Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
The strength of recommendation grading (A-D) and level of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Detection and Assessment
D - Primary care workers should be alerted by certain presentations and physical signs to the possibility that alcohol is a contributing factor and should ask about alcohol consumption.
B - Abbreviated forms of Alcohol Use Disorders Identification Test (AUDIT) (e.g., Fast Alcohol Screening Test (FAST)), or Attempts to Cut back on drinking, being Annoyed at criticisms about drinking, feeling Guilty about drinking, and using alcohol as an Eye-opener (CAGE) plus two consumption questions, should be used in primary care when alcohol is a possible contributory factor.
C - In Accident & Emergency (A&E), FAST or Paddington Alcohol Test (PAT) should be used for people with an alcohol related injury.
B – Tolerance to the effects of alcohol, Worry about drinking, Eye-opener, Amnesia, felt the need to K cut down on your drinking (TWEAK) and Tolerance, Annoyed by someone criticizing your drinking, felt the need to Cut down, Eye-opener (T-ACE) (or shortened versions of AUDIT) should be used in antenatal and preconception consultations.
B - Biological tests are useful when there is reason to believe that self reporting may be inaccurate.
A – General Practitioners (GPs) and other primary care health professionals should opportunistically identify hazardous and harmful drinkers and deliver a brief (10 minute) intervention.
A - The intervention should, whenever possible, relate to the patient’s presenting problem and should help the patient weigh up any benefits as perceived by the patient, versus the disadvantages of the current drinking pattern.
D - Training for general practitioners, practice nurses, community nurses, and health visitors in the identification of hazardous drinkers and delivery of a brief intervention should be available.
B - Routine antenatal care provides a useful opportunity to deliver a brief intervention for reducing alcohol consumption.
B - Motivational interviewing techniques should be considered when delivering brief interventions for harmful drinking in primary care.
D - When medication to manage withdrawal is not needed, patients should be informed that at the start of detoxification they may feel nervous or anxious for several days, with difficulty in going to sleep for several nights.
A - Benzodiazepines should be used in primary care to manage withdrawal symptoms in alcohol detoxification, but for a maximum period of seven days.
D - For patients managed in the community, chlordiazepoxide is the preferred benzodiazepine.
D - Clomethiazole should not be used in alcohol detoxification in primary care.
C - Provided attention is paid to any acute or chronic physical illness, elderly patients should be managed the same way as younger patients.
B - Antiepileptic medication should not be used as the sole medication for alcohol detoxification in primary care.
B - Antipsychotic drugs should not be used as first line treatment for alcohol detoxification.
D - Patients with any sign of Wernicke-Korsakov syndrome should receive Pabrinex in a setting with adequate resuscitation facilities. The treatment should be according to British National Formulary (BNF) recommendations and should continue over several days, ideally in an inpatient setting.
D - Local protocols for admitting patients with delirium tremens should be in place.
Referral and Follow Up
A - Access to relapse prevention treatments of established efficacy should be facilitated for alcohol dependent patients.
B - When the patient has an alcohol related physical disorder, the alcohol treatment agency should have close links with the medical and primary care team.
D - The principles of stepped care should be followed for patients with alcohol problems and dependence.
B - Primary care teams should maintain contact over the long term with patients previously treated by specialist services for alcohol dependence.
C - Alcohol dependent patients should be encouraged to attend Alcoholics Anonymous.
D - If patients are referred to a lay service, agencies where lay counsellors use motivational interviewing and coping skills training should be utilised.
Medications to Prevent Relapse
B - Acamprosate is recommended in newly detoxified dependent patients as an adjunct to psychosocial interventions.
C - Supervised oral disulfiram may be used to prevent relapse but patients must be informed that this is a treatment requiring complete abstinence and be clear about the dangers of taking alcohol with it.
Alcohol Dependence and Psychiatric Illness
B - Patients with an alcohol problem and anxiety or depression should be treated for the alcohol problem first.
B - If depressive symptoms persist for more than two weeks following treatment for alcohol dependence, consideration should be given to using a selective serotonin reuptake inhibitor (SSRI) or referring for counseling or specialist psychological treatment along with the relapse prevention treatment.
D - If severe anxiety symptoms persist for more than two weeks in abstinent patients, consideration should be given to using a selective serotonin reuptake inhibitor (SSRI), or referring for specialist psychological treatment along with the relapse prevention treatment.
B - Patients with psychotic disorder and alcohol dependence should be encouraged to address their alcohol use and may benefit from motivational, cognitive behavioural, family, and nonconfrontational approaches.
C - The primary care team should help family members to use behavioural methods which will reinforce reduction of drinking and increase the likelihood that the drinker will seek help.
Grades of Recommendation
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Nonanalytic studies (e.g. case reports, case series)
4: Expert opinion