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Alcohol-use disorders

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What is covered

This interactive flowchart covers preventing, diagnosing and managing alcohol-related disorders, including hazardous and harmful drinking, alcohol dependence and the physical complications of alcohol use.
Align actions to prevent harmful drinking with strategies to prevent obesity at a community level to ensure a coherent, integrated approach (see what NICE says on obesity: working with local communities).

Updates

Updates to this interactive flowchart

12 August 2019 Updated on publication of alcohol interventions in secondary and further education (NICE guideline NG135).
13 November 2018 Subcutaneous automated low-flow pump implantation for refractory ascites caused by cirrhosis (NICE interventional procedures guidance 631) added to complications of alcohol-related liver disease.
11 April 2017 Updated following the update of alcohol-use disorders: diagnosis and management of physical complications (NICE guideline CG100).
31 March 2016 Structure revised and summarised recommendations replaced with full recommendations.
24 March 2015 Rifaximin for preventing episodes of overt hepatic encephalopathy (NICE technology appraisal guidance 337) and alcohol: preventing harmful alcohol use in the community (NICE quality standard 83) added.
25 November 2014 Nalmefene for reducing alcohol consumption in people with alcohol dependence (NICE technology appraisal guidance 325) added.
25 June 2013 SonoVue for contrast-enhanced ultrasound imaging of the liver (NICE diagnostics guidance 5) added.
31 August 2011 Alcohol dependence and harmful alcohol use (NICE quality standard 11) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on preventing, diagnosing and managing alcohol-related disorders in an interactive flowchart

What is covered

This interactive flowchart covers preventing, diagnosing and managing alcohol-related disorders, including hazardous and harmful drinking, alcohol dependence and the physical complications of alcohol use.
Align actions to prevent harmful drinking with strategies to prevent obesity at a community level to ensure a coherent, integrated approach (see what NICE says on obesity: working with local communities).

Updates

Updates to this interactive flowchart

12 August 2019 Updated on publication of alcohol interventions in secondary and further education (NICE guideline NG135).
13 November 2018 Subcutaneous automated low-flow pump implantation for refractory ascites caused by cirrhosis (NICE interventional procedures guidance 631) added to complications of alcohol-related liver disease.
11 April 2017 Updated following the update of alcohol-use disorders: diagnosis and management of physical complications (NICE guideline CG100).
31 March 2016 Structure revised and summarised recommendations replaced with full recommendations.
24 March 2015 Rifaximin for preventing episodes of overt hepatic encephalopathy (NICE technology appraisal guidance 337) and alcohol: preventing harmful alcohol use in the community (NICE quality standard 83) added.
25 November 2014 Nalmefene for reducing alcohol consumption in people with alcohol dependence (NICE technology appraisal guidance 325) added.
25 June 2013 SonoVue for contrast-enhanced ultrasound imaging of the liver (NICE diagnostics guidance 5) added.
31 August 2011 Alcohol dependence and harmful alcohol use (NICE quality standard 11) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Alcohol-use disorders: prevention (2010) NICE guideline PH24
Rifaximin for preventing episodes of overt hepatic encephalopathy (2015) NICE technology appraisal guidance 337
Extracorporeal albumin dialysis for acute liver failure (2009) NICE interventional procedure guidance 316
Alcohol: preventing harmful use in the community (2015) NICE quality standard 83
Alcohol-use disorders: diagnosis and management (2011) NICE quality standard 11
LiverMultiScan for liver disease (2019) NICE medtech innovation briefing 181

Quality standards

Alcohol: preventing harmful use in the community

These quality statements are taken from the alcohol: preventing harmful use in the community quality standard. The quality standard defines clinical best practice for preventing harmful alcohol use in the community and should be read in full.

Quality statements

Awareness training for health and social care staff

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

Health and social care staff receive alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol.

Quality measure

Structure:
a) Evidence of local arrangements to ensure that alcohol awareness training that promotes respectful, non-judgmental care is delivered to all health and social care staff who potentially work with patients or service users who misuse alcohol.
b) Evidence of local arrangements to ensure that local patient and service user feedback, in the form of surveys and complaints, is collected, analysed and acted upon within all health and social care settings.
Process:
Proportion of health and social care staff potentially working with patients or service users who misuse alcohol, who have successfully completed alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol.
Numerator – the number of people in the denominator completing alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol.
Denominator – the number of health and social care staff potentially working with patients or service users who misuse alcohol.

What the quality statement means for each audience

Service providers ensure they deliver alcohol awareness training that promotes respectful, non-judgmental care, to all staff potentially working with patients or service users who misuse alcohol, and collect and act upon patient and service user feedback, in the form of surveys and complaints.
Health and social care professionals potentially working with patients or service users who misuse alcohol complete alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol, embed this training into their routine practice, and use local patient and service user feedback policies and surveys.
Commissioners ensure they commission services that provide alcohol awareness training that promotes respectful, non-judgmental care, for all staff potentially working with patients or service users who misuse alcohol, and which collect and act upon patient and service user feedback, in the form of surveys and complaints.
People who misuse alcohol are cared for by health and social care staff who have received training in alcohol awareness that includes respectful and non-judgmental care, and have the opportunity to feedback their experience of staff attitudes using a survey or complaints procedure.

Source guidance

Data source

Structure:
a) and b) Local data collection.
Process:
Local data collection.

Definitions

For the purposes of this statement, health and social care staff are defined as any worker potentially having contact with people who misuse alcohol in any health or social care setting, including those working in criminal justice, prison, community or voluntary sector settings.
There should be a stepped approach to alcohol awareness training provision, depending on staff roles and the nature of contact with people who misuse alcohol. As a minimum, all workers who potentially have contact with people who misuse alcohol should complete basic training that promotes a respectful and non-judgmental attitude to people who misuse alcohol and which takes into account the stigma and discrimination often associated with alcohol misuse.
NICE’s guideline on alcohol-use disorders: prevention recommends that health and social care professionals providing care for people at risk of hazardous (increasing risk) and harmful (high-risk) drinking in NHS-commissioned services should receive training in providing alcohol screening and structured brief advice and if there is local demand, should also be trained to deliver extended brief interventions.
Staff training should also cover provision of information to people misusing alcohol, appropriate to the worker's role.

Equality and diversity considerations

NICE’s guildeline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence reports of stigma in healthcare settings towards people who misuse alcohol in general. In addition, women can be more likely to experience stigma in relation to their drinking than men and people from minority ethnic groups might find it more difficult to openly discuss their emotional problems due to cultural factors, such as cultural honour and respect. People who are homeless can be particularly vulnerable to discrimination. This quality statement advances equality by ensuring equitable staff conduct towards all patients, service users and clients, including those who (potentially) misuse alcohol.

Opportunistic screening and brief interventions

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

Health and social care staff opportunistically carry out screening and brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking as an integral part of practice.

Quality measure

Structure:
a) Evidence of local arrangements to ensure that healthcare staff opportunistically carry out screening and brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking on a routine basis.
b) Evidence of local arrangements to ensure that social care staff opportunistically carry out screening with people who may be at an increased risk of harm from alcohol and people who have alcohol-related problems, and deliver brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking.
c) Evidence of local arrangements within the commissioning framework to ensure that brief interventions are reviewed to ensure effective practice.
Process:
a) Proportion of people aged 16 years and over in the locally defined target population who receive alcohol screening.
Numerator – the number of people in the denominator receiving alcohol screening.
Denominator – the number of people aged 16 years and over in the locally defined target population for alcohol screening.
b) Proportion of people aged 18 and older identified as hazardous (increasing risk) or harmful (high-risk) drinkers who receive structured brief advice.
Numerator – the number of people in the denominator receiving structured brief advice.
Denominator – the number of people aged 18 and older identified as hazardous (increasing risk) or harmful (high-risk) drinkers.
c) Proportion of people aged 16 or 17 identified as hazardous (increasing risk) or harmful (high-risk) drinkers and people aged 18 and older not responding to structured brief advice for hazardous or harmful drinking, who receive an extended brief intervention.
Numerator – the number of people in the denominator receiving an extended brief intervention.
Denominator – the number of people aged 16 or 17 identified as hazardous or harmful drinkers and people aged 18 and older not responding to structured brief advice for hazardous (increasing risk) or harmful (high-risk) drinking.
Outcome:
Decrease in the quantity and frequency of alcohol consumption in the locally defined target population.

What the quality statement means for each audience

Service providers ensure that healthcare staff opportunistically carry out alcohol screening and brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking on a routine basis, and that social care staff opportunistically carry out alcohol screening with people who may be at an increased risk of harm from alcohol and deliver brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking.
Healthcare professionals ensure they opportunistically carry out screening and brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking as an integral part of practice and on a routine basis.
Social care professionals ensure they opportunistically carry out screening for people who may be at an increased risk of harm from alcohol and deliver brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking.
Commissioners ensure they commission services that opportunistically carry out screening and brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking as an integral part of practice, and develop commissioning frameworks that review this practice to ensure effectiveness.
People aged 16 and over are asked questions about their drinking during contact with health and social care professionals, and may be offered some brief advice about what this means or a longer session to help reduce their drinking.

Source guidance

Alcohol-use disorders: prevention (2010) NICE guideline PH24, recommendations 5, 7 and 9.

Data source

Structure: a), b) and c) Local data collection.
Process:
a) GP practices delivering the current Directed Enhanced Service (DES) specification for the Alcohol-related risk reduction scheme, England are required to send to commissioners an audit of:
  • Number of newly-registered patients aged 16 and over within the financial year who have had the shortened standard test (FAST or AUDIT-C – both abbreviated versions of the alcohol use disorders identification test [AUDIT]).
  • Number of newly-registered patients aged 16 and over who have screened positive using a short test during the financial year, who then undergo a fuller assessment using a validated tool (for example, AUDIT) to determine increasing risk, higher risk, or probable alcohol dependence.
The current National patient survey of PCTs collects the following data:
  • Whether people have been asked by someone at their GP practice/health centre in the last 12 months about how much alcohol they drink.
And data on respondents' discussions with their GP, someone else at the surgery, another doctor or any other medical professional is available from the ONS drinking survey.
b) The DES requires participating GP practices to audit the number of newly-registered patients who have been identified as drinking at increasing risk or higher risk levels who have during that period received a brief intervention to help them reduce their alcohol-related risk.
c) Local data collection.
Outcome:
Data on prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.

Definitions

The following definitions are adapted from NICE's guideline on alcohol-use disorders: prevention.
'Screening' involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. The term is not used here to refer to national screening programmes such as those recommended by the UK National Screening Committee (UK NSC). Screening should be carried out with a validated alcohol questionnaire (such as the AUDIT).
'Brief intervention' comprises either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists.
Screening and extended brief interventions are recommended in people aged 16 or 17 years. Screening and structured brief advice are recommended as the first step in people aged 18 years and older. For those who do not respond to structured brief advice, an extended brief intervention is recommended.
For the purposes of this statement, health and social care staff are defined as any professional working in any health or social care setting, including those working in criminal justice, prison, community or voluntary sector settings who regularly come into contact with people at risk of harm from the amount of alcohol they drink.
NHS professionals should consider discussing alcohol consumption during new patient registrations at a GP practice, when screening for other conditions, and when managing chronic disease or carrying out a medicine review. Discussions should also take place when promoting sexual health, when seeing someone for an antenatal appointment and when treating minor injuries.
Social care professionals should focus on people who may be at an increased risk of harm and people who have alcohol-related problems. People who may be at an increased risk of harm from alcohol include those:
  • at risk of self-harm
  • involved in crime or other antisocial behaviour
  • who have been assaulted
  • at risk of domestic abuse
  • whose children are involved with child safeguarding agencies
  • with drug problems.
Figure 5 in the full guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence provides a care pathway for case identification and possible diagnosis for adults, including criteria for brief interventions, extended brief interventions, and specialist referral.

Equality and diversity considerations

Lower screening thresholds may be needed when assessing older and younger people. In addition, by recommending that those aged 16 and 17 receive extended brief interventions (rather than structured brief advice) it may reduce the number of opportunities to receive an intervention, as extended brief interventions may be less readily available. Lower screening thresholds should also be considered for women and some black and minority ethnic groups too.
Discussions broaching the subject of alcohol and screening should be sensitive to people's culture and faith, and tailored to their needs. Discussions with young people should be sensitive to the person's age, their ability to understand what is involved and their emotional maturity. Relevant specialists should be consulted when it is not appropriate to use an English language-based screening questionnaire, for example when dealing with people whose first language is not English or who have a learning disability.

Referral to specialist alcohol services

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

People who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and are able to access specialist alcohol treatment.

Quality measure

Structure:
a) Evidence of local arrangements to ensure effective identification of people who may benefit from specialist assessment or treatment for alcohol misuse.
b) Evidence of the use of a local referral pathway in accordance with NICE's guidelines on alcohol-use disorders: prevention and alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence to ensure that people who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services.
c) Evidence of a local needs assessment highlighting gaps in and barriers to accessing specialist alcohol treatment as well as prevalence of alcohol misuse. Estimated burden of alcohol misuse and uptake of specialist treatment should be broken down by key equality groups such as women, people from minority ethnic groups, people who are homeless and people in different age groups.
d) Evidence of audit of waiting times in specialist alcohol services from initial referral to assessment, assessment to treatment start, and total waiting time from referral to starting treatment.
Process:
Proportion of people meeting NICE guidance criteria for referral to specialist alcohol services who are referred to specialist alcohol services.
Numerator – the number of people in the denominator referred to specialist alcohol services.
Denominator – the number of people meeting NICE guidance criteria for referral to specialist alcohol services.
Outcome:
a) Proportion of people in the local population estimated to be dependent on alcohol who access specialist alcohol services.
Numerator – the number of people in the denominator accessing specialist alcohol services.
Denominator – the number of people in the local population estimated to be dependent on alcohol.
NICE’s guideline on alcohol-use disorders: prevention recommends that commissioners should ensure at least one in seven dependent drinkers can get treatment locally.
b) Decrease in the quantity and frequency of alcohol consumption in people who misuse alcohol.

What the quality statement means for each audience

Service providers ensure that access pathways are implemented for referring to specialist alcohol services and that appropriate arrangements are in place for self-referral for people who may benefit from specialist assessment or treatment for alcohol misuse.
Health and social care professionals ensure they are aware of local access pathways and offer referral to specialist alcohol services to people who may benefit from specialist assessment or treatment for alcohol misuse.
Commissioners ensure they commission services that implement effective access pathways to specialist alcohol services and commission specialist alcohol services with capacity for at least one in seven of the estimated dependent drinking population to access treatment.
People who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and are able to access specialist alcohol treatment.

Source guidance

Data source

Structure:
a), b), c) Local data collection.
d) Local data collection. The National Alcohol Treatment Monitoring System collects data on people presenting for structured treatment in specialist alcohol services; 'date referred to modality', 'date of first appointment offered for modality' and 'triage date' are collected. 'Modality start date' records when the person actually starts a treatment modality.
Process:
GP practices delivering the Directed Enhanced Service specification for the Alcohol-related risk reduction scheme, England are required to send to commissioners an audit of:
  • Number of newly registered patients scoring 20 or more on the full ten-question alcohol-use disorders identification test (AUDIT) questionnaire who have been referred for specialist advice for dependent drinking during that period.
The National Alcohol Treatment Monitoring System collects data on referral routes into specialist alcohol services for people who present for structured specialist treatment, that is, those who complete a structured treatment assessment.
Outcome:
a) Data on prevalence of alcohol misuse in adults is available from the NHS Adult Psychiatric Morbidity Survey in England. The National Alcohol Treatment Monitoring System collects data on people receiving structured alcohol treatment, but does not differentiate between harmful drinkers and people with alcohol dependence.
b) Local data collection. Data on prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.

Definitions

See quality statement 2 on opportunistic screening and brief interventions for a definition of brief interventions.
NICE’s guideline on alcohol-use disorders: prevention recommends that referral for specialist treatment is considered for people aged 16 years and older if they:
  • show signs of moderate or severe alcohol dependence or
  • fail to benefit from structured brief advice and an extended brief intervention and desire to receive further help for an alcohol problem or
  • show signs of severe alcohol-related impairment or related comorbid condition (for example, liver disease or alcohol-related mental health problems).
Referral for young people aged 16 or 17 years must be to services that deal with young people.
NICE’s guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends that people should be referred to specialist services for assessment of need where staff making the referral are not competent themselves to identify harmful drinking or alcohol dependence. It also recommends that service users who typically drink over 15 units of alcohol per day and/or who score 20 or more on the AUDIT should be considered for assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal.
Figure 5 in the full guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence provides a care pathway for case identification and possible diagnosis for adults, including referral to specialist assessment.
Access to specialist alcohol services for those who might benefit from specialist treatment requires a responsive treatment system. A responsive treatment system is a pathway that ensures appropriate case identification and subsequent referral to specialist services, which respond appropriately to referrals and provide ease of access to treatment. Treatment access should include appropriate arrangements for self-referral.
People who are likely to benefit from specialist alcohol treatment who accept a referral to specialist alcohol services should expect the service to make contact with them as soon as possible. During any period of waiting, the service user remains under the care of the referrer (for example, their GP), who should continue monitoring and address any urgent needs as appropriate.

Equality and diversity considerations

This statement promotes equality by ensuring that all people who may benefit from specialist alcohol services are offered a referral and can access specialist alcohol services for assessment and treatment.
Currently, some equality groups may be under-referred, such as older adults (due to a lack of clinical suspicion or misdiagnosis) and young adults presenting at emergency departments or in primary care.
Homeless people can have difficulty accessing appointment-only services, women can regard services less suited to their needs in terms of children and childcare, and people from minority ethnic groups may find a lack of ethno-cultural peers and staff a barrier to treatment access. There is a risk that people who are housebound (which may include a large number of older people) currently wait longer to access specialist treatment.
Outreach and assertive engagement techniques should be considered with some of these groups who may otherwise find it difficult to engage in treatment.

Trained and competent specialist staff

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

People accessing specialist alcohol services receive assessments and interventions delivered by appropriately trained and competent specialist staff.

Quality measure

Structure:
a) Evidence of local implementation of current guidance from the Royal College of Psychiatrists and Royal College of General Practitioners on Delivering quality care for drug and alcohol users: the roles and competencies of doctors.
b) Evidence of local arrangements to ensure that all staff carrying out initial assessments in specialist alcohol services are trained in the key elements of motivational interviewing.
c) Evidence of local arrangements to ensure that care coordination with other agencies (for example, housing, employment and social care) is delivered by appropriately trained and competent staff working in specialist alcohol services.
d) Evidence of local arrangements to ensure the use of competence frameworks developed from relevant treatment manuals that guide the structure and duration of psychological interventions for people who misuse alcohol.
e) Evidence of local arrangements to ensure that staff responsible for assessing and managing assisted alcohol withdrawal are trained and competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms, and the use of drug regimens appropriate to the setting in which the withdrawal is managed.
f) Evidence of local arrangements to ensure that staff working in specialist alcohol services receive appropriate monitoring and supervision.
Process:
Proportion of staff carrying out assessments or delivering interventions in specialist alcohol services who are Drugs and Alcohol National Occupational Standards (DANOS) compliant.
Numerator – the number of people in the denominator who are DANOS compliant.
Denominator – the number of staff carrying out assessments or delivering interventions in specialist alcohol services.
Outcome:
Decrease in the quantity and frequency of alcohol consumption in people who misuse alcohol.

What the quality statement means for each audience

Service providers ensure that specialist staff carrying out assessments or delivering interventions for alcohol misuse are appropriately trained and competent in accordance with current national guidance.
Health and social care professionals carrying out assessments or delivering interventions for alcohol misuse as part of specialist alcohol treatment ensure they are aware of current national guidance, participate in appropriate training, and engage in evaluation and supervision of their practice.
Commissioners ensure they commission specialist alcohol services with an adequate specialist workforce in accordance with current national guidance and where staff training and competence are monitored and maintained.
People accessing specialist alcohol services are assessed by and receive treatment from appropriately trained and competent specialist staff.

Source guidance

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) NICE guideline CG115, recommendations 1.2.1.6, 1.3.1.1, 1.3.1.5 (key priority for implementation) and 1.3.2.1

Data source

Structure:
a) to f) Local data collection.
Process:
Local data collection.
Outcome:
Local data collection. Data on the prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.

Definitions

At the time of publication (June 2011), current national guidance on a specialist workforce includes:
DANOS should be considered a minimum requirement for practitioners in specialist alcohol services. In addition, relevant specialists will be required for some assessments and interventions, such as mental health assessments and delivery of cognitive behavioural therapy.
The level and type of training or specialism required will vary across different stages of the treatment system. Exact workforce composition and planning should be determined locally in accordance with local need. Provision for ongoing monitoring and evaluation of practice competence, for example, by using video and audio tapes and external audit and scrutiny, should be assured.

Assessment in specialist alcohol services – adults

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

Adults accessing specialist alcohol services for alcohol misuse receive a comprehensive assessment that includes the use of validated measures.

Quality measure

Structure:
a) Evidence of local arrangements to ensure that adults accessing specialist alcohol services for alcohol misuse receive a comprehensive assessment that includes the use of validated measures.
b) Evidence of local arrangements to ensure the use of a standardised comprehensive assessment form for adults accessing specialist alcohol services.
c) Evidence of regular local audit of case files for adults in specialist alcohol services to ensure adherence to all assessment domains.
d) Evidence of local arrangements in specialist alcohol services for effective coordination with other agencies relevant to adult service users.
Process:
a) Proportion of adults accessing specialist alcohol services for alcohol misuse who receive a comprehensive assessment.
Numerator – the number of people in the denominator receiving a comprehensive assessment.
Denominator – the number of adults accessing specialist alcohol services for alcohol misuse.
b) Proportion of adults accessing specialist alcohol services for alcohol misuse who are assessed using appropriate and validated measures for each applicable assessment domain.
Numerator – the number of people in the denominator assessed using appropriate and validated measures for each applicable assessment domain.
Denominator – the number of adults accessing specialist alcohol services for alcohol misuse.

What the quality statement means for each audience

Service providers ensure they implement validated measures for assessing adults accessing specialist alcohol services for alcohol misuse, and provide a standardised assessment form to ensure that all components of a comprehensive assessment are completed for every person.
Health and social care professionals ensure they complete all components of a comprehensive assessment including the use of validated measures, for adults accessing specialist alcohol services for alcohol misuse.
Commissioners ensure they commission specialist alcohol services that use validated measures for assessing adults accessing specialist treatment for alcohol misuse, and ensure that all components of a comprehensive assessment are completed for every person.
Adults accessing specialist alcohol services for alcohol misuse receive a full assessment of the different areas in which they might need help.

Source guidance

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) NICE guideline CG115, recommendations 1.2.1.4, 1.2.1.5, 1.2.2.5, 1.2.2.6 (key priority for implementation), 1.2.2.7 and 1.3.2.3

Data sources

Structure:
a), b), c) and d) Local data collection.
Process:
a) The National Alcohol Treatment Monitoring System collects data on people presenting for structured treatment in specialist alcohol services; 'triage date' is collected, which is the date that triage/initial assessment took place (this is not necessarily a comprehensive assessment). It also collects data at the start of treatment for the numbers of drinking days in the last 28 days (self-report) and typical numbers of units consumed in an average drinking day.

Definitions

NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends the following validated assessment tools to assess the nature and severity of alcohol misuse:
  • Alcohol Use Disorders Identification Test (AUDIT) for identification and as a routine (drinking) outcome measure
  • Severity of Alcohol Dependence Questionnaire (SADQ) or Leeds Dependence Questionnaire (LDQ) for severity of dependence
  • Alcohol Problems Questionnaire (APQ) for the nature and extent of the problems arising from alcohol misuse.
The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) may be used to assess the severity of alcohol withdrawal.
NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends considering a comprehensive assessment for all adults referred to specialist 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, 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 (including housing)
  • cognitive function (using, for example, the Mini-Mental State Examination [MMSE])
  • readiness and belief in ability to change.
Comorbid mental health problems should also be assessed as part of any comprehensive assessment, because many comorbid problems (though not all) will improve with treatment for alcohol misuse.
Any initial assessment, which may take place as a triage or as part of the comprehensive assessment, should also assess:
  • the pattern and severity of alcohol misuse (using AUDIT) and severity of dependence (using SADQ)
  • the need for urgent treatment including assisted withdrawal
  • any associated risk to self or risk to others
  • the presence of any comorbdities or other factors that may need further specialist assessment or intervention.

Equality and diversity considerations

When assessing the severity of alcohol dependence and determining the need for assisted withdrawal, the criteria should be adjusted for women, older people and younger people.
All assessments should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People who need a comprehensive assessment should have access to an interpreter or advocate if needed.

Assessment in specialist services – children and young people

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

Children and young people accessing specialist services for alcohol use receive a comprehensive assessment that includes the use of validated measures.

Quality measure

Structure:
a) Evidence of local arrangements to ensure that children and young people accessing specialist services for alcohol use receive a comprehensive assessment that includes the use of validated measures.
b) Evidence of local arrangements to ensure the use of a standardised comprehensive assessment form in specialist services accessed by children and young people for alcohol use.
c) Evidence of regular local audit of case files for children and young people in specialist services accessed by children and young people for alcohol use, to ensure adherence to all assessment domains.
d) Evidence of local arrangements in specialist services for effective coordination with other relevant agencies for children and young people at risk of harm from alcohol use.
Process:
a) Proportion of children and young people accessing specialist services for alcohol misuse who receive a comprehensive assessment.
Numerator – the number of people in the denominator receiving a comprehensive assessment.
Denominator – the number of children and young people accessing specialist services for alcohol use.
b) Proportion of children and young people accessing specialist services for alcohol use who are assessed using appropriate and validated measures for each applicable assessment domain.
Numerator – the number of people in the denominator assessed using appropriate and validated measures for each applicable assessment domain.
Denominator – the number of children and young people accessing specialist services for alcohol use.

What the quality statement means for each audience

Service providers ensure they implement validated measures for assessing children and young people who access specialist services for alcohol use and ensure that all components of a comprehensive assessment are completed for every person.
Health and social care professionals ensure they carry out a comprehensive assessment of multiple areas of need using a validated measure such as the Adolescent Diagnostic Interview (ADI) or the Teen Addiction Severity Index (T-ASI) for children and young people accessing specialist services for alcohol use.
Commissioners ensure they commission specialist services for children and young people at risk of harm from alcohol use that use validated measures for assessment and ensure that all components of a comprehensive assessment are completed for every person.
Children and young people attending specialist services for alcohol problems receive a full assessment of different areas in which they may need help.

Source guidance

Data source

Structure:
a), b), c) and d) Local data collection.
Process:
Local data collection. The National Drug Treatment Monitoring System collects data on young people (lower age limit 9 years old) presenting to specialist young people's drug and alcohol services; 'triage date' is collected, which is the date that triage/initial assessment took place (this is not necessarily a comprehensive assessment). Also collects data at treatment start on the numbers of drinking days in the last 28 days (self-report) and typical numbers of numbers of units consumed in an average drinking day.

Definitions

NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends that a comprehensive assessment for children and young people (supported if possible by additional information from a parent or carer) should assess multiple areas of need, be structured around a clinical interview using a validated clinical tool (such as the ADI or T-ASI), and cover the following areas:
  • consumption, dependence features and patterns of drinking
  • comorbid substance misuse (consumption and dependence features) and associated problems
  • mental and physical health problems
  • peer relationships and social and family functioning
  • developmental and cognitive needs, and educational attainment and attendance
  • history of abuse and trauma
  • risk to self and others
  • readiness to change and belief in the ability to change
  • obtaining consent to treatment
  • developing a care plan and risk management plan.
NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends that comprehensive assessments for children and young people are carried out in child and adolescent mental health services (CAMHS). NICE’s guideline on alcohol-use disorders: prevention recommends that, for children aged 10–15 years, if there is a reason to believe that there is a significant risk of alcohol-related harm, referral to either CAMHS, social care or to young people's alcohol services for treatment, should be considered.
Any initial assessment of children and young people where alcohol misuse is identified as a potential problem, which may or may not form part of the comprehensive assessment, should assess:
  • the duration and severity of the alcohol misuse (the standard adult threshold on the AUDIT for referral and intervention should be lowered for young people aged 10–16 years because of the more harmful effects of a given level of alcohol consumption in this population)
  • any associated health and social problems
  • the potential need for assisted withdrawal.
NICE’s guideline on alcohol-use disorders: prevention recommends that, for children aged 10–15 years, a detailed history of their alcohol use (for example, using the Common Assessment Framework as a guide) should be obtained. Background factors such as family problems and instances of child abuse or under-achievement at school should also be included.

Equality and diversity considerations

All assessments should be age-appropriate and accessible to children and young people with additional needs such as physical, sensory or learning disabilities, and to children and young people who do not speak or read English. Children and young people needing a comprehensive assessment should have access to an interpreter or advocate if needed.
This statement applies to people aged 10–17 years only, which is appropriate given the different needs of children and young people compared to adults who misuse alcohol.

Families and carers

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

Families and carers of people who misuse alcohol have their own needs identified, including those associated with risk of harm, and are offered information and support.

Quality measure

Structure:
a) Evidence of local arrangements to ensure that local services use promotional materials to encourage families and carers of people who misuse alcohol to access information and support.
b) Evidence of local arrangements to ensure that families and carers of people who misuse alcohol are offered written and verbal information on alcohol misuse and its management, including how families and carers can support the person who misuses alcohol.
c) Evidence of local arrangements to ensure those at risk of harm, including alcohol-related domestic violence, are offered information, advice and referral to other services where appropriate.
d) Evidence of local arrangements to ensure that services are compliant with current national guidance on safeguarding children.
e) Evidence of local arrangements to ensure that carers' assessments are offered to eligible carers of people who misuse alcohol.
f) Evidence of local arrangements to ensure provision of guided self-help for families and carers of people who misuse alcohol, including facilitating contact with support groups.
g) Evidence of local arrangements to ensure provision of family meetings for families and carers with significant problems, typically consisting of at least five weekly sessions providing information, identifying sources of stress and exploring coping behaviours.
Process:
a) Proportion of identified family members and carers (if not family) of people who misuse alcohol who receive appropriate written and verbal information.
Numerator – the number of people in the denominator receiving appropriate written and verbal information.
Denominator – the number of identified family members and carers (if not family) of people who misuse alcohol.
b) Proportion of identified family members and carers (if not family) of people who misuse alcohol who receive guided self-help and information about support groups.
Numerator – the number of people in the denominator receiving guided self-help and information about support groups.
Denominator – the number of identified family members and carers (if not family) of people who misuse alcohol.
c) Proportion of family members and carers (if not family) of people who misuse alcohol not benefiting from guided self-help and/or support groups who attend a family meeting(s).
Numerator – the number of people in the denominator attending a family meeting(s).
Denominator – the number of family members and carers (if not family) of people who misuse alcohol not benefiting from guided self-help and/or support groups.

What the quality statement means for each audience

Service providers ensure they provide and promote a range of services to support families and carers of people who misuse alcohol, and implement guidance and procedures to safeguard those at risk of harm.
Health and social care professionals ensure they follow local policies for supporting families and carers of people who misuse alcohol including carrying out carers' assessments, identifying and safeguarding those at risk of harm, and promoting and delivering support groups and family meetings.
Commissioners ensure they commission services that provide and promote a range of services to support families and carers of people who misuse alcohol, and implement guidance to safeguard those at risk of harm.
Families and carers of people who misuse alcohol have the opportunity to discuss their own needs, and can access information and support.

Source guidance

Data source

Structure:
a), b) and c) Local data collection.
d) The National Alcohol Treatment Monitoring System collects data on the parental status of people receiving structured alcohol treatment as well as pregnancy and whether the person receiving specialist treatment lives with children.
e), f) and g) Local data collection.
Process:
a), b) and c) Local data collection. See also data source for structure measure d).

Definitions

The definition of 'families' is broad and may include any relationship where regular care or contact occurs.
NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends that families and carers involved in supporting a person who misuses alcohol should have the opportunity to discuss concerns about the impact of alcohol misuse on themselves and other family members, and:
  • receive written and verbal information on alcohol misuse and its management, including how families or carers can support the service user
  • are offered a carer's assessment where necessary
  • have the opportunity, along with the service user, to negotiate about their involvement in the service user's care and the sharing of information; the healthcare professional should make sure the service user's, family's and carer's right to confidentiality is respected
  • are offered guided self-help, typically consisting of a single session, with the provision of written materials
  • receive information about, and have contact facilitated with, support groups (such as self-help groups specifically focused on addressing the needs of families and carers).
If the families and carers of people who misuse alcohol have not benefited, or are not likely to benefit, from guided self-help and/or support groups and continue to have significant problems, consideration should be given to offering them individual family meetings that:
  • provide information and education about alcohol misuse
  • help to identify sources of stress related to alcohol misuse
  • explore and promote effective coping behaviours
  • usually consist of at least five weekly sessions.
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 physical health, own alcohol use, safety, and social network and be aware of and comply with the requirements of the Children Act (2004).

Equality and diversity considerations

Discussions with families and carers of people who misuse alcohol should be individualised and culturally sensitive.

Medically assisted alcohol withdrawal – setting

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

People needing medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.

Quality measure

Structure:
a) Evidence of local arrangements to ensure that people who need medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
b) Evidence of local commissioning arrangements for provision of community-based medically assisted alcohol withdrawal in accordance with local need.
c) Evidence of local commissioning arrangements for provision of residential and inpatient medically assisted alcohol withdrawal, including provision for children and young people, and people with highly complex needs such as those at high risk of severe alcohol withdrawal syndromes, and/or with severe physical or psychiatric comorbidity.
d) Evidence of local arrangements to ensure that people in vulnerable groups who are in acute alcohol withdrawal are considered for admission to hospital for medically assisted withdrawal.
Process:
a) Proportion of adults needing medically assisted alcohol withdrawal not requiring an inpatient or residential setting, who complete a successful community-based withdrawal.
Numerator – the number of people in the denominator completing a successful community-based medically assisted alcohol withdrawal.
Denominator – the number of adults needing medically assisted alcohol withdrawal not requiring an inpatient or residential setting.
b) Proportion of people needing medically assisted alcohol withdrawal meeting criteria for inpatient or residential care who complete a successful withdrawal in an inpatient or residential setting.
Numerator – the number of people in the denominator completing successful medically assisted alcohol withdrawal in an inpatient or residential setting.
Denominator – the number of people needing medically assisted alcohol withdrawal meeting criteria for inpatient or residential care.
c) Proportion of people in defined groups in acute alcohol withdrawal who are admitted to hospital for medically assisted withdrawal.
Numerator – the number of people in the denominator admitted to hospital for medically assisted withdrawal.
Denominator – the number of people in defined groups in acute alcohol withdrawal.
Outcome:
a) Proportion of people undergoing medically assisted alcohol withdrawal (planned or unplanned) who complete withdrawal successfully and without complications.
Numerator – the number of people in the denominator completing medically assisted withdrawal successfully and without complications.
Denominator – the number of people undergoing medically assisted alcohol withdrawal (planned or unplanned).
b) Decrease in quantity and frequency of alcohol consumption in people needing medically assisted alcohol withdrawal.

What the quality statement means for each audience

Service providers ensure that people needing medically assisted alcohol withdrawal are referred to and treated in the setting (community, residential or inpatient) most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
Healthcare professionals ensure they care for people needing medically assisted alcohol withdrawal in the setting (community, residential or inpatient) most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
Commissioners ensure they commission services with adequate residential, inpatient and community-based capacity to enable their local population needing medically assisted alcohol withdrawal to be treated within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities.
People needing medically assisted alcohol withdrawal are cared for in the place most appropriate to their needs, for example, this may be at home, in a clinic or in hospital.

Source guidance

Data source

Structure:
a), b), c) and d) Local data collection.
Process:
a) Local data collection for denominator. The National Alcohol Treatment Monitoring System collects intervention type for people who present to specialist alcohol services and then start structured treatment. 'Alcohol – community prescribing interventions' is one of the interventions that can be recorded.
b) Local data collection for denominator. The National Alcohol Treatment Monitoring System collects data on the number of people receiving inpatient treatment for alcohol misuse (adults) and whether a person is in a substance misuse treatment specific residential placement (children and young people).
c) Local data collection. The International statistical classification of diseases and related health problems (ICD-10) code for alcohol withdrawal state with delirium is F10.4.
NHS Digital’s Statistics on alcohol in England reports on items prescribed for the treatment of alcohol dependence, including the setting in which they are prescribed.
Outcome:
a) Local data collection. The International statistical classification of diseases and related health problems (ICD-10) code for alcohol withdrawal state with delirium is F10.4.
b) Local data collection. Data on prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.

Definitions

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 assisted 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 (for example, psychiatric comorbidity, poor social support or homelessness), 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.
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 30 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.
Also consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups, for example, homeless and older people.
Offer inpatient care to children and young people aged 10–17 years who need assisted withdrawal.
NICE’s guideline on alcohol-use disorders: diagnosis and management of physical complications recommends that people in acute withdrawal with, or assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, should be offered admission to hospital for medically assisted alcohol withdrawal. A lower threshold for admission to hospital for medically assisted withdrawal should also be considered in certain vulnerable people, for example people who:
  • are frail
  • have cognitive impairment
  • have multiple comorbidities
  • lack social support
  • have learning difficulties
  • are 16 or 17 years.
Young people under 16 years who are in acute alcohol withdrawal should be offered admission to hospital for physical and psychosocial assessment, in addition to medically assisted alcohol withdrawal.

Equality and diversity considerations

A lower threshold for inpatient assisted withdrawal, whether planned or unplanned, should be considered for people who are homeless, older people and children and young people, to ensure their safety.

Medically assisted alcohol withdrawal – drug regimens

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

People needing medically assisted alcohol withdrawal receive medication using drug regimens appropriate to the setting in which the withdrawal is managed in accordance with NICE guidance.

Quality measure

Structure:
Evidence of local arrangements to ensure that people with suspected, or at high risk of developing, Wernicke's encephalopathy are offered thiamine in accordance with NICE's guidelines on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence and alcohol-use disorders: diagnosis and management of physical complications.
Process:
a) Proportion of people undergoing planned medically assisted alcohol withdrawal who receive medication using drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
Numerator – the number of people in the denominator receiving medication using drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
Denominator – the number of people undergoing medically assisted alcohol withdrawal.
b) Proportion of people in acute (unplanned) alcohol withdrawal who receive medication using drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis and management of physical complications.
Numerator – the number of people in the denominator receiving medication using drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis and management of physical complications.
Denominator – the number of people in acute (unplanned) alcohol withdrawal.
Outcome:
Proportion of people undergoing medically assisted alcohol withdrawal (planned or unplanned) who complete withdrawal successfully and without complications.
Numerator – the number of people in the denominator completing medically assisted withdrawal successfully and without complications.
Denominator – the number of people undergoing medically assisted alcohol withdrawal (planned or unplanned).

What the quality statement means for each audience

Service providers ensure that people undergoing planned medically assisted alcohol withdrawal are prescribed medication that is administered using drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence and people in acute (unplanned) withdrawal are prescribed medication that is administered using drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis and management of physical complications.
Healthcare professionals caring for people undergoing planned medically assisted alcohol withdrawal ensure they use drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence and, for people in acute (unplanned) withdrawal, use drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis and management of physical complications.
Commissioners ensure they commission services for planned medically assisted alcohol withdrawal that use drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence and for people in acute (unplanned) withdrawal, that use drug regimens in accordance with NICE's guideline on alcohol-use disorders: diagnosis and management of physical complications.
People undergoing medically assisted alcohol withdrawal are given medication in a manner (frequency and amount) determined by the place where withdrawal is carried out.

Source guidance

Data source

Structure:
Local data collection.
Process:
a) Local data collection.
b) Local data collection.
NHS Digital’s Statistics on alcohol in England reports on items prescribed for the treatment of alcohol dependence, including the setting in which they are prescribed.
Outcome:
Local data collection. The International statistical classification of diseases and related health problems (ICD-10) code for alcohol withdrawal state with delirium is F10.4.

Definitions

All prescribing for medically assisted alcohol withdrawal should be carried out in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, section 1.3.5, recommendation 1.3.7.6, and NICE's guideline on alcohol-use disorders: diagnosis and management of physical complications, recommendations 1.1.3.1 and 1.1.3.4 on drug regimens for assisted withdrawal.
Prescribers should use each drug’s summary of product characteristics (SPC) with regard to current licensed indications, contraindications and special considerations to inform their decision about a person they are prescribing for. If a drug is used at a dose or for an application that does not have UK marketing authorisation, informed consent should be obtained and documented.

Wernicke's encephalopathy

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

People with suspected, or at high risk of developing, Wernicke's encephalopathy are offered thiamine in accordance with NICE guidance.

Quality measure

Structure:
Evidence of local arrangements to ensure that people with suspected, or at high risk of developing, Wernicke's encephalopathy are offered thiamine in accordance with NICE's guidelines on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence and alcohol-use disorders: diagnosis and management of physical complications.
Process:
a) Proportion of people misusing alcohol, meeting NICE guidance criteria for prophylactic oral thiamine, who receive oral thiamine.
Numerator – the number of people in the denominator receiving prophylactic oral thiamine.
Denominator – the number of people misusing alcohol, meeting NICE guidance criteria for prophylactic oral thiamine.
b) Proportion of people misusing alcohol, meeting NICE guidance criteria for parenteral thiamine followed by oral thiamine, who receive parenteral thiamine followed by oral thiamine.
Numerator – the number of people in the denominator receiving parenteral thiamine followed by oral thiamine.
Denominator – the number of people misusing alcohol, meeting NICE guidance criteria for parenteral thiamine followed by oral thiamine.
Outcome:
Proportion of people misusing alcohol who have Wernicke's encephalopathy or Wernicke-Korsakoff syndrome.
Numerator – the number of people in the denominator with Wernicke's encephalopathy or Wernicke-Korsakoff syndrome.
Denominator – the number of people misusing alcohol.

What the quality statement means for each audience

Service providers ensure that systems are in place to provide thiamine in accordance with NICE guidance to people with suspected, or at high risk of developing, Wernicke's encephalopathy.
Healthcare professionals ensure they offer thiamine in accordance with NICE guidance to people with suspected, or at high risk of developing, Wernicke's encephalopathy.
Commissioners ensure they commission services that provide thiamine in accordance with NICE guidance for people with suspected, or at high risk of developing, Wernicke's encephalopathy.
People with suspected, or at high risk of developing, Wernicke's encephalopathy, which is a condition that affects the brain and nervous system, and is caused by a lack of thiamine (also called vitamin B1) in the body, are offered thiamine (either as tablets or as an injection followed by tablets, depending on the situation) to help prevent the condition developing or getting worse.

Source guidance

Data source

Structure:
Local data collection.
Process:
a) Local data collection.
b) Local data collection. The International statistical classification of diseases and related health problems (ICD-10) code for Wernicke's encephalopathy is E51.2 and alcohol amnesic syndrome is F10.6.
Outcome:
See process b) data source for information relevant to the numerator. Data on the prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.

Definitions

NICE's guideline on alcohol-use disorders: diagnosis and management of physical complications recommends that thiamine is offered to people at high risk of developing, or with suspected, Wernicke's encephalopathy. Thiamine should be given in doses toward the upper end of the 'British national formulary' (BNF) range.
Prophylactic oral thiamine should be offered to harmful or dependent drinkers:
  • if they are malnourished or at risk of malnourishment or
  • if they have decompensated liver disease or
  • if they are in acute withdrawal or
  • before and during a planned medically assisted alcohol withdrawal.
Parenteral thiamine followed by oral thiamine should be offered to people with suspected Wernicke's encephalopathy and harmful or dependent drinkers if they:
  • are malnourished or at risk of malnourishment or
  • have decompensated liver disease and in addition
    • attend an emergency department or
    • are admitted to hospital with an acute illness or injury.
In addition, NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends offering parenteral thiamine followed by oral thiamine to people entering planned assisted alcohol withdrawal in specialist inpatient alcohol services or prison settings who are malnourished, at risk of malnourishment or have decompensated liver disease.

Equality and diversity considerations

This statement applies only to groups at high risk of developing Wernicke's encephalopathy. People with alcohol dependence who are homeless are likely to be included in this group.

Psychological interventions and relapse prevention medication for adults

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

Adults who misuse alcohol are offered evidence-based psychological interventions, and those with alcohol dependence that is moderate or severe can in addition access relapse prevention medication in accordance with NICE guidance.

Quality measure

Structure:
a) Evidence of local arrangements to ensure that adults who misuse alcohol are offered evidence-based psychological interventions appropriate to their circumstances, in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
b) Evidence of local formal evaluation of psychological interventions within the commissioning framework, including routine review and follow-up, to ensure adherence to evidence based practice.
c) Evidence of local arrangements to ensure that people with moderate or severe alcohol dependence are considered for relapse prevention medication after a successful medically assisted withdrawal.
Process:
a) Proportion of adults accessing specialist services for alcohol misuse who receive evidence-based psychological interventions in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
Numerator – the number of adults in the denominator receiving evidence-based psychological interventions in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
Denominator – the number of adults accessing specialist services for alcohol misuse.
b) Proportion of adults with moderate or severe alcohol dependence completing a successful medically assisted withdrawal who receive relapse prevention medication.
Numerator – the number of adults in the denominator receiving relapse prevention medication.
Denominator – the number of adults with moderate or severe alcohol dependence completing a successful medically assisted withdrawal.
Outcome:
a) Decrease in the quantity and frequency of alcohol consumption in people who misuse alcohol.
b) Reduction in the rates of relapse to heavy drinking.

What the quality statement means for each audience

Service providers ensure provision of evidence-based psychological interventions in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, and ensure that relapse prevention medication is offered to those with moderate or severe alcohol dependence following a successful withdrawal.
Healthcare professionals use competence frameworks developed from relevant treatment manuals to ensure they offer and deliver evidence-based psychological interventions to adults misusing alcohol and consider relapse prevention medication for those with moderate or severe alcohol dependence following a successful withdrawal.
Commissioners ensure they commission services that provide evidence-based psychological interventions in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, which are offered to adults accessing specialist treatment for alcohol misuse, and that relapse prevention medication is offered to those with moderate or severe alcohol dependence following a successful withdrawal.
Adults who misuse alcohol are offered psychological treatment, and those with moderate or severe alcohol dependence may also receive medication to help them stay alcohol-free following a successful withdrawal from alcohol.

Source guidance

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) NICE guideline CG115, recommendations 1.3.1.5 (key priority for implementation), 1.3.3.1 (key priority for implementation) 1.3.3.2–1.3.3.7, 1.3.4.4, 1.3.6.1 (key priority for implementation), 1.3.6.2 and 1.3.6.3

Data source

Structure:
a), b) and c) Local data collection.
Process:
a) Local data collection. The National Alcohol Treatment Monitoring System collects data on intervention type for people in structured specialist treatment. 'Alcohol – structured psychosocial interventions' can be recorded although the details of the intervention cannot be specified.
b) Local data collection. NHS Digital's Statistics on alcohol in England reports on items prescribed for the treatment of alcohol dependence, including relapse prevention medication.
Outcome:
a) Local data collection. Data on the prevalence of alcohol misuse in adults is available by region from the NHS Adult Psychiatric Morbidity Survey in England.
b) Local data collection of relapse rates. See also data source for process b).

Definitions

NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence defines moderate dependence as an SADQ score of between 15 and 30 and a need for assisted alcohol withdrawal, which can typically be managed in a community setting unless there are other risks. Severe alcohol dependence is defined as an SADQ score of more than 30 and a need for assisted alcohol withdrawal, typically in an inpatient or residential setting.
NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends the following psychological interventions for harmful drinkers and people with alcohol dependence:
  • behavioural couples therapy where people have a regular partner who is willing to participate in treatment
  • cognitive behavioural therapies
  • behavioural therapies
  • social network and environment-based therapies.
Recommendations 1.3.3.4–1.3.3.7 provide guidance on the duration and frequency of these psychological interventions.
In addition, acamprosate or oral naltrexone in combination with a psychological intervention should be considered for people with moderate and severe alcohol dependence following successful withdrawal. Disulfiram may be considered if acamprosate and oral naltrexone are not suitable for clinical reasons or if it is the informed service user's choice.
Acamprosate and oral naltrexone may also be considered for harmful drinkers and people with mild alcohol dependence who have not responded to psychological interventions alone, or who have specifically requested a pharmacological intervention.
All prescribing should be carried out in accordance with NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Prescribers should use each drug's summary of product characteristics (SPC) with regard to current licensed indications, contraindications and special considerations to inform their decision about a person they are prescribing for. If a drug is used at a dose or for an application that does not have UK marketing authorisation, informed consent should be obtained and documented.

Equality and diversity considerations

This statement promotes equality of access to evidence-based psychological interventions as well as relapse prevention medication for those most likely to benefit.

Specialist interventions for children and young people

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

Children and young people accessing specialist services for alcohol use are offered individual cognitive behavioural therapy, or if they have significant comorbidities or limited social support, a multicomponent programme of care including family or systems therapy.

Quality measure

Structure:
Evidence of local provision in specialist services of individual cognitive behavioural therapy and multicomponent programmes of care tailored to children and young people accessing these services for alcohol use, which may include multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy.
Process:
a) Proportion of children and young people with limited comorbidities and good social support accessing specialist services for alcohol use who receive individual cognitive behavioural therapy.
Numerator – the number of people in the denominator receiving individual cognitive behavioural therapy.
Denominator – the number of children and young people with limited comorbidities and good social support accessing specialist services for alcohol use.
b) Proportion of children and young people with significant comorbidities and/or limited social support accessing specialist services for alcohol use who receive a multicomponent treatment programme of care including family or systems therapy.
Numerator – the number of people in the denominator receiving a multicomponent treatment programme of care including family or systems therapy.
Denominator – the number of children and young people with significant comorbidities or limited social support accessing specialist services for alcohol use.
Outcome:
Decrease in quantity and frequency of alcohol consumption in children and young people with identified alcohol-related problems.

What the quality statement means for each audience

Service providers ensure that systems are in place to provide children and young people accessing specialist services for alcohol use with individual cognitive behavioural therapy or, for those with significant comorbidities or limited social support, multicomponent programmes of care including family or systems therapy.
Health and social care professionals ensure they support children and young people accessing specialist services for alcohol use to receive individual cognitive behavioural therapy or, for those with significant comorbidities or limited social support, a multicomponent programme of care including family or systems therapy.
Commissioners ensure they commission specialist services with provision specifically for children and young people at risk of harm from alcohol use, with adequate provision of individual cognitive behavioural therapy or, for those with significant comorbidities or limited social support, multicomponent programmes of care including family or systems therapy.
Children and young people receiving specialist support for alcohol use are offered a psychological treatment called cognitive behavioural therapy (or CBT for short) or, if they have other health or family problems, they are offered different types of help including psychological treatment that involves their family and other people in their life.

Source guidance

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) NICE guideline CG115, recommendations 1.3.7.8 (key priority for implementation), 1.3.7.10, 1.3.7.11, 1.3.7.12 and 1.3.7.13

Data source

Structure:
Local data collection.
Process:
a) and b) Local data collection. The National Drug Treatment Monitoring System collects data on intervention type for young people (lower age limit 9 years old) starting treatment in specialist young people's drug and alcohol services. There are a number of intervention types that can be recorded, including 'Psychosocial – cognitive behavioural therapy' and 'Psychosocial – family work', although the nature of these is not specified and they are not currently reported by primary substance (that is, alcohol or drugs).
Outcome:
Local data collection.From 2011–12 the National Drug Treatment Monitoring System will start to record the frequency of drinking days at treatment start and at treatment exit (for planned exits only) if alcohol is the young person's main 'drug' of choice. NHS Digital conducts surveys on smoking, drinking and drug use among young people in England.

Definitions

Multicomponent treatment programmes may include multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy. NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence makes recommendations about the content, structure and duration of these therapies in recommendations 1.3.7.10, 1.3.7.11, 1.3.7.12 and 1.3.7.13.

Equality and diversity considerations

This statement applies to people aged 10–17 years only, which is appropriate given the different needs of children and young people compared with adults who misuse alcohol. In general the range of specialist services for younger people is less comprehensive than for adults. This statement therefore promotes equality in providing interventions suited to the needs of children and young people.

Outcomes monitoring

This quality statement is taken from the alcohol-use disorders: diagnosis and management quality standard. The quality standard defines clinical best practice for the diagnosis and management of alcohol-use disorders and should be read in full.

Quality statement

People receiving specialist treatment for alcohol misuse have regular treatment outcome reviews, which are used to plan subsequent care.

Quality measure

Structure:
a) Evidence of local implementation of the Alcohol Use Disorders Test (AUDIT) and the Alcohol Problems Questionnaire (APQ) for outcome monitoring in specialist alcohol services.
b) Evidence of local arrangements to ensure that interventions for people receiving specialist treatment for alcohol misuse are the subject of routine outcome monitoring.
c) Evidence of regular local audit of case files in specialist alcohol services to ensure that people receiving treatment for alcohol misuse have an individualised care plan that is frequently reviewed and revised based on treatment outcomes.
Process:
Proportion of people receiving specialist treatment for alcohol misuse who have a current individualised care plan.
Numerator – the number of people in the denominator with a current individualised care plan.
Denominator – the number of people receiving specialist treatment for alcohol misuse.
Outcome:
Proportion of people accessing specialist alcohol services who achieve their treatment goals.
Numerator – the number of people in the denominator achieving their treatment goals.
Denominator – the number of people accessing specialist alcohol services.

What the quality statement means for each audience

Service providers ensure systems are in place for the regular review of treatment outcomes in people receiving specialist treatment for alcohol misuse, and for individualised care plans to be based on outcome reviews.
Health and social care professionals ensure they regularly review treatment outcomes in people receiving specialist treatment for alcohol misuse, and maintain care plans to be individualised and current based on outcome reviews.
Commissioners ensure they commission specialist alcohol services that review regularly treatment outcomes in people receiving specialist treatment for alcohol misuse, and maintain care plans to be individualised and current based on outcome reviews.
People receiving specialist treatment for alcohol misuse have their treatment reviewed regularly and have the opportunity to be involved in planning further care, based on these reviews.

Source guidance

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) NICE guideline CG115, recommendations 1.2.1.4, 1.3.1.5 (key priority for implementation), 1.3.1.6 and 1.3.2.3

Data source

Structure:
a), b) and c) Local data collection.
Process:
Local data collection for the numerator. The National Alcohol Treatment Monitoring System collects data on the number of people receiving specialist alcohol treatment.
Outcome:
Local data for detail on achievement of specific treatment goals. The National Alcohol Treatment Monitoring System collects data on the number of people receiving specialist alcohol treatment and discharge status.

Definitions

NICE's guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence recommends that all interventions for people who misuse alcohol should be the subject of routine outcome monitoring and that this be used to inform decisions about continuation of both psychological and pharmacological treatments. If there are signs of deterioration or no indications of improvement, consideration should be given to stopping the current treatment and the care plan reviewed.
The AUDIT tool may be used as a routine outcome measure for drinking-related outcomes and the APQ may be used for monitoring changes in alcohol-related problems.

Under-age sales

This quality statement is taken from the alcohol: preventing harmful use in the community quality standard. The quality standard defines clinical best practice for preventing harmful alcohol use in the community and should be read in full.

Quality statement

Trading standards and the police identify and take action against premises that sell alcohol to people under 18.

Rationale

It is illegal to sell alcohol to anyone under 18. Reviewing licences is a key part of the Licensing Act (2003), and amendments to the Act that came into force in 2012 doubled fines for, and made it easier to shut down, businesses found to be persistently selling alcohol to people under 18. All local licensing authorities should make full use of this legislation to protect children and young people from the risks of alcohol.

Quality measures

Structure
a) Evidence that trading standards and the police are identifying premises that sell alcohol to people under 18.
Data source: Local data collection.
b) Evidence that trading standards and the police are taking action against premises that sell alcohol to people under 18.
Data source: Local data collection.
Outcome
Incidence of licensed premises found to sell alcohol to people under 18.
Data source: Local data collection.

What the quality statement means for different audiences

Trading standards and the police work in partnership with public health teams and other responsible authorities to ensure that licensed premises are not selling alcohol to people under 18, and identify and take action against those that break the law. Partnership work can coordinate the approach, improve efficiency and enable sharing of resources.
Public health teams commission trading standards to carry out operations on licensed premises. They can also provide intelligence that identifies licensed premises that need to be reviewed and that supports a licence review.
People in the community can be sure that trading standards, the police and other agencies (such as public health teams) work together to identify and take action against businesses licensed to sell alcohol (such as pubs, nightclubs, supermarkets and local shops) that sell alcohol to children and young people under 18. This might include reviewing or withdrawing an alcohol licence, issuing fines or, in extreme cases, closing the premises. This should help to stop children and young people buying alcohol and so protect them from the risks of harmful (high-risk) alcohol use.

Source guidance

Alcohol-use disorders: prevention (2010) NICE guideline PH24, recommendation 4

Definitions of terms used in this quality statement

Identifying premises that sell alcohol to people under 18
Trading standards and the police work together and lead on this, but might also work in partnership with directors of public health and public health teams. In most local authority areas the police tend to concentrate on targeting premises with 'on' licences (that is, allowing consumption of alcohol on the premises), whereas trading standards concentrate on retail outlets selling alcohol. Methods to identify premises that are selling alcohol to people under 18 might include using test purchases by 'mystery shoppers', surveillance or using shared intelligence and the history of the premises. The use of covert investigation techniques by public authorities requires Regulation of Investigatory Powers Act (RIPA) authorisations. Whether RIPA authorisations are needed for conducting test purchases will depend on the operation.
[NICE's guideline on alcohol-use disorders: prevention, recommendation 4, adapted by expert opinion]
Taking action against premises that sell alcohol to people under 18
Formal action against premises selling alcohol to people under 18 should follow an enforcement policy and be in line with national codes of practice governing the way that age-restricted sales are enforced; for example, Age restricted products and services: a code of practice for regulatory delivery (Office for Product Safety and Standards). Responsible authorities, such as public health teams, can take action by requesting reviews of licensed premises and making representations at review hearings. Public health teams can also use available data and work with other responsible authorities to support their case. Licence reviews can result in steps to address the problem (for example, modifying the conditions of the licence or removing the premises' supervisor), or suspending or revoking a licence if sales to people under 18 continue. Other actions that can be taken against premises include fines, advice and warnings, closure notices, issuing cautions and prosecution.
[Expert opinion]

Alcohol education

This quality statement is taken from the alcohol: preventing harmful use in the community quality standard. The quality standard defines clinical best practice for preventing harmful alcohol use in the community and should be read in full.

Quality statement

Schools and colleges include alcohol education in the curriculum.

Rationale

Schools and colleges have an important role to play in helping children and young people to understand the harmful consequences of alcohol and in combating harmful (high-risk) drinking. Alcohol education should be used to increase knowledge about alcohol use and its effects. Learning and teaching about alcohol should be contextualised as part of promoting positive messages and values about keeping healthy and safe. Teachers and children and young people should be able to have open discussions about alcohol in the context of wider social norms, since one-way information-giving is not as effective in engaging children and young people in the topic and in affecting attitudes, values and behaviour.

Quality measures

Structure
Evidence that schools and colleges include alcohol education in the curriculum.
Data source: Local data collection. Ofsted inspection reports contain information on the achievement of pupils, quality of teaching, behaviour and safety of pupils, and leadership and management for all schools and colleges. Also contained within the Health and Social Care Information Centre's Smoking, Drinking and Drug Use Among Young People in England.
Outcome
Rates of absence from school or college related to alcohol.
Data source: Local data collection.

What the quality statement means for different audiences

Head teachers and school governors include alcohol education in the curriculum. Although alcohol education is not a statutory part of the curriculum, quality statements describe best practice that goes beyond minimum statutory requirements and can be used to help organisations improve quality.
Staff who have the trust and respect of the children and young people in the school or college deliver alcohol education as part of the curriculum. Staff should have received appropriate training and be able to provide accurate information using appropriate techniques.
Local authorities advocate that schools and colleges in their area include alcohol education in the curriculum. Public health teams can offer help with education and training of staff and provide schools and colleges with information and materials for teaching.
Children and young people in schools and colleges learn about keeping healthy and safe, and about alcohol use and its effects. This is done by giving them the chance to talk about the issues involved. This should help them to develop the knowledge, attitudes and skills needed to support their health and wellbeing.

Source guidance

Alcohol interventions in secondary and further education (2019) NICE guideline NG135, recommendation 1.1.1

Definitions of terms used in this quality statement

Schools
All schools (including academies, free schools and alternative provision academies) and pupil referral units (see the Department for Education's explanation of types of schools) and further education and sixth-form colleges as set out under the Further and Higher Education Act 1992 (see the Department for Education's keeping children safe in education).
Colleges
Colleges include:
  • academies and city technology colleges
  • further education colleges and sixth-form colleges.
Alcohol education
Specific time should be allocated within the school curriculum to help children and young people to develop the knowledge, attitudes and skills needed to support their own health and wellbeing. Alcohol education should be part of the whole-school approach, tailored for different age groups and take different learning needs into account (based, for example, on individual, social and environmental factors). It should aim to encourage children not to drink, delay the age at which young people start drinking and reduce the harm it can cause among those who do drink. Alcohol education programmes should:
  • increase knowledge of the potential damage alcohol use can cause – physically, mentally and socially (including the legal consequences)
  • provide the opportunity to explore attitudes to – and perceptions of – alcohol use
  • help develop decision-making, assertiveness, coping and verbal and non‑verbal skills
  • help develop self-esteem
  • increase awareness of how the media, advertisements, role models and the views of parents, peers and society can influence alcohol consumption.

Equality and diversity considerations

It is important to take individual, social, cultural, economic and religious factors into account when delivering alcohol education, and to tailor it to the needs of the children and young people. Groups that may be at increased risk of under‑age drinking and alcohol abuse, such as lesbian, gay, bisexual and transgender (LGBT) young people, should be considered.

Schools and colleges involve parents, carers, children and young people

This quality statement is taken from the alcohol: preventing harmful use in the community quality standard. The quality standard defines clinical best practice for preventing harmful alcohol use in the community and should be read in full.

Quality statement

Schools and colleges involve parents, carers, children and young people in initiatives to reduce alcohol use.

Rationale

A school or college's approach to alcohol in the context of the curriculum and its policies, values and environment is more effective if parents, carers, children and young people are involved. This means that children and young people's views are considered and that parents and carers are included in discussions and decisions in an effort to ensure consistent messages about alcohol outside school or college.

Quality measures

Structure
Evidence that schools and colleges involve parents, carers, children and young people in initiatives to reduce alcohol use.
Data source: Local data collection. Ofsted inspection reports contain information on the achievement of pupils, quality of teaching, behaviour and safety of pupils and leadership and management for all schools and colleges.

What the quality statement means for different audiences

Head teachers and school governors ensure that they consult and involve parents, carers, children and young people in discussions and decisions about, as well as in the implementation of, initiatives to reduce alcohol use. Although alcohol education is not a statutory part of the curriculum, quality statements describe best practice that goes beyond minimum statutory requirements and can be used to help organisations improve quality.
Parents and carers have the chance to be involved in discussions and decisions about ideas and plans that schools and colleges have for reducing alcohol use, and in putting these ideas into practice. This means that parents and carers know about the plans and can support them at home if they choose to.
Children and young people are involved in discussions and decisions about ideas and plans at their school or college for reducing alcohol use. They are also involved in putting these ideas into practice. This means that they will know what is planned and are more likely to back the plans.

Source guidance

Alcohol interventions in secondary and further education (2019) NICE guideline NG135, recommendation 1.1.1

Definitions of terms used in this quality statement

Schools
All schools (including academies, free schools and alternative provision academies) and pupil referral units (see the Department for Education's explanation of types of schools) and further education and sixth-form colleges as set out under the Further and Higher Education Act 1992 (see the Department for Education's keeping children safe in education).
Colleges
Colleges include:
  • academies and city technology colleges
  • further education colleges and sixth-form colleges.
Involve parents, carers, children and young people
This might include consulting parents, carers, children and young people about initiatives to reduce alcohol use, gathering their opinions through discussions and involving them in decisions about, and in the implementation of, initiatives.
[Adapted from NICE's guideline on alcohol interventions in secondary and further education. Also see the section on making it as easy as possible for people to get involved in NICE's guideline on community engagement]
Initiatives to reduce alcohol use
Initiatives to reduce alcohol use might include alcohol education programmes and using a 'whole‑school' approach. A 'whole‑school' approach should cover policy development, the school environment and the professional development of (and support for) staff.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Cognitive behavioural therapies focused on alcohol-related problems should usually consist of one 60-minute session per week for 12 weeks.
In severe alcohol dependence higher doses will be required to adequately control withdrawal and should be prescribed according to the SPC. Make sure there is adequate supervision if high doses are administered.
Prescribe and administer medication for assisted withdrawal within a standard clinical protocol. The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam).
In a fixed-dose medication regimen, titrate the initial dose of medication to the severity of alcohol dependence and/or regular daily level of alcohol consumption. Gradually reduce the dose of the benzodiazepine over 7-10 days to avoid alcohol withdrawal recurring.
For service users having assisted withdrawal, particularly those who are more severely alcohol dependent or those undergoing a symptom-triggered regimen, consider using a formal measure of withdrawal symptoms such as the CIWA–Ar.
Be aware that benzodiazepine doses may need to be reduced for older people.
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.
For harmful drinking (high-risk drinking) or mild dependence, without significant comorbidity, and if there is adequate social support, consider a moderate level of drinking as the goal of treatment unless the service user prefers abstinence or there are other reasons for advising abstinence.
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 treatment, consider a harm reduction programme of care. However, ultimately the service user should be encouraged to aim for a goal of abstinence.
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.
Maddrey's discriminant function (DF) was described to predict prognosis in alcohol-related hepatitis and identify patients suitable for treatment with steroids. It is 4.6 x [prothrombin time – control time (seconds)] + bilirubin in mg/dl. To calculate the DF using bilirubin in micromol/l divide the bilirubin value by 17.
https://www.mdcalc.com/maddreys-discriminant-function-alcoholic-hepatitis ‘View MDCALC website’
A symptom-triggered approach involves tailoring the drug regimen according to the severity of withdrawal 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.
A symptom-triggered approach involves tailoring the drug regimen according to the severity of withdrawal 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.
A symptom-triggered regimen involves treatment tailored to the person's individual needs. These are determined by the severity of withdrawal signs and symptoms. The patient is regularly assessed and monitored, either using clinical experience and questioning alone or with the help of a designated questionnaire such as the CIWA-Ar. Drug treatment is provided if the patient needs it and treatment is withheld if there are no symptoms of withdrawal.
An agreed threshold document from the LSCB or safeguarding partnership that sets out risk factors and considerations for what to do when worried about a child. (From September 2019, all local authority areas in England should have completed their transition from LSCBs to safeguarding partnerships.)
For the purposes of this guidance, all schools (including academies, free schools and alternative provision academies) and pupil referral units (see the Department for Education's explanation of types of school) and further education and sixth-form colleges as set out under the Further and Higher Education Act 1992 (see the Department for Education's keeping children safe in education).
Universal alcohol education addresses all pupils in the school and is delivered to groups of pupils without assessing for risk. Targeted interventions are for children and young people who are not necessarily seeking help but are identified as being vulnerable to alcohol misuse because of risk factors that they have.
This may include children and young people:
  • whose personal circumstances put them at increased risk
  • who may already be drinking alcohol
  • who may already be regularly using another harmful substance, such as cannabis.
An ethos and environment that supports learning and promotes the health and wellbeing of everyone in the school community. The aim is to ensure pupils feel safe, happy and prepared for life in and beyond school. It covers:
  • curriculum subjects
  • general school policies on social, moral and spiritual wellbeing
  • cultural awareness.
It also promotes a proactive relationship between the school, children, young people and their parents or carers, outside agencies and the wider community.
Harmful drinking (high-risk drinking) is:
  • a pattern of alcohol consumption that is causing mental or physical damage (ICD-10, DSM-V).
  • consumption (units per week): Drinking 35 units a week or more for women. Drinking 50 units a week or more for men.
Hazardous drinking (increasing risk drinking) is:
  • a pattern of alcohol consumption that increases someone's risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. The term is currently used by the World Health Organization to describe this pattern of alcohol consumption. It is not a diagnostic term.
  • consumption (units per week): Drinking more than 14 units a week, but less than 35 units a week for women. Drinking more than 14 units a week, but less than 50 units for men.
Alcohol dependence is a cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. For further information, please refer to: 'Diagnostic and statistical manual of mental disorders' (DSM-IV) (American Psychiatric Association 2000) and 'International statistical classification of diseases and related health problems – 10th revision' (ICD-10) (World Health Organization 2007).
Alcohol dependence is a cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. For further information, please refer to: 'Diagnostic and statistical manual of mental disorders' (DSM-IV) (American Psychiatric Association 2000) and 'International statistical classification of diseases and related health problems – 10th revision' (ICD-10) (World Health Organization 2007).

Glossary

adolescent diagnostic interview
(a cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use: someone who is alcohol-dependent may persist in drinking, despite harmful consequences; they will also give alcohol a higher priority than other activities and obligations; for further information please refer to: 'Diagnostic and statistical manual of mental disorders' (DSM-IV) (American Psychiatric Association 2000) and 'International statistical classification of diseases and related health problems – 10th revision' (ICD-10) (World Health Organization 2007))
(a programme designed to reduce alcohol consumption or any related problems; it could involve a combination of counselling and medicinal solutions)
(alcohol-use disorders cover a wide range of mental health problems as recognised within the international disease classification systems (ICD-10, DSM-IV): these include hazardous and harmful drinking and alcohol dependence)
alcohol problems questionnaire
Advertising Standards Authority
(AUDIT is an alcohol screening test designed to see if people are drinking harmful or hazardous amounts of alcohol; it can also be used to identify people who warrant further diagnostic tests for alcohol dependence)
blood alcohol concentration
(this can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention): both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists)
(this can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention): both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists)
child and adolescent mental health service
(the Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA–Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of the alcohol withdrawal syndrome, and to monitor and medicate patients throughout withdrawal)
(liver disease complicated by jaundice, ascites, variceal bleeding or hepatic encephalopathy)
(when the drug is being taken by someone other than for whom it was prescribed)
(this is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing: the aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change)
(this is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing: the aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change)
(involves starting treatment with a standard dose, not defined by the level of alcohol withdrawal, and reducing the dose to zero over 7-10 days according to a standard protocol)
(involve starting treatment with a standard dose, not defined by the level of alcohol withdrawal, and reducing the dose to zero over 7-10 days according to a standard protocol)
(FRAMES is an acronym summarising the components of a brief intervention: feedback (on the client's risk of having alcohol problems), responsibility (change is the client's responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change))
gammahydroxybutyrate
gamma glutamyl transferase
genito-urinary medicine
General Medical Council's
Leeds dependence questionnaire
(the term 'looked after' has a specific legal meaning: it refers to children and young people who are provided with accommodation on a voluntary basis for more than 24 hours; this compares with the term 'in care' which refers to those who are compulsorily removed from home and placed in care under a court order)
local safeguarding children board
mini-mental state examination
Paddington alcohol test
Personal, Social and Health Education
(responsible authorities have to be notified of all licence variations and new applications and can make representations regarding them: the Licensing Act 2003 lists responsible authorities; they include the police, environmental health, child protection service, fire and rescue and trading standards)
relationships and sex education
severity of alcohol dependence questionnaire
(in relation to licensed premises, this describes a specific geographical area where there are already a lot of premises selling alcohol – and where the awarding of any new licences to sell alcohol may contribute to an increase in alcohol-related disorder)
(for the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder: practitioners may use any contact with clients to carry out this type of screening; the term is not used here to refer to national screening programmes such as those recommended by the UK National Screening Committee)
selective serotonin reuptake inhibitors
summary of product characteristics
(a course of study in which pupils study the same topics in ever-increasing complexity throughout their time at school to reinforce previous lessons)
(a brief intervention that takes only a few minutes to deliver)
teen addiction severity index
(intervention for children and young people who are not necessarily seeking help but who have risk factors that make them vulnerable to alcohol misuse)
(interventions for children and young people who are not necessarily seeking help but who have risk factors that make them vulnerable to alcohol misuse)
(a programme designed to reduce alcohol consumption or any related problems. It could involve a combination of counselling and medicinal solutions)
(in the UK, alcoholic drinks are measured in units: each unit corresponds to approximately 8 g or 10 ml of ethanol; the same volume of similar types of alcohol (for example, 2 pints of lager) can comprise a different number of units depending on the drink's strength (that is, its percentage concentration of alcohol))
(education that addresses all pupils in the school. It is delivered to groups of pupils without assessing their risk)
(education that addresses all pupils in the school. It is delivered to groups of pupils without assessing their risk)

Paths in this pathway

Pathway created: May 2011 Last updated: August 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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