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NICE ALCOHOL GUIDELINES

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Ed Day

on 18 May 2016

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Transcript of NICE ALCOHOL GUIDELINES

An Introduction to
NICE GUIDANCE FOR ALCOHOL TREATMENT

Dr Ed Day
edward.day@kcl.ac.uk

http://pathways.nice.org.uk/pathways/alcohol-use-disorders
? Suppresses conditioned withdrawal craving by effects on calcium channels and NMDA receptors

19 trials – mainly European (1 UK)
moderate to severe dependence
+ psychosocial treatment

Small significant effect in promoting abstinence vs. placebo (RR=0.83, 95% CI=0.77-0.88) - most pronounced at 6 months

Significantly fewer relapsing to heavy drinking (RR=0.9, 95% CI=0.81-0.99)
Side effects:
diarrhoea with abdominal pain 10%
vomiting, pruritis, bullous skin reactions more rarely

Contraindications:
pregnancy & breast feeding
renal insufficiency (serum creatinine >120micromol/L)
severe hepatic failure

No significant drug interactions
Drinking and abstinence by reducing the positively reinforcing, pleasurable effects of alcohol and by reducing the craving for alcohol

27 trials vs placebo and 4 vs acamprosate – mostly US
mild to severe dependence
+ psychosocial treatment

Small significant effect favouring naltrexone on rates of relapse to heavy drinking (RR=0.83, 95% CI=0.75-0.91)
Mean drinks per drinking day less in naltrexone group
Less days of heavy drinking during the trial
Side effects:
nausea (10%) – more common at start/female/lighter drinkers
headache (7%)
abdominal pain, reduced appetite, tiredness

Emergency pain relief needs to be at higher doses to overcome the opioid antagonism, but with careful respiratory monitoring

Hepatic toxicity is possible at 50mg/day
LFTs should be monitored periodically (caution if 4-5x above normal)
Much less high quality evidence available
Blinding is difficult

3 trials disulfiram vs placebo, 1 trial disulfiram vs acamprosate, 2 trials disulfiram vs naltrexone, 1 trial disulfiram vs topiramate

Oral disulfiram not significantly different to placebo in preventing participants lapsing to alcohol use (RR=1.05, 95%CI=0.96-1.15)
In comparison with acamprosate or naltrexone, disulfiram increased the time to first drink and the number of drinking days
Disulfiram-alcohol interaction
warn and check capacity
alcohol in food, perfumes, aerosols
risk may last for 7 days
Fatal reactions with >1g/day (cardiovascular complications)
Side effects:
acute hepatitis
neuropathy
drowsiness, fatigue, abdominal pain, nausea & diarrhoea
Contraindications:
cardiovascular problems
severe personality disorder, suicidal risk, psychosis
pregnancy & breast feeding
Caution with renal failure, hepatic or respiratory disease, diabetes mellitus and epilepsy
Acamprosate
“treatment … should be initiated as soon as possible after the withdrawal period and should be maintained if the patient relapses”
takes 5 days to reach steady state
can reduce glutamatergic hyperactivity activity and so cell death
some practitioners start it before withdrawal ends

Naltrexone
safe to start whilst still drinking and during assisted withdrawal

Disulfiram
start at least 24 hours after the last alcoholic drink
Patients who are doing well may be advised to remain on medication for at least 6 months
Continuation beyond 12 months would need to be justified
Stopping the medication until the patient engages with treatment may be necessary
ACAMPROSATE
NALTREXONE
DISULFIRAM
ORGANISATION & DELIVERY OF CARE
Organising Principles of Care
Evaluating the Organisation of Care
The Assessment of Harmful Drinking & Alcohol Dependence
Determining the Appropriate Setting for the Delivery of Care
KEY PRIORITIES FOR IMPLEMENTATION
Identification & Assessment in all Settings
General Principles for all Interventions
Interventions for Harmful Drinking & Mild Alcohol Dependence
Assessment in Specialist Alcohol Services
Assessment for Assisted Alcohol Withdrawal
Interventions for Moderate & Severe Alcohol Dependence
Assessment & Interventions for Children & Young People who Misuse Alcohol
Interventions for Conditions Comorbid with Alcohol Misuse
AUDIT >15
Alcohol use:
consumption
collateral info
dependence (LDQ/SADQ)
alcohol-related problems (APQ)
Other drug misuse
Physical health problems
Psychological & Social problems
Cognitive function (MMSE)
Readiness & belief in change
Promote Abstinence + Prevent Relapse
Intensive, Structured, Community-Based
Limited social support OR complex physical or psychiatric needs OR not responded to briefer interventions
Delivered by appropriately trained and competent staff
Regular supervision from competent individuals
Routinely use outcome measures
Engage in monitoring and evaluation of adherence and practice competence
Offer a psychological intervention focused specifically on alcohol-related cognitions, behaviour, problems and social networks
DRINK > 15 UNITS/DAY
AUDIT > 20
Acamprosate or Naltrexone
Individual psychological intervention - weekly for 12 weeks
Build a trusting relationship and provide info
Working with and supporting families and carers
1
Case Identification / Diagnosis
2
3
4
Withdrawal Assessment
Triage Assessment
Comprehensive Assessment
presence of alcohol use disorder
level of consumption
harmful drinking vs dependence
presence of risks
capacity to consent to treatment
experience/outcome of past treatment
willingness to engage in treatment
possible co-existing problems
urgency of referral
in need of assisted withdrawal
severity of dependence
level of consumption
co-morbidity
availability of support
setting
urgency
integrate into wider treatment program
PROBLEMS - CARE PLAN - OUTCOMES
Alcohol use and related consequences
Motivation and self-efficacy
Co-occurring problems
Risk assessment
alcohol
self-harm
harm to others
harm from others
self-neglect
safeguarding children
Treatment goals
Capacity to consent
Formulation of care and risk management plans
pattern and severity of alcohol misuse (using AUDIT) and severity of dependence (using SADQ)
need for urgent treatment including assisted withdrawal
any associated risks to self or others
comorbidities/other factors that may need further specialist assessment/intervention
agree the initial treatment plan (considering user's preferences/outcomes of past treatment
PSYCHOLOGICAL & PSYCHOSOCIAL INTERVENTIONS
"The evidence for the superiority of one form of treatment over another in the field of alcohol has been difficult to find"
Better than no intervention, but none better than another
THERAPIST ALLIANCE
alliance vs technique
'Dodo bird effect'
positive association of alliance with better outcomes

THERAPIST COMPETENCE
more competent therapists lead to better outcomes
BRIEF INTERVENTIONS - psychoeducational / motivational
SELF-HELP
TWELVE STEP FACILITATION
COGNITIVE BEHAVIOURAL THERAPY - coping skills / social skills training / relapse prevention
BEHAVIOURAL - cue exposure / contingency management / aversion therapy
MOTIVATIONAL ENHANCEMENT THERAPY
SOCIAL NETWORK & ENVIRONMENT-BASED THERAPIES - SBNT / CRA
COUNSELLING - couples therapy
FAMILY-BASED INTERVENTIONS - functional / brief strategic / multisystemic / 5-step / multidimensional / CRAFT
PSYCHODYNAMIC THERAPY - short-term / supportive expressive
PHYSICAL THERAPIES - meditation / acupuncture
Case Management
Assertive Community Treatment
Stepped Care
PHARMACOLOGICAL INTERVENTIONS
outpatient - 2 to 4 contacts per week
intensive community - 4-7 days/week
drugs + psychosocial support
fixed-dose medication regimens in community settings
fixed-dose or symptom-triggered regimens in inpatient settings
monitor every other day + network member
use of CIWA-Ar
Reduced dose in young people, older people and liver impairment
INPATIENT/RESIDENTIAL
>30 units/day
>30 on SADQ
History of seizures or DTs
Concurrent dependence on other drugs
Psychiatric or physical co-morbidity
Homeless/vulnerable
Harmful drinkers or mildly dependent
BCT > TAU, active controls and other interventions
CBNT/SBMT/Behavioural Therapies > TAU or control
Evidence for CM + standard care contradictory
MET/TSF = other interventions (lack of evidence vs TAU or control)

MET 1-6 weeks, TSF 12 weeks, CBT 2-24 weeks, BT 6-12 weeks, SBNT 8-16 weeks, BCT 4-12 weeks

MI and TSF best seen as components of any effective psychosocial intervention

Limited evidence for counselling, short-term psychodynamic therapy, mutli-modal therapy, self-help based treatment, psychoeducational interventions and mindfulness
reduced threshold for AUDIT
refer to CAMHS for assessment of needs
assess multiple areas of need (Adolescent Diagnostic Interview or Teen Addiction Severity Index)
inpatient care if require assisted withdrawal
individual CBT if limited comorbidities and good social support
multicomponent programme if not
consider acamprosate/naltrexone


Building a trusting relationship & providing info
Working with and supporting families and carers
MOTIVATIONAL INTERVENTION
Care Coordination & Case Management
Value of community support groups and self-help groups
UK launch May 2013
Reduction of drinking in adults with alcohol dependence
+ high drinking risk level (>7.5 units/day men, 5 units women
+ no physical withdrawal symptoms
+ no need for immediate detoxification
Continuous psychosocial support - adherence and reducing drinking
[Acamprosate or naltrexone not licensed to reduce drinking in non-dependent or mildly dependent populations
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