Alcohol: treatment for alcohol misuse

Introduction

The treatment options available for alcohol misuse depend on whether drinking is hazardous, harmful or dependent, and whether the patient is trying to drink less (moderation) or give up drinking completely (abstinence). At-risk drinkers may initially be given or referred to a short counselling session, known as an Alcohol Brief Intervention (ABI). This may follow on from an alcohol-related accident or injury. Further treatment can involve specialist counselling or other forms of therapy to achieve moderation or abstinence. Abstinence will usually be recommended for people with moderate to severe dependency. Sometimes medication is prescribed to help successfully achieve abstinence and prevent relapse.

Alcohol Brief Interventions

An Alcohol Brief Intervention (ABI) is a short, evidence-based, structured conversation about alcohol consumption with a patient or service-user that seeks, in a non-confrontational way, to motivate and support the individual to think about and/or plan a change in their drinking behaviours in order to reduce their consumption and/or their risk of harm.

As part of a wider performance management programme for NHS Scotland, the Scottish Government, in 2008/09, set a Health Improvement, Efficiency, Access and Treatment target for Alcohol Brief Interventions (HEAT H4), which required NHS Boards to deliver an agreed number of interventions. Resources for alcohol brief interventions can be found on the Public Health Scotland website.  In 2012/13 this target became a HEAT standard and since 2015/16 ABI delivery has been linked to the NHS Scotland Local Delivery Plan (LDP) Standard. The standard is measured in three priority settings – primary care, accident & emergency, and antenatal. From 2012/2013 this also included wider settings (e.g. prisons, pharmacies, dentistry or social work/care).

The LDP Standard has two elements: it stipulates a minimum number of ABIs to be delivered in Scotland in any setting (61,081 in 2019/20), and specifies that a minimum of 80% (48,865 in 2019/20) of those ABIs need to be delivered in priority settings. In addition, the standard states that NHS Boards should carry out screenings using an appropriate screening tool, and follow up with an ABI where required. Both the screening and the ABI (if applicable) are delivered in line with national guidance.

ABI figures are reported annually by Public Health Scotland. Key points from the 2019/20 alcohol brief interventions data are:

• Whilst the number of ABIs delivered in recent years has fallen from a peak of 104,356 in 2013/14, there were 75,616 ABIs delivered in 2019/20, which is 23.8% more than the 61,081 ABIs to be delivered as set out in the LDP standard.
• Nine of the fourteen NHS Boards met or exceeded their LDP standard for delivery of all ABIs.
• Just over two thirds of ABIs (67.2%) were delivered in the designated priority settings of primary care (52.7%), Accident & Emergency departments (12.4%) and antenatal settings (2.2%). The remaining 32.8% were delivered in non-priority settings.
• Overall, 50,833 ABIs were delivered in priority settings in 2019/20, which is 1,968 more ABIs than the number of priority settings ABIs associated with the standard (48,865). Six NHS Boards met or exceeded their LDP standard for ABIs delivered in priority settings.

Drug & Alcohol Information System (DAISy)

Data from specialist drug and alcohol treatment service providers was previously collected in the Drug and Alcohol Treatment Waiting Times (DATWT) database. In April 2021, the Drug & Alcohol Information System (DAISy) went live for all NHS Scotland Boards. DAISy is a national database developed to collect drug and alcohol referral, waiting times and outcome information from staff delivering specialist drug and alcohol treatment.  Reports on drug and alcohol treatment services in 2021/22 and beyond should be based entirely on DAISy data.

The Scottish Government set a target that by March 2013, 90% of people who need help with their drug or alcohol problem will wait no longer than three weeks for treatment that supports their recovery (HEAT Target A11). The target was achieved and has now become a Local Delivery Plan (LDP) standard. All recent (quarterly) publications can be found in the Drug & Alcohol Publications section on the PHS website. The percentage of waits longer than three weeks is also an indicator included in the ScotPHO Profile, where data is shown at Scotland, NHS Board and ADP level.

The first report providing an overview of initial assessments for specialist drug and alcohol treatment services in Scotland during 2021/22 and 2022/23 was published in June 2023, with an accompanying Excel workbook.

Medications to treat alcohol dependency

NICE guidelines recommend that harmful drinkers and people with mild alcohol dependence are offered a psychological intervention (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol-related cognitions, behaviour, problems and social networks. However, for those who have not responded to psychological interventions alone, or who have specifically requested a pharmacological intervention, medication is available for prescription. These medications to treat alcohol dependency include:

• Acamprosate – this works by affecting levels of chemicals in the brain thought to be partially responsible for inducing a craving for alcohol.
• Naltrexone – this works by blocking the opioid receptors in the body, stopping the effects of alcohol.
• Disulfiram – this works by causing unpleasant physical reactions when any alcohol is drunk (e.g. nausea, chest pain, vomiting, dizziness).
• Nalmefene –works by blocking the opioid receptors in the body, stopping the effects of alcohol.

For people with moderate and severe alcohol dependence who are successfully trying to withdraw, prescription of acamprosate or naltrexone; or disulfiram is an option (all in combination with a psychological intervention).

The Excel workbook Drugs used in Alcohol Dependence (159 KB) contains information on the dispensing of drugs for the treatment of alcohol dependency in Scotland (BNF section 4.10.1). Note that Naltrexone is not specific to treatment for alcohol dependence and is therefore not included in the tables. Table 1 (159 KB) provides information on the number of patients who have been prescribed any alcohol dependence drug, based on prescriptions where the Community Health Index (CHI) number was recorded (the CHI number is a unique 10-character numeric identifier, allocated to each patient on first registration with the system). The CHI capture rate (the percentage of items with a valid CHI attached) should be considered when interpreting any trends in patient data. CHI capture rates have changed over the years presented and the impact of this on the number of patients identified is hard to ascertain.

The CHI capture rates are shown in the Introduction tab of the Excel workbook. In 2019/20, the recording of CHI varied between 91.5% for the drug nalmefene, to 95.8% for acamprosate. 

Table 2 (159 KB) shows a summary of the number of dispensed items, gross ingredient costs, defined daily doses (see definition in the Introduction tab of the Excel file), and the defined daily doses per 10,000 population per day for each year from 2009/10 to 2019/20 in Scotland for each of the drugs.

Table 3 (159 KB) provides a breakdown for each drug at NHS Health Board level, for each year from 2009/10 to 2019/20.

Key points:

• In 2019/20, there were 8,915 patients dispensed drugs for alcohol dependency, a 1.3% increase from the previous year (8,804 patients). The number of patients had previously decreased between 2015/16 and 2018/19.
• In 2019/20 61% of those dispensed drugs for alcohol dependence were male and 39% were female. These percentages have changed little over the available time series.
• In 2019/20, there were 5,751 patients dispensed acamprosate, 4,221 dispensed disulfiram and 59 dispensed nalmefene.
• The gross ingredient cost of drugs for alcohol dependence was approximately £2.7 million in 2019/20, this is a 12.7% increase compared with 2018/19.
• The number of people receiving treatment with drugs for alcohol dependence is higher in the more deprived areas; in 2019/20 there were five times as many patients living in the most deprived areas compared to the least deprived areas. Nearly two fifths (39%) of patients dispensed drugs for alcohol dependence lived in the 20% most deprived areas.
• As chart 1 shows below, the proportion of older patients (50+) dispensed drugs for alcohol dependency is increasing over time. In 2009/10, patients aged 50 and older made up 51% of the patients dispensed drugs for alcohol dependency, rising to 60% in 2019/20. Trends by 5-year age group can be found in Table 1 (159 KB) of the Excel workbook. Trends are not linear for all age groups, particularly 45-49 and 50-54 year olds.

More information about prescribed items in Scotland can be found at the Public Health Scotland website under the Prescribing & Medicines topic and in the Public Health Scotland monthly prescribing activity data publications.