK population or one that is
similar to the UK population.
Tool characteristics and administrative properties
The assessment tool should have well-validated cut-offs in the patient population of
interest. Furthermore, and dependent on the practitioner skill-set and the setting, tools
were evaluated for the time needed to administer and score them as well as the nature
of the training (if any) required for administration or scoring. Lastly, the cost of the
tool and copyright issues were also considered.
5.17.3 Outcome of the narrative synthesis
The studies initially identified were the result of the original quantitative review
search and sift. A total of 73 tools were identified and 34 were excluded from the
review, leaving 39 assessment questionnaires and clinical interview tools that were
considered for a narrative review.
The clinical interview tools identified did not form a part of the narrative review
of assessment questionnaires. Most (n = 5) were excluded as being not feasible for
routine use in a UK NHS setting (see criteria above).
The outcome of the initial sift and the exclusion criteria applied was discussed with
the GDG, and the preliminary list of 39 assessment tools were put forward for possible
inclusion in the narrative synthesis. Using the additional criteria (that is, clinical utility,
psychometric data and characteristics of the tool), this discussion resulted in a subset of
five questionnaires (excluding the CIWA-Ar) being included in the subsequent narrative
synthesis. Of these included assessment tools, three measure the domain of alcohol
dependence, one assesses alcohol-related problems and one assesses motivation. These
assessment tools are described below accordingly. Table 14 displays information
pertaining to the questionnaires which met criteria for a narrative review. Table 15 and
Table 16 provide information of the domain the tool assesses (for example, dependence,
problems and so on) and indicates if the tool is appropriate for the assessment of young
people or adults (see Section 5.22 for a review of the assessment of children and young
people). Additionally, Table 15 displays the characteristics of the assessment question-
naires included in the narrative review. This table gives more extensive information,
such as the scale and cut-offs, number of items, time to administer and score, whether
training is required for use, copyright/cost of the tool, and the source reference.
Table 16 identifies the questionnaires and clinical interview tools identified in the
original sift but excluded for the reasons outlined above.
Organisation and delivery of care
122

Organisation and delivery of care
123
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.
Organisation and delivery of care
125

In developing this review the GDG were mindful of the need for all assessments
and interventions to be carried out by competent individuals (for example,
Krishnamurthy et al., 2004; MoCAM; Department of Health, 2006a), and thus this
chapter should be read with this clear expectation in mind. It should also be noted that
the accuracy of the assessment of alcohol consumption from self-reported alcohol
consumption can be enhanced (Sobell & Sobell, 2003) by interviewing individuals
who are not intoxicated, giving written assurances of confidentiality, encouraging
openness and honesty, asking clearly-worded questions and providing memory aids
to recall drinking (such as drinking diaries).
5.18 THE ASSESSMENT OF ALCOHOL DEPENDENCE
From the initial review, and using the criteria outlined in Section 5.16.2, the GDG
identified three measures for inclusion in the narrative review of tools to measure
alcohol dependence. These were the AUDIT (Babor et al., 2001); the SADQ
(Stockwell et al., 1979); and the LDQ (Raistrick et al., 1994). Information on the
characteristics of these three questionnaires is summarised in Table 14 and Table 15.
5.18.1 Alcohol Use Disorders Inventory Test
The AUDIT questionnaire was developed by the WHO and designed to identify
people who have an alcohol-use disorder. Although the AUDIT was not primarily
developed as a measure of alcohol dependence, and indeed contains items from three
domains (alcohol consumption, alcohol dependence and alcohol-related problems), it
may have utility in assessment of alcohol dependence, particularly by staff who are
not working in specialist alcohol treatment services (for example, GPs and acute
hospital and mental healthcare staff). Unlike many of the other published assessment
questionnaires, previous literature assessing the psychometric properties of the
AUDIT is extensive. The AUDIT has ten items constructed across three domains:
consumption (items 1 to 3); dependence (items 4 to 6); and problems (items 7 to 10).
The development of the AUDIT revealed that a score of 16 or more represented high
levels of alcohol misuse. In a UK primary-care sample the AUDIT, with a cut off of
at least 8, using CIDI as the gold standard, was found to identify alcohol-dependent
patients with a sensitivity of 84% and specificity of 83% (Coulton et al., 2006). The
AUDIT has a maximum score of 40 with the following categories being defined: 1 to
7, low-risk drinking; 8 to 15, hazardous drinking; 16 to 19, harmful drinking; and 20
or more, possible alcohol dependence (Room et al., 2005). However, for cut-offs
higher than 8 (which could be used to identify harmful or dependent drinkers as
opposed to hazardous drinkers), the specificity remains much the same, but the sensi-
tivity of the AUDIT appears to reduce drastically. For example, at a cut-off score of 15,
sensitivity for DSM–III diagnosed ‘abuse’ or ‘dependence’ was 49% (Fleming et al.,
1991). Even at a much lower cut-off of 12 points, Barry and Fleming (1993) reported
a sensitivity of 21% (lifetime diagnosis) and 36% (current diagnosis). At a cut-off of
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11 points, Schmidt and colleagues (1995) reported a sensitivity of 11% for diagnosed
‘abuse’ or ‘dependence’.
The AUDIT has been found in a number of studies in various settings and popu-
lations to have high internal consistency (Barry & Fleming, 1993; Fleming et al.,
1991; Hays et al., 1995; Schmidt et al., 1995; Thomas & McCambridge, 2008).
However, data is not readily available on test–retest reliability except from a study in
a young adult population (mean age 20.3 years) in which the authors report high
test–retest reliability (Thomas & McCambridge, 2008).
The correlation between AUDIT score and severity of dependence has been inves-
tigated in a severely dependent sample of participants (n = 1134, 84.9%) scoring in
the higher range of AUDIT scores (20 to 40 points) (Donovan et al., 2006).
Correlation analyses results revealed that an AUDIT score of 8 to 15 was mostly
correlated with mild (53.3%) and moderate (41.7%) severity, a score of 16 to 19 was
mostly correlated with moderate (55.7%) and mild (37.1%) severity, and a score of
20 to 40 points was mostly correlated with moderate (55.7%) and severe (29.5%)
dependence. The authors conclude that AUDIT may therefore be applicable in a
clinical setting for assessing severity of alcohol dependence in a treatment-seeking
population.
The AUDIT score categories described relate to adults. Professional judgement as
to whether to revise scores downwards should be considered for; women (including
those who are or planning to become pregnant), young people (under 18 years),
people aged 65 years or over and those with significant mental health problems
(O’Hare et al., 2006).
The AUDIT is predominantly used for opportunistic screening purposes in non-
treatment seeking populations (for example, primary care). However, it has some
clinical utility because it can be used either as the basis for a brief intervention or
as a referral to specialist services. The AUDIT is routinely used for screening in
the UK and is freely available to download. Further, although it requires minimal
training for administration and scoring by trained personnel, it is quick and easy
to use. The AUDIT manual (Babor et al., 2001) states that clinical judgement
should be exercised when using the proposed cut-offs if other evidence presented
is contrary to the AUDIT score, especially for those who have a history of alcohol
dependence.
5.18.2 Severity of Alcohol Dependence Questionnaire
The SADQ was developed by Stockwell and colleagues (1979). It is a 20-item ques-
tionnaire with a maximum score of 60. Five elements of the alcohol dependence
syndrome (Edwards & Gross, 1976) examined are:
� Physical withdrawal (items 1 to 4)
� Affective withdrawal (items 5 to 8)
� Withdrawal relief drinking items (9 to 12)
� Alcohol consumption items (13 to 16)
� Rapidity of reinstatement items (17 to 20).
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Stockwell and colleagues (1983) reported that the SADQ (Stockwell et al., 1979
and 1983) has the following: high test–retest reliability (correlation coefficient ranged
from 0.55 to 0.82 across individual questions); good content, criterion and construct
validity; and is correlated with physician and self-reported ratings of withdrawal
severity, and the quantity of medication to be prescribed during alcohol withdrawal.
However, the SADQ questions assessing consumption and frequency of drinking did
not correlate with liver function and blood tests. This may be more an indication of
the limited sensitivity and specificity of the liver function tests than a reflection on the
performance of the SADQ (Coulton et al., 2006).
SADQ scores of at least 31 indicate severe alcohol dependence (Stockwell et al.,
1983), with higher scores predicting increased severity of alcohol withdrawal symp-
toms (Shaw et al., 1998; Stockwell et al., 1983). Severe dependence, because of the
risk of severe alcohol withdrawal symptoms, is often used as a clinical decision aid
in deciding on the need for inpatient assisted alcohol withdrawal programmes and an
inclusion criterion for inpatient care.
Severe alcohol dependence (SADQ score of at least 31) particularly in those with
comorbid problems or who lack social support (see below), may require inpatient
assisted withdrawal programme (Raistrick et al., 2006). The professional will need to
consider if the severity of alcohol dependence and associated alcohol withdrawal
symptoms identified before considering a prescribing strategy. Current clinical prac-
tice, in the experience of the GDG, suggests that those identified as scoring less than
15 on the SADQ usually do not require medication to assist alcohol withdrawal.
The SADQ identifies not just dependence but indicates the severity of dependence
and hence has utility in a clinical setting. It is routinely used in the UK and is freely
available to download or from the author. The SADQ takes very little time to admin-
ister and does not require training for administration or scoring.
5.18.3 Leeds Dependence Questionnaire
The LDQ (Raistrick et al., 1994) is a ten-item questionnaire that is based on a psycho-
logical understanding of dependence and has applicability to the measurement of
dependence for any substance. A score greater than 21 out of a possible 30 indicates
severe dependence. The LDQ has been reported to have acceptable concurrent valid-
ity when compared with other instruments such as the SADQ (R = 0.69, p �0.0001),
is independent of other possible covariates such as gender and age, was found in a
sample of patients attending the Leeds Addiction Unit to have high internal consis-
tency (Heather et al., 2001) (one factor accounted for 64.2% of the variance) and had
high test–retest reliability in a variety of populations (0.95) (Raistrick et al., 1994).
The LDQ has also been found to be sensitive to change over the course of treat-
ment in alcohol dependent adults (Tober et al., 2000); however, it appears to show a
ceiling effect and does not reflect those at the more severe end of dependence
(Heather et al., 2001). Ford (2003) evaluated the use of the LDQ in a psychiatric
population and reported excellent internal reliability and acceptable concurrent valid-
ity with clinical opinion. The authors conclude that the LDQ is a sensitive to the
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degree of substance dependence and applicable to a population with severe mental
health problems in an inpatient setting. The LDQ has also been found to have high
internal consistency in a ‘juvenile delinquent’ sample (Lennings, 1999).
In a young adult population (18 to 25 years old) undergoing residential treatment
for substance dependence, the LDQ was reported to have high internal consistency,
acceptable (but lower than expected) concurrent validity when compared with
DSM–IV dependence criteria and PDA (Kelly et al., 2010). Additionally, in a young
adult population (mean age 20.3 years), the LDQ had satisfactory test–retest reliabil-
ity and internal consistency (Thomas & McCambridge, 2008).
The LDQ is an applicable diagnostic measure of severity of alcohol dependence
and hence can be used for other purposes in a clinical setting, such as for setting
treatment goals and outcome monitoring. Further, it is brief and does not require
training for administration and scoring. It was developed and validated in the UK,
and is free to use.
5.19 THE ASSESSMENT OF PROBLEMS ASSOCIATED
WITH ALCOHOL MISUSE
5.19.1 Introduction
The causal relationship between alcohol consumption and alcohol-related problems
such as adverse social consequences, physical disease and injury is well established
(Drummond, 1990; Rehm et al., 2009). The extent to which problems are attributable
to alcohol means that those presenting for clinical interview may experience consid-
erable problems that are diagnostically important in helping to establish if the patient
is experiencing harmful alcohol use or alcohol dependence.
From the initial review, the GDG identified one measure for inclusion in the narra-
tive review of tools for measuring problems associated with alcohol misuse; this is the
APQ (Drummond, 1990). Several other questionnaires were identified that included
alcohol related problem items, but these were mixed with other conceptual content (for
example, dependence symptoms). Information on the characteristics of the APQ are
summarised in Table 14 and Table 15.
5.19.2 Alcohol Problems Questionnaire
The APQ (Drummond, 1990) was developed for use as a clinical instrument and
assesses problems associated with alcohol alone, independent of dependence. The
APQ is a 44-item questionnaire (maximum possible score of 44) which assesses eight
problem domains (friends, money, police, physical, affective, marital, children and
work). The first five domains make up 23 items that are common to all individuals.
The maximum score of 23 is derived from these items to arrive at a common score for
all individuals.
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In the original validation study of the APQ, Drummond (1990) reported that the
APQ common score (based on the common items) was significantly highly correlated
with total SADQ score (R = 0.63) and drinking quantity as indicated by the alcohol
consumption items of the SADQ (R = 0.53). Partial correlations, however, (which
control for each item included in the analyses) revealed that there was a highly signif-
icant relationship between alcohol-related problems and alcohol dependence that is
independent of the quantity of alcohol consumed (Drummond, 1990). Williams and
Drummond (1994) similarly reported a highly significant correlation between the
APQ common score and the SADQ (R = 0.51), and a significant partial correlation
between the APQ common score and SADQ (controlling for alcohol consumption)
(R = 0.37). However, when controlling for dependence, the partial correlation
between alcohol problems as measured by the APQ and alcohol consumption was
low, which suggests that dependence may mediate the relationship between these two
variables (Williams & Drummond, 1994). The results of these two studies indicate
that the APQ has high reliability and validity for assessing alcohol-related problems
in an alcohol-dependent population. The APQ is quick and easy to administer.
5.20 THE ASSESSMENT OF MOTIVATION
Self-awareness, with respect to the adverse consequences of drinking, levels of moti-
vation and readiness to change drinking behaviour, vary enormously across the
population presenting for alcohol treatment. The need to assess such issues is widely
accepted. For example, Raistrick and colleagues (2006) noted that ‘an understand-
ing of the service user’s motivation to change drinking behaviour is a key to effec-
tive treatment and can be used to decide on the specific treatment offered’. A number
of methods have been developed to aid the assessment of motivational status; these
are usually linked to the cycle of change developed by Prochaska and DiClemente
(1983) and are designed to site drinkers at specific stages within the cycle. The key
stages of change are pre-contemplation (seemingly unaware of any problem),
contemplation (aware and considering change), preparation (decision to change
taken, planning what to do), action (doing it) and maintenance (working to secure
the change).
From the initial review the GDG identified two related measures for possible
inclusion in the narrative synthesis of tools to measure motivation in people with alco-
hol misuse problems; these are the RCQ (Rollnick et al., 1992) and the RCQ-TV
(Heather et al., 1999). The original RCQ is for a harmful and hazardous non-treat-
ment seeking population and hence is not described in this narrative review.
5.20.1 Readiness to Change Questionnaire – treatment version
The RCQ-TV (Heather et al., 1999) was developed from the original RCQ for use
in a treatment-seeking alcohol misuse population. Both versions refer to drinking
reduction. However, the treatment version also refers to abstinence from drinking.
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The RCQ-TV has 15 items and three subscales (pre-contemplation, contemplation
and action). The items are scored from −2 (strongly disagree) to �2 (strongly agree),
with a maximum of �10 and minimum of −10.
Heather and colleagues (1999) found low item–total correlations for the pre-
contemplation, contemplation and action scale of the RCQ-TV. Internal consisten-
cies were low to moderate (Cronbach’s � ranged from 0.60 to 0.77 across subscales).
Test–retest reliability was adequate (R = 0.69 to 0.86 across subscales). With regard
to concurrent validity, those in the contemplation group reported drinking more than
those in the action group, had less desire to stop drinking and reported less confi-
dence in being able to stop drinking. The various subscales on the RCQ-TV corre-
lated significantly with their URICA equivalents (that is, pre-contemplation,
contemplation and action), although correlations were small in magnitude (for
example, R = 0.39 to 0.56).
Participants who had been in treatment for more than 6 months or who had had
any treatment were more likely to be in the action group than those treated for less
than 6 months or those who had had no treatment (x
2
= 8.75, p �0.005). Similarly,
those initially assigned to the action group were more likely than those in the contem-
plation group to have a good outcome at follow-up. This result remained when re-
classifying participants at follow-up.
Heather and Hönekopp (2008) examined the properties of the standard 15-item
version as well as a new 12-item version of the RCQ-TV in the UKATT sample of
participants. The authors reported that there was little difference between the two
versions. For example, the internal consistency of the 15-item version ranged from
� = 0.64 to 0.84 across subscales and for the 12-item version � = 0.66 to 0.85
across subscales. Both versions showed adequate consistency over time when
assessed at 3- and 12-month follow-up. Heather and Hönekopp (2008) also assessed
the construct validity of both versions of the RCQ-TV by analysing their correla-
tion with other important variables, namely PDA, DDD and alcohol problems
(using the APQ). Both versions showed a low correlation with these items at base-
line but high correlations at 3- and 12-month follow-up, indicating that the RCQ-
TV may have good predictive value. However, the shorter version was better able
to predict outcome (unsigned predictive value of 12-item version varied between
R = 0.19 to 0.43).
Because the RCQ-TV has seen specifically developed for a treatment-seeking
population, it has value for both treatment planning and monitoring. Furthermore, it
is short and requires no training for administration. Although it is copyrighted, it is
available at no cost by contacting the original developers. However, the RCQ-TV
adopts a very narrow focus on motivation and does not add much value to what could
be obtained from a well-structured clinical interview.
5.20.2 Evidence summary
The above narrative review identifies a number of tools used in the assessment of
several domains of alcohol misuse that met the criteria set out at the beginning of this
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section and which the GDG considered to be feasible and appropriate to use in an
NHS or related setting. They are:
� The Alcohol Use Disorders Inventory Test (AUDIT) – for case identification and
initial assessment of problem severity.
� The Severity of Alcohol Dependence Questionnaire (SADQ) – to assess the pres-
ence and severity of alcohol dependence.
� The Leeds Dependence Questionnaire (LDQ) – to assess the presence and sever-
ity of alcohol dependence.
� The Alcohol Problems Questionnaire (APQ) – to assess the nature and extent of
the problems associated with of alcohol misuse.
� The Readiness to Change Questionnaire – Treatment Version (RCQ-TV) – to
assess the motivation to change their drinking behaviour.
The assessment tools above can only be fully effective when they are used as part
of a structured clinical assessment, the nature and purpose of which is clear to both
staff and client. The nature and purpose of the assessment will vary according to what
prompts the assessment (for example, a request for help from a person who is
concerned that they are dependent on alcohol, or further inquiries following the diag-
nosis of liver disease which is suspected to be alcohol related).
The following section of the guideline aims to review the structures for the deliv-
ery of assessment services. The following review will then provide the context in
which the recommendations for assessment are developed.
5.21 SPECIAL POPULATIONS – OLDER PEOPLE
No assessment tools specifically developed for treatment-seeking older people who
misuse alcohol were identified. A number of assessment tools for screening in an
older population have been developed. However, screening tools are outside the scope
of this guideline. Please see the public health guideline (NICE, 2010a) for a review
of screening tools.
5.22 SPECIAL POPULATIONS – CHILDREN AND YOUNG PEOPLE
5.22.1 Introduction
A number of instruments that aid in the identification and diagnosis of alcohol misuse
in children and young people are available. In considering the development of the
assessment tools for children and young people, the GDG considered the framework
set out within the Models of Care for Alcohol Misusers (Department of Health,
2006a), but felt that the service structures for children and adolescent services, the
nature of the problems presented by children, and the need for an integrated treatment
approach with child and adolescent services meant that this service model needed
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significant modification. After consideration, the GDG decided to concentrate on two
key areas for assessment tools:
1) Case identification/diagnostic assessment
2) Comprehensive assessment.
The remainder of this review is therefore structured around these two areas. The
clinical questions set out below relate specifically to these two areas.
5.22.2 Clinical questions
The clinical questions which the GDG addressed, and from which the literature
searches were developed were:
a) What are the most effective (i) diagnostic and (ii) assessment tools for alcohol
dependence and harmful alcohol use in children and young people (aged 10 to 18
years)?
b) What are the most effective ways of monitoring clinical progress in alcohol depend-
ence and harmful alcohol use in children and young people (aged 10 to 18 years)?
5.22.3 Definition and aim of review of diagnostic and assessment tools for
alcohol dependence and harmful alcohol use
This section was developed in conjunction with the review of assessment tools, and
the structure and format for the delivery assessment of alcohol services for adults. The
strategy for identifying potential tools was the same as adopted for the adult review.
See Section 5.15.2 for databases searched and clinical review protocol, and procedure
for evaluating assessment tools for inclusion in diagnostic accuracy meta-analyses.
As was the case with the review of adult assessment tools, the original intention
was to conduct a quantitative review assessing the sensitivity, specificity and positive
predictive value of the instruments for case identification, diagnosis, assessment and
alcohol-related problems in children and young people. However, the search failed to
identify sufficient data to allow for a quantitative review. As a result, a narrative
synthesis of the tools was undertaken and the conclusions are presented below. The
identification and subsequent criteria necessary for inclusion in the narrative review
of assessment tools were that:
� the tool assesses primarily alcohol and not drugs
� the tool has either been developed for use in children and young people or has
been validated in this population
� the tool has established and satisfactory psychometric data (for example,
validity/reliability and sensitivity/specificity)
� the tool assesses a wide range of problem domains (for example, dependence,
quantity/frequency of alcohol consumed, alcohol-related problems and so on)
� the tool has favourable administrative properties (for example, copyright, cost,
time to administer and so on).
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5.22.4 Narrative synthesis of assessment tools for children and young people
Case identification/diagnosis
From the review of the literature, using the stipulated inclusion and exclusion criteria
and properties outlined above, the GDG identified three tools for case identification in
children and young people. These were the AAIS (Mayer & Filstead, 1979), the ADI
(Harrell & Wirtz, 1985) and AUDIT (Babor et al., 2001). Both the AAIS and ADI have
both been developed for use in an adolescent population. However, the AAIS has not
been adequately validated and the ADI, although claiming adequate reliability and
validity data, is not routinely used in the UK. As was the case in the review of adult
assessment tools, the AUDIT questionnaire was found to be the most appropriate and
suitable for use as a case identification/diagnostic instrument. For a review of the
psychometric properties and characteristics of the AUDIT, see Section 5.18.1. The
need for a revised cut-off in young people using the AUDIT questionnaire was evalu-
ated. Chung and colleagues (2000) recommended modification of the AUDIT so that
it is more appropriate to young people. Two studies using representative populations
suggest a cut off score of 4 or more (Chung et al., 2000; Santis et al., 2009).
Comprehensive assessment instruments
As part of the systematic review and associated search strategies, a number of clini-
cal interview tools which provide a comprehensive assessment of alcohol misuse in
children and young people specifically were identified. These are: the ADI (Winters
& Henly, 1993); the CASI-A (Meyers et al., 1995); the CDDR (Brown et al., 1998);
the Diagnostic Interview Schedule for Children (DISC; Piacentini et al., 1993); the
SCID SUDM (Martin et al., 1995a); the SUDDS-IV (Hoffman & Harrison, 1995);
and the Teen Addiction Severity Index (T-ASI; Kaminer et al., 1991). Based on the
criteria outlined above, the clinical interview tools that met inclusion criteria and are
included in this narrative review are the ADI, DISC and T-ASI (see Table 17 below
for characteristics of these tools). The GDG made a consensus-based decision to
exclude the CASI-A, CDDR, SCID SUDM and SUDDS-IV from the narrative review
because these tools have been developed for the use in an adolescent population over
the age of 16 years old only, and hence may be inappropriate for use with children
under that age. See Table 16 for characteristics of these excluded tools.
Adolescent Drinking Index
The ADI is a comprehensive assessment instrument which provides a DSM–III–R-
based psychiatric diagnosis of alcohol abuse or dependence in 12- to 18-year-olds. As
well as substance and alcohol ‘abuse’/‘dependence’, the ADI also assesses a variety
of other problems such as psychosocial stressors, cognitive impairment, and school
and interpersonal functioning. The ADI as a clinical instrument has been reported to
have good inter-rater reliability (alcohol ‘abuse’ = 0.86; alcohol ‘depend-
ence’ = 0.53), test–retest reliability (0.83), significant concurrent validity among all
variables (range = 0.58 to 0.75), adequate criterion validity assessed by agreement
with a clinician rating (alcohol ‘abuse’ k = 0.71; alcohol dependence k = 0.82), and
high sensitivity and specificity for alcohol ‘abuse’ (both 0.87) and dependence (0.90
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and 0.95, respectively) (Winters & Henly, 1989; Winters et al., 1993). The ADI takes
50 minutes to complete and can be obtained at a cost from the developer.
Diagnostic Interview Schedule for Children
The DISC provides a diagnosis of alcohol ‘dependence’ or ‘abuse’ based on DSM–IV
criteria. It has been found to be highly sensitive in identifying young people who have
previously been diagnosed as having a substance-use disorder (sensitivity = 75%)
(Fisher et al., 1993). However, although the DISC has been found to have acceptable
reliability and validity data, this has been for non-substance specific psychiatric disor-
ders (see Jensen et al., 1995; Piacentini et al., 1993; Schaffer et al., 1996; Schwab-
Stone et al., 1996). It is also relatively lengthy (1 to 2 hours), and copyrighted.
Teen Addiction Severity Index
The T-ASI is a semi-structured clinical interview designed to provide a reliable and
valid measure in the evaluation of substance misuse in adolescents. It has 126 items
that provide severity ratings for psychoactive substance use, school or employment
status, family function, peer-social relationships, legal status and psychiatric status.
The T-ASI has satisfactory inter-rater reliability (R = 0.78) and has been found to
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Assessment Number of items and format Time to administer and
instrument by whom
Training required for
administration; time to
score; by whom
Adolescent Diagnostic 213 items (not all asked), Approximately 50 minutes
Interview (ADI) structured interview (depends on number of
substances used), trained
personnel
Yes; 15 to 20 minutes; trained
personnel
Diagnostic Interview Variable depending on 1 to 2 hours; trained personnel
Schedule for Children module assessed, structured
(DISC) interview
Scoring algorithms are No; immediate; computer
provided by National Institute program
of Mental Health – DISC
Teen Addiction Severity 154 items (seven subscales), 20 to 45 minutes; trained
Index (T-ASI) structured interview personnel
Yes; 10 minutes; non-trained
personnel
Table 17: Characteristics of clinical interview tools for children and
adolescents included in the narrative review

have utility in both the clinical identification of alcohol dependence or harmful alco-
hol use, as well as in the assessment of changes of severity over time as a response to
treatment, and hence may be applicable as an outcome monitoring tool (Kaminer
et al., 1991). Kaminer and colleagues (1993) also established that the T-ASI could
adequately distinguish between 12- to 17-year-olds with and without substance-use
disorders as defined by the DSM–III-R. The T-ASI has an added benefit as it can be
administered in less than 30 minutes, it is free to use and not copyrighted.
No measures of alcohol problems, such as the APQ for adults, was identified and
nor was any specific instrument, such as the RCQ-TV for motivation, identified.
Use of biological markers
The review of adult alcohol misuse identified that no particular biological markers
were of value in achieving a diagnosis of harmful or dependent drinking. Given that
clinically significant changes in liver enzymes are rare in adults, even in those with
established alcohol dependence (Clark et al., 2001), it seems unlikely that the routine
use of such biological markers is of value in children and young people. However, the
use of urine analysis or breath testing to determine the presence during treatment
and/or assessment of drug or alcohol misuse may be of value in assessing the verac-
ity in the overall assessment, but should not be used as a diagnostic marker.
5.22.5 Evidence summary
The GDG identified that the AUDIT is appropriate for case identification of alcohol
misuse in children and young people, but with the proviso that the cut-offs are
adjusted downwards to a score of 4 or more. Also, modification of AUDIT items to
make them relevant to adolescents should be considered. The advantages identified
for adults (that it is brief, and easy to administer and score) remain the same.
The review of tools to aid a comprehensive assessment in children and young
people identified three possible tools – the ADI, the DISC and the T-ASI. The review
identified some problems with the DISC including population in which it was stan-
dardised, its duration and its cost. The other two instruments (the ADI and the T-ASI)
met the criteria chosen by the GDG and therefore both could be used as part of a
comprehensive assessment of alcohol misuse. However, although the T-ASI is free to
use, the ADI can only be obtained at a monetary cost. Furthermore, the T-ASI has util-
ity as an outcome monitoring tool and, although perhaps too long for routine use (30
minutes), it may have value as an outcome measure for periodic reviews. As with the
adult assessment, these tools should be used and interpreted by trained staff. The
comprehensive interview should not only assess the presence of an alcohol-use disor-
der, but also other comorbid and social problems, development needs, educational
and social progress, motivation and self-efficacy, and risk. A child/young person may
be competent to consent to a treatment; this depends on the age and capacity of the
child and assessment of competence. Where appropriate, consent should be obtained
from parents or those with parental responsibility. The aim of the assessment should
be, wherever possible, to set a treatment goal of abstinence.
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5.23 THE STRUCTURE AND CONTENT OF THE ASSESSMENT
INTERVIEW
5.23.1 Introduction
In developing this section of the chapter the GDG drew on publications on the struc-
turing and settings for the delivery of alcohol services (MoCAM; Department of
Health, 2006a) and also the two recent NICE guidelines on the treatment and manage-
ment of alcohol related problems (NICE, 2010a and 2010b). The NICE guidelines
were particularly important in setting the context for and limits of this review. A
number of authors have set out the aims and components of an assessment for alco-
hol misuse including Edwards and colleagues (2003), MoCAM (Department of
Health, 2006a) and Raistrick and colleagues (2006).
The following sections describe in some detail the key aspects of alcohol misuse. The
extent to which they are addressed in the description of the different assessment systems
that follow will vary according to the needs of the individual, the service in which the
assessment is delivered, the specific purpose of the assessment and the competence of the
staff undertaking the assessment. Nevertheless all staff undertaking an assessment of
alcohol misuse will need to be familiar with the issues described below.
5.23.2 Alcohol use and related consequences
For harmful alcohol use or alcohol dependence to be identified, three domains need
to be addressed: alcohol consumption, features of alcohol dependence and alcohol
problems (Allen, 2003; Edwards et al., 2003). It should be remembered that to arrive
at a diagnosis of harmful alcohol use, alcohol dependence needs to be excluded and
therefore dependence features need to be considered for all those undergoing diag-
nostic clinical interview (ICD–10; WHO, 1992). Baseline alcohol consumption and
severity of alcohol dependence have been identified as potentially significant predic-
tors of treatment outcome (Adamson et al., 2009).
Consumption
Harmful effects of alcohol use have been found to be influenced by both the amount
and pattern of alcohol consumption (Rehm et al., 2004). Assessing typical daily and
weekly alcohol consumption and comparing findings with recommended levels of
alcohol consumption is therefore a useful starting point.
Individuals may present at different stages of a drinking cycle, so it is important
to acknowledge that the absence of current alcohol use does not exclude the patient
from being diagnosed with an alcohol-use disorder (WHO, 1992). Therefore an
overview of the patient’s current drinking status, preferred type of alcohol/brand
consumed, the setting in which this occurs and general amount consumed is an impor-
tant part of a assessment (Edwards et al., 2003; MoCAM; Department of Health,
2006a). Usually the assessment of consumption and frequency relies on the evalua-
tion of self-reported alcohol consumption. Sobell and Sobell (2003) considered
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previous reviews of the validity and reliability of self-reported alcohol consumption
and found enhanced accuracy in individuals who were: (i) alcohol free when inter-
viewed; (ii) given written assurances of confidentiality; (iii) interviewed in a setting
that encourages openness and honesty; (iv) asked clearly worded questions; and (v)
provided with memory aids to recall drinking (that is, drink diaries), because those
interviewed with alcohol in their system tended to underestimate their consumption.
Previous reviews support the concept of enquiring about the patient’s typical drink-
ing day (Edwards et al., 2003; Rollnick et al., 1999). The notion of focusing on the
typical drinking day allows staff to concentrate on what may normally occur in the
absence of other factors that may influence large variations in alcohol consumption
(such as stress, finances and life events) and which may be misleading. Regular high-
level alcohol consumption may indicate tolerance to alcohol that has a significant
relationship to alcohol dependence and consequent alcohol withdrawal.
The evolution of the patient’s current alcohol consumption over time needs to be
considered in order to identify significant patterns of alcohol use that are diagnosti-
cally important. In a more detailed assessment, the concept of drinking milestones
may help to identify significant drinking-related instances from the time of first drink
through to present alcohol consumption patterns. Edwards and colleagues (2003)
suggests the inclusion of milestones such as age at first alcoholic drink, first drinking
most weekends, first drinking daily and when they commenced drinking at the current
levels. Additionally, it is important to document when the patient recognises the
following: when they first felt alcohol was a problem; the heaviest period of alcohol
consumption; and significant periods where they have experienced being alcohol free.
Seeking clarification with regard to typical quantities of alcohol consumed at signif-
icant milestones will help establish the development of potential alcohol misuse.
Dependence
People who are dependent on alcohol develop adjustments to alcohol being present or
absent in the body. Regular alcohol consumption can result in central nervous system
changes that adapt to and compensate for the depressant effects of alcohol on the body.
If this adaptation occurs, these changes may also result in the central nervous system
being hyper-excited when alcohol levels are reduced, presenting characteristic alcohol
withdrawal symptoms. Sensitive exploration of the six individual alcohol dependence
criteria will confirm a diagnosis and help the individual to understand and acknowl-
edge the condition that they are experiencing (Edwards et al., 2003). It is generally
accepted that a number of aspects of dependence should be covered in a comprehen-
sive assessment, including tolerance, neglecting activities and interests, compulsion,
physiological withdrawal and drinking despite problems (Maisto et al., 2003).
Tolerance
Regular alcohol drinkers become tolerant to the central nervous system effects of
alcohol (Kalant, 1996). There appears to be a number of individual factors that influ-
ence the development of tolerance to alcohol including metabolic, environmental and
learned factors (Tabakoff et al., 1986). There is no simple clinical tool to directly
measure alcohol tolerance. However, increasing consumption levels and a reduced
Organisation and delivery of care
138

effect of the same amount of alcohol over time are indicative of tolerance. The effect
of blood alcohol concentration on an individual will decrease as tolerance develops
(Hoffman & Tabakoff, 1996), but even in tolerant individuals high-level alcohol
consumption will still impair functioning and judgement. Nevertheless, people with
very high alcohol tolerance will be able to tolerate a high blood alcohol concentration
that would be fatal to a non-tolerant individual.
Alcohol withdrawal
Staff will need to understand and recognise the features of alcohol withdrawal to
accurately arrive at a diagnosis of alcohol dependence. Alcohol withdrawal symptoms
need to be differentiated from other clinical characteristics and conditions that may
present similarly.
Alcohol withdrawal symptoms include:
� Tremor
� Nausea
� Sweating
� Mood disturbance including agitation and anxiety
� Disturbed sleep pattern
� Hyperacusis – sensitivity to sound
� Hyperthermia – increased body temperature
� Tachycardia – increased pulse rate
� Increased respiratory rate
� Tactile and/or visual disturbances – itching, burning and so on.
Severe alcohol withdrawal symptoms include:
� Hallucinations – auditory, visual and/or tactile
� Alcohol withdrawal seizures – grand mal-type seizures
� DTs – coarse tremor, agitation, fever, tachycardia, profound confusion, delusions
and hallucinations.
People who are moderately or severely alcohol dependent will develop an acute
alcohol withdrawal syndrome when they abruptly stop or substantially reduce their
alcohol consumption. People who are mildly dependent may experience some milder
symptoms of alcohol withdrawal including sweating, nausea, and mild tremor but
generally do not require medical treatment. Withdrawal symptoms develop as early as
6 to 8 hours after abrupt reduction or cessation of alcohol intake.
Table 18 provides an illustration of alcohol withdrawal symptoms against a time-
line since last drink. The time from last drink to onset of withdrawal symptoms
reduces with increasing severity of dependence, such that people who are severely
alcohol dependent may begin to experience withdrawal within a few hours of the last
drink.
The individual may describe the use of alcohol to avoid or relieve the effects of
alcohol withdrawal, which would further demonstrate dependence to alcohol.
Compulsion
An individual’s compulsion to consume alcohol is commonly reported when an
alcohol-dependent drinker attempts to control or stop use. This has been described as
Organisation and delivery of care
139

urges or cravings (Drummond & Phillips, 2002). The intensity of craving is highly
correlated with the severity of dependence. Certain situations and emotional states
(cues) that influence the presence and intensity of alcohol craving, as these may be an
important factor in precipitating future drinking episodes (Drummond, 2000). Not
everyone who is alcohol dependent reports alcohol craving, and craving per se does
not inevitably lead to relapse. However, for some service users it can be an unpleas-
ant and troubling symptom.
Neglecting activities and interests
Individuals who are dependent on alcohol may describe a reduction or change in their
participation in activities they hold as important (Edwards & Gross, 1976). As alco-
hol becomes increasingly more salient to the drinker the need to obtain, consume
and/or recover from excessive alcohol consumption takes higher priority in their lives
relative to usual obligations and interests. Identifying the salience alcohol has for the
individual by exploring past and current interests with them is an important factor to
establish.
Drinking despite problems associated with alcohol
Alcohol-related problems can occur in the absence of alcohol dependence (that is,
accidents, legal problems and so on). However, a person who is dependent on alcohol
may maintain drinking behaviour despite experiencing harmful effects of alcohol
such as harm to the liver and depressed mood (Edwards & Gross, 1976). The individ-
ual may continue to drink despite criticisms from family, friends and work colleagues.
This can be difficult to establish because the individual may not make a connection
between their drinking and the consequences, or may be embarrassed about
discussing problems related to their drinking. Part of the process of the assessment is
to help the individual make these causal connections through motivational interview-
ing techniques.
Organisation and delivery of care
140
Timeline from last drink Alcohol withdrawal symptoms
Onset: 6 to 8 hours Generalised hyperactivity, tremor, sweating,
Peak: 10 to 30 hours nausea, retching, mood fluctuation,
Subsides: 40 to 50 hours tachycardia, increased respirations, hypertension and
mild pyrexia
Onset: 0 to 48 hours Withdrawal seizures
Onset: 12 hours Auditory and visual hallucinations may
Duration: 5 to 6 days develop that are characteristically frightening
Onset: 48 to 72 hours DTs: coarse tremor, agitation, fever, tachycardia,
profound confusion, delusions and hallucinations
Table 18: Timeline for the emergence of alcohol withdrawal symptoms

Other substances of misuse
The assessment of alcohol misuse is often complicated by the presence of co-occur-
ring conditions; these, along with the implications for assessment, are outlined below.
Comorbid opioid and alcohol dependence
In treatment services for opioid dependency, about a quarter to a third of patients will
have problems with alcohol (Department of Health, 2007). In addition, prognosis for this
group can be poor with many showing limited changes in drinking behaviour. A recent
systematic review about whether alcohol consumption is affected during the course of
methadone maintenance treatment concluded that alcohol use is not likely to reduce by
just entering such programmes, with most studies reporting no change (Srivastava et al.,
2008). In the UK National Treatment Outcome Research Study, 25% of people misusing
opiates were drinking heavily (more than 10 units per day) at the start of the study and 4
to 5 years later about a quarter were continuing to do so (Gossop et al., 2003).
Comorbid cocaine and alcohol dependence
Cocaine use is increasing in England (NHS Information Centre & National Statistics,
2009), and comorbid cocaine and alcohol dependence is commonly seen and can be
challenging to treat. There is little known in the UK about the level of this comorbid-
ity in alcohol treatment services. In the US Epidemiological Catchment Area study,
85% of cocaine-dependent patients were also alcohol dependent (Regier et al., 1990).
In a sample of 298 treatment-seeking cocaine users, 62% had a lifetime history of
alcohol dependence (Carroll et al., 1993). In a sample of people in contact with drug
treatment agencies (mainly for opiate addiction and in the community abusing
cocaine), heavy drinking was common. Those using cocaine powder were more likely
to drink heavily than those using crack cocaine (Gossop et al., 2006).
When taken together, cocaine and alcohol interact to produce cocaethylene, an
active metabolite with a half-life three times that of cocaine. In addition alcohol
inhibits some enzymes involved in cocaine metabolism, so can increase its concentra-
tion by about 30% (Pennings et al., 2002). Due to the presence of cocaethylene,
which has similar effects to cocaine and a longer half-life, this leads to enhanced
effects. For instance, taken together cocaine and alcohol result in greater euphoria and
increased heart rate compared with either drug alone (McCance-Katz et al., 1993; see
Pennings et al., 2002).
Comorbid alcohol and benzodiazepine dependence
Benzodiazepine use is more common in patients with alcohol misuse than in the
general population, with surveys reporting prevalence of around 10 to 20% (Ciraulo
et al., 1988; Busto et al., 1983). In more complex patients it can be as high as 40%,
which is similar to that seen in psychiatric patients. A proportion of alcohol misusers
who take benzodiazepines will be benzodiazepine dependent. For some individuals,
their growing dependence on benzodiazepines began when a prescription for with-
drawal from alcohol was extended and then repeatedly renewed. For others the
prescription may have been initiated as a treatment for anxiety or insomnia, but then
was not discontinued in line with current guidelines.
Organisation and delivery of care
141

Comorbid alcohol and nicotine dependence
Many patients with alcohol misuse smoke cigarettes, which leads to an extra burden
of morbidity and mortality in addition to the alcohol misuse. The prevalence of smok-
ing has been estimated at around 40% in population-based studies of alcohol-use
disorder and as much as 80% in people with alcohol dependence who are seeking
treatment (Grant et al., 2004b; Hughes, 1995). Comorbidity is higher in men than
women and in younger compared with older people (Falk et al., 2006). Comorbid
nicotine and alcohol dependence has been comprehensively reviewed recently by
Kalman and colleagues (2010).
Motivation and self-efficacy
The assessment of an individual’s willingness to engage in treatment can vary consid-
erably and has been the subject of considerable debate. Assessment can be effective
as an intervention in itself and has been shown to influence behaviour change
(McCambridge & Day, 2008), increasing an individual’s confidence towards change
that may prompt reductions in alcohol consumption (Rollnick et al., 1999). Being
sensitive to the individual’s needs, developing rapport and a therapeutic alliance have
all been identified as important aspects in the effective engagement of an individual
who drinks excessively (Najavits & Weiss, 1994; Raistrick et al., 2006; Edwards
et al., 2003). Indeed, there is evidence to suggest that a premature focus on informa-
tion gathering and completion of the assessment process may have a negative impact
on the engagement of the patient (Miller & Rollnick, 2002). Where this approach is
adopted, there is some evidence to suggest that initial low levels of motivation are not
necessarily a barrier to an effective assessment and the future uptake of treatment
(Miller & Rollnick, 2002).
An openness to discussion aimed at understanding a person’s reasons for seeking
help and the goals they wish to attain has also been positively associated with engage-
ment in assessment and treatment (Miller, 1996). The individual’s personal drinking
goals can then be acknowledged and used as a basis for negotiation once the assess-
ment is completed (Adamson et al., 2010).
Alcohol-related problems present in a number of different settings, often concur-
rently (for example, a person may present as depressed in primary care subsequent to
a brief admission for acute pancreatitis, both related to excessive alcohol intake).
Therefore, effective assessment systems need to be linked to equally effective
communication between those involved in the care and treatment of people with
alcohol-related problems (Maisto et al., 2003). Sharing of information between
agencies should be encouraged to maximise safety and effectiveness of treatment
(MoCAM; Department of Health, 2006a).
5.24 FRAMEWORK FOR ASSESSMENT OF ALCOHOL MISUSE
As noted above, the presentation of alcohol-related problems are rarely straightfor-
ward and can span a wide range of settings and organisations. This complexity of
presentation is often matched by a need for comprehensive assessment and treatment
Organisation and delivery of care
142

responses. It is therefore important that clear structures are in place to identify and
assess the presenting problems, to determine the most appropriate treatment option
and, where necessary, to make an appropriate referral. This section reviews the
evidence, albeit limited, for the organisation and delivery of assessment systems. In
doing so it not only draws on the evidence that relates directly to the organisation and
delivery of care (see Section 2 of this chapter) but also on the evidence reviewed in
the two other NICE guidelines on prevention and early detection of hazardous and
harmful drinking (NICE, 2010a) and on management of alcohol-related physical
complications (NICE, 2010b). This section also draws on other parts of this guideline
that consider evidence relevant to a framework for the assessment of alcohol misuse.
It should be noted that the framework of assessment in this guideline is not specifi-
cally concerned with the opportunistic screening for hazardous and harmful drinking
that is covered by the NICE (2010a) guideline on prevention and early detection.
However, it is important that the assessment framework considers both those who
seek treatment and those who do not respond to brief interventions.
In developing the framework for assessment, the evidence for the discussion of
stepped-care systems in Section 2 of this chapter was particularly influential. The
evidence review provided no convincing evidence to suggest a significant variation
for the stepped-care framework set out in Models of Care for Alcohol Misusers
(MoCAM; Department of Health, 2006a) developed by the National Treatment
Agency. Building on the framework in MoCAM, a conceptualisation for the assess-
ment (and management) of harmful drinking and alcohol dependence at four-levels
emerges
16
:
1. Case identification/diagnosis
2. Withdrawal assessment
3. Triage assessment
4. Comprehensive assessment.
These four levels, which are defined below, take account of the broad approach to
the delivery of assessment and interventions across different agencies and settings
including primary healthcare, third sector providers, criminal justice settings, acute
hospital settings and specialist alcohol service providers. It should be noted, however,
that this does not follow a strictly stepped-care model because an assessment for with-
drawal could follow from a triage and a comprehensive assessment. Withdrawal
assessment was not included in the MoCAM assessment framework as a separate
assessment algorithm, but was considered by the GDG to merit separate inclusion in
these guidelines. Alcohol withdrawal assessment is an area of clinical management
that often requires immediate intervention. This is particularly apparent where an
alcohol dependent individual may experience acute alcohol withdrawal as a conse-
quence of an admission to an acute hospital ward (NICE, 2010b) due to an acute
health problem, or has been recently committed to prison.
The framework for assessment (see Figure 4) sits alongside the four-tiered
conceptual framework described in MoCAM (Department of Health, 2006a) and
Organisation and delivery of care
143
16
The terms ‘levels’ and ‘tiers’ are adopted from MoCAM (Department of Health, 2006a) to facilitate ease
of understanding and implementation.

assumes that only appropriately skilled staff will undertake the assessment elements.
The Drug and Alcohol National Occupational Standards (DANOS) (Skills for Health,
2002, and Skills for Care
17
) set out the skills required to deliver assessment and inter-
ventions under the four-tiered framework. The different levels of assessment will
require varying degrees of competence, specialist skills and expertise to undertake the
more complex assessments.
5.25 THE FRAMEWORK FOR ASSESSMENT OF ALCOHOL MISUSE
5.25.1 Case identification and diagnosis
Aims
Case identification and, following on from that, diagnosis seek to identify individuals
who are in need of intensive care-planned treatment because of possible alcohol
dependence, those with harmful alcohol use who are in need of or have not responded
to brief interventions and those experiencing comorbid problems which may compli-
cate the treatment of the alcohol misuse. Given the overall stepped framework in
which the assessment takes place it is anticipated that this level of care would have
two main objectives:
a) To identify those individuals who need an intervention (see Chapters 6 and 7) for
harmful or alcohol dependence
b) To identify those who may need referral for a comprehensive assessment and/or
withdrawal assessment including those who:
– have not responded to an extended brief intervention
– have moderate to severe alcohol dependence or otherwise may need assisted
alcohol withdrawal
– those that show signs of clinically significant alcohol-related impairment (for
example, liver disease or significant alcohol-related mental health problems).
Organisation and delivery of care
144
Level 1:
Case identification/diagnosis
Trained and competent staff in all services
providing Tier 1 to 4 interventions
Level 2:
Withdrawal assessment
Trained and competent staff in all services
providing Tier 1 to 4 interventions
Level 3:
Triage assessment
Trained and competent staff in all services
providing Tier 2 to 4 interventions
Level 4:
Comprehensive assessment
Trained and competent staff in all services
providing Tier 3 to 4 interventions (and some
Tier 2 interventions)
Figure 4: Assessment levels
17
See www.skillsforcare.org.uk.

Settings
Case identification and diagnosis should be available across the whole range of
healthcare and related services (for example, GPs, accident and emergency
departments, children and families social services, and specialist alcohol treatment
agencies).
Method
This level of assessment should consider:
� establishing the probable presence of an alcohol-use disorder
� the level of alcohol consumption (as units
18
of alcohol per day or per week)
� where an alcohol-use disorder is suggested, distinguish harmful drinking from
alcohol dependence
� establishing the presence of risks (for example, self-harm, harm to others,
medical/mental health emergencies and safeguarding children)
� establishing the capacity to consent to treatment or onward referral
� experience and outcome of previous intervention(s)
� establishing the willingness to engage in further assessment and/or treatment
� establishing the presence of possible co-existing common problems features
(for example, additional substance misuse, medical, mental health and social
problems)
� determining the urgency of referral and/or an assessment for alcohol withdrawal.
The treatment options that follow immediately on from this initial assessment,
with the exception of assisted withdrawal, will focus on harmful or dependent drink-
ing. A significant number of individuals may already have received brief intervention
and not benefited from them; if this is the case then the individual will need to be
referred for a comprehensive assessment. See Figure 5 for an outline of the care path-
way for the case identification and possible diagnosis for adults.
5.25.2 Level 2: withdrawal assessment
Aims
Assessment of the need for a medically managed withdrawal, the potential risks (for
example, DTs or seizures) and the most appropriate setting in which to manage with-
drawal. A key factor will be determining whether the withdrawal management should
take place in a community, inpatient or residential setting. This section of the guide-
line should be read in conjunction with the section on planned assisted alcohol with-
drawal in this guideline and the reader should also refer to the guideline on the
management of unplanned acute withdrawal (NICE, 2010b). It should be noted that
assisted withdrawal from alcohol should not be seen as a standalone treatment for
Organisation and delivery of care
145
18
The UK unit definition differs from definitions of standard drinks in some other countries. For example,
a UK unit contains two thirds of the quantity of ethanol compared with a US ‘standard drink’.

Organisation and delivery of care
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alcohol dependence but rather as an often essential initial intervention within a
broader care plan including psychosocial or pharmacological therapies to prevent
relapse. Specifically, the withdrawal assessment should aim:
a) to identify those individuals who need an assisted withdrawal because of alcohol
dependence
b) to identify:
� the severity of the dependence
� the level of alcohol consumption
� the presence of comorbid factors such as substance misuse, severe psychiatric
disorders, significant physical illness or disability
� the availability of personal and social support and housing support
c) to identify in which setting a withdrawal can be most clinically- and cost-effectively
and safely managed
d) to determine the urgency with which the assisted withdrawal should be provided
e) to provide sufficient information to properly integrate the assisted withdrawal
programme into a wider care plan.
Settings
Withdrawal assessments take place in a number of healthcare settings; the manage-
ment of those presenting in a state of unplanned withdrawal in acute medical settings
is dealt with in NICE (2010b). However, although this guideline’s recommendations
are focused primarily on the management of planned withdrawal, a number of the
recommendation in this guideline will be relevant to the assessment of all individu-
als who are alcohol dependent and at risk of developing withdrawal symptoms.
Primary care, prisons, police custody, general hospitals, secondary care mental
health services, and specialist drug and alcohol services are all settings in which the
need for a withdrawal assessment may arise. These varied settings mean that the
nature of the assessment will vary depending on the resources and skills available in
those settings. However, as described in Section 4 of this chapter, there is evidence
that assisted withdrawal from alcohol can be safely and effectively delivered in all
of those settings provided that an assessment has been performed to determine the
most appropriate environment in which to undertake the withdrawal and the regimen
required (Maisto et al., 2003). The impact of comorbid conditions and their implica-
tions for the choice of withdrawal setting is described more fully in Section 4. A
number of reviews (for example, NICE, 2010b; Raistrick et al., 2006) highlight
factors that suggest the need for residential or inpatient withdrawal programmes.
These include: those who are at high risk
19
of developing alcohol withdrawal
seizures or DTs; those with a history of polydrug use; significant cognitive impair-
ment; the homeless; and those with an illness that requires medical/surgical or
psychiatric treatment.
19
There is a higher risk of developing DTs in people with a history of seizures or DTs and/or signs of auto-
nomic over-activity with a high blood alcohol concentration.
Organisation and delivery of care
147

Methods
Those who experience a significant degree of alcohol dependence will typically exhibit
alcohol withdrawal symptoms 6 to 8 hours after their last drink, with peak effect of
alcohol withdrawal symptoms occurring after between 10 to 30 hours (see guideline
on management of alcohol-related physical complications; NICE, 2010b). However
the onset of withdrawal varies with severity of dependence such that people who are
severely dependent will experience withdrawal earlier after stopping drinking than
those who are less dependent. Early diagnosis of alcohol dependence will help to initi-
ate proactive management strategies for the individual and reduce risks to the patient.
The NICE guideline on management of alcohol-related physical complications
(NICE, 2010b) reviewed the tools for the assessment and monitoring of patients who
are alcohol dependent and at risk of developing alcohol withdrawal. The guideline
recommends the use of a validated tool to support clinical judgement in the assess-
ment of alcohol withdrawal. Furthermore, the guideline recommended the use of an
assessment tool in situations particularly where staff are less experienced with the
assessment and management of alcohol withdrawal. The guideline identified the
CIWA-Ar as a valuable tool for measuring alcohol withdrawal symptoms. The guide-
line also noted that a delay in assessment and treatment of withdrawal of more than
24 hours is associated with greater withdrawal complications.
After establishing the possibility of alcohol misuse it is important to establish first
whether or not dependence is present; in all settings this is a two stage process. The
first stage involves the identification of those at risk of dependence and withdrawal.
The preferred aid to a clinical assessment is the AUDIT questionnaire. An AUDIT
score greater than 20 is an indication of likely alcohol dependence and the need for
withdrawal assessment (Babor et al., 2001). If it is not possible to complete an
AUDIT questionnaire then regular consumption of alcohol of 15 to 20 or greater units
per day suggests likely dependence. Although there is no absolute level of daily or
weekly alcohol consumption which indicates the likelihood of alcohol dependence,
the SADQ score (a measure of the severity of dependence – see above) correlates with
high-level alcohol consumption (Stockwell et al., 1979). Others support the view that
typical drinks per drinking day is a useful indicator of the severity of alcohol depend-
ence and need for alcohol withdrawal management (Shaw et al., 1998). There are a
number of methods to establish alcohol quantity and frequency including direct
patient report, drinking diaries and retrospective recording systems (Sobell & Sobell,
2003), although previous reviews have identified that such techniques vary in accu-
racy (Raistrick et al., 2006). However it should be noted that both AUDIT scores and
typical drinks per day should be adjusted for gender (Reinert & Allen, 2007), age
(both for older adults [Beullens & Aertgeerts, 2004] and adolescents [McArdle,
2008]) and people with established liver disease (Gleeson et al., 2009).
The second stage involves an assessment of the severity of alcohol dependence.
Again, a formal assessment tool is the preferred means to identify the severity of
dependence in this guideline. The review of such tools for this guideline revealed that
the SADQ (Stockwell et al., 1979 and 1983) has broad clinical utility because it iden-
tifies the presence and severity of alcohol dependence, predicts withdrawal severity
Organisation and delivery of care
148

and acts as a useful guide for the quantity of medication to be prescribed during alco-
hol withdrawal.
5.25.3 Withdrawal assessment in children and young people
As has already been noted, the diagnosis and identification of withdrawal symptoms
in children and young people is difficult. This means that the potential for harm
through under-identification of alcohol withdrawal on young people is considerable.
Unfortunately, there is little direct evidence to guide the process of withdrawal
management, including both its identification and treatment in young people. In the
development of this section the GDG drew extensively on the review of assisted with-
drawal for adults, contained both in the NICE guideline for acute withdrawal (NICE,
2010b) and for planned withdrawal within this guideline. In essence, the data used to
support much of this review is an extrapolation from a data set developed from the
management of withdrawal in adults. The principle that the GDG approached this
data with is one of considerable caution and a desire to, as far as possible, reduce any
significant harm arising from withdrawal symptoms in young people.
Identification of need for assisted alcohol withdrawal
Identification of withdrawal should be based on careful assessment of the pattern,
frequency and intensity of drinking. The limited data available for review, the
evidence from adults and the greater vulnerability of young people to the harmful
effects of alcohol led the GDG to conclude that there should be a significant reduc-
tion in the threshold for young people for initiating withdrawal management. The
threshold that has been established for adults of an AUDIT score of more than 20, an
SADQ score of more than 20 or the typical consumption of 15 units per day is not
appropriate for adolescents. In adolescents, binge drinking is common (defined as
more than five units of alcohol on any one occasion) and a pattern of frequent binge
drinking (for example, a pattern of two or more episodes of binge drinking in a
month) or an AUDIT score of 15 should alert the clinician to possible dependence and
trigger a comprehensive assessment. The presence of any potential withdrawal symp-
toms should be taken seriously and a comprehensive assessment initiated. A range of
factors including age, weight, previous history of alcohol misuse and the presence of
co-occurring disorders will also influence the threshold for initiating a comprehensive
assessment and withdrawal management. See Figure 6 for a summary of the care
pathway for withdrawal assessment.
5.25.4 Level 3: brief triage assessment
Aims
A brief triage assessment should be undertaken when an individual first contacts a
specialist alcohol service, and it has the aim of developing an initial plan of care
(MoCAM; Department of Health, 2006a). Failure to identify clinical and/or social
Organisation and delivery of care
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Organisation and delivery of care
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priorities may result in an individual being directed to inappropriate services or lost
to any form of care. Typically, people presenting for a triage assessment may be harm-
ful drinkers who have not benefitted from an extended brief intervention (see NICE,
2010a) and/or those with an AUDIT score of more than 20, or have been referred to
or have self-referred to a specialist alcohol services.
A brief triage assessment is not simply a brief assessment of alcohol misuse only.
The focus is equally on the management risk, identification of urgent clinical or social
problems to be addressed and accessing the most appropriate pathways of care for
alcohol misuse. The triage assessment therefore incorporates the common elements
of assessment identified above with the aim of establishing the severity of the indi-
vidual’s problems, the urgency to action required and referral to the most appropriate
treatment interventions and service provider.
Specifically the triage assessment should establish:
� the need for emergency or acute interventions, for example referral to accident
and emergency for an acute medical problem or to a crisis team for a mental health
emergency
� presence and degree of risk of harm to the person or others (including children)
due to alcohol or substance misuse and related problems (medical, mental health,
social and criminal)
� the appropriate alcohol treatment intervention(s) and setting(s) for the problems
assessed
� an appropriate level of communication and liaison with all those involved in the
direct care and management of the individual
� the need for a further comprehensive specialist assessment (see Section 5.25.5 below)
� the need to agree follow-up plans.
Settings
All specialist alcohol services (including those that provide combined drug and alco-
hol services) should operate a triage assessment according to agreed local procedures.
This level of assessment is not intended to be a full assessment of an individual’s
needs on which to base a care plan. The triage assessment should identify immediate
plans of care through the use of standardised procedures to ensure that all clinically
significant information and risk factors are captured in one assessment. Incorporating
tools and questionnaires as an adjunct to the clinical interview will help improve
consistency of decision making.
Methods
The triage assessment should include:
� alcohol use history including:
– typical drinking; setting, brand, and regularity
– alcohol consumption using units of alcohol consumed on a typical drinking day
– features of alcohol dependence
– alcohol-related problems
– adjunctive assessment tools (including the AUDIT and SADQ) to inform the
assessment of risk and the immediate and future clinical management plan
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151

� co-occurring problems (medical, mental health, substance misuse, social and
criminal)
� risk assessment
� readiness and motivation to change.
Risk assessment
The increasing importance of risk assessment in the clinical decision-making
process has led to a number of tools being developed to systematically screen for
high-risk problems and behaviours which draw on a common framework for risk
assessment systems in mental health (Department of Health, 2006a). In the NHS, it
is expected that local protocols are agreed that specify the elements and tools for
risk assessment to be applied (MoCAM; Department of Health, 2006a).
Establishing these protocols and standards will also identify the competencies
required for the collation and interpretation of risk to develop a risk management
plan.
The risk assessment process should review all aspects of the information collected
during the clinical interview and, where appropriate, consider results from investiga-
tions, questionnaire items, correspondence and records, and liaison with other profes-
sionals as well as family and carers, to formulate an assessment of risks to the
individual, to others and to the wider community. The risk assessment should
consider the interaction between comorbid features to arrive at an informed opinion
of the severity of risk and the urgency to act.
MoCAM (Department of Health, 2006a) identifies that risk assessment should
consider the following domains:
� risks associated with alcohol use or other substance misuse (such as physical
damage or alcohol poisoning)
� risk of self-harm or suicide
� risk of harm to others (including risk of harm to children and other domestic
violence, harm to treatment staff and risk of driving while intoxicated)
� risk of harm from others (including being a victim of domestic abuse)
� risk of self-neglect
� safeguarding-children procedures (must be included).
Where risks are identified, a risk management plan that considers monitoring
arrangements, contingency plans and information sharing procedures needs to be
developed and implemented (MoCAM; Department of Health, 2006a). Guidance
developed for those working with patients with mental health problems indicates that
the most effective risk assessments and risk management plans are developed by
multidisciplinary teams and in collaboration between health and social care agencies
(Department of Health, 2007).
Urgency to act
The urgency to act will be linked to the severity and level of risks identified from all
the information gathered and should consider:
� The individual’s intentions to carry out acts of self-harm or harm to others
� The state of distress being experienced by the individual
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� The severity of comorbid medical or mental health conditions and the sudden
deterioration of the individual’s presentation
� The safeguarding needs of children/young people.
5.25.5 Level 4: comprehensive assessment
Aims
A comprehensive assessment should be undertaken where an individual experiences
significant comorbidity, moderate or severe alcohol dependence or presents a high
level of risk to themself or others. This group will often require structured and/or
intensive interventions and is often involved with multiple agencies. Those present-
ing with complex problems will require their care to be planned and co-ordinated.
The comprehensive assessment aims:
� to determine the exact nature of problems experienced by the individual across
multiple domains
� to specify needs to inform development of a care plan
� to identify planned outcomes to be achieved and methods to assess these outcomes
Settings
Comprehensive assessment is undertaken by specialist alcohol services that provide
Tier 3 and 4 interventions, although some Tier 2 services with sufficiently experienced
staff may also offer comprehensive assessments as outlined by MoCAM (Department
of Health, 2006a).
Methods
Comprehensive assessment should not be seen as a single event conducted by one
member of the multidisciplinary team, although coordination of the assessment
process may bring real benefit (see Section 5.3 for a review of care coordination and
case management). The complex nature of the problems experienced by an individual
with long-standing alcohol misuse or dependence suggests that the comprehensive
assessment may need to be spread across a number of appointments and may typically
involve more than one member of the multidisciplinary team. A range of expertise will
often be necessary to assess the nature of problems. Comprehensive assessment may
require specific professional groups to undertake tasks such as physical examination,
prescribing needs, social care needs, psychiatric assessment and a formal assessment
of cognitive functioning. Specialist alcohol services conducting comprehensive assess-
ments therefore need to have access to: GPs and specialist physicians, addiction
psychiatrists, nurses, psychologists and specialist social workers.
The comprehensive assessment should include an in-depth consideration and
assessment of the following domains:
� alcohol use and related consequences
– alcohol consumption
– alcohol dependence
– alcohol-related problems
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� motivation
� self-efficacy
� co-occurring problems
– substance misuse
– physical health history and problems
– mental health history and problems
– social functioning and problems
� risk assessment
� treatment goals
� assessment of the service user’s capacity to consent to treatment
� formulation a plan of care and risk management plan.
5.25.6 Methods of physical investigation
Breath/blood alcohol level
Alcohol is excreted in the breath and its concentration in the breath is correlated with
blood alcohol concentration. On average it takes approximately 1 hour to eliminate
one unit of alcohol from the body; however, the elimination rate varies between indi-
viduals and is more rapid in people who are alcohol dependent than those who are not
(Allen et al., 2003; Ugarte et al., 1977). Breath alcometers reliably measure the breath
alcohol concentration in a non-invasive way. Blood/breath alcohol concentration may
be a useful part of the clinical assessment in the following areas:
� Although self report has been found to be a reliable indicator of levels of alcohol
consumption in treatment-seeking populations, patients with alcohol in their
system at the time of assessment are more likely to underestimate their levels of
alcohol consumption (Sobell & Sobell, 2003).
� Clinicians have a responsibility to discuss drink-driving concerns with patients
and their responsibilities in reporting this to the Driver and Vehicle Licensing
Agency (DVLA, 2010). Service users who have driven on the way to an assess-
ment and who are over the legal limit for driving (80 mg/100 ml) need to be
advised not to drive until they are legally able to do so.
Blood investigations
There are a number of biomarkers suggested to be clinically useful in the assessment
of alcohol-related physical harm (Allen et al., 2003), monitoring of clinical outcome
and as a motivational enhancement strategy (Miller et al., 1992). However, in people
who are seeking treatment for alcohol misuse, biomarkers do not offer any advantage
over self-report measures in terms of accuracy of assessing alcohol consumption
(Allen et al., 2003; Sobell & Sobell, 2003), and are less sensitive and specific than the
AUDIT in screening for alcohol misuse (Drummond & Ghodse, 1999).
Gamma-glutamyl transferase (GGT) has a sensitivity of 50 to 70% in the detec-
tion of high levels of alcohol consumption in the last 1 to 2 months and a specificity
of 75 to 85% (Drummond & Ghodse, 1999). Reasons for false positive results include
Organisation and delivery of care
154

hepatitis, cirrhosis, cholestatic jaundice, metastatic carcinoma, treatment with
simvastatin and obesity.
Mean corpuscular volume has a sensitivity of 25 to 52% and specificity of 85 to
95% in the detection of alcohol misuse. It remains elevated for 1 to 3 months after
abstinence. Reasons for false positives include vitamin B12 and folate deficiency,
pernicious anaemia, pregnancy and phenytoin (Allen et al., 2003; Drummond &
Ghodse, 1999).
Carbohydrate-deficient transferrin (CDT) has greater specificity (80 to 98%) than
other biomarkers for heavy alcohol consumption, and there are few causes of false
positive results (severe liver disease, chronic active hepatitis) (Schwan et al., 2004).
However, routine CDT monitoring is not routinely available and there remains some
debate about how best to measure it. Evidence suggests that the test is less sensitive
in women (Anton & Moak, 1994). CDT increases and recovers more rapidly than
GGT in response to a drinking binge, increasing within 1 week of onset of heavy
drinking, and recovery typically occurs in 1 to 3 weeks compared with 1 to 2 months
for GGT (Drummond & Ghodse, 1999).
Advantages of blood investigations as part of the initial assessment include:
� screening for alcohol-related physical conditions that may need further investiga-
tion and onward referral
� providing baseline measures of alcohol-related damage (in some patients) against
which to measure improvement and act as motivational enhancement strategy
� objective measurement of outcome, particularly when combined (for example,
CDT and GGT; Allen et al., 2003) and in conjunction with other structured
outcome measures (Drummond et al., 2007).
Hair and sweat analysis
As alcohol is rapidly excreted from the body, there is currently no reliable or accurate
way of measuring alcohol consumption in the recent past and the mainstay of
outcome measurement is self-report (Sobell & Sobell, 2003). This is less useful for
regulatory monitoring purposes and so there is a growing interest by manufacturers
in the design of biomarkers for recent alcohol consumption. Studies to date focus on
hair and skin sweat analysis, but there is currently a lack of evidence to recommend
their use in routine clinical care (Pragst & Balikova, 2006).
Assessment of alcohol-related physical harm
The assessment of alcohol-related physical harm is an important component of a
specialist service (Edwards et al., 2003). The aims of such an assessment are to:
� identify physical health problems that require immediate attention and onward
referral to appropriate acute medical care
� identify physical health problems that are a consequence of the alcohol misuse
and require monitoring, and potential future referral
The relationship between alcohol-related physical health problems and level of
alcohol consumption is complex (Morgan & Ritson, 2009), as is the presence of phys-
ical signs in relation to underlying pathology. Consequently, patients presenting with
Organisation and delivery of care
155

longstanding, severe alcohol dependence may have few overt physical signs, but have
significant underlying organ damage (for example, liver disease). Others may present
with significant symptoms (for example, gastritis) or signs (for example, hyperten-
sion) that may resolve without active treatment once the service user abstains.
Liver/gastrointestinal problems
Alcohol-related liver disease often develops ‘silently’ over a 10 to 15 year period and
blood tests of liver function (alanine amino transferase [ALT]) may only become
abnormal at quite advanced stages of disease, so a test that is within the normal range
does not exclude liver damage (Prati et al., 2002). Equally, raised ALT may be the
result of induction of liver enzymes by alcohol rather than an indication of liver
pathology (Drummond & Ghodse, 1999). Other laboratory test results including GGT
and serum aspartate amino transferase (AST) may be raised in people who misuse
alcohol, but do not necessarily indicate the presence of significant organ damage as a
result of enzyme induction (Bagrel et al., 1979). Patients with signs of severe (decom-
pensated) liver disease (for example, presenting with jaundice, fluid retention, spon-
taneous bruising or hepatic encephalopathy) will need urgent specialist medical care
from a hepatology service. Symptoms of anorexia, nausea, vomiting and diarrhoea,
and malabsorption syndromes are common in people who misuse alcohol. In many
cases these symptoms resolve with treatment of the underlying alcohol misuse, but
people with significant pain or evidence of gastrointestinal blood loss will need refer-
ral for further investigation.
Cardiovascular
Alcohol has a dose-related effect on blood pressure in addition to blood pressure
being elevated during alcohol withdrawal (Xin et al., 2001). Patients who present
with hypertension or who are already prescribed anti-hypertensive medication will
need to have this reviewed as treatment progresses.
Neurological
Wernicke’s encephalopathy classically presents with a triad of symptoms (ataxia,
confusion and ophthalmoplegia), but in practice this triad only occurs in a minority
of cases (Thomson & Marshall, 2006). Given the severity of brain damage
(Wernicke–Korsakoff syndrome [WKS]) that may occur if the condition is
untreated, clinicians need to have a high index of suspicion particularly in those
patients who are malnourished and have any of the following clinical signs: ataxia,
ophthalmoplegia, nystagmus, acute confusional state, or (more rarely) hypotension
or hypothermia. Patients presumed to have a diagnosis of WE will need immediate
treatment or onward referral (NICE, 2010b).
Symptoms of peripheral neuropathy are common (30 to 70%) in people who
misuse alcohol (Monteforte et al., 1995). The symptoms are predominantly sensory
(although muscle weakness is also seen) and include numbness, pain and hyperaes-
thesia in a ‘glove and stocking’ distribution, primarily in the legs. Symptoms should
be monitored and will require referral if they do not improve with alcohol
abstinence.
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156

5.25.7 Mental health: comorbidity and cognitive functioning
Alcohol is strongly associated with a wide range of mental health problems, particu-
larly depression, anxiety and self-harm (Weaver et al., 2003). In addition, many
patients have deficits in cognitive function that may not be identified without system-
atic investigation (Evert & Oscar-Berman, 1995). The presence of psychological
distress and/or comorbid psychiatric diagnoses, particularly if undetected, may have
a substantial impact on treatment engagement and progress, leading to suboptimal
treatment outcomes (Weaver et al., 2003).
There are significant challenges in the assessment and diagnosis of mental health
comorbidity. Some symptoms may be the direct result of excessive alcohol consumption
or withdrawal and these tend to reduce once abstinence has been achieved (Brown et al.,
1995). The same symptoms may, however, also be the result of a comorbidity that
requires parallel treatment, but the presence of which may also worsen the alcohol
misuse. Finally, there are comorbid conditions (for example, social anxiety and some
forms of cognitive impairment) that are not apparent whilst the person is drinking, but
which emerge following abstinence and may have an impact on retention in treatment.
Depression and anxiety
Although many symptoms of depression or anxiety may be directly attributable to
alcohol misuse, many people still reach the threshold for a diagnosis of a psychiatric
disorder. For instance, 85% of patients in UK alcohol treatment services had one or
more comorbid psychiatric disorders including 81% with affective and/or anxiety
disorders (34% severe depression; 47% mild depression; 32% anxiety) and 53% had
a personality disorder (Weaver et al., 2003). Such high levels of comorbidity are not
surprising given that the underlying neurobiology of depression or anxiety and alco-
holism have many similarities, particularly during withdrawal (Markou & Koob,
1991). In addition there are shared risk factors because twin studies reveal that the
presence of one disorder increases the risk of the other disorder (Davis et al., 2008).
There is a high prevalence of comorbidity between anxiety and alcohol misuse,
both in the general and clinical populations. Anxiety disorders and alcohol depend-
ence demonstrate a reciprocal causal relationship over time, with anxiety disorders
leading to alcohol dependence and vice versa (Kushner et al., 1990). Panic disorder
and generalised anxiety disorder can emerge during periods of alcohol misuse;
however, the association with obsessive-compulsive disorder is less robust.
Social phobia and agoraphobia often predate the onset of alcohol misuse. The
prevalence of social anxiety ranges from 8 to 56% in people who misuse alcohol,
which makes it the most prevalent psychiatric comorbidity. People who are alcohol
dependent and have comorbid social anxiety disorder show significantly more symp-
toms of alcohol dependence, higher levels of reported depression, and greater prob-
lems and deficits in social support networks as compared with alcohol dependent
patients without social anxiety (Thevos et al., 1999).
The relationship between alcohol and depression is also reciprocal in that depres-
sion can increase consumption, but depression can also be caused or worsened by
alcohol misuse (Merikangas et al., 1996).
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157

Sleep disorders
Sleep disorders (commonly insomnia) increase the risk of alcohol misuse and also
contribute to relapse (Brower, 2003; Krystal et al., 2008). Whilst many people believe
that alcohol helps them sleep, this is not the case. Although onset of sleep may be
reduced after drinking alcohol, disruption to sleep patterns occur later in the night
such as rapid eye-movement rebound and increased dreaming, as well as sympathetic
arousal (Krystal et al., 2008). Abstinence may reveal a sleep disorder that the person
has not been entirely aware of because they have always used alcohol to sleep.
Insomnia is also a prominent feature of both acute and protracted alcohol withdrawal
syndromes, the latter of which can last for 3 to 12 months.
Eating disorders
There is substantial evidence that alcohol misuse and eating disorders commonly co-
occur (Sinha & O’Malley, 2000). In specialist alcohol inpatient treatment, the preva-
lence of eating disorders can be as high as 40%. Commonly, an eating disorder exists
together with other psychiatric disorders such as depression. In people with an eating
disorder, up to half have been reported to misuse alcohol (Dansky et al., 2000). A
number of studies have found the strongest relationship for bulimia nervosa, followed
by patients suffering from binge eating disorder and eating disorder not otherwise
specified (EDNOS) (Gadalla & Piran, 2007). No association has been reported
between anorexia nervosa and alcohol misuse. In a study of European specialist
eating-disorder services, alcohol consumption was higher in patients with EDNOS
and bulimia nervosa than anorexia nervosa, but a greater lifetime prevalence of alco-
hol misuse was not found (Krug et al., 2009).
Psychosis
Patients with psychotic disorders (including schizophrenia and bipolar disorder) are
vulnerable to the effects of alcohol and at increased risk of alcohol misuse (Weaver
et al., 2003). Approximately 50% of patients requiring inpatient psychiatric treatment
for these disorders will also misuse alcohol (Barnaby et al., 2003; Sinclair et al.,
2008). However, a smaller proportion of patients will present without a diagnosis of
an underlying psychotic or mood disorder, which will need to be identified as part of
a comprehensive assessment. For a more thorough review of this area see the NICE
guideline on psychosis and substance misuse (NICE, 2011a).
Self-harm and suicide
There is a significant but complex association between alcohol misuse and self-harm
and suicide. Approximately 50% of all patients presenting to hospital following an
episode of self-harm have consumed alcohol immediately before or as part of the act
of self-harm (Hawton et al., 2007). The mortality by suicide in patients who present
following an episode of self-harm is significantly increased in the next 12 months (66
times that of the general population) (Zahl & Hawton, 2004) and this risk remains
high after many years (Owens et al., 2002). However, recent data from a long-term
follow-up study suggests that the mortality of self-harm patients appears to be caused
by alcohol-related conditions as much as suicide (Sinclair et al., 2009). For people
Organisation and delivery of care
158

whose self-harm occurs only when intoxicated, abstinence from alcohol was recog-
nised as the effective intervention (Sinclair & Green, 2005). Alcohol dependence has
been shown to increase the risk of suicide by five to 17 times, with the RR being
greatest in women (Wilcox et al., 2004).
Cognitive impairment
Prolonged cognitive deficits are seen in 50 to 80% of people with alcohol dependence
who have undergone assisted alcohol withdrawal (Bates et al., 2002). Cognitive
impairments frequently improve significantly once abstinence has been achieved and
so should be reassessed after 2 to 3 weeks of abstinence (Loeber et al., 2009).
A number of assessment tools can be used to assess cognitive function in people
who misuse alcohol have been identified. These include the Mini-Mental State
Examination (MMSE; Folstein et al., 1975); the Cognitive Capacity Screening
Examination (CCSE; Jacobs et al., 1977); the Neuropsychological Impairment Scale
(NIS; O’Donnell & Reynolds, 1983); and the Cognitive Laterality Battery (CLB;
Gordon, 1986).
The MMSE (Folstein et al., 1975) is a cognitive screening instrument widely used
in clinical practice and has been established as a valid and reliable test of cognitive
function (Folstein et al., 1975). It measures orientation, registration, short-term
memory, attention and calculation, and language. A score of 17 or less is considered
to be severe cognitive impairment, 18 to 24 to be mild to moderate impairment and
25 to 30 to be normal or borderline impairment. It has the advantage of being brief,
requiring little training in administration and interpretation, free to use, and is
designed to assess specific facets of cognitive function (Small et al., 1997). The
MMSE has been found to have high sensitivity for detecting moderate to severe
cognitive impairment as well as satisfactory reliability and validity (see Nelson and
colleagues [1986] for a review). The MMSE can be utilised as a brief screening tool
as well as for assessing changes in cognitive function over time (Brayne et al., 1997).
It must be noted, however, that the MMSE has been found to be sensitive to educa-
tional level in populations where educational levels are low (Escobar et al., 1986; Liu
et al., 1994). Therefore, the cut-offs used to identify cognitive impairment may need
to be adjusted for people who misuse alcohol with few years of formal education
(Crum et al., 1993; Cummings, 1993). Furthermore, the MMSE has been criticised
for not being sensitive enough for those in various cultures where the education levels
are low and participants may fail to respond correctly to specific items (Escobar et al.,
1986; Iype et al., 2006; Katzman et al., 1988; Liu et al., 1994). Because of this, it is
necessary (and often practised) to amend and adjust aspects of the MMSE to increase
applicability to a particular cultural setting. For example, a Hindi version of the
MMSE, the Hindi Mental State Examination (Ganguli et al., 1995) was designed to
address some of the cultural problems with the MMSE and to make it more applica-
ble to an Indian cultural setting.
Most research evaluating the accuracy, reliability and validity of the MMSE has
been in the assessment of age-related cognitive impairment and dementia, whereas
research in the field of alcohol and substance misuse is limited. However, the MMSE
has been utilised in substance-misuse research (Smith et al., 2006). Additionally, it
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has been highlighted that the MMSE mainly assesses verbal cognitive function and is
limited in assessing non-dominant hemisphere skills and executive functions (Bak &
Mioshi, 2007). This could lead to frontal-dysexecutive and visuospatial symptoms
going undetected.
The CCSE (Jacobs et al., 1977) was designed to screen for diffuse organic mental
syndromes. The CCSE has 30 items that provide information on the areas of orienta-
tion, digit span, concentration, serial sevens, repetition, verbal concept formulation
and short-term verbal memory. A score of less than 19 has been suggested as indica-
tive of organic dysfunction (Haddad & Coffman, 1987; Hershey et al., 1987; Jacobs
et al., 1977). As with most cognitive screening instruments, the CCSE has been stud-
ied extensively in people with dementia (Nelson et al., 1986). It has been found to
have adequate reliability and validity in detecting cognitive impairment (Foreman,
1987; Villardita & Lomeo, 1992). However, the CCSE has been found to be sensitive
to age and education (Luxenberg & Feigenbaum, 1986; Omer et al., 1983) and has
been found to have a high false-negative rate and hence low sensitivity (Nelson et al.,
1986; Schwamm et al., 1987). Furthermore, Gillen and colleagues (1991) and
Anderson and Parker (1997) reported that the CCSE did not adequately distinguish
between cognitively impaired and non-impaired people who misuse substances.
The NIS is a 50-item scale that has been designed to identify brain damage. The
reliability and validity of the NIS has been previously reported in normal and
neuropsychiatric populations (O’Donnell et al., 1984a and 1984b), as well as having
a sensitivity of between 68 and 91% and a specificity of between 43 and 86%
(O’Donnell et al., 1984b). Errico and colleagues (1990) further reported predictive
validity, and test–retest reliability in a sample of people undergoing assisted alcohol
withdrawal.
The CLB was developed to measure visuospatial and verbosequential functioning,
with tests administered on a sound/sync projector, and takes 80 minutes for administra-
tion. However, the CLB has been reported to have limited clinical utility in the assess-
ment of cognitive function in an alcohol-dependent population (Errico et al., 1991).
Addenbrooke’s Cognitive Evaluation (ACE; Mathuranath et al., 2000) was devel-
oped as a brief test of key aspects of cognition which expanded on the MMSE by
assessing memory, language and visuospatial abilities in greater depth, as well as
including assessment of verbal fluency. ACE is designed to be sensitive to the early
stages of dementia (Mioshi et al., 2006) and was found to detect dementia earlier and
discriminate more between different subtypes of dementia than the MMSE
(Mathuranath, 2000). To comprehensively assess cognitive impairment, ACE can be
used in a cognitive test battery along with tests which assess other cognitive domains
(Lezak, 1995; Spreen & Strauss, 1998), such as the Trail-Making Test, Part B (Army
Individual Test Battery, 1944) or the Block Design subtest of the revised Wechsler
Adult Intelligence Scale (Wechsler, 1981). Mioshi and colleagues (2006) developed a
revised version of the test, ACE-R, which addressed previously-identified weaknesses
in the original test and made it easier to administer. Bak and colleagues (2007) found
that ACE-R has a good specificity for the detection of dementia (94%) with a speci-
ficity of 89% (at a cut-off score of 88/100). The ACE-R is administered as a bedside
test, takes approximately 16 minutes to complete and consists of five sections each
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designed to assess a specific cognitive domain (Mioshi et al., 2006). Although the
ACE-R takes longer to administer than some other tests for cognitive impairment, such
as the MMSE, it has been found to have a high level of patient acceptability and can
be administered without specialist training (Larner, 2007). The ACE and ACE-R tests
are published in 19 languages, although no evidence was found regarding the effect of
cultural or educational differences on testing outcomes.
The ACE has been used in screening for cognitive dysfunction in people who
misuse alcohol (Gilchrist & Morrison, 2004), although no research in this field using
ACE-R could be identified. Additionally, research into the efficacy and sensitivity of
ACE-R in assessing substance induced cognitive impairment is negligible. It has been
suggested, however, that it is possible to extrapolate the validity of the ACE as an
instrument to assess age-related cognitive impairment and apply it in assessing cogni-
tive impairment in people who misuse alcohol. The increased sensitivity of ACE in
relation to the MMSE may mean that it is subtle enough to identify people who
misuse alcohol that have mild cognitive impairment who are able to function success-
fully in the community but have a history of non-engagement with alcohol services
(personal communication, Ken Wilson, October, 2010).
Childhood abuse
A history of physical and/or sexual abuse is common in patients seeking treatment for
alcohol misuse, particularly women (Moncrieff et al., 1996). Patients identified with
childhood trauma who wish for further intervention should be referred to appropriate
services once they have reached a degree of stability in terms of their alcohol use
(guideline on PTSD; NCCMH, 2005).
Family and relationships
Relationships with partners, parents, children and significant others are often affected
by alcohol misuse (Copello et al., 2005). Families and carers also suffer significantly
in their own right, with an increased incidence of mental disorder (Dawson et al.,
2007). Involvement of partners or family can help identify the needs of the help seek-
ing individual. The prevalence of alcohol misuse in the victims and perpetrators of
domestic violence provides an important rationale for the exploration of these issues.
Employment
The status of the individual’s occupation is significant in terms of the individual’s
ability to remain economically active. Past employment history may indicate the indi-
vidual’s capacity to obtain and retain employment. Employment history might
provide insights into factors that maintain the individuals drinking status that need to
be explored. Those assessing employed individuals will need to consider potential
risks to the person, colleagues and the public because of excessive drinking (for
example, when the individual has responsibility for the safety of others).
Criminality and offending
Assessment of criminality and offending behaviour should encompass a number of
factors including the presence and onset of criminal activity, the severity of offending
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behaviour, the relationship between offending and alcohol consumption and/or alcohol
withdrawal, and the presence of violence and aggressive behaviour, and hence risk
to others. Liaison with criminal justice services is necessary to ensure that appropriate
co-ordination of care, and effective communication and information-sharing protocols,
are in place.
Fitness to drive
For people who misuse alcohol and continue to drive a motor vehicle, clinical staff
have a duty to advise the individual that it is the duty of the license holder or license
applicant to notify the DVLA of any medical condition that may affect safe driving.
There are circumstances in which the license holder cannot or will not notify the
DVLA. Clinicians will need to consult the national medical guidelines of fitness to
drive in these circumstances (DVLA, 2010).
5.25.8 Goals for drinking behaviour
The information collated from the comprehensive assessment will identify the type
and severity of the alcohol misuse experienced, and the presence and significance of
comorbid problems. This information should be considered alongside the individual’s
preferred drinking goals as basis for a negotiated care plan with drinking goals spec-
ified. Previous reviews and studies (Adamson et al., 2010; Heather et al., 2010;
Raistrick et al., 2006) have identified that:
� Individuals seeking abstinence from alcohol should be supported in their aim
regardless of their severity of problems.
� Individuals with comorbid problems for which continued drinking is clearly
contraindicated should be strongly advised that abstinence should be considered.
� Individuals who seek non-abstinence goals (that is, moderation or controlled
drinking) usually experience less severe problems and should be supported.
However, where a practitioner identifies that abstinence should be promoted but
the individual seeks non-abstinence as a goal, a negotiated approach should be
supported where abstinence is considered if moderation goals prove unsuccessful.
� If the individual is uncertain as to which goal to pursue, further motivational inter-
ventions should be considered to arrive at a consensus approach.
� Treatment goals need to be regularly reviewed and changed where indicated. Staff
should adopt a flexible approach to goal setting that recognises the above param-
eters.
5.25.9 Formulating a care plan and risk management plan
The intention of any assessment whether triage, withdrawal or comprehensive is to
arrive at a care plan that takes into account the individual’s views and preferences, and
those of their family and carer’s where indicated, as well as any safeguarding issues.
The development of a care plan needs to address the presenting alcohol misuse and
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consider the impact of treatment on existing problems (MoCAM; Department of
Health, 2006a). It should take account of the presence, severity and complexity of
problem areas that in turn will influence the choice of treatment interventions,
medications and/or settings that are offered.
The care plan should be developed in negotiation with the individual (National
Treatment Agency for Substance Misuse, 2006). The care plan may include short-,
intermediate- and long-term objectives in addition to any contingency planning
needed where risk increases. Care plans need to be shared with those also involved in
providing care to the individual as planned treatment interventions and medications
may have significant interactions with existing or planned care for other problems or
conditions.
5.25.10 Outcome monitoring
Outcome monitoring is important in assessing how treatment for alcohol misuse is
progressing. The main aim of outcome evaluation should be to assess whether there
has been a change in the targeted behaviour following treatment. Outcome monitor-
ing aids in deciding whether treatment should be continued or if further evaluation
and a change of the care plan is needed. There are three important areas of outcome
monitoring: deciding what outcome to measure; how to measure outcomes (the
appropriate tools); and when to measure outcomes. Routine outcome monitoring
(including feedback to staff and patients) has been shown to be effective in improv-
ing outcomes (Lambert et al., 2002). Routine session-by-session measurement
provides a more accurate assessment of overall patient outcomes (Clark et al., 2009).
What outcome should be measured?
Assessment of alcohol consumption (for example, intensity and frequency of drink-
ing) is a basic component of outcome monitoring. For example, Emrick (1974) states
that monitoring abstinence post-treatment is a significant predictor of psychosocial
functioning. Alcohol-related problems or harm have also been suggested to be impor-
tant in outcome monitoring. Longabaugh and colleagues (1994) state that outcome
measurement should contain a range of assessment domains and include life function-
ing (such as physical health and social functioning). Alcohol problems are the only
assessment domain significantly associated with drinking outcome measures (PDA,
DDD, first drink) (Project MATCH Research Group, 1997 and 1998). This suggests
that alcohol-related problem outcome measures should be assessed in addition to
alcohol consumption.
How should outcome be measured?
When selecting a suitable tool for outcome monitoring there are a number of factors
that need to be considered, as suggested in a review of by Raistrick and colleagues
(2006). An outcome monitoring tool should be:
� universal and not constrained by any particular substance or social group
� have proven validity and reliability, and have published psychometric properties
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� sensitive to change
� easily readable and in a neutral language
� either practitioner-completed, self completed, or a combination of both
� appropriate for the clinical population.
The outcome measure that is applicable to all tiers of services is assessing the
level of alcohol consumption by interviewing the patient about their quantity and
frequency of alcohol consumption, but the use of a formal measure will improve the
reliability and validity of measurement (Sobell et al., 1979). The most valid and reli-
able measures of alcohol consumption include a diary method to obtain drinking data
(Sobell & Sobell, 2003). However, measures such as the Timeline Followback ques-
tionnaire (Sobell & Sobell, 2003) are more feasible to administer in the research
setting rather than a routine clinical setting. Some clinical services in the UK use
prospective weekly drinking diaries that are self-completed by service users, but their
reliability and validity is unknown.
A number of assessment tools have been designed specifically for outcome meas-
urement in addiction treatment. They all measure multiple domains of functioning,
but their comprehensiveness, utility and specificity to alcohol treatment vary. The
most widely used tools for outcome measurement are the Addiction Severity Index
(ASI), AUDIT, the Maudsley Addiction Profile (MAP), the Christo Inventory for
Substance Misuse Services (CISS), the Comprehensive Drinker Profile (CDP), the
Routine Evaluation of the Substance-Use Ladder of Treatments (RESULT) and the
Treatment Outcomes Profile (TOP). The GDG evaluated the clinical utility of these
tools in alcohol treatment on the extent to which each tool has sufficient validity and
reliability data in an alcohol dependent population and if the tool has high usability
(that is, it is easy to read and understand, it does not require extensive training for use
and it is brief). Table 19 describes the characteristics of the outcome measurement
tools identified.
The GDG excluded the ASI because it was excluded in the earlier review of
primary outcome tools and also is too lengthy for use as an outcome monitoring tool.
The CISS, CDP, MAP and RESULT were also excluded because they have not been
adequately validated in an alcohol-dependent clinical sample in the UK. Lastly, the
TOP is primarily used in a drug misusing population with only limited psychometric
data for alcohol-dependent clinical samples. The protocol for reporting TOP states
explicitly that ‘the reporting of the TOP for adult primary alcohol users is not
required’ (National Treatment Agency for Substance Misuse, 2010) and therefore the
TOP is not being applied in routine practice.
Based on these criteria, a GDG consensus-based decision was made that the
AUDIT has the greatest utility as a routine outcome monitoring tool to evaluate
drinking-related outcomes. The AUDIT questionnaire is already widely used. It
contains several relevant drinking domains in addition to alcohol consumption (prob-
lems and dependence). The time taken to complete the AUDIT (less than 2 minutes)
also lends itself to use in routine practice. The AUDIT-C (Bush et al., 1998) is a three-
item version of the AUDIT which measures only alcohol consumption; that is,
frequency of drinking, quantity consumed on a typical occasion and the frequency of
heavy episodic drinking (six or more standard drinks on a single occasion). Bush and
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colleagues (1998) reported that the AUDIT-C performed better than the full AUDIT
in detecting heavy drinking and was just as effective as the full AUDIT in identifying
active alcohol misuse or dependence. The study also found that using a cut-off of 3
out of a possible 12 points, the AUDIT-C correctly identified 90% of active alcohol
‘abuse’/‘dependence’ and 98% of patients drinking heavily. However, other studies
have reported that a cut-off of 5 or more for men and 4 or more for women results in
the optimal sensitivity and specificity for detecting any alcohol-use disorders
(Dawson et al., 2005b; Gual et al., 2002). In addition, the AUDIT-C has been found
to be equally effective in detecting alcohol-use disorders across ethnic groups (Frank
et al., 2008). However, it should be noted that the AUDIT-C has been reported to have
a high false positive rate when used as a screening tool (Nordqvist et al., 2004).
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Outcome Is there adequate Does the tool have Source study
monitoring tool psychometric data high usability (for
in primarily alcohol example, readable,
dependent short time to
population? administer, limited
training required)?
Addiction Severity Yes (but validity No – requires a McLellan and
Index (ASI) and reliability are trained interviewer colleagues (1980)
questionable) and takes 50 to
60 minutes
Alcohol Use Yes – extensive data Yes – takes 2 minutes Babor and
Disorders that supports validity colleagues (2001)
Identification Test and reliability
(AUDIT)
Maudsley Addiction No Yes – takes 20 minutes Marsden and
Profile (MAP) colleagues (1998)
Christo Inventory for No Yes – takes Christo and
Substance Misuse 10 minutes colleagues (2000)
Services (CISS)
Comprehensive No No – requires a Miller and Marlatt
Drinker Profile trained interviewer (1987)
(CDP) and takes 2 hours
Routine Evaluation No Yes – takes Raistrick and Tober
of the Substance- 30 minutes (2003)
Use Ladder of
Treatments
(RESULT)
Treatment Outcomes No – primarily in Yes – one page, Marsden and
Profile (TOP) drug misuse 20 items colleagues (2007)
population
Table 19: Characteristics of routine outcome monitoring tool

Nevertheless, the ease of use and the already established relationship between
frequency/quantity of drinking and alcohol misuse/dependence give the AUDIT-C
credence for the use of outcome monitoring.
The APQ has been widely used in alcohol treatment outcome studies as a meas-
ure of alcohol-related problems in the UK (for example, Drummond, 1990;
Drummond et al., 2009; UKATT Research Team, 2005). Furthermore, it is quick and
easy to administer. Therefore, the APQ can be used to measure alcohol-related prob-
lems in conjunction with a drinking-related outcome tool such as the AUDIT-C.
However, the ten-item AUDIT still has the advantage of measuring a wider range of
domains in one simple validated questionnaire and therefore more readily lends itself
to routine clinical outcome monitoring.
When should outcome be measured?
Most changes in drinking behaviour and the largest reduction in severity of drinking
occurs in the first 3 months of treatment (Babor et al., 2003; Weisner et al., 2003).
Initial benefits in drinking-related outcomes may be more apparent at 3 months, but
other non-drinking domains such as social functioning and global health may need
longer to show improvements following treatment. Because there is a high attrition
rate in many alcohol services this can result in poor response rates in routine outcome
monitoring. This underlines the importance of routine session-by-session measure-
ment and the utility of a brief measure such as the AUDIT or a prospective weekly
drinking diary. The latter requires considerable cooperation of service users and is of
unknown reliability and validity.
5.25.11 Special populations
A framework for assessment for children and young people with alcohol problems
As with the adult assessment, the use of any assessment tool needs to be set in
context. The context here is that all children who are beyond initial identification
should be offered an assessment within specialist CAMHS. Although recommenda-
tions are made below for the use of specific measures to assess the nature and extent
of the alcohol misuse and related problems, it was also the view of the GDG that the
assessment should take place in the context of a comprehensive overall assessment of
the mental health, educational, and social care needs of the children and young
people, in line with current best practice (Department for Education and Skills, 2007).
In common with good assessment practice in CAMHS services, the involvement of
parents, carers and others (for example, schools) is an essential part of any assess-
ment. It should also be noted that parents not only have a key role as informants, advi-
sors and participants in the process of assessment, but they also have a key role to play
in the development of any future treatment plans. It is therefore important that wher-
ever possible they are involved from the beginning.
The overall structure of assessment (at least for the assessment of alcohol misuse)
is provided by the assessment tools reviewed above. However, whatever assessment
tool is used from both the child and adult literature, (Harrington et al., 1999, and see
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Chapter 5) suggest that the following domains need to be considered as part of any
assessment of alcohol related problems in children and young people:
� Alcohol use – consumption, dependence features and associated problems
� Comorbid substance misuse – consumption, dependence features and
associated problems
� Motivation
� Self-efficacy
� Other problem domains
– Physical history and problems
– Mental health and problems
– Social functioning
– Educational attainment and attendance
– Peer relationships
– History of abuse and trauma
– Family functioning and relationships
� Risk assessment
� Developmental needs of the young person
� Treatment goals
� Obtaining consent to treatment
� Formulation of a care plan and risk management plan.
An additional point to bear in mind is the use of further informants. For example,
in terms of the assessment of consumption, the use of other informants such as
parents, carers or schools may assist in detailing the history of consumption, and in
clarifying the level and veracity of use.
As was identified in the introduction, the presentation of alcohol misuse or
dependence does not typically follow the pattern seen in adults. More often, a pattern
of binge drinking is observed that is often accompanied by drug misuse. It is impor-
tant, therefore, to detail both the pattern of drinking and the comorbid drug misuse. It
should also be noted that adolescents may have lower prevalence of withdrawal symp-
toms along with a lower tolerance. Both of these factors may contribute to continued
high alcohol intake, particularly of binge drinking, with consequent serious implica-
tions for psychological and physical health but without the ‘warning signs’ of emerg-
ing withdrawal symptoms.
History of trauma and abuse
It has already been noted that comorbidity of substance misuse is significantly higher
in adolescents who misuse alcohol. It is also important to note that alcohol misusing
adolescents have a significant increased rate of physical abuse (by a factor of 6 to 12)
and a significant increased rate of sexual abuse (by up to a factor of 20) (Clark et al.,
1997a). Given that it is possible that these histories may have a significant aetiologi-
cal role in the development of alcohol misuse, it is important that these issues are part
of assessment. It is also likely that a history of trauma has an impact for the likely
comorbidity, for example the existence of PTSD (Clark et al., 2003), and also that it
may be associated with poor response to treatment and the need for more complex
treatment interventions.
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5.25.12 Evidence summary
Content of the clinical assessment
The literature review identified a number of components of a structured clinical inter-
view. These included assessment of the current extent and history of drinking, associ-
ated potential for withdrawal, the likelihood of withdrawal, the need for review of
associated physical health problems, the examination of mental health and the impact
of alcohol on social, personal, occupational and educational functioning. It also identi-
fied that the impact of alcohol on the family would be an important issue also to be
considered. Considerable emphasis on the literature reviewed was placed on the impor-
tance of engaging people with alcohol-related problems in treatment and negotiating
appropriate goals. It is clear from the literature that for people who are moderately and
severely dependent drinkers, the initial goal should be one of abstinence. For others who
are harmful and mildly dependent drinkers, it may be possible to consider a reduction
in drinking as a reasonable treatment goal. However, past history of unsuccessful
attempts to moderate drinking should be born in mind when making these assessments.
There is little evidence that indicates the identification and assessment methods
needed for assisted withdrawal in children and young people. Therefore, the GDG
makes a consensus-based decision to extrapolate from the review of the adult litera-
ture and combine this with expert opinion. The group concluded that a comprehen-
sive assessment and an assessment for assisted withdrawal should be offered to all
children and young people with established binge drinking, an AUDIT score of more
than 15 and those who consume more than five units per day, but this decision should
also take into consideration other factors such as age, weight, previous history of
alcohol misuse and the presence of co-occurring disorders.
The review of formal assessment measures also considered a number of measures
of motivation (readiness to change). It was not felt by the group that the quality of
these measures (in part because of impracticality of these measures which were
designed primarily for use in research) warranted their use in standard clinical care.
However, a consideration of a patient’s readiness and/or motivation for change is a
vital part of assessment.
Physical investigations
An awareness of and inquiry into the nature of commonly presenting physical health
problems with alcohol misuse are important. This guideline, and other related NICE
guidelines (NICE, 2010a and 2010b), considered the value of biomarkers; for exam-
ple, liver function tests as indicators for diagnosis of alcohol-related disorders. From
the reviews conducted for this and the other NICE guidelines it was concluded that
these measures have insufficient sensitivity and specificity compared with validated
assessment methods such as the AUDIT. However, for people with specific physical
health problems, for those whom regular feedback on a particular biological marker
may act as a motivational tool and those for whom pharmacological treatments may
require liver function tests (for example, naltrexone and disulfiram), these measures
may have an important part to play in the ongoing treatment and management of alco-
hol misuse. No evidence was identified in this or the other NICE guidelines (2010a
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and 2010b) to support the use of other biomarkers (for example, hair analysis) for
routine clinical use in assessment or outcome monitoring of alcohol misuse.
Assessment of comorbid substance misuse
It is recognised that smoking, drinking and drug taking behaviours cluster together
(Farrell et al., 2001) and that excessive drinkers with high AUDIT scores are more
likely to have used drugs in the past (Coulthard et al., 2002). Therefore, the evidence
suggests that co-existing substance misuse should be assessed. Clinical assessment
should include the type of drug and its route of administration, the quantity and the
frequency with which it is used.
Assessment of comorbid mental health problems
Mental health problems which co-exist with alcohol misuse can have a significant
impact, both on the treatment and long-term outcome of the alcohol-related problem.
However, depression and anxiety can often develop as a consequence of alcohol
misuse. At assessment there is no reliable way of determining whether a comorbid
mental health problem is primary or secondary to alcohol misuse. This means that
symptoms of comorbid mental disorders need to be monitored throughout the course
of assessment and treatment. A common presentation in alcohol misuse is suicidal
ideation. This needs to be assessed and actively managed as part of an overall risk
management process. The GDG considered that as, a minimum, the re-assessment of
common mental disorders should occur 3 to 4 weeks following abstinence from alco-
hol. At this point, consideration may be given to treatment. NICE guideline for the
management of these disorders should be consulted.
Cognitive impairment
Cognitive impairment is present in most people who misuse alcohol presenting for
treatment. These impairments, which may be transitory, are, however, often missed in
the initial assessment. The evidence reviewed suggested that the MMSE has reason-
able validity as an initial identification tool and should be supplemented with specific
questions to detect duration extent or functional impairment. There is also evidence to
suggest that the ACE-R has good sensitivity for diagnosing mild cognitive impairment.
However, it does not assess all aspects of cognitive function and should be used as a
part of a specialist comprehensive assessment test battery in conjunction with an exec-
utive test such as the Block Design subtest of the Wechsler Adult Intelligence Scale
(WAIS-III) (Wechsler, 1945/1997) or the Trail-Making Test, Part B (Army Individual
Test Battery, 1944). It is not possible to conduct an effective cognitive assessment in
people who misuse alcohol who are actively drinking. Unless there is evidence of gross
cognitive impairment that may require further and immediate investigation, the GDG
took the view that adequate assessment of cognitive impairment is best left until 3 to
4 weeks following abstinence from alcohol. At this point if significant cognitive
impairment persists, it should be subject to more formal assessment including conduct-
ing a more detailed history and neuropsychological testing. Those patients presenting
acutely with a confused state and significant memory loss may be suffering from WE
and should be assessed and treated accordingly (see NICE, 2010b).
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Organisation and delivery of assessment
The evidence for the organisation and delivery of the range of assessment was
reviewed. This included a review of the currently recommended assessment systems
in England and, in particular, the MoCAM stepped-care framework. This approach
begins with an initial case identification/diagnostic assessment. Here, the emphasis is
on brief assessments that can be administered by staff in a range of services in health-
care and related settings. There is good evidence from the assessment tools reviewed
above that scores on measures such as the AUDIT and SADQ provide a useful indi-
cation of the appropriate level of intervention needed. There is also evidence that
people who misuse alcohol can be assessed in a relatively brief triage assessment. The
guideline also reviewed the evidence for the factors to be considered in a withdrawal
assessment. Finally, the indications for and content of comprehensive assessment was
reviewed. In summary the GDG felt that a stepped approach to assessment in line
with that set out in MoCAM (Department of Health, 2006a) was appropriate.
Outcome monitoring
The GDG reviewed the evidence for the use of routine outcome monitoring. A range
of assessment tools were considered as part of the overall view of assessment tools.
Although these measures are effective at identifying the presence or severity of the
disorder, most were felt unsuitable or impractical for routine outcome measurement.
The evidence suggested that the AUDIT questionnaire provides a valid, reliable and
feasible method to monitor outcome in routine clinical care. Prospective weekly
drinking diaries, whilst widely used in clinical services, are of unknown reliability
and validity. The routine use of breath alcohol concentration measurement was not
supported by the evidence either in initial assessment or routine outcome monitoring,
although it has a useful place in monitoring abstinence in the context of an assisted
withdrawal programme. The GDG therefore favoured the AUDIT (specifically the
first three questions from the questionnaire with subsequent questions only used for
6-month follow-up) as a routine measure, but recognised that in some services, espe-
cially Tier 3 and Tier 4 specialist services, an additional, more detailed assessment
measure may also be used. The GDG also favoured the APQ as an outcome monitor-
ing tool when assessing alcohol-related problems.
5.26 FROM EVIDENCE TO RECOMMENDATIONS
Assessment tools
The review of assessment tools identified a number of measures which had suffi-
ciently robust psychometric properties to be used in routine clinical care. In addition
to these factors, the GDG also used its expert knowledge to assess the benefit and
feasibility of their use in routine care. As a case identification tool (that is, one that
would indicate whether or not further treatment was required) the AUDIT question-
naire is the most appropriate instrument. On occasions where the AUDIT question-
naire was not available and/or not practical, then a simple typical daily alcohol
consumption measure could also be used as an indicator of potential need for
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treatment. For people suspected of having alcohol dependence, the use of the SADQ
or the LDQ were supported by the GDG as effective instruments to measure the
severity of alcohol dependence in order to guide further management. For assessing
the extent of problems associated with alcohol misuse, the APQ was identified as
meeting all the necessary criteria. In addition, on the basis of the NICE guideline on
the management of alcohol-related physical complications review (NICE, 2010b), the
CIWA-Ar was judged to be the most appropriate instrument to measure alcohol with-
drawal symptoms.
Content of the clinical assessment and the organisation and delivery of assessment
systems
It is important to recognise that the use of individual assessment tools alone, such as
those identified above, does not constitute a comprehensive assessment. The evidence
suggested that, in addition to a historical and recent history of drinking, the associ-
ated physical and mental health problems, and the impact on health and social and
economic problems, should also be assessed. This section also identified the impor-
tance of the impact on family (including, importantly, children). It is also important
to recognise that a key aspect of effective assessment is the process of engaging
people and identifying treatment goals. For example, determining whether absti-
nence, which is the initial preferred goal for moderately and severely dependent
drinkers, or moderation of alcohol consumption is the preferred goal. The GDG there-
fore decided to provide detail on the content of the range of assessment domains. The
GDG also reviewed the evidence for the organisation and delivery of assessment
systems and supported the established system recommended within MoCAM
(Department of Health, 2006a). This may require additional specialist assessment
resources and systems to ensure that individuals have the capacity and competency to
deliver these assessments.
Physical investigations
The review for this guideline (based in significant part on parallel work undertaken
on other NICE guidelines; NICE, 2010b) established that physical investigations (in
particular, blood tests including measures of liver function) are not sufficiently sensi-
tive or specific measures for routine use in specialist alcohol services. However,
biomarkers can have added benefit as motivational tools by providing feedback on
progress and in assessing suitability for some pharmacological interventions (for
example, naltrexone and disulfiram). The GDG also considered that the measurement
of breath alcohol is a useful, objective part of the clinical monitoring in the manage-
ment of assisted alcohol withdrawal.
Assessment of comorbid substance misuse
The presence of comorbid substance misuse is associated with poorer outcomes for
those with alcohol misuse and the GDG reviewed evidence on this along with the
recommendation in the NICE (2007a) guideline on psychosocial management of
substance misuse. It was agreed that assessment of comorbid drug misuse should
therefore be a part of routine assessment of alcohol misuse. Consideration should be
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given to the use of biological testing (for example, of urine or saliva samples) as part
of a comprehensive assessment of drug misuse, but clinicians should not rely on it as
the sole method of diagnosis and assessment.
Assessment of comorbid mental health problems
Comorbid mental health problems are a common presentation in people who misuse
alcohol. It is important that this is assessed at initial presentation. However, it should
be noted that for many people, symptoms of, for example, depression and anxiety
may remit following 3 to 4 weeks of abstinence from alcohol. It is therefore often not
appropriate or necessary to instigate treatment for the disorder at the point of the
initial assessment. Careful monitoring and reassessment of mental health symptoms
following abstinence are an important part of the assessment procedure. Treatment of
mental health disorders that persist beyond 3 to 4 weeks after abstinence should be
considered.
Routine outcome monitoring
Routine outcome monitoring is an essential part of any effective healthcare system
provision. The AUDIT questionnaire was identified as the most reliable and feasible
measure for routine outcome monitoring. Prospective drinking diaries are of
unknown reliability and validity. The APQ was also identified as beneficial for the
assessment of alcohol-related problems when monitoring treatment outcome.
Competence of staff
It is essential that clinicians performing assessments of people who misuse alcohol
should be fully competent to do so.
Children and young people
Due to the lack of sufficient evidence specifically for children and young people, the
GDG decided to adopt a modified version of the assessment framework adopted for
adults. As with the adult review the GDG favoured the use of the AUDIT tool as a case
identification/screening tool and this is consistent with the approach adopted the NICE
prevention and brief intervention guideline (NICE, 2010a) However, the GDG decided
to adjust the threshold for AUDIT in light of evidence that this increased the sensitivity
for adolescent alcohol misuse. For a more comprehensive assessment, the GDG recom-
mended two possible assessment tools and the integration of any assessment of alcohol
misuse into a comprehensive assessment of the needs of the child or young person.
5.26.1 Recommendations
Identification and assessment
General principles
5.26.1.1 Staff working in services provided and funded by the NHS who care for
people who potentially misuse alcohol should be competent to identify
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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.
5.26.1.2 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.
5.26.1.3 When conducting an initial assessment, as well as assessing alcohol
misuse, the severity of dependence and risk, consider the:
� extent of any associated health and social problems
� need for assisted alcohol withdrawal.
5.26.1.4 Use formal assessment tools to assess the nature and severity of alcohol
misuse, including the:
� AUDIT for identification and as a routine outcome measure
� SADQ or LDQ for severity of dependence
� Clinical Institute Withdrawal Assessment for Alcohol scale, revised
(CIWA-Ar) for severity of withdrawal
� APQ for the nature and extent of the problems arising from alcohol
misuse.
5.26.1.5 When assessing the severity of alcohol dependence and determining the
need for assisted withdrawal, adjust the criteria for women, older people,
children and young people
20
, and people with established liver disease who
may have problems with the metabolism of alcohol.
5.26.1.6 Staff responsible for assessing and managing assisted alcohol withdrawal
(see Section 5.30.2) should be competent in the diagnosis and assessment
of alcohol dependence and withdrawal symptoms and the use of drug regi-
mens appropriate to the settings (for example, inpatient or community) in
which the withdrawal is managed.
5.26.1.7 Staff treating people with alcohol dependence presenting with an acute
unplanned alcohol withdrawal should refer to ‘Alcohol-use disorders: diag-
nosis and clinical management of alcohol-related physical complications’
(NICE clinical guideline 100).
Assessment in all specialist alcohol settings
Treatment goals
5.26.1.8 In the initial assessment in specialist alcohol services of all people who
misuse alcohol, agree the goal of treatment with the service user. Abstinence
is the appropriate goal for most people with alcohol dependence, and people
who misuse alcohol and have significant psychiatric or physical comorbidity
(for example, depression or alcohol-related liver disease). When a service
user prefers a goal of moderation but there are considerable risks, advise
strongly that abstinence is most appropriate, but do not refuse treatment to
service users who do not agree to a goal of abstinence.
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20
See Section 5.22 for assessment of children and young people.

5.26.1.9 For harmful drinking or mild dependence, without significant comorbidity,
and if there is adequate social support, consider a moderate level of drink-
ing as the goal of treatment unless the service user prefers abstinence or
there are other reasons for advising abstinence.
5.26.1.10 For people with severe alcohol dependence, or those who misuse alcohol
and have significant psychiatric or physical comorbidity, but who are
unwilling to consider a goal of abstinence or engage in structured treat-
ment, consider a harm reduction programme of care. However, ultimately
the service user should be encouraged to aim for a goal of abstinence.
5.26.1.11 When developing treatment goals, consider that some people who misuse
alcohol may be required to abstain from alcohol as part of a court order or
sentence.
Brief triage assessment
5.26.1.12 All adults who misuse alcohol who are referred to specialist alcohol serv-
ices 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
� 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
5.26.1.13 Consider a comprehensive assessment for all adults referred to specialist
alcohol services who score more than 15 on the AUDIT. A comprehensive
assessment should assess multiple areas of need, be structured in a clinical
interview, use relevant and validated clinical tools (see Section 5.16), 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 LDQ)
– alcohol-related problems (using, for example, 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]
21
)
� readiness and belief in ability to change.
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174
21
Folstein and colleagues (1975).

5.26.1.14 Assess comorbid mental health problems as part of any comprehensive
assessment, and throughout care for the alcohol misuse, because many
comorbid problems (though not all) will improve with treatment for alco-
hol misuse. Use the assessment of comorbid mental health problems to
inform the development of the overall care plan.
5.26.1.15 For service users whose comorbid mental health problems do not signifi-
cantly improve after abstinence from alcohol (typically after 3–4 weeks),
consider providing or referring for specific treatment (see the relevant
NICE guideline for the particular disorder).
5.26.1.16 Consider measuring breath alcohol as part of the management of assisted
withdrawal. However, breath alcohol should not usually be measured for
routine assessment and monitoring in alcohol treatment programmes.
5.26.1.17 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.
5.26.1.18 Consider brief measures of cognitive functioning (for example, MMSE) to
help with treatment planning. Formal measures of cognitive functioning
should usually only be performed if impairment persists after a period of
abstinence or a significant reduction in alcohol intake.
SECTION 4 – DETERMINING THE APPROPRIATE
SETTING FOR THE DELIVERY OF EFFECTIVE CARE
5.27 INTRODUCTION
This section is concerned with identifying the settings in which to deliver clinical care
for people who misuse alcohol. It begins with a review of planned assisted with-
drawal, which is linked to and draws heavily on the review conducted for the NICE
guideline on management of alcohol-related physical complications (NICE, 2010b).
It then considers the range of settings in which assisted withdrawal and the interven-
tions covered in Chapters 6 and 7 of this guideline may be best provided, including
community, residential and inpatient settings.
The majority of services provide treatment for alcohol misuse in community or
outpatient settings, whereby a patient is visited at home by a health or social care
professional or attends a clinic or a day hospital. There are also approximately 200
voluntary or independent sector providers of residential rehabilitation treatment for
drug or alcohol misuse in England (National Treatment Agency, 2009b). The services
that they offer can be differentiated according to factors such as the principal aims of
treatment, patient group and length of stay. Residential rehabilitation services may
offer medically assisted withdrawal from alcohol, but usually only as a prelude to
longer-term rehabilitation or aftercare. Finally, medically-managed inpatient facilities
are usually run by the NHS, and a review of national provision in 2004 highlighted
Organisation and delivery of care
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77 NHS hospitals that admitted patients for drug or alcohol withdrawal, and a further
28 non-statutory or private providers (Day et al., 2005).
Current practice in the management of assisted withdrawal, and the general provi-
sion of alcohol treatment services, tends to follow MoCAM (Department of Health,
2006a) guidance that suggested community settings were preferred for the treatment
of the majority of people who misuse alcohol, as they are seen as more cost effective
and more likely to promote change in their drinking behaviour in a normal social
environment. However, it was noted that some people would require treatment in
hospital or in supported residential accommodation, including those who are severely
dependent, have a history of withdrawal complicated by seizures or DTs, are in poor
physical or psychological health, are at risk of suicide, or misuse drugs. Homeless
people, those who lack social support or stability, or those who have had previous
unsuccessful attempts at withdrawal in the community may also require inpatient
treatment. MoCAM also stipulated that inpatient assisted withdrawal should lead
seamlessly into structured care-planned treatment and support, whether delivered in
the community or in residential rehabilitation services. However, it should also be
noted, as discussed at the beginning of this chapter, that there is considerable varia-
tion in practice (including in the settings) in which services are provided.
A number of authors have considered the possible benefits of treatment in a resi-
dential setting (Gossop, 2003; Mattick & Hall, 1996; McKay et al., 1995; Weiss,
1999). In considering the potential benefits of any setting, it is useful to distinguish
between the provision of withdrawal management and the provision of further treat-
ment and rehabilitation. Residential settings provide a high level of medical supervi-
sion and safety for individuals who require intensive physical and/or psychiatric
monitoring, and the possibility of more intensive treatment may also help patients
who do not respond to interventions of lower intensity. Residential settings may also
offer the patient respite from their usual social milieu (that is, the people and places
associated with alcohol use) and improved continuity of care. However, the protec-
tiveness of a residential unit may also be one of its main disadvantages – it may limit
opportunities for the patient to develop new coping strategies (Annis, 1996). Time
away from work or study, reduced family contact and the stigmatisation associated
with some residential service settings may also be potential disadvantages of residen-
tial care (Strang et al., 1997). Finally, residential settings are considerably more
expensive than non-residential alternatives.
Previous reviews of studies of residential treatment for alcohol misuse conducted
in the 1980s concluded that residential/inpatient treatment had no advantages over
outpatient treatment (Annis, 1996; Miller & Hester, 1986). Furthermore, every
controlled study of length of inpatient treatment found no advantage in longer over
shorter stays, or in extended inpatient care over assisted withdrawal alone (Annis,
1996; Miller & Hester, 1986). However, the authors noted a variety of methodologi-
cal problems with the studies, not least that the nature of the treated populations
varied substantially, from general psychiatric patients assessed for alcohol misuse and
outpatient problem drinkers to inpatient alcoholics (Miller & Hester, 1986). Miller
and Hester also noted in their study that a course of outpatient treatment averaged less
than 10% of the cost of inpatient treatment. Therefore, even if residential settings
Organisation and delivery of care
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afforded a modest advantage in overall effectiveness, preference might still be given
to non-residential treatment based on cost effectiveness.
Further research conducted since the mid-1980s has challenged some of these
conclusions. In a review of the literature, Finney and colleagues (1996) found 14
studies in which setting effects might have been detected. Of these studies, seven
found significant setting effects on one or more drinking-related outcomes, with five
favouring inpatient over outpatient treatment and a further two favouring day hospi-
tal over inpatient treatment (Finney et al., 1996). In all but one instance in which a
significant effect emerged, patients in the more effective setting received more inten-
sive treatment, and participants were not ‘pre-selected’ for their willingness to accept
random assignment. Other potential methodological problems were also identified.
As mentioned above, it is often thought that an inpatient or residential setting will
benefit patients from social environments where heavy drinking is common and
encouraged by allowing the patient a period of respite. However, some studies
randomised participants to inpatient or outpatient treatment after an initial period of
inpatient treatment for medically-assisted withdrawal. Finney and colleagues (1996)
commented that this treatment setting contamination might bias studies toward no-
difference findings.
5.28 REVIEW QUESTIONS
1. In adults in planned alcohol withdrawal, what is the clinical efficacy, cost effec-
tiveness, safety of, and patient satisfaction associated with:
� preparatory work before withdrawal
� different drug regimens
� the setting (that is, community, residential or inpatient)?
2. 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?
3. In adults with harmful or dependent alcohol use, what are the preferred structures
for and components of community-based and residential specialist alcohol serv-
ices to promote long-term clinical and cost-effective outcomes?
5.29 ASSISTED ALCOHOL WITHDRAWAL
5.29.1 Introduction
This section is concerned with planned assisted alcohol withdrawal. It should be read
in conjunction with the NICE guideline on management of alcohol-related physical
complications (NICE, 2010b); the reviews conducted for that guideline informed the
Organisation and delivery of care
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decisions of the GDG. Previous research assessing the settings for assisted with-
drawal from alcohol has yielded a considerable amount of debate about the safety,
efficacy and cost effectiveness of the various options available. Settings for assisted
withdrawal include the community (where assisted withdrawal may be delivered in a
day hospital setting), in specialist community alcohol teams or in primary care,
specialist inpatient and specialist residential settings. In addition, assisted withdrawal
programmes are also provided in the prison healthcare system, police custody and a
range of acute general medical settings. This section is also concerned with the indi-
cations for inpatient assisted withdrawal. Some further details about the settings in
which assisted withdrawal can take place are given below. Special populations or
patient groups who may be at risk of complications are considered separately in
Sections 5.29.6 and 5.30.7.
Community settings
In a community setting, a person undergoing assisted withdrawal lives in their own
accommodation throughout the treatment. A spectrum of treatment intensity is also
possible. Day hospital treatment (sometimes known as ‘partial hospitalisation’; see
Mee-Lee et al., 2001) may involve the patient attending a treatment facility for up to
40 hours per week during working hours, Monday to Friday, and returning home in
the evening and weekends. This facility may be located within an inpatient or residen-
tial rehabilitation unit, or may be stand-alone. It is likely to be staffed by a multidis-
ciplinary team, with input from medical and nursing staff, psychologists,
occupational therapists, social workers, counsellors, and other staff specialising in
debt, employment or housing issues. Other community assisted withdrawal
programmes may invite the patient to attend for appointments with a similar range of
multidisciplinary staff, but at a much lower frequency and intensity (for example,
once or twice a week), or they may be provided by GPs often with a special interest
in treating alcohol-related problems. Alternatively, staff may visit the patient in their
own home to deliver interventions. Between these two options are most intensive
community-based options, where an increased frequency of community visits and
some limited use of office or team-based treatment may form part of an intensive
community programme.
Inpatient and residential settings
In inpatient and residential settings, the service user is on-site for 24 hours a day for
the duration of assisted withdrawal. Inpatient and residential settings encompass a
spectrum of treatment intensity. At one end lie specialist units within either acute
medical or psychiatric hospitals, dedicated to the treatment of alcohol or drug prob-
lems (known as ‘inpatient units’). Such units have specialist medical and nursing
input available 24 hours a day, and are staffed by a multidisciplinary team that may
also include psychologists, occupational therapists, social workers, counsellors, and
other staff specialising in debt, employment or housing issues. At the other end of the
spectrum are facilities usually known as ‘residential rehabilitation’ units, which are
usually provided by the non-statutory sector and not sited within hospital premises.
Although the goal of such units is usually the provision of longer-term treatment
Organisation and delivery of care
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(3 to 12 months) aimed at enhancing the patient’s ability to live without using alcohol,
increasingly they also provide an initial period of assisted withdrawal. Such units may
also have access to medical and nursing input over the full 24-hour period, but this is
usually at a lower level of intensity and more likely to utilise non-specialist staff (for
example, GPs). Such units are more likely to adopt a ‘social model’ rather than a
‘medical model’, and may be staffed by both professionals and individuals in recov-
ery. In addition, a number of prisons may offer a high level of medical supervision
including, where necessary, admission to the hospital wing of the prison.
5.29.2 Aim of review and review protocol
The initial aim of this review was to perform a systematic meta-analysis of RCT data
that addressed the review question. However, only one well-designed RCT assessing
the benefits and harms of different settings for assisted withdrawal has been
published (Hayashida et al., 1989). Therefore, the GDG decided to assess all avail-
able studies and provide a narrative review. The review team assessed the literature
identified from the search conducted by the NICE guideline on management of alco-
hol-related physical complications (NICE, 2010b); full details of the search strate-
gies can be found in that guideline. Studies were considered for inclusion in a
narrative review for this guideline if they met the inclusion criteria (see Chapter 3)
and if the population being assessed in the study reflected the scope of this guideline
(see Appendix 1). Furthermore, studies were considered for inclusion in the narra-
tive review using the clinical review protocol in Table 20. The key outcomes of inter-
est were: the efficacy of the setting for assisted withdrawal (for example, the patient
successfully completed the programme and remained abstinent during the period
assisted withdrawal); the safety profile (for example, the development of complica-
tions, and hence the patient factors that indicate that a non-residential setting for
assisted withdrawal is unsuitable or unsafe); and participation in consequent rehabil-
itation treatment. Other outcomes of interest are patient satisfaction and other patient
and physician related factors.
5.29.3 Studies considered
Five studies comparing different settings for assisted withdrawal were identified. Of
these, one was an RCT (Hayashida et al., 1989), three were retrospective matching
studies (Bartu & Saunders, 1994; Parrott et al., 2006; Stockwell et al., 1991) and one
was a retrospective case study comparing patient characteristics in different settings
(Allan et al., 2000). In addition, five open prospective studies (Collins et al., 1990;
Drummond & Chalmers, 1986; Feldman et al., 1975; Soyka & Horak, 2004; Stinnett,
1982) and an RCT assessing adding a brief psychological intervention to home-based
assisted withdrawal (Alwyn et al., 2004) were also identified. These additional stud-
ies did not compare different settings for assisted withdrawal but reported treatment
outcomes for a community setting for assisted withdrawal.
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The literature search also identified studies and systematic reviews evaluating
circumstances in which inpatient admission for assisted withdrawal may be appropri-
ate, as well as special populations and patient groups whom may require inpatient
assisted withdrawal from alcohol. These studies are considered separately.
5.29.4 Narrative review of settings for assisted withdrawal
Studies comparing different settings for assisted withdrawal
Apart from the Hayashida and colleagues (1989) study, the studies discussed above
were observational in design and participants were only matched for severity of alco-
hol dependence. Furthermore, although these studies indicated that it is feasible for
assisted withdrawal to take place in a community setting for a severely dependent
population, it is probable that a number of patients with significant comorbidities and
previous history of seizures where excluded. As these patients form a significant
proportion of those who are referred to and receive inpatient or residential assisted
withdrawal, caution is needed when interpreting these results.
Only one randomised trial (Hayashida et al., 1989), conducted in a US
Department of Veterans Affairs (VA) medical centre, compared the effectiveness
and safety of inpatient (n = 77) and outpatient (n = 87) assisted withdrawal. Patients
with serious medical or psychiatric symptoms, predicted DTs and a very recent
history of seizures were excluded from this study. The authors reported that more
inpatients than outpatients completed assisted withdrawal. However, inpatient
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180
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO,
Cochrane Library; see the NICE guideline on manage-
ment of alcohol-related physical complications (NICE,
2010b) for search strategies
Date searched Systematic reviews from 1993 to March 2010. All
other searches from database inception to March 2010
Study design Systematic reviews, RCTs
Patient population Adults (over 18 years old)
Patients with alcohol withdrawal syndrome
Outcomes Main outcomes: severity of withdrawal; completion
rates; abstinence during assisted withdrawal; safety
(development of complications); participation in further
rehabilitation treatment after assisted withdrawal
Other outcomes: patient and physician factors
Table 20: Clinical review protocol for the evaluation of different settings for
assisted withdrawal from alcohol

treatment was significantly longer and more costly than outpatient treatment.
Additionally, both groups had similar reductions in problems post-treatment when
assessed at 1- and 6-month follow-up. Although abstinence was statistically signif-
icantly higher for the inpatient group at 1-month follow-up, these differences were
not observed at 6-month follow-up. The authors concluded that outpatient assisted
withdrawal should be considered for people with mild-to-moderate symptoms of
alcohol withdrawal.
Stockwell and colleagues (1991) compared a retrospective inpatient sample
(n = 35) with a group receiving home-based assisted withdrawal (n = 41). The two
samples were matched for age, sex and drinking severity. Patients undertaking home-
based assisted withdrawal were severely dependent (SADQ score = 28.7; mean alco-
hol consumption 174.6 units per week) and had a high level of alcohol-related
problems (APQ score = 4.6). The authors reported that home-based assisted with-
drawal was as safe and effective for a severely dependent population as inpatient care.
However, the matched inpatient sample did not include anyone with severe alcohol
withdrawal syndrome or physical or psychiatric symptoms and, therefore, is not
representative of an inpatient population.
Bartu and Saunders (1994) also compared people undertaking home-based
assisted withdrawal (n = 20) with patients in an inpatient specialist unit (n = 20).
Patients were matched for age, sex, presence of social support, absence of medical
complications and severity of withdrawal symptoms. It was reported that home-based
assisted withdrawal was as beneficial as inpatient assisted withdrawal. It should be
noted, however, that the matched inpatient sample was not representative of a typical
inpatient, who may be severely dependent and have several complications.
Parrott and colleagues (2006) compared alcohol-focused outcomes and cost of
residential (n = 54) with any day (n = 49) settings for assisted withdrawal in the UK
and reported similar alcohol-focused outcomes (PDA and DDD). This paper mainly
discusses cost implications and is reviewed in the health economic section (Section
5.29.7).
In a comparison between home-based assisted withdrawal (n = 29) and day
hospital services (n = 36) in severely dependent patients, Allan and colleagues
(2000), in a UK-based study, evaluated the types of patients selected for home-
based assisted withdrawal, its safety and efficacy, and patient satisfaction and
involvement in further treatment. Participants in both groups were severely depend-
ent (two thirds had a SADQ score of over 30), although the day hospital group
drank significantly more at baseline (home-based group = 178 units, day hospital
group = 194 units in the week before assisted withdrawal). Furthermore, although
both groups had alcohol-related problems, as assessed by the APQ, the day hospi-
tal group had significantly more severe problems and social instability. The authors
reported that there were no significant differences between the groups in the
proportion of participants who completed assisted withdrawal, complication rates
(which were low) and uptake of treatment post withdrawal. However, it should be
noted that this study did not match participants in both settings but aimed to assess
the characteristics of the patients who use home-based and day hospital assisted
withdrawal.
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Prospective studies evaluating outpatient assisted withdrawal
Further studies assessing the treatment outcomes and characteristics of patients in
various settings were identified from the literature search. These studies were open
prospective studies and aimed to evaluate the safety and efficacy of outpatient assisted
withdrawal. Feldman and colleagues (1975) evaluated an outpatient treatment
programme for alcohol withdrawal (n = 564). The authors reported that only 47%
required outpatient assisted withdrawal and 19% required inpatient assisted with-
drawal. Outpatient assisted withdrawal was successful and had a low dropout rate of
14%. However, the authors attributed this success to the early involvement of the
family, the use of withdrawal medication and involvement in peer group therapeutic
activity. The results of an earlier study reflected these findings (Alterman et al.,
1988). The investigators reported that ambulatory assisted withdrawal was relatively
successful for mild-to-moderate alcohol withdrawal symptomatology.
Soyka and Horak (2004) assessed the efficacy and safety of outpatient assisted
withdrawal in a German open prospective study. Alcohol dependent participants were
excluded if they presented with severe alcohol-related disorders, such as seizures or
psychosis, or major psychiatric and medical comorbidity. Some participants referred
to the treatment clinic had to be admitted for inpatient care (n = 348), leaving 331
patients to be treated in an outpatient setting. The study reported very high comple-
tion rates (94%) for patients in an outpatient assisted withdrawal programme.
Furthermore, outpatient assisted withdrawal was associated with increased participa-
tion in further treatment (91% of initial sample). Soyka and Horak (2004) addition-
ally found that of those who completed assisted withdrawal successfully, all entered
either motivationally- or psychotherapy-based treatment.
Stinnett (1982) evaluated the effectiveness and safety of 116 participants referred for
outpatient assisted withdrawal in an alcoholism treatment centre. Fifty per cent
completed treatment, and 89% of these completers went on to continue with follow-up
rehabilitation treatment. Collins and colleagues (1990) assessed the efficacy of a UK-
based outpatient alcohol withdrawal programme. Of those deemed suitable for outpa-
tient assisted withdrawal (n = 76; 44% of all referrals), 79% successfully completed the
treatment. These patients were severely alcohol dependent (91% had an SADQ score
greater than 30). However, not all studies have reported such favourable completion
rates. For example, in a severely dependent sample of 26 patients (77% with a SADQ
score greater than 31), Drummond and Chalmers (1986) reported that only 23% of
patients completed assisted withdrawal and 19% attended a follow-up 1 month later.
In a UK-based RCT, Alwyn and colleagues (2004) evaluated the addition of a
brief psychological intervention to GP-managed home-based assisted withdrawal.
The psychological intervention consisted of five 30-minute sessions with motiva-
tional, coping skills and social support approaches. The study reported that both the
control and the psychological intervention group (total n = 91) showed significant
improvements in drinking outcomes from baseline to follow-up (3- and 12-month)
indicating that home-based assisted withdrawal was effective. In addition, the psycho-
logical intervention group showed significantly greater improvements than the
control group at 12-month follow-up. These results suggest that there is benefit in
adding a brief psychological intervention to assisted withdrawal.
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From the patients’ perspective, it has been suggested that gains made in inpatient
assisted withdrawal may not be easily transferable to the patient’s home and social
environment (Bischof et al., 2003). Undertaking assisted withdrawal in a home or
outpatient setting enables the patient to retain important social contacts that may
facilitate their attempts to achieve abstinence as well as subsequent rehabilitation.
Patients can continue in employment (if appropriate) and be in a familiar environment
with family support, which may help to minimise stress and anxiety and help to moti-
vate them. It has also been suggested that the home environment is also less stigma-
tising than an inpatient setting for assisted withdrawal (Allen et al., 2005). In a study
assessing patients’ perceptions and fears of alcohol withdrawal, Allen and colleagues
(2005) found that patients were fearful and concerned about the psychiatric residen-
tial setting for assisted withdrawal and expressed feelings of stigmatisation associated
with being in an ‘institutional’ setting. The authors also reported no difference in
patient satisfaction between a home and outpatient setting for assisted withdrawal.
Additionally, patient satisfaction with outpatient assisted withdrawal services have
also been found to be high when administered in an intensive day programme
(Strobbe et al., 2004). Stockwell and colleagues (1990) found that three quarters of
patients preferred their home as the setting for assisted withdrawal, and two fifths and
one third were unwilling to undergo withdrawal in, respectively, a psychiatric hospi-
tal and a general hospital. The patients also emphasised the importance of support
from the nurse supervising their assisted withdrawal, the breathalyser, medications,
telephone support service and the involvement of supporters, familiar surroundings,
privacy and confidentiality, and being able to stay with their family.
Another factor that may be relevant to the provision of home or outpatient assisted
withdrawal is availability of treatment capacity. An early report (Stockwell et al.,
1986) revealed that in the Exeter Health Authority, GPs arranged as many home-
based assisted withdrawals as hospital-based. However, of the home-based assisted
withdrawals, two fifths were unsupervised. Approximately a third of GPs were reluc-
tant to take medical responsibility for home-based assisted withdrawal, but of those
who were happy to, they reported a preference for this setting. Winters and McGourty
(1994) also surveyed GPs in Chester and Ellesmere Port. Approximately 60%
reported that they provided home-based assisted withdrawal from their practices.
However, 10% believed specialist help was required. Additionally, they reported that
unsuccessful home-based assisted withdrawal was usually due to lack of support at
weekends and lack of patient motivation. Over 20% of Northumberland GPs reported
carrying out home-based assisted withdrawals in the last year (Kaner & Masterson,
1996). Similar to Winters and McGourty (1994), most GPs stressed the importance of
having daily supervision as well as more information about the process of assessing
patients for suitability for home-based assisted withdrawal.
5.29.5 Inappropriate admission for residential assisted withdrawal
In services with ready access to inpatient facilities for assisted withdrawal, there is
evidence to suggest that given the likelihood of medical complications more
Organisation and delivery of care
183

patients are admitted than is necessary. Whitfield (1980) reported that only 5% of
people who misuse alcohol require hospitalisation for withdrawal management.
Booth and colleagues (1996) assessed appropriate and inappropriate utilisation of
inpatient services for assisted withdrawal for alcohol in the US. The study, which
randomly sampled a number of patients admitted into VA medical centres, found
that only 16% of alcoholics undergoing inpatient assisted withdrawal were appro-
priately admitted, and that the majority of these had medical or neurological
complications such as liver cirrhosis, chest pains, kidney failure, gastrointestinal
bleeding and seizures, and therefore met admission criteria. However, 84% were
admitted for the purpose of monitoring alone and did not meet Appropriateness
Evaluation Protocol criteria for inpatient admission. Furthermore, the majority of
inappropriately admitted patients did not develop any serious complications that
could have justified inpatient care. These patients had lengthy admission length of
11 days on average, which has serious cost implications. An earlier study (Booth
et al., 1991) also reported similar findings, albeit with a higher percentage (55%)
of appropriate admissions.
The implementation of a standardised policy that guides the decision about
inpatient admission or outpatient assisted withdrawal in a small community hospi-
tal resulted in a significant reduction in the number of admissions (Asplund et al.,
2004). Furthermore, no patients needed hospitalisation for withdrawal complica-
tions, which indicates that outpatient assisted withdrawal is safe for the majority of
patients without prior complications as identified by a thorough assessment.
Outpatient assisted withdrawal may be more appropriate for a population with less
severe problems. In a sample of male military veterans enrolled in outpatient with-
drawal, Webb and Unwin (1988) reported that 54% successfully completed outpa-
tient assisted withdrawal, 22% were admitted for inpatient care and 24% dropped
out of the treatment. The group referred for inpatient care had a significantly higher
level of dependence (measured by SADQ score) than those who successfully
completed outpatient assisted withdrawal. This would suggest that inpatient
assisted withdrawal may be more appropriate for patients with more severe alcohol
dependence.
5.29.6 Special populations
Medical or psychiatric comorbidities
For the majority of people who misuse alcohol, outpatient or home-based assisted
withdrawal appears to be safe, viable and effective (see above). However, for a minor-
ity of patients, a non-residential setting for assisted withdrawal may be inappropriate
or unsafe. An inpatient setting may be more appropriate for the management of
moderate to severe withdrawal symptoms such as DTs and seizures, comorbid
medical, surgical and psychiatric problems (for example, suicidal ideation), preg-
nancy, or if the patient is not able to take medication by mouth (Bischof et al., 2003;
Blondell et al., 2002; Blondell, 2005; Dukan et al., 2002; Ferguson et al., 1996;
Kraemer et al., 1997; Saitz & O’Malley, 1997). There is evidence to suggest that a
Organisation and delivery of care
184

history of multiple prior episodes of assisted withdrawal may lead to an increased risk
of seizures and withdrawal problems (Booth & Blow, 1993; Brown et al., 1988;
Lechtenberg & Worner, 1990), and so a number of previous unsuccessful attempts at
outpatient assisted withdrawal may also suggest the need for referral to an inpatient
setting. Dependence on drugs can increase the risks associated with withdrawal and
also the duration and severity of withdrawal symptoms, therefore patients with
comorbid drug misuse disorders may require treatment in an inpatient setting. In addi-
tion, Pettinati and colleagues (1993) found that those with high psychiatric comorbid-
ity and/or poor social support benefited more from inpatient than outpatient
treatment.
Children and young people
No evidence evaluating the safety and efficacy of different settings for withdrawal
management in children and young people was identified. The GDG therefore drew
from the adult literature with special consideration to the additional problems often
associated with alcohol misuse in children and young people (for example, problems
with school, family, crime and mental health). A significant concern of the GDG for
children and young people was with the identification of potential dependence and
subsequent withdrawal. In formulating recommendations about the appropriate
setting for assisted withdrawal, the GDG considered that the safety issues concerning
assisted withdrawal might differ for children (aged 10 to 15 years) and young people
(aged 16 to 18 years).
Older people
The GDG did not identify any clinical evidence evaluating the efficacy and safety of
different settings for assisted withdrawal specifically for older people. However,
research suggests that older patients (aged 60 years and above) are more at risk of
cognitive and functional impairment during withdrawal and hence should be consid-
ered for inpatient care (Kraemer et al., 1997).
Homeless patients
Homeless patients requiring assisted withdrawal may also require inpatient care
unless other shelter and accommodation can be arranged. For example, in a large
study assessing the effectiveness of an ambulatory assisted withdrawal programme
in the VA system in the US (Wiseman et al., 1997), half of the patients were home-
less. The study reported that 88% of patients successfully completed assisted with-
drawal and 96% of these successful completers were referred for further treatment
on either an inpatient or an outpatient basis. However, the programme provided
supported housing for the homeless during the period of assisted withdrawal.
Although low socioeconomic status and homelessness may make outpatient
assisted withdrawal more challenging, they are not necessarily contraindications
for treatment failure and hence should be assessed on a more detailed individual
basis. O’Connor and colleagues (1991) reported that socially disadvantaged
people were not at an increased risk of unsuccessful assisted withdrawal in an
outpatient setting.
Organisation and delivery of care
185

5.29.7 Health economics evidence
Systematic literature review
The literature search identified only one economic study that assessed the cost effec-
tiveness and cost utility of different settings for assisted withdrawal (Parrott et al.,
2006). The study evaluated two UK-based withdrawal programmes for people
dependent on alcohol. The first intervention was a 10-day assisted withdrawal in a
22-bed facility in Manchester staffed by mental health nurses with support from
a local GP. The first part of the intervention involved managing withdrawal safely
whilst the second part involved social care interventions. The second intervention was
a brief hospitalisation programme based at a Newcastle NHS inpatient unit. This
involved 3-day inpatient assisted withdrawal, if required, followed by attendance at a
day programme. Patients in this programme were also given counselling based on
cognitive-behavioural principles, including motivational intervention prior to struc-
tured interventions aimed at abstinence or moderate drinking. Both programmes were
compared with no intervention rather than with each other because baseline data was
compared with clinical and economic outcome data collected at 6 months after imple-
mentation. The economic analysis adopted a societal perspective. It included costs to
the NHS, other alcohol treatment services, social services and the criminal justice
system. The outcome measures used were QALYs for the cost-utility analysis and
reduction in units of alcohol per day and reduction in percentage of drinking days in
the cost-effectiveness analysis. QALYs were estimated using EQ-5D scores obtained
from participants in the study.
In the cost-effectiveness analysis, the cost per unit reduction in alcohol consump-
tion was £1.87 in the Manchester sample and £1.66 in the Newcastle sample. The cost
per reduction of one drink per day was £92.75 in the Manchester sample and £22.56
in the Newcastle sample. The cost per percentage point reduction in drinking was
£30.71 in the Manchester sample and £45.06 in the Newcastle sample. In the cost-
utility analysis, the ICER per QALY gained, compared with no intervention, was
£65,454 (£33,727 when considering treatment costs only) in the Manchester sample
and £131,750 (£90,375 treatment costs only) in the Newcastle sample. Overall, the
authors concluded that both alcohol withdrawal programmes improved clinical
outcomes at a reasonable cost to society. However QALY differences were not signif-
icant over 6 months, with both ICERs well above current NICE thresholds for cost-
effectiveness.
The validity of the study results is limited by the absence of a non-treatment group
for both alcohol withdrawal programmes as changes in clinical outcomes may have
occurred without the interventions. Also, the within-group before-and-after study
design meant that time-dependent confounding variables could not be controlled for.
Data for each programme were collected from single centres, which may limit gener-
alisability of the study findings to other UK centres. The small patient sample-size in
both centres and substantial loss to follow-up also limits the robustness of the analy-
sis. It should be noted that patients in the two centres were different in terms of
severity of dependence, the number and severity of alcohol-related problems, and
Organisation and delivery of care
186

socioeconomic status, and therefore direct comparison of costs and outcomes associ-
ated with each intervention is not appropriate. No sensitivity analyses were performed
to test the robustness of the base case results.
Summary of existing economic evidence
The findings of Parrott and colleagues (2006) suggest that both programmes may be
cost effective in terms of reduction in alcohol consumption rather than QALYs
gained. The settings, costs reported and measure of benefit adopted in the study make
this study directly applicable. However, the effectiveness evidence is not without
limitations: the comparator of ‘no treatment’ may not be relevant and the robustness
of the results was not fully explored in sensitivity analyses.
Cost analysis of assisted withdrawal in different settings
The cost effectiveness of assisted withdrawal across different settings was considered
by the GDG as an area with potentially significant resource implications. As previ-
ously discussed, clinical evidence was derived from studies with different designs and
therefore it was not possible to synthesise the clinical data in order to conduct a
formal economic evaluation. Nevertheless, existing clinical evidence does not suggest
that the effectiveness of home-based or outpatient assisted withdrawal attempted in
outpatient/home settings differs significantly from that of assisted withdrawal
provided in inpatient/residential settings. Therefore, a simple cost analysis was under-
taken to estimate costs associated with assisted withdrawal that are specific to the
setting in which assisted withdrawal is provided.
Three different assisted withdrawal settings were considered in the cost analysis:
inpatient/residential, outpatient and home-based. The healthcare resource-use esti-
mates for each setting were based on descriptions of resource use in studies included
in the systematic literature review of clinical evidence. Information was mainly
sought in studies conducted in the UK, as clinical practice and respective resource
use described in these studies is directly relevant to the guideline context. After
reviewing the relevant literature it was decided to utilise resource-use estimates
reported in Alwyn and colleagues (2004), which were then adapted according to the
expert opinion of the GDG to reflect current routine clinical practice within the
NHS. The estimated resource use was subsequently combined with national unit
costs to provide a total cost associated with provision of assisted withdrawal in the
three settings assessed. Unit costs were derived from national sources (Curtis, 2009;
Department of Health, 2010) and reflected 2009 prices. It should be noted that the
cost estimates reported below do not include the cost of drugs administered to people
undergoing assisted withdrawal. However, such a cost is expected to be similar
across all assisted withdrawal settings and therefore its omission is unlikely to
significantly affect the relative costs between different options assessed.
Inpatient/residential assisted withdrawal
According to Alwyn and colleagues (2004), inpatient/residential assisted withdrawal
lasts for 2 weeks and requires an extra outpatient visit. The GDG estimated that
Organisation and delivery of care
187

inpatient assisted withdrawal may last longer, between 2 and 3 weeks. The unit cost
of NHS adult acute mental health inpatient care is £290 per patient day (Department
of Health, 2010). The unit cost of hospital outpatient consultant drug and alcohol
services is £85 per face-to-face contact for a follow-up visit (Department of Health,
2010). By combining the above resource-use estimates with the respective unit costs,
the total cost of inpatient/residential assisted withdrawal is estimated to range
between £4,145 and £6,175 per person treated.
Outpatient assisted withdrawal
Outpatient assisted withdrawal is estimated to require six outpatient attendances
(Alwyn et al., 2004). The unit cost of a face-to-face contact with hospital outpatient
consultant drug and alcohol services is £181 for the first visit and £85 for each follow-
up visit (Department of Health, 2010). By combining these data, the total cost of
outpatient assisted withdrawal is estimated at £606 per person treated.
Home-based assisted withdrawal
Alwyn and colleagues (2004) estimated that home-based assisted withdrawal
requires six CPN home visits lasting 30 minutes each. The GDG were of the opin-
ion that the first of these visits should be replaced by an outpatient visit to alcohol
consultant services, so that appropriate assessment is carried out before starting
assisted withdrawal. Moreover, the GDG advised that the travel time of the health-
care professional providing home-based assisted withdrawal should be taken into
account. Considering that home visits often take place in remote areas, the GDG
estimated that the travelling time of the healthcare professional staff was likely to
range between 1 and 2 hours per home visit. The unit cost of a face-to-face contact
with outpatient consultant drug and alcohol services is £181 for the first visit
(Department of Health, 2010). The unit cost of a CPN is not available for 2009. The
total cost of home-based assisted withdrawal was therefore based on the unit cost
of community nurse specialists (Band 6), as this type of healthcare professional is
expected to provide home-based assisted withdrawal. The unit cost for community
nurse specialists is £35 per working hour and £88 per hour of patient contact
(Curtis, 2009). This unit cost includes salary (based on the median full-time equiv-
alent basic salary for Agenda for Change (AfC) Band 6 of the January to March
2009 NHS Staff Earnings estimates for qualified nurses), salary oncosts, capital
and revenue overheads, as well as qualification costs. The unit cost per working
hour was combined with the estimated travelling time, while the unit cost per hour
of patient contact was combined with the estimated total duration of home visiting.
A £4 travel cost was assumed for each visit. By combining all the above data, the
total cost of home-based assisted withdrawal was estimated to range between £596
and £771.
Summary
The cost analysis indicates that, provided that the different assisted withdrawal
settings have similar effectiveness, then outpatient and home-based assisted with-
drawal are probably less costly (and thus potentially more cost effective) than
Organisation and delivery of care
188

inpatient assisted withdrawal, resulting in an estimated cost saving of approximately
£3,400 to £5,600 per person treated.
5.29.8 Clinical and health economic evidence summary
The evidence indicates that a community setting for assisted withdrawal is as effec-
tive and safe for the majority of patients as an inpatient or residential assisted with-
drawal as long as the patient is without serious medical contraindications. It is also
likely to be more cost effective as cost savings of between £3,400 to £5,600 per
person may be generated The evidence reviewed is limited because there is only one
RCT, but it should be noted that it is extremely difficult to undertake an RCT in this
area given the clinicians concerns about the relative safety for more severely depend-
ent patients. The GDG (drawing on the evidence in the reviews conducted for this
guideline) therefore decided that it was important to consider the following factors
when determining whether a community or residential/inpatient assisted withdrawal
is the most appropriate:
� a history of epilepsy or withdrawal-related seizures or DTs during previous
assisted withdrawal
� a significant psychiatric or physical comorbidity (for example, chronic severe
depression, psychosis, malnutrition, congestive cardiac failure, unstable angina or
chronic liver disease)
� a significant learning disability
� significant cognitive impairment
� homelessness
� pregnancy
� children and young people
� older people
5.30 EVALUATING DOSING REGIMES FOR ASSISTED
WITHDRAWAL
5.30.1 Introduction
This section assesses the safety, efficacy, cost effectiveness and patient satisfaction
associated with different medication regimens used in assisted withdrawal from
alcohol. When undertaking assisted withdrawal, the patient is required to stop alco-
hol intake abruptly, and the ensuing withdrawal symptoms are treated with medica-
tion, usually benzodiazepines. Once the withdrawal symptoms are controlled, the
medication can be gradually reduced and stopped at a rate that prevents withdrawal
symptoms re-emerging but without creating over-sedation. Key elements of the
process are to provide a large enough initial dose to prevent severe withdrawal symp-
toms including seizures, DTs, severe anxiety or autonomic instability, but to with-
draw the medication at a rate which prevents re-emergence of symptoms or serious
Organisation and delivery of care
189

complications such as DTs or seizures. Special populations with indications for
specific dosing regimens are discussed in Section 5.30.7.
5.30.2 Definitions of dosing regimen methods
Fixed-dose regimen
A fixed-dose (FD) regimen involves starting treatment with a standard dose deter-
mined by the recent severity of alcohol dependence and/or typical level of daily alco-
hol consumption, followed by reducing the dose to zero usually over 7 to 10 days
according to a standard protocol.
Table 21 gives an example of a titrated FD regimen (Ghodse et al., 1998; South
West London and St George’s Mental Health NHS Trust, 2010). Note that due to the
gradual rate of reduction, with higher starting doses, the duration of treatment is
longer than with lower starting doses. A common error in management of alcohol
withdrawal is too rapid reduction of chlordiazepoxide, which can result in emer-
gence or re-emergence of severe alcohol withdrawal symptoms. Another common
error is too low a starting dose of chlordiazepoxide. This can be avoided by taking
account of typical daily alcohol consumption and/or SADQ score in determining the
starting dose. In addition, the response to FD withdrawal regimes should be moni-
tored using a validated tool such as the CIWA-Ar (Sullivan et al., 1989) and the dose
of medication adjusted upwards or downwards accordingly in the early stages of
withdrawal. In severe alcohol dependence the doses of chlordiazepoxide required
may exceed the British National Formulary (BNF) prescribing range. It is more clin-
ically effective to increase the dose of chlordiazepoxide to adequately control alco-
hol withdrawal symptoms than to add another type of medication (for example,
haloperidol).
The first dose of medication should be given before withdrawal symptoms
begin to emerge. Delay in initiating chlordiazepoxide treatment can result in
withdrawal symptoms either becoming difficult to control or the emergence of
complications such as DTs or seizures. Therefore, in people with severe alcohol
dependence, the first dose should be given before the breath alcohol concentration
falls to zero, as withdrawal will emerge during the falling phase of breath alcohol
concentration. The more severe the alcohol dependence, the earlier withdrawal
symptoms emerge after last alcohol intake. Some people who are severely alcohol
dependent can experience withdrawal with a blood alcohol concentration of
100 mg per 100 ml or more.
Symptom-triggered regimen
A symptom-triggered (ST) approach involves tailoring the drug regimen according to
the severity of withdrawal and complications the patient is displaying. The patient is
monitored on a regular basis and pharmacotherapy is administered according to the
patient’s level of withdrawal symptoms. Pharmacotherapy only continues as long as
the patient is displaying withdrawal symptoms and the administered dose is
Organisation and delivery of care
190

dependent on the assessed level of alcohol withdrawal. Withdrawal symptoms are
usually assessed by clinical assessment including observation and interview, and/or
with the use of a validated withdrawal measurement tool such as the CIWA-Ar. See
Table 22 for an example of an ST dosing regimen (NICE, 2010b).
Organisation and delivery of care
191
Typical recent 15 to 25 units 30 to 49 units 50 to 60 units
daily consumption
Severity of alcohol MODERATE SEVERE VERY SEVERE
dependence SADQ score 15 to 25 SADQ score 30 to 40 SADQ score 40 to 60
Starting doses of 15 to 25 mg q.d.s.
1
30 to 40 mg q.d.s. 50 mg q.d.s.
chlordiazepoxide
Day 1 (starting dose) 15 q.d.s. 25 q.d.s. 30 q.d.s. 40 q.d.s.* 50 q.d.s.*
Day 2 10 q.d.s. 20 q.d.s. 25 q.d.s. 35 q.d.s. 45 q.d.s.
Day 3 10 t.d.s.
2
15 q.d.s. 20 q.d.s. 30 q.d.s. 40 q.d.s.
Day 4 5 t.d.s. 10 q.d.s. 15 q.d.s. 25 q.d.s. 35 q.d.s.
Day 5 5 b.d.
3
10 t.d.s. 10 q.d.s. 20 q.d.s. 30 q.d.s.
Day 6 5 nocte
4
5 t.d.s. 10 t.d.s. 15 q.d.s. 25 q.d.s.
Day 7 5 b.d. 5 t.d.s. 10 q.d.s. 20 q.d.s.
Day 8 5 nocte 5 b.d. 10 t.d.s. 10 q.d.s.
Day 9 5 nocte 5 t.d.s. 10 q.d.s.
Day 10 5 b.d. 10 t.d.s.
Day 11 5 nocte 5 t.d.s.
Day 12 5 b.d.
Day 13 5 nocte
Table 21: Titrated fixed-dose chlordiazepoxide protocol for treatment of
alcohol withdrawal (Ghodse et al., 1998; South West London and St George’s
Mental Health NHS Trust, 2010)
Note. * Doses of chlordiazepoxide in excess of 30 mg q.d.s. should only be prescribed in
cases where severe withdrawal symptoms are expected and the patient’s response to the
treatment should always be regularly and closely monitored. Doses in excess of 40 mg q.d.s.
should only be prescribed where there is clear evidence of very severe alcohol dependence.
Such doses are rarely necessary in women and never in the elderly or where there is severe
liver impairment.
1
Quater die sumendus (four times a day);
2
ter die sumendum (three times a day);
3
bis die
(twice daily);
4
At night.

Front-loading regimen
A front-loading regimen involves providing the patient with an initially high dose of
medication and then using either an FD or ST dosing regimen for subsequent assisted
withdrawal. See Table 22 for an example of a front-loading dosing regimen (NICE,
2010b).
5.30.3 Aim of review and review protocol
As stated above, this section is concerned with the safety, efficacy, cost effectiveness
and patient satisfaction of different dosing regimens for assisted withdrawal and their
appropriateness in various treatment settings. Furthermore, this section aims to eval-
uate medication for assisted withdrawal that is not appropriate or safe in a setting
without 24-hour monitoring. The GDG identified that there would be insufficient
RCT literature available to answer the review question, therefore it was decided by
consensus to include all available studies in a systematic narrative review of the
evidence. The review team assessed the literature identified from the search
conducted by the NICE guideline on management of alcohol-related physical compli-
cations (NICE, 2010b); full details of the search strategies can be found in that guide-
line. Studies were considered for inclusion in the narrative synthesis if they met the
inclusion criteria (see Chapter 3) and if the population being assessed in the study
reflected the scope of this guideline (see Appendix 1). Furthermore, studies were
considered for inclusion in the narrative synthesis using the clinical review protocol
described in Table 23. The outcomes of interest were the efficacy (management of
alcohol withdrawal syndrome, duration of treatment and amount of medication
Organisation and delivery of care
192
Dosing regimen Day 1 Day 2 Day 3 Day 4
Symptom triggered 20 to 30 mg as needed up to hourly, based on symptoms
1
Front loaded
2
100 mg every 50 to 100 mg 50 to 100 mg None
2 to 4 hours every 4 to 6 every 4 to 6
until sedation hours as hours as
is achieved; needed needed
then 50 to
100 mg every
4 to 6 hours
as needed
Table 22: Examples of symptom-triggered and front-loaded dosing regimens
for treating alcohol withdrawal with chlordiazepoxide
Note.
1
These symptoms include pulse rate greater than 90 beats per minute, diastolic blood
pressure greater than 90 mm Hg or signs of withdrawal.
2
Frequently, very little additional medication is necessary after initial loading.

required), safety (development of complications), as well as patient and physician
satisfaction of the dosing regimens.
In addition, the review team conducted a search for studies that evaluated patient
indications for inpatient assisted withdrawal. The review team also reviewed the
safety of using different types of medication for assisted withdrawal in a setting that
does not have 24-hour clinical monitoring, which is the more typical situation in clin-
ical practice. Due to the nature of the review question, the GDG identified that there
would be a lack of RCT literature (confirmed by the original RCT search for this
guideline) and hence a search was conducted for systematic reviews. The review team
assessed the available literature identified from the search conducted by the NICE
guideline on management of alcohol-related physical complications (NICE, 2010b).
5.30.4 Studies considered
Twelve studies evaluating the efficacy and safety of different regimens for assisted
withdrawal were identified. Nine of these studies compared an ST regimen of admin-
istering alcohol withdrawal medication (with or without front-loading) with an FD
regimen (Daeppen et al., 2002; Day et al., 2004; Hardern & Page, 2005; Lange-
Asschenfeldt et al., 2003; Manikant et al., 1993; Saitz et al., 1994; Sullivan et al.,
1991; Wasilewski et al., 1996; Weaver et al., 2006), and three studies compared usual
non-protocol routine based hospital care to an ST regimen (DeCaroulis et al., 2007;
Jaeger et al., 2001; Reoux & Miller, 2000). The characteristics and settings of the
included studies can be found in Table 24.
Organisation and delivery of care
193
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane
Library; see the NICE guideline (NICE, 2010b) on
management of alcohol-related physical complications
for search strategies
Date searched Systematic reviews from 1993 to March 2010. All
other searches from database inception to March 2010
Study design Systematic reviews; RCTs
Patient population Adults (over 18 years old); patients with alcohol with-
drawal syndrome
Outcomes Main outcomes: severity of withdrawal; duration of
treatment; total amount of medication; incidence of
seizures and DTs or other complications
Other outcomes: patient and physician satisfaction;
completion rates
Table 23: Clinical review protocol for the evaluation of different dosing
regimens for assisted withdrawal from alcohol

Organisation and delivery of care
194
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Organisation and delivery of care
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g
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e
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(
2
0
0
7
)
T
i
m
e

t
o

r
e
a
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h

s
y
m
p
t
o
m

c
o
n
t
r
o
l
S
T

(
7
.
7

[
4
.
9
]

h
o
u
r
s
)

s
i
g
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f
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c
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s
h
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h
a
n

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o
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t
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e

F
D

(
1
9
.
4

[
9
.
7
]

h
o
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r
s
)
(
p
=
0
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0
0
2
)
T
o
t
a
l

a
m
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n
t

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f

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e
d
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d
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(
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0
4
4

[
5
3
4
]

m
g
)

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n
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f
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y

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e
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s

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h
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n

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t
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F
S

(
1
6
7
7

[
9
3
7
]

m
g
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(
p
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0
1
4
)
D
u
r
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t
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o
f

t
r
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t
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t
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f
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e

b
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g
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p
s
H
a
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n
d

P
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(
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T
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l

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m
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f

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r
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T
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m

f
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t
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d
m
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8

h
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r
s
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f
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c
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t
l
y

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h
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r

t
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a
n

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l
a
r

d
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s
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n
g

(
1
1
0

h
o
u
r
s
)

(
p
=
0
.
0
8
6
)
J
a
e
g
e
r

a
n
d

c
o
l
l
e
a
g
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s

(
2
0
0
1
)
D
u
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t
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f

t
r
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m
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N
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f
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d
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c
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b
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t
w
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n

g
r
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p
s
T
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t
a
l

a
m
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t

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f

m
e
d
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c
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q
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N
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c
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b
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n

g
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p
s
I
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c
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c
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f

c
o
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p
l
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c
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s

N
o

s
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f
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n

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n
c
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c
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f

c
o
m
p
l
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n
s

o
v
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a
l
l
;

S
T

h
a
d

s
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g
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f
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-
c
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t
l
y

l
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s

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n
c
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d
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n
c
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f

D
T
s

(
p
=
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.
0
4
)

(
S
T
=
2
0
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5
%
;

u
s
u
a
l

c
a
r
e
=
6
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9
%
)
L
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A
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c
h
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f
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d
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a
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T
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m
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m
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T

(
m
e
d
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a
n

4
3
5
2

[
4
5
8
9
]

m
g
)

s
i
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n
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f
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c
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y

l
e
s
s

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n

F
D

(
m
e
d
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a
n

9
9
2
1

[
6
5
9
9
]
)

c
o
l
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(
2
0
0
3
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(
p
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0
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0
0
4
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D
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n

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f

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r
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t
m
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S
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m
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d
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a
n

4
.
2

[
2
.
9
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h
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s
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s

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n

F
D

(
m
e
d
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a
n

7
.
5

[
3
.
3
]
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(
p
=
0
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0
3
)
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n
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f

c
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m
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(
1
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p
r
o
v
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d
:

S
T
=
6
7
m
g
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D
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2
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0
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g
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e
v
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t
y

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f

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R
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a
m
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(
8
2
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7

[
1
5
3
.
6
]

m
g
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s
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(
3
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7
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5

[
9
8
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2
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m
g
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(
p
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0
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u
m
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(
1
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[
3
.
1
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)

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e
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r
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e

(
1
0
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4

[
7
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9
]
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(
p
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0
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1
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r
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t
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n

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(
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0
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[
2
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.
7
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h
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r
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r
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c
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e

(
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[
6
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(
p
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6
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A
d
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(
m
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d
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a
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h
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r
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s
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n

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(
m
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r
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p

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c
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t
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n
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(
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n
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t
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(
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4
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v
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g

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h
o
s
p
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e

(
p
=
0
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6
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r
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d
m
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w
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n

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p
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b
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(
6
9
%
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r
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t
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r

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h
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n

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D

(
5
0
%
)

(
n
o
n
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s
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g
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f
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c
a
n
t
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(
p
=
0
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0
6
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r
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t
m
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t

a
f
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s
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n

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n
d

c
o
l
l
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a
g
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s

(
1
9
9
1
)
T
o
t
a
l

a
m
o
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n
t

o
f

m
e
d
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c
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t
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n

r
e
q
u
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d
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T

(
5
0
m
g
)

s
i
g
n
i
f
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c
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n
t
l
y

l
e
s
s

t
h
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n

F
D

(
7
5
m
g
)

(
p
=
0
.
0
4
)
D
u
r
a
t
i
o
n

o
f

t
r
e
a
t
m
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n
t
N
o

s
i
g
n
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f
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c
a
n
t

d
i
f
f
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r
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n
c
e

b
e
t
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n

g
r
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p
s
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m
b
e
r

o
f

p
a
t
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e
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t
s

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q
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i
r
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n
g

S
T

(
3
3
%
)

s
i
g
n
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f
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c
a
n
t
l
y

m
o
r
e

t
h
a
n

F
D

(
1
2
.
8
%
)

(
p
=
0
.
0
5
)
<
2
0
m
g

o
f

m
e
d
i
c
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t
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n
R
a
t
e

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f

d
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s
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h
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a
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n
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t

m
e
d
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c
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l

a
d
v
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e
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n
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f
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c
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b
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n

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p
s
R
a
t
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s

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f

c
o
m
p
l
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c
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t
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n
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s
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f
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c
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t

d
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f
f
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r
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c
e

b
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t
w
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n

g
r
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p
s
W
a
s
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l
e
w
s
k
i

a
n
d

c
o
l
l
e
a
g
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e
s

(
1
9
9
6
)
T
o
t
a
l

a
m
o
u
n
t

o
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Organisation and delivery of care
197

5.30.5 Narrative summary of findings
Medication use and duration of treatment
The results of most studies favoured the use of ST over FD regimens for outcomes
assessing medication use and duration of treatment. The ST approach resulted in
lower medication needed (Daeppen et al., 2002; Day et al., 2004; DeCaroulis
et al., 2007; Lange-Asschenfeldt et al., 2003; Reoux & Miller, 2000; Saitz et al.,
1994; Sullivan et al., 1991; Wasilewski et al., 1996; Weaver et al., 2006), lower
frequency of administration (Daeppen et al., 2002; Reoux & Miller, 2000) and a
shorter duration of treatment (Daeppen et al., 2002; Day et al., 2004; Lange-
Asschenfeldt et al., 2003; Reoux & Miller, 2000; Saitz et al., 1994). However, not
all studies assessing these outcomes reported results favouring an ST approach.
Sullivan and colleagues (1991) and Jaeger and colleagues (2001) found no differ-
ence between ST front-loading and FD front-loading regimens in terms of length
of stay, and Jaeger and colleagues (2001) reported no significant difference
between groups in total dose of medication required. Hardern and Page (2005)
found no difference in dose administered and length of stay between ST and regu-
lar FD regimens.
Severity of withdrawal symptoms
DeCaroulis and colleagues (2007) reported significantly less time to reach symptom
control in the ST protocol group when compared with an FD regimen. Saitz and
colleagues (1994) found no difference between an ST and FD regimen in time taken
from admission to achieving a CIWA-Ar score of less than 8. Manikant and
colleagues (1993) and Day and colleagues (2004) also found no significant difference
in severity of withdrawal (using the CIWA-Ar) between an ST front loading and an
FD regimen.
Rates of complications or adverse effects
Jaeger and colleagues (2001) reported significantly fewer episodes of DTs in the ST
regimen group when compared with routine care but found no difference in overall
complication rates. Other studies, however, reported no difference between ST and
other FD regimens/routine care in rates of complications and adverse effects (for
example, incidence of seizures, DTs and hallucinations) (Lange-Asschenfeldt et al.,
2003; Reoux & Miller, 2000; Saitz et al., 1994; Sullivan et al., 1991). In Wasilewski
and colleagues’ (1996) study, although patients in the ST front loading group had a
significantly shorter duration of delirium than the FD group, no significant difference
was observed in somatic disorders and abnormalities. Additionally, Day and
colleagues (2004) did not find a significant difference between ST front loading and
FD regimens in self-reported adverse symptoms.
Other outcomes
Other outcomes, including patient satisfaction, discharge against medication advice,
use of co-medication and protocol errors, were reported in the reviewed studies.
Organisation and delivery of care
198

Daeppen and colleagues (2002)
22
and Sullivan and colleagues (1991) reported that
there were no significant differences in patient comfort level between groups, and
Day and colleagues (2004) reported no significant difference between ST front load-
ing and FD regimens in terms of patient satisfaction. Two studies (Saitz et al., 1994;
Sullivan et al., 1991) reported no difference between ST and FD regimens in terms of
rates of discharge against medical advice, and Lange-Asschenfeldt and colleagues
(2003) found no difference in use of co-medication. Weaver and colleagues (2006)
reported significantly more protocol errors in the ST group as opposed to the FD regi-
men group.
Symptom-triggered assisted withdrawal in a general medical setting
The studies reviewed above are not likely to be reflective of patients with complex
problems who typically are admitted to a general hospital ward for medical treatment
and present with withdrawal symptoms (that is, they are undergoing unplanned with-
drawal) (Hecksel et al., 2008). For example, although the Jaeger and colleagues’
(2001) study found fewer episodes of DTs in the ST regimen group, patients were
excluded from the study if they presented with medical comorbidities. In a general
admissions unit, this in effect would exclude any post-surgical patients (Hecksel
et al., 2008). Additionally, Reoux and Miller (2000) excluded any patients with
complex medical histories, and Sullivan and colleagues (1991) did not take into
account medical comorbidity. Therefore, Hecksel and colleagues (2008) suggested
that in these studies, which have assessed an ST approach in a non-specialist general
medical setting, patients that are most likely to develop complications such as DTs
have not been investigated using the CIWA-Ar tool and therefore some uncertainty
about its value with this population remains (Ferguson et al., 1996).
The majority of the ST studies were conducted in addiction specialist inpatient
settings or psychiatric hospitals, which have highly trained specialist staff familiar
with the ST dosing regimen and methods (Daeppen et al., 2002; Day et al., 2004;
Lange-Asschenfeldt et al., 2003; Manikant et al., 1993; Reoux & Miller, 2000; Saitz
et al., 1994; Wasilewski et al., 1996). When dosing regimens were compared in non-
alcohol specialist settings (that is, in general hospital medical wards), extensive train-
ing was delivered to staff (Jaeger et al., 2001; Sullivan et al., 1991; Weaver et al.,
2006). For example, in the study by Sullivan and colleagues, training was delivered
over a 6-month period with the assistance of clinical nurse specialist in alcohol and
substance misuse. In the Hardern and Page (2005) study, a retrospective audit
compared the use of an ST regime (which had been introduced in the medical admis-
sions unit) with regular fixed dosing. However, nurses who were trained to use the
scoring tool were frequently unavailable when the patient was admitted. This is
reflective of the competing demands on staff in a non-addiction treatment setting.
This variability can also be observed in different non-specialist departments such as
emergency departments (Kahan et al., 2005).
Organisation and delivery of care
199
22
In Daeppen and colleagues’ (2002) study, 60.3% of patients did not require pharmacological assisted
withdrawal.

Nurses, whether in a specialist unit, psychiatric ward, general medical ward or in
the community, play a vital role in successful assisted withdrawal. Stockwell and
colleagues (1990) found both patients and family members rated the support from
community nurses as more important than medication for assisted withdrawal.
Nursing staff in specialist addiction treatment centres are highly skilled and trained in
all aspects of the medical management of alcohol withdrawal (Cooper, 1994), and
have a working knowledge of current working practices and liaise with other staff and
services (Choudry, 1990). This may well have an impact on the efficacy of the ST
programmes in the studies above.
Most physicians and nurses working in general medical wards are not specialists in
the management of alcohol dependence. This is a concern because the first point of
contact for many alcohol-dependent people is not a specialist addiction unit, but more
usually a general physician in a non-specialist treatment setting such as a general medical
ward (O’Connor & Schottenfeld, 1998). Nurses in general medical practice may also
lack specialised knowledge and education about addiction and assisted withdrawal
(Coffey, 1996; Happell & Taylor, 1999; Ryan & Ottlinger, 1999). Even if training were
provided, the obstacles to ensuring comprehensive training in a general medical setting
also needs consideration (Moriarty et al., 2010; Schumacher et al., 2000).
Bostwick and Lapid (2004) reported on the use of an ST approach by psychia-
trists at the Mayo Clinic in Rochester, Minnesota. A CIWA-Ar controlled protocol
was not effective in managing alcohol withdrawal and patients deteriorated with use
of an ST approach. In these specific cases reported by Bostwick and Lapid (2004),
patients were assumed to be presenting with pure alcohol withdrawal syndrome.
However, because no thorough clinical interview was utilised and the patients could
not communicate effectively, medical staff did not ascertain whether the apparent
presenting alcohol withdrawal symptoms were a result of other acute medical
conditions such as sepsis, pain and shock. In another study of admissions in Mayo
Clinics, Hecksel and colleagues (2008) found that half of patients receiving ST
assisted withdrawal did not meet criteria using the CIWA-Ar. The investigators
reported that 44% of patients given this protocol had not been drinking and 23%
were unable to communicate effectively. Surprisingly, of those who could commu-
nicate, 64% were not currently drinking but were still receiving ST medication.
Again, and reflective of Bostwick and Lapid’s (2004) study, medical histories were
overlooked by physicians with a slight hint at alcohol use in the patient’s history
informing a decision to use this approach. Physicians also regularly assumed that
autonomic hyperactivity and psychological distress were a result of alcohol with-
drawal and hence a high CIWA-Ar score was attained, resulting in unnecessary
benzodiazepine treatment. The investigators concluded that in patients with a
history of alcohol dependence who are likely to develop adverse effects (DTs and
seizures), a CIWA-Ar-based ST approach is not appropriate and a more patient-
centred, personalised approach to medication management that goes beyond the
CIWA-Ar is needed. Furthermore, in medical and surgical patients with a history of
drinking, the ST approach to medication management has not been proven.
Bostwick and Lapid (2004) and Hecksel and colleagues (2008) also conclude that
an ST approach is not appropriate for patients with complex medical and surgical
Organisation and delivery of care
200

comorbidities, and hence may not be suitable for many patients presenting with
alcohol withdrawal syndrome in a general medical setting.
Medication not appropriate for use in a setting without 24-hour monitoring
The use of certain medications for assisted withdrawal may not be appropriate in non-
residential settings such as an outpatient clinic or the patient’s home. Outpatient
medication should be administered orally, have low potential for misuse or overdose,
and have few side effects (O’Connor et al., 1994).
Contraindications for benzodiazepines and chlormethiazole in non-residential
settings identified in the literature are set out below.
Benzodiazepines
Although long-acting benzodiazepines (such as chlordiazepoxide and diazepam) are
preferred for patients with alcohol withdrawal syndrome, short-acting benzodiazepines
(such as oxazepam) may be preferred in those for whom over-sedation must be
avoided, in people with liver disease who may not be able to metabolise long-acting
agents efficiently, and in people with chronic obstructive pulmonary disease (COPD)
(Blondell, 2005; Mayo-Smith et al., 2004). However, apart from patients with liver
failure and those with COPD (who may well be managed as inpatients; see above),
short-acting benzodiazepines may not be suitable for outpatient assisted withdrawal
due to the risk of breakthrough seizures (Mayo-Smith, 1997). Furthermore, short-
acting benzodiazepines (such as oxazepam and halazepam) may have a greater poten-
tial for misuse than benzodiazepines (such as diazepam, chlordiazepoxide, alprazolam
and lorazepam) (Griffiths & Wolf, 1990; McKinley, 2005; Soyka & Horak, 2004).
Chlormethiazole
Chlormethiazole is used in inpatient care as it has a short half-life (Majumdar, 1990).
However, it requires close medical supervision and is therefore not recommended for
non-residential settings such as outpatient clinics, patients’ homes and prisons.
Furthermore, it is addictive (although this is unlikely to develop in the short time
period of an assisted withdrawal) and, more importantly, it can have fatal conse-
quences in overdose resulting from coma and respiratory depression, especially when
taken with alcohol (Gregg & Akhter, 1979; Horder, 1978; McInnes et al., 1980;
McInnes, 1987; Stockwell et al., 1986).
5.30.6 Assisted withdrawal in the prison setting
Research evaluating assisted withdrawal in custodial settings such as police custody
and the prison setting is scarce. Individuals taken into police custody are often under
the influence of alcohol and some of these individuals may be alcohol dependent
(Naik & Lawton, 1996). Deaths in UK police custody have been associated with alco-
hol intake (Yoshida et al., 1990) and 86% of fatalities in police custody are associated
with recent alcohol consumption and alcohol dependence (Giles & Sandrin, 1990).
However, there is little guidance on the assessment and management of alcohol
Organisation and delivery of care
201

withdrawal in police custody or prison settings but also evidence to suggest that any
such guidance is not always followed (Ghodse et al., 2006).
People received into prison carry a heightened risk of suicide in the early days of
their custody; one third of all prison suicides happen within the first week of imprison-
ment (Shaw et al., 2003). This phase coincides with alcohol withdrawal for around one
in five prisoners, and the above study found an association between alcohol dependence
and risk of suicide. Alcohol dependence is commonplace among people entering prison:
the most recent national study of prisoners to be conducted found that 6% of all prison-
ers returned AUDIT scores of 32 and above (Singleton et al., 1998). (It should be noted
that screening with AUDIT now forms part of the assessment of alcohol misuse in the
prison service). The break in consumption that begins with arrest means that many
people with alcohol dependence arrive in prison in active states of withdrawal. This
position is further complicated by the high levels of comorbid drug (including opiates,
benzodiazepines and cocaine) misuse in the prison population (Ramsay, 2003). Due to
the increased risk of suicide, severity of alcohol dependence and high risk of develop-
ing withdrawal effects, clinical management of alcohol withdrawal should begin on the
day of reception into custody. The preferred agent of assisted withdrawal in the prison
service is chlordiazepoxide (Department of Health, 2006c).
Following alcohol withdrawal, there is some evidence that alcohol treatment
programmes addressing offending behaviour can reduce rates of re-offending (Hollis,
2007; McCulloch & McMurran, 2008), but these studies both lack a well-matched
control group. A comparative study of a modified therapeutic community and a stan-
dard mental health intervention for the treatment of male prisoners with both mental
health and substance misuse problems found evidence that the therapeutic community
group re-offended at a significantly reduced rate (Sacks et al., 2004). Because alco-
hol is prohibited in prison, the majority of people with alcohol dependence will
remain alcohol-free prior to their release.
5.30.7 Assisted alcohol withdrawal dosing regimens for special populations
Children and young people
The use of the same drug regimens as for adults should be used, with doses appropriately
adjusted for age and alcohol consumption. The evidence for favouring either ST or FD
regimens with children and young people remains uncertain as there are no trials which
have investigated this issue. Nevertheless whichever regimen is chosen there is a clear
requirement for very close monitoring of withdrawal symptoms. Given the uncertainty
identified in this guideline about the capacity of staff to manage symptom triggered with-
drawal, where symptoms are easily identifiable it was suggested that a cautious approach
to the management of symptoms in young people is a fixed dose regimen but with very
close symptom monitoring using a validated rating scale such as the CIWA-Ar.
Older people
As noted earlier, older people can have higher levels of physical comorbidity, cogni-
tive impairment, a lower capacity to metabolise alcohol and medications, and be in
Organisation and delivery of care
202

receipt of a larger number of medications than younger people. In addition, older
people can be more frail and prone to accidents and falls. Therefore it is prudent to
have a lower threshold for admission for inpatient assisted alcohol withdrawal in
older people who misuse alcohol. Further, doses of benzodiazepines may need to be
reduced in older people compared with guidelines for younger adults.
5.30.8 Clinical evidence summary
There is some evidence to suggest that for assisted withdrawal, an ST regimen
reduces medication use and duration of treatment and, therefore, is preferred in
settings where 24-hour monitoring is available and the staff are highly trained in the
use of this regimen. However, the evidence is not conclusive and some previous
research has found no difference between ST and FD regimens in efficacy as well as
for other outcomes such as rates of complication and patient experience. Furthermore,
the studies that have evaluated this question were conducted in settings where 24-hour
monitoring from trained staff is available and in the majority of cases these are
specialist addiction units; where this was not the case, the staff involved in these stud-
ies were extensively trained (for periods up to 6 months) for the purpose of the study.
Due to the skill required to treat alcohol withdrawal with an ST regimen, there is
a higher possibility of protocol errors where staff are not highly trained. This suggests
that in a non-specialist inpatient setting the ST approach may not be feasible, because
staff in general medical settings may not have the training, expertise and resources to
conduct an ST regimen. Therefore, in non-specialist general settings, a tapered FD
regimen may be more appropriate for assisted withdrawal.
There are currently no RCTs that assess the efficacy of an ST regimen for assisted
withdrawal in an outpatient setting. This may be because the use of an inpatient or
specialist ST dosing regimen in a community setting is unpractical as 24-hour is not
possible, or ad hoc monitoring is not appropriate. The gradual tapering FD regimen
is therefore more appropriate for outpatient assisted withdrawal as it involves provid-
ing medication in specified doses for a predetermined number of days. The medica-
tion dose is gradually reduced until cessation as in inpatient FD regimes. The
evidence also indicates that chlormethiazole is not appropriate for use in outpatient
assisted withdrawal because there is a high risk of misuse and overdose.
It is common for people with alcohol dependence who are taken into police custody
to develop alcohol withdrawal syndrome. However, previous research suggests that the
alcohol withdrawal syndrome is not always detected in this setting. Staff should be
aware of the importance of identifying potential or possible alcohol withdrawal and be
trained in the use of tools to detect alcohol dependence (for example, the AUDIT).
Furthermore, due to the risk of suicide and medical complications that could develop as
a consequence of alcohol withdrawal, the management of the alcohol withdrawal
syndrome should be instituted immediately upon entry into custody.
There is no direct evidence that suggests added benefit of an ST regimen over an
FD regimen for children and young people. However, as the GDG believe that all
assisted withdrawal for children and young people should take place in an inpatient
Organisation and delivery of care
203

setting which should have 24-hour monitoring and care, and a tapered FD approach
should be used.
There should be a lower threshold for admission for inpatient assisted withdrawal
in older people. Further, doses of benzodiazepine medication for assisted withdrawal
may need to be reduced compared with guidelines for younger adults.
5.31 FROM EVIDENCE TO RECOMMENDATIONS: ASSISTED
WITHDRAWAL
This section draws on the preceding reviews of assisted withdrawal settings and drug
regimens; the summaries of these reviews can be found in Sections 5.29 and 5.30.
The evidence indicated that a community setting for assisted withdrawal is as clin-
ically effective and safe for the majority of patients as an inpatient or residential
setting, and it is also likely to be more cost effective. The GDG agreed that both effi-
cacy and safety outcomes were of critical importance for this review. The GDG there-
fore decided that community-based assisted withdrawal should be the first choice for
most people. However, the GDG was aware that some of those with more severe alco-
hol dependence, often with complex comorbidities, were often excluded from the
studies reviewed. Consequently, the severity and complexity of the population in
these studies was not representative of those who would typically require inpatient
withdrawal management. The GDG considered this, as well as other evidence
presented that might inform this issue, and identified a number of factors that would
indicate that a residential or inpatient setting may be preferred to a community
setting. They also considered which of the factors would suggest that assisted with-
drawal should be managed in an inpatient setting with access to 24-hour specialist
doctors and nurses with expertise in managing alcohol withdrawal in the context of
significant comorbidity. The factors the GDG considered important are as follows:
� a history of epilepsy or withdrawal-related seizures or DTs during previous
assisted withdrawal
� significant psychiatric or physical comorbidity (for example, chronic severe
depression, psychosis, malnutrition, congestive cardiac failure, unstable angina or
chronic liver disease)
� significant learning disability
� significant cognitive impairment
� a history of poor adherence and previous failed attempts
� homelessness
� pregnancy
� children and young people
� older people.
The review of drug regimens for assisted withdrawal drew on the NICE guideline on
management of alcohol-related physical complications (NICE, 2010b) for both the initial
review of the medication regimens and to ensure that there was a comprehensive and
coherent approach to assisted withdrawal across both guidelines. The GDG was, there-
fore, concerned to build on the other guideline and develop recommendations that were
Organisation and delivery of care
204

feasible for use in a range of settings, both specialist and non-specialist in inpatient, resi-
dential and community (including primary care) services. After carefully considering the
evidence, the GDG came to the conclusion that symptom-triggered assisted withdrawal
was only practical in those inpatient settings that contained 24-hour medical monitoring
and high levels of specially trained staff. The GDG therefore took the view that the
preferred method for assisted withdrawal was an FD regimen for community and resi-
dential settings. In addition, the GDG also considered how some of the complex comor-
bidities often encountered in specialist alcohol services may be best managed. In
particular the GDG were concerned to provide advice on the management of comorbid
alcohol and benzodiazepine misuse. This was of concern because the GDG recognised
the need to go above recommended BNF dosages for people who were dually depend-
ent to reduce the likelihood of seizures. In the absence of any evidence from the studies
reviewed, the GDG reached agreement on this issue by consensus.
Given the uncertainty about the severity of withdrawal symptoms, and the potential
negative consequences of withdrawal for children and young people, the GDG concluded
that there should be a lower threshold in the admission criteria for children and young
people who misuse alcohol than for adults, and that specialist advice should be made
available to the healthcare professional. The GDG also felt that it was prudent that all
assisted withdrawal for children aged 10 to 15 years take place in an acute inpatient or
residential setting with significant medical and nursing staff availability on a 24-hour
basis. For young people aged 16 to 18 years, if withdrawal management is conducted in
a community setting (that is, a non-residential setting where the young person does not
sleep in the unit), particular care needs to be taken in monitoring the young person.
The GDG did not identify any evidence evaluating different dosing regimens for
children and young people. The GDG suggest an inpatient setting with 24-hour moni-
toring for 10- to 15-year-olds for assisted withdrawal. There is a lack of clinical
evidence suggesting the appropriate dose of medication for assisted withdrawal for
children and young people as well as older people. However the GDG felt that the
dose should be lower than that provided for a working-age adult taking into consid-
eration the age, size, and gender of the individual.
Dose regimes for older people undergoing assisted withdrawal may need to be
reduced compared with guidelines for younger adults.
5.31.1 Recommendations
Assessment and interventions for assisted alcohol withdrawal
[Refer to 5.31.1.19–5.31.1.22 for assessment for assisted withdrawal in children and
young people]
5.31.1.1 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 with-
drawal, or
� assessment and management in specialist alcohol services if there are
safety concerns (see 5.31.1.5) about a community-based assisted with-
drawal.
Organisation and delivery of care
205

5.31.1.2 Service users who need assisted withdrawal should usually be offered a
community-based programme, which should vary in intensity according to
the severity of the dependence, available social support and the presence of
comorbidities.
� For people with mild to moderate dependence, offer an outpatient-
based withdrawal programme in which contact between staff and the
service user averages 2–4 meetings per week over the first week.
� For people with mild to moderate dependence and complex needs
23
, or
severe dependence, offer an intensive community programme following
assisted withdrawal in which the service user may attend a day
programme lasting between 4 and 7 days per week over a 3-week period.
5.31.1.3 Outpatient-based community assisted withdrawal programmes should
consist of a drug regimen (see 5.31.1.7–5.31.1.18) and psychosocial
support including motivational interviewing (see 6.23.1.1).
5.31.1.4 Intensive community programmes following assisted withdrawal should
consist of a drug regimen (see 7.15.1.1–7.15.1.3) supported by psychological
interventions including individual treatments (see 7.15.1.1–7.15.1.3), group
treatments, psychoeducational interventions, help to attend self-help groups,
family and carer support and involvement, and case management (see 5.11.1.2).
5.31.1.5 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:
– significant psychiatric or physical comorbidities (for example,
chronic severe depression, psychosis, malnutrition, congestive
cardiac failure, unstable angina, chronic liver disease) or
– a significant learning disability or cognitive impairment.
5.31.1.6 Consider a lower threshold for inpatient or residential assisted withdrawal
in vulnerable groups, for example, homeless and older people.
Drug regimens for assisted withdrawal
5.31.1.7 When conducting community-based assisted withdrawal programmes, use
fixed-dose medication regimens
24
.
5.31.1.8 Fixed-dose or symptom-triggered medication regimens
25
can be used in
assisted withdrawal programmes in inpatient or residential settings. If a
Organisation and delivery of care
206
23
For example, psychiatric comorbidity, poor social support or homelessness.
24
A fixed dose regimen involves starting treatment with a standard dose, not defined by the level of alco-
hol withdrawal, and reducing the dose to zero over 7 to 10 days according to a standard protocol.
25
A symptom-triggered approach involves tailoring the drug regimen according to the severity of with-
drawal and any complications. The service user is monitored on a regular basis and pharmacotherapy only
continues as long as the service user is showing withdrawal symptoms.

symptom-triggered regimen is used, all staff should be competent in moni-
toring symptoms effectively and the unit should have sufficient resources
to allow them to do so frequently and safely.
5.31.1.9 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.
5.31.1.10 Prescribe and administer medication for assisted withdrawal within a stan-
dard clinical protocol. The preferred medication for assisted withdrawal is
a benzodiazepine (chlordiazepoxide or diazepam).
5.31.1.11 In a fixed-dose regimen, titrate the initial dose of medication to the severity
of alcohol dependence and/or regular daily level of alcohol consumption. In
severe alcohol dependence higher doses will be required to adequately
control withdrawal and should be prescribed according to the Summary of
Product Characteristics (SPC). Make sure there is adequate supervision if
high doses are administered. Gradually reduce the dose of the benzodi-
azepine over 7–10 days to avoid alcohol withdrawal recurring
26
.
5.31.1.12 Be aware that benzodiazepine doses may need to be reduced for children
and young people
27
, older people, and people with liver impairment (see
5.31.1.13).
5.31.1.13 If benzodiazepines are used for people with liver impairment, consider one
requiring limited liver metabolism (for example, lorazepam); start with a
reduced dose and monitor liver function carefully. Avoid using benzodi-
azepines for people with severe liver impairment.
5.31.1.14 When managing withdrawal from co-existing benzodiazepine and alcohol
dependence increase the dose of benzodiazepine medication used for
withdrawal. Calculate the initial daily dose based on the requirements for
alcohol withdrawal plus the equivalent regularly used daily dose of
benzodiazepine
28
. This is best managed with one benzodiazepine (chlor-
diazepoxide or diazepam) rather than multiple benzodiazepines. Inpatient
withdrawal regimens should last for 2–3 weeks or longer, depending on the
severity of co-existing benzodiazepine dependence. When withdrawal is
managed in the community, and/or where there is a high level of benzodi-
azepine dependence, the regimen should last for longer than 3 weeks,
tailored to the service user’s symptoms and discomfort.
Organisation and delivery of care
207
26
See Table 21.
27
At the time of publication of the NICE guideline (February 2011), benzodiazepines did not have UK
marketing authorisation for use in children and young people under 18. Informed consent should be
obtained and documented.
28
At the time of publication of the NICE guideline (February 2011), benzodiazepines did not have UK
marketing authorisation for this indication or for use in children and young people under 18. Informed
consent should be obtained and documented. This should be done in line with normal standards of care for
patients who may lack capacity (see www.publicguardian.gov.uk or www.wales.nhs.uk/consent) or in line
with normal standards in emergency care.

5.31.1.15 When managing alcohol withdrawal in the community, avoid giving
people who misuse alcohol large quantities of medication to take home to
prevent overdose or diversion
29
. Prescribe for installment dispensing, with
no more than 2 days’ medication supplied at any time.
5.31.1.16 In a community-based assisted withdrawal programme, monitor the serv-
ice user every other day during assisted withdrawal. A family member or
carer should preferably oversee the administration of medication. Adjust
the dose if severe withdrawal symptoms or over-sedation occur.
5.31.1.17 Do not offer clomethiazole for community-based assisted withdrawal
because of the risk of overdose and misuse.
5.31.1.18 For managing unplanned acute alcohol withdrawal and complications
including delirium tremens and withdrawal-related seizures, refer to NICE
clinical guideline 100.
Special considerations for children and young people who misuse alcohol –
assessment and referral
5.31.1.19 If alcohol misuse is identified as a potential problem, with potential physi-
cal, 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 harm-
ful effects of a given level of alcohol consumption in this population)
� any associated health and social problems
� the potential need for assisted withdrawal.
5.31.1.20 Refer all children and young people aged 10–15 years to a specialist child and
adolescent mental health service (CAMHS) for a comprehensive assessment
of their needs, if their alcohol misuse is associated with physical, psycholog-
ical, educational and social problems and/or comorbid drug misuse.
5.31.1.21 When considering referral to CAMHS for young people aged 16-17 years
who misuse alcohol, use the same referral criteria as for adults (see
5.26.1.8–5.26.1.18).
5.31.1.22 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 vali-
dated 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
Organisation and delivery of care
208
29
When the drug is being taken by someone other than for whom it was prescribed.

� 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.
5.31.2 Research recommendation
5.31.2.1 What methods are most effective for assessing and diagnosing the presence
and severity of alcohol misuse in children and young people?
This question should be answered in a programme of research that uses a cross-
sectional cohort design testing:
� the sensitivity and specificity of a purpose-designed suite of screening and case
identification measures of alcohol misuse against a diagnostic gold standard
(DSM–IV or ICD–10)
� the reliability and validity of a purpose-designed suite in characterising the nature
and the severity of the alcohol misuse in children and young people and their
predictive validity in identifying the most effective treatment when compared with
current best practice.
Particular attention should be paid to the feasibility of the measures in routine care and
the training required to obtain satisfactory levels of accuracy and predictive validity. The
programme needs to be large enough to encompass the age range (10 to 17 years) and
the comorbidity that often accompanies alcohol misuse in children and young people.
Why this is important
Alcohol misuse is an increasingly common problem in children and young people.
However, diagnostic instruments are poorly developed or not available for children
and young people. In adults there is a range of diagnostic and assessment tools (with
reasonable sensitivity and specificity, and reliability and validity) that are recom-
mended for routine use in the NHS to both assess the severity of the alcohol misuse
and to guide treatment decisions. No similar well-developed measures exist for chil-
dren and young people, with the result that problems are missed and/or inappropriate
treatment is offered. The results of this study will have important implications for the
identification and the provision of effective treatment in the NHS for children and
young people with alcohol-related problems.
5.32 RESIDENTIAL AND COMMUNITY SETTINGS FOR THE
DELIVERY OF INTERVENTIONS FOR ALCOHOL MISUSE
5.32.1 Introduction
This section assesses the settings that are most clinically and cost effective in the deliv-
ery of interventions to reduce alcohol consumption, promote abstinence and reduce
Organisation and delivery of care
209

relapse. In the UK most such interventions are provided in community settings, usually
by a specialist alcohol team. However, some services are provided in residential
settings, usually following a period of residential assisted withdrawal. There is consid-
erable debate in the UK regarding the value of residential treatment and, specifically,
for which alcohol-related problems a residential unit is most appropriate.
As with the previous reviews, caution is needed in the assessment and interpretation
of the evidence as it is possible that some of the most severely dependent patients may
have been excluded from the studies (for example, Pettinati et al., 1993). In addition, as
others have identified, it is possible to confuse the setting with treatment intensity and
duration (for example, Finney et al., 1996; Mosher et al., 1975). Another problem arises
when separating the benefits of a period of inpatient or residential assisted withdrawal
from the effects of continued residential psychosocial treatment (see Walsh et al., 1991).
Also, as is the case when evaluating many complex interventions, it is difficult to iden-
tify which elements of the intervention are mutative; for example McKay and colleagues
(1995) and Rychtarik and colleagues (2000a) evaluated the same treatment in both resi-
dential and non-residential settings and reported that the milieu (that is, living in the resi-
dential setting for 24 hours a day) added little to the likelihood of a positive outcome of
treatment. Relatively few studies in the area report differential outcomes based on patient
characteristics, but the picture that does emerge is reasonably consistent. The most
commonly studied predictor variables in the treatment of alcohol dependence have been
measures of alcohol problem severity and social stability. More severe and less socially
stable patients who misuse alcohol seem to fare better in inpatient (or more intensive
treatment), whereas among married patients with stable accommodation, fewer years of
problem drinking, and less history of treatment, outpatient (and less intensive) treatment
yields more favourable outcomes than inpatient treatment (Kissin et al., 1970; McLellan
et al., 1983; Orford et al., 1976; Smart et al., 1977; Stinson, 1970; Willems et al., 1973).
Finally, some studies provide limited descriptions of the interventions (in particular the
comparator interventions) and this, along with the different healthcare systems in which
the studies took place, makes interpretation of the evidence challenging.
5.32.2 Clinical review protocol
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Table 25 (further information about the
search for health economic evidence can be found in Chapter 3).
5.32.3 Studies considered
30
The review team conducted a new systematic search for RCTs that assessed the bene-
ficial and detrimental effects of different settings for the delivery of alcohol treatment
Organisation and delivery of care
210
30
Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
tal letters (primary author and date of study publication, except where a study is in press or only submit-
ted for publication, then a date is not used).

interventions after an assisted withdrawal programme and related health economic
evidence (see Section 5.29.7).
A variety of different treatment settings are described in the research literature.
Services were designated as: inpatient units; residential units; day hospitals (also
known as partial hospitalisation or day centres); or outpatient based interventions of
differing intensity and duration (involving attendance at an outpatient clinic, home
visits, a combination of both, or containing some limited elements of a day
programme). These are in line with the definitions set out in Section 1 of this chapter).
It is also important to note that most of the studies included in this review are North
American, with few studies conducted in the UK or Europe. They cover a diverse range
of populations, including some very specific samples (that is, employment schemes, VA
populations), which may limit generalisability to the UK treatment population.
Fourteen trials met the eligibility criteria set by the GDG, providing data on 2,679
participants. All of the studies were published in peer-reviewed journals between
1972 and 2005. Summary study characteristics of the included studies are presented
in Table 26. (Further information about both included and excluded studies can be
found in Appendix 16c).
A meta-analyses was conducted for an adult population only as there was not
enough evidence to perform a meta-analysis for children and young people.
Residential units versus outpatient treatment
Of the 14 included trials, three involved a comparison of residential units versus
outpatient treatment. RYCHTARIK2000A compared a residential unit versus an
outpatient setting; CHAPMAN1988 compared a 6-week inpatient programme with a
6 week outpatient programme. WALSH1991 compared compulsory inpatient treat-
ment versus compulsory attendance at AA; this study was atypical in that the sample
Organisation and delivery of care
211
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane Library
Date searched Database inception to March 2010
Study design Systematic reviews; RCTs. Systematic reviews from 1993 to
March 2010. All other searches from database inception to
March 2010
Patient population Diagnosed with having an alcohol-use disorder (alcohol
dependence or harmful alcohol use)
Interventions Residential treatment settings versus community treatment
settings; duration of residential treatment (long versus short)
Outcomes Relapse; lapse (non-abstinence); number of participants
consuming alcohol; PDA; drinking frequency measures
(for example, mean number of drinking days, number of intoxi-
cated days, number drinking daily); quantity of alcohol meas-
ures (for example, DDD)
Table 25: Databases searched and inclusion/exclusion criteria for clinical evidence

Organisation and delivery of care
212
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t

a
v
a
i
l
a
b
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(
6
)

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D
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(
3
0

d
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p
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a
d
m
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)

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1
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(
6
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9
)
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h
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p
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2
6
.
6

(
3
2
.
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(
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6

(
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h
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p
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6

(
2
8
.
9
)
(
7
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N
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v
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T
r
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m
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l
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(
1
)

6

w
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k
s
(
1
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R
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:

2
8

t
o

3
1

d
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s
(
1
)

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n
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:

2
2
.
7
7

2
8

d
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(
1
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9

d
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v
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2
1

d
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(
2
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2
8

d
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(
2
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R
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:

2

t
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3

w
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k
s
d
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t
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1
2

w
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k
s
(
2
)

7

t
o

2
0

d
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s

v
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s
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3

(
3
)

3

w
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k
s
(
3
)

(
6
)

R
a
n
g
e
:

2
8

t
o

(
2
)

R
a
n
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:

2
8

t
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3
1

d
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s
t
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6

w
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k
s
3
1

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(
3
)

9

d
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v
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2
1

d
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(
7
)

D
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h
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p
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:

2

t
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3

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:

u
p

t
o

6
0

d
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s
C
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d
Organisation and delivery of care
213

Organisation and delivery of care
214
R
e
s
i
d
e
n
t
i
a
l

u
n
i
t

R
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s
i
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D
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h
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p
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R
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u
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S
h
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d
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v
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v
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v
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d
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h
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p
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t
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u
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d
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t
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p
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L
e
n
g
t
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o
f

f
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l
l
o
w
-
(
1
)

6

a
n
d

1
8

m
o
n
t
h
s
(
1
)

N
o
t

a
v
a
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l
a
b
l
e
(
1
)

3
,

6

a
n
d

9

m
o
n
t
h
s
1
2

m
o
n
t
h
s
(
1
)

3

a
n
d

6

m
o
n
t
h
s
u
p

(
i
f

a
v
a
i
l
a
b
l
e
)
(
2
)

6
,

9
,

1
2
,

1
5

a
n
d

(
2
)

6
,

1
2
,

1
8

a
n
d

(
2
)

6
,

9
,

1
2
,

1
5

a
n
d

(
2
)

3

a
n
d

1
2

m
o
n
t
h
s
1
8

m
o
n
t
h
s
2
4

m
o
n
t
h
s
1
8

m
o
n
t
h
s
(
3
)

2
,

4
,

7
,

1
0

a
n
d

1
3

(
3
)

1
,

3
,

6
,

1
2
,

1
8

a
n
d

2
4

(
3
)

3
,

6

a
n
d

1
2

m
o
n
t
h
s
m
o
n
t
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m
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t
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s

p
o
s
t
-
t
r
e
a
t
m
e
n
t
(
4
)

1
2

m
o
n
t
h
s
(
5
)

6
,

9
,

1
2
,

1
5

a
n
d

1
8

m
o
n
t
h
s
(
6
)

3
,

6
,

9

a
n
d

1
2

m
o
n
t
h
s
(
7
)

6

a
n
d

1
2

m
o
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A
b
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r

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-
(
1
)

(
2
)

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a
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a
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a
b
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a
b
s
t
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p
r
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r

(
3
)

N
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-
a
b
s
t
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n
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t
o

t
r
i
a
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(
4
)

(
5
)

N
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t

a
v
a
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l
a
b
l
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(
6
)

C
o
m
b
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e
d

w
i
t
h

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n
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t
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p
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a
s
s
i
s
t
e
d

w
i
t
h
d
r
a
w
a
l
(
7
)

N
o
t

a
v
a
i
l
a
b
l
e
C
o
u
n
t
r
y
(
1
)

N
e
w

Z
e
a
l
a
n
d
(
1
)

(
3
)

U
S
(
1
)

(
2
)

U
S
F
i
n
l
a
n
d
(
1
)

(
3
)

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S
(
2
)

(
3
)

U
S
(
4
)

C
a
n
a
d
a
(
5
)

U
S
(
6
)

G
e
r
m
a
n
y
(
7
)

U
S
T
a
b
l
e

2
6
:
(
C
o
n
t
i
n
u
e
d
)

consisted of workers at an industrial plant in the US who were part of an employee
assistance programme and whose jobs were at risk should they fail to attend treat-
ment. A 3-week period of residential treatment was followed by a year of job proba-
tion, during which attendance at AA meetings at least three times per week, sobriety
at work and weekly checks with the programme staff were compulsory if the person
wanted to keep their job. The outpatient treatment group were referred and offered an
escort to a local AA meeting, which they were advised to continue attending at least
three times a week for a year. They were treated in the same way as participants in
the residential group for the following year.
Residential units versus day hospital
Of the 14 included trials, seven (BELL1994; LONGABAUGH1983; MCKAY1995;
MCLACHLAN1982; RYCHTARIK2000A; WEITHMANN2005; WITBRODT2007)
involved a comparison of residential rehabilitation units versus day hospital. All seven
trials had a 28-day length of stay in treatment. Both MCKAY1995 and
WITBRODT2007 looked at day hospital versus residential rehabilitation treatment,
with the populations being split into a self-selected arm and a randomised arm.
Day hospital versus outpatient treatment
Two trials out of the 14 involved a comparison of day hospital versus outpatient treat-
ment (MORGENSTERN2003; RYCHTARIK2000A).
Residential unit versus residential unit
Of the 14 included trials, one (KESO1990) involved a comparison of two different
types of residential treatment, assessing the efficacy of two different therapeutic
approaches. The Kalliola programme was based on the Hazelden or Minnesota
model, with a focus on AA 12-step principles with abstinence as the designated treat-
ment goal, whereas the Jarvenpaa programme was a more traditional approach to resi-
dential rehabilitation without the focus on AA 12-step principles.
Short versus long duration inpatient treatment
Three of the 14 trials involved a comparison of different lengths of admission to inpa-
tient treatment. MOSHER1975 compared a 9-day versus a 30-day inpatient stay.
STEIN1975 compared a 9-day residential inpatient stay with a 9-day stay with an
additional 25 days of residential rehabilitative care. PITTMAN1972 compared a
group receiving 7 to 10 days of inpatient care only with 3 to 6 weeks of inpatient care
with an additional option of further outpatient aftercare.
5.32.4 Clinical evidence for residential and community settings for the
delivery of alcohol treatment interventions
Evidence from the important outcomes and overall quality of evidence are presented
in Table 27, Table 28, Table 29, Table 30 and Table 31. The associated forest plots are
in Appendix 17b.
Organisation and delivery of care
215

Organisation and delivery of care
216
O
u
t
c
o
m
e

o
r

s
u
b
g
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p
k
T
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t
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S
t
a
t
i
s
t
i
c
s
E
f
f
e
c
t

(
9
5
%

C
I
)
Q
u
a
l
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t
y

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f

t
h
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v
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d
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n
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(
G
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)
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A

a
t

3
-
m
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t
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f
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u
p
1
1
1
9
S
M
D

(
I
V
,

R
a
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m
,

9
5
%

C
I
)
0
.
2
2

(
-
0
.
1
4
,

0
.
5
8
)




M
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a
t

3
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m
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9
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%

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(
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3
4
,

0
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3
8
)




H
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p
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%

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0
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2

(
0
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6
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1
.
3
2
)




M
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p
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1
8
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m
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8
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(
M
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R
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9
5
%

C
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1
.
3
0

(
0
.
8
7
,

1
.
9
5
)




M
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a
p
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(
n
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m
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o
f

p
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n
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a
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t

2
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r

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1
5
6
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(
M
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,

R
a
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m
,

9
5
%

C
I
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0
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7
6

(
0
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6
1
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0
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9
4
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H
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f
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p
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d
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k
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6
0
g

a
b
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1
4
6
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(
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9
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C
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6
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(
0
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2
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6
6
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a
l
c
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d
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k
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d
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a
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M
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6
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m
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f
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p
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6
0
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a
b
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1
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8
R
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(
M
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,

R
a
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d
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m
,

9
5
%

C
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0
.
6
6

(
0
.
2
9
,

1
.
4
8
)




a
l
c
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h
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l

o
n

a

d
r
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n
k
i
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g

d
a
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a
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M
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A
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1
8
-
m
o
n
t
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f
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l
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w
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u
p
T
a
b
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2
7
:
R
e
s
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t
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u
n
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t

v
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t
r
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t

O
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t
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m
e

o
r

s
u
b
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r
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p
k
T
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t
a
l

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t
a
t
i
s
t
i
c
s
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f
f
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c
t

(
9
5
%

C
I
)
Q
u
a
l
i
t
y

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f

t
h
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e
v
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n
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(
G
R
A
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)
A
b
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t
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A

a
t

3
-
m
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f
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p
1
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1
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(
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,

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a
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m
,

9
5
%

C
I
)
0
.
2
3

(
-
0
.
1
3
,

0
.
5
9
)




M
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R
A
T
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A
l
c
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h
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l

c
o
n
s
u
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p
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c
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s
2
1
6
9
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(
I
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,

R
a
n
d
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m
,

9
5
%

C
I
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u
b
t
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t
a
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s

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n
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D
r
i
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k
s

p
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d
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k
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d
a
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t

1
1
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1
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(
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,

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9
5
%

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I
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(
-
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3
4
,

0
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3
7
)




3
-
m
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t
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f
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p
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%

C
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3
3

(
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2
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,

0
.
9
0
)




a
t

3
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m
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f
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,

R
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9
5
%

C
I
)
0
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7
6

(
0
.
1
7
,

1
.
3
5
)




a
t

6
-
m
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n
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f
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,

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a
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,

9
5
%

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I
)
0
.
5
1

(
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t

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9
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M
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2
8
:
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u
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v
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h
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p
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t
a
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C
o
n
t
i
n
u
e
d
Organisation and delivery of care
217

Organisation and delivery of care
218
O
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t
c
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m
e

o
r

s
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p
k
T
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(
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%

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f
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3
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8
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1
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1
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y




M
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d
a
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6
-
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f
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M
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H
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9
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m
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s

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f

t
r
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a
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n
t
)
Organisation and delivery of care
219

Organisation and delivery of care
220
O
u
t
c
o
m
e

o
r

s
u
b
g
r
o
u
p
k
T
o
t
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E
f
f
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t

(
9
5
%

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I
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Q
u
a
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t
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f

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v
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n
c
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(
G
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A
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)
L
a
p
s
e

(
n
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n
-
a
b
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t
i
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n
c
e
)

3
5
1
3
R
R

(
M
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,

R
a
n
d
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m
,

9
5
%

C
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b
t
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a
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s

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n
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y
P
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t
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t
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a
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3
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M
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6
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m
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f
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p
1
2
0
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R

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0
5

(
0
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9
1
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1
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2
1
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M
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A
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t

7
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m
o
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t
h

f
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l
l
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w
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p

1
5
8
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R

(
M
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,

R
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m
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9
5
%

C
I
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0
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8
6

(
0
.
6
0
,

1
.
2
3
)




M
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A
t

1
0
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m
o
n
t
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f
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1
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M
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m
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5
%

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8
2

(
0
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5
8
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1
.
1
6
)




M
O
D
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A
T
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A
t

1
3
-
m
o
n
t
h

f
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l
l
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w
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u
p
1
5
8
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R

(
M
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,

R
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n
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m
,

9
5
%

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I
)
0
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9
5

(
0
.
6
4
,

1
.
4
0
)




M
O
D
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R
A
T
E
N
u
m
b
e
r

c
o
n
s
u
m
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n
g

a
l
c
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h
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l

6
0
%

1
2
0
0
R
R

(
M
-
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,

R
a
n
d
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m
,

9
5
%

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9
5

(
0
.
7
8
,

1
.
1
4
)




t
o

9
0
%

o
f

t
h
e

t
i
m
e

a
t

3
-
m
o
n
t
h

M
O
D
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R
A
T
E
f
o
l
l
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w
-
u
p
N
u
m
b
e
r

c
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n
s
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m
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n
g

a
l
c
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l

6
0
%

1
2
0
0
R
R

(
M
-
H
,

R
a
n
d
o
m
,

9
5
%

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1
.
0
9

(
0
.
9
1
,

1
.
3
0
)




t
o

9
0
%

o
f

t
i
m
e

a
t

6
-
m
o
n
t
h

M
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D
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R
A
T
E
f
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l
l
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w
-
u
p
N
u
m
b
e
r

c
o
n
s
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m
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n
g

a
l
c
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h
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l

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e
s
s

1
2
0
0
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(
M
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,

R
a
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m
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9
5
%

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0
1

(
0
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8
2
,

1
.
2
4
)




t
h
a
n

6
0
%

o
f

t
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m
e

a
t

3
-
m
o
n
t
h

M
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D
E
R
A
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f
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w
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u
p
N
u
m
b
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r

c
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n
s
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a
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c
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s

1
2
0
0
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(
M
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H
,

R
a
n
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m
,

9
5
%

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8
2

(
0
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6
1
,

1
.
0
9
)




t
h
a
n

6
0
%

o
f

t
i
m
e

a
t

6
-
m
o
n
t
h

M
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D
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R
A
T
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f
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l
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w
-
u
p
T
a
b
l
e

3
1
:
S
h
o
r
t

v
e
r
s
u
s

l
o
n
g
e
r

d
u
r
a
t
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n

i
n
p
a
t
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e
n
t

t
r
e
a
t
m
e
n
t

5.32.5 Clinical evidence summary
Residential unit versus outpatient treatment
Residential unit treatment was no more effective than an outpatient treatment in main-
taining abstinence or in reducing the number of DDD at 3-month follow-up
(RYCHTARIK2000A). Furthermore, there was no significant difference observed
between treatment in a residential unit and a day hospital in reducing the number of
participants drinking more than 60 g of alcohol per drinking day at 6-month follow-
up (CHAPMAN1988).
A residential unit setting was significantly more effective than an outpatient
setting in increasing the number of participants abstinent at 2-year follow-up in only
one study (WALSH1991). This study population was atypical and is unlikely to be
representative of patients attending UK alcohol treatment services, and the study
included treatment elements that would be difficult to replicate in the UK.
Based on the GRADE method outlined in Chapter 3, the quality of this evidence
is moderate and further research is likely to have an important impact on the confi-
dence in the estimate of the effect and may change the estimate (for further informa-
tion, see Table 27).
Residential unit versus day hospital
On measures of alcohol consumption, there was no significant difference between a
residential unit and a day hospital on DDD day at 3-month follow-up. At 6-month
follow-up, there was a significant difference between the two groups favouring day
hospital treatment on mean number of drinking days, based on the results of the
MCKAY1995 study. This effect did not remain at 12-month follow-up, however
there was a trend (p = 0.08) slightly favouring day hospital treatment. It should be
noted that this study had both a randomised and self-selected sample, and, because
inclusion into this analysis was restricted to RCTs, only the randomised population
was used. However, the results from the self-selected sample parallel the results from
the randomised arm. The self-selected participants did not do any better on drinking
outcomes than those who were randomly assigned at 6- or 12-month follow-up. Any
differences that did emerge from the self-selected group, tended to favour the partial
hospitalisation group (day hospital), as found in the randomised sample.
On rates of relapse or lapse to alcohol at 6 and 12 months post-treatment, there
were no significant differences between residential unit and day hospital treatment.
Additionally, there were no significant differences in the number of participants
drinking daily at 6-month follow-up (LONGABAUGH1983), or in the PDA at
3-month follow-up (RYCHTARIK2000A).
One study found that more participants were retained in treatment in the residen-
tial setting than the day hospital setting (BELL1994). However, this study included a
mixture of participants with primary drug and alcohol misuse problems, and so the
results may not be representative of individuals presenting to an alcohol treatment
service.
Based on the GRADE methodology outlined in Chapter 3, the quality of this
evidence is moderate and further research is likely to have an important impact on the
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confidence in the estimate of the effect and may change the estimate (for further
information see Table 28).
Day hospital versus outpatient treatment
A day hospital was not found to be any more effective than a less intensive outpatient
setting in terms of PDA or DDD at 3-month follow-up. However, it is important to
consider that the MORGENSTERN2003 study contained a mixture of both primary
drug and alcohol users, so these results may not be generalisable to the wider popu-
lation presenting for treatment of alcohol problems.
Based on the GRADE methodology outlined in Chapter 3, the quality of this
evidence is moderate to high and further research is likely to have an important
impact on the confidence in the estimate of the effect and may change the estimate
(for further information, see Table 29).
Residential unit versus residential unit
When analysing two different therapeutic approaches to residential treatment, no
difference was found between the two different residential treatment models (Kalliola
and Jarvenpaa) on reducing the number of participants who relapsed between 4- and
12-month follow-up.
Based on the GRADE methodology outlined in Chapter 3, the quality of this
evidence is moderate and further research is likely to have an important impact on the
confidence in the estimate of the effect and may change the estimate (for further
information, see Table 30).
Short duration versus longer duration level (inpatient)
There was no significant difference between a 21-day inpatient stay and an extended
9-day inpatient stay at reducing the number of participants consuming alcohol post-
treatment, or at 3- or 6-month follow-up (MOSHER1975). A longer duration in an
inpatient setting was no more effective in preventing lapse (non-abstinence) than a
shorter duration in an inpatient setting. No effect remained at 6-, 7-, 10- and 13-month
follow-up.
Based on the GRADE methodology outlined in Chapter 3, the quality of this
evidence is moderate and further research is likely to have an important impact on the
confidence in the estimate of the effect and may change the estimate (for further
information, see Table 31).
5.32.6 Additional trials assessing different treatment settings
Randomised controlled trials
There are several additional studies that were well-conducted trials but could not be
included in meta-analyses and did not evaluate the treatment settings as defined
above. These studies nevertheless found similar results that support this meta-
analysis. Chick (1988) compared simple advice with amplified advice (simple
advice plus one session of motivational interviewing) with extended treatment,
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which included the offer of further outpatient appointments, inpatient, or day treat-
ment. There were no differences between the advice groups or the extended treat-
ment on abstinence outcomes at 2-year follow-up, nor on drinking frequency
outcomes. There were no significant differences found on alcohol consumed in 7
days prior to follow-up, frequency of drinking over 200 g per day in the past year,
period of abstinence in the past year, or on other measures such as employment or
marital situation. Edwards and Guthrie (1966) assigned participants to an average
of 9 weeks of inpatient or outpatient treatment, and found no significant differences
on measures of drinking at 6- and 12-month follow-up. Lastly, Eriksen (1986a)
assigned 17 ‘alcoholics’ who were post-assisted withdrawal to either immediate
inpatient treatment or a 4-week waitlist control. Results indicated no significant
differences between groups on outcomes of days drinking, or on other outcomes
such as sick leave or institutionalisation.
Predictor studies
Even in the absence of overall differences in treatment outcomes between residen-
tial and outpatient settings, it is possible that certain types of patients derive differ-
ential benefits or harms from being treated in these alternative settings. This is the
central issue in matching patients to optimal treatment approaches. Relatively few
of the above studies report differential outcome based on patient characteristics,
but a reasonably consistent picture does emerge – although it should be pointed out
this is often based on post hoc analysis of non-randomised populations and so
should be treated with caution. The GDG considered this issue, the main evidence
points of which are summarised below; in doing so the GDG drew on the existing
systematic review developed by the Specialist Clinical Addiction Network
(Specialist Clinical Addiction Network, 2006) for the consensus statement on in-
patient treatment.
The most commonly studied predictor variables in the treatment of alcohol
dependence have been measures of problem severity and social stability. More
severe and less socially stable patients who misuse alcohol seem to fare better in
inpatient or more intensive treatment (possibly outpatient based), whereas among
married patients with stable accommodation, fewer years of problem drinking and
less history of treatment, outpatient (and less intensive) treatment yields more
favourable outcomes than inpatient treatment (Kissin et al., 1970; McLellan et al.,
1983; Orford et al., 1976; Smart, 1977; Stinson, 1979; Willems, 1973). When
heterogeneous populations of people who misuse alcohol are averaged together,
the consistent finding is of comparable (or better) outcomes from outpatient as
opposed to residential treatment (McLellan et al., 1983). Moos and colleagues
(1999) found in an effectiveness trial of inpatient treatment of different theoretical
orientations within the VA treatment system that longer lengths of stay were asso-
ciated with better outcomes. Likewise, in Project MATCH, patients who received
inpatient treatment prior to 12 weeks of outpatient care had better drinking
outcomes than those who went directly into outpatient care (Project MATCH
Research Group, 1997).
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5.32.7 Special populations
No clinical evidence evaluating the efficacy of different settings for the treatment of
alcohol misuse were identified for children, young people or older populations.
5.32.8 Health economic evidence
Systematic literature review
One study was identified in the systematic search of the economic literature that
considered the cost effectiveness of different settings for rehabilitation treatment for
people with an alcohol-use disorder (alcohol dependence or harmful alcohol use)
(Pettinati et al., 1999). Details of the methods used for the systematic search of the
economic literature are described in Chapter 3.
The study by Pettinati and colleagues (1999) assessed the cost-effectiveness of
inpatient versus outpatient treatment of people with alcohol dependence. Both inpa-
tient and outpatient treatment programmes followed the same multi-modal clinical
approach based on the traditional 12-step programme of AA. This involved individ-
ual, marital, family and group counselling provided in the intensive treatment
period, including 4 weeks of inpatient and 6 weeks of outpatient treatment. The
primary difference between the inpatient and outpatient programmes was the
amount of treatment hours and attendance at support groups. Inpatients attended
educational and therapy sessions from 9 a.m. to 5 p.m., and attended an AA meet-
ing in the evening, whilst outpatients were expected to attend individual and/or
group sessions approximately one to two evenings a week, and AA meetings on the
evenings that they did not attend therapy sessions as well as a family educational
programme at the weekends. The study population consisted of 173 patients with a
formal diagnosis of alcohol dependence but no other substance dependence. The
primary outcome measure used in the study was the probability of returning to
significant drinking over 12 months. This was defined as three or more alcoholic
drinks in one sitting, admission to an inpatient or detoxification centre or incarcer-
ation due to alcohol-related disorders. A US healthcare payer perspective was
adopted for the analysis. Resource use and cost items included the total number of
treatment service hours attended during the intensive treatment programme each
week via interviews with the subject. A weighted cost-to-charge ratio was applied
to the billing charges for services to adjust for geographic- or institution-specific
charges.
Rather than calculate ICERs, the authors presented cost-effectiveness ratios by
dividing treatment costs by the probability of returning to significant drinking. For
treatment responders, the inpatient:outpatient cost-effectiveness ratio was calculated
for the 3-month follow-up as 4.5:1, at the 6-month follow-up as 5.3:1 and at the
12-month follow-up as 5.6:1. For treatment responders, the mean (SD) cost of
successfully completing inpatient treatment was $9,014 ($2,986) versus $1,420
($619), (p �0.01); a ratio of 6.5:1. The validity of the study findings are limited it
was based on a non-randomised study design within the US healthcare system which
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may not be generalisable to the UK setting. Only the costs of treatment were
included in the cost analysis, with no consideration of any subsequent healthcare and
very little detail was given by the authors on resource use and cost estimation.
Finally, health outcomes, which were not formally combined with cost differences
to compute ICERs.
Cost analysis of rehabilitation treatment in different settings
The cost effectiveness of rehabilitation treatment for people with an alcohol-use
disorder in different settings was considered by the GDG as an area with potentially
significant resource implications. A formal economic evaluation comparing different
rehabilitation settings was not attempted due to time constraints and problems in
synthesising relevant clinical evidence. Nevertheless, a cost analysis was undertaken
to estimate costs associated with rehabilitation treatment of people who misuse alco-
hol in different settings in the UK. The results of this analysis were considered by the
GDG alongside the findings of the clinical effectiveness review, to make a judgement
regarding the cost effectiveness of different settings for rehabilitation treatment.
Two different settings for rehabilitation treatment were considered in the analysis:
residential settings and day hospital (partial hospitalisation) settings. The healthcare
resource-use estimates for each setting were based on descriptions of resource use in
studies included in the systematic literature review of clinical evidence. Studies
conducted in the UK were limited in this review. Therefore, resource-use estimates
from studies conducted outside the UK were refined using the expert opinion of the
GDG to reflect current routine clinical practice within the NHS. The estimated
resource use was subsequently combined with national unit costs to provide a total
cost associated with rehabilitation treatment in the three settings assessed. Unit costs
were derived from national sources (Curtis, 2009; Department of Health, 2010) and
reflected 2009 prices.
Residential treatment unit
The duration of treatment in this setting has been reported to vary from 4 weeks
(Sannibale et al., 2003) to 60 days (Zemore & Kaskutas, 2008). Both studies were
conducted outside the UK. The GDG estimated that residential treatment typically
lasts 12 weeks (3 months) in the UK setting. No unit costs for residential treatment
for people with an alcohol-use disorder provided within the NHS are available.
Residential units for people who misuse drugs/alcohol provided by the voluntary
sector cost £808 per resident week (Curtis, 2009). By combining estimated duration
of residential treatment with the respective unit cost, the total cost of residential reha-
bilitation treatment is estimated at £9,696.
Day hospital treatment
According to Zemore and Kaskutas (2008) and McKay and colleagues (1995), the
duration of rehabilitation treatment taking place in day hospitals ranges between
2 and 4 weeks. The GDG considered 4 weeks to be a reasonable duration of day
hospital rehabilitation in the UK. McKay and colleagues (1995) reported that partic-
ipants in their study attended a day hospital 5 days per week. The GDG estimated that
Organisation and delivery of care
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frequency of attendance in day hospital rehabilitation should be between 5 and 7 days
per week. UK unit costs of such services are not available. The NHS unit cost of
mental health day care is £102 per attendance (Department of Health, 2010).
However, this facility is likely to provide, on average, non-specialist services and
therefore this unit cost is expected to be somewhat lower than the cost of a day
hospital rehabilitation service. On the other hand, Parrott and colleagues (2006)
reported a local unit cost of a day hospital assisted withdrawal and rehabilitation
service for people who are alcohol dependent of £129 per day (uplifted from the
originally reported cost of £109 per day in 2004 prices, using the Hospital and
Community Health Services pay and prices inflation indices provided in Curtis,
2009). Using the range of these two unit costs and combining them with the esti-
mated resource use, the total cost of a day hospital rehabilitation treatment for
people who misuse alcohol is estimated to range from £2,040 (for a 5-day per week
programme, using the lower unit cost) to £3,612 (for a 7-day per week programme,
using the higher unit cost).
Summary
The cost analysis indicates that, as expected, day hospital treatment is less costly than
residential rehabilitation.
5.32.9 Clinical and health economic evidence summary
A range of treatment settings were reviewed for treatment taking place after an
assisted withdrawal programme. These included: inpatient facilities, residential units,
outpatient treatment, and day hospital treatment. For all the treatment settings, the
evidence in support of them was assessed to be of a high or moderate quality using
GRADE profiles.
Overall, inpatient settings were not seen as any more effective than outpatient, or
day hospital settings. The exception to this was that day hospital settings were
favoured over inpatient settings in one study on improving drinking outcomes at
6- and 12-month follow-up. Additional time in an inpatient setting did not improve
outcomes and a standard, shorter inpatient stay seemed to be equally as effective.
Furthermore, three studies (BELL1994; MORGENSTERN2003; WITBRODT2007)
included people who misused both drugs and alcohol, and it can be difficult to disentan-
gle the effects for those with a primary alcohol-misuse problem. However, alcohol data
were reported separately from other substances and it was possible to use these data in
this review.
The studies also include a wide range of different programmes. For example, the
nature of the outpatient programmes in these studies varied considerably in content,
duration and intensity. However, the results of the meta-analysis are in line with the
findings of previous reviews assessing the effectiveness of residential versus non-
residential treatment (for example, Finney et al., 1996). A cost analysis undertaken
for this guideline indicated that day hospital treatment incurs considerably lower
costs than residential treatment.
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Taking both cost and clinical effectiveness evidence into account, these results
suggest that once an assisted withdrawal programme has been completed a psychoso-
cial treatment package delivered in a non-residential day hospital or community treat-
ment programme
31
is likely to be the more cost-effective option.
5.32.10 From evidence to recommendations
The GDG conducted a systematic review evaluating the efficacy of residential and
community settings for the delivery of interventions for alcohol misuse. A meta-analysis
was conducted evaluating drinking related critical outcomes identified by the GDG
such as relapse, lapse, drinking frequency and drinking quantity. The evidence from
this review suggests that community settings are at least as effective as residential units
and less costly in providing effective treatment alcohol misuse. The evidence did not
show any additional benefit of residential-based interventions. The GDG therefore
recommend a community setting as the preferred setting for delivering effective treat-
ment. For some of the more severely dependent patients there is some evidence to
suggest that more intensive programme are more effective, but the GDG took the view
that these intensive programme can also be provided in the community in the form of
day hospital or similarly intensive community-based programmes. The GDG took the
view that a small number of people who are alcohol dependent may benefit from resi-
dential treatment after assisted withdrawal and identified the homelessness as such a
group. It should be noted that the evidence base is this topic areas is limited for a
number of reasons. Firstly, the clinical studies use varied descriptions of the settings
evaluated. Secondly, outcomes assessed across studies were also heterogeneous, which
meant that not all studies could be included in the meta-analysis. Thirdly, the majority
of studies included in the review are based in the US, covering a diverse range of popu-
lations (for example, employment schemes, VA populations), thus limiting the gener-
alisability to a UK setting. The GDG considered these limitations in the interpretation
of the results of the systematic review and when making recommendations.
5.32.11 Recommendations
Interventions to promote abstinence and relapse prevention
5.32.11.1 For people with alcohol dependence who are homeless, consider offering
residential rehabilitation for a maximum of 3 months. Help the service user
find stable accommodation before discharge.
5.32.11.2 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.
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31
The costs of such a programme are likely to be lower than a day hospital programme given its reduced
intensity.

5.32.12 Research recommendations
5.32.12.1 For people with moderate and severe alcohol dependence who have signif-
icant comorbid problems, is an intensive residential rehabilitation
programme clinically and cost effective when compared with intensive
community-based care?
This question should be answered using a prospective cohort study of all people
who have moderate and severe dependence on alcohol entering residential and inten-
sive community rehabilitation programmes in a purposive sample of alcohol
treatment services in the UK. It should report short- and medium-term outcomes
(including cost-effectiveness outcomes) of at least 18 months’ duration. Particular
attention should be paid to the characterisation of the treatment environment and the
nature of the interventions provided to inform the analysis of moderators and media-
tors of treatment effect. The outcomes chosen should reflect both observer and serv-
ice user-rated assessments of improvement (including personal and social
functioning) and the acceptability of the intervention. The study needs to be large
enough to determine the presence or absence of clinically important effects, and
mediators and moderators of response should be investigated. A cohort study has been
chosen as the most appropriate design as previous studies in this area that have
attempted to randomise participants to residential or community care have been
unable to recruit clinically representative populations.
Why this is important
Many people, in particular those with severe problems and complex comorbidities, do
not benefit from treatment and/or lose contact with services. One common approach
is to offer intensive residential rehabilitation and current policy favours this. However,
the research on the effectiveness of residential rehabilitation is uncertain with a
suggestion that intensive community services may be as effective. The interpretation
of this research is limited by the fact that many of the more severely ill people are not
entered into the clinical trials because some clinicians are unsure of the safety of the
community setting. However, clinical opinion is divided on the benefits of residential
rehabilitation, with some suggesting that those who benefit are a motivated and self-
selected group who may do just as well with intensive community treatment, which
is currently limited in availability. Given the costs associated with residential treatment
and the uncertainty about outcomes, the results of this study will have important
implications for the cost effectiveness and provision of alcohol services in the NHS.
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6 PSYCHOLOGICAL AND PSYCHOSOCIAL
INTERVENTIONS
6.1 INTRODUCTION
This chapter is concerned with structured psychological interventions used to help
people who experience alcohol dependence or harmful alcohol use. These approaches
have been the focus of much research and debate over the years.
Psychological interventions for people experiencing alcohol misuse or depend-
ence have traditionally made use of the interaction between the service user and a
therapist, worker, helper or counsellor (the latter terminologies may vary depending
on services and settings). In addition, more recently, there has been some growth and
expansion in the use of self-help-based interventions that involve the use of DVDs,
books, computer programmes or self-help manuals.
Psychological approaches vary depending on the theoretical models underpinning
them. Broadly, psychological interventions can be classified into behavioural, cogni-
tive, psychodynamic, humanistic, systemic, motivational, disease, and social and envi-
ronmental. The emphasis of each therapy is different, depending on the theoretical
underpinning of the approach. Behavioural approaches, for example, are based on the
premise that excessive drinking is a learned habit and therefore influenced by princi-
ples of behaviour. The latter can hence be used to teach the individual a different
behavioural pattern that will reduce the harm emerging from excessive drinking.
Cognitive approaches, on the other hand, emphasise the role of thinking and cognition
either prior to engaging in drinking behaviour or to prevent or avoid lapse or relapse.
Social approaches focus the work on the social environment, for example families or
wider social networks. In some instances, a combination of approaches is used and
described under the term of ‘multimodal’ treatment, guided by the rationale that a
combination of approaches is more powerful than each individual component. Each
category of intervention is discussed in more detail later in this chapter within sub-
sections describing the studies reviewed that are relevant to each type of approach.
Whilst the rationale and theoretical frameworks for treatments have been clearly
articulated in the various research studies, the evidence for the superiority of one form
of treatment over another in the field of alcohol has been difficult to find (Miller &
Wilbourne, 2002). This has led to the general view in the field that whilst psycholog-
ical interventions are better than no intervention, no single approach is superior to
another. In this chapter, where available, the evidence for each psychological inter-
vention is assessed in relation to three comparators: (i) is the intervention superior to
treatment as usual or a control condition? (ii) is the intervention superior to other
interventions? and (iii) is the intervention superior to other variants of the same type
of approach (for example, behavioural cue exposure [BCE] versus behavioural self-
control training [BSCT])?
Psychological and psychosocial interventions
229

Psychological and psychosocial interventions
230
The review of this literature is of significant importance, given the potential wide
use of psychological interventions in NHS and non-statutory services as well as the
need to provide an evidence base to inform and guide the implementation and use of
these approaches. It is important to note that previous influential reviews of alcohol
treatment (for example, ‘Mesa Grande’, Miller & Wilbourne, 2002) have combined
findings from a large number of trials that included a wide range of populations (for
example, opportunistic versus help-seeking, mild versus severe dependence). In the
current review, only studies that involved treatment-seeking populations experiencing
harmful drinking or alcohol dependence were included and therefore the number of
trials meeting these criteria was reduced to make them relevant to the population
addressed in this guideline.
Finally, psychological treatments can also be used to help people experiencing
harmful alcohol use or dependence to address coexisting problems such as anxiety
and depression. These approaches are not covered within this review and the reader
is referred to the separate NICE guidelines that address psychological interventions
for specific mental health problems. Healthcare professionals should note that,
although the presence of alcohol misuse may impact, for example, on the duration of
a formal psychological treatment, there is no evidence supporting the view that
psychological treatments for common mental health disorders are ineffective for
people who misuse alcohol. A number of NICE mental health guidelines have specif-
ically considered the interaction between common mental health problems and drug
and alcohol use. For example, NICE guidelines, such as for anxiety (NICE, 2004) or
obsessive-compulsive disorder (NICE, 2006a), provide advice on assessment and the
impact that drug and alcohol misuse may have on the effectiveness or duration of
treatment. There is also some evidence to suggest that the active treatment of comor-
bid mental health problems may improve drug and alcohol substance misuse
outcomes (Charney et al., 2001; Hesse, 2004; Watkins et al., 2006). This may be
particularly important for service users who have achieved abstinence (note that
symptoms of depression and anxiety may remit following successful treatment of the
alcohol problem), but whose alcohol use is at risk of returning or escalating due to
inadequately treated anxiety or depression.
6.1.1 Current practice
Services for people who are alcohol dependent and harmful drinkers are commonly
delivered by statutory and non-statutory providers. The field is undergoing rapid
change across different areas of the country due to the impact of the commissioning
process. Traditionally, services have been provided by teams where the detoxification
and counselling aspects of treatment have been fairly clearly separated. Within the
NHS, teams tend to consist of different disciplines including nurses, counsellors,
medical practitioners and, less often, other professions such as psychologists and
occupational therapists. Teams are commonly under-resourced with practitioners
having high caseloads and limited access to supervision. Most practice involves an
eclectic approach that combines strategies from various psychological approaches. A

more recent development involves contracts between commissioners and providers
that may determine, for example the number of sessions to be delivered, yet this is
rarely informed by the evidence and tends to be driven by pragmatic or resource
issues (Drummond et al., 2005).
Whilst the research literature to date has concentrated mostly on the comparison
of well-defined treatment interventions commonly incorporated into treatment manu-
als, this stands in contrast to what is normally delivered in routine practice. Despite
the research on psychological treatments, current UK practice is not underpinned by
a strong evidence base and there is wide variation in the uptake and implementation
of psychological approaches to treatment across services (Drummond et al., 2005).
A number of factors may contribute to the low implementation of evidence-based
psychological interventions. First, there is a lack of availability of reviews of the
current evidence in a clear and practical format that can be accessible to practition-
ers, managers and commissioners. This has led to a weak dissemination of the
evidence base concerning psychological interventions for alcohol misuse within
routine service provision. Second, there is the varied composition of the workforce
with a range of training experiences, not all of which include training in the delivery
of psychological interventions. Furthermore, as noted by Tober and colleagues
(2005), training programmes for the management of substance misuse vary widely in
content with no consensus on methods to provide and evaluate such training or to
maintain its effects. Supervision of psychological interventions is equally varied and
not always available. Finally, there is a tendency in the field to eclecticism fuelled by
the perception that all approaches are either equally valid or equally ineffective.
6.2 THERAPIST FACTORS
Several therapist factors that could potentially affect treatment have been considered,
including demographics, professional background, training, use of supervision and
competence. Two related aspects are dealt with below, namely the therapeutic alliance
and therapist competence.
6.2.1 The therapeutic alliance
There are various definitions of the therapeutic alliance, but in general terms it is
viewed as a constructive relationship between therapist and client, characterised by a
positive and mutually respectful stance in which both parties work on the joint enter-
prise of change. Bordin (1979) conceptualised the alliance as having three elements:
agreement on the relevance of the tasks (or techniques) employed in therapy; agree-
ment about the goals or outcomes the therapy aims to achieve; and the quality of the
bond between therapist and patient.
There has been considerable debate about the importance of the alliance as a
factor in promoting change, with some commentators arguing that technique is inap-
propriately privileged over the alliance, a position reflected in many humanistic
Psychological and psychosocial interventions
231

models where the therapeutic relationship itself is seen as integral to the change
process, with technique relegated to a secondary role (for example, Rogers, 1951).
The failure of some comparative trials to demonstrate differences in outcome between
active psychological therapies (for example, Elkin, 1994; Miller & Wilbourne, 2002)
is often cited in support of this argument and is usually referred to as ‘the dodo-bird
hypothesis’ (Luborsky et al., 1975). However, apart from the fact that dodo-bird find-
ings may not be as ubiquitous as is sometimes claimed, this does not logically imply
that therapy technique is irrelevant to outcome. Identifying and interpreting equiva-
lence of benefit across therapies remains a live debate (for example, Ahn & Wampold,
2001; Stiles et al., 2006) but should also include a consideration of cost effectiveness
as well as clinical efficacy (NICE, 2008a).
Meta-analytic reviews report consistent evidence of a positive association of the
alliance with better outcomes with a correlation of around 0.25 (for example, Horvath
& Symonds, 1991; Martin et al., 2000), a finding that applies across a heterogeneous
group of trials (in terms of variables such as type of therapy, nature of the disorder,
client presentation, type of measures applied and the stage of therapy at which meas-
ures are applied). However, it is the consistency rather than the size of this correlation
that is most striking because a correlation of 0.25 would suggest it could account for
only 6% of the variance in the outcome. Specific studies of the role of the alliance in
drug and alcohol treatment programmes have been conducted. Luborsky and colleagues
(1985), Connors and colleagues (1997) and Ilgen and colleagues, (2006) reported a rela-
tionship between treatment outcomes, but others (for example, Ojehagen et al., 1997)
have not. Ojehagen and colleagues (1997) suggest that this discrepancy between the
various studies may have arisen from methodological differences between the studies;
in contrast to Luborsky and colleagues (1985), Connors and colleagues (1997) and
Ilgen and colleagues (2006), in Ojehagen and colleagues’ (1997) study ratings of the
alliance were made by an independent rater from video tapes as opposed to ratings
made by the therapist early in treatment. This is consistent with other studies; for exam-
ple, Feeley and colleagues (1999) reported that alliance quality was related to early
symptom change. Therefore, it seems reasonable to debate the extent to which a good
alliance is necessary for a positive outcome of an intervention, but it is unlikely to be
sufficient to account for the majority of the variance in outcome.
6.2.2 Therapist competence
Studies of the relationship between therapist competence and outcome suggest that all
therapists have variable outcomes, although some therapists produce consistently
better outcomes (for example, Okiishi et al., 2003). There is evidence that more
competent therapists produce better outcomes (Barber et al., 1996 and 2006; Kuyken &
Tsivrikos, 2009). This is also the case for psychological interventions in the alcohol
field; the Project MATCH Research Group (1998) reported therapist differences that
impact on outcome. A number of studies have also sought to examine more precisely
therapist competence and its relation to outcomes; that is, what is it that therapists do
to achieve good outcomes? A number of studies are briefly reviewed here.
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232

This section draws on a more extensive review of the area by Roth and Pilling
(2011), which focused on CBT because this area had the most extensive research. In
an early study, Shaw and colleagues (1999) examined competence in the treatment of
36 patients treated by eight therapists offering CBT as part of the National Institute
of Mental Health trial of depression (Elkin et al., 1989). Ratings of competence were
made on the Cognitive Therapy Scale (CTS). Although the simple correlation of the
CTS with outcome suggested that it contributed little to outcome variance, regression
analyses indicated a more specific set of associations; specifically, when controlling
for pre-therapy depression scores, adherence and the alliance, the overall CTS score
accounted for 15% of the variance in outcome. However, a subset of items on the CTS
accounted for most of this association.
Some understanding of what may account for this association emerges from three
studies by DeRubeis’s research group (Feeley et al., 1999; Brotman et al., 2009). All
of the studies made use of the Collaborative Study Psychotherapy Rating Scale
(CSPRS: Hollon et al., 1988), subscales of which contained items specific to CBT.
On the basis of factor analysis, the CBT items were separated into two subscales
labelled ‘cognitive therapy – concrete’ and ‘cognitive therapy – abstract’. Concrete
techniques can be thought of as pragmatic aspects of therapy (such as establishing the
session agenda, setting homework tasks or helping clients identify and modify nega-
tive automatic thoughts). Both DeRubeis and Feeley (1990) and Feeley and
colleagues (1999) found some evidence for a significant association between the use
of ‘concrete’ CBT techniques and better outcomes. The benefits of high levels of
competence over and above levels required for basic practice has been studied in most
detail in the literature on CBT for depression. In general, high severity and comorbid-
ity, especially with Axis II pathology, have been associated with poorer outcomes in
therapies, but the detrimental impact of these factors is lessened for highly competent
therapists. DeRubeis and colleagues (2005) found that the most competent therapists
had good outcomes even for patients with the most severe levels of depression.
Kuyken and Tsivrikos (2009) found that therapists who are more competent have
better patient outcomes regardless of the degree of patient comorbidity. In patients
with neurotic disorders (Kingdon et al., 1996) and personality disorders (Davidson
et al., 2004), higher levels of competence were associated with greater improvements
in depressive symptoms. Although competence in psychological therapies is hard to
measure in routine practice, degrees of formal training (Brosan et al., 2007) and expe-
rience in that modality (James et al., 2001) are associated with competence and are
independently associated with better outcomes (Burns & Nolen-Hoeksema, 1992).
All therapists should have levels of training and experience that are adequate to
ensure a basic level of competence in the therapy they are practicing, and the highest
possible levels of training and experience are desirable for those therapists treating
patients with severe, enduring or complex presentations. In routine practice in serv-
ices providing psychological therapies for depression, therapists should receive regu-
lar supervision and monitoring of outcomes. Roth and colleagues (2010) reviewed the
training programmes associated with clinical trials as part of a programme exploring
therapist competence (Roth & Pilling, 2008). They showed that clinical trials are
associated with high levels of training, supervision and monitoring–factors that are
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not always found in routine practice. This is partly due to the inadequate description
of training programmes in the trial reports. However, there is an increasing emphasis
on describing the process of training in clinical trials, the report by Tober and
colleagues (2005) being a notable recent publication describing the training
programme for UKATT.
Trepka and colleagues (2004) examined the impact of competence by analysing
outcomes in Cahill and colleagues’ (2003) study. Six clinical psychologists (with
between 1 and 6 years’ post-qualification experience) treated 30 clients with depres-
sion using CBT, with ratings of competence made on the CTS. In a completer sample
(N 21) better outcomes were associated with overall competence on the CTS
(r 0.47); in the full sample this association was only found with the ‘specific CBT
skills’ subscale of the CTS. Using a stringent measure of recovery (a Beck
Depression Inventory score no more than one SD from the non-distressed mean), nine
of the ten completer patients treated by the more competent therapists recovered,
compared with four of the 11 clients treated by the less competent therapists. These
results remained even when analysis controlled for levels of the therapeutic alliance.
Miller and colleagues (1993) looked at therapist behaviours in a brief (two-
session) ‘motivational check-up’; they identified one therapist behaviour (a
confrontational approach) that was associated with increased alcohol intake. Agreeing
and monitoring homework is one of the set of ‘concrete’ CBT skills identified above.
All forms of CBT place an emphasis on the role of homework because it provides a
powerful opportunity for clients to test their expectations. A small number of studies
have explored whether compliance with homework is related to better outcomes,
although rather fewer have examined the therapist behaviours associated with better
client ‘compliance’ with homework itself. Kazantzis and colleagues (2000) report a
meta-analysis of 27 trials of cognitive and/or behavioural interventions that contained
data relevant to the link between homework assignment, compliance and outcome. In
19 trials, clients were being treated for depression or anxiety; the remainder were seen
for a range of other problems. Of these, 11 reported on the effects of assigning home-
work in therapy and 16 on the impact of compliance. The type of homework varied,
as did the way in which compliance was monitored, although this was usually by ther-
apist report. Overall there was a significant, although modest, association between
outcome and assigning homework tasks (r 0.36), and between outcome and home-
work compliance (r 0.22). While Kazantzis and colleagues (2000) indicate that
homework has greater impact for clients with depression than anxiety disorders, the
number of trials on which this comparison is made is small and any conclusions must
therefore be tentative.
Bryant and colleagues (1999) examined factors leading to homework compliance
in 26 clients with depression receiving CBT from four therapists. As in other studies,
greater compliance with homework was associated with better outcome. In terms of
therapist behaviours, it was not so much therapists’ CBT-specific skills (such as skil-
fully assigning homework or providing a rationale for homework) that were associ-
ated with compliance, but ratings of their general therapeutic skills and particularly
whether they explicitly reviewed the homework assigned in the previous session.
There was also some evidence that compliance was increased if therapists checked
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how the client felt about the task being set and identified potential difficulties in
carrying it out.
6.3 MATCHING EFFECTS/SEVERITY
One of the main challenges in providing services for alcohol treatment is to increase
the effectiveness of the interventions offered. The concept of tailoring treatments to
particular types of clients to increase effectiveness has been appealing to researchers
both in terms of its logical plausibility and as a possible explanation for the reason
why no one intervention has universal effectiveness. However, despite this, there is
limited evidence to date that matching people with alcohol misuse or dependence to
treatment approaches demonstrates effectiveness.
In 1989 the NIAAA began the largest national multisite RCT of alcoholism treat-
ment matching, entitled Matching Alcoholism Treatments to Client Heterogeneity
(Project MATCH). This study outlined matching hypotheses that were investigated
across both ‘outpatient’ and ‘aftercare’ settings following inpatient or day hospital
treatment. Clients were randomly allocated to one of three manual-guided treatment
approaches individually offered, namely cognitive behavioural coping-skills therapy,
MET or TSF therapy (Project MATCH Research Group, 1997). However, tests of the
primary matching hypotheses over the 4- to 15-month follow-up period revealed few
matching effects. Of the variables considered, psychiatric severity was considered an
attribute worthy of further consideration because this alone appeared to influence
drinking at 1-year follow-up. A UK trial later explored client treatment-matching in
the treatment of alcohol misuse comparing MET with SBNT (UKATT Research
Team, 2007), the findings of which strongly supported those of Project MATCH in
that none of the five matching hypotheses was supported at either follow-up point on
any outcome measure.
Despite the limited findings from these major trials, other studies have detected
more positive conclusions that have highlighted methodological considerations asso-
ciated with matching. Several studies have acknowledged the usefulness of matching
treatment approaches for individuals who are experiencing severe psychiatric co-
morbidity. In a trial comparing people with alcohol dependence with a range of
psychiatric impairments, more structured coping-skills training yielded lower relapse
rates at 6-month follow-up (Kadden et al., 1989). Studies that looked specifically at
matching in the context of psychiatric disturbance have acknowledged that the sever-
ity of the psychiatric presentation has a negative impact upon the relapse rates (Brown
et al., 2002), although matching appears to have assisted in retaining individuals in
treatment (McLellan et al., 1997). Although in some cases no significant differences
have been detected between overall relapse rates when matching treatments at 2
years’ follow-up, relapse to alcohol was found to have occurred more slowly where
high psychiatric co-morbidity is matched with more structured coping-skills training
(Cooney et al., 1991).
The importance of service user choice in relation to self-matching treatments has
been associated with more positive outcomes in two studies (Brown et al., 2002;
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UKATT Research Group, 2007), whilst other trials have emphasised the negative
consequences of ‘mismatching’ including earlier relapse (Cooney et al., 1991),
poorer outcomes (Karno & Longabaugh, 2007) and increased need of support serv-
ices (Conrod et al., 2000).
Treatment providers are now required to consider not only treatment efficacy but
also cost effectiveness, and for this reason treatment matching has remained an
appealing option (Moyer et al., 2000). However, for the findings of matching trials to
be meaningful, one must consider a variety of methodological issues. Many of the
recent studies considered have involved small samples, comparing a diverse range of
variables both in terms of sample characteristics and treatment process factors
(McLellan & Alterman, 1991). It has been suggested that for trials to provide more
meaningful findings, there is a need for a clearer focus on matching questions which
then focus upon well-specified treatments that have clear goals with specific patient
populations. In this way, such designs may be more likely to provide interpretable
results as well as a clearer understanding of the processes likely to be responsible for
such findings.
Despite the steady development of patient-treatment matching studies in relation
to alcohol dependence, the outcomes to date indicate that there is no single treatment
that is effective for all clients. There continue to be many obstacles to matching
clients to specific treatment programmes in real world settings and for many organi-
sations patient–treatment matching remains impractical. Research would appear to
indicate that the nature and severity of co-morbid and complex presentations such as
psychiatric disturbance have a negative impact upon treatments for addiction, and this
is arguably an area for further research (McLellan et al., 1997). It has been suggested
that, given the diversity of presentations and the large number of variables implicated
in such research, the development of reliable and generalisable measures will be
important for both the effective training and evaluation of treatment-matching effi-
cacy (McLellan & Alterman, 1991).
6.4 SETTING THE CONTEXT FOR 12-STEP FACILITATION AND
ALCOHOLICS ANONYMOUS
The 12-step principles were first set out in a publication by AA in the 1950s. AA
describes itself as a ‘Fellowship’ and AA groups are widely available in the UK as
support networks for people with alcohol dependence. AA is a self-help movement
with the 12-step principles at the core. The 12 steps lay out a process that individuals
are recommended to follow, based on an assumption that dependence on alcohol is a
disease and therefore a goal of lifelong abstinence should be promoted. Membership
is entirely voluntary and free of charge, there is a spiritual element to participation
and life-long membership is encouraged. Attendance has been associated with
successful abstinence from alcohol in a number of studies (see Ferri and colleagues
[2006] for a systematic review).
Most 12-step treatment is predicated on the understanding that the treatment
would fail without subsequent attendance at 12-step fellowship meetings. However, a
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common problem in the treatment of alcohol dependence with AA or 12-step groups
is that people who misuse alcohol frequently discontinue AA involvement at the end
of their designated treatment period and usually do not continue with aftercare treat-
ment (Kaskutas et al., 2005; Kelly et al., 2003; Moos et al., 2001; Tonigan et al.,
2003). As a result, manual-guided TSF has been developed as an active standalone or
adjunctive intervention which involves: introducing the person who misuses alcohol
to the principles of AA and the 12 steps of treatment (for example, Project MATCH
Research Group, 1993), providing information on AA facilitates in the geographical
area, and engaging with the client in setting goals for attendance and participation in
the meetings. The aim of TSF is to maintain abstinence whilst in treatment and to
sustain gains made after treatment concludes. This guideline is concerned with the
use of TSF as an active intervention in the treatment of alcohol dependence and harm-
ful alcohol use. An evaluation of the classic AA approach is outside the scope of this
guideline.
6.5 REVIEW OF PSYCHOLOGICAL THERAPIES
6.5.1 Aim of review
This section aims to review the evidence for psychological interventions without
pharmacological interventions for the treatment of alcohol dependence and harmful
alcohol use. The literature reviewed in this section is focused on a reduction or cessa-
tion of drinking and hence assesses any outcomes pertaining to this. Most of the liter-
ature in the field is focused on adults over the age of 18 years. However, for young
people under the age of 18 years old, literature assessing the clinical efficacy of
psychological therapies for alcohol misuse alone (without comorbid drug misuse) is
limited. The psychological evidence below is for an adult population only and a
review of the evidence for the treatment of young people is described in Section 6.22.
Psychological interventions were considered for inclusion in the review if they
were:
� Planned treatment
� For treatment-seeking participants only (of particular importance for the brief
interventions because the scope did not cover opportunistic brief interventions –
see scope, Appendix 1)
� Manual-based or, in the absence of a formal manual, the intervention should be
well-defined and structured
� Ethical and safe
The following psychological therapies used in the treatment of alcohol misuse
were considered for inclusion in this guideline:
� Brief interventions (planned only)
– for example, psychoeducational and motivational techniques
� Self-help based treatments
– brief self-help interventions (including guided self-help/bibliotherapy)
� TSF
Psychological and psychosocial interventions
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� Cognitive behavioural-based therapies
– standard cognitive behavioural therapy
– coping skills
– social skills training
– relapse prevention
� Behavioural therapies
– cue exposure
– BSCT
– contingency management
– aversion therapy
� MET
� Social network and environment-based therapies
– social behaviour and network therapy (SBNT)
– the community reinforcement approach
� Counselling
– couples therapy (including behavioural couples therapy and other variants of
couples therapy)
� Family-based interventions
– functional family therapy
– brief strategic family therapy
– multisystematic therapy
– five-step family interventions
– multidimensional family therapy
– community reinforcement and family training
� Psychodynamic therapy
– short-term psychodynamic intervention
– supportive expressive psychotherapy.
In addition, physical therapies such as meditation and acupuncture are also
covered in this review.
Good quality RCT evidence for the clinical efficacy of some of the psychological
therapies listed was not always available. Therefore, the evidence summaries in this
chapter describe the psychological therapies for which evidence of sufficient quality
(see Chapter 3 for methodological criteria) was available. There are a number of
useful studies that add value to the RCT data presented and they are included in this
review. For the purpose of this guideline, and to obtain an overview of the available
literature, studies that have met other methodological criteria are described in the
evidence summaries of the individual therapies.
Full characteristics of included studies, forest plots and GRADE profiles can be
found in Appendix 16d, 17c and 18c, respectively, because they were too extensive to
place within this chapter.
6.5.2 Review questions
Primary review questions addressed in this chapter:
Psychological and psychosocial interventions
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1. 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).
6.6 OUTCOMES
There were no consistent critical outcomes across studies and outcomes were mainly
continuous in nature. This variability in outcomes poses some difficulties in pooling
data from different studies. Therefore, continuous outcomes were grouped into three
categories:
� Abstinence, for example,
– percentage/proportion of days abstinent
– abstinent days per week/month
– longest duration abstinent
� Rates of consumption, for example,
– percentage/proportion of days heavy drinking
– drinking days per month
– days drinking greater than X drinks per week
� Amount of alcohol consumed, for example,
– DDD
– mean number of drinks per week
– grams of alcohol per drinking day
– number of drinks per drinking episode.
Dichotomous outcomes included:
� abstinence (number of participants abstinent)
� lapse (number of participants who have drank at all)
� relapse (number of participants who have drank more than X number of drinks)
� attrition (the number of participants leaving the study for any reason).
Studies varied in their definition of these dichotomous terms. For example, the
number of drinks defined as constituting a relapse varied.
6.7 MOTIVATIONAL TECHNIQUES
6.7.1 Definition
Motivational enhancement therapy (MET) is the most structured and intensive moti-
vational-based intervention. It is based on the methods and principles of motivational
interviewing (Miller et al., 1992). It is patient centred and aims to result in rapid inter-
nally-motivated changes by exploring and resolving ambivalence towards behaviour.
Psychological and psychosocial interventions
239

The treatment strategy of motivational interviewing is not to guide the client through
recovery step-by-step, but to use motivational methods and strategies to utilise the
patient’s resources. A more specific manualised and structured form of motivational
interviewing based on the work of Project MATCH is usually utilised (Project
MATCH Research Group, 1993).
Brief motivational interventions include the computerised Drinker’s Check-Up
(DCU), which assesses symptoms of dependence, alcohol-related problems and moti-
vation for change, and ‘feedback, responsibility, advice, menu, empathy, self-efficacy’
(FRAMES; Bien et al., 1993
32
).
6.7.2 Clinical review protocol (motivational techniques)
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Chapter 3 (further information about the
Psychological and psychosocial interventions
240
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO,
Cochrane Library
Date searched Database inception to March 2010
Study design RCT (at least ten participants per arm)
Population Adults (over 18 years old)
At least 80% of the sample meet the criteria for alco-
hol dependence or harmful alcohol use (clinical diag-
nosis or drinking more than 30 drinks per week)
Excluded populations Hazardous drinkers and those drinking fewer than 30
drinks per week
Pregnant women
Interventions Motivational techniques
Comparator Control or other active intervention
Outcomes Abstinence
Amount of alcohol consumed
Rates of consumption
Relapse (>X number of drinks or number of partici-
pants who have relapsed)
Lapse (time to first drink or number of participants
who have lapsed)
Attrition (leaving the study early for any reason)
Table 32: Clinical review protocol for the review of motivational techniques
32
www.drinkerscheckup.com.

search for health economic evidence can be found in Section 6.21 of this chapter). See
Table 32 below for a summary of the clinical review protocol for the review of moti-
vational techniques.
6.7.3 Studies considered for review
33
The review team conducted a systematic review of RCTs that assessed the beneficial
or detrimental effects of motivational techniques in the treatment of alcohol depend-
ence or harmful alcohol use. See Table 33 for a summary of the study characteristics.
It should be noted that some trials included in analyses were three- or four-arm trials.
To avoid double counting, the number of participants in treatment conditions used in
more than one comparison was divided (by half in a three-arm trial and by three in a
four-arm trial).
Eight trials relating to clinical evidence met the eligibility criteria set by the GDG,
providing data on 4,209 participants. All eight studies were published in peer-reviewed
journals between 1997 and 2007. A number of studies identified in the search were
initially excluded because they were not relevant to this guideline. Studies were
excluded because they did not meet methodological criteria (see Chapter 3). When
studies did meet basic methodological inclusion criteria, the main reason for exclusion
was not meeting the drinking quantity/diagnostic criteria; that is, participants were not
drinking enough to be categorised as harmful or dependent drinkers, or less than 80%
of the sample met criteria for alcohol dependence or harmful alcohol use. Other
reasons were that treatment was opportunistic as opposed to planned, the study was not
directly relevant to the review questions, or no relevant alcohol-focused outcomes were
available. A list of excluded studies can be found in Appendix 16d.
Motivational techniques versus minimal intervention control
Of the eight included trials, three that involved a comparison of motivational tech-
niques versus control met the criteria for inclusion. HESTER2005 assessed the
drinker’s check-up versus waitlist control; ROSENBLUM2005b investigated MET
plus relapse prevention versus information and referral only; and SELLMAN2001
assessed MET versus feedback only. The included studies were conducted between
2001 and 2005. The 5-year follow-up outcomes were obtained from Adamson and
Sellman (2008).
Motivational techniques versus other active intervention
Of the eight included trials, six assessed motivational techniques versus another active
intervention met criteria for inclusion. DAVIDSON2007 investigated MET versus cogni-
tive behavioural broad spectrum therapy; MATCH1997 assessed MET versus both CBT
and TSF; SELLMAN2001 compared MET with non-directive reflective listening
Psychological and psychosocial interventions
241
33
Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
tal letters (primary author and date of study publication, except where a study is in press or only submit-
ted for publication, then a date is not used).

Psychological and psychosocial interventions
242
Motivational versus minimal Motivational versus other
intervention control active intervention
K (total N) 3 RCTs (N = 433) 6 RCTs (N = 3818)
Study ID (1) HESTER2005 (1) DAVIDSON2007
(2) ROSENBLUM2005b (2) MATCH1997
(3) SELLMAN2001 (3) SELLMAN2001
(4) SHAKESHAFT2002
(5) SOBELL2002
(6) UKATT2005
Diagnosis (1) AUDIT score 8� (1) DSM alcohol dependent
(2) DSM alcohol dependent/abuse (2) DSM alcohol
(3) DSM alcohol dependent dependent/abuse
(3) DSM alcohol dependent
(4)–(5) Not reported
(6) DSM alcohol dependent/abuse
Baseline severity (1) DDD: approximately 7 (1) PDA: approximately
(2) Not reported 30%, percent days heavy
(3) Mild/moderate dependence drinking: approximately 63%
Unequivocal heavy drinking more (2) PDA: approximately
than six times (in 6 months prior 30%, DDD: approximately 16
to treatment): 90.2% (3) Unequivocal heavy
drinking six or more times in
6 months prior to treatment: 90.2%
(4) Weekly Australian units
per week: approximately 32 units
(5) Number of drinking days
per week: approximately
5.5 days, DDD: approximately 5
(6) PDA: 29.5%, number of
DDD: 26.8 drinks
Number of sessions Range: 1 to 12 sessions Range: 1 to 12 sessions
Length of treatment Range: 1 to 6 weeks Range: 1 to 12 weeks
Length of follow-up Range: 1 month to 5 years Range: 6 months to 5 years
Setting (1) Computer-based intervention (1) Outpatient treatment centre
(2) Homeless soup-kitchen (2) Clinical research unit
(3) Outpatient treatment centre (3)–(4) Outpatient treatment centre
(5) Mail information
(6) Outpatient treatment centre
Treatment goal (1) Abstinence or drinking (1)–(2) Abstinence or drinking
reduction/moderation reduction/moderation
(2) Drinking reduction/moderation (3)–(5) Not explicitly stated
(3) Not explicitly stated (6) Abstinence or drinking
reduction/moderation
Country (1)–(2) US (1)–(2) US
(3) New Zealand (3) New Zealand
(4) Australia
(5) US
(6) UK
Table 33: Summary of study characteristics for motivational techniques

(counselling); SHAKESHAFT2002 assessed FRAMES with CBT; SOBELL2002
compared motivational enhancement/personalised feedback with psychoeducational
bibliotherapy/drinking guidelines; and, lastly, UKATT2005 investigated MET versus
SBNT. The included studies were conducted between 1997 and 2007.
6.7.4 Evidence summary
34
The GRADE profiles and associated forest plots for the comparisons can be found in
Appendix 18c and Appendix 17c, respectively.
Motivational techniques versus minimal intervention control
One computerised session of MET (drinker’s check up) was significantly better than
control in reducing average drinks per day at 1-month follow-up (moderate effect
size). However, this finding was based on the results of a single study. Furthermore,
no significant difference in average drinks per day and DDD was observed between
the drinker’s check up and control at 2- and 12-month follow-up.
MET (with relapse prevention) (ROSENBLUM2005b) was significantly more
effective than control at reducing heavy alcohol use when assessed at 5-month follow-
up (moderate effect size). This was further supported by the SELLMAN2001 study,
which favoured MET over control in the number of people who drank excessively and
frequently (ten or more drinks, six or more times) at 6-month follow-up (large effect
size). However, this effect was not observed at long follow-up assessment (5 years).
Although no significant difference was observed between groups in reducing the days
on which any alcohol was consumed, the analyses showed a trend favouring MET
with relapse prevention over control (p = 0.07). No significant difference in attrition
rates were observed between MET and control groups across studies.
The quality of this evidence is moderate and further research is likely to have an
important impact on confidence in the estimate of the effect. An evidence summary
of the results of the meta-analyses can be seen in Table 34.
Motivational techniques versus other active intervention
The clinical evidence showed that no significant difference could be found between
motivational techniques and other active interventions in maintaining abstinence at up
to 15-month follow-up. Furthermore, no difference between groups was observed in
reducing the number of participants who had lapsed or reducing heavy drinking at all
follow-up points.
Other therapies (namely CBT and TSF) were more effective than motivational
techniques in reducing the quantity of alcohol consumed when assessed post-treat-
ment. However, the effect size was small (0.1) and was no longer seen at longer
follow-up points of 3 to 15 months.
34
Sensitivity analyses were conducted to assess the effect of combining studies investigating brief motiva-
tional techniques with structured MET studies. The findings were found to be robust in sensitivity analy-
sis and the effects found were not determined by the intensity and duration the motivational intervention.
Psychological and psychosocial interventions
243

Psychological and psychosocial interventions
244
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Lapse or relapse
Lapsed up until 6-month follow-up
At 6 months 82 RR (M-H, Random, 95% CI) 0.90 (0.77, 1.06)
Lapsed >12-month follow-up
At 5-year follow-up 56 RR (M-H, Random, 95% CI) 1.03 (0.77, 1.37)
Amount of alcohol consumed
Amount of alcohol consumed
up to 6-month follow-up
Average drinks per day (log
transformed) over entire
assessment period at 1-month
follow-up 61 SMD (IV, Random, 95% CI) -0.67 (-1.20, -0.15)
Average drinks per day (log
transformed) over entire
assessment period at 2-month
follow-up 61 SMD (IV, Random, 95% CI) -0.46 (-0.97, 0.06)
DDD (log transformed) at
1-month follow-up 61 SMD (IV, Random, 95% CI) -0.17 (-0.68, 0.34)
DDD (log transformed) at
2-month follow-up 61 SMD (IV, Random, 95% CI) 0.21 (-0.30, 0.72)
Amount of alcohol consumed
7- to 12-month follow-up
Average drinks per day (log
transformed) over entire
assessment period at 12-month
follow-up 61 SMD (IV, Random, 95% CI) -0.20 (-0.71, 0.31)
DDD (log transformed) at
12-month follow-up 61 SMD (IV, Random, 95% CI) 0.36 (-0.15, 0.88)
Rates of consumption
Rates of consumption up to
6-month follow-up
Days any alcohol use at
5-month follow-up 139 SMD (IV, Random, 95% CI) -0.31 (-0.64, 0.03)
Days heavy alcohol use
(more than four drinks) at
5-month follow-up 46 SMD (IV, Random, 95% CI) -0.70 (-1.30, -0.11)
Table 34: Motivational techniques versus control evidence summary
Continued

Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Rate of consumption up to
6-month follow-up
Exceeded national drinking
guidelines at least once at
6-month follow-up 82 RR (M-H, Random, 95% CI) 0.89 (0.66, 1.19)
Exceeded national drinking
guidelines six or more times
at 6-month follow-up 82 RR (M-H, Random, 95% CI) 0.89 (0.66, 1.19)
Drank at least ten standard
drinks at least once at
6-month follow-up 82 RR (M-H, Random, 95% CI) 0.77 (0.58, 1.03)
Drank at least ten drinks six
or more times at 6-month
follow-up 82 RR (M-H, Random, 95% CI) 0.66 (0.43, 1.00)
Rates of consumption >12-month
follow-up
Exceeded national drinking
guidelines at least once at
5-year follow-up 56 RR (M-H, Random, 95% CI) 0.90 (0.60, 1.36)
Exceeded national drinking
guidelines six or more times at
5-year follow-up 56 RR (M-H, Random, 95% CI) 0.92 (0.52, 1.62)
Drank at least ten standard drinks
at least once at 5-year follow-up 56 RR (M-H, Random, 95% CI) 0.64 (0.34, 1.22)
Drank at least ten drinks six or
more times at 5-year follow-up 56 RR (M-H, Random, 95% CI) 0.72 (0.29, 1.74)
Attrition (dropout)
Attrition (dropout) post-treatment 290 RR (M-H, Random, 95% CI) 1.09 (0.76, 1.57)
Attrition (dropout) up to 6-month
follow-up 82 RR (M-H, Random, 95% CI) Not estimable
At 6-month follow-up 82 RR (M-H, Random, 95% CI) Not estimable
Attrition (dropout) at 7- to
12-month follow-up 61
At 12 months 61 RR (M-H, Random, 95% CI) 0.89 (0.30, 2.61)
Attrition (dropout) >12-month
follow-up 82 RR (M-H, Random, 95% CI) 1.30 (0.68, 2.48)
At 5-year follow-up 82 RR (M-H, Random, 95% CI) 1.30 (0.68, 2.48)
Table 34: (Continued)
Psychological and psychosocial interventions
245

No significant difference was observed between groups in attrition rates post-
treatment or at 3-month follow-up. However, other therapies were more effective at
retaining participants at 6-month follow-up (low effect size). Follow-up periods
longer than 6 months did not indicate any significant difference between groups.
The quality of this evidence is moderate, therefore further research is likely to
have an important impact on confidence in the estimate of the effect. An evidence
summary of the results of the meta-analyses can be seen in Table 35.
6.8 12-STEP FACILITATION
6.8.1 Definition
TSF is based on the 12-step or AA concept that alcohol misuse is a spiritual and
medical disease (see Section 6.4 for a discussion of AA). As well as a goal of absti-
nence, this intervention aims to actively encourage commitment to and participation
in AA meeting. Participants are asked to keep a journal of AA attendance and partic-
ipation, and are given AA literature relevant to the ‘step’ of the programme that they
have reached. TSF is highly structured and manualised (Nowinski et al., 1992) and
involves a weekly session in which the patient is asked about their drinking, AA atten-
dance and participation, given an explanation of the themes of the current sessions,
and goals for AA attendance are set.
6.8.2 Clinical review protocol (12-step facilitation)
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Chapter 3 (further information about the
search for health economic evidence can be found in Section 6.21). See Table 36
below for a summary of the clinical review protocol for the review of TSF.
6.8.3 Studies considered for review
The review team conducted a systematic review of RCTs that assessed the benefi-
cial or detrimental effects of TSF in the treatment of alcohol dependence or harm-
ful alcohol use. See Table 37 for a summary of the study characteristics. It should
be noted that some trials included in analyses were three- or four-arm trials. To
avoid double counting, the number of participants in treatment conditions used in
more than one comparison was divided (by half in a three-arm trial, and by three in
a four-arm trial).
Six trials relating to clinical evidence met the eligibility criteria set by the GDG,
providing data on 2,556 participants. All six studies were published in peer-reviewed
journals between 1997 and 2009. A number of studies identified in the search were
initially excluded because they were not relevant to this guideline. Studies were
Psychological and psychosocial interventions
246

Psychological and psychosocial interventions
247
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Abstinence
Abstinent post-treatment 1801 SMD (IV, Random, 95% CI) 0.08 (�0.02, 0.18)
Abstinence up to 6-month follow-up 2476 SMD (IV, Random, 95% CI) 0.02 (�0.06, 0.10)
At 3-month follow-up 835 SMD (IV, Random, 95% CI) 0.09 (�0.12, 0.30)
At 6-month follow-up 1641 SMD (IV, Random, 95% CI) �0.01 (�0.11, 0.10)
Abstinence – 7- to 12-month follow-up
At 9-month follow-up 1616 SMD (IV, Random, 95% CI) 0.05 (�0.06, 0.15)
At 12-month follow-up 1672 SMD (IV, Random, 95% CI) 0.04 (�0.07, 0.15)
Abstinence >12-month follow-up
At 15-month follow-up 1573 SMD (IV, Random, 95% CI) 0.06 (�0.05, 0.16)
Lapse or relapse
Lapsed up to 6-month follow-up
At 6 months 82 RR (M-H, Random, 95% CI) 0.93 (0.78, 1.10)
Lapsed >12-month follow-up
At 5 year follow-up 48 RR (M-H, Random, 95% CI) 1.02 (0.75, 1.40)
Rates of consumption
Rate of consumption post-treatment
Percent heavy drinking days 149 SMD (IV, Random, 95% CI) 0.05 (�0.27, 0.37)
Rate of consumption up to 6-month
follow-up 115 SMD (IV, Random, 95% CI) 0.02 (�0.35, 0.38)
Binge consumption (occasions in
prior 30 days where at least seven
(males) or five (females) drinks
consumed at 6 months 115 SMD (IV, Random, 95% CI) 0.02 (�0.35, 0.38)
Rate of consumption up to
6-month follow-up
Exceeded national drinking
guidelines at least once at
6-month follow-up 82 RR (M-H, Random, 95% CI) 0.83 (0.63, 1.10)
Exceeded national drinking
guidelines six or more times at
6-month follow-up 82 RR (M-H, Random, 95% CI) 0.83 (0.63, 1.10)
Drank at least ten standard drinks
at least once at 6-month follow-up 82 RR (M-H, Random, 95% CI) 0.80 (0.60, 1.07)
Table 35: Motivational techniques versus other intervention evidence
summary
Continued

Psychological and psychosocial interventions
248
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Drank at least ten or more
drinks six or more times at
6-month follow-up 82 RR (M-H, Random, 95% CI) 0.69 (0.45, 1.05)
Rate of consumption –7- to
12-month follow-up
Number of days drinking per
week at 12-month follow-up 657 SMD (IV, Random, 95% CI) 0.00 (�0.15, 0.15)
Days with more than five
drinks at 12 months 657 SMD (IV, Random, 95% CI) �0.08 (�0.23, 0.08)
Rates of consumption
>12-month follow-up
Exceeded national drinking
guidelines at least once at
5-year follow-up 48 RR (M-H, Random, 95% CI) 0.96 (0.61, 1.51)
Exceeded national drinking
guidelines 6 or more times at
5-year follow-up 48 RR (M-H, Random, 95% CI) 0.85 (0.47, 1.53)
Drank at least ten standard
drinks at least once at 5-year
follow-up 48 RR (M-H, Random, 95% CI) 0.88 (0.41, 1.88)
Drank at least ten or more
drinks six or more times at
5-year follow-up 48 RR (M-H, Random, 95% CI) 1.17 (0.38, 3.61)
Amount of alcohol consumed
Amount of alcohol consumed
post-treatment
DDD 1652 SMD (IV, Random, 95% CI) 0.10 (�0.00, 0.20)
Amount of alcohol consumed
up to 6-month follow-up 2380 SMD (IV, Random, 95% CI) 0.05 (�0.04, 0.13)
DDD at 3-month follow-up 624 SMD (IV, Random, 95% CI) �0.04 (�0.20, 0.12)
DDD at 6-month follow-up 1641 SMD (IV, Random, 95% CI) 0.08 (�0.02, 0.18)
Drinks per week at 6 months 115 SMD (IV, Random, 95% CI) 0.09 (�0.27, 0.46)
Amount of alcohol consumed –7-
to 12-month follow-up
DDD at 9-month follow-up
DDD at 12-month follow-up 2771 SMD (IV, Random, 95% CI) 0.01 (�0.07, 0.08)
Drinks per week at 12 months 657 SMD (IV, Random, 95% CI) �0.01 (�0.16, 0.14)
Table 35: (Continued)
Continued

Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Amount of alcohol consumed
>12-month follow-up
DDD at 15-month follow-up 1573 SMD (IV, Random, 95% CI) 0.05 (�0.05, 0.16)
Attrition (dropout)
Attrition (dropout) post-treatment 2022 RR (M-H, Random, 95% CI) 0.70 (0.31, 1.59)
Attrition (dropout) up to 6 months
follow-up 2719 RR (M-H, Random, 95% CI) 1.37 (1.05, 1.80)
At 3-month follow-up 762 RR (M-H, Random, 95% CI) 1.36 (0.84, 2.18)
At 6-month follow-up 1957 RR (M-H, Random, 95% CI) 1.38 (1.00, 1.92)
Attrition (dropout) at 7- to
12-month follow-up
At 9-month follow-up 1641 RR (M-H, Random, 95% CI) 1.85 (0.83, 4.11)
At 12-month follow-up 3130 RR (M-H, Random, 95% CI) 1.15 (0.87, 1.52)
Attrition (dropout) >12-month
follow-up 1676 RR (M-H, Random, 95% CI) 0.86 (0.55, 1.35)
At 15-month follow-up 1594 RR (M-H, Random, 95% CI) 1.27 (0.52, 3.08)
At 5-year follow-up 82 RR (M-H, Random, 95% CI) 0.75 (0.45, 1.27)
Table 35: (Continued)
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane Library
Date searched Database inception to March 2010
Study design RCT (at least ten participants per arm)
Population Adults (over 18 years old)
At least 80% of the sample meet the criteria for alcohol depend-
ence or harmful alcohol use (clinical diagnosis or drinking more
than 30 drinks per week)
Excluded populations Hazardous drinkers and those drinking fewer than 30 drinks per week
Pregnant women
Interventions TSF
Comparator Control or other active intervention
Outcomes Abstinence
Amount of alcohol consumed
Rates of consumption
Relapse (>X number of drinks or number of participants who have
relapsed)
Lapse (time to first drink or number of participants who have lapsed)
Attrition (leaving the study early for any reason)
Table 36: Clinical review protocol for the review of 12-step facilitation
Psychological and psychosocial interventions
249

excluded because they did not meet methodological criteria (see Chapter 3). When
studies did meet basic methodological inclusion criteria, the main reason for exclu-
sion was that the studies were assessing the efficacy of 12-step groups (that is, AA)
directly (not TSF) and hence were also naturalistic studies. Other reasons included a
drug and not alcohol focus, secondary analysis and not being directly relevant to the
current guideline. A list of excluded studies can be found in Appendix 16d.
12-step facilitation versus other active intervention
Of the six included trials, five compared TSF with another active intervention. The
comparator against TSF was CBT (EASTON2007), couples therapy and psychoedu-
cational intervention (FALSSTEWART2005; FALSSTWEART2006), MET and CBT
(MATCH1997), and coping skills (WALITZER2009).
Comparing different formats of 12-step facilitation
Two included studies assessed one form of TSF versus another. TIMKO2007 evalu-
ated intensive TSF versus standard TSF. In the standard TSF condition, people who
misuse alcohol were given an AA schedule and encouraged to attend sessions.
Counsellors and patients reviewed relapse prevention, but treatment was more
focused on psychoeducation. In the intensive TSF condition, standard treatment was
provided and counsellors actively arranged AA meeting attendance. Participants were
encouraged to keep an AA attendance journal. WALITZER2009 assessed a directive
approach to TSF versus a motivational approach to TSF in addition to treatment-as-
usual (coping skills).
6.8.4 Evidence summary
The GRADE profiles and associated forest plots for the comparisons can be found in
Appendix 18c and Appendix 17c, respectively.
12-step facilitation versus other active interventions
The clinical evidence revealed no significant difference between TSF and other active
interventions in maintaining abstinence, reducing heavy drinking episodes when
assessed post-treatment and at various follow-up points up to 12 months. TSF was
significantly better than other active interventions in reducing the amount of alcohol
consumed when assessed at 6-month follow-up. However, the effect size was small
(SMD =�0.09) and no significant difference between groups was observed for any
other follow-up points.
No significant difference in attrition rates was observed between TSF and other
active interventions in attrition post-treatment and up to 6-month follow-up. However,
those receiving TSF were more likely to be retained at 9-month follow-up, although
his difference was not observed at 12- and 15-month follow-up.
The quality of this evidence is high, therefore further research is unlikely to
change confidence in the estimate of the effect. An evidence summary of the results
of the meta-analyses can be seen in Table 38.
Psychological and psychosocial interventions
250

Psychological and psychosocial interventions
251
TSF versus other active
intervention Different formats of TSF
K (total N) 5 RCTs (N = 1221) 2 RCTs (N = 456)
Study ID (1) EASTON2007 (1) TIMKO2007
(2) FALSSTEWART2005 (2) WALITZER2009
(3) FALSSTWEART2006
(4) MATCH1997
(5) WALITZER2009
Diagnosis (1)–(2) DSM alcohol dependent (1)–(2) Not reported
(3)–(4) DSM IV alcohol
dependent/abuse
(5) Not reported
Baseline severity (1) Approximately 19 years of (1) ASI alcohol score:
alcohol use, alcohol use in past approximately 0.28
28 days: approximately 6 days (2) PDA: 35.4%, percent days
(2) Percent days heavy drinking: heavy drinking: 32.7%
56 to 59% across treatment groups
(3) PDA: 40 to 44% across
treatment groups
(4) PDA: approximately 30,
DDD: approximately 16 drinks
(5) PDA: 35.4%, percent days
heavy drinking: 32.7%
Number of sessions Range: 12 to 32 sessions (1) 1 session
(2) 12 sessions in which TSF
was in addition to other
treatment
Length of treatment 12 weeks Unclear
Length of follow-up Range: 3 to 15 months Range: 3 to 12 months
Setting (1)–(3) Outpatient treatment (1)–(2) Outpatient treatment
centre centre
(4) Clinical research unit
(5) Outpatient treatment centre
Treatment goal (1) Drinking reduction/moderation (1)–(2) Not explicitly stated
(2) Not explicitly stated
(3) Abstinence
(4) Abstinence or drinking
reduction/moderation
(5) Not explicitly stated
Country (1)–(5) US (1)–(2) US
Table 37: Summary of study characteristics for 12-step facilitation
Comparing different formats of 12-step facilitation
Directive TSF was more effective at maintaining abstinence than motivational TSF up
to 12-month follow-up (RR =�0.41 to �0.81 across follow-up points). However, no
difference between groups was observed in reducing heavy drinking episodes.

Psychological and psychosocial interventions
252
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Abstinence
Abstinence post-treatment 1860 SMD (IV, Random, 95% CI) 0.04 (�0.10, 0.18)
Abstinence up to 6-month follow-up
PDA at 3-month follow-up 340 SMD (IV, Random, 95% CI) �0.05 (�0.41, 0.31)
PDA at 6-month follow-up 1975 SMD (IV, Random, 95% CI) �0.03 (�0.23, 0.16)
Abstinence 7- to 12-month follow-up
PDA at 9-month follow-up 1942 SMD (IV, Random, 95% CI) 0.00 (�0.18, 0.18)
PDA at 12-month follow-up 1911 SMD (IV, Random, 95% CI) �0.01 (�0.21, 0.19)
Abstinence >12-month follow-up
At 15-month follow-up 1573 SMD (IV, Random, 95% CI) �0.01 (�0.12, 0.09)
Rates of consumption
Rate of alcohol consumption
post-treatment
Percentage days heavy
drinking at post-treatment 99 SMD (IV, Random, 95% CI) �0.01 (�0.47, 0.45)
Rate of alcohol consumption
up to 6-month follow-up
Percentage days heavy drinking
at 3-month follow-up 301 SMD (IV, Random, 95% CI) �0.13 (�0.43, 0.17)
Percentage days heavy drinking
at 6-month follow-up 296 SMD (IV, Random, 95% CI) �0.08 (�0.42, 0.26)
Rate of alcohol consumption –7-
to 12-month follow-up
Percentage days heavy drinking
at 9-month follow-up 288 SMD (IV, Random, 95% CI) 0.13 (�0.14, 0.40)
Percentage days heavy drinking at
12-month follow-up 282 SMD (IV, Random, 95% CI) 0.15 (�0.28, 0.58)
Amount of alcohol consumed
Amount of alcohol consumed
post-treatment 1651 SMD (IV, Random, 95% CI) 0.01 (�0.13, 0.15)
Amount of alcohol consumed
up to 6-month follow-up
At 6-month follow-up 2194 SMD (IV, Random, 95% CI) �0.09 (�0.17, �0.00)
Amount of alcohol consumed
7- to 12-month follow-up
Table 38: 12-Step Facilitation versus other intervention evidence summary
Continued

In addition, intensive TSF was significantly more effective than standard TSF in
maintaining abstinence at 12-month follow-up (RR = 0.81).
No significant difference between TSF methods was observed in attrition post-
treatment or at various follow-up points up to 12 months.
Additionally, KAHLER2004 was identified as assessing brief advice to facilitate
AA involvement versus a motivational enhancement approach to facilitate AA
involvement. This study could not be included in analyses because data could not be
extracted. However, the study reported that although AA attendance was associated
with better drinking outcomes, the more intensive motivational enhancement format
of facilitating involvement did not improve involvement in AA and hence did not
result in better alcohol outcomes.
The quality of this evidence is moderate, therefore further research is likely to
have an important impact on confidence in the estimate of the effect and may change
the estimate (see Appendix 18c). An evidence summary of the results of the meta-
analyses can be seen in Table 39.
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
At 9-month follow-up 1615 SMD (IV, Random, 95% CI) �0.04 (�0.15, 0.06)
At 12-month follow-up 1594 SMD (IV, Random, 95% CI) �0.09 (�0.20, 0.01)
At 6-month follow-up 1640 SMD (IV, Random, 95% CI) �0.09 (�0.19, 0.01)
Amount of alcohol consumed
>12-month follow-up
At 15-month follow-up 1573 SMD (IV, Random, 95% CI) �0.04 (�0.14, 0.07)
Attrition (dropout)
Attrition (dropout)
post-treatment 1864 RR (M-H, Random, 95% CI) 1.11 (0.73, 1.70)
Attrition (dropout) up to 6-month
follow-up
At 3-month follow-up 227 RR (M-H, Random, 95% CI) 0.57 (0.19, 1.73)
At 6-month follow-up 1853 RR (M-H, Random, 95% CI) 1.21 (0.29, 5.11)
Attrition (dropout) 7- to 12-month
follow-up
At 9-month follow-up 1837 RR (M-H, Random, 95% CI) 0.37 (0.15, 0.88)
At 12-month follow-up 1930 RR (M-H, Random, 95% CI) 1.21 (0.55, 2.65)
Attrition (dropout) >12-month
follow-up
At 15-month follow-up 1594 RR (M-H, Random, 95% CI) 0.46 (0.16, 1.37)
Table 38: (Continued)
Psychological and psychosocial interventions
253

Psychological and psychosocial interventions
254
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Abstinence
PDA up to 6 months follow-up
At 3-month follow-up 102 SMD (IV, Random, 95% CI) �0.40 (�0.79, �0.00)
At 6-month follow-up 97 SMD (IV, Random, 95% CI) �0.41 (�0.81, �0.01)
PDA 7- to 12-month follow-up
At 9-month follow-up 95 SMD (IV, Random, 95% CI) �0.57 (�0.98, �0.16)
At 12-month follow-up 95 SMD (IV, Random, 95% CI) �0.58 (�0.99, �0.17)
Lapse or relapse
Number of participants lapsed 7- to
12-month follow-up
At 12-month follow-up 307 RR (M-H, Random, 95% CI) 0.81 (0.66, 1.00)
Rates of consumption
Percentage of days heavy drinking
up to 6-month follow-up
At 3-month follow-up 102 SMD (IV, Random, 95% CI) �0.20 (�0.59, 0.19)
At 6-month follow-up 97 SMD (IV, Random, 95% CI) �0.07 (�0.47, 0.33)
Percentage of days heavy drinking
at 7- to 12-month follow-up
At 9-month follow-up 95 SMD (IV, Random, 95% CI) �0.20 (�0.60, 0.20)
At 12-month follow-up 95 SMD (IV, Random, 95% CI) �0.09 (�0.50, 0.31)
Attrition (dropout)
Attrition (dropout) post-treatment 345 RR (M-H, Random, 95% CI) 1.01 (0.55, 1.84)
Attrition (dropout) up to
6-month follow-up
At 3-month follow-up 111 OR (M-H, Fixed, 95% CI) 0.29 (0.06, 1.44)
At 6-month follow-up 102 OR (M-H, Fixed, 95% CI) 1.53 (0.24, 9.57)
Attrition (dropout) 7- to
12-month follow-up
At 9-month follow-up 97 RR (M-H, Random, 95% CI) 1.02 (0.07, 15.86)
At 12-month follow-up 440 RR (M-H, Random, 95% CI) 1.04 (0.52, 2.06)
Table 39: Comparing different formats of 12-step facilitation evidence
summary

6.9 COGNITIVE BEHAVIOURAL THERAPY
6.9.1 Definition
CBT encompasses a range of therapies, in part derived from the cognitive behav-
ioural model of affective disorders in which the patient works collaboratively with
a therapist using a shared formulation to achieve specific treatment goals. Such
goals may include recognising the impact of behavioural and/or thinking patterns
on feeling states and encouraging alternative cognitive and/or behavioural coping
skills to reduce the severity of target symptoms and problems. Cognitive behav-
ioural therapies include standard CBT, relapse prevention, coping skills and social
skills training.
Standard cognitive behavioural therapy
Standard CBT is a discrete, time-limited, structured psychological intervention,
derived from a cognitive model of drug misuse (Beck et al., 1993). There is an
emphasis on identifying and modifying irrational thoughts, managing negative mood
and intervening after a lapse to prevent a full-blown relapse.
Relapse prevention
A CBT adaptation based on the work of Marlatt and Gordon (1985), this incorpo-
rates a range of cognitive and behavioural therapeutic techniques to identify high-
risk situations, alter expectancies and increase self-efficacy. This differs from
standard CBT in the emphasis on training people who misuse alcohol to develop
skills to identify situations or states where they are most vulnerable to alcohol use,
to avoid high-risk situations, and to use a range of cognitive and behavioural strate-
gies to cope effectively with these situations (Annis, 1986; Marlatt & Gordon,
1985).
Coping and social skills training
Coping and social skills training is a variety of CBT that is based on social learning
theory of addiction and the relationship between drinking behaviour and life prob-
lems (Kadden et al., 1992; Marlatt & Gordon, 1985). Treatment is manual-based
(Marlatt & Gordon, 1985) and involves increasing the individual’s ability to cope
with high-risk social situations and interpersonal difficulties.
6.9.2 Clinical review protocol (cognitive behavioural therapies)
Information about the databases searched and the inclusion/exclusion criteria used for
this Section of the guideline can be found in Chapter 3 (further information about the
search for health economic evidence can be found in Section 6.21). See Table 40
below for a summary of the clinical review protocol for the review of cognitive behav-
ioural therapies.
Psychological and psychosocial interventions
255

6.9.3 Studies considered for review
The review team conducted a systematic review of RCTs that assessed the beneficial
or detrimental effects of cognitive behavioural therapies in the treatment of alcohol
dependence or harmful alcohol use. See Table 41 for a summary of the study charac-
teristics. It should be noted that some trials included in analyses were three- or four-
arm trials. To avoid double counting, the number of participants in treatment
conditions used in more than one comparison was divided (by half in a three-arm trial,
and by three in a four-arm trial).
Twenty RCT trials relating to clinical evidence met the eligibility criteria set by the
GDG, providing data on 3,970 participants. All 20 studies were published in peer-
reviewed journals between 1986 and 2009. A number of studies identified in the search
were initially excluded because they were not relevant to this guideline. Studies were
excluded because they did not meet methodological criteria (see Chapter 3). When stud-
ies did meet basic methodological inclusion criteria, the main reasons for exclusion
Psychological and psychosocial interventions
256
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane
Library
Date searched Database inception to March 2010
Study design RCT (at least participants per arm)
Population Adults (over 18 years old)
At least 80% of the sample meet the criteria for alcohol
dependence or harmful alcohol use (clinical diagnosis or
drinking more than 30 drinks per week)
Excluded populations Hazardous drinkers and those drinking fewer than 30
drinks per week
Pregnant women
Interventions Cognitive behavioural therapies
Comparator Control or other active intervention
Outcomes Abstinence
Amount of alcohol consumed
Rates of consumption
Relapse (>X number of drinks or number of participants
who have relapsed)
Lapse (time to first drink or number of participants who
have lapsed)
Attrition (leaving the study early for any reason)
Table 40: Clinical review protocol for the review of cognitive
behavioural therapies

were not having alcohol-focused outcomes that could be used for analysis and not meet-
ing drinking quantity/diagnosis criteria (that is, participants were not drinking enough
to be categorised as harmful or dependent drinkers, or less than 80% of the sample met
criteria for alcohol dependence or harmful alcohol use). Other reasons were that the
study was outside the scope of this guideline, presented secondary analyses, and was
drug-focused or did not differentiate between drugs and alcohol, and was focused on
aftercare. A list of excluded studies can be found in Appendix 16d.
Cognitive behavioural therapies versus treatment as usual or control
35
Three studies compared CBT with treatment as usual or control. BURTSCHEIDT2002
assessed CBT versus coping skills versus treatment as usual (unstructured, non-
specific support and therapy). MONTI1993 investigated cue exposure with coping
skills against control (unspecified treatment as usual and daily cravings monitoring).
ROSENBLUM2005B assessed relapse prevention with MET versus control (infor-
mation and referral only).
Cognitive behavioural therapies versus other active intervention
Thirteen studies assessed CBT versus another active intervention. CONNORS2001 was
complex in design and investigated alcohol-focused coping skills with or without the
addition of life coping skills and with or without the addition of psychoeducational
interventions at different intensities. Additionally, the study investigated the difference
between low- and high-intensity treatment of these conditions. The results of the 30-
month follow-up were obtained from Walitzer and Connors (2007). The other studies
included in this analyses were DAVIDSON2007 (broad-spectrum treatment versus
MET), EASTON2007 (CBT versus TSF), ERIKSEN1986B and LITT2003 (both
assessed coping skills versus group counselling), LAM2009 (coping skills versus BCT
with/without parental skills training), MATCH1997 (CBT versus both MET and TSF),
MORGENSTERN2007 (coping skills with MET versus MET alone), SANDAHL1998
(relapse prevention versus psychodynamic therapy), SHAKESHAFT2002 (CBT versus
FRAMES), SITHARTHAN1997 (CBT versus cue exposure), VEDEL2008 (CBT
versus BCT) and WALITZER2009 (coping skills versus TSF).
Comparing different formats of cognitive behavioural therapy
Six studies investigated one form of CBT versus another form of CBT.
BURTSCHEIDT2001 investigated CBT versus coping skills; MARQUES2001
assessed group versus individual CBT); CONNORS2001 investigated different inten-
sities of alcohol-focused coping skills; LITT2009 assessed a packaged CBT program
versus an individual assessment treatment program, which was cognitive behavioural
in nature; MONTI1990 investigated communication skills training (both with and
without family therapy) as well as cognitive behavioural mood management training;
and ROSENBLUM2005A investigated relapse prevention versus relapse prevention
with motivational enhancements.
Psychological and psychosocial interventions
257
35
Treatment as usual and control were analysed together because treatment as usual was unstructured,
unspecified and brief, and similar to what would be classified as control in other studies.

Psychological and psychosocial interventions
258
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2
0
0
7
(
3
)

C
O
N
N
O
R
S
2
0
0
1
(
4
)

E
R
I
K
S
E
N
1
9
8
6
B
(
4
)

L
I
T
T
2
0
0
9
(
5
)

L
A
M
2
0
0
9
(
5
)

M
O
N
T
I
1
9
9
0
(
6
)

L
I
T
T
2
0
0
3
(
6
)

R
O
S
E
N
B
L
U
M
2
0
0
5
A
(
7
)

M
A
T
C
H
1
9
9
7
(
8
)

M
O
R
G
E
N
S
T
E
R
N
2
0
0
7
(
9
)

S
A
N
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L
1
9
9
8
(
1
0
)

S
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2
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0
2
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1
1
)

S
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T
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N
1
9
9
7
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1
2
)

V
E
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L
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0
8
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1
3
)

W
A
L
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T
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0
0
9
D
i
a
g
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s
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1
)

(
2
)

D
S
M

a
l
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h
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l

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p
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n
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t
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1
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(
3
)

D
S
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l
c
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h
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l

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p
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n
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t
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(
3
)

D
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l
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n
d
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t
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3
)

N
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t

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p
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r
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e
d
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4
)

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t

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p
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r
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d
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4
)

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l
c
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h
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l

d
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p
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n
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t
/
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b
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s
e
(
5
)

(
8
)

D
S
M

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l
c
o
h
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l

(
5
)

D
S
M
/
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C
D

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l
c
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h
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l

d
e
p
e
n
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n
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p
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n
d
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t
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a
b
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s
e
(
6
)

D
S
M

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l
c
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h
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l

d
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p
e
n
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n
t
/
a
b
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s
e
(
9
)

D
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M

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l
c
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l

d
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p
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n
d
e
n
t
(
1
0
)

N
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t

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p
o
r
t
e
d
(
1
1
)

N
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t

r
e
p
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t
e
d
(
1
2
)

D
S
M

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l
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l

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p
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n
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)

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d
T
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l
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:
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f

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(
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d
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1
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e
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f

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d
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r
e
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7
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.
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%
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)

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f

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c
o
r
e
:

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.
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7
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f

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:

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9
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D
:

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2
.
1

d
r
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n
k
s
,

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D
A
:

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7
%
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p
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n
d
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n
c
e
:

6
6
%
N
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m
b
e
r

o
f

h
e
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v
y

d
r
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n
k
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g

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s

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n

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t

P
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c
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f

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l
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a
y
s

:

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5
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i
n
k
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n
g
:

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5
%
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p
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c
e
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1
8
.
1
%
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e
r

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f

p
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b
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m

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r
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n
k
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g

d
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y
s

i
n

(
3
)

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t

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e
p
o
r
t
e
d
(
2
)

P
D
A
:

a
p
p
r
o
x
i
m
a
t
e
l
y

3
0
%
l
a
s
t

9
0

d
a
y
s
:

1
6
.
5
P
e
r
c
e
n
t
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g
e

d
a
y
s

h
e
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v
y

d
r
i
n
k
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n
g
:

M
e
a
n

w
e
e
k
l
y

c
o
n
s
u
m
p
t
i
o
n
:

3
6
.
5

d
r
i
n
k
s
a
p
p
r
o
x
i
m
a
t
e
l
y

6
3
%
S
A
D
D
*
*

s
c
o
r
e

a
b
s
t
i
n
e
n
c
e
/
m
o
d
e
r
a
t
e

(
3
)

A
p
p
r
o
x
i
m
a
t
e
l
y

1
9

y
e
a
r
s

o
f
r
a
t
e
s
:

1
7
a
l
c
o
h
o
l

u
s
e
(
3
)

P
e
r
c
e
n
t
a
g
e

o
f

s
a
m
p
l
e

s
e
v
e
r
e

A
l
c
o
h
o
l

u
s
e

i
n

p
a
s
t

2
8

d
a
y
s
:

d
e
p
e
n
d
e
n
c
e
:

8
.
3
%
a
p
p
r
o
x
i
m
a
t
e
l
y

6

d
a
y
s
P
e
r
c
e
n
t
a
g
e

o
f

s
a
m
p
l
e

m
o
d
e
r
a
t
e

(
4
)

P
r
e
v
i
o
u
s

a
l
c
o
h
o
l
i
s
m

i
n
p
a
t
i
e
n
t

d
e
p
e
n
d
e
n
c
e
:

6
6
%
s
t
a
t
u
s
:

6
6
.
7
%
P
e
r
c
e
n
t
a
g
e

o
f

s
a
m
p
l
e

m
i
l
d

(
5
)

P
D
A
:

a
p
p
r
o
x
i
m
a
t
e
l
y

3
7
%
d
e
p
e
n
d
e
n
c
e
:

1
8
.
1
%
(
6
)

D
r
i
n
k
i
n
g

d
a
y
s

6

m
o
n
t
h
s

p
r
i
o
r

A
v
e
r
a
g
e

m
o
n
t
h
l
y

a
b
s
t
i
n
e
n
t

d
a
y
s
:

t
o

i
n
t
a
k
e
:

7
2
%
1
0
.
1

d
a
y
s
(
7
)

P
D
A
:

a
p
p
r
o
x
i
m
a
t
e
l
y

3
0
%
A
v
e
r
a
g
e

m
o
n
t
h
l
y

l
i
g
h
t

d
a
y
s
:

6
.
1

d
a
y
s
D
D
D
:

a
p
p
r
o
x
i
m
a
t
e
l
y

1
6

d
r
i
n
k
s
A
v
e
r
a
g
e

m
o
n
t
h
l
y

m
o
d
e
r
a
t
e

d
a
y
s
:

8

d
a
y
s
(
8
)

D
D
D
:

9
.
5

d
r
i
n
k
s
A
v
e
r
a
g
e

m
o
n
t
h
l
y

h
e
a
v
y

d
a
y
s
:

5
.
7

d
a
y
s
A
D
S

c
o
r
e
:

1
2
.
2
(
4
)

P
r
o
p
o
r
t
i
o
n

d
a
y
s

a
b
s
t
i
n
e
n
c
e
:
(
9
)

D
u
r
a
t
i
o
n

o
f

a
l
c
o
h
o
l
0
.
1
9

d
a
y
s
d
e
p
e
n
d
e
n
c
e
:

1
1

y
e
a
r
s
P
r
o
p
o
r
t
i
o
n

d
a
y
s

h
e
a
v
y

d
r
i
n
k
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n
g
:

R
e
p
o
r
t
e
d

m
o
r
n
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n
g

d
r
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n
k
i
n
g
:

7
5
.
5
%
a
p
p
r
o
x
i
m
a
t
e
l
y

0
.
5
9

d
a
y
s
(
1
0
)

W
e
e
k
l
y

A
u
s
t
r
a
l
i
a
n

u
n
i
t
s

p
e
r
(
5
)

P
e
r
c
e
n
t
a
g
e

o
f

p
o
s
s
i
b
l
e

d
r
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n
k
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n
g

w
e
e
k
:

a
p
p
r
o
x
i
m
a
t
e
l
y

3
2

u
n
i
t
s
d
a
y
s

a
b
s
t
i
n
e
n
t
:

a
p
p
r
o
x
i
m
a
t
e
l
y

4
3
%
C
o
n
t
i
n
u
e
d
Psychological and psychosocial interventions
259

Psychological and psychosocial interventions
260
C
o
g
n
i
t
i
v
e

b
e
h
a
v
i
o
u
r
a
l

C
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D
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s

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f

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h
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r
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p
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v
e
r
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u
s

T
A
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t
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s
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S
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c
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r
e
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1
8
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1
N
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r

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f

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s
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b
l
e

D
D
D
:

1
1

d
r
i
n
k
s
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m
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d

C
o
n
t
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l

Q
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e
s
t
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n
a
i
r
e
N
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m
b
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r

o
f

a
c
t
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a
l

D
D
D
:

1
7

d
r
i
n
k
s
(
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C
Q
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s
c
o
r
e
:

1
3
.
0
5
P
e
r
c
e
n
t
a
g
e

p
o
s
s
i
b
l
e

d
r
i
n
k
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n
g

d
a
y
s

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n

C
D
S
E
S

s
c
o
r
e
:

3
5
.
9
3
w
h
i
c
h

h
e
a
v
y

d
r
i
n
k
i
n
g
:

4
5
%
D
r
i
n
k
i
n
g

d
a
y
s

p
e
r

m
o
n
t
h
:

(
6
)

N
u
m
b
e
r

o
f

d
a
y
s

a
b
s
t
i
n
e
n
t

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n

p
a
s
t

2
0
.
2

d
a
y
s
3
0

d
a
y
s
:

1
4

d
a
y
s
C
o
n
s
u
m
p
t
i
o
n

p
e
r

o
c
c
a
s
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o
n
:

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S
I

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l
c
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h
o
l

s
c
o
r
e
:

a
p
p
r
o
x
i
m
a
t
e
l
y

0
.
4
7
8
.
8
2

d
r
i
n
k
s
(
1
2
)

6
2
%

a
l
c
o
h
o
l

d
e
p
e
n
d
e
n
t
5
0
%

d
r
a
n
k

s
e
v
e
n

o
r

m
o
r
e

u
n
i
t
s
5
7
%

d
r
a
n
k

d
a
i
l
y

o
r

n
e
a
r
l
y

d
a
i
l
y
(
1
3
)

P
D
A
:

3
5
.
4
%
P
e
r
c
e
n
t
a
g
e

o
f

d
a
y
s

h
e
a
v
y

d
r
i
n
k
i
n
g
:

3
2
.
7
%
N
u
m
b
e
r

o
f

s
e
s
s
i
o
n
s
R
a
n
g
e
:

6

t
o

2
6

s
e
s
s
i
o
n
s
R
a
n
g
e
:

6

t
o

2
6

s
e
s
s
i
o
n
s
R
a
n
g
e
:

1
2

t
o

2
3

s
e
s
s
i
o
n
s
L
e
n
g
t
h

o
f

t
r
e
a
t
m
e
n
t
R
a
n
g
e
:

2

w
e
e
k
s

t
o

6

m
o
n
t
h
s
R
a
n
g
e
:

1
0

w
e
e
k
s

t
o

6

m
o
n
t
h
s
R
a
n
g
e
:

6

t
o

1
0

w
e
e
k
s
L
e
n
g
t
h

o
f

R
a
n
g
e
:

0

t
o

6

m
o
n
t
h
s
R
a
n
g
e
:

3

t
o

1
8

m
o
n
t
h
s

R
a
n
g
e
:

3

t
o

1
8

m
o
n
t
h
s
f
o
l
l
o
w
-
u
p

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Psychological and psychosocial interventions
261

6.9.4 Evidence summary
The GRADE profiles and associated forest plots for the comparisons can be found in
Appendix 18c and Appendix 17c, respectively.
Cognitive behavioural therapies versus treatment as usual or control
Cognitive behavioural therapies were significantly better than control at reducing
heavy drinking episodes but no significant difference between groups was observed
for a reduction in days any alcohol is used (assessed post-treatment) or the number of
participants who have lapsed and relapsed (assessed at 3-month follow-up) when
compared with treatment as usual. However, resulting in a moderate effect size,
cognitive behavioural therapies were significantly better than treatment as usual in
reducing the number of participants who lapsed and relapsed when assessed at 6-
month follow-up. No difference between groups was observed in attrition rates post-
treatment or at 6-month follow-up.
The quality of this evidence is moderate, therefore further research is likely to
have an important impact on confidence in the estimate of the effect and may change
the estimate (see Appendix 18c for full GRADE profile).
One study assessing cognitive behavioural therapies versus control could not be
added to the meta-analyses. Källmén and colleagues 2003 could not be included
because the data was presented in an unusable format. The study reported that the
control group (unstructured discussion) drank significantly less alcohol at 18-month
follow-up than the group receiving coping skills. An evidence summary of the results
of the meta-analyses can be seen in Table 42.
Cognitive behavioural therapies versus other active intervention
Meta-analyses results revealed no significant difference between cognitive behav-
ioural therapies and other therapies in maintaining abstinence both post-treatment
and up to 15-month follow-up. A single study, however, did favour coping skills over
counselling in the number of sober days at 12-month follow-up, and another single
study favouring relapse prevention over psychotherapy at 15-month follow-up.
However, these single outcomes do not reflect the meta-analyses results described
above. In addition, cognitive behavioural therapies were found to be more effective
at maintaining abstinence/light days when assessed up to 18-month follow-up (based
on data by CONNORS2001). No significant difference was observed between
groups in reducing heavy drinking episodes and the amount of alcohol consumed
both post-treatment and up to 18-month follow-up. A single study outcome (ERIK-
SEN1986B) favoured coping skills over counselling in reducing the amount of alco-
hol consumed, but, again, this single study was not reflective of other analyses with
similar variables.
The VEDEL2008 study assessed severity of relapse in their sample. The results
indicated that other active intervention (namely CBT) was more effective than
couples therapy (namely BCT) in reducing occasions in which participants lapsed
(drank over six drinks on one occasion) or relapsed (drank more than six drinks most
Psychological and psychosocial interventions
262

days of the week), but no significant difference was observed in the number of partic-
ipants who relapsed on a regular basis (a few times a month). It must be noted that
effect sizes were small and the results of a single study cannot be generalised.
No significant difference was observed between CBT and other active therapies in
attrition rates.
The quality of this evidence is high, therefore further research is unlikely to
change confidence in the estimate of the effect. An evidence summary of the results
of the meta-analyses can be seen in Table 43 and Table 44.
Comparing different formats of cognitive behavioural therapies
For maintaining abstinence, an individual assessment treatment programme was
significantly more effective than a packaged CBT program when assessed post-treat-
ment (moderate effect size, based on a single study). However, for the same compar-
ison, no significant difference was observed between groups in reducing heavy
drinking episodes. The addition of motivational enhancement to relapse prevention
Psychological and psychosocial interventions
263
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Rates of consumption
Rates of consumption post-treatment
Number of days any alcohol use 139 SMD (IV, Random, 95% CI) �0.31 (�0.64, 0.03)
Number of days heavy alcohol use
(more than 4 drinks) 46 SMD (IV, Random, 95% CI) �0.70 (�1.30, �0.11)
Lapse or relapse
Lapse up to 6 months follow-up
At 3-month follow-up 34 RR (M-H, Random, 95% CI) 1.27 (0.64, 2.54)
At 6-month follow-up 137 RR (M-H, Random, 95% CI) 0.75 (0.57, 0.99)
Relapse up to 6-month follow-up
At 3-month follow-up 30 RR (M-H, Random, 95% CI) 1.57 (0.69, 3.59)
At 6-month follow-up 133 RR (M-H, Random, 95% CI) 0.55 (0.38, 0.80)
Attrition (dropout)
Attrition (dropout) post-treatment 324 RR (M-H, Random, 95% CI) 1.07 (0.74, 1.53)
Attrition (dropout) up to 6-month
follow-up
At 3-month follow-up 32 RR (M-H, Random, 95% CI) Not estimable
At 6-month follow-up 135 RR (M-H, Random, 95% CI) 0.53 (0.18, 1.54)
Table 42: Cognitive behavioural therapies versus TAU or control
evidence summary

Psychological and psychosocial interventions
264
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Abstinence
Abstinence post-treatment
Days abstinent 1901 SMD (IV, Random, 95% CI) �0.09 (�0.21, 0.03)
Abstinence up to 6-month follow-up
PDA at 3-month follow-up 280 SMD (IV, Random, 95% CI) 0.14 (�0.23, 0.51)
PDA at 6-month follow-up 1946 SMD (IV, Random, 95% CI) 0.02 (�0.12, 0.17)
Abstinence from 7- to 12-month
follow-up
PDA at 9 months 1886 SMD (IV, Random, 95% CI) �0.01 (�0.14, 0.13)
PDA at 12 months 1887 SMD (IV, Random, 95% CI) 0.01 (�0.12, 0.15)
Number of sober days at 12-month
follow-up 23 SMD (IV, Random, 95% CI) �1.67 (�2.65, �0.70)
Abstinence >12-month follow-up
PDA at 15-month follow-up 1702 SMD (IV, Random, 95% CI) �0.06 (�0.16, 0.04)
Number of days abstinent at
15-month follow-up 44 SMD (IV, Random, 95% CI) 0.64 (0.03, 1.24)
PDA at 18-month follow-up 128 SMD (IV, Random, 95% CI) �0.22 (�0.57, 0.13)
Abstinent/light (one to three standard
drinks) up to 6-month follow-up
At 6-month follow-up 61 SMD (IV, Random, 95% CI) �0.94 (�1.48, �0.40)
Abstinent/light (one to three standard
drinks) 7 to 12-month follow-up
At 12-month follow-up 61 SMD (IV, Random, 95% CI) �0.84 (�1.40, �0.27)
Abstinent/light (one to three standard
drinks) >12-month follow-up
At 18-month follow-up 61 SMD (IV, Random, 95% CI) �0.74 (�1.26, �0.21)
Lapse or relapse
Days to first drink at 18-month
follow-up 128 SMD (IV, Random, 95% CI) 0.15 (�0.20, 0.50)
Days to first heavy drinking day at
18-month follow-up 128 SMD (IV, Random, 95% CI) �0.09 (�0.44, 0.26)
Relapse (more than six units most
days of the week) post-treatment 48 RR (M-H, Random, 95% CI) 0.39 (0.18, 0.86)
Table 43: Cognitive behavioural therapies versus other interventions evidence
summary (1)
Continued

Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Regular relapse (more than six
units a few times a month)
post-treatment 48 RR (M-H, Random, 95% CI) 1.56 (0.44, 5.50)
Severe lapse (more than six units
on one occasion) post-treatment 48 RR (M-H, Random, 95% CI) 2.33 (1.01, 5.38)
Rates of consumption
Rates of consumption
post-treatment
Percentage of heavy drinking days 149 SMD (IV, Random, 95% CI) �0.05 (�0.37, 0.27)
Rate of consumption up to
6-month follow-up
Proportion days heavy drinking
at 3-month follow-up 280 SMD (IV, Random, 95% CI) 0.18 (�0.21, 0.57)
Proportion days heavy drinking
at 6-month follow-up 275 SMD (IV, Random, 95% CI) 0.15 (�0.26, 0.55)
Drinking days per month at
6-month follow-up 42 SMD (IV, Random, 95% CI) 0.61 (�0.01, 1.23)
Binge consumption (occasions in
prior 30 days where at least 7
(males) or 5 (females) drinks
consumed at 6-month follow-up 115 SMD (IV, Random, 95% CI) �0.02 (�0.38, 0.35)
Rate of consumption –7- to
12-month follow-up
Proportion days heavy drinking
at 9-month follow-up 271 SMD (IV, Random, 95% CI) �0.04 (�0.29, 0.20)
Proportion days heavy drinking
at 12-month follow-up 267 SMD (IV, Random, 95% CI) 0.03 (�0.25, 0.30)
Rate of consumption at
>12-month follow-up
Days >80 g of absolute alcohol
at 15-month follow-up 44 SMD (IV, Random, 95% CI) 0.06 (�0.53, 0.65)
Proportion days heavy drinking
at 15 months 128 SMD (IV, Random, 95% CI) �0.07 (�0.42, 0.27)
Proportion days heavy drinking
at 18 months 190 SMD (IV, Random, 95% CI) �0.20 (�0.50, 0.10)
Table 43: (Continued)
Psychological and psychosocial interventions
265

Psychological and psychosocial interventions
266
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Amount of alcohol consumed
Amount of alcohol consumed
post-treatment 1788 SMD (IV, Random, 95% CI) 0.02 (�0.19, 0.22)
Amount of alcohol consumed up
to 6-month follow-up
Number of participants consuming
at hazardous/harmful levels
weekly – at 6-month follow-up 295 RR (M-H, Random, 95% CI) 1.09 (0.80, 1.49)
Number of participants binge
drinking had at least 12 binge
episodes in previous 30 days – at
6-month follow-up 295 RR (M-H, Random, 95% CI) 1.12 (0.84, 1.49)
Number of participants binge
drinking at all (at least one binge
episode in previous 30 days)
at 6-month follow-up 295 RR (M-H, Random, 95% CI) 0.95 (0.87, 1.05)
Units of alcohol per week at
5-month follow-up 48 SMD (IV, Random, 95% CI) 0.20 (�0.37, 0.77)
Units of alcohol per week at
6-month follow-up 45 SMD (IV, Random, 95% CI) 0.16 (�0.42, 0.75)
Drinks per occasion/drinking
day at 6 months 1683 SMD (IV, Random, 95% CI) 0.07 (�0.13, 0.26)
Drinks per week at 6 months 115 SMD (IV, Random, 95% CI) �0.09 (�0.46, 0.27)
Amount of alcohol consumed – 7-
to 12-month follow-up
Alcohol consumption (centilitres
pure alcohol) at 12-month
follow-up 24 SMD (IV, Random, 95% CI) �1.15 (�2.02, �0.27)
DDD at 9-month follow-up 1615 SMD (IV, Random, 95% CI) �0.03 (�0.13, 0.08)
DDD at 12-month follow-up 1683 SMD (IV, Random, 95% CI) 0.07 (�0.04, 0.17)
Amount of alcohol consumed
>12-month follow-up 1618 SMD (IV, Random, 95% CI) �0.02 (�0.12, 0.08)
Grams absolute alcohol per
drinking day at 15-month follow-up 44 SMD (IV, Random, 95% CI) �0.07 (�0.66, 0.53)
DDD at 15-month follow-up 1574 SMD (IV, Random, 95% CI) �0.02 (�0.12, 0.09)
Attrition (dropout)
Attrition (dropout) post-treatment 2267 RR (M-H, Random, 95% CI) 1.05 (0.61, 1.80)
Table 44: Cognitive behavioural therapies versus other interventions evidence
summary (2)
Continued

Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Attrition (dropout) – up to
6-month follow-up
At 3-month follow-up 200 RR (M-H, Random, 95% CI) 1.29 (0.60, 2.78)
At 6-month follow-up 2296 RR (M-H, Random, 95% CI) 0.93 (0.59, 1.48)
Attrition (dropout) – 7- 12-month
follow-up
At 9-month follow-up 1788 RR (M-H, Random, 95% CI) 1.61 (0.76, 3.40)
At 12-month follow-up 1988 RR (M-H, Random, 95% CI) 1.27 (0.47, 3.41)
Attrition (dropout) – >12-month
follow-up 1773 RR (M-H, Random, 95% CI) 1.75 (0.84, 3.64)
At 15-month follow-up 1643 RR (M-H, Random, 95% CI) 1.65 (0.77, 3.52)
At 18-month follow-up 130 RR (M-H, Random, 95% CI) 4.29 (0.21, 85.82)
Table 44: (Continued)
did not reduce the number of possible drinking days (at 6-month follow-up) and
analyses favoured standard relapse prevention (moderate effect size). Furthermore,
the addition of family therapy to coping skills did not show any significant benefit.
Also, no significant difference in various drinking outcomes was observed between
coping skills and other types of cognitive behavioural therapies (for example, cogni-
tive behavioural mood-management training [CBMMT] when assessed at 6-month
follow-up. No difference between CBT and coping skills were observed in the
number of participants who had lapsed or relapsed at 6-month follow-up. No differ-
ence in attrition rates was observed between the various types of CBT.
More intensive coping skills was significantly better than standard coping skills at
maintaining abstinent/light drinking at 12-month follow-up (moderate effect size) but
this benefit was no longer significant at 18-month follow-up. Individual CBT was
significantly more effective than group CBT in reducing the number of heavy
drinkers at 15-month follow-up.
The quality of this evidence is moderate, therefore further research is likely to
have an important impact on confidence in the estimate of the effect. An evidence
summary of the results of the meta-analyses can be seen in Table 45 and Table 46.
Psychological and psychosocial interventions
267

Psychological and psychosocial interventions
268
Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Abstinence
Abstinence post-treatment 110 SMD (IV, Random, 95% CI) 0.39 (0.01, 0.77)
Abstinence up to 6-month follow-up
At 15-week follow-up 186 SMD (IV, Random, 95% CI) �0.31 (�0.60, �0.02)
Percentage of possible drinking days
(any day not in inpatient treatment or
jail) abstinent at 6-month follow-up 94 SMD (IV, Random, 95% CI) �0.10 (�0.52, 0.32)
Abstinent/light (one to three standard drinks)
drinking days up to 6-month follow-up
At 6-month follow-up 61 SMD (IV, Random, 95% CI) �0.39 (�0.90, 0.12)
Abstinent/light (one to three standard drinks)
drinking days 7- to 12-month follow-up
At 12-month follow-up 61 SMD (IV, Random, 95% CI) �0.65 (�1.21, �0.09)
Abstinent/light (one to three standard drinks)
drinking days >12-month follow-up
At 18-month follow-up 61 SMD (IV, Random, 95% CI) �0.38 (�0.96, 0.20)
Rates of consumption
Rates of consumption post-treatment
Proportion of heavy drinking days (men 110 SMD (IV, Random, 95% CI) 0.34 (�0.04, 0.72)
more than six and women more than
four drinks)
Rates of consumption up to
6-month follow-up
Percentage of possible days (any day not
in inpatient treatment or jail) heavy (more
than six) drinking at 6-month follow-up 94 SMD (IV, Random, 95% CI) �0.22 (�0.65, 0.20)
Rates of consumption >12-month
follow-up
Number of drinking days at
15-month follow-up 106 SMD (IV, Random, 95% CI) �0.03 (�0.41, 0.35)
Number of problem drinking days
at 15-month follow-up 106 SMD (IV, Random, 95% CI) 0.24 (�0.14, 0.62)
Number of heavy drinking days
at 15-month follow-up 106 SMD (IV, Random, 95% CI) 0.37 (�0.01, 0.75)
Amount of alcohol consumed
Amount of alcohol consumed up
until 6-month follow-up
Number of drinks per possible drinking
day (any day not in inpatient treatment
or jail) at 6-month follow-up 94 SMD (IV, Random, 95% CI) �0.30 (�0.73, 0.13)
Number of actual DDD at 6-month
follow-up 94 SMD (IV, Random, 95% CI) �0.49 (�1.44, 0.47)
Table 45: Comparing different formats of CBT evidence summary

Outcome or subgroup N Statistical method Effect estimate
(SMD, 95% CI)
Lapse or relapse/ other outcomes
Number of participants lapsed – up to
6-month follow-up 63 RR (M-H, Random, 95% CI) 1.09 (0.70, 1.70)
At 6 months 63 RR (M-H, Random, 95% CI) 1.09 (0.70, 1.70)
Number of participants relapse – up to
6-month follow-up 63 RR (M-H, Random, 95% CI) 1.03 (0.53, 2.03)
At 6 months 63 RR (M-H, Random, 95% CI) 1.03 (0.53, 2.03)
Number of days to first drink (lapse)
up until 6-month follow-up 94 SMD (IV, Random, 95% CI) 0.19 (-0.23, 0.61)
At 6-month follow-up 94 SMD (IV, Random, 95% CI) 0.19 (-0.23, 0.61)
Number of days to first heavy drink
(relapse) up until 6-month follow-up 94 SMD (IV, Random, 95% CI) 0.11 (-0.31, 0.53)
At 6-month follow-up 94 SMD (IV, Random, 95% CI) 0.11 (-0.31, 0.53)
Number heavy drinkers more than 20
drinks per week and more than 10%
heavy days (five or more drinks per
occasion) at 15-month follow-up 100 RR (M-H, Random, 95% CI) 2.86 (1.26, 6.48)
Attrition (dropout)
Attrition (dropout) post-treatment 204 RR (M-H, Random, 95% CI) 0.87 (0.44, 1.71)
Attrition (dropout) up to 6-month
follow-up 515 RR (M-H, Random, 95% CI) 1.07 (0.69, 1.68)
At 15-week follow-up 230 RR (M-H, Random, 95% CI) 1.11 (0.65, 1.90)
At 6 months 285 RR (M-H, Random, 95% CI) 0.99 (0.44, 2.23)
Attrition (dropout) 7- to 12-month
follow-up 132 RR (M-H, Random, 95% CI) 0.89 (0.06, 13.57)
At 12-month follow-up 132 RR (M-H, Random, 95% CI) 0.89 (0.06, 13.57)
Attrition (dropout) >12-month follow-up 285 RR (M-H, Random, 95% CI) 0.99 (0.42, 2.35)
At 15-month follow-up 155 RR (M-H, Random, 95% CI) 0.87 (0.55, 1.39)
At 18-month follow-up 130 RR (M-H, Random, 95% CI) 4.43 (0.22, 88.74)
Table 46: Comparing different formats of CBT evidence summary
6.10 BEHAVIOURAL THERAPIES (EXCLUDING CONTINGENCY
MANAGEMENT)
36
6.10.1 Definition
Behavioural interventions use behavioural theories of conditioning to help achieve
abstinence from drinking by creating negative experiences/events in the presence of
36
See Section 6.11 for a review of contingency management.
Psychological and psychosocial interventions
269

Psychological and psychosocial interventions
270
alcohol, and positive experiences/events in alcohol’s absence. Behavioural therapies
considered for review included cue exposure, behavioural self-control training, aver-
sion therapy and contingency management. Variants of two therapies (cue exposure
and behavioural self-control training) which were based on a similar theoretical
understanding of the nature of alcohol misuse, were considered as a single entity for
the purposes of the review. Contingency management, although a behavioural inter-
vention, was analysed separately because it is based on the classic reinforcement
model and has no alcohol specific formulation (see Section 6.11 for evidence review).
Aversion therapy was excluded because it is no longer routinely used in alcohol-
misuse treatment in the UK.
Cue exposure
Cue-exposure treatment for alcohol misuse is based on both learning theory and
social learning theory models and suggests that environmental cues associated with
drinking can elicit conditioned responses, which can in turn lead to a relapse (Niaura
et al., 1988). The first case study using cue exposure treatment for excessive alcohol
consumption was reported by Hodgson and Rankin (1976). Treatment is designed to
reduce cravings for alcohol by repeatedly exposing the service user to alcohol-related
cues until they ‘habituate’ to the cues and can hence maintain self-control in a real-
life situation where these cues are present.
Behavioural self-control training
Behavioural self-control training is also referred to as ‘behavioural self-management
training’ and is based on the techniques described by Miller and Muno´z (1976).
Patients are taught to set limits for drinking and self-monitor drinking episodes,
undergo refusal-skills training and training for coping with behaviours in high-risk
relapse situations. Behavioural self-control training is focused on a moderation goal
rather than abstinence.
6.10.2 Clinical review protocol (behavioural therapies)
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Appendix 16d (further information about
the search for health economic evidence can be found in Section 6.21). See Table 47,
below, for a summary of the clinical review protocol for the review of behavioural
therapies.
6.10.3 Studies considered for review
The review team conducted a systematic review of RCTs that assessed the beneficial
or detrimental effects of behavioural therapies in the treatment of alcohol dependence
or harmful alcohol use. See Table 48 for a summary of the study characteristics. It
should be noted that some trials included in analyses were three- or four-arm trials.

To avoid double counting, the number of participants in treatment conditions used in
more than one comparison was divided (by half in a three-arm trial, and by three in a
four-arm trial).
Six RCT trials relating to clinical evidence met the eligibility criteria set by the
GDG, providing data on 527 participants. All six studies were published in peer-
reviewed journals between 1988 and 2006. A number of studies identified in the
search were initially excluded because they were not relevant to this guideline.
Studies were excluded because they did not meet the methodological criteria (see
Chapter 3). When studies did meet basic methodological inclusion criteria, the main
reasons for exclusion were not having alcohol-focused outcomes that could be used
for analysis, and not meeting drinking quantity/diagnosis criteria, that is, participants
were not drinking enough to be categorised as harmful or dependent drinkers or less
than 80% of the sample meet criteria for alcohol dependence or harmful alcohol use.
A list of excluded studies can be found in Appendix 16d.
Electronic databases CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane
Library
Date searched Database inception to March 2010
Study design RCT (at least ten participants per arm)
Population Adults (over 18 years old)
At least 80% of the sample meet the criteria for alcohol
dependence or harmful alcohol use (clinical diagnosis
or drinking more than 30 drinks per week)
Excluded populations Hazardous drinkers and those drinking fewer than 30
drinks per week
Pregnant women
Interventions Behavioural self-management, behavioural self-
management training, behavioural self-control training,
cue exposure (alone or with CBT or coping skills),
moderation-oriented cue exposure
Comparator Control or other active intervention
Outcomes Abstinence
Amount of alcohol consumed
Rates of consumption
Relapse (>X number of drinks or number of partici-
pants who have relapsed)
Lapse (time to first drink or number of participants who
have lapsed)
Attrition (leaving the study early for any reason)
Table 47: Clinical review protocol for the review of behavioural therapies
Psychological and psychosocial interventions
271

Psychological and psychosocial interventions
272
Behavioural Behavioural therapies Different formats of
therapies versus versus other active behavioural therapy
control/TAU intervention
K (total N) 2 RCTs (N = 134) 4 RCTs (N = 3420) 2 RCTs (N = 199)
Study ID (1) ALDEN1988 (1) ALDEN1988 (1) HEATHER2000
(2) MONTI1993 (2) KAVANAGH2006 (2) KAVANAGH2006
(3) SITHARTHAN1997
(4) WALITZER2004
Diagnosis (1) Not reported (1) Not reported (1) Not reported
(2) DSM alcohol (2) DSM alcohol dependent (2) DSM alcohol
dependent (3) Not reported dependent
(4) 85% had low level
alcohol dependence and
15% had moderate levels
Baseline severity (1) Consuming >84 (1) Consuming >84 standard (1) SADQ-C score: 18.7
standard ethanol ethanol units per week APQ score: 10.1
units per week (2) SADQ-C score: DDD: 19.96;
(2) ADS score: 20.7 approximately 13.7 abstinent days: 19.14%
SMAST score: 9.97 AUDIT score: (2) SADQ-C score:
DDD: 12.1; abstinent approximately 28 approximately 13.7
days: 47%; heavy Weekly alcohol consump- AUDIT score:
drinking days: 45% tion: approximately 37 approximately 28
(3) SADQ-C score: 18.81 Weekly alcohol
ICQ score: 13.05 consumption:
CDSES* score: 35.93 approximately 37
Drinking days per month:
20.2; consumption per
occasion: 8.82
(4) ADS score: 8.4
Abstinent days/month: 11.0;
Frequency of more than six
drinks per drinking period
per month: 5.1
Number of sessions Range: 6 to 12 Range: 6 to 12 8 sessions
Length of treatment Range: 6 to 12 weeks Range: 6 to 12 weeks 8 weeks
Length of follow-up Range: 6 to 24 months Range: 3 to 12 months Range: 3 to 12 months
Setting (1) Outpatient clinical (1)–(4) Outpatient clinical (1)–(2) Outpatient
research unit research unit clinical research unit
(2) Inpatient VA
medical centre
Treatment goal (1) Drinking reduction/ (1)–(4) Drinking reduction/ (1)–(2) Drinking
moderation moderation reduction/moderation
(2) Not explicitly stated
Country (1) Canada (1)–(3) Australia (1) UK
(2) US (4) US (2) Australia
Table 48: Summary of study characteristics for behavioural therapies
Note. *CDSES = Controlled Drinking Self-Efficacy Scale.

Behavioural therapies versus control
Of the six included trials, there were two involving a comparison of behavioural ther-
apies versus control which met criteria for inclusion. ALDEN1988 assessed behav-
ioural self-management training versus waitlist control and MONTI1993 assessed
cue exposure with coping skills versus control (treatment as usual and daily cravings
monitoring). The included studies were conducted between 1988 and 1993.
Behavioural therapies versus other active interventions
Of the six included trials, four trials that evaluated behavioural therapies versus other
active interventions met criteria for inclusion. Behavioural and other active therapies
were as follows: ALDEN1988 (behavioural self-management versus developmental
counselling); KAVANAGH2006 (cue exposure plus CBT versus emotional cue expo-
sure plus CBT); SITHARTHAN1997 (cue exposure versus CBT); WALITZER2004
(behavioural self management versus BCT with alcohol-focused spousal involvement
and alcohol-focused spousal involvement alone). The included studies were
conducted between 1988 and 2006.
Comparing different formats of behavioural therapy
Of the six included trials, two trials that assessed one type of behavioural therapy
versus another met criteria for inclusion. The behavioural therapies in the
HEATHER2000 study were moderation-oriented cue exposure and behavioural self-
control training. In the KAVANAGH2006 study, they were cue exposure (plus CBT)
and emotional cue exposure (plus CBT). The included studies were conducted
between 2000 and 2006.
6.10.4 Evidence summary
The GRADE profiles and associated forest plots for the comparisons can be found in
Appendix 18c and Appendix 17c, respectively.
Behavioural therapies versus control/treatment as usual
The review evidence indicated that behavioural therapies were more effective than
control in reducing the amount of alcohol consumed (SMD =�0.97, large effect size)
and maintaining controlled drinking (SMD =�0.60, medium effect size) when
assessed post-treatment. However, it must be noted that this was based on a single
study.
No significant difference was observed between behavioural therapies and control
in maintaining abstinence when assessed post-treatment. Furthermore, no significant
difference could be found between behavioural therapies and control in the number
of participants who lapsed or re