UK National Institute for Health and Clinical Excellence: Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

England's NICE (National Institute for Health and Clinical Excellence) put out this guideline in February of 2011.   It gives a view of a national public health system addressing the problem of alcoholism.  The approaches seen here may be come more common in the US if health care reform leads to a more systematic cost sensitive approach.

The guideline is available at: http://www.nice.org.uk/nicemedia/live/13337/53191/53191.pdf.

The authors note a prevalence of alcohol dependence of 4% and harmful drinking of 25% in the UK.

For harmful drinking and mild dependence, behavioral approaches are recommended. The guideline suggests outpatient counseling, 60 minutes weekly for 12 weeks for most patients. More intensive outpt treatment is reserved for people "with moderate and severe alcohol dependence who have:  very limited social support (for example, they are living alone or have very little contact with family or friends) or complex physical or psychiatric comorbidities or [who have ] not responded to initial community-based interventions"

Residential rehabilitation is advised for the homeless but otherwise not much discussed. The benefit of residential vs community treatment is listed as a research questions.

Treatment with acamprosate or oral naltrexone is advised, with a course of 6 months.  The medication can be considered a failure if no improvement by 4-6 weeks.  Depot IM naltrexone is not mentioned, neither is topiramate. Disulfiram is mentioned as an option for motivated patients with family members to monitor use.  Concurrent counseling is advised. 

Outpatient withdrawal treatment is discussed. They advise patients be seen at least every other day.  Fixed or symptom triggered dose of chlordiazepoxide or diazepam is recommended, although no dosing regimen is given. Withdrawal treatment is expected to last 7-10 days. They advise family monitoring when possible. 

Inpatient withdrawal treatment is advised for patients drinking more than 30 units per day, hx of seizures or DTs, people with cardiovascular, hepatic  psychiatric comorbidities and for those on concurrent benzodiazepines.  

Benzodiazepine is expected to be treated inpt over 2-3 weeks or outpt over more than 3 weeks with tapering doses. Use of seizures medications is not discussed.