NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 31 March 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Person aged 10 or over who drinks more than 15 units of alcohol per day or scores 20 or more on AUDIT No additional information 2 Principles of care 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. 3 Assessment For service users who typically drink over 15 units of alcohol per day and/or who score 20 or more on the AUDIT, consider offering: an assessment for and delivery of a community-based assisted withdrawal, or assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal. Quality standards The following quality statement is relevant to this part of the pathway. Alcohol-use disorders: diagnosis and management quality standard 3. Referral to specialist alcohol services 4 Outpatient programme When to offer outpatient programmes 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. Page 3 of 25

4 Treatment Outpatient-based community assisted withdrawal programmes should consist of a drug regimen and psychosocial support including motivational interviewing. When conducting community-based assisted withdrawal programmes, use fixed-dose medication regimens. 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. Be aware that benzodiazepine doses may need to be reduced for older people. When managing alcohol withdrawal in the community, avoid giving people who misuse alcohol large quantities of medication to take home to prevent overdose or diversion. Prescribe for instalment dispensing, with no more than 2 days' medication supplied at any time. In a community-based assisted withdrawal programme, monitor the service user every other day during assisted withdrawal. A family member or carer should preferably oversee the administration of medication. Adjust the dose if severe withdrawal symptoms or over-sedation occur. Do not offer clomethiazole for community-based assisted withdrawal because of the risk of overdose and misuse. Monitoring 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. Quality standards The following quality statement is relevant to this part of the pathway. Page 4 of 25

5 Alcohol-use disorders: diagnosis and management quality standard 8. Medically assisted alcohol withdrawal setting 5 Inpatient programmes for person aged When to offer inpatient programmes Offer inpatient care to children and young people who need assisted withdrawal. Medication Consult the SPC and adjust drug regimens to take account of age, height and body mass, and stage of development of the child or young person 1. Fixed-dose medication regimens or symptom-triggered medication regimens [See page 16] can be used in assisted withdrawal programmes in inpatient settings. 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. 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. Be aware that benzodiazepine doses may need to be reduced for children and young people 2. Monitoring 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. 1 If a drug does not have UK marketing authorisation for use in children and young people under 18, informed consent should be obtained and documented. Page 5 of 25

6 2 At the time this pathway was created (May 2011), benzodiazepines did not have UK marketing authorisation for use in children and young people under 18. Informed consent should be obtained and documented. Page 6 of 25

7 Quality standards The following quality statement is relevant to this part of the pathway. Alcohol-use disorders: diagnosis and management quality standard 8. Medically assisted alcohol withdrawal setting 6 Inpatient or residential programme for person aged 18 or over When to consider inpatient or residential programmes 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. Consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups, for example, homeless and older people. For people with alcohol dependence who are homeless, consider offering residential rehabilitation for a maximum of 3 months. Help the service user find stable accommodation before discharge. NICE has produced a pathway on service user experience in adult mental health services. Medication Fixed-dose medication regimens or symptom-triggered medication regimens [See page 16] can be used in assisted withdrawal programmes in inpatient or residential settings. Page 7 of 25

8 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. 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. Be aware that benzodiazepine doses may need to be reduced for older people. Monitoring 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. Quality standards The following quality statement is relevant to this part of the pathway. Alcohol-use disorders: diagnosis and management quality standard 8. Medically assisted alcohol withdrawal setting 7 Additional considerations for complex needs Malnourishment or decompensated liver disease Offer parenteral thiamine followed by oral thiamine to prevent Wernicke-Korsakoff syndrome in people who are entering planned assisted alcohol withdrawal in specialist inpatient alcohol services or prison settings and who are malnourished or at risk of malnourishment (for example, people who are homeless) or have decompensated liver disease. Liver impairment Be aware that benzodiazepine doses may need to be reduced for people with liver impairment. Page 8 of 25

9 If benzodiazepines are used for people with liver impairment, consider one requiring limited liver metabolism (for example, lorazepam); start with a reduced dose and monitor liver function carefully. Avoid using benzodiazepines for people with severe liver impairment. Coexisting benzodiazepine and alcohol dependence When managing withdrawal from co-existing benzodiazepine and alcohol dependence increase the dose of benzodiazepine medication used for withdrawal. Calculate the initial daily dose based on the requirements for alcohol withdrawal plus the equivalent regularly used daily dose of benzodiazepine 1. This is best managed with one benzodiazepine (chlordiazepoxide or diazepam) rather than multiple benzodiazepines. Inpatient withdrawal regimens should last for 2 3 weeks or longer, depending on the severity of co-existing benzodiazepine dependence. When withdrawal is managed in the community, and/or where there is a high level of benzodiazepine dependence, the regimen should last for longer than 3 weeks, tailored to the service user's symptoms and discomfort. Other complications For managing unplanned acute alcohol withdrawal and complications including delirium tremens and withdrawal-related seizures, see acute alcohol withdrawal in this pathway. Quality standards The following quality statement is relevant to this part of the pathway. Alcohol-use disorders: diagnosis and management quality standard 10. Wernicke's encephalopathy 8 Intensive community programmes following successful withdrawal Intensive community programmes following assisted withdrawal should consist of a drug regimen supported by psychological interventions including individual treatments, group treatments, psychoeducational interventions, help to attend self-help groups, family and carer support and involvement, and case management. 1 At the time this pathway was created (May 2011), benzodiazepines did not have UK marketing authorisation for this indication, or for use in children and young people under 18. Informed consent should be obtained and documented. This should be done in line with normal standards of care for patients who may lack capacity (see the Page 9 of 25

10 Department of Health's advice on consent or or in line with normal standards in emergency care. Page 10 of 25

11 Person aged After a careful review of the risks and benefits, specialists may consider offering acamprosate 1 or oral naltrexone 2 in combination with cognitive behavioural therapy to young people who have not engaged with or benefited from a multicomponent treatment programme. Mild alcohol dependence 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, consider offering acamprosate 3 or oral naltrexone in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) or behavioural couples therapy. Moderate and severe alcohol dependence Consider offering interventions to promote abstinence and prevent relapse as part of an intensive structured community-based intervention for people with moderate and severe alcohol dependence who have: very limited social support (for example, they are living alone or have very little contact with family or friends) or complex physical or psychiatric comorbidities or not responded to initial community-based interventions. Consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol misuse (see psychological interventions in this pathway). Consider offering acamprosate or oral naltrexone in combination with behavioural couples therapy to service users who have a regular partner and whose partner is willing to participate in treatment (see psychological interventions in this pathway). Consider offering disulfiram 4 in combination with a psychological intervention to service users who: have a goal of abstinence but for whom acamprosate and oral naltrexone are not suitable, or prefer disulfiram and understand the relative risks of taking the drug. Page 11 of 25

12 1 At the time of this pathway was created (May 2011), acamprosate did not have UK marketing authorisation for use longer than 12 months. Informed consent should be obtained and documented. 2 At the time this pathway was created (May 2011), oral naltrexone did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. 3 Note that the evidence for acamprosate in the treatment of harmful drinkers and people who are mildly alcohol dependent is less robust than that for naltrexone. At the time this pathway was created (May 2011), acamprosate did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. 4 All prescribers should consult the SPC for a full description of the contraindications and the special considerations of the use of disulfiram. Page 12 of 25

13 Mild to moderate alcohol dependence and complex needs or severe dependence For people with mild to moderate dependence and complex needs, 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. Quality standards The following quality statement is relevant to this part of the pathway. Alcohol-use disorders: diagnosis and management quality standard 11. Psychological interventions and relapse prevention medication for adults 9 Acamprosate or naltrexone Conduct a comprehensive medical assessment before starting treatment Before starting treatment with acamprosate or oral naltrexone conduct a comprehensive medical assessment (baseline urea and electrolytes and liver function tests including GGT). In particular, consider any contraindications or cautions (see the SPC), and discuss these with the service user. Acamprosate If using acamprosate, start treatment as soon as possible after assisted withdrawal. Usually prescribe at a dose of 1998 mg (666 mg three times a day) unless the service user weighs less than 60 kg, and then a maximum of 1332 mg should be prescribed per day. Acamprosate should: usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it 1 be stopped if drinking persists 4 6 weeks after starting the drug. Service users taking acamprosate should stay under supervision, at least monthly, for 6 months, and at reduced but regular intervals if the drug is continued after 6 months. Do not use blood tests routinely, but consider them to monitor for recovery of liver function and as a motivational aid for service users to show improvement. 1 At the time of publication (February 2011), acamprosate did not have UK marketing authorisation for use longer than 12 months. Informed consent should be obtained and documented. Page 13 of 25

14 Naltrexone If using oral naltrexone 1, start treatment after assisted withdrawal. Start prescribing at a dose of 25 mg per day and aim for a maintenance dose of 50 mg per day. Draw the service user's attention to the information card that is issued with oral naltrexone about its impact on opioidbased analgesics. Oral naltrexone should: usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it be stopped if drinking persists 4 6 weeks after starting the drug. Service users taking oral naltrexone should stay under supervision, at least monthly, for 6 months, and at reduced but regular intervals if the drug is continued after 6 months. Do not use blood tests routinely, but consider them for older people, for people with obesity, for monitoring recovery of liver function and as a motivational aid for service users to show improvement. If the service user feels unwell advise them to stop the oral naltrexone immediately. 10 Disulfiram Before starting treatment with disulfiram, conduct a comprehensive medical assessment (baseline urea and electrolytes and liver function tests including GGT). In particular, consider any contraindications or cautions (see the SPC), and discuss these with the service user. If using disulfiram, start treatment at least 24 hours after the last alcoholic drink consumed. Usually prescribe at a dose of 200 mg per day. For service users who continue to drink, if a dose of 200 mg (taken regularly for at least 1 week) does not cause a sufficiently unpleasant reaction to deter drinking, consider increasing the dose in consultation with the service user. Before starting treatment with disulfiram, test liver function, urea and electrolytes to assess for liver or renal impairment. Check the SPC for warnings and contraindications in pregnancy and in the following conditions: a history of severe mental illness, stroke, heart disease or hypertension. Make sure that service users taking disulfiram: stay under supervision, at least every 2 weeks for the first 2 months, then monthly for the following 4 months if possible, have a family member or carer, who is properly informed about the use of disulfiram, oversee the administration of the drug Page 14 of 25

15 are medically monitored at least every 6 months after the initial 6 months of treatment and monitoring. Warn service users taking disulfiram, and their families and carers, about: the interaction between disulfiram and alcohol (which may also be found in food, perfume, aerosol sprays and so on), the symptoms of which may include flushing, nausea, palpitations and, more seriously, arrhythmias, hypotension and collapse the rapid and unpredictable onset of the rare complication of hepatotoxicity; advise service users that if they feel unwell or develop a fever or jaundice that they should stop taking disulfiram and seek urgent medical attention. 11 Drugs not to be routinely used Do not use antidepressants (including SSRIs) routinely for the treatment of alcohol misuse alone. Do not use GHB for the treatment of alcohol misuse. Benzodiazepines should only be used for managing alcohol withdrawal and not as ongoing treatment for alcohol dependence. 12 Staff competencies Staff responsible for assessing and managing assisted alcohol withdrawal should be competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms and the use of drug regimens appropriate to the settings (for example, inpatient or community) in which the withdrawal is managed. If a symptom-triggered medication regimen [See page 16] is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely. 1 At the time of publication (February 2011), oral naltrexone did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Page 15 of 25

16 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. Glossary Acute alcohol withdrawal The physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time. ADI Adolescent diagnostic interview Alcohol dependence 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). CI Confidence interval. There is always some uncertainty in research. This is because a small group of people is studied to predict the effects of an intervention on the wider population. The confidence interval is a way of expressing how certain we are about the findings from a study, using statistics. It gives a range of results that is likely to include the 'true' value for the population. Page 16 of 25

17 The CI is usually stated as '95% CI', which means that the range of values has a 95 in a 100 chance of including the 'true' value. For example, a study may state that 'based on our sample findings, we are 95% certain that the 'true' population blood pressure is not higher than 150 and not lower than 110'. In such a case the 95% CI would be 110 to 150. A wide confidence interval indicates a lack of certainty about the true effect of the test or treatment often because a small group of patients has been studied. A narrow confidence interval indicates a more precise estimate (for example, if a large number of patients have been studied). Alcohol misuse Used in this pathway to refer to harmful drinking and alcohol dependence. Alcohol treatment A programme designed to reduce alcohol consumption or any related problems. It could involve a combination of counselling and medicinal solutions. Alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as 'alcohol-specific'. If it is only partly caused by alcohol it is described as 'alcohol-attributable'. Alcohol-use disorders 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. OR Odds ratio. Odds are a way to represent how likely it is that something will happen (the probability). An odds ratio compares the probability of something in one group with the probability of the same thing in another. An odds ratio of 1 between two groups would show that the probability of the event (for example a person developing a disease, or an intervention working) is the same for both. Page 17 of 25

18 Sometimes probability can be compared across more than two groups in this case, one of the groups is chosen as the 'reference category', and the odds ratio is calculated for each group compared with the reference category. For example, to compare the risk of dying from lung cancer for non-smokers, occasional smokers and regular smokers, non-smokers could be used as the reference category. Odds ratios would be worked out for occasional smokers compared with non-smokers and for regular smokers compared with non-smokers. APQ alcohol problems questionnaire ASA Advertising Standards Authority AUDIT 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. BAC Blood alcohol concentration RCT Randomised controlled trial. A study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or intervention. One group (the experimental group) receives the intervention being tested, the other (the comparison or control group) receives an alternative intervention, a dummy intervention (placebo) or no intervention at all. The groups are followed up to see how effective the experimental intervention was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias. Brief interventions 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 Page 18 of 25

19 reduce their alcohol consumption (sometimes even to abstain) and can be carried out by nonalcohol specialists. CIWA Ar 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. CAMHS child and adolescent mental health service DCSF Department for Children, Schools and Families Diversion when the drug is being taken by someone other than for whom it was prescribed. Extended brief intervention 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. ES Effect size. A measure that shows the magnitude of the outcome in one group compared with that in a control group. For example, if the absolute risk reduction is shown to be 5% and it is the outcome of interest, the effect size is 5%. The effect size is usually tested, using statistics, to find out how likely it is that the effect is a result of the treatment and has not just happened by chance (that is, to see if it is statistically significant). Page 19 of 25

20 Extended brief interventions 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. Fixed-dose medication regimen 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 Fixed-dose medication regimens 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 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). i NICE analysts have calculated this figure using data from the original study. ICER Incremental cost effectiveness ratio. A measure of the cost effectiveness of a treatment or health intervention. It estimates how much more the benefits of a certain treatment cost, compared with other treatments or health interventions. GHB gammahydroxybutyrate Page 20 of 25

21 NNT Number needed to treat. The average number of people who need to receive an intervention to get a positive outcome. For example, if the NNT is four, then 4 people would have to receive the intervention to ensure one of them gets better. The closer the NNT is to one, the better the intervention. However, as with most data, caution is needed when considering whether results apply to populations beyond the sample described in the original study. GGT gamma glutamyl transferase GUM Genito-urinary medicine Harmful drinking A pattern of alcohol consumption that is causing mental or physical damage. Hazardous drinking 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 WHO to describe this pattern of alcohol consumption. It is not a diagnostic term. LDQ Leeds dependence questionnaire Looked-after children 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. Page 21 of 25

22 QALY Quality-adjusted life year. A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health. QALYS are calculated by estimating the years of life remaining for a person following a particular treatment or intervention and weighting each year with a quality of life score (on a zero to one scale). It is often measured in terms of the person's ability to perform the activities of daily life, freedom from pain and mental disturbance. Lower-risk drinking Regularly consuming 21 units per week or less (adult men) or 14 units per week or less (adult women). It is also known as 'sensible' or 'responsible' drinking. Medically assisted alcohol withdrawal The deliberate withdrawal from alcohol by a dependent drinker under the supervision of medical staff. Prescribed medication may be needed to relieve the symptoms. It can be carried out at home, in the community or in a hospital or other inpatient facility. Mild alcohol dependence a score of 15 or less on SADQ MMSE mini-mental state examination Moderate alcohol dependence a score of on SADQ PCTs primary care trusts Page 22 of 25

23 SD Standard deviation. A measure used to summarise numerical data and describe how 'spread out' a set of measures (or 'values') are from the average. For example, the average height of a group of schoolchildren can be calculated using the total of all their heights added together and then divided by the number of schoolchildren in the group. Standard deviation measures the 'spread' of those heights. So, in the example it tells you whether all those in the group were about the same height or whether some were very tall and some were short. PAT Paddington alcohol test Responsible authorities 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. SADQ severity of alcohol dependence questionnaire Saturated 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. Schools For the purposes of this pathway, schools include: state-sector, special and independent primary and secondary schools; city technology colleges, academies and grammar schools; pupil referral units, secure training and local authority secure units; and further education colleges. Page 23 of 25

24 Screening For the purposes of this pathway, 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. SSRIs selective serotonin reuptake inhibitors Severe alcohol dependence A score of 31 or more on SADQ SPC summary of product characteristics Structured brief advice a brief intervention that takes only a few minutes to deliver T-ASI teen addiction severity index Treatment A programme designed to reduce alcohol consumption or any related problems. It could involve a combination of counselling and medicinal solutions. Unit 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). Page 24 of 25

25 Sources Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) NICE guideline CG115 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT nice@nice.org.uk Page 25 of 25