Alcohol: treatment for alcohol misuse

Introduction

The treatment options available for alcohol misuse depend on whether drinking is hazardous, harmful or dependent, and whether the patient is trying to drink less (moderation) or give up drinking completely (abstinence). Problem drinkers may initially be referred to a short counselling session, known as a brief intervention. This may be following on from an alcohol-related accident or injury. Further treatment can involve more (specialist) counselling or other forms of therapy to achieve moderation or abstinence. Abstinence will usually be recommended for people with moderate to severe dependency. Sometimes medication is prescribed to help successfully achieve abstinence.

Alcohol Brief Interventions

An alcohol brief intervention (ABI) is a short, evidence-based, structured conversation about alcohol consumption with a patient or service user that seeks, in a non-confrontational way, to motivate and support the individual to think about and/or plan a change in their drinking behaviours in order to reduce their consumption and/or their risk of harm. The HEAT H4 Alcohol Brief Interventions was initially a three-year target, with an extension for a fourth year in 2011/12. In 2012/13 this became a HEAT standard. The standard is measured in three priority settings – primary care, accident & emergency and antenatal, and from 2012/2013 also in wider settings. The standard states that NHS Boards should carry out screenings using an appropriate screening tool, and followed by an alcohol brief intervention where required. Both the screening and the brief intervention (if applicable) are delivered in line with national guidance, which is based on SIGN 74 Guidelines.

NHS Boards report their ABI figures quarterly to ISD and these figures are pulled together in an Annual report that is made available from the Drug & Alcohol Publications section on the ISD website. The key points from the 2015/16(134KB) report are:

  • In 2015/16 there were 97,245 Alcohol Brief Interventions (ABI) carried out in Scotland. This is 59% more than the 61,081 set out in the Local Delivery Plan (LDP) standard for 2015/16.
  • At national level both the target for all ABI delivery and the expectation of delivery of 80% of the target in priority settings were met. All but one NHS Board (NHS Western Isles) exceeded their target for ABI delivery in 2015/16.
  • There is large variation between individual NHS Boards in the distribution of ABI delivery across settings. There has been a three-fold increase in the number of ABIs delivered by 'wider' settings (other than priority settings) in the last three-year period.

Alcohol Use Disorders Identification Test (AUDIT)

The Alcohol Use Disorders Identification Test (AUDIT)(172.00 KB) was developed by the World Health Organization (WHO) to identify persons with hazardous and harmful patterns of alcohol consumption. It consists of 10 multiple-choice questions about recent alcohol use, alcohol dependence symptoms, and alcohol-related problems. Each response has a score ranging from 0 to 4 and the sum of all scores determines the categories of intervention required. The guidance suggests that the following interpretation be given to the AUDIT scores:

  • Scores between 8 and 15 are most appropriate for simple advice focused on the reduction of hazardous drinking.
  • Scores between 16 and 19 suggest brief counselling and continued monitoring.
  • Scores of 20 or above warrant referral to a specialist for further diagnostic evaluation and possible treatment for alcohol dependence.

National Drug & Alcohol Treatment Waiting Times

Data from specialist drug and alcohol treatment service providers are collected in the Drug and Alcohol Treatment Waiting Times database which went live across Scotland on 1 April 2011. The system enables the measurement of the full wait from referral to treatment for both drug and alcohol services, and calculates the time a person waits for treatment. Information is also collected on whether the individual could not or did not attend offered appointments and allows for periods of unavailability to be recorded. Previously, information was only collected on drug treatment waiting times. Trend data for drug waiting times prior to April 2011 is not published as the current data is not comparable with
data from the old system. All recent (quarterly) publications can be found in the Drug & Alcohol Publications section on the ISD website.

The Scottish Government has set a target that by March 2013, 90% of people who need help with their drug or alcohol problem will wait no longer than three weeks for treatment that supports their recovery. The percentage of waits longer than 3 weeks is an indicator included in the ScotPHO Alcohol Profile, where data is shown at Scotland, NHS Board and Alcohol & Drug Partnership level. From the start of reporting in April 2011 the percentage of people waiting for less than 3 weeks initially gradually increased and has now broadly stabilised; 96.2% of the 6,984 people who started alcohol treatment between April and June 2015 had waited 3 weeks or less, compared to 97.3% (of 7,613 people) in the same quarter in 2014 (see Table 1 National Drug & Alcohol Waiting times report).

Medications to treat alcohol dependency

NICE guidelines recommend that harmful drinkers and people with mild alcohol dependence are offered a psychological intervention (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol-related cognitions, behaviour, problems and social networks. However, for those who have not responded to psychological interventions alone, or who have specifically requested a pharmacological intervention, prescription of acamprosate or oral naltrexone (in combination with an individual psychological intervention) is an option. Also, for people with moderate and severe alcohol dependence who are successfully trying to withdraw, prescription of acamprosate or naltrexone; or disulfiram is an option (all in combination with a psychological intervention). In October 2013 nalmefene was accepted for use in Scotland.  It is indicated for the reduction of alcohol consumption in adults with alcohol dependence who have a high drinking risk level, without physical withdrawal symptoms and who do not need immediate detoxification. High drinking risk level is defined as alcohol consumption of more than 60 g/day (7.5 units/day) in men and more than 40 g/day (5 units/day) in women. It should be prescribed only in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption.

  • Acamprosate – this works by affecting levels of chemicals in the brain thought to be partially responsible for inducing a craving for alcohol.
  • Naltrexone – this works by blocking the opioid receptors in the body, stopping the effects of alcohol.
  • Disulfiram – this works by causing unpleasant physical reactions when any alcohol is drunk (e.g. nausea, chest pain, vomiting, dizziness).
  • Nalmefene – accepted for use in Scotland in October 2013, works by blocking the opioid receptors in the body, stopping the effects of alcohol.

The Excel file Drugs used in Alcohol Dependence (150 KB) details dispensing of drugs for the treatment of alcohol dependency in Scotland (BNF section 4.10.1). Note that Naltrexone is not specific to treatment for alcohol dependence so is therefore not included in the tables. Table 1 shows the number of patients who have been prescribed any alcohol dependence drug, based on prescriptions where the CHI number was recorded. The CHI capture rate (the percentage of items with a valid CHI attached) should be considered when interpreting any trends in patient data. CHI capture rates have been increasing in recent years, but the impact of this on the number of patients identified is hard to ascertain.

The evidence available suggests that the impact is small when considering the scale of change in CHI capture rate as presented. The CHI capture rates are shown in the Introduction tab of the Excel file and in the latest year vary between 79.4% for the new drug Nalmefene, to 96.2% for Acamprosate. Table 2 shows a summary of the number of dispensed items, gross ingredient costs, defined daily doses (see definition under the Introduction tab of the Excel file), and the defined daily doses per 10,000 population per day for each year from 2005/06 to 2015/16 in Scotland for each of the drugs. Table 3 gives a breakdown for each drug at NHS Health Board level.

Key points:

  • In 2015/16, 9,475 patients were dispensed drugs for alcohol dependency. Since 2009/10 there has been a 4% increase in the number of patients dispensed drugs for alcohol dependency.  However, this increase coincides with a period of improved CHI capture on prescriptions and it is difficult to establish the extent to which the increase is the result of improved data collection.

  • In 2015/16 5,758 patients were dispensed acamprosate, 4,830 were dispensed disulfiram and 171 were dispensed nalmefene.

  • The gross ingredient cost of drugs for alcohol dependence was £1.7 million in 2015/16, this is a 40% increase compared with 2014/15.  Recent changes in the price of disulfiram account for much of the increase in expenditure on drugs for alcohol dependence.

  • Over the last seven years (where patient detail was captured), treatment with drugs for alcohol dependence has been most common in patients between 45 and 49 years of age. In 2015/16, 80% of the patients dispensed drugs for alcohol dependence were aged between 35 and 59. Treatment in younger age groups has decreased and in older age groups slightly increased.

  • In 2015/16, 62% of those dispensed drugs for alcohol dependence were male.

  • Treatment with drugs for alcohol dependence is much more common in the more deprived areas; in 2015/16 five times more patients were living in the most deprived quintile compared to the least deprived quintile. Around one third of patients dispensed drugs for alcohol dependence lived in the 20% most deprived areas.

More information about prescribed items in Scotland can be found at the ISD Website under the Prescribing & Medicines topic.

Please note: If you require the most up-to-date data available, please check the data sources directly as new data may have been published since these data pages were last updated. Although we endeavour to ensure that the data pages are kept up-to-date, there may be a time lag between new data being published and the relevant ScotPHO web pages being updated.