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## Complete Summary

#### GUIDELINE TITLE

The management of harmful drinking and alcohol dependence in primary
care. A national clinical guideline.

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). The management of
harmful drinking and alcohol dependence in primary care. A national
clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate
Guidelines Network (SIGN); 2003 Sep. 39 p. (SIGN publication; no. 74).
\[158 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

Any amendments to the guideline in the interim period will be noted on
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Harmful drinking and alcohol dependence

#### GUIDELINE CATEGORY

Counseling\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Psychology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Pharmacists\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### GUIDELINE OBJECTIVE(S)

To provide evidence-based recommendations for the management of patients
with harmful drinking and alcohol dependence

#### TARGET POPULATION

Patients with alcohol dependence, hazardous or harmful drinking seen in
primary care (general practice and community nursing) and among those
attending, but not admitted from, Accident & Emergency (A&E) Departments

The guideline does not address some specific situations:

-   patients already in specialist care

-   patients admitted to general or psychiatric hospitals

-   driving

-   drinking related to vocational or professional issues (e.g., for van
    drivers, surgeons, or teachers with alcohol problems)

-   adolescents with an alcohol problem

-   child safety

-   the management of alcohol-related organ damage

-   treatment of carers and family members of patients with an alcohol
    problem.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Clinical history and patient self-assessment

2.  Screening tests:

    -   AUDIT (Alcohol Use Disorders Identification Test)

    -   CAGE (Attempts to **C**ut back on drinking, being **A**nnoyed at
        criticisms about drinking, feeling **G**uilty about drinking,
        and using alcohol as an **E**ye-opener)

    -   FAST (Fast Alcohol Screening Test)

    -   PAT (Paddington Alcohol Test)

    -   TWEAK (**T**olerance to the effects of alcohol, **W**orry about
        drinking, **E**ye-opener, **A**mnesia, felt the need to **K**
        cut down on your drinking)

    -   T-ACE (**T**olerance, **A**nnoyed by someone criticizing your
        drinking, felt the need to **C**ut down, **E**ye-opener)

3.  Biological markers including mean red blood cell volume (MCV), serum
    gamma glutamyl transferase (GGT), and carbohydrate deficient
    transferring (CDT)

4.  Blood alcohol count (BAC)

**Management**

1.  Brief interventions in the primary care, accident & emergency, and
    antenatal setting

2.  Motivational interviewing

3.  Detoxification in the primary care setting and the inpatient setting

4.  Pharmacological detoxification including benzodiazepines (diazepam,
    chlordiazepoxide), clomethiazole, antiepileptic drugs, antipsychotic
    drugs, and vitamin supplements

5.  Hospital admission for delirium tremens

6.  Referral and follow-up

7.  Psychosocial interventions (e.g., Alcoholic Anonymous)

8.  Acamprosate or disulfiram for prevention of relapse

9.  Selective serotonin reuptake inhibitor (SSRI) for patients with
    anxiety or depression

#### MAJOR OUTCOMES CONSIDERED

-   Presence of comorbid physical and/or psychiatric illness

-   Total alcohol consumption

-   Episodes of binge drinking

-   Length of time of sobriety/reduced alcohol consumption following
    intervention

-   Number and severity of relapses

-   Morbidity and mortality associated with harmful drinking and alcohol
    dependence

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A systematic review of the literature was carried out using an explicit
search strategy devised by a Scottish Intercollegiate Guidelines Network
(SIGN) Information Officer. Databases searched include Medline, Embase,
Healthstar, Cinahl, PsychINFO, Alcohol and Alcoholism, and the Cochrane
Library. The year range covered was 1995 to 2001. Internet searches were
carried out on various Web sites including the New Zealand Guidelines
Programme, the UK Health Technology Assessment programme, the National
Institute on Alcohol Abuse and Alcoholism Alcohol (NIAAA) and Alcohol
Problems Science Database (ETOH), and the US National Guidelines
Clearinghouse. The Medline version of the main search strategies can be
found on the SIGN Web site in the section covering supplementary
guideline material. The main searches were supplemented by material
identified by individual members of the development group. All selected
papers were evaluated by two members of the group using standard SIGN
methodological checklists before conclusions were considered as
evidence.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of randomized
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+**: Well-conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies

High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**: Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Nonanalytic studies (e.g. case reports, case series)

**4**: Expert opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Scottish Intercollegiate Guidelines Network (SIGN) carries out
comprehensive systematic reviews of the literature using customized
search strategies applied to a number of electronic databases and the
Internet. This is often an iterative process whereby the guideline
development group will carry out a search for existing guidelines and
systematic reviews in the first instance and, after the results of this
search have been evaluated, the questions driving the search may be
redefined and focused before proceeding to identify lower levels of
evidence.

Once papers have been selected as potential sources of evidence, the
methodology used in each study is assessed to ensure its validity. SIGN
has developed checklists to aid guideline developers to critically
evaluate the methodology of different types of study design. The result
of this assessment will affect the level of evidence allocated to the
paper, which in turn will influence the grade of recommendation it
supports.

Additional details can be found in the companion document titled \"An
Introduction to the SIGN Methodology for the Development of
Evidence-based Clinical Guidelines\" (Edinburgh \[UK\]: Scottish
Intercollegiate Guidelines Network. \[SIGN publication; no. 50\]).
Available from the [SIGN Web
site](http://www.sign.ac.uk/methodology/index.html).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The process for synthesizing the evidence base to form graded guideline
recommendations is illustrated in the companion document titled \"An
Introduction to the SIGN Methodology for the Development of
Evidence-based Clinical Guidelines.\" (Edinburgh \[UK\]: Scottish
Intercollegiate Guidelines Network. \[SIGN publication; no. 50\],
available from the [SIGN Web
site](http://www.sign.ac.uk/methodology/index.html).

Evidence tables should be compiled, summarizing all the validated
studies identified from the systematic literature review relating to
each key question. These evidence tables form an important part of the
guideline development record and ensure that the basis of the guideline
development group\'s recommendations is transparent.

In order to address how the guideline developer was able to arrive at
their recommendations given the evidence they had to base them on, SIGN
has introduced the concept of considered judgement.

Under the heading of considered judgement, guideline development groups
are expected to summarise their view of the total body of evidence
covered by each evidence table. This summary view is expected to cover
the following aspects:

-   Quantity, quality, and consistency of evidence

-   Generalisability of study findings

-   Applicability to the target population of the guideline

-   Clinical impact (i.e., the extent of the impact on the target
    patient population, and the resources need to treat them.)

Guideline development groups are provided with a pro forma in which to
record the main points from their considered judgement. Once they have
considered these issues, the group is asked to summarise their view of
the evidence and assign a level of evidence to it, before going on to
derive a graded recommendation.

The assignment of a level of evidence should involve all those on a
particular guideline development group or subgroup involved with
reviewing the evidence in relation to each specific question. The
allocation of the associated grade of recommendation should involve
participation of all members of the guideline development group. Where
the guideline development group is unable to agree on a unanimous
recommendation, the difference of opinion should be formally recorded
and the reason for dissent noted.

The recommendation grading system is intended to place greater weight on
the quality of the evidence supporting each recommendation, and to
emphasise that the body of evidence should be considered as a whole, and
not rely on a single study to support each recommendation. It is also
intended to allow more weight to be given to recommendations supported
by good quality observational studies where randomised controlled trials
(RCTs) are not available for practical or ethical reasons. Through the
considered judgement process guideline developers are also able to
downgrade a recommendation where they think the evidence is not
generalisable, not directly applicable to the target population, or for
other reasons is perceived as being weaker than a simple evaluation of
the methodology would suggest.

On occasion, there is an important practical point that the guideline
developer may wish to emphasise but for which there is not, nor is their
likely to be, any research evidence. This will typically be where some
aspect of treatment is regarded as such sound clinical practice that
nobody is likely to question it. These are marked in the guideline as
\"good practice points.\" It must be emphasized that these are
[not]{.underline} an alternative to evidence-based recommendations, and
should only be used where there is no alternative means of highlighting
the issue.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The grade of recommendation relates to the strength of the evidence on
which the recommendation is based. It does not reflect the clinical
importance of the recommendation.

**A**: At least one meta-analysis, systematic review of randomized
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

#### COST ANALYSIS

**Cost Effectiveness of Disulfiram and Acamprosate**

The health technology assessment by the National Health Service (NHS)
Quality Improvement Scotland included meta-analyses of the efficacy and
cost effectiveness of medications for relapse prevention and found
evidence of efficacy for disulfiram (supervised) and acamprosate. This
was also the conclusion of a health technology assessment by the Swedish
Council on Technology Assessment in Health Care and a literature review
for the Aberdeen Health Economics Research Unit

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A national open meeting is the main consultative phase of Scottish
Intercollegiate Guidelines Network (SIGN) guideline development, at
which the guideline development group presents its draft recommendations
for the first time. The national open meeting for this guideline was
held on 29 April 2002 and was attended by around 150 representatives of
all the key specialties relevant to the guideline. The draft guideline
was also available on the SIGN Web site for a limited period at this
stage to allow those unable to attend the meeting to contribute to the
development of the guideline.

The guideline was also reviewed in draft form by a panel of independent
expert referees, who were asked to comment primarily on the
comprehensiveness and accuracy of interpretation of the evidence base
supporting the recommendations in the guideline.

As a final quality control check, the guideline is reviewed by an
Editorial Group comprising the relevant specialty representatives on
SIGN Council to ensure that the specialist reviewers´ comments have been
addressed adequately and that any risk of bias in the guideline
development process as a whole has been minimised.

Each member of the guideline development group then approved the final
guideline for publication.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*Note from the Scottish Intercollegiate Guidelines Network (SIGN) and
National Guideline Clearinghouse (NGC): In addition to these
evidence-based recommendations, the guideline development group also
identifies points of best clinical practice in the original guideline
document.*

The strength of recommendation grading (A-D) and level of evidence (1++,
1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the \"Major
Recommendations\" field.

**Detection and Assessment**

*Clinical History*

**D** - Primary care workers should be alerted by certain presentations
and physical signs to the possibility that alcohol is a contributing
factor and should ask about alcohol consumption.

*Screening*

**B** - Abbreviated forms of Alcohol Use Disorders Identification Test
(AUDIT) *(e.g., Fast Alcohol Screening Test (FAST))*, or Attempts to
**C**ut back on drinking, being **A**nnoyed at criticisms about
drinking, feeling **G**uilty about drinking, and using alcohol as an
**E**ye-opener (CAGE) plus two consumption questions, should be used in
primary care when alcohol is a possible contributory factor.

**C** - In Accident & Emergency (A&E), FAST or Paddington Alcohol Test
(PAT) should be used for people with an alcohol related injury.

**B** -- **T**olerance to the effects of alcohol, **W**orry about
drinking, **E**ye-opener, **A**mnesia, felt the need to **K** cut down
on your drinking (TWEAK) and **T**olerance, **A**nnoyed by someone
criticizing your drinking, felt the need to **C**ut down, **E**ye-opener
(T-ACE) (or shortened versions of AUDIT) should be used in antenatal and
preconception consultations.

*Biological Markers*

**B** - Biological tests are useful when there is reason to believe that
self reporting may be inaccurate.

**Brief Interventions**

**A** -- General Practitioners (GPs) and other primary care health
professionals should opportunistically identify hazardous and harmful
drinkers and deliver a brief (10 minute) intervention.

**A** - The intervention should, whenever possible, relate to the
patient´s presenting problem and should help the patient weigh up any
benefits as perceived by the patient, versus the disadvantages of the
current drinking pattern.

**D** - Training for general practitioners, practice nurses, community
nurses, and health visitors in the identification of hazardous drinkers
and delivery of a brief intervention should be available.

**B** - Routine antenatal care provides a useful opportunity to deliver
a brief intervention for reducing alcohol consumption.

**B** - Motivational interviewing techniques should be considered when
delivering brief interventions for harmful drinking in primary care.

**Detoxification**

**D** - When medication to manage withdrawal is not needed, patients
should be informed that at the start of detoxification they may feel
nervous or anxious for several days, with difficulty in going to sleep
for several nights.

**A** - Benzodiazepines should be used in primary care to manage
withdrawal symptoms in alcohol detoxification, but for a maximum period
of seven days.

**D** - For patients managed in the community, chlordiazepoxide is the
preferred benzodiazepine.

**D** - Clomethiazole should not be used in alcohol detoxification in
primary care.

**C** - Provided attention is paid to any acute or chronic physical
illness, elderly patients should be managed the same way as younger
patients.

**B** - Antiepileptic medication should not be used as the sole
medication for alcohol detoxification in primary care.

**B** - Antipsychotic drugs should not be used as first line treatment
for alcohol detoxification.

**D** - Patients with any sign of Wernicke-Korsakov syndrome should
receive Pabrinex in a setting with adequate resuscitation facilities.
The treatment should be according to British National Formulary (BNF)
recommendations and should continue over several days, ideally in an
inpatient setting.

**D** - Local protocols for admitting patients with delirium tremens
should be in place.

**Referral and Follow Up**

**A** - Access to relapse prevention treatments of established efficacy
should be facilitated for alcohol dependent patients.

**B** - When the patient has an alcohol related physical disorder, the
alcohol treatment agency should have close links with the medical and
primary care team.

**D** - The principles of stepped care should be followed for patients
with alcohol problems and dependence.

**B** - Primary care teams should maintain contact over the long term
with patients previously treated by specialist services for alcohol
dependence.

**C** - Alcohol dependent patients should be encouraged to attend
Alcoholics Anonymous.

**D** - If patients are referred to a lay service, agencies where lay
counsellors use motivational interviewing and coping skills training
should be utilised.

*Medications to Prevent Relapse*

**B** - Acamprosate is recommended in newly detoxified dependent
patients as an adjunct to psychosocial interventions.

**C** - Supervised oral disulfiram may be used to prevent relapse but
patients must be informed that this is a treatment requiring complete
abstinence and be clear about the dangers of taking alcohol with it.

*Alcohol Dependence and Psychiatric Illness*

**B** - Patients with an alcohol problem and anxiety or depression
should be treated for the alcohol problem first.

**B** - If depressive symptoms persist for more than two weeks following
treatment for alcohol dependence, consideration should be given to using
a selective serotonin reuptake inhibitor (SSRI) or referring for
counseling or specialist psychological treatment along with the relapse
prevention treatment.

**D** - If severe anxiety symptoms persist for more than two weeks in
abstinent patients, consideration should be given to using a selective
serotonin reuptake inhibitor (SSRI), or referring for specialist
psychological treatment along with the relapse prevention treatment.

**B** - Patients with psychotic disorder and alcohol dependence should
be encouraged to address their alcohol use and may benefit from
motivational, cognitive behavioural, family, and nonconfrontational
approaches.

**Advising Families**

**C** - The primary care team should help family members to use
behavioural methods which will reinforce reduction of drinking and
increase the likelihood that the drinker will seek help.

**[Definitions]{.underline}**:

**Grades of Recommendation**

**A**: At least one meta-analysis, systematic review of randomized
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of RCTs, or RCTs
with a very low risk of bias

**1+**: Well-conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies

High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**: Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Nonanalytic studies (e.g. case reports, case series)

**4**: Expert opinion

#### CLINICAL ALGORITHM(S)

Algorithms are provided in the original guideline document for
\"Screening and Brief Interventions\" and \"Assisting Withdrawal from
Alcohol\" (see Annex 7 in the original guideline document)

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Improved detection and treatment of alcohol problems within primary
    care settings

-   Reduced total alcohol consumption and episodes of binge drinking

-   Increased length of time of sobriety/reduced alcohol consumption

-   Effective use of medication for alcohol dependence detoxification

-   Decreased number of relapses

-   Reduced depressive symptoms and anxiety in patients with comorbid
    psychiatric illness

#### POTENTIAL HARMS

**Screening**

-   False positive results may occur with serum gamma glutamyl
    transferase (GGT) and mean red blood cell volume (MCV) due to other
    causes of elevation.

**Medication**

*Benzodiazepines*

-   Benzodiazepines can cause temporary cognitive slowing and may
    interfere with learning and planning. This, and the need to avoid
    benzodiazepine dependence, are reasons for keeping the length of
    treatment to a maximum of seven days.

-   All benzodiazepines have a potential for misuse, but diazepam is the
    benzodiazepine most associated with misuse and alcohol related
    fatality. If used in community detoxification, diazepam requires
    supervision to avoid misuse.

-   The risk of accumulation of benzodiazepine in the elderly patient
    needs to be considered.

*Pabrinex*

-   There is a very small risk of anaphylaxis with parenteral vitamin
    supplementation. This is less likely with the intramuscular route.
    There has been one case of anaphylaxis solely attributable to
    intramuscular Pabrinex since 1996.

*Disulfiram*

-   Disulfiram has unwanted effects in some patients, and carries
    special warnings.

*Fluoxetine*

-   Fluoxetine seems to reduce the beneficial effect of cognitive
    behavioural therapy in the type of patients characterised by early
    onset and prominent social problems. Therefore caution should be
    exercised in prescribing selective serotonin reuptake inhibitors
    (SSRIs) to patients characterised by early onset of alcohol problems
    and antisocial behaviour.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

**Situations Where Inpatient Detoxification Would be Advised**

The following list is based on expert opinion and comprises validated
and best practice contraindications to managing withdrawal at home.

Hospital detoxification is advised if the patient:

-   is confused or has hallucinations

-   has a history of previously complicated withdrawal

-   has epilepsy or a history of fits

-   is undernourished

-   has severe vomiting or diarrhoea

-   is at risk of suicide

-   has severe dependence coupled with unwillingness to be seen daily

-   has a previously failed home-assisted withdrawal

-   has uncontrollable withdrawal symptoms

-   has an acute physical or psychiatric illness

-   has multiple substance misuse

-   has a home environment unsupportive of abstinence

**Note**: If admission to hospital is unavailable or the patient
refuses, specialist opinion should be sought to aid risk assessment.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline is not intended to be construed or to serve as a standard
of medical care. Standards of care are determined on the basis of all
clinical data available for an individual case and are subject to change
as scientific knowledge and technology advance and patterns of care
evolve. These parameters of practice should be considered guidelines
only. Adherence to them will not ensure a successful outcome in every
case, nor should they be construed as including all proper methods of
care or excluding other acceptable methods of care aimed at the same
results. The ultimate judgement regarding a particular clinical
procedure or treatment plan must be made by the doctor, following
discussion of the options with the patient, in light of the diagnostic
and treatment choices available. It is advised however, that significant
departures from the national guideline or any local guidelines derived
from it should be fully documented in the patient´s case notes at the
time the relevant decision is taken.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Implementation of national clinical guidelines is the responsibility of
local National Health Service (NHS) organizations and is an essential
part of clinical governance. It is acknowledged that not every guideline
can be implemented immediately on publication, but mechanisms should be
in place to ensure that the care provided is reviewed against the
guideline recommendations and the reasons for any differences assessed
and, where appropriate, addressed. These discussions should involve both
clinical staff and management. Local arrangements may then be made to
implement the national guideline in individual hospitals, units and
practices, and to monitor compliance. This may be done by a variety of
means including patient-specific reminders, continuing education and
training, and clinical audit.

Key points for audit are identified in the original guideline document.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). The management of
harmful drinking and alcohol dependence in primary care. A national
clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate
Guidelines Network (SIGN); 2003 Sep. 39 p. (SIGN publication; no. 74).
\[158 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Sep

#### GUIDELINE DEVELOPER(S)

Scottish Intercollegiate Guidelines Network - National Government Agency
\[Non-U.S.\]

#### SOURCE(S) OF FUNDING

Scottish Executive Health Department

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Guideline Development Group*: Dr. Jonathan Chick (*Chair*), Consultant
Psychiatrist, Alcohol Problems Clinic, Royal Edinburgh Hospital; Dr.
Carole Allan, Clinical Psychologist, Gartnavel Royal Hospital, Glasgow;
Dr Bahar Ashraf-Uzzaman, General Practitioner, Airdrie, Lanarkshire; Mr.
Ken Barrie, Director, Centre for Alcohol and Drug Studies, University of
Paisley; Mr Richard Brooks, Health Economist, Strathclyde University,
Glasgow; Mr Robert Burns, Lay Representative; Professor Peter Brunt,
Consultant Physician, Aberdeen Royal Infirmary; Ms Francesca Chappell,
Information Officer, Scottish Intercollegiate Guidelines Network; Dr
Alan Clubb, General Practitioner, Musselburgh; Dr Alex Crawford,
Director, Renfrew Council on Alcohol, Paisley; Ms Marie Egan, Community
Psychiatric Charge Nurse, Invergordon, Ross-shire; Dr Sandy Elder,
Consultant Occupational Physician, Lanarkshire; Dr Ali El-Ghorr,
Programme Manager, Scottish Intercollegiate Guidelines Network; Ms Fiona
Everett, Nurse Lecturer, Bell College, Hamilton; Dr Ciara Flanigan,
Consultant Psychiatrist, Leverndale Hospital, Glasgow; Sister Michelle
Jamieson, Senior Nurse, Accident and Emergency Department, Royal
Infirmary of Edinburgh; Ms Alison MacKinnon, Pharmacist, Sunnyside Royal
Hospital, Angus; Dr Claire McIntosh, Specialist Registrar, Alcohol
Problems Clinic, Royal Edinburgh Hospital; Mr David Pattison Health
Promotion Manager, Forth Valley National Health Services Board,
Stirling; Mr Walter Simpson, Lay Representative; Dr Richard Watson,
General Practitioner, Glasgow

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

All members of the Scottish Intercollegiate Guidelines Network (SIGN)
guideline development groups are required to complete a declaration of
interests, both personal and non-personal. A personal interest involves
payment to the individual concerned (e.g., consultancies or other
fee-paid work commissioned by or shareholdings in the pharmaceutical
industry); a non-personal interest involves payment which benefits any
group, unit or department for which the individual is responsible (e.g.,
endowed fellowships or other pharmaceutical industry support). Details
of the declarations of interest of any guideline development group
member(s) are available from the Scottish Intercollegiate Guidelines
Network executive.

#### GUIDELINE STATUS

This is the current release of the guideline.

Any amendments to the guideline in the interim period will be noted on
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/guidelines/published/numlist.html).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Quick reference guide: The management of harmful drinking and
    alcohol dependence in primary care, Scottish Intercollegiate
    Guidelines Network, 2003. 1 p. Available in Portable Document Format
    (PDF) from the [Scottish Intercollegiate Guidelines Network (SIGN)
    Web site](http://www.sign.ac.uk/guidelines/published/numlist.html).

-   SIGN 50: A guideline developer´s handbook. Edinburgh (Scotland):
    Scottish Intercollegiate Guidelines Network. (SIGN publication; no.
    50). Available from the [SIGN Web
    site](http://www.sign.ac.uk/methodology/index.html).

-   Appraising the quality of clinical guidelines. The SIGN guide to the
    AGREE (Appraisal of Guidelines Research & Evaluation) guideline
    appraisal instrument. Edinburgh (Scotland): Scottish Intercollegiate
    Guidelines Network, 2001. Available from the [SIGN Web
    site](http://www.sign.ac.uk/methodology/agreeguide/index.html).

-   Slattery J, Chick J, Cochrane M, Craig J, Godfrey C, Kohli H,
    Macpherson K, Parrott S, Quinn S, Single A, Tochel C, Watson H.
    Prevention of relapse in alcohol dependence. Health Technology
    Assessment Report 3. Glasgow (Scotland): Health Technology Board for
    Scotland; 2003. Available in Portable Document Format (PDF) from the
    [Scottish Medicines
    Consortium](http://docs.scottishmedicines.org/docs/pdf/Alcohol Report.pdf).

#### PATIENT RESOURCES

The following are available:

-   Understanding HTBS advice: prevention of relapse in alcohol
    dependence. Glasgow (Scotland): Health Technology Board for
    Scotland; 2002 Dec. Available in Portable Document Format (PDF) from
    the [Scottish Medicines
    Consortium](http://docs.scottishmedicines.org/docs/pdf/HTBS ALCOHOL UNDERSTANDING.pdf).

-   Advice to patients on withdrawing from alcohol at home. Edinburgh
    (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 1 p.
    Electronic copies: Available in Portable Document Format (PDF) from
    the [SIGN Web site](http://www.sign.ac.uk/pdf/pat74.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on May 3, 2004. The information
was verified by the guideline developer on December 1, 2004. This
summary was updated by ECRI on August 15, 2005, following the U.S. Food
and Drug Administration advisory on antidepressant medications. This
summary was updated by ECRI Institute on November 6, 2007, following the
U.S. Food and Drug Administration advisory on Antidepressant drugs.

#### COPYRIGHT STATEMENT

Scottish Intercollegiate Guidelines Network (SIGN) guidelines are
subject to copyright; however, SIGN encourages the downloading and use
of its guidelines for the purposes of implementation, education, and
audit.

Users wishing to use, reproduce, or republish SIGN material for
commercial purposes must seek prior approval for reproduction in any
medium. To do this, please contact <sara.twaddle@nhs.net>.

Additional copyright information is available on the [SIGN Web
site](http://www.sign.ac.uk/guidelines/published/copyright.html).

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
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Readers with questions regarding guideline content are directed to
contact the guideline developer.

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Date Modified: 11/3/2008