Introduction

This introduction sets out how to use the guidelines, their aim, who they are for, what they are and their scope. It also summarises information on alcohol-related harms and health inequalities.

Chair’s preface

I am delighted to be able to write this preface to the first UK clinical guidelines for alcohol treatment. I had the pleasure of chairing a hugely talented expert reference group in undertaking this work. We were a multidisciplinary group from across the 4 nations of the UK and were informed by a group of experts with lived experience. Their voice was central in framing and reviewing the work of the expert group and I am very grateful to all those who gave their time and wisdom to this endeavour.

Harmful and dependent use of alcohol carries a substantial cost to our society’s wellbeing. Deaths caused by alcohol are at an all-time high, with rates rising further since the COVID-19 pandemic. We know that illness and death related to alcohol consumption is highest in the groups of our society who live in the most socially and economically deprived areas, and those in the lowest income brackets.

Good quality alcohol treatment has a crucial role in reducing alcohol harms and wider health inequalities. I have spent my professional life working clinically in alcohol and drug treatment services and over the decades have had access to several editions of UK-wide guidelines for the treatment of drug dependence. I know therefore at first hand the benefit to clinicians and practitioners of having authoritative and comprehensive guidance in the clinic and to inform teaching and development of the workforce.

However, these guidelines are not only for people working in specialist alcohol treatment services, but for everybody working to improve the outcomes of people with alcohol dependence or harmful patterns of alcohol use. This could be in primary, community or acute healthcare, social care (children’s and adult), the criminal justice system, homelessness and housing services, employment, and voluntary sector services across the UK.

These guidelines set out a person-centred and holistic standard of care, informed by the voice of people with lived experience, the scientific evidence base and professional consensus. It is the standard that we should all expect for our friends and family, and it will improve equality of healthcare provision between people with alcohol use disorders and those with other health conditions.

My hope is that these guidelines will provide a clear model for those providing services, whether clinicians, practitioners or managers. My hope too is that they will enable people in need of help, and their families, to know what they should expect.

Planning and commissioning of alcohol treatment services and the workforce has different approaches and models across the UK, and has been and continues to be subject to change. These guidelines set out a clear framework and expectation of what well planned and commissioned services and its workforce look like. They will support people in planning and commissioning roles, whatever shape these take in the future.

The aim of the guidelines is ultimately to improve outcomes for people living with harmful use of alcohol and alcohol dependence and to do this by supporting everybody who plans, commissions and delivers services in ensuring that they are of the highest quality.

Dr Louise A Sell, MRCP, FRCPsych

Chair of the alcohol clinical guidelines development group

How to use these guidelines

These guidelines are organised into 2 parts.

Part 1 covers chapters 1 to 12. It includes guidance on the core elements of alcohol treatment. All these chapters are relevant for practitioners who work in specialist alcohol treatment services or who provide specialist alcohol treatment in other settings.

Part 2 covers chapters 13 to 27. It includes guidance for providing the core elements of alcohol treatment in specific settings and for specific populations. Practitioners should use the guidance relevant to the settings and populations they work in or with.

Chapter 1 summarises the main themes identified by the experts through experience group during the development of the guidelines. Chapter 2 summarises the main principles of care that underpin alcohol treatment. Each of the remaining chapters (3 to 27) begins with a summary of the main points contained in that chapter.

To navigate the guidelines, you can browse each named chapter individually from the contents page or search for topics using the search bar at the top of the manual.

You can also search within chapters to find the words or topics you are looking for guidance on. To bring up the find bar, we recommend using the keyboard shortcuts:

  • Ctrl + F (in PC web browsers)
  • Command + F (in Mac web browsers)

For mobile devices (like phones or tablets), use your web browser’s ‘Find in page’ or ‘Find on page’ function, generally available through the settings or additional options menu.

About these guidelines

The aim of these guidelines is to improve the quality of alcohol treatment so that people with patterns of harmful drinking and alcohol dependence get better help and support and achieve better outcomes.   

Who the guidelines are for

These guidelines on treatment for alcohol dependence and harmful drinking are for:

  • clinicians and practitioners working in specialist alcohol (and drug) treatment services
  • alcohol treatment clinicians and practitioners working in other settings such as primary or secondary healthcare or criminal justice settings
  • clinicians and practitioners whose work brings them into contact with people with problem alcohol use in other services including primary, community and acute healthcare, adult and children’s social care, criminal justice, homelessness and housing, employment and voluntary sector services
  • commissioners and managers responsible for planning services to meet the needs of people with problem alcohol use

What the guidelines are

These are the first UK guidelines on the clinical management of harmful drinking and alcohol dependence. They are based on current evidence and professional consensus on how to provide alcohol treatment for the majority of people, in most instances. The guidelines have the same status across England, Scotland, Wales and Northern Ireland.

The guidelines do not provide rigid protocols on how clinicians must deliver alcohol treatment interventions for all in their care. Professionals are expected to take the recommendations in the guidelines fully into account when exercising their judgement, alongside the individual needs, preferences and values of the person they are treating.

The guidelines do not override the responsibility of clinicians and practitioners to make decisions that are appropriate to the circumstances of the individual person with problem alcohol use, consulting with that person (and family members or carers, if appropriate). However, where clinicians decide to operate outside the specific recommendations in these guidelines, they should be able to demonstrate (and should record) the rationale for their decisions.

Local commissioners, strategic managers and service providers have a responsibility to develop services that apply these guidelines. They should do so in the context of local need and national priorities for funding and developing services. They must also consider their duties to:

  • eliminate unlawful discrimination
  • advance equality of opportunity
  • reduce health inequalities

Recommendations in these guidelines are consistent with those duties.

The guidelines and other published guidance

These guidelines integrate evidence on treatment and support for people with alcohol dependence or harmful drinking patterns, including evidence from National Institute for Health and Care Excellence (NICE) clinical guidelines:

These guidelines provide recommendations for how NICE guidance can be put into practice. The guidelines also cover some additional areas, not addressed by NICE. For example, they include aspects of recovery and considerations for specific settings and populations.

These guidelines are not intended to replace clinical guidance and quality standards issued by each of the UK administrations or professional bodies for clinicians. This is a single set of guidelines for the whole of the UK that provides a framework of best practice upon which locally appropriate policies and procedures can be based.

Clinicians and practitioners, commissioners and strategic managers should consider these guidelines alongside national guidance. There are some examples of relevant national guidance for each of the UK administrations at the end of this chapter.

The status of the guidelines

These guidelines have no specific statutory status. However, they set out the quality of care for the appropriate treatment of alcohol dependence and harmful drinking. There are separate, defined legal obligations for prescribing controlled drugs that clinicians should act in line with.

Registered professionals providing alcohol treatment are required to follow the guidance for their own profession and also other national guidelines relevant to their work.

These guidelines are a companion to Drug misuse and dependence: UK guidelines on clinical management (the ‘orange book’).

The guidelines as best practice

These guidelines set out best practice for alcohol treatment, based on:

  • the available evidence
  • specialist clinical consensus
  • the voice of people with lived experience of problem alcohol use

They describe what people with alcohol dependence and harmful patterns of drinking need.

We do not expect that all local areas will immediately fully meet all the recommendations, but they should work towards them and have a clear understanding of areas where they do not comply and the reasons why. Some services might need to make changes in culture and practice and develop more flexible ways of providing interventions. The guidelines set out ambitious best practice for clinicians and other practitioners, commissioning systems and service providers against which to measure progress.

The process for developing the guidelines

The Department of Health and Social Care led the development of these guidelines in partnership with representatives from the Scotland, Wales and Northern Ireland governments.

A group of expert clinicians and other professionals from the alcohol treatment sector met regularly to advise on developing the content. They discussed expert presentations and agreed evidence-based recommendations for each of the main topics. Alongside this, a group of people with lived experience of alcohol dependence, treatment and recovery met regularly to advise on the same content. Representatives from the lived experience group presented their recommendations at each meeting of the larger expert group meetings. There were 12 subgroups that met to agree on evidence-based recommendations for specialist topics that were then ratified by the wider expert group.

These guidelines are based on evidence. In some areas of practice, there are evidence gaps and, in those cases, guidance is based on clinical consensus from the larger expert group. Where recommendations are based on clinical consensus this is noted.

We ran a public consultation on the guidelines which received many responses from people in the alcohol treatment sector, some of which were very detailed. Many of the points suggested were incorporated into the guidelines.

You can find a list of members of the clinical guidelines development group, the lived experience group and other contributors in annex 4.

Definitions of harmful drinking and alcohol dependence

Patterns of alcohol-related risk and harm exist on a continuum and there are several ways of describing categories within that continuum.

This guidance uses definitions of harmful drinking and alcohol dependence set out in the World Health Organization’s (WHO) International Classification of Diseases, 11th Revision (ICD-11).

In ICD-11, harmful drinking is defined in the entry Harmful pattern of use of alcohol and alcohol dependence is defined in the entry Alcohol dependence.

You can read more about these terms in the glossary, which also contains other terms used to describe various patterns of alcohol use.

Alcohol harms

UK chief medical officers’ low risk drinking guidelines say that to keep health risks from alcohol to a low level it is safest for both men and women not to drink more than 14 units a week on a regular basis. And for adults who regularly drink as much as 14 units per week, it is best to spread their drinking evenly over 3 or more days.

A significant proportion of the UK population regularly drink above low risk levels and there is evidence of high levels of alcohol-related harm across the UK (see section on ‘Alcohol-specific deaths’). People with harmful patterns of drinking and alcohol dependence experience adverse health and social consequences. Partners, children and families of people with problem alcohol use as well as their communities also often experience harm.

Alcohol health harms

The public health burden of alcohol: evidence review found that alcohol is a causal factor in over 60 health conditions, including:

  • long-term conditions, such as liver disease, cardiovascular disease, various forms of cancer including breast and bowel, and diseases of the central nervous system
  • acute conditions from accidental injuries, violence and alcohol poisoning

Alcohol is an important factor for mental ill health and is a risk factor for depression, anxiety and suicide.

Alcohol-specific deaths

Alcohol-specific deaths are deaths from conditions wholly caused by alcohol. Most alcohol-specific deaths are due to alcohol-related liver disease. There have been substantial increases in alcohol-specific death rates across the UK since 2019.

The Office for National Statistics (ONS) report Alcohol-specific deaths in the UK: registered in 2023 found that:

  • 10,473 alcohol-specific deaths were registered in the UK, the highest number on record, but the rate of alcohol-specific deaths (15.9 per 100,000 people) decreased slightly compared with 2022 (16.6 deaths per 100,000 people)
  • the rate of alcohol-specific deaths for men remained around double the rate for women (21.9 and 10.3 deaths per 100,000 people, respectively), which is consistent with previous years
  • England and Wales had an increase in the rate of alcohol-specific deaths compared with 2022 (15.0 and 17.7 deaths per 100,000 people, respectively)
  • Scotland and Northern Ireland continued to have the highest rate of alcohol-specific deaths (22.6 and 18.5 deaths per 100,000 population, respectively), with the rate in Scotland remaining unchanged and a decrease in Northern Ireland compared with 2022
  • the North East had the highest rate of alcohol-specific deaths of any English region (25.7 deaths per 100,000) and the East of England had the lowest rate (11.5 deaths per 100,000)

These figures are only for deaths caused wholly by alcohol. Numbers of alcohol-related deaths (deaths from conditions that are wholly or partially caused by alcohol) are much higher.

Alcohol and health inequalities

Health inequalities are usually defined as systematic differences in health outcomes between socioeconomic groups. There are also systematic differences in health outcomes between other groups such as between different ethnic groups.

Alcohol harm and deprivation

Alcohol-related illness and deaths are substantially higher in people living in the most socially and economically deprived areas and people in lower income groups.

For example:

In 2023, the ONS data set Alcohol-specific deaths in the UK shows that the alcohol-specific mortality rate in the most deprived fifth of the population compared to the least deprived was:

  • 3.6 times higher for men and 3 times higher for women in England
  • 3.6 times higher for men and 1.9 times higher for women in Wales

The National Records of Scotland report Alcohol-specific deaths 2023 shows that the mortality rate for alcohol-specific deaths was 4.5 times higher in the most deprived fifth of the population than in the least deprived.

In Northern Ireland, the report Alcohol specific deaths in Northern Ireland, 2023 shows that looking at the most recent 5 years together (2019 to 2023), there were almost 4 times as many alcohol-specific deaths in the most deprived areas compared to the least deprived areas.

These inequalities exist even though people in the most deprived areas on average have similar or lower levels of alcohol consumption.

There is evidence of several factors that contribute to alcohol-related health inequalities for people experiencing the highest levels of socioeconomic deprivation. Factors include:

  • the direct impact of the social determinants of health including poverty, poor housing and related psychosocial stress
  • differing distribution and patterns of drinking
  • the multiplicative effect of harmful alcohol use alongside other health risk behaviours such as smoking and poor nutrition that are also influenced by deprivation (meaning that the sum of the harms is greater than what people would experience if they only had one of these health risk behaviours)
  • alcohol-specific environmental factors such as the higher density of outlets for on-sales (such as pubs and restaurants) and off-sales (such as off licences and supermarkets) of alcohol in more deprived areas

The role of evidence-based alcohol treatment in reducing alcohol harms and health inequalities

Effective, evidence-based alcohol treatment and support, delivered by competent, well-supported staff, is vital to reducing harm and health inequalities for those people who experience the highest levels of harm.

Alcohol treatment services do this by helping people with harmful drinking patterns and alcohol dependence to:

  • stop or reduce alcohol use
  • access other services for help with physical and mental health conditions and social needs such as benefits and debt advice, domestic abuse support
  • develop and access resources for longer-term recovery through involvement with social networks and peer support, housing support and employment support

Alcohol treatment services also have an important role in ensuring that children, partners or carers who are affected by a family member with problem alcohol use can access the help they need, including child and adult safeguarding where appropriate.

Accessible and inclusive services that target and meet the needs of people experiencing the highest levels of deprivation and multiple disadvantage are important in reducing health inequalities.

Reducing harms across the population

These guidelines are about individual alcohol treatment. Interventions to prevent or reduce alcohol harm at population level are outside their scope. However, it is important to recognise that alcohol treatment alone cannot reduce the high levels of alcohol-related harm in the UK and that prevention measures at a population level are necessary to achieve this.

WHO recommends population measures that target affordability, availability (ease of purchase) and acceptability (social norms around alcohol use) as these approaches have the strongest evidence. Effective prevention at population level and alcohol treatment are both vital to reduce harm and achieve better outcomes for individuals, families and communities.