Closed consultation

UK clinical guidelines for alcohol treatment: core elements of alcohol treatment

Published 16 October 2023

1. Alcohol treatment and recovery: priorities

A group of experts through experience contributed to the development of these clinical guidelines. Group members had experience of alcohol treatment and recovery and were active in recovery organisations. The group’s input is integrated throughout the guidelines. The list below summarises the themes the group identified as priorities for providing high quality alcohol treatment and recovery (see definition of recovery in the glossary).

1. Alcohol treatment should take place in the context of a recovery-oriented system of care where clinicians, support staff, peers and people engaged in treatment all have roles to play.
2. People should be able to access personalised care from any part of the treatment and recovery system.
3. A non-judgemental, empathic approach and staff working together with people in treatment is essential.
4. Peers and recovery communities can play a central role in supporting recovery at all stages of the treatment and recovery journey.
5. Individual treatment and recovery plans should include flexible recovery goals from the start, and the focus on recovery-oriented activities will increase during treatment and after they leave.
6. Services need to work together so people with alcohol problems who also have mental health conditions do not get turned away. People should be able to get help for both conditions in a shared approach.
7. Services need to engage and support people from diverse communities. They should co-produce service plans with diverse communities and work flexibly in a culturally sensitive way to do this.

You can find a list of members of the experts through experience group in annex 4.

2. Principles of care

2.1 Introduction

These principles of care should underpin all support for people experiencing problems with alcohol. They are relevant to practitioners in any health, social care, or community service working with a person with an alcohol problem. References to these principles of care appear throughout the guidelines.

The principles are based on the clinical consensus of the alcohol guidelines development group and are based on National Institute for Health and Care Excellence (NICE) guidelines.

2.2 Experience of care

Principles 2.2.2 to 2.2.5 are based on the NICE clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) and other evidence as referenced.

2.2.1 Building a trusting relationship

Practitioners should work to build a trusting relationship with people with alcohol problems, taking a supportive, empathic and non-judgemental approach.

Practitioners should ensure that a compassionate and humanising approach is evident in every contact with people with alcohol problems.

Over time, a trusting relationship can develop into a strong therapeutic alliance, with the practitioner and the person working together to achieve the person’s goals. A strong therapeutic alliance is essential to effective treatment and is associated with better treatment outcomes.

You can read more about therapeutic alliance in chapter 5 on psychosocial interventions.

2.2.2 Reducing stigma

Services and practitioners should work to reduce stigma.

People with alcohol problems experience stigma in society and in some healthcare and support services. Research consistently identifies stigma as a major barrier to help-seeking and treatment engagement for people with alcohol problems (Kilian and others 2021).

The World Health Organization European framework for action on alcohol 2022 to 2025 (PDF, 2.2MB) includes a priority action for healthcare services to reduce social stigma and discrimination that prevent people from accessing alcohol treatment. Services and practitioners should address policies, practices and attitudes that can contribute to experiences of stigma, ensuring people feel respected, heard, and not judged or treated differently because of their alcohol use. Physical and mental health services and social care services should not exclude people from care that they need on the basis that they have an alcohol problem.

Language used to describe people with alcohol problems can also be stigmatising. Preferred language and terminology around alcohol use can vary between individuals and over time. It is useful for services to regularly review the language they use, by speaking to people with lived experience to understand what language they find stigmatising and what are their preferred terms.

Practitioners should be aware that people’s experiences of stigma and discrimination may mean that they minimise their alcohol problem.

2.2.3 Privacy and dignity

People seeking treatment for their alcohol problems have a right to privacy and can expect to be treated with respect and in a way that preserves their dignity. Practitioners should make sure that any care or treatment takes place in private and appropriate settings, including by having welcoming and safe waiting areas and suitable and pleasant confidential spaces. Conversations about a person’s needs or their treatment should always take place in private settings. Physical examinations should take place in private and appropriately equipped settings.

2.2.4 Confidentiality and information sharing

Services and practitioners should maintain clear confidentiality policies which they should discuss with each person at the start of their treatment and recovery journey. Policies should outline the boundaries of confidentiality, including the process for seeking the person’s consent before disclosing their information to any external agencies or individuals.

It is important that people seeking support for alcohol problems understand what confidentiality means and how and when information can be shared without consent, for example if a safeguarding issue is identified.

Services should develop information sharing agreements with partner agencies. Information sharing between agencies can support an integrated approach to helping people with alcohol problems to address their health and support needs.

Local agreements between services should describe and support suitable information sharing arrangements that are consistent with legal and ethical obligations and avoid unnecessary barriers or delays. Where possible and with the person’s consent, information sharing agreements should be accompanied by shared access to relevant sections of the person’s electronic health records between services. This can help services to access the most recent relevant information rapidly. Agreements should also set out how services, with the person’s consent, will share information with families and carers.

2.2.5 Access to information

All healthcare services and support services should be able to provide basic information on what the local alcohol treatment service offers and how to access the service.

Alcohol treatment services should provide appropriate information to people seeking help about:

• their service
• the nature of alcohol problems
• available evidence-based treatments including their risks and benefits

Providing this information supports shared decision making (see section 2.2.6 below).

Services should make comprehensive written information available in an accessible format considering the person’s literacy, sensory ability, cognitive ability, and neurodiversity (see definition of neurodiversity in the glossary). Practitioners should avoid clinical language and jargon, and if they need to use it, they should explain what it means. Where English is not the person’s first language, services should offer an independent interpreter (someone not known to the person) if they need one. Services should also translate written or video information into the person’s language if necessary.

Where practitioners in the alcohol treatment service communicate with other healthcare professionals, they should provide the person with copies of any letters or medical reports and check that the person understands the content.

2.2.6 Shared decision making and person-centred treatment

Services should provide care based on shared decision making and train practitioners in this approach.

Shared decision-making means practitioners and people with alcohol problems work together to agree on the treatment and support the service will provide for the person. The person should always be at the centre of decisions about their own care unless they are lacking in mental capacity (see annex 1 for legislation and guidance on mental capacity). Where people lack capacity to share in decision making, the practitioner should still aim to provide a service tailored to the individual needs of the person, consulting family members or carers on the person’s needs where appropriate.

Practitioners should:

• inform each person that they have choices about their care
• help each person to think about the treatment options
• provide information on associated risks and benefits of each treatment option
• support each person to decide on their preferred choice of treatment

Shared decision making is the basis for developing individually tailored, person centred treatment and recovery support. Practitioners should always take account of a person’s individual needs, strengths and aspirations, and their family and social situation, when offering them treatment and recovery support.

NICE guideline Shared decision making (NG197) provides more information.

People who attend alcohol treatment services or have lived experience of alcohol problems should also be involved in decisions about the design and delivery of the service.

2.2.7 A strengths-based approach

Services and practitioners should take a strengths-based approach when working with people who have alcohol problems. A strengths-based approach means that practitioners help people to identify their personal strengths (for example, their skills and aspirations) and assets in their community (for example, their supportive social networks). A strengths-based approach does not mean ignoring problems. Practitioners should help people identify and address problems, but this should not be the only focus of treatment. Practitioners should support people to use their personal and community strengths to support their treatment and build their recovery.

Practitioners should help people access peer-based recovery support services from the beginning of treatment because these organisations show what people with lived experience can achieve and can instil hope, resilience and a sense of community (see section 2.5.2 on recovery support services).

2.2.8 Trauma-informed practice

Services and practitioners should provide trauma-informed practice.

A high proportion of people with alcohol problems have had experience of childhood trauma and a significant proportion have also experienced trauma as adults. The experience of trauma can be individual (for example, child abuse) or collective (for example, war). Many people use alcohol as an attempt to manage the impact of trauma on their lives.

Trauma-informed practice aims to increase practitioners’ awareness of how trauma can negatively affect individuals and communities, and their ability to feel safe or develop trusting relationships with health and care services and their staff. It aims to improve the accessibility and quality of services by creating culturally sensitive, safe services that people trust and want to use.

The purpose of trauma-informed practice is not to treat trauma-related difficulties, which is the role of trauma-specialist services and practitioners. Instead, it seeks to address the barriers that people affected by trauma can experience when accessing health and care services.

Trauma-informed practice is based on 6 principles:

1. Safety.
2. Trust.
3. Choice.
4. Collaboration.
5. Empowerment.
6. Cultural consideration.

You should read comprehensive guidance providing a working definition of trauma-informed practice for practitioners working in the health and care sector.

2.2.9 Family involvement

Services and practitioners should involve family members or carers in a person’s care where the person consents and it is appropriate. They should also offer support to family members and carers in their own right. There is evidence that family involvement in a person’s care can lead to better treatment outcomes (Copello and others 2006).

If the person consents to a family member being involved, practitioners should discuss and agree with the person engaged in alcohol treatment, and then the family member or carer, what is the appropriate level and type of family involvement. Practitioners should also agree with the person in treatment and their family member or carer what information will be shared and what information will remain confidential to each of them.

Services should offer family members and carers information on alcohol problems and alcohol treatment and offer appropriate support for their involvement with the person’s care.

Family and carers may have their own support needs and services should offer information on how family members can be affected by a person’s alcohol problem. Practitioners should offer initial support (including support for urgent needs) and where appropriate, offer extended support or let families and carers know about self-help resources, as well as local and national support organisations for families of people with alcohol problems.

Practitioners should be aware what level of caring responsibility entitles a carer to a carer’s assessment and they should refer the family member or carer for one where appropriate (see definition of carer’s assessment in the glossary). You can find information about legislation and guidance on carers in annex 1.

Services should offer information and support to family members and friends, even where the person with the alcohol problem is not attending the treatment service (Orford and others 2013).

You can read more about interventions involving families in chapter 5 on psychosocial interventions.

Practitioners should also consider the needs of any children in the family who are in regular contact with the person with an alcohol problem and provide information on local services for children and families. Services should have procedures for both child and adult safeguarding and practitioners should be trained to identify child and adult safeguarding needs and make referrals to children’s or adult social care. They must work in line with national child and adult safeguarding legislation and organisational procedures. You can find information on child and adult safeguarding legislation and guidance in annex 1.

2.3 Equality, diversity and inclusion

Service policies, procedures and ethos, and practitioners’ approach should be based on the principles of equality, diversity and inclusion and aim to reduce health inequalities. They should promote equitable access and personalised treatment that meets the diverse needs of all groups and local communities.

2.3.1 Promoting equality, diversity and inclusion

Alcohol problems and inequalities

People with alcohol problems have much higher levels of illness and early death than the general population (Roerecke and Rehm 2013). Alcohol treatment services and wider health and social care support services can help to reduce these health inequalities. They can do this by providing accessible and inclusive services which are tailored to each person’s specific needs.

Within the wider group of people with alcohol problems, some also experience discrimination and disadvantage for other reasons. This can affect how easy it is for them to access and engage with services and whether the treatment and support meets their particular needs. People may experience discrimination or disadvantage including in some healthcare services based on:

• stigma around alcohol problems
• their protected characteristics (see below for more information about these)
• severe and multiple disadvantage

The term severe and multiple disadvantage in this guidance (Bramley and others 2019) refers here to people who experience 2 or more of the following:

• alcohol and drug problems
• homelessness and rough sleeping
• mental health conditions
• contact with the criminal justice system
• domestic violence and abuse

Other groups that experience social exclusion, disadvantage and health inequalities are known as inclusion health groups. These include:

• vulnerable migrants
• Gypsy, Roma and Traveller communities
• sex workers
• people experiencing modern slavery

People who experience severe and multiple disadvantage often find it very difficult to access healthcare, including alcohol treatment services and they also often experience extremely poor physical and mental health in comparison to the general population.

People with protected characteristics

There is a public sector equality duty for services to consider the need to reduce disadvantage and meet the particular needs of people with protected characteristics.

Protected characteristics mean that it is against the law to discriminate against anyone because of:

• age
• disability
• sex
• race, including colour, nationality, ethnic or national origin
• religion or belief
• being pregnant or on maternity leave
• sexual orientation
• gender reassignment
• being married or in a civil partnership

For more information on protected characteristics, read Discrimination: your rights.

Local actions to develop inclusive services

Local commissioners and services should work with local people, communities and organisations. In particular, they should work with representatives of groups with protected characteristics and groups experiencing severe and multiple disadvantage and health inequalities to:

• assess local need for alcohol treatment using equality impact assessment processes to understand the diverse needs of their local population and to identify which people and groups are under-represented or experiencing poor outcomes in their services
• develop ways to target and increase access for each local under-represented group
• tailor services and interventions to meet the diverse needs of their local population, particularly people with protected characteristics, those experiencing severe and multiple disadvantage and those who are under-represented in treatment services

Services should develop an inclusive service ethos which means:

• people with lived experience of alcohol problems from different groups and local communities contribute to service commissioning, planning and delivery
• there is a diverse team of practitioners and where possible, peer support workers, who are culturally competent (see section 2.3.2 below)

You can read more about developing inclusive services in chapter 25.

2.3.2 Cultural competence

Services and individual practitioners should be culturally competent. Services should make sure their staff receive training and supervision to develop this important competency.

The term ‘cultural competence’ refers to the ability of organisations and individual practitioners to effectively deliver services that meet the social, faith, cultural, and linguistic needs of people from diverse groups and communities. Cultural competence involves policies, behaviours, awareness, attitudes, knowledge and skills at an organisational and a practitioner level that promote effective interactions with, and equitable treatment for people from diverse backgrounds.

Culture intersects with other factors that shape identity and experience such as gender, sexual orientation, gender identity, age, disability, and socioeconomic resources. These combined factors affect how easy it is for each person to engage with alcohol treatment services and what kind of treatment approach will meet their needs. Cultural competence in this guideline means working effectively and equitably with people from all cultures and across intersecting identities. It also means challenging the discrimination and exclusion that people experience and the resulting impact on their treatment and recovery outcomes.

While cultural competence involves sensitivity and knowledge about other people’s cultures, it is important not to label people or make stereotypical assumptions. Everyone is unique and treatment and recovery support should always be based on understanding the person as an individual and tailoring interventions to meet their specific needs.

Practitioners should also understand how their own culture and background can influence their perspective. Services should support them through training and supervision to challenge any unconscious bias that can affect their practice.

2.3.3 Accessible services

Services should make sure that they are easy to get to, welcoming and easy to engage with for everyone in the diverse local population.

Services should review their treatment processes and procedures and amend them to address any factors that might prevent people from accessing or engaging in treatment. This will include offering appointment times that can accommodate parents with childcare responsibilities and people who work in the day. Also, services should be offered at sites that are easy to access by public transport so that people in any part of the local area can get there easily. The services should be in places where people feel physically safe, for example in areas with good lighting.

Services should have flexible engagement arrangements to meet the needs of specific groups, including those with protected characteristics. For example, these arrangements might include:

• satellite services in primary care for people who would not want to go to a specialist alcohol and drug service, because of their concerns about stigma
• satellite services in community services and organisations used and trusted by specific groups such as specific minority ethnic groups, LGBTQ+ groups, older people
• access to services and facilities for people with physical disabilities
• initial contact and (where appropriate) further appointments online or by phone for people who find it very difficult to attend a service in person
• methods of communication and information adapted to the needs of people with physical, sensory or cognitive disabilities, neurodiversity or limited literacy

Services should make arrangements to help the most vulnerable people experiencing severe and multiple disadvantage to access treatment. This might include offering direct access (drop in) sessions at treatment service sites. They can also offer to take the service to the person in their home, or a community setting of their choice. You can read more about this in chapter 9 on assertive outreach and a multi-agency team around the person.

Where possible, services should employ diverse staff teams that include staff and peer support workers who are members of local groups or communities. These team members can contribute cultural perspectives on how to increase access and can support relationship building with communities and individuals seeking treatment. Where language prevents some people from accessing treatment, services should provide independent interpreters.

2.3.4 Better care for people with co-occurring mental health conditions

Commissioners and providers of alcohol treatment services and mental health services should work together to make sure that people with co-occurring alcohol problems and mental health conditions can access treatment and support for both conditions.

Co-occurring mental health conditions and alcohol problems are common among people in alcohol treatment and mental health services. But there is evidence from the Recovery Partnership that services often exclude people with these co-occurring conditions so they cannot access the care they need (see the definition of co-occurring conditions in the glossary).

Alcohol treatment services and mental health services should respond flexibly to people with co-occurring alcohol and mental health conditions to actively prevent their exclusion from services.

Guidance on better care for people with co-occurring mental health, and alcohol and drug use conditions outlines the following principles to support this approach:

1. Everyone’s job. Mental health and alcohol and drug use services have a joint responsibility to meet the needs of people with co-occurring conditions by working together to reach shared solutions.
2. No wrong door. Providers of alcohol and drug, mental health and other services should have an open door policy for people with co-occurring conditions and make every contact count. Treatment for the co-occurring conditions should be available no matter which service they first contact.

No wrong door does not mean that everyone should receive ongoing care at the service they first attend, but it does mean that all services and practitioners should be:

• proactive, flexible, compassionate and anti-discriminatory in their response
• able to offer an initial rapid assessment, address any urgent physical and mental health needs and refer the person onto an appropriate specialist service if needed
• active in planning longer term care with other services

Services should work together to develop and maintain collaborative pathways of care and a shared approach to treatment and recovery planning so multiple agencies can provide a co-ordinated response to the person’s individual needs.

You can read more on people with co-occurring mental health conditions in chapter 18.

2.4 Quality governance

Alcohol treatment services and recovery support services must have comprehensive quality frameworks to help them deliver evidence-based treatments and care, by practitioners with appropriate competences.

2.4.1 Quality governance frameworks

Quality governance is a term used to describe processes that assure delivery of high-quality services. Quality governance may also be known as clinical governance or care governance. Health and social care organisations and some individuals are directly and statutorily accountable for elements of quality governance.

Organisational components to assure quality governance include:

• clear lines of responsibility and accountability
• quality improvement activities, including regular quality audits of services
• policies that manage risk
• procedures to identify and remedy poor performance

The main components of an effective service are:

• delivering interventions in line with the evidence base
• having a competent workforce, who are effectively supported and supervised (see section 2.5 below)
• working in partnership with other services to deliver positive outcomes

Services need to make sure they have appropriate policies and procedures in place to support these professional and organisational objectives.

Commissioners and senior clinicians in the local healthcare system should take a leading role in reviewing serious incidents and significant adverse events, including alcohol and drug related deaths. The purpose of reviewing serious incidents is to make sure everybody learns from the incident and that there is a structure to support improvements and to monitor their impact.

Alcohol treatment services should also have their own internal processes for reporting and reviewing serious incidents.

Individual practitioners and the organisations in which they work normally have a duty for:

• incident reporting
• contributing to investigation and review
• risk assessment
• risk management
• safeguarding assessment and management
• infection control

Services should refer to more detailed guidance on quality governance and quality standards. For example, guidance that applies to England includes:

• Alcohol and drug treatment quality governance guidance
• Commissioning quality standard for alcohol and drug services

NICE quality standard Alcohol-use disorders: diagnosis and management (QS11) applies to England and Wales.

There is some content in each of the documents that is relevant across the UK.

2.4.2 Measuring outcomes

Services should routinely monitor all interventions for people with alcohol problems. Services can use several outcome measures. These include formal tools that measure self-reported changes in alcohol use and aspects of health, wellbeing and recovery. For example:

• treatment outcome profile (included within the ‘adult combined review form’ for England)
• Substance Use Recovery Evaluator (SURE)

Where relevant, practitioners can also use tests including blood tests, liver screening or other health screening tests to measure health outcomes.

They should also record the outcome of treatment when the person leaves treatment, so the service can review whether they achieved their alcohol use goal.

Practitioners should make outcome measures central to a person’s treatment and recovery planning process. Practitioners should plan all clinical interventions with personalised and mutually agreed outcomes in mind and routinely review progress against these outcomes with the person.

When they review the outcomes, practitioners may agree with the person to alter these outcomes or the interventions they are providing to achieve them.

Supervisors and practitioners should review outcomes in clinical supervision, as this can help to identify staff training and development needs.

Services should also include monitoring of treatment outcomes across all those who use the service as part of regular quality audits.

2.5 A skilled and competent workforce

All alcohol treatment clinicians, including those in registered and non-registered roles, need to have appropriate competencies for their clinical roles and receive training and supervision to achieve and maintain them.

2.5.1 Clearly defined competencies

Competencies need to be agreed and clearly defined at a local or service level for the full range of roles covered in these guidelines, based on relevant national competency or capability frameworks and national occupational standards.

2.5.2 Professional development structures

Training and professional development structures and resources are essential to develop and maintain the required competencies. Important components of this include:

• individual or peer supervision
• personal development plans
• mentoring
• other forms of professional support

2.5.3 The role of professional bodies

The professional regulatory bodies are responsible for setting the standards of behaviour, competence and education of regulated healthcare professionals. These bodies include the:

• Health and Care Professions Council
• General Medical Council
• General Pharmaceutical Council
• Nursing and Midwifery Council

These bodies also are responsible for registering professionals who meet those standards and taking action where the standards are not met. Clinicians in registered roles who deliver alcohol treatment need to have appropriate certification, such as specialist registration, and meet professional revalidation requirements.

2.5.4 Competencies and qualifications for non-registered staff

It is particularly important for staff who are not from one of the registered professions and do not have the additional support of a professional body (like alcohol and drug workers), to be properly trained, supported, and supervised by their employers to carry out their roles effectively. Locally agreed role descriptions or person specifications should set out the competencies and qualifications required for non-registered staff, based on relevant national occupational standards and capability or competency frameworks.

Volunteers and peer mentors may also have relevant qualifications for their roles and need to be appropriately supported and trained by the services they work in. It is also important that the roles of volunteers and peer mentors are clearly defined.

2.5.5 Updating knowledge and skills

All clinicians have a professional obligation to update their knowledge and skills base in line with emerging evidence and developments in practice.

2.5.6 Non-clinical skills

Non-clinical skills such as leadership and management are also important and need to be supported by employers.

2.5.7 Supervision and appraisal

Supervision and reflective practice structures are essential for effective interventions, particularly psychosocial interventions. They are an important part of good clinical governance. alongside monitoring intervention quality and outcomes.

Annual appraisal is mandatory for all clinicians working in the NHS and is established good practice in other settings.

2.5.8 A full range of competencies in each local area

Each local alcohol treatment system will need to have doctors providing treatment, ranging from those able to provide medical services for the treatment of comorbidities to those with specialist competencies in treating alcohol dependence. Other health and social care professionals with a range of competencies are also needed in a treatment system.

Multidisciplinary teams are essential to alcohol treatment and should include nurses, psychologists, and social workers.

2.5.9 Alcohol specific competencies

Most alcohol treatment and drug treatment is integrated into single alcohol and drug treatment services. Many of the competencies needed to treat and support recovery from alcohol dependence are the same as those needed to treat and support recovery from drug dependence. However, some of the competencies needed to deliver the interventions in this guideline are specific to alcohol. So, it’s vital to maintain a sufficient level of alcohol specialism in teams in integrated alcohol and drug treatment services.

2.5.10 Therapeutic alliance

Evidence and feedback from people with lived experience consistently tell us that the working relationship, or the therapeutic alliance, between clinicians (including drug and alcohol workers) and the people they support is vital to the effectiveness of all interventions. This is particularly true for psychosocial interventions. Knowing this helps us to focus on relevant competencies such as:

• active listening
• giving structured feedback
• reflective practice
• a non-judgemental approach

It’s also important to focus on caseload size and the staffing to patient ratio in services, to make sure staff have the time they need to develop supportive relationships.

2.5.11 Training future alcohol specialists

All alcohol treatment systems need to have the resources, time and expertise, including qualified supervisors, to support training places for the next generation of alcohol specialists. This includes psychologists, nurses and addiction psychiatrists.

2.6 A recovery-oriented system of care

2.6.1 Working together to develop a recovery-oriented system of care

Commissioners, services and lived experience recovery organisations (LEROs) should work together to develop and maintain a recovery-oriented system of care (ROSC).

Serious alcohol use disorders are long term conditions that can involve cycles of abstinence and relapse (see definitions of alcohol use disorder and abstinence in the glossary). For some people, this can happen over several years and they may make many attempts to change. An episode of treatment that leads to abstinence often does not mean that the person is free from dependence in the long term. Instead, people with serious alcohol problems typically need a personal programme of sustained recovery support and management to remain free from alcohol dependence. People with more severe dependence and more complex needs will usually need to change behaviour, outlook and identity over an extended period to sustain abstinence. People going through these changes often describe themselves as being ‘in recovery’.

Recovery is about building up positive benefits that can help the person to sustain abstinence (or moderate drinking where appropriate) and to develop a life that is meaningful to them. It requires the person, their family and other supportive people around them to develop aspirations and hope. Recovery can be associated with different types of support and interventions or can occur without any formal external help, so it can be achieved in different ways. It is a process, not a single event, and takes time to achieve and effort to maintain. The person must sustain recovery voluntarily for it to be lasting, although the recovery journey can sometimes start or be supported by court-ordered interventions such as community sentencing requirements.

The ROSC framework was designed to support communities in the co-ordination of services supporting recovery from substance use disorders (Ashford and others 2020). Structured treatment services and recovery support services are organised into a framework that incorporates the whole health and social care system. The ROSC should be easy to navigate, transparent and respond to the cultural diversity of the community where it operates.

The best system contains contributions from experts by training and from experts by experience. Recovery support, including peer-based support, is important right from the beginning of the person’s treatment and recovery journey. But there is likely to be a gradual transition from a focus on professional treatment interventions towards self-care and peer-support as the process of recovery develops.

Alcohol treatment services and recovery services (including LEROs) are components of an integrated system and each should deliver their component to the highest level. Treatment services should link with recovery support services (see section 2.6.2 below) and resources in the surrounding community.

Overall, outcomes improve significantly when episodes of structured treatment are combined with long-term recovery support (Simoneau and others 2018).

You can read about recovery support in section 5.6 of chapter 5 on psychosocial interventions, chapter 6 on recovery support services and chapter 7 on employment support.

2.6.2. Recovery support services

Alcohol treatment services should support and work together with local recovery support services.

Research conducted in the US found that people who have had an alcohol use disorder take 5 years or more before their risk of meeting criteria for alcohol use disorder in the following year drops below 15% (White 2012). This is the approximate annual risk in the general population.

So, it is essential for people to have ongoing monitoring and support to remain free from alcohol dependence. Recovery support services are a collection of community services provided by professional or peer-based organisations. This includes LEROs, which are formal organisations led by people with lived experience. Recovery support services aim to support a person’s recovery process so they achieve their long-term goals.

Recovery support services, including peer-based support services, can provide emotional and practical support for continuing abstinence (or controlled drinking where that is appropriate). They can also provide daily structure and rewarding alternatives to alcohol use. This is a process of gathering healthy life resources, often known as recovery capital, which can include:

• housing
• education
• employment
• social resources
• improved health and wellbeing

The research evidence base for recovery support services is developing, and much (but not all) of the evidence comes from the US (Simoneau and others 2018, Sheedy and others 2009). Similarly, the Advisory Council on the Misuse of Drugs (ACMD) report Recovery from drug and alcohol dependence: an overview of the evidence found that a lot of the research on recovery was from the US.

There is guidance on recovery support services in chapter 6.

2.6.3 Access to peer support and lived experience recovery organisations

Commissioners and providers of alcohol treatment services should work with and support local peer-based organisations, including LEROs.

Peer-based support organisations and mutual aid groups such as Alcoholics Anonymous or SMART Recovery can help support and sustain recovery-oriented journeys for people affected by alcohol problems before, during and after treatment. Effective peer support can:

• enhance motivation
• help members to develop a positive identity
• improve coping mechanisms and social skills
• offer benefits from helping others

Local arrangements for peer-based support will vary. They can be commissioned separately from treatment services or exist as part of the service. The range of support these organisations offer also varies. Whatever the arrangement, services should support peer-based organisations by involving them in service design and working with them to offer people integrated recovery oriented treatment and support. Practitioners should inform a person about peer-based support as part of the treatment and recovery planning process and help them to access this.

Peer-based support organisations can become more resilient and more effective where they have a voice, a role, and support within the system. These organisations can also have a role in promoting a positive view of recovery in the wider local community.

In areas where peer-based support organisations do not exist, commissioners and services should consider developing them. You can read more about peer-based support organisations in chapter 6 on recovery support services.

2.7. Local strategic partnerships

These guidelines are about clinical practice, rather than strategic planning. However, many of the recommendations in these guidelines involve effective working between alcohol treatment services and partner services. Local strategic partnerships are essential to develop and maintain effective multi-agency working arrangements.

In each local area, there should be an active partnership between commissioners and provider organisations from the alcohol and drug treatment system, organisations for people with lived experience, and leaders of wider health, care, and criminal justice systems.

The partnership should work together to develop, implement and review joint strategic plans to meet the multiple needs of people with alcohol dependence in their local population. The strategic partnership should establish integrated care pathways, information sharing and joint working agreements, and regularly review the effectiveness of these arrangements.

The membership of local partnerships will vary according to national and local arrangements. In England, local partnerships are a requirement. Drug strategy guidance for local partners sets out the role of partnerships and says that their plans should sufficiently address alcohol dependence and wider alcohol related harm.

Local partnerships should usually include system leaders and service providers from:

• lived experience recovery organisations, including families and carers
• primary and secondary healthcare, including mental health care
• housing and homelessness services
• child and adult safeguarding services
• police, probation and prison healthcare
• education and employment support services
• community services working with groups likely to experience alcohol problems (such as domestic abuse agencies)
• organisations working with underserved groups (such as specific ethnic minorities)

An effective strategic partnership makes it possible for services to work together to provide integrated individual treatment and recovery support. Alcohol treatment practitioners, practitioners from partner services and peer-based support organisations should work together to offer an integrated personalised package of care tailored to the person’s individual needs. They should involve the person with alcohol problems in all their decisions about treatment and recovery.

2.8 References

Ashford R, Brown A, Ryding R and Curtis B. Building recovery ready communities: the recovery ready ecosystem model and community framework. Addiction Research and Theory 2020: volume 28, issue 1, pages 1-11

Bramley G, Fitzpatrick S and Sosenko F. Hard Edges Scotland full report. Heriot-Watt University 2019: pages 44-47

Copello A, Templeton L and Velleman R. Family interventions for drug and alcohol use: is there best practice? Current Opinion in Psychiatry 2006: volume 19, issue 3, pages 271-276

Kilian C, Manthey J, Carr S, Hanschmidt F, Rehm J, Speerforck S and Schomerus G. Stigmatization of people with alcohol use disorders: an updated systematic review of population studies. Alcohol: Clinical and Experimental Research 2021: volume 46, issue 12, pages 899-911

Orford J, Velleman R, Natera G, Templeton L and Copello A. Addiction in the family is a major but neglected contributor to the global burden of adult ill-health. Social Science and Medicine 2013: volume 78, pages 70-77

Roerecke M, Rehm J. Alcohol use disorders and mortality: a systematic review and meta-analysis. Addiction September 2013: volume 108(9): pages 1562 to 1578.

Sheedy C and Whitter M. Guiding principles and elements of recovery-oriented systems of care: what do we know from the research? (PDF, 1MB). Substance Abuse and Mental Health Services Administration, 2009

Simoneau H, Kamgang E, Tremblay J, Bertrand K, Brochu S and Fleury MJ. Efficacy of extensive intervention models for substance use disorders: A systematic review. Drug and Alcohol Review 2018: volume 37, issue S1, pages S246-S262

White W. Recovery/remission from substance use disorders: an analysis of reported outcomes in 415 scientific reports, 1868-2011 (PDF, 2MB). Philadelphia Department of Behavioral Health and Intellectual Disability Services and Great Lakes Addiction Technology Transfer Center, 2012

3. Identification and brief interventions

3.1 Main points

Health and social care services should routinely identify people with alcohol use disorders using a validated screening tool such as the alcohol use disorders identification test (AUDIT) or a short form of it.

Health and social care staff should offer alcohol brief interventions (ABI) to people whose alcohol use significantly increases risks to health (hazardous drinking) or is harming their health (harmful drinking) but who are not dependent on alcohol.

Health and social care staff should also offer a referral for specialist alcohol assessment, and to primary or secondary care to people who are drinking harmfully and have alcohol-related physical or mental health conditions.

Health and social care staff should not offer an ABI to people who are identified as possibly dependent but should offer them referral for a specialist alcohol assessment.

3.2 Introduction

These guidelines are mainly for treating harmful drinking and alcohol dependence, but this chapter provides guidance on identifying and responding to the full spectrum of alcohol use disorders.

The term alcohol use disorder (AUD) includes any pattern of alcohol use that significantly increases risks to health (hazardous drinking or regularly drinking above the low risk guidelines) or causes harm (harmful drinking or dependence).

People with AUD use many different healthcare services and this provides an important opportunity for health and care staff to identify and support them. The Public Health England evidence review on the public health burden of alcohol found that alcohol use is a causal factor in over 60 medical conditions. Around a quarter of adults in the UK are estimated to have an AUD.

Most people with an AUD do not need specialist treatment but may benefit from alcohol brief interventions (ABI), sometimes known as screening and brief interventions (see definition of brief interventions in the glossary). ABI includes a range of approaches which vary in length. In England, the term identification and brief advice (IBA) is commonly used to describe shorter ABI approaches.

3.3 Identification (screening) alcohol use disorders in non-alcohol specialist settings

3.3.1 Settings for AUD identification

Identification of AUDs should take place across a range of settings, so that people are routinely asked about their alcohol use. Primary care, hospitals and mental health settings are particularly important for identifying people with AUDs and also for providing brief interventions or referring people for specialist alcohol assessment where appropriate.

Relevant health and criminal justice services should include alcohol risk identification (screening) tools in standard assessment practices where possible. Where AUD identification tools are not included in standard assessments, practitioners should be trained and supported to ask questions about alcohol use and provide simple brief interventions.

Asking everybody if they are willing to answer some questions about their alcohol use normalises the subject and maximises the chance of identifying AUDs where there are no obvious signs or symptoms. For example, saying “I usually ask some questions about alcohol use here. Are you OK to go through some now with me?” is an effective way to start a brief intervention.

3.3.2 AUDIT scores

The alcohol use disorders identification test (AUDIT) is the gold standard for AUD identification. Services should use the UK version that measures alcohol use in ‘units’ in questions 2 and 3. US versions of AUDIT measure alcohol use using ‘standard drinks’. UK guidance on levels of drinking is based on units and a ‘standard drink’ is not equivalent to a unit.

The AUDIT does not give a clinical diagnosis but indicates which AUD category a person falls into based on their score. Possible AUDIT scores are:

0 to 7: no current AUD

A score between 0 and 7 indicates that the person is drinking at a level that does not significantly increase lifetime risk of alcohol-related ill health.

8 to 15: hazardous or increasing risk drinking

A score between 8 and 15 indicates that the person is increasing their risk of a range of alcohol-related issues and they should be offered brief intervention.

16 to 19: harmful or higher risk drinking

A score between 16 and 19 indicates that the person is drinking at a level that is harmful to their health and they should be offered brief intervention. Some harmful drinkers will need a further healthcare intervention or a specialist alcohol assessment. Harmful drinkers with symptoms of alcohol dependence, physical health conditions such as liver disease, or mental health conditions such as depressive disorder should be made aware of the link between alcohol and their condition. You should refer them for specialist alcohol assessment or a healthcare intervention from their GP or appropriate specialist.

20 or more: possible alcohol dependence

A score of 20 or more indicates that the person is likely to have at least some level of alcohol dependence and they should be referred for specialist alcohol assessment.

You should use AUDIT scores to guide appropriate interventions and support, but the scores should not override clinical judgement in individual cases where there are other risks (for example symptoms of alcohol dependence, physical health or mental health conditions).

3.3.3 Short form validated screening questionnaires

In a variety of settings where time is limited, you can use short form validated screening questionnaires such as the following.

These screens consist of selected questions from the AUDIT questionnaire and can be used to identify people who may have an AUD. A positive screen (for example, an AUDIT-C score of 5 or more) should prompt you to complete the full AUDIT questionnaire. The full AUDIT score will identify which people could benefit from brief interventions and which people might need specialist alcohol assessment or a healthcare intervention.

AUDIT-C

Alcohol use disorders identification test for consumption (AUDIT- C) is a tool that consists of the three consumption questions from the full AUDIT. The AUDIT-C can be used to quickly assess the person’s level of risk to alcohol harm. If the person’s AUDIT-C score is 5 or more, you should use the full AUDIT questionnaire with them, because the score suggests they are drinking at a level that could cause or is causing harm to themselves or others.

ASSIST-Lite

Alcohol, Smoking and Substance Involvement Screening Tool–Lite (ASSIST-Lite) is a short screening tool for use with adults (aged 18 or over). It can help to identify alcohol, drug and tobacco smoking-related risks. You can use it during assessments, care planning, one-to-one or review sessions. There is one version of the tool for mental health services and another for other health and social care services.

FAST

Fast alcohol screening test (FAST) is a tool consisting of a subset of 4 questions from the full AUDIT, asked in 2 stages. FAST was initially developed for use in emergency departments but can be used in a variety of health and social care settings.

M-SASQ

Modified-single alcohol screening questionnaire (M-SASQ) is a test to quickly assess people at risk of alcohol harm. It comprises one question from the full AUDIT and was developed for use in emergency departments but can be used in other settings where time is limited.

3.3.4 Routine AUD identification

All relevant healthcare services should routinely identify AUDs. For instance, discussions should take place during new patient registrations or when screening for other conditions. Health and social care services should use initiatives like Making Every Contact Count (MECC) to identify AUDs and offer ABIs. Health and social care services should ensure that effective pathways are in place, including referral to services that can provide specialist alcohol assessment and treatment or other types of care where needed.

Making effective identification an integral part of your service provision will include organisational commitment, monitoring and regular training in brief intervention approaches.

Digital resources can play a role in supporting identification, but you should consider and implement them carefully. Read more about digital interventions in section 5.8.3 in chapter 5 on psychosocial interventions.

3.4 Brief interventions in general and non-specialist settings

3.4.1 The aim of ABIs in general settings

The main goal of using ABIs in general and non-specialist settings is to identify and engage people who do not need alcohol treatment but whose drinking may be a risk to their long-term health and wellbeing. This will include most people identified as drinking at hazardous and harmful levels.

ABIs focus on giving people information about risk and motivating them to reduce their drinking towards lower risk levels. They also provide an important opportunity to identify people who are alcohol dependent and any harmful drinkers who may need specialist assessment or intervention.

3.4.2 Delivering appropriate ABI approaches

ABI is a general approach to opportunistic brief interventions in non-specialist settings. However, there are different approaches to ABI depending on the person’s alcohol use, risk and harms, and responses to interventions.

Hazardous drinkers usually do not have significant alcohol-related problems, so are well-suited to simple ABI approaches such as IBA. Many harmful drinkers will also benefit from brief interventions where they do not need specialist assessment.

ABIs are non-treatment interventions that are effective in prompting people to reduce their drinking on their own. ABI typically involves:

• giving feedback on the person’s level of risk (for example, explaining the meaning of the AUDIT score) and if appropriate, encouraging people to talk about their reasons for change
• identifying strategies to support alcohol reduction goals
• other simple motivational components such as those set out by the FRAMES (see definition of FRAMES in the glossary) approach (feedback, responsibility, advice, menu, empathy, self-efficacy)

You should deliver ABIs in a way that makes the person feel encouraged and supported by using a motivational, person-centred approach. Staff delivering ABIs should be trained in a way that incorporates these principles of motivational interventions. You can read more about motivational interventions in section 5.7 on motivational interviewing.

For people who have not responded to ABI, healthcare (or other frontline) staff should offer extended brief intervention (EBI). EBI approaches are for people who have not been identified as needing specialist alcohol assessment but have not responded to simple IBA. EBI should build on simpler IBA approaches by using further motivational and self-efficacy enhancement techniques.

For people drinking at harmful (higher risk) levels, you should offer ABIs (including IBA or extended brief interventions) if there are no indications that the person needs to be referred for specialist alcohol assessment (see below).

3.4.3 Referral for harmful and dependent drinkers

You should offer harmful drinkers (AUDIT score of 16 to 19) the appropriate ABI. You should also offer harmful drinkers who have an alcohol related health condition (such as liver disease or depressive disorder) or other health needs:

• referral for specialist alcohol assessment (see chapter 4 on assessment and treatment and recovery planning)
• information about treatment options
• referral to their GP
• referral to other healthcare provider as appropriate

You should also offer referral for specialist alcohol assessment to harmful drinkers who have received simple or extended brief interventions and continue to drink harmfully (see definition of extended brief interventions in the glossary). You should always consider the most appropriate responses for people’s individual circumstances and encourage them to receive specialist alcohol assessment or additional support where there are any signs of risk or complexity.

You should not offer ABI to people you identify as possibly alcohol dependent (AUDIT score of 20 or more), but you should offer them a referral for specialist alcohol assessment. If the person is in the community, you should offer them a referral to the local community alcohol treatment service and if they are an inpatient in hospital, you should refer them to an alcohol specialist in the hospital. This is particularly important for people who may be at risk of physical dependence.

If you refer a person for specialist assessment, you should do this in an encouraging way, listening to their concerns and discussing them. The person might feel stigma or fear about going to an alcohol treatment service, so it’s important to be as supportive as possible when you refer them.

Where a person does not want to engage in treatment, you should offer information about services and try to find future opportunities to refer or follow up.

4. Assessment and treatment and recovery planning

4.1 Main points

Assessment should involve the assessor and the person working together to reach a shared understanding of the person’s alcohol problem and their wider needs, strengths and goals.

Services should provide straightforward access to assessment which should start as soon as possible after referral.

Assessment should include a focus on engagement. To help the person engage in treatment, the assessor should use an empathic and non-judgemental approach and integrate motivational interventions into the assessment process.

Services should use validated assessment tools to support assessment, but these should not take the place of a structured clinical interview with the person.

Assessment involves the person choosing an alcohol use goal. Severity of dependence and complexity of need provide broad indicators for appropriate alcohol use goals, but these should always be mutually agreed between the person and the assessor.

Services should offer an initial assessment. This should include:

• an overview of the person’s alcohol use, severity of their alcohol dependence, and any need to assess the person for medically assisted withdrawal
• identifying any other urgent treatment needs, and any immediate risks
• agreeing an initial alcohol use goal and an action plan to address urgent needs and risks

Services should then offer a comprehensive assessment that builds on the initial assessment. This should include:

• reviewing the person’s level and pattern of alcohol use and severity of dependence, and any other substance use
• assessing the person’s strengths and assets
• assessing needs in the areas of mental health, physical health, social factors and criminal justice
• agreeing a treatment and recovery plan that includes broader recovery goals

Risk assessment, including safeguarding, is an important part of any assessment and should result in a detailed risk management plan. This plan should be regularly reviewed and adjusted at any time that risks change.

Comprehensive assessment may take place over several sessions, but this should not delay the start of treatment.

Based on the assessment, the assessor or allocated keyworker should agree a treatment and recovery plan with the person that specifies their treatment and recovery goals, as well as interventions and actions to meet those goals (see definition of keyworker in the glossary).

The keyworker, supported by the multidisciplinary team, should regularly review the treatment and recovery plan (see definition of multidisciplinary team in the glossary). They should also adjust the plan at any time it is clear that it is not helping the person to meet their goals.

Where appropriate, assessment, treatment and recovery planning, and risk management planning should include contributions from:

• clinicians from the multidisciplinary team in the alcohol treatment service
• other professionals working with the person
• family members, partners or friends
• peer supporters who can help welcome the person to the service

4.2 Introduction

4.2.1 Assessment in community alcohol treatment services and other considerations

This chapter describes assessment, and treatment and recovery planning for harmful (high risk) drinking and alcohol dependence, in specialist community alcohol treatment services for adults. There will be additional considerations for specific populations, settings, and interventions which you will find in other parts of these guidelines including:

• acute hospital settings (chapter 16)
• criminal justice settings (chapter 17)
• pregnancy and perinatal care (chapter 24)
• parents (chapter 26)
• older people (section 25.8 in chapter 25)
• young people (chapter 23)
• assessment for pharmacological interventions including medically assisted withdrawal (chapter 10 on pharmacological interventions, chapter 11 on community based medically assisted withdrawal and chapter 12 on specialist inpatient medically assisted withdrawal)
• assessment and formulation for psychosocial interventions (chapter 5 on psychosocial interventions)

4.2.2 Terminology

Community alcohol treatment practitioners in several different roles can carry out an assessment depending on local arrangements, so this chapter refers to the ‘assessor’ rather than specifying a professional role. More than one practitioner will be involved in some assessments. For example, if the assessor is not a clinician, clinicians may carry out some components of the assessment. In these situations, the chapter refers to the assessor who continues to carry out the core assessment and co-ordinate the involvement of other professionals as the ‘main assessor’.

4.3 Aims

Assessment in community alcohol treatment services involves gathering and considering information on the person’s needs, risks, and strengths. This includes diagnosing the presence of alcohol dependence or harmful drinking, identifying co-occurring health conditions and social factors that need addressing, and longer-term recovery goals. The assessor and the person use the information to develop a shared formulation. A formulation is a framework to understand how the person’s alcohol problem began and developed, the factors that maintain it, and potential resources to address it. It is the basis for agreeing a personalised treatment and recovery plan.

You can read more about formulation in chapter 5 on psychosocial interventions.

Assessment also aims to engage the person in treatment. It is an important opportunity to begin building a therapeutic alliance and to address potential barriers to engagement such as personal anxieties or practical constraints.

Where appropriate, assessment should involve:

• relevant healthcare and support services and organisations
• partners, family and friends
• peer-based support networks including lived experience recovery organisations (LEROs)

4.4 Principles

4.4.1 Staff competence

Assessment for harmful drinking and alcohol dependence in alcohol treatment services is a skilled intervention. Practitioners should be trained and competent to deliver it and they should receive regular supervision from individuals competent in both the intervention and supervision.

4.4.2 Access to assessment

Services should provide straightforward access to assessment, which should start as soon as possible after referral. Studies have shown that rapid access to assessment and treatment improves engagement in treatment (Passetti and others 2008). You can collect a person’s initial information remotely by phone or online, but the assessment should involve an in person meeting wherever possible.

You should time appointments to take account of a person’s commitments, such as childcare and employment, and offer the appointments in a location they can access easily. Offering appointment windows (such as a whole morning) rather than a set time can increase accessibility.

Several vulnerable and socially excluded groups, including people experiencing severe and multiple disadvantage, are less likely to approach services or engage with standard assessment processes. Services need to develop targeted and flexible ways of helping people from those groups access assessment such as assertive outreach or ‘in-reach’ to services or community organisations like homelessness support services.

You can read more about flexible engagement processes in chapter 25 on developing inclusive services and chapter 9 on alcohol assertive outreach and a multi-agency team around the person.

4.4.3 Engagement

Assessment is often the first face-to-face contact the person has with the service and it is an opportunity to begin building a therapeutic alliance. An empathic, non-judgemental approach based on the principles of trauma-informed care and cultural competence can help to build trust and support engagement.

You can read more about these important principles of care in chapter 2.

Assessment and engagement can be thought of as the first phase of the person’s treatment and recovery journey and the person may begin to make changes during this process. The assessor can support engagement by using a motivational approach. See section 4.18.7 below on motivation, readiness and belief in the ability to change.

If you provide welcoming introductory communication before a person’s first appointment, as well as clear information about the service, the process of assessment and confidentiality, it can help to encourage their attendance from the earliest stage. Friendly reminders about appointments (via text if that’s useful to the person) can support attendance. There are many reasons why a person may miss an appointment. So, non-judgemental follow-up of a missed appointment, with another offer of what might make it easier for them to attend, can help them to stay engaged. You should communicate information avoiding clinical language and in accessible formats considering:

• first language
• literacy
• sensory disability
• cognitive disability
• neurodiversity

Interpreters (including sign language) who are not known to the person should be available to make sure there is equal access to assessment.

The assessment should take the form of a structured clinical interview (a conversation aimed at assessing the person’s treatment and recovery needs). The assessor will need to record information in a structured way, but a ‘checklist’ approach to assessment is not a good way to engage the person. Assessment and formulation should be a collaborative process, where the assessor and the person develop a shared understanding of their treatment and recovery needs. It is more effective to use open questions, reflective listening and dialogue. If the assessor is able to respond quickly to the person’s own priorities, such as the need for medically assisted withdrawal or a social need such as debt advice, this may improve their engagement.

4.5 Multidisciplinary and multi-agency assessment

Assessment will often require input from more than one practitioner. Where the person needs a medically assisted withdrawal or has complex, high risk physical or mental health conditions, the assessment will require input from a specialist clinician from the multidisciplinary team (MDT). Designated leads (or appropriately competent practitioners) for child safeguarding, adult safeguarding and domestic abuse should be available to advise on relevant components of individual assessments, in line with national guidelines and organisational procedures.

You can find a list of relevant legislation and statutory guidance in annex 1.

The assessor should have access to supervision and advice from the MDT and will agree with the MDT when input from specialist clinicians is needed. The main assessor will usually continue with the core assessment, incorporating the specific components carried out by members of the MDT.

Where the person is working with other services, the assessor should ask these services to contribute relevant information to the assessment. They may also invite a keyworker from another service to attend an assessment appointment if this will help the person to attend. Where a person has complex needs and is working with more than one service, care plans (treatment and recovery plans) will need to be aligned or integrated.

You can read more on multi-agency treatment planning in section 4.19 on treatment and recovery planning in this chapter.

4.6 Risk assessment and safeguarding

Assessing risk should be part of any assessment. The aim of risk assessment is to develop a plan that prioritises and minimises or eliminates risks to the person in treatment and to others. All assessors should be competent to identify immediate risks at initial assessment and to work with the person and with other services to manage risks appropriately.

Risks are constantly changing, so assessors should review and develop the initial risk management plan with the person during comprehensive assessment. Keyworkers, and the MDT or wider clinical team, should then regularly review risk management plans, involving the person in reviews.

Assessors conducting risk assessments should:

• confirm the person’s history with other relevant services the person has accessed
• work with any services the person is currently accessing to assess risk
• make referrals to other agencies if needed as part of a risk management plan

Assessors should assess the ability of the person and any of their support networks to contribute to managing risks. Family members may have an agreed and specified role.

Services should have organisational procedures for escalating and managing immediate risks and assessors should have access to advice and supervision from relevant members of the MDT.

Services should have organisational policies and procedures for addressing child safeguarding, adult safeguarding, domestic abuse and mental capacity which are aligned with the relevant national legislation and statutory guidance.

You can find a list of relevant legislation and guidance in annex 1.

You can read more about risk management planning in section 4.19.

4.7 Involving and supporting partners, family and friends

Involving supportive partners, family members or friends at assessment can encourage the person to attend and contribute important information. It is essential that assessors get consent from the person to contact partners, family or friends as some people will not want their family to be involved. If the person does not choose to involve them initially, the assessor can repeat the offer later in assessment because some people may become more open to this as they engage. There is evidence that involving family members in treatment is linked to improved outcomes (Copello and others 2009).

Partners, family members and friends may have support needs in their own right. The assessor should offer information and support, whether or not they want to be actively involved in the person’s treatment (see section 4.17.6 below).

4.8 Involving members of peer-based support networks or LEROs

People with lived experience can play a valuable role in supporting people to attend assessment. In some services, members of peer-based support networks or LEROs meet with people informally in the waiting room before their assessment, or the assessor introduces them as part of the assessment process. The person with lived experience can share their experience of treatment and recovery and the role of the treatment service and show that it is possible to move forward. In some areas, people can access LEROs before accessing the treatment service and the LERO may introduce them to the treatment service.

4.9 Harm reduction interventions

Assessors should work on the principle of Making Every Contact Count (MECC) and use assessment as an opportunity to offer harm reduction information and interventions. Harm reduction information includes (but is not limited to):

• the risks of stopping drinking suddenly and advice on reducing safely for people who are alcohol dependent
• the decrease in tolerance after a period of abstinence and the risks of drinking at pre-abstinence levels (see definition of tolerance in the glossary)
• increased risk of overdose when drugs and alcohol are taken together
• other harms related to mixing drugs, for example cocaine and alcohol are more toxic when taken together

People who are alcohol dependent should usually be prescribed thiamine (oral or intramuscular) to reduce the risk of developing Wernicke’s encephalopathy, which can cause temporary or permanent brain damage.

You can read about prescribing and administering thiamine in chapter 10 on pharmacological interventions.

You can find guidance on harm reduction interventions in chapter 8 on harm reduction.

4.10 Unplanned withdrawal

All assessors in alcohol treatment services should be competent to identify withdrawal symptoms and recognise when a person is in acute withdrawal, which can lead to severe complications such as:

• seizures
• delirium tremens
• Wernicke’s encephalopathy

You should read guidance on managing complications in withdrawal in chapter 10 on pharmacological interventions.

4.11 Tools to support assessment

The National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) recommends that assessors use validated tools at assessment such as those listed below. Tools are intended to support assessment, but they should not replace a structured clinical interview, which provides more detailed information on needs, risks, strengths, and goals.

4.11.1 Alcohol use disorders identification test

To identify level of risk of alcohol harm and possible dependence, the assessor should use a validated tool that measures frequency and quantity of alcohol consumed, such as the Alcohol use disorders identification test (AUDIT).

AUDIT is the gold standard identification tool recommended for specialist services. In wider healthcare settings, shorter or abbreviated tools may also help to identify people who need specialist assessment.

You can read more about AUDIT and shorter or abbreviated tools in chapter 3 on identification and alcohol brief interventions.

4.11.2 Tools to assess the severity of alcohol dependence

To assess presence or severity of dependence (mild, moderate or severe), assessors can use a validated tool such as the following.

Severity of Alcohol Dependence Questionnaire

The Severity of Alcohol Dependence Questionnaire (SADQ is a 20-item self-administered questionnaire measuring the severity of alcohol dependence based on drinking habits and symptoms experienced after drinking.

Leeds dependence questionnaire

The Leeds dependence questionnaire (LDQ) includes questions on alcohol and other substances. It is a 10-item, self-completion questionnaire designed to measure the presence and severity of dependence on any drug, including alcohol.

4.11.3 Alcohol Problems Questionnaire

The Alcohol Problems Questionnaire (APQ) is a validated 44-item questionnaire to assess the nature and extent of problems associated with harmful alcohol use and alcohol dependence (see definitions of harmful alcohol use and alcohol dependence in the glossary).

The APQ is available on page 486 and 487 of the full guideline for NICE CG115.

4.11.4 Withdrawal assessment tools

Specialist clinicians, competent to assess the need for medically assisted withdrawal should use a validated scale to assess the severity of withdrawal, such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar). This is a 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.

4.11.5 Tools to measure outcomes

To measure treatment outcomes, the practitioner should use a validated outcome measurement tool such as the following.

TOP

The treatment outcome profile (TOP) is the outcome monitoring tool used by substance misuse services in England. It is included within the ‘adult combined review form’.

SURE

The Substance Use Recovery Evaluator (SURE) is a patient-reported outcome measure to measure recovery from drug and alcohol dependence.

4.12 Tests to support assessment

4.12.1 Blood tests

Blood tests should not be used routinely for identifying and diagnosing alcohol use disorders. However, services should consider testing service users’ blood:

• as part of the assessment for medically assisted withdrawal (see chapter 11 on community based medically assisted withdrawal)
• as part of the assessment for some relapse prevention medication (see section 10.5 of chapter 10 on pharmacological interventions)
• to help identify specific alcohol related physical health needs where indicated by the healthcare assessment (see section 4.18.11 on assessing physical health below)
• as part of regular review of the person’s health where they continue to use alcohol at a harmful or dependent level, and this is clinically indicated

If a community treatment service is unable to provide the required blood tests, there should be an agreed pathway for tests to be carried out in the alcohol treatment system or the wider health care system.

4.12.2 Transient elastography

NICE guideline Cirrhosis in over 16s: assessment and management (NG50) recommends that people drinking at harmful levels (35 units or more per week for women, 50 units or more per week for men) for 3 months or more should be referred for liver exploration using transient elastography (scan). Some areas use other ways of screening for liver disease.

You can find more information on screening for liver disease in appendix K in chapter 19 on people with co-occurring physical health conditions.

4.12.3 Breath alcohol

Several factors influence how quickly alcohol is absorbed into and eliminated from the body. So, breath alcohol concentration can vary between different people who have consumed the same amount of alcohol. On average it takes about one hour to eliminate one unit of alcohol in adults, but this may be quicker in some people who are alcohol dependent.

Breath alcohol should not normally be measured as part of an initial assessment or for monitoring outcomes, but it is measured during medically assisted withdrawal to confirm that the person has not consumed alcohol. Also, practitioners should not use arbitrary cut off levels for breath alcohol concentration to determine whether a person can access health services. Clinicians should consider the therapeutic value of breath alcohol measurement and explain this to the person before requesting a breath sample.

Breath alcohol measurement can sometimes help to add information to a comprehensive assessment if it is carried out with the full agreement of the person and the results discussed with them. For example, it can help to assess a person who appears sedated, has slurred speech or is confused. A negative result will exclude alcohol as a cause, but a positive result does not exclude other possible causes such as intoxication with other substances, head injury or stroke.

Clinicians should not use breath alcohol measures to contradict a person’s self-reported alcohol consumption. It is best to measure breath alcohol before asking how much the person has drunk on that day, then interpret the result together with the person.

The clinicians taking breath alcohol measurement need to understand their responsibility to discuss drink-driving concerns with people and to report concerns to the Driver and Vehicle Licensing Agency (DVLA).

You can read about reporting concerns to the DVLA in annex 3.

4.13 Alcohol use goals

4.13.1 Setting goals

At initial assessment, the assessor and the person should agree an alcohol treatment goal which they should review during the comprehensive assessment. Severity of dependence and complexity of need provide broad indicators for appropriate alcohol use goals, but these should always be individually tailored and mutually agreed between the person and the assessor. It is important the goal is in line with the person’s wishes, as there is evidence that this is associated with positive outcomes (Henssler and others 2020). The goal will then be regularly reviewed as part of the treatment and recovery planning process and adjusted where appropriate.

4.13.2 Abstinence

Abstinence will be the appropriate goal for most people with moderate or severe alcohol dependence. It will also be the appropriate goal for most people with mild dependence and for harmful drinkers who have significant physical health or mental health conditions (for example, alcohol-related liver disease or clinical depression). Any person choosing a goal of abstinence should be supported to work towards that. However, if the person prefers a goal of moderate drinking (see below), they should be supported in that goal. If there are considerable risks involved, the assessor should advise that abstinence is most appropriate and should support a negotiated approach where the person can consider abstinence if they do not achieve moderate drinking. People initially preferring a moderate drinking goal can switch to an abstinence treatment goal at a later point.

4.14 Moderate drinking

Moderate drinking may be an appropriate goal for most people with mild dependence and harmful (higher risk) drinkers who:

• do not have significant physical or mental health conditions
• have adequate social support

If the person meets the above criteria, they can consider a moderate drinking goal unless they prefer a goal of abstinence, or there is some other reason for abstinence.

Moderate drinking is defined in this guideline as drinking within the chief medical officers’ guidelines for lower risk drinking (up to 14 units per week).

A goal of moderate drinking is commonly known as controlled drinking or non-abstinent recovery (see definition of controlled drinking in the glossary). There is some evidence that tools such as the Impaired Control Scale may be appropriate for helping to identify the suitability of a controlled drinking goal (Heather and Dawe 2005). Moderate drinking goals should be regularly reviewed.

4.15 Harm reduction

You should consider a harm reduction strategy for people who are severely dependent or who have complex needs if they do not opt for a goal of abstinence or structured treatment. Complex needs include significant co-occurring mental health or physical health conditions.

However, the practitioner should ultimately encourage a goal of abstinence. A harm reduction strategy will involve advice and interventions to reduce harm to a person’s physical and mental health and may (although not necessarily) include some reduction in alcohol use as a specific goal. Evidence shows a reduction in health harms when people reduce consumption, even though they may still be drinking at harmful or dependent levels (Witkiewitz and others 2020).

4.16 Reviewing goals and monitoring the person’s health

Regular review of treatment and recovery goals is an essential element of the treatment and recovery planning process, and the goals should be adjusted where appropriate. You should regularly review a person’s health when they continue to drink harmfully or dependently and this should inform the consideration of their alcohol use goals.

4.17 Initial assessment

4.17.1 Offering an initial assessment

Services should offer an initial brief assessment (sometimes referred to as triage assessment) to all adults referred to community alcohol treatment services. For people whose AUDIT score is 16 or over, following initial assessment, services should offer comprehensive assessment, which is the next stage of assessment. This should follow immediately after initial assessment.

4.17.2 Aims and outcomes of initial assessment

The aims of initial assessment are to:

• introduce the person to the service
• gain an overview of the person’s alcohol use and severity of dependence
• identify any urgent treatment needs
• identify any urgent risks to be managed
• identify any co-occurring physical or mental health conditions or support needs requiring assessment or intervention from specialist clinicians

Outcomes of initial assessment should include:

• establishing an initial alcohol use goal with the person
• deciding whether the person needs to be assessed for medically assisted withdrawal
• agreeing an initial action plan to address any urgent needs, manage urgent risks, and set out the next steps in the assessment process

With the person’s consent, the assessor should contact their GP and any relevant services they are attending so they can contribute to the assessment.

4.17.3 Initial assessment of alcohol use, severity of dependence and need for medically assisted withdrawal

Assessing alcohol use and severity of dependence

The assessor should carry out a clinical interview to assess the person’s alcohol use and severity of dependence. This should include:

• alcohol use (approximate number of units and pattern) over the last 1 to 4 weeks
• examination of a typical drinking day (number of units and pattern of alcohol use)
• features and severity of dependence including psychological dependence using tools such as SADQ or LDQ
• alcohol use throughout the person’s life
• history of withdrawal symptoms, including any complications (see annex 2 for a summary of withdrawal symptoms)
• past periods of abstinence or moderate drinking and previous treatment outcomes

See section 4.11 above for information on AUDIT, SADQ and LDQ.

Need for assessment for medically assisted withdrawal

Services should consider offering an assessment for medically assisted withdrawal to people drinking more than 15 units per day or scoring 20 or more on AUDIT.

When assessing the severity of alcohol dependence and determining the need for medically assisted withdrawal, the assessor should adjust the criteria to take account of how dependence can affect different groups, including:

• women
• older people
• children and young people
• people with established liver disease who may have problems with the metabolism of alcohol

You can read more information on adjusting criteria for these groups in chapter 10 on pharmacological interventions.

Initial assessment should determine whether there may be an urgent need for medically assisted withdrawal, for example if the person is physically unwell or has previously experienced severe complications in withdrawal.

Doctors, nurses or pharmacists responsible for assessing and managing medically assisted alcohol withdrawal should be competent to diagnose and assess alcohol dependence and withdrawal symptoms. They should also be competent to use drug regimens appropriate to the setting (community or inpatient) in which medically assisted withdrawal is managed.

Treatment services should ensure there are processes to support quick and seamless internal referral for assessment for medically assisted withdrawal.

You can find guidance on assessment for medically assisted withdrawal in chapter 10 and section 11.5 on assessment for community-based medically assisted withdrawal.

4.17.4 Initial assessment of risks and urgent treatment or support needs

You should read this section with section 4.6 on risk assessment and safeguarding above.

Assessors should carry out an assessment of immediate needs and risks at the first meeting with the person. They will need training and therapeutic competencies to ask the assessment questions and to respond sensitively to the answers.

Assessors should record if the person is in contact with other services and any medication they are prescribed.

Assessors should identify urgent risks or urgent treatment needs, including:

• acute unplanned withdrawal
• suspected incipient Wernicke’s encephalopathy
• decompensated liver disease

There is guidance on these conditions in chapter 10 on pharmacological interventions.

Assessors should also identify other urgent risks or urgent needs, including:

• blackouts and risky behaviour while intoxicated
• suicidal ideation, self-harm or severe self-neglect
• acute mental health conditions
• malnourishment (see NICE clinical guideline Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32) for advice on screening)
• drug use, including misusing prescribed or over-the-counter medication
• child safeguarding
• adult safeguarding
• mental capacity concerns (see annex 1 for relevant guidance on mental capacity)
• domestic abuse (either as a survivor or a perpetrator)
• risk to others such as serious violence, sexual violence, sexual exploitation, stalking, human trafficking and modern slavery

• social support needs, including homelessness, urgent financial and debt problems

• continuity of care needs for people leaving prison
• physical health or mental health conditions needing specialist assessment or intervention
• pregnancy (see chapter 24 on pregnancy and perinatal care)

There is further information on most of these risks and needs in section 4.18 below.

The assessor should ask the person about their own children, other children in the home and children they are in close contact with, including ages, and dates of birth of children and the level of contact they have with them. They should also record information on other adults living in the home or visiting regularly. Information should be corroborated with other services involved with the person where possible. The service will need this information, for example if a safeguarding referral is necessary and the person disengages from treatment.

4.17.5 Agreeing an alcohol use goal

The assessor and the person should agree an initial treatment goal for alcohol use. They can revisit this during the course of the comprehensive assessment. Alcohol use goals are described in section 4.13 above.

4.17.6 Family and support networks

With the person’s consent, they can invite a supportive partner, family member or friend to contribute to the ongoing assessment and action plan. Where appropriate, the assessor should offer information and support to the person’s partner, family member or friend.

The assessor should actively support the person to access mutual aid (such as Alcoholics Anonymous (AA) or SMART Recovery) and local peer-based support networks or a LERO, if they agree to this (see section 5.6.3 on helping people to access mutual aid and peer-based support in chapter 5 on psychosocial interventions on ways to do this).

4.17.7 Initial action plan

Following initial assessment, the assessor and the person should agree an initial action plan based on the person’s initial alcohol use goal, immediate needs, and any risks identified. The plan will include:

• an initial alcohol use goal and a broad plan for treatment to be reviewed at comprehensive assessment

• arranging assessment for medically assisted withdrawal if needed

• specific risks, actions to manage risks, and the person responsible for the action
• prescribing thiamine supplementation (see chapter 10 on pharmacological interventions)
• referrals to and communication with other services
• the date of the next appointment for comprehensive assessment
• the likely date the person will begin structured treatment if they have agreed to that

The plan should also state when each action will be completed as this is important for achieving positive outcomes.

4.17.8 Information

The assessor should offer accessible information about:

• the nature and treatment of harmful drinking and alcohol dependence
• available treatment options
• harm reduction (see section 4.9 on harm reduction interventions)

Information should be communicated in a way which is understandable to the person (with language translation and interpretation if needed).

4.18 Comprehensive assessment

4.18.1 Access to comprehensive assessment

Alcohol treatment services should consider offering a comprehensive assessment for anyone who scores 16 or more on the AUDIT, building on information already gathered at initial assessment.

A comprehensive assessment of need may take place over several sessions, but this process should never delay the person receiving treatment that they need as identified at initial assessment.

Services should prioritise people based on risk and urgency of treatment need and should ensure that people get treatment immediately where necessary. For example, if someone urgently needs medically assisted withdrawal or a mental health crisis intervention. Where this is the case, the assessor can schedule appointments for comprehensive assessment around urgent treatment interventions. Where the person has no urgent treatment needs, comprehensive assessment should follow immediately after their initial assessment.

4.18.2 Aims and outcomes of comprehensive assessment

The comprehensive assessment builds on the initial assessment and provides an opportunity to explore the person’s goals and develop a package of support that provides structure and care to maximise their recovery.

The aim of comprehensive assessment is to gather and consider information, so the assessor and the person can agree a treatment and recovery plan (see definition of treatment and recovery plan in the glossary).

The assessment process will involve developing a shared formulation. Formulation provides a framework to understand how the person’s alcohol problem began and developed, the factors that maintain it, and potential resources to address it.

You can read more about formulation in chapter 5 on psychosocial interventions.

The outcomes of comprehensive assessment will include:

• a collaboratively agreed personalised treatment and recovery plan
• a risk management plan

Both plans should be regularly reviewed and adjusted to take account of the person’s progress through treatment and changes in their circumstances.

You can read more about treatment and recovery planning and risk management in section 4.19.

4.18.3 The areas of need and strength that comprehensive assessment covers

Comprehensive assessment involves the assessor working together with the person using a clinical interview approach to explore multiple areas of need, including:

• alcohol use
• drug use, including prescription and over-the-counter medication and smoking tobacco
• individual strengths and recovery capital
• motivation, readiness and belief in ability to change
• harmful gambling
• mental health, including cognitive function
• physical health
• pregnancy and the perinatal period
• criminal justice involvement
• social factors, for example housing and debt
• partner and family relationships, including support needs of adult family members
• impact of parental alcohol use on children and young people

We expand on each of these areas of need in the following sections.

4.18.4 Alcohol use

Reviewing changes in alcohol use

The comprehensive assessment should explore any changes in the person’s alcohol use since the initial assessment or last appointment. The assessor should review:

• the person’s alcohol use (approximate number of units per day and pattern) over the last 1 to 4 weeks (see chapter 8 on harm reduction for information on units)
• a typical drinking day for the person (number of units and pattern of their alcohol use)
• features and severity of dependence including psychological dependence using tools such as SADQ or LDQ (see section 3.10 on tools to support assessment above)
• alcohol use throughout the person’s life
• history of withdrawal symptoms, including any complications (see annex 2 for a summary of withdrawal symptoms)
• alcohol-related problems, using an appropriate tool such as APQ (see section 4.11 on tools to support assessment above)
• past periods of abstinence or moderate drinking and any previous treatment outcomes

The assessor should review any risks related to their alcohol use identified at initial assessment and include them in the risk management plan.

Using a drink diary

Regularly completing a retrospective drink dairy can help to provide a fuller picture of the person’s alcohol use. This involves the assessor and the person in treatment recording the number of units per day and pattern of alcohol use over the preceding week or weeks before each appointment. Services in the UK also find it helpful to use a prospective drink diary where the person monitors their own drinking by completing it each day. However, there is no research evidence on using a drink diary in this way, so its reliability and validity is unknown.

You can see some example drink diaries in section 8.13 in chapter 8 on harm reduction.

Exploring the context of alcohol to develop a formulation

The assessor and the person can explore the following elements to develop a shared formulation to understand the person’s alcohol use.

Factors that may predispose the person to harmful drinking or dependence (for example, adverse childhood experiences, family history of alcohol use).

Factors that may trigger alcohol use (for example, depressed mood, interpersonal conflict).

Factors that may maintain alcohol use (for example, social networks where harmful drinking is the norm, ongoing stress from social circumstances or discrimination).

Factors that may be protective and support recovery (for example, supportive social networks, rewarding activities as alternatives to drinking).

Reviewing past attempts at abstinence or moderate drinking can help identify factors linked to past successes and identify obstacles to maintaining change. Exploring previous periods of abstinence may also provide insights into withdrawal symptoms and whether the person experienced these when taking withdrawal medication.

You can find further guidance on clinical formulation in section 5.4 of chapter 5 on psychosocial interventions.

4.18.5 Co-occurring drug use or dependence

The assessor should collect information on:

• types of substances the person uses, including illicit drugs, prescribed medications and over-the-counter medication
• quantity, frequency and pattern of use
• routes of administration (including injecting)
• sources of drugs obtained
• past and current harmful or dependent use (including any experience of withdrawal symptoms)
• tobacco use and any smoking cessation support offered (see appendix L on smoking and lung health in chapter 19 on co-occurring physical health conditions)

You should identify a person’s use of illicit drugs or misuse of prescribed or over-the-counter medications at initial assessment and review this throughout their treatment. Common substances used in the alcohol treatment population are cannabis, powder cocaine and prescription medications such as benzodiazepines. As well as the harms specific to the substance, their combined use can increase specific risks such as fatal overdose as well as other health harms (for example, cocaine and alcohol are more toxic in combination) (Pennings and others 2002).

It is important to establish any need for interventions targeted at the person’s drug use, as well as interventions for their alcohol use. The formulation should enable this process and help to understand the function of the drug use for the person. It is not unusual for people to substitute one substance for another, so you should undertake ongoing review of alcohol and other drug use throughout treatment.

If you establish a treatment need for other drug use, this should generally be managed in the team providing the alcohol treatment. However, if the person is opiate dependent and requires opiate substitute treatment (OST), then the team managing the OST should take over the person’s care managing their alcohol treatment as well as their drug treatment.

It is not in the person’s interests to have dependence on different substances managed in different teams. Where services are not integrated, drug and alcohol treatment services, joint working with the local drug treatment service and aligned treatment and recovery plans will be essential.

You can find guidance on pharmacological interventions for people in alcohol treatment with co-occurring drug use or dependence, including benzodiazepine dependence, in chapter 10 on pharmacological interventions.

The assessor should offer relevant harm reduction advice on the risks of concurrent problematic alcohol and drug use. You can find guidance on this in chapter 8 on harm reduction.

Drug misuse and dependence: UK guidelines on clinical management provides extensive guidance on treating people with drug problems, including section 6.5 on alcohol in drug treatment.

4.18.6 Assessing strengths and recovery capital

Assessing the person’s strengths and recovery capital is an important part of assessment. Recovery capital refers to healthy life resources, such as:

• housing
• education
• employment
• social networks
• health and wellbeing

You can read more about integrating and supporting recovery and developing recovery capital in section 5.6 on integrating and supporting recovery in chapter 5 on psychosocial interventions.

Evidence shows that most people who experience alcohol dependence make attempts to reduce or stop using alcohol without the help of specialist services (Tucker and Simpson 2011). The person may already be drawing on their recovery capital to make changes or have experience of doing so. Assessment should identify strengths and assets that could help them to stop or reduce their drinking and support them to make longer term changes after they complete treatment.

Areas to consider include:

1. Individual resources. For example, coping strategies, past successes in making changes in alcohol use or in other areas of their life, levels of personal responsibility, mental and physical health, skills and interests such as education, training and volunteering.
2. Cultural or faith-based resources. For example, values, beliefs, attitudes, practices and communities.
3. Social factors. For example, stable finances and employment, safe and stable accommodation.
4. Social network resources. For example, support from and obligations to family, partners, children and friends, as well as participation in mutual aid, peer-based support networks or LEROs.

While there may be more focus on treatment interventions at the beginning of the person’s treatment and recovery journey, the process of helping the person to identify and develop recovery capital begins at assessment and continues throughout their treatment.

You can read more about integrating and supporting recovery and developing recovery capital in section 5.6.

4.18.7 Motivation, readiness and belief in the ability to change

Assessing a person’s motivation and readiness for change is important at assessment and throughout treatment. The assessor can gain some understanding of the person’s motivation by asking what has led them to seek treatment and what they hope to get from it. This information can help to inform the treatment and recovery plan.

Assessing motivation and readiness for change can help to:

• set goals and select interventions that reflect the person’s priorities, and their current level of motivation
• inform how the assessor might enhance the person’s motivation
• identify specific barriers to readiness for change and actions to reduce them

Since motivation is continually changing, practitioners should continually review a person’s priorities, plans and goals.

The World Health Organization’s International Classification of Diseases (11th revision) defines alcohol dependence by including features such as impaired control, physiological changes, and increased prioritisation of drinking behaviours. It is common for people entering treatment to believe that they will not be able to change. This might mean they seem to be initially resistant to recovery or even engagement in treatment.

NICE CG115 recommends that assessors should carry out a motivational intervention as part of the initial assessment. The intervention should contain the main elements of motivational interviewing, including:

• helping people to recognise problems or potential problems related to their drinking
• helping to resolve ambivalence and encourage positive change and belief in the ability to change
• adopting a persuasive and supportive rather than an argumentative and confrontational position

4.18.8 Harmful gambling

The Public Health England (PHE) gambling related harms evidence review showed that there is evidence of a clear association between increased weekly alcohol consumption with harmful gambling. This supports the rationale for screening for gambling as part of a comprehensive assessment. Services should consider using a brief screening tool such as the 3-item short-form Problem Gambling Severity Index (PGSI-SI mini-screen), one of 5 brief screening tools identified by a meta-analysis as having satisfactory diagnostic accuracy for detecting harmful gambling (Dowling and others 2019).

The relationship between harmful gambling and alcohol use can be usefully explored and understood through the process of formulation and can inform the appropriate intervention. This may include referral to a local or regional specialist gambling service and practical support such as debt counselling may also be required. There are increasing numbers of NHS clinics for people experiencing harmful gambling and people with co-occurring alcohol use should not be excluded from these clinics.

The assessor should offer information on the spectrum of harms that can be associated with gambling, and signpost to treatment and support such as the National Gambling Helpline (Great Britain only), gambling blocking software and gambling self-exclusion tool.

4.18.9 Mental health

The importance of mental health assessment for people with alcohol use disorders

It is common for people with alcohol use disorders to experience problems with their mental health. One study found that 70% of a sample of people from community substance use treatment in England also met criteria for common mental health problems (Delgadillo and others 2012).

The service and the assessor should act on the principle of ‘no wrong door’. This means that nobody should be turned away from an alcohol treatment service (or from a mental health service) because they have co-occurring alcohol use and mental health conditions.

The main assessor, who may not be a clinician, should be competent and supported to recognise mental health conditions and risks that need an urgent response. They should refer the person to a clinician in the alcohol treatment service, their GP, a mental health crisis service or hospital emergency department as appropriate. Section 4.17.4 on initial assessment of risks and urgent treatment needs describes urgent mental health risks.

It is important that an assessment of the person’s mental health is always included in a comprehensive assessment for alcohol treatment. A person’s mental health conditions may be undiagnosed or untreated and the assessor should ask questions about their mental health even if the person has no formal diagnosis.

Carrying out the mental health assessment

With the person’s consent, the main assessor should ask their GP and any mental health service working with the person to contribute relevant information to the assessment. The assessor should confirm the person’s:

• past or current mental health conditions
• involvement with mental health services, including any crisis services and any inpatient admissions
• current mental health risks
• current medication

If the main assessor does not have specialist competence in mental health, they should arrange for a member of the MDT with specialist competence to carry out further assessment of the person’s mental health. If the person has a severe mental health condition or may be at risk due to their mental health, a clinician should offer a mental health assessment as quickly as possible (see definition of severe mental health condition in the glossary).

Assessors should also ask about:

• any current diagnosis
• history of mental health conditions and any current symptoms or concerns
• historic or current trauma
• past and current contact with mental health services
• current prescribed medication
• common mental health problems, including non-severe depression and anxiety
• suicidal thoughts or intentions, self-harm and severe self-neglect
• symptoms of severe mental illness, such as psychosis and bipolar mood disorder

Where assessors are trained and supervised to use formal assessment tools for mental health conditions, these may be helpful to support assessment. For example, they can use the:

• patient health questionnaire (PHQ-9) to screen for depression
• generalised anxiety disorder assessment (GAD-7)
• eating disorder examination questionnaire (EDE-Q)
• primary care post-traumatic stress disorder screen (PC-PTSD)

Having a co-occurring mental health condition can increase the person’s level of risk. The assessor should consider how alcohol intoxication and withdrawal interact with aspects of the person’s mental health. For example, research has shown that intoxication can increase the risk that a person may act on their suicidal ideation (Kaplan and others 2013). See section on suicide risk and self-harm below for guidance.

Planning treatment for both alcohol use and mental health conditions

People with co-occurring conditions should receive treatment for both conditions. Depending on the competencies of staff in the alcohol treatment service and in the mental health service, and on the severity of mental health condition, treatment for both conditions may be offered by:

• the alcohol treatment service
• the mental health service
• both services working together with the person

The assessor, supported by the MDT, should agree a clear plan with the person and any relevant services for how both conditions will be treated. If the alcohol treatment service and a mental health service will both be working with the person, it is essential that they co-ordinate care, share information and align or integrate treatment and recovery plans (care plans). See the section 4.19.4 on multidisciplinary and multi-agency treatment and section 4.19.5 on recovery planning and risk management planning below.

There should be a named person responsible for co-ordinating the person’s care. NICE clinical guideline Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (CG120) recommends that if the person has a severe mental health condition, the keyworker from the mental health service should usually be the named care co-ordinator.

You should also read more detailed guidance on joint working between mental health services and alcohol treatment services in chapter 18 on co-occurring mental health and alcohol use conditions.

Monitoring a person’s mental health need while they are in treatment

In some cases, mental health conditions (particularly anxiety or depression) may begin to improve after a few weeks of abstinence or significant reductions in alcohol use. However, for some people, mental health conditions do not improve and there is a risk that if they are not offered mental health support when they need it, they may return to problematic drinking.

The period after medically assisted withdrawal or a significant reduction in alcohol use is best described as one of ‘watchful waiting’. The appropriate member of the MDT in the alcohol treatment service should provide:

• ongoing assessment of the person’s mental health need
• support to manage continued low mood or feelings of anxiety
• a quick start to treatment for the co-occurring mental health condition if it is needed

People who need quick access to mental health treatment

For some people, comprehensive assessment of both their alcohol dependence and their mental health will clearly indicate that waiting to start treatment for mental health is not appropriate. These people will need a mental health support package to be in place before they start medically assisted withdrawal. The main assessor or clinician in the alcohol treatment service and the mental health clinician will need to closely co-ordinate the mental health support and the medically assisted withdrawal. For people with immediate mental health needs who do not require a medically assisted withdrawal, the same principles apply. The clinicians from both services will need to co-ordinate care, involving the person in planning and decisions about interventions.

Pharmacological interventions for co-occurring mental health conditions

There will be specific considerations when delivering pharmacological interventions for some people with co-occurring mental health conditions.

You should read about co-occurring mental health conditions in section 10.6.5 in chapter 10 on pharmacological interventions.

Suicide risk and self-harm

Risk factors for suicide and self-harm

Research has shown that alcohol, both through intoxication and dependence, is a factor in a significant proportion of suicides (Kaplan and others 2013).

Suicide attempts and successful suicide are more common among people with alcohol use conditions, mental health conditions and people with chronic long-term physical health conditions. People in alcohol treatment services often have all 3 of these conditions.

Practitioners in alcohol services, with the support of the MDT, should be competent to identify risk of suicide and self-harm and to identify intent to act on thoughts. They should be able to make sure people can access suitable care, including emergency care and a place of safety where necessary. People who self-harm are at greater risk of suicide.

Comprehensive assessment should include questions on risk factors for suicide and self-harm, including:

• past history of self-harm and suicidal behaviour
• history of childhood or adult trauma or abuse
• mental health conditions related to self-harm or suicidal behaviour
• family history of suicide
• current thoughts or plans of suicide
• current thoughts of self-harm or plans to self-harm
• current or recent pattern of self-harm or suicidal behaviour
• current stressors that may contribute to self-harm or suicidal behaviour

NICE guideline Self-harm: assessment, management and preventing recurrence (NG225) provides detailed guidance on self-harm. Services should work in line with these guidelines. They should have procedures for managing the risk of self-harm and suicide and make sure staff are trained and supported to identify and act on these risks.

Identifying and managing immediate risk of suicide or self-harm

If the assessor identifies an immediate risk of self-harm or suicide, or the person attends the assessment immediately after an episode of self-harm or suicidal behaviour, they should access support from the MDT or appropriate clinical support. They should address any immediate physical health care needs related to the self-harm and arrange emergency medical support if necessary. They should also arrange for the person to have a psychosocial assessment from a specialist mental health professional as soon as possible.

The assessor should identify whether the person has access to the means of self-harm (for example, tablets) and discuss removing this or reducing other forms of immediate risk with the person.

Where appropriate, the assessor should ask the person for consent to involve family members and inform the person about circumstances where confidentiality might be broken. The assessor should also tell the person and if relevant their family member about local support that they can access in an emergency.

NICE NG225 states that psychosocial assessment should not be denied because the person is intoxicated or has been drinking. The alcohol treatment service may need to act as an advocate with crisis mental health or emergency services to make sure that people can access appropriate care, including when intoxicated.

Chapter 16 on acute hospital settings provides more guidance on managing self-harm in an acute setting.

The assessor or keyworker should seek advice from a specialist mental health professional for the ongoing management of the person’s condition. They should also be supported by the MDT when planning care and assessing risk. Self-harm may indicate that the person has difficulty managing their emotions and they may need specialist treatment from a mental health service, such as dialectical behaviour therapy.

4.18.10 Cognitive function

Assessors should be able to identify potential signs of acute Wernicke’s encephalopathy (WE), which is a medical emergency.

You can find guidance on symptoms of WE and how to respond in chapter 10 on pharmacological interventions.

Some people accessing treatment with alcohol dependence will have a degree of (non-acute) alcohol related brain damage (ARBD). Assessors should ask about signs of memory loss and difficulties with day to day functioning. These may be signs that the person has short or long term brain damage.

The most common cause of ARBD is Wernicke-Korsakoff syndrome (WKS), a serious complication of deficiency of thiamine (vitamin B1), for which the most common cause is alcohol dependence. WKS can cause lasting brain injury. There are also other forms of alcohol related brain damage, such as alcohol related dementia and cognitive impairment, as a result of traumatic brain injury.

Trained practitioners should consider using brief measures of cognitive functioning, such as the mini Addenbrooke’s Cognitive Examination (mini ACE) and should refer people whose scores indicate a need for more specialist cognitive assessment. These referrals could be either within the service if there is a clinician with appropriate competencies, or through standard pathways for services for cognitive impairment. People with ARBD should not be excluded from these pathways.

A clinician with relevant specialist competencies should carry out a thorough multidisciplinary assessment of the person, which considers their day-to-day functional ability as well as any cognitive test score. Cognitive testing in a person who is acutely intoxicated is of no value. But clinicians can test a person who is currently drinking as long as they recognise that there will be some acute effects of alcohol such as acute memory impairment that should resolve when the person stops drinking.

People with a cognitive disability that is not caused by alcohol use, such as learning disability or dementia, may also present for assessment. Services may need to adjust assessment and interventions for people who have problems with memory, learning new things and planning. These problems can be experienced by people with ARBD and by people with a cognitive disability which is not related to alcohol use.

Family members or practitioners from support services should contribute to the assessment where the person agrees. Assessors should work with practitioners from other services and the person to develop a treatment and recovery plan tailored to the person’s needs in a way they can understand.

You can find comprehensive guidance on ARBD, including about adjusting interventions, in chapter 20 on ARBD.

4.18.11 Physical health

Why physical health assessment is important

People with alcohol dependence have higher levels of physical health problems and die at an earlier age than the general population. Alcohol use disorders can cause over 60 serious physical health conditions or make existing conditions worse. This includes:

• alcohol related liver disease
• cardiovascular disease
• several cancers, including cancer of the oral cavity and pharynx, oesophagus, female breast, colorectum, larynx, liver, stomach, pancreas, lung and gallbladder
• alcohol related brain damage (see section 4.18.10 on cognitive function above)

You can find a comprehensive list of alcohol related health conditions in chapter 19 on co-occurring physical health conditions.

People presenting for assessment may also have physical health conditions unrelated to their alcohol use. Physical health conditions may be undiagnosed or untreated. It is important that people with alcohol dependence can access a thorough assessment of their physical health.

With the person’s consent, the assessor should ask their GP and any other healthcare services working with the person to contribute relevant information to the assessment. They should confirm:

• any past or current significant health conditions
• current medication
• any allergies

Liver screening

The assessor should also refer the person for liver screening.

NICE NG50 recommends that anyone drinking at harmful (high risk) levels (35 units or more per week for women, 50 units or more per week for men) for 3 months or more should be referred for transient elastography. Some areas use alternative tests for detecting cirrhosis.

You can read more about liver screening tests in appendix K on co-occurring physical health conditions.

Services should be aware of the local pathway for liver screening and the assessor should refer people where necessary. Where community alcohol treatment services provide transient elastography, they should make sure that staff are trained in performing the scan and interpreting the results. Screening for alcohol related liver disease should include a measure of liver fibrosis (such as transient elastography), in addition to liver function blood tests, because normal liver blood tests do not exclude advanced fibrosis.

Referral to primary care

The main assessor, who may not be a clinician, should be able to recognise physical health conditions that need urgent assessment and treatment and refer the person to a clinician within the service, their GP, or the hospital emergency department as appropriate. Section 4.17.4 on initial assessment of risks and urgent treatment needs describes urgent physical health risks.

If the person is not registered with a GP, the assessor should help them to register. In some areas, a member of peer-based support networks may accompany the person to GP appointments for support. Alcohol treatment services and practitioners should be aware of current guidance about eligibility for primary care, so they can advocate on behalf of vulnerable migrants and people who are experiencing homelessness.

You can read more about people’s right to register with a GP in section 21.4.4 in chapter 21 on homelessness.

Healthcare assessment

Once a person’s urgent physical healthcare needs have been addressed, the assessor should arrange for them to have a full healthcare assessment (unless they have already recently received one). Some or all of the healthcare assessment may be carried out in the alcohol treatment service unless the person prefers their GP to do it. People with alcohol dependence may be reluctant to approach healthcare services due to past negative experiences, stigma, or difficulties in keeping appointments. Some people may find it easier to engage with a healthcare assessment in the alcohol treatment service and the clinician may be able to offer the assessment over several sessions. Depending on local arrangements, clinicians in alcohol treatment services will be able to carry out most of the healthcare assessment but may need to request that the GP and specialist healthcare services carry out some of the relevant tests. Referrals to specialist healthcare services will usually be requested via the person’s GP.

The questions, examinations and tests below are not all that needs to be done. The assessing clinician will need to account for the person’s individual medical history and current circumstances.

Medical history

There is some overlap between the questions asked to assess physical health needs and the questions in an alcohol (and drug use) assessment (including assessment for medically assisted withdrawal).

The clinician may need to ask some urgent questions about the issues below, for example before the person can access a medically assisted withdrawal. They can ask other questions at a later stage.

1. Symptoms that are a physical health concern when the person presents for assessment.

2. Past or current medical history, including liver disease, cardiovascular disease, cancers, pancreatitis, respiratory disease, injuries, operations and hospital admissions.

3. Any prescribed medication.

4. Any history or symptoms of cognitive impairment (alcohol related brain damage or cognitive impairment due to other causes).

5. Any history or symptoms of malnutrition or poor diet.

6. Tobacco smoking (see appendix L on smoking and lung health).

7. Illicit drug use, including misuse of prescribed and over-the-counter medications (see section 4.18.5 on drug use in this chapter).

8. Any allergies or sensitivities.

9. Any current oral health problems and recent dental check-up or treatment.

10. Menstrual and pregnancy history, contraception history and cervical screening, if this is relevant.

11. Concerns about sexual health or (if appropriate) blood-borne viruses, HIV or Hepatitis B and C.

12. History of screening and vaccinations received.

General health examinations and assessments

The clinician should carry out the following general health assessments or examinations early in the assessment process.

The clinician should pay attention to any symptoms or complaints the person describes and assess (and where appropriate examine) their body systems including:

• gastrointestinal system, including the liver
• cardiovascular system
• respiratory system

The clinician should measure weight and blood pressure. Baseline measurement can be useful in monitoring a person’s progress and may be needed where there are concerns.

Additional examinations and testing

The following investigations and physical examinations may sometimes be required. They may be provided within the alcohol treatment service, by the GP or by specialist healthcare services, depending on local arrangements.

Based on the person’s history, risks, symptoms or findings of previous general physical examinations, further physical examinations and testing required may include:

• detailed examination of gastrointestinal system and liver
• screening for liver stiffness via transient elastography or alternative screening tests (see section on liver screening above)
• detailed examination of cardiovascular and respiratory systems

• electrocardiogram (ECG), chest X-rays and pulmonary function tests such as peak flow and FEV/FVC

• pregnancy testing
• examination of dentition (the arrangement or condition of a person’s teeth)
• other blood tests to assess liver function, renal function, thyroid function and haematological indices
• neurological examination (indications include loss of sensation, organic causes of confusion, forgetfulness, convulsions, blackouts)
• formal cognitive testing and assessment
• urine testing for markers of conditions such as diabetes and infection and drugs of dependence

Health information and harm reduction

The clinician should encourage the person to consider the impact of their alcohol use on their health. Test results may be an opportunity to discuss health goals and strengthen motivation to change their alcohol use.

Using the principles of MECC, the clinician or main assessor should offer the person clear, accessible information on health risks related to alcohol use, as well as general health information.

You can find information on health risks related to alcohol use in chapter 8 on harm reduction. This should include information and advice for pregnant women and anyone who could become pregnant (see section 4.18.12 below and chapter 24 on pregnancy).

General health information would include:

• nutrition and diet
• smoking cessation and harm reduction and referral to smoking cessation service (see appendix L on smoking and lung health)
• contraception, safer sex, and referral to sexual health service where appropriate
• information about local NHS dental services or direct referral to special care dental services if appropriate

Pharmacological interventions

Clinicians will need to consider the impact of physical health conditions when delivering pharmacological interventions for medically assisted withdrawal and relapse prevention (see glossary for definitions of medically assisted withdrawal and relapse prevention). For example, the impact of advanced liver disease.

You can find guidance on pharmacological interventions for people with liver disease in section 10.6.6 in chapter 10 on pharmacological interventions.

Joint working with primary care and secondary care health services

Good communication between keyworkers and clinicians in the alcohol treatment service and clinicians in primary and secondary healthcare services is essential. Alcohol treatment service clinicians can provide specialist knowledge about alcohol dependence and can act as an advocate for the person, challenging stigma where necessary.

There should be information sharing agreements in place between alcohol treatment services and relevant healthcare services. In some areas, primary care services can help alcohol treatment services access a person’s electronic health records to make information sharing quicker and more effective.

4.18.12 Pregnancy and the perinatal period

Services should treat pregnant women as a priority for assessment and for treatment. Any delay in starting treatment may increase the risk to the mother and the fetus. They should urgently assess the needs of pregnant women, even if they are currently drinking below the usual threshold for accessing an assessment, or if they have a history of problematic alcohol use but are not currently drinking. This is to reduce risks to the fetus and the mother.

The assessor should inform the woman of the UK chief medical officers’ advice, which says that:

• if you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum
• drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk
• the risk of harm to the baby is likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy

However, if the woman is or might be alcohol dependent, it is important to advise her not to stop suddenly as this could cause harm to the baby or to her. The assessor should arrange an assessment for medically assisted withdrawal as soon as possible.

You should read guidance on assessment of pregnant women in chapter 24 on pregnancy and perinatal care.

4.18.13 Criminal justice system involvement

Criminal justice considerations in the assessment

This section provides guidance on assessment in specialist alcohol treatment services in the community.

You can read guidance on assessment and treatment in criminal justice settings in chapter 17 on criminal justice.

The assessor should ask about any involvement with the criminal justice system. This may include previous or current:

• arrests
• fines
• outstanding charges and warrants
• probation
• license conditions
• imprisonment

Where the person is working with a criminal justice worker or being supervised by the probation service, those staff should contribute information to the assessment and treatment and recovery planning.

The assessment should consider the nature of offences as part of risk assessment. For example, if the person committed violent or other serious offences, and whether they might pose risks to other people using the service or staff. The assessment should also include information about child safeguarding or adult safeguarding concerns and whether the person is subject to multi-agency public protection arrangements (MAPPA).

The assessor should consider any links between alcohol use, alcohol dependence and offending. For example, if a person committed offenses when intoxicated or whether their current period of alcohol use followed release from prison without support. Treatment and recovery planning may include goals on alcohol use and related offending and will need to take account of any alcohol treatment orders issued by the court, or license conditions.

Continuity of care

People leaving prison should be treated as a priority for assessment, so there is continuity of care between custody and the community. Alcohol treatment services should have agreed care pathways with treatment services in prisons so there is continuity of care which:

• supports treatment engagement
• ensures referral to relevant services
• reduces re-offending
• reduces homelessness
• reduces alcohol related harm

It’s important there is good communication and information sharing between prison services and the local alcohol treatment service before the person is released. This is so they can be offered an assessment appointment immediately after release. Some alcohol treatment services provide in-reach into prisons to strengthen community of care.

The Office for Health Improvement and Disparities manages a SPOC (single point of contact) criminal justice directory for England and Wales. This ensures that contact details of all prison healthcare teams, community-based treatment providers and probation teams are easily accessible to enable more effective referral and communication between these agencies. You can request access to the SPOC criminal justice directory by contacting SPOC-OHID@dhsc.gov.uk.

The person may have practical and social needs that should be assessed to help them reintegrate into the community after release from prison. The assessor should identify and address any urgent needs as quickly as possible. The alcohol treatment service should have links with statutory, voluntary, community and social enterprise organisations that provide recovery focused services for people who have recently left prison and their families.

Assessors should provide harm reduction information including information about:

• decreased tolerance to alcohol following a period of abstinence and the risks of consuming at the level they did before going to prison
• risks of combining alcohol with other substances, such as increased risk of overdose and increased toxicity of alcohol and cocaine when these are taken together

You can read guidance on harm reduction in chapter 8.

4.18.14 Social factors

The PHE evidence review on the public health harms of alcohol found that alcohol dependence and alcohol health harms are strongly associated with socioeconomic deprivation.

Poverty and social exclusion may be a cause and a consequence of alcohol dependence and related health harms. These factors can prevent people engaging in treatment, for example if the person has basic unmet needs such as for food and shelter.

Assessors should ask about:

• debt, or financial and benefits problems
• homelessness and housing needs, including unhealthy or unsafe housing conditions
• any community safety problems, such as harassment or anti-social behaviour directed at the person by neighbours
• employment status and any employment problems

You can find guidance on assessing employment needs in chapter 7 on employment support.

You can find guidance on people experiencing homelessness in chapter 21.

Assessors should identify any social care needs, including:

• the person’s need for a care assessment, for example for home care or personal care (see annex 1 for national legislation and guidance relating to a care assessment)
• what support they have to help with social isolation

Assessors should have a wide range of links to local support services and community organisations so they can make effective referrals for social support. In some areas, members of peer-based support networks or LEROs may be able to help people to do things like fill out forms and attend appointments.

4.18.15 Relationships with partner, family, friends and community

Considering partners, family and friends in the assessment

Assessment should include consideration of:

• relationships with partner, family and friends
• the impact of the person’s alcohol use on those people and relationships
• the person’s social support networks
• risks, including domestic abuse and adult safeguarding

For some people, improving family relationships, including with children, is an important goal and motivating factor.

Reviewing social support networks

It is important to review the person’s social support network early on in the assessment. Research shows that the nature and extent of this can be a significant influence on the person’s recovery journey (Litt and others 2007).

The assessor should help the person identify:

• members of their social network (partner, family, friends and community) that could be involved in supporting treatment and recovery
• family members (including children and young people) who may need support
• any contact the person has with people in recovery, mutual aid (such as AA or SMART Recovery) and LEROs

This process should begin at assessment and continue throughout treatment. It is an important element of structured support which is normally provided by a keyworker (see glossary for definitions of structured support and keyworker).

You can read guidance on structured support in chapter 5 on psychosocial interventions.

With consent of the person with the alcohol problem, there are several ways that family members, partners and friends can be involved in their treatment.

You can read guidance on involving family, friends and social networks in treatment in section 5.7.6 of chapter 5 on psychosocial interventions.

The treatment and recovery plan should address any gaps in the person’s support network, or areas they would like to develop. If the person has very limited social support, it’s important that they access mutual aid, or a peer-based support network or a LERO as soon as possible. The assessor should help the person to attend one of these organisations. In many areas, a member of one of these groups will be available to accompany the person to a group if the person agrees to this. Some areas have peer mentoring schemes which may provide additional support for the person.

You can read more about assessing strengths and gaps in the person’s social support network in section 5.7.6 in chapter 5 on psychosocial interventions.

Domestic abuse

The definition of domestic abuse used in these guidelines is taken from the Domestic Abuse Act 2021. It includes:

• physical or sexual abuse
• violent or threatening behaviour
• controlling or coercive behaviour
• economic abuse
• psychological, emotional or other abuse

There is a high prevalence of domestic abuse among people with harmful drinking and alcohol dependence. People attending treatment services may be victims, survivors, or perpetrators of domestic abuse. This is not limited to intimate partner abuse and may involve one or more family members. Victims or survivors of domestic abuse and perpetrators rarely disclose this at first contact with treatment. So, practitioners should ask routine questions about domestic abuse at initial assessment, at comprehensive assessment and during treatment. Initial assessment should always take place in a private setting. Staff in alcohol treatment services should be trained to ask routine questions on domestic abuse.

If the assessor knows or suspects domestic abuse is happening, they should address any immediate risks in line with organisational procedures. Where the assessment indicates domestic violence, they should make referrals to:

• a domestic abuse service
• the multi-agency risk assessment conference (MARAC) or similar risk management forum
• child or adult safeguarding services

Established referral pathways and effective joint working with these and other relevant partner services will be essential to identify and manage risks.

You can find more information on domestic abuse and links to relevant guidelines in chapter 22 on domestic abuse.

NICE public health guideline Domestic violence and abuse: multi-agency working (PH50) includes recommendations for assessing concerns about domestic abuse.

Adult safeguarding

Where a vulnerable adult is at risk of harm, services must act in line with the safeguarding principles in the relevant national legislation and guidance and local organisational adult safeguarding procedures.

You can find links to statutory guidance on adult safeguarding in annex 1 on legislation.

The assessor should identify any risks to the person as a vulnerable adult, including:

• abuse or neglect by family members or carers
• severe self-neglect
• abuse or exploitation from others, such as financial or sexual exploitation
• modern slavery and human trafficking
• stalking

Assessors should also consider whether the person could be a safeguarding risk to vulnerable adults they care for or are in contact with, in any of the ways listed above.

If the assessor identifies adult safeguarding risks, they should make a referral to adult safeguarding services and work closely with them and other relevant partner services. Staff in alcohol treatment services should know how to make an adult safeguarding referral.

The service should provide accessible information on:

• the circumstances in which the service would make an adult safeguarding referral
• what is likely to happen after they make a referral to statutory adult safeguarding services

Assessors should work to maintain engagement with the person and offer support following an adult safeguarding referral if the person does not agree with the referral.

4.18.16 Assessing the impact of parental alcohol use

Assessing the needs of children of alcohol using parents

Although most assessors in adult alcohol treatment services will not meet with the children of the person they are assessing, they should consider the needs of these children, because they are required to do so by statutory guidance. Statutory guidance includes the Department for Education’s Working together to safeguard children (England) and equivalent other national guidance.

You should read detailed guidance on assessment of the needs of children and young people affected by parental alcohol use in chapter 26.

Child safeguarding

Services should assess the risks to children cared for by the person, or in contact with them, as soon as possible. Parents often have fears about involving statutory safeguarding services or losing their children, so it is crucial that assessors ask questions sensitively, explain why they are asking these questions and why it is their duty to ask them. Services should provide parents with information on the circumstances in which the service would make a child safeguarding referral and what is likely to happen after a referral to children’s social care.

Where a child may be at risk of significant harm as defined by the Children Act 2004, assessors must act according to relevant national statutory guidance and organisational child safeguarding procedures.

You can find links to legislation and statutory guidance on child safeguarding in annex 1.

Assessors should work to maintain engagement with the person and offer support after a child safeguarding referral.

Support needs of parents, children, young people and families

Assessors should still consider support needs for parents and children, even if the assessment finds no risks to children that meet the threshold outlined in relevant legislation and guidance for a safeguarding referral. Effective support can prevent risks from escalating, promote children’s wellbeing and strengthen family functioning.

Families might benefit from:

• parenting support
• social or therapeutic support for children and young people (including young carers) or for the whole family
• practical support with social needs

The alcohol treatment service should have agreed pathways to targeted support for vulnerable families (early help) and young carers services. It should also provide information on universal services such as children’s centres or youth activities.

Support for partners, adult family members and friends

Alcohol treatment services should provide information and support to partners, family members or friends affected by a person’s alcohol use, including when the person with the alcohol problem is not attending treatment. Assessors should offer family members, partners and friends an appointment to discuss the impact of the person’s alcohol use on their own wellbeing and on other family members. The family, partners or friends should have their own appointment separate from the person in treatment, so there is a space for them to disclose information confidentially. The assessor should make it clear that there will be confidentiality for the partner, family member or friend, and for the person with the alcohol problem.

NICE CG115 recommends that:

“when the needs of families and carers of people who misuse alcohol have been identified:

• offer guided self-help, usually consisting of a single session, with the provision of written materials
• provide information about, and facilitate contact with, support groups (such as self-help groups specifically focused on addressing the needs of families and carers)”

Where family members and friends spend a significant amount of time caring for a person with an alcohol problem, they are entitled to a carer’s assessment to assess their eligibility for support. Staff in alcohol treatment services should know how to make a referral for a carer’s assessment and should refer the relevant person with their consent. The NICE guideline Supporting adult carers (NG150) provides further guidance on this.

You can find links to relevant national legislation and guidance on carer’s assessments in section 3 of annex 1.

Some partners, family members and friends may only need information or a single support session, but others may be experiencing significant strain and may need further assessment of their needs and support.

You should read section 5.9 in chapter 5 on psychosocial interventions, which describes an evidence-based approach to offering support to partners, family and friends.

4.19 Treatment and recovery planning

4.19.1 Overview

Treatment and recovery planning is an essential part of organising and reviewing personalised treatment interventions and recovery support for a person with alcohol problems.

Treatment and recovery planning in alcohol treatment services is usually co-ordinated by a keyworker with oversight from an MDT. It is a collaborative process (between the keyworker and the person), which can help to build and strengthen the therapeutic alliance.

Treatment and recovery planning may also involve:

• other professionals from the alcohol treatment service or from external agencies
• people with lived experience of alcohol problems (peers)
• partners, family members and friends

4.19.2 The role of the keyworker in treatment and recovery planning

The keyworker is a single named practitioner who:

• meets regularly with the person in treatment
• co-ordinates their treatment and recovery planning and delivery of care
• provides structured support

Structured support involves using specific psychosocial interventions that are common to evidence-based psychological treatments for alcohol and drug use.

You can read guidance on structured support in section 5.5 in chapter 5 on psychosocial interventions.

The keyworker is generally the practitioner in most regular contact with the person. The keyworker may be an NHS or third sector alcohol practitioner, or sometimes a nurse, doctor or other appropriate professional.

In some cases, or at certain times, other clinicians in the MDT will deliver the main interventions, such as medically assisted withdrawal or specialised psychological treatments. However, the keyworker will still co-ordinate and monitor the overall treatment and recovery plan.

4.19.3 Developing a treatment and recovery plan

After the comprehensive assessment, the assessor and the person should agree a broad treatment and recovery plan. If the assessor does not continue to work with the person, the service will allocate a keyworker, who will further develop the treatment and recovery plan with the person.

The keyworker should be supported by the MDT to develop and regularly review the treatment and recovery plan. The person should be fully involved in the planning process through regular discussions with the keyworker.

A treatment and recovery plan is a constantly evolving record and action plan that has the following core components:

1. The person’s agreed treatment and recovery goals.

2. Specific, clear interventions and actions to help achieve the goals.

3. Clear information on who is taking which actions.

4. Monitoring progress, identifying where actions and goals have been achieved and resetting these as needed.

The keyworker and the person will agree the person’s treatment and recovery goals and the interventions and actions to help achieve those goals based on the comprehensive assessment of the person’s needs. They will prioritise these needs using a formulation.

Commissioners and services should make sure that each local system can offer a menu of evidence-based interventions including:

• psychosocial interventions
• pharmacological interventions
• recovery support interventions

Keyworkers should be familiar with the range of treatment options and be able to provide accurate information on each of these in a way that the person can understand. They should discuss the aims of each intervention, and any risks and benefits in the context of the person’s circumstances and their preferences. This should include both verbal information and written information in accessible formats. The keyworker can then support the person to make an informed choice about their preferred treatment and recovery support interventions.

NICE provides a useful guide on information for the public about treating harmful drinking (high-risk drinking) and alcohol dependence in England and Wales that is set out in CG115. Although this guidance is for England and Wales, it will still be useful in Scotland and Northern Ireland. The guide focuses mainly on treatment interventions offered by alcohol treatment services. The keyworker will also need to provide information on local recovery support services and community resources.

You can read more about integrating and supporting recovery in section 5.6 of chapter 5 on psychosocial interventions.

You can read more about recovery support services in chapter 6.

The person should have access to a copy of their treatment and recovery plan. This will usually be a written document. But keyworkers can also use an audible format (such as a recording) or offer the information visually (such as, node link mapping, videos, or easy read formats). It is important that the plan is easy for the person to understand and contribute to. Treatment is likely to be more effective if the person plays an active role in agreeing goals and designing and reviewing their own treatment and recovery plan.

4.19.4 Multidisciplinary and multi-agency treatment and recovery plans

There may be several professionals involved in helping to address the person’s identified goals in their treatment and recovery plan. This may include other staff in the alcohol treatment service or professionals from other agencies. Each professional should be named and their contact details included in the plan, along with the keyworker as the primary point of contact.

The keyworker will often need to communicate and share information with several different services and organisations including:

• mental health services
• housing and homelessness services
• children’s services
• maternity services
• adult social care services
• probation services and prisons
• financial, benefits and debt advice
• domestic abuse and sexual violence services
• community and voluntary services
• education, training and employment services
• LEROs

Keyworkers should make sure they have consent from the person before communicating with other professionals. In situations such as safeguarding, where consent is not required, it is still good practice to ask for consent unless this would put a child or adult at further risk. But the keyworker must share relevant information even if the person does not give consent.

Professionals from different agencies will need to communicate with one another to make sure everyone has clear expectations and to ensure good care co-ordination. They will need to clearly agree who has overall responsibility for co-ordinating the person’s care. This will usually be the keyworker from the alcohol treatment service, but in some situations another professional will be the lead care co-ordinator. For example, if the person has a severe mental health condition, the keyworker from the mental health service should usually be the named care co-ordinator.

Agencies will need to work together and with the person to integrate treatment and recovery plans (care plans) and risk management plans (see sections below) so there are no contradictions. They will also need to co-ordinate timetabling of appointments to make it possible for the person to attend them all.

When the keyworker from the alcohol treatment service reviews the treatment and recovery plan, they should involve other professionals who are working with the person. All professionals involved should share information in between reviews if there are relevant changes in the person’s situation. Information sharing and care co-ordination can be supported by shared record keeping, so agencies should consider whether it is possible and appropriate to have a single shared set of case records. For example, in some areas, primary care services can help alcohol treatment services to access a person’s electronic health records to make information sharing quicker and more effective.

The keyworker (or where appropriate, a specialist clinician) from the MDT should contribute to multi-agency case conferences, such as child protection conferences or mental health care planning reviews. They can do this either by sharing recent information in writing or by attending in person.

4.19.5 Risk management

Comprehensive assessment may identify risks to the person or risks that they may pose to others. Services should have clinical risk management procedures and a proforma. The keyworker is responsible for co-ordinating risk management planning with the oversight of the MDT.

Risk management plans should clearly identify the:

• specific risks
• actions to manage the risks
• person responsible for taking actions

Risk management plans will build on initial action plans are likely to be expanded following comprehensive assessment. See section 4.17 above on initial assessment.

The keyworker will carry out risk management planning alongside treatment and recovery planning. Wherever possible, the person should be involved in this process and agree to goals and actions to manage risks. Risks are usually addressed in a separate risk management plan that is clearly accessible to relevant staff on the person’s records and agreed actions should normally inform the treatment and recovery plan. Sometimes the keyworker and MDT will identify risks (such as safeguarding or offending risks) that they have a duty to act on even if the person does not agree. The keyworker should discuss these risks and the actions they will take with the person. These risks and actions should form part of the risk management plan with the keyworker named as the person responsible for relevant actions. If the person continues to disagree with the actions, these will remain part of the risk management plan but not form part of the treatment and recovery plan, which should be collaboratively agreed.

The risks to a person can constantly change, so keyworkers will need to regularly review a person’s risk assessments and risk management plans. Changes in any of the risk areas (such as alcohol and drug use, physical health, mental health or social factors) may affect the level of risk in another area. For example, increased risk related to a person’s mental health might increase a child safeguarding risk, even where the person’s alcohol use has not changed. A sole keyworker might not be able to see the interaction of risk across all areas, so it is important that the service provides supervision and that there are regular reviews of the risks across the MDT. Keyworkers will need to amend the identified risk management actions if risks or related factors change, or if the actions have not been effective.

Where the person is involved with other services, keyworkers should make sure they update other professionals to any relevant changes in risk when these occur. And they should seek input from professionals in these other services as part of regular reviews of the risk management plan.

4.19.6 The treatment and recovery planning process

Goals and goal setting

Goals in a treatment and recovery plan will include alcohol use goals. See section 4.13 on alcohol use goals.

These goals are broadly based on the severity of dependence and complexity of need, but they also need to be discussed and agreed with the person, so they are tailored to individual need.

As well as setting goals related to alcohol use and other substance use, treatment and recovery planning will also involve setting several wider goals. So, treatment and recovery goals commonly include:

• withdrawing safely and achieving abstinence
• achieving moderate (controlled) drinking where appropriate
• reducing harmful or risky behaviours associated with the alcohol use (for example, sexual risk taking or gambling)
• addressing any drug use, including misusing prescribed and over-the-counter medication
• reducing health (physical and mental), social, family, crime and other problems directly related to alcohol use
• reducing various health (physical and mental), social, family or crime problems, or other problems not directly related to alcohol use (for example, accommodation, income or debt)
• optimising a person’s physical and mental wellbeing (for example, building social support networks, strengths and resilience in recovery)
• engaging with mutual aid organisations, such as AA or SMART Recovery, peer-based support networks or LEROs
• achieving longer term personal recovery goals (for example, education, training or employment and voluntary work)
• strengthening relationships with partners, improving parenting skills and strengthening family relationships

At the start of the treatment process, it can be helpful for treatment and recovery planning to focus on goals that are a priority for the person. The person can help to make their treatment more effective by choosing goals that enable them to see small or incremental changes in specific areas in a reasonable time. This can:

• promote a sense of achievement
• increase motivation
• enhance self-esteem and self-efficacy
• help to build the therapeutic alliance

Effective treatment and recovery goals are usually SMART (specific, measurable, agreed, realistic and time-limited) and reflect individual personal preferences.

Setting and working towards treatment and recovery goals is a central element of the structured support provided by a keyworker.

You can read detailed guidance on providing structured support in chapter 5 on psychosocial interventions.

Reviewing the plan and monitoring outcomes

The keyworker should regularly review the treatment and recovery plan with the person. Where partners, family members or friends are involved in a person’s treatment, it may be helpful for them to contribute to reviews, if the person consents to this. The keyworker should also ask other relevant professionals to contribute (see section 4.19.4 on multidisciplinary and multi-agency treatment and recovery plans). The results of any health investigations and results of outcome measures should be included.

Keyworkers need to routinely use outcome measures to monitor the effectiveness of the treatment and recovery plan. They should use screening tools, such as AUDIT, or outcome monitoring tools, such as TOP or SURE. See section 3.10 for a description of these tools and outcome measures.

Reviewing progress using the treatment and recovery plan and agreed outcome measures can help to engage the person and enhance their motivation. The plan can then be revised or updated based on the review. The keyworker should arrange formal reviews at regular intervals involving the other professionals working with the person and family members, partner or friends where appropriate.

As well as conducting these regular formal reviews, the keyworker and the person should monitor progress session by session. Working together on a shared agenda at the start of each session may be helpful so that goals and actions can be adjusted as they go along.

At the beginning of treatment, the treatment and recovery plan will normally focus more on interventions offered by the alcohol treatment service and other professionals. And the keyworker may be more active in helping the person to access early recovery support. As the person’s recovery journey progresses there is often a transition, and the person may take on more actions and responsibility for their recovery. For example, by engaging in education, training or employment or becoming more active in mutual aid organisations and LEROs.

Planning for leaving treatment and recovery check ups

The treatment and recovery planning process includes preparing the person for leaving treatment. The length of treatment should be tailored to a person’s individual needs and their treatment should not end until they have met their treatment and early recovery goals and established support networks. While some people may be able to achieve treatment and recovery goals relatively quickly, those with more severe dependence or more complex needs may need to be in treatment for longer and their progress may not be straightforward.

You can find more information on recovery in chapter 5 on psychosocial interventions.

Planning for leaving treatment should include agreeing actions for the person as they continue their recovery journey. Keyworkers should make arrangements with the person for recovery management check-ups, with their consent. Recovery check-ups are regular appointments by phone, online, or in person, offered by the keyworker for a period after the person has left treatment. The keyworker and the person should agree a period of time based on individual circumstances, but this will normally be for at least 6 months and may be for longer. The aim of these recovery check-ups is to provide support and encouragement, acknowledge progress and respond quickly if the person returns to problematic alcohol use or has any other significant problems.

The keyworker and the person should agree a re-engagement plan, with the person’s consent. This can include actions the person can take and who they will contact if they begin to use alcohol problematically again. For example, actions might be to contact the keyworker and attend an AA meeting. It can also include actions the keyworker can take if they are not able to contact the person (such as contacting a family member or another professional or making a home visit). Services should make sure that anybody getting back in touch to re-engage in treatment gets seen as soon as possible, so they can get quick help to stop drinking and maintain their recovery.

Core keyworker skills for treatment and recovery planning

There are several core skills that keyworkers need for assessment and treatment and recovery planning. These include:

• assessment skills
• knowledge of harmful drinking and alcohol dependence
• motivational, clinical and planning skills, underpinned by active listening
• ability to build a trusting relationship and therapeutic alliance
• cultural competence (see chapter 2 on principles of care)
• a trauma-informed approach (see chapter 2 on principles of care)
• knowledge of local of interventions and ability to choose appropriate interventions
• skills in multidisciplinary and multi-agency assessment
• skills in treatment and recovery planning and care co-ordination

4.20 References

Copello A, Velleman R and Templeton L. Family interventions in the treatment of alcohol and drug problems. Drug And Alcohol Review 2005: volume 24, issue 4, pages 369-385

Delgadillo J, Godfrey C, Gilbody S and Payne S. Depression, anxiety and comorbid substance use: association patterns in outpatient addictions treatment. Mental Health and Substance Use 2013: volume 6, issue 1, pages 59-75

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5. Psychosocial interventions

5.1 Main points

Psychosocial interventions are an essential part of treatment for everyone. They should always take place in the context of a broader personalised treatment and recovery plan.

Effective psychological treatments and structured support are evidence-based practices which should be underpinned by a positive therapeutic alliance.

Structured support involves using specific psychosocial interventions which are common to evidence-based psychological treatments for alcohol and drug use. These common factors include:

• a strong therapeutic alliance
• session structure and goal direction
• interventions to develop alternative rewards and activities to alcohol use
• engagement with social networks that are recovery-oriented
• building self-efficacy and coping skills to maintain abstinence or control drinking

Structured support is generally delivered in community alcohol services by a keyworker.

Services should offer formal psychological treatments focused specifically on alcohol-related cognitions, behaviour, problems and social networks according to individual need. Formal psychological treatments include:

• cognitive behavioural therapies
• behavioural therapies
• social network and environment-based therapies

These treatments are generally provided by a specialist member of the multidisciplinary team (MDT) alongside a keyworker who provides structured support.

The assessment and formulation determine the choice of psychosocial intervention. Formulation is a framework for understanding information gathered in the assessment. It helps the person to make sense of their situation and informs treatment and recovery planning.

Practitioners need to monitor interventions to see it they are effective, and if they are ineffective, they should adjust them based on a revised formulation agreed with the person.

Treatment can be thought of as a journey through engagement, to behaviour change and early recovery, with the formulation determining the selection of interventions to support this process.

The intensity of support you offer should be based on the severity of the person’s alcohol dependence and any co-occurring complex needs. Most people can receive appropriate support in the community, but inpatient or residential services may be required for those with the most severe and complex needs.

Mutual aid, peer-based support and lived experience recovery organisations (LEROs) have been found to be effective in supporting recovery. Practitioners should support people to engage with these groups and organisations.

Practitioner competence affects the effectiveness of psychosocial interventions. Services should provide training and clinical supervision to all practitioners in the interventions they provide. Practitioners will need varying levels of specialist training depending on whether they deliver structured support or formal psychological treatments. Supervisors should be trained in supervision and trained in the psychosocial interventions they are overseeing.

5.2 Introduction

This chapter describes how practitioners can deliver psychosocial interventions for harmful drinking and alcohol dependence, consisting of structured support and formal psychological treatments. It focuses on how practitioners can develop a personalised treatment and recovery plan based on assessment, formulation and working with the person, and where appropriate, their family.

5.2.1 Aims

Psychosocial interventions are used to support people to:

• initiate and sustain changes in their alcohol use, including abstinence, moderate drinking (see definition of moderate drinking in the glossary) and reducing harm
• maintain engagement with pharmacological interventions
• address social or psychological issues that are contributing to, or made worse by alcohol use
• prevent a return to problematic alcohol use
• build recovery capital (see definition of recovery capital in the glossary term) strengths and assets to sustain long-term change

5.2.2 Principles of care

You should read this chapter with chapter 2, which provides more detail on the principles of care that are essential to delivering alcohol treatment. These principles are the basis for this chapter and are vital for delivering psychosocial interventions.

There is evidence that the approach and style of delivering alcohol treatment is equally (if not more) important than the specific content of the interventions (Ashton and Witton 2004 to 2006). There is more about this in the National Institute for Health and Care Excellence (NICE) guidance Patient experience in adult NHS services: improving the experience of care for people using adult NHS services.

The following principles of care are vital to establishing a therapeutic alliance between the practitioner and the person and for agreeing a personalised treatment and recovery plan. They should inform the service ethos and the approach of individual practitioners providing psychosocial interventions.

1. Build a trusting relationship, and work in a supportive, empathic, and transparent way.

2. Respect the person’s confidentiality, privacy, and dignity.

3. Understand how stigma and discrimination associated with alcohol use can affect how the person comes into treatment, their self-esteem and their ability to acknowledge the full impact of their dependence.

4. Work in a trauma-informed way (see section 2.2.8 in chapter 2 on principles of care).

5. Work in a culturally competent way (see section 2.3.2 in chapter 2 on principles of care).

5.3 A framework for delivering psychosocial interventions

5.3.1 Psychosocial interventions: what they are

The term psychosocial interventions refers to a broad range of structured interventions, techniques and practical help that support people to achieve their treatment and recovery goals. Psychosocial interventions address both psychological and social needs, which are often interconnected.

Psychological interventions include interventions focused specifically on alcohol-related cognitions, behaviour, problems, and social networks.

Social interventions include practical help with basic needs such as accommodation and income, and encouragement to engage with rewarding activities, mutual aid and peer-based support.

The specific focus of a psychosocial intervention will vary according to the person’s needs and goals, the setting in which it is delivered and the practitioner’s role and training. However, both psychological and social elements are essential in most people’s treatment.

Psychosocial interventions include structured support and formal psychological treatments. In community alcohol treatment services, a keyworker (see definition of keyworker in the glossary) is allocated to provide structured support and co-ordinate care throughout the person’s treatment journey.

You can read about structured support in sections 5.3.7 and section 5.5 of this chapter.

Formal psychological treatments are generally provided by a specialist member of the MDT alongside a keyworker providing structured support.

You can read about formal psychological treatments in section 5.7 of this chapter.

Where a person needs pharmacological interventions, psychosocial interventions should also be provided as part of an integrated personalised treatment and recovery plan. You will need additional psychosocial interventions to address complexities associated with harmful drinking and alcohol dependence, such as co-occurring mental health conditions, cognitive impairment, drug dependence or gambling.

5.3.2 Guiding principles for developing a clinical formulation

Formulation establishes an overview of the person, their alcohol use, maintaining factors and associated problems. An initial formulation is based on findings from the assessment. Formulation is then reviewed and amended to reflect the person’s response to specific treatment interventions and their progress towards recovery goals.

Good formulation allows the practitioner and person with alcohol dependence to evaluate which evidence-based psychosocial intervention may help and why. It is also a chance to identify potential barriers that could prevent progress. By using the formulation to explain how the intervention should work, the practitioner can instil hope that things can change for the better and to help the engagement process.

A personalised formulation should:

• be developed together with the person receiving treatment
• be based on a shared understanding of the issues
• normalise the person’s life experiences
• respond to individual needs
• be communicated avoiding unnecessary clinical terminology and in an accessible format, considering first language, literacy, sensory disability, cognitive impairment and neurodiversity

The formulation explains why particular diagnoses or interventions are indicated and which treatment and recovery goals are important to the person. Formulation should also identify how a person’s strengths can be best used to support their recovery.

5.3.3 Framework overview for delivering psychosocial interventions

Figure 1 outlines a framework for delivering psychosocial interventions. It shows the context for an effective personalised treatment and recovery plan.

Treatment takes place within a broader recovery-oriented system of care. It starts with engaging a person with an assessment of their treatment needs. An allocated keyworker is essential to build and maintain a therapeutic relationship, while providing structured support to the person to enable them to overcome their alcohol problems. Keyworking takes place throughout a person’s treatment journey.

There are 3 main phases to this journey:

1. Assessment and engagement, which includes assessment and formulation.

2. Behaviour change, which includes interventions for mild, moderate and severe dependence.

3. Early recovery, which includes interventions to maintain behaviour change and support recovery.

Assessment and formulation include a person’s physical and mental health and social needs and assessing and managing complexity continues throughout the treatment and recovery journey.

You can find more information on each of the phases in section 5.3.9.

Figure 1: a framework for delivering psychosocial interventions

5.3.4 Delivering psychosocial interventions in a recovery-oriented system of care

This chapter focuses on psychosocial interventions which are delivered by practitioners. However, this is just one element within a broader range of support and activities that could be integral to the person’s recovery journey.

Recovery is a process that is more than achieving abstinence or moderate drinking. It describes the development of recovery capital and broader wellbeing over time.

Recovery capital is healthy life resources, like:

• housing
• education
• employment
• supportive social networks, including mutual aid and peer-based support
• health and wellbeing

A wide range of services and organisations can contribute to a person’s treatment and recovery journey at different stages. When alcohol services and partner organisations work together in an integrated way, they are part of a recovery-oriented system of care (ROSC).

Mutual aid, peer-based support and LEROs are an important part of a ROSC and can be central to the person’s recovery journey. Outcomes improve significantly when treatment engagement is combined with long-term recovery support (Simoneau and others 2018).

For more information, see chapter 6 on recovery support services.

5.3.5 Assessment and formulation

In community treatment settings, everyone with an AUDIT score of 16 or more should be offered a comprehensive assessment of their alcohol use, severity of dependence, complexity of need and their strengths.

You can read about comprehensive assessment in chapter 4 on assessment and treatment and recovery planning.

Building on the assessment, the practitioner and the person develop a shared formulation. This is a way of making sense of the person’s alcohol problem. They look at factors that may have made them vulnerable to developing the problem, what may have triggered it, what helps maintain it and what resources the person can use to address it.

The shared formulation informs the choice of interventions included in their treatment and recovery plan. This process helps to involve the person in decisions about their treatment and can support engagement with their treatment and recovery plan. Practitioners should adjust the formulation based on ongoing assessment, and the person’s progress towards their treatment and recovery goals.

You can read about a clinical approach to formulation in section 5.4 of this chapter.

5.3.6 Alcohol use goals

Identifying the appropriate alcohol use goals is vital to effective alcohol treatment. Alcohol use goals should be informed by assessment and formulation and you should regularly review these as part of the treatment and recovery planning process.

You can read more about identifying and agreeing alcohol use goals in chapter 4 on assessment and treatment and recovery planning.

Severity of dependence and complexity of need are broad indicators of what alcohol use goals should be. However, alcohol use goals should be aligned with what the person wants and regularly assessed at review.

In general, the psychosocial interventions set out in this chapter can be used whether a person’s alcohol use goal is abstinence or moderate drinking. However, some approaches are more appropriate for certain goals (for example, behavioural self-control training for moderate drinking goals).

5.3.7 Structured support

Alcohol treatment services in community settings should allocate a keyworker to each person to help their treatment and recovery process and to co-ordinate their care. The keyworker will be responsible for providing structured support.

Structured support involves using specific psychosocial interventions which are common to evidence based psychological treatments for alcohol and drug use (Moos 2007). Section 5.5 sets out these common factors and describes how the keyworker provides structured support.

Using this approach to frame the use of specific interventions is a pragmatic and flexible approach to providing treatment. These psychosocial interventions can be described as evidence-based practices to highlight the distinction from a comprehensive formal psychological treatment approach (Manuel and others 2011).

Keyworkers should adapt structured support to a person’s needs based on assessment and the formulation. This should account for the severity of dependence and any associated physical health, mental health, or social complexities.

Structured support may include practical help and co-ordination of care from a MDT, and across agencies and recovery support services. Alongside a keyworker providing structured support, a specialist member of the MDT may provide a formal psychological treatment where required.

Services should provide training and regular clinical supervision to practitioners who provide structured support, which should be underpinned by a quality governance framework.

You can read more about structured support in section 5.5.

5.3.8 Severity of dependence and complexity

Assessment and formulation should identify the severity of alcohol dependence and complexity of a person’s need and should determine the choice of interventions to address these.

In many cases, the intervention intensity will increase according to the severity of dependence or complexity of need. People with harmful drinking but low dependence severity and low complexity (for example, strong social support and no mental health conditions) may respond to a less intensive intervention focused on motivational enhancement and goal setting (such as extended brief interventions).

People with moderate and severe dependence and complex needs (for example, physical and mental health conditions and additional drug use) are likely to need medically assisted withdrawal and psychosocial interventions will need to be integrated around this. They are more likely to benefit from ongoing structured support, more intensive interventions, and multi-agency working to support recovery outcomes. The highest treatment intensity programme is inpatient medically assisted withdrawal followed by intensive therapeutic support in a residential setting. This is suitable for a small number of people with the most complex needs.

Severe dependence and greater complexity will often (but not always) occur together. People with mild dependence may not need pharmacological interventions but may still have highly complex needs. For example, a person with a depressive disorder may not be alcohol dependent but heavy drinking episodes may exacerbate their depression and increase risk of self-harm. So, they may require a more intensive intervention, including crisis intervention, to help them manage their drinking and associated risks.

5.3.9 Treatment phases

Services may find it helpful to see treatment for harmful drinking or alcohol dependence as part of a recovery journey. This journey through treatment and recovery can be thought of as having 3 broad phases which can be described as:

• assessment and engagement
• behaviour change
• early recovery

These broad phases can help to inform the psychosocial interventions and level of support the person needs at different points of the journey. The practitioner and the person should agree on the interventions and priorities for action during the ongoing assessment and formulation process. The practitioner should understand which interventions are likely to be useful as the person progresses through their recovery journey.

At the start of the treatment journey, interventions are likely to be focused on stopping or reducing drinking and will be delivered by practitioners. As the journey progresses, the person is likely to be more active in directing their own recovery, participating in a range of activities outside of treatment, including peer-based support.

The phases are only broad indicators and not rigid categories. For example, although there will be more focus on recovery-oriented activities in the early recovery phase, establishing recovery-oriented social networks are also important at the beginning of the journey. Mutual aid groups, peer-based activities and lived experience recovery organisations can provide these.

5.4 Clinical formulation

5.4.1 Clinical formulation: aims and objectives

A clinical formulation builds on the comprehensive assessment (see chapter 4) and provides a framework to understand how the person’s alcohol problem began and developed, the associated difficulties and the person’s strengths and resources. It is also a way to identify the appropriate interventions to help the person change their alcohol use.

So, clinical formulation is a way to further understand the person and their relationship with alcohol, while organising the information gathered as part of assessment. Information to develop a formulation can also be collected from:

• existing clinical reports
• clinical interviews
• observations
• standardised questionnaires
• referral information
• previous treatment summaries
• knowledge of possible diagnoses

Clinical formulation allows practitioners to understand the person’s problems, which are often multiple and complex, but also to identify skills and strengths that they can develop. The clinical formulation is also a chance to review a person’s response to interventions and adjust the treatment plan if the interventions are ineffective.

5.4.2 Formulation framework

The ‘5 Ps’ model is one way of structuring a clinical formulation. It involves looking at how different factors in a person’s life affect their alcohol use (known as the presenting problem). These factors are split into 4 groups, which are:

• predisposing factors (vulnerability factors)
• precipitating factors (triggers)
• perpetuating factors (maintaining factors)
• protective factors (modifying factors)

Predisposing factors

Predisposing factors are background factors that may have contributed to the development of a person’s alcohol problems. This might include biological, family, and socioeconomic factors and adverse childhood experiences. For example, some people may have grown up in environments where excessive alcohol use was a normal part of socialising or a way of dealing with difficulties. Some people could have started using alcohol as a way of coping with low self-esteem and difficult experiences caused by negative life events.

Precipitating factors

Precipitating factors are those that have triggered an episode of problematic alcohol use. Internal precipitating factors can include:

• negative mood states
• difficult memories
• intrusive thoughts
• withdrawal symptoms
• cravings

External precipitating factors relate to the person’s social and environmental situation, and can include:

• unstable housing
• loss of role or employment
• conflict with others
• experience of discrimination

Perpetuating factors

Perpetuating factors are those that maintain problem alcohol use. Internal perpetuating factors might include beliefs about the positive effects of using alcohol. They could also include a strong desire to get rid of or escape from unwanted:

• cognitive events (for example, intrusive memories, negative thoughts, or low self-esteem)
• physical sensations (for example cravings and withdrawal symptoms, pain, insomnia, or tiredness)
• emotional feelings (for example, depression and anxiety symptoms)
• social responsibilities (for example, social contact, parenting, or sustaining jobs)

Environmental factors like unstable housing and relationship difficulties may also be important perpetuating factors. Formulation can be used to show the service user how alcohol use, intoxication and dependence can maintain these perpetuating factors and make them worse.

Protective factors

Protective factors are those that limit a person’s alcohol intake or have the potential to support a reduction in alcohol use. Internal protective factors include:

• personal strengths
• abilities, such as coping skills
• individual and cultural values

External protective factors include:

• close family or social support networks
• employment
• meaningful activities
• cultural and faith organisations
• mutual aid and peer-based support including LEROs

Identifying these factors can help build hope and self-efficacy (or confidence in their ability to change behaviour). Exploring previous periods of moderate alcohol intake or abstinence can be a useful way to identify protective factors and coping skills. A lack of protective factors also highlights areas that need to be developed, for example, linking the service user with peer support and recovery communities.

5.5 Structured support: common factors in effective treatment

As outlined in section 5.3.7, structured support involves using psychosocial interventions which are common to evidence based psychological treatments for alcohol and drug use (Moos 2007, Manuel and others 2011). These common factors (or change mechanisms), include:

• a strong therapeutic alliance
• session structure and goal direction
• interventions to develop alternative rewards and activities to alcohol use
• engagement with social networks that are recovery-oriented
• building self-efficacy and coping skills to control drinking or maintain abstinence

This section provides guidance on each of these factors.

5.5.1 Therapeutic alliance

A strong therapeutic alliance is vital to treatment. Evidence shows that a strong alliance between the practitioner and person is associated with significantly better outcomes relating to treatment goals and a range of quality of life measures (Maisto and others 2015, Connors and others 1997).

Confrontational approaches are not effective and are likely to lead to treatment disengagement (Miller and others 2001). An empathic and supportive approach and working towards shared goals is important to develop a therapeutic alliance.

Core competencies in building a therapeutic alliance include being able to:

• work together
• engage a person appropriately while showing warmth and care
• build trust and adopt a personal style suitable to the person
• adjust the nature and intensity of the intervention to reflect where the person is in their journey
• understand and work with a person’s emotional context and motivation

Services need to make sure they have regular clinical supervision to help practitioners develop their therapeutic engagement skills. Services should ensure that they prioritise these competencies and values when recruiting staff.

5.5.2 Support, structure and goal direction

Psychosocial interventions should be suitably structured and goal-directed, while open to review. Setting and working to a clear session agenda linked to a treatment and recovery plan is essential to this process. The practitioner should deliver evidence-based interventions informed by assessment and formulation.

Practitioners should support the person to identify their own goals, and regularly review and adjust these where necessary. Supporting people to set and achieve goals can help people improve their mood and encourage greater self-efficacy.

Structure and goal direction should not come at the expense of the therapeutic alliance. The person should feel supported to make progress with their goals while developing autonomy and self-efficacy.

There is more information on treatment and recovery planning, including goal setting, in chapter 4.

There are tools or techniques to support keyworking. For example, mapping (sometimes known as node-link mapping) is a simple technique for presenting verbal information visually (with diagrams or maps). Research has shown mapping can support positive treatment engagement and outcomes for keyworkers delivering structured support (Beckwith and others 2019).

You can read more about mapping in Routes to recovery from substance addiction, which is a manual to help healthcare practitioners build an effective plan for recovery.

Examples of interventions a keyworker can provide include:

• forming a collaborative agenda at the start of every session
• agreeing goals to work on between sessions and ensuring these are reviewed at the next session
• modelling problem-solving when setbacks happen and the person does not achieve their goals
• encouraging the person to develop a daily routine that promotes mental and physical wellbeing (such as exercising and eating well)
• identifying additional support needs and arranging referrals to other professionals and agencies

5.5.3 Rewards and rewarding activities

Developing positive and meaningful alternatives to alcohol use is a central part of recovery. For example, alcohol and drinking behaviours are likely to have formed a significant part of a person’s life. They will often need to find new ways of spending their time and new sources of meaning and enjoyment.

A person-centred and strength-based approach can support the person to identify and develop rewarding activities that are most meaningful to them.

Keyworkers can use the behavioural principle of positive re-enforcement to support change. This can include:

• reflecting back the person’s positive comments about change, and affirming their strengths and resources
• helping the person’s support network to reward them when they achieve their alcohol use goals
• providing direct rewards or incentives for remaining abstinent
• planning for a more rewarding lifestyle

Planning for a more rewarding lifestyle could include:

• education
• volunteering
• employment
• hobbies
• sports
• cultural and faith-based activities
• peer-based support

Examples of interventions a keyworker can provide are:

• identifying alternative activities to drinking that connect with the person’s values and have intrinsic meaning and purpose to them
• providing practical assistance to help the person reconnect with past valued activities that are not related to drinking and encouraging them to try new things
• encouraging the person to explore and engage in educational or vocational opportunities
• identifying and encouraging contact with friends and family members who can provide practical assistance and company to engage in non-drinking related activities

5.5.4 Social support and recovery-oriented norms

People with alcohol dependence and those drinking at harmful levels have usually developed social networks and relationships in which heavy alcohol use is the norm. This can lead to a loss of contact with supportive people or being excluded from activities and events where heavy drinking is less acceptable. In turn this can undermine efforts to change, so it is important to encourage people to establish or re-establish connections with people or groups who can provide useful support. There is evidence that changes in a person’s social network from one that reinforces drinking to one that reinforces abstinence significantly increases the probability of abstinence (Litt and others 2007).

Evaluating and adjusting these networks can help start abstinence or reduced drinking, as well as support longer term change once treatment is completed.

Identifying strengths and deficits in the person’s social support should be part of ongoing assessment. The keyworker should regularly encourage the person to use the helpful support available to them and to develop new support networks.

Support from family, partner and friends can be very useful where this is available. You can read more about this in chapter 4 on assessment and treatment and recovery planning and in section 5.6 below.

Mutual aid groups such as Alcoholics Anonymous (AA) or SMART Recovery, peer-based support and LEROs are valuable resources that offer sources of meaning and support networks free from alcohol.

It is important that services make recovery visible through work with peer-based support groups and local LEROs. Contact with people in recovery can promote hope and optimism that change is desirable and possible.

Some people, particularly those with harmful drinking or mild dependence, may be less willing to engage in groups like AA. But practitioners should still help them evaluate and find positive social and support networks. Practitioners should also help people aiming for moderate drinking to find networks or resources to support those goals, for example Moderation Management groups or digital resources to support their alcohol use goals.

Examples of interventions a keyworker can provide include:

• mapping a person’s social network to identify underused recovery assets and making a plan to increase contact with these people
• supporting people to engage in local mutual aid groups or any other recovery focused group
• helping the person to get a peer mentor
• helping the person consider being a peer mentor themselves, when they are ready

5.5.5 Self-efficacy and coping skills

Self-efficacy describes the person’s confidence in their ability to make or maintain changes to their alcohol use. Self-efficacy develops as people implement and observe change (McKellar and others 2008).

Throughout treatment, keyworkers should emphasise any improvements and associated gains in confidence. Keyworkers can use techniques from several treatment approaches that build self-efficacy, such as motivational interviewing which identifies strengths and resources for change (McKellar and others 2008).

Some treatment approaches more specifically target and develop self-efficacy (Kadden and Litt 2011). For example, cognitive behavioural therapy (CBT) approaches to alcohol use focus on developing skills to increase a person’s ability to cope with high risk drinking situations and life stressors, to help increase their self-efficacy to avoid or control alcohol use.

CBT-based relapse prevention is a comprehensive package of interventions. Keyworkers can integrate elements of this formal psychological treatment within structured support.

Examples of interventions a keyworker can provide include:

• promoting the use of drink diaries to identify high risk situations and to make proactive plans to cope with them
• looking together at life stressors and working out how these can be reduced
• teaching craving management strategies
• teaching drink refusal skills
• helping the person to manage low mood by encouraging good sleep hygiene and daily activity
• helping the person to learn to manage anxiety by teaching relaxation techniques
• developing an emergency plan to ensure an unintended drinking episode does not escalate to regular uncontrolled drinking
• ensuring the person has a robust plan in place to support recovery when they are discharged from structured treatment, which anticipates future challenges and has a clear route back to getting professional support

5.6 Integrating and supporting recovery

This section focuses on the role of the keyworker in promoting recovery goals and helping the person to integrate support from recovery support services in their treatment and recovery plan.

It takes 5 years or more before the risk of returning to problematic alcohol use drops below the 15% in the general population (White 2012). So, ongoing monitoring and management to maintain recovery is essential. Recovery support should begin early in treatment and continue after the person has left. Outcomes improve significantly when treatment is combined with long-term recovery support (Simoneau and others 2018).

There are several measures that you can use to assess recovery strengths and capital. These measures include tools such as the Substance Use Recovery Evaluator (SURE).

5.6.1 Recovery support services

When alcohol treatment services work together with organisations providing recovery support, they can be considered to be part of a recovery-oriented system of care.

You can read more about psychosocial interventions in a recovery-oriented system of care in section 5.3.4.

The keyworker needs to make sure psychosocial interventions are integrated with support from other services. Recovery support services are a range of services and organisations delivered by professionals or by peers that promote the long-term outcomes of a person’s recovery process. They are services that provide emotional and practical support to maintain abstinence or moderate drinking, as well as daily structure and rewarding alternatives to alcohol and drug use.

5.6.2 The role of the keyworker

Recovery can involve changes in a person’s behaviour, lifestyle and identity, as well as developing internal and external resources to support these changes. The keyworker should support the person through this process and help them to engage with recovery support services. This involves:

• using a strengths-based approach and working with them to identify recovery goals from the start of treatment and throughout the treatment journey
• helping people to identify and assess their recovery capital
• being informed about local recovery support services, including peer-based support services
• establishing and maintaining communication with local recovery support services
• supporting the person to access recovery support services and activities (sometimes called assertive linkage)
• having regular conversations with the person about accessing recovery support
• continuing to support the person after they have completed their treatment through a mutually agreed schedule of recovery check-ups (see section 4.19.6)

It can sometimes take time for a person to build confidence and motivation to engage, but the keyworker should discuss various recovery support options from the start and throughout treatment. This is particularly important as the person moves toward leaving treatment (Humphreys 1999).

Recovery support and activities can enhance treatment throughout the person’s journey. As recovery develops, there is often a transition to increasing self-care and peer support, which will be integral to supporting recovery after leaving treatment.

If the person wants to volunteer to offer peer support themselves while they are still in treatment, the keyworker should help them to consider whether the timing and the role are right for them and find out what support will be available to them in their role. There is evidence that people benefit from offering peer support, but they need to have clarity about the role, and training and supervision to prevent a negative impact on their own health and wellbeing (Greer and others 2021).

5.6.3 Helping people to access mutual aid and peer-based support including LEROs

There are now a wide range of recovery support services, including peer-based support services and organisations. Their structures and activities vary widely across the different parts of the UK. The most common peer-based recovery support services in the UK fall broadly into the following 3 groups.

1. Peer-based support that is linked to a particular service.

2. Lived experience recovery organisations (LEROs), which are autonomous organisations led by people with lived experience.

3. Mutual aid groups such as AA and SMART Recovery, which are independent organisations offering a specific recovery programme that people follow together.

The activity of peer-based support and LEROs varies from offering a specific kind of support, like making recovery visible and welcoming new people into an alcohol treatment service, to peer-led organisations that offer a full range of non-clinical services.

Chapter 6 summarises a range of recovery support services and activities.

Keyworkers should encourage and support people to engage with peer-based support and mutual aid in a reflective and collaborative way. Simply providing information or leaving people to make contact themselves increases the risk that they will drop out or not attend (Humphreys 1999).

Practitioners should discuss the value of these recovery-oriented groups by exploring the person’s experiences or views about them and set goals to engage with them in the future as part of the treatment and recovery plan (Timko and others 2006). For people with extensive alcohol-orientated social networks, helping them to engage with mutual aid may be particularly important.

Helping people access peer-based support and mutual aid can include:

• introducing the person to an existing group member and setting up an appointment to attend a meeting
• encouraging the person to phone the local or national helpline for the mutual aid group while the keyworker is present
• going with the person to the first meeting
• setting up a review appointment to address concerns and encourage further engagement
• encouraging the person to sample a variety of meetings or groups (if these are available) to find groups they are most comfortable with

5.6.4 Helping people to access employment support and community resources

There is strong evidence that being in good quality employment supports a person’s health and wellbeing. So, alcohol treatment practitioners should ensure that people in treatment can make informed choices about employment and accessing employment support.

You can find detailed guidance on accessing employment support in chapter 7.

5.6.5 Post treatment monitoring and support: recovery check-ups

For many people, recovery from alcohol dependence is a long-term process and there is a risk of returning to problematic drinking for several years after treatment (White 2012). So ongoing monitoring and management to promote long-term recovery is crucial.

Services should support recovery through ‘recovery check-ups’ to strengthen recovery outcomes. These check-ups involve keyworkers regularly contacting people (by prior arrangement) who have left treatment, to offer encouragement and to identify any extra support they might need.

You can read more about recovery management check-ups in chapter 4 on assessment and treatment and recovery planning.

5.7 Psychological treatments: selection and delivery

This section details several psychological treatments for people with alcohol problems that are recommended by NICE in the guidelines Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115), or are interventions with an emerging evidence-base and are supported by clinical consensus of the alcohol guidelines development group.

5.7.1 Selecting and using psychological treatments

Practitioners can use these psychological treatments in different settings, such as in community and residential settings.

You can find information on using brief interventions for people who do not require specialist treatment in chapter 3 on identification and brief interventions.

Selecting a specific psychological treatment depends on:

• assessment and formulation
• the availability of suitably qualified staff
• a supporting supervision and governance structure for the treatment

Practitioners can deliver these interventions one to one and most can be adapted to be delivered to a group. Practitioners can also deliver some of these interventions using digital technologies like online video.

5.7.2 Motivational interviewing and motivational enhancement therapy

Motivational interviewing (MI) and motivational enhancement therapy (MET, a form of MI) are evidence-based approaches to alcohol treatment. MI can be valuable in developing a strong therapeutic alliance and throughout treatment. But MI could be particularly important at a person’s initial assessment to build engagement and it can be combined with other effective interventions (Moyers and others 2005).

MI principles also support effective brief interventions. These need a non-judgmental approach from the practitioner to help the person recognise the problems associated with their alcohol use and to motivate them to change their behaviour.

MI techniques focus on exploring why the person might be unsure or hesitant about changing their drinking or other behaviour that might be preventing recovery. The practitioner should elicit the person’s own reasons for change, to motivate them to make or strengthen their commitment to behaviour change. When using MI techniques, practitioners should use non-judgmental tone and language. Other MI specific skills include:

• asking open questions
• providing affirmations that support the change process
• reflective listening to highlight the person’s desire and ability to change their behaviour (change talk)
• summarising the ideas the person has expressed

MET is a structured approach that combines MI techniques with elements such as feedback on assessments or test results (normative feedback, for example highlighting discrepancy between typical alcohol use and the person’s use). MET can be used as a standalone treatment, or along with other psychosocial or pharmacological treatment modalities.

Developing MI skills can be difficult because they may go against the practitioner’s instincts to offer advice without considering whether the person is ready to act upon it. MI requires quality professional training and ongoing reflective practice supported by supervision.

5.7.3 Behavioural approaches

Behavioural approaches focus on changing the environmental or social circumstances to support a person to change their drinking. Based on the concept of conditioning, behavioural approaches aim to modify learned behaviours. Since people learn to drink in specific drinking environments, this can encourage or inhibit alcohol consumption. For example, heavy alcohol use may be the norm in the person’s family and social networks, so becomes reinforced.

Behavioural approaches include interventions that aim to unlearn (or ‘extinguish’) conditioned cues to alcohol. For example, ‘extinguish-focused approaches’ include behavioural self-control training to reduce cravings to drink. Other behavioural interventions may help people develop recovery-supporting behaviours through support from others or specific rewards for positive behaviour. For instance, community reinforcement approach (CRA) or contingency management (CM) aim to reinforce abstinence and non-drinking behaviours. However, as NICE CG115 points out, there is still a limited evidence base for CM in alcohol treatment.

CRA is based on the principle that addictive behaviours involve reinforcers (for example, learned environmental cues) that maintain the behaviour. Building motivation and engaging in alternative, rewarding activities shifts the person’s reinforcement cues towards recovery-oriented behaviours. Positive social activities are important reinforcement goals, but engaging in peer support, therapies or other suitable activities may also be valuable.

Behavioural self-control training (or behavioural self-management training) involves developing strategies including managing high risk drinking situations. For example, by learning drink-refusal skills or setting clear drinking limits. Behavioural self-control training is often used for people who have a moderate drinking goal.

CM provides incentives such as monetary rewards for specific behaviours. This can include rewards for staying abstinent, attending treatment or other recovery-supporting activities. CM is typically used alongside other interventions and has some supporting evidence for alcohol specific outcomes. CM requires well defined behaviour targets (for example attendance at the service) and a clear monitoring system to ensure it is delivered consistently and ethically.

5.7.4 Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) approaches aim to change addictive behaviours by changing unhelpful cognitions (alcohol related thoughts and images) and behaviours that maintain or contribute to drinking. CBT enables people to recognise these thoughts and change the way they think and behave to support their recovery.

Relapse prevention

CBT-based relapse prevention, developed from Marlatt and Gordon’s model, is a widely delivered intervention for harmful drinking and dependence (Marlatt and Donovan 2005). The approach identifies the main contributors to a return to problematic drinking (or relapse) and interventions which include:

• identifying high-risk drinking situations and learning how to manage them
• coping with urges and cravings, and challenging expected positive outcomes from drinking
• identifying and challenging personal permissions and justifications to drink, for example when a person says, “I deserve a treat” or “other people are drinking, why can’t I?”
• drink-refusal skills training
• identifying lifestyle factors such as stress and social networks that encourage drinking and seeking to manage these better
• setting up self-reward systems for successful behaviours

Relapse prevention should be integral to treatment, enabling people to understand how to maintain changes in their behaviour and make progress in their recovery. Relapse prevention considers any returns to problematic alcohol use as a process rather than a standalone event. So, it focuses on developing strategies to reduce the likelihood of drinking, for example through coping skills or building self-efficacy and by attending to longer-term lifestyle stressors.

Relapse prevention also identifies how a ‘slip’ (a temporary or short return to problematic use) can be seen as a manageable event or even learning opportunity, rather than as a trigger for a full-blown relapse. It also helps people to change their thinking on how they see a slip.

Interventions for moderate drinking goals

NICE CG115 recommends that psychological interventions for abstinence broadly apply to moderate drinking goals (for more information on moderate drinking goals, see section 4.14). A formulation-based package of behavioural and cognitive interventions should form the basis of the approach.

A moderate drinking goal should be in line with the UK chief medical officers’ low risk drinking guidelines. So, a person with a moderate drinking goal should aim for no more than 14 units per week, spread over 3 days or more with alcohol-free days.

An initial period of abstinence may be valuable (where the person does not need medically assisted withdrawal) before beginning moderate drinking. A period of abstinence can allow the person to adjust a range of factors to support a moderate drinking goal. For example, recognising situations or feelings that lead to drinking, developing skills to manage these and adapting social behaviours and other daily habits to support moderate drinking.

Several psychosocial approaches are particularly suited to moderate drinking goals. For example, exploring past and future motivations for a person’s drinking and evaluating these as part of a moderate drinking plan is likely to be important.

CBT and CBT-based relapse prevention interventions are suitable to support moderate drinking goals. (Marlatt and Gordon 1985). Additional strategies to support moderate drinking goals include:

• setting clear limits for drinking
• self-monitoring of alcohol consumption, for example keeping a drinks diary
• methods to control the rate of drinking, for example alternating alcoholic drinks with soft drinks and not participating in buying rounds
• analysing triggers for excessive drinking, for example the role of stress or anxiety

5.7.5 Third wave approaches and mindfulness

More recent developments of CBT (sometimes referred to as ‘third-wave CBT’ or ‘contextual CBT’) are based on mindfulness orientated approaches and include:

• acceptance and commitment therapy
• mindfulness-based relapse prevention
• dialectical behavioural therapy

Third wave approaches differ from traditional CBT as they focus on helping the person change their relationship to unhelpful thinking patterns (for example believing “I cannot cope without a drink”) and emotions rather than changing thoughts directly. This is done using mindfulness and acceptance strategies to increase awareness of these unhelpful thoughts and feelings and to enable more flexible responses that support recovery.

Mindfulness comes from Buddhist meditation traditions focusing on observing and accepting thoughts, emotions, and sensations (for example cravings) in a non-judgemental way. Mindfulness encourages people to focus on the present moment without judgement or reaction. Then, people can accept negative thoughts or feelings that they experience, rather than seeing them as something that needs to be fixed.

Research on the relationship between mindfulness and substance use behaviours found these practices were associated with a range of positive wellbeing measures (Karyadi and others 2014). And greater ability to be mindful was associated with better managing cravings among people with alcohol-related problems. Mindfulness based relapse prevention brings together the practice of mindfulness within the relapse prevention model. There is emerging evidence that mindfulness-based relapse prevention leads to reduced negative emotions, stress and other potential internal triggers (Byrne and others 2019, Bowen and others 2014).

There is some evidence that mindfulness can reduce cravings and support abstinence (Karyadi and others 2014) and that acceptance and commitment therapy may be effective as a treatment for substance dependence (Byrne and others 2019). There is also evidence that dialectical behavioural therapy, which incorporates mindfulness techniques, is effective for people with emotional regulation difficulties who use substances (Maffei and others 2018). So, third wave interventions may be promising approaches to support alcohol treatment outcomes and to assist in relapse prevention.

5.7.6 Interventions supported by family or social networks

Involving family, friends and networks in treatment

The nature and extent of a person’s social network can influence their recovery outcomes. Social network interventions are based on the principle that harmful drinking and alcohol dependence occur in a social context that can enhance or undermine behaviour change. These interventions aim to improve the quality of relationships and reduce stress by:

• improving communication and problem-solving
• reinforcing behaviour consistent with changing drinking and recovery
• reducing unhelpful behaviours that may undermine efforts to change drinking

Improving how a person functions in a social network (family, friends, community) that supports abstinence or moderate drinking is an important recovery asset. NICE CG115 recommends involving families, partners and friends in treatment as long as the person in treatment has given consent.

It is important to review support networks of any person with alcohol dependence as part of their assessment. The practitioner should ask what they think about each network member’s attitude to supporting them in their treatment and how willing they might be to be more formally involved. The keyworker can use mapping to help to review social networks (see also section 5.5.2 on support, structure and goal direction).

Talking about social networks and the benefits of involving others in treatment provides an opportunity to ask the person if they think their family members or significant others are affected and might want support (see section 5.9 for more information).

Practitioners should establish the boundaries of confidentiality and consent to contact family members or significant others at an early stage of treatment. This can be helpful if the person in treatment drops out of contact with the service. This can be formalised as part of a re-engagement plan.

Effective family-focused interventions

There is evidence that several family-focused interventions are effective for treating alcohol problems and can indirectly support and protect children affected by parental alcohol use (Templeton 2010). These can broadly be grouped into 3 approaches:

1. Work with adult family members and significant others to help the person with alcohol dependence to enter and engage with treatment.
2. Involve both the person with alcohol dependence and their adult family members and significant others in the treatment intervention.
3. Interventions responding to the needs of the adult family members and significant others without the person drinking involved. This support should be available regardless of whether the person with alcohol dependence is engaged in treatment or not (Copello and others 2005, Orford and others 2013).

The following 2 sections focus on the first 2 approaches and describe the main interventions that involve the wider social network to support behaviour change in adults with alcohol dependence.

You can find details of interventions that involve the family to prevent or reduce substance misuse by children and young people in chapter 23 on young people.

Social behaviour and network therapy

NICE CG115 recommends social network and environment based therapies that focus on alcohol related problems. Social behaviour and network therapy (SBNT) is an example of these. It directly engages a person’s wider social network in the treatment process. The practitioner uses SBNT to support the person to explore and build social network support for changing their alcohol consumption and other problematic behaviour.

SBNT encourages a person to:

• be open about their goals
• be clear about their plans to cope with any return to problematic drinking
• improve communication within their social network

These interventions aim to support the person with alcohol dependence through the treatment journey, and, where necessary, back into treatment. SBNT brings together elements of network therapy, social aspects of the community reinforcement approach, relapse prevention and approaches involving families and concerned others.

Practitioners can use SBNT to help the person pursue a goal of abstinence or moderation. The coping strategies developed through SBNT are useful during and after completing treatment.

Behavioural couples therapy

NICE CG115 recommends using behavioural couples therapy (BCT) for people who have a partner who is willing to participate in supporting the person to change their drinking. It is not recommended if the partner is also drinking problematically or there is a history of violence in the relationship.

BCT is a structured approach that focuses on improving the quality of the relationship through improved communication and planned structured activities. It also includes aspects of CBT-based relapse prevention. BCT may be appropriate for either abstinence or moderate drinking goals, determined by assessment and formulation.

5.8 Modes of delivery

This section describes ways that you can deliver psychosocial interventions other than through individual (in person) sessions.

You can find information on mutual aid groups and groups run by peer networks or LEROs in chapter 6 on recovery support services.

5.8.1 Psychosocial interventions delivered in groups

This section includes psychosocial interventions delivered in groups by trained alcohol practitioners.

There is evidence that several interventions for substance misuse disorders delivered on a one to one basis can also be effectively delivered in groups (Weiss and others 2004).

Facilitating any group requires a high level of skill. Meeting the needs of multiple service users is more complex than one to one work. Services should ensure that therapeutic approaches to groupwork are evidence-based and that group facilitators are trained in groupwork and the specific group intervention they deliver. Facilitators should also receive clinical supervision by a supervisor trained in supervision and in groupwork and in the specific intervention they supervise, so that groups are safe and viable and achieve positive outcomes.

Group interventions can offer therapeutic opportunities that are not available in one to one sessions (Yalom and Leszcz 2020). For example, groups can help people realise they are not alone in their experiences, and so can reduce feelings of shame and create a sense of belonging. Support and challenges from peers in a safe environment can be powerful in motivating people to change, and group members can learn from one another’s experience. Groups can also help people learn to interact with others.

However, there are significant risks of attrition from groups in community treatment settings, so it’s important to have competent facilitation and a focus on maintaining engagement throughout.

Groups can be highly structured (for example, a mindfulness-based relapse prevention group). Alternatively, they could be less structured support groups where members share their experience of working towards their treatment and recovery goals.

The choice of specific group offered should be based on the setting, practitioner and supervisor competences, and the identified needs of the service users. Groups may aim to address the needs of any service user assessed as appropriate or the needs of a particular group (for example, women or LGBTQ+ people).

Groups may include:

• CBT groups such as relapse prevention (Wenzel and others 2012) including coping skills training (see section 5.7.4 above) and mindfulness based groups (see section 5.7.5 above)
• behavioural groups, for example groups with a focus on cue exposure (see section 5.7.3 above)
• interactional (also called interpersonal) groups
• psychoeducational groups providing information on alcohol dependence, health behaviours and recovery resources

There is little evidence on psychoeducational groups, but NICE CG115 recommends them as part of an intensive community programme and they provide practical help to reduce harm and build recovery resources.

Some services run groups focused on engagement and social or recreational activities. These can be an important part of supporting recovery as identified in section 5.6.

The parameters of a group intervention will vary according to its purpose and clinical leads will need to advise on:

• therapeutic approach and target group membership
• threshold of access (a closed group for one cohort only, cohorts joining at agreed points in a rolling schedule, or an open group that people can join at any time)
• attendance at all sessions expected or optional drop ins
• the length of time each group runs for and number of group sessions
• ground rules describing boundaries and acceptable behaviour
• adaptations for accessibility for individual members

The decision to offer a person a group intervention should be based on their assessment and formulation and mutually agreed with the keyworker. There should be an explicit connection in the treatment and recovery plan between their goals and how the group can help to meet them.

Group interventions can be a valuable part of a person’s treatment. However, groups should not replace the offer of one to one interventions. These should always be available for people who do not want to engage in groups. The practitioner should assess any mental health conditions (for example, social phobia) and assess any risks the person might pose to others, and their suitability for a group intervention.

People are often anxious about groups and practitioners should address their concerns. Services offering group interventions should describe how groups can support recovery and have an induction process for newcomers to ensure they feel welcomed and supported.

The practitioner should share information on the purpose of the group, how it will run, and the ground-rules. They should communicate information accessibly, considering group members’ language, literacy, sensory disability, cognitive disability and neurodiversity. It may be appropriate to introduce the new person to a peer who has experienced the group intervention and can share their experience of it, to help support engagement.

5.8.2 Intensive community and residential programmes

Intensive programmes consist of a range of groups and recovery-oriented activities to support people achieving their alcohol use goals (Orchowski and Johnson 2012, Coco and others 2019). These programmes provide support in the early weeks or months of abstinence, promote recovery, and strengthen social functioning.

Intensive programmes are:

• usually delivered in residential settings
• generally abstinence based
• include a focus on participation in communal activities

Intensive programmes can be delivered in community settings with sufficient capacity and staff competence. NICE CG115 recommends an intensive community programme after medically assisted withdrawal for people with complex needs who are mildly or moderately dependent, or for those who are severely dependent. It recommends that an intensive community programme should contain:

• 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
• case management

Intensive community programmes usually require the person to attend for 4 to 5 days per week, and residential programmes require attendance for at least 5 days per week, with some requirements during weekends for a fixed period of time. There is no clear evidence about the best length of the programme. In the UK, intensive community programmes generally last between 4 and 12 weeks. The length of a programme should ideally be tailored to the individual’s needs. NICE CG115 recommends that a residential programme lasts up to 12 weeks.

You can find more guidance on intensive community and residential programmes in chapter 14 residential and intensive structured day treatment.

Practitioners in community alcohol services may have the opportunity to make referrals to an intensive community or residential based programme. Assessing whether such a referral is appropriate is a skilled job and there should be input from the MDT or a senior clinician. Intensive group programmes will usually be suitable for people who have engaged with standard treatment, but not appeared to benefit from it. However, there will be some people assessed as appropriate to move directly into an intensive programme.

Programmes are usually tailored to people with more severe dependence and with complex needs. These are usually orientated around the needs of people who need a high level of support to establish the foundations of their recovery and may require help in structuring their time and activities. However, some people with complex needs will require a more flexible, less intensive approach. Residential support may be most useful for people with little social support, including those experiencing homelessness.

There is wide variation in therapeutic approaches and programme requirements. It is important that the service and the practitioner are familiar with the approach and the requirements of the programme or programmes they are considering. The keyworker should communicate all relevant information to the person in an accessible way and should help the person to think through whether or not they want to engage in the treatment. And if they do, the keyworker should arrange visits.

The keyworker should ensure they have fully informed consent before making a referral. Where the referral is for residential treatment, the keyworker should find the results of the most recent inspection report (from the relevant inspection body) and only refer to services that are rated good quality or higher. They should share this information with the person so the person can make an informed decision. It’s important to prepare the person before they start the residential programme because it can help to reduce the risk of disengagement.

The keyworker should maintain contact with the person and with the staff of the structured group programme. The keyworker should arrange for early re-engagement with community treatment services for people who do not complete residential treatment and for those who need ongoing treatment and support after completing the programme.

5.8.3 Digital interventions

Definition of digital interventions

Services may offer digital and other remote interventions alongside in-person treatment to increase choice and accessibility for people with alcohol problems. The term ‘digital interventions’ in alcohol services covers a broad range of applications which enable remote support, which may combine both digital and in-person approaches as part of a person’s treatment and recovery plan. Or it could mean fully remote treatment provided using video or phone.

In these guidelines, ‘digital interventions’ refers to any interactive digital programme where there is contact between a practitioner and a person with alcohol problems, to support them to change their behaviour. This can involve real time contact on video platforms like Skype or Zoom, in place of in-person support. It can also involve contact using email or text chat, or phone-based support, where treatment is offered by a practitioner by phone to complement other methods, or for the entirety of the treatment.

This definition of digital interventions does not include digitally-delivered information or screening tools that are offered in isolation, without any involvement from a practitioner.

Evidence of effectiveness

There is limited (but growing) evidence of the effectiveness of digital interventions in alcohol treatment and recovery. There is emerging evidence to support the use of digital interventions to prevent alcohol use disorders. For example, screening and alcohol brief interventions to reduce consumption. These interventions are appropriate for people drinking at increasing risk and those drinking at harmful levels who do not need specialist assessment or additional healthcare support. There is currently less evidence for treatment of people with alcohol dependence, or people drinking at harmful levels who need specialist treatment. As more evidence on digital interventions emerges, these guidelines may be updated.

The Office for Health Improvement and Disparities has published guidance on providing remote and in-person interventions for alcohol and drug treatment services.

Offering digital interventions

Services can offer digital interventions to people seeking help for alcohol problems where they are available, if they are appropriate after assessment and review, and if the person wants them. Services should continue to offer in-person support where the person prefers it, and especially where it will encourage ongoing engagement with treatment. Digital interventions should not replace the option of in-person treatment. Some people will not have access to digital technology or may not have digital skills, so services should ensure that these people can access all interventions in person.

Potential benefits and limitations

Digital interventions offer some potential benefits to services and to people who need treatment, including:

• addressing geographical barriers, especially for people in rural communities or with limited transport options due to a lack of driving licence or public transport
• providing flexibility, as well as cost and time efficiency, especially for people with caring responsibilities
• enabling people with mobility issues to engage with treatment more easily
• addressing stigma-related barriers, including those experienced by some faith groups

However, digital interventions also involve potential limitations and risks, including identifying:

• alcohol and drug use during the session
• signs of urgent health crisis
• undiagnosed physical and mental health conditions
• poor self-care
• general health issues

These limitations should be acknowledged in the assessment and in treatment planning. And from the start of treatment, practitioners should be aware of the need to manage risk in light of these.

Services can deliver in-person interventions in a way that minimises distractions and makes them more likely to be effective. But it’s difficult to guarantee that digital interventions will take place in a distraction-free environment, and this might reduce their effectiveness. Practitioners should take steps to reduce distractions. For example, they can encourage people to complete the intervention in a quiet room free of distractions, where this is possible.

Policies to support delivery of digital interventions

Practitioners can gather initial information for assessment remotely, but there should normally be an in-person assessment. This enables the practitioner to complete a comprehensive assessment, including:

• the need for medically assisted withdrawal
• physical and mental health
• medical tests to be carried out where indicated

Services using digital interventions should make sure that practitioners receive appropriate training so they are digitally competent. This includes understanding the ways that the therapeutic relationship can be established and maintained using digital interventions, as well being technically competent.

Services should maintain policies to address safeguarding and confidentiality when working digitally. Practitioners should receive training in managing safeguarding and confidentiality when working remotely. For example, they should always check whether the person is alone in the room. This will be particularly important where there are risks of domestic abuse. Services should also undertake a data protection impact assessment and maintain policies and procedures to protect confidentiality during remote interventions. And this should be discussed with the person.

Co-production, evaluation and sharing best practice are likely to be valuable in the future development of digital interventions to support alcohol treatment delivery. As services develop their digital interventions, they should seek feedback from people receiving and completing treatment to inform future developments.

5.9 Interventions for adult family members, partners and friends

Problematic alcohol and drug use can affect not only the people using these substances, but also members of their social network, including family and friends.

Members of the person’s social network can contribute to the treatment and recovery process, but they may also have support needs of their own. This section focuses specifically on providing support for adult family members and friends.

You can read more about when and how to involve adult family members, partners or friends in psychosocial treatment interventions of a loved one in section 5.7.6 of this chapter. You can find guidance on interventions to support children affected by problematic parental alcohol use in chapter 26.

Many family members, partners and friends experience stress as a result of living with a person with alcohol problems. This stress can cause physical and psychological symptoms, affect their ability to cope, and affect the amount and quality of the social support they receive.

Services should offer families, partners and friends:

• information on alcohol problems and how they can be affected
• an appointment to provide support
• an initial assessment of any urgent needs, where indicated

They should have clear, agreed arrangements covering confidentiality for both the person in treatment and the family member. Where a person does not agree to their personal information being shared with their family, partner or friends, the practitioner should provide general information about alcohol problems and treatment and how families can be affected. This may help to reduce stress.

The stress-strain-coping-support model has been shown to reduce family members’ signs of strain (physical and psychological symptoms) and improve their coping mechanisms (Copello and others 2000). This involves a 5-step approach:

1. Give the family member the opportunity to talk about the problem.
2. Provide them with relevant information.
3. Explore how the family member responds to and copes with their relative’s substance problems.
4. Explore and enhance social support for the family member.
5. Discuss the possibilities of being referred for further support (Copello and others 2010).

Practitioners should assess risks such as domestic abuse, suicidality, and safeguarding concerns. And where indicated, they should produce an initial safety plan and refer to appropriate services.

Practitioners delivering the 5-step approach need to be trained in the approach and regularly supervised by suitably qualified practitioners.

Providing this support to a family member can also help the person in treatment to recognise the extent of their alcohol problem, while enhancing engagement and treatment outcomes. However, this is an indirect secondary effect of the intervention and not its primary objective.

Family members or friends who spend a significant amount of time caring for a person with an alcohol problem are entitled to a formal carer’s assessment to see if they are eligible for social care and support services. Each of the UK nations has legislation and guidance covering carer’s support entitlement. You can find the relevant laws and guidance in annex 1.

Practitioners should discuss the carer’s assessment with adult family members and carers and have established pathways with local services responsible for providing carers’ assessments so they can make referrals as appropriate.

There are self-help groups which provide support for families, including:

• Al-Anon
• Families Anonymous
• SMART Family and Friends
• NACOA

Evidence has shown these to be beneficial (Miller and others 1999). Practitioners should encourage family members to use local resources that support affected family members and carers.

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6. Recovery support services

6.1 Main points

Recovery support services are community services and interventions that can provide emotional and practical support for ongoing recovery from alcohol dependence.

Recovery support services include professional health and care services, community services and peer-based support services. Most are run by a combination of professional staff and people with lived experience. Some peer-based support services are run entirely by people with lived experience.

Recovery support is important throughout a person’s treatment and recovery journey and is vital when the person has finished structured treatment. Some people never attend treatment but use peer-based support and other recovery support services to achieve their recovery goals.

It is important that keyworkers know what services and support are available in their local area so they can help a person access their preferred service as part of their treatment and recovery plan.

Alcohol treatment services should have active working relationships and agreed pathways with all the recovery support services and organisations in their local area.

6.2 Overview

6.2.1 Recovery support services

Recovery support services are community services and interventions that can provide emotional and practical support for ongoing recovery from alcohol dependence. These services help people to develop recovery capital.

Recovery capital is the healthy life resources that people can use to begin to recover and maintain recovery, including:

• supportive social networks
• housing
• education
• employment
• health and wellbeing

Recovery support services include professional health and care services, community services and peer-based support services.

A 2017 systematic review on recovery support services in the US (PDF, 1.2MB) found evidence that recovery support services help people to begin and maintain recovery and improve their quality of life.

6.2.2 Supporting treatment and recovery

Recovery support is important throughout a person’s treatment and recovery journey and is vital when the person has finished structured treatment. Some people never attend treatment but use peer-based support and other recovery support services to achieve their recovery goals.

Recovery support services can contribute to a person’s recovery journey by:

• engaging the person in treatment and supporting their engagement
• complementing treatment as part of the person’s treatment and recovery plan
• offering continuous recovery support after the person finishes formal treatment
• helping the person re-enter treatment if they need to
• increasing opportunities for the person to volunteer or seek employment
• offering harm reduction advice and information to people outside treatment
• offering peer support services for family members

Recovery support services offer a wide range of interventions, but they all have a sense of social connection and community. It is important that keyworkers know what services and support are available in their local area so they can help a person access their preferred service as part of their treatment and recovery plan. Alcohol treatment services should have active working relationships and agreed pathways with all the recovery support services and organisations in their local area. You can read more about co-ordination between treatment services and recovery support services in section 2.5 of chapter 2 on principles of care.

The 2017 review found evidence of effectiveness for the recovery support services described below.

Most of these services are run by a combination of professional staff and people with lived experience. However, some peer-based support services are run entirely by people with lived experience.

These services and interventions are organised in different ways across different areas and are known by various names, so these might be called something slightly different in your area. They include:

• peer-based recovery support services
• mutual aid
• recovery community centres
• recovery housing

• recovery support services in educational settings

• recovery management check-ups

6.3 Peer-based recovery support services

6.3.1 Groups and organisations

Peers are people who share an experience. In the context of recovery support, peers with lived experience of alcohol dependence and of recovery use this experience to offer non-clinical support to others who are working towards recovery.

Peer-based recovery support services include a broad range of peer-based interventions and organisations that support people to develop their recovery capital and take part in a recovery community. These services offer a positive culture that can help to reinforce recovery-oriented norms. A peer-based recovery support service extends beyond representing people attending the treatment service (often known as service user involvement) and provides a range of support for people who are currently attending, who are no longer attending, or who have not attended structured treatment.

Peer-based recovery services are often provided by people who are volunteering or employed by an alcohol treatment service. The peer-based service may be distinct from but supported by the rest of the alcohol treatment service and have a dedicated co-ordinator who might be a peer or a member of staff. The support they offer ranges from a specific intervention, such as individual peer support to introduce a person to the service, to a full programme of individual and group peer-based support and activities.

A lived experience recovery organisation (LERO) may also provide peer-based recovery support services. These are autonomous organisations led by people with lived experience of alcohol dependence. LEROs also differ in the interventions they offer and often have a focus on promoting and developing recovery support services. Their activities include:

• offering physical space for recovery-related activities and service delivery
• offering peer-based recovery support services
• organising and engaging in advocacy efforts to improve policy and increase the availability of recovery resources and services
• educating the local community on alcohol dependence and the recovery process

In many areas, there are also peer-based support services for families, partners and friends. Also, some peer-based support activities for people in recovery are open to family and friends.

The 2017 review found evidence that peer-based recovery support can help reduce alcohol use, reduce relapse and support and maintain treatment engagement.

6.3.2 Individual peer support

Peer based organisations often offer support to individuals as well as offering group activities. Local areas vary in the range of individual peer support that is available. As people gain experience and stability in recovery, they can volunteer to offer peer support, which can be beneficial to both the person offering the support and the person receiving it. Individual peer support can be thought of in 3 broad categories, which may overlap.

Peer support in treatment

A person may offer peer support to others while they are still in treatment. They can represent the views and concerns of individuals or groups of people in treatment to the treatment service staff and commissioners. They may also be active in organising community events involving people in treatment and their families. They could also be involved in commissioning, designing and monitoring the service. Role titles for this kind of peer support include:

• lived experience advocate
• service user representative

Peer support while in recovery

A person who is in recovery (often in early recovery just out of treatment) may take on a peer support role (often as a volunteer) drawing on their own lived experience. They show that recovery is possible and either help others into treatment, or to progress in treatment, or to establish themselves in early recovery. People in this role can offer practical and emotional support such as:

• introducing people to a service
• accompanying people to mutual aid or other recovery support groups (‘buddying’)
• accompanying people to healthcare and other appointments
• representing their wishes (‘peer advocacy’)

Role titles for this kind of peer support include:

• peer supporter
• peer volunteer
• recovery champion

Mentoring or coaching

A person who has been in stable recovery for some time may choose to supplement their lived experience by gaining some formal training and certification in a mentoring or coaching role. People in this peer support role are trained to offer informational, emotional, social and practical support to people with alcohol problems. They may offer this as a volunteer or in a paid role. They show that recovery is possible and help people to build on their recovery capital. They will often work with people in early recovery after they have left treatment but may work with people at different stages of the recovery journey. Role titles for this kind of peer support include:

• recovery coach
• peer mentor

6.4 Mutual aid

Mutual aid groups offer a specific programme to support recovery that people follow together. Groups such as Alcoholics Anonymous (AA) or SMART Recovery provide a recovery-oriented support network with a focus on abstinence.

6.4.1 Alcoholics Anonymous

Alcoholics Anonymous (AA) is the most widely established form of mutual aid with active groups all over the UK, online and internationally. They describe the organisation as “a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism”.

The Alcoholics Anonymous website provides information on local in person and online groups. Groups are organised based on the principles of 12 steps to build recovery and on supporting each other. People can use groups at any stage of their recovery journey and some people achieve recovery through AA without ever entering treatment. People may drop into groups on an occasional basis according to need or follow the 12-step programme in a structured way with the support of a sponsor (another member of AA who is further on in recovery). Some AA groups are open to family members or professionals who are interested in understanding more about AA.

6.4.2 Other 12 step groups

Other 12 step fellowships based on the same principles as AA include Narcotics Anonymous (NA), Cocaine Anonymous (CA) and Al-Anon (for families and friends of alcoholics).

The Cochrane review Alcoholics Anonymous and other 12‐step programs for alcohol use disorder found good evidence for both their effectiveness in supporting abstinence and other alcohol related outcomes.

Twelve step fellowships maintain independence from professional bodies and make sure they remain led by people in recovery in a volunteer capacity. They do not accept funding from external sources. However, many fellowships have links with alcohol treatment services and some AA groups take place in treatment services or in LEROs.

6.4.3 SMART Recovery

Self-management and recovery training (SMART) Recovery groups are alternative mutual aid groups informed by rational emotive behaviour therapy principles. Their approach is based on group discussion and support and learning practical skills and using tools to manage various addictive behaviours and lead fulfilling lives. SMART Recovery groups are usually run by a combination of professional staff and people with lived experience. The availability of SMART Recovery meetings has grown over recent decades and there are many groups in the UK.

The SMART Recovery website provides information on local in person and online groups and training materials. SMART Recovery groups are open to anyone considering or aiming to achieve abstinence and people can join directly. SMART Recovery also works in partnership with treatment services, including residential and prison services which often host meetings. SMART Recovery champions work with people in treatment to develop peer-led SMART Recovery groups.

Moderation Management is a mutual aid group to support people with controlled and reduced drinking goals but is not widely established in the UK.

6.5 Recovery community centres

A recovery community centre is a physical base or hub that provides space for a recovery-oriented community and a wide range of individual and group peer-based recovery support. Recovery community centres may offer recovery focused groups and relapse prevention support groups. They can also offer a structure and a programme of meaningful activities such as:

• sports
• recreational activities
• education
• employment support

They might also host mutual aid groups (see section above on mutual aid). The centres may have links with local community activities and groups such as community gardening projects, local food banks and community kitchens. They may also offer individual peer support, often called peer mentoring or recovery coaching.

Recovery community centres are usually run by LEROs but may also be run by treatment providers, and usually have a mix of employed professional staff (often peers) and peer volunteers. Some community centres are open to the public, such as recovery cafes. Recovery community centres support people in recovery and help to build local recovery communities. They also promote recovery communities as contributors to wider local communities.

6.6 Recovery housing

Recovery housing is stable accommodation that provides an alcohol and drug free environment. This can be a vital element of recovery support for people who have previously experienced homelessness or who were living in an environment where heavy drinking was the norm. Recovery housing usually involves sharing accommodation and so provides a recovery focused community. People may live in recovery housing while in treatment or after the end of structured treatment.

Most (though not all) recovery housing has some level of staffing, but the level of available support varies widely across different schemes, as do standards of care. Some recovery housing is registered with the Care Quality Commission or equivalent national regulator. It is important for the keyworker and the person to understand the level of available support and regulation so they can consider whether the project meets the person’s needs.

6.7 Recovery support in educational settings

Recovery support services in educational settings are well established in the US, but there are currently very few in the UK. These provide an alcohol and drug free social network and activities in a university or college setting. This is an important support in an environment where regular alcohol and drug use is normal. These programmes can provide:

• peer support
• advocacy
• support to access alcohol treatment
• help with problems affecting people’s studies

Recovery housing may also be available on campus.

6.8 Recovery check-ups

Recovery check-ups are an agreed series of scheduled in-person or phone appointments with the person after they leave a treatment service. Recovery check-ups provide encouragement, identify and address any problems and help people to rapidly return to treatment if they have relapsed. You can also use video appointments.

Recovery check-ups are generally provided by keyworkers from alcohol treatment services. You can find guidance on recovery check-ups in chapter 4 on assessment and treatment and recovery planning.

Some peer-based support services and LEROs provide recovery check-ups later in the person’s recovery journey or where the person has never attended a treatment service.

7. Employment support

7.1 Main points

Dame Carol Black’s 2016 independent review into alcohol, drugs, obesity and employment highlighted the mutually reinforcing benefits of employment and recovery.

Employment and accessing employment support can and should be part of the recovery planning process. Autonomy is central to this, although treatment providers should be aware that some of their service users may be subject to welfare benefit conditionality and be required by Jobcentre Plus to look for work.

Good links between treatment providers and employment support providers (including Jobcentre Plus and, where available, individual placement and support services), ideally with a case management approach, can help service users navigate potentially complex systems and rules.

Access to welfare benefits advice can help people to make informed decisions about employment and particular roles.

7.2 Overview

This chapter outlines things that services can do to improve employment opportunities for people with harmful and dependent drinking. There is strong evidence that being in good quality employment supports a person’s health and wellbeing. So, alcohol treatment practitioners should ensure that people in treatment can make informed choices about employment and accessing employment support.

7.3 Accessing employment support

7.3.1 Engaging service users to support employment

Alcohol treatment services should develop and sustain links to employment support. Dame Carol Black’s 2016 independent review recommended that employment should be addressed at the same time as treatment and recovery support, rather than at the end of structured treatment. As well as being a barrier to employment, using alcohol can cause and be a consequence of:

• workplace stress
• difficulties at work
• job loss

Practitioners should discuss the person’s attitudes to employment and what they expect from it when they first access the service. They should also discuss this at each review, in a non-directive way. If practitioners discuss employment and access to employment support early in the person’s treatment, and review it regularly, this will enable the person to make an informed decision about their options. Practitioners should also discuss job security and retention with people who are currently employed, and they should know where to refer people who are at risk of losing their job.

The period around starting a job can be stressful, as can transitioning to a new environment and adopting workplace routines. So, the treatment provider or an employment support provider should make extra support available to people starting work particularly those who have not worked before or not worked for some time. They should offer to contact them more often, if possible, as well as offering to go with the person to work on the first days and offering to support them with managing their first wages and any changes to their benefit claims.

7.3.2 Respecting service user autonomy in employment support

For people who are not already in employment, or receiving employment support, or have not been referred to a mandatory programme, it is important that they decide when (or if) they are referred to employment support.

There are some circumstances where a person may be the subject of conditions where this may not be possible. For example, where a person:

• is on job-ready social security benefits and is expected to undertake particular activities to remain eligible for those benefits (conditionality)
• has been the subject of a mandatory referral to a Department for Work and Pensions (DWP) commissioned or co-commissioned programme, or a programme commissioned by a devolved government

Services should ensure that there is a single point of contact (SPOC) and regular, effective communication between the local Jobcentre Plus or Jobs and Benefits office. This will ensure that employment support and benefit conditionality supports treatment and recovery rather than working separately to it (see section 7.3.5 on benefit conditionality and support options below).

Jobcentre Plus work coaches and managers have access to the Flexible Support Fund. This is a discretionary fund that they can use for costs related to a person starting work, for example buying clothing or tools, or covering travel expenses. The Flexible Support Fund is also sometimes used by DWP to commission specialist services to meet local priorities and unmet local need. This could include specialist employment support for people accessing community treatment for substance use.

7.3.3 Understanding the role of employment

Services should promote access to employment and employment support to all their service users. This should take place at or shortly after initial assessment, and then regularly throughout treatment.

While employment is generally associated with recovery and wellbeing, not all employment will help with this. A review on the relationship between work, health and wellbeing found that sometimes employment does not result in improved health and wellbeing. For example, the beneficial health effects depend on the nature and quality of work a person does.

The jobs that are often the most accessible to people with limited experience include jobs that are low paid, insecure and with limited autonomy and routes for progression.

So, where services provide or help people access employment support, they should try to support them into stable and secure work that matches what the person wants to do. Although, they need to be realistic about the sorts of jobs that might be initially available to them. An entry-level job can provide a direct or indirect route to a better one following the ABC path: any job, better job, career.

7.3.4 Individual placement and support

Commissioners and alcohol treatment providers should consider making available individual placement and support (IPS). IPS is a highly personalised form of employment support with evidence that it is effective for people experiencing mental health problems and related conditions. There are several important differences between IPS and conventional employment support. For example, IPS employment specialists engage employers directly to explore opportunities for their clients. IPS also provides in-work support, including supporting the person in their new workplace while they adjust to their new role.

The government’s 10-year drug strategy commits to making IPS available in community alcohol (and drug) treatment in every part of England by 2024 to 2025. This mirrors a significant expansion of IPS in mental health services backed by NHS England. You can find a range of IPS resources at the Centre for Mental Health and at IPS Grow, a website funded by NHS England and the DWP to support the national roll-out of IPS in mental health services.

7.3.5 Benefit conditionality and support options

Jobcentre Plus requires people who are on out-of-work benefits (such as Jobseeker’s Allowance or the Universal Credit all work-related requirements) to fulfil the requirements of their Claimant Commitment, or face a sanction (a temporary reduction or suspension of payments). People on these benefits who are accessing structured treatment for alcohol (and drug) use can have their Claimant Commitment temporarily suspended under current legislation (see section 1.4 of the guide on Universal Credit for people claiming it). This is to allow the person to focus on engaging in treatment and recovery for a period of up to 6 months.

People in treatment who are receiving other benefits (for example Employment and Support Allowance or Universal Credit no work-related requirements, work-focused interview requirement or work preparation requirement groups) may have little or no contact with Jobcentre Plus or the Jobs and Benefits office. However, they may still be able to access some Jobcentre Plus or Jobs and Benefits office services and can also ask to discuss referral to specialist employment support programme.

7.3.6 Facilitating access to welfare benefits advice

The welfare benefits system is complex and keyworkers, clinicians and claimants themselves are unlikely to fully understand it. In-work benefits are among the most complex aspects of the system. Alcohol services should ensure that people have access to high-quality welfare benefits advice throughout treatment, including about benefit conditionality and financial planning, to help them make informed decisions about work. Citizens Advice offer welfare benefits advice among other services. Also, there are several charities that provide information and support for people wanting to access welfare benefits, including Turn2Us.

Ensuring that people in treatment have access to welfare benefits advice can help them to maximise their income, avoid problems and make informed decisions about financial implications of taking a particular job. This includes whether they will be financially better off in work, and if so, by how much. As well as mainstream DWP benefits (and legacy tax credits administered by HM Revenue and Customs), services should be able to signpost people to local authority schemes, including the:

• Local Welfare Assistance scheme
• Council Tax Reduction scheme
• Discretionary Housing Payments scheme

7.4 Establishing joint working to support employment

7.4.1 Employment support agency links

Treatment services should develop links with Jobcentre Plus, or Jobs and Benefits offices in Northern Ireland, and other relevant local employment support providers. This is made easier with designated, named points of contact at each service.

Good and regular communication between the treatment service and the local Jobcentre Plus or Jobs and Benefits office should mean that:

• both services can manage referrals from Jobcentre Plus or the Jobs and Benefits office to treatment
• people feel that they can disclose alcohol and drug problems and services will deal with this appropriately
• the Jobcentre Plus or Jobs and Benefits office can apply conditionality easements when needed
• services can better co-ordinate treatment and employment support around the person and adjust these to take account of changing circumstances (including referral to specialist employment support programmes)

Co-locating Jobcentre Plus or Jobs and Benefits office work coaches in treatment services may be an effective way of providing employment support and resolving welfare benefits queries. Peer mentors or other staff from treatment services based in Jobcentre Plus or Jobs and Benefits offices may help people to navigate sometimes complex and potentially intimidating Jobcentre Plus processes.

While it is appropriate for staff at treatment services and Jobcentre Plus or Jobs and Benefits offices to work together, a SPOC approach can be an effective way of ensuring continuity. The points of contact at either end could be a service manager, team leader or IPS team leader on the treatment side, and a partnership manager or disability employment adviser on the Jobcentre Plus side, and equivalent positions in Jobs and Benefits offices in Northern Ireland. Individual services and Jobcentre Plus offices or Jobs and Benefits offices could establish a simple service level agreement, although this is not essential.

7.4.2 Case management approach

A case management approach means that there is co-ordination between the alcohol treatment service and the person’s Jobcentre Plus or Jobs and Benefits office work coach (or their adviser if they have been referred to an external specialist programme). This approach can ensure that people can access conditionality easements (reducing or removing work-related requirements) when appropriate and any referrals to further employment support are informed by their progress with treatment and recovery.

When an alcohol treatment service refers someone to employment support, or they are already accessing employment support, the keyworker and employment support provider should adopt a case management approach to help co-ordinate treatment and other support. It is important to avoid a situation where treatment support and employment support have conflicting requirements. For example, a person in alcohol treatment may find it difficult to manage a claimant commitment requiring a large part of each week be spent on work search activities alongside attending a structured day programme.

7.4.3 Engagement with primary care

Treatment services should use established links with local GPs to ensure that they are aware of local employment support options. Doctors issue fit notes to people to provide evidence of the advice they have given about their fitness for work. The fit note is intended to be a positive process that looks at people’s strengths as well as their health conditions and capacity. GPs will be aware that patients may have conflicting priorities when requesting a fit note. For example, people wanting access to health-related benefits as opposed to interest in appropriate work or employment support. So, GPs should as a minimum know where to signpost patients for advice.

7.4.4 Recognising other health and wellbeing needs

People in treatment for alcohol use and dependence are likely to experience poor overall health and may have accumulated health harms because of their alcohol use. Ongoing support and access to treatment and medical care, including flexibility around appointment times, is essential to support employment and wellbeing. Treatment services offering flexible opening, or at least flexible appointments, can be a good way of ensuring that working people in treatment can continue to access support.

7.5 Engaging employers

Treatment providers should engage with employers in their local community. The primary aim of engaging with employers should be to reach people with treatment needs and to support employers to be more informed about alcohol use, treatment, recovery and employment.

Engaging with employers can:

• help to support people in treatment to remain in work
• help reach under-served parts of the community
• build relationships that could support future employment opportunities for people in treatment
• offer a way to contact employees who might need advice or treatment but feel reluctant to engage with alcohol services
• offer an opportunity to help employers improve their workplace alcohol policies

7.6 Safeguarding and risk management

Treatment services should have policies to guide responses to concerns about people in treatment working in safety-critical roles. Some safety-critical roles are defined in legislation, but more broadly this means any role where health and safety would be unacceptably compromised by someone being impaired due to alcohol (or drug) use. Risk assessment processes and any safeguarding matters relating to work should be:

• comprehensive
• transparent
• involve the service user at the earliest stage

Services will be aware that ongoing alcohol (and drug) use may pose risks in safety-critical occupations, and that this could pose a range of issues depending on the circumstances, including ethical, legal and reputational. Risk assessments should take employment into consideration and should always be done with the person. Where a workplace risk is identified, services will need to carefully consider the details of each case.

8. Harm reduction

8.1 Main points

A harm reduction approach or philosophy frames the aim of alcohol treatment as reducing harms associated with a person’s alcohol use. Harm reduction can be understood as a continuum, with small changes at one end of the continuum and complete abstinence at the other.

A goal of abstinence is usually the appropriate goal for people who are moderately or severely alcohol dependent.

If a person is unwilling to consider abstinence, this should not be a reason to deny them support from the alcohol treatment service. The practitioner can agree a harm reduction approach with the person which focuses on reducing health and social harms associated with harmful drinking and alcohol dependence.

Working with a person to reduce harm can build therapeutic rapport and help people with more complex needs to engage in treatment.

Assessment, including risk assessment, and treatment and recovery planning are central to care for people working on harm reduction goals. These processes need to be tailored to the needs of each individual and provided flexibly.

Keyworkers should regularly review harm reduction goals with the person and discuss any barriers that prevent them working towards abstinence. Clinicians should review the health of people who continue to drink at harmful or dependent levels.

A harm reduction approach may (although will not always) involve the person reducing their alcohol use. Any reduction in alcohol use, even among dependent drinkers, can reduce alcohol related harm.

If a person who is moderately alcohol dependent wants to reduce their alcohol use rather than abstain, a clinician should assess whether there are any safety considerations that indicate this approach is not appropriate.

If the person is assessed as appropriate, the clinician can develop a plan for gradual reduction with the person and work with the keyworker (if the clinician is not the keyworker) to monitor and support the person through the planned reduction.

Clinicians should prescribe oral or parenterally (intramuscularly) administered thiamine because this can reduce the risk of Wernicke-Korsakoff syndrome and other neurological consequences of harmful alcohol use.

Staff in alcohol treatment services and staff working in wider health and social care services should be trained to provide alcohol harm reduction information and advice.

Alcohol harm reduction information and advice includes telling people about:

• the risks of stopping drinking suddenly and advice not to do this
• the decrease in tolerance after a period of abstinence and the risks of drinking at pre-abstinence levels
• risks related to intoxication and alcohol poisoning
• the increased risk of overdose and other harms when drugs (including prescription and over the counter medication) and alcohol are taken together
• specific advice for older people, young people and women who are pregnant or may become pregnant

8.2 A harm reduction approach

8.2.1 Overview

A harm reduction approach or philosophy frames the aim of alcohol treatment as reducing the harms associated with a person’s alcohol use. Abstinence and harm reduction approaches can be seen in an unhelpfully polarised way that makes their goals seem mutually exclusive. Instead, it can be helpful to understand harm reduction on a continuum, with small changes at one end of the continuum and complete abstinence at the other.

Harmful drinkers and people with alcohol dependence often experience physical, mental health or social harms associated with their alcohol use. Assessment, treatment and support to address those harms is vital to effective alcohol treatment and recovery. So, a harm reduction approach is relevant to everyone who engages in alcohol treatment, whatever their alcohol use goal.

In the context of a harm reduction approach to alcohol treatment, there are particular considerations for people with alcohol dependence who are not ready or willing to choose a goal of abstinence or moderation (‘moderation’ is defined in these guidelines as drinking up to 14 units per week). For this group of people, harm reduction becomes the main focus of the work, although practitioners should review this with them regularly.

8.2.2 Assessment and treatment and recovery planning

Assessment and treatment and recovery planning processes, including risk assessment and risk management, are central to the care of a person who is working towards harm reduction goals. A choice to focus solely on harm reduction should not mean the person misses out on these essential processes, which should be tailored to their individual needs.

You should read chapter 4 on assessment and treatment and recovery planning.

Harm reduction goals and interventions should be part of a broader treatment and recovery plan. This may include longer term recovery goals such as joining peer-based support groups or working towards employment. Treatment and recovery planning should include agreeing a contingency plan with the person. This should include actions the keyworker will take if the person disengages from treatment, such as making follow up phone calls or contacting a family member and relevant services.

8.2.3 A flexible service approach

Services may need to be flexible in how they provide assessment and treatment and recovery planning and harm reduction interventions. People experiencing multiple disadvantage often find it very difficult to attend a service for regular appointments. These people often have 2 or more needs including:

• alcohol or drug problems
• homelessness
• mental health problems
• recently involved in the criminal justice system
• experiencing domestic abuse

Assertive outreach and co-ordinating a multi-agency team around the person are ways to flexibly deliver harm reduction approaches tailored to the needs of those who find it difficult to use structured alcohol treatment services without targeted support. Services may offer flexibility in other ways. For example, they may need to keep cases open for longer, even where the person misses several appointments.

You can find guidance on assertive outreach and multi-agency team around the person in chapter 9.

8.3 Harm reduction goals

8.3.1 Acute harm reduction goals

A treatment and recovery plan should include harm reduction goals across the areas that are covered by the comprehensive assessment. Chapter 4 describes assessment and treatment and recovery planning for a wide range of longer-term harms including physical health, mental health and social harms.

A person’s acute harm reduction goals can include an alcohol use goal of reduced drinking, even if their drinking remains at harmful or dependent levels. Goals can also include a reduction of risks and harms related to:

• alcohol related brain damage, including Wernicke-Korsakoff syndrome
• unplanned acute withdrawal
• reduced tolerance after a period of abstinence
• intoxication, including alcohol poisoning
• additional drug use, including over the counter and prescribed medications

8.3.2 Agreeing harm reduction goals

A goal of abstinence is generally recommended for people who meet any of the following criteria.

The person is moderately alcohol dependent (who drinks between 15 units and 30 units a day and scores between 15 and 30 on the Severity of Alcohol Dependence Questionnaire (SADQ).

The person is severely alcohol dependent (who drinks approximately 30 units or more a day and scores 30 or more on the SADQ).

The person has a significant or unstable mental health or physical health condition.

Abstinence is generally recommended for people meeting these criteria because it has the greatest affect in reducing risks to health and sustaining longer term change (Mann and others 2017). However, if a person is not ready or willing to agree to a goal of abstinence, the practitioner should consider a harm reduction strategy and discuss this option with the person. The practitioner should inform the person of any significant risks involved with their continued alcohol use, for example risks to their physical or mental health. If the person still does not opt for a goal of abstinence, the practitioner should then work with the person on developing a practical and personalised plan that addresses their harm reduction goals.

A treatment and recovery plan that focuses on harm reduction may (although will not necessarily) include a reduction in alcohol use as a specific goal. Ultimately, the practitioner should encourage a goal of abstinence as this will have the greatest effect in reducing risks to the person. However, evidence shows that any reduction in alcohol use is associated with a reduction in health harms, even though the person may still be drinking at harmful or dependent levels (Witkiewitz and others 2021).

A harm reduction focused plan will involve a practitioner providing information and interventions to reduce physical health, mental health and social harms. Even if the person does not reduce their alcohol use at first, if the practitioner and the person can agree a plan that helps reduce the harms and risks related to their alcohol use, this is a positive outcome. It can even help to prevent premature death.

Establishing a therapeutic alliance and achieving outcomes valued by the person can also help to enhance their motivation and they may go on to choose a goal of reduced drinking or abstinence at a later stage.

8.3.3 Reviewing alcohol use goals

While an approach that focuses solely on reducing harms may be the most useful way to work with a person initially, practitioners should never assume that a person is incapable of achieving abstinence or making significant reductions in their alcohol use. They should review alcohol use goals with the person at frequent defined intervals and adjust the plan as appropriate. Some people may continue to drink harmfully or dependently, and clinicians should regularly review their health and take actions to address any deterioration.

8.3.4 Motivation

A person’s unwillingness to consider a goal of abstinence or moderation should not prevent them accessing support from an alcohol treatment service. An individual harm reduction focused plan is based on tailoring treatment to the person’s level of motivation at the time they are assessed. It also attempts to enhance their motivation to change. A harm reduction approach should attempt to make use of the principles, processes and communication skills of motivational interviewing. You can find more information on motivational interviewing in section 5.7.2 in chapter 5 on psychosocial interventions.

Training and supervision in motivational interventions and in a trauma-informed approach should help practitioners to understand ambivalence as a natural part of any decision about behaviour change. It will also help practitioners consider how the experience of trauma might contribute to the person’s ambivalence towards abstinence or moderation. You can find more information on trauma-informed care in section 2.2.8 in chapter 2 on principles of care.

Addressing potential barriers to engagement can positively affect the person’s motivation. For example, if a person is experiencing homelessness, supporting them to access safe and secure accommodation is the priority and can enhance their motivation to address their alcohol use at a later stage.

8.4 Reducing alcohol use when a person is alcohol dependent

8.4.1 Supporting people to reduce alcohol use: overview

A specialist clinician should assess whether the person is suitable for a gradual planned alcohol reduction.

Once the person has been assessed as suitable, the clinician and keyworker (if the clinician is not the keyworker) should make arrangements to support the person to do this. They should agree the role each will have in monitoring and supporting the person as they reduce their alcohol use (see sections 8.4.3 and 8.4.4 below for an overview of the roles of specialist clinicians and non-clinical keyworkers). They can then help the person make a plan to reduce their alcohol use safely, regularly reviewing progress, recognising achievement, and offering ongoing motivational support.

For further guidance on supporting people to reduce their alcohol use, see section 8.7 on developing and monitoring a gradual alcohol reduction plan and section 8.8 for a step-by-step approach to reducing alcohol consumption below.

8.4.2 Risks and benefits of reducing alcohol use when a person is alcohol dependent

For people who are alcohol dependent, there are benefits and risks involved in cutting down their alcohol use. Any reduction in alcohol use can reduce harm to health (Witkiewitz and others 2021). But reducing alcohol use when someone is alcohol dependent, especially when the reduction is sudden, can result in acute withdrawal symptoms. There is evidence that untreated withdrawal can cause short or long-term brain damage and there is a risk of serious complications, including:

• seizures
• delirium tremens
• Wernicke-Korsakoff syndrome

See section 10.4 in chapter 10 on pharmacological interventions for guidance on complications in withdrawal.

8.4.3 The role of the multidisciplinary team or specialist clinician

The multidisciplinary team (MDT), or a clinician competent in diagnosing and assessing alcohol dependence and withdrawal symptoms, should be responsible for:

• assessing the suitability of the person for reducing alcohol use without medication
• developing a personalised alcohol reduction plan
• monitoring the impact of the alcohol reduction on the person

8.4.4 The role of the non-clinical keyworker

In addition to the input from the MDT or specialist clinician, the keyworker (who might not be the clinician) should offer psychosocial support to the person throughout their planned reduction. Non-clinical keyworkers should be trained to offer support for planned alcohol reduction.

The service should have an escalation process so the keyworker can receive advice and supervision from the MDT or lead clinician if there are any signs of risk to the person’s health. Non-clinical keyworkers should be trained to recognise symptoms of withdrawal complications that mean the person should be referred to hospital as an emergency. See step 3 in section 8.8 below for a list of these symptoms.

8.5 Assessing the suitability of a planned gradual reduction in alcohol use

8.5.1 Assessing suitability and safety considerations

If a person who is dependent on alcohol does not want to go through a medically assisted withdrawal (detoxification) but wants to cut down their alcohol use, a specialist clinician should assess the appropriateness of a gradual reduction plan. The clinician will need to take account of the person’s needs, risks and strengths as outlined in their comprehensive assessment.

The clinician should consider indications that it would not be safe for the person to reduce alcohol without medication, due to the high risk of serious complications in withdrawal.

The alcohol guidelines development group recommends that the person should not reduce alcohol without medication if they:

• are assessed as severely dependent (likely to be drinking more than 30 units a day and score 30 or more on the SADQ)
• have experienced serious complications in withdrawal in the past (such as seizures (fits), hallucinations or delirium tremens, or Wernicke-Korsakoff syndrome)
• have epilepsy
• have significant unstable physical health or mental health

If the person meets any of the criteria above, the clinician should provide the person with information on why they recommend against reducing alcohol without medication and recommend that the person has a medically assisted withdrawal. If the person still does not want to have a medically assisted withdrawal, the clinician should advise the person to continue to drink at a steady rate, without sudden reductions or heavy drinking episodes. They should continue to monitor the person’s health and to review and address any barriers the person may experience to opting for medically assisted withdrawal.

8.5.2 Recommending medically assisted withdrawal

For people who are moderately or severely dependent, the National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) recommends medically assisted withdrawal to achieve abstinence and this is the safest and best practice option.

If the person has a goal of moderation, this is often best achieved following a period of abstinence. So, medically assisted withdrawal will also be an appropriate intervention if the person is aiming at moderation. The clinician assessing the person should recommend and offer medically assisted withdrawal. They should discuss the risks and benefits of this intervention, providing verbal and written (or visual or audio) information in a way the person can easily understand, using independent interpreters and translation if necessary.

The clinician should only consider planned alcohol reduction without medication if:

• the person then makes an informed decision that they do not want to have a medically assisted withdrawal
• there are no safety considerations that indicate the risk is too high (see list above in section 8.5.1 on assessing suitability and safety considerations)

8.5.3 Information on the risks and benefits of planned alcohol reduction

The clinician should discuss the risks and benefits of planned alcohol reduction with the person and provide verbal and written or other accessible information in a way that the person can easily understand. Information should include advice against stopping or cutting down alcohol too suddenly, information on withdrawal symptoms and the risk of complications in withdrawal.

See section 10.4 in chapter 10 on pharmacological interventions for guidance on complications in withdrawal.

8.6 Supporting people with different severity of dependence

8.6.1 People who are moderately alcohol dependent

A person who is moderately alcohol dependent will drink approximately 15 to 30 units a day and score approximately 15 to 30 on SADQ For example, on a daily basis, people drinking above 15 units a day could be drinking one of the following:

• half a bottle of spirits (40% alcohol by volume (ABV))
• one and a half bottles of wine (12.5% ABV)
• 8 pints of lower strength beer (3.6% ABV)
• 6 cans (440ml) of higher strength lager, cider or beer (5.5% ABV)
• 4 cans (440ml) of super lager or 2 litres of super strong cider (8% ABV)

The spirits example needs to specify that it is a 750ml bottle. The wine example needs to be increased to a 750ml bottle of 12.5% ABV (where 1.5 bottles would be 14 units) since neither 1.5times a 700ml or 750ml bottle contains 14 units. The super strength lager example should be 4 cans at 440ml which gives you 14.08 units.

You can use the step-by-step approach in section 8.8 below to support people with moderate dependence to reduce their alcohol use where there are no safety considerations as outlined in section 8.5.1 above.

8.6.2 People who are severely alcohol dependent

The alcohol guidelines development group recommend that people who are severely alcohol dependent do not reduce their alcohol use without medication and the clinician should discuss the reasons for this with the person (see section 8.5 above on assessing the suitability of a planned gradual reduction in alcohol use).

In the exceptional circumstance where a person who is severely dependent opts to cut down their alcohol use without medication against medical advice, the clinician should arrange a medical or nursing review. They should also provide personalised advice on the risks, making sure that the person has understood the information. They can then agree an individual plan for reduction and how often this should be reviewed. The clinician can follow all the advice given in section 8.6 for people who are moderately dependent but people who are severely dependent should cut down at a slower rate and be very aware of any withdrawal symptoms.

As there are higher risks for people who are severely dependent, the MDT or specialist clinician should closely monitor the person as they reduce their alcohol use. If they start to experience uncomfortable withdrawal symptoms (such as sweating, shaking, anxiety and nausea), this means they are cutting down too quickly. In that case, they need to drink a steady amount for a week, then cut down by smaller amounts over a longer period of time.

As the risks are higher for people with severe dependence, it is particularly important to advise the person to have somebody to support them as they cut down. The clinician should make sure the person and the person supporting them understand they should call an ambulance or go immediately to the hospital emergency department if they see signs of serious complications (see step 3 in section 8.8 below on serious complications in withdrawal).

8.7 Developing and monitoring a gradual alcohol reduction plan

8.7.1 Developing a plan

The clinician should develop a plan for gradual alcohol reduction with the person. The plan will include:

• monitoring the person’s current level of alcohol use
• the agreed initial level of reduction (how may units they aim to reduce by) and pace of reduction (how many days they aim to remain at each level of consumption)
• arrangements for the clinician to monitor the impact of the reduction
• arrangements for psychosocial support (keyworker and where appropriate, family members or friends)
• arrangements for prescribing thiamine (see section 8.9 below)
• when working with parents or carers, arrangements for supporting children or vulnerable adults where appropriate

8.7.2 Working with parents and carers who are cutting down on drinking

When developing a plan with a parent or carer, you should help them to consider the support that their family or children might need during the period when they are cutting down their alcohol use. For example, where appropriate, whether the children (or any adult the person is caring for) could stay with supportive relatives or friends, or whether professionals can offer support if necessary.

The practitioner should work with professionals involved with the family to co-ordinate care for the person and their family if this is needed. As always, practitioners should work in line with safeguarding legislation and organisational procedures. You can find information on child and adult safeguarding legislation and guidance in annex 1.

Family members and friends may also want to access support through organisations such as Al Anon and Adfam. Alcohol treatment services should provide advice for family members who are supporting the person.

8.8 The step-by-step approach to reducing alcohol consumption

The guidance on gradually reducing alcohol use in this section is based on clinical consensus of the alcohol guidelines development group.

This step-by-step approach is for people who are moderately dependent on alcohol and have been assessed as suitable for gradual alcohol reduction by a specialist clinician.

Step 1: work out how much the person drinks

Work out how much the person drinks in a day. A drink diary can be useful to record this (see section 8.13 in chapter 8 on harm reduction for examples of drink diaries). You should ask them to be accurate and explain that minimising their own use can increase risk when deciding on the reduction rate.

Ask the person to write down each drink they have, when they have it and help them to find out how many units the drink has in it. They can work it out with an online or printed unit calculator (see section 8.13 for an example of a unit calculator). Alternatively, the percentage of alcohol on the side of the bottle or can represents the number of units in a litre. If the person agrees, a family member or friend could help with this.

Step 2: make a plan

Once the person knows how much they have been drinking, suggest they keep their drinking at that level for at least 3 days (and up to 7 days), before starting to cut down.

Agree with the person what level of consumption they are aiming to achieve.

Suggest they try to space out their drinks, particularly in the middle of the day. They should measure drinks using the same glass, measuring cup or can, or ask a family member to do this for them. Suggest they record how much they drink each day in a drink diary.

Offer your support as they cut down and arrange regular meetings and phone calls with the person to monitor their wellbeing and enhance their motivation (see step 5 on cutting down at their own pace below).

Suggest they ask an appropriate family member or friend to support them and encourage them to arrange regular in-person and phone contact with them. Remind them they can use organisations that offer online and telephone support. For example, the Alcoholics Anonymous helpline or national alcohol helplines (see section 8.13 below for more details on these resources).

Wherever possible, speak to a family member or friend and provide them with information about the process.

You should also tell the person and the family member that they should call an ambulance if the person seems to be experiencing serious withdrawal complications (see step 3 below).

If the person is a parent or carer, discuss the support needs of their family members (see section 6.2 on working with parents and carers above).

Step 3: tell them about serious complications in withdrawal

Advise them to watch out for serious complications, including:

• symptoms worsening to the point of severe shaking and very heavy sweating
• seizures (fits)
• seeing, hearing or feeling things that are not there (hallucinations or delirium tremens)
• feeling confused about where they are, what time it is, who they are with (symptoms of Wernicke-Korsakoff syndrome)
• poor co-ordination and unsteadiness on their feet (symptoms of Wernicke-Korsakoff syndrome)

If any of these serious complications occur, they or the person providing support should call an ambulance immediately or go to the hospital emergency department for urgent medical help.

Inform them and the person supporting them that changes in mood and volatility can sometimes occur during a reduction programme.

Step 4: provide advice on health and wellbeing during gradual alcohol reduction

Reassure them that although people often describe feeling frightened and alone when they are reducing or stopping drinking, it can help if they let their keyworker, friends and family know how they feel. Tell them they should try to distract themselves with things that they enjoy.

Tell them that sleep may remain a problem for a while, but that they should keep to a routine and be patient.

If the person is prescribed thiamine orally, remind them to make sure they take it (see section 8.9 on prescribing thiamine below) and advise them to try and eat foods high in thiamine (B1), such as meat, fish, brown bread and rice. You can also suggest they keep well-hydrated by drinking plenty of water.

Advise them on relapse prevention strategies including managing urges and cravings and taking part in distracting and meaningful activities (see section 5.7.4 in chapter 5 on psychosocial interventions).

Provide advice sheets for the person and their family member or friend. For example, this could include information on:

• diet
• sleep
• cravings
• concentration and mood
• coping strategies

You should include contact numbers for the alcohol treatment service and for other support, such as helplines. Advice sheets should be easy for the person (and the person supporting them) to understand and take into account the person’s language and communication needs.

Step 5: cut down gradually at their own pace

It’s important to cut down gradually at a pace that suits the person but aim at cutting down by no more than 10% a day. If they are drinking more than 25 units a day, are over 65 or their general health is not good, they may need to cut down more slowly. For example, this could be no more than 10% every 4 days.

It is important that the person cuts down at a pace that suits them. They may want to reduce by 10% or less and stay at that level for several weeks or months. Help the person, and where appropriate the family member or friend, to work out what 10% of their intake is in units and how much of their usual alcoholic drink that would be.

If they start to experience uncomfortable withdrawal symptoms (sweating, shaking, anxiety, nausea), this means they are cutting down too quickly. In that case, they need to drink a steady amount for several days again, then cut down by smaller amounts over a longer period of time.

Step 6: arrange regular and frequent review

Arrange regular and frequent review supported by a clinician to identify any withdrawal symptoms (see step 4 above) or worsening physical or mental health.

How often you review the person should be agreed with the MDT or senior clinician overseeing the reduction.

Ask about withdrawal symptoms, any health problems and changes in their mood and volatility.

Refer and support the person to access medical help if their physical or mental health worsens.

Offer motivational support and recognise the person’s progress.

If the person is not managing to reduce their drinking, review the plan and amend if appropriate. Offer motivational support and help the person to address barriers to progress.

8.9 Prescribing thiamine to prevent alcohol related brain damage and other neurological consequences

In people who drink at harmful or dependent levels over a period of time, there is a risk of both short and long term alcohol related brain damage, including Wernicke-Korsakoff syndrome. Chapter 20 provides comprehensive guidance on alcohol related brain damage.

Wernicke-Korsakoff syndrome is preventable. Prescribing oral or intramuscularly administered thiamine can prevent or reduce the risk of Wernicke-Korsakoff syndrome and other neurological consequences, such as peripheral neuropathy.

Thiamine can be prescribed orally or intramuscularly in the community. You should prescribe thiamine based on individual assessment and the type of healthcare setting you are treating the person in. Thiamine is recommended for people undergoing medically assisted withdrawal and also for people who continue to drink at harmful and dependent levels. Section 10.4.3 in chapter 10 on pharmacological interventions provides guidance on prescribing and administering thiamine.

8.10 Managed alcohol programmes

Managed alcohol programmes are comprehensive harm reduction programmes of care that aim to support people drinking harmfully or dependently to manage their alcohol use and its associated harms. These programmes involve alcohol treatment practitioners distributing an agreed amount of alcohol each day to support people to drink at a steady pace. Drinking at a steady pace is less harmful than very heavy episodic drinking and periods of unplanned withdrawal.

These guidelines do not include guidance on managed alcohol programmes as there is currently little high quality evidence on their effectiveness to base guidance on (Magwood and others 2020). There are also very few formal managed alcohol programmes in the UK, so few UK clinicians have gained clinical expertise in this area. The alcohol guidelines development group recommend that more research in this area would be useful.

8.11 Driving while under the influence of alcohol

People who drink heavily and daily may not appear or feel intoxicated because they will have developed tolerance to alcohol. Tolerance is the need to drink more alcohol to get the same or desired effect, and it develops in people who drink heavily and regularly. They are likely to be over the legal driving limit on a daily basis and should be advised not to drive.

The practitioner should advise people who are alcohol dependent or who regularly drink at harmful levels not to drive. They should explain to the person that their alcohol use condition means they are not fit to drive and that they should inform the Driver and Vehicle Licensing Agency (DVLA). The practitioner should explain that although they may not feel intoxicated, their functioning and judgment will still be affected. You can find more information on drink driving in annex 3.

8.12 Harm reduction information and advice

8.12.1 Overview

This section on harm reduction information and advice, and its associated appendices below, is relevant for practitioners in alcohol treatment services. It is also relevant for staff in a range of other health and social care settings, such as homelessness services who work with people who are alcohol dependent or drink harmfully.

Services should make available simple, clear, written alcohol harm reduction information and practitioners should understand this information and be able to provide advice verbally. Services should also provide information in other formats (such as graphic, video or audio) and in translation for people whose first language is not English. You should make this information and advice available so it can be provided at a one-off occasion to support a Making Every Contact Count (MECC) approach.

Alcohol treatment practitioners can also provide information and advice over several sessions (either individual or group) using a psychoeducational approach. A psychoeducational approach involves the practitioner providing information and support to the person so they can better understand and make changes in their alcohol use and associated problems. The information may be new to the person, and it can prompt conversation about risks and benefits associated with their alcohol use. This can help the person to make informed choices about ways to manage acute harms and risks as part of their personalised harm reduction plan.

You should offer to provide harm reduction information to family members or friends supporting the person. Some of the advice, such as actions to take in a medical emergency, will be addressed specifically to family members and friends.

8.12.2 Providing harm reduction information and advice on specific areas

When providing harm reduction information and advice, it is useful to include:

• information and advice for people who are alcohol dependent not to stop drinking suddenly
• information and advice about reduced tolerance and risks of intoxication including alcohol poisoning
• information and advice about intoxication and related risks
• information and advice about alcohol poisoning
• information and advice about concurrent alcohol use and prescribed medications or illicit drug use
• harm reduction information and advice for specific populations

Appendices A to F provide more detailed guidance on providing harm reduction information and advice.

8.13 Harm reduction resources

Helplines and meetings

Alcoholics Anonymous a free confidential helpline and website with information on local mutual aid meetings for people who need help with their drinking.

Drinkline, a free, confidential helpline for people who are concerned about their drinking, or someone else’s. Call 0300 123 1110 (weekdays 9am to 8pm, weekends 11am to 4pm).

If you are in Scotland, you can contact Drinkline Scotland for free on 0800 7314 314 (weekdays 9am to 9pm, weekends 10am to 4pm).

Wales DAN 24/7 is a bilingual drug and alcohol helpline. Call free on 0808 808 2234 or text DAN to 81066. DAN 24/7 calls will not appear on home itemised call lists.

SMART Recovery holds both face-to-face and online meetings that support people in managing harmful drinking and other behaviours. You can find out about meetings on the SMART Recovery website.

Alcohol unit calculator

Alcohol Change UK have published a number of interactive tools to help people check out their drinking, including a unit calculator which allows them to find out how many units are in a particular drink or to check out how much they’re drinking on a weekly basis.

Drink diaries

Encouraging people to self-monitor and record their alcohol use is a useful intervention. It can help with assessment, and it can also help people to have more self-awareness around drinking situations and to understand the consequences of drinking.

People can record information on paper diary sheets or using digital apps. The diaries can be individually tailored to the person’s treatment needs and the interventions they are receiving, but would typically include:

• the date and time
• a description of the drinking circumstances
• the amount they drank in units or drinks
• the person’s thoughts and feelings
• the consequences of drinking

Drink diary examples

The following are examples of drink diaries currently used in treatment settings.

The Turning Point alcohol usage guide contains:

• a downloadable drink diary
• information for people on how to use the tool and how to calculate units
• advice about reducing alcohol consumption

The Catalyst alcohol support resource provides:

• a downloadable drink diary
• information and support about alcohol use
• Information about alcohol units

8.14 References

Magwood O, Salvalaggio G, Beder M, Kendall C, Kpade V, Daghmach W and others. The effectiveness of substance use interventions for homeless and vulnerably housed persons: a systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PLoS ONE 2020: volume 15, issue 1, e0227298

Mann K, Aubin HJ and Witkiewitz K. Reduced drinking in alcohol dependence treatment, what is the evidence? European Addiction Research 2017: volume 23, issue 5, pages 219-230

Royal College of Psychiatrists. Our invisible addicts (2nd edition), College Report CR211. RCPsych 2018

Witkiewitz K, Kranzler HR, Hallgren KA and others. Stability of drinking reductions and long-term functioning among patients with alcohol use disorder. Journal of General Internal Medicine 2021: volume 36, pages 404-412

Appendix A: advising people who are alcohol dependent not to stop drinking suddenly

A1. Withdrawal symptoms and complications

People who are moderately or severely alcohol dependent will experience withdrawal symptoms after stopping drinking (as early as between 6 to 8 hours).

If they suddenly stop or substantially reduce their alcohol use, they will experience acute alcohol withdrawal syndrome, which can lead to severe complications and can even be fatal.

There is a comprehensive list of alcohol withdrawal symptoms and complications in annex 2.

A2. Information and advice

For people who may be moderately or severely alcohol dependent, the practitioner should:

• describe withdrawal symptoms and explain they are a sign of alcohol dependence
• advise them that they should not stop drinking or substantially reduce their alcohol use suddenly
• advise them that stopping suddenly or reducing their alcohol use too quickly can lead to severe complications and can even be fatal
• briefly describe severe complications and how to recognise them
• advise them and anyone who supports them to call an ambulance if the person experiences severe withdrawal complications
• inform them that the safest way to stop drinking and the best treatment advice is to have a medically assisted withdrawal (detox)
• inform them you can offer or refer the person for an assessment by an alcohol specialist clinician for medically assisted withdrawal

If the person does not want to stop drinking at dependent levels, the practitioner should advise them to maintain their drinking at a steady level and space out drinks evenly to help reduce the occurrence of withdrawal symptoms.

If the person does not want a medically assisted withdrawal, but they plan to reduce their drinking, see section 8.5 for guidance on planned gradual reduction.

Appendix B: reduced tolerance and risks of intoxication including alcohol poisoning

B1. Alcohol tolerance

Tolerance is the need to drink more alcohol to get the same or desired effect, and it develops in people who drink heavily and regularly. The effect of blood alcohol concentration on a person will decrease as tolerance develops. Although, even in people who have developed tolerance, a high level of alcohol use will still impair functioning and judgement. NICE CG115 (full guideline) found that people with very high alcohol tolerance will be able to tolerate a high blood alcohol concentration that would be fatal to a non-tolerant person.

After a period of abstinence, tolerance is greatly reduced. If a person returns to drinking at their pre-abstinence level, the effects of blood alcohol concentration will be much greater than they were before they became abstinent. There is a risk they may experience fatal alcohol poisoning. People who have had an unplanned period of abstinence, for example during time in custody or in hospital, may be particularly at risk of returning to drinking at pre-abstinence levels.

B2. Information and advice

The practitioner should provide information and advice to the person on tolerance and alcohol poisoning, including:

• what tolerance is and how it develops
• how tolerance is reduced after a period of abstinence
• how the risks of intoxication including alcohol poisoning increase after a period of abstinence (see appendix C below on intoxication and related risks)
• the increased risk of taking other drugs in addition to drinking after a period of abstinence (appendix E below on concurrent use of prescribed medications or illicit drugs)

Appendix C: intoxication and related risks

C1. Overview

Intoxication from drinking too much and too quickly may involve significant impairments in:

• motor co-ordination
• reaction time
• judgement and decision-making
• impulse control

It can also involve:

• drowsiness
• digestive problems
• dehydration

At higher levels of blood alcohol content there is a risk of alcohol poisoning.

The level of consumption that leads to significant impairment will vary according to factors such as:

• body size
• whether the person has eaten
• tolerance
• health, including liver function

Intoxication can be associated with several risky behaviours and expose people to risks from others (see section C4 below on mitigating risky behaviour while intoxicated).

C2. Information and advice: intoxication

The practitioner should provide information and advice about intoxication that includes:

• a summary of the UK chief medical officers’ alcohol guidelines on lower risk, increasing risk, high risk drinking levels and single occasion drinking
• a summary of common short-term risks, such as injuries (including head injuries), falls, road traffic accidents, accidents with machinery, drownings and burns
• a summary of common increased risky behaviours, such as unsafe sex which can result in unplanned pregnancies or sexually transmitted diseases
• information about a person’s increased risk of violence (as a perpetrator), including domestic violence
• information about a person’s increased vulnerability to domestic abuse (as a victim) and to sexual assault
• information about a person’s increased risk of self-harm (including suicide)
• information about the increased risk of problems at work including absence

C3. Information and advice: managing alcohol use

Information and advice on managing alcohol use can include:

• drinking at a slower pace, including avoiding drinking in a round where there can be pressure to drink at a faster pace
• alternating between alcoholic drinks with soft drinks or water
• drinking lower strength drinks
• eating before drinking
• start drinking later or finishing earlier
• avoiding areas or activities associated with heavy drinking or heavy drinking social networks
• drinking with people who drink at lower risk levels, where possible
• avoiding taking alcohol and drugs together

C4. Information and advice: mitigating risky behaviour while intoxicated

Information and advice on mitigating risky behaviour while intoxicated should be individually tailored and can form part of a treatment and recovery plan. Examples include advice on:

• avoiding drink driving or operating machinery (see annex 3 for responsibilities of staff relating to drink driving)
• arranging with a supportive friend or family member to stay together during the evening, and travel home together
• installing smoke detectors and removing trip hazards in the home (for people who are frequently very intoxicated and for older people who are at greater risk of falls)
• information about local sexual health services and what they provide
• discussing contraception and the risks of alcohol exposed pregnancies (see appendix F below on women who are pregnant or may become pregnant)
• specific advice for people who are at risk of domestic abuse (see chapter 22 on domestic abuse)
• specific advice and support on self-harm including suicidal ideation (for guidance on providing information and support for people who self-harm, see the NICE guideline Self-harm: assessment, management and preventing recurrence (NG225))

Appendix D: alcohol poisoning

D1. Overview

Alcohol poisoning (sometimes known as alcohol overdose) can result when a person drinks a toxic amount of alcohol, particularly if this takes place over a short space of time. This leads to high blood alcohol levels which the liver cannot process. The level of consumption that leads to alcohol poisoning will vary according to factors such as:

• body size
• health, including liver function
• tolerance

However, drinking above 12 units, especially during a short space of time, is a broad indicator of risk of alcohol poisoning.

Alcohol poisoning may be experienced by people who are relatively inexperienced with alcohol use and unaware of its toxic effects. However, people who are alcohol dependent can also experience alcohol poisoning and there is an increased risk of this if they drink heavily following a period of abstinence where their tolerance to alcohol has decreased (see appendix B on reduced tolerance and risks of intoxication including alcohol poisoning).

Alcohol poisoning affects the automatic functions of the body, including breathing, heart rate and gag reflex (which prevents choking), so it puts the person at risk of a coma and of death.

D2. Signs and symptoms of alcohol poisoning

Signs and symptoms of alcohol poisoning may not all be present at the same time. They include:

• confusion
• vomiting
• seizures (fits)
• slow breathing
• pale or bluish skin
• cold and clammy skin
• unconsciousness

D3. Information and advice

As well as describing the signs and symptoms of alcohol poisoning, practitioners should provide information and advice on alcohol poisoning including telling people that:

• they can experience alcohol poisoning if they drink a large amount in a short space of time and that they should pace their alcohol use (see appendix C on intoxication and related risks)
• a person with suspected alcohol poisoning is a medical emergency and whoever is with them should call an ambulance immediately
• a person with suspected alcohol poisoning should not be left alone
• a person with suspected alcohol poisoning should be helped to stay upright and awake if possible and helped to drink water if possible
• if a person with suspected alcohol poisoning is unconscious, they should be placed on their side with their ear to the ground with a cushion under their head (the recovery position)
• a person with suspected alcohol poisoning should not be made to vomit as there will be a risk of choking (as the gag reflex is not functioning)
• symptoms of alcohol poisoning may worsen even after the person has stopped drinking and is unconscious

Appendix E: concurrent use of prescribed medications or illicit drugs

E1. Overview

Advice on concurrent use of alcohol and prescribed medications or illicit drugs (drinking and taking drugs together) will usually be provided by qualified staff at specialist alcohol and drug treatment services. In these services, identifying a person’s concurrent alcohol and substance use should take place at initial assessment and subsequent treatment reviews. There are many different interactions between prescribed medication and illicit drugs, so a clinician should make an individual assessment of the risks to the person and provide them with tailored advice. The British National Formulary (BNF) provides information on interactions between alcohol and prescribed medicines.

The alcohol or drug treatment practitioner should support the person to reduce risks related to concurrent use of alcohol and prescribed medications and illicit drugs. They may need to agree additional treatment plans focused specifically on drug use. Section 5.1 provides guidance on pharmacological interventions for concurrent alcohol and illicit drugs or prescribed medications. Drug misuse and dependence: UK guidelines on clinical management provides guidance on drug use, including alcohol in drug treatment, in section 6.5.

Staff in other health and social care services should inform a person suspected of concurrent use that taking alcohol and drugs together can increase risks of overdose and other serious health risks. They should also refer the person to an alcohol and drug treatment service.

E2. Information and advice on concurrent use

Information and advice on concurrent use of alcohol and prescribed medications or illicit drugs should include the:

• increased risk of overdose due to reduced tolerance following a break in regular or dependent use of alcohol or an illicit substance or prescribed medication
• risks related to the specific additional illicit drugs and prescribed medication
• additional risks when both alcohol and drugs are used together

You can read guidance on risks related to specific illicit drugs and prescribed medications in Drug misuse and dependence: UK guidelines on clinical management.

Information and advice on additional risks of using alcohol and illicit drugs or prescribed medications should include:

• risk of overdose from using sedative medications and depressant drugs with alcohol (this includes both prescribed drugs and those obtained illicitly, for example pregabalin, gabapentin, benzodiazepines and opioids, including opioid substitute medications methadone and buprenorphine)
• using illicit drugs such as heroin, or drugs sold as having the look of genuine prescribed medications have an additional risk as their strength and effects can vary
• alcohol and opioids (including methadone or buprenorphine) taken together increase the risk of slowing your rate of breathing, which can lead to death
• physical health harms of stimulant drugs, especially cocaine when it is taken with alcohol (cocaethylene is formed by the liver when cocaine and ethanol coexist in the blood and some evidence shows that cocaethylene is more cardiotoxic than cocaine or alcohol on their own)

Appendix F: specific populations

Practitioners can also provide harm reduction information tailored to specific populations.

F1. Older people

The ageing process makes people more susceptible and at risk of the physical and mental health harms caused by alcohol (RCPsych 2018).

In addition to general harm reduction information, there are harms that older people are more likely to experience. These harms are described in section 25.8 of chapter 25 on developing inclusive services. Services should have written information tailored to older people and practitioners should be trained to provide this information verbally to older people.

F2. Women who are pregnant or may become pregnant

The UK chief medical officers’ advice on low risk drinking is that women who are pregnant or think they could become pregnant should completely avoid alcohol.

Practitioners should provide information on the risks of alcohol use in pregnancy and advise women who are pregnant to avoid alcohol. However, midwives, alcohol treatment practitioners and other healthcare professionals should advise women who are (or who could be) alcohol dependent not to stop drinking suddenly. This is because withdrawal complications risk harm to the fetus and the mother. They should rapidly refer the woman to specialist alcohol treatment to be assessed for medically assisted withdrawal (so they can stop drinking safely) and to specialist antenatal care if they are not already engaged with this. They will also need to make a safeguarding referral if the unborn child is at risk of significant harm.

You should read section 24.5.2 in chapter 24 on pregnancy and perinatal care on providing information and advice.

F3. Young people

Young people and practitioners can find harm reduction information tailored to young people on the website FRANK.

See also chapter 23 on alcohol treatment and support for young people for more information on harm reduction.

9. Alcohol assertive outreach and a multi-agency team around the person

9.1 Main points

Very vulnerable people with alcohol dependence who are experiencing severe and multiple disadvantage are often known to local services. They may have repeated contacts with acute and emergency services but they are often not engaged in appropriate ongoing treatment and support.

This group of people are unlikely to approach or engage with standard alcohol treatment provided at a service base.

Vulnerable people with alcohol dependence experiencing severe and multiple disadvantage need integrated care that addresses their various needs in a co-ordinated way.

Assertive outreach combined with a multi-agency team around the person are ways to engage and provide care tailored to the needs of vulnerable people with alcohol dependence experiencing severe and multiple disadvantage.

Assertive outreach involves a service making proactive and persistent attempts to make contact with a person and build a relationship with them, using a trauma-informed approach.

Assertive outreach removes some of the barriers to treatment by bringing the service to the person in settings where they feel comfortable and that they can access easily.

Commissioners and services developing assertive outreach should identify vulnerable people with alcohol dependence with high levels of need and risk in their local area and agree referral pathways into the service with partner agencies.

A multi-agency team around the person involves agencies working together to share information and co-ordinate integrated care for vulnerable people with high levels of complex need. You can read more about what a multi-agency team around the person means in section 9.7.

Many local areas co-ordinate care and manage risks for vulnerable people with alcohol dependence through multi-agency forums that meet regularly.

A multi-agency team around the person should provide joint assessment and management of risk and share information based on information sharing agreements.

Assertive outreach practitioners and services should tailor interventions to the needs of vulnerable people with alcohol dependence who experience severe and multiple disadvantage. They can do this using a harm reduction approach if the person is not ready to change their alcohol use.

9.2 Introduction

This chapter provides guidance on providing alcohol assertive outreach as part of a multi-agency team to support vulnerable people with alcohol dependence and high levels of unmet need, to reduce the health inequalities they experience.

Alcohol assertive outreach and a multi-agency team around the person are ways of engaging and supporting people that alcohol treatment services often do not reach.

An assertive outreach approach is a way of working where practitioners support and deliver interventions wherever it’s most appropriate, rather than asking a person to engage with treatment in a particular service or place. After a person has been referred to the assertive outreach service, practitioners make proactive and persistent (‘assertive’) attempts to contact them to help them to engage with support (see section 9.6).

A multi-agency team around the person is a way of working that involves services and organisations working together to share information and co-ordinate integrated care for vulnerable people with high levels of complex need (see section 9.7).

You should read this chapter with chapter 21 on people experiencing homelessness which provides more extensive guidance on providing appropriate care for that group of people.

9.3 Evidence

There is evidence from a systematic review that assertive outreach for people with severe mental illness is effective (Dieterich and others 2010).

There is also evidence that a combination of assertive outreach and a multi-agency team around the person can be effective in helping vulnerable people with alcohol dependence achieve a range of positive outcomes. This evidence includes:

• a limited number of peer reviewed studies
• large scale programme evaluations
• small scale service evaluations

The studies identify positive outcomes (Drummond and others 2017, CFE Research and the University of Sheffield 2022, Bailey and others 2020). These include:

• an increase in treatment engagement
• reduced alcohol use
• reduced emergency service use
• fewer hospital admissions

9.4 Who assertive outreach and a team around the person can support

An assertive outreach approach combined with a multi-agency team around the person can help very vulnerable people who drink dependently and experience severe and multiple disadvantage.

People experiencing severe and multiple disadvantage are defined here as people who experience 2 or more of:

• alcohol and drug use
• homelessness, including rough sleeping
• involvement with the criminal justice system
• mental health problems
• domestic violence and abuse

They may also have other difficulties or specific needs.

Hard Edges: mapping severe and multiple disadvantage in England found that factors that cause severe and multiple disadvantage are a combination of structural factors, including:

• poverty and long-term economic marginalisation
• family and individual history, including childhood trauma
• very poor educational experiences

An approach combining alcohol assertive outreach and a multi-agency team around the person supports people who:

• are drinking harmfully or dependently
• have very high levels of unmet need (physical and mental health, social care, safeguarding, or material resources)
• have not engaged or have not benefited from alcohol treatment services
• may be at a high level of risk or pose risk to others
• may lack mental capacity or need support to recognise their care needs and to engage with services

In each local area there will be a relatively low number of very vulnerable people with alcohol dependence who experience severe and multiple disadvantage and are not engaged in ongoing treatment and support. Numbers will vary across regions and local areas and are likely to be bigger in areas with high levels of deprivation.

9.5 Developing targeted referral pathways

Commissioners and services need to identify vulnerable people with high levels of need and risk who are not engaging in alcohol treatment services. They should then develop targeted referral pathways into the assertive outreach service in agreement with partner agencies. This will often involve emergency and acute services or the police and community safety services, since this group of people is more likely to have contact with acute and emergency services. Other relevant services include:

• services for people experiencing homelessness
• primary care
• community mental health services
• criminal justice services
• services for domestic abuse or sexual violence or exploitation

Some areas have established multi-agency forums for managing care for vulnerable people with alcohol dependence or other groups of people with high levels of risk. They can use these forums to identify people who are known to member agencies but not in contact with treatment services (see section 9.7.2 on setting up multi-agency forums).

There is also evidence to suggest that community alcohol treatment services can identify people who may currently benefit from assertive outreach by looking at people with previous unsuccessful alcohol treatment episodes (Passetti and others 2008).

9.6 Assertive outreach

9.6.1 Making it easier to access treatment

Vulnerable people experiencing severe and multiple disadvantage often find it extremely difficult to access or remain in treatment. For example, they might fear treatment services based on previous negative experiences or have difficulty forming trusting relationships because of past trauma. They might also experience barriers that are service-related, such as stigmatising services with inflexible opening times or procedures for missed appointments.

An assertive outreach approach helps to remove these barriers by meeting people in settings that are familiar to them. This could be at their home, in a community venue or in services they already attend, such as services for people experiencing homelessness.

9.6.2 How assertive outreach works

After a person has been referred to the assertive outreach service, practitioners make proactive and persistent (‘assertive’) attempts to contact them to help them to engage with support. Practitioners should contact the person at least once a week (with the person’s consent). And they should continue to make supportive contact even if the person does not attend agreed meetings.

Practitioners should be flexible in the way they make contact and communicate about appointments. They should use whatever method the person prefers, including text, phone, email, letter and in-person visits in a setting the person finds comfortable. They can also support engagement in practical ways, such as providing transport costs or phone data.

Large scale service evaluations and qualitive research show that a supportive relationship between the assertive outreach practitioner and the person is central to this approach (CFE Research and others 2020, Ward and Holmes 2016). Hard Edges: mapping severe and multiple disadvantage in England found many people experiencing severe and multiple disadvantage have experienced trauma as children. As adults, this often means they find it difficult to form trusting relationships. It is important that practitioners take an empathic, trauma-informed approach and focus on developing a relationship with the person at the person’s pace, which is likely to take some months, and in some cases, years.

You can read more about trauma-informed approach in the Working definition of trauma-informed practice.

9.6.3 Role of assertive outreach practitioners

The role of the assertive outreach practitioner providing face to face support is central to the assertive outreach approach, but they do not work alone. The practitioner should always be part of or supervised by:

• a multidisciplinary team in the alcohol treatment service
• another relevant service like a homelessness service
• a team working specifically with people with severe and multiple disadvantage

Assertive outreach practitioners should also be working in a co-ordinated way with other services in contact with the person, through the multi-agency team around the person.

9.6.4 Aims of assertive outreach

The aims of assertive outreach are to:

• engage people who experience barriers to accessing or completing treatment
• support the person’s motivation to make changes in their alcohol use and other areas of their life
• encourage the person’s belief in their capacity to change
• reduce harm and manage risk
• tailor components of care and specific interventions to meet the person’s needs
• help people to access other services they need
• co-ordinate care and contribute to a co-ordinated multi-agency approach
• work with family members or friends where appropriate and with the person’s consent
• prepare people for structured treatment and recovery where appropriate

9.6.5 Different models of assertive outreach

There are different models of alcohol assertive outreach. For example, it could be provided by:

• a community alcohol treatment service
• a hospital alcohol care team or hospital ‘frequent attenders’ service
• a multidisciplinary homeless health service that includes specialist alcohol treatment practitioners
• an outreach service for people experiencing severe and multiple disadvantage that includes specialist alcohol treatment practitioners

This chapter does not consider specific models but provides guidance relevant to most alcohol assertive outreach services, which have several components in common.

9.6.6 Essential components of alcohol assertive outreach

A national survey of alcohol assertive outreach teams proposes the following 6 essential components of alcohol assertive outreach (Fincham-Campbell and others 2018).

1. A maximum caseload of between 10 and 20 patients per practitioner.
2. Input from a multidisciplinary team in form of input from at least 3 different professions including nurses, medical and psychology or community support and drug workers.
3. Regular contact between patient and practitioner (at least once a week).
4. At least 50% of contacts occurring outside of the service settings, either in patients’ homes or local community settings.
5. A focus on both health and social care needs, including accommodation, finance, leisure, occupation, and physical and mental health.
6. Extended care provided for a prolonged period of 12 months.

Programme evaluations of projects working with people with severe and multiple disadvantage have identified that caseloads as low as 6 to 10 may be needed when working with people who have the most severe and multiple disadvantage (CFE Research and others 2020). Practitioners may need to contact people mostly in their homes or in the community (at least 50% of the time as noted in point 4 above) for a prolonged period of time (Drummond and others 2017).

9.7 A multi-agency team around the person

9.7.1 What a multi-agency team around the person does

Vulnerable people with alcohol dependence who experience severe and multiple disadvantage and have high levels of need are usually known to local services, but they are often not engaged in ongoing treatment and support. They are more likely to use acute or emergency services than planned health and social care. And where they are engaged with acute and emergency services, these may be only responding to one of their problems.

Vulnerable people with alcohol dependence who experience severe and multiple disadvantage need co-ordinated and integrated care that addresses all their needs and risks. Section 24.4.1 in chapter 24: people experiencing homelessness provides more guidance on integrated care (for people experiencing homelessness, but also relevant to other vulnerable people). Developing and maintaining a multi-agency team around the person is a way of providing integrated care for vulnerable people with high levels of need and risk.

A multi-agency team around the person should:

• share and record information about the person between services based on local information sharing agreements
• jointly assess the person’s needs and risks
• co-ordinate and jointly plan the management of the person’s care and involve the person wherever possible in the planning
• co-ordinate and jointly manage risks to the person or risks they pose to others and involve the person in risk management planning wherever possible
• agree who is the main care co-ordinator for the person
• allocate and review tasks to member agencies and review progress
• meet regularly to jointly review the person’s care
• co-ordinate so the person can access all the care they need from the minimum number of services possible

9.7.2 Setting up multi-agency forums

A multi-agency team around the person that carries out the functions listed above can be organised in different structures.

Wherever possible, commissioners and service providers should work together across local systems to set up multi-agency forums that can receive referrals and co-ordinate integrated care for the most vulnerable people with alcohol dependence and high levels of unmet need.

Multi-agency forums bring together services that come into contact with this group of people and meet regularly to co-ordinate care for each person referred to the forum. The forums share information and professional expertise. Forum member services that are relevant to each person’s needs will form a team around the person and agree a co-ordinator for the team. They will then work together to provide care for the person outside of the regular meetings of the forum and report back to the forum regularly.

Multi-agency forums regularly review care for individuals so they will identify problems with pathways between services. They will also identify policies and procedures that make it difficult for vulnerable people with alcohol dependence and high levels of need to access appropriate care. Forum members can then work together to remove some of these barriers.

Local areas may choose to establish multi-agency forums that are solely for integrating care for vulnerable people with alcohol dependence and high needs and risks. An example of this is the Blue Light model designed by Alcohol Change UK.

Some local areas may have established multi-agency forums to co-ordinate care for vulnerable adults. For example, a multi-agency adult safeguarding hub or forum to co-ordinate care for people with severe and multiple disadvantage. An example of the latter are forums established by some of the Fulfilling Lives project partnerships (CFE Research and others 2020). Commissioners of alcohol treatment services can propose that these types of forums include referrals and multi-agency care co-ordination for vulnerable people with alcohol dependence with high needs and high risks.

In areas with no appropriate multi-agency forum, services in contact with very vulnerable people with high needs and high risks should have an alternative system in place. This is so the practitioner who is co-ordinating care can quickly arrange a multi-agency risk management meeting about a particular person. Services should then agree ongoing joint working arrangements that include regular multi-agency review meetings.

Various things need to be made clear when setting up a multi-agency forum, including:

• terms of reference
• membership
• referral procedures
• task allocation
• procedures for members to report information to the forum
• information sharing agreements

9.7.3 Information sharing

Information sharing is crucial to co-ordinating care and managing risk for vulnerable people with alcohol dependence and experiencing severe multiple disadvantage. They may only have sporadic contact with several agencies and without effective information sharing, each agency might be unaware of information that another agency is holding. An analysis of adult safeguarding reviews has shown that lack of information sharing is often a factor when serious incidents occur.

There should be formal information sharing agreements and mechanisms between all organisations involved in the multi-agency forum and with any organisation the person is referred to. The agreement should make clear how information will be shared at regular reviews and between regular reviews if the person’s situation or risks change. Where possible, partner agencies should have access to a shared electronic case record.

9.8 Care for vulnerable people with severe and multiple disadvantage

9.8.1 Overview

Alcohol services and assertive outreach practitioners should offer the same components of care that the service offers to people attending standard community alcohol treatment. But they will need to do this in a way and at a pace that is tailored to the complex needs of vulnerable people experiencing severe and multiple disadvantage. They will need to be flexible in their approach so they can engage people effectively in support and treatment.

The following sections give some examples of tailoring care to meet the individual needs of very vulnerable people with severe and multiple disadvantage.

9.8.2 Assessing the person’s needs

The assertive outreach practitioner should aim to follow the guidance in chapter 4 on specialist assessment but will need to work very flexibly to carry out the assessment, using an informal approach.

Assertive outreach practitioners (or designated care co-ordinator if this is someone else) should gather information from other agencies in the multi-agency team around the person as part of a joint assessment of need and risk to provide a comprehensive picture. Wherever possible, they should do this with the person’s consent. But in some situations where the person is at risk or poses risks to others, they can share information without the person’s consent.

Gathering information from partner agencies can help to reduce the number of questions about sensitive personal issues that the practitioner needs to ask the person when they first meet. This can help to reduce stress for the person.

The assertive outreach practitioner should:

• carry out the assessment in an informal and conversational way
• keep paperwork to a minimum during the appointment (although they should record their notes after the meeting)
• tailor the duration of each appointment to the needs of the person and not expect the person to engage for a full hour if this is difficult for them

Once they have gathered information on urgent needs and risks, the practitioner may need to carry out the rest of the assessment very gradually and informally over several meetings. This will allow time to build trust and help the person to feel safe before discussing sensitive personal issues.

It is important that the practitioner shows they believe in the person’s capacity to make changes from the beginning and throughout their contact.

9.8.3 Assessing and managing risk

While tailoring their approach to the person, the assertive outreach practitioner should aim to follow guidance in chapter 4 on assessment and treatment and recovery planning in:

• section 4.17.4 on initial assessment of risks and urgent treatment or support needs
• section 4.19.4 on multidisciplinary and multi-agency treatment and recovery plans

Very vulnerable people with alcohol dependence experiencing severe and multiple disadvantage often pose high levels of risk to themselves and sometimes pose high levels of risk to others. So, assessing and managing risk is vital. One of the main functions of the team around the person is to carry out a multi-agency risk assessment and agree a multi-agency risk management plan, involving the person in this process wherever possible. Where appropriate they should also involve family members who can offer an additional perspective and information. Services should inform partner agencies whenever there is a change in risk, in line with their local information sharing agreement and they should review the risk management plan regularly.

9.8.4 Understanding and using adult safeguarding and legislative frameworks

Assertive outreach practitioners working with vulnerable people with severe and multiple disadvantage should understand and act in line with the relevant national legal frameworks.

Practitioners should follow their organisational procedures on:

• adult safeguarding
• child safeguarding
• the Mental Capacity Act
• the Mental Health Act

All of these can often apply with this group of people. There is information on these frameworks in annex 1 on legislation and guidance across the UK.

Information sharing is vital where there are risks to the person or to others. While it is good practice to ask for the person’s consent to share information, practitioners can share information without consent where:

• there are adult or child safeguarding concerns
• the person lacks mental capacity
• the person is in a mental health crisis and is at risk or posing risk to others

Services should have organisational procedures for managing these situations, including procedures for sharing information without consent.

9.8.5 A harm reduction approach

Taking a harm reduction approach

The alcohol practitioner and the person should consider setting alcohol use goals as part of the person’s treatment and recovery plan (sometimes called support plan). This should be based on a comprehensive multidisciplinary assessment and tailored to the person’s current situation.

A harm reduction approach will often be appropriate for very vulnerable people with alcohol dependence experiencing severe and multiple disadvantage.

You can read guidance on alcohol use goals, including a harm reduction strategy, in chapter 4 on assessment and treatment and recovery planning.

A harm reduction approach aims to reduce immediate and longer-term harms, risks and health inequalities that the person is experiencing. It involves actions to address a person’s:

• physical health
• mental health
• social care needs, including housing needs

The person may not be ready to reduce their alcohol use initially, but meeting these needs is a positive outcome. This can encourage the person and increase their motivation to engage in alcohol treatment at a later stage.

Practitioners should also offer specific interventions to reduce alcohol related harm. For example, with the person’s consent, they should arrange for a clinician to prescribe thiamine to reduce the risk of alcohol related brain damage. They should also provide harm reduction advice tailored to the person’s situation.

Chapter 10 on pharmacological interventions provides guidance on prescribing thiamine.

You should read chapter 8 on a harm reduction approach for people with alcohol dependence.

Making changes in alcohol use

A focus on reducing harms may be the most useful way to work with a vulnerable person experiencing severe multiple disadvantage. But practitioners should never assume that the person is incapable of making significant reductions in their alcohol use or achieving abstinence. Practitioners should regularly review a person’s goals with this in mind and adjust the goals as appropriate.

Where the person continues to drink harmfully or dependently, the service should regularly review their health, and take action to address any deterioration.

9.8.6 Linking people to other services

Linking people to relevant services and helping them to navigate complicated systems is often a vital part of the role of an assertive outreach practitioner.

Practitioners should be aware of local support pathways and, where relevant, assertively link the person to:

• primary and secondary healthcare services, including mental health
• social care
• the criminal justice system
• housing support
• domestic abuse services
• peer support services and mutual aid
• local community organisations

Assertively linking the person to these other services means that the practitioner:

• provides the person with information on the service tailored to their individual needs
• helps the person to talk through their anxieties
• helps the person to complete any forms required by services, or completes the forms on their behalf
• helps the person to make an appointment or makes the appointment for them
• introduces the person to the professional they will see by phone or in person
• sends text or phone reminders
• accompanies the person to the appointment
• arranges with a peer to accompany the person to the appointment
• provides transport tickets where needed

Practitioners may need to advocate for the person, providing the other services with information on what might help the person to engage. They may also need to ask the services for some flexibility, for example around referral criteria or missed appointments.

9.8.7 Supporting the person over time

Vulnerable people experiencing severe and multiple disadvantage will usually need to be in contact with alcohol treatment services for longer than average and may be in contact for more than a year.

Wherever possible, they should have a continuous relationship with one keyworker (usually the assertive outreach practitioner) to help with building a trusting relationship.

Transitions (significant changes in the person’s circumstances) are often stressful and associated with an increased risk that vulnerable people return to harmful behaviours, including more harmful alcohol use. This can be the case even if there is a positive transition, like moving into stable accommodation or leaving prison. The muti-agency team around the person should consider increasing support at times of transition. A consistent keyworker who the person trusts can help the person manage the stress involved with transitions.

Well before the assertive outreach relationship ends, practitioners should gradually introduce people to other services to help them build a support network. These might include:

• lived experience recovery organisations (LEROs)
• mutual aid
• peer- based support groups that provide social activities

There is guidance on recovery support services in chapter 6.

9.8.8 Supporting the person to engage with structured alcohol treatment

If the person’s motivation increases, the assertive outreach practitioner can help prepare them for structured treatment and accompany them to the service base.

If the person is already attending a peer-based organisation, a peer could accompany them to the service. Or the assertive outreach practitioner could introduce the person to a peer supporter who had joined the treatment service after initially engaging with an assertive outreach practitioner. That peer supporter can then share their experience of the process.

Services may need to make small changes to their procedures to become accessible to people with severe and multiple disadvantage. This might include allowing for more missed appointments and longer periods of engagement. They will also need to allow for staff time to contribute to meetings of the multi-agency team around the person.

Assertive outreach can continue while the person engages with the treatment service to help the person make the transition to structured treatment at the service base. For example, the assertive outreach practitioner might schedule some meetings with the person away from the service base and some at the service base for a period while they adjust.

Transitions of any kind (even including positive transitions) can be vulnerable times. There is an increased risk that the person could return to problematic behaviour, so it is important that the person has adequate support during this time.

9.9 Staff competences and governance

9.9.1 Staff competences

Assertive outreach and multi-agency working is highly skilled work and practitioners need to have a range of advanced competences and specialist knowledge.

You can find information on staff competences in manuals and programme evaluations in the resources section at the end of the chapter.

Important skills that practitioners should have include:

• building and maintaining relationships with very vulnerable people
• communicating with vulnerable people and with professionals
• trauma-informed practice
• assessment of vulnerable people
• risk assessment and risk management
• advocacy
• multi-agency working
• using a friendly, informal approach while maintaining professional boundaries
• crisis management and conflict resolution
• management of challenging behaviour
• resilience under pressure

Important knowledge that practitioners should have for assertive outreach includes:

• alcohol dependence and associated health harms
• flexible engagement processes
• harm reduction approaches and information
• strengths based approaches
• evidence-based alcohol interventions
• mental health conditions
• the impact of trauma
• adult safeguarding legislation and procedures
• mental capacity and mental health legislation and procedures

9.9.2 Staff support and governance

Assertive outreach practitioners should receive regular input from a multidisciplinary team, including medical, nursing and alcohol and drug treatment specialists in their organisation.

There should be clear lines of accountability in their organisation for:

• reporting and escalating risks and clinical concerns
• regular clinical supervision
• training

Caseloads for assertive outreach need to be much smaller than the average caseload in alcohol services. This is because people with severe and multiple disadvantage who are not engaged with services usually have high levels of need and risk and require more intensive interventions. Caseload size will depend on how the caseload is made up but can range between a maximum of 6 to 20 (see section 9.6.6 for more information).

Risks can be higher when staff are working away from the service base. So, services should have comprehensive policies and procedures for assessing and managing risks to staff.

9.10 Resources

Alcohol Change UK

Alcohol Change UK ‘s Blue Light Project develops alternative approaches and pathways for drinkers who are not in contact with treatment services but have complex needs. Resources include a manual and evaluations of services using a Blue Light model.

Alcohol Change UK has also published a manual on assertive outreach.

Fulfilling Lives

The National Lottery Community Fund invested £112 million over 8 years in local partnerships in 12 areas across England helping people experiencing multiple disadvantage to access more joined-up services tailored to their needs. The Fulfilling Lives website brings together learning from the programme, including national and local programme evaluations.

Making Every Adult Matter

The Making Every Adult Matter (MEAM) approach network helps local areas design and deliver better co-ordinated services for people experiencing multiple disadvantage. The MEAM website describes their approach and includes a 5-year (2017 to 2022) evaluation of the programme.

9.11 References

Bailey M, Ward M and Steele A. Sandwell Blue Light: an approach to support treatment-resistant drinkers. Perspectives in Public Health 2020: volume 140, issue 2

CFE Research and the University of Sheffield. A summary of programme achievements, evaluation findings, learning and resources (PDF, 697KB), 2022

CFE Research and the University of Sheffield, with the Systems Change Action Network. What makes an effective multiple disadvantage navigator? Workforce development and multiple disadvantage (PDF, 251KB), 2020

Dieterich M, Irving CB, Park B and Marshall M. Intensive case management for severe mental illness. Cochrane Database of Systematic Reviews, 2010

Drummond C, Gilburt H, Burns T, Copello A, Crawford M, Day E, Deluca P, Godfrey C, Parrott S, Rose A, Sinclair J and Coulton S. Assertive community treatment for people with alcohol dependence: a pilot randomized controlled trial. Alcohol and Alcoholism 2017: volume 52, issue 2, pages 234-241

Fincham-Campbell S, Kimergård A, Wolstenholme A, Blackwood R, Patton R, Dunne J, Deluca P and Drummond C. A national survey of assertive outreach treatment services for people who frequently attend hospital due to alcohol-related reasons in England. Alcohol and Alcoholism 2018: volume 53, issue 3, pages 277-281

Passetti F, Jones G, Chawla K, Boland B and Drummond C. Pilot study of assertive community treatment methods to engage alcohol-dependent individuals. Alcohol and Alcoholism 2008: volume 43, issue 4, pages 451-455

Ward M. and Holmes M. Working with change resistant drinkers: the project manual. Alcohol Concern, 2014

10. Pharmacological interventions

10.1 Main points

Pharmacological interventions are used:

• for medically assisted withdrawal from alcohol
• to prevent and manage specific complications of withdrawal from alcohol
• to prevent Wernicke-Korsakoff syndrome (WKS) in people at high-risk who continue to drink alcohol, as well as those undergoing withdrawal
• to reduce craving, prevent relapse and promote abstinence
• to reduce alcohol consumption in specific groups of people who have a high drinking risk level

Pharmacological interventions to manage alcohol withdrawal can be provided in a range of settings. Clinicians will need to plan the setting and regimens for medically assisted withdrawal based on a full assessment of the patient, considering a range of factors including the:

• severity of dependence
• complexity of need
• skills and resources needed to provide the intervention effectively and safely

The main purpose of medication in medically assisted withdrawal is to help people with alcohol dependence to stop drinking without experiencing withdrawal complications. These can include seizures, delirium tremens and Wernicke-Korsakoff syndrome.

Benzodiazepine reducing regimens are the pharmacological treatment to manage withdrawal from alcohol. Regimens can be fixed-dose or symptom-triggered. However, symptom-triggered withdrawal management is a specialist approach that should only be applied by staff trained in the approach in a well-resourced hospital setting.

If a person experiences any severe withdrawal complications during medically assisted withdrawal in the community, it should be treated as an emergency. You should provide appropriate emergency care (if available) and call an ambulance.

The choice of relapse prevention medication will need to be based on full assessment of the patient, their preference and ability to comply with the regimen.

Clinicians should provide thiamine supplementation to all people about to undergo or undergoing medically assisted withdrawal. However, it’s essential to offer vitamin prophylaxis to all people who drink harmfully and dependently, whether or not they intend to undergo medically assisted withdrawal.

Where possible, clinicians should explore options for medication to support relapse prevention and promote abstinence with the person before they start making plans for medically assisted withdrawal.

Particular considerations apply when using pharmacological interventions for people from specific groups or with coexisting conditions (see section 10. 6 for guidance on this).

10.2 Context

10.2.1 General principles

You should always use pharmacological interventions as part of a broad treatment plan.

You should choose which pharmacological intervention to use based on good assessment and be clear about the goals and purpose for prescribing medication, considering the patient’s views and preferences.

When using medication, you will need to monitor the patient for effectiveness and for any unwanted effects. People who are particularly unwell will need skilled nursing and medical care, for example they are in severe acute withdrawal.

Where there is a choice of recommended medications or regimens that are equally effective, it is usually better for clinical teams to work with the option with which they are most experienced. For example, although you can use a range of benzodiazepine drugs to manage acute alcohol withdrawal, skilled care and monitoring is more important than the choice of drug.

Medication regimens will vary, depending on the setting where they are administered. Each organisation or service should have written policies and procedures on administering pharmacological interventions that are appropriate to the setting and level of competence of the staff.

Prescribers should adhere to the:

• General Medical Council guidance Good practice in prescribing and managing medicines and devices
• Royal Pharmaceutical Society’s prescribing competency framework
• British National Formulary (BNF) guidance on non-medical prescribing, where appropriate

Clinicians should administer medication in line with Royal Pharmaceutical Society guidance Professional guidance on the administration of medicines in healthcare settings (PDF, 319KB).

You should also be aware of potential interactions between alcohol and prescribed drugs. You can view this information on the BNF’s interactions for alcohol website.

You should provide information about medication in a way that is accessible to the person, considering:

• their preferred language
• their level of literacy
• any sensory disability
• any cognitive impairment
• any neurodiversity

You will need to consider whether the patient has mental capacity to make decisions about their treatment. You can find information on mental capacity in annex 1 on relevant legislation and guidance.

10.2.2 Off-label or unlicensed use of medicines: prescribers’ responsibilities

There are situations when clinicians might decide that using unlicensed medicines or using medicines outside the terms of the licence (known as off-label use) is in the best interest of the patient, based on available evidence.

Prescribers should be aware of their responsibilities when prescribing unlicensed or off-label medications, outlined in the Medicines and Healthcare products Regulatory Agency (MHRA) guidance Off-label or unlicensed use of medicines: prescribers’ responsibilities.

10.2.3 The importance of setting and staff skills

Pharmacological interventions take place in a variety of settings, including:

• primary care
• community alcohol services
• specialist inpatient units
• acute (general) hospitals

It is important that the setting in which you deliver a pharmacological intervention is the appropriate place for the intervention. For example, some community alcohol services are well set up to administer Pabrinex (B vitamins including thiamine) on-site for patients who continue to drink and are at high risk of Wernicke’s encephalopathy (WE). Other alcohol services may need to make alternative arrangements, such as referring them to an acute hospital. As another example, many specialist inpatient units will need to transfer people to acute general hospital settings to manage severe medical complications, such as delirium tremens or WE. Other specialist inpatient units that are closely aligned to general hospitals may be able to manage these complications without transfer.

This chapter goes on to describe the approaches a service can take, depending on the setting and skill set of the staff. It is important that the:

• clinicians and practitioners involved in providing the intervention are appropriately skilled and competent
• setting in which the intervention is taking place is appropriate for the intervention and for the patient’s needs
• service provider has clinical governance, supervision and assurance systems in place to ensure staff are appropriately skilled and settings are appropriate

10.2.4 Setting for medically assisted withdrawal based on severity of dependence and complexity of need

Clinicians will need to plan the setting and regimens for medically assisted withdrawal based on:

• the patient’s severity of dependence
• all assessed patient risk factors
• the patient’s needs and circumstances

You can find guidance on assessing someone for medically assisted withdrawal in chapter 4 on assessment and treatment and recovery planning, chapter 11 on community based medically assisted withdrawal and chapter 12 on specialist inpatient medically assisted withdrawal.

People who need medically assisted withdrawal should normally be offered community-based medically assisted withdrawal tailored to the severity of their dependence, available social support, and any co-occurring physical health or mental health conditions.

Based on the National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) and clinical consensus from the guidelines development group, medically assisted withdrawal should normally occur in an inpatient setting if the person:

• drinks over 30 units of alcohol per day or have a score of more than 30 on the Severity of Alcohol Dependence Questionnaire
• has a history of epilepsy or experience of withdrawal-related seizures or delirium tremens
• has been assessed as being at high risk of WE and needs parenteral thiamine and if a sufficiently skilled, trained and resourced team to administer it are not available in the community setting (clinicians should follow guidance in section 3.3 on preventing and managing Wernicke-Korsakoff syndrome)
• needs concurrent withdrawal from alcohol and benzodiazepines
• has a significant mental health or physical health condition (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease)
• has a significant learning disability or cognitive impairment

People who do not have an appropriate family member or trusted friend to stay with them during the medically assisted withdrawal should normally be offered medically assisted withdrawal in a residential or inpatient setting and not a community-based setting.

You should consider a lower threshold for inpatient medically assisted withdrawal for vulnerable groups. This includes people experiencing homelessness and older people. You should also consider an inpatient setting for pregnant women (see section 10.6.4 on prescribing in pregnancy and the perinatal period).

In some circumstances, you can offer community-based medically assisted withdrawal to people who meet one of the criteria above for inpatient or residential medically assisted withdrawal. You should base this decision on a careful assessment of the risks and benefits of providing this intervention, while also considering what the patient wants. In these exceptional cases, both assessment and treatment should only be carried out by an experienced multidisciplinary team. This team should include senior medical leadership who are able to provide an increased level of monitoring, for example in a day hospital unit. There should also be an established pathway into inpatient medically assisted withdrawal so the person can be admitted immediately if they experience severe complications.

Chapter 11 on community-based medically assisted withdrawal gives detailed guidance on delivering community-based medically assisted withdrawal.

There is guidance on delivering medically assisted withdrawal in inpatient settings in chapter 16 on acute hospital settings and in chapter 12 on specialist inpatient medically assisted withdrawal units.

10.2.5 Specific groups

Specific considerations apply when using pharmacological interventions for:

• young people
• older adults
• pregnant women
• people with concurrent physical or mental health problems or other complexities

You can read more about considerations for specific groups in section 10.6, which you should read along with the guidance on specific pharmacological interventions below.

10.3 Prescribing medication for management of withdrawal from alcohol

It is important to read this section along with section 10.4 on preventing complications of withdrawal. You should also read:

• chapter 11 on medically assisted withdrawal in the community
• section 16.5 on medically assisted alcohol withdrawal and section 16.6 on withdrawal complications
• chapter 12 on specialist inpatient medically assisted withdrawal units

10.3.1 Main purpose of medication in medically assisted withdrawal

The main purpose of medication in medically assisted withdrawal is to enable people with alcohol dependence to stop drinking without experiencing complications of withdrawal, which are:

• seizure
• delirium tremens
• Wernicke-Korsakoff syndrome

Medication also eases discomfort and distress associated with withdrawal and so helps the person to plan with confidence to prevent future relapses.

10.3.2 Planned and unplanned withdrawal

This section provides guidance on planned medically assisted withdrawal following assessment and preparation. Section 16.1.3 in chapter 16 on acute hospital settings provides guidance on unplanned medically assisted withdrawal in hospital.

If a patient has stopped drinking in an unplanned way and is beginning to experience withdrawal symptoms (shaking, sweating, anxiety) which are not yet acute, you should tell them about the risks of stopping drinking suddenly. You should also consider offering an assessment for a planned medically assisted withdrawal.

If the person is severely alcohol dependent, it may be appropriate for them to continue to drink at a steady pace (to avoid potential complications), avoiding episodes of increased heavy alcohol use or periods without alcohol until they can access medically assisted withdrawal. In this situation, you should arrange access to medically assisted withdrawal as quickly as possible.

If the person is mildly or moderately alcohol dependent, you can advise them to cut down gradually while they are waiting for medically assisted withdrawal if they want to do this, with the support of the alcohol service. There is guidance on stopping drinking gradually in chapter 8 on harm reduction.

Sometimes, a patient might present to a community treatment service when they are already in acute withdrawal. Symptoms of acute withdrawal include intense shaking and may include:

• seizures
• delirium tremens
• suspected WE

In this situation, you should arrange for the patient to be transferred to an appropriate setting immediately. This could be an acute hospital emergency department or an appropriately resourced specialist inpatient setting.

You can find guidance on managing acute withdrawal in chapter 16 on acute hospital settings.

10.3.3 Benzodiazepine withdrawal regimens

Benzodiazepine reducing regimens are the pharmacological treatment of choice to manage withdrawal from alcohol. The choice of specific regimen will depend on the individual and the setting. In all settings, regular skilled monitoring of symptoms and of the effects or medication is an essential component of care.

For planned medically assisted withdrawal, selecting an appropriate setting for the person is an important consideration. See section 10.2.4 for guidance on setting.

10.3.4 Choice of regimen

Fixed dose regimens (with a specified schedule of reducing daily dose, subject to daily review) are suitable for medically assisted withdrawal in the community.

The initial dose of medication should be titrated to the severity of a person’s alcohol dependence or their regular daily level of alcohol consumption. There are example regimens provided in section 10.7 on benzodiazepine withdrawal regimens.

Fixed-dose regimens should include some flexibility:

• to give additional ‘top-up’ doses in case the person’s symptoms are not adequately controlled
• to reduce the dose to avoid over-sedation before the next daily review

This flexibility is supported by clinical consensus of the guidelines development group.

The prescribing regimen can include a single additional dose and the person supporting the patient can be advised on the situations in which this should be given. For instance, if there are breakthrough withdrawal symptoms present in the morning before the reviewing team are able to attend. If the additional dose is used, the monitoring team should review whether the prescribed doses are adequate or whether the regimen should be reviewed by the prescriber.

In hospital settings, you can use either fixed dose regimens or symptom-triggered regimens. In contrast to fixed dose regimens, the symptom-triggered approach does not follow a pre-planned reduction schedule but has a flexible dosing system in response to careful monitoring of the person’s withdrawal symptoms. A symptom-triggered approach only continues as long as the patient shows withdrawal symptoms. This is a specialist approach that requires all team members to be trained to ensure that it can be applied consistently and safely.

Hospitals intending to use symptom-triggered regimens should consider investing in additional training and competency assessment to ensure that this can be done safely. One of the roles of a specialist alcohol care team (ACT) can be to support safe and consistent use of this approach. However, in hospitals where there is no ACT or suitably trained staff, it is more appropriate to use fixed-dose regimens with daily review.

The quality of monitoring of the person’s response to medication is important with both fixed dose and symptom-triggered regimens.

10.3.5 Choice of drug

Chlordiazepoxide or diazepam are the most commonly used benzodiazepines. There are sample regimens for both of these in section 10.7.2.

You can choose benzodiazepines with a shorter half-life, such as oxazepam, for people who potentially metabolise medication more slowly, such as those with extensive liver disease or older patients. This is to avoid patients gradually becoming over-sedated. However, you can also use chlordiazepoxide successfully for these patients, and the quality, level and skill of monitoring is more important than the choice of benzodiazepine.

Chlordiazepoxide and diazepam are recommended by NICE CG115 and are licenced for use in medically assisted withdrawal. Other recommended benzodiazepines do not have a specific license but may be used for this purpose (see section 10.2.2 on off-label and unlicensed prescribing).

There is a MHRA safety alert for the use of benzodiazepines and opioids.

10.3.6 Using carbamazepine as an alternative to a benzodiazepine for managing withdrawal

Carbamazepine is an effective alternative medication for medically assisted withdrawal from alcohol. There are specific (though uncommon) circumstances in which it is a helpful alternative to benzodiazepines. These include situations where the patient has:

• a history of adverse reaction or allergy to benzodiazepine drugs (although uncommon, this can be fatal)
• a preference for carbamazepine (for example, people who have a history of harmful use or dependence on benzodiazepine drugs and who do not want to take them in this context)

You can use carbamazepine in inpatient settings for managing concurrent withdrawal from alcohol and benzodiazepine drugs.

You can find more information on concurrent withdrawal from alcohol and benzodiazepines in section 10.6.1.

Carbamazepine is not licenced for management of withdrawal. See section 10.2.2 on unlicensed or off-label prescribing.

Also, for patients who are pregnant, you should be aware of the MHRA safety review on using antiepileptic drugs in pregnancy.

10.3.7 Using clomethiazole

Clomethiazole was used historically to manage alcohol withdrawal but has been replaced by benzodiazepine drugs, which are safer. NICE CG115 recommends that you should not use clomethiazole for medically assisted withdrawal in the community, where the preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam). For further guidance, see chapter 11 on community-based medically assisted withdrawal.

In inpatient settings, clomethiazole has no advantages over benzodiazepines in managing withdrawal.

10.4 Prescribing medication to prevent and to manage specific complications of withdrawal

You should read this section along with:

• chapter 11 on community-based medically assisted withdrawal
• chapter 12 on specialist inpatient medically assisted withdrawal
• chapter 16 on acute hospital settings
• chapter 20 on alcohol related brain damage

10.4.1 Preventing and managing withdrawal seizures

Withdrawal seizures

Withdrawal seizures are grand mal epileptiform seizures (a seizure causing loss of consciousness and violent muscle contractions) occurring usually 12 to 48 hours after stopping or significantly reducing alcohol consumption. It is important to note that seizures can occur with a breathalyser reading greater than zero in people with severe alcohol dependence. Several seizures may occur, but status epilepticus (a seizure that lasts longer than 5 minutes, or more than 1 seizure in a 5-minute period, without returning to a normal level of consciousness between episodes) is rare.

If a person has a seizure during medically assisted withdrawal in the community, this should be treated as an emergency. Provide appropriate emergency care as available and call an ambulance.

Preventing withdrawal seizures

Preventing withdrawal seizures is one of the main aims of medically assisted withdrawal. Identifying people at risk will enable you to effectively plan their care, to reduce the likelihood of this complication.

Initial assessment should identify the following risk factors in as much detail as possible, including any history of:

• previous withdrawal seizures
• epilepsy

Other factors such as electrolyte disturbance can contribute to seizure risk. You should detect and correct this before planned withdrawal, where possible.

People at risk of severe withdrawal should generally undergo medically assisted withdrawal in a specialist inpatient unit or in hospital. Those at high risk are likely to need a higher dose regimen of long-acting benzodiazepine.

There is no evidence to support prophylactic use of additional anticonvulsant medication to prevent seizures in high-risk individuals, and you should not initiate additional anticonvulsant medication. Your focus should be on adequate dosing with the chosen benzodiazepine, in line with the British Association for Psychopharmacology (BAP) updated guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity (PDF, 1.13MB).

For people who are already on established anticonvulsant medication to treat epilepsy, you should continue the antiepileptic treatment dose along with the medically assisted withdrawal medication. You should then monitor their medication levels to ensure they stay within the therapeutic range.

10.4.2 Preventing and managing delirium tremens

Recognising delirium tremens

Delirium tremens usually emerges between day 2 and 3 (occasionally up to day 5) of alcohol withdrawal in a severely alcohol dependent person. This is a medical emergency and requires immediate transfer to an inpatient setting with 24 hour medical and nursing care. It is crucial that you are alert to the possibility of delirium tremens developing in people undergoing alcohol withdrawal. One of the main aims of medically assisted withdrawal is to prevent the onset of delirium tremens.

Delirium tremens is a toxic confusional state, characterised by:

• disorientation
• agitation
• tachycardia (heart rate of more than 120 beats per minute)
• hypertension (20mmHg (millimetre of mercury) rise in systolic blood pressure)
• fever
• hallucinations (auditory, olfactory, and visual)
• marked tremor
• sleeplessness
• paranoid ideation

These symptoms may not always all be present at the same time.

Risk factors for delirium tremens include:

• previous seizures or delirium
• many co-existing physical health problems
• low potassium
• low magnesium
• thiamine deficiency

Under-treated withdrawal is also a significant factor. Recognising delirium tremens is important. NICE clinical guidelines Alcohol-use disorders: diagnosis and management of physical complications (CG100) recommends using lorazepam or haloperidol, but there is now international clinical consensus that the treatment should be different from delirium arising from other causes, and larger doses of benzodiazepines are required (ASAM 2020, Schuckit 2014, Mayo-Smith and others 2004). Haloperidol can lower the threshold for seizures.

For guidance on managing delirium tremens see chapter 16 on acute hospital settings.

Preventing delirium tremens in medically assisted withdrawal

Many potential cases of delirium tremens can be prevented by quickly starting appropriate treatment, as outlined in section 10.4.3 below on pharmacological management of withdrawal and on vitamin prophylaxis.

If there is high risk of delirium tremens, planned medically assisted withdrawal should take place in a specialist alcohol treatment unit with appropriate staffing, or in an acute hospital setting with alcohol specialist input.

Managing established delirium tremens

If the person develops delirium tremens despite preventative efforts as outlined above, you should treat it as a medical emergency. If delirium tremens emerges during medically assisted withdrawal in the community, you must transfer the person to an acute hospital as an emergency.

If the person is being managed in a specialist inpatient medically assisted withdrawal unit that is not in an acute hospital, you should consider transferring the patient to an acute medical setting, depending on resources available to the unit.

Where necessary and appropriate, you should consider using the Mental Health Act or Mental Capacity Act to be able to transfer the person if they are mentally ill and are a danger to themselves or others or lack capacity. You can find more information on the Mental Health Act and Mental Capacity Act in annex 1 on legislation and guidance across the UK.

Medical and nursing management of delirium tremens is described in more detail in chapter 16 on acute hospital settings and chapter 12 on specialist inpatient medically assisted withdrawal.

10.4.3 Preventing and managing Wernicke-Korsakoff syndrome

Wernicke-Korsakoff syndrome (WKS) is a serious complication of deficiency of thiamine (vitamin B1), for which the most common cause is alcohol dependence. This can result in lasting brain injury, so preventing this complication is vital. See chapter 20 on alcohol related brain damage.

Vitamin prophylaxis to prevent WKS

Many alcohol-dependent people are at risk of developing WKS due to thiamine deficiency. They may also have deficiencies in other vitamins. You should provide thiamine supplementation to all people about to undergo or undergoing medically assisted withdrawal. However, it’s essential to offer vitamin prophylaxis in all people who drink harmfully and dependently, whether or not they intend to undergo medically assisted withdrawal.

The risk of anaphylactic reaction from parenteral vitamins has sometimes deterred clinicians from using them, but the risks of failing to correct thiamine deficiency are significant. You should consider the following points:

1. Absorption of oral thiamine from the intestine is saturated at 5 to 10 milligrams (mg) per dose in healthy people and can be reduced to negligible amounts in people with alcohol dependence, especially those with malnutrition. So, the oral route will not be adequate to replace depleted thiamine in a significant proportion of these people (Tallaksen and others 1993, Weber and Kewitz 1985).

2. Thiamine stores need to be replaced as quickly as possible and high circulating levels of thiamine are needed for passive diffusion into the central nervous system (based on clinical consensus of the guidelines development group).

3. For people who need parenteral thiamine, the risk of anaphylaxis is very low: less than 1 in 5,000,000 for intravenous (IV) infusion and lower still for the intramuscular (IM) route (Cook and others 1998, Thomson and Marshall 2006). See also the MHRA drug safety update on Pabrinex allergic reactions.

Pharmacological regimen for vitamin prophylaxis

The appropriate regimen for vitamin prophylaxis will depend on whether the person:

• is considered to be at lower risk
• has no signs of WE but is at high risk of it developing
• is showing signs of incipient WE

Thiamine should be given orally or parentally as described below.

People in the lower risk group should be given thiamine 50mg oral 4 times daily. In practice, all people presenting to services with alcohol dependence should receive oral treatment as they would in the lower risk group, if they do not meet criteria for the higher risk regimen.

People in the at-risk group can have a range of conditions, including:

• significant weight loss
• poor diet
• signs of malnutrition
• memory disturbance
• previous history of WE
• suspected Wernicke-Korsakoff syndrome

You should consider the following for people in the at-risk group.

1. For patients in the community: 1 pair of Pabrinex ampoules intramuscularly once daily for 3 to 5 days.
2. For patients in inpatient settings: 1 pair of Pabrinex ampoules intramuscularly once daily for 5 to 7 days.
3. Injections should be given by appropriately skilled, trained, and resourced staff.
4. If the person is significantly underweight with limited tissue for IM injection, has a clotting problem, or prefers IV rather than IM Pabrinex, they should be transferred to an inpatient setting.
5. Pabrinex should be followed by a course of oral thiamine.
6. Some practitioners also prescribe vitamin B compound-strong if they are concerned about the patient having multiple vitamin deficiencies. It is unclear whether this is cost-effective, but you can consider it if you have well-founded nutritional concerns.

Incipient Wernicke’s encephalopathy

Incipient WE is characterised in most cases by confusion, in some cases with classical symptoms of ataxia, memory disturbance and ophthalmoplegia. People with suspected WE should immediately be transferred to an inpatient setting with 24 hour medical and nursing staffing.

You can find guidance on managing WE in chapter 16 on acute hospitals settings and chapter 12 on specialist inpatient medically assisted withdrawal.

Preventing Wernicke-Korsakoff syndrome in people who continue to drink alcohol

NICE CG100 recommends that clinicians should give prophylactic parenteral thiamine followed by oral thiamine to people with a harmful or dependent pattern of drinking if they:

• attended an emergency department
• were admitted to hospital with an acute injury or illness
• are malnourished or at risk or malnourishment
• have decompensated liver disease

There are opportunities to provide Pabrinex to people at high risk of developing WKS in primary care and other community settings, even if there are no plans for them to undergo medically assisted withdrawal.

Acute WE does not occur only when people stop drinking, and people who are malnourished or have decompensated liver disease remain at risk while they continue to drink alcohol.

Appropriately skilled and resourced services should assess and offer parenteral thiamine to people at high risk when they present to services, even if they do not imminently plan to undergo medically assisted withdrawal. The benefits of this outweigh the low risk of anaphylaxis (see also chapter 16 on acute hospital settings and chapter 20 on alcohol related brain damage). If Pabrinex is unavailable in the community alcohol service, there should be a pathway in place to ensure it is available in another setting, such as a primary care hub.

Patients with any degree of risk of WE, who choose not to have Pabrinex, should be offered oral thiamine.

10.5 Pharmacological interventions for preventing relapse and promoting abstinence

10.5.1 Principles for prescribing for relapse prevention and promoting abstinence

Planning medication to support relapse prevention

Medication can be an important addition to psychosocial treatment and recovery plans, yet clinicians often under-use evidence-based pharmacological treatments. This could be because both clinicians and people seeking help are unaware of all the options.

Where possible, you should explore options for medication to support relapse prevention and promote abstinence with the person before you start making plans for medically assisted withdrawal. This allows you to carry out baseline assessments, so you are ready to prescribe in a seamless plan after the end of the patient’s withdrawal. This also allows (off-label) acamprosate treatment to begin before withdrawal. If you need to carry out medically assisted withdrawal without prior planning, you should consider relapse prevention medication before the patient completes withdrawal.

Integrating pharmacological and psychosocial interventions in primary care or community alcohol services

You should prescribe medication for relapse prevention in the context of a psychosocial treatment and recovery plan. This does not mean that you need to provide complex formal psychological treatments, and the lack of specialised approaches should not stop someone accessing relapse prevention medication.

If the person has not received treatment from a specialist alcohol service, their GP should offer them a referral and encourage them to attend the specialist service. If they decline referral, or if they have completed their treatment at a specialist alcohol service, regular monitoring and review by the GP along with supportive contact in primary care will help them to benefit from medication.

The GP should provide information about:

• alcohol use disorders
• the purpose of the medication
• how to manage safe adherence to a medication regimen

The GP should also encourage the person to engage with mutual aid groups and lived experience recovery organisations. They should also return to the offer of a referral to a specialist alcohol service where appropriate and encourage the person to attend.

10.5.2 First-line pharmacological interventions

Acamprosate and naltrexone are first-line options for pharmacological treatment to support relapse prevention, following successful withdrawal from alcohol for people with moderate to severe dependence.

Acamprosate

Indications

Acamprosate is usually well-tolerated, and mild gastrointestinal disturbance is the most commonly reported side effect (see section on acamprosate in the British Association for Psychopharmacology guidelines (PDF, 1.13MB)). It is a first-line treatment for relapse prevention and you should consider it as an option for all people who are undergoing or have completed a medically assisted withdrawal, as well as for people with alcohol dependence who have managed to withdraw without medication but still need help with relapse prevention.

Acamprosate can be started before or during medically assisted withdrawal. Acamprosate is thought to have potential to reduce toxicity and neuronal impairment during the withdrawal process, although this is not clearly established (Kalk and Lingford-Hughes 2014). Prescribing acamprosate before completing withdrawal ensures that the person can benefit in the vulnerable period when medication to manage withdrawal symptoms has finished. This prescribing is outside the summary of product characteristics (SPC), but it is common practice and it is supported by clinical consensus of the alcohol guidelines development group. The Royal Pharmaceutical Society provides an overview of SPCs.

Baseline investigations and monitoring

You should determine the person’s body weight before prescribing, because a lower dose schedule is used for adults who weigh under 60kg.

Baseline blood tests should include hepatic and renal function. Since acamprosate is predominantly excreted via the kidneys, you should not prescribe it for people with severe renal impairment (for example, creatinine of more than 120 micromoles per litre). You can use acamprosate with caution at a reduced dose in people with mild renal impairment, if you think the benefits outweigh the risks (Ashley and Currie 2009). Naltrexone is an alternative option.

You should not give acamprosate to people with severe hepatic impairment, but you can give it to people with mild to moderate hepatic impairment if there is ongoing monitoring.

For people with acceptable baseline blood test results, repeated blood test monitoring is not essential. Although it may be helpful in treatment generally to provide feedback on a person’s improvement (for example, if liver enzymes were elevated at baseline but have since come down).

Dose schedule

Appropriate doses are 666mg (2 tablets), 3 times daily, for adults whose weight is 60kg and over. Adults under 60kg are advised to take a total of 1,332mg daily in divided doses (for example, 2 tablets (666mg) in the morning, one tablet (333mg) in the afternoon and one (333mg) more in the evening).

You should prescribe for people with mild to moderate renal impairment with caution (Ashley and Currie 2009) and in consultation with the BNF guidance on prescribing in renal impairment.

Prescribing arrangements

You can prescribe acamprosate in primary care, community alcohol services or hospital. When a person starts being prescribed acamprosate in community alcohol services or hospital, it is generally in their best interests that prescribing is transferred to primary care when possible. This allows them to move on from specialist services while continuing to benefit from the medication.

There is no specific time limit on prescribing acamprosate, but a common approach is to prescribe for 6 months, with an extension to 12 months for people who experience ongoing benefit.

You should stop prescribing acamprosate after 4 to 6 weeks if the person is continuing to drink alcohol and has experienced no reduced drinking days and alcohol consumption.

Naltrexone

Indications

Naltrexone is a non-selective opioid antagonist that reduces the rewarding effect of alcohol and therefore the motivation to drink alcohol. Several meta-analyses and systematic reviews have concluded that naltrexone reduces a person’s return to heavy drinking, by reducing the risk that a lapse progresses to a full relapse (NICE 2011).

Naltrexone is a first-line treatment for relapse prevention and you should consider it as an option for all people who are undergoing or have completed a medically assisted withdrawal. You should also consider it for people with alcohol dependence who have managed to withdraw without medication but who need help with relapse prevention.

Specific considerations

Naltrexone is an opioid-receptor antagonist, so you should not prescribe it for people who:

• are prescribed opioid medication
• use non-prescribed opioids regularly or intermittently
• are likely to need opioid medication

Naltrexone administered to opioid-dependent people can cause life-threatening withdrawal symptoms. If you suspect a patient of using or being dependent on opioids, they must undergo a naloxone provocation test. This is unless you can verify by a urine test that they have not taken any opioids for 7 to10 days before starting naltrexone treatment.

Baseline investigations and monitoring

Baseline blood tests should include hepatic and renal function. Repeat blood tests are not needed for everyone but are advised for:

• older people
• people with comorbidity, including obesity
• feedback on improvement of physical health, where that would be useful

You should not prescribe naltrexone for people with severe or acute hepatic impairment, acute hepatitis, or liver failure.

You can prescribe naltrexone for people with mild to moderate hepatic impairment with ongoing monitoring

Dose schedule

The typical dose is 25mg as an initial dose increasing to 50mg daily.

Prescribing arrangements

You can prescribe naltrexone in primary care, hospitals, or community alcohol services. When a person starts being prescribed naltrexone in community alcohol services or hospitals, it is generally in their best interest that prescribing is transferred to primary care when possible because this allows them to move on from specialist services while continuing to benefit from the medication.

There is no specific time limit on prescribing naltrexone, but a common approach is to prescribe for 6 months, with an extension to 12 months for people who experience ongoing benefit.

You should stop prescribing naltrexone after 4 to 6 weeks if the person is continuing to drink alcohol and has experienced no benefit.

Choosing between acamprosate or naltrexone as first-line treatment

There are currently no clear indicators of which people respond best to which first-line treatments. Some studies (including Mann and others 2018) have been based on the proposed mechanisms of action of the 2 drugs.

Based on these studies, acamprosate is likely to be of more benefit for people motivated by the ‘relief’ effects of alcohol (such as easing anxiety) by operating on the upregulated glutamatergic system (brain functions) found in alcohol dependence.

Naltrexone is more likely to benefit people whose alcohol use is mainly motivated by seeking the ‘positive reward’ effects of alcohol (since naltrexone blunts these effects) and so, a person who has a history of recurrent lapses (unrelated to anxiety) may be more likely to benefit from naltrexone.

Precision in choice of medication remains an area for further investigation to identify clear predictors of effectiveness.

In practice, the choice between acamprosate and naltrexone as first-line treatment is likely to be shaped by factors such as:

• the person’s previous experience and preference
• medical factors, such as the person’s renal or liver function or concurrent opioid use
• practical details, such as the person’s preference for 3 times daily or once daily dosing

10.5.3 Second-line pharmacological interventions

Disulfiram

Indications

Disulfiram is a second-line treatment for people with moderate or severe alcohol dependence who have successfully completed withdrawal and want to maintain abstinence. NICE CG115 recommends that it should be considered for:

• people who have a goal of abstinence but for whom acamprosate and naltrexone are not suitable
• people who prefer disulfiram and understand the rationale and relative risks of taking the drug

Disulfiram acts by blocking aldehyde dehydrogenase (an enzyme), causing accumulation of aldehyde if a person drinks alcohol. This results in adverse effects including nausea, flushing and palpitations. So, it acts as a deterrent to alcohol use. The patient must not start disulfiram until 24 hours after they consumed their last alcoholic drink. Patients (and where relevant their families) must be warned that a disulfiram-alcohol reaction is potentially dangerous.

It’s very important that you inform the patient about the adverse consequences from disulfiram from taking even small amounts of alcohol. This involves informing them about the effects and about what food, drink and other products to avoid, including ingesting alcohol accidentally in food products or even from absorbing alcohol on the skin from cosmetic products. You should also inform the person that there is a potential for a reaction with alcohol up to 14 days after stopping disulfiram.

You should warn patients, and their families and carers, about the rare complication of liver damage, which can have rapid onset and be unpredictable. You should also advise patients that if they feel unwell or develop a fever or jaundice, they should stop taking disulfiram and seek urgent medical attention.

There are several medical conditions for which disulfiram should be prescribed with caution or is even contraindicated. These include:

• hypertension
• ischaemic heart disease
• stroke
• psychiatric comorbidities, such as psychosis and severe personality disorder

Prescribers should ensure they have access to the patient’s full medical history, and they should check on drug interactions, cautions and contraindications to prescribing in the SPC.

Where possible, clinicians should advise that a supportive family member or friend witnesses the doses. This has been shown to enhance the medication’s effectiveness by helping the patient comply with the regimen.

Baseline investigations and monitoring

Baseline blood tests should include hepatic and renal function. Ongoing blood test monitoring should be guided by the results of baseline tests and the medical history.

Dose schedules

In the UK, the usual dose of disulfiram is 200mg daily, though higher doses are sometimes used for people who do not experience adverse effects with alcohol at this dose.

In the SPC, there is an example of an initial loading dose regimen with higher doses being given in the first few days. However, it is common and acceptable to start on 200mg daily without an initial loading regimen.

Prescribing arrangements

You can prescribe disulfiram in primary care, community alcohol services or hospitals. It is usual for disulfiram to be started and initially monitored by specialist alcohol services. When a person starts being prescribed disulfiram in community alcohol services or in hospital, they should be transferred to primary care prescribing, when possible, because this allows them to move on from specialist services while continuing to benefit from the medication.

Prescribers should review the person at least every 2 weeks for the first 2 months, then monthly for the following 4 months.

There is no specific time limit on prescribing but for subsequent, longer term prescription, monitoring at least 6-monthly is recommended by the guidelines development group.

Baclofen

Use of baclofen in the UK

Baclofen is a GABA-B agonist that is licensed for other uses in the UK. It is not included in NICE CG115

Several studies have evaluated its use to support abstinence from alcohol since the NICE clinical guideline was published and there has been an international consensus statement on its use (Agabio and others 2019).

Baclofen is included in this guideline, although you should be clear that its use in the UK for the treatment of alcohol use disorders would be off-label. You should refer to MHRA guidance on prescribing medications that are unlicensed or outside the terms of their existing license (see section 1.2). Prescribers should also refer to the SPC.

Indications

You should not use of baclofen for patients who are still drinking alcohol or for managing alcohol withdrawal.

You can consider baclofen as a second line treatment for relapse prevention following successful withdrawal from alcohol for people who have:

• not responded to first-line treatments (acamprosate or naltrexone)
• contraindications to prescribing first-line medications, for example those who have advanced liver disease

The SPC also states that cases of misuse, abuse and dependence have been reported with baclofen. You should exercise caution when prescribing baclofen to patients with a history of substance use and they should be monitored for symptoms of baclofen misuse, abuse, or dependence. For example, this includes cases of dose escalation, drug-seeking behaviour or a development of tolerance.

You should prescribe baclofen with caution in people with comorbid conditions, particularly:

• epilepsy (effect on seizure threshold)
• mood disorder (risk of manic or hypomanic episodes)
• current suicidal ideation or a history of suicide attempts (risk of intentional overdose)

Baseline investigations and monitoring

Baseline blood tests should include hepatic and renal function. Clinicians should refer to the SPC. However, you can prescribe baclofen with caution for people with hepatic or renal impairment.

You do not need to repeat blood test monitoring for everyone, but you should be guided by the patient’s medical history.

You must monitor liver enzymes in patients with hepatic impairment. You may need to adjust dosing for people with renal impairment.

Dose schedules

Research shows very wide variations in the size of the dose of baclofen, but we do not recommend using high doses. Clinical consensus of the guidelines development group is that baclofen:

• should be started at a low dose and slowly titrated, with a typical maximum of 60mg daily
• should not be stopped abruptly, but slowly reduced (for example, 5mg to 10mg per week) to avoid withdrawal symptoms

Prescribing arrangements

Baclofen should only be prescribed by a specialist clinician who takes responsibility for the ongoing monitoring of the patient.

10.5.4 Other drugs used for relapse prevention

Other drugs that are used for relapse prevention in alcohol use disorders include:

• topiramate
• gabapentin
• sodium oxybate

While these drugs are used elsewhere in the world, they are not routinely used in the UK due to the lack of evidence.

10.5.5 Drugs that should not be used for relapse prevention

Antidepressant medication

Many people seeking help for alcohol use disorders have already been prescribed antidepressant medication. This may be appropriate if you are clear that the purpose of the prescription is to treat a pre-existing or concurrent depressive disorder, but there is no role for antidepressant medication specifically to treat an alcohol use disorder. You should not prescribe antidepressant drugs (including selective serotonin reuptake inhibitors) with the purpose of preventing relapse in alcohol use disorders.

Benzodiazepines and z-drugs

You should not start prescribing benzodiazepines or z-drugs (sleeping tablets with effects similar to benzodiazepines, such as zopiclone or zolpidem) (or continue them after managing withdrawal) with the goal of relapse prevention or promoting abstinence from alcohol.

For some people, it may still be appropriate to use these drugs for their standard recommended uses, such as for the short-term management of anxiety or insomnia.

10.5.6 Pharmacological intervention to reduce alcohol use: nalmefene

Use of nalmefene in the UK

Nalmefene is an opioid receptor antagonist at mu and delta subtypes and partial agonist at kappa subtype. In 2014, NICE published a technology appraisal on nalmefene.

Nalmefene has a marketing authorisation in the UK for the reduction of alcohol consumption in adult patients with alcohol dependence who have a high drinking risk level without physical withdrawal symptoms and who do not require immediate detoxification.

You should only start prescribing nalmefene for patients who continue to have a high drinking risk level 2 weeks after initial assessment and it should be prescribed alongside psychosocial interventions.

Indications

Nalmefene is not suitable for people with moderate or severe alcohol dependence or who are non-dependent drinkers.

The target group for this pharmacological intervention is people with mild dependence, without complications, whose aim is to continue to drink alcohol at a reduced level and who are prepared to engage in concurrent psychosocial interventions.

Psychosocial interventions are the mainstay of treatment for this defined group, and most people will not require a pharmacological intervention. However, you can consider prescribing nalmefene for people in this group for whom a psychosocial intervention alone is not proving adequate. You should ask the patient to record their alcohol consumption for at least 2 weeks before deciding to start nalmefene.

If you do prescribe nalmefene, you should only do so alongside psychosocial interventions in a primary care setting or in specialist alcohol services.

Specific considerations

As nalmefene is an antagonist and partial agonist, you should not prescribe it for people who take opioid medication, either regularly or intermittently, or for those who are likely to need opioid medication. You should not prescribe nalmefene for people who:

• have a current or recent opioid dependence
• are in opioid withdrawal
• have a recent history of acute alcohol withdrawal syndrome

Baseline investigations and monitoring

Baseline blood tests should include hepatic and renal function. You should avoid prescribing nalmefene to people with severe hepatic or renal impairment and prescribe it with caution to people with mild to moderate hepatic impairment.

Repeated blood test monitoring is not essential though it may be helpful in treatment overall, for feedback to the person on improvement in their health.

10.6 Pharmacological interventions for specific groups of people

10.6.1 Pharmacological treatments for people using alcohol and other drugs

People who use drugs and who are dependent on alcohol should be offered alcohol treatment interventions, including support for alcohol reduction and cessation either in the community or as an inpatient. You should follow up this with psychological and pharmacological interventions to prevent relapse.

You can find detailed guidance on addressing alcohol-related problems with people who are in treatment for drug dependence in section 6.5 of Drug misuse and dependence: UK guidelines on clinical management.

Concurrent alcohol and opioid dependence

Management of withdrawal from alcohol

Alcohol dependence is a common comorbidity in people with opioid dependence, and people with this combination of problems are at high risk of death from the combined sedative effects of opioids and alcohol in overdose, as explained in NICE CG115. Treatment for both problems should be integrated so they are managed together.

The UK drug treatment clinical guidelines are clear that optimising medication for opioid dependence is important. Some people will wish to undergo medically assisted withdrawal from alcohol while maintaining stable opioid substitution treatment (OST). This may be because they want to stop drinking alcohol but also want to continue to benefit from ongoing OST. Or they may want to withdraw from both alcohol and opioid drugs in due course but want to deal with alcohol first.

When planning medically assisted withdrawal, clinicians must consider the degree of supervision required for its safe management alongside OST. Some people will need inpatient services or intensive community support such as day-patient supervision. This decision needs to be based on the factors that are considered for all people undergoing medically assisted withdrawal from alcohol, together with any additional factors related to their opioid use.

The UK drug treatment clinical guidelines recommend that when a person wants to withdraw from both alcohol and opioid drugs, you should plan assisted withdrawal from alcohol first, particularly if they are going to be managed in a community setting. Simultaneous withdrawal from both alcohol and opioid drugs is challenging and is best managed in an inpatient setting. There is MHRA safety information on concurrent use of benzodiazepines and opioids.

Medication for relapse prevention

You should not prescribe naltrexone for people with ongoing opioid dependence or those who use opioid drugs intermittently. Because naltrexone is an opioid antagonist, you can prescribe it to support a patient to maintain their abstinence from opioid drugs (after their abstinence is clearly established), as recommended by the NICE technology appraisal guidance Naltrexone for the management of opioid dependence (TA115).

For people who have achieved abstinence from both alcohol and opioid drugs, and want to maintain this, you can prescribe naltrexone as long as there are no other contraindications, with the aim of supporting abstinence from both.

There is a lack of studies looking at the use of acamprosate in people who are also dependent on opioids. However, given its safety and tolerability, there is no reason why acamprosate should not be used to support abstinence from alcohol, following medical assessment and the guidance on prescribing acamprosate (see section 10.5.2 on acamprosate above).

There is also a lack of studies of the use of disulfiram to support abstinence from alcohol in people dependent on opioids. If you are considering using disulfiram, you need to perform a medical assessment and follow the guidance on prescribing disulfiram (see section 10.5.3 on disulfiram above).

Baclofen has potential to cause sedation if it is given alongside opioid medication such as methadone or buprenorphine.

Nalmefene is an opioid antagonist and should not be prescribed for people who are using prescribed or unprescribed opioid drugs (see section 10.5.6 on nalmefene above).

Concurrent alcohol and cocaine use

Management of withdrawal from alcohol

If a person takes cocaine with alcohol, some effects (including euphoria and increased heart rate) may be enhanced compared to using either substance alone.

You should offer support and treatment to people with alcohol dependence who also use cocaine, to help them achieve abstinence from alcohol, whether or not they intend to stop using cocaine. When planning medically assisted withdrawal, you must consider the degree of supervision required for its safe management. If a person is unlikely to be able to stop using cocaine during the period of withdrawal from alcohol, there is a potential for problematic increases in blood pressure and heart rate during withdrawal. This means some people will need inpatient services or intensive community support.

Medication for relapse prevention

There have been a small number of studies of the potential effect of acamprosate to support abstinence from cocaine, and while the findings are inconclusive, acamprosate has been well-tolerated (Kampman and others 2011). It is appropriate to offer acamprosate to support abstinence from alcohol in people who use cocaine (see the considerations described in section 10.5.2 on acamprosate above).

There have been several trials of naltrexone and disulfiram in comorbid alcohol and cocaine misuse. For naltrexone, it is so far unclear whether this is effective, but there is a possible association between disulfiram and abstinence from both alcohol and cocaine (Pettinati and others 2008).

You can offer either naltrexone or disulfiram to support abstinence from alcohol in people who also use cocaine, based on their medical history and current health, as well as their choice (see section 10.5.2 on naltrexone and section 10.5.3 on disulfiram).

Concurrent alcohol and benzodiazepine dependence

Management of withdrawal

Concurrent use of a prescribed benzodiazepine or z-drug (such as zopiclone or zolpidem) is common in patients with alcohol dependence. These drugs are often prescribed in primary care or initiated by mental health services.

If you need to plan concurrent withdrawal from both alcohol and benzodiazepines, you should consider managing the person in an inpatient setting. This is because the dose of benzodiazepine medication used for withdrawal will need to be higher. You should base their initial daily dose on the requirements for alcohol withdrawal plus the equivalent regularly used daily dose of benzodiazepine. When the person has been using unprescribed benzodiazepines, this is difficult to assess and they are likely to need an inpatient setting.

Withdrawal is best managed with one benzodiazepine (chlordiazepoxide or diazepam) rather than multiple benzodiazepines. Concurrent withdrawal from alcohol and benzodiazepines will take longer than withdrawal from alcohol alone, so you should plan inpatient admissions for 2 to 3 weeks or longer, depending on the severity of co-existing benzodiazepine dependence.

Concurrent withdrawal from alcohol and benzodiazepines is best managed in an inpatient setting. When withdrawal is managed in the community, the regimen may need to last for several weeks, depending on the person’s symptoms and discomfort, as recommended by NICE CG115. It will also be necessary to involve senior specialist clinicians.

Some people requiring medically assisted withdrawal from alcohol are already receiving a prescription for a stable regular daily dose of a benzodiazepine or z-drug, possibly for another indication. They may not want any change to this prescribed medication while they undertake alcohol withdrawal. In these circumstances, the regular medication can be maintained as a baseline while they undergo withdrawal from alcohol, with a planned reducing regimen of chlordiazepoxide or diazepam. The person may then decide (at a later date) on a plan to reduce and stop the regularly prescribed medication.

As for all medically assisted withdrawal from alcohol, you should consider the degree of supervision required for its safe management alongside use of current medication.

Medication for relapse prevention

You can offer pharmacological interventions for preventing relapse to alcohol use to people who have benzodiazepine dependence. If you do this, the same considerations as for all people will apply. However, you should note that for people who continue to take benzodiazepine medication, increased sedation can occur if they take baclofen.

10.6.2 Prescribing for older people

You should read this section with section 25.8 on older people in chapter 25 on developing inclusive services.

Screening older people

At a whole population level, Office for National Statistics data on adult drinking habits in Great Britain has shown a downward trend in alcohol consumption among younger adults over recent years, while 45 to 65 year olds are the highest consuming group. There is an increasing prevalence of alcohol problems in older populations (people aged 65 years and over). Routine screening for alcohol use risk among older people should be part of any ongoing comprehensive assessment in any health or social setting (RCPsych 2018).

Issues to consider when prescribing for older people

Older adults are more likely to:

• have other mental health issues
• have other physical health issues
• be taking other medication

You will therefore need to make appropriate dose adjustments for age-related pharmacokinetic and pharmacodynamic changes and carry out regular monitoring (Butt and others 2020, Lingford-Hughes and others 2012, Haber and others 2009). But this should not be a deterrent to using medication, as it can play a crucial role in treatment and recovery and you should always consider using it. Refer to BNF guidance on prescribing in the elderly.

Pharmacological management of withdrawal for older people

NICE CG115 recommends that benzodiazepines remain the treatment of choice for managing withdrawal in older people, alongside nutritional supplements. See section 2 on prescribing medication for managing withdrawal from alcohol. However, you can consider prescribing a shorter-acting benzodiazepine, such as oxazepam (off-label), where you have concerns about accumulation and subsequent over-sedation.

Clinicians are less likely to be familiar with such shorter-acting benzodiazepines compared with other benzodiazepines that are more commonly used, such as chlordiazepoxide or diazepam. So, it may be preferable to use familiar benzodiazepines with careful titration and choice of dose. Given the patient is likely to have physical comorbidity and be at risk of nutritional deficiencies, it is essential to assess them for potential complications, and for WE, as well as continuing to monitor them during withdrawal. So, you need to consider whether a community or inpatient setting is most suitable for withdrawal.

Pharmacological management of relapse prevention for older people

There is limited evidence about the efficacy and safety of prescribing relapse prevention medication in this population. If we assume that treating older people with relapse prevention medication has similar results to the working age adult population, you can consider using it for older people with moderate to severe alcohol dependence if you think that the benefits outweigh the risks for an individual (Butt and others 2020, Lingford-Hughes and others 2012, NICE 2011).

When using naltrexone in older people, you should monitor their liver function tests before and during medically assisted withdrawal and at 3 months and 6 months afterwards.

Acamprosate may require dose adjustment due to age-related kidney disease. Using acamprosate in people aged 65 and over is off-label due to lack of evidence on its use in that age group (see SPC).

Disulfiram is less likely to be appropriate to use, due to the number of contraindications and cautions that apply to older adults. Though research has shown that it can be safe and effective if the person is medically fit (Zimberg 2005).

10.6.3 Prescribing for young people

There are specific considerations when prescribing for young people. You should also read this section along with chapter 23 on young people and the BNF for children.

NICE CG115 covers young people aged 10 years and older and includes a specific pathway for 10 to 17 year-olds. For those young people who require medically assisted withdrawal, you can use benzodiazepines (chlordiazepoxide or diazepam) with doses adjusted based on their:

• age
• height
• weight

NICE CG115 recommends inpatient admission in an age-appropriate setting with access to specialist expertise.

There is limited evidence from trials investigating the efficacy or use of relapse prevention medications in young people. Also, relapse prevention medications are not licensed for use in under 18 year olds because of the lack of evidence to guide their use and safety in younger people. There are some pilot placebo-controlled or open-label randomised control trials of acamprosate, naltrexone or disulfiram in young people (mainly 15 to 19 years old) but all the studies are small and their results should be interpreted very cautiously (Clark 2012).

There are no studies of nalmefene or baclofen in young people, though baclofen is used for other indications in this age group. It is reasonable to extrapolate evidence of relapse medication efficacy from adults for use in young people.

NICE CG115 recommends that specialists consider acamprosate and naltrexone “in combination with cognitive behavioural therapy to young people aged 16 and 17 years who have not engaged with or benefited from a multicomponent treatment programme”.

10.6.4 Prescribing in pregnancy and during breastfeeding

Alcohol use during pregnancy

This section focuses on alcohol treatment prescribing interventions in pregnancy and during breastfeeding. There is guidance on other aspects of working with women during pregnancy and the perinatal period, and on fetal alcohol spectrum disorder in chapter 24 on pregnancy and perinatal care.

Psychosocial interventions are the mainstay of managing alcohol problems during pregnancy, though evidence comes primarily from experience rather than clinical trials.

Many women who continue to drink excessively in pregnancy are likely to have several co-occurring conditions including mental health disorders. Some will also smoke tobacco or use other substances, so comprehensive assessment for alcohol treatment by a clinician with mental health and substance use expertise is crucial (McAllister-Williams and others 2017).

It is essential that all services involved with the woman during pregnancy and in the postnatal period work together to co-ordinate care and share information appropriately. This will include joint multidisciplinary and multi-agency assessment, and care-planning, including safeguarding, maternity services and other relevant services such as mental health or domestic abuse services (NICE 2010).

If a woman is undergoing medically assisted withdrawal while pregnant or in the postnatal period, child safeguarding services should normally be involved. The clinicians and staff involved with the mother must follow national guidance (see annex 1 on legislation and statutory guidance) and their service procedures on child safeguarding.

See section 24.7.4 in chapter 24 on pregnancy and perinatal care for further guidance on safeguarding in pregnancy. And see section 24.9.2 in chapter 24 on pregnancy and perinatal care for further guidance on multi-agency assessment and multi-agency care-planning.

Pharmacological management of withdrawal in pregnancy

For women who require medically assisted withdrawal during pregnancy, you can use chlordiazepoxide. You should consider if it’s best to do this as an inpatient with antenatal team, so that they can appropriately monitor the mother and the fetus.

There are concerns about using benzodiazepines during pregnancy due to their potential teratogenic effects (birth defects). However, the risks from continued excessive alcohol consumption and complications from alcohol withdrawal, such as seizures and delirium tremens, significantly outweigh any risks from the doses and duration of benzodiazepines used for medically assisted withdrawal (McAllister-Williams and others 2017, ASAM 2020, Reus and others 2018, Heberlein and others 2012).

You should not use carbamazepine in pregnancy for safety reasons.

There is a MHRA drug safety update about using antiepileptic drugs in pregnancy.

Women undergoing medically assisted withdrawal during pregnancy will need thiamine supplementation as described in section 10.4.3 on preventing and managing WKS. Pregnant women should also take folic acid supplements as advised in the NICE public health guideline Maternal and child nutrition (PH11). Women should follow advice from the GP and specialist midwife on other aspects of nutritional support.

You can undertake medically assisted withdrawal with pregnant women in any trimester, though if it’s close to their delivery, you must consider the impact of withdrawal from alcohol or benzodiazepines on the baby. The baby will need specialist paediatric monitoring if it is born during the medically assisted withdrawal. Any enduring alcohol withdrawal in the mother should be appropriately treated. The baby should be assessed and then assessed again regularly throughout infancy for fetal alcohol spectrum disorder.

Section 24.8.3 in chapter 24 on pregnancy and perinatal care provides more guidance on caring for the new-born baby.

Relapse prevention in pregnancy

Abstinence from alcohol is strongly recommended in pregnancy. The UK chief medical officers’ low-risk drinking guidelines advise that the safest approach is to avoid drinking any alcohol during pregnancy. Due to lack of safety data, relapse prevention medication cannot be routinely recommended.

The BNF advises that acamprosate and naltrexone should be avoided during pregnancy unless the potential benefit outweighs risk. But treatment may be considered in individual cases based on the balance of risk and discussion with the mother. Women who become pregnant while taking acamprosate or naltrexone will generally be advised to stop taking these.

You should avoid using disulfiram in the first trimester due to potential teratogenic effects of acetaldehyde.

The BNF for baclofen states that the manufacturer advises using it in pregnancy only if the potential benefit outweighs risk (as it was found to produce toxicity in animal studies).

The BNF for nalmefene states that the manufacturer advises to avoid its use during pregnancy (as it was found to produce toxicity in animal studies).

Pharmacological management of withdrawal for women who are breastfeeding

In general, the health benefits of breastfeeding mean that it should be encouraged whenever possible. When a breastfeeding woman consumes alcohol, it is readily transferred into breast milk. The amount received by the baby will depend on the timing of feeding related to when the alcohol was consumed. Alcohol is likely to cause lethargy, drowsiness and poor feeding in babies. It also presents a risk of hypoglycaemia. So, you should strongly recommend that breastfeeding mothers do not consume alcohol.

Alcohol treatment services should prioritise women who are alcohol dependent and have babies, including those who are breastfeeding, for rapid assessment for and provision of medical assisted withdrawal.

There is a lack of well-conducted studies to guide how you provide advice about breastfeeding in the context of prescribed medication. You should get specialist advice when planning and providing individually tailored pharmacological interventions for women who are breastfeeding. Useful sources of specialist advice include the Breastfeeding network and the Specialist Pharmacy Service safety in breastfeeding guidance.

Clinicians should discuss the risks and benefits of medically assisted withdrawal when breastfeeding with the woman so a shared decision about treatment can be made. However, clinicians should recommend that the woman stop breastfeeding while taking the medication to avoid adverse effects in the baby if the medication is transferred in the breast milk. This may be particularly relevant if large doses of benzodiazepines are used during the medically assisted withdrawal.

There should be a multidisciplinary approach to supporting the woman and baby and this should include input from neonatal paediatricians and specialist breastfeeding advice and support for the mother. The mother can be supported to express milk during the medically assisted withdrawal, to increase the chance that she can continue to lactate and resume breastfeeding after the medically assisted withdrawal has finished.

Women may vary in their approach to risk. If the mother makes a fully informed choice not to stop breastfeeding, the clinician should seek specialist advice on the relative risks and benefits and any actions they can take to mitigate risks associated with breastfeeding during medically assisted withdrawal.

Relapse prevention for women who are breastfeeding

Psychological approaches and social support are the mainstay of relapse prevention for women who want to start or continue breastfeeding.

You should discuss the risks and benefits of relapse prevention medication with the woman so a shared decision can be made. However, due to the lack of comprehensive evidence available, you should routinely recommend that women who are breastfeeding should avoid pharmacological treatment to prevent relapse using medications such as acamprosate, naltrexone and disulfiram.

The lack of studies looking at long-term outcomes after taking relapse prevention medication during breastfeeding introduces a degree of uncertainty and mothers may vary in their approach to risk. In exceptional circumstances you might want to consider prescribing relapse prevention medication if the woman has requested this based on a fully informed understanding of risks and benefits.

If you are considering treatment, you should undertake comprehensive assessment of risk for each individual woman who is breastfeeding. You should also get individualised specialist advice on prescribing relapse prevention medication for the woman who is breastfeeding (see section above on pharmacological management for useful sources of specialist advice on prescribing and breastfeeding). Pharmacological principles suggest using the lowest possible effective dose, for the shortest time. For example, this might only be during periods of a particularly high risk of relapse. You should not consider pharmacological treatment as a single option without accompanying psychological support or interventions to help reduce risk of relapse.

Due to the lack of information on safety, you should avoid prescribing disulfiram. If considering prescribing relapse prevention medication in exceptional circumstances, you should consider alternatives (acamprosate or naltrexone).

10.6.5 Prescribing for people with co-occurring mental health conditions

Many people with alcohol problems have co-occurring mental health disorders or their symptoms. When you are considering treatment with medication you should do a comprehensive assessment with the patient to understand the relationship between their alcohol use and any other mental health symptoms or disorders.

Evidence shows that you should treat both their alcohol problems and mental health disorder in their own right as treating one does not necessarily lead to resolution of the other (Lingford-Hughes and others 2012, Haber and others 2009). There is no evidence that a treatment for a mental health disorder is less effective when it is co-occurring with alcohol problems, so treatment should follow usual guidelines, for example NICE guidelines.

There is more guidance on other aspects of working with co-occurring mental health conditions in chapter 18 on co-occurring mental health conditions.

Pharmacological management of withdrawal for people with co-occurring mental health conditions

There are no specific safety issues to consider when choosing a benzodiazepine in people with a co-occurring mental health condition, and you can follow guidelines outlined in this chapter. However, you will need to check the BNF and SPC for interactions of medicines used for medically assisted withdrawal against an individual’s current medication.

Pharmacological management of relapse prevention for people with co-occurring mental health conditions

Abstinence, or at least a reduction in a person’s alcohol consumption, is important to improving their mental health symptoms and conditions. You should consider prescribing relapse prevention medication for people with moderate or severe alcohol dependence alongside psychosocial or psychological interventions (Lingford-Hughes and others 2012, NICE 2011, Barnes and others 2020, Goodwin and others 2016, Cleare and others 2015).

There are no safety considerations for any of the relapse prevention medications except for disulfiram which is contraindicated in psychosis and severe personality disorder and where there is risk of suicide (see SPC and BNF).

You should also avoid using baclofen where there is a risk of:

• psychotic disorders
• significant mood disorders, including hypomanic and manic episodes
• current or past suicidal ideation or attempts (see SPC and BNF) (Sinclair and others 2016, Agabio and others 2018)

Naltrexone has been the most studied and reviewed medication with evidence to support it improving alcohol dependence when comorbid with a range of mental health conditions (Lingford-Hughes and others 2012). This includes for:

• depression
• post-traumatic stress disorder
• bipolar disorder

Not all naltrexone trials have reported efficacy compared with placebo.

There is evidence that disulfiram can be effective, even in disorders included in its contraindications and cautions (such as psychosis) (Rosenstand and others 2022). However, in circumstances where disulfiram is contraindicated it should only be prescribed by specialist teams, given the potential risks and interactions.

There is an association between alcohol problems and depression, and antidepressant use among people with alcohol problems is common. However, reviews of the evidence show that the effectiveness of antidepressant medication is reduced while people are drinking heavily. It remains important to offer medication such as acamprosate or naltrexone and monitor for efficacy (Agabio and others 2018, Foulds and others 2015, Iovenio and others 2011, Nunes and Levin 2004, Torrens and others 2005).

See section 10.5.1 for guidance on prescribing for relapse prevention.

10.6.6 Prescribing for people with liver disease

Pharmacological management of withdrawal in people with alcohol-related liver disease

There is no specific evidence on which to base the management of alcohol withdrawal in people with advanced alcohol-related liver disease (ARLD). People with decompensated cirrhosis (complicated by jaundice, ascites, variceal bleeding, renal impairment, sepsis or hepatic encephalopathy) and alcohol withdrawal can be challenging to manage. In these cases, you should seek advice from a healthcare professional with experience in the management of liver disease, hepatic encephalopathy and withdrawal, as recommended by NICE CG100.

Specific treatment considerations will depend on the severity of liver disease and the severity of withdrawal risk. People with advanced ARLD should be admitted to hospital for withdrawal.

In general, you can consider using a shorter-acting benzodiazepine in people with compromised liver function, such as oxazepam or lorazepam. This includes jaundice (bilirubin of more than 80), coagulopathy (INR of more than 1.5) and in particular, the presence of hepatic encephalopathy. You can use longer-acting benzodiazepines (for example chlordiazepoxide and diazepam) with the knowledge that people with compromised liver function will:

• need less
• metabolise slower
• have greater accumulation (NICE 2011)

Expertise available in the service, guidance and the quality and skill of monitoring is more important than the choice of benzodiazepine. You should take care not to over-sedate the person. If hepatic encephalopathy worsens, you should stop the benzodiazepine, and if it is needed later, you should prescribe it at a lower dose.

Pharmacological management of relapse prevention in people with alcohol-related liver disease

Abstinence from alcohol is a vital goal for people with ARLD since abstinence improves outcomes in all stages of the disease. There should be established care pathways between specialist liver services and alcohol treatment services, in line with guidance on alcohol treatment pathways. You should consider pharmacotherapy for relapse prevention for people with ARLD. However, many of the drugs available have not specifically been tested in people with advanced ARLD.

Of the relapse prevention drugs recommended by NICE CG115, disulfiram and naltrexone are metabolised in the liver, whereas acamprosate is not. You should avoid using disulfiram for people with advanced ARLD because of potential hepatotoxicity (Forns and others 1994, EASL 2018, Fix and others 2020). Naltrexone has not been studied systematically in people with advanced ARLD.

Acamprosate has a generally good safety profile and is not metabolised in the liver. While there is preliminary data suggesting safety in people with Childs’ A and B cirrhosis, there are no trials of repeatedly administering acamprosate in people with cirrhosis (Pugh and others 1973).

Using either disulfiram or naltrexone is not recommended in people with advanced ARLD.

Based on limited data, acamprosate is probably safe and may be used (Crabb and others 2020).

In clinical practice, it is important to make the distinction between people with advanced ARLD and those with less severe liver disease. For the latter group, relapse prevention medication could be safely used with appropriate monitoring. People with advanced ARLD will have at least one of:

• significant synthetic dysfunction (impaired ability to synthesise proteins), indicated by jaundice (bilirubin of more than 80)
• coagulopathy (INR of more than 1.5)
• hepatic encephalopathy (decline in brain function that occurs as a result of severe liver disease)

You should involve specialist hepatology services in diagnosis.

Baclofen is currently the only pharmacotherapy for alcohol use disorder for which there is randomised controlled trial data in people with cirrhosis (including those with decompensated cirrhosis but excluding hepatic encephalopathy) (Addolorato and others 2007). Further confirmatory studies are required and there are still questions on optimal dosing and duration of treatment. However, it does appear that baclofen may be useful in people with ARLD cirrhosis and alcohol use disorder.

Pharmacological interventions to reduce alcohol use in liver disease

As described earlier in this chapter, NICE recommends using nalmefene to reduce alcohol consumption in a defined group of people who have mild alcohol dependence with a high drinking risk level without physiological withdrawal symptoms. Nalmefene has not been tested in people who have ARLD cirrhosis, and for these people the goal should be abstinence rather than reduction. However, you can use nalmefene for people with earlier stage liver disease who can benefit from a reduction goal if abstinence is not feasible, provided they meet the criteria described in section 10.5.6 on nalmefene above.

10.7 Benzodiazepine withdrawal regimens

10.7.1 Overview

Individual needs, circumstances and setting

The following benzodiazepine withdrawal regimens are examples only, based on the clinical consensus of the alcohol guidelines development group. They are not protocols that must be followed.

Clinicians should make prescribing decisions based on individual needs, circumstances and setting.

The regimens suggested in this section are suitable for people with moderate dependence (15 to 30 units of alcohol per day and a Severity of Alcohol Dependence Questionnaire (SADQ) score of 15 to 30) who undergo medically assisted withdrawal in community or, where indicated, in inpatient settings. There are 3 suggested tiers of dosage for each drug. You should select the dosage based on the number of units the person drinks per day, the SADQ score within the range, and other clinical factors.

Adapting regimens

Although such regimens often work with no need for change, community staff will need experienced prescribers for support if regimens require adaptation (if doses need to be reduced or withheld). For people who show objective alcohol withdrawal symptoms and score high on alcohol withdrawal scales such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar), the doses may need to be increased. These regimens include the option to provide an additional daily dose to be used PRN (if needed) based on telephone advice or face-to-face advice from the clinician monitoring the medically assisted withdrawal. This can be useful as it helps control symptoms, while allowing clinicians the time to adapt the regimen and supply the additional medication that the person will need.

Higher doses than are shown in these regimens are likely to be needed in cases of severe dependence, but these should usually be managed in inpatient settings (see section 10.2.4). If higher doses are considered in the community in exceptional circumstances, for example where the person declines admission, then an experienced team with senior medical leadership is essential.

The BNF contains a safety alert from the MHRA about prescribing benzodiazepines along with opioids.

10.7.2 Example regimens for planned, fixed-dose alcohol withdrawal (moderate dependence)

Chlordiazepoxide

Table 1: alcohol withdrawal regimen (moderate dependence) for chlordiazepoxide 5mg capsules

Start dose chlordiazepoxide 15mg QDS (4 times daily).

Day	8am (number of capsules to take)	12:30pm (number of capsules to take)	5pm (number of capsules to take)	10pm (number of capsules to take)	PRN (only to be taken if recommended by a doctor or nurse)	Total number of capsules to take per day (without PRN)	Total number of capsules to take per day (with PRN)
1	15mg (3)	15mg (3)	15mg (3)	15mg (3)	15mg (3)	12	15
2	10mg (2)	10mg (2)	10mg (2)	10mg (2)	10mg (2)	8	10
3	10mg (2)	Stop	10mg (2)	10mg (2)	10mg (2)	6	8
4	5mg (1)		5mg (1)	5mg (1)	5mg (1)	3	4
5	5mg (1)		Stop	5mg (1)	5mg (1)	2	3
6	Stop			5mg (1)	Stop	1	1
7				Stop		Stop	Stop

Table 2: alcohol withdrawal regimen (moderate dependence) for chlordiazepoxide 5mg capsules

Start dose chlordiazepoxide 20mg QDS (4 times daily).

Day	8am (number of capsules to take)	12:30pm (number of capsules to take)	5pm (number of capsules to take)	10pm (number of capsules to take)	PRN (only to be taken if recommended by a doctor or nurse)	Total number of capsules to take per day (without PRN)	Total number of capsules to take per day (with PRN)
1	20mg (4)	20mg (4)	20mg (4)	20mg (4)	20mg (4)	16	20
2	15mg (3)	15mg (3)	15mg (3)	15mg (3)	15mg (3)	12	15
3	10mg (2)	10mg (2)	10mg (2)	10mg (2)	10mg (2)	8	10
4	10mg (2)	Stop	10mg (2)	10mg (2)	10mg (2)	6	8
5	5mg (1)		5mg (1)	5mg (1)	5mg (1)	3	4
6	5mg (1)		Stop	5mg (1)	5mg (1)	2	3
7	Stop			5mg (1)	Stop	1	1
8				Stop		Stop	Stop

Table 3: alcohol withdrawal regimen (moderate dependence) for chlordiazepoxide 5mg capsules

Start dose chlordiazepoxide 25mg QDS (4 times daily).

Day	8am (number of capsules to take)	12:30pm (number of capsules to take)	5pm (number of capsules to take)	10pm (number of capsules to take)	PRN (only to be taken if recommended by a doctor or nurse)	Total number of capsules to take per day (without PRN)	Total number of capsules to take per day (with PRN)
1	25mg (5)	25mg (5)	25mg (5)	25mg (5)	25mg (5)	20	25
2	20mg (4)	20mg (4)	20mg (4)	20mg (4)	20mg (4)	16	20
3	15mg (3)	15mg (3)	15mg (3)	15mg (3)	15mg (3)	12	15
4	10mg (2)	10mg (2)	10mg (2)	10mg (2)	10mg (2)	8	10
5	10mg (2)	Stop	10mg (2)	10mg (2)	10mg (2)	6	8
6	5mg (1)		5mg (1)	5mg (1)	5mg (1)	3	4
7	5mg (1)		Stop	5mg (1)	5mg (1)	2	3
8	Stop			5mg (1)	Stop	1	1
9				Stop		Stop	Stop

Diazepam

In the UK, use of diazepam to treat alcohol use disorders is ‘off-label’. For more information on off-label prescribing, see MHRA guidance Off-label or unlicensed use of medicines: prescribers’ responsibilities. You can also read section 10.2.2 on unlicensed or off-label prescribing. Prescribers should refer to the summary of product characteristics (SPC).

Table 4: alcohol withdrawal regimen (moderate dependence) for diazepam 2mg tablets

Start dose diazepam 6mg QDS (4 times daily).

Day	8am (number of tablets to take)	12:30pm (number of tablets to take)	5pm (number of tablets to take)	10pm (number of tablets to take)	PRN (only to be taken if recommended by a doctor or nurse)	Total number of tablets to take per day (without PRN)		Total number of tablets to take per day (with PRN)
1	6mg (3)	6mg (3)	6mg (3)	6mg (3)	6mg (3)	12		15
2	4mg (2)	4mg (2)	4mg (2)	4mg (2)	4mg (2)	8		10
3	4mg (2)	Stop	4mg (2)	4mg (2)	4mg (2)	6		8
4	2mg (1)		2mg (1)	2mg (1)	2mg (1)	3		4
5	2mg (1)		Stop	2mg (1)	2mg (1)	2		3
6	Stop			2mg (1)	Stop	1		1
7				Stop		Stop	Stop

Table 5: alcohol withdrawal regimen (moderate dependence) for diazepam 2mg tablets

Start dose diazepam 8mg QDS (4 times daily).

Day	8am (number of tablets to take)	12:30pm (number of tablets to take)	5pm (number of tablets to take)	10pm (number of tablets to take)	PRN (only to be taken if recommended by a doctor or nurse)	Total number of tablets to take per day (without PRN)	Total number of tablets to take per day (with PRN)
1	8mg (4)	8mg (4)	8mg (4)	8mg (4)	8mg (4)	16	20
2	6mg (3)	6mg (3)	6mg (3)	6mg (3)	6mg (3)	12	15
3	4mg (2)	4mg (2)	4mg (2)	4mg (2)	4mg (2)	8	10
4	4mg (2)	Stop	4mg (2)	4mg (2)	4mg (2)	6	8
5	2mg (1)		2mg (1)	2mg (1)	2mg (1)	3	4
6	2mg (1)		Stop	2mg (1)	2mg (1)	2	3
7	Stop			2mg (1)	Stop	1	1
8				Stop		Stop	Stop

Table 6: alcohol withdrawal regimen (moderate dependence) for diazepam 2mg tablets

Start dose diazepam 10mg QDS (4 times daily).

Day	8am (number of tablets to take)	12:30pm (number of tablets to take)	5pm (number of tablets to take)	10pm (number of tablets to take)	PRN (only to be taken if recommended by a doctor or nurse)	Total number of tablets to take per day (without PRN)	Total number of tablets to take per day (with PRN)
1	10mg (5)	10mg (5)	10mg (5)	10mg (5)	10mg (5)	20	25
2	8mg (4)	8mg (4)	8mg (4)	8mg (4)	8mg (4)	16	20
3	6mg (3)	6mg (3)	6mg (3)	6mg (3)	6mg (3)	12	15
4	4mg (2)	4mg (2)	4mg (2)	4mg (2)	4mg (2)	8	10
5	4mg (2)	Stop	4mg (2)	4mg (2)	4mg (2)	6	8
6	2mg (1)		2mg (1)	2mg (1)	2mg (1)	3	4
7	2mg (1)		Stop	2mg (1)	2mg (1)	2	3
8	Stop			2mg (1)	Stop	1	1

10.8 References

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11. Community based medically assisted withdrawal

11.1 Main points

Community based medically assisted withdrawal should be available within every local treatment system. People should be able to access it easily and promptly.

People who are moderately dependent on alcohol (who typically drink 15 to 30 units per day and score between 15 to 30 on the Severity of Alcohol Dependence Questionnaire (SADQ)) should be offered an assessment for community medically assisted withdrawal.

People who are severely dependent on alcohol (who typically drink 30 units or more per day and score 30 or more on SADQ) should normally be offered a specialist inpatient withdrawal.

Staff responsible for assessing and managing community medically assisted withdrawal should be competent in diagnosing and assessing alcohol dependence and withdrawal symptoms. They should also be competent using recommended drug regimens appropriate for a community setting.

Specialist assessment for medically assisted withdrawal should include assessing the appropriateness of a community setting against specific safety considerations.

Where the person has experienced medically assisted withdrawal in recent months, the clinician should carefully assess the risk-benefit ratio of offering the intervention.

An appropriate family member or friend should stay with the person during the medically assisted withdrawal process for support and to call an ambulance in an emergency.

The clinician or keyworker and the person should agree a plan for organising their support and their time during the medically assisted withdrawal, and the ongoing treatment they will move on to immediately after completion.

The clinician should discuss and provide accessible information on the medically assisted withdrawal process and on severe complications that should trigger a call for an ambulance, including:

symptoms worsening to the point of severe shaking and very heavy sweating

• seizures
• delirium tremens
• incipient Wernicke’s encephalopathy

The clinician should prescribe prophylactic oral thiamine or administer parenteral (intramuscular) thiamine based on assessment.

Clinicians should follow guidance on prescribing and managing alcohol withdrawal in chapter 10 on pharmacological interventions.

The clinician should be in daily contact with the person during the first 3 days of the medically assisted withdrawal and should see the person face to face at least every other day during the first week. On the days when the clinician does not see the person, they should monitor the person’s condition remotely.

Clinical monitoring should include using a breathalyser, assessing withdrawal symptoms using a validated measure of withdrawal symptoms, such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) and monitoring the effects of medication.

In the exceptional circumstance that a person has complex needs or is severely dependent and is assessed as suitable for community based medically assisted withdrawal, there is likely to be increased risk to them. So, they should be closely monitored by an experienced multidisciplinary team.

People with severe alcohol dependence will require higher doses of benzodiazepines to adequately control withdrawal and increased supervision. A senior specialist clinician should determine the programme, including the drug regimen, on a case-by-case basis.

Clinicians should prescribe for short dispensing intervals, with no more than 2 days medication supplied per prescription. This will help to prevent overdose or diversion (the drug being taken by someone other than the person it was prescribed for).

If the person drinks alcohol, the medically assisted withdrawal should generally be discontinued. If this happens, the service should offer the person alternative support within the service.

After completing a successful community based medically assisted withdrawal, the treatment service should offer the person psychosocial interventions and relapse prevention medication.

11.2 Introduction

This chapter describes the broader context of care in which community medically assisted withdrawal is provided.

You should read this chapter with chapter 10 on pharmacological interventions, which provides detailed guidance on prescribing for the management of withdrawal from alcohol, including for preventing and managing specific complications.

11.3 Settings and the treatment pathway

11.3.1 Overview

Most people who are moderately dependent on alcohol (who typically drink 15 to 30 units per day and score between 15 to 30 on the SADQ) and some people who are mildly dependent (who typically drink less than 15 units per day with some signs of dependence) will need medically assisted withdrawal to prevent significant withdrawal symptoms when stopping drinking. It will be appropriate to carry this out in the community unless there are safety concerns that indicate that the person needs more specialised medical and nursing care, or the more intensive monitoring provided in an inpatient setting.

You can find more information on the indications for providing medically assisted withdrawal in an inpatient or residential setting rather than a community setting in section 11.5.5 below.

11.3.2 A range of clinical teams and different settings

A range of clinical teams may provide community based medically assisted withdrawal in several different settings, including:

• specialist community alcohol (and drug) treatment services delivering the intervention at the service or in the person’s home
• primary care where GPs have the appropriate specialist competencies, or where GPs work with specialist community alcohol treatment services (see chapter 15 on primary care and community health services)
• some hospital based alcohol care teams offer planned community based medically assisted withdrawal

11.3.3 Home based medically assisted withdrawal

Some local alcohol (and drug) treatment systems provide community based medically assisted withdrawal in the home to people who are assessed as eligible. In other areas, services usually deliver the intervention from a service base. Services have a duty to ensure their activities are accessible to people with protected characteristics (see information and guidance on the Equality Act 2010). So, the treatment system should be able to provide medically assisted withdrawal in the home for people who cannot attend the service base because of a disability, including a long-term mental health condition.

Home based medically assisted withdrawal may also be appropriate in rural areas where travel to the service base several days a week may be difficult enough to deter people from attending.

The service procedure for delivering home based medically assisted withdrawal should be aligned with its home based working and lone working procedures.

11.3.4 The treatment pathway

People should be able to easily access community based medically assisted withdrawal wherever they are in the treatment and recovery system and at the stage in their treatment journey when they need it.

If there are no exclusionary factors (see section 11.5.5 for a summary of criteria for inpatient or residential medically assisted withdrawal), a person may be offered planned community based medically assisted withdrawal at any of the stages below. So, this could be after:

• initial or comprehensive assessment
• a period of engagement with harm reduction interventions
• returning to dependent drinking during a treatment episode

The referral pathways between different parts of the treatment and recovery system should be effective and clear to everyone who works within it and to the referring agencies.

The clinician who delivers community based medically assisted withdrawal is often not the person’s keyworker and may be based in a different part of the alcohol treatment system. It is essential to have good communication and joint planning between staff, and to involve the person (and family member where appropriate), before, during and after community based medically assisted withdrawal. There should be a seamless transition to ongoing treatment and support following community based medically assisted withdrawal, because gaps in treatment may increase the risk of returning to problematic drinking.

11.4 Principles for delivering community based medically assisted withdrawal

11.4.1 Staff competence

Staff responsible for assessing and managing community based medically assisted withdrawal should be suitably qualified clinicians. They should be specialist and competent in diagnosing and assessing alcohol dependence and withdrawal symptoms and using recommended drug regimens appropriate for a community setting. Staff should also have access to regular clinical supervision and when necessary, consultation from a senior clinician or multidisciplinary team (MDT).

11.4.2 Written procedure

Service providers should have a written procedure that covers all elements of delivering and supervising community based medically assisted withdrawal within their service.

11.4.3 Access to medically assisted withdrawal

Services should offer assessment for community based medically assisted withdrawal as quickly as possible as there is evidence that a prompt offer of treatment at a point when the person is open to changing their drinking can increase the likelihood that they will engage in treatment (Passetti and others 2008). There is also a risk that the person’s health could deteriorate if access to the intervention is delayed.

Services should provide medically assisted withdrawal as soon as a competent clinician has assessed a person as needing it, the person consents, and adequate preparations are in place. In cases where the person has had repeated episodes of medically assisted withdrawal, the clinician will need to assess relative risks and benefits of proceeding. This is discussed in section 11.5.5 below and in chapter 10 on pharmacological interventions.

Services should minimise any barriers to accessing medically assisted withdrawal. These barriers might include:

• lack of staff capacity within the service, including lack of specialist clinicians
• long waiting times for assessment and referral for the intervention
• excessive requirements for people to show they are motivated, such as a requirement to attend a series of groups

11.4.4 Integrating pharmacological and psychosocial interventions

Community based medically assisted withdrawal is centred around a pharmacological intervention, but psychosocial interventions should be an integral part of the treatment programme. Both these elements are important and can reinforce one another. The psychosocial element may be particularly important to maximise chances of maintaining abstinence for people who have undergone several previous episodes of community based medically assisted withdrawal.

People will often be anxious about stopping drinking. Taking an empathic, supportive, and collaborative approach will help to engage and encourage the person, as well as family members supporting them. Assessment and monitoring of medically assisted withdrawal should always involve motivational interventions.

You can find more information on motivational interventions in chapter 5 on psychosocial interventions.

The medically assisted withdrawal process also presents an opportunity for brief psychosocial interventions, like providing information on physical and mental health harms and considering how the person might reduce or manage some of the harms they experience.

Giving the person feedback on tests can be helpful in showing care and activating behaviour change. This might include:

• breathalyser readings
• blood test results
• liver screening results
• blood pressure readings
• cognitive tests

11.5 Assessment for community-based medically assisted withdrawal

You should read this section along with chapter 10 on pharmacological interventions.

The following recommendations on assessment for community based medically assisted withdrawal draw on the National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) and on the clinical consensus of the alcohol guidelines development group.

11.5.1 Assessing severity of dependence

Initial assessment should include assessing the severity of the person’s dependence and their need for medically assisted alcohol withdrawal. You can find guidance on assessing severity of dependence in section 4.17.3 in chapter 4 on assessment. Services should offer an assessment for medically assisted alcohol withdrawal to people with a goal of abstinence who typically drink:

• over 15 units of alcohol per day or score over 20 on AUDIT (Alcohol Use Disorders Identification Test)

• under 15 units a day but have a previous history of significant withdrawal symptoms (for example, people with a low body weight)

Community based medically assisted withdrawal will usually be suitable for people who are moderately dependent (typically drink 15 to 30 units daily or score between 15 and 30 on SADQ) and do not have complex needs that require the intensive monitoring provided in an inpatient setting. It may also be suitable for people drinking less than 15 units per day with a previous history of significant withdrawal symptoms. You can find a summary of criteria for inpatient or residential medically assisted withdrawal in section 11.5.5 below.

A breathalyser reading provides additional information at assessment for medically assisted withdrawal. Blood alcohol content readings may sometimes indicate a higher level of consumption than the AUDIT and SADQ scores, which both rely on self-reporting. A breathalyser reading correlated with the level of intoxication can indicate the likely severity of withdrawal symptoms. For example, if the person has a high blood alcohol content reading and does not appear intoxicated, this may indicate tolerance to alcohol and an increased risk of severe withdrawal.

When assessing the severity of alcohol dependence and the need for assisted withdrawal, clinicians should adjust the criteria for:

• women
• pregnant women
• older people
• children and young people
• people with advanced alcohol related liver disease who may have problems with the metabolism of alcohol

You should seek specialist advice from a senior clinician or MDT when assessing pregnant women, young people, older people, people with liver disease, people with concurrent drug use and people with concurrent mental health conditions for medically assisted withdrawal.

You should read the guidance on prescribing and managing withdrawal for these groups in section 5 of chapter 10 on pharmacological interventions.

For children and young people aged between 10 and 17 years old, NICE CG115 recommends inpatient medically assisted withdrawal in an age appropriate setting with access to staff with specialist expertise.

You can find guidance on medically assisted withdrawal for young people in section 23.6.1 of chapter 23: alcohol treatment and support for young people.

11.5.2 Assessing risk that severe medical complications will occur in withdrawal

You should read this section along with section 10.4 in chapter 10 on pharmacological interventions, which provides detailed guidance on assessing severity of risk of complications in withdrawal, prescribing and managing withdrawal.

The main complications in withdrawal that can occur are:

• seizures
• delirium tremens
• Wernicke-Korsakoff syndrome

You should assess the risk that these complications may occur during medically assisted withdrawal. Severity of dependence, history of these complications during previous medically assisted withdrawal and individual health factors will contribute to the level of risk.

If there are factors that indicate the risk is high, the service should offer the person a referral for medically assisted withdrawal in an inpatient setting instead of a community based intervention. You can find a summary of criteria for offering medically assisted withdrawal in an inpatient or residential setting in section 11.5.5 below.

11.5.3 General medical history and current health

The clinician should take a general medical history and assess the person’s current physical and mental health. There is more detailed guidance on assessing physical and mental health in chapter 4 on assessment. The potential impact of medically assisted withdrawal on any physical or mental health condition will inform decisions about prescribing and managing withdrawal, including the setting. Section 10.6 in chapter 10 on pharmacological interventions provides guidance on prescribing medically assisted withdrawal for specific groups of people.

The clinician should assess whether the person will need oral thiamine or parenteral intramuscular (IM) thiamine, also known as Pabrinex. They should also assess what setting is best to administer this. You should follow the guidance on prescribing and administering thiamine to reduce the risk of Wernicke’s encephalopathy and Wernicke-Korsakoff syndrome in section 10.4.3 of chapter 10 on pharmacological interventions.

The clinician will need to consider the impact of a person’s drug use on prescribing and managing withdrawal, including using or misusing prescribed or over the counter medication. This will depend on the substance and pattern of use. If the person has a drug dependence as well as an alcohol dependence, the clinician should consider an inpatient setting. Community medically assisted withdrawal should only be offered where the staff are sufficiently skilled, trained and resourced to manage the complexity of concurrent drug use. You should follow the guidance on medically assisted withdrawal where there is concurrent drug use or dependence in section 10.6.1 of chapter 10 on pharmacological interventions.

Where the person requires medically assisted withdrawal from benzodiazepines in addition to alcohol, services should offer this in an inpatient setting. If the clinician decides to offer withdrawal management in the community after carrying out a careful assessment of risk and benefit, they should follow the guidance in section 10.6.1 of chapter 10 on pharmacological interventions.

The clinician should arrange for liver function and renal function tests to be carried out before starting the intervention to pick up on any safety concerns or indications that adaptations are needed. Based on individual assessment of health, additional tests may be indicated.

The clinician should carry out a baseline assessment of cognitive function using a validated tool, such as the mini-Addenbrooke’s Cognitive Examination (mini-ACE). This will show any difficulties the person has retaining information in the short term that might impact on their ability to consent to treatment, even if their cognitive function will improve in the longer term.

With consent, the clinician should inform the person’s GP that they plan to deliver a community based medically assisted withdrawal and obtain information on any medication the GP is prescribing.

11.5.4 Level of support and identifying barriers

Services should generally only offer community based medically assisted withdrawal where there is a family member or trusted friend available to supervise the process and to call an ambulance if the person experiences severe complications. It is preferable if a family member, carer, or trusted friend supervises the medication. If the clinician is considering offering community based medically assisted withdrawal where this support is not available, they should follow the guidance in section 11.5.5.

The clinician should establish what level of support is available to the person. Comprehensive assessment of the person should include an assessment of the strengths and any risks (such as intimate partner violence) they face within the family support network. If the clinician is not the practitioner who carried out that assessment, they should refer to it, to ensure that the family member is appropriate to provide support to the person during medically assisted withdrawal. You can find more information about involving a person’s partners, family and friends in section 4.7 of chapter 4 on assessment.

The clinician should consider how any individual barriers to maximising the person’s chances of completing the process can be addressed. Barriers might include personal issues such as needing to assertively set boundaries with friends drinking at harmful levels who may want to visit, or practical issues such as pressure not to be absent from work or caring responsibilities.

11.5.5 Summary of criteria for offering medically assisted withdrawal in a specialist inpatient or residential setting and not in the community

It is important to determine whether medically assisted withdrawal can be carried out safely in the community. This will depend on a person’s:

• severity of dependence
• medical history, including history of complications in withdrawal
• current health
• potential sources of support

Specialist inpatient medically assisted withdrawal

Clinicians should base decisions on whether to refer people for specialist inpatient medically assisted withdrawal on individual clinical assessment. But they should normally refer people who meet one or more of the following criteria:

1. They drink over 30 units of alcohol per day or have a score of more than 30 on SADQ.
2. They have a history of epilepsy, or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes.
3. They are assessed as at high risk of Wernicke’s encephalopathy (WE). Based on individual assessment, it may be possible to offer them medically assisted withdrawal in the community if parenteral (intramuscular) thiamine is available on site and there is a sufficiently skilled, trained, and resourced team to administer it. Clinicians should follow guidance in section 10.4.3 on WE and medically assisted withdrawal in chapter 10 on pharmacological interventions.
4. They have co-occurring harmful or dependent substance use, including prescribed and over the counter medication, which requires management, or concurrent medically assisted withdrawal from alcohol and one or more substances.

5. They have a severe mental health condition (for example, psychosis, severe depression or suicidal ideation) that makes medically assisted withdrawal in a community or residential setting potentially unsafe.

6. They have a significant physical health condition (for example, chronic liver disease, malnutrition, congestive cardiac failure or unstable angina) that makes medically assisted withdrawal in a community or residential setting potentially unsafe.
7. They have a significant learning disability or cognitive impairment.
8. They are pregnant (see more information on pregnancy and medically assisted withdrawal in chapter 10 on pharmacological interventions).

Medically assisted withdrawal in a residential setting

People who do not have an appropriate family member or trusted friend to stay with them during the medically assisted withdrawal, but otherwise meet the criteria for community based medically assisted withdrawal, should normally be offered medically assisted withdrawal in a residential setting and not a community based setting. See section 12.3 in chapter 12 on specialist inpatient medically assisted withdrawal for a description of residential medically assisted withdrawal.

Clinicians should consider a lower threshold for referring vulnerable groups and people who are frail to specialist inpatient medically assisted withdrawal. This includes people experiencing homelessness, older people, and very young people.

In some circumstances, you can offer community based medically assisted withdrawal to people who meet one of the criteria above for inpatient or residential medically assisted withdrawal. You should base this decision on a careful assessment of the risks and benefits of providing this intervention, while also considering what the person wants. In these exceptional cases, both assessment and treatment should only be carried out by an experienced MDT with senior medical leadership who are able to provide an increased level of monitoring, for example in a day hospital unit. There should also be an established pathway into inpatient medically assisted withdrawal so that the person can be admitted immediately if they experience severe complications.

11.5.6 Repeated episodes of medically assisted withdrawal

During the assessment, the clinician should consider the number of previous medically assisted withdrawal episodes (either community based or inpatient) the person has experienced. There is evidence that repeated withdrawal episodes at relatively short intervals can cause damage to cognitive functioning (Booth and Blow 1993, Becker 1998). Where the person has experienced medically assisted withdrawal in recent months, the clinician should carefully assess the risk-benefit ratio of offering the intervention. They should discuss relative risks and benefits with the person and inform them of the increasing risk of seizures and cognitive impairment associated with repeated medically assisted withdrawal at short intervals.

11.6 Preparing for community based medically assisted withdrawal

11.6.1 Preparing a person for medically assisted withdrawal

Preparing a person for medically assisted withdrawal should take place during assessment or shortly after the assessment in a follow up appointment.

The clinician should prescribe prophylactic oral thiamine or administer parenteral (intramuscular) thiamine, also known as Pabrinex, based on the guidance in section 10.4 of chapter 10 on pharmacological interventions.

Community based medically assisted withdrawal is a significant undertaking. People (including family members and friends) will need information and a chance to ask questions and discuss anxieties. They will also need to make practical arrangements such as organising support and cancelling commitments for the duration of the medically assisted withdrawal.

Preparation for community based medically assisted withdrawal should include:

• identifying an appropriate family member or trusted friend to stay with the person during the process for support, and to call an ambulance if the person experiences complications (see section 10.4 on prescribing medication to prevent and to manage specific complications of withdrawal in chapter 10 on pharmacological interventions)
• discussing results of blood tests with the person
• psychosocial support including motivational interviewing
• meeting with the person and family member or friend so they can ask questions and raise concerns
• a mutually agreed plan detailing how the person will organise their support and manage their time during the medically assisted withdrawal
• a mutually agreed plan for ongoing treatment and support immediately after completing medically assisted withdrawal
• an offer of peer support as this may be useful to reduce anxiety and support motivation

You should also communicate verbal and written information to the person on:

• the medically assisted withdrawal process and arrangements for monitoring meetings
• any support they will need from a family member or friend
• managing their medication
• severe complications that should trigger a call for an ambulance (see section 10.4 on prescribing medication to prevent and to manage specific complications of withdrawal in chapter 10 on pharmacological interventions)

You should make the information fully accessible for the person. For example, you should consider their:

• preferred language
• literacy
• sensory disability
• cognitive impairment
• neurodiversity

11.6.2 Additional preparation on a case by case basis

Some people may need additional preparation between assessment and receiving community medically assisted withdrawal for practical reasons, due to complex needs, or because they are ambivalent about starting. Clinicians should only delay the start of medically assisted withdrawal if an assessment of the person’s individual needs shows it is in their interest to do this.

There is little evidence to suggest that people always need to attend a series of preparation groups before accessing medically assisted withdrawal. This may be very difficult for some people who are physically dependent or have complex needs. Having a requirement like this risks excluding some people who could benefit from medically assisted withdrawal.

Preparation groups can be helpful for people who are contemplating change or are not sure if they are ready for medically assisted withdrawal. They can provide support in thinking through pros and cons and discussing any fears. Support from members of peer-based support services may also be helpful so the person can hear from others who have experienced community based medically assisted withdrawal and are now in recovery.

If there is a waiting list, the service should offer the person individual support and some services offer the option of additional group support while waiting. Services should make it clear to people on waiting lists that the wait is due to limited resources and any offer of group support is optional. They do not have to attend groups to access medically assisted withdrawal.

Clinicians should review the assessments of people on a waiting list regularly. This is because:

• a person’s level of risk may change
• community based medically assisted withdrawal might no longer be suitable
• a person may require urgent treatment

They should review the assessment as close as possible to the start of medically assisted withdrawal.

11.6.3 Safeguarding children and vulnerable adults

Where the person is caring for children or a vulnerable adult, preparation for medically assisted withdrawal should include arrangements for a trusted and responsible person to care for the children or vulnerable adult where necessary. Where children’s social care or adult safeguarding services are working with the family, the clinician should involve them in these arrangements. Practitioners must work within statutory guidance and their organisational safeguarding procedures for children and vulnerable adults.

With consent, practitioners should support the person who will undergo medically assisted withdrawal to discuss the plans for this with their children and other family members in an appropriate way.

Children and adult family members, including vulnerable adults, may also benefit from support outside of the medically assisted withdrawal process. Practitioners should offer support to family members or provide phone and online contact details for relevant support organisations. There is guidance on support for families in chapter 5 on psychosocial interventions.

11.7 Community based medically assisted withdrawal programmes

A community based medically assisted withdrawal programme should vary in intensity according to a person’s:

• severity of dependence
• available social support
• co-occurring conditions, such as physical or mental health conditions

11.7.1 Mild or moderate dependence

The clinician delivering the medically assisted withdrawal to people with mild or moderate dependence (without complex needs) should be in daily contact with them during the first 3 days when risks are likely to be highest. They should see the person face to face at least every other day during the first week. On the days when the clinician does not see the person, they should monitor the person’s condition remotely.

Meetings should include:

• an assessment of withdrawal symptoms using a validated measure of withdrawal symptoms, such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) and of the effects of medication
• being very alert for signs of incipient Wernicke’s encephalopathy and Wernicke-Korsakoff syndrome, and for delirium tremens
• using a breathalyser to confirm the person is alcohol free
• a chance for the person to share their experience and ask any questions
• a chance for the family member or friend to share observations and ask questions (with consent from the person)
• psychosocial support such as motivational interventions and cravings management
• issuing of prescriptions (where there are no safety concerns)
• discussion with the clinical supervisor or MDT if there are any other concerns

The clinician should call an ambulance immediately if the person is experiencing complications such as:

• symptoms worsening to the point of severe shaking and very heavy sweating
• seizures
• delirium tremens
• incipient Wernicke’s encephalopathy

See section 10.4 in chapter 10 on pharmacological interventions chapter for detailed guidance on prescribing for and managing these serious complications.

If the person reports drinking or the breathalyser shows that they have been drinking alcohol, the medically assisted withdrawal should generally be discontinued. If this happens, the service should offer the person alternative support. People with alcohol dependence may need several attempts to become abstinent but they may feel a sense of failure or shame at not completing a medically assisted withdrawal. The clinician or keyworker should offer encouragement and using a non-judgemental approach, review with the person what additional or alternative support they might need for a future attempt at stopping drinking.

If the person continues to drink, the clinician should consider continuing to prescribe oral thiamine and, where appropriate, parenteral (intramuscular) thiamine to prevent Wernicke-Korsakoff syndrome. You should follow the guidance on preventing and managing Wernicke-Korsakoff syndrome in section 10.4.3 of chapter 10 on pharmacological interventions.

If the person manages to remain alcohol free throughout the medically assisted withdrawal and they feel well enough, encourage them to access additional support between monitoring appointments, such as a keywork session, support groups, peer support or mutual aid.

After completing a successful community based medically assisted withdrawal, the treatment service should offer the person psychosocial interventions. You can find guidance on psychosocial interventions in chapter 5.

Services should also offer relapse prevention medication unless there are concerns about the safety of prescribing this for the person. You can find guidance on prescribing relapse prevention medication, including contraindications in section 10.5.1 of chapter 10 on pharmacological interventions.

11.7.2 Mild or moderate dependence with complex needs, or severe dependence

In the exceptional circumstance that a person has complex needs or is severely dependent and is assessed as suitable for community based medically assisted withdrawal, there is likely to be increased risk to them and they should be closely monitored by an experienced MDT.

People with severe alcohol dependence will require higher doses of benzodiazepines to adequately control withdrawal, prescribed according to the summary of product characteristics for the chosen medication. Make sure there is adequate supervision if high doses are administered and gradually reduce the dose over 7 to 10 days to avoid alcohol withdrawal recurring. A senior specialist clinician should determine the programme, including the drug regimen, on a case by case basis.

Immediately after medically assisted withdrawal, NICE CG115 recommends that people with complex needs or severe dependence should have access to a day programme for 4 to 7 days a week over a 3-week period. This day programme should include:

• keywork (case management) support
• individual psychosocial interventions
• group support
• psychoeducational interventions
• assertive linkage to peer support
• mutual aid and family and carer support and involvement where appropriate

The clinician should also offer relapse prevention medication unless there are concerns about the safety of prescribing this for the person. You can find guidance on prescribing relapse prevention medication, including contraindications, in section 10.5.1 of chapter 10 on pharmacological interventions.

11.8 Drug regimens for assisted withdrawal

You should follow guidance on prescribing and managing alcohol withdrawal in chapter 10 on pharmacological interventions.

When managing alcohol withdrawal in the community, avoid giving people large quantities of medication to take home. This will help to prevent overdose or diversion (the drug being taken by someone other than the person it was prescribed for). Prescribe for short dispensing intervals, with no more than 2 days medication supplied per prescription.

11.9 References

Passetti F, Jones G, Chawla K, Boland B and Drummond C. Pilot study of assertive community treatment methods to engage alcohol-dependent individuals. Alcohol and Alcoholism 2008: volume 43, issue 4, pages 451-455

Booth B and Blow F. The kindling hypothesis: further evidence from a U.S. national survey of alcoholic men. Alcohol and Alcoholism 1993: volume 28, issue 5, pages 593-598

Becker H. Kindling in alcohol withdrawal. Alcohol Health and Research World 1998: volume 22, issue 1, pages 25-33

12. Specialist inpatient medically assisted withdrawal

12.1 Main points

Specialist inpatient medically assisted withdrawal units provide medically assisted withdrawal to people with severe dependence or complex needs. They require specified specialist competencies and systems to do this.

Every local treatment system should have a pathway so that people with the highest levels of need can access specialist inpatient medically assisted withdrawal. People should be able to access it easily and without any unnecessary delays.

Specialist inpatient medically assisted withdrawal units should have a thorough admissions process to assess whether the unit can safely manage the withdrawal process for each patient.

Each patient should have a multi-agency treatment and recovery plan that includes plans for ongoing treatment and recovery support after discharge.

Core elements of specialist inpatient withdrawal include specialist competencies and systems including:

• a skilled multidisciplinary team led by an addiction specialist, normally a consultant addiction psychiatrist
• medical and nursing staff with a range of specialist competencies
• ability to identify and manage severe withdrawal complications including seizures, delirium tremens and Wernicke’s encephalopathy
• ability to assess and manage complex co-occurring physical health, mental health, additional drug use conditions, alcohol related brain damage and other complexities
• ability to implement relevant legislation and statutory guidance for safeguarding, mental capacity and mental health
• tailored psychosocial interventions and pharmacological interventions
• staffing arrangements that offer out of hours cover that are adequate for the safe running of the unit and the number of patients they treat
• an extensive range of referral pathways, including a rapid pathway to acute hospital care
• multi-agency working partnerships with community alcohol treatment services, health, social care, criminal justice and community agencies

Residential settings providing medically assisted withdrawal that do not have the core elements in place (as outlined in this chapter) do not have the appropriate capacity to manage people with more severe withdrawal complications or complex co-occurring conditions. These settings are suitable for people with alcohol dependence who would otherwise meet the criteria for community based medically assisted withdrawal but are lacking adequate social support.

12.2 Introduction

This chapter describes the core elements of specialist inpatient medically assisted withdrawal, usually referred to as specialist inpatient detoxification units. You should read this chapter alongside:

• chapter 10 on pharmacological interventions
• chapter 11 on community based medically assisted withdrawal
• chapter 16 on alcohol care in acute hospitals

12.3 Medically assisted withdrawal in different settings

Medically assisted withdrawal occurs in several different inpatient, community healthcare and other residential settings, in both a planned way and as part of unscheduled care. Settings include the following.

12.3.1 Community-based medically assisted withdrawal

Community-based medically assisted withdrawal is usually provided by the community alcohol treatment service but may be provided in other community settings, such as primary care or by a community mental health team.

You can read about community based medically assisted withdrawal in chapter 11.

12.3.2 Residential settings

Medically assisted withdrawal is provided by some residential rehabilitation services and in some supported housing settings. See section 12.6 below for further definition and distinction between residential medically assisted withdrawal settings and specialist inpatient medically assisted withdrawal units.

12.3.3 Specialist inpatient medically assisted withdrawal units

Specialist inpatient medically assisted withdrawal units are set up to provide medically assisted withdrawal to people with severe dependence or complex co-occurring conditions, including physical health, mental health, additional drug comorbidities and other complexities. These services require specialist competencies and systems tailored to manage people with complex needs. They are the subject of this chapter and described in detail below.

12.3.4 Acute hospital settings

People may be provided with medically assisted withdrawal in an acute general hospital setting following an admission for acute alcohol withdrawal, or admission for other reasons. In some areas, planned specialist inpatient medically assisted withdrawal is provided within an acute hospital as part of a planned local pathway. Hospital alcohol care teams provide additional specialist expertise where these exist.

You can read about medically assisted withdrawal in acute settings in chapter 16.

12.3.5 Mental health hospital settings

People may be provided with medically assisted withdrawal in an inpatient mental health hospital setting following admission. You can read about medically assisted withdrawal in inpatient mental health settings in chapter 18 on co-occurring mental health conditions.

12.4 Criteria for referring people for specialist inpatient medically assisted withdrawal

Clinicians should base decisions on whether to refer people for specialist inpatient medically assisted withdrawal on individual clinical assessment. But they should normally refer people who meet one or more of the following criteria.

1. They drink over 30 units of alcohol per day or have a score of more than 30 on the Severity of Alcohol Dependence Questionnaire (SADQ).
2. They have a history of epilepsy, or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes.
3. They are assessed as at high risk of Wernicke’s encephalopathy (WE). Based on individual assessment, it may be possible to offer them medically assisted withdrawal in the community if parenteral thiamine is available on site and there is a sufficiently skilled, trained, and resourced team to administer it. Clinicians should follow guidance in section 10.4.3 on WE and medically assisted withdrawal in chapter 10 on pharmacological interventions.
4. They have co-occurring harmful or dependent substance use that requires management, or concurrent medically assisted withdrawal from alcohol and one or more substances.
5. They have a severe mental health condition (for example, psychosis, severe depression or suicidal ideation) that makes medically assisted withdrawal in a community or residential setting potentially unsafe.
6. They have a significant physical health condition (for example, chronic liver disease, malnutrition, congestive cardiac failure or unstable angina) that makes medically assisted withdrawal in a community or residential setting potentially unsafe.
7. They have a significant learning disability or cognitive impairment.
8. They are pregnant (see more information on pregnancy and medically assisted withdrawal in chapter 10 on pharmacological interventions).

Clinicians should consider a lower threshold for referring vulnerable groups and people who are frail to specialist inpatient medically assisted withdrawal. This includes people experiencing homelessness, older people, and very young people.

12.5 Pathways for accessing specialist inpatient medically assisted withdrawal

Access to specialist inpatient medically assisted withdrawal is an essential part of any local alcohol treatment system. Every local area should have a pathway so that people with the highest levels of need can access appropriate treatment, including accessing specialist inpatient services.

If a local area does not have access to specialist inpatient medically assisted withdrawal unit as described in this chapter, there should be an alternative pathway so people with complex physical and mental health conditions can access the care they need. For example, a local agreement between commissioners and services that people with high risks spend at least 48 hours on a medical ward or medical assessment unit to stabilise their condition, before going on to complete medically assisted withdrawal in an appropriate specialist setting.

Commissioners and services should work to reduce any barriers that prevent people having rapid access to specialist inpatient medically assisted withdrawal such as prolonged funding processes or standard requirements. Clinicians should determine the urgency of need for rapid access for each individual.

Practitioners in community alcohol treatment services (and other referrers) should consider a person’s need for specialist inpatient medically assisted withdrawal at their first assessment. Where clinical assessment identifies a need for specialist inpatient medically assisted withdrawal, they should refer the person without any unnecessary delays.

A standard requirement that people should attend a fixed number of groups to prepare them for specialist inpatient medically assisted withdrawal is not helpful. This is because it may create a barrier for people with severe and complex needs who may not be able to comply with this requirement. It is important that people being referred to specialist inpatient medically assisted withdrawal know what to expect from this treatment. Practitioners also need to make sure that the person already has in place an aftercare and contingency plan for after they are discharged. But these processes should not cause unnecessary delays in referring them to treatment.

12.6 Distinguishing between specialist inpatient and residential medically assisted withdrawal

12.6.1 Background

In 2006, the Specialist Clinical Addiction Network consensus project published Inpatient treatment of drug and alcohol misusers in the National Health Service. This report distinguished between different levels of clinical input and supervision offered by inpatient or residential units providing medically assisted withdrawal. It introduced the terms ‘medically managed’ and ‘medically monitored’ to describe these different kinds of provision, which are still used in the treatment sector.

However, there is now some confusion and a lack of shared understanding about the kind of units that the 2 terms ‘medically managed’ and ‘medically monitored’ refer to. For this reason, the alcohol guidelines development group has not used these terms. Instead, this chapter introduces the terms ‘specialist inpatient medically assisted withdrawal’ and ‘residential medically assisted withdrawal’. The chapter goes on to distinguish between these different settings and gives a detailed description of the core elements that units need to provide ‘specialist inpatient medically assisted withdrawal’ from alcohol. These units were formerly referred to as ‘medically managed’ inpatient settings. The core elements of specialist medically assisted withdrawal units described below are based on clinical consensus of the alcohol guidelines development group.

12.6.2 Residential medically assisted withdrawal settings

Residential settings providing medically assisted withdrawal that do not have the core elements in place (as outlined in section 12.7 below) do not have the appropriate capacity to manage people with more severe withdrawal complications or complex co-occurring conditions. These guidelines refer to those services as residential medically assisted withdrawal settings.

Residential medically assisted withdrawal settings are suitable for people with alcohol dependence who would otherwise meet the criteria for undergoing a community based medically assisted withdrawal but are lacking adequate social support. Residential medically assisted withdrawal settings are important and provide a supportive environment for managing people with limited psychosocial support. They also support people who would benefit from an environment free from alcohol or drug using networks while going through medically assisted withdrawal.

Residential medically assisted withdrawal settings were formerly referred to as ‘medically monitored’ settings. These settings need to ensure that they meet the criteria and follow the guidance for a community medically assisted withdrawal set out in chapter 11 on community medically assisted withdrawal. There is no further information about residential medically assisted withdrawal settings in this chapter.

12.6.3 Defining specialist inpatient medically assisted withdrawal units

Specialist inpatient medically assisted withdrawal units are services that are staffed with appropriately trained specialist medical and nursing staff. These appropriately trained staff are able to manage people with more severe withdrawals and the associated complex physical and mental health conditions they can experience. The provision can be in the NHS, non-statutory or the private sector and may be in specialist units, which also provide stabilisation and management of withdrawal for drug use disorders.

Within this group of specialist inpatient medically assisted withdrawal units there is wide variability in the workforce and the complexity of medically assisted withdrawal that they can manage. The guidance in section 12.7 below describes core elements of service provision for all specialist inpatient medically assisted withdrawal units. Specialist inpatient units can provide additional elements beyond these core elements if suitably staffed and equipped. Examples of additional elements that could enhance service provision are also included below.

All units should operate with a comprehensive quality assurance framework. They should assure themselves that staff have the appropriate competencies, and the unit has the appropriate facilities, systems, and protocols to meet the needs of their patients. All units need to have pathways to acute or psychiatric hospital to meet the needs of patients if required.

12.7 Core elements needed in a specialist inpatient medically assisted withdrawal unit

12.7.1 A skilled and competent workforce

Core elements

All specialist inpatient medically assisted withdrawal units should have a workforce with relevant skills and competence. Core elements of a skilled and competent workforce include the following.

1. An addiction specialist leading the service. In most cases, this will be a consultant addiction psychiatrist or a specialist with a similar standard of training and expertise and acknowledged on the appropriate specialist register of the General Medical Council.
2. Registered nurses and doctors with different competencies, including registered mental health nurses, registered general nurses and doctors on the specialist register.
3. Staff with competencies in assessment for inpatient specialist medically assisted withdrawal and in comprehensive assessment of patient needs.

4. All clinical staff are competent in providing evidence-based medically assisted withdrawal, including identifying and managing severe complications. This should be in line with the relevant National Institute for Health and Care Excellence (NICE) clinical guidelines Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) and Alcohol-use disorders: diagnosis and management of physical complications (CG100).

5. A team with several specific physical health and mental health competencies. This should include competencies to assess and manage a patient’s complex physical health, mental health, concurrent drug use, and other complexities described in section 12.7.2 below.
6. Competence in the team to manage alcohol medically assisted withdrawal for pregnant patients, except where they have complex co-occurring conditions (see section 10.6.4 in chapter 10, for guidance on medically assisted withdrawal and pregnancy). In Scotland, pregnant women are generally admitted to the maternity hospital for medically assisted withdrawal, under the care of multidisciplinary specialist antenatal substance use teams.
7. Competence in the team to provide a therapeutic environment and psychosocial interventions appropriate to the patients’ stage of their treatment journey.
8. All staff undertake regular supervision and training to develop and maintain their competencies in line with clinical governance requirements. There should be mechanisms in place to monitor and ensure revalidation takes place for staff who are required to do so.
9. Access to or support from additional specialist staff including from: - pharmacy - psychotherapy or psychology - other specialist services, for example physiotherapy and occupational therapy
10. People with lived experience of alcohol dependence are involved in service provision. This could include paid employees, volunteers or peer mentors. People with lived experience should also receive appropriate training, supervision and support.

Nursing competencies

All units should assure themselves that there are adequate numbers of nursing staff at a suitable grade to manage the service safely. All units require specific nursing competencies, which include the following.

1. At least one registered mental health nurse (RMN) with a minimum of 6 months experience in a specialist inpatient medically assisted withdrawal unit should be part of the team on every shift. Larger services will require more staff in their teams and possibly more than one RMN, depending on need.
2. An adequate number of registered nurses and healthcare assistants to staff the unit safely, depending on its size. Staff should be competent to use evidence based assessment tools, risk management formulation and care plans.
3. Registered nurses with enhanced skills and experience of assessing and managing complex medically assisted withdrawal, complex physical health, mental health and drug use conditions and other complexities as described in section 12.7.2 below.
4. Registered nurses who are competent in using patient group directions (PGDs).
5. Registered nurses who are competent in undertaking electrocardiograms (ECGs).
6. Registered nurses who are competent in undertaking relevant nursing tasks such as: - administering parenteral thiamine - dressing wounds - performing venepuncture - giving advice on blood-borne virus testing and vaccination - managing medications such as possible side effects, concordance (reaching an agreement with the patient about prescribing and administering their medicines), and interactions

Additional elements that can enhance service provision

Some units have staff with relevant additional skills and competencies. Examples include:

• nurses trained in administering intravenous (IV) medication
• nurses trained to cannulate
• staff are able to manage patients with neurocognitive deficits, such as patients with alcohol related brain damage (ARBD) who need regular medication reviews to avoid over medication, falls and confusion
• specialist psychology provision, including neuropsychology for patients with ARBD dedicated to the unit
• a social worker dedicated to the unit
• specialist pharmacy provision dedicated to the unit
• allied health professionals dedicated to the unit, such as physiotherapists, dieticians, occupational therapists and speech and language therapists

12.7.2 Managing patients with complex needs

Core elements of managing complex needs that all specialist inpatient medically assisted withdrawal units should provide are set out below.

Admission and assessment

All specialist inpatient units should have a thorough admissions process where referrers are required to provide clinical information, including medical history and the results of physical examinations and tests, for each person they refer. An appropriately trained clinician from the specialist inpatient unit should screen the information on each new referral to assess whether the unit can safely manage the withdrawal process.

On accepting the patient into the unit, the team should further assess their physical, psychological, forensic and social needs, including any experience of domestic abuse. The clinicians responsible for screening and assessment should ask the referrer for any additional relevant information on the patient’s needs and any risks. They should also develop a personalised care plan, which includes post-discharge planning. In specific cases, a member of the team may need to meet the referrer and the patient before their admission to the unit to discuss expectations of treatment and work together on a care plan.

Multi-agency working and pathways

All specialist inpatient medically assisted withdrawal units should have working relationships with other relevant health and social care services to support people with complex or multiple support needs. All units should work with the relevant community alcohol treatment service (or other referrer) and the patient’s GP before and during treatment. Referrers and other relevant services should contribute to care planning, including discharge planning where appropriate. Patients will sometimes come from different local areas to the specialist inpatient unit and the community alcohol treatment services can offer relationships with and referrals to local services.

Identifying and managing severe alcohol withdrawal complications

Core elements

All specialist inpatient medically assisted withdrawal units should identify and immediately manage severe alcohol withdrawal complications. These complications can include delirium tremens and seizures. Core elements of this provision include the following.

1. Staff competent to use recognised alcohol withdrawal scales to inform prescribing, for example the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar), and recognised early warning scales, for example the Royal College of Physicians’ National Early Warning Score (NEWS 2).
2. Staff competent in assessing and identifying the onset of severe withdrawal complications and intervening to prevent their escalation.
3. Skilled nurses competent in managing severe withdrawal complications, including delirium tremens, seizures and overdose.
4. The unit has procedures for escalating medication regimens when severe withdrawal complications occur.
5. The unit has developed treatment protocols and guidelines for recognising and immediately managing severe alcohol withdrawal complications.
6. The unit has an agreed pathway to acute physical and mental health hospital care where needed.

Additional elements that can enhance service provision

Some units with suitably trained and experienced medical and nursing staff and appropriate facilities may be able to treat acute complications of withdrawal without transferring patients to an acute setting. Those units should have clear criteria for escalating care to safely manage and treat severe withdrawal complications. Where units are able to offer this, the person can receive tailored care in a specialist setting throughout the process of medically assisted withdrawal.

You can read more about identifying and treating severe withdrawal complications in chapter 10 on pharmacological interventions and in chapter 16 on acute hospital settings.

Assessing and managing Wernicke’s encephalopathy

Core elements

All specialist inpatient units should be able to assess patients at risk of Wernicke’s encephalopathy (WE) and those with incipient WE and manage this appropriately. Core elements of this provision include the following.

1. Staff competent to identify patients at risk of developing WE (incipient Wernicke’s encephalopathy).
2. Staff competent to treat patients at risk of WE with intramuscular thiamine.
3. The unit has an established pathway for patients with incipient WE so that they can access treatment immediately. There is also an established pathway to an acute hospital.
4. The unit has an agreed treatment pathway for patients with established Wernicke-Korsakoff syndrome (WKS).

Additional elements that can enhance service provision

Some units have specialist clinical competencies and facilities to provide high dose intravenous Pabrinex in patients with suspected or confirmed WE. This is so patients can be treated in the unit and not transferred to an acute setting.

You can read more guidance on WE in chapter 10 on pharmacological interventions and in chapter 16 on acute hospital settings. You can also find more guidance on WKS in chapter 20 on alcohol related brain damage.

Assessing and managing complex physical health conditions

Core elements

All specialist inpatient medically assisted withdrawal units should be able to assess and manage a patient’s complex physical health conditions. This includes alcohol-related conditions, such as liver disease, as well as more common physical health conditions unrelated to alcohol. Core elements of this provision include team competencies and arrangements in the following areas.

1. Staff are able to assess patients using early warning scales such as the NEWS 2. As a minimum this needs to be completed 6 times during the first 72 hours of admission. There should also be procedures in place for escalating any concerns about the patient’s condition and managing them if they start deteriorating.
2. Staff are able to assess and manage pregnant women for specialist inpatient alcohol treatment. In Scotland, pregnant women are generally admitted to the maternity hospital for medically assisted withdrawal, under the care of multidisciplinary specialist antenatal substance use teams.
3. Staff are able to assess and manage patients for medical emergencies. The team should include nurses qualified to provide immediate life support (ILS) and basic life support (BLS). Other competencies include assessing and managing patients for anaphylaxis, overdose and naloxone prescribing.
4. Staff are able to assess and manage patients for common medical conditions, for example diabetes, myopathy, balance, falls and mobility issues.
5. Staff are able to undertake investigations, such as blood tests, ECGs, venous thromboembolism (VTE) risk, and can understand the laboratory results and act on those results.
6. Staff are able to assess and manage malnourished patients.
7. Staff are able to identify and manage patients with alcohol-related liver disease.
8. Staff are able to provide smoking cessation interventions and manage chronic obstructive pulmonary disease (COPD).
9. The unit has pathways into relevant local primary and secondary care services, and social care services, and staff are aware of these pathways.
10. The unit has an agreed pathway for transferring patients to an acute hospital in an emergency.

It’s important to note that the list above contains a combination of competencies that the team needs to have (as a team, not necessarily for every staff member in the team) and relevant arrangements they need to have in place, such as appropriate procedures and equipment. This applies to the core elements set out in the following sections as well.

Additional elements that can enhance service provision

Some units have additional staff competencies and facilities for assessing and managing complex physical health conditions. These could include the following.

1. Appropriately trained staff with higher level physical health skills, including GPs and physicians, able to assess and provide initial treatment for a range of alcohol-related physical health conditions.
2. Staff with experience in using vitamin K for clotting disorders.

3. Staff who are able to assess and manage specialist alcohol treatment for pregnant women with other complex co-occurring conditions, such as severe mental health conditions.

4. Some units have access to urgent laboratory results and integrated record systems.
5. Some units can offer virtual ward rounds with primary and secondary care services as an expansion of multidisciplinary team (MDT) working.

Assessing and managing mental health conditions

Core elements

All specialist inpatient medically assisted withdrawal units should be able to provide assessment and management of mental health conditions. Mental health problems may manifest during medically assisted withdrawal or may be part of an ongoing co-occurring mental health condition. These could include common mental health conditions, such as depression and anxiety, and severe mental health conditions, such as psychosis. Core elements of this provision include team competencies and arrangements in the following areas.

1. Staff are able to carry out a mental health assessment, risk assessment and manage mental health conditions.
2. Staff are able to assess mental capacity and apply appropriate legislation to manage issues where people lack capacity to make decisions about their care and treatment (see annex 1 for relevant national legislation and guidance).
3. Staff have knowledge and experience of the Mental Health Act, Mental Capacity Act Deprivation of Liberty Safeguards (for people who lack the mental capacity to make decisions about their care and treatment), or equivalent legislation in the devolved nations. They should also understand how these apply to patients undergoing medically assisted withdrawal (see annex 1 for relevant national legislation and guidance).
4. The unit has robust risk management plans and safeguarding procedures in place to either implement these legal frameworks or urgently transfer the patient to the appropriate facility.
5. The unit has clearly established pathways to inpatient and community mental health services.
6. The team provides trauma-informed care, recognising that many patients will have experienced trauma. The unit has developed pathways for ongoing management of trauma-related mental health difficulties both during and after medically assisted withdrawal.

You can read more about trauma-informed care in chapter 2 on the principles of care.

Additional elements that can enhance service provision

Where units have the appropriate quality governance frameworks, facilities and staff competencies they may be able to provide one or both of the following elements.

1. Staff manage severe acute behavioural disturbances associated with imminent risk to self and others, for example through using the Mental Health Act or equivalent national legislation, rapid tranquillisation and seclusion, as appropriate (see annex 1 for information on national legislation and guidance).
2. Staff with appropriate approval in the team are able to assess and apply the Mental Health Act and manage patients detained under the Act or other equivalent national legislation.

Medically assisted withdrawal in patients with co-occurring substance use

Core elements

All units should have competencies to manage medically assisted withdrawal from alcohol in patients who are using a range of licit and illicit drugs, including opiates, stimulants or sedatives, in addition to alcohol. Some patients will continue to be prescribed medication (for example, methadone or benzodiazepines) during the medically assisted withdrawal, while some patients will require medically assisted withdrawal from additional substances as well as alcohol. Core elements of managing patients with co-occurring drug use include the following.

1. Staff competence within the team to understand and assess the importance of co-occurring substance use and how this may affect the medically assisted withdrawal from alcohol.
2. The unit has appropriate protocols and procedures for managing a range of complex medically assisted withdrawal often required in this group. For example, this could include patients who are also using benzodiazepines, GBL, new psychoactive substances, crack cocaine or methadone.

Additional elements that can enhance service provision

Some units will have the necessary staff competence and arrangements in place to manage more complex medically assisted withdrawal from alcohol and one or more substances at the same time.

You can read more about medically assisted withdrawal from alcohol for people who have co-occurring drug use, including co-occurring benzodiazepine dependence, in chapter 10 on pharmacological interventions. You can read guidance on drug use and dependence, including medically assisted withdrawal, in Drug misuse and dependence: UK guidelines on clinical management.

Alcohol related brain damage

Core elements

All specialist medically assisted withdrawal units should have competencies and procedures to identify ARBD and develop assessment and referral protocols for ongoing management. Core elements of this provision include the following.

1. Competence within the team and procedures to complete routine psychometric screening for ARBD using a validated tool, such as the Addenbrooke’s Cognitive Examination III (ACE III). The team may also use the Montreal Cognitive Assessment t this test is copyrighted and requires registration and payment.
2. The unit has established pathways for referring patients for a specialist cognitive assessment and treatment where ARBD is suspected or indicated following screening.
3. Staff have knowledge and expertise in applying the Mental Capacity Act or equivalent national legislation in relation to patients with ARBD.
4. Staff tailor communication and psychosocial interventions to the needs of people with ARBD (see chapter 20 on alcohol related brain damage for guidance on tailoring communication and interventions).
5. The unit has a multidisciplinary approach to discharge planning.

Additional elements that can enhance service provision

Some units have access to a full multidisciplinary team during the admission to assess the ongoing treatment requirements for patients with ARBD and help refer them into appropriate therapeutic settings. The team can include input from neuropsychology, social work, physiotherapy and occupational therapy.

You can find guidance on ARBD in chapter 20.

12.7.3 Safeguarding

Core elements

All specialist inpatient medically assisted withdrawal units should comply with national safeguarding legislation and statutory guidance. You can find information on safeguarding legislation and statutory guidance for each of the UK nations in annex 1. Core elements of this provision include the following.

1. The unit has organisational safeguarding procedures and governance structures in place. It complies with relevant national legislation on child and adult safeguarding.
2. All staff trained in child and adult safeguarding and able to make a safeguarding referral.
3. The unit has mechanisms to involve patients’ family, partner or appropriate friends in safeguarding risk assessment, care planning and treatment decisions.
4. All staff trained to make routine enquires on domestic abuse and respond appropriately to current risks.

Additional elements that can enhance service provision

Additional elements that can enhance service provision include some units having access to dedicated social workers.

12.7.4 Psychosocial interventions

Core elements

All specialist inpatient medically assisted withdrawal units should provide therapeutic support based on the principles of care set out in chapter 2. Core elements of therapeutic support include the following.

1. The unit’s ethos and approach of staff towards patients is non-judgmental, empathic and non-stigmatising.
2. Staff provide culturally competent care.
3. The service and staff provide a trauma-informed approach to care. This means helping people to manage distressing thoughts and feelings that might become apparent during the medically assisted withdrawal process and assessing the person for any ongoing trauma treatment they may need.
4. Individual and group psychosocial interventions are available, and staff are proactive in encouraging patients to engage in psychosocial support based on individual assessment. The service offers psychosocial interventions including: - motivational interventions - psychoeducational interventions providing information on alcohol dependence and harm reduction advice (see chapter 8 on harm reduction) - relapse prevention support and recovery planning for patients after discharge
5. Staff help patients to access mutual aid groups (such as Alcoholics Anonymous and SMART Recovery programmes) that may run in the unit and promote their value as part of a recovery support plan after they have completed medically assisted withdrawal.
6. Staff identify mental health conditions and provide support and information for ongoing management of these conditions through psychological therapy services, such as the improving access to psychological therapies (IAPT) programme and bereavement services.
7. Staff provide information and support for families, partners or supporting friends.

Additional elements that can enhance service provision could include

Additional elements that can enhance service provision could include some units having:

• 7-day availability of a therapeutic support service
• initial psychological support based on evidence-based approaches, such as cognitive behavioural therapy (CBT) for common mental health conditions, including post-traumatic stress disorder (PTSD)
• mindfulness-based relapse prevention
• family interventions delivered by a family therapist, such as initial assessment and referral for ongoing support
• couples-based interventions delivered by a couples or family therapist, such as initial assessment and referral for ongoing support

You can find detailed guidance on psychosocial interventions in chapter 5.

12.7.5 Pharmacological interventions for relapse prevention

Core elements

All clinicians in specialist inpatient medically assisted withdrawal units should be competent to provide pharmacological interventions for relapse prevention, including prescribing acamprosate, naltrexone and disulfiram.

Additional elements that can enhance service provision

Experienced specialist clinicians may also prescribe baclofen and other novel medications based on clinical assessment. This should be done in consultation and with agreement of clinicians continuing the care plan after discharge.

You can find guidance on pharmacological interventions for relapse prevention in chapter 10 on pharmacological interventions.

12.7.6 Out of hours cover

Core elements

All specialist inpatient medically assisted withdrawal units should have arrangements for out of hours cover and make sure that these are adequate for the safe running of the unit and the number of patients they treat. Core elements of this provision will include:

1. At least one registered ILS trained nurse and one other appropriately trained member of staff. Larger units require additional staff.
2. 24-hour in-person clinical cover for acute assessment and management of withdrawals.
3. Out of hours on call cover arrangements that can: - provide access to medications - arrange for replacement staff to respond to any staff shortages - respond to medical emergencies and overall be able to manage acute withdrawals - respond to safeguarding concerns and incidents affecting the safe running of the unit - have a duty doctor, consultant psychiatrist or senior clinical manager available on call to support these arrangements

Additional elements that can enhance service provision

Additional elements that can enhance service provision include some units having access to on-call pharmacist provision.

12.7.7 Referral pathways

Services have 2-way referral pathways, and they communicate effectively with these other relevant services to provide comprehensive assessment, care and discharge planning for their patients. All units should be able to confidentially share patient information across systems. Pathways should include:

• primary care, secondary care and acute hospitals
• primary, secondary and crisis mental health services
• safeguarding and social care services
• community alcohol treatment services and residential rehabilitation services
• psychological services
• memory clinics housing and homelessness services
• criminal justice services
• community services, such as domestic abuse services
• lived experience recovery organisations (LEROs) and mutual aid groups
• support organisations for family members and carers