Guidelines for the Treatment of Alcohol Problems

255 Pages·2009·1.19 MB·English

Guidelines for the
Treatment of Alcohol Problems
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Prepared for the Australian Government Department of Health and Ageing
by Paul Haber, Nicholas Lintzeris, Elizabeth Proude and Olga Lopatko
June 2009
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Guidelines for the Treatment of Alcohol Problems
ISBN: 1-74186-976-5
Online ISBN: 1-74186-977-3
Publications Number: P3 -5625
Copyright Statements:
Paper-based publications
© Commonwealth of Australia 2009
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced
by any process without prior written permission from the Commonwealth. Requests and inquiries concerning
reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney-General’s
Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca
Internet sites
© Commonwealth of Australia 2009
This work is copyright. You may download, display, print and reproduce this material in unaltered form only
(retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any
use as permitted under the Copyright Act 1968, all other rights are reserved. Requests and inquiries concerning
reproduction and rights should be addressed to Commonwealth Copyright Administration, Attorney-General’s
Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca
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Contents
Acknowledgements vi
Summary of recommendations vii
1. Introduction 1
Purpose of the guidelines 1
Structure of the guidelines 1
Evidence-based health care 3
Community and population approaches to alcohol problems 4
A note on terminology 4
2. Prevalence of alcohol consumption and related harms in Australia 7
Prevalence of alcohol use 7
Alcohol-related harm 8
3. Screening, assessment and treatment planning 13
Screening 13
Comprehensive clinical assessment 21
Treatment planning 32
4. Brief interventions 41
Who to target for brief interventions 41
How to deliver brief interventions 42
Who can deliver brief interventions? 43
Where should brief interventions be delivered? 43
Limitations of brief intervention 45
5. Alcohol withdrawal management 49
Alcohol withdrawal syndrome: Clinical presentation 49
Assessment and treatment matching 51
Supportive care 57
Medications for managing alcohol withdrawal 61
Treating severe withdrawal complications 68
Wernicke–Korsakoff’s syndrome 76
6. Psychosocial interventions for alcohol use disorders 81
Overview of psychosocial interventions 81
When to use psychosocial interventions 82
Choosing psychosocial interventions: a stepped care approach 82
Motivational interviewing 85
Cognitive behavioural interventions 86
Relapse prevention strategies 89
Residential rehabilitation programs 89
7. Pharmacotherapies for alcohol dependence 93
Naltrexone 93
Acamprosate 96
Combined acamprosate and naltrexone 98
Disulfiram 98
Other medications 101
Integration with psychosocial treatments 102
Increasing medication adherence 102
Selecting medications for individual patients 103
8. Self-help programs 107
Alcoholics Anonymous 107
SMART Recovery® 110
Self-help for families 111
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9. Specific populations 115
Adolescents and young people 115
Pregnant and breastfeeding women 121
Indigenous Australians and people from other cultures 130
Older people 135
Cognitively impaired patients 138
10. Comorbidities 145
Physical comorbidity 145
Co-occurring mental and alcohol-use disorders 147
Polydrug use and dependence 153
11. Aftercare and long-term follow-up 161
Aftercare 161
Working with the persistent problem drinker 161
Appendixes 165
Appendix 1 Screening and diagnostic instruments 167
Appendix 2 Diagnostic criteria for alcohol use disorders 195
Appendix 3 Withdrawal scales 197
Appendix 4 Alcohol and drug interactions 202
Appendix 5 Getting through alcohol withdrawal: A guide for patients and carers 205
Appendix 6 A guide for people with alcohol-related problems 208
Appendix 7 Disulfiram Agreement 213
Appendix 8 Treatment guidelines for mental disorders 214
Appendix 9 Standard drinks 215
Glossary 221
Acronyms 225
References 229
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Tables and Figures
Table 1.1: Categories of evidence and strength of recommendations 3
Table 3.1: AUDIT-C 17
Table 3.2: Matters to be covered in a comprehensive assessment 22
Table 3.3: How dependent on alcohol is your patient? 26
Table 3.4: Mental health assessment scales 29
Table 4.1: FLAGS brief intervention structure 42
Table 5.1: Signs and symptoms of alcohol withdrawal 49
Table 5.2: Characteristics of ambulatory, residential and inpatient hospital withdrawal settings 53
Table 5.3: Admission criteria for different withdrawal settings 54
Table 5.4: Example of symptom-triggered regimen 63
Table 5.5: Example of fixed-schedule regimen 64
Table 5.6: Post-ictal signs and symptoms: comparing epilepsy and alcohol withdrawal seizures 70
Table 5.7: DSM-IV-TR diagnostic criteria for substance withdrawal delirium 73
Table 8.1: The SMART Recovery® 4-Point Program™ 111
Table 10.1: Alcohol use and physical complications 146
Table 10.2: Clinical profile and treatment plans for withdrawal from alcohol and other drugs 158
Figure 2.1: Lifetime risk of death from alcohol-related injury per 100 male drinkers,
by number of standard drinks per occasion and frequency of occasions 9
Figure 2.2: Lifetime risk of death from alcohol-related injury per 100 female drinkers,
by number of standard drinks per occasion and frequency of occasions 9
Figure 3.1: Screening 20
Figure 3.2: Stepped care approach for delivering health care services 36
Figure 3.3: Assessment and treatment planning 38
Figure 5.1: Alcohol withdrawal syndrome progression 50
Figure 5.2: Selecting benzodiazepine regimens for alcohol withdrawal 65
Figure 6.1: Stepped care approach for delivering health care services 83
Figure 10.1: Level of care quadrants 148
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Acknowledgements
A competitive tender from the Australian Government Department of Health and Ageing funded this project.
The authors are grateful to Professor Richard Mattick for permission for unrestricted use of material from previous
editions of these guidelines.
Authors
Chapter 1 Introduction Prof Paul Haber, A/Prof Nicholas Lintzeris
Chapter 2 Prevalence of alcohol consumption and related harms Dr Elizabeth Proude
in Australia
Chapter 3 Screening, assessment and treatment planning Prof Paul Haber, A/Prof Nicholas Lintzeris
Chapter 4 Brief interventions Dr Elizabeth Proude
Chapter 5 Alcohol withdrawal management A/Prof Nicholas Lintzeris
Chapter 6 Psychological interventions for alcohol use disorders Dr Claudia Sannibale, A/Prof Nicholas
Lintzeris
Chapter 7 Pharmacotherapies for alcohol dependence Dr Kirsten Morley, Prof Paul Haber,
A/Prof Nicholas Lintzeris
Chapter 8 Self-help programs Ms Genevieve Baijan
Chapter 9 Specific populations
Adolescents and young people Dr Yvonne Bonomo
Pregnant and breastfeeding women Prof Charlotte de Crespigny
Indigenous Australians and people from other cultures A/Prof Kate Conigrave, A/Prof Sawitri
Assanangkornchai
Older people Dr Celia Wilkinson, A/Prof Nicholas
Lintzeris, Prof Paul Haber
Cognitively impaired patients Dr Glenys Dore, A/Prof Stephen Bowden
Chapter 10 Comorbidities
Physical comorbidity Prof Bob Batey
Co-occurring mental disorders Dr Andrew Baillie
Polydrug use and dependence Dr Adam Winstock, A/Prof Nicholas
Lintzeris
Chapter 11 Aftercare and long-term follow-up A/Prof Nicholas Lintzeris, Prof Bob Batey
Project Advisory Committee members who gave advice on the overall project, were consulted throughout,
and reviewed the Guidelines: Professor Steven Allsop, Curtin University WA; Associate Professor Robert Ali,
University of Adelaide; Professor Robert Batey, New South Wales Health; Dr Andrew Baillie, Macquarie University;
Professor Margaret Hamilton, University of Melbourne; Dr Anthony Shakeshaft, NDARC, University of New South
Wales; Associate Professor Kate Conigrave, Sydney South West Area Health Service; Professor John Saunders,
University of Queensland; Ms Andrea Stone, RN, Sydney South West Area Health Service; Professor Nick Zwar,
University of New South Wales.
Guidelines Group members who provided advice on the content and format of the Guidelines, some of whom
also reviewed chapters of both the Guidelines and the Review of the Evidence: Ms Genevieve Baijan, Dept of
Psychology, University of Sydney; Dr Roger Brough, General Practitioner, Warrnambool, Victoria; Ms Rosalyn
Burnett, Drug and Alcohol Nurses of Australia; Mr Steve Childs, Area Drug and Alcohol Service, North Sydney
Central Coast Area Health; Professor Charlotte de Crespigny, University of Adelaide; Dr John Furler, Dept of
General Practice, University of Melbourne; Dr Michael McDonough, Western Health Victoria; Dr Bridin Murnion,
Sydney South West Area Health; Dr Claudia Sannibale, NDARC, University of New South Wales; Dr Hester
Wilson, General Practitioner, Newtown, Sydney.
Additional thanks to Dr Alan Gijsbers, Professor Jon Currie, Dr Phil Renner, Mr Paul Colwell, Dr Julie Erskine and all
the other professionals who attended focus groups or took part in interviews, and to Annie Cooney for conducting
the focus groups and interviews.
Notwithstanding the support from many colleagues, the lead authors (Paul Haber, Nicholas Lintzeris, Elizabeth
Proude and Olga Lopatko) accept final responsibility for the accuracy and content of this document.
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Summary of recommendations
Screening
Recommendation Strength of Level of evidence
recommendation
3.1 Screening for risk levels of alcohol consumption and A Ia
appropriate intervention systems should be widely
implemented in general practice and emergency
departments.
3.2 Screening for risk levels of alcohol consumption and D IV
appropriate intervention systems should be widely
implemented in hospitals.
3.3 Screening for risk levels of alcohol consumption and D IV
appropriate intervention systems should be widely
implemented in community health and welfare settings.
3.4 Screening for risk levels of alcohol consumption and D IV
appropriate intervention systems should be widely
implemented in high-risk workplaces.
3.5 Quantity–frequency estimates is the recommended way D IV
to detect levels of consumption in excess of the NHMRC
2009 guidelines in the general population.
3.6 AUDIT is the most sensitive of the currently available A I
screening tools and is recommended for use in the
general population.
3.7 In pregnant women, quantity–frequency estimation is D IV
recommended to detect any consumption of alcohol.
T-ACE and TWEAK questionnaires may be used in this
population to detect consumption at levels likely to place
the foetus at significant risk of alcohol-related harm.
3.8 Direct measures of alcohol in breath and/or blood can D II
be useful markers of recent use and in the assessment
of intoxication.
3.9 Indirect biological markers (liver function tests or A Ia
carbohydrate-deficient transferrin) should only be
used as an adjunct to other screening measures as
they have lower sensitivity and specificity in detecting
at-risk people than structured questionnaire approaches
(such as AUDIT).
Comprehensive assessment
Recommendation Strength of Level of evidence
recommendation
3.10 Assessment should include patient interview, D IV
structured questionnaires, physical examination,
clinical investigations and collateral history. The length of
the assessment should be balanced against the
need to keep the patient in treatment and address
immediate concerns.
3.11 A quantitative alcohol history should be recorded. A I
3.12 Motivation to change should be assessed through B II
direct questioning, although expressed motivation has
only a moderate impact on treatment outcome.
3.13 Assessment of the patient’s alcohol-related problems, S –
diagnosis and severity of dependence should be recorded.
3.14 Assessment for alcohol-related physical health problems S –
should be routinely conducted. A medical practitioner
should assess patients at risk of physical health problems.
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Recommendation Strength of Level of evidence
recommendation
3.15 Assessment for mental health problems, such as anxiety, S –
depressive symptoms and suicidal risk, should be routine,
including mental stage examination. Referral for further
specialist assessment may be needed if significant mental
problems are suspected.
3.16 Screening for cognitive dysfunction should be conducted if S –
the clinician suspects the patient has cognitive impairment.
Referral to a clinical psychologist or neuropsychologist for
further testing may be appropriate. The need for formal
cognitive assessment is generally deferred until the patient
has achieved several weeks of abstinence.
3.17 Collateral reports should be incorporated in the S –
assessment where inconsistencies appear likely, with the
patient’s permission where possible, and subject to legal
and ethical boundaries.
3.18 The social support for the patient should be assessed S –
and this information should be incorporated into the
management plan.
3.19 Clinicians should determine if the patient cares for S –
any children under the age of 16, and act according to
jurisdictional guidelines if there are any concerns about
child welfare.
3.20 In the event of suspected or continuing concerns S –
over safety of the patient or others, specialist consultation
is advised.
Assessment
Recommendation Strength of Level of evidence
recommendation
3.21 Assessment should lead to a clear, mutually acceptable D IV
comprehensive treatment plan that structures specific
interventions to meet the patient’s needs.
3.22 Patients should be involved in goal setting and A I
treatment planning.
3.23 Treatment plans should be modified according to S –
reassessment and response to interventions (stepped
care approach).
3.24 Evidence-based treatment should be offered in a clinical S –
setting with the appropriate resources based on the
patient’s needs.
3.25 Alcohol dependence is a chronic and relapsing disorder S –
such that long-term care is generally appropriate through
self-help programs, primary care or other interventions
that are acceptable to the patient.
Brief interventions
Recommendation Strength of Level of evidence
recommendation
4.1 Brief interventions are effective in reducing alcohol use A Ia
in people with risky pattern of alcohol use and in non-
dependent drinkers experiencing alcohol-related harms
and should be routinely offered to these populations.
4.2 Brief interventions are not recommended for people A Ib
with more severe alcohol-related problems or alcohol
dependence.
4.3 Brief interventions may consist of the five components of A Ia
the FLAGS acronym: feedback, listening, advice, goals, and
strategies (or equivalent).
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Recommendation Strength of Level of evidence
recommendation
4.4 Brief advice may be sufficient for those drinking above S –
NHMRC recommendations but not experiencing harm.
4.5 Brief interventions should be implemented in general A Ia
practice and other primary care settings.
4.6 Brief interventions should be implemented in emergency A Ia
departments and trauma centres.
4.7 Brief interventions should be implemented in general D IV
hospital settings.
4.8 Brief interventions in community health and welfare D IV
settings may be used, but should not be a sole
intervention strategy.
4.9 Brief interventions in high-risk workplaces may be used, D IV
but should not be a sole intervention strategy.
Alcohol withdrawal: patient assessment and treatment planning
Recommendation Strength of Level of evidence
recommendation
5.1 The risk of severe alcohol withdrawal should be assessed B II
based on current drinking patterns, past withdrawal
experience, concomitant substance use, and concomitant
medical or psychiatric conditions.
5.2 Successful completion of alcohol withdrawal does not A Ia
prevent recurrent alcohol consumption and additional
interventions are needed to achieve long-term reduction
in alcohol consumption.
5.3 Realistic goals of clinicians, patients and their carers for D IV
withdrawal services include: interrupting a pattern of
heavy and regular alcohol use, alleviating withdrawal
symptoms, preventing severe withdrawal complications,
facilitating links to ongoing treatment for alcohol
dependence, providing help with any other problems
(such as accommodation, employment services).
5.4 Ambulatory withdrawal is appropriate for those with mild D IV
to moderate predicted withdrawal severity, a safe ‘home’
environment and social supports, no history of severe
withdrawal complications, and no severe concomitant
medical, psychiatric or other substance
use disorders.
5.5 Community residential withdrawal is appropriate for those D IV
with predicted moderate to severe withdrawal,
a history of severe withdrawal complications, withdrawing
from multiple substances, no safe environment or social
supports, repeated failed ambulatory withdrawal attempts,
and with no severe medical or psychiatric comorbidity.
5.6 Inpatient hospital treatment is appropriate for those with S –
severe withdrawal complications (such as delirium or
seizures of unknown cause), and/or severe medical
or psychiatric comorbidity.
5.7 Hospital addiction medicine consultation liaison services S –
should be accessible in hospitals to aid assessment,
management and discharge planning.
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