Closed consultation

UK clinical guidelines for alcohol treatment: specific settings and populations

Published 16 October 2023

This was published under the 2022 to 2024 Sunak Conservative government

13. Community alcohol treatment and recovery services

13.1 Main points

Community alcohol treatment services should:

• provide a positive experience of care for people who are stigmatised and disadvantaged
• promote a trauma-informed therapeutic environment that can help engage and involve people in their treatment
• make sure the service is accessible to anyone who needs alcohol treatment
• promote equitable access and personalised treatment that meets the diverse needs of the local population, including people with protected characteristics and socially excluded groups
• implement a quality governance framework informed by strong clinical leadership to help deliver safe, appropriate care and evidence-based treatment
• make sure that integrated drug and alcohol services are inclusive for people whose main problem is alcohol (primary alcohol problem)
• be part of a recovery-oriented system of care which offers alcohol treatment integrated with longer-term recovery support
• involve peer-based networks and organisations in service feedback, design, monitoring and in delivering recovery support
• work in partnership with the wider health and social care system, criminal justice system and community services at a strategic and a service level
• develop service level agreements and information sharing protocols with partner services to provide integrated care to people with multiple needs and support transitions from one service to another
• have competent, caring staff who are well-trained and supervised and have appropriate caseloads
• provide quick and easy access to initial assessment, urgent treatment and risk management, and comprehensive assessment
• offer a named keyworker and personalised, collaborative treatment and recovery planning for each person in treatment
• offer evidence-based alcohol focused psychosocial, recovery support, pharmacological and harm reduction interventions

13.2 Introduction

In every local area there should be community alcohol treatment and recovery services for adults and for young people. These services should:

• provide a positive experience of care
• be designed to meet the alcohol treatment needs of the local community
• be easy to access
• provide evidence-based interventions

Most people access alcohol treatment in community services and those who need planned inpatient or residential treatment can access this through referral from community services.

Most of these alcohol clinical guidelines are relevant for community alcohol treatment and recovery services. So, this chapter summarises the main elements of adult community alcohol treatment and recovery services and directs you to other sections in the guidelines that provide more detailed guidance on each element.

Chapter 23 provides guidance on community alcohol treatment and support for young people.

13.3 Core elements of community alcohol treatment

13.3.1 Principles of care

You should read guidance on principles of care in chapter 2.

These principles should form the foundation of a community alcohol treatment and recovery service.

They include service and system arrangements and clinical practice that contribute to:

• a positive experience of care
• equality, diversity and inclusion
• quality governance
• a recovery-oriented system of care
• local strategic partnerships

13.3.2 Designing services to meet the alcohol treatment needs of the local community

Community alcohol treatment services should be based on the unique needs of the local area they serve.

Each local strategic partnership should co-produce an assessment of local need involving local people and communities in the process, including those with lived experience of alcohol problems. If community services are combined alcohol and drug treatment services, the distinct needs of people with alcohol problems and people with drug problems should be identified. The community alcohol treatment and recovery service should be aware of the needs assessment and of any changing local needs.

Service providers should design services so that they are accessible to everyone in their local area. They should work with people with protected characteristics and socially excluded groups to identify their needs and co-produce plans to target and tailor services to those groups.

You can read more about targeting and tailoring services in:

• chapter 25 on developing inclusive services
• chapter 9 on alcohol assertive outreach and a multi-agency team around the person
• chapters on specific populations in part 2 of the guidelines (chapters 18 to 27)

13.3.3 Service ethos

Creating a positive service ethos

Service ethos describes the culture and feel of a service. There are a number of things that a service can do to make sure they have a positive ethos, including having:

• strong clinical leadership
• engaged staff
• clear and supportive management direction
• a service framework based on the principles of care outlined in chapter 2

Making good first impressions

First impressions of a treatment service can have a lasting impact on a person. These impressions can affect their experience of assessment, how they engage with the treatment process and ultimately affect their treatment outcomes.

Services can avoid or limit stigmatising and stereotyping people with alcohol problems by paying attention to:

• how staff interact with people on the phone
• how staff interact with people face-to-face at reception or in clinical interactions
• how the service ethos is portrayed in its information about itself
• the environment in which assessment and treatment take place

This applies to people who need alcohol treatment, as well as their family or carers.

13.3.4 Meeting the needs of people with primary alcohol problems in integrated drug and alcohol treatment services

Integrated drug and alcohol services should be organised so that people with primary alcohol problems:

• feel they are in the right place to seek help
• get a treatment offer that is tailored to their alcohol treatment needs
• feel safe and supported

To make integrated drug and alcohol services more inclusive to people with alcohol problems, the services should make sure that:

• the service name is inclusive (not called a drug treatment service)
• there is visible information on site specifically for people with a primary alcohol problem
• the service is promoted to people with primary alcohol problems using targeted service information
• they offer evidence-based alcohol-focused interventions
• they have a dedicated alcohol team or staff with alcohol specific competences
• they have information about alcohol and alcohol treatment options available and staff are competent to discuss these options with people
• it’s clear that people can make their own choices about treatment options
• they offer to host Alcoholics Anonymous (or other alcohol focused peer-based groups) on the service site

13.4 Partnership working

Community alcohol treatment and recovery services provide specialist alcohol treatment and recovery support, but they cannot meet all the needs of people with alcohol problems or their families. So, it’s essential that they work in partnership with other local services and with peer-based organisations to meet those needs. Community alcohol treatment and recovery services have a vital role to play in the wider partnership approach.

13.4.1 Working with peer-based support organisations

In some areas, peer support networks are closely linked to the community alcohol treatment service and in others they are independent lived experience recovery organisations. Community alcohol treatment services should involve peer-based support organisations or networks in the service.

You can read more about working with peer-based support organisations in section 2.5.3: access to peer support and lived experience recovery organisations.

You can read guidance on peer-based recovery support in chapter 6 on recovery support services.

13.4.2 Integrated care pathways with partner services

Local strategic partnerships should agree how local systems will work together to meet the needs of people with alcohol problems. The community alcohol treatment and recovery service has an important role in making and maintaining service level agreements to support integrated care pathways and address any problems with the pathway.

With each partner service, community alcohol services should agree:

• clear referral pathways into the community alcohol treatment and recovery service
• how the alcohol service can refer people to the partner service
• joint working arrangements, setting out who is responsible for what
• information sharing agreements and mechanisms
• to attend and contribute to multi-agency case conferences and care planning reviews

Commissioners and service managers need to allocate time and provide training for staff to work in partnership with other services. Where possible it is helpful for a named staff member in the community alcohol service and in each partner service to lead on partnership working.

Services should make sure that all their staff are aware of and updated on the pathways and related information sharing protocols.

13.4.3 Co-ordinating care with partner services

Service level agreements with partner systems and services should include agreements between the community alcohol treatment and recovery services and a wide range of other services, including:

• liver screening and liver departments in hospitals
• alcohol care teams in local acute hospitals
• community and crisis mental health services
• neuropsychology (for alcohol related brain damage)
• local primary care networks
• antenatal services
• early help and child safeguarding service
• adult social care and safeguarding services
• criminal justice services including police custody suites, courts and prisons
• homelessness and housing services
• domestic abuse services
• community services working with people with protected characteristics or socially excluded groups, including people experiencing severe and multiple disadvantage

You can read more guidance on partnership working with these services in the relevant chapters on specific settings and specific populations in part 2 of the guidelines.

13.4.4 Continuity of care and transitions

Transitions from one service to another, or one setting to another, are often vulnerable times for people, even when transitions are about making progress in recovery. Services need to work in partnership so that people:

• stay engaged with services throughout the transition and settle into the new service
• get the level of support they need to manage the transition (which can mean a temporary increase in support)

Adult community alcohol treatment services should have ongoing agreed continuity of care arrangements with several services. These services include:

• young people’s community alcohol treatment service
• specialist inpatient medically assisted withdrawal
• residential rehabilitation
• hospital alcohol care teams
• prison substance misuse or healthcare services

When a person makes one of these transitions, both (or all) services involved and the person should agree an individually tailored transition plan. This should be agreed well ahead of the transition, so the person is appropriately supported at a vulnerable time.

You can read more guidance on these transitions in other parts of the guidelines, including:

• 9.8 Care for vulnerable people with severe and multiple disadvantage (in assertive outreach)
• 12.7.2 Managing complex needs (multi-agency working and pathways for when people leave specialist medically assisted withdrawal)
• 14.4 The journey through an intensive residential treatment programme
• 16.10 Discharging patients from acute hospitals to ongoing treatment and care
• 17.5 Alcohol treatment in prisons
• 17.6 Continuity of care in criminal justice settings: release, resettlement and recovery
• 18.7 Inpatient mental health settings
• 23.7 Managing co-occurring alcohol and mental health problems for young people
• 23.8 Transition from young people’s services to adult services
• 24.7 Supporting pregnant women who are alcohol dependent or who are drinking heavily

13.5 Caring and competent staff

Community alcohol treatment and recovery services should be staffed with a multidisciplinary team that includes:

• doctors
• nurses
• psychologists
• social workers
• other practitioners

Caring and competent staff are vital to an effective community alcohol treatment and recovery service. Staff should be able to form therapeutic alliances with people who are stigmatised, often marginalised and with high levels of trauma. This requires care and skill.

Staff also need alcohol specific competences. In integrated drug and alcohol services there should be enough staff with alcohol specific competences and specialist expertise to meet alcohol treatment need.

You can read guidance on staff competences in section 2.5 on a skilled and competence workforce.

13.6 Assessment

The community alcohol service should provide quick and easy access to:

• initial assessment
• urgent treatment and risk management
• comprehensive assessment including risk assessment

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.

You can find guidance on assessment in chapter 4 on assessment and treatment and recovery panning.

13.7 Personalised treatment and recovery planning

Based on the assessment and discussion of available treatment and recovery support interventions, the assessor or allocated keyworker should agree a treatment and recovery plan with each person. Care should always be personalised and plans should be regularly reviewed.

Each person should also have a risk management plan that is regularly reviewed.

You can find guidance on treatment and recovery planning in chapter 4: assessment and treatment and recovery planning.

13.8 A range of evidence-based alcohol interventions

Community alcohol treatment and recovery services should have a range of evidence-based alcohol interventions available. These should include:

• psychosocial interventions
• access to recovery support interventions
• pharmacological interventions
• harm reduction interventions

The range of treatment options (in-house or through referral) should be clear to the person when they enter treatment and during their assessment.

Clinicians and other practitioners should provide accessible information on the risks, benefits and known outcomes of interventions, so the person can make their own choices.

13.8.1 Psychosocial interventions

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.

The service should offer everyone in treatment a named keyworker who provides structured support. Structured support involves using specific psychosocial interventions that are common to evidence-based psychological treatments for alcohol and drug use.

Services should also offer formal psychological treatments focused specifically on alcohol-related problems according to individual need. These treatments are generally provided by a specialist member of the multidisciplinary team alongside a keyworker who provides structured support.

You can find guidance on structured support and formal psychological treatments in chapter 5 on psychosocial interventions.

13.8.2 Recovery support interventions

Keyworkers should help people to set recovery goals in their treatment and recovery plan and help them to access appropriate recovery support interventions. Recovery support is important from the beginning and throughout treatment and especially after the person has left structured treatment.

Recovery support interventions can include:

• involvement in recovery-oriented peer-based activities and mutual aid
• employment support
• education, training and volunteering
• involvement in social networks
• recovery check-ups after the person has left structured alcohol treatment and re-engagement plans

Alcohol treatment and recovery services should have pathways and joint working arrangements with recovery support services including peer-based organisations so they can help people access emotional and practical support for their ongoing recovery from alcohol dependence.

You can read about the keyworker’s role in promoting recovery goals in section 5.6 on integrating and supporting recovery.

You can read more about recovery support services in chapter 6 on recovery support services and in chapter 7 on employment support.

13.8.3 Pharmacological interventions

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 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

You can read more guidance in:

• chapter 10 on pharmacological interventions
• chapter 11 on community based medially assisted withdrawal

13.8.4 Harm reduction interventions

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 that focuses on reducing health and social harms associated with harmful drinking and alcohol dependence. They should regularly review this approach with the person and monitor their health.

You can read more guidance in chapter 8 on harm reduction.

13.9 Commissioning and contracting community alcohol treatment services

Commissioning and contracting arrangements vary across the UK. These processes can play an important role in shaping community alcohol treatment and recovery services.

Where services are integrated alcohol and drug services, service specifications should set out distinct requirements for alcohol treatment and for drug treatment. These guidelines focus on service delivery rather than commissioning and contracting but the Office for Health Improvement and Disparities’ Commissioning quality standard provides guidance on commissioning drug and alcohol treatment services. The standard applies to England but some of the content may be useful for other UK nations.

14. Residential treatment and intensive structured day treatment

14.1 Main points

Residential and intensive day programmes are an important part of a recovery-oriented system of care.

Services should be trauma-informed and have clear clinical governance structures and policies including for staff supervision.

Programmes may be based on different therapeutic approaches and these should be explicit to enable service user choice.

Residential treatment focused on abstinence should be available for people with the most complex needs, particularly people who are homeless.

Day programmes can provide intensive support to people in their communities and a useful addition for people living in supported accommodation.

There should be as seamless transition as possible into residential and intensive day programmes for people completing medically assisted withdrawal.

It is important to prepare people for intensive programmes but not at the expense of making it hard for them to access.

Attention should be paid to help the person integrate back into their local community before they leave the programme.

14.2 Introduction

This section provides guidance on residential treatment and structured day treatment.

Intensive treatment programmes can be provided in either a residential rehabilitation setting or a community treatment service or a day hospital. These programmes are designed to meet the needs of people who need a higher level of support to achieve their treatment and recovery goals than they could receive in standard community alcohol treatment (Orchowski and Johnson 2012, Coco and others 2019).

Residential rehabilitation programmes are one of the longest established forms of treatment for alcohol and drug dependence. A recent systematic review of research published between 2013 and 2018 found moderate quality evidence for the effectiveness of residential treatment in improving outcomes across a number of substance use and life domains (de Andrade and others 2019).

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 residential treatment for people who are experiencing homelessness.

The NICE clinical guideline Drug misuse in over 16s: psychosocial interventions (CG51) recommends considering residential treatment for people who are seeking abstinence and who have significant comorbid physical, mental health or social (for example, housing) problems and have not benefited from previous community treatment. The clinical consensus of the alcohol guidelines development group is that these criteria are also applicable to people with alcohol dependence.

There are mixed findings on the effectiveness of residential treatment compared with structured day treatment of a similar intensity and duration. NICE CG115 recommends more research in this area because studies are limited, and no recent comparative studies have been reviewed.

14.3 Intensive structured treatment programmes

14.3.1 Types of intensive structured programmes

Intensive structured treatment programmes, whether in a residential or day setting, support people to achieve abstinence and encourage their recovery. Intensive programmes usually provide daily structure and a focus on health, personal and social functioning, as well as recovery goals.

The programmes are varied because they are based on different therapeutic approaches and use a range of different treatment components. Programmes are usually abstinence based and include:

• individual sessions
• structured group work and participating as a member of a community
• social and recovery-oriented activities
• encouragement to join mutual aid groups or peer-based recovery support services
• family support and involvement where appropriate

There is no clear evidence about optimal treatment length, although several studies have found that longer programmes (lasting 3 months or more) are associated with better treatment outcomes (Eastwood and others 2018, Helena Kennedy Centre for International Justice 2017).

The length of time somebody should be in an intensive treatment programme should be tailored to their needs but should also allow enough time for them to:

• engage with the programme
• build trust with the staff
• commit to the treatment community
• work on individual change
• get ready for reintegration to their community after treatment

The time needed for all of this will vary from person to person.

14.3.2 Residential treatment

Residential rehabilitation services are an important part of a recovery-oriented system of care. Every local area should provide access to this treatment option for the minority of people who require intensive support to achieve abstinence and begin their recovery.

Residential rehabilitation services are facilities where residents stay overnight, usually for several months. They are run by voluntary and private sector organisations and in Scotland there is also some statutory provision.

Residential treatment provides a daily structure and safe place for people who may have come from unsafe circumstances, including rough sleeping or living in an abusive situation. It provides a complete break from current social networks that revolve around alcohol use or from high-risk situations in the community. People who are susceptible to returning to drinking or who have vulnerable mental health may need the 24-hour support that these services can provide, beyond the formal programme interventions. A placement in residential treatment can give people the space to build recovery capital and develop the skills they need to sustain longer-term recovery and reintegration into the community.

Entering residential treatment and returning to the community can both be challenging transitions. Both these transitions require preparation and planning to minimise people’s risk of leaving treatment unplanned, or them returning to problematic drinking after they leave (see section 14.4.6 below).

Some residential services provide medically assisted withdrawal before the person moves on to the main part of the intensive structured programme.

You can find guidance on medically assisted withdrawal in chapter 10 on pharmacological interventions, chapter 11 on community medically assisted withdrawal and chapter 12 on inpatient medically assisted withdrawal.

14.3.3 Intensive structured day treatment

A structured day programme may be a more accessible treatment option for people who do not want or need residential treatment, such as those who have a good local support system and stable and secure accommodation.

In the UK, intensive structured day treatment programmes generally require the person to attend for 4 or 5 days each week and normally last between 4 and 12 weeks. Ideally the length of treatment should be tailored to the needs of the person.

Intensive day treatment provides a high level of structure and support, while allowing the person to maintain day to day contact with their support networks and remain in their accommodation. People usually attend intensive day treatment while living at home, but some programmes are designed for people living in supported accommodation for the duration of their treatment, which can offer additional stability to support recovery.

Intensive day programme participants typically return home each evening and have to manage weekends without access to treatment activities. Real world exposure to everyday issues or drinking cues during the treatment programme may help them to practice their new skills and techniques and link in with local recovery support networks as these challenges arise (Leighton 2016).

14.3.4 Core elements of intensive treatment programmes

All intensive treatment programmes (day or residential) should have:

• a coherent treatment programme with a clear rationale and therapeutic framework
• a consistent risk assessment process, both for medically assisted withdrawal (if the service provides this) and the psychosocial programme
• a comprehensive assessment process that fully involves the person with alcohol dependence, and leads to a personalised treatment and recovery plan
• clear links between the assessed needs of a person and the interventions they receive
• evidence-based group interventions delivered by trained staff who receive clinical supervision for a groupwork approach and for the specific interventions
• individual key working support with a named keyworker that runs alongside the group programme
• a focus on community reintegration throughout the programme, encouraging people to build recovery capital by getting involved in mutual aid groups or peer-based recovery support services
• individually agreed plans for ongoing treatment and recovery support after the person has left the programme (sessional, day or extended residential depending on assessed need)
• strong links with community alcohol treatment services who should contribute to planning for ongoing treatment and recovery support after the person leaves the programme

14.3.5 Therapeutic approach

Intensive structured treatment programmes use a range of therapeutic, recovery-focused approaches. These include programmes where the central focus is therapeutic community, the 12-step model, and programmes based on cognitive behavioural therapy (CBT). Other approaches used in UK settings have included faith-based programmes, or personal and skills development-based models. Most residential rehabilitation programmes are now fairly eclectic and draw on a range of interventions. There is no strong evidence to support one approach over another.

The perceived quality of the programme is an important indicator of outcome. For example, one study reported that people who saw their residential treatment programme as more involving, cohesive, well-organised, and oriented toward independence and self-understanding had better drinking-related outcomes (Moos and Finney 1983).

In both residential and community settings, evidence suggests that an effective programme has a welcoming, accepting ethos and a highly structured and predictable programme. These factors are likely to be more important than the theoretical basis or exact content of the programme because they provide the context for building trust, commitment, and starting to make significant change (Leighton 2017).

Intensive structured treatment programmes tend to be based on the therapeutic value of being part of a community. This can include formal structured activities in which staff and residents are expected to participate (such as community meetings), and peers offering support to each other. Peers can support one another as part of formal group therapy. Peers who are further on in the treatment programme can also act as role models as they interact with newer participants during daily shared activities. Participating in the community helps people to gain social skills in an alcohol-free environment.

14.3.6 Trauma-informed care and cultural competence in intensive structured treatment programmes

Services and practitioners should apply all of the core principles of care outlined in chapter 2 to intensive structured treatment programmes.

Services should recognise the importance of trauma-informed care and related staff competencies. Intensive treatment programmes have the potential to trigger traumatic memories because of their intensity and focus on groupwork. And, in the worst case, can seriously retraumatise participants. This may be particularly relevant in residential settings where shared living arrangements mean that people are always near one another when they are feeling vulnerable. Providers of intensive treatment programmes should develop and maintain a trauma-informed treatment environment. All staff should be trained in trauma-informed care.

Cultural competence is essential for all services and practitioners. Given the intensity of day and residential structured programmes, services should make extra effort to make sure they are safe and effective for people with a range of differences, including:

• culture
• ethnicity
• gender
• sexual orientation
• age
• physical ability

Services should provide training in cultural competence and regularly review their staff’s cultural competence.

14.3.7 Quality governance

There should be a strong focus on the overall service quality and on quality governance for intensive structured treatment programmes.

You can find guidance on quality governance in chapter 2 on principles of care.

Residential treatment services should be registered with national regulators (such as the Care Quality Commission in England) and comply with their standards.

Intensive structured programmes are complex to deliver. Staff should have training and competencies in:

• counselling, psychotherapy or psychology
• groupwork
• the therapeutic approach the service uses

The service should provide regular clinical supervision by a professional trained in supervision and also trained and experienced in the interventions being supervised.

Where residential treatment services offer medically assisted withdrawal, it is vital they have the appropriate facilities and staff competence to work with the people they offer this intervention to.

There is guidance on specialist inpatient medically assisted withdrawal in chapter 10 on pharmacological interventions, chapter 11 on community medically assisted withdrawal and chapter 12 on inpatient medically assisted withdrawal.

14.4 The journey through an intensive treatment programme

14.4.1 Assessment for an intensive treatment programme in community alcohol treatment services

Comprehensive assessment and treatment and recovery planning

Community alcohol services should consider intensive structured programmes as a treatment option during comprehensive assessment, and during treatment and recovery plan reviews.

Most people who want residential or intensive day treatment programmes will have previously engaged in standard treatment interventions in the community. Some people, such as those experiencing homelessness or severe and multiple disadvantage, might not be able to respond to less intensive interventions. So, intensive structured treatment may be appropriate for them from the start of their treatment journey.

It is complex to assess whether a person should be referred to an intensive treatment programme. There should be input from the multidisciplinary team or a senior clinician with experience of assessing people for residential treatment. The decision to refer should be reached collaboratively with the person, based on clinical assessment and discussion about their preference.

Co-occurring mental and physical health conditions

You should invite other services involved in the person’s care and their family members to contribute to the assessment, with the person’s consent. In cases where a person has a co-occurring severe mental health or physical health condition, practitioners need to work closely with the community mental health team or the physical health treatment team to make decisions about the suitability of a placement.

There is some evidence that outcomes are improved when residential settings offer treatment for both mental health conditions and substance use conditions (Brunette and others 2004, Essex County Council 2016).

For more information about working with co-occurring conditions, see chapter 18 on co-occurring mental health conditions and chapter 19 on co-occurring physical health conditions.

Medically assisted withdrawal

Intensive structured treatment usually follows medically assisted withdrawal, which can be provided in a community, residential or specialist inpatient setting depending on the person’s assessed need. If medically assisted withdrawal is not provided in the residential treatment setting, or if the person requires specialist inpatient medically assisted withdrawal, the referrer and the person will need to plan for the medically assisted withdrawal. And where possible they need to arrange for an immediate transfer to the intensive structured programme after the medically assisted withdrawal.

Chapter 12 on inpatient medically assisted withdrawal provides guidance on criteria for specialist inpatient and for residential medically assisted withdrawal.

No unnecessary delays

It is important to prepare with the person for both medically assisted withdrawal and for a residential or intensive day programme, but you should also consider the urgency of the person’s need, based on their physical and mental health. The preparation should be based on the person’s assessed needs. There should be no standard requirements that everyone attends a set number of groups before accessing intensive structured treatment, because these requirements can create barriers to accessing treatment.

Once the person has made a fully informed decision to undertake medically assisted withdrawal followed by residential treatment or intensive structured day treatment, services should work together to make sure there are no unnecessary delays. People who are assessed as being in need of intensive structured treatment are likely to be vulnerable and have the highest levels of need and risk. So, it’s important that they can access residential and intensive structured day programmes as easily as possible. Delays can be demotivating to a person with severe dependence and risk people changing their minds about joining an intensive programme. Commissioners and services should make sure that processes for agreeing funding and related arrangements are as streamlined as possible.

People referred to intensive treatment programmes often have poor health. If there are any unavoidable delays before admission, a clinician in the referring service should regularly review the person’s physical and mental health. If their needs and risks change, the service should consider different interventions. The keyworker should continue to provide support to the person throughout this time, to keep them engaged in the treatment journey and monitor any risks.

14.4.2 Preparation in community treatment services

It is good practice to prepare people for intensive treatment. Research has shown that this improves people’s retention, engagement and their awareness of the benefits of the programme they are going to enter (Essex County Council 2016). You should do this by:

• giving them up to date, accessible information (verbal and written or video) about available options
• arranging visits to the programme where possible
• discussing relevant concerns or questions about the programme

If a person is assessed as needing an intensive treatment programme, the keyworker should help them think carefully about whether or not they want to engage in it. They should consider:

• the intensity of the groupwork experience
• how the staff delivering the programme help people to manage the pressures of participating
• how the person might respond to this experience

For people considering a residential placement, keyworkers should help them think about the potential impact of leaving their home community and living close to other people with complex recovery needs. If they have specific cultural needs, they will need to consider how these can be met within the programme.

Arranging visits can help people to make a decision and the keyworker should encourage them to visit the service before accepting a place. It may also help the person to talk with someone who has been through the programme.

The keyworker should ensure they have the person’s fully informed consent before making a referral.

14.4.3 Assessment in residential or community intensive programmes

Staff who deliver intensive programmes also have an important role to play in assessing people’s suitability and preparing them for admission to their programme. These staff should help people prepare by giving them pre-admission advice about:

• behaviour boundaries and how to interact with others on the programme
• the kind of emotional experiences that joining the programme can evoke and how the staff can support people to manage these
• how the programme is balanced to offer formal therapeutic activities, social activities and activities that contribute to recovery
• how group therapy works, including rules for confidentiality and acceptable behaviour and how a new participant will be inducted into the group
• how groups can be run in a safe way
• how a person’s family or wider community can be involved in the programme

Research shows that if a person stays in the treatment programme and completes it, this is associated with improved treatment outcomes (Eastwood and others 2018). There is emerging evidence that particular practices can help enhance engagement and retention in a residential setting. These include:

• motivational interviewing (Carroll and others 2006)
• using senior staff to induct new residents into treatment (De Leon 2000)
• increasing the focus on the therapeutic relationship in staff training and supervision (Meier and others 2006)

14.4.4 Personalised treatment and recovery planning

It is important that anybody taking part in an intensive structured programme sets and agrees their own personal treatment goals and timelines for the programme. They should also get to regularly review their own progress against their goals. This allows the treatment and recovery plan to be personalised to meet their own needs in the context of the overall goals of the programme.

You can read guidance on treatment and recovery planning in chapter 4.

When a person is in an intensive structured programme, it is good practice that they keep in regular communication with a named keyworker in their home community alcohol service about their progress, priorities for action and next steps.

There are a number of issues that might affect the success of the person’s eventual re-integration into the community, and you should consider these when developing their treatment and recovery plan during their time on the intensive structured programme. These issues can include:

• finding accommodation for people without housing
• encouraging them to develop new skills, such as helping them access education, training and employment opportunities
• engaging with recovery support services including peer-based networks
• re-establishing family links so they have family support when they leave the programme

14.4.5 Preparing for discharge from community or residential intensive programmes

Inter-agency communication is vital during the treatment programme and when the person leaves, whether in a planned or unplanned way. It is good practice to agree confidentiality boundaries with the person at the start of their treatment, so you can discuss arrangements for ongoing treatment and support and put these in place, regardless of how the placement ends. You need to plan the person’s ongoing treatment and recovery support in good time to enable a smooth transition to a reduced level of support.

All intensive programme providers should develop policies to reduce the risk of negative outcomes for people who do not complete the treatment programme.

14.4.6 Considerations specific to discharge planning in residential programmes

Successful outcomes after residential treatment

There is good evidence for the importance of ongoing treatment and support, as well having a job and stable housing, as factors that predict successful outcomes after residential rehabilitation (Helena Kennedy Centre for International Justice 2017). There is also evidence of positive outcomes for people who engage with 12-step support when they leave residential rehabilitation (de Andrade and others 2019).

There is often a high risk of the person returning to problematic alcohol use in the period immediately after residential treatment. So, it is very important that there is a plan in place for continuous care between the residential and community alcohol treatment services. The plan should also include arrangements for other support, including:

• housing
• welfare benefits
• mental healthcare
• physical healthcare

People should be actively supported to access mutual aid and peer-based recovery support services in their home community.

Re-engaging with community-based treatment services

At the start of a person’s residential treatment, you should agree pathways for them to re-engage with community-based treatment services as soon as possible after they leave the programme. This includes agreeing relevant pathways and agreed actions keyworkers will take if people leave the programme before completing treatment.

Planning for continuity of care may include arrangements for transporting the person back to their home, or how local treatment and recovery support services will be notified when they are about to be discharged. It will be useful to have an agreement so residential staff can quickly contact the community treatment keyworker to let them know when somebody is being discharged. Verbal communications at the point of discharge should be followed up in writing. The residential service and the community based keyworker should also agree who will contact the person’s GP with current health information including details of any medication they are taking. They should provide information in writing to the GP immediately following discharge.

Contact and support after residential treatment

If people have complex needs and less social stability, especially if they have no fixed address, you should be clear with them about what contact and support they can access after the formal end of residential treatment. You should make every effort not to discharge anybody from the programme when they have no secure accommodation to return to.

Resource

The Scottish Government published the good practice guide Pathways into, through and out of residential rehabilitation in Scotland to help improve residential rehabilitation pathways. Although it was developed for Scotland, it sets out principles of good practice for pathways that are useful to all 4 nations.

14.5 References

Brunette MF, Mueser KT and Drake RE. A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders. Drug and Alcohol Review 2004: volume 23, issue 4, pages 471-481

Carroll KM, Ball SA, Nich C, Martino S, Frankforter TL, Farentinos C, Kunkel L, Mikulich-Gilbertson SK, Morgenstern J, Obert JL, Polcin D, Snead N and Woody GE. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study. Drug and Alcohol Dependence 2006: volume 81, issue 3, pages 301-312

Coco GL, Melchiori F, Oieni V, Infurna MR, Strauss B, Schwartze D, Rosendahl J and Gullo S. Group treatment for substance use disorder in adults: a systematic review and meta-analysis of randomized-controlled trials. Journal of Substance Use and Addiction Treatment 2019: volume 99, pages 104-116

de Andrade D, Elphinston RA, Quinn C, Allan J and Hides L. The effectiveness of residential treatment services for individuals with substance use disorders: a systematic review. Drug and Alcohol Dependence 2019: volume 201, pages 227-235

De Leon G. The therapeutic community: theory, model, and method. Springer Publishing, 2000

Eastwood B, Peacock A, Millar T, Jones A, Knight J, Horgan P, Lowden T, Willey P and Marsden J. Effectiveness of inpatient withdrawal and residential rehabilitation interventions for alcohol use disorder: a national observational, cohort study in England. Journal of Substance Use and Addiction Treatment 2018: volume 88, pages 1-8

Essex County Council organisational intelligence. SHARP community rehabilitation in Essex: programme evaluation. Essex County Council, 2016

Helena Kennedy Centre for International Justice. Residential treatment services: evidence review (PDF, 792KB). Sheffield Hallam University, 2017

Leighton T. SHARP intensive day treatment. Integrated approaches to drug and alcohol problems. Routledge 2016: pages 43-55

Leighton T. Inside the black box: an exploration of change mechanisms in drug and alcohol rehabilitation projects (PDF, 3.3MB). University of Bath, 2017

Meier PS, Donmall MC, McElduff P, Barrowclough C and Heller RF. The role of the early therapeutic alliance in predicting drug treatment dropout. Drug and Alcohol Dependence 2006: volume 83, issue 1, pages 57-64

Moos RH and Finney JW. The expanding scope of alcoholism treatment evaluation. American Psychologist 1983: volume 38, issue 10, pages 1036-1044

Orchowski LM and Johnson JE. Efficacy of group treatments for alcohol use disorders: a review. Current Drug Abuse Reviews 2012: volume 5, issue 2, pages 148-57

15. Primary care and community health services

15.1 Main points

A significant proportion of patients in primary care and community health services are drinking at levels that risk harm to their health.

Primary care and community health services can reduce alcohol related harm by:

• routinely identifying people with alcohol use disorders using a validated screening tool and providing brief interventions at an early stage
• referring patients who are probably dependent, and those with alcohol related health conditions to specialist alcohol treatment services

GPs and their teams can help support a patient’s recovery from alcohol dependence by:

• working with alcohol treatment services and sharing information with the patient’s consent
• contributing to multidisciplinary, multi-agency care planning, risk management and safeguarding for patients with multiple and complex needs
• identifying, managing and arranging secondary healthcare for patients with alcohol related physical and mental health conditions and other health conditions
• offering harm reduction advice and interventions to patients who continue to drink at harmful or dependent levels
• helping family members to access support where they need it
• reducing barriers to accessing primary healthcare for all people with alcohol problems, including socially excluded people and communities experiencing the worst health outcomes

Some primary care teams include GPs or nurses with appropriate competencies to provide specialist alcohol treatment interventions (for example, medically assisted withdrawal), and they may be commissioned to offer these.

There should be strong strategic leadership and senior level commitment to support primary care and community health services to carry out their role in preventing and managing alcohol related harm in their patients. An appointed alcohol lead can help to prioritise effective interventions and pathways for the full range of alcohol use disorders.

Organisational structures for reducing alcohol harm vary across the UK. In England, primary care networks and integrated care systems provide important opportunities to address alcohol harm at a whole system level and to reduce the health inequalities.

15.2 Introduction

The chapter describes the crucial role that primary care services and community health services can play in:

• preventing and reducing harm experienced by people with alcohol use disorders
• contributing to their patients’ treatment and recovery

15.3 Primary care services and community health services

Primary care services include GPs and their teams, pharmacists, and opticians. GPs may be supported by wider multidisciplinary teams or networks.

Community health services cover a wide range of services and provide care for people of all ages. Some community health teams support people with complex health and care needs. Examples include:

• district nurses
• specialist nurses for long term conditions
• falls prevention services

Community health services also include health promotion services such as health visiting services or sexual health services. These services can be run by the NHS, local authorities or third sector organisations.

Local arrangements vary, but in many areas community services work across health and social care and include a wide range of professionals such as GPs, community nurses, social workers and mental health nurses.

15.4 Alcohol use disorders

The term alcohol use disorder (AUD) describes any pattern of alcohol use that involves regularly drinking above 14 units per week. The UK chief medical officers’ low risk drinking guidelines recommend that to keep health risks from alcohol to a low level it is safest not to drink more than 14 units a week on a regular basis. Alcohol use disorders include:

• hazardous drinking (also called increasing risk drinking)
• harmful drinking (also called higher risk drinking)
• alcohol dependence

The appendix at the end of this chapter explains these different types of alcohol use disorder and appropriate interventions.

A significant proportion of the UK population have alcohol use disorders.

An Office for Health Improvement and Disparities analysis for the Local Alcohol Profiles for England estimated that in England, just over 21% of the adult population are drinking above the recommended low risk guidelines. This consists of:

• 8.2 million (17.7% adult population) are drinking at hazardous levels
• 1.7 million (3.6% adult population) are drinking at harmful levels
• 0.6 million (1.4% adult population) are alcohol dependent and potentially in need of specialist alcohol treatment (this group are a sub-group mostly of the group of people who are drinking harmfully)

Most people with an AUD do not need specialist alcohol treatment but may benefit from alcohol brief interventions (ABI), sometimes known as screening and brief interventions.

Any trained healthcare practitioner can offer identification using a validated tool and structured brief advice in 10 minutes.

15.5 Identification of alcohol use disorders and brief interventions

15.5.1 The importance of identification and brief interventions

People with AUD use many different healthcare services, including primary care services and community healthcare services. This provides a crucial opportunity for health and care staff to identify them and offer a brief intervention or referral to specialist alcohol treatment where required. Offering brief interventions for people who are drinking at hazardous or harmful levels can help prevent further health harms.

Chapter 3 sets out guidance on providing identification and brief interventions. It includes guidance on several validated AUD identification tests and on appropriate interventions based on the patient’s level of alcohol related health risk. Identification and brief advice should be embedded within standard assessment processes. Where this is not the case, healthcare staff can offer brief opportunistic interventions in line with the Make every contact count (MECC) approach.

15.5.2 National requirements for screening and brief interventions

In England, the General Medical Services contract requires primary care providers to offer all adults an alcohol risk screening (identification) when they register with a GP. The National Institute for Health and Care Excellence (NICE) public health guideline Alcohol use disorders: prevention (PH24) recommends that people whose screening shows that they are above low risk should be offered brief advice. Or, if their screening shows they are potentially dependent, they should be referred for specialist assessment.

The NHS Health Check, commissioned by local authorities from a range of providers including primary care services, includes the requirement that people receiving the Health Check are offered an alcohol risk assessment. NICE PH24 recommends that people whose screening shows they are above low risk to be offered brief advice. Or if their screening shows they are potentially dependent, they should be referred for specialist assessment.

NICE PH24 states that managers of NHS-commissioned services must ensure staff have enough time and resources to carry out screening and brief intervention work effectively.

15.5.3 Training and skills for identification and brief intervention

NICE PH24 says that managers of NHS-commissioned services must ensure staff are trained to provide alcohol identification (screening) and structured brief advice. If there is local demand, staff should also be trained to deliver extended brief interventions.

Identification and brief advice can be offered by any healthcare practitioner who has been trained. Training can be provided in a session lasting approximately 40 minutes. Health Education England provides a module on alcohol identification and brief advice with pathways for primary care services, community pharmacists, dental teams and hospitals.

Training should ensure that practitioners have sufficient knowledge and skills to:

• routinely initiate appropriate identification (screening) questions
• understand AUD categories and appropriate responses
• use an empathic, non-judgmental approach
• use non-stigmatising AUD terminology that is person centred and does not label people
• provide effective person-centred brief interventions
• make referrals to specialist alcohol treatment services where appropriate

Practitioners involved in delivering specialist alcohol treatment interventions (for example medically assisted withdrawal) require additional competencies. The Royal College of Psychiatrists and Royal College of GPs’ Delivering quality care for drug and alcohol users: the roles and competencies of doctors provides guidance on appropriate competencies for clinicians who provide specialist alcohol treatment interventions.

15.6 The role of GPs and their teams

Interventions and support offered by GPs and their teams to people with alcohol use disorders varies depending on local commissioning arrangements, clinical competencies within the wider primary care team and local partnership arrangements. However, all GPs and their teams will provide some interventions to:

• prevent and manage health harms in their patients with alcohol use disorders
• work with specialist alcohol services to support patients in their treatment and recovery

15.6.1 Expectations of GPs and their teams

All GPs and their teams could:

• routinely identify patients with alcohol use disorders and offer brief interventions
• with patients’ consent, refer them to specialist community alcohol treatment services
• work with alcohol treatment services (where patients are in specialist alcohol treatment) to support patients to achieve their recovery goals and share information appropriately
• contribute to a multidisciplinary and multi-agency care plan to support recovery and manage risks where patients have complex needs in addition to alcohol problems
• identify possible alcohol-related health conditions and (with patient consent) arrange for further investigations
• refer to relevant specialist secondary healthcare care services where indicated and keep alcohol treatment services informed
• encourage people with alcohol use disorders to take up the routine screening and vaccinations that are offered to the general population
• provide advice on alcohol use and pregnancy
• refer women who are pregnant and drinking harmfully to specialist antenatal care and specialist alcohol treatment services
• offer alcohol harm reduction advice and interventions based on the MECC approach
• identify and act on risks to the person and to others such as child safeguarding and adult safeguarding (see annex 1 on relevant legislation and statutory guidance for more information)
• ask about social circumstances and offer social prescribing for people who need social support and care
• consider the needs of people from inclusion health groups (see section 15.6.10 below for more information)

Some GPs and their teams who have appropriate competences can also offer specialist alcohol treatment interventions, for example, medically assisted withdrawal. There is guidance on specialist alcohol treatment interventions in primary care in section 15.6.9 below.

15.6.2 Working with specialist alcohol treatment services

Referring patients to alcohol treatment services

After screening with a validated tool, healthcare practitioners should offer referral for specialist alcohol assessment and treatment to:

• people identified as probably alcohol dependent
• people drinking at harmful levels who have an alcohol related physical health condition (for example liver disease) or mental health condition (for example severe depression)
• people drinking at harmful levels who have not responded to brief interventions

It’s common for people who drink harmfully or dependently to be anxious or ambivalent about approaching an alcohol treatment service. Reasons for this can include:

• stigma and fear of being judged
• difficulties in trusting services due to a history of trauma
• poor past experiences of alcohol treatment
• lack of understanding about what alcohol treatment involves

Most people need some support to approach and engage with an alcohol treatment service.

Primary care staff can help their patients to engage with alcohol treatment by having a conversation with them about what it will involve and acknowledging their anxieties. They could use an approach based on the principles of motivational interventions. There is guidance on motivational interventions in chapter 5 on psychosocial interventions.

The primary care service should have information provided by the local community alcohol treatment service (or at least their website address) to share with the patient. They should also have information on local mutual aid groups (for example Alcoholics Anonymous or SMART Recovery) and local peer-based recovery services. There is more information on mutual aid and peer-based support in chapter 6 on recovery support services.

Some people who are not ready to access specialist alcohol treatment may be happy to access mutual aid or peer-based recovery groups for support. If the person does not want treatment, it’s helpful to raise the option at a later appointment.

Wherever possible, with the patient’s consent, primary care staff should make a referral by contacting the alcohol treatment service, rather than expecting the person to refer themselves. This allows the alcohol treatment service to contact the person and encourage them to attend and follow up if the person misses the appointment. This approach is associated with increased engagement in alcohol treatment services (Passetti and others 2008). A referral can also provide the alcohol treatment service with information on the person’s health and on any risks. Since people are often ambivalent about alcohol treatment, it is helpful for the referrer to follow up the outcome of a referral or a planned self-referral.

Ongoing collaboration with alcohol treatment services

After a patient is referred to specialist alcohol treatment, there should be ongoing information sharing between services, with the patient’s consent. The services could share information about:

• changes in physical and mental health
• changes in medication
• progress in alcohol treatment
• plans for recovery
• any significant risks to the patient or others

Information sharing agreements should be in place and be transparent to the patient. Wherever possible, with the patient’s consent, GPs and their teams should support access by the community alcohol treatment services to the patient’s electronic health records so that the services can share information effectively and quickly.

The GP will sometimes contribute to the treatment provided by the specialist alcohol treatment service, for example by contributing information to the comprehensive assessment carried out by the alcohol treatment service.

In systems where alcohol treatment services cannot carry out or organise blood tests, GPs could provide or organise liver function or renal function tests as part of the assessment for medically assisted withdrawal carried out by the alcohol treatment service.

Depending on commissioning arrangements, GPs can also continue to prescribe relapse prevention medication after a patient has been discharged from the alcohol treatment service. If the patient has completed their specialist alcohol treatment episode and is ready to move on in their recovery journey, they can continue to benefit from medication with regular monitoring and review, along with supportive contact in primary care. Chapter 10 on pharmacological interventions provides guidance on prescribing relapse prevention medication.

Contributing to multidisciplinary, multi-agency care planning and risk management

Some patients with alcohol dependence have multiple and complex needs, such as:

• co-occurring mental health conditions
• history of trauma
• multiple physical health conditions
• alcohol related brain damage
• domestic abuse (as a victim or a perpetrator)
• child safeguarding risks
• adult safeguarding, including extreme self-neglect

Working effectively with people with multiple and complex needs requires a multidisciplinary, multi-agency approach. The GP and their team will have important contributions to make to multidisciplinary care planning and review, and to ongoing risk management, including safeguarding.

15.6.3 Identifying and managing alcohol related health conditions

Evidence of alcohol-related health conditions

The public health burden of alcohol: evidence review found that there are over 60 health conditions associated with harmful drinking and alcohol dependence. Common alcohol related health conditions include:

• alcohol related liver disease
• cardiovascular disease
• cancers including oral cavity, pharynx, oesophagus, larynx, breast, colorectum
• alcohol related brain damage including Wernicke-Korsakoff syndrome
• mental health conditions including anxiety and depression
• increased risk of self-harm including suicide

There is more information on these alcohol-related health conditions in chapter 19 on co-occurring physical health conditions.

The role of the GP and their team in identifying and managing alcohol related health conditions

GPs and their teams are in a position to identify probable alcohol-related health conditions and to refer the patient for investigations. Depending on the condition and the severity, they can then manage this in primary care or refer to the relevant specialist secondary healthcare service.

When a clinician in specialist alcohol treatment services identifies a probable alcohol related health condition, in most healthcare systems the pathway to access specialist care for other health conditions is through the GP.

People who drink at harmful and dependent levels often have poor health and may also have poor self-care. So, the GP has a vital role in identifying health conditions and helping the patient to manage alcohol related health conditions.

Liver disease

Liver disease is responsible for most (approximately 80%) deaths that are caused wholly by alcohol in the UK.

It is important to screen for liver disease as it often does not show outward symptoms until it is at an advanced stage. Identifying liver disease at an earlier stage will help to reduce severe illness and deaths.

The NICE guideline Cirrhosis in over 16s: assessment and management (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.

In some areas where transient elastography is not currently available, the pathways involve alternative tests for detecting cirrhosis. Screening for alcohol related liver disease should include a measure of liver fibrosis, in addition to liver function blood tests, because normal liver function tests and gamma-glutamyl transferase (GGT) tests do not exclude cirrhosis.

There is more detailed guidance on liver screening tests in appendix K of chapter 19 on co-occurring physical health conditions.

Primary care services should refer people for further investigations or specialist management of liver disease where this is indicated by screening.

Scottish Health Action on Alcohol Problems (SHAAP) guidance Alcohol-related liver disease: guidance for good practice includes recommendations for GPs in Scotland on screening for liver disease. The good practice recommendations in this guidance may be of interest to healthcare staff in other parts of the UK.

Cardiovascular disease

There is a close relationship between drinking alcohol and hypertension (high blood pressure). Risk of high blood pressure starts at lower levels of alcohol use for women (from approximately 2 units per day) than for men. High blood pressure accounts for most alcohol-related hospital admissions for cardiovascular disease. In England, approximately half of all hospital admissions where alcohol is a primary or secondary cause, are for cardiovascular disease. Screening and management of high blood pressure among people with alcohol use disorders could help to reduce their risk and hospital admissions.

See chapter 19 on co-occurring physical health conditions for more information.

Cancers

There is strong evidence for an association between alcohol use and cancer, including cancers of the:

• lip, oral cavity and pharynx
• oesophagus
• larynx
• colon
• rectum
• liver and intrahepatic bile ducts
• breast

The risk is increased in men who also smoke. However, for women who have never smoked, the risk of alcohol-related cancers, mainly breast cancer, increases even within the range of up to around 2 units per day.

See chapter 19 on co-occurring physical health conditions for more information.

Patients who drink harmfully and dependently may miss screening appointments. Primary care services can support patients who drink harmfully or dependently by prompting them to take up regular screening and by considering whether proactive screening (for example for breast cancer) might be appropriate.

Alcohol related brain damage: 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. Many alcohol-dependent people are at risk of developing WKS due to thiamine deficiency. They may also have deficiencies in other vitamins.

People with alcohol dependence should be prescribed thiamine supplementation before 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. In the community, clinicians should prescribe thiamine either orally or parenterally (intramuscular) depending on the patient’s level of risk. If patients are not attending alcohol treatment services, vitamin prophylaxis can be an opportunity for primary care staff to help prevent severe harm.

You can find:

• guidance on prescribing and giving thiamine in chapter 10 on pharmacological interventions
• more detailed guidance on alcohol related brain damage in chapter 20

15.6.4 Non-alcohol related health conditions

People who drink harmfully or dependently often have poor health and may have health conditions unrelated to their alcohol problem. They can neglect their health or be wary of taking up routine screening and vaccinations for various reasons, including difficulty in trusting services due to a history of trauma or bad experiences of services.

Healthcare professionals can also miss non-alcohol related health conditions, assuming symptoms are related to their alcohol use. Primary care staff can help to reduce harm by encouraging their patients with alcohol problems to take up routine screening and vaccinations and by checking they have done this.

15.6.5 Pregnancy and the perinatal period

Alcohol use during pregnancy can affect fetal development throughout pregnancy and cause birth defects and perinatal complications. It can result in fetal alcohol spectrum disorder (FASD), a term that describes the wide range of outcomes that can result from prenatal alcohol exposure, including lifelong physical, cognitive, behavioural and mental health difficulties.

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. However, women who are or could be alcohol dependent should be advised not to stop drinking suddenly because this can increase risk to the fetus and the mother. Instead, they should be rapidly referred to specialist alcohol treatment for an assessment for medically assisted withdrawal. They should also be referred to a specialist or substance misuse midwife if they are not engaged in antenatal care.

Women who drink heavily during pregnancy and the perinatal period will require a multidisciplinary, multi-agency approach to care planning and safeguarding. Primary care services will have an important role to play as part of this approach.

Chapter 24 provides guidance on working with women during pregnancy and the perinatal period.

15.6.6 Providing harm reduction information and advice

Working on the principle of Making every contact count (MECC), healthcare practitioners can help to prevent short term harm by providing harm reduction information and advice on acute risks to people with alcohol dependence, including:

• the risks of stopping drinking suddenly and on reducing their drinking 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
• increased risk of overdose when someone takes drugs and alcohol together
• other harms related to mixing drugs, for example cocaine and alcohol are more toxic when taken together

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

15.6.7 Identifying and responding to risks and safeguarding

Harmful drinking and alcohol dependence is associated with an increased risk of:

• domestic abuse (both as a victim and as a perpetrator)
• sexual violence
• child safeguarding concerns
• adult safeguarding concerns

Being aware of this will help primary care staff to identify any risks to the safety of the patient and people they are in contact with, and to respond to these in line with statutory guidance and organisational procedures. There is information on statutory guidance on safeguarding in annex 1 on legislation and guidance across the UK.

15.6.8 Identifying support needs of family members

A person’s alcohol problems can put considerable strain on their family members. As well as identifying safeguarding risks (both child and adult), primary care staff can support family members by asking about their own support needs and referring them for a carer’s assessment where appropriate. You can find information on legislation and guidance on support for carers in annex 1.

Primary care staff can support family members by providing information on:

• alcohol problems
• how alcohol problems can affect family members
• local or national support services for family members

Local alcohol treatment services often provide support for family members.

15.6.9 Offering specialist alcohol treatment interventions in primary care

Some primary care services are commissioned to provide specialist alcohol treatment interventions for harmful drinkers and people with alcohol dependence. Models vary across local areas and include commissioning a primary care team that has members with specialist alcohol treatment competences, or commissioning partnership arrangements where specialist nurses from the local alcohol treatment service provide regular surgeries in primary care settings.

Primary care settings provide an important opportunity to treat people who drink harmfully or dependently who may not be willing or able to engage with specialist alcohol treatment services. Specialist practitioners can provide treatment tailored to the individual patient and co-ordinate their care. They can also raise awareness about the needs of patients with alcohol dependence among the primary care team.

Primary care practitioners with alcohol specialist competencies should follow the guidance in the chapters in part 1 of these guidelines. This includes guidance on:

• assessment in chapter 4
• pharmacological interventions in chapter 10
• psychosocial interventions in chapter 5

Where formally commissioned treatment models are in place, commissioners and primary care services should ensure patients have access to the full range of options in the local recovery-oriented system of care.

15.6.10 The needs of inclusion health groups

Inclusion health group is a term used to describe people who experience:

• social exclusion
• poor access to healthcare
• multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma)
• stigma and discrimination
• poor health outcomes

The guidance Inclusion health: applying All Our Health provides more information on the needs of inclusion health groups.

People with alcohol dependence are an inclusion health group. The Department of Health and Social Care’s guidance on the preparation of integrated care strategies (England) define them as an inclusion health group. Within the wider group of people with alcohol dependence, there are groups that experience particularly poor access to healthcare and the worst health outcomes. These groups include:

• people experiencing homelessness
• vulnerable migrants
• Gypsy, Roma and Traveller groups
• sex workers
• people in contact with the criminal justice system, especially prisoners
• victims of modern slavery

Primary care services can help to reduce the extreme health inequalities that these groups of people experience by:

• understanding the needs of people with alcohol dependence, particularly those who experience extreme social exclusion and the poorest health outcomes
• removing some of the access barriers to their services
• tailoring interventions to meet the needs of inclusion health groups

The approach of the service and its healthcare staff to people from these groups can help to make the service more inclusive. People with alcohol problems experience stigma in some healthcare services, and research consistently identifies stigma as a major barrier to them seeking help and engaging with treatment (Kilian and others 2021). So, a non-stigmatising, non-judgemental and trauma-informed approach is vital. You can find more information on a trauma-informed approach in the working definition of trauma-informed practice.

Primary care services and staff should all understand entitlements to their services and avoid mistakenly excluding the most vulnerable people. People in England, Scotland and Wales are entitled to register with GPs even if they cannot provide proof of address or identification, and regardless of their immigration status.

There is guidance on this issue for the UK nations in:

• the Primary medical care policy and guidance manual (pages 154 to 155), which provides guidance for England on registration without ID or a permanent address
• Access to healthcare in the Health Literacy Place toolkit, which provides information for Scotland
• Entitlement to NHS services and first time registration, which provides guidance for Northern Ireland

There are many other actions that primary care staff, managers and strategic leaders can take to reduce the health inequalities these groups of people experience and to improve their health outcomes. The resource list below includes guidance on health inclusion. Some of the guidance is for England, but much of the content is relevant for primary care services in other UK nations.

15.7 Strategic leadership

There should be strong strategic leadership and senior level commitment to support primary care and community health services to carry out their role in preventing and managing alcohol related harm in their patients.

An appointed alcohol lead can help to prioritise effective interventions and pathways for the full range of alcohol use disorders.

Organisational structures for primary care and community health systems vary across UK nations. So, there will be different ways that alcohol harm reduction interventions can be delivered in these. In England, primary care networks and integrated care systems provide important opportunities to address alcohol harm at a whole system level and to reduce the health inequalities experienced by people who drink harmfully or dependently.

Commissioners and healthcare system leaders should consider the needs of people with alcohol dependence as an inclusion health group. They should also consider whether they should commission specific services to reduce barriers to access to primary care and to improve health outcomes for people with alcohol dependence, and particularly those experiencing multiple and severe disadvantage. Examples might include:

• targeted outreach services for specific socially excluded local communities
• collaboration with homelessness health teams
• interpreting services

There is a list of resources below that provides information and support for healthcare professionals, including primary care services, on addressing the needs of inclusion health groups.

15.8 Resources

Inclusion Health: applying All Our Health provides information to help front-line health and care staff, managers and strategic leaders to improve access and health outcomes for inclusion health groups.

Inclusion health self-assessment tool for primary care networks helps primary care networks to assess their engagement with inclusion health groups. It takes about 10 minutes to complete. After completion, the tool provides a guide to tailored actions the primary care network can take to address health inequalities into its everyday activities.

The Migrant health guide can support primary care practitioners in caring for patients who have come to the UK from overseas. It includes:

• information on migrants’ entitlement to the NHS
• guidance for assessing new patients
• tailored health information for over 100 countries
• guidance on a range of communicable and non-communicable diseases and health issues

The Doctors of the World Safe Surgeries initiative supports GP practices that commit to taking steps to tackle the barriers faced by excluded groups in accessing primary healthcare. The initiative provides a range of support, including:

• resources to support practice staff
• simple guides to NHS entitlement
• translated posters for patients
• training for clinical and non-clinical staff on migrants’ entitlement to NHS care

For specific resources on homelessness and health see Homelessness: applying All Our Health and chapter 21 on people experiencing homelessness.

Improving Roma health: a guide for health and care professionals supports health and care professionals to improve services by better understanding the health outcomes that some people in the Roma community face.

How to tackle health inequalities in Gypsy, Roma and Traveller communities: a guide for health and care services was developed by Friends, Families and Travellers. The guide includes actions to reduce health inequalities in the Gypsy, Roma and Traveller communities and to increase access to primary care.

The UK modern slavery and exploitation helpline and resource centre provides access to information and support for victims, the public, statutory agencies, and businesses.

15.9 References

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

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

Appendix G: alcohol use disorders: different levels of health risk and appropriate interventions

G1. Hazardous drinking

Definition

The term hazardous drinking (also called increasing risk drinking) describes a pattern of alcohol use that increases the risk of harm to the physical or mental health of the person drinking or to others. Hazardous drinking has not yet reached the level of having caused harm.

Drinking levels and AUDIT scores

Drinking levels and alcohol use disorders identification test (AUDIT) scores are used to indicate hazardous drinking.

Drinking level: 14 to 35 units a week for women and 14 to 50 units a week for men.

AUDIT score: 8 to 15 (see section 3.3.2 for guidance on using AUDIT).

Effective interventions

Identification and brief advice (IBA) (also called screening and brief intervention). This involves assessing alcohol related health risks with the person using a validated tool (such as AUDIT) and offering brief structured advice on cutting down.

Any healthcare worker can deliver IBA after a 40-minute training module. IBA can be offered in:

• primary care
• other community health settings
• hospital emergency departments

G2. Harmful drinking

Definition

Harmful drinking (also called high risk drinking) is a pattern of alcohol use that has harmed the physical or mental health of the person who is drinking or of others.

Drinking levels and AUDIT scores

Drinking levels and AUDIT scores are used to indicate harmful drinking.

Drinking level: above 35 units a week for women and above 50 units a week for men.

AUDIT score: 16 to 19 (see section 3.3.2 for guidance on using AUDIT).

Effective interventions

IBA (as above) or extended brief intervention where needed. You can read more about identifying alcohol use disorders and brief interventions in section 15.5.

A minority of higher risk drinkers may need specialist alcohol treatment if they have:

• not benefited from alcohol brief interventions
• an alcohol related health condition

G3. Alcohol dependence

Definition

This guideline uses the definition of alcohol dependence in International Statistical Classification of Diseases and Related Health Problems 11th revision (ICD-11).

You can find a summary of this definition of alcohol dependence in the glossary.

What this means

Alcohol dependence involves people continuing to drink despite the consequences. They experience psychological dependence, and with more severe dependence, physical withdrawal symptoms when they stop drinking. Drinking in this way is likely to cause psychological, physical, and social harms.

Effective interventions

If screening a person with a validated tool indicates that a person has possible alcohol dependence, you should refer them to specialist alcohol treatment.

In specialist alcohol treatment services, they will receive:

• a specialist alcohol assessment
• psychosocial and pharmacological interventions in the community for most people
• specialist inpatient detoxification or residential rehabilitation for a minority of people with severe dependence or complex needs

16. Alcohol care in acute hospitals

16.1 Main points

Overview

This chapter is about managing alcohol use disorders and complications of alcohol use in acute hospital settings, including:

• identifying and assessing alcohol use disorders
• dealing with acute alcohol withdrawal
• managing medically assisted alcohol withdrawal
• managing complications of alcohol withdrawal, such as seizures, delirium tremens, alcohol related brain damage and deteriorating patients
• treating patients with co-occurring physical and mental health conditions including those in crisis
• discharge to ongoing treatment in mental health and community services

Identifying and assessing alcohol use disorders

Hospitals will need staff with appropriate skills to identify alcohol use disorders, assess risk and provide specialist treatment interventions. In some hospitals, specialist staff are organised as alcohol care teams.

Patients with alcohol use disorder present to acute hospitals with a wide range of primary diagnoses and the presence of alcohol use disorder may not always be obvious to the patient or to clinical staff. There will need to be a system in place for identifying health risk from alcohol and gauging the severity of alcohol use disorder among all inpatients throughout the hospital.

There should be clinicians competent to carry out assessment of immediate alcohol-related risk as well as specialist assessment of severity of dependence, potential impact of dependence on a patient’s treatment and recovery and risk of complications of withdrawal.

Patients should not be refused assessment because they are intoxicated. Clinicians will need to assess the patient’s:

• degree of intoxication
• mental capacity
• immediate risk

A series of assessments of risk and temporary inpatient admission may be necessary.

Dealing with acute alcohol withdrawal

Patients presenting in acute withdrawal or at high risk of withdrawal complications should:

• be admitted
• provided with medically assisted withdrawal
• referred for ongoing treatment of their alcohol dependence on discharge from hospital

Emergency departments should not indiscriminately refer patients to general hospitals for unplanned medically assisted withdrawal, but managed withdrawal should not be refused because it is unplanned. Clinicians should assess the need for admission for medically assisted withdrawal based on:

• assessment of risk of withdrawal complications
• co-existing physical or mental health conditions
• social support available to them
• vulnerability or frailty or risk of self-harm

Children and young people aged 10 to 17 who need medically assisted withdrawal should be admitted to an age-appropriate inpatient setting with access to specialist expertise for physical and psychosocial assessment.

Managing medically assisted alcohol withdrawal

Benzodiazepine reducing regimens are the pharmacological treatment of choice 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.

Medically assisted withdrawal should be supported with psychosocial interventions.

Managing complications of alcohol withdrawal

Delirium tremens is a severe complication of withdrawal and is preventable by appropriate pharmacological withdrawal management. Patients with delirium tremens should be immediately admitted to a suitably equipped and staffed acute hospital unit or suitably equipped specialist medically assisted withdrawal unit.

For patients experiencing delirium tremens, you should use adequate doses of benzodiazepines to manage severe alcohol withdrawal before you consider using neuroleptics (antipsychotic medication). You should not use neuroleptics as monotherapy, other than in exceptional circumstances.

As managing delirium tremens differs in important respects from managing other types of delirium, hospitals should have a specific protocol in place for treating delirium tremens as part of their alcohol treatment guidelines.

Any patients with or at high risk of Wernicke’s encephalopathy should be offered regimens of parenteral B vitamins as treatment or prophylaxis.

Co-occurring physical and mental health conditions

Alcohol dependent patients may be suffering several concurrent problems. Where you identify 2 or more chronic conditions co-occurring, patients are likely to benefit from increased nursing observations and frequent review by the junior medical team.

Patients admitted for withdrawal or complicated withdrawal may exhibit challenging behaviour. It is important to understand the reasons why this might occur. You may need to review the patient’s:

• medication and dosages
• address nicotine replacement
• encourage carers’ and families’ involvement

It is vital to assess a patient’s capacity to consent to treatment, including their decision to self-discharge.

Discharge to ongoing treatment in mental health and community services

You should initiate relapse prevention medication in hospital, following or concurrently with medically assisted withdrawal. You should also make appropriate arrangements for follow-up with repeat prescription of relapse prevention medication in the community.

Wherever possible, patients should complete medically assisted withdrawal once they have started, either in the hospital or in the community.

Patients should be discharged in a planned, safe way with a seamless transition to wrap-around care in the community including ongoing specialist alcohol treatment.

So that care pathways are effective and seamless, local services need to be planned in an integrated way at local strategic planning and commissioning level.

16.2 Context

16.2.1 Alcohol use disorders in acute hospital settings

In this chapter, we use the term alcohol use disorder (AUD) in its broadest sense, meaning any alcohol consumption that causes risk to health, including:

• increasing-risk drinking
• higher-risk drinking
• dependent patterns of drinking

AUD has a disproportionate impact on emergency department attendances and hospital admissions. Research has estimated that 1 in 5 adults admitted to hospital drinks alcohol at harmful levels. As many as 1 in 10 adults admitted to hospital are alcohol dependent (Roberts and others 2019).

All levels of AUD increase the lifetime risk of alcohol-related conditions and risk increases with severity of the AUD. There are over 20 wholly alcohol-attributable or ‘alcohol-specific’ conditions in the International Classification of Diseases 11th Revision (ICD-11). These are conditions that are specifically caused by alcohol, for example alcohol poisoning or alcohol-related liver disease (ARLD). There are over 200 partially alcohol-attributable or ‘alcohol-related conditions’, which include all alcohol-specific conditions. They also include conditions where alcohol use is causally implicated in some but not all cases, for example high blood pressure, various cancers and falls (Jones and Bellis 2014, Rehm and others 2010).

Patients with AUD can present to any team in the hospital, through either the elective route or the emergency route. Patients can arrive at the emergency department with a range of conditions that can lead to alcohol-related emergency admissions. These include but are not limited to:

• mental health conditions
• poisonings (including overdoses)
• misadventure, such as near drowning
• head injury
• laceration
• central nervous system conditions
• cardiovascular conditions
• diabetic conditions
• gastrointestinal conditions
• haematological conditions (Phillips and others 2019)

A sustainable and well-organised hospital-wide system needs to be in place to ensure hospitals are able to identify and care for patients with AUD.

16.2.2 Managing alcohol dependence in acute hospitals

Acute hospitals can effectively manage the care of patients with AUD by making sure that:

• they have a strategy and operational systems in place to identify and manage alcohol use disorders and alcohol-related harms
• they work with commissioners and partner organisations to build effective care pathways throughout the alcohol treatment system
• they have clear alcohol-related policies and procedures, make staff aware of them and provide staff training to apply them
• they have governance structures to monitor hospital data, audit clinical practice and encourage quality improvement
• staff throughout the hospital are trained to identify and manage AUD

Hospitals should also make sure that there are specialist staff with the appropriate competencies, which are set out in the journal article Clinical competencies for the care of hospitalized patients with alcohol use disorders. If staff have these competencies, they will be able to:

• undertake a comprehensive alcohol assessment and monitor the patient’s progress
• provide the specialist advice and care to enable evidence-based, high-quality treatment across the hospital system
• oversee the identification and management of all aspects of medically assisted withdrawal, and its complications, across a range of clinical presentations
• deliver psychosocial interventions (such as motivational interviewing) to engage patients to address their AUD (see chapter 5 on psychosocial interventions)
• safely discharge the patient, or transfer their care to the community
• oversee training to deliver alcohol brief intervention (ABI) in the hospital

16.2.3 Secondary care alcohol specialist teams can improve care

There are various terms used to describe secondary care specialist alcohol services in the UK. For example, alcohol liaison services (ALS) or alcohol care teams (ACTs). There is also variation in how these services are configured.

This guideline uses the term ACTs, meaning multidisciplinary secondary care specialist alcohol services that broadly conform to the evidence based core service descriptor for alcohol care teams. This includes having the appropriate numbers of specialist staff for the size of the hospital site it covers.

Services that provide only in-reach from community alcohol services are a valuable accompaniment to ACTs, but these work best with an optimally-staffed ACT within the hospital. Hospitals with no ACT or specialist alcohol provision as part of mental health liaison services should still try to implement the principles in section 16.2.4 below, within their resources and in line with local need.

16.2.4 Main principles of alcohol care in acute hospitals

The main principles of alcohol care in acute hospitals are as follows. Hospitals should:

• screen all inpatients for AUD (see chapter 3 on identification and brief interventions)
• assess the severity of AUD to inform the appropriate intervention (see chapter 4 on assessment and treatment and recovery planning)
• identify and manage medically assisted withdrawal from alcohol during admission to hospital
• screen and identify important comorbidities such as ARLD (NICE 2016) or mental health problems (NICE 2011) and arrange access to appropriate treatment
• provide meaningful psychoeducation and support for people being admitted to hospital with alcohol-related conditions
• organise access to community alcohol treatment services, mutual aid groups and lived experience organisations (LEROs)
• collaborate with other local commissioning and provider agencies to ensure they have integrated pathways across primary care, secondary care and community care in line with the core service descriptor for alcohol care teams

16.2.5 Identifying alcohol use disorders and alcohol health risk

Patients with AUD often do not recognise the extent of their alcohol use, or that it may be causing them harm, so admission to hospital is an opportunity for intervention for all patients with AUD.

Staff throughout the hospital should be able to:

• routinely assess inpatients for alcohol risk
• provide brief advice for increasing-risk and higher-risk drinkers
• refer people with possible dependence for specialist assessment

Patients who have not approached community alcohol treatment services before may be having their AUD identified for the first time when they present to an acute hospital. Any alcohol use can carry a significant stigma for people across different social groups, cultures and religions. So, hospitals need to work with them sensitively and confidentially to help them recognise risk or ongoing problems, which is vital to help them change behaviour.

Where hospitals have ACTs, the ACT should promote a culture that destigmatises AUD. They should also provide education and training to medical, nursing and other colleagues across providers, including those in services that provide ABI and management of alcohol dependence.

The National Institute for Health and Care Excellence (NICE) public health guideline Alcohol-use disorders: prevention (PH24) recommends the alcohol use disorders identification test (AUDIT) to identify risk levels from alcohol use. There are short forms of AUDIT (which were originally developed as pre-screens) if time is short. Using AUDIT tools is covered in detail in chapter 3 on identification and brief interventions.

When assessing alcohol risk in people under 18, you should assess their ability to consent to alcohol-related interventions and treatment. Some will require parental or carer involvement. You can find more about assessing alcohol risk in people under 18 in section 23.4.4 of chapter 23 on alcohol treatment and support for young people.

16.3 Alcohol assessment

You can find detailed guidance on specialist alcohol assessment in chapter 4 of this guideline. In this section, we focus on aspects of assessment that should occur in an acute hospital setting. You will often have to do an initial assessment with patients in emergency care.

16.3.1 Assessment considerations

If a patient’s screening assessment indicates potential alcohol dependence, or if their initial assessment indicates immediate risk, they should receive further assessment. At all stages, assessment should consider risk from:

• alcohol withdrawal
• alcohol withdrawal seizures (see section 16.6.1 on assessing risk of complications in withdrawal)
• delirium tremens (see section 16.6.3 on identifying risk and managing delirium tremens)
• alcohol related brain damage (see chapter 20 on ARBD)
• mental health crisis (see appendix H on co-occurring mental health crisis)
• co-occurring physical and mental health conditions (see appendix J on co-occurring physical health conditions)

16.3.2 Initial alcohol assessment

Initial alcohol assessment should focus on assessing a patient’s immediate needs and risk from:

• alcohol withdrawal
• complications of withdrawal
• complexities from co-occurring conditions

Based on the initial assessment, clinicians will need to decide whether to admit the patient because of identified risks, or not to admit them. For people who are alcohol dependent but not admitted to hospital, clinicians should tell the patient to avoid a sudden reduction in alcohol intake and refer them to community alcohol treatment. This is because a sudden reduction in alcohol intake can result in severe withdrawal in dependent drinkers.

16.3.3 Further alcohol assessment and monitoring

Patients who are admitted to hospital via emergency care and inpatients whose screening assessment indicates potential alcohol dependence, should have further assessment of:

• the severity of their dependency
• risk of complications of withdrawal
• co-occurring complexities and social circumstances
• potential impact of their dependence on their ongoing physical and pharmacological treatment and recovery

This assessment should be carried out by a competent clinician, such as a member of the ACT (in hospitals where ACT or equivalent specialist input exists). You should use structured self-evaluation questionnaires like the severity of alcohol dependence questionnaire (SADQ) to support clinical judgement in assessment of severity of dependence. There is more information on SADQ and other assessment tools in chapter 4 on assessment.

Patients with alcohol dependence may be admitted for an alcohol-related condition or for a condition not related to alcohol, requiring medically assisted withdrawal while they are treated for that condition.

16.3.4 Assessing intoxicated patients

You should not refuse a patient an assessment because they are intoxicated. You may need to do a series of assessments of risk, for example every 45 minutes.

There are several issues to consider when assessing intoxicated patients.

You should undertake a clinical assessment of intoxication and capacity.

You should not delay psychiatric assessment. However, there is still dynamic risk (risk that changes with time and circumstance) related to intoxication, which means that you should wait until the patient is not clinically intoxicated to undertake a re-assessment to inform onward care. You may need to consider temporary inpatient admission if you feel that the level of risk is too great.

You should give the patient regular physical observations using the Royal College of Physicians’ National early warning score (NEWS 2). You should also use a validated alcohol withdrawal scale for people you suspect are alcohol dependent, such as the:

• Clinical Institute Withdrawal Assessment-Alcohol revised (CIWA-Ar) scale
• Glasgow modified alcohol withdrawal scale

The Glasgow modified alcohol withdrawal scale (GMAWS) is a 5-point tool that allows clinicians to objectively rate withdrawal symptoms (tremor, sweating, hallucination, orientation and agitation), and guide the treatment they offer.

Part of the assessment should involve checking if the patient has an underlying alcohol use disorder, and if they do, how severe it is.

Staff should be aware of the possible respiratory depressant effects of rapid tranquilisation medication and alcohol, as outlined in the alcohol dependence section of the BNF (British National Formulary).

16.3.5 Assessing mental capacity and managing challenging behaviour

Some patients with severe alcohol dependence can present to acute services with cognitive or behavioural disturbance, due to a confusional state, such as alcohol withdrawal delirium tremens or Wernicke’s encephalopathy (WE). There may also be other reasons why patients lack mental capacity either temporarily or permanently. This can make clinical assessment or managing behaviour more difficult.

Healthcare professionals should treat patients with empathy, dignity and respect, including recognising that withdrawal states and craving can involve significant suffering. Where ACTs exist, they are often used to manage behavioural challenges because of their experience with complex capacity assessment, negotiations and boundary-setting.

You can find further guidance on assessment of mental capacity for people with ARBD in chapter 20.

You can find information on national legislation and statutory guidance on assessing mental capacity and ability to consent to treatment in annex 1. This guidance is not intended to supersede local organisational policies on managing patients subject to the Mental Capacity Act 2005, safeguarding of vulnerable adults, or addressing violence and aggression.

You can find further guidance on managing challenging behaviour during treatment in section 16.7 below.

16.4 Acute alcohol withdrawal

Hospitals should admit anyone presenting with acute alcohol withdrawal, or who are assessed to be at high risk of developing alcohol withdrawal seizures or delirium tremens. Patients in acute withdrawal need immediate assessment after admission by a healthcare professional skilled in assessing and managing alcohol withdrawal. The hospital should also provide treatment for medically assisted withdrawal as outlined in section 16.5 below.

Patients who are treated for acute withdrawal should be offered a referral to specialist services for ongoing treatment of alcohol dependence after they are discharged from hospital.

16.5 Medically assisted alcohol withdrawal

16.5.1 Assessment of risk of alcohol withdrawal

Alcohol withdrawal symptoms generally start within 6 to 24 hours after stopping drinking and can last around a week. Patients with a history of alcohol dependence who present to services after weeks of abstinence will not suffer withdrawal symptoms. You should bear in mind that patients self-reporting their drinking may not be accurate, so it will be important to use clinical judgement. They should be asked about withdrawal symptoms after stopping drinking, which include (but are not limited to):

• sweating
• shaking
• palpitations
• headache
• nausea or vomiting
• anxiety or agitation
• insomnia or disturbed sleep

Patients might also have withdrawal complications, such as seizures and delirium tremens.

Hospital staff should look for signs of WE and assess patients where necessary.

The NICE clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) recommends the CIWA-Ar scale to assess withdrawal risks for patients in general hospital settings. The alcohol guidelines development group also recommend using the alcohol withdrawal scale (AWS) or the GMAWS. The GMAWS is designed specifically for inpatient use.

16.5.2 Assessing the need for medically assisted withdrawal admission

Ideally, patients should undergo planned medically assisted withdrawal provided by specialist staff in dedicated addictions services, for example a community alcohol treatment service or an inpatient detoxification unit. However, patients can present with multiple competing healthcare needs that will influence where medically assisted withdrawal should take place.

Emergency departments should not indiscriminately refer patients to general hospitals for unplanned medically assisted withdrawal, because unplanned hospital medically assisted withdrawal is associated with poorer outcomes than planned medically assisted withdrawal in a dedicated unit (Quelch and others 2018). However, alcohol dependent patients who need to be admitted to hospital should not be denied medically assisted withdrawal just because it is unplanned.

In the absence of another medical rationale for admission, NICE clinical guideline Alcohol-use disorders: diagnosis and management of physical complications (CG100) outlines the factors you need to consider before admitting a person for medically assisted withdrawal.

Examples of relevant factors to consider, based on NICE CG100, include the following.

1. You should offer admission to anyone presenting with or at risk of complicated withdrawal including seizures, delirium tremens or those with signs of WE (see assessment of risk of WE in section 16.6.1 below).

2. You should consider a lower threshold for admitting people:

• who are lacking in social support, for example people experiencing homelessness
• with significant physical or mental health comorbidities, cognitive impairment or learning disability
• who are frail or vulnerable in other ways

3. You should admit children and young people aged 10 to 17 who need assisted withdrawal to an age-appropriate setting with access to specialist expertise for physical and psychosocial assessment, as well as medically assisted withdrawal. You should base assisted withdrawal for children and young people aged 10 to 17 on the recommendations for adults. Consult the summary of product characteristics and adjust drug regimens to take account of age, height and body mass, and the stage of development of the child or young person.

NICE guideline Self harm: assessment, management and preventing recurrence (NG225) recommends that all healthcare professionals and social care practitioners “consider admission to a general hospital after an episode of self-harm if:

• there are concerns about the safety of the person (for example, the person is at risk of violence, abuse or exploitation) and psychiatric admission is not indicated
• safeguarding planning needs to be completed and psychiatric admission is not indicated
• the person is unable to engage in a psychosocial assessment (for example, because they are too distressed or intoxicated)”

People with potential or diagnosed alcohol dependence who are not admitted to hospital should be advised not to stop drinking suddenly as this can lead to dangerous acute withdrawal.

16.5.3 Managing withdrawal in the general hospital setting

Managing alcohol withdrawal requires specialist skills and you should read guidance on medically assisted withdrawal in chapter 10 on pharmacological interventions.

ACTs can play an important role in supporting medically assisted withdrawal in hospital, and where they exist, they should be involved as early as possible. It’s very important to discuss patients’ drinking goals, such as low-risk drinking or abstinence, and securing appropriate support after discharge from hospital.

NICE CG100 gives guidance on symptom-triggered medically assisted withdrawal in inpatient settings, which has been associated with lower benzodiazepine requirements and a shorter length of stay. A symptom-triggered approach requires sufficient numbers of appropriately trained staff. In some settings with fewer appropriately trained staff, a fixed dose regimen may be safer, particularly for patients at high risk of severe withdrawal and complexities.

Clinicians responsible for the clinical governance of medically assisted withdrawal provision (such as ACTs), or those responsible for acute clinical team leadership, should assess the nursing staffing levels and the capability and training of nursing and allied staff. This is to decide whether symptom-triggered medically assisted withdrawal, fixed dose medically assisted withdrawal or a hybrid approach would be appropriate and safe to use for people at high risk of severe withdrawal.

In hospitals where ACTs exist, the ACTs should provide regular training across acute wards to familiarise staff with:

• structured withdrawal assessment tools
• the possible consequences of under-treatment
• the need for adequate monitoring of respiratory rate and oxygen saturations

The ACTs can also provide mobility assistance where high doses of benzodiazepines have affected patients’ balance.

16.5.4 Using carbamazepine as an alternative to a benzodiazepine to manage withdrawal

NICE CG100 recommends carbamazepine as 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 using carbamazepine for patients with a:

• history of adverse reaction or allergy to benzodiazepine drugs (although uncommon, this can be fatal)
• 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)

Carbamazepine can also be used in inpatient settings to manage concurrent withdrawal from alcohol and benzodiazepine drugs. You can find more information on concurrent withdrawal from alcohol and benzodiazepines in section 10.6.1 of chapter 10 on pharmacological interventions.

Carbamazepine is not licenced for the management of withdrawal. See section 10.2.2 in chapter 10 on pharmacological interventions on unlicensed or off-label prescribing. Also, you should note the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety update about using antiepileptic drugs in pregnancy and section 10.6.4 on medically assisted withdrawal in pregnancy in chapter 10 on pharmacological interventions.

16.5.5 Managing alcohol withdrawal in people with alcohol-related liver disease

You should read guidance on medically assisted withdrawal for people with ARLD in section 10.6.6 in chapter 10 on pharmacological interventions.

16.5.6 Psychosocial interventions to support medically assisted withdrawal and ongoing abstinence

During medically assisted withdrawal, all staff should actively listen and support the patient and give them information on how to manage withdrawal symptoms and where to access help and support. Patients need to understand that they have had a detox if they leave hospital after completing medically assisted withdrawal, because they may not realise this.

Trained staff should help the patient explore any ambivalence they have towards treatment of their alcohol dependence and encourage them to access ongoing support to maintain abstinence. The staff can also discuss with the patient:

• how important they think it is to change their drinking behaviour after they leave hospital
• how confident they feel about being able to change their behaviour

If the patient understands the risks and harms from alcohol, especially using their current health problems as a focus, it can help to:

• build motivation for change
• identify goals
• agree initial plans that can be started when they are discharged from hospital

You can find out more about exploring readiness to change and encouraging engagement with further support in chapter 4 on assessment and treatment and recovery planning in section 4.18.7 on motivation, readiness and belief in the ability to change.

16.6 Withdrawal complications

16.6.1 Assessing risk of complicated withdrawal

Complications of alcohol withdrawal include seizures and delirium tremens. You should assess patients for risk of complicated withdrawal because this will affect decisions about admitting them to hospital, and it will inform treatment for people admitted for other reasons.

You should offer admission to people who:

• have complicated withdrawal
• are at risk of developing complicated withdrawal (NICE 2017)
• have signs of WE

Refer to section 10.4 in chapter 10 on pharmacological interventions to prevent and manage specific complications of withdrawal.

16.6.2 Managing seizures

The mainstay for managing alcohol withdrawal seizures is with benzodiazepines. NICE CG100 advocates administering a short-acting benzodiazepine, such as lorazepam, while acknowledging that this is not a licensed indication for the drug. The dose suggested in the BNF for treating seizures (although alcohol is not specified as a cause) is 4 milligrams (mg) intravenously via a large vein, followed by another dose of 4mg after 10 minutes, if necessary.

NICE CG100 also states that the anti-epileptic drug phenytoin should not be used to treat alcohol withdrawal seizures. Benzodiazepines are generally favoured (Amato 2010) over anti-epileptic drugs, and this is also the case with newer antiepileptic drugs.

Following an alcohol withdrawal seizure, you should monitor patients 1 to 2 hourly for 6 to 14 hours. They should be closely monitored for delirium and the need for intravenous (IV) fluids as electrolyte abnormalities may contribute (ASAM 2020). NICE CG100 recommends that if a patient has an alcohol withdrawal seizure during medically assisted withdrawal, their withdrawal treatment regimen should be reviewed. This is because seizures occurring during medically assisted withdrawal reflect suboptimal dosing.

16.6.3 Identifying risk and managing delirium tremens

This section provides guidance on managing delirium tremens in the acute general hospital rather than a specialist detoxification setting with the competence to manage delirium tremens.

Symptoms and risk factors of delirium tremens

Delirium tremens is a preventable complication that research has found to occur in around 3% to 5% of people admitted to hospital for alcohol withdrawal (Schuckit 2014). It is an agitated delirium that causes:

• disorientation and confusion
• hallucinations which are often visual
• persecutory beliefs
• restlessness

It develops around 72 hours after the last drink. Risk factors for delirium tremens include:

• previous seizures or delirium
• low potassium
• low magnesium
• thiamine deficiency
• systemic disease

As managing delirium tremens differs in important respects from managing other types of delirium, hospitals should have a specific protocol in place for treating delirium tremens as part of their alcohol treatment guidelines.

Guidelines for treating delirium tremens

NICE CG100 covers recommendations on managing and treating delirium tremens. Since the publication of NICE CG100, guidelines have been published in the US and Australia. These are the:

• American Society of Addiction Medicine (ASAM) alcohol withdrawal management guideline
• Australian guidelines for the treatment of alcohol problems

While these more recent guidelines largely reflect expert consensus rather than new evidence, they provide further detail about managing delirium tremens, which clinicians may find helpful.

Managing delirium tremens

The sections below outline the recommendations of the alcohol guidelines development group drawing on the UK, US and Australian guidelines.

A patient with delirium tremens should:

• be treated in a suitability equipped and staffed acute hospital unit or suitably equipped specialist medically assisted withdrawal unit
• receive one to one nursing care
• receive frequent measurement of their vital signs, respiratory rate and saturations

The patient with delirium tremens should receive a thorough examination and a set of suitable investigations to detect alternative or contributing causes of delirium tremens, which you should treat if present. Other causes can include:

• subdural haematoma
• Wernicke’s encephalopathy (see section below on the importance of vitamin treatment for potential WE in delirium tremens)
• hepatic encephalopathy
• hypoxia
• sepsis
• metabolic disturbance
• intoxication or withdrawal from other drugs

Patients will benefit from a multidisciplinary approach to the management of delirium tremens, with input from the:

• acute medical team
• alcohol care team
• liaison psychiatry team and intensive care unit outreach team, if necessary

Delirium tremens is a disturbance of mind or brain, which can affect a person’s ability to understand, retain, use and weigh information relevant to treatment decisions, and can affect their egal capacity to make decisions. This is defined in the Mental Capacity Act 2005. The treating team should undertake a formal assessment of the patient’s mental capacity to make decisions about their medical treatment, including if they refuse treatment and want to leave hospital. If the patient lacks capacity to make such decisions, the team will need to put in place appropriate safeguards. You should also involve a person’s family and carers in any decision-making, where appropriate. You can find more information in the NICE guideline Decision-making and mental capacity (NG108).

Pharmacological intervention for delirium tremens

The goal of pharmacological treatment of delirium tremens is to produce a rousable but sedated state in the patient, similar to a light sleep.

Pharmacological management of delirium tremens is different from other forms of behavioural disturbance. This is because benzodiazepines should be a first line treatment. You should use adequate doses of benzodiazepines to manage severe alcohol withdrawal before you consider using neuroleptics (antipsychotic medication) (see section on neuroleptics below). You should not use neuroleptics as monotherapy (treating the condition with a single drug), other than in exceptional circumstances.

You should review the patient’s withdrawal regimen if they develop delirium tremens (NICE 2017). This is because cases of delirium tremens may arise through untreated, or under-treated withdrawal. To prevent delirium tremens from developing, it is important to:

• identify patients early who are at risk of severe withdrawal
• monitor patients frequently with a validated withdrawal tool (you can find more about withdrawal tools in chapter 10 pharmacological interventions)
• prescribe patients an appropriate amount of a suitable benzodiazepine, based on their assessed score

Benzodiazepines

Benzodiazepines are the mainstay of treatment for delirium tremens (Mayo-Smith and others 2004).

Benzodiazepines used as a first-line treatment may include:

• oral or intramuscular lorazepam (NICE recommends oral lorazepam as first-line)
• oral diazepam, as recommended in the Australian guidelines
• oral chlordiazepoxide, which the alcohol guidelines development group agree is appropriate, based on clinical experience

Oral chlordiazepoxide is licenced for alcohol withdrawal. Oral diazepam is not licensed for alcohol withdrawal but is frequently used for this purpose as is listed in the BNF treatment summary on medically assisted withdrawal. Intramuscular diazepam is licensed for alcohol withdrawal but is not recommended because of erratic and variable absorption. Oral lorazepam does not have a license for the treatment of alcohol withdrawal but is frequently used for this purpose (see section 10.2.2 on off-label and unlicensed prescribing in chapter 10 on pharmacological interventions).

You should tailor the benzodiazepine dose to the person based on a specific hospital protocol for delirium tremens and specialist advice from, for example, the hospital’s alcohol care team, liaison psychiatry team or other clinicians experienced in the treatment of alcohol withdrawal. While NICE CG100 does not specify a dose for oral or parenteral lorazepam for the treatment of delirium tremens, it is the consensus of the alcohol guideline development group that high doses of whichever benzodiazepine is used may be required to treat delirium tremens adequately. High dose benzodiazepines carry a risk of respiratory depression and so it is essential to frequently monitor the patient, including saturations and respiratory rate.

When giving benzodiazepines, use either a symptom-triggered regimen (see section 10.3.4 on choice of regimen in chapter 10 on pharmacological interventions) or loading (as recommended by US and Australian guidance. Loading is a regimen where specific doses of benzodiazepine are given frequently until light sedation is achieved and then no more given until the following day. As an example of a benzodiazepine loading regimen, the Australian guidelines recommend loading with 20mg diazepam orally given hourly up to 80mg in total over 24 hours (in some cases this may need to be exceeded). Both symptom-triggered and loading regimens aim to achieve rapid control of symptoms and neither of them is a conventional fixed-dose regimen where benzodiazepines are administered 4 times a day.

The choice of regimen will depend on available expertise and resources. Both symptom-triggered and loading approaches require all team members to be trained to ensure that it can be applied consistently and safely (see section 10.3.4 on choice of regimen in chapter 10 on pharmacological interventions).

If a patient is unable to take oral benzodiazepines, you should use parenteral benzodiazepines (NICE 2017). You should not give IV benzodiazepines outside emergency department resuscitation or high dependency settings. This is because of the risk of respiratory depression and the required skills profile of staff. In other settings, you should use an intramuscular route of administration. If you give repeated boluses of IV benzodiazepines to patients, you should be aware of the potential complication of hyponatraemia (low levels of sodium in the blood) and acidosis (high levels of acid in the body).

Neuroleptics

NICE CG100 recommends haloperidol for treatment of delirium tremens as an option where oral lorazepam is declined or symptoms persist. However, the consensus of the alcohol clinical guidelines development group (and clinical guidelines from other countries) is that neuroleptics such as haloperidol should:

• not be given as first line treatment or monotherapy for delirium tremens
• only be used as an adjunct to benzodiazepine treatment where adequate doses have failed to manage the behavioural disturbance
• not replace adequate doses of benzodiazepines

Vitamin treatment for potential Wernicke’s encephalopathy in delirium tremens

Any change in mental status including delirium can be a sign of Wernicke’s encephalopathy (WE) if accompanied by one of the other criteria, which are:

• a history of poor nutrition
• ataxia (disorders that affect co-ordination, balance and speech)
• any eye movement abnormality (Caine and others 1997)

Clinicians should have a high index of suspicion that WE can be a contributing factor to the delirium and treat as necessary. You can find information on administering Pabrinex (B vitamins including thiamine) to treat WE in section 5.4 below.

It is important to treat potential WE. You should not exclude using Pabrinex because of rare instances of allergic reactions to it. IV is preferable as the intramuscular (IM) route is painful.

16.6.4 Alcohol related brain damage

Screening for alcohol related brain damage

You should read guidance on screening for ARBD in chapter 20.

ARBD often goes unrecognised in patients in general hospitals. ACTs are well placed to detect ARBD cases because they should have the skills to assess cognition where there are any concerns, using a tool such as the Addenbrooke’s cognitive examination III (ACE-III) test. They can also recognise the subtleties of confabulation, for example patients recounting the reason they were admitted last time, rather than this time.

Treatment for alcohol related brain damage (Wernicke’s encephalopathy)

ACTs or liaison psychiatry teams should specify treatment regimens of parenteral B vitamins for patients with ARBD and support medical teams to assess patients’ capacity (see section 20.9 on assessment of capacity in chapter 20 on ARBD).

In a general hospital, some investigations and interventions are easier to deliver, such as:

• brain imaging
• occupational therapy (OT) functional assessment
• full treatment dose of intravenous B vitamins

Onward care after being discharged from hospital and responsibility for onward care and assessment should be agreed with the appropriate teams as part of standard pathways for memory impairment. Patients with ARBD should not be excluded from these.

You should discharge patients with ARBD to an alcohol-free setting where they can access cognitive rehabilitation. Appropriate discharge planning will involve close collaboration between a number of professionals and other people, including:

• the admitting team
• occupational therapy
• the ACT or liaison psychiatry team
• hospital and local authority social work teams
• family members or significant others

Patients at risk of Wernicke’s encephalopathy

You can give patients at risk of WE 2 pairs of Pabrinex ampoules intravenously daily for 3 to 5 days in hospital if they:

• are significantly underweight and have limited tissue for intramuscular (IM) injection
• have a clotting problem
• prefer IV rather than IM Pabrinex

Incipient Wernicke’s encephalopathy

WE is characterised in most cases by confusion and in some cases with classical symptoms of ataxia (disorders that affect co-ordination, balance and speech), memory disturbance and ophthalmoplegia (eye muscle paralysis).

You should diagnose WE in patients with any 2 of the following 4 criteria, which are:

• evidence of dietary deficiencies, for example nutritional peripheral neuropathy (you can ask the patient if they have pins and needles in their hands or feet)
• confusion or delirium
• cerebellar signs
• any eye-movement abnormality, such as nystagmus or ocular nerve palsy (Caine and others 1997)

Patients with WE can also present with unexplained hypothermia and hypotension (Cook and others 1998).

If you diagnose WE, the patient will need the following treatment and monitoring:

1. Immediate treatment with 2 pairs of Pabrinex ampoules (or an equivalent of 500mg thiamine) 3 times daily by IV infusion for 5 days.
2. If the patient is still confused, you should check their magnesium level and correct it if it’s low. This is because magnesium is required for thiamine replacement to be effective.
3. If the patient is still symptomatic after 5 days of treatment, they should receive a further 1 pair once daily for a further 3 to 5 days for as long as clinical improvement continues and another cause for their confusion should be explored. See the BNF page on vitamin B substances with ascorbic acid.
4. You should take appropriate steps to manage the small risk of anaphylaxis, like having a setting with facilities for treating anaphylaxis and appropriately trained staff available during the infusion. See also the MHRA drug safety update about allergic reactions to Pabrinex.
5. If the patient has already received IM Pabrinex and subsequently develops incipient WE, they should still receive the full dose as set out above.
6. Pabrinex should be followed by a course of oral thiamine.
7. You should consider checking or re-checking magnesium where patients do not improve with Pabrinex. Magnesium is a co-factor for converting thiamine to the active form in the liver. Hypomagnesaemia is a documented cause of WE that does not respond to treatment.

16.6.5 Managing deteriorating alcohol dependent patients

As outlined above, alcohol dependent patients may be suffering several concurrent problems, including dehydration, malnutrition, electrolyte derangement, sepsis and traumatic injury.

Alcohol dependence is associated with needing intensive care for lower respiratory infections and a higher risk of adult respiratory distress syndrome following trauma (Gupta and others 2019, Kózka and others 2020, Tignanelli and others 2019). It is beyond the scope of this guideline to consider treatment for alcohol dependence in intensive care settings, where management is based on physiological principles. However, healthcare professionals who care for patients with alcohol dependence in acute hospital settings should be aware that patients can quickly deteriorate.

Where you identify multimorbidity (2 or more chronic conditions co-occurring), patients are likely to benefit from increased nursing observations and frequent review by the junior medical team. We recommend that there is clear communication between people directly managing the patient, such as emergency department staff, ACT and medical and nursing staff. There should also be early contact between these staff and intensive care outreach or on-call intensive care unit doctors to inform them about the patient and seek advice.

16.7 Managing challenging behaviour

Staff in acute hospitals often have to deal with challenging behaviour from patients admitted for withdrawal or complicated withdrawal. The guidance in this section is based on clinical consensus of the guideline development group.

16.7.1 Reasons for challenging behaviour

Challenging behaviour from patients may be a response to their unmet needs, including compulsion to drink, and may need you to:

• review the patient’s medication and dosages (see section 10.3 on medically assisted withdrawal in chapter 10 on pharmacological interventions)
• understand their priorities
• review the arrangements for them receiving visitors
• address nicotine replacement
• encourage carers’ and families’ involvement to help mitigate against difficult behaviours

Assessing a patient’s capacity to consent to treatment, including their decision to self-discharge, is a vital part of managing behavioural challenges. This capacity can fluctuate throughout medically assisted withdrawal, particularly if they are in severe withdrawal, so clinicians need to be aware that that behavioural disturbance can emerge from a confusional state.

16.7.2 Behavioural contracts

If the patient has capacity to make decisions about their treatment but has been behaving in a way that makes continued treatment too dangerous (for example, drinking alcohol while being prescribed benzodiazepines for medically assisted withdrawal), you can consider having a behavioural contract with clear expectations and consequences. You should not use a behavioural contract where the patient is incapacitated.

Making decisions about behavioural contracts requires a careful balance of risks and benefits to the patient. Ideally, you should follow a multidisciplinary approach, fully involving the patient.

16.8 Co-occurring physical and mental health conditions

AUD is often accompanied by mental health and physical health conditions that may influence the choice of treatment for alcohol dependence and the treatment for physical health conditions in acute hospitals.

When assessing patients, clinicians should understand that it’s possible that the patient might have a co-occurring condition, including:

• a co-occurring mental health crisis (you can find out more about co-occurring mental health crisis in appendix H)
• alcohol-related liver disease (you can find more about ARBD in the liver disease section of appendix J)
• alcohol-related hepatitis (you can find more about this in the hepatitis section of appendix J)
• refeeding syndrome if they are malnourished (you can find more about this in the nutrition section of appendix J)

16.9 Relapse prevention treatment

Relapse prevention treatment is covered in detail in chapter 10 on pharmacological interventions.

NICE CG115 recommends initiating relapse prevention medication in hospital following or concurrently with medically assisted withdrawal. It also recommends making appropriate arrangements for psychosocial support and follow-up with repeat prescription.

You should make sure there are clear follow-up procedures, so that the patient is prescribed relapse prevention medications for the appropriate timescale. You should continue to monitor the relapse prevention medication, and ask questions about:

• concordance (interaction and co-operation between patients and healthcare professionals, which addresses patients’ needs)
• concordance strategies
• access to a range of psychosocial interventions, if people want it (you can find more comprehensive guidance on psychosocial interventions in chapter 5)

16.10 Discharging patients to ongoing treatment and care

16.10.1 Safely discharging patients from hospital

Discharging a patient safely from hospital to care in the community that meets all their needs (wrap-around care) requires the right services to be available to them. And this means that these services need to be planned in an integrated way at local strategic planning and commissioning level.

Research has shown that alcohol-related readmissions to hospital happen when the patient:

• was discharged against medical advice
• had incomplete withdrawal treatment programmes and clinical complexity (Yedlapati and Stewart 2018, Blackwood and others 2020)
• was discharged to live on the streets (Phillips and others 2022)

Wherever possible, patients should complete medically assisted withdrawal once they have started, either in the hospital or in the community, with a seamless transition to wrap-around care. Decisions about when to discharge people and what care package they need should be based entirely on multidisciplinary assessment and the plan of action that’s most likely to be successful for the patient. You can find guidance on comprehensive, multidisciplinary assessment in chapter 4 on assessment and treatment and recovery planning.

It is essential that discharge planning considers the risks of complicated withdrawal and the patient’s physical or mental health possibly deteriorating in the community.

Completing the course of treatment under the care of the ACT (if one is available) can help:

• reduce risks associated with withdrawal
• enhance opportunities for the person to engage in further treatment and services (Chambers and others 2020)
• optimise the use of parenteral vitamins

Clinicians managing the medically assisted withdrawal should support continued abstinence from alcohol by:

• encouraging the sharing of goals and plans with carers and relatives
• providing information on mutual aid, peer-support services, care services and helplines
• making direct referral for engagement with community alcohol treatment services and other relevant support services, where agreed with the patient

16.10.2 Continuing medically assisted withdrawal outside of acute hospitals

Where people have good support networks and no significant physical or mental health complications, it may be beneficial for them to continue and complete medically assisted withdrawal outside the hospital in the community. People with more complex needs might require an alternative setting, such as specialist inpatient detoxification.

Assessing the patient’s suitability to complete medically assisted withdrawal in an alternative setting should only be done by a competent alcohol specialist, after a detailed assessment of the patient’s needs. The assessing specialist must ensure the receiving service can provide appropriate withdrawal management, support and maintain parenteral nutrition according to the patient’s needs. Transferring the patient should only be done in line with a mutually agreed care pathway with a clear discharge plan agreed between the hospital, the receiving service and the patient.

16.10.3 Transfer to specialist mental health services

Patients may require transfer to specialist mental health services. The mental health team should assess all patients who need this transfer. The mental health team must identify and agree the clinical needs of the patient before transfer, in collaboration with the alcohol specialist and the patient. They should write a plan with arrangements for joint working, specifying which service is ‘lead service’ and what strategies they will use if the patient disengages from either service.

16.10.4 Referral to alcohol treatment services

The ACT or the managing multidisciplinary team (MDT) should be responsible for referring patients to the alcohol treatment provider and other providers of their ongoing care package. This means that the ACT or MDT will need to understand providers’ capacity, protocols, and inclusion and exclusion criteria. They will also need to share accurate information about the patient and their treatment with the service providers.

When the patient is discharged from hospital, there should be a clear handover of responsibility for the care package to the provider, for example to a community alcohol treatment service keyworker and prescriber.

It is not usually appropriate to discharge patients who need ongoing treatment for their alcohol dependence and expect them to self-refer to a community alcohol treatment service. The clinical consensus is that this can introduce an unnecessary barrier to the patient’s continued care, and it’s also inefficient, because of the need to duplicate assessments.

Where ACTs exist, they should take responsibility for liaison with community alcohol treatment services and handing over important information, including the patient’s risk to self and others. The ACTs should also make plans, as necessary, for:

• continuing medically assisted withdrawal in the community
• arranging aftercare following unplanned medically assisted withdrawal
• continuing relapse prevention treatment

Whether ACTs are in place or not, in-reach provision from community alcohol treatment services is valuable. Where this provision exists, the in-reach worker should meet with the patient before discharge to provide information and orientation about their ongoing care.

16.11 People experiencing severe and multiple disadvantage

A study based on 2 London hospitals found that 9% of patients with AUD accounted for 29% of emergency department visits in this group (HIN 2017). People experiencing severe and multiple disadvantage including AUD often have multiple admissions or emergency department attendances related to alcohol during a relatively short period (Drummond 2016, Blackwood and others 2017, Blackwood and others 2020, Blackwood and others 2021).

Patients with AUD with high individual use of secondary care services are more likely to:

• be men
• be aged in their 50s
• live in income deprived areas
• have mental and physical health comorbidities (Blackwood and others 2017)

While they are likely to attend the emergency department with an alcohol-related condition (Blackwood and others 2017), they may not think that alcohol dependence is their main problem (Parkman and others 2017) and say that medical attention for physical injuries and pain is their main reason for attendance. These people require additional attention because a larger proportion of this group is diagnosed with alcohol-related cirrhosis in the subsequent 5 years than those who do not attend frequently (Blackwood thesis 2019).

Community-based services for people experiencing severe and multiple disadvantage are covered in detail in chapter 9 on assertive outreach and a multi-agency team around the person.

16.12 References

Amato L, Minozzi S, Vecchi S and Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database of Systematic Reviews 2010

American Society of Addiction Medicine. Alcohol withdrawal management guideline. ASAM 2020

Blackwood R, Lynskey M and Drummond C. Use of routinely collected Hospital Episode Statistics to describe alcohol-related frequent attenders to hospitals. Lancet 2017: volume 389, issue S27

Blackwood, R. The identification of nature and natural history of alcohol related frequent attenders to hospital. Doctoral thesis. King’s College London, 2019

Blackwood R, Wolstenholme A, Kimergård A, Fincham-Campbell S, Khadjesari Z, Coulton S, Byford S, Deluca P, Jennings S, Currell E, Dunne J, O’Toole J, Winnington J, Finch E and Drummond C. Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial. BMC public health 2020: volume 20, article number 332

Blackwood R, Lynskey M and Drummond, C. Prevalence and patterns of hospital use for people with frequent alcohol-related hospital admissions, compared to non-alcohol and non-frequent admissions: a cohort study using routine administrative hospital data. Addiction 2021: volume 116, issue 7, pages 1700-1708

Caine D, Halliday G, Kril J and Harper C. Operational criteria for the classification of chronic alcoholics: identification of Wernicke’s encephalopathy. Journal of Neurology, Neurosurgery and Psychiatry 1997: volume 62, issue 1, pages 51-60

Chambers S, Baldwin D and Sinclair J. Course and outcome of patients with alcohol use disorders following an alcohol intervention during hospital attendance: mixed method study. British Journal of Psychiatry Open 2020: volume 7, issue 1, article E6

Cook C, Hallwood P and Thomson A. B vitamin deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol and Alcoholism 1998: volume 33, issue 4, pages 317-336

Ferrari A, Norman R, Freedman G, Baxter A, Pirkis J, Harris M, Page A, Carnahan E, Degenhardt L, Vos T and Whiteford H. The burden attributable to mental and substance use disorders as risk factors for suicide: findings from the Global Burden of Disease Study 2010 (PDF, 1.4MB). PLoS ONE 2014: volume 9, issue 4, article e91936

Gupta N, Lindenauer P, Yu PC, Imrey P, Haessler S, Deshpande A, Higgins T, Rothberg M. Association Between Alcohol Use Disorders and Outcomes of Patients Hospitalized With Community-Acquired Pneumonia. JAMA network open 2019: volume 2, issue 6, e195172

Hawton K, Casañas I Comabella C, Haw C and Saunders K. Risk factors for suicide in individuals with depression: a systematic review. Journal of Affective Disorders 2013: volume 147, issues 1-3, pages 17-28

Health Innovation Network: South London. Tackling alcohol misuse in NHS hospitals: a resource pack (PDF, 4.5MB). HIN 2017

Jones L and Bellis M. Updating England-specific alcohol-attributable fractions (PDF, 3.5MB). Liverpool John Moores University, 2014

Kózka M, Sega A, Wojnar-Gruszka K, Tarnawska A, Gniadek A. Risk factors of pneumonia associated with mechanical ventilation. International Journal of Environmental Research and Public Health 2020: volume 17, issue 2, page 656

Mayo-Smith M, Beecher L, Fischer T and others. Management of alcohol withdrawal delirium: an evidence-based practice guideline. Archives of Internal Medicine 2004: volume 164, issue 13, pages 1405-1412

Mehanna H, Moledina J and Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. British Medical Journal 2008: volume 336, article 1495

National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Annual report 2019: England, Northern Ireland, Scotland and Wales. University of Manchester, 2019

National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and management of physical complications (CG100). NICE 2017

National Institute for Health and Care Excellence. Cirrhosis in over 16s: assessment and management (NG50). NICE 2016

National Institute for Health and Care Excellence. Common mental health problems: identification and pathways to care (CG123). NICE 2011

Parkman, T, Neale, J, Day, E, and Drummond, C. Qualitative exploration of why people repeatedly attend emergency departments for alcohol-related reasons. BMC health services research 2017: volume 17, issue 1, article 140

Phillips T, Coulton S and Drummond C. Burden of alcohol disorders on emergency department attendances and hospital admissions in England. Alcohol and Alcoholism 2019: volume 54, issue 5, pages 516-524

Phillips T, Coleman R and Coulton S. Predictors of 30-day readmissions among adults treated for alcohol withdrawal in acute hospitals in England. Alcoholism: clinical and experimental research 2022: volume 46, issue S1

Quelch D, Pucci M, Coleman J and Bradberry S. Hospital management of alcohol withdrawal: elective versus unplanned admission and detoxification. Alcohol Treatment quarterly 2018: volume 37, issue 3, pages 278-284

Rehm J, Baliunas D, Borges GL, Graham K, Irving H, Kehoe T, Parry CD, Patra J, Popova S, Poznyak V, Roerecke M, Room R, Samokhvalov AV, Taylor B. The relation between different dimensions of alcohol consumption and burden of disease: an overview. Addiction 2010: volume 105, issue 5, pages 817-843

Roberts E, Morse R, Epstein S, Hotopf M, Leon D and Drummond C. The prevalence of wholly attributable alcohol conditions in the United Kingdom hospital system: a systematic review, meta-analysis and meta-regression. Addiction 2019: volume 114, issue 10, pages 1726-1737

Robins J, Morley K, Hayes R, Ross K, Pritchard M, Curtis V and Kalk N. Alcohol dependence and heavy episodic drinking are associated with different levels of risk of death or repeat emergency service attendance after a suicide attempt. Drug and Alcohol Dependence 2021: volume 224, article 108725

Schuckit M. Recognition and management of withdrawal delirium (delirium tremens). New England Journal of Medicine 2014: volume 371, issue 22, pages 2109-2113

Suicide Prevention Consortium. Insights from experience: alcohol and suicide. Samaritans, 2022

Thursz M, Richardson P, Allison M and others. Prednisolone or pentoxifylline for alcoholic hepatitis. New England Journal of Medicine 2015: volume 372, pages 1619-1628

Tignanelli C, Hemmila M, Rogers M, Raghavendran K. Nationwide cohort study of independent risk factors for acute respiratory distress syndrome after trauma. Trauma Surgery and Acute Care Open 2019: volume 4, e000249

Urban C, Arias S, Segal D, Camargo Jr C, Boudreaux E, Miller I and Betz M. Emergency Department patients with suicide risk: Differences in care by acute alcohol use. General Hospital Psychiatry 2018: volume 63, pages 83-88

Van Boekel L, Brouwers E, Van Weeghel J and Garretsen H. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug and Alcohol Dependence 2013: volume 131, issue 1-2, pages 23-35

Yedlapati S and Stewart S. Predictors of alcohol withdrawal readmissions. Alcohol and Alcoholism 2018: volume 53, issue 4, pages 448-452

Appendix H: co-occurring mental health crisis

H1. Evidence for co-occurring alcohol and mental health problems

Research shows that people presenting to emergency departments following self-harm and suicidal acts (such as overdose) or acute psychiatric symptoms is associated with intoxication and chronic alcohol use disorder (Phillips and others 2019).

Alcohol dependence increases risk of people completing suicide by 9.8 times (Ferrari 2014). Both alcohol dependence and alcohol use at harmful levels are associated with repeated suicidal acts and increased mortality after attending an emergency department (Hawton and others 2013).

Up to 57% of patients in secondary mental health care who die by suicide have a co-occurring substance use problem (NCISH 2019). However, patients who are intoxicated when they present to hospital following a suicide attempt are more likely to be discharged home than those who are not (Urban and others 2018, Robins and others 2021).

Qualitative research suggests that alcohol use remains a major barrier to accessing crisis care (Suicide Prevention Consortium 2022). Patients who use substances are reported to be stigmatised by health workers because of the perception that they are “violent, manipulative and unmotivated” (Van Boekel 2013). Stigma like this can create barriers to people accessing mental health services.

H2. Guidance on working with people who have co-occurring conditions

Public Health England published guidance on the care of people with co-occurring mental health and alcohol and drug use conditions. The guidance has 2 main principles:

1. Everyone’s job: providers of mental health and alcohol and drug services have a joint responsibility to meet the needs of individuals 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 have an open-door policy for individuals with co-occurring conditions and make every contact count. Treatment for any of the co-occurring conditions is available through every contact point.

This guidance makes it clear that there should be an agreed and understood care pathway to ensure patients’ needs can be met appropriately.

Patients presenting following a suicidal act, or in suicidal crisis, should receive care in accordance with NICE guideline Self-harm: assessment, management and preventing recurrence (NG225) for treatment in emergency departments. The following guidance is taken from NICE NG225 and clinical consensus of the alcohol guidelines development group:

When a person attends the emergency department following an episode of self-harm, offer referral to age-appropriate liaison psychiatry services or for children and young people, crisis response service (or an equivalent specialist mental health service or a suitably skilled mental health professional) as soon as possible after arrival, for a psychosocial assessment and support and assistance alongside physical healthcare.

An age-appropriate liaison psychiatry professional or a suitably skilled mental health professional should see and speak to the person at every attendance after an episode of self-harm.

Do not use breath or blood alcohol concentration to delay assessment.

If the person who has self-harmed is intoxicated with alcohol, agree with the person and colleagues what immediate assistance is needed, for example, support and advice about medical assessment and treatment.

Patients presenting with self-harm or suicidal acts should be offered psychosocial assessment at triage. Assessment should include structured and well-documented assessment of the severity of the alcohol use disorder. In addition, a thorough psychiatric assessment should be undertaken including a psychiatric history, including the relationship between psychiatric symptoms and alcohol use, and mental state examination.

Consider admission to a general (acute) hospital after an episode of self-harm if the person is unable to engage in a psychosocial assessment (for example, because they are too distressed or intoxicated).

If the person is not able to participate in the psychosocial assessment, ensure that they have regular reviews, and complete a psychosocial assessment as soon as possible.

Focus the assessment on the person’s needs and how to support their immediate and long-term psychological and physical safety.

Mental health professionals should undertake a risk formulation as part of every psychosocial assessment.

If a person has self-harmed and presents to services but wants to leave before a full psychosocial assessment has taken place, assess the person’s safety and any mental health problems before they leave.

Mental health professionals should discuss with the person harm minimisation strategies that could help to avoid, delay or reduce further episodes of self-harm and reduce complications - for example, the impact of alcohol and recreational drugs on the urge to self-harm.

Where possible, the decision to refer for further assessment and or treatment or to discharge the patient should be agreed by both the patient and assessor. The decision to discharge a person without follow-up following an act of self-harm should include assessment of social and personal problems, which may increase risk and may be amenable to therapeutic or social interventions, not based solely upon the presence of low risk of repetition of self-harm and the absence of a mental illness.

The chronicity of suicidal thinking and whether this remains in steady state or has reached a crisis should be considered. The goal of such an assessment should be to provide a holistic formulation and risk management plan drawn from this, as well as guide onward care which may include both community addictions services and primary or secondary mental health services.

When prescribing medicines to someone who has previously self-harmed or who may self-harm in the future, healthcare professionals should take into account factors including the patient’s recreational drug and alcohol use, the risk of misuse, and possible interaction with prescribed medicines.

H3. Understanding the severity of both alcohol and mental health conditions

It is important to understand the relative severity of both alcohol use disorder and co-occurring mental health disorder to understand where the clinical concern should focus. Someone who has recently begun to drink at harmful levels to manage depression will require a different pathway from someone with severe alcohol dependence and depression (see figure 2). You should do a full risk assessment and document it clearly.

H4. Do not exclude people from mental health services because of alcohol use

You should not exclude patients from mental health interventions because of their drinking status and alcohol and mental health services need to work together to be most beneficial.

NICE NG225 recommends a cognitive behavioural therapy-based approach to prevent repeated self-harm and states that professionals should not use “substance use or coexisting conditions as reasons to withhold psychological interventions for self-harm”.

Figure 2: patient assessment matrix

Source: NJ Kalk, King’s College Hospital, 2020

Figure 2 is intended to help healthcare professionals understand where their patient is in terms of their alcohol use, mental health and social stressors. It shows axes in 3 planes, which are:

• severity of alcohol use disorder
• severity of psychiatric disorder
• severity of social stressors

It asks where their patient is in the matrix between the axes. This will help them to formulate a care plan.

Where ACTs exist, their make-up and skillset varies, but all staff members should be trained in commonly occurring mental disorders and suicide risk assessment. However, patients should not be excluded from formal psychiatric assessment because they are under the care of an ACT.

All professionals should be aware that repeated episodes of self-harm increase the risk of self-injury death. They should also be aware that self-harm linked to alcohol intoxication is particularly associated with recurring self-harm (Hawton and others 2013), particularly in patients with alcohol dependence (Robins and others 2021).

Appendix J: co-occurring physical health conditions

J1. Liver disease

Screening for liver disease

You should consider underlying alcohol-related liver disease (ARLD) for anyone presenting to hospital with alcohol-related physical harm. Signs and symptoms related to ARLD develop late in the progression of the disease and a high proportion of people with ARLD will have no clinical symptoms nor significant blood test abnormalities.

Eventually, their liver may fail to function sufficiently and will ‘decompensate’. This is the stage at which ARLD becomes clinically apparent (see below). The risk of developing liver disease, and subsequent decompensation, decreases with abstinence (or reduced alcohol consumption), so it’s important to detect liver disease early and begin interventions.

The NICE guideline Cirrhosis in over 16s: assessment and management (NG50) recommends screening for ARLD in harmful drinkers by measuring liver fibrosis, as well as liver function blood tests, because normal liver blood tests (bilirubin, albumin, transaminases) do not exclude advanced fibrosis. Appropriate liver screening tests are covered in chapter 19 on co-occurring physical health conditions.

Care for people with liver disease

People diagnosed with significant fibrosis or cirrhosis should be followed-up by a specialist in liver disease.

Alcohol abstinence is a vital goal for people with ARLD, since abstinence improves outcomes in all stages of ARLD. However, the patient should not be excluded from treatment if they do not accept this goal initially. Guidance on developing pathways for alcohol treatment outlines that it is better to engage the person, rather than alienate them if they fail to agree to or achieve abstinence.

There should be effective care pathways between specialist liver services and alcohol treatment services in the hospital and in the community.

Cirrhosis

The European Association for the Study of the Liver (EASL) clinical practice guidelines recommends that if you suspect that a patient has cirrhosis, you should measure serum bilirubin, albumin, prothrombin time (INR) and platelet count to evaluate their liver function and the presence of portal hypertension.

Other liver blood tests may indicate alcohol excess (gamma glutamyl transferase (GGT) and raised aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio). They may also suggest alcohol as the cause of liver disease. But the EASL clinical practice guidelines points out that these tests cannot be used to determine the severity of fibrosis or cirrhosis and test results can be entirely normal, even in people with cirrhosis.

Other causes of liver disease

NICE CG100 recommend you should evaluate alternative causes of liver disease in high-risk drinkers with abnormal liver blood test results. In particular, risk factors for the other common liver diseases in the UK (non-alcoholic fatty liver disease and hepatitis C infection) include the metabolic syndrome (obesity, type 2 diabetes mellitus) or injecting drug use.

Ultrasonography (US) helps to exclude other causes of liver disease and may help you to assess advanced disease (for example, splenomegaly, irregular hepatic contour) and its complications (for example, ascites, hepatocellular carcinoma), whatever the causes. However, US cannot establish alcohol as the specific cause of a person’s liver disease nor reliably assess hepatic fibrosis.

Decompensated liver disease

Clinical signs of decompensated liver disease include:

• jaundice, shown by yellow discolouration of the skin and sclera (whites of the eyes)
• spider naevi, shown by red star-shaped markings on the face and upper body which blanche when pressed
• easy bruising
• swollen abdomen, caused by ascites (fluid in the abdomen), which patients often mistake for weight gain
• swollen legs
• confusion, such as reversal of day-night waking pattern, drowsiness, poor memory

The patient may also complain of fatigue, itching, abdominal pain and nausea.

The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report Alcohol related liver disease: measuring the units recommends that people with decompensated cirrhosis should be managed by a specialist with experience in managing patients with liver disease. Decompensated cirrhosis is a medical emergency with a high mortality. In particular, heavy drinkers presenting with new-onset jaundice, who have suspected alcohol-related hepatitis, can progress rapidly to liver failure and have a significant short-term mortality (30% at 90 days and 56% at one year) (Thursz and others 2015). Effective early intervention improves outcomes. When you are assessing people who have presented with decompensated cirrhosis, you should determine the precipitating causes and treat the patient appropriately.

A decompensated cirrhosis care bundle, as recommended by NCEPOD, can help to standardise and optimise the patient’s management in the first 24 hours, when specialist input might not be available. Patients should be reviewed by the gastroenterology or liver team at the earliest opportunity (ideally within 24 hours). You should quickly escalate care for patients with ARLD, who deteriorate acutely and whose background functional status is good. The medical and critical care teams should work closely when making escalation decisions.

Referral for liver transplantation

The UK liver advisory group has produced updated guidelines on liver transplantation for alcohol-related liver disease in the UK.

Alcohol-related pancreatitis

For guidance on diagnosis and management of alcohol related pancreatitis, see the NICE CG100.

J2. Nutrition support

Nutritional support for alcohol-related hepatitis

NICE CG100 recommends assessing the nutritional requirements of people with acute alcohol-related hepatitis. This includes offering nutritional support if needed and considering using nasogastric tube feeding (see NICE clinical guideline Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32)).

Assessing nutritional status

Many alcohol-dependent patients have poor nutritional status. When you suspect that they do, refer them to a dietician.

NICE CG32 recommends that all patients admitted to hospital should be:

• assessed to determine their body mass index (BMI)
• screened for unintentional weight loss
• asked if they have eaten little or nothing for the last 5 days

NICE CG32 highlights that patients with decompensated cirrhosis secondary to alcohol, and patients with alcohol dependence who often drink alcohol instead of eating, are at particular risk of malnourishment.

Nutritional assessment is especially important with particular conditions such as alcoholic ketoacidosis (AKA), which is associated with periods of complete lack of food. AKA is a clinical syndrome seen mostly in patients with chronic AUD and often seen in patients who have a pattern of heavy episodic drinking. Typical patients are usually chronic drinkers who are unable to tolerate oral nutrition for a 1 to 3 day period (Howard and Bokhari 2022).

NICE CG32 recommends providing nutritional assessment and support for people who have:

• a BMI of lower than 18.5
• a BMI of lower than 20 and greater than 5% weight loss in the past 3 to 6 months
• had little oral intake in the past 5 days

Poor nutrition is a risk factor for Wernicke’s encephalopathy (WE), which can cause temporary or permanent brain damage. You should follow the guidance on screening for risk of WE, in section 10.4 of chapter 10 on pharmacological interventions. Guidance on managing WE in acute hospital settings is covered in section 16.6.4 of this chapter.

It’s important to be aware that the metabolic demand produced by acute physical illness in general hospitals will increase the risk of WE.

The NCEPOD report on alcohol related liver disease also recommends that in the care bundle for decompensated cirrhosis, people who are actively drinking are treated with a treatment regimen of parenteral thiamine and other B vitamins.

Refeeding syndrome

Refeeding is a metabolic disturbance that can occur when nutrition is restored in people who are starved or significantly malnourished. It can happen to people who are admitted to hospital for treatment of alcohol use disorders, so it’s important to screen people for risk of refeeding syndrome, specifically those who:

• are very underweight (BMI of less than16) or have lost more than 15% body weight over 3 to 6 months
• have not been eating for the preceding 10 days or more before admission
• have low levels of serum magnesium, phosphate or potassium
• have had severe vomiting or diarrhoea

After identifying people at high risk of refeeding syndrome, you should check their electrolytes, particularly:

• sodium
• potassium
• calcium
• phosphate
• magnesium

Refeeding syndrome should always be managed in an acute hospital setting. Research has shown that alcohol dependent patients are considered at high risk of refeeding syndrome (Mehanna and others 2008), particularly those with cirrhosis and those with a history of poor nutrition. Refeeding syndrome is characterised by potentially fatal shifts in electrolyte and fluid balance that occur when malnourished patients begin to take in food again. Patients at risk of refeeding syndrome should be reviewed by a dietician within 48 hours. NICE CG32 advises an initial rate of 10 calories per kilogram of body weight per day (kcal/kg/day) in high risk or 5 kcal/kg/day in extreme risk.

Patients should receive regular blood test monitoring of phosphate, magnesium, calcium and potassium, with careful correction of abnormalities. You should not use 5% glucose as a rehydration fluid because it is likely to worsen both Wernicke’s encephalopathy and electrolyte disturbances.

There are cardiac complications of electrolyte deficiencies, particularly arrhythmias, so the alcohol guidelines development group advise electrocardiogram (ECG) monitoring or telemetry to record severe low electrolyte levels. Electrolytes should be monitored daily for 5 days and then 3 times weekly until stable. You should quickly replace electrolytes when required.

Management of refeeding should be accompanied in all cases by a multivitamin preparation and thiamine replacement immediately before and during the first 10 days of refeeding. This will help prevent neurological complications such as WE.

17. Alcohol treatment in the criminal justice system

17.1 Main points

People with alcohol use disorders in the community justice system are entitled to care that is safe and effective at a standard that is equivalent to care in the community. Care should be delivered by staff with appropriate competencies.

To address the needs of people with alcohol use disorders, healthcare staff should take opportunities at all points in the criminal justice system to identify, assess and treat people, as well as make appropriate referrals.

Healthcare staff should be competent to manage:

• alcohol use disorders
• complex co-occurring conditions
• risks in custody suites and secure settings

Effective communication and co-ordination between alcohol treatment staff, other healthcare services and criminal justice services is essential to provide integrated and continuous care for people throughout the criminal justice system.

Healthcare staff should re-assess, plan support and share clinical information when people move from one criminal justice setting to another so there is no interruption in medication and treatment can continue.

Alcohol intoxication and withdrawal both put the person at risk of medical or mental health complications and are associated with deaths in police custody and in prison. The clinical safety needs of people in those settings is the highest priority.

A suitably competent clinician should comprehensively assess anyone identified as potentially alcohol dependent or intoxicated on arrival in a police custody suite or prison and start medically assisted withdrawal.

It is essential to monitor anyone who is intoxicated or in withdrawal in police custody suites or in prison. Healthcare staff may also need to monitor other clinical risks.

Healthcare staff are responsible for clinical monitoring. Non-clinical custodial staff in police custody and in prisons also carry out observations. There should be standard protocols and staff training for carrying out these observations.

Communication between healthcare staff and non-clinical custodial staff about the person’s condition should be accurate and up to date.

People should be offered care planned evidence-based psychosocial interventions and recovery support from entry into prison and throughout their stay.

Prison based services and community services should have systems for sharing clinical information and arranging a smooth transition to community alcohol treatment after release.

Probation (criminal justice social work) and community alcohol treatment services should have clear partnership arrangements and information sharing agreements to support people to engage in alcohol treatment as part of a community sentence.

17.2 Introduction

This chapter provides guidance on safe and effective alcohol treatment and care for people in contact with the criminal justice system in the community and in secure settings.

Criminal justice systems vary across England and Wales, Scotland and Northern Ireland. This chapter summarises important principles for people working in those systems to consider.

Commissioners and managers of health and criminal justice systems should have local protocols and operating procedures for delivering alcohol treatment in criminal justice community and secure settings. These protocols and procedures should be based on the most recent evidence and national guidelines, including these guidelines.

17.3 Providing healthcare in criminal justice settings

There is a high proportion of people with alcohol and drug use disorders among people in contact with the criminal justice system (Bebbington and others 2017, Perkins and others 2022). So, healthcare providers can intervene at several points in the system, in different settings, to address their needs. These settings include:

• police custody suites
• diversion to mental health services where this is available
• courts
• prisons
• probation services
• community alcohol treatment services

Effective communication and co-ordination between healthcare providers in these settings, and with non-clinical justice staff, is essential to ensure integrated and continuous care for people throughout the system and after they return to the community.

Treatment in the criminal justice system should be based on the principles of care in chapter 2 including taking a trauma-informed practice and a non-stigmatising approach.

17.4 Alcohol treatment in police custody suites

17.4.1 Overview

In this section we summarise the main considerations for working with people with alcohol use disorders in police custody. The Royal College of Physicians’ Detainees with substance use disorders in police custody: guidelines for clinical management (also known as ‘the blue guidelines’) provides detailed guidance for healthcare professionals and custodial staff across the UK.

People who have been arrested are detained in police custody suites while police decide whether to charge them with a crime. Police custody suites are usually based in large police stations. The person detained will have contact with staff including:

• custody sergeants who manage the custody suite, including the care and welfare of detained people
• custody detention officers whose main role is to ensure the dignity and welfare of the people detained in custody suites
• healthcare professionals with clinical and forensic competencies to work in a custodial environment
• liaison and diversion workers or drug arrest referral workers who assess and refer detainees with mental health or alcohol or drug disorders (these services are not available in all areas)

A review of deaths in police custody in England and Wales between 2004 to 2005 and 2014 to 2015 found that alcohol or drugs featured as causes in nearly half of deaths (49%) and as associated factors in 82% of the deaths (Lindon and Roe 2017). Managing intoxication and treating alcohol withdrawal in police custody is essential to prevent physical and mental health complications and deaths (IPCC 2011).

17.4.2 Competencies for clinicians working in police custody

Several different healthcare professionals work in criminal justice settings and there are multidisciplinary teams in many large police custody suites. It is essential that all healthcare professionals working in police custody have specific training, competencies and clinical support to assess and manage people with alcohol and drug disorders. These professionals also need to be able to manage complicated co-occurring physical and mental health problems in the police custody setting.

You can find the necessary competencies for clinicians working in police custody in appendix A of the blue guidelines.

17.4.3 Considerations for working in police custody suites

The clinical safety needs of people detained in police custody suites is the highest priority, given the distress experienced by the people, and the need for urgent assessments.

Alcohol intoxication and withdrawal both put the person at risk of medical or mental health complications and are associated with deaths in police custody. Clinical staff must be competent to assess and manage alcohol intoxication and withdrawal.

Healthcare staff should be competent to screen, assess and manage all urgent needs and risks in police custody, including the risks of self-harm and suicide and any urgent physical and mental health conditions.

Healthcare staff should be able and competent to arrange urgent transfers to hospital if required. For example, if the person is experiencing severe complications of alcohol withdrawal.

Where it is indicated in the assessment, healthcare staff should arrange for people with co-occurring mental health conditions to be assessed under the Mental Health Act 1983 by suitably qualified mental health professionals.

Healthcare staff should be able to assess whether the person has mental capacity to consent to treatment.

Healthcare staff are responsible for clinical monitoring and non-clinical custodial staff also carry out observations. There should be standard protocols and staff training for carrying out these observations.

Communication between healthcare staff and non-clinical custodial staff about the person’s health and current risks should be accurate and continuous, because the person’s condition may change rapidly.

All healthcare staff and non-clinical custodial staff should be trained to make simple assessments of whether a person can be roused and what actions to take if there are any difficulties in rousing them.

Healthcare staff should:

• know the person’s rights
• be aware of issues of consent
• understand their role in providing an opinion on the person’s fitness to be interviewed if custodial staff request this

17.4.4 Assessment in police custody

Comprehensive assessment

In police custody suites, a comprehensive assessment, appropriate monitoring and re-assessments are crucial.

In addition to a full assessment of alcohol intoxication and dependence, clinicians should:

• assess the person for co-occurring physical or mental health conditions
• assess the person for any urgent social care needs
• make a comprehensive risk assessment

Following an initial comprehensive assessment, clinicians should continue to monitor and re-assess people who are detained. This is essential to manage alcohol intoxication and withdrawal and to monitor any other risks, since a person’s condition can change quite rapidly. There must be a place in the custody suite where varied levels of monitoring and re-assessment can take place.

There is guidance on comprehensive assessment, including risk assessment in chapter 4 on assessment and treatment and recovery planning.

Information gathering

Clinicians should consult custody staff at an early stage in assessment, because they can provide information on when the person was arrested. This can help the clinician assess when someone last used alcohol. Information about the person’s presentation and behaviour from custody staff and the police risk assessment can also support the clinicians’ risk assessment.

Clinicians should gather as much clinical information as possible about the person from primary or secondary health services, or community alcohol services. However, they may not always be able to obtain this information within the required timescale.

Mental capacity and fitness for interview

The clinician will need to assess the person’s mental capacity to agree to assessment and treatment. There are several reasons a person may be assessed as not having mental capacity to consent, including severe intoxication. There is information on legislation and guidance on mental capacity in annex 1.

Clinicians may also be asked by custody staff for their opinion on whether the person is fit to be interviewed by the police. There is guidance on fitness for interview in chapter 4 of the blue guidelines.

Sharing assessments and plans with custody staff

Clinicians should communicate relevant information about a person’s assessed alcohol disorder and health needs and their risk assessment with custody staff. They should also share the risk management plan, so custody staff are aware of the person’s needs. Sharing information also enables custody staff to make better decisions about charging and disposals, and to pass on information to courts to inform sentencing.

Where people do not need medically assisted withdrawal, they may still benefit from psychosocial alcohol treatment in the community, or in prison. By accurately assessing a person and referring them to treatment and further support, clinicians can effectively address healthcare problems to improve their health outcomes and reduce reoffending.

17.4.5 Intoxication in police custody

Assessing and managing a person who is intoxicated

Clinicians assessing the person should note their symptoms and signs of intoxication. There is a full list of signs of intoxication, and of severe intoxication in section 3.3 of the blue guidelines.

The clinician should also take baseline observations of their:

• pulse
• blood pressure
• temperature
• oxygen saturation
• consciousness levels (see section on monitoring a person who is intoxicated in police custody below)

Clinicians should not manage people who are severely intoxicated in custody suites, in particular those who are unable to walk unaided or speak to provide a coherent history. The person should be transferred to hospital for observation and treatment.

Symptoms of intoxication can continue to worsen for a while after the person has stopped drinking. Alcohol poisoning (overdose) can lead to coma and death, and symptoms can worsen for some time after the person has stopped drinking.

Clinicians should consider the possibility of illnesses, injury, or mental conditions other than intoxication. A person who is drowsy and smells of alcohol may also have concurrent medical problems including:

• drug intoxication or overdose
• epilepsy or seizures
• head injuries
• hypoglycaemia (low blood sugar)
• infections
• metabolic causes (for example, diabetes mellitus)
• encephalopathy (either Wernicke’s or caused by infections), which causes damage or disease to the brain

There is detailed guidance on making a differential diagnosis in section 3.3 of the blue guidelines.

A breath test may be useful to confirm alcohol use, but this should never be a substitute for a full assessment. Clinicians and non-clinical staff should be aware that a breath test reading of a low blood alcohol level does not necessarily mean that the person is not alcohol dependent or at risk. They should not assume that certain breath test levels can be defined as safe without further assessment.

Monitoring a person who is intoxicated in police custody

A person who is intoxicated in police custody is at risk of experiencing health complications and in some cases their behaviour can pose a risk to others. The person should be monitored regularly, because their condition can change quite rapidly.

The clinician is responsible for carrying out clinical monitoring and assessing the frequency of observation the person needs. Custody staff are usually responsible for carrying out regular observations and for alerting healthcare staff or calling an ambulance if they are not able to rouse the person, or the person’s health seems to be significantly deteriorating.

The clinician should decide on the level of observation based on a full risk assessment and the guidance provided in appendix C of the blue guidelines. This guidance describes standardised levels of observation. It specifies that the minimum level of observation for people under the influence of alcohol or drugs, or whose level of consciousness causes concern, is ‘intermittent observation’.

This observation involves:

• visiting the detainee and rousing them at least every 30 minutes
• carrying out physical visits and checks even if you are using CCTV and other technologies to support the observation
• asking the detainee questions at frequent intervals

All visits to the detainee should follow the guidance in appendix B of the blue guidelines. However, if the person’s risk assessment indicates a heightened level of risk (for example self-harm, suicide risk or other significant mental or physical vulnerability) they should be under constant observation or ‘close proximity observation’.

You can find details on each observation level and what they involve in appendix C of the blue guidelines.

The clinician should inform the custody staff of the risk management plan and agree arrangements for the level of observation required.

All clinical monitoring by healthcare staff and regular observations by non-clinical custodial staff must be carefully documented, so any changes in the person’s condition can be detected.

Urgent medical attention when a person cannot be easily roused

Intoxication can lead to over-sedation, which in some cases can lead to fatal respiratory depression.

Anyone in police custody who meets any of the following criteria requires urgent medical attention.

1. It is difficult to rouse them (wake them up) by calling their name or gently shaking them.
2. They cannot answer simple questions.
3. They cannot respond to simple commands.

It is important that all healthcare and custodial staff involved with people detained in custody are trained to carry out these simple assessments of whether someone can be roused. They should also remember that a person who smells of alcohol and seems drowsy may have other serious and urgent physical problems that are making it difficult to rouse them.

You can find guidance on actions to rouse people and how to respond in appendix B of the blue guidelines.

Non-clinical custodial staff should rapidly inform a healthcare professional or urgently call an ambulance if they have difficulty rousing a person or there is significant deterioration of the person’s condition.

A healthcare professional undertaking an assessment when a person cannot be roused should be trained in the Royal College of General Practitioners’ (RCGP) Alcohol: management in primary care certificate or equivalent national training. In Northern Ireland, clinicians should know the Northern Ireland alcohol use disorders care pathway – management in the acute hospital setting.

Clinical staff should use a standardised system to monitor for early warning signs of deterioration in condition or loss of consciousness. For example, they can use the Royal College of Physicians’ National early warning score (NEWS 2) guidance.

The clinician should arrange for the person to be transferred to an external hospital if there are concerns about their level of consciousness or their condition following their assessment.

17.4.6 Managing alcohol withdrawal in police custody

Severe withdrawal complications

People with alcohol dependence might only be in police custody a short while, but they may begin to experience alcohol withdrawal which puts them at risk. It is essential that clinicians assess and diagnose alcohol dependence and its severity and start early treatment to avoid the severe complications that can occur in withdrawal, which in some cases can be fatal.

All healthcare staff and non-clinical custodial staff should be aware of the signs of severe withdrawal complications and understand that they are a medical emergency. These include:

• delirium tremens
• acute confusion
• seizures
• Wernicke-Korsakoff syndrome

Anyone experiencing these complications should be transferred to hospital immediately.

For guidance on managing severe withdrawal complications, see section 10.4 of chapter 10 on pharmacological interventions.

Treating alcohol withdrawal

There is guidance in section 17.5.5 below on alcohol withdrawal in prisons which is also relevant for treating withdrawal in police custody suites and the clinician should follow this.

The clinician should assess whether it is safe for a medically assisted withdrawal to be managed in the custody suite. People with a history of severe complications in withdrawal should be transferred to hospital. The clinician should review any past records for the person which show complications in withdrawal in police custody suites. People with severe dependence and complex co-occurring conditions, including co-occurring drug dependence, may also need to be transferred to hospital.

People being treated for alcohol withdrawal in police custody should be clinically monitored using a validated tool such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) scale and should be observed regularly. You should follow guidance on observation levels in appendix C of the blue guidelines. The clinician should assess the level of observation needed. This should be at least every 30 minutes but may require more intensive observation, where the person has co-occurring conditions or they are at risk, for example of suicide.

When a person is being treated for alcohol withdrawal, clinicians should also follow the guidance above in section 17.4.5 on monitoring a person who is intoxicated in police custody and on providing urgent medical attention when a person cannot be easily roused.

17.5 Alcohol treatment in prisons

This section focuses on alcohol treatment in prisons but much of it can be applied to other secure settings including immigration and removal centres (see section 17.7 below) and secure hospitals.

17.5.1 The prison population

In 2021 to 2022, the average annual prison population was:

• 78,536 people in England and Wales
• 7,504 people in Scotland
• 1,494 people in Northern Ireland

This is a total of 87,534 people in the UK as a whole. Many more people than this pass through prison in a year. Some people have short stays in prison while others are there for many years.

Evidence (Bebbington and others 2017, Wright and others 2019) shows that compared to the general population, people in prison experience high levels of:

• alcohol and drug use and dependence
• mental health conditions
• some physical health conditions
• social support needs

Many people have a history of trauma. There are also very low levels of literacy and some prisoners do not speak English.

Healthcare teams often need to work with prisoners moving through a system where there is pressure on availability of prison places. Prison systems need access to healthcare staff who can competently assess and monitor people with alcohol dependence, especially during the early days in prison, and increasingly across all categories of prison.

17.5.2 Equivalence of treatment and care in secure settings

The principle of equivalence of care as set out in RCGP Secure Environments Group position statement Equivalence of care in secure environments in the UK is particularly important for people in prisons and similar secure settings.

Equivalent care does not mean that care is exactly the same in community and secure settings. There are situations where healthcare provision affects security decision making (for example, the need for frequent access to monitor a patient). Healthcare providers have a duty to understand the potential impact of their actions and work with their non-clinical prison colleagues to find appropriate solutions so people can receive the care to which they are entitled.

17.5.3 Governance for alcohol treatment in prisons

Commissioners and providers of health and justice services should develop a clinical and quality governance strategy to ensure safe and effective treatment and care for people with alcohol and drug problems in secure settings.

Local protocols should be in place that adequately reflect:

• the current evidence base
• these clinical guidelines
• any other authoritative guidance on implementing alcohol treatment and care in secure settings, for example Drug misuse and dependence: UK guidelines on clinical management

Protocols should include guidance on collaborative working between healthcare and non-clinical prison staff to manage risk.

The Royal Pharmaceutical Society‘s Professional standards for optimising medicines for people in secure environments provides a framework to support the commissioning and provision of safe, quality services in secure settings. These standards are for anyone working in or with secure settings in England, but they may also be useful in other parts of the UK.

Each prison should have a HM Prison and Probation Service site-specific drugs strategy, or an equivalent strategy in other UK nations. This strategy should include the management of people with alcohol dependence or alcohol use problems.

It is the responsibility of any commissioners and managers to ensure healthcare staff in prisons are adequately resourced and supported in their roles to meet service demand.

Commissioners and managers of health and justice services should make sure there are sufficient competent staff and medical facilities to provide appropriate treatment and care for people with alcohol dependence.

17.5.4 Staff competencies

Competencies needed by staff for working in prisons include the following.

Competencies for doctors working with alcohol and drug use

The Royal Colleges of Psychiatrists and General Practitioners’ report Delivering quality care for drug and alcohol users: the roles and competencies of doctors (PDF, 404KB) lists competencies for doctors. These are not specific to secure settings but identify competencies for working with alcohol and drug use at generalist, intermediate and specialist levels.

Providing safe and effective care

Providing safe and effective alcohol treatment and care in a prison setting is complex and skilled work due to the high levels of need and risk in the prison population, and the operational constraints of the setting.

Care should be delivered by clinicians and allied staff who are:

• suitably competent
• well led
• properly supervised
• operating within a clear quality and clinical governance framework that supports safe and effective service delivery

Healthcare staff, including alcohol treatment staff, should have a thorough understanding of the needs and the risks of the prison population and should be able to confidently assess and manage individual clinical risk in the prison environment. This will involve regular re-assessments.

Clinicians responsible for assessing and managing medically assisted alcohol withdrawal should be competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms and in using recommended drug regimens appropriate to the prison setting.

As people with alcohol dependence often have complex co-occurring needs, clinicians should be competent in procedures for clinical monitoring for both alcohol and drug withdrawal or stabilisation, and other systems for monitoring risk. For example, this could include NEWS 2 for assessing and responding to acute illness and risk management systems for preventing suicide such as Assessment, Care in Custody and Teamwork assessments.

Training and supervision

Commissioners and providers of health and justice services should make sure that healthcare staff and prison officers are appropriately trained and supervised and are competent to carry out their roles when working with people with alcohol dependence.

Healthcare staff providing psychosocial interventions to people with alcohol dependence should be trained and supervised by a supervisor with experience of working in secure environments.

All healthcare staff and prison officers in contact with prisoners should have essential first aid training, including training for the person first on the scene in an emergency.

Working together

Clinical and healthcare staff and prison officers should be competent in working together to provide integrated care and manage risk.

Healthcare staff responsible for alcohol treatment should be competent to work collaboratively with other healthcare teams in the prison, and with community alcohol treatment services, to provide integrated care.

17.5.5 Considerations for delivering alcohol treatment and care in prisons

Opportunities to access treatment and recovery support

Prison is an opportunity for people with alcohol dependence who have not effectively engaged with community services to access:

• alcohol treatment and support for longer term recovery
• treatment and care for co-occurring mental health and physical health conditions
• health promotion and related social prescribing
• peer networks and peer mentoring

Alcohol withdrawal

When a person is admitted to prison and identified as potentially alcohol dependent, a suitably trained and competent clinician should provide a comprehensive assessment and manage the risks of alcohol intoxication and withdrawal at reception.

The clinician should treat alcohol withdrawal in line with local evidence-based protocols and these guidelines. Consumption of medication for alcohol withdrawal should always be supervised in prison.

People who are intoxicated or at risk of acute alcohol withdrawal should only be placed in a prison with 24-hour healthcare provision and where appropriately trained staff can carry out enhanced, regular observations.

If the person shows clinical signs of delirium tremens, Wernicke’s encephalopathy, or alcohol withdrawal seizures, clinicians should arrange an emergency hospital transfer.

Clinical monitoring and observation

The clinician should arrange for safe and appropriate levels of clinical monitoring and observation during alcohol withdrawal or intoxication based on individual assessment and guided by local protocols that set out different levels of observation. They should work with prison officers to arrange easy access to the person.

Managing self-harm and suicide risks

All staff (healthcare and prison officers) should understand the increased risks of self-harm and suicide for people on their first night in prison and the early weeks after. They should also understand that people with alcohol dependence or who are intoxicated are at particularly high risk of suicide.

Local protocols and procedures should support an integrated approach to providing safe care for people with alcohol dependence. Clinicians and healthcare staff and non-clinical prison staff should work together to reduce harm and to manage risk, particularly the risk of fatalities.

Prescribing decisions

Clinicians need to make prescribing decisions including about polypharmacy (where the patient has been prescribed several different medicines for different conditions), accounting for risks of diversion (stockpiling by the patient, trading on the prison economy) and opportunities for supervision.

Care planning and integrated care

The clinician or alcohol treatment staff should develop a care plan with the person that links initial treatment with ongoing treatment and recovery support in prison. And when they are released, links them to community treatment.

Healthcare staff from different teams and non-clinical prison staff need to work together to provide integrated care for people with alcohol dependence and complex co-occurring conditions. Accurate and timely information sharing and excellent record keeping using the prison systems is essential.

Continuity of care

The alcohol treatment or healthcare team should work with colleagues to plan and manage continuity of care from prison entry, through court appearances, changes in prison setting, and preparing for prison release. They should share clinical information (with the person’s consent) to minimise interruption in treatment and reduce risks.

All staff should understand the increased risks the person faces after release, including the risk of:

• relapse
• decreased tolerance (the need to drink more alcohol to get the same or desired effect which develops in people who drink heavily and regularly)
• death through alcohol poisoning
• death through taking multiple illicit or prescribed drugs and alcohol together

If the person is also an opioid user, staff should understand the increased risk of opioid overdose after release and should follow the guidance in chapter 5 of Drug misuse and dependence: UK guidelines on clinical management on planning for release.

17.5.6 The patient pathway in prisons

Screening

Screening for patterns of harmful drinking and alcohol dependence should take place at the first-stage health assessment on the day the person is admitted to the prison, at reception, before they go to a cell.

The National Institute for Health and Care Excellence (NICE) guideline Physical health of people in prison (NG57) provides a template for first stage assessment which includes questions on alcohol use.

The screening assessment should include questions and actions on:

• alcohol use
• substance misuse
• physical health
• mental health
• self-harm and suicide risk

There are high levels of domestic abuse, assault and sexual violence among women who enter the prison system and screening should include sensitive questions on these areas. There is guidance on routine questions on domestic abuse in chapter 22.

If screening identifies harmful drinking or alcohol dependence, or substance use or dependence, the person should be referred to the substance misuse team or to a clinician with competencies in assessing and treating alcohol dependence and alcohol withdrawal. The clinician should then carry out a specialist assessment in reception.

Assessment

Comprehensive assessment

The clinician should comprehensively assess the person’s needs and risks. They should use validated tools to identify dependence and severity of dependence, but these tools should be used to support a clinical interview with the person, not to replace it.

You should read guidance on initial assessment and comprehensive assessment in chapter 4.

The increased isolation people experience from being in custody can amplify feelings of hopelessness and make mental and physical health symptoms worse. So, clinicians should take care to treat patients holistically by involving other appropriate services in assessment and care planning.

Where the person has co-occurring mental health conditions, the prison mental health team should assess their mental health and contribute to the comprehensive assessment.

If the clinician identifies drug dependence (including prescribed medication) in addition to alcohol dependence, the person will need concurrent treatment for their drug dependence. Medically assisted alcohol withdrawal will be more complex and requires specialist skills. See section 17.5.7 on co-occurring dependence on alcohol, illicit drugs or prescribed medication below.

Continuity of care on entry into prison

The clinician carrying out the assessment should obtain information from other services on:

• the person’s health
• prescribed medication
• planned medical appointments
• community alcohol treatment

There are a range of other services and staff that could have important clinical information about the person, including:

• primary care
• community pharmacists
• secondary care physical and mental health services
• criminal justice healthcare services inside and outside the prison
• prison staff records and observation
• community alcohol treatment services

The clinician might not be able to contact all relevant services, for example if the person enters prison in the late evening. But they should try to make contact as soon as possible so they can make a full assessment.

It is vital that there are agreed partnership arrangements between community alcohol treatment services and prison substance misuse teams or healthcare services. Community alcohol treatment services should get a person’s consent to share their clinical information with a prison substance misuse team if they are due to attend court and they know they may be sentenced to prison. The community service should share information quickly to help prison alcohol treatment services with their first assessment of need and risk.

Individual support

The first night and first weeks in prison can be extremely stressful for people who are often already vulnerable. Assessment is a chance for the person to speak to someone on an individual basis.

The principles of care set out in chapter 2 apply in secure settings as well as the community.

People with alcohol problems in the prison population have often experienced high levels of trauma and disadvantage. A trauma-informed approach, and a non-stigmatising attitude from staff can help the person to feel less isolated and distressed on entry into prison and help them go on to engage in alcohol treatment.

17.5.7 Managing urgent clinical needs and risks

Starting treatment and agreeing a plan

The clinician should start treatment to address all immediate clinical needs, including alcohol intoxication or withdrawal, and agree a risk management plan for all risks in reception.

The clinician should make sure there is a clear, recorded plan for managing clinical needs and risks. The plan should include information from other healthcare teams and actions for these teams, for example the mental health team and any relevant community services. The plan should take into account the person’s sentence and sentence planning.

The clinician should arrange for risk management plans to be regularly reviewed, especially in the early days, as risks can change quite rapidly. Clinicians should also review the plans when a person’s condition changes, and they may need increased monitoring.

The clinician should follow local protocols for recording and sharing information on risk with healthcare colleagues and with non-clinical prison staff. Keeping a person’s record up to date and accurate is essential.

Healthcare staff and prison officers should contribute to multidisciplinary prison risk management systems, for example the Assessment, Care in Custody and Teamwork process used in prisons in England and Wales.

Assessing and managing alcohol intoxication

Clinicians should assess people in prison for symptoms and signs of alcohol intoxication. Section 17.4.5 above provides guidance on assessing and managing intoxication. Alcohol intoxication can also be complicated by polydrug use or prescribed medications.

People who are intoxicated at reception (or at another time during their prison stay) should be placed where healthcare staff can carry out enhanced, regular observations to manage risks. People who are at higher risk should be in a setting where there is 24-hour observation available. Clinicians should agree arrangements with prison officers so that healthcare staff can access the person to make repeated observations at a sufficient level to keep the person safe quickly if there are any signs of concern.

The clinician, in discussion with a multidisciplinary team when appropriate, should decide on the frequency of observation based on individual personalised risk assessment. This should be related to intoxication and other risks, such as self-harm. The clinician should be guided by local protocols that specify observation levels, including minimum observation levels in reception and overnight. They should also have the option to increase the level of observation if there are changes in the person’s condition that indicate increased risk.

Where the person requires constant supervision, they should be observed by staff trained to carry out observations.

There are variations in prison systems across the UK in the role of non-clinical prison staff in carrying out observations. Observations should be led and managed by healthcare staff, but prison officers may carry out some observations. Each prison should have a protocol that sets out the respective role of healthcare staff and prison officers and guidance on observation levels.

As an example of a standardised protocol for observation levels, prisons could use the guidance set out in appendix C of the blue guidelines.

Clinicians and non-clinical prison officers should work closely together and clinicians should make sure prison officers are clear about when and how they should escalate any concerns about the person’s condition.

Assessing and managing medically assisted withdrawal

The importance of managing medically assisted withdrawal

Alcohol withdrawal is associated with significant mortality if it is undiagnosed or undertreated. About 15% of people entering custody report a history of alcohol withdrawal, although this figure is possibly an over-estimate due to an exaggeration of symptoms (Wright and others 2019).

There should be local evidence-based protocols for carrying out medically assisted alcohol withdrawal drawn up on the advice of a specialist clinician.

It is essential that appropriately competent clinicians assess and diagnose alcohol dependence including severity of dependence. Once dependence has been confirmed, the clinician should start early treatment in reception to avoid the severe complications that can occur in withdrawal.

Severe complications include:

• seizures
• delirium tremens
• Wernicke-Korsakoff syndrome

Clinicians should remember that not everyone will disclose their alcohol dependence and that alcohol withdrawal symptoms can look like or complicate symptoms of withdrawal from other substances. Alcohol withdrawal can also complicate agitated mental health presentations, because the 2 conditions together can cause distress and it can be difficult to know which condition is causing the symptoms.

You should read detailed guidance on assessment and pharmacological interventions for medically assisted withdrawal in chapter 10 on pharmacological interventions.

You should also read chapter 11 on community-based medically assisted withdrawal. Although this chapter provides guidance on community-based withdrawal, it describes the context of care when providing medically assisted withdrawal and much of this is relevant to secure settings.

Preventing and managing severe complications

Severe complications of alcohol withdrawal can pose a serious threat to a person’s health. Both treated and untreated delirium tremens are related to increased mortality. There is also risk of alcohol related brain damage if Wernicke’s encephalopathy develops. A patient’s history of severe complications is a factor in deciding how and where the medically assisted withdrawal should be managed in the prison setting.

If there are signs of delirium tremens and Wernicke’s encephalopathy, or withdrawal related seizures, the person should be immediately transferred to an external hospital with 24-hour medical and nursing care so they can receive parenteral treatment, constant observations or intensive care management if required.

See section 10.4 in chapter 10 on pharmacological interventions for more guidance on preventing and managing severe complications.

If a person’s alcohol dependence has not been identified at reception, they might present to healthcare staff or prison officers with acute withdrawal symptoms. All healthcare staff and prison officers involved in the care of people undergoing medically assisted withdrawal should be trained to recognise signs and symptoms of severe withdrawal complications and know they are a medical emergency.

Deciding on the appropriate setting for medically assisted withdrawal

The clinician, and where appropriate the multidisciplinary team, will need to assess how the medically assisted withdrawal can be managed in prison. This will be based on an individual assessment of:

• severity of dependence
• history and current risk of severe withdrawals
• complexity of co-occurring physical and mental health conditions

People undergoing medically assisted withdrawal should be placed in a prison with 24-hour healthcare and where enhanced, regular observations can take place. Some people with severe dependence and very complex co-occurring conditions will need constant monitoring from a healthcare team and should be treated in a prison hospital unit.

In the most complex cases with the highest risks, or rapidly deteriorating conditions, patients may need to be transferred to an external acute hospital.

Monitoring during medically assisted withdrawal

People who are treated for withdrawal must be monitored regularly to check for:

• withdrawal symptoms
• any signs of severe complications
• over-sedation

Over-sedation can lead to respiratory depression. Depending on the complexity of the person’s needs, they may have other monitoring requirements, for example for drug withdrawals or for mental health symptoms or self-harm.

Clinicians should have access to their patients so they can carry out monitoring as often as required for safe care.

The quality, level and skill of clinical monitoring is an important factor in successfully managing medically assisted alcohol withdrawal. 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)
• monitoring the effects of medication

The level of monitoring required will depend on several factors including:

• severity of alcohol dependence (assessed with a validated tool)
• risks of severe complications
• co-occurring substance use or dependence
• co-occurring physical health and mental health conditions
• risk of self-harm or suicide

The clinician, in discussion with the multidisciplinary team where appropriate, should determine how often the person should be clinically monitored and observed, based on individual assessment guided by local protocols.

For people undergoing severe withdrawal, monitoring may need to be every 30 minutes, but it can be less often for those stable on adequate withdrawal regimens. However, at the very least, monitoring should be done several times a day for people in prisons being prescribed a regimen to support withdrawal from alcohol.

Care and support levels should be increased based on outcomes of clinical monitoring and ongoing repeated assessment of other risks.

Clinicians are responsible for carrying out clinical monitoring. In some cases they may request trained prison officers to carry out observations. The clinician should lead on these arrangements and they should be guided by local protocols. See section 17.5.5 on clinical monitoring and observation above.

Prescribing for medically assisted withdrawal

There is a risk that people might stockpile and abuse their medication or divert it (trade to other prisoners for them to use) or have it stolen. For this reason, the Royal College of General Practitioners’ guidance Safer prescribing in prisons (PDF, 769KB) recommends that the consumption of medication for alcohol misuse and drug misuse is always directly supervised in prison and this should be done in line with local protocols. Clinicians should work with non-clinical prison staff to arrange timings of medicine doses, so they are in line with the prescribed dose regimen to manage the withdrawal safely.

Benzodiazepines (for example chlordiazepoxide or diazepam) are the recommended pharmacological treatments for alcohol withdrawal. In the rare situation where the person cannot take oral medication, the clinician should arrange for them to be transferred to a general hospital where they can receive parenteral treatment.

The clinician should be aware that prisoners might falsely claim to be alcohol dependent to obtain benzodiazepines. If there is no clinical information to confirm the person is alcohol dependent, the clinician should immediately start to observe the person regularly. Then they should normally only prescribe benzodiazepines if they observe withdrawal symptoms beginning to develop.

A fixed and adequate dose regimen of a long-acting benzodiazepine is likely to be the most suitable regimen for medically assisted alcohol withdrawal in prison. A symptom triggered regimen will not normally be suitable because this requires a team trained in the approach and enough clinical staff to carry out careful hourly monitoring. You can read guidance on fixed dose and symptom triggered regimens in section 10.3.4 in chapter 10 on pharmacological interventions.

Chapter 10 also provides guidance on benzodiazepine regimens.

The clinician should prescribe thiamine to any patient undergoing medically assisted withdrawal to reduce the risk of Wernicke’s encephalopathy during withdrawal. Section 10.4.3 of chapter 10 on pharmacological interventions provides guidance on prescribing thiamine.

Polypharmacy

People in the prison population often have several long-term health conditions and the clinician should consider the risks of polypharmacy (prescribing several medicines for several different conditions at the same time). The person may also have been using illicit drugs or abusing prescribed medication.

The person may have already been prescribed benzodiazepines for alcohol withdrawal (for example, in the police custody suite). NICE NG57 recommends that medication for alcohol withdrawal should not be stopped until medically assisted withdrawal has been completed.

Clinicians must consider contraindications for prescribing other medicines when prescribing benzodiazepines (a sedative) for medically assisted withdrawal.

NICE NG57 and Safer prescribing in prisons (PDF, 769KB) recommends that clinicians should carry out a reconciliation of medicines so there is a complete and accurate list of the person’s medicines recorded. This includes:

• identifying an accurate list of the person’s current medicines
• noting any discrepancies with current medicines in use
• documenting any changes

It may not always be possible to obtain information on the person’s health or medication on the first day, but clinicians should try to get this information within the first few days the person is in prison. The clinician needs to be aware that the person may be falsely claiming that they are prescribed medicines or high doses of medicines.

The Safer prescribing in prisons guidance says that polypharmacy is not recommended for people with addiction problems in prison or the community. The clinician needs to decide whether to continue some or all of the medications, taking into account the risks in stopping any medication and the risk of diversion. These are complex prescribing decisions requiring a high level of skill. When making decisions, the clinician should consult other healthcare teams where relevant, for example the mental health team or pharmacists. The clinician should aim to simplify the prescription and make it as safe as possible. They need to be particularly careful in managing medicines in the first few days when risks of suicide are high and they might not have all the relevant information about a person.

Co-occurring dependence on alcohol, illicit drugs or prescribed medication

The process is more complex if the person who needs medically assisted alcohol withdrawal has a co-occurring dependence on illicit drugs or prescribed medication. It will require more care and increased monitoring from a multidisciplinary team with specialist input.

Concurrent alcohol dependence and opioid dependence

There is guidance on treatment in prison for misuse or dependence on several illicit substances and on benzodiazepines in chapter 5 of Drug misuse and dependence: UK guidelines on clinical management. It includes guidance that clinicians should follow on opiate substitute prescribing, including guidance on concurrent alcohol and opioid dependence.

Clinicians need to take particular care when they are assessing and prescribing for people with concurrent opioid use (or other analgesics with habit forming potential) and alcohol dependence. This is because there is a high risk of oversedation and fatal respiratory depression when benzodiazepines and opioids are taken together. There is important safety information from the Medicines and Healthcare products Regulatory Agency (MHRA) and the Commission of Human Medicines on Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression. Clinicians should also consider the risk of over-sedation in patients who have been prescribed anti-depressants.

Concurrent benzodiazepine dependence

If the patient has concurrent alcohol dependence and benzodiazepine dependence, the clinician should treat the alcohol withdrawal before any withdrawal from benzodiazepines, as benzodiazepines are used to manage alcohol withdrawal. You should follow guidance in section 10.6.1 on medically assisted withdrawal for alcohol when a person is also dependent on benzodiazepines in chapter 10 on pharmacological interventions.

Close observation and clinical monitoring are required when a patient with concurrent alcohol dependence and benzodiazepine dependence is undergoing medically assisted alcohol withdrawal. They may need to be treated in the hospital unit in the prison.

There is further guidance on benzodiazepine withdrawal, including where there is concurrent alcohol dependence, in section 5.4.6.7 in chapter 5 of Drug misuse and dependence: UK guidelines on clinical management.

Concurrent alcohol, opioid and benzodiazepine dependence

The management of polydrug and alcohol dependence requires specialist skills. Clinicians should take great care if the person has concurrent dependence on alcohol, opiates and benzodiazepines and treatment will require input from a specialist clinician and a multidisciplinary team.

Chapter 5 of Drug misuse and dependence: UK guidelines on clinical management includes guidance on managing medications in prison. It recommends that clinicians avoid prescribing people more than 2 drugs with sedative potential on the first night or for the first few days unless they confirm that:

• a clear medicines reconciliation has been carried out
• the person has fully adhered to their current prescriptions

Clinicians must use careful clinical judgement on what prescribed medications with sedative potential should be withheld from people in the early days in prison, before a full medicines reconciliation process led by pharmacists has taken place.

Concurrent alcohol dependence and cocaine use

Healthcare staff should intensively monitor a patient with alcohol dependence who has been using or is also dependent on cocaine. Normally, they should be in the prison hospital unit where there is 24-hour healthcare. There are risks of problematic increases in blood pressure and increased heart rate during alcohol withdrawal and there can be a risk of sudden death.

Management of stimulant withdrawal is associated with several risks and requires input from specialist addiction clinicians and often mental health teams.

You should read the guidance on managing stimulant withdrawal in the first week in section 5.4.6.8 in chapter 5 of Drug misuse and dependence: UK guidelines on clinical management.

Monitoring when there is concurrent alcohol dependence and drug dependence

When carrying out medically assisted withdrawal from alcohol in people with a concurrent drug dependence, close clinical monitoring and regular observation is required for the safety of the patient. This is because in some cases (as outlined above), there is a risk of death.

The clinician, in discussion with the multidisciplinary team, should carry out a careful assessment and decide on the appropriate setting for medically assisted withdrawal. This decision should be based on the:

• risk factors that are considered for all people undergoing medically assisted alcohol withdrawal (see section 10.2.4 of chapter 10 on pharmacological interventions)
• patient’s drug use

Medically assisted withdrawal for people with concurrent alcohol and drug dependence may require monitoring in the prison hospital unit where there is 24-hour care. In the most complex cases, patients may need to be admitted to an external hospital.

Assessing and monitoring for risk of self-harm and suicide

There is an increased risk of self-harm and suicide on the first night and the first weeks in prison among the prison population. Both alcohol intoxication and alcohol dependence are associated with increased risk of suicide (Kaplan and others 2013). A systematic review shows that alcohol misuse in the year before entry into prison is a risk factor for suicide in prison (Zhong and others 2021).

Evidence suggests that the distress caused by withdrawal in an already highly stressful situation may be a factor in the high levels of suicide among people with alcohol dependence entering prison (Backet 1987).

It is essential that the clinician assesses the risk of self-harm and suicide and involves the mental health team if there are signs that the person is at current risk or specialist assessment is needed.

Where a patient is assessed as at risk of self-harm or suicide with suicidal ideation and intent, the clinician, healthcare staff and prison officers should follow the local prison suicide prevention protocol. They should observe the patient based on this protocol until the mental health team can assess the patient. Close clinical monitoring and intensive observation is required for the safety of the patient.

If a patient is assessed as at risk of self-harm or suicide, this should trigger the prison’s multidisciplinary risk management process, for example the Assessment, care in custody and teamwork (ACCT) process in England and Wales. Clinicians and allied healthcare staff should make sure risks are recorded clearly and promptly in the patient’s record. They should also make sure that all relevant staff, including prison officers, are:

• informed of the risks and the risk management plan
• understand the rationale for the plan
• understand the agreed level of observation and clinical monitoring

Managing deteriorating health and emergencies

Prisons should have local protocols that set out how healthcare staff and prison officers should respond to situations in which a person’s health quickly deteriorates or is in a health emergency.

NICE NG57 provides guidance on what these protocols should include.

All secure environments need close working relationships between prison officers and healthcare providers, including mental health teams, and local hospital emergency departments to manage emergencies.

With the patient’s consent, clinicians should tell all healthcare staff and prison officers if someone has a chronic health condition that could deteriorate or has allergies. In emergencies, healthcare staff should share relevant confidential clinical information in line with their duty to do so.

If there is a concern about the patient’s condition, the clinician or multidisciplinary team should develop a clear plan for managing their condition that is shared with all relevant healthcare and prison staff. The clinician should carry out regular clinical assessments to identify signs that the person’s condition is deteriorating or there is an emergency, using a standardised early warning system, for example NEWS 2. They should escalate the patient’s care to include increased monitoring or transfer them to an external hospital, where this is indicated.

Staff need to know how to respond if they are concerned that someone may not be conscious. Prisons should have local protocols for checking if a person can be roused. For example, appendix B in the blue guidelines provides guidance on these checks.

All healthcare staff and all prison officers should know how to carry out simple checks to see if a person can be roused.

If an officer finds that they cannot wake up a prisoner by either speech or light touch, they should inform the on-call clinical staff member immediately, who should attend to do a formal clinical check on their consciousness level or call an ambulance.

All healthcare staff and all prison officers in contact with prisoners should have essential first aid training, including training for the person first on the scene in an emergency.

17.5.8 Care planning

Developing the care plan

The clinician or a member of the substance misuse team should develop a care plan (also called treatment and recovery plan) for anyone needing alcohol treatment in prison or other secure setting. To meet the principle of equivalent care to the community, they should offer personalised care planned treatment and recovery support to people:

• with alcohol dependence
• who drink at harmful levels and have co-occurring physical health or mental health conditions

The care plan should be started at reception, linked with plans for further assessments and care planning throughout the person’s time in prison and at pre-release, and should extend to treatment and support in the community.

The plan should be reviewed regularly and when there is a change in the person’s circumstances.

There is guidance on treatment and recovery planning in chapter 4.

Planning for continuity of care

Plans should include actions to provide continuity of care if the person attends court appearances or moves to a different setting. Alcohol treatment staff (or the care co-ordinator where people have complex needs) should make sure all relevant clinical information is passed on to the next setting with the person’s consent. This should include information about:

• their alcohol problem
• current alcohol treatment they are receiving
• any medication they are taking

Medications should also be transferred to the next setting. For more information on continuity of care leading up to release see section 17.6 below.

Multidisciplinary integrated care

It is likely that several teams will be involved in the care of prisoners with alcohol dependence, including from:

• healthcare (for example, mental health team, substance misuse team)
• prison officers
• community services

Assessment, care planning and risk reduction needs to be multidisciplinary and integrated. Good communication between community alcohol treatment services, prison healthcare teams and prison officers is essential from when the person enters prison through to transfer or release back into the community.

For people with the most complex needs, a multidisciplinary team should be involved in developing and monitoring their care plan and there should be an identified care co-ordinator.

Psychosocial interventions and recovery support

Everyone requiring alcohol treatment should be offered psychosocial interventions. Chapter 5 provides guidance on psychosocial interventions.

Staff providing psychosocial interventions should be trained in the interventions they offer and have the appropriate competencies. They should also receive supervision from a qualified clinical supervisor. Providing psychosocial interventions in a prison setting requires advanced skills. Mental health symptoms can be intensified and there are heightened risks of:

• self-harm
• suicide
• violence

NICE guideline Mental health of adults in contact with the criminal justice system (NG66) provides guidance on considerations when offering mental health interventions in prisons.

Prison provides an opportunity for alcohol treatment practitioners to support the person with alcohol dependence to identify and work toward their recovery goals and help them to build recovery capital. There is guidance on building recovery capital in chapter 5 on psychosocial interventions and chapter 6 on recovery support services.

There may be opportunities for the person to develop skills and activities that can help them towards employment or education on their release. These may include:

• literacy skills
• education classes
• occupational skills
• physical exercise

There may also be opportunities for them to join mutual aid groups, for example Alcoholics Anonymous, or meet with peer support workers, and so begin to build recovery-oriented support networks. Alcohol treatment staff should help people to engage with these groups.

Harm reduction and health promotion

People with alcohol dependence are often not aware of the health risks of harmful drinking and alcohol dependence. Alcohol treatment practitioners should provide them with information on health risks and offer harm reduction information and advice. There is guidance on harm reduction information and advice in chapter 8.

Care plans should also include relevant health promotion interventions. For example, these could include interventions to:

• stop smoking
• lose weight
• increase exercise levels

Prison is also an opportunity to help people access routine vaccinations and scans they have missed. You can find guidance on physical health assessment in section 4.18.11 in chapter 4 on assessment and treatment and recovery planning.

17.6 Continuity of care: release, resettlement and recovery

17.6.1 The importance of continuity of care

A significant proportion of people in prison serve short sentences, often a few months or less. This means people with alcohol problems have less time to develop a stable recovery and any progress they make in prison can be difficult to maintain when they are released.

People who have served long sentences will be making a significant transition when they leave prison. This is likely to be a stressful experience for them and it can increase their risk of relapse, even if they have been abstinent for a long time.

Prison substance misuse services, wider prison healthcare services and community treatment providers are all responsible for making sure that people transferring from prison to the community have good continuity of care. There should be effective communication systems and pathways between substance misuse teams in prisons and community alcohol treatment services.

Joint planning between prison healthcare and community services should aim to:

• help the person engage in community alcohol treatment and recovery support services after release
• ensure the person is referred to relevant support for health and social needs
• reduce re-offending
• reduce homelessness
• reduce alcohol related harm

If a prisoner on remand has a planned court date, it’s best practice for the prison- based alcohol treatment provider to:

• inform community alcohol treatment services about the date
• tell them the outcome of the court appearance

If this has not happened, the prison treatment service providers may need to check that anybody released in an unplanned way from court has information about and a referral to specialist alcohol treatment in the community.

17.6.2 Pre-release care planning

Care planning for release is essential and should begin about 6 weeks before release. For prisoners with very short sentences, planning for release should begin at the comprehensive assessment in the first week in prison.

A clinician should carry out a health assessment with the person and summarise information on their health and treatment needs and the risks to the person and others. If a multidisciplinary team has been involved with the person’s care, they should be involved in the pre-release health assessment and care plan.

NICE NG57 provides guidance on pre-release health assessments. The assessment should include information on:

• the person’s alcohol dependence
• the alcohol treatment and recovery support they received in prison
• any relapse prevention medication they have been prescribed before release

The pre-release care plan should be based on this assessment and the substance misuse team’s assessment of the person’s ongoing needs for alcohol treatment and recovery support.

The pre-release care plan should be written and should include:

• prison-based pharmacological, psychosocial and recovery support interventions and ongoing treatment requirements from community alcohol treatment services
• details of planned appointments with community alcohol treatment services and recovery support networks
• details of planned appointments with relevant health, social care and prisoner resettlement services
• ongoing health and social support needs as outlined in the pre-release health assessment
• planned actions to reduce or manage risks to the person or to others
• details of any medication, including relapse prevention medication prescribed before release

When a person leaves prison, they should receive a copy of their pre-release assessment and care plan.

If the person is not registered with a GP, prison healthcare services should help them to register before release.

17.6.3 Information sharing between prison and community alcohol treatment services

There needs to be effective communication and information sharing between substance misuse services in the prison and the local alcohol treatment service before the person is released.

With the person’s consent, prison substance misuse services should share appropriate information, using a standard referral form, with community alcohol treatment services. This should include:

• prison-based pharmacological treatment, psychosocial and recovery support interventions they have been receiving
• wider information on the person’s physical health, mental health and social care needs, as outlined in the pre-release health assessment
• risks to the person or to others
• details of any medication, including relapse prevention medication prescribed before release

Community alcohol treatment services should continue the specific treatment interventions offered in prison.

17.6.4 Arranging an appointment with community alcohol treatment services

People being released from prison normally have complex health and social care needs. They should receive a rapid assessment from the community alcohol treatment service to avoid their situation deteriorating.

The community treatment service should offer an assessment appointment before or immediately after release. Where alcohol treatment services can provide in-reach into prisons, this can help to engage people and strengthen continuity of care. Where in-reach is not an option, video appointments (telemedicine) is an alternative way for prisoners to engage with community treatment providers.

17.6.5 Prescribing to prevent relapse

You should read section 10.5 on relapse prevention in chapter 10 on pharmacological interventions for detailed guidance on prescribing for relapse prevention and on the needs of specific groups.

Clinicians should not withhold medication that supports relapse prevention just because patients are in a secure setting. Some patients can remain abstinent from alcohol in prison without difficulty. But some may ask to start relapse prevention medication before being released from prison due to the risk of relapsing after release.

Clinicians should not prescribe naltrexone (or nalmefene) for people using prescribed or unprescribed opioid drugs, because these medications are opioid antagonists.

17.6.6 Pre-release harm reduction advice and interventions

When a person is released from prison, clinical staff should give them harm reduction advice to ensure that they keep themselves as safe as possible when they are released.

A person should receive harm reduction advice before release, including information on:

• their decreased tolerance to alcohol after a period of abstinence, including the risk of alcohol poisoning
• the increased risk of overdose if they use alcohol with illicit drugs or prescribed or over the counter medications, particularly those with sedative potential
• the risks of combining alcohol with specific substances, such as the increased toxicity of combined alcohol and cocaine

Appropriately trained prison substance misuse services staff should make sure naloxone is available to people who they think might also use opioids, in line with local protocols.

For people who have been exploited, for example through county lines or sex work, all services should take extra care to ensure they have safe transport and somewhere safe to go and are not being picked up by people who are likely to abuse them.

17.6.7 Improving continuity of care at a system level

The Public Health England guidance Continuity of care for prisoners who need substance misuse treatment is an audit toolkit and guidance on data recording for prison and community treatment providers and commissioners, to help improve continuity of care between prison and the community.

The main recommendations are as follows.

1. Prison healthcare services should consider developing a standard referral form to community treatment services.
2. Local alcohol and drug treatment systems should agree a referral protocol with their main feeder prisons.
3. Local commissioners and providers should consider establishing or expanding in-reach provision in prisons from community alcohol and drug treatment services.
4. Community alcohol treatment providers should review what they offer to people leaving prison to make sure it meets their needs and communicate this offer to their main feeder prisons.
5. Prison treatment services should review their links with resettlement services and jointly co-ordinate appointments and referrals arranged for the community (for example, to avoid appointments clashing).
6. Local community alcohol and drug treatment and recovery support services in England and Wales should ensure that their main feeder prisons are aware of the community single point of contact (SPOC).
7. Prison healthcare services and community alcohol treatment provides should only communicate personal information via a secure method, such as secure email.
8. Treatment providers in prisons should record their data in line with data guidelines so that their post-release engagement rates accurately reflect the true picture of continuity of care.

There is more detail on all of these recommendations in the guidance.

To help effective referral and communication, the Office for Health Improvement and Disparities (OHID) SPOC criminal justice directory (England and Wales) lists the contact details of all:

• prison healthcare teams
• community-based treatment providers
• probation teams

If you want to be included on the distribution list for updates, email spoc-ohid@dhsc.gov.uk.

The Welsh Government is developing standards for prison mental health care and substance misuse services, which were included as part of a consultation on substance misuse treatment and mental health services for prisons in 2022. The guidance outlines ways to ensure continuity of care and support positive treatment outcomes before a person is released from prison. Final versions will be available later in 2023.

17.7 Immigration removal centres

The guidance on alcohol treatment in prisons is relevant to immigration removal centres (IRCs). There are also some specific considerations when working in this context.

Migrants may have been exposed to trauma, before, during and after their migration journey and prevalence of mental health conditions, such as post-traumatic stress disorder (PTSD), is high among people in IRCs. The Royal College of Psychiatrists’ report Detention of people with mental disorders in immigration removal centres suggests that a high proportion of immigration detainees show clinically significant levels of depression, PTSD and anxiety. They also show intense fear, sleep disturbances, profound hopelessness, self-harm and suicidal ideation.

Services should follow trauma-informed principles and practice to help remove the barriers to access that people affected by trauma will experience.

Staff should routinely provide interpretation services to make sure they do not miss signs and symptoms of dependence and withdrawal when people do not speak English. OHID’s Migrant health guide has guidance on language interpreting and translation.

The IRC treatment service should share appropriate information about the pharmacological and psychological support that the person has received, as well as suicide and self-harm risks, with community substance misuse services. This will help ensure safe transfer from custody.

Healthcare staff in IRCs should give careful consideration to people’s language and cultural needs to make sure that their alcohol care does not suffer.

17.8 Probation services and criminal justice social work

There are several ways in which probation services (criminal justice social work services in Scotland) and alcohol treatment services work together to help people on community sentences to engage in alcohol treatment. Arrangements vary in different UK nations and even within nations, because some initiatives operate in a limited number of areas.

17.8.1 Community treatment requirements

In general, initiatives aim to reduce reoffending and divert people from short-term custodial sentences by addressing people’s alcohol dependence through community treatment requirements. If an area has good working between agencies, it’s more likely that courts will use treatment requirements. Community alcohol treatment services can contribute important information about the person’s alcohol problem and their treatment needs that can be included in the pre-sentencing report.

Examples of community treatment requirements include:

• alcohol treatment requirements as part of community orders or suspended sentence orders in England and Wales
• alcohol treatment as part of community payback orders mandated through problem solving courts in Scotland
• access to alcohol treatment before sentencing, with levels of engagement acknowledged in subsequent sentencing in substance misuse problem solving courts in Northern Ireland

17.8.2 Licence conditions

People can also be mandated to engage in alcohol treatment as part of a licence condition. Licence conditions are the rules that people must abide by when they are released from prison, if there is still part of their sentence to serve in the community.

Probation officers (social workers in Scotland) should discuss treatment plans with the community treatment provider before licence conditions are proposed. They also should discuss the plan with the person concerned.

Effective partnership working between alcohol treatment services and probation and other criminal justice services is essential to help people engage in treatment and recovery support and stay engaged.

17.8.3 Working relationships

Alcohol treatment services and criminal justice services should have working agreements that specify the responsibilities of each service in relation to treatment requirements imposed through courts, or as part of licence conditions. Arrangements should include details of the information that each service is required to share with the other and the system for sharing this confidential information. The services should clearly explain these arrangements to the person.

Alcohol treatment staff and probation staff need to work to form positive, trusting relationships with people who are supervised so they feel they have an active role in their own treatment. The principles of care set out in chapter 2 are vital to engaging people who may be ambivalent or anxious about treatment.

17.8.4 Alcohol Abstinence Monitoring Requirements

In England and Wales, the Alcohol Abstinence and Monitoring Requirement (AAMR) can be used as part of a community order or suspended sentence order for alcohol-related criminal behaviour. The AAMR imposes a total ban on drinking alcohol for up to 120 days.

A person’s compliance with the AAMR is monitored electronically using a tag that continuously monitors their sweat for the presence of alcohol. A 2021 Ministry of Justice alcohol monitoring statistics report shows evidence of high levels of compliance during the AAMR period. But there is currently no evidence of how AAMRs affect abstinence or controlled drinking outcomes when they are no longer in place.

Courts cannot impose an AAMR on someone who is alcohol dependent, or has an alcohol treatment requirement imposed or recommended as part of a community sentence.

Given the significant health risks of rapid alcohol withdrawal, sentencers should carefully consider self-reported alcohol use (which is often under-reported) before imposing an AAMR. Any decision to impose an AAMR should be supported by a thorough alcohol assessment, conducted by staff with alcohol treatment competencies, at the pre-sentence stage.

Through their normal contact with offenders, probation staff must be alert to physical signs of worsening health and be aware of what action to take and where to refer the person.

17.9 References

Backet SA. Suicide in Scottish prisons. British Journal of Psychiatry 1987: volume 151, issue 2, pages 218-221

Bebbington P, Jakobowitz S, McKenzie N, Killaspy H, Iveson R, Duffield G and Kerr M. Assessing needs for psychiatric treatment in prisoners: prevalence of disorder. Social Psychiatry and Epidemiology 2017: volume 52, pages 221-222

Independent Police Complaints Commission. Learning the Lessons: bulletin 12 (national archives). IPCC 2011

Kaplan M, McFarland B, Huguet N, Conner K, Caetano R, Giesbrecht N and Nolte K. Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System. Injury Prevention 2013: volume 19, issue 1, pages 38-43

Lindon G and Roe S. Deaths in police custody: a review of the international evidence. Home Office 2017: research report 95

Perkins A, Livingston W, Cairns B, Dumbrell J, Gardiner K, Little S and Madoc-Jones I. Prison population: substance use and wider support needs. Scottish Government 2022

Wright NMJ, Hearty P and Allgar V. Prisons and non-communicable diseases: a data-linkage survey of prevalence and associated risk-factors. British Journal of General Practice Open 2019: volume 3, issue 2

Zhong S, Senior M, Yu R, Perry A, Hawton K, Shaw J and Fazel S. Risk factors for suicide in prisons: a systematic review and meta-analysis. Lancet 2021: volume 6, issue 3, e164-e174

18. People with co-occurring mental health conditions

18.1 Main points

Main principles: everyone’s job and no wrong door

Co-occurring mental health conditions and alcohol use disorders are common among people attending mental health services and alcohol treatment services. But there is evidence that people with co-occurring conditions are often excluded from services and cannot access the care they need.

The 2 main principles for working with people who have co-occurring alcohol use disorders and mental health conditions are ‘everyone’s job’ and ‘no wrong door’.

Everyone’s job means that commissioners and providers of mental health and alcohol treatment services should share responsibility and work together to commission and plan services for people with co-occurring conditions. They should fully involve senior clinicians, people with lived experience and carers and agree local treatment pathways and information sharing agreements.

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 assessment as soon as possible, refer the person onto a specialist service if needed and support their urgent physical and mental health needs
• active in planning longer term care with other services

Assessing people with co-occurring conditions

When assessing a person, alcohol treatment practitioners and mental health practitioners should consider:

• the interrelationship of their mental health condition and alcohol use disorder
• how this affects the choice or timing of interventions
• how it affects risk and risk management plans

Agreeing a plan

Alcohol treatment services and mental health services and the person should agree and review a plan that identifies:

• the treatment interventions for each condition
• who will deliver the interventions
• whether they will be delivered at the same time or in sequence

The plan should also address other support needs. For example, physical healthcare and social support.

Co-ordinating care

A named person should co-ordinate care and act as the first point of contact for the person, their family or carer and other service providers. When someone with a co-occurring severe mental health disorder is accepted by secondary mental health services, the person should be allocated a care co-ordinator from the mental health service.

Where one service has appropriate expertise to provide treatment for both conditions, this provides consistency for the person. But expertise across services varies. Alcohol treatment services should be able to work with people with non-severe common mental health conditions, but they can refer people to mental health services to treat specific conditions if they do not have the expertise in their service. Community mental health services will usually provide mental health care and alcohol treatment for people with severe mental health conditions.

Complex needs

If a person is alcohol dependent or drinking harmfully and has complex needs, staff across all mental health settings should be trained to:

• offer screening (identification) for alcohol use disorders
• offer brief advice
• arrange a rapid alcohol assessment if the person may be alcohol dependent or is drinking harmfully and has complex needs

Inpatient services: admission and discharge

When people who are alcohol dependent are admitted to inpatient mental health services, it is vital that they are rapidly assessed for medically assisted withdrawal by someone with specialist alcohol treatment competence. The clinician should provide the person with medically assisted withdrawal or where necessary refer them to a specialist inpatient medically assisted withdrawal unit or acute hospital.

Discharge planning from mental health crisis and inpatient settings should involve preparation and planning for alcohol treatment in community mental health teams. Where a person needs more specialist input than the alcohol treatment interventions provided by community mental health teams, then their discharge planning should also involve community alcohol treatment services.

Intoxication and exclusion

Intoxication increases a person’s risk of harm to themself and to others. It is often implicated in self-harm, including suicide. However, there is evidence some people in mental health crisis who are intoxicated are excluded from appropriate care. Practitioners in mental health services and alcohol treatment services should be able to manage episodes of intoxication and mental health crisis safely, making referrals to crisis or emergency care where necessary. See chapter 16 on acute hospital settings for guidance on managing a person in mental health crisis who is intoxicated.

Access to evidence-based interventions

People with co-occurring conditions should have access to evidence-based psychosocial and pharmacological interventions. There are several National Institute for Health and Care Excellence (NICE) evidence-based guidelines recommending interventions for:

• alcohol use disorders
• mental health conditions
• co-occurring mental health and alcohol use disorders

18.2 Introduction

This chapter describes principles and approaches to treatment and support for people who experience both alcohol use disorders and mental health conditions. The guidance in this chapter uses the Public Health England guidance Better Care for people with co-occurring mental health and alcohol and drug use conditions.

18.2.1 Prevalence

Mental health problems and alcohol problems commonly occur together. Research on substance misuse and mental illness (Weaver and others 2003) showed that up to:

• 85% of alcohol service users had a past-year psychiatric disorder
• 25.5% of patients in community mental health teams reported harmful alcohol use
• 9.2% of patients in community mental health teams reported severe alcohol use problems

More recently, research on depression, anxiety and substance use (Delgadillo and others 2012) found 70% of a sample from community substance use treatment also met criteria for common mental health problems.

The National Confidential Inquiry into Suicide and Safety in Mental Health annual report 2022 found that from 2009 to 2019, 47% of people in the UK who died by suicide and were in contact with mental health services, also had alcohol problems.

There is also evidence that intoxication is a risk factor for suicide (Kaplan and others 2013).

In addition, people with co-occurring mental health and alcohol or drug use problems as a group experience poor health and earlier death than the general population (Hayes and others 2011).

18.2.2 Exclusion from services

Although co-occurring mental health conditions and alcohol use disorders are common, there is evidence from surveys (The Recovery Partnership: state of the sector 2015) that people with co-occurring conditions are often excluded from services.

Some mental health services might exclude people because they have an alcohol use disorder and some alcohol treatment services might exclude people because of their mental health. People in mental health crisis may be excluded from crisis and emergency services because they are intoxicated, increasing risks to themselves and others.

Commissioners and providers of mental health services and alcohol treatment services should work together to make sure that people with co-occurring mental health conditions and alcohol use disorders can access the care they need when they need it.

18.3 Principles

18.3.1 Main principles

The 2 main principles of care taken from the Public Health England guidance Better care for people with co-occurring mental health and alcohol and drug use conditions are:

1. Everyone’s job: providers and commissioners of 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 services in alcohol treatment, mental health services and other services should have an open door policy for people with co-occurring conditions and make every contact count (see section 3.3 on initial response and planning). Treatment for the co-occurring conditions should be available no matter which service they first contact.

18.3.2 Everyone’s job: partnership working

The way mental health services and alcohol treatment services are commissioned and planned varies across the UK, but the principle of partnership working applies to all areas.

Commissioners and providers of mental health and alcohol treatment services share responsibility for making sure that people with co-occurring conditions can access the help they need, when they need it, in an appropriate setting.

Commissioners, system leaders and senior service providers should work together to commission and plan services for people with co-occurring conditions, involving senior clinicians and people with lived experience and carers. They will also need to work closely with commissioners and providers of other relevant services, including primary care and acute physical health care and criminal justice services. They could use existing partnership forums or create a specific forum to develop and monitor care for people with co-occurring mental health and alcohol use disorders.

Commissioners and local health and social care system leaders should agree treatment pathways that enable people with co-occurring mental health conditions and alcohol use disorders to access appropriate treatment and support for both conditions. All staff working in mental health services and alcohol treatment services should be aware of these treatment pathways. Commissioners and system leaders should make sure that services publicise the treatment pathways across health, social care, and community services and to the local population so that people know how to access the help they need. The partnership should monitor the effectiveness of agreed treatment pathways and address any problems.

People with co-occurring mental health conditions and alcohol use disorders often have other needs including:

• other substance use needs
• physical health needs
• social support needs
• housing needs

Treatment pathways should specify how people can access support from these services when they need it.

The partnership should develop local information sharing agreements and (where possible) shared access to electronic patient records. This will involve agreements between NHS and third sector organisations in some local areas.

Developing and monitoring treatment pathways and information sharing agreements, with strong and visible support from senior leaders, will encourage services and practitioners to work together to provide co-ordinated and integrated care tailored to individual need.

You can find more information on working together in section 18.4 on collaborative care planning.

18.3.3 No wrong door: initial response and planning

‘No wrong door’ does not mean that people must receive care at the first service they attend, but that all services should:

• be proactive, flexible, compassionate and anti-discriminatory in their response
• offer an initial assessment as soon as possible and refer the person onto an appropriate specialist service if needed
• offer a person support for their urgent physical and mental health and social care needs, while also making plans for longer term care and support
• have a named lead who can co-ordinate care and comprehensive support from multiple providers effectively, underpinned by clear communication reflected in case notes
• explore with people why they may have stopped using services in the past and agree a plan to help them stay engaged

When someone with a co-occurring severe mental health disorder is accepted by secondary care mental health services, the person should be allocated a care co-ordinator from within the mental health service. You can find more guidance on secondary care mental health services in NICE guideline Coexisting severe mental illness and substance misuse: community health and social care services (NG58).

Practitioners in both alcohol treatment settings and mental health settings should be competent and supported to provide initial assessment and support for both conditions and work together to provide appropriate treatment.

An important part of the ‘no wrong door’ principle is that providers should be using the Making every contact count (MECC) approach. MECC helps promote health and healthy lifestyles by taking every opportunity to reduce health harms by offering advice and support to:

• stop smoking
• eat healthily
• maintain a healthy weight
• undertake the recommended amount of physical activity
• improve their mental health and wellbeing

18.3.4 Broader principles of care

People with co-occurring mental health conditions and alcohol use disorders, are stigmatised in society and sometimes within healthcare services. They have historically often been excluded from services or have had negative experience of care. Chapter 2 on principles of care sets out principles that should underpin all treatment and help to provide a better experience of care for people who have been excluded and marginalised. These principles include prioritising:

• the therapeutic relationship
• trauma-informed care
• cultural competence

18.3 Assessment

Practitioners in both alcohol treatment and mental health services should be able to:

• identify mental health conditions and alcohol use disorders
• offer initial assessment as soon as possible and initial support for urgent needs
• work together to plan and provide treatment for both conditions

Services should provide training, supervision, and procedures for escalating cases for immediate advice from the multidisciplinary team or senior clinicians so that practitioners are competent and supported to do this.

In some services there will be clinicians with the expertise to carry out a more comprehensive assessment, develop a formulation of the person’s needs and offer interventions that address both conditions. Where this is possible, it offers the person more consistency and continuity. However, expertise varies across services and this will not always be possible.

If the person is already attending a mental health service or an alcohol treatment service when they present at the other service, the assessor should involve the keyworker from the other service (with the person’s consent) in assessing and planning for the person’s needs.

Initial assessment should include consideration of the interrelationship between the person’s alcohol use and their mental health conditions, how they impact on one another and on risk and risk management planning.

Chapter 4 provides guidance on initial and comprehensive assessment for people with alcohol use disorders. Section 4.18.9 of that chapter provides guidance on assessing mental health as part of that assessment.

18.4 Collaborative care planning

18.4.1 Agreeing a co-ordinated care plan

People with co-occurring conditions should be able to access the care they need, when they need it, provided in the setting most suitable to their needs.

When local partnerships are developing or reviewing individual care plans, they should have an agreed protocol or written agreement that sets out how organisations will collaborate, share responsibilities and ensure regular communication. The protocol can include:

• mental health services
• alcohol and drug services
• primary and secondary care
• social care
• local authorities
• other organisations like housing and employment services

For each individual person, it may be appropriate to deliver interventions:

• addressing both conditions in one setting
• from both settings at the same time
• in sequence where one service leads to address a specific issue and then refers to the other for an additional unmet need

The assessors and the person should decide the way that collaborative care will be provided based on the person’s individual needs and on locally agreed treatment pathways. The availability of suitably trained and competent staff will also determine what is available locally.

Where the mental health service and the alcohol treatment service will both provide care, they should agree a care plan (treatment and recovery plan). This will identify the treatment interventions for each condition, who will deliver them and whether they will be delivered at the same time or in sequence. The plan should address other support needs including physical healthcare and social support.

Personalised risk management (safety) planning should include strategies to manage risks related to mental health and to alcohol use. Services should share information and expertise on managing these risks. There should also be contingency and crisis plans for managing loss of contact or a deterioration in the person’s mental health (including increased suicide risk) or a relapse in their alcohol use.

Mental health and alcohol services should work to one overall co-ordinated care plan. In some cases, they may have their own more detailed plans, which are aligned with the overall plan. The person should be fully involved in developing their care plan (unless they lack mental capacity). Services should also ask family members or carers to be involved where this is appropriate and the person consents.

A named person should co-ordinate care and act as the first point of contact for the person, their family or carer, and other service providers. When someone with a co-occurring severe mental health disorder is accepted by secondary care mental health services, the person should be allocated a care co-ordinator from the mental health service. You can find more guidance on secondary care mental health services in NICE NG58.

Practitioners from both services and the person should jointly regularly review the co-ordinated care plan including risk management plans and amend as appropriate. They should also agree arrangements for ongoing information sharing. The practitioners should communicate regularly and update one another if there are changes in the person’s situation or changes in risk to themselves or others. This should include sharing information on changes in the person’s pattern of alcohol use.

Services should work together to develop a shared plan with the person (and where appropriate with family members) for ongoing care before:

• a transition from one service to another (for example, between a young person’s service and an adult service)
• discharge from a service (for example, an inpatient service)

There are increased risks at both those times. You can find more guidance on this in NICE NG58.

There is further guidance on multi-agency treatment and recovery planning in chapter 4 on assessment and treatment and recovery planning.

18.4.2 Severe mental health conditions

Generally, mental health services should take the lead on delivering interventions to people with more severe mental health conditions and should address both conditions.

When alcohol treatment services are working with mental health services to provide treatment and support for people with co-occurring severe mental health and alcohol use disorders, the mental health service should lead and co-ordinate care in line with national and local practice.

Guidance for working with people with co-occurring drug and alcohol disorders and severe mental illness is set out in NICE NG58 and in NICE clinical guideline Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (CG120).

18.4.3 Common less severe mental health conditions

Alcohol treatment services should be able to work with people with non-severe common mental health conditions, but they can refer people to mental health services to treat specific conditions if they do not have the expertise within their service.

Where people have a less severe mental health condition (non-severe anxiety or depression), alcohol treatment services should start treatment for the alcohol use disorder as this may reduce the person’s psychological distress. However, once the person has reinstated control over their drinking or achieved abstinence and the mental health condition remains, the mental health service or psychological therapies service should treat the mental health condition if the alcohol treatment service does not have staff with appropriate expertise. The 2 services can then work together with the person to address both conditions. There is no evidence that delaying mental health treatment to monitor abstinence from alcohol for weeks or months is effective in helping people.

18.4.4 Co-ordinating medically assisted withdrawal (detoxification)

Where mental health services and alcohol treatment services are both working with a person, medically assisted withdrawal (detoxification) should be carefully co-ordinated.

Some people may need medically assisted withdrawal but have longstanding or severe mental health conditions, or have unstable mental health. They should have a mental health support package in place before they start withdrawal. Mental health services and alcohol treatment providers should work together to arrange this support package to help the person through the process of medically assisted withdrawal and reduce their risk of relapse. A clinician with specialist alcohol treatment expertise should assess the person for medically assisted withdrawal and recommend whether a specialist inpatient setting would be the appropriate setting due to safety considerations.

Chapter 10 on pharmacological interventions provides guidance on medically assisted withdrawal. Section 10.6.5 in chapter 10 provides brief guidance on pharmacological interventions for people with co-occurring mental health conditions.

Section 11.3 in chapter 11 provides guidance on criteria for deciding on the appropriate setting for medically assisted withdrawal based on safety considerations. Where people have unstable mental health, specialist inpatient withdrawal is usually the appropriate setting.

18.4.5 When the person does not want to engage in alcohol treatment

If the person does not want to engage with specialist alcohol treatment, depending on the severity of the mental health problem and the risk profile of the person, the mental health service will still need to remain engaged. In these circumstances, the care plan should include:

• ongoing monitoring of alcohol use
• ongoing monitoring of physical health, including access to liver screening (see NICE guideline Cirrhosis in over 16s: assessment and management (NG50) and chapter 19 appendix K on liver disease screening and management)
• motivational work
• provision of harm reduction interventions, advice and information (see guidance on harm reduction in chapter 8)

The mental health service may need to work with primary care to manage the person’s alcohol use disorder. There should be some staff in mental health services with alcohol specialist expertise

18.4.6 Managing suicide risk

People with mental health conditions and co-occurring alcohol use disorders are at increased risk of suicide and often experience one or several of the risk factors identified in the National Confidential Inquiry into Suicide and Safety in Mental Health Annual Report 2022. These include:

• previous self-harm
• multiple mental health diagnoses
• living alone
• experience of domestic abuse
• recent economic adversity

Since 2013, men aged 40 to 54 have had the highest suicide rate in the UK.

Having a policy for working with people with co-occurring mental health conditions and alcohol use disorders can help to reduce suicide risk. A 2013 national inquiry into suicide and homicide by people with mental illness (PDF 310KB) found that in England, there was a 25% fall in rates of suicide by patients in NHS trusts that had a policy on the management of patients with co-morbid alcohol and drug misuse.

When working to reduce the risk of suicide, mental health services and alcohol treatment services should work in line with:

• NICE guideline Self-harm: assessment, management and preventing re-occurrence (NG225)
• NICE NG58

Staff in mental health services and alcohol treatment services should:

• understand that both alcohol dependence and intoxication can increase risk of suicide in people with co-occurring mental health conditions
• be trained and supported by a multidisciplinary team to identify and respond to risk of self-harm and suicide, in line with organisational protocols and procedures
• mental health staff assessing risks should be trained to assess harmful drinking and alcohol dependence

You can find some guidance on assessing risk of self-harm and suicide in alcohol treatment services in chapter 4 on assessment and treatment and recovery planning.

Services and practitioners should always personalise risk management (safety) plans and tailor them to the specific needs and risks of the person. NICE NG225 states that risk assessment tools and scales should not be used to predict future suicide or repetition of self-harm, or to determine who should or should not be offered treatment or who should be discharged. The guidelines recommend that risk assessment should focus on the person’s needs and how to support their immediate and long-term psychological and physical safety.

Risk assessment should include significant dates and anniversaries and online suicide-related activity which may then form part of safety planning.

Services should have agreed pathways for managing people who are assessed as at immediate risk of suicide or self-harm. Staff should follow these procedures and seek support from the appropriate clinician or clinical team.

Collaborative care plans for ongoing care should include arrangements for immediate information sharing with the care co-ordinator and quick follow-up if a person at risk of suicide loses contact with a service.

18.5 Managing episodes of intoxication safely

People in a mental health crisis can resort to alcohol to manage their distress. Their alcohol use can also lead to an escalation in symptoms of mental ill-health including psychosis, self-harm and suicidal intent. They might present to emergency services, crisis services, inpatient mental health services or community services in a state of acute intoxication. The underlying alcohol use disorder may reflect heavy episodic drinking or a severe dependence that requires rapid medical management.

Whatever the case, the immediate priority is to make sure any acutely intoxicated person is safe and not a risk to themselves or others. People presenting in a mental health crisis, self-harming or with suicidal intent should never be turned away from services, because this could increase risks to themselves or others. Staff should support them to access suitable care, including a place of safety where necessary, and monitor their safety.

There is guidance on managing and monitoring people who are intoxicated and in mental health crisis in an acute setting in appendix H in chapter 16 on acute hospital settings.

Staff in mental health services and alcohol treatment services should be able to identify the signs of intoxication and respond appropriately to the associated risks. In particular, these risks include:

• the person not being able to maintain their own safety (for example, being disorientated, losing motor co-ordination)
• physical risks (for example, accidents or alcohol poisoning)
• disinhibition (possibly enhancing feelings of distress or anger)

There is guidance on managing alcohol poisoning in chapter 8 on harm reduction.

If someone is at risk of self-harm, including suicide, or presents after an act of self-harm, services should work in line with NICE NG225. This provides detailed guidance on self-harm. NICE NG225 states that psychosocial assessment should not be denied because the person is intoxicated or has been drinking.

Once the person is less intoxicated, a suitably competent clinician should reassess the severity of their alcohol dependence and their mental health. Staff responsible for treating or monitoring the person should (with their consent) provide harm reduction information relating to alcohol use and mental health. They should also refer the person to specialist alcohol treatment and mental health treatment where necessary and follow up the referral to make sure they have engaged with the service.

18.6 Working with people with co-occurring alcohol use disorders in mental health settings

18.6.1 Strategic leadership

There should be senior level commitment from mental health services to deliver appropriate interventions for people with co-occurring mental health and alcohol use disorders. This could require a cultural shift in the organisation to understand that working with people with alcohol use disorders is a core part of their role.

Mental health systems should work with primary care, community healthcare and secondary care to be part of a whole system approach to improve local outcomes for mental health and alcohol use disorders.

Commissioners, system leaders and providers of mental health services should work with commissioners and providers of alcohol treatment to plan services and agree treatment pathways between mental health services and alcohol treatment services. Section 18.3.2 on partnership working provides guidance on this.

Senior mental health clinicians and senior alcohol treatment clinicians should be involved in the planning and commissioning of pathways between mental health and alcohol treatment services. A designated alcohol lead in the local partnership can help to make sure that mental health services offer effective interventions and pathways for the full range of alcohol use disorders.

18.6.2 Identification (screening) of people with alcohol use disorders

Alcohol use disorders are common among people with mental health conditions, so mental health services (community based, crisis and inpatient) should provide routine identification (screening) for alcohol use disorders. Staff should be trained to carry out identification using a simple validated tool and to offer brief advice to hazardous and harmful drinkers where they have no additional complex needs. You can find guidance on identification (screening) and brief interventions in chapter 3 on alcohol brief interventions.

Where people are identified as possibly alcohol dependent or drinking at harmful levels with complicating factors (such as unstable mental health or liver disease), staff should refer the person for a specialist alcohol assessment. This assessment can be carried out in the mental health setting where there are trained staff with appropriate alcohol specialist competencies. Where practitioners with these competencies are not available, the mental health practitioner responsible for the person’s treatment should make a referral to the local specialist community alcohol treatment service.

Psychological therapists working in mental health settings should have the competence to provide a psychological formulation that integrates the function of the alcohol use with an understanding of the presenting mental health need. You can find more information on formulation in chapter 5 on psychosocial interventions. Agreeing a formulation with the person will show that the clinician wants to understand them. It can also help the person to recognise their problems and enhance their motivation to seek specialist help.

In England, the NHS talking therapies manual (formerly known as improving access to psychological therapies (IAPT)) includes a “bite-size positive practice guide” for psychological therapists on working with people who use drugs and alcohol and a link to the full drug and alcohol positive practice guide (PDF, 406KB). Some of the guidance may also be useful to mental health and psychological therapies services across the UK.

18.6.3 Referral and collaborative care planning

Section 18.3.2 on partnership working provides guidance on developing treatment pathways between mental health services and alcohol treatment services. Mental health services should make sure that staff are aware of local treatment pathways and that these pathways are clear, simple and clearly communicated to people identified as suitable for referral. Services should have information sharing agreements and systems in place so that practitioners can share information about the person (with their consent) including information on risks, and avoid them having to tell their story repeatedly to different services.

Wherever possible, mental health practitioners should refer people for alcohol treatment by contacting alcohol treatment services. Relying on a person to self-refer is unlikely to be successful. If the alcohol treatment service receives a referral, they can contact the person and encourage them to come and attend another appointment if they miss the first one. The referrer should routinely follow up with the person and with the alcohol treatment service, so they know if the person is engaging with the service.

Following the referral to specialist alcohol treatment, the practitioners from the mental health service and alcohol treatment service will need to agree whether the person’s care will be handed over to the alcohol treatment service or whether the services will work together to provide care. You should follow the guidance in section 18.4 on collaborative care planning.

18.7 Inpatient mental health settings

The guidance in this chapter is relevant to all mental health services, but there are some additional considerations for inpatient settings.

18.7.1 Medically assisted withdrawal

When people who may be alcohol dependent are admitted to inpatient mental health services, it is vital that they are quickly assessed for medically assisted withdrawal by someone with specialist alcohol treatment competence. This is important because untreated withdrawal symptoms can lead to serious complications and can even be life threatening.

Staff involved in admissions and assessment processes should be able to identify that someone may be alcohol dependent and in need of medically assisted withdrawal. All inpatient mental health settings should have local guidelines on delivering or providing access to medical assisted alcohol withdrawal. Staff involved in admissions and assessment processes should be able to arrange for the person to have a medically assisted withdrawal according to local guidelines, with support from specialist clinicians. The specialist clinician should provide the person with medically assisted withdrawal, or where necessary refer them to a specialist inpatient medically assisted withdrawal unit or acute hospital.

There is guidance on medically assisted withdrawal in chapter 10 on pharmacological interventions. This includes guidance on complications in withdrawal, and guidance on appropriate settings for medically assisted withdrawal.

18.7.2 Managing intoxication on the ward

Inpatient settings should have local protocols for managing intoxication safely on the ward and should not exclude people who are intoxicated. Staff should be aware that intoxication increases a person’s risk of harm to themself and to others. See section 18.5 on managing episodes of intoxication safely.

18.7.3 Planning for discharge

Discharge planning from mental health crisis and inpatient settings should involve preparation and planning for alcohol treatment with community mental health teams. Where specialist input is needed, the discharge planning should involve community alcohol treatment services. The transition from inpatient care to the community can be a vulnerable time when people are at increased risk of a return to problematic alcohol use If the community mental health team has appropriate expertise, they should plan alcohol treatment interventions alongside mental health interventions before discharge. This is so the person has support during that high-risk transition.

If the plan needs input from community alcohol treatment services, the practitioner co-ordinating discharge planning should involve the alcohol treatment service in planning before discharge. This is so they can offer an appointment before or just after discharge and have the information they need to provide appropriate care. Visits from people with lived experience of co-occurring mental health and alcohol use disorders can also encourage people to engage with the alcohol treatment service.

The NICE guideline Transition between inpatient mental health settings and community or care home settings (NG53) provides more guidance on planning for discharge.

18.7.4 Training and skills for staff working in mental health

All practitioners working in mental health care settings should be trained and supported to:

• carry out routine identification (screening) and brief interventions
• make an initial assessment of alcohol and drug use and respond to urgent physical and mental health needs
• identify and make effective referrals to alcohol treatment services
• participate in collaborative care planning and co-ordination
• provide alcohol harm reduction advice and interventions (see chapter 8 on harm reduction)
• understand and identify additional risks or referrals (for example, a safeguarding referral)
• safely manage episodes of intoxication

Additional skills and training will be necessary for staff working in crisis services and inpatient settings. They should be able to:

• ensure a person who is acutely intoxicated and in mental health crisis is safely managed and monitored
• assess alcohol and drug use as factors for suicide risk and include actions to reduce or manage use as part of risk management planning
• identify when a person requires medical management and medically assisted withdrawal
• safely provide a medically assisted withdrawal, according to local policy and procedures and these alcohol clinical guidelines (alcohol specialist members of the team).

NICE clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) recommends that staff responsible for assessing and managing medically assisted alcohol withdrawal should be competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms and the use of drug regimens appropriate to the setting (for example, inpatient or community) where the withdrawal is managed. This is important so staff can manage the process safely.

You can find guidance on medically assisted withdrawal in chapter 10 on pharmacological interventions and chapter 16 on acute hospital settings.

Mental health providers are responsible for ensuring practitioners are suitably trained and supported. Mental health and substance misuse commissioners should support services to make sure the above alcohol-related skills become part of their standard workforce competencies.

18.8 Working with people with co-occurring mental health conditions in alcohol treatment services

For more on assessment and collaborative care planning, see section 18.4 on collaborative care planning.

You should also read section 4.18.9 of chapter 4 on assessment and treatment and recovery planning. This provides guidance on assessing mental health as part of a comprehensive alcohol assessment. There is also guidance on planning and co-ordinating care for co-occurring conditions.

Alcohol treatment services should support people with common mental health conditions such as non-severe depression and anxiety if they are not accessing community mental health services. Practitioners should include any goals the person has around managing their mental health within their treatment and recovery plan.

Alcohol treatment services should provide access to self-help resources (print or online) to address common mental health conditions and practitioners can also support people to work through these resources if they need help to do this.

Practitioners can provide psychoeducation on the mental health condition including the role of alcohol in maintaining this condition or making it worse. For example, while people may use alcohol as an attempt to manage depression, harmful or dependent alcohol use is likely to increase depression. Cognitive behavioural approaches to relapse prevention often include this kind of psychoeducation and coping strategies for managing anxiety and depression. See section 5.7.4 in chapter 5 on psychosocial interventions for more information on cognitive behavioural interventions.

If there are staff trained and supervised to deliver recommended evidence-based interventions for the mental health conditions, then these could be provided in the alcohol treatment setting. These interventions should follow the relevant NICE guideline (or equivalent national clinical guideline) for the condition (see section 18.9 below). If the alcohol treatment service does not have staff with appropriate training and supervision, they should refer the person to a community mental health service or psychological therapies service for treatment for the condition.

18.9 Psychosocial interventions for co-occurring mental health and alcohol problems

People with co-occurring mental health and alcohol use disorders should have access to evidence- based interventions for both alcohol use disorders and mental health conditions. You can find guidance on pharmacological interventions for alcohol use disorders in chapter 10 and psychosocial interventions for people with alcohol use disorders in chapter 5.

This section details several specific mental health conditions that commonly co-occur with alcohol use disorders, although other mental health conditions not included here may also co-occur with alcohol use disorders. Suitably trained and competent practitioners can provide evidence- based interventions to address these conditions.

18.9.1 Assessment and different approaches to psychosocial treatment

As with all psychosocial interventions, assessment and formulation are essential to understand the relationship between drinking and any mental health condition and to develop treatment that addresses both. There is guidance on formulation in section 5.4 in chapter 5 on psychosocial interventions.

There are different approaches to delivering effective treatments and the evidence for the best approach is still emerging.

Where more than one service is involved, they can agree one overarching treatment and recovery plan together and each service may have their own more detailed treatment and recovery plan that sets out the interventions they will provide. Best practice includes good communication between professionals about the treatment and recovery plans. The person should be fully involved in choosing the goals and interventions that are included in treatment and recovery plans.

Where there are suitably trained staff, it may be possible to treat both conditions as part of a single intervention. This is described as a dual-focused approach.

While research in this area is still limited, evidence shows that a dual-focused approach with a combination of psychosocial treatments can be effective for:

• depressive disorder (Delgadillo and others 2015)
• bipolar disorder (Farren and McElroy 2008, Weiss and others 2009)
• post-traumatic stress disorder (Najavits 2007)

A dual-focused approach could mean adapting a single treatment approach (for example, cognitive behavioural therapy) to address both disorders at the same time, or blending 2 different evidenced-based treatments (such as cognitive behavioural therapy and motivational interviewing). A dual-focused approach may help to better engage people in treatment, because many people will not believe their alcohol use and mental health problems are easily separable. So, they might find addressing both issues in one setting makes more sense and is more convenient.

18.9.2 Depression

Primary mild or moderate depressive disorder is very common in alcohol treatment populations. Alcohol treatment services should use basic approaches to identify service users who may have depressive disorder. For example, the NICE clinical guideline Common mental health problems: identification and pathways to care (CG123) suggests asking the following 2 questions.

1. During the last month, have you often been bothered by feeling down, depressed or hopeless?
2. During the last month, have you often been bothered by having little interest or pleasure in doing things?

Answering yes to either question indicates possible depressive disorder, so you should follow this with an assessment by an appropriately trained mental health practitioner, as set out in NICE CG123. However, practitioners should also be aware that people might experience depressed mood if they have recently used alcohol, been intoxicated or they are experiencing withdrawal. Their depressed mood may improve after reducing alcohol use or after a period of abstinence, although this will not always be the case.

Practitioners should provide guided self-help based on cognitive behavioural approaches as part of routine clinical care (for example during keyworking) for mild or moderate depressive disorders (one or 2 sessions).

Dual-focus treatments that combine cognitive (for example identifying and changing unhelpful patterns of thinking), behavioural (for example behavioural activation) and motivational (for example motivational interviewing) components generally have better outcomes at follow-up than offering separate treatments in different services. If you offer treatment for depression at the same time as alcohol treatment, the psychological therapy for depression should ideally be co-located with the alcohol treatment service, because this could mean the person stays in treatment longer. You should only offer the treatment for depression in the alcohol treatment service if there are qualified practitioners trained in the approach and with the relevant clinical supervision.

Trained staff should use the following NICE clinical guidelines to treat depression.

Common mental health problems: identification and pathways to care (CG123).

Depression in adults: treatment and management (NG222).

Depression in adults with a chronic physical health problem: recognition and management (CG91).

18.9.3 Anxiety disorders

Primary mild or moderate anxiety disorders (panic disorder, social anxiety, generalised anxiety disorder) are very common in alcohol treatment populations. Alcohol treatment services should identify service users who may have anxiety disorders.

NICE CG123 suggests using the 2-item Generalised Anxiety Disorder scale (GAD-2) to ask the person about feelings of anxiety and their ability to stop or control worry.

For more information and the full GAD-2 scale see NICE GG123.

Sometimes, the person needs to be stable in their alcohol treatment before a healthcare professional can diagnose an anxiety disorder and plan treatment. Practitioners should give people advice on managing anxiety if it is indicated during assessment.

Specialist mental health services or alcohol treatment services (where staff are suitably trained and supervised) should use the standard interventions for treating and managing anxiety disorders when appropriate.

Trained staff with the necessary competences should use the following NICE guidance to treat anxiety disorders.

Social anxiety disorder: recognition, assessment and treatment (CG159).

Generalised anxiety disorder and panic disorder in adults: management (CG113).

18.9.4 Post-traumatic stress disorder and complex trauma

People in alcohol treatment have high rates of post-traumatic stress disorder (PTSD) and complex trauma, so services should be trauma-informed. Trauma-informed care requires services and practitioners to use an approach based on its core principles, which are set out in OHID’s Working definition of trauma-informed practice, and to understand the impact of trauma and recognise the signs and symptoms of PTSD. This is different to providing specialist treatment for PTSD.

It is essential that all services can identify possible PTSD and can confirm the diagnosis or refer to a specialist team for assessment. The PTSD services and the alcohol service may need to work together to deliver treatment interventions.

Treatment for PTSD requires qualified staff with specialist training and supervision. An alcohol treatment service should only provide it where trained staff are available. In most circumstances, a specialist mental health team will provide treatment.

Trauma-focused treatments with an exposure component, combined with interventions for substance misuse, have been shown to reduce PTSD severity (Najavits 2007). Some people may need stabilisation interventions (for example, to reduce risky behaviours and increase emotional regulation skills) before they start trauma-focused treatment, to help prepare them and minimise drop-out.

Treatment for complex PTSD requires a phase-based approach consisting of:

• an initial phase focusing on safety and stabilising symptoms (present-focused)
• a second phase focusing on processing traumatic memories (past-focused)
• a re-integration phase (future-focused)

Stabilising a person’s alcohol use can support this phased approach, although the specific role for alcohol treatment services in trauma treatment should be determined locally and will be dependent on the training and competencies of staff.

Trained staff should use NICE guideline Post-traumatic stress disorder (NG116).

18.9.5 Eating disorders

Eating disorders are common in alcohol treatment populations, although there is limited research in this area.

When identifying people with eating disorders, alcohol treatment practitioners should be aware of the range of indicators set out in the NICE guideline Eating disorders: recognition and treatment (NG69).

Mental health services should provide treatment for the co-occurring eating disorder with support from a specialist alcohol treatment service if required. Common components of treatment for both disorders can include psychoeducation, cognitive restructuring (identifying and changing unhelpful patterns of thinking) and teaching coping skills. Targeting psychological processes that are common to both disorders (for example, learning to manage emotions better) may be helpful for each condition.

You can find further information about treating eating disorders in NICE NG69.

18.9.6 Severe mental illness: psychosis and bipolar disorder

People with a severe mental illness need a care package co-ordinated by mental health services or a GP.

At present, there is not enough evidence to recommend dual-focused treatment to manage co-occurring psychosis and substance use disorder. Services should offer patients specific interventions for each disorder as outlined in existing NICE guidance identified below.

For bipolar disorder, services (usually mental health services) should offer dual-focused treatments based on cognitive behavioural principles that are focused on bipolar disorder and substance use disorder interactions. Evidence shows that these treatments are more effective for depressive, manic and substance use symptoms, compared to single treatment approaches (Farren and McElroy 2008, Weiss and others 2009).

Motivational interviewing (MI) offers a non-confrontational and person-centred approach to talk about alcohol use with people who have serious mental illness and co-occurring alcohol dependence. MI can be delivered as a brief intervention but can also be deployed over a longer period of time. MI could also help people with severe mental illness to engage with treatment. You can read more about MI in chapter 5 on psychosocial interventions.

Services should provide harm reduction advice as well as information about how alcohol negatively affects mood, sleep and managing emotions.

Trained staff should use the following NICE guidelines to treat severe mental illness:

• Coexisting severe mental illness and substance misuse: community health and social care services (NG58)
• Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (CG120)
• Psychosis and schizophrenia in adults: prevention and management (CG178)
• Bipolar disorder: assessment and management (CG185)

18.9.7 Personality disorder

Mental health specialists will usually treat people with personality disorders, in line with current NICE guidelines, because this is a complex condition that requires specific training and supervision.

For people with co-occurring alcohol use disorders, their mental health treatment should include helping them gain insight and control over their alcohol use. Mental health services may work with alcohol treatment services where they do not have the relevant specialist expertise to provide alcohol treatment interventions in mental health services.

Systems and pathways for emergency psychiatric care should be available to assess and manage people with co-occurring personality disorder and substance use who are experiencing a mental health crisis.

You can find more guidance on working with personality disorders in the following NICE guidelines to treat personality disorders:

• Borderline personality disorder: recognition and management (CG78)
• Antisocial personality disorder: prevention and management (CG77)

18.10 References

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 2012: volume 6, issue 1

Delgadillo J, Gore S, Ali S, Ekers D, Gilbody S, Gilchrist G, McMillan D, Hughes E. Feasibility randomized controlled trial of cognitive and behavioral interventions for depression symptoms in patients accessing drug and alcohol treatment. Journal of Substance Abuse Treatment 2015: volume 55, pages 6-14

Farren and McElroy Treatment response of bipolar and unipolar alcoholics to an inpatient dual diagnosis program. Journal of Affective Disorders 2008: volume 106, issue 3, pages 265-272

Hayes R, Chang CK, Fernandes A, Broadbent M, Lee W, Hotopf M, Stewart R. Associations between substance use disorder sub-groups, life expectancy and all-cause mortality in a large British specialist mental healthcare service. Drug and Alcohol Dependence 2011: volume 118, issue 1

Kaplan M, McFarland B, Huguet N, Conner K, Caetano R, Giesbrecht N and Nolte K. Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System. Injury Prevention 2013: volume 19, issue 1, pages 38-43

Najavits L. Seeking safety: an evidence-based model for substance abuse and trauma/PTSD. In Therapist’s guide to evidence-based relapse prevention. Editors: Witkiewitz K and Marlatt A. Academic Press 2007: pages 141-167

Weaver and others Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. The British Journal of Psychiatry 2003: volume 183, issue 4, pages 304-313

Weiss R, Griffin M, Jaffee W, Bender R, Graff F, Gallop R and Fitzmaurice G. A “community-friendly” version of integrated group therapy for patients with bipolar disorder and substance dependence: a randomized controlled trial. Drug and Alcohol Dependence 2009: volume 104, issue 3, pages 212-219

19. People with co-occurring physical health conditions

19.1 Main points

Alcohol increases the risk of many health conditions including some cancers, liver disease, cardiovascular disease, and diseases of the central nervous system.

Smoking and drinking in combination increases the risk of some alcohol related diseases.

Everyone starting alcohol treatment should receive a comprehensive physical health assessment by a clinician, which should be regularly repeated throughout treatment.

If a physical health assessment suggests concerns, people should be quickly referred for further investigation and supported to access and complete any necessary treatment.

There should be ongoing communication between clinicians in alcohol treatment services and clinicians in primary and secondary care about the person’s physical healthcare needs.

When developing a treatment and recovery plan with the person, alcohol treatment practitioners should include goals and actions related to the person’s physical health where relevant.

Alcohol treatment services should ensure their teams are aware of the latest guidance on supporting people to stop smoking and provide opportunities for them to support smokers to quit.

Alcohol treatment services should make sure there are clear local referral and care pathways to stop smoking support.

19.2 Alcohol and health risks

People who drink alcohol, especially people who drink at harmful or dependent levels, have an increased risk of a range of health problems, including:

• some cancers
• liver disease
• cardiovascular disease
• diseases of the central nervous system, such as alcohol related brain damage

Alcohol-related health risks vary according to the volume and frequency of alcohol consumed, as well as several other factors including:

• age
• sex
• body mass index (BMI)
• length of time someone has been using alcohol

In general, the more that someone drinks, the greater their risk of alcohol related health harms.

Alcohol treatment services and other health professionals should provide people with simple, accessible information on alcohol related health risks, and personalise advice on reducing health harms.

19.3 Assessing and managing physical health in alcohol treatment services

Everyone starting alcohol treatment should receive a comprehensive physical health assessment by a clinician, which should be regularly repeated throughout treatment. Clinicians should assess for health conditions that are alcohol related and those that are unrelated.

If a physical health assessment suggests concerns, people should be quickly referred for further investigation and supported to access and complete any necessary treatment.

The alcohol treatment clinician should work with the person’s GP and relevant secondary care clinicians to make sure that the person’s healthcare needs are addressed. You can find guidance on providing a physical health assessment in alcohol treatment services in chapter 4 on assessment and treatment and recovery planning.

19.4 Including physical health conditions in the treatment and recovery plan

Many people in alcohol treatment will have co-occurring physical health conditions. When developing a treatment and recovery plan with the person, alcohol treatment practitioners should include goals and actions related to the person’s physical health where relevant.

For example, a treatment and recovery plan might include:

• personal goals and actions in relation to physical health such as stopping smoking

• actions around attending healthcare appointments and reviewing outcomes
• attendance at health and wellbeing activities including support groups for people with long term conditions
• discussion of harm reduction and health information

You can find guidance on treatment and recovery planning in chapter 4 on assessment and treatment and recovery planning.

19.5 Alcohol related health risks

Public Health England’s evidence review on the public health burden of alcohol found that risks for the following diseases were increased by drinking.

19.5.1 Cancers

There is strong evidence for an association between alcohol use and cancer, including cancers of the:

• lip, oral cavity and pharynx
• oesophagus
• larynx
• colon
• rectum
• liver and intrahepatic bile ducts
• breast

Smoking and drinking alcohol increases several health risks.

There is evidence that for men who have never smoked, the risk of alcohol-related cancers is not much higher for those drinking less than 3.75 units per day (Cao and others 2015). However, for women who have never smoked, the risk of alcohol-related cancers, mainly breast cancer, increases even within the range of up to around 2 units per day.

A large scale longitudinal study found that compared to men who have never smoked and do not drink, men who smoke and drink more than 15 units a week have the highest mortality from smoking-related cancers (Hart and others 2010a). Either drinking alcohol or smoking increases the risk of getting cancer but doing both increases the risk to a greater extent than either behaviour alone.

19.5.2 Liver disease

Alcohol-related liver disease (also known as alcoholic liver disease) is a type of damage or disease to the liver caused by heavy alcohol use, including fatty liver disease, alcoholic hepatitis and cirrhosis.

Liver disease is responsible for the most (approximately 80%) deaths that are caused wholly by alcohol in the UK.

There is evidence that obesity-induced fatty liver can progress to cirrhosis and liver failure, but obesity can also increase the harm to the liver caused by alcohol use (Hart and others 2010b). In simple terms, for a person with a BMI of over 35, the liver risk doubles at any given volume of alcohol use.

It is important to screen for liver disease as it often does not show outward symptoms until it is at an advanced stage.

You can find guidance on screening and management of liver disease in appendix K at the end of this chapter.

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

19.5.3 Cardiovascular disease

Hypertension

There is a close relationship between drinking alcohol and hypertension (high blood pressure). Risk of high blood pressure starts at lower levels of alcohol use for women (from approximately 2 units per day) than for men. High blood pressure accounts for most alcohol-related hospital admissions for cardiovascular disease.

Alcohol treatment services and other health professionals should screen people who drink harmfully or dependently for high blood pressure.

Stroke

There is evidence (Ronksley and others 2011) that people who drink more than 7.5 units a day are at increased risk of incident stroke (bleeding in or around the brain or blocked artery to the brain) compared with people who do not drink at all.

Either drinking alcohol or smoking increase the risk of stroke, but smoking and drinking together increases the risk to a greater extent than either behaviour alone.

There is evidence (Hart and others 2010a) that men who smoke and drink more than 15 units per week have the highest risk of death from stroke.

Heart disease

Heavy drinking and episodic (binge) drinking increases the risk of heart disease (angina, heart attack, heart failure) and death from heart disease.

Men who smoke and drink more than 15 units per week have the highest risk of death from heart disease.

Atrial fibrillation

Binge drinking is a risk factor for atrial fibrillation (severe irregular heartbeat). However, the risk of atrial fibrillation increases with the amount the person drinks from 1.5 units per day upwards.

19.5.4 Central nervous system

Brain damage

Alcohol related brain damage (ARBD) describes various psychoneurological or cognitive conditions that are associated with long-term, heavy alcohol use and related vitamin deficiencies (particularly thiamine deficiency).

Wernicke’s encephalopathy is an acute medical emergency where alcohol withdrawal and lack of vitamin B1 causes inflammation of the brain. It has a high risk of death and if untreated, may lead to Wernicke-Korsakoff syndrome which involves irreversible memory loss. However, if caught early enough and treated with thiamine supplementation, long term brain damage is preventable.

You should read guidance on alcohol related brain damage in chapter 20.

Peripheral neuropathy

Peripheral neuropathy is damage to the nerves that results from excessive drinking. It causes symptoms that include numbness in the arms and legs and abnormal sensations such as pins and needles.

Epilepsy

There is a relationship between heavier levels of drinking and the risk of epilepsy. People dependent on alcohol can also experience withdrawal seizures.

You can find guidance on seizures in withdrawal in section 10.4.1 in chapter 10 on pharmacological interventions.

19.5.5 Acute health risks

In addition to the disease risks associated with alcohol use, there are acute (short term) health risks including injuries.

The risk of unintentional and intentional injuries resulting from drinking alcohol increases with the amount of alcohol people drink. Injuries include those arising from:

• road traffic accidents
• alcohol poisoning
• falls
• fires
• drowning and water transport incidents
• air or transport incidents
• work or machine incidents
• firearms
• inhalation and ingestion of gastric contents
• exposure to excessive cold (from passing out while outside)
• intentional self-harm or suicide

Alcohol treatment services should provide harm reduction information on the risks of injury (see chapter 8 on harm reduction).

Alcohol, both intoxication and dependence, increase the risk of self-harm and suicide.

You can find guidance on self-harm and suicide in chapter 4 on assessment and treatment and recovery planning and chapter 18 on co-occurring mental health conditions.

19.5.6 Complications of alcohol withdrawal

Withdrawing from alcohol use is associated with health consequences. In some people, these can be severe.

You can find guidance on preventing and managing complications in withdrawal in chapter 10 on pharmacological interventions.

19.6 Smoking related diseases

Smoking harms every organ in the body and causes several diseases including lung cancer. Smoking and drinking combined increases the risk of several alcohol related conditions.

People in the alcohol treatment population have higher rates of smoking than the general population. Alcohol treatment staff are in an ideal position to help reduce smoking related harm in the people in treatment.

You can find guidance on supporting people to stop smoking or reduce smoking related harm in appendix L at the end of this chapter.

19.7 References

Cao Y, Willett WC, Rimm EB, Stampfer MJ and Giovannucci EL. Light to moderate intake of alcohol, drinking patterns, and risk of cancer: results from two prospective US cohort studies. British Medical Journal 2015: issue 351, article h4238

Hart CL, Davey Smith G, Gruer L and Watt GC. The combined effect of smoking tobacco and drinking alcohol on cause-specific mortality: a 30 year cohort study. BMC Public Health 2010a: issue 10, article 789

Hart CL, Morrison DS, Batty GD, Mitchell RJ and Davey Smith G. Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies. British Medical Journal 2010b: issue 340, article c1240

Moreno C, Mueller S and Szabo G. Non-invasive diagnosis and biomarkers in alcohol-related liver disease. Journal of Hepatology 2019: volume 70, issue 2, pages 273-283

Ronksley PE, Brien SE, Turner BJ, Mukamal KJ and Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. British Medical Journal 2011: issue 342, article d671

Appendix K: liver disease: screening and management

K1. Detecting liver disease early

Signs and symptoms of alcohol related liver disease (ARLD) develop late in the progression of the disease and a high proportion of people with ARLD will have no clinical symptoms nor significant blood test abnormalities.

Eventually, their liver may fail to function sufficiently and will decompensate. This is the stage at which ARLD becomes clinically apparent. The risk of developing liver disease and subsequent decompensation decreases with abstinence (or reduced alcohol consumption). So, it’s important to detect liver disease early and begin interventions.

K2. Types of screening for liver disease

The NICE guidance Cirrhosis in over 16s: assessment and management (NG50) recommends that women drinking more than 35 units per week or men drinking more than 50 units per week should have their liver stiffness measured by transient elastography (TE, also known as Fibroscan) to determine the stage of progression of liver disease.

There are other non-invasive screening methods for liver fibrosis in development, which include the following.

Ultrasound based screening includes:

• acoustic radiation force impulse
• shear-wave

Serum fibrosis markers include:

• enhanced liver fibrosis
• liver traffic light test
• intelligent liver function test

However, research shows that these tests are currently less well validated for ARLD than TE is (Moreno and others 2019).

Healthcare professionals who perform and interpret non-invasive fibrosis tests should be trained to do so.

Any screening test should be part of a clear pathway, to make sure the tests are reviewed and acted on.

K3. Care for people with liver disease

People diagnosed with significant fibrosis or cirrhosis should be followed up by a specialist in liver disease.

Alcohol abstinence is a vital goal for people with ARLD, since abstinence improves outcomes in all stages of ARLD. However, the patient should not be excluded from treatment if they do not accept this goal initially. Guidance on developing pathways for alcohol treatment makes clear that it is better to engage the person, rather than alienate them if they fail to agree to or achieve abstinence.

There should be effective care pathways between specialist liver services and alcohol treatment services in the hospital and in the community.

You can find guidance on treating cirrhosis in appendix J on liver disease in chapter 16 on acute hospital settings.

Scottish Health Action on Alcohol Problems (SHAAP) published Alcohol-related liver disease: guidance for good practice for healthcare staff in primary and secondary health services and within alcohol treatment services. The content may also be useful for healthcare staff in other UK nations.

Appendix L: smoking and lung health

Smoking harms nearly every organ of the human body. The combined impact of smoking and drinking to excess increases various health risks.

L1. Asking a person about their smoking and related problems

Alcohol treatment services need to:

• identify a person’s history of smoking tobacco and other drugs
• provide information on the stop smoking support available locally
• help the person engage with local smoking cessation interventions or provide smoking cessation support directly
• support the person to engage with services to treat respiratory problems, including their GP or specialist respiratory health services

Clinicians should ask questions to explore potential respiratory disease, including asking about:

• current or recent history of cough, shortness of breath and symptoms of asthma, and any impairment caused by activities like walking
• previous respiratory diagnoses and any treatment for existing lung disease

Clinicians should also ask questions to explore the person’s smoking history and intentions to quit, including their:

• recent and previous levels of smoking and current quit status (for tobacco and other smoked drugs)
• desire, now or in the future, to quit tobacco smoking
• experience of previous quit attempts
• willingness to consider smoking cessation (including pharmacotherapy)
• use of e-cigarettes

L2. Physical examinations and exploring respiratory disease

Physical examination and investigations for smoking and exploring respiratory disease are normally undertaken by the GP or respiratory team, but they can be carried out by in some alcohol or drug treatment services where clinical staff have the appropriate competencies.

Examinations and investigations include:

• checking for signs of breathlessness, cough, wheeze, and other signs of respiratory (or cardiovascular) disease
• pulse oximetry, a simple test that can show unrecognised impaired lung function (this may be useful if the person is using opioids and other respiratory depressants or has had a recent opioid overdose)
• spirometry (including hand-held spirometry, which may be more easily used in non-specialist clinics) can quantify impairment that could have been caused by tobacco or other drug use

L3. Accessing interventions for respiratory problems

Clinicians can support people to access appropriate interventions for respiratory problems by:

• clearly documenting smoking and respiratory health in the patient record
• noting any observed deterioration in apparent respiratory health over time
• referring the person to their GP for investigation and treatment, if necessary (which may include full lung function tests and chest X-ray)
• supporting referral (usually by the GP) to the local specialist respiratory service or chest clinic, which may be required for people with established respiratory disease if there are health concerns (such as evidence of low oxygen levels)
• making an urgent referral to the GP or local rapid access chest clinic for any person with respiratory disease who has ‘red flag’ symptoms of chest malignancy (such as patients who report haemoptysis and weight loss)
• making an urgent referral to an emergency department for people presenting with imminently dangerous conditions such as unstable or deteriorating asthma

L4. Providing or supporting smoking cessation interventions

Staff in alcohol treatment settings also need to be competent to provide or support smoking cessation interventions.

Alcohol treatment services should:

• provide feedback to commissioners about where local stop smoking services are working well and where there are problems for people accessing support
• ensure their teams are aware of the latest guidance and interventions to help people to stop smoking
• provide learning and development opportunities for team members on how to support smokers to quit and to provide very brief advice
• make sure there are clear local referral and care pathways to stop smoking support

L5. Very brief advice

Very brief advice (VBA) has 3 components: ask, advise and act.

1. Ask and record smoking status: is the patient a smoker, ex-smoker or non-smoker?
2. Advise on the best way of quitting: a combination of stop smoking aids and specialist support.
3. Act on the patient response: build confidence, give information, refer and prescribe.

Staff can access free online training from the National Centre for Smoking Cessation and Training (NCSCT). They can also make the most of existing opportunities like the NHS Health Check to include smoking cessation support in routine clinical care.

L6. Providing different options to stop smoking

Different approaches suit different people, so if the first thing a smoker tries does not help, they should try another way to quit. Clinicians should be confident to talk to people about the different options available for stopping smoking and how effective they are. There is guidance to support conversations between clinicians and people who want to quit smoking, which will help them with what method to choose.

It may be helpful to have on-site smoking cessation services in alcohol treatment services, with behavioural interventions and prescribing available. However, staff should be aware of local pathways to engage people in smoking cessation services, whether in primary care or elsewhere.

20. Alcohol related brain damage

20.1 Main points

Services (and relevant staff) can effectively prevent, identify, treat, and manage alcohol related brain damage (ARBD) by following this guidance. The main points are set out below.

Services should develop joined up, multidisciplinary, person-centred pathways so people have access to appropriate interventions for the full spectrum of ARBD.

Services should intervene to prevent the onset of ARBD by raising awareness of the harm it causes and offering harm reduction advice, prescribing thiamine supplementation and providing medically assisted withdrawal to reduce the risk of withdrawal complications.

Services should include a brief cognitive assessment as part of the routine assessment of harmful drinkers and people with alcohol dependence in community health services, including alcohol treatment services and acute hospitals.

Services should refer people for specialist assessment and diagnosis via a standard pathway for cognitive impairment where no professional with specialist competencies in ARBD is available. Diagnosing people with ARBD early increases their chances of cognitive improvement.

Services should develop a comprehensive management plan for people diagnosed with ARBD and allocate a keyworker with expertise in ARBD (or cognitive impairment, where no specialist is available). Involve family members where appropriate.

Abstinence is crucial to support cognitive improvement. So, services should re-assess the person with ARBD regularly over 3 years and adjust their plan accordingly.

If a person with ARBD continues to drink, services should continue to offer multidisciplinary psychosocial support, and prescribe thiamine.

Services should offer multidisciplinary support and rehabilitation tailored to the stage of the person’s recovery from ARBD. Adapt psychosocial interventions to take account of the level of a person’s cognitive impairment.

Once the person has reached their optimum level of cognitive function, services should arrange access to appropriate long term care for people with permanent ARBD, tailored to their level of need.

There are specific considerations for assessing mental capacity in people with ARBD, because they may be able to carry out tasks in a structured assessment that they are unable to carry out in a less structured setting.

20.2 Overview

20.2.1 Definition of ARBD used in these guidelines

Alcohol related brain damage (ARBD) describes various psychoneurological or cognitive conditions that are associated with long term, heavy alcohol use and related vitamin deficiencies (particularly thiamine deficiency). ARBD can affect a person’s life to such an extent that independent living is no longer possible.

ARBD is not a progressive condition like dementia. If you can identify it at an early stage and the person can stay abstinent, then the prognosis can be good. So, it is very important to prevent, identify and treat ARBD. This requires establishing joined up, multidisciplinary, person-centred pathways that take account of the complex range of factors involved in preventing and managing ARBD.

The modified Oslin criteria (Oslin and Carey 2003) provides a useful framework for diagnosing ARBD as a set of conditions based on:

1. Evidence of cognitive impairment (confirmed by clinical examination or using appropriate tools, for example the mini-Addenbrooke’s cognitive examination III (mini-ACE) assessment tool).
2. Significant alcohol use is defined by the minimum average of 35 standard drinks per week for men and 28 for women (or 50 units for men and 35 units for women), for more than 5 years. The period of significant alcohol use must occur within 3 years of clinical onset of the cognitive deficits (problems with memory and reasoning).

20.2.2 The natural history of ARBD

Wernicke’s encephalopathy is an acute medical emergency where alcohol withdrawal and lack of vitamin B1 causes inflammation of the brain. It has a high mortality rate and may lead to Wernicke-Korsakoff syndrome (previously known as Korsakoff’s psychosis) if it is untreated with intravenous vitamin B1. You can find guidance on management of Wernicke’s encephalopathy in section 16.6 in chapter 16 on acute settings.

Wernicke-Korsakoff syndrome is a form of ARBD with:

• severe short-term memory problems
• varying long-term memory difficulties
• neurological signs such as impaired eye movements or unsteady walking

It is rare for people to show all the signs of Wernicke-Korsakoff syndrome, but the term is often used incorrectly to refer to more general features of ARBD.

People with ARBD need to remain abstinent from alcohol for between 3 and 6 months for their cognition to improve, as a result of not being exposed to the direct toxic effects of alcohol. During this time, someone who lacked mental capacity due to ARBD may regain capacity. People who remain abstinent will usually experience further cognitive improvement to varying degrees over the following year or two as their brain regenerates.

Professional (psychiatric) guidelines on managing alcohol and brain damage in adults (CR185) recommend improving a person’s cognition through:

• progressive socialisation
• training in daily living activities like cooking
• alcohol education

When the person achieves what is likely to be their optimal level of cognitive function, based on ongoing clinical assessment, practitioners should support them to access an appropriate setting (for example, independent living, supported living or residential care). About 50% to 70% of patients who are actively and appropriately managed and remain alcohol free will show improvement in their psychosocial functioning.

20.3 Assessing cognitive function in harmful drinkers and people with alcohol dependence

20.3.1 Assessment in health and social care settings

People with ARBD can present at a wide range of health and social care settings including alcohol treatment services. Staff in health and social care settings should consider the possibility of ARBD in any person who is drinking at harmful levels or has done so previously. There are several formal assessment tools that you can use to assess cognition.

Trained staff can routinely use the mini-ACE tool to screen for ARBD across all settings, but the longer Addenbrooke’s cognitive examination III (ACE III) is also available for suitably trained clinicians. If you need to do a more detailed assessment, you will need to get input from a neuropsychologist through established pathways for cognitive impairment. It is important that cognitive assessments include tests of frontal lobe function.

Practitioners should carry out a cognitive assessment during the initial assessment period and repeat it at appropriate intervals to review progress. Practitioners in community alcohol treatment services should routinely carry out a brief cognitive assessment as part of comprehensive assessment. They should then refer people needing more specialist cognitive assessment through established pathways with services for cognitive impairment.

The Oslin criteria recommend that patients should be abstinent for 3 months before having cognitive tests. However, clinicians should take a pragmatic approach to cognitive testing and should be clear on the distinction between using it as a diagnostic instrument versus using it as a screening tool. 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.

Although cognitive assessment tools are useful, they do not give a cut-off score that can confirm the presence or absence of ARBD. So, thorough, holistic and multidisciplinary assessment that considers their day-to-day functional ability is required to confirm ARBD.

20.3.2 Assessment in acute hospital settings

Treating alcohol dependent people admitted to acute hospitals is often complex. Comorbidities that can confuse the picture include:

• infection
• hepatic encephalopathy
• pain
• mental health issues (such as depression)

Alcohol-related cognitive impairment can easily be missed by acute hospital teams. So, it is important to have broad criteria to alert clinicians to the possibility of ARBD so they can carry out further assessment. Suitable criteria include:

1. Probable history of heavy, long-standing alcohol consumption (see Oslin criteria above).
2. Confusion, memory problems, doubt about mental capacity and concerns about risk on discharge, after withdrawal or physical stabilisation.
3. Three or more admissions into hospital or the emergency department in one year, either directly (withdrawal, unconscious) or indirectly (trauma, organ diseases) associated with drinking alcohol.

20.4 Preventing and treating ARBD

20.4.1 The evidence on preventing ARBD

The health and socioeconomic burden of ARBD is preventable. There are many points in its development where interventions can be effective.

Most of the literature about preventing ARBD is made up of case reports, correlation studies and case control studies. So, most recommendations in these guidelines are made using evidence from evidence summaries developed from systematic reviews and evidence from guidelines developed from systematic reviews.

20.4.2 Preventing the onset of ARBD

Screening in primary and secondary care for signs of harmful or dependent drinking

With the patient’s consent, clinicians in primary and secondary care should refer anyone with probable alcohol dependence or at high risk of alcohol-related harm to community alcohol treatment services. For people with a lower severity alcohol use disorder (AUD), clinicians and practitioners should offer brief interventions, which can help prevent problems such as ARBD. Chapter 3 on alcohol brief interventions provides guidance on identifying an AUD and providing brief interventions.

Raising awareness about the effects of alcohol on the brain

Research has found that knowledge of the damaging effects of alcohol on the brain is poor among people with ARBD (Boughy 2007) and healthcare professionals (Boughy 2007, Heirene and others 2018, Wilson 2011). Raising awareness of ARBD at a population level ensures that people at risk can make informed choices about their drinking. The Royal College of Psychiatrists has produced Alcohol-related brain damage patient and public information leaflet (in college report CR185, page 73) and Alcohol Change UK has several ARBD factsheets.

20.4.3 Thiamine and advice on diet

Once a clinician identifies harmful or dependent drinking in a patient, they should:

• give them advice on diet
• prescribe thiamine supplementation
• assess the patient for potential Wernicke’s encephalopathy

Chapter 10 on pharmacological interventions has detailed guidance on prescribing thiamine to prevent Wernicke-Korsakoff syndrome (WKS) and assessing patients for potential Wernicke’s encephalopathy.

20.4.4 Advice against sudden cessation of alcohol

For physically dependent drinkers, clinicians should outline the dangers of precipitated withdrawal after stopping drinking suddenly. Research suggests that the more withdrawal episodes a person experiences, the more likely they are to have cognitive impairment (Wagner Glenn and others 1988, Loeber and others 2010). Clinicians should advise patients against stopping drinking suddenly and offer an assessment for medically assisted withdrawal. You can find guidance on medically assisted withdrawal in chapter 10 on pharmacological interventions.

20.5 Preventing withdrawal related ARBD

20.5.1 Anticipate withdrawal and identify early withdrawal

Unmedicated or poorly medicated alcohol withdrawal can progress to complicated forms of withdrawal associated with ARBD. Wernicke’s encephalopathy is directly linked to ARBD and delirium tremens and seizures can also be risk factors for this. So, clinicians should identify and treat withdrawal as soon as possible.

Clinicians should closely monitor people with a higher risk of developing ARBD. These include people:

• drinking at high risk levels
• with a low body mass index (BMI)
• who regularly miss meals
• with previous episodes of complicated withdrawal
• with a long history of harmful drinking or alcohol dependence
• with other conditions associated with thiamine deficiency such as peripheral neuropathy and cerebellar disease (Thomson and others 2009)

20.5.2 Use evidence-based protocols for medical management of withdrawal

Clinicians should use evidence-based protocols for routine and more complicated withdrawals. There is detailed guidance in chapter 10 on pharmacological interventions on providing medically assisted withdrawal, including prescribing prophylactic oral or parenteral thiamine to reduce the risk of developing withdrawal complications leading to ARBD.

20.5.3 Identify and treat co-occurring illness

A patient is more likely to progress to complicated withdrawal if they have a co-occurring illness, such as an infection or gastrointestinal bleed. Early diagnosis and treatment will reduce this risk.

20.5.4 Identify and treat Wernicke’s encephalopathy

Wernicke’s encephalopathy is a complication that can occur in withdrawal. Clinicians should treat Wernicke’s encephalopathy as an emergency and manage the person in an acute medical setting. Clinicians who identify cases in the community should transfer the patient to the emergency department of an acute hospital setting immediately.

When a clinician has identified a patient with Wernicke’s encephalopathy, they should be given immediate treatment with intravenous Pabrinex. Chapter 16 on alcohol care in acute hospital settings provides detailed guidance on prescribing and administering Pabrinex.

20.6 Diagnosis and treatment of ARBD

20.6.1 Early diagnosis of ARBD and referral into appropriate service

By diagnosing ARBD early, clinicians can deliver appropriate interventions to increase the person’s chances of cognitive improvement. Early diagnosis also enables practitioners to make prompt referrals to appropriate supported accommodation if necessary. Supported accommodation can help people with ARBD to improve their day-to-day function and reduce their likelihood of returning to harmful drinking. However, ARBD is consistently underdiagnosed because of a lack of awareness among clinicians (Wilson and others, 2012) and many people are not identified until their cognitive impairment becomes severe (ARBIAS 2007). It is important that clinicians investigate the main cause of any cognitive impairment and distinguish ARBD from Alzheimer’s and vascular dementia.

Only a proportion of patients with ARBD will present to an acute hospital setting. So, cognitive screening should form part of the assessment process in community settings where at-risk people might present (for example, alcohol treatment services and primary care). For more information on assessing cognitive function in different settings, see section 20.3 above.

All patients with ARBD should have a comprehensive management plan drawn up when they are first diagnosed. The Royal College of Psychiatrists guidelines on managing alcohol and brain damage in adults (CR185) recommend that every patient has a designated keyworker who has expertise in assessing and treating adults with cognitive deficits.

20.6.2 Regular follow-up and re-evaluation

After diagnosing a person with ARBD it is important that clinicians review them on a regular basis. This is so they can assess any improvements in cognition and functioning and make appropriate changes to the management plan. The Royal College of Psychiatrists recommends reassessing a patient’s cognitive function 3 months after the initial assessment. Clinicians should then repeat this every 6 months for 3 years. It is also important to reassess a person’s cognitive function so that if it deteriorates despite not drinking alcohol, clinicians can investigate other potential causes of cognitive impairment.

20.6.3 Maintaining abstinence from alcohol

Maintaining abstinence from alcohol is crucial to support cognitive improvement. For people with established ARBD (when their cognitive function has reached optimal level) who have stopped drinking, it is important that clinicians provide ongoing support to maintain this. Clinicians will need to adapt standard psychosocial interventions for people with cognitive impairment. They should also consider prescribing relapse prevention medication.

20.6.4 People who continue to drink alcohol

For people who continue to drink alcohol (and have mental capacity to do so), practitioners should try to keep them attending services. They should do this by using approaches such as motivational interviewing (appropriately adapted for people with cognitive impairment) and helping them to access peer-based support. Practitioners should also provide people with information on what services can offer in a way that they can understand. For people not currently engaged in treatment, practitioners should try to maintain contact and be alert for signs of increased motivation to engage or the loss of mental capacity. Other health and social care practitioners should also be alert for these signs so they can make appropriate referrals.

People with alcohol dependence who continue to drink often experience unplanned episodes of withdrawal. Some of these episodes occur outside of clinical settings so the person remains at risk of repeated episodes of complicated withdrawal. Recurrent periods of thiamine deficiency cause cumulative brain damage (Crowe and El-Hadj 2002, Price and others 1988, Ciccia and Langlais 2000). So, clinicians should give prophylactic thiamine routinely to people with alcohol dependence who continue to drink, whenever they present to medical services (Thomson and others 2012). See chapter 10 on pharmacological interventions for guidance on prescribing and administering oral and parenteral thiamine.

20.7 Recovering from ARBD

20.7.1 Phases of treatment and recovery

In the absence of randomised controlled trials, evidence on treatment for ARBD is taken from retrospective clinical studies, clinical consensus statements and studies on the rehabilitation of patients presenting with acquired, traumatic brain injury.

People with ARBD usually go through 5 phases of treatment and recovery. These are:

1. Physical stabilisation.
2. Psychosocial assessment.
3. Therapeutic rehabilitation.
4. Adaptive rehabilitation.
5. Social integration and relapse prevention.

The setting of each phase can vary depending on the presenting need of the patient. But, in general, recommendations in phases 1 and 2 are directed at inpatient facilities. Recommendations in phases 3 to 5 are for less intensive social settings, such as nursing homes, care homes, supported living or independent living. The principles of management remain the same regardless of setting.

20.7.2 Phase 1: physical stabilisation

Phase 1 is primarily concerned with preventing or treating withdrawal and making sure the person is physically stable so that they are ready for further treatment. Chapter 10 on pharmacological interventions provides guidance on medically assisted withdrawal and prescribing for relapse prevention.

20.7.3 Phase 2: psychosocial assessment

Principles and interventions to help people during phase 2

Where a person stops drinking during phase 2, their intellect and ability to self-care usually improves over the next 3 to 4 months.

You should consider a number of principles and interventions to help people during this phase, including:

• developing a therapeutic relationship and offering psychosocial support (MacRae and Cox 2003, North and others 2010, Wilson and others 2012)
• promoting ‘normalisation’, such as establishing daily routines and recommending appropriate nutritional intake (planning and providing a timetable and structure may help) (ARBIAS 2009)
• arranging help for things like debt and introducing them to a support worker or advocate
• involving family and other carers where appropriate
• planning for orientation and memory support
• providing alcohol harm reduction information (see chapter 8 on harm reduction)

You could also encourage patients to start a personal journal. This may be a valuable thing for them to do because it can:

• help with recent memories (could include photographs of recent events)
• introduce the concept of routine, by providing a memory of recent events
• build a relationship between the individual and keyworker
• provide an introduction to planning (see below)

Adapting psychosocial interventions

You may have to adapt psychosocial interventions to account for ARBD. For example, in relapse prevention programmes you may need to consider the following.

1. Proactively engaging people with cognitive dysfunction, with more frequent and assertive attempts to make contact.
2. Limiting the number of subjects discussed at each appointment to allow for reduced levels of concentration and difficulties in swapping from topic to topic.
3. Providing rewards for appropriate behaviour. These may be psychological rewards such as praise, or social rewards such as attending enjoyable social activities. But all rewards should be tailored to the individual and may help recall by positively reinforcing the behaviour.
4. Increasing the length of appointments.
5. Adapting sessions to accommodate problems in remembering new information. For example, having the person repeat information as soon as it is given.
6. Offering information in various ways, including verbal, written and using diagrams.
7. Using memory cues and reminders such as diaries, electronic reminders to complete tasks, notices, colour coding to identify the person’s room and having cupboards with transparent doors.
8. Having simple rules to apply when making decisions and dealing with problems. For example, to ask a support worker or a family member if they are not sure what action they should be taking.
9. Keeping relapse prevention strategies very simple.

You can find more information on relapse prevention strategies in chapter 5 on psychosocial interventions.

20.7.4 Phase 3: therapeutic rehabilitation

Therapeutic rehabilitation programme

A therapeutic rehabilitation programme aims to gradually improve a person’s skills for daily living as their cognition improves. This process includes 3 main components.

1. Developing autonomy will help the person to be more independent and improve their ability to self-manage where cognitive or functional deficits remain (Wilson and others 2012).

2. Promoting functional recovery through:

• maintaining a journal
• planning activities
• learning skills

3. Memory support strategies, which can include:

• using a journal to provide an opportunity for regular review of progress (with the keyworker or co-therapist) and to help the person remember recent and past events and experiences
• using a whiteboard to keep a continuous and easy-to-see record of the date, day and location of recent events
• keeping lists of things to do and remember
• using visual signs and memory aids

Impulse and behaviour control, apathy, and motivational difficulties

People with ARBD may:

• have difficulty coping with stressful situations and their reactions
• react in a way that may seem disproportionate (‘catastrophic’) to the trigger event
• be prone to tiredness
• be sensitive to overstimulation
• become stressed in noisy and distracting situations or if confronted with more information than they are able to understand

Apathy and motivational difficulties are also commonly experienced by people with ARBD. These symptoms are a core feature of ARBD, and clinicians should always bear this in mind when working with these patients.

Managing alcohol

Psychosocial interventions can help people to stay abstinent from alcohol, but clinicians should adapt these interventions to take account of the cognitive impairment (see section 6.3 on phase 2 for information on adapting psychosocial interventions).

People do not usually experience alcohol craving during phase 1 of ARBD management (physical stabilisation and withdrawal). During the first 3 to 6 months of abstinence (phase 2 and early phase 3) some patients will crave alcohol and show alcohol-seeking behaviours. In addition to supporting the person to develop relapse prevention strategies, it is important that clinicians and practitioners continue to reiterate the link between drinking alcohol and physical conditions that the person has experienced, for example:

• vomiting blood
• ascites (excess fluid in the stomach)
• cancers
• blood-related problems
• further damage to memory

Developing relationships

Part of therapeutic rehabilitation involves the person building a relationship with their keyworker and improving their relationships with people who care about them, such as family or carers. This will help the person when they want to further integrate into society.

20.7.5 Phase 4: transition phase

The duration of phase 3 will vary between patients and it will slowly merge into phase 4 which is also called adaptive rehabilitation. During phase 4, the patient will reach an optimal level of cognitive and behavioural improvement. Clinicians will need to continually review the person to decide when cognitive improvement appears to have stopped.

During the transition phase, it is important to reassess the patient’s functional ability and the amount of support they will need. You should encourage autonomy where possible because excessive long-term care can demotivate the person and lead to them feeling institutionalised.

A full assessment of activities of daily living should take place. This should include a review of the person’s environment and care package to see if anything needs to be adapted. Phase 4 often involves transferring care from a setting with a high level of support to a less dependent environment or reducing carer support.

During this process the person is at an increased risk of returning to harmful drinking as they try to adapt to life without alcohol. This is a particular risk if the person is returning to their previous environment. Transferring care of this nature should be undertaken in a planned manner, working with the individual patient, keyworkers and other carers, health and care staff (including adult social care) and their family members to develop a comprehensive, multidisciplinary care plan. An identified person should co-ordinate the care plan and ensure that regular reviews are undertaken.

20.7.6 Phase 5: social integration and relapse prevention

There are 3 main therapeutic principles that you need to address in phase 5:

1. To prevent a person returning to harmful alcohol use.
2. To help a person maintain an optimum level of independence and quality of life over the long-term.
3. To help a person develop a social network.

This phase is based on evidence relating to the treatment and long-term management of care for people with alcohol use disorders. You can read more about structured support and psychosocial interventions in chapter 5 and pharmacological interventions in chapter 10.

The main goals of phase 5 are for the person to:

• maintain a personal commitment to drinking goals
• avoid spending time with heavy drinkers
• find appropriate accommodation)
• access training and education to develop their employment and life skills
• manage their personal finances (or arrange help when they are unable)
• achieve lasting lifestyle changes, such as improved diet or engagement with positive activities

20.8 Multidisciplinary, multi-agency community support

It is important to provide long-term psychosocial support for people with residual cognitive deficits from ARBD. Multi-agency long-term support which addresses the person’s physical health, mental health and social care needs, including help to establish a personalised support network, can reduce the likelihood of someone returning to harmful alcohol use (Wilson and others 2012).

Dedicated ARBD services are rare in the UK, so people with ARBD will often have their health and social care provided by a variety of different services. People with ARBD often have additional mental health conditions, so it is important that mental health services are part of the team supporting the person where relevant. It is vital that the person has a single, comprehensive care plan that all services work to. The person should also have an identified co-ordinator of care who has expertise in managing ARBD.

Part of the role of the care co-ordinator is to update the different services involved in a person’s care about the care plan. As well as sharing this information with the person and their family or carers, co-ordinators need to communicate with:

• alcohol treatment services
• community mental health teams (both adult and older adult)
• adult social care
• primary care
• secondary care services (for example hepatology)
• housing organisations
• independent mental capacity advocates
• other advocates supporting the person on issues such as attending appointments
• peer-based support

Appropriate accommodation is often the most important factor in maintaining a person’s abstinence. It is important that various levels of support are available to match the person’s needs. This can range from nursing home care to independent living with minimal support.

Some people may return to harmful alcohol use. If you think that the person has the capacity to make decisions about drinking, you should encourage them to limit or stop drinking and refer them to alcohol treatment services. If they do not have the capacity, they should usually be managed in services that are competent in managing people with severe cognitive impairment.

20.9 Assessing mental capacity in people with ARBD

20.9.1 Legislation and statutory guidance

ARBD can affect a person’s memory and reasoning, which are important factors when assessing mental capacity as defined in legislation. You can find information on the legislation and statutory guidance on mental capacity in annex 1. You should note that there are some differences in legislation relating to mental health, mental capacity, and safeguarding across the different nations of the UK.

20.9.2 Potential effects of memory deficits on capacity to make decisions

When assessing capacity, the assessor should consider the following issues.

Short-term memory

Short-term memory deficits are common among people with ARBD. Short-term memory refers to the ability to register, retain and recall new information. During a conversation there may not be any obvious signs of short-term memory deficits. The person may be able follow a conversation and hold information long enough to weigh it up and make a decision but might forget the content of the conversation (and the decision made) a few hours later.

Long-term memory

Long-term memory problems are common among people with ARBD. People with ARBD may have experienced up to 20 years of retrospective memory loss and may not have any significant understanding of their harmful drinking and that it has contributed to their current situation.

When assessing capacity, practitioners should not assume that the person remembers their own history, are aware of the amount they drink, how long they have been drinking at this level, or the social and financial consequences of this. People often lose long-term memories, so practitioners must be aware the person will make decisions when they are not fully aware of what they have been through.

Combination of short-term and long-term memory problems

A person with Wernicke-Korsakoff syndrome may have a limited short-term memory of 2 to 30 minutes and long-term memory loss of some years. The person’s current thoughts might relate only to the last few minutes or hours. Their most recent remembered events might have occurred years ago, possibly before they had alcohol problems. So, they might not understand how they came to be in their current situation and may not be able to retain information that will allow them to understand.

False memories

False memories (or confabulations) often occur in people with memory deficits who will commonly appear confused when presenting at services. People with short-term memory loss will unconsciously fill gaps in their memory with false memories to explain their current situation. A person who has memory loss and is creating false memories is vulnerable to suggestion from others. You should check anything the person says with information from a suitable professional, carer or relative about their cognitive and functional abilities.

20.9.3 Reasoning difficulties

Reasoning problems are common in people with ARBD. Signs of reasoning difficulties may not be obvious and can often be missed when examining people for cognitive impairment. In people with more advanced ARBD these signs can include:

• problems in social awareness
• not understanding the consequences of actions
• not being able to estimate risk

People with ARBD can experience difficulties in processing and understanding information they are given. In obvious cases, the person will lack motivation and have problems in changing their behaviour and routine. They may find it difficult to resist situational cues such as triggers to drinking such as stressful situations. In structured settings, such as when being assessed by a practitioner, a person may contain and regulate their behaviour. But in other, less structured circumstances, their impulsive and disinhibited behaviour may become more obvious.

20.9.4 Reasoning, understanding and weighing up problems and effects on mental capacity

When assessing someone’s mental capacity, practitioners should consider the following factors:

1. The person may find it difficult to process information and weigh up conflicting arguments. This makes it difficult to solve problems and make decisions.
2. The person may find it difficult to change from one thought to another. They are often fixated on a thought and might find it difficult to focus on other themes of conversation.
3. The person may have planning and organising problems. They could have difficulty with fundamental processes such as ordering tasks, understanding practical details and appreciating the relationship between action and outcome.
4. The person may be acting impulsively and might not be considering risk. To some extent, impulsive behaviour due to ARBD can be differentiated from impulsive behaviour caused by alcohol craving in an alcohol-dependent person without ARBD. A person with cognitive damage may show chaotic, unpredictable and high-risk behaviours in aspects of their life that are not related to alcohol and when they are not intoxicated.
5. People with severe ARBD can show apathy, difficulty changing their routine and a lack of motivation. Typically, people with severe ARBD will not take part in social activities, isolate themselves and do not engage with services or carers. ARBD is often associated with loss of self-care and social awareness.
6. People with ARBD often experience a lack of awareness (anosognosia) of their cognitive, and sometimes physical, damage. The person will often become frustrated when confronted with their problems.

20.9.5 Practical suggestions for assessing the mental capacity of a person with ARBD

Standardised tools

Clinicians should establish evidence of cognitive impairment using a standardised tool such as ACE III. You should note that ACE III cut off scores provided with the tool have not been validated in people with ARBD. A person scoring 80 or less is likely to have significant brain damage.

Main questions for assessing capacity

Clinicians should consider the following 2 questions when judging capacity in people with ARBD:

1. Does the person have capacity to make decisions about their future alcohol consumption?
2. Does the person have capacity to make decisions about the care that they need?

Further considerations for assessing capacity

The following considerations and questions might also be useful in assessing a person’s capacity.

You can give the person all the relevant information about their condition. This will involve asking them if they:

• are aware of their alcohol problem and harms
• are aware of other related problems they are facing, for example fire risk, malnutrition, hospital admissions, financial or legal problems
• are aware of the degree and nature of their cognitive damage
• know what will happen if they continue drinking

You can make sure that the person can remember the information you have given them. This will involve:

• making sure that the person can repeat the information: you can help them by summarising it and repeating it
• reminding the person’s carers to reinforce the information afterwards
• checking the person has personalised written information they can refer to
• asking them to repeat the information an hour or so later and see if they can recall what was discussed

If the person cannot recall the relevant information, courts usually accept it’s likely that they do not have capacity.

You can ask questions to check that the person understands the information. This could involve asking questions like:

• why do you need help?
• what role has alcohol played in the development of your problems?
• what practical issues do you need help with?
• how much help do you need?
• who is going to help you?
• how is this help going to be organised?

You can ask questions to check the person’s ability to reason and weigh things up. It may be useful to ask what they think are the pros and cons of the support you are offering. It might help to write this out in 2 columns (pros and cons) to help them with the reasoning process. Explore the relative ‘weight’ the person allocates to the pros and cons.

If they do not want to accept support, it may be useful to ask:

• if they understand the risks if they do not get the support
• what their reasons are for not wanting support

20.10 Frontal lobe paradox

Although not specifically described in the literature relating to ARBD, the ‘frontal lobe paradox’ refers to the very common difficulty for clinicians without specialist expertise in judging a person’s frontal lobe function during a structured interview or assessment (George and Gilbert 2018). Frontal lobe functions mainly affect a person’s:

• insight (for example, regarding their own capacity)
• ability to assess risk
• social awareness and empathy
• impulse control

Clinicians often assess a person’s cognitive function and capacity using structured, objective tests that tend not to include aspects of behaviour that are associated with frontal lobe impairment. For instance, a person might be able to perform tasks in a structured assessment where the clinician has set out clear rules and requirements for the person to follow. But the same person may not be able to self-initiate those tasks when they do not have rules and requirements to follow. If the person lacks insight into their cognitive difficulties, they will fail to make use of strategies to compensate, such as following prompts to remind them to carry out day to day tasks. And although they may perform ‘normally’ at assessment, they can be exhausted by the testing process. This is because of the extra effort they need to make due to their cognitive impairment (Manchester and others 2004).

It is important to recognise that the value of structured assessments such as ACE III to identify a person’s cognitive impairment are only reliable when the results are consistent with reports from other clinicians and significant others. The danger of basing functional evaluations on only structured interviews or assessments is that the effects of any frontal lobe impairment may not be fully evident. This can result in people not receiving the support they need.

20.11 References

ARBIAS. Looking forward: information and specialised advice on alcohol related brain impairment, 2nd edition (PDF, 15.6MB). ARBIAS 2007

ARBIAS. Annual report 2008-2009 (PDF, 4.4MB). ARBIAS 2009

Boughy L. Alcohol related brain damage: a report of the learning captured from Carenza Care in North Wales (PDF, 169KB). Report commissioned by the Care Services Improvement Partnership/Alzheimer’s Society ARBD working group 2007

Ciccia R and Langlais J. An examination of the synergistic interaction of ethanol and thiamine deficiency in the development of neurological signs and long‐term cognitive and memory impairments. Alcohol Clinical and Experimental Research 2000: volume 24, issue 5, pages 622-634

Crowe F and El Hadj D. Phenytoin ameliorates the memory deficit induced in the young chick by ethanol toxicity in association with thiamine deficiency. Pharmacology Biochemistry and Behavior 2002: volume 71, issue 1-2, pages 215-221

George MS and Gilbert S. Mental Capacity Act (2005) assessments: why everyone needs to know about the frontal lobe paradox. The Neuropsychologist 2018: volume 5, pages 59-66

Heirene R, John B and Roderique-Davies G. Identification and evaluation of neuropsychological tools used in the assessment of alcohol-related cognitive impairment: a systematic review. Frontiers in Psychology 2018: volume 9

Loeber S, Duka T, Marquez H, Nakoviks H, Heinz A, Mann K and Florand H. Effects of repeated withdrawal from alcohol on recovery of cognitive impairment under the abstinence and rate of response. Alcohol and Alcoholism 2010: volume 45, issue 6, pages 541-547

MacRae S and Cox S. Meeting the needs of people with alcohol related brain damage: a literature review on the existing and recommended service provision and models of care. University of Stirling, 2003

Manchester D, Priestley N and Jackson H. The assessment of executive functions: coming out of the office. Brain Injury 2004: volume 18, issue 11, pages 1067-1081

North L, Gillard-Owen L, Bannigan D and Robinson C. The development of a multidisciplinary programme for the treatment of alcohol related brain injury. Advances in Dual Diagnosis 2010: volume 3, issue 2, pages 5-12

Oslin W and Cary S. Alcohol-related dementia: validation of diagnostic criteria. The American Journal of Geriatric Psychiatry 2003: volume 11, issue 4, pages 441-447

Price J, Mitchell S, Wiltshire B, Graham J and Williams G. A follow-up study of patients with alcohol-related brain damage in the community. Australian Drug and Alcohol Review 1988: volume 7, issue 1, pages 83-87

Thomson A, Guerrini I and Marshall EJ. Wernicke’s encephalopathy: role of thiamine (PDF, 1.5MB). Nutrition Issues in Gastroenterology 2009: series 75

Thomson A, Guerrini I and Marshall EJ. The evolution and treatment of Korsakoff’s syndrome: out of sight, out of mind? Neuropsychology Review 2012: volume 22, pages 81-92

Wagner Glenn S, Parsons OA, Sinha R and Stevens L. The effects of repeated withdrawals from alcohol on the memory of male and female alcoholics. Alcohol and Alcoholism 1998: volume 23, issue 5, pages 337-342

Wilson K. Alcohol-related brain damage: a 21st-century management conundrum. British Journal of Psychiatry 2011: volume 199, issue 3, pages 176-177

Wilson K, Halsey A, Macpherson H, Billington J, Hill S, Johnson G, Raju K and Abbott P. The psychosocial rehabilitation of patients with alcohol-related brain damage in the community. Alcohol and Alcoholism 2012: volume 47, issue 3, pages 304-311

21. People experiencing homelessness

21.1 Main points

People experiencing homelessness have multiple and complex needs that require an integrated response across local systems and services.

Alcohol treatment commissioners and services should work with homelessness services, health, social care and community services to plan and provide integrated models of care such as co-located services, in-reach sessions, or multi-agency forums.

People experiencing homelessness should have a multi-agency assessment and care plan (treatment and recovery plan) co-ordinated by a named keyworker that addresses alcohol treatment, housing and wider health and social care needs.

People experiencing homelessness experience personal barriers (such as the impact of trauma) and service barriers (such as inflexible appointment systems) to accessing alcohol treatment services.

To reduce barriers to treatment, services need to offer flexible engagement arrangements tailored to the needs of people experiencing homelessness, such as assertive outreach or open access services.

Individual practitioners and services should work with a compassionate, non-stigmatising and trauma-informed approach to support ongoing engagement with people experiencing homelessness.

Services need to tailor treatment and recovery support to the needs of people experiencing homelessness such as offering long term support and increasing support before, during and after the move to independent housing.

A harm reduction approach that aims to reduce physical health, mental health and social harms associated with alcohol problems and with homelessness is often appropriate for people experiencing homelessness.

For people experiencing homelessness who are alcohol dependent and who want to stop drinking, services should consider offering inpatient medically assisted withdrawal.

People with lived experience of alcohol problems and of homelessness should be involved in commissioning and planning services and offering peer support to people in treatment and recovery.

Practitioners working with people with alcohol problems who are experiencing homelessness should be trained and supported to identify adult safeguarding concerns and act in line with statutory guidance as homelessness, particularly rough sleeping, is associated with increased safeguarding risks.

21.2 Introduction

The chapter provides guidance about support and treatment for people experiencing homelessness who drink harmfully or are dependent on alcohol.

21.2.1 Alcohol treatment for people experiencing homelessness

Alcohol treatment services should provide inclusive, targeted and flexible support tailored to the needs of people experiencing homelessness, including rough sleeping. They should work together with homelessness and housing support, health, social care, and community services to make sure people experiencing homelessness can access integrated care.

Commissioners and services should be aware of and work in line with the National Institute for Health and Care Excellence (NICE) guideline Integrated health and social care for people experiencing homelessness (NG214).

21.2.2 Definition

Homelessness: applying All Our Health sets out the legal definition of homelessness, which is:

“…that a household has no home in the UK or anywhere else in the world available and reasonable to occupy.”

The same All Our Health guidance gives examples of homelessness, including:

• rooflessness (without a shelter of any kind, sleeping rough)
• houselessness (with a place to sleep but temporary, in institutions or a shelter)
• living in insecure housing (threatened with severe exclusion due to insecure tenancies, eviction, domestic violence, or staying with family and friends known as ‘sofa surfing’)
• living in inadequate housing (in caravans on illegal campsites, in unfit housing, in extreme overcrowding)

People can move in and out of periods of homelessness. It can be temporary and some people experience repeated episodes of homelessness, moving in and out of short-term accommodation.

21.3 Addressing health inequalities

People experiencing homelessness experience some of the most extreme health inequalities. Data from the Office for National Statistics on deaths of homeless people in England and Wales shows that in 2020, the average age at death for people experiencing homelessness was 45.9 years for men and 41.6 years for women. This is more than 30 years lower than the average age at death of the general population of England and Wales.

Data from the National Records of Scotland on homeless deaths in 2020 shows that the most common age range for men dying while homeless is 45 to 54 and for women it is 35 to 44.

People experiencing homelessness often find health and social care services (including alcohol treatment services) difficult or impossible to access. Commissioners and services often need to make more effort and target approaches to providing care to this group of people. They should aim to reduce the health inequalities affecting people experiencing homelessness by allocating resources and tailoring services to meet their specific needs. This is so alcohol treatment is available and accessible to people experiencing homelessness and provided to the same standards and quality as it is for the rest of the alcohol treatment population.

21.4 Integrated care

21.4.1 Integrated care for people experiencing homelessness

People experiencing homelessness often have multiple and complex needs that require an integrated response across local systems and services, including:

• primary care
• acute care
• mental health care
• social care
• housing and housing support
• alcohol and drug services
• peer-based support organisations
• domestic abuse services
• community and voluntary sector services

All integrated care should be based on a trauma-informed approach and care environments should be psychologically informed (see section 21.5.2 on supporting and maintaining engagement below).

21.4.2 Commissioning and planning integrated services

NICE NG214 recommends that commissioners and planners of services for people experiencing homelessness involve commissioners of other relevant health and social care services in their planning.

Alcohol treatment commissioners and services should be aware of how alcohol treatment fits into the local model of integrated care aimed at addressing the needs of their local population experiencing homelessness.

21.4.3 Providing integrated care

Models of integrated care for people experiencing homelessness vary. In areas with high numbers of people experiencing homelessness, NICE NG214 recommends that multi-agency teams provide integrated care (including alcohol treatment) through one service. In areas where multi-agency teams do not exist, alcohol treatment services and practitioners should work with homelessness and housing services, and relevant health and social care services, to provide integrated treatment and support.

Models for providing integrated care can include the following:

1. Direct and rapid links between alcohol treatment services and local housing, street outreach and rough sleeping services.
2. Practitioners from homelessness services provide regular sessions in alcohol treatment services, for advice and referral (known as in-reach).
3. Practitioners from alcohol treatment services provide regular sessions for street outreach teams, rough sleeping services and temporary accommodation (outreach).
4. Peer-based support and lived experience recovery organisations are involved in the design and delivery of the service.
5. A regular multi-agency forum that assesses, co-ordinates, plans and reviews support for vulnerable people experiencing severe and multiple disadvantage, in an integrated way (see chapter 9 for more guidance on multi-agency forums).
6. A multidisciplinary, multi-agency team formed around one individual to assess, co-ordinate, plan and review support for vulnerable people experiencing severe and multiple disadvantage in an integrated way (see chapter 4 for more guidance on assessment and treatment and recovery planning).
7. Alcohol treatment services, mental health services and services for people experiencing homelessness operate on the principle of ‘no wrong door’ for people with co-occurring mental health and alcohol use conditions, so they can access care from any point across any of these services.

You can read more about care for people with co-occurring mental health and alcohol use conditions in chapter 18 on co-occurring mental health conditions.

Making Every Adult Matter outlines the benefits of integration. This may include building skills, exchanging knowledge, experiences, and examples of good practice, as well as leading local innovation and systems change.

21.4.4 Individual integrated treatment and support

Services should make sure alcohol treatment practitioners know when a person needs to be referred to specialist homelessness support services, including specialist homeless health and social care (where these exist). Services should also have processes in place to make sure referrals are made quickly.

Practitioners should contribute to multi-agency assessment and person-centred, multi-agency treatment and recovery planning, using local arrangements. There is guidance on multi-agency treatment and recovery planning in chapter 4 on assessment and treatment and recovery planning.

Practitioners should give people accessible information about their rights to health and social care services and how to access them.

Practitioners should be aware that people have the right to register with a GP without a permanent address. The Primary medical care policy and guidance manual (pages 154 to 155) makes this clear for England, and the Health Literacy Place toolkit provides similar information for Scotland. Practitioners should give people information on how to register with a GP, provide a GP access card where possible (see resources section below) and support them to register. Peer supporters or other advocates may accompany the person to help them with this process.

You can find guidance and resources for registering with a GP at the end of the chapter.

21.5 Reaching people experiencing homelessness and tailoring treatment to meet their needs

People experiencing homelessness should have access to the full range of evidence-based interventions (described in part 1 of this guidance), based on individual assessed need. This section outlines additional considerations for reaching people experiencing homelessness and tailoring treatment to meet their needs.

21.5.1 Increasing access to alcohol treatment

People experiencing homelessness may not be able to access alcohol treatment services for reasons that relate to past trauma, such as a difficulty in forming trusting relationships. They might also experience barriers that are service-related such as stigmatising services with inflexible opening times or procedures for missed appointments.

Services and practitioners need to reduce barriers that prevent people accessing and engaging in treatment. Ways that they can improve access include:

1. Bringing the service to people who need it. This can include outreach on the street and in-reach in services for people experiencing homelessness, like day centres, hostels, and other forms of temporary accommodation. Outreach and in-reach both help to remove barriers to engagement. You can find guidance on assertive outreach in chapter 9 on assertive outreach and a multi-agency team around the person.
2. Direct access services where people can drop in without an appointment on some days or any day of the week.
3. Flexible opening times and appointments, including broad appointment times, like a whole morning rather than a fixed time.
4. Co-locating alcohol treatment services with homelessness services or relevant health and social care services.
5. Service bases that are close to where people live and easy to access by public transport.
6. Providing practical help, for example with transport costs or data for phones.
7. Giving people the option of referral to the service either by self-referral or by a professional.
8. Having peer support and advocates available when needed.
9. Allowing people to contact the service and have appointments by phone and online. But also recognising that some people will not have relevant skills or access to the internet or a phone.
10. Providing professional interpreters and translation where needed.
11. Providing accessible information about alcohol treatment taking into account people’s literacy, language, sensory disabilities, cognitive disabilities, and neurodiversity.
12. Using a harm reduction approach (see section 21.7 below).

Alcohol treatment services and practitioners should realise there are many reasons why a person may not be able to provide proof of their identity or their address. If a person says that they live in the area covered by a service, but cannot produce proof, they should not be refused access.

Alcohol treatment services and practitioners should be aware of the Department of Health and Social Care Guidance on implementing the overseas visitor charging regulations (page 34). This explains that community drug and alcohol treatment services (which it calls “first point of contact services”) are free of charge to overseas visitors, regardless of immigration status, if the providers consider the services provided are ‘equivalent services’ to primary medical services (if they do not then the services may be chargeable). This can include people who have a no recourse to public funds status.

21.5.2 Supporting and maintaining engagement

Building a trusting relationship

Building and maintaining a trusting relationship is vital to help people stay engaged in treatment. Services and practitioners should use a compassionate, non-judgmental, and non-stigmatising approach, treating people with dignity and respect. These principles should underpin all alcohol treatment, but they are particularly important for people experiencing homelessness because they are more likely to experience stigma and discrimination.

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

A longer period of contact is often required when working with people experiencing homelessness. For many people, this includes time to build relationships and remove barriers to engagement before they opt to make changes in their alcohol use.

Trauma-informed practice

Hard Edges: mapping severe and multiple disadvantage in England shows that many people who have experienced homelessness have also experienced significant trauma during their lives and may continue to experience traumatic events while in treatment or while experiencing homelessness. So, a trauma-informed approach is particularly important.

A trauma-informed approach recognises that trauma can affect a person’s ability to feel safe in services, develop trusting relationships with their staff or manage their emotions. Trauma-informed practice seeks to remove the barriers that people affected by trauma can experience when accessing care and services.

You can read about a trauma-informed practice in chapter 2 on principles of care.

A trauma-informed approach includes the way staff communicate with people and support them. It also includes creating service environments that are psychologically informed. Psychologically informed environments are based on an understanding of the psychological needs of people with a history of complex trauma. And they are organised to address these needs, and to support people to make changes. Community alcohol treatment services should be psychologically informed, and alcohol treatment practitioners can also contribute to psychologically informed environments in services where they provide in-reach (such as hostels and day centres).

See resources section below for more on psychologically informed environments.

Addressing diverse needs

Services and practitioners should provide inclusive person-centred care, to address the diverse range of needs of people experiencing homelessness and tailor treatment and support appropriately. For example, needs and risk vary across age, gender, ethnicity and sexual orientation. And the issues that have led someone to become homeless also vary.

Proactive engagement approach

Practitioners should proactively try to engage people experiencing homelessness. This can include making repeated attempts to contact them and following up missed appointments in an encouraging way. Practitioners should be flexible in the way they make contact and communicate about appointments and use whatever method the person prefers, including text, phone, internet, letter and in-person visits.

Flexible delivery of interventions

Commissioners and services need to be flexible in the way they deliver alcohol treatment interventions to meet the needs of people experiencing homelessness.

The following recommendations are based on NICE NG214 and on clinical consensus of the alcohol guidelines development group.

If services have waiting lists for assessment or specific treatment interventions, they should consider giving priority to people experiencing homelessness. This is because their circumstances could mean they are at higher risk of their condition deteriorating and even premature death.

People who have experienced homelessness, especially rough sleeping, may need long term support to help them sustain recovery. Services should consider offering extended periods of treatment and support so the person can form trusting relationships with individual keyworkers. Longer term support can also help the person if their circumstances become stable enough for them to engage with treatment and achieve positive outcomes.

Wherever possible, each person should have one keyworker throughout their treatment to help develop good therapeutic alliance. Services should consider reducing caseloads for practitioners working with people experiencing homelessness, so they can provide flexible and regular contact over an extended period.

People experiencing homelessness may find it difficult to attend appointments due to their life circumstances. So, services should not have policies that require them to discharge people after a particular number of missed appointments.

Services and practitioners should be aware that the transition to independent living can be very stressful. The additional responsibilities may increase their risk of returning to previous behaviours, including problematic alcohol use. So, practitioners should consider increasing the support they offer before, during and after these transitions. End of treatment planning (including recovery check-ups and re-engagement plans) is particularly important for this group of people.

You can read guidance on end of treatment planning in chapter 4 on assessment and treatment and recovery planning.

Assertive outreach is an approach that can be useful when working with people who experience severe and multiple disadvantage, including those experiencing homelessness. There is guidance on assertive outreach in chapter 9 on assertive outreach and a multi-agency team around the person.

21.6 Peer support and involving people with lived experience

21.6.1 Involving people in service provision

People with lived experience of homelessness can play a valuable role in service provision, by helping to improve the quality of targeted services. So wherever possible, commissioners and services should include people with lived experience of alcohol problems and homelessness in all aspects of service provision including:

• needs assessment
• service design
• commissioning processes
• quality governance processes
• service promotion
• service delivery

21.6.2 Peer-based support

Peer-based support is a valuable component of treatment for people who are homeless or experiencing rough sleeping. For example, peers can:

• show that change and recovery are possible
• help someone to form good relationships with services and practitioners
• make sure the person attends their appointments
• act as an advocate for the person in different situations

People with lived experience of homelessness and alcohol problems may be particularly welcomed by people experiencing homelessness.

Any peer-based support should be provided as a component of a personalised treatment and recovery plan and not instead of it. So, alcohol practitioners should be responsible for drawing up and co-ordinating treatment and recovery plans with the person. Commissioners of peer-based support should make sure that the peers involved have access to training, supervision and support from treatment services.

You can read more on the role of people with lived experience and peer-based support in chapter 6 on recovery support services and chapter 5 on psychosocial interventions.

21.7 A harm reduction approach

21.7.1 Taking a harm reduction approach

The alcohol practitioner and the person should consider alcohol use goals as part of the person’s holistic treatment and recovery plan. This should be based on a comprehensive multidisciplinary assessment.

A harm reduction approach will often be appropriate for people experiencing homelessness, particularly those experiencing rough sleeping.

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 and 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.

Service provision targeted at practical needs such as putting on breakfast clubs and serving hot food and drinks may help to reduce harm by providing nutrition, reducing isolation and beginning to build relationships.

You should read chapter 8 on harm reduction which provides guidance on several harm reduction interventions appropriate for people experiencing homelessness, including rough sleeping.

21.7.2 Making changes in alcohol use

A focus on reducing harms may be the most useful way to work with a particular person experiencing homelessness. 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.

21.8 Access to medically assisted withdrawal and residential rehabilitation

21.8.1 Medically assisted withdrawal

For people experiencing homelessness who are alcohol dependent and who want to stop drinking, services should consider offering inpatient medically assisted withdrawal, including for people who are not severely dependent. They are likely to have several physical or mental healthcare needs and will require a safe, stable setting for medically assisted withdrawal where their health can be monitored.

For more information on the criteria for specialist inpatient or residential medically assisted withdrawal, see section 12.4 in chapter 12 on inpatient medically assisted withdrawal.

The person, the alcohol practitioner and relevant members of the multidisciplinary team should jointly assess whether this treatment option would meet the person’s needs. And if it would, the practitioners should make sure the person has adequate support before, during and after each stage of the treatment journey. This is important because transitions to and from residential treatment can be very stressful times. The alcohol treatment practitioner should continue contact with the person throughout their time in inpatient or residential treatment.

21.8.2 Residential rehabilitation

There should be an agreed multidisciplinary plan so that the person has adequate support immediately after the medically assisted withdrawal and in the longer term. They will need ongoing support and treatment, such as residential rehabilitation, after medically assisted withdrawal. This is because they will be at risk of returning to problematic drinking and its associated physical and mental health problems and potential threats to safety. So, the plan should include arrangements for suitable accommodation when they leave treatment (either by completing it or dropping out).

These arrangements should include support for their physical health, mental health and social care needs alongside accommodation. The accommodation and support offered should be based on their individual assessed health and social care needs. The identified keyworker should make sure care is co-ordinated and relevant information shared between all the services working with the person.

21.8.3 End of life care

People experiencing homelessness die 30 years earlier on average than the general population. Some people may require end of life care. Practitioners (in alcohol treatment and homelessness services) working with people experiencing homelessness should be trained and supported to recognise signs of deteriorating health. Health services should provide end of life care and practitioners should also contribute to a multi-agency personalised end of life care plan, to provide appropriate and respectful care.

21.9 Safeguarding

Homelessness, and particularly rough sleeping, is associated with increased safeguarding risks. They are more likely to be a vulnerable adult at risk of abuse or neglect, including self-neglect. They may also be a safeguarding risk to others, including vulnerable adults or children. Commissioners and services should be aware of findings of adult safeguarding reviews relating to people experiencing homelessness and recommendations for practice (see resources section below).

Commissioners and services should support alcohol treatment practitioners to understand and apply laws and related statutory guidance that are relevant to people experiencing homelessness. Support from commissioners and services should include training for practitioners so that they can recognise signs of abuse and neglect (including self-neglect) and know how to make adult safeguarding and child safeguarding referrals. Practitioners should also know how to assess mental capacity or should be aware of the organisational procedure for assessing mental capacity where there are relevant concerns about a person. There should be clear organisational procedures for practitioners to access support and supervision for safeguarding concerns.

Practitioners must make safeguarding referrals in line with legislation, statutory guidance and organisational procedures.

You can find information on adult safeguarding legislation and statutory guidance in annexe 1.

21.10 Resources

Evaluation of the impact of psychologically informed environments describes what psychologically informed environments (PIE) are and evaluates the impact on staff and on services of introducing PIE training. The evaluation took place in several services for vulnerable people with multiple needs.

Homeless palliative care toolkit provides information and resources for frontline staff supporting people who are homeless and who have significant health needs.

The Local Government Association has published reports that provide good practice recommendations based on an analysis of adult safeguarding reviews and homelessness. The third report includes input from people with lived experience.

1. Analysis of safeguarding adult reviews: April 2017 to March 2019.
2. Adult safeguarding and homelessness: a briefing on positive practice.
3. Adult safeguarding and homelessness: experience informed practice.

GP access cards for England, Scotland and Wales provide information on the right to access a GP that people can show to GP surgeries. Practitioners can print them and use them to provide information to people experiencing homelessness and people with concerns about their immigration status. They should encourage people to use them and follow up on whether they were able to register.

22. People experiencing or perpetrating domestic abuse

22.1 Main points

There is a high proportion of both victims and perpetrators of domestic abuse in the alcohol treatment population, compared to the general population.

Harmful or dependent drinking alone do not directly cause domestic abuse, but they may increase the risk of domestic abuse occurring and increase the risk of more serious harm resulting from domestic abuse.

Alcohol treatment services should have domestic abuse policies and procedures that they regularly review.

Alcohol treatment services should make sure staff are trained to:

• respond to disclosure (by a victim or perpetrator)
• ask about domestic violence and abuse
• assess immediate safety
• refer to domestic abuse services

Services should have pathways and working arrangements with specialist domestic abuse services and practitioners should be aware of these.

Asking about and responding to domestic abuse should be a routine part of the role of alcohol treatment practitioners

Practitioners should offer referral to specialist domestic abuse services for victims and for perpetrators and also work with these services to reduce immediate risk and offer longer term support.

Domestic abuse puts children at risk of significant harm, including where they are not the direct targets of the abuse. Practitioners must act in line with child and adult safeguarding legislation and organisational guidance.

When working with a perpetrator of domestic abuse, the safety of adult victims and affected children is the priority.

Where both partners in an abusive relationship have an alcohol problem, services should make arrangements so that both partners can access alcohol treatment but the victim does not attend the same service as the perpetrator.

The person (victim or perpetrator) and their family are likely to need help from several services. Practitioners should work with relevant services so there is an integrated multi-agency approach to their care.

Alcohol treatment services should be a part of local strategic multi-agency partnerships to reduce domestic abuse.

Services and practitioners should follow protocols for multi-agency bodies that manage high risks for victims or perpetrators of domestic abuse, such as:

• multi-agency risk assessment conference (MARAC)
• multi-agency public protection arrangements (MAPPA)
• adult and child safeguarding referrals, assessments and conferences

22.2 Introduction

This chapter provides guidance on identifying and responding to domestic abuse in alcohol treatment services. This includes victims and perpetrators of domestic abuse.

Addressing domestic abuse requires a co-ordinated multi-agency response and, alcohol treatment services should be part of this multi-agency response.

22.2.1 Definition of domestic abuse

England, Wales, Scotland and Northern Ireland each have national legislation that defines domestic abuse. The legislation is:

• England and Wales: Domestic Abuse Act 2021
• Wales: Violence Against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015
• Northern Ireland: Domestic Abuse and Civil Proceedings Act (Northern Ireland) 2021
• Scotland: Domestic Abuse (Scotland) Act 2018

You can find more details on all this legislation in annex 1 on relevant legislation and guidance.

Treatment services should be aware of the definition in their relevant national legislation and associated guidance.

The term domestic abuse includes abuse between intimate partners as well as abuse between adult family members. For example, adult sons or daughters abusing their parents. Other forms of abuse carried out by or at the request of family members include “honour” based violence, forced marriage and female genital mutilation.

The terms victim and survivor are used interchangeably in the research literature. In this chapter, we largely use the term victim, but many people go on to become survivors of domestic abuse.

22.2.2 Domestic abuse and alcohol

The World Health Organization (WHO) guidance Preventing intimate partner and sexual violence against women: taking action and generating evidence identified alcohol as one of 50 risk factors that increase a person’s likelihood of being a victim or a perpetrator of domestic abuse.

There are different explanations that link alcohol use and domestic abuse. Whether alcohol use plays a causal, contributory or other role in domestic abuse remains an area of debate (Jones and others 2019).

WHO suggests that alcohol problems alone do not directly cause domestic abuse, but they may increase the risk of domestic abuse occurring and increase the risk of more serious harm resulting from domestic abuse. Domestic abuse is also more likely and more severe when both the perpetrator and victim have been drinking. Some victims of domestic abuse use alcohol as an attempt to self-medicate by drinking to relieve the symptoms of trauma resulting from the abuse.

The Home Office report Key findings from analysis of domestic homicide reviews: October 2019 to September 2020 found that alcohol and drug use was a perpetrator vulnerability in around a third of cases.

A study shows that around 60% of men in alcohol or drug misuse treatment were violent to their intimate partners in preceding year. (O’Farrell and others 2004).

22.2.3 Prevalence of domestic abuse victimisation

Women and men can be victims of abuse and violence in heterosexual and LGBTQ+ relationships.

Alcohol Change UK’s Rapid evidence review: alcohol’s contribution to violence in intimate partner relationships found:

• a strong association between alcohol use and intimate partner violence (IPV) perpetration and victimisation in heterosexual relationships
• women appear to be at a higher risk of having physical IPV perpetrated against them by a male partner who has been drinking than the other way around
• alcohol-related IPV occurring in lesbian, gay, bisexual or transgender relationships is understudied

The Office for National Statistics report Domestic abuse in England and Wales overview: November 2022, using data from the Crime Survey for England and Wales, estimated that 5% of adults (6.9% women and 3% men) aged 16 years and over experienced domestic abuse in the year to March 2022. This is an estimated 2.4 million adults. The Children’s Commissioner report CHLDRN – Local and national data on childhood vulnerability estimated that, between 2019 and 2020, approximately 1 in 15 children under the age of 17 live in households where a parent is a victim of domestic abuse.

Research suggests that around 1 in 20 women have experienced extensive physical and sexual violence during their life, compared with 1 in 100 men (Scott and McManus 2016). Of these women:

• more than half have a common mental health problem
• 1 in 5 have experienced homelessness
• around a third have an alcohol problem

22.3 Working with victims of domestic abuse

22.3.1 Overview

This section summarises guidance, best practice principles and recommendations on addressing domestic abuse that is relevant to alcohol treatment and recovery services. They have been drawn from a range of guidance developed by national domestic abuse and substance use specialists, including:

• Against Violence and Abuse’s (AVA) Complicated matters: a toolkit addressing domestic and sexual violence, substance misuse and mental ill-health (PDF, 1.02MB)
• National Institute for Health and Care Excellence (NICE) public health guideline Domestic violence and abuse: multi-agency working (PH50)
• Alcohol Concern and AVA’s Domestic abuse and change resistant drinkers: preventing and reducing harm (PDF, 770KB)

22.3.2 Domestic abuse policies and procedures in alcohol treatment services

Alcohol treatment services should have domestic abuse policies and procedures that they regularly review. These should include:

• lines of accountability for managing risks and providing advice on domestic abuse
• staff training and supervision for work involving domestic abuse
• clinical processes for assessing immediate risk, escalating the risk internally, making referrals to domestic abuse services, and collaborative safety planning
• information sharing protocols
• supporting staff who have been affected by domestic abuse

22.3.3 Staff training

Working with domestic abuse is complex and sensitive, often linked to high risks. Commissioners and services should make sure staff are trained to ask about and respond to domestic abuse in a way that prioritises the victim’s safety.

Practitioners should be trained to level 2 on domestic abuse, as described in NICE PH50, and outlined below.

Level 1 is training to respond to a disclosure of domestic abuse (as a victim or a perpetrator) sensitively and in a way that ensures people’s safety. Practitioners trained to level 1 should also be able to direct people to specialist domestic abuse services.

Level 2 is training to ask about domestic abuse in a way that makes it easier for people to disclose it. This involves:

• understanding which groups of people are likely to experience higher levels of domestic abuse
• risk factors for domestic abuse
• how it affects people’s lives
• their role and the role of other professionals in intervening safely
• responding with empathy and understanding
• assessing someone’s immediate safety
• referring to specialist domestic abuse services

Training should include an understanding of honour-based violence, forced marriage and female genital mutilation and an understanding of equality and diversity issues.

Training should be ongoing, and staff should have supervision and support for their work with domestic abuse.

It can be helpful if services appoint a named domestic abuse lead, with appropriate training and competence, to promote good practice and provide support and supervision to staff. In some services the safeguarding lead also leads on domestic abuse.

To support staff working with victims and perpetrators of domestic abuse, services can access online training resources, some of which are free. These include:

• AVA training for professionals
• Respect training on working with perpetrators of domestic abuse

22.3.4 Pathways with domestic abuse services

Increasing safety for victims of domestic abuse needs a multi-agency approach at a strategic and a practice level.

Commissioners and service providers should agree pathways and working arrangements between alcohol treatment services and specialist domestic abuse services. They should make sure that frontline practitioners from both services:

• are aware of the pathways
• know how to make referrals
• know what each service offers

Alcohol treatment services should work with domestic abuse services, other health and social care services and the person to provide integrated care and reduce risk.

In some areas, alcohol treatment services and domestic abuse services provide in-reach sessions in each other’s services to reduce barriers and support partnership working.

Services should regularly update staff about pathways and working arrangements with domestic abuse services.

22.3.5 Information sharing protocols

Services should have information sharing protocols with all other agencies working with people experiencing domestic abuse. Confidentiality is important for everyone that comes to alcohol treatment services, but it is particularly vital for people experiencing domestic abuse. This is because any information that gets to a perpetrator can put the victim at increased risk of abuse.

Alcohol treatment services should develop or adapt protocols for sharing information about people at risk of, experiencing and perpetrating domestic abuse within their service and between services. The protocol should specify:

• the duty of confidentiality
• what information can be shared and with whom
• circumstances in which information can be shared without consent

It is always best to have consent to share information, but information can be shared without consent for child safeguarding and if an adult is at serious risk. A practitioner should involve the accountable professional in the service or organisation (for example, domestic abuse lead or safeguarding lead) if they are making a decision about sharing information without consent.

The protocol should specify technical information sharing systems, which must be secure.

Services should make sure practitioners are aware of the information sharing protocols and regularly review them with staff.

22.3.6 Promoting an environment that encourages disclosure

Alcohol treatment services should clearly display information in waiting areas and other suitable places about the support they offer for people affected by domestic violence and abuse. They should also display it where people can read it in private, like toilets. Information should include contact details of relevant local and national helplines.

Services should display information in local community languages, in accessible formats, and in simple language.

If a service is using interpreters, these should be independent from the person’s family so that victims can speak confidentially and potential risks from family members are avoided. Human traffickers can pose as family members and offer to interpret to intimidate the person and control what they disclose.

A perpetrator and victim should not be seen in the same service because this will put the victim at risk.

Domestic abuse is traumatic, and victims of domestic abuse may have multiple experiences of trauma. So, it’s important that services and practitioners use a trauma-informed approach.

Offering a choice of either a male or female practitioner may help the person to feel safe enough to discuss their situation.

22.3.7 Asking about and responding to domestic abuse

Alcohol treatment practitioners should ask about and respond to domestic abuse as a routine part of their work. Trained practitioners should know how to ask and respond sensitively and in a way that prioritises people’s safety.

The practitioner should explain the service’s duty of confidentiality and the circumstances when information can be shared without consent. Practitioners should reassure people that their attendance at the service and their treatment and support will never be discussed with the perpetrator.

Services should make sure that questions about domestic abuse are routinely part of assessment.

Any questions or discussion about domestic abuse should happen when the person is alone and in a completely private setting. A victim is unlikely to disclose abuse and can be put at greater risk if they are asked about their experience in the presence of the perpetrator or in some cases, other family members.

Victims of abuse may find it hard to disclose because they are afraid of the perpetrator finding out, being judged, or intervention from local children’s services. However, they may appreciate the chance to disclose, and practitioners asking about domestic abuse can help build trust and confidence between the person and the practitioner. Sensitive questions and an empathic approach can help to encourage the person to disclose their experience.

People often do not disclose abuse when they first contact services, so practitioners should ask them again as they build a relationship, or if they see indications that the person is experiencing domestic abuse. For example, they may refer to their partner not allowing them to do something or appear fearful.

22.3.8 Helpful questions

When asking questions to someone who may be a victim of domestic abuse, it might be helpful to frame the questions by providing an explanation, such as:

“We know that many of our service users have experiences of being hurt or frightened by a partner or family member. They can sometimes struggle with how they feel and might use alcohol, medication or other drugs to manage, so we ask everyone about these issues.”

Also, you can start with broad, generic questions, such as:

• how are things at home?
• how are things with your partner?
• how are you feeling?
• how are you managing at the moment?

Then, where appropriate, you can follow up with more direct questions that use non-judgemental language, for example:

• how do you and your partner work out arguments?
• do arguments ever result in you feeling put down or bad about yourself?
• do arguments ever result in hitting, kicking or pushing?
• has anyone ever made you feel frightened or scared at home?
• do you ever feel controlled by your partner?

If the person has an injury, rather than asking how it happened, ask “who hurt you?”.

Active listening helps establish rapport and build trust. It helps the person to disclose their feelings and helps to gather information. The practitioner could ask more questions to clarify the extent of abuse disclosed and to identify the level of risk that exists, such as:

• do you feel safe right now?
• do you feel safe leaving this appointment, or going home?
• what do you fear might happen in future? (to find out about what types of violence or abuse could happen to them)
• what threats has the perpetrator made to you or your children?

22.3.9 Responding to a disclosure of domestic abuse or concern the person is at risk

Referring to specialist domestic abuse services

When a victim discloses current or past experience of domestic abuse, practitioners should:

• respond with empathy and understanding
• complete the service risk assessment for domestic abuse
• offer referral to specialist domestic abuse services for immediate risks or for longer term support

The practitioner should also discuss the case with their manager and the domestic abuse lead or safeguarding lead. They should discuss the risk assessment and what to do next.

Risk assessments and risk management plans should adequately reflect the seriousness of the risk associated with problem drinking and domestic abuse and the fact that this can change rapidly.

People are often anxious about contacting domestic abuse services, so practitioners should offer to make the initial referral or support the person to make contact. The practitioner should be familiar with local domestic abuse services, so they can explain what they offer and how they can help the victim.

Current risk

If a victim and any children are currently at risk, their safety is the priority. Specialist domestic abuse services can intervene to help the person to create a safety plan. Services for victims at current risk include:

• advocacy
• refuges
• multi-agency risk assessment conference (MARAC) for people at high risk

People at high risk will need a multi-agency response to reduce risk and to address health and care needs. In England in Wales services should refer them to the local MARAC.

A MARAC is a regular meeting where information is shared to provide a fuller picture of risk to adult and child victims, between representatives of:

• independent domestic violence advocate services
• housing services
• children’s services
• the Probation Service
• primary care
• mental health
• alcohol and drug services
• adult social care

Alcohol treatment services should follow local protocols for making referrals to MARAC or equivalent multi-agency structure. In some parts of the UK, services use the specialist domestic abuse risk assessment Safe Lives ‘Dash risk checklist’ as a referral to MARAC.

After information sharing, the MARAC agrees co-ordinated actions to reduce risk. Member organisations share information in between meetings to monitor risk and improve safety.

Alcohol treatment services should be members of their local MARAC and related multi-agency panels, for example multi-agency public protection arrangements (MAPPA). These take a multi-agency approach to monitoring and managing people who pose a risk to others, including domestic abuse perpetrators.

No consent for referral to domestic abuse services

If the person does not agree to access specialist domestic abuse services or give consent to share information, the practitioner should inform their manager and the organisational domestic abuse lead or accountable professional and discuss next steps. In some cases, the practitioner will need to share information without the person’s consent. This includes situations where children are at risk or an adult is at serious risk of harm.

The practitioner must follow child and adult safeguarding legislation and organisational procedures, and organisational information sharing protocols. They should inform the victim and explain their reasons unless doing so would put children at further risk.

Longer term support

Domestic abuse affects many aspects of a person’s life. If the person is not currently at risk of harm but has been affected by domestic abuse, specialist domestic abuse services can intervene to provide legal, emotional and social support.

Services include:

• floating support and outreach
• legal advice and advocacy
• housing support
• support groups
• skills training

22.4 Child safeguarding

A significant proportion of perpetrators of domestic abuse are violent towards their children or children of the victim. Even where children are not direct victims of violence, witnessing or being aware of domestic abuse in the home puts them at risk of significant harm and are grounds for a child safeguarding referral.

Practitioners must follow national safeguarding legislation and guidance and organisational procedures. The Domestic Abuse Act 2021 in England defines children as victims of domestic abuse even where they are not direct targets of abuse.

22.5 An integrated multi-agency approach

People experiencing or affected by domestic abuse often have many needs and experience severe and multiple disadvantage including:

• homelessness
• contact with the criminal justice system
• mental health conditions
• trauma
• poverty

Several of these factors can increase vulnerability to domestic abuse.

People at risk of or affected by domestic abuse will not all meet the high risk threshold for MARAC (or the threshold set by an equivalent multi-agency structure) but they still need a multi-agency approach. Practitioners should work with multiple agencies including:

• domestic abuse services
• children’s services
• adult social care
• the police
• healthcare
• mental health services
• housing

Services need flexible engagement approaches to make it easier for women with severe and multiple disadvantage to access the service. They also need to reach out to groups who might not usually approach services, including women from ethnic minority groups. There is guidance on developing inclusive services in chapter 25.

Women coming to alcohol treatment who have experienced domestic abuse are likely to benefit from access to women-specific, trauma-informed services. Mixed gender alcohol services can feel intimidating and uncomfortable and can re-traumatise some women. Holding women’s groups or sessions in an area where male clients cannot enter, see into or potentially harass women leaving, can help to create emotional safety for women.

22.6 Working with perpetrators of domestic abuse

22.6.1 General principles

Similar principles apply to services and staff working with perpetrators of domestic abuse as they do for working with victims of domestic abuse. This includes practitioners sensitively asking about current and historic domestic abuse as part of standard practice.

Any interventions with the perpetrator must prioritise increasing the safety of the adult victim and children (if they have any).

22.6.2 Acting on a disclosure of domestic abuse

After a perpetrator discloses domestic abuse, practitioners should discuss this as soon as possible with appropriate staff members and follow their local domestic abuse procedures. They should discuss any disclosures with:

• their line manager
• child and adult safeguarding lead
• domestic abuse lead
• other relevant staff

The practitioner, appropriate lead and line manager should then agree on actions to take. Alcohol treatment staff should work with other agencies to make sure the adult victim and their children are accessing safeguarding and support as their safety is the priority. They should share information to reduce risks in line with their local procedures.

Practitioners should:

• follow protocols for MARAC, MAPPA and adult and child safeguarding referrals
• be clear with people about how and when they will need to break confidentiality
• be aware of local resources and be confident about how to use local pathways to specialist domestic abuse services for perpetrators and for victims
• continue to support and work positively with the perpetrator and give them hope and optimism that it’s possible to change their behaviour

Perpetrators of domestic abuse may need help and have their own complex needs, possibly including their own histories of abuse or neglect. This does not reduce responsibility for the abuse but may suggest they need to be referred to support services or a Respect accredited perpetrator programme. This will hold the person accountable as well as helping them to access support for their own experiences, if needed (Ward and others 2016).

22.6.3 A framework for substance misuse services to work with perpetrators

There is a lack of evidence about the effectiveness of interventions in alcohol treatment to address domestic abuse perpetration (Jones and others 2019).

King’s College London has published A framework for working safely and effectively with men who perpetrate intimate partner violence in substance use treatment settings (PDF, 949 KB). The guidance is specific to drug and alcohol treatment services and clarifies the capabilities staff need for working with men who use drugs and alcohol and who perpetrate intimate partner violence. These capabilities include:

• knowledge
• attitude and values
• ethical practice
• skills and reflection
• professional development

22.7 References

Scott S and McManus S. Hidden hurt: violence, abuse and disadvantage in the lives of women. DMSS research for Agenda 2016

O’Farrell T, Murphy C, Stephan S, Fals-Stewart W and Murphy M. Partner violence before and after couples-based alcoholism treatment for male alcoholic patients: the role of treatment involvement and abstinence. Journal of Consulting and Clinical Psychology 2004: volume 72, issue 2, pages 202-217

Ward M, Holly J, Allwright L, Booker LA, Holmes M and Pierce M. Domestic abuse and change resistant drinkers: preventing and reducing the harm. Learning lessons from domestic homicide reviews (PDF, 769KB). Part of Alcohol Concern’s Blue Light Project and in partnership with AVA’s Stella Project 2016

23. Alcohol treatment and support for young people

23.1 Main points

Specialist alcohol treatment and the competencies for working effectively with young people are different to those for adults.

Specialist alcohol treatment services working with young people should be fully integrated and aligned with other local young people’s services for at-risk populations. Treatment fits into a wider context of safeguarding young people from harm.

All frontline practitioners working with children and young people under the age of 18 should be trained so they can:

• routinely undertake screening to identify young people at risk from alcohol and drug use
• offer brief advice where appropriate
• refer young people drinking at harmful or potentially dependent levels on to specialist services for assessment

Practitioners should undertake comprehensive assessment alongside other involved agencies to ensure continuity of care and to develop jointly agreed personalised care plans.

The legal framework for getting informed consent to treat children and young people is different to the framework for adults. Staff working with young people in specialist alcohol and drug services should have a thorough understanding of capacity and consent issues for under 18s.

A strong therapeutic relationship and good communications skills are important for helping young people to achieve change.

The evidence shows that motivational interviewing and cognitive behavioural and family therapies can help young people to reduce alcohol and other drug use and related harms. All interventions should be age appropriate.

Although alcohol dependence is rare in under 18s, medically assisted withdrawal must be available when a young person is assessed as physically dependent.

Medically assisted withdrawal is only one component of a young person’s care plan and specialist staff should deliver the intervention along with relevant psychological therapies and mental health interventions within a clinical governance framework.

Practitioners delivering interventions to young people should:

• be trained and have the skills required for each specific intervention
• have access to ongoing supervision from an appropriately qualified professional

Co-occurring mental health and alcohol problems are common among young people. The young people’s specialist alcohol and drug service and mental health services for young people need to co-ordinate care to ensure mental health and substance misuse needs are met concurrently.

Young people’s specialist alcohol and drug services should agree arrangements for transition with the services the young person will move to, and plans to meet ongoing need, before the young person leaves the treatment service.

23.2 Introduction

This chapter provides evidence-based guidance on alcohol treatment for young people under 18 years old. Young people’s alcohol and drug use is very different from adults. Concepts used in adult treatment (such as recovery) do not always apply to people aged under 18. Some specialist young people’s drug and alcohol services are commissioned for young adults up to the age of 24. These services need to ensure the support they offer is age appropriate. They need to identify and respond to developmental needs and put in place transition arrangements to other service for young adults who have ongoing support needs.

Alcohol use has been decreasing among young people in the UK over the last decade. However, a proportion of young people who drink still drink heavily and experience harm. Young people’s alcohol use varies, but more typically involves experimenting or binge drinking. This risks serious short and long term health problems and social consequences, and is a significant public health concern. Remaining alcohol free is the healthiest, safest and recommended option for children under 15 years old (Donaldson 2009), drinking in small amounts (for example, not more than 1 or 2 units) usually does not cause significant health problems.

23.3 Alcohol use and alcohol harm in young people

23.3.1 Factors associated with alcohol use in young people

As young people journey from childhood to adulthood, they go through a period of rapid developmental change. This is associated with an increase in impulsive and risky behaviour.

Certain risk factors and vulnerabilities increase the likelihood of young people using drugs, alcohol or tobacco. Generally, the earlier young people drink, particularly heavily, the more harm they will experience in later years (Bonomo and others 2004, DeWit and others 2000, Kuntsche and Gmel 2013, Hingson and others 2006).

Common risk factors associated with problematic alcohol use, include:

• experiencing abuse and neglect (including emotional abuse)
• having a mental health condition or a behavioural disorder
• certain personality traits (such as impulsiveness or sensation seeking)
• poor school attendance and engagement
• involvement in anti-social behaviour or offending
• early sexual activity
• being exposed to parental drug and alcohol use
• growing up in a marginalised or deprived community

Generally, the more risk factors a young person has, the more likely they are to use drugs or alcohol. However, there is evidence that other factors can protect young people from developing problem behaviours, which can be understood as resilience (the ability to bounce back from adversity).

The 2018 United Nations Office on Drugs and Crime report on preventing drug use summarises the evidence on resilience. It identifies important protective factors that help make young people less vulnerable to substance use and other risky behaviours. These include:

• physical and emotional wellbeing
• good social relationships and support
• personal and social competence

Other literature identifies important predictors of wellbeing, including:

• positive family relationships
• a sense of belonging at school and in local communities
• good relationships with adults outside the home
• positive activities and hobbies

23.3.2 Alcohol related harm in young people

Alcohol intoxication, heavy use and dependence have wide ranging health, social, and criminal consequences. Alcohol use can be a cause of vulnerability as well as a consequence of it. Drinking alcohol can increase a young person’s susceptibility to:

• violence
• risky sexual behaviours
• self-harm, including suicide
• accidents

There is evidence young people may be particularly vulnerable to the negative effects of alcohol, particularly binge drinking (McCambridge and others 2011).

Alcohol use may be particularly harmful to young people due to harm to the developing brain. Alcohol use is associated with poorer cognitive functioning which can lead to educational and social problems (Toumbourou and Catalano 2005, Lees and others 2020). Alcohol use is also associated with a range of mental health problems in adolescence, particularly attention deficit hyperactivity disorder (ADHD) and exclusion from schools (Costello and others 2000).

Alcohol use is a risk factor for drug taking and is associated with an increased prevalence of smoking. Some young people experience problems with both alcohol and drugs.

There are important differences between boys and girls that affect their tendency to binge drink. Girls are more vulnerable to binge drinking in response to stress caused by trauma than boys. Girls are also more likely to have anxiety and depressive disorders. In contrast, in boys it is conduct disorder that is associated with binge drinking. (Foster and others 2014, Kilpatrick and others 2003).

A mental health assessment should include an assessment of alcohol use and a young person coming to treatment for support for alcohol use should also be assessed to see if they have any mental health needs. There is generally a complex interdependence of mental health, alcohol use and social and educational difficulties.

23.4 Age-appropriate specialist services for young people

23.4.1 Treating young people

Specialist alcohol and drug treatment for young people is different to adult treatment. This is related to factors such as:

• maturity and young people’s capacity to consent to treatment
• parental responsibility (see the resources section at the end of the chapter for the legal meaning of this term)
• safeguarding duties
• the legal framework
• developmental needs
• the patterns of substance use problems

While the principles of quality governance apply to all alcohol and drug treatment services, there are specific considerations and actions for services for children under 18 years old. These need to be incorporated into service policies and quality governance arrangements. You can find more information on quality governance in chapter 2 on the principles of care.

23.4.2 The role of specialist alcohol and drug services and commissioners

Specialist alcohol and drug service commissioners and services should ensure that alcohol and drug treatment is fully integrated and aligned with other local young people’s services for the same at-risk groups. There should be clear and comprehensive referral pathways and agreements that confirm joint working arrangements to address the multiple vulnerabilities and complex needs young people experience.

Services should have policies and agreements that set out information sharing arrangements with other agencies, including children’s social care and education services, and also with parents and carers.

Specialist alcohol and drug service commissioners and services should ensure that:

• treatment is safe and delivered in line with evidence-based guidance (see below) by competent and supported staff
• the service complies with relevant guidance (see below) for young people’s alcohol and drug use provision
• the service is operating within local safeguarding frameworks for assessing children and young people’s needs
• a clinical care pathway is in place for the small number of young people requiring a pharmacological intervention

Services should ensure that interventions are age appropriate and based on the child’s needs. They should also follow the National Institute for Health and Care Excellence (NICE) guideline Transition from children’s to adults’ services for young people using health or social care services (NG43).

In 2012, the Royal College of Psychiatrists’ College Centre for Quality Improvement (CCQI) published Practice standards for young people, which sets out criteria for comprehensive assessment, integrated care planning and delivering interventions, as well as on transferring care after completing treatment, for community-based specialist young people’s drug and alcohol services.

The Royal College of Paediatrics and Child Health’s Healthcare standards for children and young people in secure settings has guidance on meeting the needs of young people with alcohol or substance use disorders in secure settings in England.

Services should monitor the extent to which staff routinely follow locally agreed thresholds to identify young people at risk, including concerns around:

• safeguarding
• school non-attendance
• adverse childhood experiences
• mental health problems

Where appropriate, services should record and monitor:

• how often these locally agreed risk thresholds are used as a prompt for further action
• the number of young people identified as being at risk of harm from their alcohol use
• the number of young people identified as needing a comprehensive assessment and treatment interventions

Commissioners and services should make sure that young people’s treatment services are separate from adult services. The design and delivery of specialist services for children and young people should be non-stigmatising, and accessible and engaging for young people. Information should be in young person-friendly formats. Technology such as text messaging, video calls and online appointment booking systems may also help to engage young people and help retain them in treatment.

23.4.3 The role of practitioners

Practitioners in young people’s treatment services should:

• be able to assess capacity of the young person to give consent for the appropriate interventions (Gillick competence)
• understand the developmental needs of children and young people and apply this understanding to each individual assessment and formulation
• understand parental responsibility (as defined in legislation) and how to support effective parental involvement
• be competent to deliver the specific interventions they offer
• routinely work with other agencies and professionals in the best interests of the young person
• understand the different legal, statutory and policy frameworks for children, young people and families
• be aware of the current relevant guidance and organisational procedures on safeguarding children
• develop individualised care packages with the young person and their parents or carers and working with wider children and family services where appropriate
• consider gender differences, other protected characteristics and the impact of inequality in developing the care plan, for example young girls and women are more likely to experience mental health problems and to be exposed to sexual exploitation and abuse
• offer flexible appointments to fit with young people’s school or college timetables, or appropriate other commitments

You can find more information on the legal, statutory and policy frameworks for young people in annex 1 on legislation and statutory guidance and in the resource section at the end of this chapter.

It is important to make all decisions in the best interests of the child or young person. Practitioners should offer confidential care, but they must share information in line with safeguarding requirements and local information sharing agreements when it is necessary to protect a young person from abuse or neglect. All staff should understand how and when it is appropriate to share information and with whom. Staff must be able to explain what the confidentiality policy means to young people when they access the service, including explaining how they will handle disclosures if there are safeguarding concerns.

23.4.4 Identifying young people at risk of alcohol and drug use

All frontline practitioners working with young people under 18 should routinely undertake screening to identify young people at risk of alcohol and drug use. This includes universal, targeted and specialist services across:

• healthcare
• social care
• education
• youth justice system
• third sector and community sector

Practitioners should know:

• when a young person needs a detailed comprehensive assessment
• which service to refer them to for the assessment
• how to refer to safeguarding services and other services to meet any other urgent needs the young person has

Practitioners need to work with all other services involved in the young person’s care.

The NICE guideline Alcohol-use disorders: prevention (PH24) endorses several validated screening tools, but the most commonly used for young people is the Alcohol use disorders identification test for consumption (AUDIT C). The thresholds for levels of risk when using AUDIT C with a young person under the age of 18 are different to thresholds used for adults. When screening young people between 10 and 17 years old, an AUDIT C score of 3 or more identifies high risk drinking. Young people who score 5 or more should be offered a comprehensive assessment to assess alcohol and drug use (Coulton and others 2018), and other possible related issues such as:

• education
• family functioning
• mental health problems
• physical health
• other vulnerabilities

Research in adolescent populations in schools and A&E found no benefits to delivering brief interventions over screening alone (Drummond and others 2014, Deluca and others 2020). Screening alone potentially raises awareness of high-risk drinking and may be enough to start behaviour change (McCambridge and Day 2008). Screening is also able to identify young people drinking at harmful and dependent levels who could benefit from referral to specialist services for assessment, or those who need a safeguarding referral in line with statutory guidance and organisational procedures.

Young people at increased risk of developing problematic forms of substance use include those:

• in the youth justice system

• who do not attend school regularly

• with mental health needs or behavioural problems, particularly where the problem behaviours start early
• who are looked after
• who are not in education, employment, or training
• who are homeless
• who have caring responsibilities

This makes youth offending services, children’s social care services, child and adolescent mental health services (CAMHS) and schools important settings for early identification of at-risk young people and for referring them to specialist services. However, some vulnerable groups may not be well represented in mainstream schools.

Commissioners need to work with their contracted services to make sure there are comprehensive local arrangements across all frontline children’s services, CAMHS and GPs. This is to make sure young people who do not attend school, or who are excluded, are offered screening for problematic behaviours. This includes screening for alcohol and other drugs, supported by appropriate referral and preventative measures.

All young people should be given advice about sexual heath, mental health and drugs and alcohol to support resilience. These issues are interrelated and advice should address them in an integrated way and not as discrete issues.

Schools have a role to play in delivering interventions that prevent and reduce alcohol use among children and young people. NICE guideline Alcohol interventions in secondary and further education (NG135) recommends that schools should adopt a whole-school approach to alcohol education that includes universal and targeted interventions. In addition to classroom-based curriculum activities and pastoral support, schools are encouraged to provide preventative and educational activities involving parents, carers, families and communities. Schools should also develop strong connections and clear referral pathways between the school and young people’s specialist alcohol services for the most vulnerable pupils who need assessment and further support.

Specialist alcohol treatment services do not need to be involved in planning or providing classroom-based alcohol education but may have a role in training school staff and helping to develop referral pathways.

Teaching about alcohol and other drugs is compulsory in England in personal, social, health and economic (PSHE) education. This includes relationships education, relationships and sex education and health education for all children and young people in all schools. The PSHE Association has developed resources to support schools teach about alcohol and drug use, including lesson plans for children with special educational needs and disabilities. These resources help teachers to plan age-appropriate lessons and to feel confident about informing young people about the law, risks and consequences associated with alcohol use. This allows pupils to learn how to manage influences and pressure, and to stay healthy and safe.

23.4.5 Comprehensive assessment

Specialist alcohol and drug practitioners responsible for alcohol and drug assessments for young people should have training and experience in establishing rapport and engaging with children and young people. They are also responsible for working in partnership with other professionals and agencies to make sure young people have all their needs assessed. This might include working with:

• CAMHS
• GPs
• statutory children’s services
• the youth justice system
• education services
• the parent or carer, if appropriate

For the assessment to be comprehensive it needs to be undertaken by a team of specialists that have the competence to assess the young person’s wider developmental and mental health needs.

Undertaking a drug and alcohol assessment helps the clinician to understand a young person’s needs and to decide a formulation that will guide the interventions they offer the young person. You can find a full description of what is meant by clinical formulation in chapter 5 on psychosocial interventions.

You should tell young people and their parents or carers about the process of their assessment and what the aims are. Assessment is a continuing process and you should not attempt to do it in one sitting, although you should consider alcohol and drug related risks and other urgent risks at the first interview (see section on risk assessment below).

Young people often need time to develop trust in a new relationship with a practitioner and may need help to reflect on aspects of their lives for their needs to be identified. Practitioners can get information from the young person, parents and carers and other professionals. Sometimes it is helpful to corroborate information gained from one source with another.

The assessment should review:

• alcohol and other drug use
• patterns of use, frequency, how much they consume
• any signs of alcohol dependence (see definition of alcohol dependence in the glossary)
• factors contributing to vulnerabilities and resilience (including offending and social networks)
• risks and safeguarding concerns
• education
• physical health, including medication they take
• sexual health and pregnancy
• mental health, including medication, suicidal ideation (thoughts) or risk of self-harm
• neurodiversity
• adverse childhood experiences
• relationships, family issues, community and school networks

Professionals and services involved in a young person’s care should share relevant information to support high quality care in line with multi-agency information sharing agreements.

You should get consent from the young person before you share confidential information. But, where you cannot get consent, you will need to assess the young person’s individual circumstances. This will help you determine whether to disclose confidential information against the child’s wishes, in line with safeguarding legislation and local safeguarding procedures. You should also discuss the young person’s circumstances with your line manager and consider your agency’s policies. You should clearly document any decision to disclose information without consent, setting out:

• the reasons for disclosure
• details of who signed off the decision
• details of what needs to change before full confidentiality will be reinstated

23.4.6 Risk assessment

Assessing risk is an important part of any comprehensive assessment. Risk assessment should inform the content of the care plan and should consider the person’s risk to self and the risk to others. Identifying immediate alcohol and drug related risk is vital for protecting young people’s wellbeing and ensuring that interventions to reduce these risks are prioritised. Multiple risk factors can mean that the overall risk to the young person is higher.

Factors to consider and act on in any risk assessment include:

• mental health, such as deliberate self-harm, attempted suicide and signs of psychosis
• violence to self or others
• physical health, such as overdose or co-existing health problems
• alcohol and drug use in risky contexts such as in association with older people, sexual exploitation, offending or in dangerous physical environments
• high-risk behaviour linked to dose, substance used, route of administration and combinations of substances used together
• age
• child protection, with any concerns about risk being dealt with urgently in line with statutory guidance and local policy and procedure

You can find details of relevant child safeguarding legislation and statutory guidance in annex 1.

23.4.7 Parental responsibility and the contribution of parents and carers

Young people do not live in isolation and although individual family circumstances will vary, all will have some relationship with a parent, carer or significant adult. You cannot undertake a full assessment of a young person’s needs without considering the perspective of the people who support them. While some young people will want to be seen in confidence, many will not. You should encourage parents and carers to be involved where possible because they can play an important role in helping young people to change their behaviour.

You should create opportunities for parents and young people to discuss the situation together as well as ensuring that young people are also allowed to discuss their concerns and give their perspective alone.

Consent to treatment or to information sharing can be given by the parent or carer who hold parental responsibility for the child or young person as defined by legislation (you can find details of the relevant legislation in the resource section at the end of this chapter). However, in some cases, young people may not want their parents or carers to know that they have requested support for their substance use and you should consider their wishes. There are circumstances when it may be appropriate for the young person to consent to their own treatment and information sharing and these are outlined in section 3.8 below.

You must understand the legal concept of parental responsibility and how it applies to your work. There is information on parental responsibility in the resource section at the end of this chapter.

23.4.8 Competence to consent to treatment

Treatment cannot start without informed consent. The legal position on consent and refusal of treatment by young people under the age of 18 is different to that for adults. Staff should get voluntary consent from the young person, or the person with parental responsibility as appropriate, before starting any intervention.

Across the UK there is no specific age when a child becomes competent to consent to treatment other than in Scotland where under the Age of Legal Capacity (Scotland) Act 1991 it is a young person’s 16th birthday that draws the line between childhood and adulthood. Usually, competence to consent to their own treatment will depend on the maturity of the child and the seriousness and complexity of the treatment being proposed.

In England, Wales and Northern Ireland, where the young person is assessed as competent to give their consent to treatment, this is known as ‘Gillick competence’. Generally, young people aged 16 to 17 are presumed capable of consenting to their own treatment if appropriately informed. Children under 16 are not necessarily considered legally competent to give consent to treatment. Practitioners need to assess Gillick competence if the child wants to go ahead with treatment without their parents’ or carers’ knowledge or consent. It would be very unusual for a child of under 13 years to be offered treatment without first getting parental consent.

In Scotland, the Age of Legal Capacity (Scotland) Act requires the medical practitioner attending a child under the age of 16 years to consider whether the child is capable of understanding the nature and possible consequences of the procedure or treatment. If the child is assessed as capable, the practitioner must seek the consent of the child rather than of the parent. In practical terms, practitioners should look for signs that the child can consent on this basis from when the child is about 12 years old.

It is important that all staff working with young people in specialist alcohol and drug services know how to assess a young person’s capacity to understand all aspects of the proposed treatment intervention. This includes training to ensure understanding of the legal framework for obtaining valid consent. There is information about competence to consent in the resources section at the end of this chapter.

Even when a child or young person is assessed as competent, it is good practice to involve the child’s family in the decision making process, but only if the child consents to their information being shared. And practitioners should ask the young person their views, wishes and feelings so that they are involved in, understand and agree decisions about their treatment, regardless of their competence. Staff should always record the outcome of the assessment of competence to consent in the case notes.

23.4.9 Care planning

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

Clinical formulation allows practitioners to understand the young person’s problems, which are often multiple and complex, but also to identify skills and strengths that they can develop. For young people, the formulation needs to consider their development, education, family environment and safeguarding.

The findings of the assessment and the clinical formulation should be summarised in a written care plan.

Since there are a wide range of factors that can lead to alcohol problems, this plan should not only address the alcohol or drug use problems, but all other areas affecting a young person’s ability to function. The care plan should:

• summarise the findings of the assessment and the clinical formulation
• describe the young person’s agreed goals and preferred outcomes
• describe how the young person’s needs are to be addressed, including the interventions offered to them
• outline arrangements agreed with other services and agencies to meet wider needs
• have a named keyworker responsible for ensuring care is co-ordinated across all the relevant agencies

The care plan should be multidisciplinary, including planned interventions from other agencies and a variety of psychosocial interventions for alcohol and mental health problems. It should also include pharmacological interventions and other treatments, where appropriate.

Alcohol and drug practitioners have an important role in co-ordinating care and (where necessary) responding appropriately to crises, delivering interventions that aim to:

• reduce the young person’s alcohol and drug use
• improve their resilience
• support positive decision-making
• enhance their understanding of actions and consequences
• improve their educational engagement and social functioning
• improve their mental health and wellbeing
• increase the support they are receiving for neurodiverse needs
• encourage positive relationships with other people who are not dependent on alcohol or other substances
• involve parents and carers to improve their well-being, develop their parenting skills and strengthen family relationships

The keyworker should review the care plan at regular intervals. This gives the young person (and their parents or carer) a chance to consider whether the treatment is helping, and to monitor progress against agreed goals.

23.4.10 Involving parents or carers

Involving parents or carers and providing them with support and information on alcohol and other substances can:

• improve their ability to cope with their child’s problems
• reduce problematic alcohol and drug use among parents and their children
• improve treatment retention
• improve the child’s engagement in education
• reduce the child’s involvement in anti-social behaviour and offending
• strengthen family relationships

23.5 Psychosocial interventions

23.5.1 Common factors

The evidence base for specific psychosocial interventions for young people under the age of 18 is limited. Recommendations are often made using research from adult, young adult, and university student populations rather than under 18s, often based on research from outside the UK.

As with psychosocial interventions for other conditions, meta-analyses have shown that substance use treatment programmes help young people to reduce alcohol and drug use, although there is less information on longer term outcomes (Dennis 2004, Tanner-Smith and others 2016).

The evidence is inconclusive on recommending one type of intervention above another (Godley and others 2004). But the literature suggests that delivering an intervention based on a clear theoretical model is more likely to make a positive difference to outcomes and engagement than offering a less structured intervention.

Some psychotherapeutic factors have been found to be common to all effective treatment (Peterson 2019 JCPP), including:

• therapeutic alliance
• empathy
• warmth and authenticity
• a persuasive rationale for the formulation agreed between the young person and practitioner, which encourages ambition and confidence in each young person’s capacity to achieve change

Good interpersonal factors explain much of the change associated with psychosocial interventions, so are essential for any treatment.

The literature describes the therapeutic alliance as a collaborative and effective bond between the therapist and patient. There is evidence for the positive role of the therapeutic alliance in some specialist substance misuse treatment interventions for young people (Shelef and others 2005, Tetzlaff and others 2005, Hogue and others 2006). So, it is important that practitioners in specialist treatment services have good interpersonal skills and are able to communicate with young people in a way that engages their trust and builds this relationship.

23.5.2 Psychological treatments for young people

Offering and providing psychological treatments

Psychological treatments that practitioners could consider for a young person’s care plan are set out below. These are recognised structured interventions that can be offered by a competent practitioner. Practitioners delivering these interventions should be trained in the approach, should have the skills required for the specific intervention offered and should have access to ongoing supervision from an appropriately qualified professional. These interventions should be offered alongside support for the young person’s social and educational needs, such as helping them to take part in social, educational and recreational activities.

Motivational interviewing and enhancement therapy

Motivational interviewing (MI) and motivational enhancement therapy (MET) principles are used extensively in young people’s treatment services, although the evidence is mainly from adults. However, there is some evidence to support the use of MI and MET with young people either alone (Walker and others 2006) or in combination with cognitive behavioural therapy (Dennis and others 2004). The general clinical consensus is that MI and MET techniques are important in engaging young people.

There is guidance on MI in chapter 5 on psychosocial interventions.

Cognitive behavioural therapy

Services can offer cognitive behavioural therapy (CBT) for children and young people aged 10 to 17 years who have alcohol problems and have limited comorbidities (other conditions coexisting with alcohol problems) and good social support. This is a time-limited, structured psychological intervention recommended by NICE CG115.

CBT can be effective in reducing alcohol use as well as other related problems. You can find guidance on CBT in chapter 5 on psychosocial interventions.

Practitioners should adapt the CBT programme to the different stages of young people’s development. Although the learning principles of CBT operate similarly for adults and young people, the behavioural targets of change, and how rewards for achievement are negotiated, will vary depending on the age and developmental level of the young person. For some young people, this may involve adding components to the programme to develop basic social and coping skills (Waldron and Kaminer 2004).

Skills training

Skills training helps young people develop the knowledge, attitude and skills they need to cope with difficult life situations and to manage their emotions. These are important factors in supporting them to make healthy choices and to reduce harmful behaviours. This might include skills for resisting social pressure or dealing with feelings of exclusion. Learning new personal or social skills can be a component of CBT interventions, but skills training can also be offered as a standalone approach.

The NICE guideline Drug misuse prevention: targeted interventions (NG64) recommends skills training is offered to children and young people and to their parents and carers. Practitioners will need to consider whether to offer these training sessions to children and young people and their parents and carers together, or as separate sessions.

Multicomponent programmes including family support and family therapies

Multicomponent interventions combine 2 or more intervention approaches. The exact combination of components in a programme depends on the specific needs of the young person. The components of the intervention should be agreed in partnership with the young person, their family, the specialist alcohol and drug treatment service and any other agencies involved in their care.

NICE CG115 recommends multicomponent programmes based on various approaches to family therapy for young people with significant co-morbidities and limited social support.

These are all intensive programmes provided over an extended period, generally between 3 to 6 months, with family sessions and individual interventions for both the young person and their parents or carers. Delivering these interventions is resource intensive, and needs trained and experienced practitioners, strong supervisory structures, and small caseloads.

Residential rehabilitation

There is little evidence that residential units and therapeutic communities are effective for young people. It is likely that young people attending residential units will have significant alcohol and drug problems with multiple comorbidities including conduct disorders. They may also be involved in the criminal justice system and might have been referred by the courts or welfare system. So, these units need to have a skilled multidisciplinary team creating a safe environment in which children and young people can feel secure and engage in multicomponent programmes for both alcohol and other comorbidities.

23.5.3 Recovery support

Many models of recovery are for adult populations and generally adopt an abstinence approach, which may not be acceptable to young people. Even if they reduce their alcohol consumption and improve other factors such as their attendance at school, some young people will come back to services with problematic alcohol use and high-risk behaviours because of repeated intoxication. Services need to have contingency plans to manage a return to harmful alcohol use and associated risks.

There is limited evidence that self-help groups, like Alcoholics Anonymous, are effective for young people (Kelly and others 2000, Kelly and Urbanoski 2012). Before encouraging any young person to join a self-help group, it is important for practitioners to consider the potential risks of them joining in sessions with influential older group members, including safeguarding risks. Other forms of group support activities tailored to young people may be more appropriate.

23.6 Prescribing for young people

23.6.1 Medically assisted withdrawal

Before treatment

Chapter 10 on pharmacological interventions provides guidance on medically assisted withdrawal, and this section notes specific considerations and adjustments for young people. Clinicians prescribing and managing medically assisted withdrawal should follow the guidance in chapter 10 alongside this section and they should also consult the British National Formulary for Children (BNFC).

Alcohol dependence in young people is rare. But a minority of young people may be dependent on alcohol. Medically assisted withdrawal is needed if a young person is assessed as physically dependent.

Medically assisted withdrawal should be only one component of a young person’s alcohol or drug treatment plan. It should be based on a comprehensive assessment, including risk assessment. Specialist staff should deliver this intervention along with relevant psychological therapies and mental health interventions within a clinical governance framework.

Before any treatment for dependence, it is important that a clinical history has determined alcohol dependence. It is important that anxiety symptoms or an anxiety disorder are not confused with withdrawal symptoms and inappropriate treatment started.

Poly-drug use is an important consideration. Clinicians will need to carefully assess the level of dependence on any substance, particularly if alcohol and drugs, such as opiates and benzodiazepines, are used together.

Pathway to treatment

NICE CG115 covers children and young people aged 10 years and older and includes a specific pathway for those aged 10 to 17 years old. For those young people who require medically assisted withdrawal, clinicians can use benzodiazepines (chlordiazepoxide or diazepam) with doses adjusted based on their:

• age
• height
• weight

NICE recommends inpatient admission for medically assisted withdrawal in an age-appropriate setting with access to specialist expertise.

There should be a clear pathway from the community-based specialist treatment service into and out from the hospital, offering medically assisted withdrawal as this can reduce unnecessary delay and help to improve patient safety.

Particular care is required in settings such as secure estates, residential services, acute or mental health hospitals, to ensure that treatments are available for the management of withdrawal if required.

Involving the right people

Age-appropriate pharmacological interventions for substance misuse need to involve specialist services and staff such as:

• paediatricians
• practitioners from the specialist substance misuse service
• primary care
• CAMHS staff
• addiction psychiatrists
• nursing staff

When a young person needs pharmacological management, it is good practice to involve their parents and carers, even if the young person has been assessed as competent to consent to their own treatment. Practitioners should do as much as they can to make sure they are involved.

Prescribing specifically for young people

Many medications for alcohol dependence will be off-label for under 18 year olds.

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 guidance Off-label or unlicensed use of medicines: prescribers’ responsibilities.

Children and young people respond differently to medications than adults and younger children respond differently than older children. So, clinicians need to show detailed care and attention when making prescribing decisions for children and young people.

It is important that any young person offered medically assisted withdrawal is closely monitored by competent specialist staff. What this looks like in practice will be based on clinical judgement determined on a case by case basis, but prescribing should be regularly reviewed.

You can find more information on pharmacological interventions for young people in Department of Health and Social Care guidance on the pharmacological management of substance misuse among young people.

23.6.2 Relapse prevention

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 based on small groups 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 after a careful review of the risks and benefits, specialist clinicians can consider offering acamprosate or oral naltrexone along with CBT to young people over 16 who have not benefited from or engaged with a multicomponent treatment programme.

23.7 Managing co-occurring alcohol and mental health problems

Occasional alcohol and drug use, persistent use and dependence can all cause (or exacerbate) mental health problems and interfere with mental health treatments. Co-occurring mental health and alcohol problems are common among young people in young people’s mental health services and in alcohol and drug services.

It is important that all young people with significant alcohol and drug problems receive a comprehensive assessment of their mental health, including:

• coexisting neuro-disabilities
• risk of self-harm
• autistic spectrum disorders
• ADHD
• emerging personality issues
• learning difficulties

Mental health treatment will often involve paediatric services and child and adolescent mental health services. There needs to be active communication and co-ordination between these services and young people’s substance misuse services.

Any treatment for comorbid conditions should be underpinned by carefully co-ordinated care that addresses a young person’s personal, family, health and social care needs. Practitioners need to take particular care of young people who have alcohol problems and suicidal ideation (suicidal thoughts), because treatment can be challenging and requires a carefully monitored integrated approach between the mental health service provider and the treatment service.

The treatments for comorbid mental health disorders will vary but require:

• more intensive case management
• careful monitoring and co-ordination
• continuity of care
• proactive engagement
• continued training and supervision of all staff

For ADHD and psychotic disorders, there needs to be:

• engagement by all professionals involved (including CAMHS clinicians and alcohol and drug treatment services)
• a good working relationship between these professionals
• a named mental health practitioner co-ordinating the young person’s care
• co-ordinated delivery of multiple psychosocial interventions, alongside pharmacological treatments for mental ill-health
• multidisciplinary and multi-agency care plans with regular reviews

23.8 Transition to adult services

23.8.1 Transition to adult alcohol treatment services

You should provide services based on a young person’s need, not only on their age. If a young person’s service can meet the needs of a person aged 18 or over better than an adult service, without putting other young people who use the service at risk, then this would be the most appropriate placement. So, commissioners should allow services to be flexible when considering transitional arrangements to make sure that any transfer of an 18 year old into adult alcohol treatment services is in the young person’s best interests.

Where a young person is making the transition to an adult alcohol service, the young people’s service should make a plan with the adult service and the young person. This should be a stepped approach:

1. Sharing information about the young person’s needs to support the referral.
2. Introduce the young person to the adult keyworker and arrange several joint appointments involving the young person and both services.
3. Introduce the young person’s parents or carers to the new service and discuss their role in their child’s care.
4. The young people’s service should develop a new care plan with the adult service and the young person.
5. Both services should make sure that the young person’s wider needs are addressed within the care plan.
6. Set a review date that the young person, the specialist young person’s worker and the new adult services worker will attend.

23.8.2 Transition to other services

In many cases, an 18 year old who needs support for their alcohol use may need interventions from other services such as housing, education, primary care, and employment support. In these cases, the care co-ordinator could be based in one of these services. Involved professionals and the young person should agree the most appropriate professional to co-ordinate care.

All young people in alcohol treatment should have a transitional care plan devised before their 18th birthday. This should be developed in consultation with the young person, by the young person’s alcohol and drug treatment service and the adult alcohol and drug treatment service or other agency. The care plan should identify ongoing needs and which organisation is best able to meet these.

It is important to note that transitional stages in different services such as youth offending teams, CAMHS, and statutory children’s services, occur at different ages or developmental stages. These different arrangements should be detailed in the transitional care plan so everybody is clear about which agencies are involved, what they are offering and when this support is due to end.

23.9 Resources

Overview

Specialist alcohol treatment and the competencies for working effectively with young people are different to those for adults. The resources below provide information on the different legal, statutory and policy frameworks for working with children, young people and their families.

Parental responsibility

All mothers and most fathers have legal rights and responsibilities as a parent. This is known as parental responsibility. You can find out more about what parental responsibility is and who has parental responsibility on GOV.UK.

Parental responsibility is defined by UK legislation in:

• the Children Act 1989 (England and Wales)
• the Children (Scotland) Act 1995
• The Children (Northern Ireland) Order 1995

Child safeguarding

Child safeguarding legislation and statutory guidance applies to both young people’s services and adult services. You can find more information on the legislation and statutory guidance for each UK nation in annex 1.

Capacity to consent to treatment

The legal position on consent and refusal of treatment by young people under the age of 18 is different to that for adults. Staff should get voluntary consent from the young person, or the person with parental responsibility as appropriate, before starting any intervention.

The Care Quality Commission (CQC) has published a brief guide on capacity and competence to consent in under 18s (PDF, 80KB), which summarises the policy position and details relevant guidance and legislation in England.

When practitioners are trying to decide whether a child is mature enough to make decisions about the things that affect them, they often talk about whether the child is Gillick competent or whether they meet the Fraser guidelines. Legislation defining the legal age at which a young person has capacity to consent to treatment differs across the 4 UK nations. However, in practice, all UK nations except Scotland use the 1985 Gillick judgement to determine if a child has the ability to make their own medical decisions. In Scotland, it is provision within the Age of Legal Capacity (Scotland) Act 1991 (Section 2(4)) that informs practitioner decisions about the capacity of a child under the age of 16 years to consent to their own treatment.

You can read more about Gillick competency and Fraser guidelines and making decisions about capacity to consent to treatment at the:

• NSPCC learning website
• CQC GP mythbuster website
• General Medical Council ethical guidance for doctors website

Confidentiality

The NHS code of practice provides guidance to NHS and NHS-related organisations about patient information confidentiality issues and briefly outlines expectations and exceptions around confidentiality for children and young people.

23.10 References

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Clark D. Pharmacotherapy for adolescent alcohol use disorder. CNS drugs 2012: volume 26, issue 7, pages 559-569

Costello E, Armstrong T and Erkanli A. Report on the developmental epidemiology of comorbid psychiatric and substance use disorders. National Institute on Drug Abuse, 2000

Coulton S, Alam F, Boniface S, Deluca P, Donoghue K, Gilvarry E, Kaner E, Lynch E, Maconochie I, McArdle P, McGovern R, Newbury-Birch D, Patton R, Phillips CJ, Phillips T, Rose H, Russell I, Strang J and Drummond C. Opportunistic screening for alcohol use problems in adolescents attending emergency departments: an evaluation of screening tools. Journal of Public Health 2018: volume 41, issue 1, pages e53–e60

Deluca P, Coulton S, Alam F, Boniface S, Donoghue K, Gilvarry E, Kaner E, Lynch E, Maconochie I, McArdle P, McGovern R, Newbury-Birch D, Patton R, Pellatt-Higgins T, Phillips C, Phillips T, Pockett R, Russell IT, Strang J and Drummond C. Screening and brief interventions for adolescent alcohol use disorders presenting through emergency departments; a research programme including two RCTs. Programme grants for applied research 2020: volume 8, issue 2

Dennis M, Godley S, Diamond G, Tims FM, Babor T, Donaldson J, Liddle H, Titus JC, Kaminer Y, Webb C, Hamilton N and Funk R. The cannabis youth treatment (CYT) study: main findings from two randomized trials. Journal of Substance Use and Addiction Treatment 2004: volume 27, issue 3, pages 197-203

DeWit D, Adlaf E, Offord D and Ogborne A. Age at first alcohol use: a risk factor for the development of alcohol disorders. American Journal of Psychiatry 2000: volume 157, issue 5, pages 745-750

Donaldson L. Guidance on consumption of alcohol by children and young people (PDF, 1MB). Department of Health, 2009

Drummond C, Deluca P, Coulton S, Bland M, Cassidy P, Crawford M, Dale V, Gilvarry E, Godfrey C, Heather N, McGovern R, Myles J, Newbury-Birch D, Oyefeso A, Parrott S, Patton R, Perryman K, Phillips T, Shepherd J, Touquet R, Kaner E. The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial. Plos ONE 2014: volume 9, issue 6

Foster K, Hicks B, Iacono W and McGue M. Alcohol use disorder in women: risks and consequences of an adolescent onset and persistent course. Psychology of Addictive Behaviors 2014: volume 28, issue 2, pages 322-335

Godley S, Dennis M, Godley M and Funk R. Thirty-month relapse trajectory cluster groups among adolescents discharged from outpatient treatment. Addiction 2004: volume 99, issue s2, pages 129-139

Hingson R, Heeran T and Winter M. Age at drinking onset and alcohol dependence: age at onset, duration and severity. Archives of Pediatrics and Adolescent Medicine 2006: volume 160, issue 7, pages 739-746

Hogue A, Dauber S, Stambaugh LF, Cecero JJ and Liddle HA. Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems. Journal of Consulting and Clinical Psychology 2006: volume 74, issue 1, pages 121-129

Kelly J, Myers M and Brown S. A multivariate process model of adolescent 12 step attendance and substance use outcome following inpatient treatment. Psychology of Addictive Behaviours 2000: volume 14, issue 4, pages 376-389

Kelly J and Urbanoski K. Youth recovery contexts: the incremental effects on 12 step attendance and involvement on adolescent outpatient outcomes. Alcoholism Clinical and Experimental Research 2012: volume 36, issue 7, pages 1219-1229

Kilpatrick D, Ruggiero K, Acierno R, Saunders BE, Resnick HS and Best CL. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: results from the national survey of adolescents. Journal of Consulting and Clinical Psychology 2003: volume 71, issue 4, pages 692-700

Kuntsche E and Gmel G. Alcohol consumption in late adolescence and early adulthood-where is the problem? Swiss Medical Weekly 2013: volume 143, number 2930, article w13826

Lees B, Meredith L, Kirkland A, Bryant BE and Squeglia LM. Effect of alcohol use on the adolescent brain and behaviour Pharmacology, Biochemistry and Behavior 2020: volume 192, article 172906

McCambridge J, McAlaney J and Rowe R. Adult consequences of late adolescent alcohol consumption: a systematic review of cohort studies. PLoS medicine 2011: volume 8, issue 2, article e1000413

McCambridge J and Day M. Randomized controlled trial of the effects of completing the Alcohol Use Disorders Identification Test questionnaire on self‐reported hazardous drinking. Addiction 2008: volume 103, issue 2, pages 241-248

Peterson B. Common factors in the art of healing. Journal of child psychology and psychiatry 2019: volume 60, issue 9, pages 927-929

Shelef K, Diamond G, Diamond G and Liddle HA. Adolescent and parent alliance and treatment outcome in multidimensional family therapy. Journal of Consulting and Clinical Psychology 2005: volume 73, issue 4, pages 689-698

Tanner-Smith E, Katarzyna T, Steinka-Fry M, Hensman Kettrey H and Lipsey M. Adolescent substance use treatment effectiveness; a systematic review and meta-analysis. Vandebilt University, 2016

Tetzlaff B, Kahn J, Godley S, Godley MD, Diamond GS and Funk RR. Working alliance, treatment satisfaction, and patterns of posttreatment use among adolescent substance users. Psychology of Addictive Behaviors 2005: volume 19, issue 2, pages 199-207

Toumbourou JW and Catalano RF. Predicting developmentally harmful substance use. Preventing harmful substance use (editors: T Stockwell, PJ Gruenewald, JW Toumbourou and W Loxley), 2005

Walker D, Roffman R, Stephens R, Wakana K and Berghuis J. Motivational enhancement therapy for adolescent marijuana users: a preliminary randomized controlled trial. Journal of Consulting and Clinical Psychology 2006: volume 74, issue 3, pages 628-632

Waldron H and Kaminer Y. On the learning curve; the emerging evidence supporting cognitive-behavioural therapies for adolescent substance abuse. Addiction 2004: volume 99, issue s2, pages 93-105

24. Pregnancy and perinatal care

24.1 Main points

Guidance for maternity services and alcohol treatment services

Alcohol can affect fetal development throughout pregnancy and can cause fetal alcohol spectrum disorder and perinatal complications.

Alcohol problems, severe and multiple disadvantage and deprivation all increase the risk of a woman dying during pregnancy and up to a year after giving birth. Services should be designed to reduce these health inequalities.

Maternity, alcohol treatment and other healthcare professionals should support women to reduce or stop their alcohol use as quickly and safely as possible. This reduces the ongoing exposure to the fetus and the risk and severity of future disability.

National Institute for Health and Care Excellence (NICE) quality standard Fetal alcohol spectrum disorder (QS204) recommends that:

“Midwives and other healthcare professionals should give women clear and consistent advice on avoiding alcohol throughout pregnancy, and explain the benefits of this, including preventing fetal alcohol spectrum disorder (FASD) and reducing the risks of low birth weight, preterm birth and the baby being small for gestational age”.

Midwives and other healthcare professionals should advise women who are, or who could be, alcohol dependent not to stop drinking suddenly as this can increase risk to them and to the fetus. They should rapidly refer the woman for a specialist assessment for medically assisted withdrawal.

The NICE guideline Antenatal care (NG201) recommends at the first (booking) appointment and throughout pregnancy maternity staff ask women about their alcohol use. Services can consider using tools for screening for alcohol use during pregnancy.

Maternity staff should rapidly refer women who are drinking heavily, are alcohol dependent, or have a history of alcohol problems to a specialist alcohol treatment service. They should also refer them to the specialist maternity pathway for substance misuse or women with complex needs.

Women who drink heavily during pregnancy are often vulnerable and experience severe multiple disadvantage. Healthcare professionals need to use a non-judgemental and trauma-informed approach and prioritise helping the woman to engage in antenatal care, alcohol treatment, safeguarding and other services.

Professionals should use a multidisciplinary and multi-agency approach to co-ordinate care during pregnancy and the perinatal period for the mother, baby and father or partner.

Where there is risk of significant harm to the unborn child or baby, professionals must make a child safeguarding (child protection) referral in line with national legislation and guidance and organisational procedures.

When a woman is alcohol dependent, there are specific considerations to provide maternity care during pregnancy, at the birth and in the early postnatal period. The baby will need to be monitored by neonatal paediatricians after its birth and may require specialist interventions.

Guidance for alcohol treatment services

Alcohol treatment services should prioritise referrals for women who are pregnant or have a baby, even if the woman is not currently drinking. This is to reduce risks to the fetus (and later the baby) and to the mother.

Alcohol treatment services should offer flexible support and remove any barriers to engagement. For example, they should offer home visits where possible.

Alcohol treatment services should recognise that pregnancy and the perinatal period is a vulnerable time for women who have an increased risk of relapse, mental health problems and domestic abuse. They should offer frequent and regular psychosocial support and extend the period of support where necessary.

There are specific considerations for services when they provide pharmacological interventions to women during pregnancy and during breastfeeding. See section 10.6.4 in chapter 10 for more information about these considerations.

Parental alcohol use is an established risk factor for sudden unexpected deaths in infancy. All services should be able to give accurate advice on safe sleeping for babies.

Where there has been significant prenatal alcohol exposure, the child will need ongoing monitoring. If children do not meet developmental milestones, clinicians should refer them through local FASD diagnostic and support pathways or (if there is no local pathway) to the national FASD clinic.

Clinicians in alcohol treatment services and other healthcare professionals should offer advice on contraception to women with alcohol problems. Where there has been an alcohol exposed pregnancy, they should offer advice on contraception soon after the birth of the baby.

24.2 Introduction

This chapter includes guidance on:

• providing information on the risks of alcohol use during pregnancy for all pregnant women
• identification, support and treatment for women with alcohol dependence or who drink heavily

The guidance is for clinicians and practitioners working with women during pregnancy and the perinatal period. The term ‘perinatal period’ used in this chapter means pregnancy and up to one year after birth.

The guidance is relevant for all practitioners working across maternity services, alcohol treatment services and other health services unless there is a statement saying that it is specifically for maternity services or for alcohol treatment services.

24.3 Prenatal alcohol exposure and fetal alcohol spectrum disorder

The UK has the fourth highest estimated prevalence of alcohol use during pregnancy in the world (Popova and others 2017). Alcohol is a teratogen, which means it can affect fetal development throughout pregnancy and cause birth defects and perinatal complications. NICE QS204 states that alcohol use in pregnancy increases the risks of:

• low birth weight
• preterm birth
• the baby being small for gestational age

Research has also shown that alcohol use in pregnancy has a significant risk of miscarriage in the first trimester (Kesmodel and others 2002).

Prenatal alcohol exposure (PAE), which occurs when a woman drinks alcohol during pregnancy, can result in FASD. FASD is a term that describes the wide range of outcomes that can result from PAE, including lifelong physical, cognitive, behavioural, and mental health difficulties. At the more severely affected end of the spectrum, FASD can effect facial features and growth. However, it is now well-recognised in research and in clinical practice that the facial features (described in national guidance like NICE QS204 and the Scottish Intercollegiate Guidelines Network (SIGN) guideline156 as ‘sentinel’ features) are only found in a minority of babies with FASD.

Reducing fetal alcohol exposure reduces the risk of FASD. However, it is not possible to quantify a ‘safe’ level of alcohol use. 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.

24.4 Risks to women during or up to a year after pregnancy

The report Saving lives, improving mothers’ care (PDF, 3.7MB) (by Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK)) found that 8% of women who died during or up to a year after pregnancy in the UK in 2017 to 2019 experienced severe and multiple disadvantage. The main elements of multiple disadvantage included:

• mental health diagnosis
• alcohol and drug use
• domestic abuse

In 16% of women who died between 6 weeks and a year after birth alcohol or drugs were the cause. Also, multiple adversity (including abuse in their own childhood or as an adult, children’s social care involvement and children taken into care) featured highly among women who died.

There are differences in maternal mortality rates between white women and women from other ethnic backgrounds, including:

• more than a fourfold difference with women from black backgrounds
• a twofold difference with women from mixed ethnic backgrounds
• almost a twofold difference with women from Asian ethnic backgrounds

Also, women from the most deprived areas have the highest levels of maternal mortality. It is vital that services are designed to respond to these increased risks, and staff are aware of them. Staff need to work together to provide supportive personalised multidisciplinary care to reduce these health inequalities.

24.5 Principles and interventions for working with all pregnant women

24.5.1 Principles

The principles for working with pregnant women are:

1. Provide personalised care for women during pregnancy and in the perinatal period.
2. Support women who are pregnant to reduce (and when safe to stop) their alcohol use as quickly as possible to reduce the ongoing exposure to the fetus and the risk and severity of future disability.
3. Support women in a non-judgemental, non-stigmatising way.

These principles are based on consensus of the alcohol guidelines development group.

24.5.2 Providing advice on avoiding alcohol use in pregnancy

NICE QS204 recommends that:

“Midwives and other healthcare professionals should give women clear and consistent advice on avoiding alcohol throughout pregnancy, and explain the benefits of avoiding alcohol, including preventing fetal alcohol spectrum disorder (FASD) and reducing the risks of low birth weight, preterm birth and the baby being small for gestational age.”

It also recommends that:

“They provide verbal and written advice, based on the UK chief medical officers’ low-risk drinking guidelines, that the safest approach is to avoid drinking any alcohol during pregnancy. This includes information that the risk of harm to the baby is likely to be low if only small amounts of alcohol have been consumed but that further drinking should be avoided. They use a non-judgemental approach, discuss any concerns, and provide support and information according to the woman’s needs, which may include a structured conversation, help to stop drinking through a brief intervention or referral to specialist services.”

Midwives, alcohol treatment practitioners, and other healthcare professionals should advise women who are (or who may be) alcohol dependent not to stop drinking suddenly, because withdrawal complications risk harm to the fetus and the mother. Professionals should rapidly refer these women to specialist alcohol treatment to be assessed for medically assisted withdrawal, so they can stop drinking safely (see section 24.9 on specialist alcohol treatment below).

The verbal and written information and advice that services provide should be easy to understand and available in accessible formats including easy read and in a range of languages that reflect the demographics of the population. Services should arrange for independent interpreters (not a family member or friend) to be available for women who do not speak English as their first language.

24.5.3 Asking pregnant women about their alcohol use

NICE NG201 recommends that at the first (booking) appointment and throughout pregnancy maternity staff ask women about their alcohol use.

NICE QS204 recommends:

“Talking about and recording alcohol consumption during pregnancy allows personalised discussions about the risks of alcohol use as part of routine healthcare throughout pregnancy. It also gives opportunities to offer tailored support and interventions if the woman wishes to cut down or stop drinking. This may reduce risks and improve outcomes for the mother and baby. Women should be asked about their alcohol consumption in a sensitive, non-judgemental way. Women who wish to discuss their alcohol use should be asked about the quantity, frequency, and pattern of drinking, and this should be documented in their maternity records. This information may also help support early diagnosis and treatment for children with fetal alcohol spectrum disorder (FASD).”

Early diagnosis and treatment can improve future outcome.

24.5.4 Screening tools

Some services use screening tools when they ask women about their alcohol use. But if they are using screening tools, these should be used to support the conversation, not replace it. Forming a trusting relationship where the woman feels able to talk about her alcohol use is vital. Conversations based on the principles of motivational interviewing can help women to talk about their drinking and consider change.

You can find guidance on motivational interviewing in chapter 5 on psychosocial interventions.

The advice on levels of health risk that accompanies most alcohol screening tools is based on the UK chief medical officers’ low risk drinking guidelines, which refer to health risk for adults. Risk to the fetus is likely to begin at much lower levels than risk to adults. Although reducing fetal alcohol exposure reduces the risk of FASD, it is not possible to quantify a ‘safe’ level of alcohol use during pregnancy. The guidelines refer to research that shows the risks of low birth weight, preterm birth and being small for gestational age may all be increased if mothers drink above 1 to 2 units per day during pregnancy.

Currently there is only limited evidence for the use of screening tools in pregnancy.

In a systematic review of alcohol use screening tools the following screening tools were found to be helpful in screening for risky drinking (Burns and others 2010).

Alcohol use disorders identification test for consumption (AUDIT-C), a test to quickly identify alcohol harm.

TWEAK (an acronym based on the subjects of the screening questions: tolerance, worry, ’eye-opener’, amnesia, ‘cut down’), a screening test consisting of 5 questions designed to identify pregnant women who are at risk of harmful drinking.

T-ACE (an acronym based on the subjects of the screening questions: tolerance, annoyance, cut-down, ‘eye-opener’), a tool used to screen for risky alcohol use in pregnant women.

However, the review’s authors recommended caution, saying that there should be further evaluations of questionnaires for prenatal alcohol consumption. Other research has shown that the effectiveness of these tools may also vary according to cultural context (Russell 1994). In services that use screening tools, staff should be trained to use them and to interpret the scores to inform an appropriate intervention.

The Scottish SIGN guideline156 recommends that services consider using AUDIT-C, TWEAK and T-ACE screening tools, but also says there are potential limitations to these tools.

24.6 Initial interventions in maternity services to support women to stop or reduce alcohol use

Section 24.8 is guidance for staff in maternity services. Maternity staff should also read guidance in the rest of this chapter except section 24.9, which is for staff in alcohol treatment services.

Maternity staff and other healthcare professionals should offer women who use alcohol during pregnancy an intervention based on an individual assessment of the level of their alcohol use and other relevant risk factors.

Interventions could include the following.

24.6.1 Very low levels of alcohol use

For very low levels of alcohol use and no other risk factors, services should provide appropriate information and guidance to support the woman’s decision making. They should then continue to review the woman’s alcohol use and advise that avoiding alcohol is safest for the fetus and the mother.

24.6.2 Previous problems with alcohol use or co-occurring conditions

For women who have had previous problems with alcohol use, or who are drinking above very low levels and have additional needs such as a mental health condition, services should offer:

• a brief alcohol intervention (staff should be trained to offer this)
• a referral to community alcohol treatment service for psychosocial support

Services should refer the woman to a specialist midwife or substance misuse midwife (via local specialist maternity pathways) and other relevant services.

24.6.3 Alcohol dependent or drinking heavily

For women who are alcohol dependent or drinking heavily, services should advise them not to stop drinking suddenly, because of the risks to the fetus and the mother. Services should:

• refer the woman and help her to quickly access specialist alcohol treatment
• refer the woman to a specialist midwife or substance misuse midwife (via local specialist maternity pathways)
• provide a contact number for a named specialist midwife or doctor
• refer the woman to other relevant services, such as children’s social care for safeguarding, domestic abuse or mental health

Women will often be involved with several services, so it’s important that they can have a consistent relationship with healthcare professionals in those services.

24.6.4 Alcohol as a coping strategy

Healthcare professionals should be aware that women who have a history of using alcohol as a coping strategy are at significantly increased risk from stressful events during pregnancy (for example, relationship conflict, domestic abuse, safeguarding assessments, pregnancy-related problems) even if they are not using alcohol regularly. Signposting women to additional support such as mental health support or domestic abuse services and referring them to community alcohol treatment services can help and encourage them to develop alternative self-support strategies.

24.7 Supporting pregnant women who are alcohol dependent or who are drinking heavily

24.7.1 Principles

The following principles are for staff in maternity services, alcohol treatment services, other healthcare staff (midwives, nurses, doctors) and staff in other relevant services.

These principles are based on consensus of the alcohol guidelines development group.

1. Make every effort to provide accessible care and to engage pregnant women who are alcohol dependent or drinking heavily. This could be women in antenatal care, alcohol treatment and other relevant services.

2. Recognise that pregnant women who are alcohol dependent or drink heavily are often vulnerable, have complex needs and experiences of past or current trauma. So, use a trauma-informed approach and treat women with respect. You can read more about this in the OHID Working definition of trauma-informed practice.

3. Make sure that pregnant women have the information they need to make decisions and to give consent, in line with General Medical Council’s guidance on decision making and consent, the Nursing and Midwifery Council’s code on professional standards of practice and behaviour and the 2015 Montgomery ruling.
4. Act to safeguard the unborn child and newborn baby in line with national legislation and organisational safeguarding procedures. The duty to act to protect a child at risk of significant harm includes the unborn child (see annex 1 on legislation and guidance).
5. Make sure the woman can access a comprehensive assessment of her needs, including alcohol use, illicit drug use, misuse of prescribed and over the counter medication, domestic abuse and mental health.
6. Take a multidisciplinary, multi-agency approach involving maternity services, alcohol treatment services, health visiting and other relevant services such as children’s social care and domestic abuse throughout pregnancy, at birth and after birth.
7. Involve partners and family members, where it is safe and appropriate and the woman wants this.
8. Support partners and family members in their own right, even where it is not appropriate for them to be involved in the woman’s care.

24.7.2 Understanding and addressing vulnerability and complex needs

Women who are alcohol dependent or drinking heavily during pregnancy are likely to be vulnerable and experience multiple disadvantage (also referred to as multiple and complex needs). NICE clinical guideline Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors (CG110) notes that vulnerable women who experience multiple disadvantage are less likely to access and adhere to antenatal care and guidance.

It is vital for the health of the woman and the health of the unborn child that maternity services, alcohol treatment services, health visitors and other healthcare and social care services can engage and effectively support them. How effectively the woman is engaged with these services will depend on staff understanding the complex psychological and social factors vulnerable women experience and responding appropriately. Teenage and young parents are vulnerable and will need support tailored to their needs.

24.7.3 Supporting and maintaining engagement

Barriers to getting help

Pregnant women who are alcohol dependent or drink heavily can experience anxieties that deter them from seeking help or engaging with support, including:

• problems in forming trusting relationships because of past or current trauma
• fear or guilt about the impact of their alcohol use on their unborn child
• fear that their baby may be removed into care
• anxieties based on previous bad experiences of services

Vulnerable women might be unaware of available help. They may also experience other barriers to accessing services, including:

• inflexible appointment times
• geographically inaccessible services
• service information that is not accessible or easy to understand
• stigma (feeling judged by staff and others accessing services)
• lack of staff with competence to work with vulnerable women

Recent migrants, refugees and asylum seekers may experience language or cultural barriers or have fears about their immigration status. Some vulnerable migrants might have no recourse to public funds.

How services can improve access to support and treatment

Services and staff should work to reduce barriers to engagement by:

• building trusting relationships
• having straightforward access and flexible engagement processes
• providing clear information that encourages shared decision making

Services can build trusting relationships by making sure their staff are trauma-informed and culturally competent. They should provide continuity of care between midwifery and health visiting services with a consistent team and named practitioner that co-ordinates care during pregnancy, birth and in the postnatal period.

You can find more guidance on continuity of care in NICE NG201 and Public Health England guidance on care continuity between midwifery and health visiting services.

Antenatal and alcohol treatment services should work to reduce barriers to access by:

• timing appointments to suit the person
• meeting women where they live or at another service they attend
• offering to pay transport costs

Staff should take a proactive and persistent approach, including sending friendly reminder texts or calls for appointments and missed appointments.

Services should provide clear information and advice, including about:

• the risks of alcohol use in pregnancy
• the risks to women with alcohol dependence of stopping drinking suddenly
• accessing their services and other relevant services provided elsewhere
• what to expect after they give birth, including medical care the baby may need
• any potential involvement of child safeguarding services

All information you provide to the woman should be accessible and tailored to their particular needs, including considering:

• first language
• literacy
• sensory impairment
• cognitive impairment
• neurodiversity

You can find more guidance on providing information to women during pregnancy in NICE NG201 and NICE CG110.

24.7.4 Safeguarding

Services must make a safeguarding referral, in line with national legislation and organisational safeguarding procedures, where there:

• is a significant risk of harm to the unborn child or baby due to ongoing heavy drinking or alcohol dependence during pregnancy
• are other issues of concern, such as mental health problems or domestic abuse

Early referral to child safeguarding services helps the agencies to co-ordinate care for the mother and baby and to safeguard the baby. You can find more information on child safeguarding guidance (which includes unborn children) in annex 1.

If the safeguarding referral is against the parent’s wishes, the practitioner making the referral should explain the reason for the referral and that there is a legal requirement for them to do so (unless this would put a child at further risk) and respond sensitively to the parent’s concerns. The practitioner should try to maintain remote or in-person contact with the woman to support her and monitor her wellbeing. Women who have had other children removed may be particularly vulnerable.

24.7.5 Multidisciplinary, multi-agency assessment and care planning

All services involved with the woman during pregnancy and the perinatal period will need to 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 and alcohol treatment services working together

Access to maternity and alcohol treatment services, and engagement with them, is essential for a safe and healthy pregnancy for the woman and the baby. These services should agree two-way referral pathways and working relationships with each other. Vulnerable women may also need urgent access to services for co-occurring conditions such as mental health or social factors, like domestic abuse.

The optimal care for pregnant women with alcohol problems is a specialist multidisciplinary clinic for alcohol and drug use in pregnancy, provided by maternity and specialist alcohol treatment services working together. Where this is not available locally, services will need to co-ordinate multidisciplinary, multi-agency care and appropriate information sharing.

What multidisciplinary, multi-agency care planning involves

Multidisciplinary, multi-agency care planning should cover pregnancy, birth, and the perinatal period. Maternity and alcohol treatment services need to work together and:

• be clear about the role of each agency and which professional is responsible for each agreed task
• assess, manage and review risks as they change throughout the pregnancy, at the birth and in the perinatal period
• plan maternity care and alcohol treatment interventions
• make sure they include safeguarding (child safeguarding services will lead on the safeguarding plan)
• involve the woman’s GP
• address co-occurring conditions including substance use, mental health, physical health complications, and social factors such as domestic abuse
• make sure referrals and support to access appropriate agencies are made without any unnecessary delays
• arrange support for parenting during pregnancy and in the perinatal period
• include support for the partner in care planning (where necessary)
• wherever possible, fully involve the woman in the assessment and care planning, taking into account her views on her own needs and those of her unborn child
• keep the woman informed of any changes to plans
• involve partners or family members in assessment and care planning, where this is appropriate and with the woman’s consent
• make clear agreements between services about sharing information, and regularly review and update the information
• share information on attendance, missed appointments and alcohol consumption with members of the team working with the woman and the baby
• align service care plans and consider developing one integrated care plan
• consider developing shared electronic notes which can be seen by relevant professionals

It is always best practice to ask consent to share information. However, you can share information without consent if the unborn or child is at risk of significant harm.

If the mother loses a baby through miscarriage, death, or there are plans to remove the baby into care, you will need to provide support for the parents such as perinatal mental health or bereavement support.

24.7.6 Family involvement

Services should assess strengths and risks of the family network as part of the multi-agency assessment and child safeguarding services will usually lead on this. Family members can contribute to assessment and care planning, where it is appropriate and with the woman’s consent. Family members can play an important role in supporting the woman to stop or reduce her alcohol use during pregnancy and the perinatal period.

The woman’s partner can contribute to supporting her where there are no indications of risk to the woman or the fetus. NICE NG201 recommends that maternity staff ask all women about domestic abuse in a kind, sensitive manner at the first antenatal (booking) appointment, or at the earliest opportunity when she is alone.

Staff should make a careful assessment of the level of any risk posed by the partner and make a child safeguarding referral where there is a risk to the unborn child and the mother. They should work with domestic abuse services to reduce risk to the woman and unborn child and follow relevant legislation and organisational procedures on domestic abuse. The partner should not be involved in assessment and planning for the woman’s needs in situations where they pose a risk of perpetrating domestic abuse.

Services should offer the partner access to information and support where indicated. If the father or partner also has alcohol or drug problems, services should encourage them to access alcohol or drug treatment. The Department for Education report Children’s needs: parenting capacity (second edition) suggests an association between fathers who drink heavily and increased risk of babies with lower birth weight or heart defects, and spontaneous abortion and neonatal deaths are associated with heavy drinking of either parent.

24.7.7 After the birth: multidisciplinary, multi-agency care

Multidisciplinary care plans for women who are alcohol dependent or drink harmfully (including those who stop drinking during pregnancy) should cover the period immediately after the birth and for the first year of the baby’s life.

Local services should continue to work together to offer mothers and babies (and fathers or partners where they are involved) tailored support. These include:

• maternity services
• alcohol treatment services
• health visiting services
• safeguarding services
• GPs and primary care
• other relevant services

Support needs can include support for the woman’s own mental health, and for the developing relationship between parent and baby and help to manage conflict between parents. This support could come from:

• the perinatal mental health team
• health visitors
• adult mental health services
• other relevant services

In England, referrals to the perinatal mental health team will be fast-tracked for women with complex needs, including alcohol and drug problems.

Services should work together to provide appropriate support to maximise the chance of the ideal outcome of the mother and baby safely remaining together.

Services should offer support to both parents following the birth, including where the baby dies or is taken into care.

24.8 Maternity care for women who are alcohol dependent or drinking heavily

This section provides brief guidance for maternity services. This guidance should be considered alongside NICE guidelines:

• NICE CG110
• NICE NG201
• NICE QS204

24.8.1 Additional antenatal appointments and care

NICE NG201 recommends additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs. This is relevant for women who are alcohol dependent or drinking heavily during pregnancy.

If there has been PAE, you should arrange for the woman to have extra growth scans in addition to the 20-week fetal anomaly scan.

Evidence of fetal growth restriction could be due to a variety of reasons, including:

• poor mental health
• poor maternal diet
• perinatal alcohol exposure
• substance use
• maternal health problems, for example with blood pressure

Where there is PAE and poor fetal growth, you should share this information with neonatal paediatric teams for postnatal assessment, because PAE as a cause of poor fetal growth can be overlooked.

Maternity staff should be aware that liver damage due to long term alcohol use or hepatitis C in mothers may increase the risk of transmission of hepatitis C from the mother to the fetus during pregnancy or the baby at or after birth. If the woman has a history of injecting drug use, services should offer to test for blood-borne viruses and explain why that is important.

24.8.2 Birth plan

For women who are alcohol dependent or drinking heavily, maternity staff should work with the woman wherever possible to devise a carefully considered specialist labour and birth plan.

The plan should include and address:

• risk of seizures, especially in association with hypertension
• risk of arriving in an intoxicated state in labour, which may be due to concerns about inadequate pain relief or for other reasons
• safeguarding arrangements

24.8.3 The newborn baby with PAE

Newborn infants with PAE will require monitoring by a specialist neonatal paediatric team Increased risks to newborn infants include intrauterine growth restriction which can lead to complications, such as hypoglycaemia (low blood sugar).

If mothers are alcohol dependent or have recently used alcohol before delivery (within the previous 24 hours), then the baby might not respond normally at the time of delivery and in the early postnatal period. This can lead to an increased chance of needing resuscitation support at the birth.

This can also affect the baby’s metabolism and cause drowsiness, resulting in poor feeding. Both these factors increase the risk of hypoglycaemia. Specialist neonatal paediatric teams should test for this regularly according to local protocols. The baby may need feeding support with the help of a nasogastric tube until they are able to feed normally.

Where there has been PAE throughout pregnancy, the baby may show evidence of acute withdrawal in the first couple of days after birth and may develop seizures consistent with acute alcohol withdrawal. Clinicians should follow local protocols for treating and monitoring the baby.

Complex neurodevelopmental problems resulting from FASD may not appear until many years later, although a small number of babies could show features consistent with FASD. If there has been significant PAE, or babies have clinical features consistent with FASD, clinicians working with the baby should identify the baby as being ‘at risk of FASD due to PAE’ and refer them for follow-up using local pathways.

If a child is adopted and later needs to be assessed for developmental problems, it is useful to have Information on PAE so this can be considered as part of the assessment.

When considering safeguarding issues concerning the newborn infant, clinicians must act in line with child safeguarding legislation and guidance (see section 24.7.4 on safeguarding above). They should carry out any agreed actions recorded in the safeguarding birth plan and share all relevant information with local children’s social care services.

24.9 Specialist alcohol treatment

This section is guidance for alcohol treatment services. Alcohol treatment clinicians and practitioners should also read the guidance in the rest of this chapter (except section 24.6 and 24.8 which are for maternity services).

You should read this section together with section 24.7 on supporting pregnant women who are alcohol dependent or drinking heavily.

24.9.1 Assessment for alcohol treatment during pregnancy

You should read this section along with chapter 4 on assessment and treatment and recovery planning, which provides guidance on specialist assessment for alcohol treatment. This section includes additional guidance that is specific to assessment during pregnancy and the perinatal period.

Prioritising pregnant women

Pregnant women should be regarded as a priority for alcohol treatment. Alcohol treatment services should fast track pregnant women into treatment and engage them as early as possible, to reduce risk to the fetus and the mother.

The threshold for access to assessment and treatment should be lower for pregnant women than for the general treatment population, due to these risks. Services should offer assessments to any pregnant women who are referred from another service or who have referred themselves, including women who are not currently drinking but have had an alcohol problem in the past. This is to make sure they have adequate treatment and support during a time when they may be vulnerable to relapse.

Women may also become pregnant while in treatment so alcohol treatment services should offer pregnancy tests and let women know these are available. The guidance below is relevant whether the woman is a new referral to the service or is already engaged in treatment.

Initial assessment

At the initial assessment, the assessor should:

• seek to build a trusting relationship using a trauma-informed approach
• discuss antenatal care and make an urgent referral through the local maternity services pathway, if the woman is not engaged with this already
• speak to the woman’s GP, maternity services, and other relevant services
• make a safeguarding (child protection) referral in line with legislation and organisational safeguarding procedures, where there may be a risk of significant harm to the unborn child (see section 24.7.4 on safeguarding)
• refer the woman to sexual health services or to her GP for advice and counselling if she is considering a termination
• provide accessible information and advice on the risks of alcohol use during pregnancy, including FASD, as set out in section 24.5 on principles and interventions for working with all pregnant women
• take actions to support and maintain the woman’s engagement with treatment (see section 24.7.3)
• Involve fathers, partners or family members where safe and appropriate (see section 24.7.6 on family involvement)

Alcohol treatment services should have established effective pathways with maternity and midwifery services. In many areas, this will be through specialist midwife services or a named substance misuse midwife. If the woman is not yet engaged with antenatal care, the alcohol treatment practitioner should rapidly refer her through these pathways. If there are no local specialist or substance use maternity pathways the alcohol treatment practitioner should refer the woman to the local named safeguarding midwife.

Assessing for medically assisted withdrawal and health conditions

If the woman is (or may possibly be) alcohol dependent, a specialist clinician in the alcohol treatment service should assess them for medically assisted withdrawal as quickly as possible. They should then arrange access to medically assisted withdrawal where required. They should discuss risks and benefits of this intervention with the woman and provide the necessary information for her to make an informed decision about the treatment.

Medically assisted withdrawal for pregnant women should normally be offered in a specialist inpatient setting with the necessary facilities and staff competencies. The plan for medically assisted withdrawal and for subsequent care should involve the obstetrician (see section 24.9.6 on pharmacological interventions below). The multi-agency team should also assess whether it would be appropriate for the woman to begin residential rehabilitation after medically assisted withdrawal.

The specialist clinician should make a thorough assessment of the woman’s:

• substance use, including illicit drug use and abuse of prescribed and over the counter medication
• tobacco use
• physical health
• mental health needs

The clinician should provide ongoing monitoring of the woman’s physical and mental health and share information with maternity services, primary and secondary care health services.

Assessing social factors including domestic abuse

The main assessor should make sure they assess social factors, including domestic abuse, since pregnancy is a risk factor for domestic abuse. During pregnancy, domestic abuse may increase or begin for the first time. So, assessors, specialist clinicians and keyworkers should be vigilant and ask sensitively about domestic abuse at assessment and subsequent reviews and make referrals where necessary. (section 24.9.1 provides guidance on domestic abuse). They should also be aware that women who have experienced sexual trauma may find pregnancy and giving birth stressful and potentially retraumatising. Staff should take particular care to use a trauma-informed approach for all aspects of the woman’s care.

24.9.2 Multi-agency assessment and treatment and recovery planning

When carrying out the assessment and developing a personalised treatment and recovery plan with the woman, alcohol treatment clinicians and practitioners should make referrals where appropriate and work jointly with other relevant services and contribute to a multidisciplinary, multi-agency approach. You should follow the guidance in section 24.7.5 on a multidisciplinary and multi-agency approach.

It is particularly important that treatment and recovery plans and risk management plans are frequently reviewed. This is because the woman’s needs and risks could change significantly throughout pregnancy and then after the birth.

The personalised alcohol treatment and recovery plan should be aligned with other plans including antenatal plans and safeguarding plans. Services should share relevant information with one another as the needs or risks of the woman of the unborn child change.

24.9.3 Assessment and treatment and recovery planning after the birth

Services should recognise that the perinatal period (pregnancy and a year after the birth) can be a vulnerable time, where the woman may be at greater risk of returning to problematic alcohol use and of mental health problems. Even if a woman did not drink during her pregnancy, she may be at greater risk of returning to problematic alcohol use after the birth of the baby. Section 9 below sets out some of the risks to the woman and baby in the first year after birth and includes recommendations for reducing risks.

The alcohol treatment practitioner should work with other agencies in the multi-agency team to make sure the woman can access appropriate support for their mental health and for parenting where needed. For example, from the perinatal mental health team. You should read the guidance in section 24.7.7 on this.

The alcohol treatment keyworker should seek to re-engage the woman soon after the birth and continue to review the woman’s alcohol use regularly. The keyworker should offer flexible support to the woman. For example, alcohol treatment services should consider offering home visits in the early weeks or months after the birth.

The alcohol treatment service should offer the woman ongoing psychosocial support for as long as she needs it. Services should not stop offering the woman support based on a policy that sets standard limits for length of time in treatment. Decisions about ending alcohol treatment should be part of multidisciplinary, multi-agency care planning and review and should fully involve the woman.

In some areas there may be specialist services for children, parents and families affected by problem parental alcohol use. Where this is the case, the woman should be introduced to this service and offered the option of engaging with it.

24.9.4 Women presenting to the service in the first year after birth

Women presenting to the alcohol treatment service for the first time in the year after giving birth should be treated as a priority and offered assessment and treatment as quickly as possible. This is because of the increased risks to mother and baby during this period. Assessment and treatment planning should then follow the recommendations above and in section 24.10 below. If the baby is at risk of significant harm, the service must make a child safeguarding referral and follow national safeguarding guidance and organisational procedures (see annex 1 for information on national legislation and guidance).

24.9.5 Psychosocial interventions

The alcohol treatment service keyworker should offer structured support at frequent and regular intervals during pregnancy and in the year after the birth to make sure the woman is adequately supported around risk of relapse at a vulnerable time. Where the alcohol treatment service has trained psychologists, they should offer psychological treatments, if the assessment shows this is appropriate. You can find guidance on psychosocial interventions in chapter 5.

The alcohol treatment service should co-ordinate the psychosocial support they provide with other services in the multi-agency team and provide advocacy where necessary. You can find further information on multi-agency working in section 24.7.5 and 24.7.7.

24.9.6 Pharmacological interventions

You can find guidance on pharmacological interventions during pregnancy and while the woman is breastfeeding in section 10.6.4 in chapter 10 on pharmacological interventions. You should read this if you are considering prescribing for medically assisted withdrawal during pregnancy or for women who are breastfeeding. Medication for relapse prevention is not recommended during pregnancy or while the woman is breastfeeding.

24.10 Reducing risk of deaths in mothers and babies

24.10.1 Sudden unexpected deaths in infancy

Parental alcohol use is an established risk factor for sudden unexpected deaths in infancy. An analysis of 38 serious case reviews of sudden unexplained deaths in infancy showed the majority of deaths involved the combination of parental alcohol or drug misuse and co-sleeping (parents and babies sleeping in the same bed or on the same sofa or armchair) (Garstang and Sidebotham 2018). This is a frequent finding in sudden unexplained deaths in infancy more generally (Blair and others 2009). All services should provide consistent advice on safe sleeping arrangements using the NHS advice on reducing the risk of sudden infant death syndrome. This is everyone’s responsibility, not just one service or practitioner.

24.10.2 Maternal mental health and deaths

Harmful drinking or alcohol dependence is a significant risk factor for maternal death up to a year after birth (see section 24.4 on risks to women during or up to a year after pregnancy above). The MBRRACE-UK report Saving lives, improving mother’s care (PDF, 3.7MB) makes the following recommendation for action by all health professionals:

“Women with substance misuse are often more vulnerable and at greater risk of relapse in the postnatal period, even if they have shown improvement in pregnancy. Ensure they are reviewed for re-engagement in the early postpartum period where they have been involved with addictions services in the immediate preconception period or during pregnancy.”

Women who experience multiple disadvantage and multiple adversity are at increased risk of mental illness and suicide in the perinatal period (see section 24.4 above). The MBRRACE-UK report includes the following 2 recommendations:

“New expressions or acts of violent self-harm are ‘red flag’ symptoms and should always be regarded seriously. New and persistent expressions of incompetency as a mother or estrangement from the infant are ‘red flag’ symptoms and may be indicators of significant depressive disorder.”

“Loss of a child, either by miscarriage, stillbirth and neonatal death or by the child being taken into care increases vulnerability to mental illness for the mother and she should receive additional monitoring and support.”

You can find guidance on self-harm in the NICE guideline Self-harm: assessment, management and preventing recurrence (NG225).

24.11 Ongoing monitoring of the child’s development

If you have concerns that children born to mothers with problematic alcohol use during pregnancy have delayed or atypical development outcomes, you should arrange for regular monitoring and review of developmental milestones. This can be done by a health practitioner such as a health visitor, school nurse or GP.

If children do not meet developmental milestones, you should refer them through local FASD diagnostic and support pathways, typically this will mean referring the child to local services for children with established neurodevelopmental issues. You should discuss any need for assessment sensitively with the parents in a non-judgemental way. Where local pathways do not exist, you can refer children and adults to the national FASD clinic (UK wide).

24.12 Contraception and family planning

To reduce the risk of alcohol-exposed pregnancies, clinicians and healthcare practitioners (including those in alcohol treatment services) should advise women about the risks of PAE, including FASD.

They should provide information on the risks and benefits of various contraception options, including long-acting reversible contraception (LARC) to women with alcohol problems of child-bearing age, or refer women to sexual health services for this advice.

If a woman has given birth after an alcohol exposed pregnancy, clinicians should discuss contraception with her soon after the birth to reduce the risk of further PAE.

Clinicians should be sensitive to where this advice would not be appropriate. For example, some transgender women are unable to conceive and some women may be unable to conceive or give birth for other reasons.

There should be referral pathways in place to sexual health services, including an enhanced pathway for women who are assessed as being at risk of an alcohol exposed pregnancy.

24.13 Training

NICE QS204 recommends that commissioners should make sure that midwives providing antenatal care:

• are aware of the risks to the fetus of drinking alcohol in pregnancy and the advice in the UK chief medical officers’ low-risk drinking guidelines on alcohol consumption in pregnancy
• have training on FASD awareness
• have training in alcohol brief interventions (see chapter 3 on alcohol brief interventions)

The alcohol clinical guidelines development group recommend that alcohol treatment services make sure their practitioners also receive training in the above areas.

NICE CG110 recommends that training should be given to:

• healthcare professionals on multi-agency needs assessment and national guidelines on information sharing
• healthcare professionals on the social and psychological needs of women with alcohol or drug problems
• healthcare staff and non-clinical staff, such as receptionists, on how to communicate sensitively with women with alcohol or drug problems

The alcohol clinical guidelines development group also recommend that:

• training should include trauma-informed practice and awareness-raising about stigma experienced by pregnant women, particularly women who have previously had children removed from their care (see section 2.2.2 on stigma in chapter 2 on principles of care)
• healthcare practitioners’ knowledge could be enhanced through multi-agency training where maternity care staff, alcohol treatment staff and social workers share their expertise

24.14 References

Blair P, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EMA and Fleming P. Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. British Medical Journal 2009: volume 339, article number b3666

Burns E, Gray R and Smith LA. Brief screening questionnaires to identify problem drinking during pregnancy: a systematic review. Addiction 2010: volume 105, issue 4, pages 601-614

Garstang J and Sidebotham P. Qualitative analysis of serious case reviews into unexpected infant deaths. Archives of Disease in Childhood 2019: volume 104, issue 1, pages 30-36

Kesmodel U, Wisborg K, Olsen SF, Henriksen TB and Secher NJ. Moderate alcohol intake in pregnancy and the risk of spontaneous abortion. Alcohol and Alcoholism 2002: volume 37, issue 1, pages 87-92

Popova S, Lange S, Probst C, Gmel G and Rehm J. Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. The Lancet Global Health 2017: volume 5, issue 3, e290-e299

Russell M. New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK, and others. Alcohol Health and Research World 1994: volume 18, issue 1, pages 55-61

25. Developing inclusive services

25.1 Main points

Making alcohol treatment accessible to everyone

Alcohol treatment and recovery support should be accessible to everyone who needs it and should be delivered in a way that meets the needs of diverse groups of people and communities.

Some people with protected characteristics and socially excluded groups experience barriers to accessing alcohol treatment services. Services may not adequately meet their needs unless they tailor their treatment offer to these groups.

Variations of experience

There is wide variation in experience within any group of people who share a protected characteristic or belong to a socially excluded group. Factors such as age, ethnicity, gender, sexual orientation, gender identity, disability, socioeconomic status intersect and contribute to a person’s individual experience.

Involving different groups in commissioning processes

Commissioners should work with people and groups with protected characteristics and those from socially excluded groups when assessing local need for alcohol treatment, using equality impact processes. Together they should identify barriers to accessing treatment and the distinct needs of particular groups.

Commissioners and services should work in partnership with people and groups with protected characteristics and people from socially excluded groups when planning, designing, and delivering services to:

• reduce barriers to accessing alcohol treatment and recovery support for particular groups
• improve the experience of people in treatment
• tailor treatment and recovery support approaches to the needs of particular groups

Cultural competence

Organisations and practitioners should be culturally competent (see section 2.3.2 on cultural competence for a definition). Services should have a framework and service ethos that promotes equality, diversity and inclusion. This should include policies and processes, equality audits and training for staff and peer support workers.

Services should have a diverse team of practitioners, and where possible peer support workers, who are trained and supported to be culturally competent.

Promotion and reaching out to particular groups

Services should promote themselves to underserved groups. In partnership with people in the group they are aiming to reach, they should design appropriate promotional messages and material, and promote the service through various media and in settings people are likely to use.

Services should reach out to people and communities using flexible engagement approaches, including:

• partnership work and satellites with community organisations
• community outreach
• bases in generic health centres
• home visits

Peer support workers from a similar group or background can play an important role in helping people to engage in treatment.

Having an inclusive and non-judgemental culture

The culture of the service and the approach of practitioners is important in helping people who are anxious or ambivalent to engage in treatment. The service should look and feel inclusive and be able to make adjustments, such as for disabled people, and meet people’s communication needs, such having an independent interpreter available when needed.

Practitioners should have a non-judgemental approach based on empathy, trauma-informed practice and cultural competence. This will help to build a therapeutic alliance which is vital to helping people engage in treatment.

Practitioners should never make assumptions about the person’s needs because they have a particular protected characteristic or are from a particular socially excluded group. They should listen to the person’s own understanding of their needs. Treatment and recovery plans should be personalised to meet the person’s unique goals and treatment needs.

Joint working arrangements

Services should have referral pathways and joint working arrangements with community organisations aimed at particular groups.

It’s important that the main alcohol treatment service works in partnership with local specialist services and peer-based organisations.

Adapting interventions and other arrangements

It may be appropriate to adapt interventions to meet the needs of a particular group of people. Service staff, clinical supervisors and people from the relevant group should be involved in adapting interventions.

It may be appropriate to offer designated meetings or spaces for particular groups in alcohol treatment services to create a sense of emotional safety and an opportunity to share common experience.

Commissioning specialist services

Commissioners and services can consider whether specialist services for a particular group might be appropriate in their area. If a specialist service is commissioned or already exists, commissioners should consider joint commissioning with the main alcohol treatment service.

25.2 Why we need inclusive services

People with alcohol problems often experience stigma associated with their alcohol use, including in healthcare services, and many experience socioeconomic disadvantage. Within this group of people, some experience further discrimination and disadvantage based on:

• their protected characteristics (see below for more information about these)
• severe and multiple disadvantage
• specific groups experiencing extreme social exclusion

These factors can affect how easy it is for people with alcohol problems to access and engage with services. They may also have particular unmet needs. So, alcohol treatment services need to design and deliver services that are inclusive and tailor their treatment offer to meet these people’s needs.

25.2.1 Protected characteristics

There is a public sector equality duty for services in England, Scotland and Wales to consider the need to reduce disadvantage and meet the particular needs of people from protected groups.

The Health and Social Care (Reform) Act (Northern Ireland) 2009 places a duty on each health and social care trust to “exercise its functions with the aim of improving the health and social well-being of, and reducing health inequalities between, those for whom it provides, or may provide, health and social care”.

It is against the law to discriminate against anyone because of:

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

These are called protected characteristics. For more information on protected characteristics, read Discrimination: your rights on GOV.UK.

People will often have more than one protected characteristic and may experience the cumulative effect of discrimination or disadvantage based on the intersection of those characteristics.

25.2.2 Severe and multiple disadvantage

The term ‘severe and multiple disadvantage’ (Bramley and others 2019) refers here to people who experience 2 or more of:

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

25.2.3 Inclusion health groups

Other groups that experience social exclusion, disadvantage and health inequalities are known as inclusion health groups. See section 25.10 for more on inclusion health groups.

25.3 Structure of this chapter

The rest of this chapter is in 2 main parts. The first outlines some shared principles that will help to develop inclusive services. The second is a set of summaries showing actions that services could take to become more inclusive and meet the needs of some specific groups of people, which are:

• ethnic minority groups
• LGBTQ+ groups
• women
• older people
• people with learning disabilities
• inclusion health groups

These summaries give examples of what commissioners, services and practitioners can do to reduce barriers to access and to tailor services for particular groups. Research evidence for these areas is often limited. So, the guidance is based on recurring themes in the research, as well as evidence from practice and lived experience.

25.4 Principles for developing inclusive services

Principles to help develop inclusive services include:

• assessing local need for alcohol treatment working with people and communities
• promoting equality, diversity and inclusion
• promoting the service to local groups and communities
• using flexible, targeted approaches to reach underserved groups
• supporting people to engage in treatment
• offering alcohol harm reduction interventions
• tailoring treatment and recovery support

You can find more information about these principles below.

25.4.1 Assessing local need for alcohol treatment working with people and communities

Equality impact assessments

Local populations vary widely. So, alcohol treatment should be based on a thorough assessment of local need. Commissioners are normally responsible for making local needs assessments, involving strategic partners. Services should be aware of the diverse needs of their local population and can contribute to needs assessments.

Local needs assessments should include equality impact assessment processes to understand the diverse needs of local populations including:

• people with protected characteristics
• people experiencing severe and multiple disadvantage
• inclusion health groups

Working with local people and communities when assessing need

When assessing need and planning services, commissioners and service providers should seek the views of local people and communities, including community organisations. This should include the views of people from underserved groups.

Commissioners and service providers need to hear about:

• the barriers specific groups experience when accessing and engaging with alcohol treatment
• how these groups think services could improve access

Commissioners, service providers, people with lived experience and local people and communities can then work in partnership to develop a needs assessment and develop services designed to:

• remove service barriers to accessing alcohol treatment and recovery support
• improve the experience of people in treatment
• tailor treatment and recovery support approaches to the needs of particular groups

The resources section at the end of this chapter includes guidance on working together with people and communities.

25.4.2 Promoting equality, diversity and inclusion

Providing equal access and appropriate treatment to diverse populations requires an organisation to be culturally competent (see section 2.3.2 on cultural competence for a definition). The organisation should have a framework and a service ethos that promotes equality, diversity and inclusion that should include:

• recruiting a diverse staff team, which contributes a range of perspectives to treatment provision
• developing organisational policies and practices that promote equality, diversity and inclusion, including equality audits
• training and supervision in delivering treatment based on principles of equality, diversity and inclusion, with enough time and space for staff to develop their practice
• staff training and support to develop cultural competence
• staff training and supervision on addressing discriminatory behaviour from colleagues or people in treatment, so that people can engage in treatment in a safe space

25.4.3 Promoting the service to local groups and communities

There is international evidence that people with alcohol problems underuse alcohol treatment services (Rehm and others 2015). Alcohol treatment services should be promoted very widely and in ways that will reach local underserved populations.

There are many ways that services can advertise and promote their services locally, including through:

• local and community media including radio, newspapers, community websites and social media
• attending community events and local meeting places
• public facilities like laundrettes and community centres
• community organisations that represent or have links with specific underserved communities or groups with protected characteristics
• wider health and social care services, including children and family services

Some of the most marginalised people may not have access to digital platforms, so it’s important to use other forms of media, to make sure there is equitable access to information about treatment for everyone.

The promotional messages and images that you use should be clear that alcohol treatment is free and available to everyone and that diverse populations will be welcomed. Examples include:

• positive images showing diverse populations
• service information or health information tailored to specific groups or communities
• information in languages spoken in the community
• easy read information for people with literacy problems and other accessible formats for people with sensory disabilities

You should involve people from the groups the information is aimed at in designing information and promoting the service and make sure that the images and language you use are not stigmatising.

25.4.4 Using flexible, targeted approaches to reach underserved groups

Some groups of people are unlikely to come to a service for a range of reasons including:

• past experiences of discrimination or marginalisation in services
• perceptions that alcohol treatment services are not inclusive
• stigma about alcohol linked to religion, culture or gender
• lack of knowledge about alcohol problems and alcohol treatment services
• language or communication needs
• fears that children may be taken into care
• fears about immigration status
• difficulty making or keeping appointments due to life circumstances
• travel problems for people who are frail or have physical disabilities
• lack of public transport or cost of transport

Alcohol treatment services need to make proactive attempts to reach underserved populations, using flexible, tailored approaches including:

• working in partnership with community organisations and peer support organisations who have established relationships with specific underserved groups
• running in-reach sessions (see definition of in-reach in the glossary) or being co-located with partner services or community organisations
• joint working with support workers from organisations that work with specific groups
• community awareness raising about alcohol harm and alcohol services
• having open access services so appointments are not necessary
• assertive outreach, including home visits (see chapter 9 on alcohol assertive outreach and a multi-agency team around the person)
• running sessions in general health and wellbeing services, so people do not have to attend an identifiable alcohol treatment service
• having an option of digital interventions so people can make initial contact without coming to a service site
• having independent interpreters or staff who speak community languages available

25.4.5 Supporting people to engage in treatment

Practitioner approach

Practitioners should encourage people to engage with alcohol treatment by:

• having inclusive attitudes
• building trusting relationships
• discussing potential barriers to ongoing engagement with each person

The principles of care in chapter 2 that should underpin all alcohol treatment will help to engage people from groups that experience barriers to accessing and engaging in treatment. These principles include:

• having a non-stigmatising approach
• putting the person at the centre of their own care and personalising treatment
• using trauma-informed practice (see the Office for Health Improvement and Disparities’ (OHID) working definition of trauma-informed practice for more information)
• cultural competence

Building a therapeutic alliance is vital to effective treatment and will be particularly important where people from underserved groups are ambivalent or anxious about engaging in treatment. Building a therapeutic alliance takes time and requires attention. So, staff need manageable caseload sizes and people will need to be engaged long enough for them and the practitioner to build an effective therapeutic alliance. Once they have established a therapeutic alliance, it’s important for the person to keep the same keyworker because changes in keyworker can be very disruptive. There is guidance on therapeutic alliance in chapter 5 on psychosocial interventions.

Discussing how to reduce barriers to engaging in treatment

At referral, services should make it standard practice to ask if there are any adjustments that the person needs to engage in treatment, so they can make these arrangements before the person attends. For example, services can ask about:

• independent interpreters
• adjustments for physical, sensory or learning disabilities or alcohol related brain damage
• mental health conditions, for example social phobia

At assessment, the practitioner can discuss needs with the person in more detail.

Practitioners should discuss with the person how they can work together to reduce any barriers that could stop them engaging in treatment. Barriers can include:

• practical barriers, like appointment times
• physical safety issues, such as women experiencing domestic abuse
• emotional safety issues, for example fears related to previous experiences of discrimination or trauma

The service should do things that make it easier for people to engage with treatment. For example:

• timing appointments around childcare or working arrangements
• making sure a woman who has experienced intimate partner violence is not seen at the same service or site as the perpetrator
• involving a family member, support worker or peer, with the person’s consent
• providing clear information on confidentiality
• offering interventions tailored to a person’s individual needs (see section 25.3.8 below)

Wherever possible, it’s important that people have a choice about their keyworker or peer support worker. For example, women who have experienced domestic or sexual violence may prefer to have a woman keyworker.

Peer support can often help to support engagement, so the practitioner should introduce the person to peer-based support organisations or individual peers where appropriate. In some areas, there are independent lived experience recovery organisations (LEROs) that some people find more accessible than treatment services. People may engage with LEROs instead of treatment services, or the LERO can help them to engage with treatment services when they are ready.

There are more examples of reducing barriers to engagement for particular groups in sections 25.5 to 25.10 below.

25.4.6 Offering alcohol harm reduction interventions

Practitioners should offer alcohol harm reduction interventions where people are not yet ready to enter structured treatment.

If people from underserved populations are unsure about accessing structured treatment but they have established a relationship with a practitioner (for example, an outreach worker), this provides an opportunity to offer harm reduction interventions. These harm reduction interventions may be beneficial in themselves and can help to strengthen a person’s engagement in treatment. The practitioner can offer access to structured treatment again at a later stage. There is guidance on harm reduction in chapter 8.

25.4.7 Tailoring treatment and recovery support

Personalised treatment and recovery plans

Alcohol treatment services and practitioners should deliver treatment and recovery interventions in a culturally competent way and that meet the person’s individual needs.

The person should be at the centre of their treatment and recovery planning and this should be tailored to meet their individual needs and goals. Practitioners should be aware of specific needs that may be relevant for people from particular groups, but they should never make assumptions about the person’s needs because they have a particular protected characteristic or are from a particular disadvantaged group. Practitioners should try to understand the person’s own unique identity and needs and take account of this when working with them to address their alcohol problems.

Alcohol treatment services need to work with other organisations to help people access inclusive treatment and recovery support. There are a number of organisations and groups that can help people recover by showing what recovery looks like and giving them tailored support, advocacy and community. These include:

• diverse recovery communities
• peer support networks
• community organisations serving specific populations

Tailoring treatment interventions

It may be appropriate to tailor psychosocial interventions, so they are more relevant and effective for specific groups of people. Clinical advisors and people from the group the intervention is targeting should be involved in considering how to tailor interventions. There are some examples of tailoring interventions below in sections 25.4 to 25.9.

Practitioners should make sure any presentations or work sheets that they use in treatment interventions are inclusive. For example, when running a relapse prevention group they should make sure that any examples of high-risk situations they discuss with the group include the kind of situations that might be risky for people in the group.

Some people with protected characteristics or from socially excluded groups might need or may benefit from having the option of dedicated treatment groups or activities, which are specifically for people with particular characteristics or from particular groups (for example, women-only groups or LGBTQ+ specific groups). This can help to create emotional safety where people feel aspects of their identity and experience may be better understood and accepted, or where people can talk about shared experiences that may have been painful or traumatic.

Addressing discriminatory behaviour in group settings

Many treatment services create shared environments where people in treatment meet with others, like treatment in groups or open access drop-in sessions. Staff need training and supervision so they can address discriminatory behaviour appropriately in group settings in a treatment service.

25.5 Ethnic minority groups

25.5.1 Language

Language is important and we aim to use inclusive language in this guidance. We realise there are different views on language to write about ethnicity, but these guidelines use the Writing about ethnicity guide for GOV.UK.

25.5.2 Prevalence and harms

Alcohol dependence occurs in all ethnic groups. But the evidence on prevalence of harmful or dependent drinking in ethnic minority groups is very limited.

A rapid evidence review of drinking problems and interventions in black and minority ethnic communities found that overall, there are higher rates of abstinence and lower rates of harmful drinking among ethnic minority groups compared to the white British group (Gleeson and others 2019). However, there is some evidence that says rates of alcohol dependence may be similar for some ethnic minority groups and white groups (Drummond and others 2004).

The evidence review found concerns about problematic drinking and alcohol harm among:

• South Asian men, and Sikh men in particular (Bayley and Hurcombe 2011, Galvani and others 2013)
• refugees and asylum seekers (Horyniak and others 2016)
• Irish nationals living in England, Wales and Scotland (Hurcombe and others 2010)
• Polish migrants (Herring and others 2019)

It also found concerns among service providers that the prevalence of harmful drinking in most ethnic minorities is under reported due to stigma and inadequate recording.

The Scottish health survey - topic report: equality groups found that between 2008 and 2011, people in most ethnic minority groups were less likely to drink at hazardous or harmful levels than the national average.

White British and white Irish respondents were most likely to have exceeded the recommended daily limit on their heaviest drinking day in the previous week.

Office for National Statistics (ONS) data on deaths caused by alcohol is not routinely analysed by ethnic group.

Scottish research on health and ethnicity found that Indian men had a 75% higher risk of alcohol related liver disease than white Scottish men (Bahla and others 2016). It also found that white Irish men and women described as “any mixed background” had almost double the risk of alcohol-related diseases, compared to the white Scottish population. However, the causes of these differences in alcohol related diseases are not clear.

There is some evidence from England that South Asian men are over-represented for alcohol related cirrhosis (Douds and others 2003). And that Sikh men in particular are over-represented for liver cirrhosis (Hurcombe and others 2010).

25.5.3 Considerations for services

Variation between ethnic minority groups

There is wide variation between and within ethnic minority groups in rates of harmful alcohol use and attitudes to drinking and drinking problems.

Commissioners and services should adapt the guidance in the two sections below (25.5.4 and 25.5.5) to the needs of specific ethnic minority groups in their local area and practitioners should tailor interventions to each individual.

Inequality and discrimination

The NHS Race and Health Observatory Ethnic inequalities in healthcare: a rapid evidence review found strong evidence of ethnic inequalities in access to general healthcare services and in experience of care. Other research shows this is also the case for alcohol treatment (Hurcombe and others 2010).

Experience of institutional and interpersonal racism in treatment services has led to a lack of trust that prevents people accessing services. Tackling inequality and discrimination in services and building trust should be a priority.

Stigma and shame

Harmful alcohol use is stigmatised across British society. But in some ethnic minority groups there is additional stigma associated with mental ill health and with religious prohibitions on alcohol use. This is most often reported for South Asian ethnic minority groups.

Culturally, alcohol use can be considered and experienced as a source of individual, family and community shame, so people are less likely to seek help from outside the family. Alcohol use or alcohol problems among women in South Asian ethnic groups and Muslim groups more widely is often considered unacceptable and more likely to remain hidden, including from the family (Gleeson and others 2019). Services should work with local people and communities to find acceptable ways for them to access treatment.

Monitoring ethnicity

It’s important that services record a person’s (self-defined) ethnicity so they can have information about alcohol treatment access and outcomes for different ethnic minority groups. Services should make sure they carry out ethnic monitoring consistently.

Vulnerable migrants

Section 25.10 on inclusion health groups includes guidance on vulnerable migrants.

25.5.4 Reducing barriers to treatment

Assessing need for alcohol treatment among ethnic minority groups

Commissioners should use census, national and local data, and information from local services on ethnicity and religion to identify which ethnic minority groups in their area are underserved. However, available data will be limited. Commissioners should work with underserved ethnic minority groups, including people with lived experience of alcohol problems and alcohol treatment, when carrying out the needs assessment and the equality impact assessment.

Working in partnership with people from ethnic minority groups and communities

Commissioners and services should have an ongoing partnership with local ethnic minority people and communities because building trust and developing accessible and culturally appropriate interventions takes time. This work requires:

• leadership
• dedicated managerial and staff capacity
• resources for promoting the service in community languages through different media and interpreters

Commissioners and service providers should work with a range of people from local ethnic minority communities to do the needs assessment and improve access to treatment. This includes:

• community organisations
• community leaders
• treatment staff
• people in treatment and their family members
• peer-based organisations

Partnerships should include people and community leaders representing different perspectives within an ethnic minority group or community, including different:

• ages
• genders
• sexual orientation
• abilities
• religions (including people with no religion)

Partnerships should co-produce:

• a needs assessment
• an understanding of barriers to accessing treatment and what can help people to access it
• interventions to engage and appropriately support people from ethnic minority communities

There is guidance on working with people and communities to reduce health inequalities in the resources section.

Recruiting an ethnically diverse workforce

Services should aim to recruit a workforce at all levels of seniority that is diverse and broadly representative of local ethnic groups. Staff from ethnic minority groups should be able to contribute to service planning and development. Services should make sure there are equal opportunities for staff from ethnic minority backgrounds, including for:

• training
• supervision
• career development

Working with ethnic minority peer-based networks

Services should support and work with ethnic minority and faith peer-based recovery networks and services who understand the needs of their communities. Peer involvement can help to build trust and reduce stigma by providing a range of support including co-delivering community outreach.

Being proactive and flexible in helping people to access the service

Services should help people to access treatment in flexible ways as described in sections 25.4.3 and 25.4.4. They should tailor those principles to meet the needs of the specific ethnic minority groups they are aiming to engage. An example of a flexible, targeted approach to reaching a community is the Under the Influence Recovery Podcast produced by the Sikh Recovery Network and Turning Point (see resources section for more details).

Research reports differences among people from ethnic minority groups about how they prefer to seek help. For example, some would prefer to access help through a GP, while others would prefer to access help from their family and would prefer home visits. (Hurcombe and others 2010). So, services should provide different options.

Reducing language barriers

Language is repeatedly identified as a major barrier to accessing services. Services can do several things to reduce this barrier, including having:

• a service policy for working with interpreters
• resources for trained, independent interpreters and translation services
• a range of formats for communicating information, including video or audio
• basic training for staff in working with interpreters and considerations for practice
• allowing additional time for sessions with interpreters because everything is repeated
• where appropriate, employing staff who can speak community languages

You should not use translation software because it may not be accurate for describing complex problems and alcohol treatment needs.

The OHID migrant health guide has useful guidance on language interpretation and translation.

Ensuring confidentiality and anonymity

When reaching out to communities where alcohol is religiously prohibited or there is cultural stigma associated with alcohol problems, services should:

• offer appointments in generic healthcare settings like GP practices or health and wellbeing centres
• offer home visits and online contact
• emphasise confidentiality and anonymity in all your promotional messages

Community awareness raising about alcohol and alcohol treatment

If services think that local ethnic minority communities lack knowledge about alcohol harms and alcohol treatment services, they should offer awareness raising sessions tailored to the needs of these communities. These sessions could be part of broader sessions on health and wellbeing (in person or online) to avoid the stigma associated with alcohol use. Ethnic minority community representatives should be involved in identifying need for community awareness raising, as well as planning and delivering the sessions.

Reducing financial barriers

People from ethnic minority groups are over-represented among those experiencing the highest levels of socioeconomic deprivation.

To help with this, services should:

• make it clear the service is free in promotional literature
• be geographically accessible so transport costs are not too much
• consider offering support with transport costs

Practitioners should also support people to work towards any recovery goals they have for training and employment.

25.5.5 Tailoring treatment for ethnic minority groups

Cultural competence

Research repeatedly shows that treatment services need cultural competence. Services and practitioners should be culturally competent. There is a description of cultural competence in chapter 2 on principles of care.

Organisational cultural competence

Quality governance audits should include equality audits.

Services should make sure their staff receive training and supervision to develop cultural competence.

The culture of the service should feel inclusive to diverse ethnic groups. For example, service arrangements should take account of:

• religious or ethical dietary requirements
• religious requirements such as prayer times
• religious and cultural festivals

Practitioner cultural competence

Practitioner cultural competence includes offering treatment and support that take account of the person’s cultural and faith-based perspectives and experiences, but does not make stereotypical assumptions.

Practitioners need skills in building a therapeutic alliance with people from cultures that are different to their own and to be able to reflect on how their own culture and background influences their perspective. Services should support them through training and supervision to challenge unconscious bias that can affect their practice.

Cultural competence can also involve understanding the impact of racism or discrimination on the person’s wellbeing and whether they see this as a factor in their alcohol use.

Diversity within ethnic minority groups

Services and practitioners should recognise the diversity within any ethnic and cultural group. People from the same ethnic, cultural or faith background are diverse and will have different intersecting identities and experience which contribute to their identity. These include:

• gender
• age
• sexual orientation
• disabilities
• socioeconomic status

If a person has several intersecting factors, they are likely to experience more discrimination and disadvantage. This can then affect their alcohol problem and their experience of healthcare, and their individual treatment needs will vary.

Treating the person as an individual

Practitioners should always offer treatment based on understanding the person as an individual and not make assumptions based on their ethnicity or faith. They should tailor interventions to meet the person’s unique needs. Treatment should be based on the principles of care set out in chapter 2, including a non-stigmatising, empathic, trauma-informed approach.

Considering women’s needs

Women who drink harmfully or dependently experience more stigma than men in all communities across British society (Gleeson and others 2019). In ethnic minority groups where alcohol use is religiously prohibited and culturally unacceptable, women experience additional stigma. This often leads to their drinking being hidden or not discussed, including at times within the family. It also puts women at increased risk of harm if they feel they cannot ask for help. Services should target information for women in those ethnic minority groups, offering free, confidential and discrete support.

Adapting psychosocial interventions

There have been no UK-based randomised controlled trials of psychosocial alcohol interventions adapted to meet specific cultural or religious needs. Evaluations of specialist projects contain some examples of adapted interventions (see resources section below). If services want to adapt interventions, they should work with their senior clinical staff and with members of ethnic minority groups to develop adaptations.

Working with family members

Some people will not want to involve family in their treatment because of stigma and shame. But where there is consent, services should involve families in supporting the person’s treatment.

In communities where alcohol problems are often not shared outside the family, women are more likely to ask about help on behalf of a family member. There may be particular stress on women who usually provide care and support within the family, as well as potential risks like domestic abuse. So, services should make sure women family members can access culturally appropriate support for their own needs. You can read more on working with families in chapter 5 on psychosocial interventions.

Considering specialist projects or services

Commissioners, service providers and community representatives should consider whether specialist projects or services should be commissioned alongside mainstream alcohol treatment services. The limited evidence reports mixed stakeholder views on whether alcohol services designed for people from particular ethnic or faith-based groups, or for people from ethnic minorities in general, would be more helpful than mainstream alcohol treatment services. But the evidence would support local areas considering if it’s appropriate to have a specialist service (Hurcombe and others 2010, Gleeson and others 2019).

There are examples of specialist projects for ethnic minority communities resources section below. If there are local specialist services that offer support to people from ethnic minorities with alcohol problems, alcohol treatment services should work with them. Even where there are local specialist services for ethnic minority groups, mainstream alcohol treatment services should still be culturally competent and provide appropriate treatment for people from ethnic minorities. People should always have a choice of which service they want to attend and it may be appropriate for them to attend both.

Alcohol treatment service providers should discuss with people from ethnic minorities or faith groups whether a dedicated group or activity within the service programme would help meet their needs.

25.6 LGBTQ+ people

25.6.1 Language

LGBTQ+ stands for lesbian, gay, bisexual, transgender, queer (or questioning) and other identities. We realise that there are versions of this acronym that include other sexualities and identities like intersex, asexual and non-binary, but we use LGBTQ+ in this guidance.

25.6.2 Prevalence and harms

Studies of alcohol use in LGBTQ+ populations consistently show higher rates of increasing risk (hazardous) and higher risk (harmful) drinking as defined by the UK chief medical officers’ low risk drinking guidelines.

The Health Survey for England found that around 7% of lesbian, gay or bisexual adults reported drinking at harmful (higher risk) levels from 2011 to 2018. This was higher than the approximately 4% of heterosexual adults reporting drinking at higher risk.

All studies in a review of alcohol use among sexual and gender minority communities in the UK found higher rates of drinking above low risk levels (as defined by UK chief medical officers’ low risk drinking guidelines) in LGBTQ+ populations compared to heterosexual or cisgender populations (Meads and others 2023).

There is little UK research on alcohol and trans people (Glynn and van den Berg 2017) but the Trans Mental Health Study 2012 (PDF, 2.7MB) found that 47% of trans people who responded were drinking above low risk levels defined by the UK chief medical officers. Approximately 24% of the heterosexual population and 32% of the lesbian, gay and bisexual population in England drink above low risk levels.

There is a lack of evidence about alcohol related harm among LGBTQ+ people, but because their rates of harmful drinking are higher, they are likely to experience increased health harms compared to the heterosexual population.

There is evidence that lesbian, gay and bisexual people have higher rates of substance misuse, mental illness and higher risk of self-harm and suicide than the heterosexual population (King and others 2008). Discrimination and prejudice contribute significantly to these higher risk levels.

The Stonewall report LGBT health in Britain suggests that 12% of trans people and 11% of non-binary people made an attempt to take their own life in the previous year, compared to 2% of LGBTQ+ people who are not trans.

Harmful alcohol use is also a risk factor for mental illness (Weaver and others 2003) and for self-harm and suicide (Kaplan and others 2013).

25.6.3 Considerations for services

Explanations for higher prevalence of alcohol problems

Explanations for higher prevalence of alcohol problems among LGBTQ+ people compared to the heterosexual population vary. Two research reports, London Friend’s Out of your mind and What are LGBTQ+ people’s experiences of alcohol services in Scotland? by Scottish Health Action on Alcohol Problems, identify the following themes.

1. LGBTQ+ social activities tend to centre on bars and clubs, and this may be the first place LGBTQ+ people explore their sexual and gender identity with others.

2. Alcohol use has an important role in LGBTQ+ communities and drinking above low risk levels is often the norm.

3. LGBTQ+ people use alcohol:

• to boost self-esteem and confidence in social situations
• as an attempt to cope with the stress of discrimination or harassment

4. Some people see experiences and feelings linked to their LGBTQ+ identity as a cause of their alcohol problem, and some see other factors as more relevant.

Emotional and physical safety in alcohol treatment services

The same research reports highlight concerns about emotional or physical safety in alcohol treatment services for LGBTQ+ people.

LGBTQ+ people often reported that they:

• anticipated that alcohol treatment services would not be LGBTQ+ inclusive
• experienced or witnessed discrimination based on sexual orientation or gender identity in alcohol treatment services

The research findings on alcohol treatment services are consistent with research on the LGBTQ+ people’s experience of wider healthcare services. The Stonewall report LGBT health in Britain found that in the last year:

• 1 in 7 (14%) lesbian, gay, bi and trans (LGBT) people have avoided treatment for fear of discrimination because they are LGBT
• 1 in 8 LGBT people (13%) have experienced some form of unequal treatment from healthcare staff because they are LGBT
• 6% of LGBT people, including 20% of trans people, had witnessed negative remarks from healthcare staff

The London Friend and Scottish Health Action on Alcohol Problems reports found that LGBTQ+ people’s experience of alcohol treatment services was that staff:

• often made assumptions based on heterosexual norms
• did not usually ask about their sexual orientation or gender identity
• were often not aware of aspects of LGBTQ+ experience

They were also concerned that peers at the service would not be LGBTQ+ inclusive and would judge them negatively or would not understand their experience.

Under-representation of LGBTQ+ in needs assessments

Although there is evidence that LGBTQ+ people are at higher risk of harmful alcohol use, the Out of your mind report found that LGBTQ+ people’s alcohol and drugs needs were poorly represented in local needs assessment.

25.6.4 Reducing barriers to treatment

Commissioners and services should work with LGBTQ+ people and organisations to identify their needs as part of their equality impact processes for their local needs assessment. They should also involve LGBTQ+ people and organisations in planning services to meet their needs. They should consider where different LGBTQ+ people may have separate and distinct needs.

Services should record sexual orientation and gender identity so that commissioners and services can monitor take up of the service and outcomes for LGBTQ+ people.

Service equality, diversity and inclusion policies and processes should explicitly include the needs of LGBTQ+ people.

Commissioners and services should make sure that all staff are trained and culturally competent to work with LGBTQ+ people. Training should include:

• improved understanding of LGBTQ+ people’s experiences and their needs in alcohol treatment services
• a particular focus on the experience and needs of trans people because research suggests that staff have particularly low levels of understanding of the experience and needs of trans people and high levels of discrimination
• challenges to stereotypes and assumptions based on heterosexual and gender identity norms
• information about alcohol use among LGBTQ+ populations
• appropriate ways to ask people about their sexual orientation and gender identity
• how to discuss if their LGBTQ+ identity is a factor in their alcohol use
• how to challenge discrimination or lack of understanding about LGBTQ+ people in group settings

Services should target promotional messages for LGBTQ+ people (see section 25.4.3) and actively reach out to LGBTQ+ people and communities to support them to engage in alcohol treatment (see section 25.4.4).

Commissioners and services should consider carrying out an LGBTQ+ audit of the alcohol treatment service to find any gaps in inclusive practice and develop a plan to address these. There is an example of an LGBTQ+ audit tool in appendices A to C of the Out of your mind report. It includes LGBTQ+ audit tools and guidance for commissioners, services and practitioners.

It may be helpful for services to appoint an LGBTQ+ champion to share information and promote good practice.

25.6.5 Tailoring treatment to meet the needs of LGBTQ+ people

Asking about sexual orientation or gender identity

At initial assessment, practitioners should avoid assumptions about a person’s sexual orientation or gender identity. If the person does not share this information, practitioners should sensitively ask about their sexual orientation or gender identity.

Providing a safe environment

Safe and confidential care is vital for everyone in alcohol treatment services. A significant proportion of LGBTQ+ people identified a need for better safety in alcohol treatment services, as outlined in the Out of your mind and What are LGBTQ+ people’s experiences of alcohol services in Scotland? reports. So, services and practitioners should take particular care to provide treatment that helps them feel safe. A number of things can contribute to creating a safe environment, including:

• service policies
• service ethos
• inclusive service information
• staff training

It is vital that the therapeutic approach of practitioners establishes a feeling of safety so people can focus on changing their alcohol use. The principles of care in chapter 2 says that including a non-judgemental, empathic and trauma-informed approach is important in developing a therapeutic alliance and a safe therapeutic space.

Personalise treatment and recovery plans

Practitioners should always treat people as unique individuals and not make assumptions about the person’s sexual orientation or gender identity. Treatment and recovery plans should be personalised.

Assessing risk

Assessing for risk of self-harm and suicide should be a standard part of assessment for everyone in alcohol treatment. Practitioners should be aware of the higher risk levels for self-harm and suicide among LGBTQ+ people, particularly trans people. There is guidance on assessment, including self-harm, in chapter 4 on assessment and treatment and recovery planning.

Specialist LGBTQ+ services

There is a lack of research on whether specialist services are more effective for LGBTQ+ people, but the Out of your mind report found that respondents were positive about the benefits of a specialist LGBTQ+ service. Many felt it was a safer environment where they felt understood. LGBTQ+ respondents had different views on whether they preferred a specialist service or an inclusive generic alcohol treatment service, but thought there should be options.

Commissioners should consider whether a specialist LGBTQ+ service, working in partnership with the main alcohol treatment service, would be worth having on a local or a regional level.

Even if there is a local specialist LGBTQ+ alcohol service, general alcohol treatment services should still be inclusive and effective for LGBTQ+ people. This could include offering dedicated LGBTQ+ groups or spaces.

Alcohol-free activities

Since alcohol plays an important role in many LGBTQ+ social settings, people can benefit from the option of LGBTQ+ alcohol-free spaces and activities. Services and practitioners should be aware of local LGBTQ+ peer-based groups and mutual aid groups, and other LGBTQ+ groups that do not involve drinking and support people to access them.

Diversity among LGBTQ+ people

Services and practitioners should recognise the diversity within LGBTQ+ groups. LGBTQ+ people and communities include people with a range of sexual orientations and gender identities. They also have different intersecting identities and experience which contribute to their identity, which include:

• gender
• age
• ethnicity, culture and religion
• abilities
• socioeconomic status

If a person has several intersecting factors, they are likely to experience more discrimination and disadvantage. This can then affect their alcohol problem and their experience of healthcare, and their individual treatment needs will vary.

For example, women can benefit from gender specific groups and spaces and LGBTQ+ people from minority ethnic groups can benefit from support from others who have had similar experiences.

Services and practitioners should consider all intersecting aspects of a person’s identity and experience.

25.7 Women

25.7.1 Prevalence and harms

The Health Survey for England, 2021 part 1 reported that:

• 2% of women in England were drinking at harmful (higher risk) levels
• 5% of men in England were drinking at harmful (higher risk) levels

Almost 139,000 women in England were estimated to be alcohol dependent in 2014 to 2015, which is 23% of all estimated dependent adults (Pryce and others 2017).

The ONS report Alcohol-specific deaths in the UK: registered in 2021 shows there were 3,293 female alcohol-specific deaths. The rate of alcohol specific deaths has increased for both women and men since 2019.

OHID analysis of over 20 years of alcohol death data found that in 2021, women accounted for 34% of all alcohol-specific deaths. Over time, female deaths typically account for around a third of all alcohol-specific deaths.

25.7.2 Considerations for services

Severe and multiple disadvantage

Research by Against Violence and Abuse shows that many women using alcohol treatment services experience multiple disadvantage which are made worse by the fact that they experience them as women. Women in alcohol treatment services are often vulnerable and a high proportion have experienced both childhood and adult trauma.

Health harms for women

Women experience health harms at lower levels of alcohol consumption than men. The UK chief medical officers’ low risk drinking guidelines advise that the risk of harmful (higher risk) drinking begins at 35 units per week and above for women, and at 50 units per week for men. Chapter 19 on people with co-occurring physical health conditions describes health harms, including the risk of breast cancer in women, which increases at levels as low as 2 units per day.

Women’s needs beyond their role as mothers and carers

It is vital that pregnant women and women with children receive support and safeguarding where appropriate. However, services should address women’s needs and experiences beyond their role as mothers and carers.

Diversity among women

Women are diverse and have different intersecting identities and experience which contribute to their identity, including:

• ethnicity, culture, and religion
• age
• ethnicity, culture and religion
• abilities
• socioeconomic status

If a person has several intersecting factors, they are likely to experience more discrimination and disadvantage. This can then affect their alcohol problem and their experience of healthcare, and their individual treatment needs will vary.

Pregnancy

Alcohol use, especially harmful or dependent alcohol use, poses significant risks to pregnant women and the fetus. Alcohol treatment services should:

• prioritise treatment for pregnant women
• help pregnant women to access antenatal care
• contribute to safeguarding the fetus or baby

There is guidance on pregnancy and perinatal care in chapter 24.

Women as parents

Women are more often responsible for childcare than men. Services and practitioners need to consider parenting when planning services and developing individual treatment and recovery plans. There is guidance on parents in alcohol treatment in chapter 26.

25.7.3 Reducing barriers to treatment

Commissioning and planning services

Commissioners and services should consider the needs of women as part of equality impact assessment processes when carrying out a needs assessment and planning services. They should involve women with lived experience of alcohol dependence and alcohol treatment, as well as specialist organisations for women, including those working with women experiencing severe and multiple disadvantage. The distinct needs of different groups of women should be considered in the assessment.

A gender sensitive non-stigmatising approach

Research shows that stigma experienced by people with alcohol problems in society is greater for women than for men (Schober and Annis 1996). Feelings of shame and anticipation of stigma from services are barriers to women accessing treatment (Thom 1987).

Services and practitioners should provide:

• a non-stigmatising service culture that treats women with dignity and respect
• service information with positive strengths-based images and messages targeted at women (you can find more information on taking a strengths-based approach in section 2.2.7)
• practitioners with non-judgemental, empathic attitudes who show they understand the impact of stigma on women

Women only spaces

Women can feel intimidated in mixed gender environments and may need or benefit from women only spaces (see section 24.7.4 on tailoring treatment below).

Services and practitioners trained to work with domestic abuse

Current or recent domestic abuse can be a barrier to women accessing treatment, because the perpetrator can prevent the woman from attending.

If the perpetrator is attending the local alcohol treatment service, the service should arrange for the woman to be seen by another service, or at least on a separate site in a completely confidential setting.

Services and practitioners should be trained to work with women experiencing domestic abuse. There is guidance on working with victims and perpetrators of domestic abuse in chapter 22.

Parent friendly services

Women can feel anxious and receive conflicting messages, where they are labelled bad mothers because of their alcohol use, but also experience barriers to treatment like lack of childcare and fear of losing their children to social services (Peralta and Jauk 2011).

Services and practitioners should offer:

• a non-judgemental and empathic approach to mothers with alcohol problems
• appointment times to take account of childcare responsibilities
• access to appropriate childcare or flexibility so the woman can arrange childcare

There is guidance on working with parents in chapter 26.

Reducing financial barriers

Women in treatment may have fewer financial resources than men in treatment. Services should:

• make it clear the service is free in their promotional literature
• be geographically accessible so transport costs are not too much
• consider offering support with transport costs

Reaching women who are unlikely to approach alcohol treatment services

Services should follow the guidance in section 25.4.3 on promoting the service and section 25.4.4 on reaching people. They should use these approaches with women, including specific groups of women who are less likely to approach services. For example, section 25.5.4 has advice on reducing barriers for women in some ethnic minority groups affected by cultural norms that particularly stigmatise women who drink or have alcohol problems.

Chapter 9 on assertive outreach and a multi-agency team around the person provides guidance on working with people who experience severe and multiple disadvantage.

25.7.4 Tailoring treatment for women

Gender responsive service culture

Being gender-responsive means creating an environment that reflects an understanding of the realities of the lives of women and responds to their strengths and challenges (Covington and Bloom 2007).

The service should understand and acknowledge that gender makes a difference to some of the causes of people’s alcohol problems and to alcohol treatment needs. For example, there should be an organisational understanding of how women experience safety, or lack of it, and barriers they can experience in mixed gender environments.

Women only services and spaces

Some women will feel intimidated by mixed gender services, where there are normally more men than women. Women who have experienced traumatic abuse from men may not feel physically or emotionally safe in mixed gender alcohol treatment services.

Services should:

• be in locations that reduce physical risks (such as being well–lit, accessible through open streets not narrow alleys or subways and well-staffed)
• increase emotional safety by offering women only groups or spaces where women can share aspects of their experience as women in an environment that is free from mixed gender dynamics
• provide the option of women-only residential treatment
• promote a culture where women are supported to report any sexual harassment they experience at the service
• consider offering women only services

A gender sensitive trauma-informed approach

A high proportion of women with alcohol dependence have experienced trauma including:

• childhood abuse (emotional, physical or sexual)
• adult abuse including domestic abuse, sexual violence or exploitation

Services and practitioners should take a trauma-informed approach, which takes account of the kind of trauma women are more likely to experience than men. Women are more likely than men to experience abuse from people they are in relationship with, which erodes trust in relationships.

For women who have experienced multiple traumas, it is likely to take time to build trust. Practitioners should be trained and supervised to develop a therapeutic alliance using a trauma-informed approach.

A personalised treatment and recovery plan

Each woman should be at the centre of her own care. The practitioner should work with her to develop a treatment and recovery plan that addresses her unique personal goals and needs and not make assumptions based on her gender or other aspects of her identity.

For women who have experienced trauma, at an appropriate stage in the woman’s treatment, the multidisciplinary team should consider with the woman whether a referral to a specialist psychological service for post-traumatic stress is appropriate.

There is guidance on treatment and recovery planning in chapter 4.

Working in partnership with organisations that work with women and women’s issues

Services should have pathways with local women’s organisations and practitioners should support women to access relevant organisations. This should include support to access women-only mutual aid and peer-based recovery support.

A strengths-based approach

Women with alcohol dependence who have experienced abuse and multiple disadvantage often have very low self-esteem. A strengths-based approach can help to gradually build confidence and a belief in their capacity to change. Support from women peers who are further on in recovery can also show that change is possible.

Supporting women to gain education and employment skills

Education and employment are important aspects of recovery and services should support women to access education, training and employment if they want this. Financial independence provides increased opportunities for autonomy. If women are parents, employment support should be tailored around their childcare responsibilities.

Working with women during pregnancy and the year after birth

Alcohol treatment services should prioritise treatment for pregnant women, help them to access antenatal care and contribute to safeguarding the baby.

Services should provide information about the risks of drinking during pregnancy to any women who could become pregnant.

There is guidance on pregnancy and perinatal care in chapter 24.

Harm reduction information and advice for women

Since women experience health harms at lower levels of alcohol consumption than men, it is important that alcohol services provide them with information on health harms, including the increased risk of breast cancer.

Chapter 19 provides guidance on physical health harms and chapter 8 provides guidance on harm reduction.

25.8 Older people

25.8.1 Prevalence and harms

Alcohol use and associated harm is increasing more among people between 65 and 74 in England, Scotland and Wales, and between those aged 60 and 75 in Northern Ireland, than in any other age group (Wadd and others 2017).

The Adult Psychiatric Morbidity Survey 2014 shows that between 2007 and 2014, in England, overall levels of harmful and dependent drinking remained stable but trends varied between age groups. Harmful drinking became less common among 16 to 24 year-olds (6.2% in 2007, 4.2% in 2014), but more common in 55 to 64 year-olds (1.4% in 2007, 2.8% in 2014).

The ONS report Alcohol-specific deaths in the UK: registered in 2021 shows 58% of alcohol-specific deaths were of people over 55 years old. It also found 51% of alcohol-specific deaths were of people aged 55 to 75 years (premature deaths).

25.8.2 Considerations for services

Age sensitive treatment

The Royal College of Psychiatrists’ (RCPsych) report Our invisible addicts provides detailed guidance on working with older people with alcohol and drug problems. The report notes that the ageing process makes people more susceptible and at risk of the physical and mental health harms caused by alcohol.

They are also more likely to:

• have other mental health issues
• have other physical health issues
• be taking medication that can interact negatively with alcohol, by reducing or compounding its effects

This means it is very important to identify older people who are drinking harmfully or dependently and offer them age sensitive treatment.

Conditions associated with ageing

Older people are particularly likely to be vulnerable to alcohol related brain damage (RCPsych 2018).

Alcohol use in later life can exacerbate or accelerate the start of conditions that are associated with ageing, such as:

• cognitive impairment
• high blood pressure
• imbalance
• increased risk of falls and injuries, particularly when a person is also taking prescription or over the counter medication

Harmful and heavy alcohol use can lead to greater bone density loss for post-menopausal women and alcohol may worsen feelings of anxiety and depression that are related to hormonal fluctuations (Hannan and others 2000).

Alcohol use in older adults

Older adults who drink alcohol harmfully or dependently fall broadly into 2 categories:

1. People who have had alcohol problems for many years.
2. People who have developed alcohol problems as older adults.

People with a long history of problem alcohol use which persists into later life often have a number of comorbidities and health conditions associated with ageing. These people may have had previous unsuccessful experiences of treatment and be reluctant to try again.

For people who developed alcohol problems as older adults, this is usually associated with difficult life transitions such as retirement, bereavement or loss of sense of purpose (Holley-Moore and Beach 2015).

Psychosocial factors such as social isolation, financial problems, life events, pain and insomnia also have strong associations with alcohol misuse (RCPsych 2018).

Agism and age discrimination

A study of drinking in older people (Wadd and others 2017) found:

• examples of ageism and age discrimination in the alcohol sector
• several residential treatment services did not accept people over a certain age

In Great Britain, it is illegal to discriminate against a person based on their age. Referral criteria should not be based on age alone.

25.8.3 Reducing barriers to treatment

Including age in equality impact assessments

Commissioners and services should include actions to address inequalities based on age in their impact assessments. Older people with lived experience and organisations working with older people should contribute to the equality impact assessment and service design.

Making sure referral criteria are not based on age alone

Commissioners, community alcohol treatment services and residential rehabilitation services should all make sure that decisions about referring a person, and accepting a person for residential rehabilitation, are based on whether the person can benefit from the service, and whether the service can meet their treatment needs, not on age alone.

Raising awareness about alcohol use and older people among relevant organisations

Professionals in health and social care services often do not identify alcohol problems in older people. There is also evidence that healthcare professionals are more likely to refer older people with alcohol problems for clinical management, rather than alcohol treatment (Wadd and others 2017).

Alcohol treatment services should work with local organisations for older people, such as Age UK, and broader health and social care services to:

• raise awareness among staff of the increasing level of alcohol problems in older people and how to recognise signs of an alcohol problem
• encourage routine screening of older people in health and social care services using a validated tool such as the alcohol use disorders identification test (AUDIT)
• agree and review pathways between services

Barriers related to attitudes and awareness of older people

Older people may be less willing to approach services than younger adults because they are:

• particularly concerned about stigma and feel asking for help is shameful
• reluctant to try again after previous unsuccessful experiences of treatment
• unaware of treatment services

Approaches for promoting the service (see section 25.4.3) and flexible processes for engagement (see section 25.4.4) targeted to the needs of older people are important to attract and encourage them into treatment.

Adapting screening thresholds

Services that carry out alcohol screening should have a lower threshold for referring older adults into alcohol treatment because they are likely to experience harm at lower levels of consumption than other adults. Referral criteria for alcohol treatment services should take account of the fact that older people can need treatment at lower levels of consumption.

Staff training and support to challenge ageism

Service policies and training for staff should challenge beliefs about older people that can act as a barrier to them accessing treatment. For example, some professionals might believe that it is too late for older people to change, even though there is evidence that older people achieve better alcohol treatment outcomes than younger adults (Oslin and others 2002).

Disability adjustments

Older people who are frail or disabled may need adjustments so they can access services and receive appropriate support if they have sensory disabilities. If older people are unable to access the service site, services should provide home visits.

Avoiding busy waiting rooms

Busy waiting rooms in alcohol and drug treatment services where most people are younger can feel stressful for older people. Services should find ways of managing this. For example, they can offer appointments for older people at designated times or at alternative sites.

25.8.4 Tailoring treatment for older people

Referral

At referral, practitioners should ask if there are any disability adjustments the person needs so they can access and make use of the service, for example full disabled access or large print information. Services should invite carers and family members to the assessment, with the person’s consent.

Age sensitive assessments

Assessment of dependence

The RCPsych report Our invisible addicts advises that the standard criteria for assessing alcohol dependence were developed in younger people, so the assessor should bear this in mind. Where possible, a geriatrician and a specialist in old age psychiatry should contribute to the assessment as well as the alcohol treatment specialist.

Physical and mental health and cognitive function

Physical health and mental health assessment, and screening for alcohol related brain damage as part of a comprehensive assessment, are particularly important for older people. They are at higher risk of alcohol-related and other physical and mental health problems, including alcohol related brain damage.

There is guidance on comprehensive assessment in chapter 4 on assessment and treatment and recovery planning.

There is guidance on alcohol related brain damage including on adapting interventions in chapter 20.

Other needs to consider

Other areas that may be particularly important to consider when assessing and planning treatment and recovery for older people include:

• diet and nutrition
• safety in their home such as fire and trip hazards
• social networks and community support
• drink driving risks
• adult safeguarding concerns
• mental capacity if the person has cognitive impairment

More frequent re-assessment

It is particularly important to review assessments frequently and if there is a change in the person’s circumstances. This is because older people often have multiple health conditions and there can be quite rapid changes in physical health, mental health, cognitive function and day to day functioning. Support and care needs may change quite rapidly.

Multi-agency assessments and treatment and recovery planning

Older people often have several health and social care needs, so it is important to work with other professionals who are supporting the person, to co-ordinate care and to integrate or align care plans. It is often important to consult with specialists who work with older people. There is guidance on multi-agency treatment and recovery planning in chapter 4. It is also often helpful to involve family members or carers with the consent of the person.

Practitioners developing treatment and recovery plans with the person should identify any age-related motivating factors such as maintaining independence and improvements in memory, sleep and energy levels.

Psychosocial interventions and recovery support

When planning and providing psychosocial interventions, practitioners should consider issues that can affect older people including:

• difficult life transitions such as retirement
• bereavement
• loss of former capacities
• loss of sense of purpose or isolation

A focus on day-to-day functioning and on social support may be helpful. Practitioners should also work with older people to plan recovery-oriented activities that will promote long term resilience and recovery. For example, older people often have experience and skills they can offer as volunteers or peer supporters.

Length and frequency of sessions may need to be adapted to the older person’s individual needs.

Pharmacological interventions

When assessing for and providing pharmacological interventions, the clinician needs to consider age related adaptations. There is guidance in section 10.6.2 on prescribing for older people in chapter 10 on pharmacological interventions.

Older people often take (and may misuse) prescribed and over the counter medications where alcohol can interact negatively and cause adverse effects. So, the clinician should consider the impact of the person’s alcohol use, all their medications and any illicit substances on the pharmacological interventions they offer (RCPsych 2018).

Age specific support

Evidence suggests that older people can achieve good outcomes from standard treatment and that age specific treatment may produce even better outcomes (RCPsych 2018). Older people respond well to age specific groups and peer-based support, so services should offer these where possible.

25.9 People with learning disabilities

25.9.1 Definition of learning disability

Mencap defines learning disability as a “reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life”. They highlight that “people with a learning disability tend to take longer to learn and may need support to develop new skills, understand complicated information and interact with other people”.

25.9.2 Prevalence and harms

There is a lack of evidence on the prevalence of harmful drinking or alcohol dependence in people with learning disabilities. People with profound learning disabilities have limited opportunities to consume alcohol problematically. However, people with mild learning disabilities and living independently in the community may be vulnerable to problem use.

Some evidence suggests that prevalence of harmful drinking in people with learning disabilities may be lower than the general population. But this may be an underestimate because prevalence estimates are normally based on people with learning disabilities who are already in in specialist services (Robertson and others 2000, Reis and others 2017).

There is some evidence that larger proportions of adolescents with mild learning disability are abstinent, but young men who begin to drink are at an increased risk for intoxication and subsequent at-risk behaviours (Reis and others 2017).

There is no evidence available on alcohol-specific deaths among people with learning disabilities.

People with learning disabilities are at increased risk of several health conditions compared to the general population including:

• epilepsy
• gastro-oesophageal reflux disease
• some cancers
• accidents
• nutritional problems

Harmful alcohol use can make these conditions worse (Williams and others 2018).

People with learning disabilities have an increased risk of mental health conditions, which harmful alcohol use can also make worse.

25.9.3 Considerations for services

Health and health inequalities

People with learning disabilities have poorer health compared to the general population as well as poorer access to NHS services. People with learning disabilities have an increased risk of several physical and mental health conditions. But there is also evidence that they have high levels of unmet health need and a higher risk of avoidable medical causes of death (Michael 2008).

Possible reasons for vulnerability to alcohol use

Research found people with learning disabilities described the main reasons for using alcohol and other drugs was to self-medicate against life’s negative experiences (Taggart 2008). These negative experiences included:

• psychological trauma caused by bereavement or abuse
• social distance from their community
• isolation
• loneliness

Other studies have identified peer pressure and low self-esteem as risk factors for alcohol use (Reis and others 2017).

Identifying people with learning disabilities

People with mild learning disabilities have not always been diagnosed with learning disability and may be difficult to identify in alcohol services. For some people, their disability can co-exist with alcohol related brain damage. Screening for cognitive impairment as part of comprehensive assessment in alcohol treatment services can help services identify people with learning disabilities. There is guidance on screening for cognitive impairment in section 4.18.10.

Adult safeguarding

People with mild learning disabilities living in the community can be victims of exploitation and abuse, so services should consider adult safeguarding needs as part of assessment.

Support to access services

People with learning disabilities might find services hard to access without additional support. They may also not benefit from standard treatment. Alcohol treatment services and learning disability services need to work together to help people with learning disabilities to access alcohol treatment and tailor support to meet their needs.

25.9.3 Reducing barriers to access to services

Commissioning and service planning

People with learning disabilities and the organisations that work with them should be involved in equality impact processes as part of needs assessment for alcohol treatment services. Services should also involve people with learning disabilities and relevant support organisations in service planning, so that their needs can be met.

The National Development Team for Inclusion’s Green Light Toolkit helps mental health services to effectively support people with learning disabilities and is relevant for alcohol treatment services. This has been designed for services in England, but the content could be relevant for other UK nations too.

Staff training and support

All staff in alcohol treatment services should be trained to be sensitive to, and aware of, the specific needs of people with learning disabilities. They should also be trained to know about human rights and disability discrimination law. Services should provide staff with clinical support and supervision to help them work effectively with people with learning disabilities.

Services should consider creating roles for staff who are specifically trained and supervised to enable them to work with people with learning disabilities.

Working with learning disability services

Alcohol and learning disability services should work together to develop and maintain pathways between services. They should also raise awareness of alcohol problems and alcohol services with local groups for people with learning disabilities. Learning disability services, family members, carers and advocates can all play an important role in identifying alcohol problems among people with learning disabilities and should be an important part of the referral into alcohol services.

Easy read information

Services should promote themselves in ways that are accessible and meaningful to people with learning disabilities, such as providing information in easy read formats. There are some examples of easy read booklets on alcohol use in the resources section.

Involving family and carers

It may be difficult for some people with learning disabilities to access services alone.

Many people with formally identified learning disabilities are supported by family or professional carers to a greater or lesser extent. Services should encourage the family or carers to help the person access and remain engaged with services.

Learning disability champions

Alcohol services should consider having learning disability champions who can:

• work with local learning disability services
• share expertise with alcohol service staff
• co-ordinate adaptations, such as providing easy read or video versions of psychoeducational interventions
• arrange training on alcohol for learning disability staff, and training on learning disability for alcohol treatment service staff

25.9.4 Tailoring treatment for people with learning disabilities

Involving family or professional carers in treatment

People with learning disabilities may depend on family or professional carers to access treatment. They might also benefit from family and carers being involved in their treatment, for example supporting them between sessions to remember and work towards their agreed alcohol use goals, or goals in other areas of their life.

Highlighting reasonable adjustments at referral

Services should ask a person about any disabilities they have at referral stage. And if the person has a learning disability or literacy difficulties, they should put a note on the referral record. This will help the assessor to make any reasonable adjustments before the assessment and from that point on.

Screening for cognitive impairment

Screening for cognitive impairment should be a routine part of comprehensive assessment for alcohol treatment. But screening is particularly important if the assessor thinks the person has a learning disability or the person tells the assessor that they have one.

If screening shows there may be cognitive impairment, the assessor should refer the person for a more specialist neuropsychological cognitive assessment or occupational therapy-led functional assessment and support them to access this.

Health assessment

A health assessment should be a part of comprehensive assessment for all people in alcohol treatment. People with learning disabilities have an increased risk of several physical health and mental health conditions.

The National Institute for Health and Care Excellence (NICE) quality standard Learning disability: behaviour that challenges (QS101) recommends that GPs should provide an annual learning disability health check. Clinicians in alcohol treatment services can help people to access this health check if they are not supported by specialist services to do so. This is important because there is evidence of high unmet health needs and avoidable deaths in people with learning disabilities (Michael 2008).

People with literacy and numeracy difficulties

Many people in the general population will have literacy or numeracy difficulties and many of the adjustments for people with learning disabilities are relevant for those people as well.

Personalised treatment and recovery plan that includes strengths

The practitioner should work with the person (and their family or carer where appropriate) to develop a personalised treatment and recovery plan that the person can understand. The plan should recognise strengths as well as needs. Longer term recovery goals are important and people with learning disabilities should be supported to access volunteering or employment if they want this. In some areas there are specialist employment projects for people with learning disabilities.

Individual sessions

People with learning disabilities may not benefit from group work, so services should make sure that they have the option of one to one work with keyworkers.

Understanding challenging behaviour

People with learning disabilities may not be able to express their feelings easily in words and this can make it difficult to accurately assess their alcohol problem. This can also lead to them exhibiting challenging behaviour. A person’s apparent lack of co-operation may be due to a lack of understanding, rather than a lack of motivation to engage in treatment. Services should be flexible in how they recognise and respond to these needs.

Adjusting length and number of sessions

People with learning difficulties are likely to find face to face appointments easier than online appointments.

Services should consider adjusting the length and number of sessions to take account of varying levels of understanding and need. Practitioners might need extra time to do assessments and plan interventions, but it may be more useful to carry out assessments and treatment planning over several shorter but more frequent sessions than they normally would.

When providing psychoeducational interventions, practitioners will often need to repeat information and exercises, particularly when there is more than a week between sessions. They will also often need to recap the coping skills the person has been practising.

Focus on behaviour

Practitioners should consider focusing less on cognitive elements and more on behavioural elements of psychosocial interventions.

Breaking down questions

Practitioners should break down questions with multiple components and ask each element one at a time.

Accessible resources

Practitioners should use accessible resources that the person can take away with them, which can include:

• easy read formats
• audio and video recordings

They can use visual prompts and pictures to help explain important concepts. They can also adapt mapping techniques. You can read more about mapping techniques in Routes to recovery from substance addiction.

The person with learning disabilities can also use audio or video as an alternative to a written drink diary or to record thoughts and feelings instead of writing them down.

Mental capacity

People with learning disabilities should be able to make decisions about their own lives. When working with people with learning disabilities, practitioners may need to determine whether the person has mental capacity to make certain decisions.

There should be clinical support for practitioners to make decisions about mental capacity. There is information on mental capacity legislation and statutory guidance in annex 1.

All staff should be trained so they understand the main points of mental capacity legislation. This includes understanding that people should not be treated as if they are unable to make a decision simply because they make what could be considered an unwise decision.

Safeguarding

People with mild to moderate learning disabilities are vulnerable to exploitation. For example, they can:

• be financially abused
• be coerced into sex work
• be working in the drug trade
• have their homes taken over for selling drugs
• experience harassment

Some people with learning disabilities and mental health conditions can be at risk because of extreme self-neglect. Practitioners should be aware of this when conducting risk assessments and they must follow national legislation and organisational guidelines on adult safeguarding. There is information on adult safeguarding legislation and guidance in annex 1.

Consultation or clinical supervision

Alcohol service staff should have working agreements with services for people with learning disabilities. They should consult specialist staff for advice on making appropriate adjustments, and where possible access clinical supervision, for work with people with learning disabilities. In turn, staff from alcohol treatment services should offer consultation, and where possible clinical supervision, to services for people with learning disabilities working with people with alcohol problems.

25.10 Inclusion health

25.10.1 Inclusion health groups

Inclusion health is a term used to describe people who:

• are socially excluded
• experience multiple intersecting risk factors for poor health (such as poverty, violence and complex trauma)
• experience stigma and discrimination
• are often not accounted for in healthcare records

These experiences often lead to barriers which prevent people accessing healthcare and lead to extremely poor health outcomes.

A systematic review of ill health and deaths in several inclusion health groups found very high levels of physical and mental ill health and much lower average age of deaths compared to the general population (Aldridge and others 2018).

Inclusion health includes any population group who is socially excluded. People with alcohol and drug problems can be considered an inclusion health group. Within the broader group of people with alcohol problems, some people experience particularly high levels of social exclusion, access to healthcare and poor health outcomes. This includes but is not limited to:

• people who experience homelessness
• vulnerable migrants
• Gypsy, Roma and Traveller groups
• sex workers
• people in contact with the criminal justice system
• victims of modern slavery

25.10.2 Reducing barriers to services for inclusion health groups

The barriers to accessing services that inclusion health groups experience will vary. But there are many barriers, related to the individual and to the services.

People may:

• have difficulty understanding and navigating the healthcare system
• have had past experiences of being turned away from services or being badly treated
• not speak the language or be able to read or write
• be afraid of punitive action after accessing services

At the same time, services may find the complex nature of the person’s problems challenging and might not have policies and competencies to respond to them.

Alcohol treatment services have expertise in working with socially excluded people and can extend this expertise so they can include all inclusion health groups.

Services and practitioners should follow the guidance Inclusion health: applying All Our Health. It provides comprehensive information to help frontline health and care staff, managers and strategic leaders to improve access and health outcomes for inclusion health groups. It includes resources for working with several inclusion health groups.

There is also guidance relevant to inclusion health groups in:

• chapter 9 on alcohol assertive outreach and a multi-agency team around the person
• chapter 17 on criminal justice settings
• chapter 21 on people experiencing homelessness

There are guides in the resource section on reducing health inequalities that are relevant to alcohol treatment services.

25.10.3 Vulnerable migrants

Vulnerable migrants living in the UK

Groups of vulnerable migrants living in the UK include:

• asylum seekers and refugees
• unaccompanied children
• people who have been trafficked
• undocumented migrants (people who are living in the UK with no legal status)
• low paid migrant workers

The OHID migrant health guide provides comprehensive guidance on working with vulnerable migrant groups.

Vulnerable migrants experience barriers to accessing services, related to their life circumstances and their immigration status.

Treatment needs of vulnerable migrants

Most migrants to the UK come to work or study and are young and healthy. However, there are some groups of migrants who may have increased health needs associated with their experiences before, during and after migration.

The migrant health guide says that practitioners should be “alert to whether a migrant is subject to vulnerability and be particularly vigilant for potential physical and mental health problems in those who are vulnerable”.

You can find advice and guidance on the mental health needs of vulnerable migrants on the mental health page of the migrant health guide.

Entitlement to care

It is essential that alcohol treatment service providers and practitioners are aware of vulnerable migrants’ entitlements to NHS care so they can access the care they need. There is different guidance for each UK country, which you can find at:

• NHS entitlements: migrant health guide (England)
• Healthcare for overseas visitors: immigration health surcharge (Scotland)
• Overseas visitors and the NHS (Wales)
• Entitlement to NHS services and first time registration (Northern Ireland)

Practitioners may need to advocate for people to access primary care.

Alcohol treatment services and practitioners in England should be aware of the Department of Health and Social Care guidance Overseas NHS visitors: implementing the charging regulations (page 34). This explains that community drug and alcohol treatment services (which it calls “first point of contact services”) are free to overseas visitors, regardless of immigration status, if the providers consider that the services they provide are equivalent services to primary medical services.

Supporting vulnerable migrants to access services

To help vulnerable migrants access treatment, services will likely need access to independent interpreters. Treatment staff also need training to work with the interpreters. Services should follow guidance on interpretation and translation when working with vulnerable migrants.

Vulnerable migrants will be unfamiliar with UK healthcare systems and unaware of alcohol treatment services. Services need to work with local support organisations to promote the service and arrange access where appropriate.

25.10.4 Gypsy, Roma and Traveller groups

Data on alcohol use

Specific data on alcohol use among people from Gypsy, Roma and Traveller (GRT) backgrounds in the UK is not currently available. It is also not currently possible to measure alcohol-related ill health in the GRT population because the ethnicity classifications for GRT groups are not included in hospital statistics data.

There is health data available that shows high levels of health inequality in GRT groups in the UK.

Life expectancy

The House of Commons Women and Equalities Committee report Tackling inequalities faced by Gypsy, Roma and Traveller communities found that people in GRT communities have life expectancies of between 10 and 12 years shorter than the general population.

Mental health

Friends, Families and Travellers’ Focus report on Gypsy, Roma and Traveller communities found they are nearly 3 times more likely to be anxious than others, and just over twice as likely to be depressed.

The Traveller Movement’s Policy briefing addressing mental health and suicide among Gypsy, Roma and Traveller communities in England reports that in Ireland, the Irish Traveller suicide rate is 6 to 7 times higher than the general population and that anecdotal evidence shows disproportionately high rates of suicide in GRT communities in England.

Reducing barriers to treatment

The ONS report Gypsies and Travellers in England and Wales: lived experiences found evidence of difficulty accessing healthcare as outlined in the sections below.

Registering with a GP

Gypsies and Travellers in England and Wales described challenges in registering with a GP surgery without a fixed address, particularly among people living in Gypsy and Traveller sites or on the roadside. This can result in delays in diagnosis and treatment.

It is essential that alcohol treatment service providers and practitioners are aware that people can access primary care without a fixed address or proof of immigration status. Practitioners may need to advocate for GRT people to access primary care. You can find more about this in chapter 15 on primary care and community health services and in the resources section below.

Lack of trust in services based on experiences of discrimination in healthcare

The ONS study found that anticipation and experiences of discrimination and derogatory attitudes of healthcare staff led to concerns among participants about the likelihood of receiving help and fears of facing negative judgement or discrimination.

If there are Gypsy, Roma or Traveller communities in a local area, the alcohol treatment commissioners and services should work with local organisations representing those communities to identify any need for alcohol treatment and design a plan with them to reach out to those communities. If there are no local organisations, services can consult national organisations representing GRT groups (see resources section below).

Low levels of literacy and lack of information

The ONS study found that low levels of literacy in GRT communities and lack of information about services also create barriers to accessing healthcare.

Stigma about alcohol problems

Work with Irish travellers in Ireland also found that problems with alcohol and drug use are stigmatised in the community so confidentiality and anonymity are very important (Carew and others 2013).

Since there is shame and stigma about alcohol problems, it might be helpful for the alcohol treatment service to work with any generic healthcare services who are reaching out to the GRT community. They can then provide information on alcohol harms and on alcohol treatment services as part of a broader approach to health. Information should be tailored to people with low literacy levels.

It could be helpful to have a dedicated practitioner who is allocated time to build up a relationship with members of the GRT community. All staff need to be culturally competent and to have knowledge about the culture of GRT communities and the discrimination and health inequalities they face.

25.11 Resources

Working with people and communities

PHE guidance Health and wellbeing: a guide to community-centred approaches outlines evidence based community-centred approaches to health and wellbeing, including community engagement service planning and co-production projects.

NHS England’s Working in partnership with people and communities: statutory guidance supports effective partnership working between people and communities to improve services.

PHE’s Health equity assessment tool provides resources and e-learning to support systematic action on health inequalities and equalities.

Ethnic minority groups

The Sikh Recovery Network and Turning Point has produced a number of videos of their Under the Influence Recovery Podcast You can find them by searching YouTube for ‘under the influence recovery podcast’. The podcast involves culturally sensitive conversations about recovery.

Culture, connection and belonging: a study of addiction and recovery in Nottingham’s BAME community reports on qualitative findings from research exploring the experiences of people from ethnic minority backgrounds who face severe and multiple disadvantage. The study also examines BAC-IN, a peer-led, culturally sensitive drug and alcohol recovery support service, and compares it with other services.

Supporting Punjabi people with alcohol problems (PDF, 1.05MB) provides guidance on best practice in how to work productively with local communities when providing alcohol services within South Asian communities in general and with the Punjabi Sikh community in particular.

Minority Communities Addiction Support Services is a Scottish charity that helps and supports people and their families affected by addiction issues in minority communities. They provide services in Glasgow and the surrounding areas.

Women

The Mapping the maze website provides a model and resources for working with women experiencing multiple disadvantage. The model focuses on how services respond to the needs of women while highlighting the gaps in provision.

People with learning disabilities

Substance misuse in people with learning disabilities: reasonable adjustments guidance summarises the resources that can be used by health professionals, social care staff and families to support people with learning disabilities and substance misuse problems.

Easy health provides easy-read information on alcohol. Registration is free.

Inclusion health groups

The Inclusion health audit tool is an online tool designed to help organisations in the voluntary, community and social enterprise sector audit their engagement with inclusion health groups to help address health inequalities.

GP access cards for England, Scotland, and Wales provide information about the right to access a GP that people can show to GP surgeries.

Friends, Families and Travellers developed a guide for tackling health inequalities in Gypsy, Roma and Traveller communities (PDF, 28.3MB), which is based on the experiences and knowledge of staff, volunteers and people from Gypsy, Roma and Traveller communities.

Improving Roma health: a guide for health and care professionals supports health and care professionals to improve services by better understanding the health outcomes that some people in the Roma community face.

25.12 References

Aldridge RW, Story A, Hwang SW, Nordentoft M, Luchenski SA, Hartwell G, Tweed EJ, Lewer D, Vittal Katikireddi S and Hayward AC. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet 2018: volume 391, issue 10117, pages 241-250

Bahla N, Caezard G, Ward HJT, Bansai N and Bhopal R on behalf of the Scottish Health and Ethnicity Linkage Study (SHELS) Collaboration. Ethnic variations in liver and alcohol related disease hospitalisations and mortality: the Scottish health and ethnicity linkage study. Alcohol and Alcoholism 2016: volume 51, issue 5, pages 593-601

Bayley M and Hurcombe R. Drinking patterns and alcohol service provision for different ethnic groups in the UK: a review of the literature. Ethnicity and Inequalities in Health and Social Care 2011: volume 3, issue 4, pages 6-17

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

Carew AM, Cafferty S, Long J, Bellerose D and Lyons S. Travellers accessing addiction services in Ireland (2007 to 2010): analysis of routine surveillance data. Journal of Ethnicity in Substance Abuse 2013: volume 12, issue 4, pages 339-355

Covington SS and Bloom BE. Gender-responsive treatment and services in correctional settings. Women and Therapy 2007: volume 29, issue 3-4, pages 9-33

Royal College of Psychiatrists. Our invisible addicts (2nd edition), College Report CR211. RCPsych 2018

Douds AC, Cox MA, Iqbal TH and Cooper BT. Ethnic differences in cirrhosis of the liver in a British city: alcoholic cirrhosis in South Asian men. Alcohol and Alcoholism 2003: volume 38, issue 2, pages 148-150

Drummond C, Oyefeso A, Phillips T, Cheeta S, Deluca P, Perryman K, Winfield H, Jenner J, Cobain K, Galea S, Saunders V, Fuller T, Pappalardo D, Baker O and Christoupoulos A. Alcohol needs assessment research project (ANARP). Department of Health 2004

Galvani S, Manders G, Wadd S and Chaudhry S. Developing a community alcohol support package: an exploratory study with a Punjabi Sikh community (PDF, 2.5MB). University of Bedfordshire and the Tilda Goldberg Centre for Social Work and Social Care 2013

Gleeson H, Thom B, Bayley M and McQuarrie T. Rapid evidence review: drinking problems and interventions in black and minority ethnic communities. Alcohol Change UK 2019

Glynn TR and van den Berg JJ. A systematic review of interventions to reduce problematic substance use among transgender individuals: a call to action. Transgender Health 2017: volume 2, issue 1, pages 45-59

Hannan MT, Felson DT, Dawson-Hughes B, Tucker KL, Cupples LA, Wilson PWF and Kiel DP. Risk factors for longitudinal bone loss in elderly men and women: the Framingham osteoporosis study. Journal of Bone and Mineral Research 2000: volume 15, issue 4, pages 710-720

Herring R, Gleeson H and Bayley M. Exploring pathways through and beyond alcohol treatment among Polish women and men in a London Borough. Alcohol Change UK 2019

Holley-Moore G and Beach B. Drink Wise, Age Well: alcohol use and the over 50s in the UK (PDF, 1.7MB). Drink Wise, Age Well 2015

Hurcombe R, Bayley M and Goodman A. Ethnicity and alcohol: a review of the UK literature. Joseph Rowntree Foundation 2010

Kaplan M, McFarland B, Huguet N, Conner K, Caetano R, Giesbrecht N and Nolte K. Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System. Injury Prevention 2013: volume 19, issue 1, pages 38-43

King M, Semlyen J, See Tai S, Killaspy H, Osborn D, Popelyuk D and Nazareth I. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008: volume 8, article number 70

Meads C, Zeeman L, Sherriff N and Aranda K. Prevalence of alcohol use amongst sexual and gender minority (LGBTQ+) communities in the UK: a systematic scoping review. Alcohol and Alcoholism 2023: agad029

Michael J and the independent inquiry into access to healthcare for people with learning disabilities. Healthcare for all: report of the independent inquiry into access to healthcare for people with learning disabilities. Department of Health, 2008

Oslin DW, Pettinati H and Volpicelli JR. Alcoholism treatment adherence: older age predicts better adherence and drinking outcomes. The American Journal of Geriatric Psychiatry 2002: volume 10, issue 6, pages 740-747

Peralta RL and Jauk D. A brief feminist review and critique of the sociology of alcohol‐use and substance‐abuse treatment approaches. Sociology Compass 2011: volume 5, issue 10, pages 882-897

Pryce R, Buykx P, Gray L, Stone A, Drummond C and Brennan A. Estimates of alcohol dependence in England based on APMS 2014, including estimates of children living in a household with an adult with alcohol dependence: prevalence, trends, and amenability to treatment. University of Sheffield 2017

Rehm J, Allamani A, Elekes Z, Jakubczyk A, Manthey J, Probst C, Struzzo P, Della Vedova R, Gual A and Wojnar M. Alcohol dependence and treatment utilization in Europe – a representative cross-sectional study in primary care. BMC Family Practice 2015: volume 16, article number 90

Reis O, Wetzel B and Häßler F. Mild or borderline intellectual disability as a risk for alcohol consumption in adolescents – a matched-pair study. Research in Developmental Disabilities 2017: volume 63, pages 132-141

Robertson J, Emerson E, Gregory N, Hatton C, Turner S, Kessissoglou S and Hallam A. Lifestyle related risk factors for poor health in residential settings for people with intellectual disabilities. Research in Developmental Disabilities 2000: volume 21, issue 6, pages 469-486

Schober R and Annis HM. Barriers to help-seeking for change in drinking: a gender-focused review of the literature. Addictive Behaviors 1996: volume 21, issue 1, pages 81-92

Taggart L. An exploration of psychosocial risk factors of hazardous alcohol use in people with learning disabilities (PDF, 244KB). School of Nursing, University of Ulster, Northern Ireland 2008

Thom B. Sex differences in help‐seeking for alcohol problems—2. Entry into treatment. British Journal of Addiction 1987: volume 82, issue 9, pages 989-997

Wadd S, Holley-Moore G, Riaz A and Jones R. Calling time: addressing ageism and age discrimination in alcohol policy, practice and research (PDF, 1.78MB). Drink Wise, Age Well 2017

Weaver T, Madden P, Charles V, Stimson G, Renton A, Tyrer P, Barnes T, Bench C, Middleton H, Wright N, Paterson S, Shanahan W, Seivewright N and Ford C. Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. The British Journal of Psychiatry 2003: volume 183, issue 4, pages 304-313

Williams F, Kouimtsidis C and Baldacchino A. Alcohol use disorders in people with intellectual disability. British Journal of Psychiatry Advances 2018: volume 24, issue 4, pages 264-272

26. Parents in alcohol treatment services

26.1 Main points

Adult alcohol treatment services and practitioners should help parents and their children to access support, and if required, protection.

Adult alcohol treatment services and practitioners have a statutory responsibility to safeguard and promote the welfare of the children.

Services should have arrangements in place to safeguard children, including policies and procedures and a designated safeguarding practitioner or safeguarding lead.

Services are responsible for making sure their staff have training at the right level for their role, supervision and appropriate competencies to carry out their safeguarding responsibilities.

Services and practitioners should work to reduce organisational and personal barriers for parents to engage in treatment.

Assessment should identify and must act on or escalate any child safeguarding concerns. Assessment and review should be ongoing. Practitioners should reassess risk to children as the circumstances of the person and the family change.

Helping a parent and their children to access early help (support for vulnerable children and families) is more effective than reacting later.

Any parent may want to consider goals around their parenting or family life as part of their treatment and recovery plan.

Alcohol treatment practitioners should contribute to multi-agency assessments, plans and reviews for children in need and child protection and early help.

The statutory guidance Working together to safeguard children (England) and equivalent national guidance stress that appropriate and timely information sharing between services is essential to safeguard children and promote their welfare. Alcohol treatment services should have information sharing policies that specify information sharing processes, as well as having information sharing agreements with children’s social care and other agencies.

Adult alcohol treatment commissioners and services should work in partnership with local organisations with statutory responsibility for child safeguarding at a strategic level to agree joint working arrangements. This includes referral pathways and information sharing agreements.

26.2 Introduction

This chapter provides guidance on how adult alcohol treatment services and practitioners can support parents or carers and help their children to access support, and if required, protection. Direct work with children is outside the scope of these guidelines.

Throughout the chapter we will use the term ‘parents’ to include anyone caring for a child.

You can find guidance on pregnancy and the perinatal period in chapter 24 and guidance on supporting adult family members in section 4.7 in chapter 4 on assessment and treatment and recovery planning.

Services and practitioners must work within national legislation and guidance on child safeguarding. Annex 1 summarises this legislation and guidance for each UK nation.

26.3 Impact of parental alcohol use on children

Not all children of parents or carers with an alcohol problem will experience harm, but they are at a greater risk of doing so. Parental alcohol misuse is a common factor in cases of child abuse, neglect and deaths. An analysis of serious case reviews between 2014 and 2017 (PDF, 2.54MB) found that parental alcohol use was recorded as present in over a third of the cases. Problematic parental alcohol use is frequently associated with other problems, such as parental mental health conditions or domestic abuse (Cleaver and others 2011, Brandon and others 2020). And children often face other adverse experiences and associated negative behavioural, health and social outcomes in adulthood (Hughes and others 2017).

The quality of care received by children is an important determinant of their future development and wellbeing (Pajulo and others 2006). Harmful drinking and alcohol dependence can reduce parenting capacity, sensitivity and attachment (Canfield and others 2017). Parents or carers who have alcohol problems have often experienced childhood trauma, maltreatment, and adversity themselves and this can also affect their parenting capacity and ability to form attachments with their children (Stith and others 2009).

26.4 A child-centred approach to safeguarding

Although most adult alcohol treatment services will not have direct contact with the children of adults in treatment, they have statutory responsibilities to safeguard and promote the welfare of children. A core principle of the Children Acts 1989 and 2004 and the Human Rights Act 1998 is that the welfare of the child is paramount. This means that services and practitioners have a statutory and professional duty to put the welfare of children before their responsibility to their adult patients (or service users) if there is any conflict of interest.

26.4.1 Organisational safeguarding arrangements

All alcohol treatment services should have comprehensive child safeguarding policies and procedures. Child safeguarding policies and procedures should include:

• an outline of relevant legislation and statutory guidance
• accountability and governance arrangements
• provision of training
• procedures for acting on and escalating safeguarding concerns
• procedures for learning from incidents and near misses
• safer recruiting processes
• responding to allegations of child abuse against staff members

Section 11 of the Children Act 2004 places a duty on services and individuals to make arrangements to safeguard children and promote child welfare. There is equivalent legislation across all UK nations. Alcohol treatment commissioners and services should be aware of the arrangements they should have in place. You can find information on child safeguarding legislation in annex 1.

26.4.2 Training, supervision and support

Service providers are responsible for ensuring their staff are competent to carry out their safeguarding and promoting the child welfare responsibilities. They should also create an environment where staff feel they can raise concerns and are supported in their safeguarding role. They should provide staff with:

• access to appropriate training and supervision in child safeguarding
• an induction to familiarise them with child protection responsibilities and the procedures they must follow

26.4.3 Safeguarding leads or designated practitioners

Organisations and agencies specialising in providing alcohol treatment should have a senior board level member with appropriate competencies to act as lead responsible for organisational safeguarding arrangements.

The statutory guidance Working together to safeguard children (England) and equivalent national guidance makes it clear that there should be a designated practitioner for child safeguarding in the organisation who can support other colleagues to recognise the needs of children, including protecting them from possible abuse or neglect. It also says the role of safeguarding leads should always be clearly defined in job descriptions and to fulfil their responsibilities effectively, organisations should give them enough:

• time
• funding
• supervision
• support

26.5 How adult alcohol treatment services can support children affected by parental alcohol use

Practitioners must refer children to children’s social care where they have concerns about a child’s welfare or safety, but their role in supporting parents and children should be wider than that.

Public Health England (PHE) guidance Parents with alcohol and drug problems: support resources says that if parents stop or reduce their alcohol use, this is likely to benefit their children. However, this is often not enough on its own to meet the needs of vulnerable children affected by parental alcohol use and other problems.

Adult alcohol treatment services can play an important role in improving outcomes for children by helping parents and children to access support. This could include:

• making a safeguarding (child protection) referral
• working with children’s social care, contributing to child in need and child protection assessments and plans
• helping parents and their children to access early help from targeted (for vulnerable families) and universal services (open to all)
• supporting parents to achieve their parenting goals as part of treatment and recovery planning
• helping parents to access practical support that impacts on the family, for example housing support, welfare rights support and employment support

For practitioners helping parents and their children to access early help services, this could include:

• parenting programmes or support from parenting professionals
• direct support or therapeutic interventions for their children or family
• universal services (open to all) such as children’s centres and youth projects

26.6 Addressing barriers to engaging in treatment

Parents and carers can face significant barriers that prevent them from accessing or engaging in alcohol treatment. All services should consider ways to help remove these barriers. They could:

• offer appointment times that take account of a person’s childcare responsibilities
• make arrangements with regulated childcare providers so children can be looked after while a parent attends treatment appointments
• offer accessible alcohol treatment and support outside of the usual setting (for example, home visits or at targeted early help services)
• make sure that practitioners understand about stigma (and the resulting fear and shame that parents may experience) and respond empathically
• address parents’ fears of involvement from children’s social care by providing information on the circumstances in which a practitioner would make a safeguarding referral and the role of social workers
• offer support through partnerships with children’s services or family nurse partnerships for young parents (for example, an alcohol treatment practitioner co-located in a children and families service on a regular basis, or participating in joint visits to a family)
• offer the option of a women only space to provide emotional safety for women
• make arrangements so that women do not have to attend a service attended by an abusive partner or ex-partner
• encourage peer support from parents who are further on in recovery, including those who have experienced intervention from children’s social care, which is no longer necessary
• involve parents (and where appropriate children and young people) in planning and developing services

26.7 Identifying the needs of parents, children and families

Chapter 4 on assessment and treatment and recovery planning provides guidance on comprehensive assessment. Comprehensive assessment in alcohol treatment services should always include assessment of the need for parenting support and the needs of their children.

26.7.1 Introducing the conversation about children

Parents are often worried that children’s social care services will become involved with their family or that their children will be taken into care. Assessors should not avoid asking questions because of this, but they need to approach the conversation about children sensitively and thoughtfully. It may be helpful to explain that as part of their safeguarding responsibility as a service, they routinely ask questions to all parents or people living with children.

26.7.2 Recording details at initial assessment

At initial assessment, the assessor should record details of the person’s children and those they are in contact with and identify any child safeguarding risks. Section 4.17 in chapter 4 on assessment and treatment and recovery planning sets out what details an assessor should record at initial assessment.

26.7.3 Identifying potential safeguarding (child protection) risks

As part of comprehensive assessment, the assessor should identify any concerns about the welfare of the child and whether there is reasonable cause to suspect a child is suffering or likely to suffer significant harm (see definition of significant harm in the glossary). This includes considering both risk and resilience factors.

Identifying the impact of the parent’s alcohol use on the safety and wellbeing of children

When assessing whether a child may be at risk, assessors should consider the effect of alcohol use on parental functioning. This includes:

• how much the parent (or parents) is drinking and the pattern of their drinking
• hangovers or withdrawal symptoms or complications
• any additional drug use
• whether both parents or other adults in the household have alcohol or drug problems

Assessors should consider the effect of the parent’s alcohol use on their capacity to:

• supervise and adequately protect children and young people from danger
• attend to children’s basic needs for food, clothing, housing, health appointments and any medical needs
• protect children and young people from contact with potentially inappropriate adults (who may also be intoxicated)
• notice signs that children and young people are being drawn into anti-social or criminal behaviour, including involvement with gangs or organised crime groups, being sexually exploited, abused on-line or drawn into radicalisation
• maintain family routines, for example getting children to school on time
• maintain age-appropriate boundaries for children and young people
• manage the family’s essential income, such as whether their income is being spent on alcohol
• show emotional availability for their children and their ability to show emotional warmth
• show emotional stability, such as whether their children are subjected to unpredictable mood swings if the parent drinks episodically or experiences withdrawal symptoms
• any other potential impacts on parenting and family life likely to result from individual circumstances

The assessor should also consider whether a child is a young carer. This means they have caring roles, either for the parent or for other family members, which would normally be carried out by an adult.

Identifying other risk factors

Alcohol problems often occur alongside other problems which may cause harm to the child.

Examples of other problems that may cause harm to a child include:

• the impact of the parent’s mental health or physical health on parenting
• any risks from the other parent or adult members of the household
• the impact of any parental conflict on parenting, the family environment, and children’s wellbeing
• domestic abuse (the Domestic Abuse Act 2021 (England) states the presence of domestic abuse in the family is grounds for safeguarding the child)
• possible physical or sexual abuse
• any concerns about a child or young person’s development or wellbeing
• other people supporting the child, for example family members and their fitness to provide that support
• frequent changes in partners living in the household

The assessor should also ask about potential resilience factors. This can include:

• effective strategies the parent has for mitigating the impact of their alcohol use on their child (for example, limiting heavy alcohol use to times when children are cared for elsewhere)
• qualities or coping skills the child has
• strengths in parenting and family life, such as stable routines and emotional warmth towards children
• family members or close friends who can provide appropriate care
• other support the parent may have (for example, from their local community)
• any professional support for the parent or the child that is already in place
• support networks or activities that the child or young person is involved in
• a supportive adult that the child can talk to (for example, a teacher)

26.8 Acting on concerns about the welfare of a child

26.8.1 Making a child safeguarding referral to children’s social care

If the practitioner has concerns about a child’s welfare, they should make a referral to local authority children’s social care. They should do this immediately if there is a concern that the child is suffering significant harm or is likely to do so. The practitioner should follow organisational procedure and consult with the relevant person in their organisation. Practitioners who make a referral should always follow up their concerns if they are not satisfied with the response. The service provider should have policies to escalate concerns within the organisation and with other agencies if safeguarding concerns are not addressed.

Services should make sure that all staff know how to:

• identify risk factors
• make a safeguarding referral and are familiar with the referral processes in their local area

26.8.2 Informing the parent

The assessor should inform the parent that they will be making a referral to children’s social care. They should do this unless they think informing the parent would put a child at further risk or impede a police investigation. It is important that the practitioner uses an empathic approach while being clear about their concerns for the child and the reasons for the referral. They should allow space for the parent to respond to this information.

It is preferable if the parent gives consent to make the referral, but their consent is not necessary if a child is experiencing or at risk of experiencing significant harm.

This is likely to be an anxious time for parents and they may not know what to expect. Practitioners should explain what will happen after the referral and offer support the as they go through the process of referral and any assessment. Practitioners should make every attempt to keep in contact with the parent, offering another appointment and following up with a friendly text or call if the parent or carer does not attend.

26.9 Young carers

Where a child or young person is identified as a young carer, they should have access to a formal young carer’s assessment if they have support needs or they or their parent request one. Community alcohol treatment services should know how to refer young people for formal young carer’s assessments and encourage the parent to discuss this with the child. You can find more information on carers (including young carers) in annex 1 on relevant legislation and guidance.

26.10 Early help

Practitioners should still consider children’s potential support needs even if they find no risks that meet the threshold for a safeguarding (child protection) referral.

Statutory guidance Working together to safeguard children (England) emphasises the importance of early help for vulnerable children and families:

“Providing early help is more effective in promoting the welfare of children than reacting later. Early help means providing support as soon as a problem emerges, at any point in a child’s life, from the foundation years through to the teenage years. Early help can also prevent further problems arising; for example, if it is provided as part of a support plan where a child has returned home to their family from care, or in families where there are emerging parental mental health issues or drug and alcohol misuse.”

Based on individual needs, children and young people can benefit from direct support, for example psychotherapeutic support or involvement with activity-based support services.

Support from parenting professionals or programmes can help parents gain parenting skills and this can also support their alcohol use goals. A review of the effectiveness of psychosocial treatment found that interventions that incorporated parenting skills into the treatment programme had the most effect on reducing parental alcohol (or drug) use (McGovern and others 2021).

If a child has been diagnosed with, or suspected of having, fetal alcohol spectrum disorder (FASD), they should receive specialist assessment and support through the local FASD diagnostic and support pathways. Typically, these pathways are for children with neurodevelopmental disorders. If specialist pathways are unavailable locally, you can refer children to the national (UK) clinic for FASD.

In some areas, there are specialist services for children and families affected by problem parental alcohol (and drug) use.

Services should make sure their staff:

• are aware of locally determined thresholds for levels of need in children and families
• know how to refer children and families to appropriate services
• know how to contribute to early help assessments

Where the threshold for a safeguarding referral outlined in statutory guidance is not met, the parent’s consent is required for a referral to children’s social care or another agency for early intervention and support.

26.11 Ongoing assessment

Assessing for child safeguarding risks or support needs for children and young people is not a one-off event. Assessment should be an ongoing process. Risks may escalate or decrease as the parent’s or the family’s circumstances change. The alcohol treatment practitioner working with the parent, supported by the multidisciplinary team, should regularly review their assessment and monitor risks. They should share information on any potential increase in risk with children’s social care and other agencies involved.

26.12 Including goals around parenting and family life in the parent’s treatment and recovery plan

Practitioners working with all parents, whether or not there are safeguarding concerns, should ask them about any goals or aspirations they have about their children or family life when agreeing a treatment and recovery plan. A parent’s concerns for their children can often be a motivating factor to make changes in their alcohol use. They can also consider what sort of support they might need to manage some of the challenges of parenting. Agreeing a treatment and recovery plan is also an opportunity to identify parenting strengths so that risks or needs are not the only focus.

Services should have information on universal children’s services (open to all) and targeted services (for vulnerable children and families) for parents to consider.

26.13 Multi-agency working with children’s social care and other services

26.13.1 Contributing to multi-agency assessments and plans

A core principle of the Children Acts 1989 and 2004 is that safeguarding is everybody’s responsibility. Alcohol treatment services and practitioners should be aware of and follow the published arrangements set out by the organisations responsible for safeguarding in the local area. This is so they can collaborate effectively with other services.

Practitioners in alcohol treatment services should contribute to:

• multi-agency assessments
• child in need and child protection plans
• reviews led by children’s social care services
• early help assessments, plans and reviews

If children’s social care services are already working with a parent who needs to be referred to the alcohol treatment service, the referral should be considered a priority, due to the risks to the children.

26.13.2 Information sharing

Working together to safeguard children says that effective information sharing between practitioners and local organisations and agencies is essential for early identification of need, assessment and service provision to keep children safe.

Serious case reviews (Sidebotham and others 2016) have highlighted that missed opportunities to record, understand the significance and share information in a timely way can have severe consequences for the safety and welfare of children. This applies when problems are first emerging or identified and when children are already known to children’s social care.

Alcohol treatment services should develop agreements with other local agencies outlining why, how and when it is appropriate to share information, as well as on how data will be handled once it is shared.

Working together to safeguard children provides guidance on information sharing.

26.13.3 Strategic partnerships

Alcohol treatment commissioners and service providers should work with organisations responsible for safeguarding across systems in the local authority.

Local areas need strong leadership and strategic partnerships so that practitioners can work well together across organisations and systems. There should be agreed working arrangements between children and family services and adult and young people’s services and these are best supported by a written protocol. In England the local safeguarding partnership provides multi-agency governance arrangements and data sharing arrangements for the system.

Agreements can be about:

• the role of alcohol treatment services (adult and young people) in local safeguarding arrangements
• information and data sharing
• the process for early help assessments and interventions for parents with alcohol problems
• the process and thresholds for referrals to children’s social care where there are safeguarding concerns
• the process for referrals into alcohol treatment services from children’s services
• multi-agency safeguarding training
• governance and evaluation

In some areas, services may be commissioned or agree to provide services in partnership. This might include an alcohol treatment practitioner based for part of the week in children’s social care, or a local authority social worker providing regular consultation to staff in alcohol treatment services.

The guidance Safeguarding and promoting the welfare of children affected by parental alcohol and drug use: a guide for local authorities provides more information on developing a protocol between children and family services and alcohol treatment services.

26.14 Resources

Parents with alcohol and drug problems: support resources is a toolkit containing guidance, data and other resources to support professionals who are helping families affected by parental alcohol and drug problems.

Families affected by drug and alcohol use is a framework for holistic family approaches and family inclusive practice for working with families affected by parental alcohol and drug use in Scotland.

26.15 References

Brandon M, Sidebotham P, Belderson P, Cleaver H, Dickens J, Garstang J, Harris J, Sorensen P and Wate R. Complexity and challenge: a triennial analysis of serious case reviews 2014 to 2017. Department for Education, 2020

Canfield M, Radcliffe P, Marlow S, Boreham M and Gilchrist G. Maternal substance use and child protection: a rapid evidence assessment of factors associated with loss of child care. Child Abuse and Neglect 2017: volume 70, pages 11-27

Cleaver H, Unell I and Aldgate J. Children’s needs - parenting capacity. Child abuse: parental mental illness, learning disability, substance misuse, and domestic violence. Second edition. Department for Education, 2011

Hughes K, Bellis M, Hardcastle KA, Sethi D, Butchart A, Mikton C, Jones L and Dunne MP. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet Public Health 2017: volume 2, issue 8, e356-e366

Pajulo M, Suchman N, Kalland M and Mayes L. Enhancing the effectiveness of residential treatment for substance abusing pregnant and parenting women: focus on maternal reflective functioning and mother-child relationship. Infant Mental Health Journal 2006: volume 27, issue 5, pages 448-465

Sidebotham P, Brandon M, Bailey S, Belderson P, Dodsworth J, Garstang J, Harrison E, Retzer A and Sorensen P. Pathways to harm, pathways to protection: a triennial analysis of serious case reviews, 2011 to 2014. Department for Education, 2016

Stith S, Liu T, Davies L, Boykin EL, Alder MC, Harris J, Som A, Mcpherson M and Dees JJ. Risk factors in child maltreatment: a meta-analytic review of the literature. Aggression and Violent Behavior 2009: volume 14, issue 1, pages 13-29

McGovern R, Newham JJ, Addison MT, Hickman M and Kaner EFS. Effectiveness of psychosocial interventions for reducing parental substance misuse. Cochrane Database of Systematic Reviews, 2021

27. Armed forces

27.1 Main points

UK armed forces (the Royal Navy, Royal Air Force and British Army) personnel have a higher prevalence of alcohol use disorders compared to a similar demographic in the general population.

Defence primary health care and mental health care staff should use every opportunity to identify people with alcohol problems, offer brief interventions or offer them evidence-based alcohol treatment. Line managers, welfare support staff, and peer support recovery champions can also help people to access treatment.

Alcohol treatment provided in the armed forces should meet recognised standards of good practice as set out in 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). Clinicians should tailor the guidance for the armed forces.

Armed forces personnel should have access to evidence-based alcohol treatment equivalent to that available to the general population.

Clinicians should promote continuity and consistency of care between Defence healthcare services and external specialist service providers.

All clinicians responsible for treating armed forces personnel should:

• be trained and competent in alcohol identification and delivering brief advice
• have the necessary specialist treatment competencies
• receive ongoing support and clinical supervision

There should be a framework in place to enable clinicians to provide good quality care suitable for the armed forces mobile population through the use of remote consultations based on Defence clinical guidance which meets the guidelines set out in NICE CG115.

Clinicians should act under the armed forces safety imperative by emphasising health and occupational risk management relating to alcohol use.

Defence Primary Healthcare commissions and provides safe and effective healthcare to meet the needs of patients and manage occupational risk. It should continue to implement the alcohol treatment pathway in line with NICE CG115 and adapt it for the armed forces.

27.2. Introduction

27.2.1 Overview

Research has suggested that alcohol problems are one of the most often reported mental disorders in UK armed forces personnel (Fear and others 2010). There is strong evidence that heavy alcohol consumption in the UK armed forces is more common than in the general population (Fear and others 2007, Thandi and others 2015). One research report (Jones and Fear 2011) observed that:

“Some doctors viewed it as wholly harmful to both social and occupational function and to health, while others argued that alcohol had specific role in lifting morale, aiding unit cohesion and protecting soldiers from adjustment disorders. Although alcoholism has always been identified as incompatible with military service, the effects of habitual heavy drinking among military personnel are less well understood.”

27.2.2 Summary of relevant research

Drinking at increasing or higher risk levels

Increased alcohol use in the military has been linked to perceived social pressure (Irizar and others 2020) and a social network that includes heavy drinking associates (Anderson and others 2020). Other research has reported that less than half of armed forces personnel who were drinking at hazardous levels recognised that they had an alcohol problem (Hines and others 2014).

Alcohol screening has recently been included as part of dental inspections for UK armed forces personnel. Ministry of Defence (MOD) statistics on alcohol use in the armed forces shows that 61% of personnel reported drinking at increasing or higher risk levels. This may underrepresent the true rates, since people in the military can be motivated to underreport their levels of drinking due to the perceived consequences of disclosing that information (Sheppard and others 2013).

Specific issues faced by armed forces personnel

Alcohol problems have been linked to work strain and functional impairment (Jones and Coetzee 2018, Rona and others 2010). People who have undergone particularly stressful military experiences are at greatest risk of misusing alcohol (Jones and Fear 2011) and reservists may be particularly vulnerable (Harvey and others 2011).

Significant factors associated with alcohol problems include having a combat role and co-morbid mental health difficulties (Knight and others 2011). Research has also identified an association between increased risk of suicide and excessive use of alcohol in military personnel (LeardMann and others 2013). Other work has identified drinking as an independent risk factor in the perpetration of intimate partner violence among US army male soldiers (Bell and others 2004).

Effectively treating armed forces personnel

Although research points to complex environmental, cultural and individual factors connected with armed forces personnel having increased drinking harms, there is a lack of work focusing on potential treatment approaches and effectiveness in serving military populations (Doherty and others 2017). Recent work in the UK and US has highlighted the promising role of digital or remote interventions, emphasising self-management of hazardous and harmful alcohol use, for serving and ex-serving armed forces personnel, where they do not need specialist pharmacological interventions. These include delivering interventions by phone and through websites and smartphone apps (Brief and others 2013, Puddephatt and others 2019, Walker and others 2017).

Family and partners

There is some research on the family situation of armed forces personnel in the context of managing alcohol problems, although the majority of work is based in the United States. A randomised control trial identified encouragement from partners as important to service personnel seeking care (Trail and others 2017).

Veterans

Research on veterans of the armed forces has implications for the development of onward treatment pathways, as people transfer out of the armed forces. A study focusing on UK ex-armed forces personnel (veterans) found no differences in the severity of reported alcohol difficulties when compared to the general population. However, veterans were more likely to be referred for alcohol support at an older age and to be admitted to hospital for longer periods (Murphy and others 2016).

Other work has pointed out factors linked to alcohol problems for veterans including:

• using other substances (Gunn and others 2019)
• depression and suicide risk (Mrnak-Meyer and others 2011)
• gambling (Davis and others 2017)

27.3 Alcohol treatment for UK armed forces personnel

27.3.1 Defence primary care and mental health

Armed forces personnel and members of the military reserve force who are actively mobilised are entitled to care provided by Defence Medical Services (DMS). Alcohol identification, brief interventions, assessment and treatment are carried out by Defence primary care and mental health clinicians. Mental health services are staffed by uniformed and civilian mental health professionals including psychiatrists, clinical psychologists and mental health nurses. For remote locations, including overseas, satellite support is provided by mental health teams.

Professionals with alcohol and drug expertise are embedded in Defence medical teams. There are various pathways to receiving alcohol assessment and treatment in Defence primary care and mental health service settings, including medical referral, self-referral, following direction to attend from line managers and signposting from peer support initiatives.

There is ongoing work to implement a more integrated Defence alcohol treatment pathway led by good practice evidence. This includes Defence Primary Healthcare (DPHC) developing detailed clinical guidance for treatment, based on NICE CG115 and adapted for an armed forces population.

27.3.2 Medically assisted withdrawal

For patients requiring medically assisted withdrawal, community–based care is provided by Defence mental health teams working alongside Defence primary care clinicians. Inpatient medically assisted withdrawal is provided through Defence contracted inpatient service providers (a consortium of NHS trusts). Preparation for medically assisted withdrawal and follow-up support is provided by Defence medical teams.

27.3.3 Local and overseas arrangements

To optimise patient care, some Defence medical teams link with specialist alcohol treatment services available to the general population. These arrangements to link with external services have generally evolved locally.

For overseas locations, additional arrangements cover medical care of dependents of armed forces personnel and UK civil servants. Patients with acute mental health conditions who need treatment in the UK can be medically evacuated. On-site or ‘field’ mental health teams provide support to personnel directly involved in military operations, including those of a combat nature.

The MOD provides a mental health programme including alcohol focused care for reservists who have been employed on military operations since 2003.

27.3.4 Alcohol and drugs

The MOD’s Joint Service Publications (JSPs) provide overall rules, policy and guidelines that apply across the armed forces. Some JSPs are relevant to managing problems with alcohol and other substances. There are different policies for managing problematic alcohol use compared to problematic drug use in the UK armed forces. JSP policy and guidance is based on a view that harmful alcohol use and alcohol dependence are preventable and recoverable. This policy and guidance provides an approach involving education, awareness and regulation alongside medical support. In some circumstances, disclosure of medical information by medical officers to the chain of command will be justifiable in the public interest. In such cases, MOD guidance is that medical officers work with patients to obtain consent for disclosure where possible, and help them to engage with treatment.

Problematic alcohol use may lead to administrative action, and this can include discharge from the armed forces. The MOD sees drug misuse (not including alcohol) as inconsistent with military service and has a zero tolerance policy. This means personnel who misuse drugs can expect to be removed from the armed forces. The Armed Forces Act allows testing for drugs and alcohol to be carried out in specified circumstances. So, there is routine random compulsory testing for controlled drugs. Under Service law there are specified alcohol limits for undertaking safety critical duties (there are no minimum accepted limits for the presence of illegal drugs), and a commanding officer can require a person to be tested if they are suspected of being over the limit.

27.3.5 Veterans

Veterans requiring specialist mental health assessment at the time of discharge, including for alcohol-related symptoms, are entitled to treatment for 6 months after leaving the armed services if they need it. If personnel are medically discharged there are processes for transferring care to the NHS.

27.4 Principles for providing alcohol treatment and recovery support under Defence Medical Services

27.4.1 General principles

Principles of care for armed forces personnel should ensure that they are able to freely access evidence-based alcohol treatment equivalent to that available to the general population. Personnel are entitled to safe and effective treatment across the range of armed forces environments where they are required to work and live.

27.4.2 Maintaining operational effectiveness and managing risk

Defence medical teams have a principal role in maintaining the operational effectiveness of the armed forces and managing risk, including performing safety critical duties. This includes:

• strengthening communication between different health care providers
• providing clear protocols for risk assessment and management
• involving other relevant people, including line managers, when necessary

Assessment and treatment of alcohol problems should be guided by evidence on effective intervention approaches.

27.4.3 Optimising engagement and recovery

Armed forces personnel might not disclose problematic alcohol and drug use to avoid potentially negative consequences for their employment. To optimise treatment success, clinicians should carry out thorough assessment using a motivational approach, including building readiness for and commitment to treatment. Interventions should emphasise general health and wellbeing, and create opportunities to encourage people to disclose alcohol and drug problems. Defence primary care and mental health teams are well placed to identify and treat co-occurring physical health and mental health conditions.

Interventions should take account of social factors linked with maintaining harmful drinking and alcohol dependence and should include peer support options. Clinicians should signpost personnel to peer support where necessary. This includes putting them in touch with armed forces recovery champions with lived experience and external mutual aid organisations.

27.4.4 Addressing the needs of the mobile armed forces population

Armed forces personnel are a mobile population subject to changes in geographical base, sometimes at short notice. Regulations restrict alcohol consumption in certain locations or during certain operational circumstances. For example, no alcohol during some periods of training or active assignment (including when off duty).

Care pathways should provide comprehensive alcohol support across different locations and when changes occur to a patient’s geographical base. Assessment of alcohol use should take account of the effects of occupational requirements and implications for treatment.

To address the needs of the mobile armed forces population, clinicians should provide remote or digital consultations (phone, video link, online). And where appropriate, they should promote evidence-based digital tools and apps to help provide information, self-monitoring and for using self-help strategies.

27.4.5 Medically assisted withdrawal

The inpatient pathway for armed forces personnel who need medically assisted withdrawal includes treatment from a contracted inpatient service provider. When providing medically assisted withdrawal, clinicians should:

• follow clear risk assessment and management protocols
• prepare the patient for medically assisted withdrawal
• provide follow-up support with a long-term recovery focus

There is guidance on medically assisted withdrawal in:

• chapter 10 on pharmacological interventions
• chapter 11 on community medically assisted withdrawal
• chapter 12 on specialist inpatient medically assisted withdrawal

27.5 Socio-cultural influences

The drinking culture in the armed forces is heavily influenced by social factors such as peer pressure and perceived approval of drinking by others. Defence public health initiatives (including alcohol pricing and availability on bases) should be developed as part of a broader strategy that includes promoting health and wellbeing initiatives within the organisation.

27.6 Future developments

DPHC provides and commissions healthcare to meet the needs of the patient and manage organisational risk. DPHC is continuing to implement the Defence primary care alcohol pathway to support the provision of alcohol prevention and treatment in the armed forces. Senior Defence clinicians have endorsed the pathway.

Implementing and adopting the pathway in a sustained way will include:

• using organisational links between the medical, public health and people support groups in Defence headquarters to enable a comprehensive approach to addressing the drinking culture in the armed forces
• using a combined approach that involves Defence medical teams delivering treatment alongside Defence public health initiatives that include price and availability controls, awareness raising, screening and referral to treatment
• strengthening governance processes for the alcohol treatment pathway
• integrating initiatives to promote healthy lifestyles and encourage a recovery ethos
• developing care and treatment pathways that take account of a person’s family situation, including affected family members (who might also be higher risk drinkers) and addressing the risk of domestic abuse and intimate partner violence
• working with peer support groups and having links to outside mutual aid organisations

Defence medical and public health groups working with NHS bodies to develop an integrated pathway for people leaving the armed forces

27.7 References

Anderson Goodell EM, Johnson RM, Latkin CA, Homish DL and Homish GG. Risk and protective effects of social networks on alcohol use problems among army reserve and national guard soldiers. Addictive Behaviors 2020: volume 103, article 106244

Bell NS, Harford T, McCarroll JE and Senier L. Drinking and spouse abuse among U.S. Army soldiers. Alcohol Clinical and Experimental Research 2004: volume 28, issue 12, pages 1890-1897

Brief DJ, Rubin A, Keane TM, Enggasser JL, Roy M, Helmuth E, Hermos J, Lachowicz M, Rybin D and Rosenbloom D. Web intervention for OEF/OIF veterans with problem drinking and PTSD symptoms: a randomized clinical trial. Journal of Consulting and Clinical Psychology 2013: volume 81, issue 5, pages 890-900

Davis AK, Bonar EE, Goldstick J, Walton MA, Winters J and Chermack ST. Binge drinking and non-partner aggression are associated with gambling among veterans with recent substance use in outpatient treatment. Addictive Behaviors 2017: volume 74, pages 27-32

Doherty AM, Mason C, Fear NT, Rona RJ, Greenberg N and Goodwin L. Are brief alcohol interventions targeting alcohol use efficacious in military and veteran populations? A meta-analysis. Drug and Alcohol Dependence 2017: volume 178, pages 571-578

Fear NT, Iversen A, Meltzer H, Workman L, Hull L, Greenberg N, Barker C, Browne T, Earnshaw M, Horn O, Jones M, Murphy D, Rona RJ, Hotopf M and Wessely S. Patterns of drinking in the UK Armed Forces. Addiction 2007: volume 102, issue 11, pages 1749-1759

Fear NT, Jones M, Murphy D, Hull L, Iversen AC, Coker B, Machell l, Sundin J, Woodhead C, Jones N, Greenberg N, Landau S, Dandeker C, Rona RJ, Hotopf M and Wessely S. What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study. Lancet 2010: volume 375, issue 9728, pages 1783-1797

Gunn R, Jackson K, Borsari B and Metrik J. A longitudinal examination of daily patterns of cannabis and alcohol co-use among medicinal and recreational veteran cannabis users. Drug and Alcohol Dependence 2019: volume 205, article 107661

Harvey SB, Hatch SL, Jones M, Hull L, Jones N, Greenberg N, Dandeker C, Fear NT and Wessely S. Coming home: social functioning and the mental health of UK reservists on return from deployment to Iraq or Afghanistan. Annals of Epidemiology 2011: volume 21, issue 9, pages 666-672

Hines LA, Goodwin L, Jones M, Hull L, Wessely S, Fear NT and Rona RJ. Factors affecting help seeking for mental health problems after deployment to Iraq and Afghanistan. Psychiatric Services 2014: volume 65, issue 1, pages 98-105

Irizar P, Leightley D, Stevelink S, Rona R, Jones N, Gouni K, Puddephatt JA, Fear N, Wessely S and Goodwin L. Drinking motivations in UK serving and ex-serving military personnel. Occupational Medicine 2020: volume 70, issue 4, pages 259-267

Jones N and Coetzee R. What drives UK military personnel to seek mental healthcare, work strain or something else? Journal of the Royal Army Medical Corps 2018: volume 164, issue 4, pages 248-252

Jones E and Fear NT. Alcohol use and misuse within the military: a review. International Review of Psychiatry 2011: volume 23, issue 2, pages 166-172

Knight T, Jones M, Jones N, Fertout M, Greenberg N, Wessely S and Fear NT. Alcohol misuse in the UK armed forces. Occupational and Environmental Medicine 2011: volume 68, issue s1

LeardMann CA, Powell TM, Smith TC, Bell MR, Smith B, Boyko EJ, Hooper TI, Gackstetter GD, Ghamsary M and Hoge C. Risk factors associated with suicide in current and former US military personnel. JAMA 2013: volume 310, issue 5, pages 496-506

Murphy D, Palmer E, Westwood G, Busuttil W and Greenberg N. Do alcohol misuse, service utilisation, and demographic characteristics differ between UK veterans and members of the general public attending an NHS general hospital? Journal of Clinical Medicine 2016: volume 5, issue 11, article 95

Mrnak-Meyer J, Tate SR, Tripp JC, Worley MJ, Jajodia A and Mcquaid JR. Predictors of suicide-related hospitalization among U.S. veterans receiving treatment for comorbid depression and substance dependence. Suicide and Life Threatening Behavior 2011: volume 41, issue 5, pages 532-542

Puddephatt JA, Leightley D, Palmer L, Jones N, Mahmoodi T, Drummond C, Rona RJ, Fear NT, Field M and Goodwin L. A qualitative evaluation of the acceptability of a tailored smartphone alcohol intervention for a military population: information about drinking for ex-serving personnel (InDEx) app. JMIR mHhealth and uHealth 2019: volume 7, issue 5, article e12267

Rona RJ, Jones M, Fear NT, Hull L, Hotopf M and Wessely S. Alcohol misuse and functional impairment in the UK Armed Forces: a population-based study. Drug and Alcohol Dependence 2010: volume 108, issue 1-2, pages 37-42

Sheppard SC, Forsyth JP, Earleywine M, Hickling EJ and Lehrbach MP. Improving base rate estimation of alcohol misuse in the military: a preliminary report. Journal of Studies on Alcohol and Drugs 2013: volume 74, issue 6, pages 917-922

Thandi G, Sundin J, Ng-Knight T, Jones M, Hull L, Jones N, Greenberg N, Rona RJ, Wessely S and Fear NT. Alcohol misuse in the United Kingdom Armed Forces: a longitudinal study. Drug and Alcohol Dependence 2015: volume 156, pages 78-83

Trail TE, Osilla KC, Pedersen ER, Gore KL, Tolpadi A and Rodriguez LM. Results from a randomized controlled trial of a web-based intervention for those concerned with their military partner’s drinking. Alcoholism: Clinical and Experimental Research 2017: volume 41, issue s1, article 306A

Walker DD, Walton TO, Neighbors C, Kaysen D, Mbilinyi L, Darnell J, Rodriguez L and Roffman RA. Randomized trial of motivational interviewing plus feedback for soldiers with untreated alcohol abuse. Journal of Consulting and Clinical psychology 2017: volume 85, issue 2, pages 99-110