1.1 The need for a guideline
Harmful drinking and alcohol dependence are common conditions which contribute considerably to morbidity, mortality and burden to the NHS, as well as causing social harm:
1.2.1 UNIT OF ALCOHOL
One “unit” in the UK usually means a beverage containing 8 g of ethanol, eg a half pint of 3.5% beer or lager, or one 25 ml pub measure of spirits. A small (125 ml) glass of average strength (12%) wine contains 1.5 units (see Annex 1 for a list of the alcohol content of a range of beverages).
1.2.2 HAZARDOUS DRINKING
The term hazardous drinking is widely used. It is synonymous with “at-risk drinking” and can be defined as the regular consumption of:
These figures derive from population studies showing the relationship of self reported levels of drinking to risk of harm. It is arbitrary which point on the risk curve is deemed to merit a warning.9, 10, 11, 12, 13 Other authorities have quoted weekly recommended upper limits for alcohol consumption of 21 units per week for men and 14 units per week for women.14
Consuming over 40 g/day alcohol on average doubles a man’s risk for liver disease, raised blood pressure, some cancers (for which smoking is a confounding factor) and violent death (because some people who have this average alcohol consumption drink heavily on some days). For women, over 24 g/day average alcohol consumption increases their risk for developing liver disease and breast cancer.9, 10, 11, 12 These studies used self reported consumption figures.
The term hazardous drinking is also used loosely to cover those who have experienced minimal as opposed to serious harm.
1.2.3 HARMFUL DRINKING
Harmful drinking is defined in the International Classification of Diseases (ICD-10) as a pattern of drinking that causes damage to physical (eg to the liver) or mental health (eg episodes of depression secondary to heavy consumption of alcohol).15 The diagnosis requires that actual damage should have been caused to the mental or physical health of the user.
1.2.4 ALCOHOL DEPENDENCE
Alcohol dependence is defined as a cluster of physiological, behavioural, and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that previously had greater value.15 A central characteristic is the desire (often strong, sometimes perceived as overpowering) to drink alcohol. Return to drinking after a period of abstinence is often associated with rapid reappearance of the features of the syndrome (priming).
A definitive diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:
1.3 Population covered by the guideline
This guideline pertains to patients with alcohol dependence, hazardous or
harmful drinking, in primary care (general practice and community nursing) and
among those attending, but not admitted from, A&E Departments.
The guideline does not address some specific situations:
A health technology assessment has been performed by NHS Quality Improvement Scotland on the prevention of relapse in alcohol dependence in specialist settings, which complements this guideline (see Annex 8).
1.4 Statement of intent
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.
1.5 Review and updating
This guideline was issued in 2003 and will be considered for review as new evidence becomes available. Any updates to the guideline in the interim period will be noted on the SIGN website: www.sign.ac.uk