Recommendation 6: supporting children and young people aged 10 to 15 years and recommendation 7: screening young people aged 16 and 17 years

New published evidence indicates that an AUDIT-C threshold of 3 may be helpful in identifying at-risk alcohol use in young people aged 10 to 17 years, and an AUDIT score of 7 was more effective at identifying alcohol dependence. This evidence could be used to provide greater clarity on screening thresholds in young people aged 10 to 17 years and could change the recommendations – currently the guideline advises using professional judgement as to whether to revise the AUDIT scores downwards when screening younger people (under the age of 18).

Recommendation 10: brief advice for adults

There has been a large amount of new evidence published on brief advice for adults in various settings and delivered by different practitioners and to different populations. The published evidence indicates that the effectiveness of brief advice is modified by the setting, delivery practitioner and population receiving the advice. Topic expert feedback also highlighted that not all settings should be delivering brief advice, and resources should focus on those settings where it has been proven to be effective. Given this new evidence, the guideline recommendation on brief advice for adults may need updating.

Recommendation 11: extended brief interventions for adults

New published evidence on extended brief interventions indicates that interventions may not be effective in all populations and settings. Currently the NICE guideline recommends offering extended brief interventions to all adults who have not responded to brief advice, but does not specify the setting or populations to target. Given this new evidence, the guideline recommendations on extended brief interventions for adults may need updating.

For further details and a summary of all evidence identified in surveillance, see appendix A1.

Selecting relevant studies

Studies were selected in line with the standard surveillance methods, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual. However, due to the amount of research available in relation to brief advice for adults (recommendation 10 in NICE’s guideline on alcohol-use disorders: prevention), only systematic reviews were included in the 2019 evidence summary, and randomised controlled trials (RCT) were summarised briefly apart from RCTs that were not covered by systematic reviews, which were included.

Alcohol-use disorders: prevention (NICE guideline PH24)

All experts who completed the questionnaire in relation to this guideline felt that it required updating. The main issues raised were changes to how alcohol services are commissioned and delivered, new evidence on brief advice, and a potential overlap between recommendations 6 and 7 in this guideline and recommendations 1.3.7.1 to 1.3.7.4 in NICE’s guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Further clarity was sought from experts on the potential overlap between guideline recommendations. The views, whilst mixed, seemed to indicate that, on balance, the recommendations complemented each another, with this guideline focussing on prevention, and the other one focussing on treatment.

Digital interventions were also raised as a potential update area by topic experts. However, NICE is currently developing a guideline on behaviour change: digital and mobile health interventions which will cover digital interventions for hazardous drinking and, as such, digital interventions were not part of the surveillance review for this guideline.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115)

All experts who completed the questionnaire in relation to this guideline felt that it required updating. The main issues raised were changes to how alcohol services are commissioned and delivered and new evidence on pharmacotherapies for withdrawal and relapse prevention. Comments were also made on a lack of resources affecting implementation of recommendations and the delivery of services, such as the provision of psychological services, as well as comments that some drugs have become licensed for alcohol dependence.

Alcohol-use disorders: prevention (NICE guideline PH24)

Overall 4 out of 6 stakeholders agreed with the proposal to update defined sections of the guideline. Comments made included:

• Support for the need to offer brief advice in settings only where there is evidence that they are effective and cost-effective.
• The need to provide additional support to groups who are underserved or for whom there are barriers in accessing services. A reference to the LGB&T briefing on Alcohol identification and brief advice, which provides information on how brief advice may be made more accessible to LGBT people. This briefing will be passed onto the NICE team planning the update of this guideline.

See appendix B1 for full details of stakeholders’ comments and our responses.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115)

Overall 4 out of 5 stakeholders agreed with the proposal to not update the guideline and 1 stakeholder did not provide any comment. Comments made included:

• We received a proposal to revise recommendation 1.2.2.8 where it suggests access to treatment of mental health disorders that persist beyond 3 to 4 weeks after abstinence, as this stands in the way of immediate treatment. The committee who developed the guideline noted that for many people, symptoms of, for example, depression and anxiety may reduce following 3 to 4 weeks of abstinence from alcohol. The committee felt it is therefore often not appropriate or necessary to instigate treatment for the disorder at the point of the initial assessment. They also noted that careful monitoring and reassessment of mental health symptoms following abstinence are an important part of the assessment procedure. We found no new evidence to change this recommendation and professionals are anticipated to safeguard individuals and take appropriate action if they are concerned about co-morbid mental health conditions. The committee felt it is therefore often not appropriate or necessary to instigate treatment for the disorder at the point of the initial assessment.
• We received a proposal to amend recommendation 1.3.3.2 to clarify that behavioural couples’ therapy should not be used where domestic violence is a current concern in the relationship. See editorial amendments for details of how this will impact recommendation 1.3.3.2.
• A stakeholder had a concern that updating the NICE guideline on alcohol-use disorders: prevention could impact upon this guideline and that all links should be appropriately updated. During the update of NICE’s guideline on alcohol-use disorders: prevention we will check and update cross-references to this guideline as needed.

See appendix B2 for full details of stakeholders’ comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Alcohol-use disorders: prevention (NICE guideline PH24)

Recommendation 5 will be amended to refresh out of date links to ‘World class commissioning’ and ‘Signs for improvement’. The recommendation will state: ‘Commissioners should ensure a local joint alcohol needs assessment is carried out in accordance with the Alcohol, drugs and tobacco: commissioning support pack and the Local alcohol services and systems improvement tool.

Recommendation 7 will be amended to add: ‘Use professional judgement as to whether to revise the AUDIT scores downwards when screening people under the age of 18’.

Recommendation 9 will be amended to remove the second sub-bullet point on younger people (under the age of 18) in relation to: ‘Use professional judgement as to whether to revise the AUDIT scores downwards when screening’.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE guideline CG115)

Recommendation 1.3.3.2 will be amended to say: ‘Offer behavioural couples’ therapy for harmful drinkers and people with mild alcohol dependence who have a regular partner who is willing to participate in treatment, unless there are indicators that the person is currently experiencing, or is a current perpetrator of, domestic abuse’.

Recommendation 1.3.3.2 will be amended to include the following cross reference: ‘For advice on the use of nalmefene for alcohol dependence see NICE’s technology appraisal guidance on nalmefene for reducing alcohol consumption in people with alcohol dependence’.

Recommendation 1.3.5.3 will be amended to add: ‘Prescribers should be aware of the following legislation and advise patients accordingly: Drugs and driving: blood concentration limits to be set for certain controlled drugs in a new legal offence (2014)’.

Recommendation 1.3.5.11 will be amended to add: ‘Prescribers should also see Addiction to benzodiazepines and codeine (July 2011)’.

Recommendation 1.3.8.4 will be amended with a cross reference to NICE’s guideline on stop smoking interventions and services, which has since replaced NICE’s guideline on smoking: brief interventions and referrals, which was published in 2006.

Footnotes 1, 5 and 16 will be amended to the new standard wording for unlicensed medicines: ‘The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information’.

Footnotes 2 and 7 will be amended to reflect changes in licensing: ‘Oral naltrexone is licensed for alcohol dependence. See the summary of product characteristics. Prescribers should follow the safety advice around opioids’.

Footnotes 12 and 13 will be amended to the new standard wording for unlicensed medicines: ‘The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information. Prescribers should check the licensing status of benzodiazepines in this age group’.

Footnote 17 will be amended to include NICE’s guideline on antisocial personality disorder: prevention and management. It will also be amended to say: ‘Also see NICE’s guideline on coexisting severe mental illness and substance misuse: community health and social care services’.