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Topic proposal

I understand that this proposal will be retained by the SIGN Programme Lead and be made available on the SIGN website for time period that the proposal is being considered. Only proposals with a completed Declaration of Interests for the principal proposer will be considered

1. What is the problem/need for a guideline/clinical scenario?

There is a need for revised SIGN Guidance for the management of harmful drinking and alcohol dependence to reflect current recommendations, policy and vulnerable groups. Currently within the Care Inspectorate there is joint work with Healthcare Improvement Scotland (HIS), NHSGGC and NHS Lothian to create an inspection methodology toolkit for drug and alcohol services. This toolkit is being designed to align inspection with current good practice and national policy for example the Scottish Government recovery agenda (Road to Recovery Drug Strategy (2008) and Alcohol Framework (2009)) and the integration of community health and social care services (Public Bodies (Joint Working) (Scotland) Act (2014)). This has arisen from joint inspection work in specialist alcohol treatment provision with particular issues raised regarding medicines management. Resources are being developed through this joint work to develop inspectors in the CI and HIS and staff in substance use services to regulate and improve the quality of substance use services in Scotland. In carrying out this work a gap was identified regarding screening, assessment and management for harmful, hazardous and dependent alcohol use since the recent SIGN 74 guideline for this area has expired. In looking at the old guideline, various policy issues have moved on, particularly around recovery and integration, and the population itself is changing as dependent alcohol users age and require different interventions. Key areas of concern are the following: (a)New meta-analysis leading to the UK CMOs’ recommending reduced limits of alcohol consumption per week for men, now equal with women, at 14 units spread over the week due to the harmful effects of alcohol consumption to reduce the risk of diseases such as cancer and liver disease. This is a change for men from 21 units per week to 14 units. The FAST and AUDIT screening tools currently used may not detect sensitively enough for this reduced limit for males? (AUDIT identifies individual with 16+ units per week.) Therefore there may be a need for another mechanism, which could be to use the existing FAST and AUDIT tools using screening levels for women across both males and females. (b) Significant focus is given to screening and harmful/hazardous alcohol use but more guidance is required for health and social care staff treating and supporting people dependent on alcohol use in specialist and secondary care (tiers 3 and 4) to ensure recovery is effectively supported in the long term. This is particularly important with the Shifting the Balance of Care (2009) agenda where treatment is increasingly more common in the community, with residential and hospital places are less readily available. (c) The Scottish Government’s Whole Population Approach has been in place since 2009 at the launch of Scotland’s Alcohol Framework to challenge Scotland’s relationship with alcohol across the population by raising consciousness of possible harmful and hazardous drinking. This was achieved through Alcohol screening and Brief Interventions (ABIs) in primary care settings, and more recently in accident & emergency, maternity and prison settings. This approach has been very successful in exceeding the HEAT target year on year and embedding this practice as a standard. What is unknown is the level of individual

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improvement. This proposal would seek to establish a process through which to follow-up on ABI activity appropriately to assess the level of individual outcomes and behaviour change at a trend level across health boards and Scotland as a whole. (d) There is varied practice across residential treatment and secondary care for alcohol treatment and it would be a goal of this proposal to establish a minimum level of evidence based treatment and care interventions for these settings to ensure safety and long term recovery beyond discharge from these services. (e) As the population of alcohol users’ ages, earlier than the general population, this causes health conditions among drinkers aged over 40 years creating the need to be cared for in older peoples’ care homes. This causes challenges for care home staff from health and social care creating a need for guidance. At times individuals may give up their tenancies or own homes to enter care homes, they may then go on to recover physically but present a challenge in this setting due to their alcohol dependence. Challenges include community living with other vulnerable residents, staff knowledge and competence in the screening and management of dependent alcohol use, and potential homelessness where individuals with alcohol dependence are discharged from the care home. This also causes a challenge for care at home staff working with older (+40 years) alcohol users in their own homes/tenancies. (f) Young people are also a vulnerable group and therefore guidance is required for services of young alcohol and drug users to ensure safe and effective interventions are delivered to this group.

2. Burden of the condition

Mortality Most recent figures 1,152 alcohol related deaths in Scotland in 2014. From this total 11 individuals were aged under 30 years and 995 were aged 45 years and over (NRS, 2015).

Incidence General acute hospital admissions and presentations with an alcohol related diagnosis: 670 per 100,000 population during 2014/15 (ISD, 2015). In addition of the total alcohol related hospital discharges of 35,926 in 2012-13, there were 1,189 young people under the age of 20 years and 26,373 aged 40 years and over, with specifically 10,231 aged over 60 years and over (ISD, 2014).

Prevalence 1 in 4 adults have problem alcohol dependence in Scotland in 2012, based on AUDIT identification (16+ units per week). (MESAS, 2014).

3. Variations

There is variation in practice in Scotland with residential treatment and secondary care detoxification, with some not providing a detoxification to alcohol users, others providing a standard dose irrespective of the level of alcohol dependency, and others providing a more tailored service based on need. In addition these services may provide health and social care interventions beyond detoxification to for example a period of six months rehabilitation. Guidance on effective, evidenced-based interventions would be helpful for this stage of provision.

In health outcomes in Scotland are unknown, with some services beginning to measure outcomes through various tools, including a mixture of validated on non-validated tools. A validated recovery outcomes web tool has been designed by Scottish Government for alcohol and drug services but this would not include for ABI activity which is carried out in wider primary care settings.

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4. Areas of uncertainty to be covered

Key question 1 Primary Care and Wider Settings ABIs - ABI and screening tool, reduced drinking CMO guidance – test out the potential solution of using the female screening approach with males Population: Adult males 18+ Intervention: changing screening tools to reflect lowered guidelines of alcohol consumption Comparator/control: current screening tools (FAST and AUDIT) effectiveness Outcome: improved health, quality of life Key area of concern: How can we develop effective screening tools to reflect the lower recommended consumption of alcohol in adult men?

Key question 2 P: Adults and older adults in all care settings (primary and community care, secondary care, residential care, care, care homes) I: Screening tools for harmful drinking C: Usual practice O: improved health, quality of life

Key question 3 ABI Outcomes (going forward) - Who/How/When to follow-up on ABI interventions P: Adults and older adults in all care settings (primary and community care, secondary care, residential care, care, care homes) I: Follow up on Alcohol screening and Brief Interventions (ABIs) to identify people at high risk C: Usual practice O: improved health, quality of life How can this information be used to change behavior?

Key question 3 Secondary Care and Specialist Treatment - Screening and interventions for dependent alcohol use P: Adults in secondary care tiers 3 and 4 I: interventions for alcohol dependency C: current standards of treatment in secondary care O: improved health, quality of life, markers of alcohol dependence

Key question 4 Secondary Care and Residential Treatment - Design minimum treatment and care interventions for these services P: Alcohol dependent patients in secondary care and residential care I: interventions for alcohol dependency C: current standards of treatment in secondary care O: improved health, quality of life, markers of alcohol dependence, transition back to community living

Key question 5 Care at Home and Care Homes - Design/identify screening and interventions for elderly care settings, this would include older people under 65 years in these environments. P: Aging population aged 40+ of alcohol dependent patients in care settings I: interventions for alcohol dependency C: current standards of treatment in care homes O: quality of life

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How can we adapt existing guidance of treatment of alcohol dependent patients in the community to incorporate 40+ adults, particularly those based in residential homes and those who are homeless?

Key question 6 Interventions for young people developing an alcohol problem through harmful, hazardous or dependent drinking, for use in young people’s alcohol services. P: young people aged under 25 years of age and/or accessing young people’s alcohol services I: interventions for alcohol dependency C: current standards of treatment for young people O: improved health, quality of life, markers of alcohol dependence

5. Areas that will not be covered

Comparison with outcomes prior to reduction in recommended limits for males.

6. Aspects of the proposed clinical topic that are key areas of concern for patients, carers and/or the organisations that represent them

Effective screening of harmful/hazardous drinking, appropriate minimum level interventions. More recovery focused interventions and approaches as part of an integrated care plan.

7. Population

Included Adults in the general public and/or dependent on alcohol individuals, and young people aged under 25 years.

Not included Children (0-12 years)

8. Healthcare setting

Included Primary and secondary care, prison establishments, alcohol (and drug) treatment and care services, older people’s health and social care services.

Not included

9. Potential

Potential to improve current practice Earlier identification of harmful drinking. Increased opportunity for recovery interventions and support and involvement of the service user and carer as part of co-production practice.

Potential impact on important health outcomes (name measureable indicators) Reduced mental and physical health harms e.g. liver, brain, nerve damage, behaviour change. Safer detoxification avoiding sigificant withdrawal.

Potential impact on resources (name measureable indicators) Not applicable at first stage. Second stage onward referral of screened individuals, possible higher numbers of service users due to greater population drinking 14 units per week compared to 16 plus units the previous safe drinking level (pre Jan 2016).

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10. What evidence based guidance is currently available?

None

Out-of-date (list) SIGN 74 – Management of harmful drinking and alcohol dependence in primary care (2004)

Current (list)

11. Relevance to current Scottish Government policies

(See section 1) Alcohol Brief Interventions (ABI) - In 2014/15 there were 99,252 Alcohol Brief Interventions carried out in Scotland. This is 62% more than the 61,081 set out in the Scottish Government HEAT standard for 2014/15. Road to Recovery Drug Policy (2008), National Alcohol Framework (2009), Quality Principles: standard expectations of care and support for drug and alcohol services (2014), and Recovery Outcomes web tool. All of which set the scene for a recovery focus in treatment and care services and improved quality and measured outcomes for service users. Public Bodies (Joint Working) (Scotland) Act 2014 which introduces integrated health and social care services in Scotland for adults (and in some cases children) in the community.

12. Who is this guidance for?

Health and social care professionals in the following settings: primary and secondary care, prison establishments, alcohol (and drug) treatment and care services, and older peole’s services.

13. Implementation

Links with existing audit programmes Current development led by the Care Inspectorate of a new inspection methodology for alcohol and drug health and social care services regulated by the Care Inspectorate and HIS. Current validation of self-assessment in Alcohol and Drug Partnerships based on the national Quality Principles, conducted by the Care Inspectorate on behalf of Scottish Government.

Existing educational initiatives

Strategies for monitoring implementation Monitoring Scotland’s Alcohol Strategy (MESAS) currently gathers information on related activity and outputs, under previous SIGN 74.

14. Primary contact for topic proposal

Joyce O’Hare (Care Inspectorate, Health Improvement Manager )

15. Group(s) or institution(s) supporting the proposal

Care Inspectorate, supported by Healthcare Improvement Scotland. This development will also be of significant interest to Scottish Government, NHS Information and Statistic Division, Scottish Prison Service, and NHS Boards.

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Declaration of Interests Please complete all sections and if you have nothing to declare please put ‘N/A

Having read the SIGN Policy on Declaration of Competing Interests I declare the following competing interests for the previous year, and the following year. I understand that this declaration will be retained by the SIGN Programme Lead and be made available on the SIGN website for time period that the proposal is being considered.

Signature:

Name: Joyce O’Hare

Relationship to SIGN: Topic proposal primary contact

Date: 5th April 2016

Date received at SIGN:

Personal Interests Remuneration from employment

Name of Employer and Post held

Nature of Business Self or partner/ relative

Specific?

Details of employment held which may be significant to, or relevant to, or bear upon the work of SIGN

Care Inspectorate, Health Improvement Manager

Inspection of Scottish health and social care services.

Self

No specific personal interests

Remuneration from self employment

Name of Business Nature of Business Self or partner/ relative

Specific?

Details of self employment held which may be significant to, or relevant to, or bear upon the work of SIGN

N/A

Remuneration as holder of paid office Nature of Office

held Organisation

Self or partner/

relative

Specific?

Details of office held which may be significant to, or relevant to, or bear upon the work of SIGN

N/A

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Remuneration as a director of an undertaking Name of

Undertaking

Nature of Business

Self or partner/ relative

Specific?

Details of directorship held which may be significant to, or relevant to, or bear upon the work of SIGN

N/A

Remuneration as a partner in a firm

Name of Partnership

Nature of Business

Self or partner/ relative

Specific?

Details of Partnership held which may be significant to, or relevant to, or bear upon the work of SIGN

N/A

Shares and securities Description of

organisation Description of

nature of holding (value need not be

disclosed)

Self or partner/ relative

Specific?

Details of interests in shares and securities in commercial healthcare companies, organisations and undertakings

N/A

Remuneration from consultancy or other fee paid work commissioned by, or gifts from, commercial healthcare companies, organisations and undertakings

Nature of work For whom undertaken and

frequency

Self or partner/ relative

Specific?

Details of consultancy or other fee paid work which may be significant of to, or relevant to, or bear upon the work of SIGN

N/A

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Details of gifts which may be significant to, or relevant to, or bear upon the work of SIGN

Non-financial interests Description of interest Self or partner/ relative

Specific?

Details of non-financial interests which may be significant to, or relevant to, or bear upon the work of SIGN

N/A

Non-personal interests Name of company, organisation or

undertaking

Nature of interest

Details of non- personal support from commercial healthcare companies, organisations or undertakings

N/A

Signature: (Health Improvement Manager) Date: 5th April 2016

Thank you for completing this form.

Please return to Roberta James SIGN Programme Lead SIGN Executive, Healthcare Improvement Scotland, Gyle Square | 1 South Gyle Crescent | Edinburgh | EH12 9EB t: 0131 623 4735 e:roberta.james@nhs.net

Data Protection

Your details will be stored on a database for the purposes of managing this guideline topic proposal. We may retain your details so

that we can contact you about future Healthcare Improvement Scotland activities. We will not pass these details on to any third

parties. Please indicate if you do not want your details to be stored after the proposal is published.

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Initial screen

Purpose: initial screening by SIGN Senior Management Team to exclude proposals that are neither

clinical, nor multi-professional, nor appropriate for the SIGN process.

1. Is this an appropriate clinical topic for a SIGN guideline? Is it a clinical topic, what is the breadth of the topic and is there a need for the guideline as identified in the proposal?

Yes, as the previous guideline SIGN 74: The management of harmful drinking and alcohol dependence in primary care has been withdrawn as it was over 10 years old, there is a need for a guideline

2. Is there a suitable alternative product which would address this topic? Would another Healthcare Improvement Scotland product better address the topic?

No

3. Has this topic been considered before and rejected? What were the reasons for rejection and are they still applicable

A joint proposal from Scottish Government and NHS Health Scotland to update SIGN 74 in 2011 was rejected as there was considered to be insufficient evidence to change the recommendations..

4. Outcome

Go forward to the next stage of topic selection The key questions need revision before scoping so ensure they are in PICO format and to narrow the remit. It needs to be clear what the desired outcomes of screening are and care settings.

YES

Reject

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Scope of recent evidence

Summary: Eleven guidelines and 12 health technology assessments were identified with publication dates ranging from 2007–2014. The guidelines were from the UK, USA, Canada and the WHO. The following topics were covered in the guidelines:

brief interventions

tests and screening tools

follow up and support

pharmacological therapy

counselling. Settings covered were primary care, community, pharmacy, acute care and schools. Patient groups included children and young people, adults, pregnant women and disadvantaged men. Five Cochrane reviews provide evidence on brief interventions, psychological, education-, family- and pharmacological-based interventions and motivational interviewing. Settings included primary care, general hospital, preoperative, school and institutional. Patient groups included pregnant and post pregnant women, adolescents and students. A further 180 systematic reviews and 2467 randomised controlled trials were identified. See Annex 1 for further details

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Annex 1

Guidelines All AHRQ guidelines have been withdrawn Association BCM. Problem Drinking. 2013. url: http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/problem_drinking.pdf The following clinical algorithms are provided in the original guideline document: •Screening - Asking About Alcohol Use •Brief Intervention For At-Risk Drinking (no abuse or dependence) •Follow up and Support HIS (2006). Harmful Drinking 1-5. This report examined the prevalence of such problems in emergency departments and was

published in November 2006. Harmful Drinking 2: Alcohol and Assaults This report looked at the number and nature of assault presentations to emergency departments in

Scotland, particularly those related to the use of alcohol, and was published in December 2006. Harmful Drinking 3: Alcohol and Self-harm The third report looks at the number and nature of self-harm presentations to emergency departments in

Scotland, particularly those related to the use of alcohol, and was published in July 2007. Harmful Drinking 4: The use of intravenous B vitamins This report looks at the number and characteristics of patients with serious alcohol problems presenting

to emergency departments in Scotland. In particular, the report gathers evidence on the treatment and management, paying particular attention to the prevalence of intravenous B vitamin administration.

Harmful Drinking 5: Alcohol and Young people This report looks at the prevalence of attendances to emergency departments in Scotland by young

people, particularly those related to the use of alcohol, the treatment and management of this particular group of patients, and was published in February 2008.

Harmful Drinking Final Report: This report summarises the findings of the five reports and the work which was carried out in 15 - 20

mainland emergency departments between October 2005 and June 2007. Examples of good practice are highlighted and recommendations for further work and service improvements are made.

Moyer VA. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med 2013;159(3):210-8 DESCRIPTION: Update of the 2004 U.S. Preventive Services Task Force (USPSTF)

recommendation statement on screening and behavioral counseling interventions in primary care to reduce alcohol misuse. METHODS: The USPSTF reviewed new evidence on the effectiveness of screening for alcohol misuse for improving health outcomes, the accuracy of various screening approaches, the effectiveness of various behavioral counseling interventions for improving intermediate or long-term health outcomes, the harms of screening and behavioral counseling interventions, and influences from the health care system that promote or detract from effective screening and counseling interventions for alcohol misuse. POPULATION: These recommendations apply to adolescents aged 12 to 17 years and adults aged 18 years or older. These recommendations do not apply to persons who are actively seeking evaluation or treatment of alcohol misuse. RECOMMENDATION: The USPSTF recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or

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hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. (Grade B recommendation)The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse in adolescents. (I statement)

National Guideline C. Substance misuse and alcohol use disorders. In: Evidence-based geriatric nursing protocols for best practice. 2012; Parameters of Assessment Screening for alcohol, tobacco, and other drug use is recommended for all community-dwelling and

hospitalized older adults. It is essential that the nurse: State the purpose of questions about substances used and link them to health and safety. Be empathic and nonjudgmental; avoid stigmatic terms such as alcoholic. Ask the questions when the patient is alcohol- and drug-free. Inquire re: patient's understanding of the question (Aalto, Pekuri, & Seppä, 2003 [Level III]). Assessment and screening tools The Quantity Frequency (QF) Index (Khavari & Farber, 1978 [Level VI]): Review all classes of drugs:

alcohol, nicotine, illicit drugs, prescription drugs, over-the counter (OTC ) drugs, and vitamin supplements, for each drug used. Record the types of drugs, including types of beverages; Frequency: the number of occasions on which the drug is consumed (daily, weekly, monthly); Amount of drug consumed on each occasion during the last 30 days. The psychological function, what the drugs does for the individual, is also important to identify. The QF Index tool should be part of the intake nursing history. The "brown bag" approach is also useful. Ask the patient to bring all drugs and supplements he or she uses in a brown bag to the interview.

Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G): Highly valid and reliable, this is a 10-item tool that can be used in all settings. Three minutes for administration. This instrument is derived from the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) with a sensitivity of 93.6% and positive predictive value of 87.2% (Blow et al., 1992 [Level III]).

The Alcohol Use Disorders Identification Test (AUDIT): This 10-item questionnaire has good validity in ethnically mixed groups and scores classify alcohol use as hazardous, harmful, or dependent. Administration: 2 minutes. Sensitivity scores range from 0.74% to 0.84% and specificity around 0.90% in mixed age and ethnic groups (Allen et al., 1997 [Level III]). This instrument is highly effective for use with older adults (Roberts, Marshall, & MacDonald, 2005 [Level III]). Its derivative, the Alcohol Use Disorders Identification Test-C ondensed (AUDIT-C ), is composed of three questions that have proved equally valid in detecting an alcohol-related problem.

Fagerström Test for Nicotine Dependence: This six-question scale provides an indicator of the severity o nicotine dependence: scores less than 4 (very low); 4 to 6 (moderate), and 7 to 10 (very high). The questions inquire about first use early in the day, amount and frequency, inability to refrain, and smoking despite illness. This instrument has good internal consistency and reliability in culturally diverse, mixed-gender samples (Pomerleau et al., 1994 [Level V]).

Atypical presentation: Men and women older than 65 years may have substance use and dependence problems even though the signs and symptoms may be less numerous than those listed in the Diagnostic and Statistical Manual of Mental Disorders 4th ed., text revision (DSM-IV TR).

Signs of central nervous system (CNS) intoxication (i.e., slurred speech, drowsiness, unsteady gait, decreased reaction time, impaired judgment, disinhibition, ataxia): Assess by individual or collateral (speaking with family members) data collection, detail the consumption of amount and type of depressant medications including alcohol, sedatives, hypnotics, and opioid or synthetic opioid analgesics. Obtain a blood alcohol level. Marked intoxication 0.3% to 0.4%, toxic effects occur at 0.4% to 0.5%, coma and death at 0.5% or higher.

Assess vital signs and determine respiratory, cardiac, or neurological depression. Assess for existing medical conditions, including depression. Arrange for emergency room or hospitalization treatment as necessary. Obtain urine for toxicology, if possible. Assess for delirium that can be confused with intoxication and withdrawal in the older adult. At-risk drinking is regular consumption of alcohol in excess of one drink per day for 7 days a week or

more than three drinks on any one occasion. Assess for readiness to change behavior using stages of change model (Prochaska & Di C lemente,

1992 [Level II]). Is drinker concerned about amount or consequences of the drinking? Has she or he contemplated

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cutting down? Does she or he have a plan for cutting down or stopping consumption? Has she or he previously stopped but then resumed risky drinking? Personalized feedback and on "at-risk drinking" results in a reduction in at risk drinking among older

primary care patients. Treatment of acute alcohol withdrawal syndrome (guidelines are modified for other C NS depressant

drugs such as barbiturates, heroin, sedative hypnotics): Assess for risk factors: (a) previous episodes of detoxification; (b) recent heavy drinking; (c) medical

comorbidities including liver disease, pneumonia, and anemia; and (d) previous history of seizures or delirium (Wetterling et al., 2006 [Level III]).

Assess for extreme C NS stimulation and a minor withdrawal syndrome evidenced in tremors, disorientation, tachycardia, irritability, anxiety, insomnia, and moderate diaphoresis. When these signs are not detected, life-threatening situations for older adults often result. When these signs are not detected, life-threatening situations for older adults often result. Withdrawal, occurring 24 to 72 hours after the last drink, can progress to seizures, hallucinosis, withdrawal delirium, extreme hypertension, and profuse diarrhea from 4 to 8 hours and for up to 72 hours following cessation of alcohol intake (delirium tremens [DTs]).

Assess neurological signs, using the C linical Institute Withdrawal Assessment for Alcohol, Revised (C IWA-Ar). This C IWA-Ar is a 10-item rating scale that delineates symptoms of gastric distress, perceptual distortions, cognitive impairment, anxiety, agitation, and headache (Sullivan et al., 1989 [Level III]).

Medicate with a short-acting benzodiazepine (lorazepam or oxazepam) in doses titrated to patient's score on the C IWA-Ar, patient's age and weight; use one third to one half recommended dose (Amato et al., 2010 [Level I]). C ontinue C IWA-Ar to monitor treatment response.

Provide emotional support and frequent reorientation in a cool, low stimulation setting; monitor hydration and nutritional intake. Give therapeutic dose of thiamine and multivitamins.

Reported sleep disturbance, anxiety, depression, problems with attention and concentration (acute care):

Assess for neuropsychiatric conditions using the mental status exam, Geriatric Depression Scale, or Hamilton Anxiety Scale.

Obtain sleep history because drugs disrupt sleep patterns in older persons. Assess intake of all drugs, including alcohol, OTC , prescription, herbal and food supplements, and

nicotine. Use "brown bag" strategy. If positive for alcohol use, assess for last time of use and amount used. Assess for alcohol or sedative drug withdrawal as indicated. Smoking cigarettes or using smokeless tobacco: Assess for level of dependence using the Fagerström Test (see the Screening Tools for Alcohol and

Drug Use section in the original guideline document). Nursing Care Strategies At-risk drinking (consumption of alcohol in excess of one drink per day for seven days a week or more

than three drinks on any one occasion) or excess alcohol consumption (more than three or four drinks on frequent occasions):

Conduct Screening, Brief Intervention, and as indicated, Referral to Treatment (Substance Abuse and Mental Health Services Administration, 2008 [Level I]):

Screen using the AUDIT-C , AUDIT, or SMAST-G. Feedback information to the client about current health problems or potential problems associated with

the level of alcohol or other drug consumption. Stress client's responsible choice about actions in response to the information provided. Advice must be clear about reducing his or her amount of drinking or total consumption. Recommend drinking according to National Institute on Alcohol Abuse and Alcoholism (NIAAA) levels for

older adults. Provide a menu of choice to the patient or client regarding future drinking behaviors. Offer information based on scientific evidence, acknowledge the difficulty of change, and avoid

confrontation. Empathy is essential to the exchange. Support self-efficacy. Help client explore options for change. Assist client in identifying options to solving the identified problem. Review the pros and cons of behavior change options presented. Help client weigh potential decisions by considering outcomes.

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Smoking cigarettes or using smokeless tobacco: Apply the 5 As Intervention ("AHRQ clinical practice guidelines," 2002): Ask: Identify and document tobacco use. Advise: Urge the user to quit in a strong personalized manner. Assess: Is the tobacco user willing to make a quit attempt at this time? Assist: If user is willing to attempt, refer for individual or group counseling and pharmacotherapy. Refer

to telephone "quitlines" in region or state. Arrange referrals to providers, agencies, and self-help groups. Monitor pharmacotherapy once quit date

is established. The U.S. Food and Drug Administration (FDA)-approved pharmacotherapies for smoking cessation are the following: Bupropion sustained release (SR) (Zyban) and nicotine replacement products such as nicotine gum,

nicotine inhalers, nicotine nasal spray, and nicotine patch. Nurse-initiated education about these medications is essential Zyban, for example, should not be combined with alcohol. Nurses working with inpatients in a case

management model were found to produce outcomes in smoking cessation (Smith et al., 2002 [Level III])

Caring, concern, and provide ongoing support Communicate caring and concern: Encourage moderate intensity exercise to reduce cravings for nicotine because 5 minutes of such

exercise is associated with short-term reduction in the desire to smoke and tobacco withdrawal symptoms (Daniel et al., 2004 [Level II]).

Arrange: Schedule follow-up contact in person or by telephone within 1 week after planned quit date. Continue telephone counseling especially those using medications and nicotine patches (Boyle et al., 2005 [Level III]; C ooper et al., 2004).

Alcohol dependence Assess patient for psychological dependence. Assess patient for (a) physiological dependence and (b) "tolerance." Psychological dependence occurs

with both abuse and dependence and is more difficult to resolve. Assess for need for medical detoxification (see the Alcohol Withdrawal in Inpatient Hospitalization

section in the original guideline document). Refer patient and family to addictions or mental health nurse practitioner or physician. Evaluate patient and family capacity to implement referral. On successful detoxification, monitor use of medications, interpersonal therapies, and participation in

self-help groups. Marijuana dependence: Little research on effective intervention for psychological dependence on

marijuana is available. Some guidance can be found in smoking cessation and self-help approaches.

Refer to steps for smoking cessation (see "Smoking C igarettes or Using Smokeless Tobacco," above). Refer patient to addiction specialist for counseling for psychological dependence and/or cognitive

behavioral therapy. Refer to community-based self-help groups such as Narcotics Anonymous, Alcoholics Anonymous, and

Al-Anon. Encourage development or expansion of patient's social support system. Heroin or opioid dependence Older long-term opioid users may continue use, relapse, and seek treatment. Methadone or

buprenorphine are current pharmacological treatment options, effective in conjunction with self-help programs and/or psychosocial interventions.

Treatment with methadone, a synthetic narcotic agonist, suppresses withdrawal symptoms and drug cravings associated with opioid dependence but requires daily dosing of 60 mg, minimum. It is dispensed only in state licensed clinics.

Buprenorphine (Subutex or Suboxone), recently approved for use in office practice by trained physicians, is an opioid partial agonist–antagonist. Alone and in combination with naloxone (Suboxone), it can prevent withdrawal when someone ceases use of an opioid drug and then be used for long-term treatment. Naloxone is an opioid antagonist used to reverse depressant symptoms in opiate overdose and at different dosages to treat dependence (C enters for Substance Abuse Treatment [C SAT], 2004 [Level VI]).

Close collaboration with the prescriber is required because these drugs should not be abruptly terminated or used with antidepressants and interact negatively with many prescription

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medications Naltrexone, a long-acting opioid antagonist, blocks opioid effects and is most effective with those who

are no longer opioid dependent but are at high risk for relapse (Srisurapanont & Jarusuraisin, 2005 [Level III]).

Treatment of the older patient who has become addicted to Oxycontin or other opioids should be done in consultation with an addictions specialist nurse or physician.

It is recommended that prescribers avoid opioids and the synthetic opioids (Demerol, Dilaudid, and Oxycontin). Opioids have high potential for addiction and

Demerol has been associated with delirium in older adults (C SAT, 2004 [Level VI]) Barbiturates should be avoided for use as hypnotics and the use of benzodiazepines for anxiety should

be limited to 4 months (U.S. Department of Health and Human Services, 2004 [Level VI]) Treatment and relapse prevention Monitor pharmacologic treatment such as naltrexone as short-term treatment for alcohol dependence.

The benefits of this treatment are dependent on adherence and psychosocial treatment should accompany its use (World Health Organization, 2000 [Level I]). Methadone or buprenorphine should be used for long-term treatment of opioid dependence.

Group psychotherapy in limited studies using a cognitive behavioral approach has produced good outcomes with older adults (Payne & Marcus, 2008 [Level III]).

Refer to community-based groups such as Alcoholics Anonymous, Narcotics Anonymous, Al-Anon groups, and encourage attendance.

Educate family and patient regarding signs of risky use or relapse to heavy or alcohol-dependent behavior.

Counsel patient to reduce drug use (harm reduction) and engage in relationship healing or building, community or intellectually rewarding activities, spiritual growth, and so on that increase valued nondrinking rewards.

Counsel in the development of coping skills: Anticipate and avoid temptation. Learn cognitive strategies to avoid negative moods. Make lifestyle changes to reduce stress, improve the quality of life, and increase pleasure. Learn cognitive and behavioral activities to cope with cravings and urges to use. Encourage development or expansion of patient's social support system. Follow-up Monitoring Evaluate for increase in substance use or misuse associated with growing numbers of aging adults. Increase outreach to targeted vulnerable populations. Document chronic care needs of older adults diagnosed with substance-related disorders. Monitor alcohol use among older adults with chronic pain. Communicate findings to all members of the caregiver team. NICE (2007). Alcohol: school-based interventions (PH7). NICE (2010). Alcohol-use disorders: diagnosis and management of physical complications CG100. NICE (2010). Alcohol-use disorders: prevention PH24. NICE. Alcohol-use disorders: diagnosis and management QS11. 2011. url: https://www.nice.org.uk/guidance/qs11# This quality standard covers the care of children (aged 10-15 years), young people (aged 16-17

years) and adults (aged 18 years and over) drinking in a harmful way and those with alcohol dependence in all NHS-funded settings. It also includes opportunistic screening and brief interventions for hazardous and harmful drinkers. The quality standard addresses the prevention and management of Wernicke's encephalopathy but does not cover the separate management of other physical and mental health disorders associated with alcohol use

NICE (2011). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence CG115. NICE (2012). Alcohol (LGB6).

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NICE. Nalmefene for reducing alcohol consumption in people with alcohol dependence. 2014. url: https://www.nice.org.uk/guidance/ta325# Nalmefene is recommended within its marketing authorisation, as an option for reducing alcohol consumption, for people with alcohol dependence: •who have a high drinking risk level (defined as alcohol consumption of more than 60 g per day for men

and more than 40 g per day for women, according to the World Health Organization's drinking risk levels) without physical withdrawal symptoms and

•who do not require immediate detoxification. The marketing authorisation states that nalmefene should: •only be prescribed in conjunction with continuous psychosocial support focused on treatment

adherence and reducing alcohol consumption and •be initiated only in patients who continue to have a high drinking risk level 2 weeks after initial

assessment NICE (2016). Alcohol Use disorders - Pathway. Health Scotland. Commentary on NICE Public Health Guidance 7: Interventions in schools to prevent and reduce alcohol use among children and young people. 2008. url: http://www.healthscotland.com/uploads/documents/6816NICEPHG007HScommentarySummary18Apr08.pdf This Summary presents Comments/Conclusions from the HS Commentary on NICE Public

Health Guidance 7 (NICEPHG007 – Public Health Intervention Guidance), published in November 2007, entitled Interventions in schools to prevent and reduce alcohol use among children and young people. These Comments/Conclusions are intended to help organisations, professionals and others make use of the NICE Guidance in a Scottish context. The Commentary does not in itself constitute formal Guidance or Guidelines. Its scope and contents are limited by those of the NICE Guidance on which it is based. The Commentary should not be seen as a full action plan or full basis for a health improvement strategy on the subject area concerned, but rather as one evidence-informed contribution to such an action plan or strategy

Health Scotland (2009). Changing Scotland’s Relationship with Alcohol: A Framework for Action. Government, S. SUMMARY 1. This Framework sets out our strategic approach to tackling alcohol misuse in Scotland. It explains the

need for action in order to help deliver Government’s Purpose and outlines how we intend to take forward the proposals contained in our discussion paper “Changing Scotland’s Relationship with Alcohol” following the outcome of our public consultation in 2008, a summary of which is contained in Annex A to this document.

2. As our discussion paper made clear, this Government is not anti-alcohol; we are antialcohol misuse. But the extent of alcohol misuse in Scotland and its impact on us all mean that the need for a new approach is overwhelming. Significant increases in the affordability of alcohol - alcohol is now 70% more affordable than in 19801 - have helped drive an increase in consumption of 19% over the same period2. This in turn has fuelled significant increases in deaths and illness.3

3. The Government is already taking action on a number of fronts which will contribute to addressing the underlying causes of, and dealing with the negative impacts resulting from, Scotland’s complex relationship with alcohol. These include the Government’s Economic Strategy and our joint work with local government to improve early years and early intervention and to address health inequalities. Through this work and through direct interventions focused on alcohol use, we are convinced of the need to take action to rebalance Scotland’s relationship with alcohol if we are to maximise our potential as individuals, families, communities, and as a country.

4. We are committed to taking action now through legislative change and a record investment in prevention treatment and services, as well as building an environment that supports culture change in the longer term. We recognise that we cannot achieve this alone and that we must work with a wide range of partners. Crucially, we must encourage individuals to reflect on their drinking and how it impacts on themselves and others.

5. But Government has a key leadership role and we are determined to rise to the challenge. Based on knowledge and understanding of alcohol misuse, its drivers, and evidence-based interventions, our Framework for Action identifies the need for sustained action in four areas:

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6. The Framework outlines a package of measures which can together reduce alcohol related harm and contribute to a successful and flourishing Scotland. Each section outlines actions already underway, existing and new commitments. The way forward has been informed and shaped by the consultation responses, an analysis of which has been undertaken by independent consultants and is published at the same time as this Framework. In relation to our consultation proposals specifically we intend to:

-cost selling of alcoholic drinks in licensed premises (p11);

-sales purchases to 21 in part or all of their Board area and provide powers for Chief Constables and Licensing Forum to request a review of their local Board’s policy

);

(p21). We do not intend to pursue separate supermarket checkouts for alcohol sales, or raise the age for those

staffing such checkouts, at the present time. WHO (2014). Guidelines for identification and management of substance use and substance use disorders in pregnancy. These guidelines contain recommendations on the identification and management of substance

use and substance use disorders for health care services which assist women who are pregnant, or have recently had a child, and who use alcohol or drugs or who have a substance use disorder. They have been developed in response to requests from organizations, institutions and individuals for technical guidance on the identification and management of alcohol and other substance use and substance use disorders in pregnant women, with the target of healthy outcomes for both pregnant and their fetus or infant.