Alcohol Pathway

Step Pathway Details
Step 1 – Triage
  • Referral: Self-referral, online, phone, via family, or professionals.
  • AUDIT Screening: Assess alcohol use with the Alcohol Use Disorders Identification Test (AUDIT).
  • AUDIT Scores:
    • 0-7: Low-risk drinking – provide positive reinforcement.
    • 8-15: Hazardous drinking – offer structured brief intervention.
    • 16-19: Harmful drinking – offer extended brief interventions (EBI).
    • 20+: Likely dependence – conduct Severity of Alcohol Dependence Questionnaire (SADQ).
  • Medical Screening: If SADQ 16+, request a GP summary and schedule a Nurse Alcohol Assessment
    Alcohol Pathway (SADQ Guidance)

    This pathway outlines when to refer clients for a nurse assessment or medical review based on their Severity of Alcohol Dependence Questionnaire (SADQ) score and presenting concerns.

    • SADQ <16 (Requesting Relapse Prevention Medication):
      • If there has been no nurse assessment in the last 3 months, refer to your locality nurse for observations and GP summary. Discuss blood test results and next steps.
      • If no immediate medical concerns are identified, no new nurse assessment may be required.
    • SADQ 16+ (No Major Concerns):
      • If the client declines a nurse assessment, inform the locality nurse.
      • If no urgent medical issues are flagged, the assessment can be conducted over the phone, then followed up with blood tests if indicated.
    • SADQ 16+ (Multiple Health Conditions):
      • Refer to the nurse, highlighting any significant health concerns or high-risk factors.
      • If SADQ is 40+ (indicating higher severity), mark as high priority for nurse assessment.
    • SADQ 16+ (Not Dependently Drinking, e.g., Binging):
      • No nurse assessment required unless otherwise indicated.
      • Prescribing decisions may be carried out directly by the medic or nurses as needed.

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  • Physical Health Check: Ask 12 alcohol-related physical health questions to identify immediate health concerns.
    • Twelve Questions to Ask about Alcohol-Related Physical Ill Health

    These 12 questions are designed for the generic worker to ask when discussing alcohol-related physical health. They aim to raise awareness of the potential risks of alcohol to one’s health. Please ensure you ask for permission before proceeding and encourage the individual to seek medical advice (e.g. contact their GP or NHS 111) if any issues arise.

    1. Do you ever experience a painful feeling of heaviness or tightness in your chest?

    This question explores whether there have been any symptoms of a heart attack. If the individual answers “yes,” ask when they last experienced the pain and its duration. If the symptoms are active, advise immediate medical attention – call 999 for an ambulance.

    2. Have you coughed or noticed blood in your vomit?

    This question is aimed at identifying gastrointestinal issues such as a Mallory-Weiss tear. Bright red blood or a “coffee grounds” appearance in vomit may indicate a serious problem. If the response is positive, advise the person to seek medical attention promptly.

    3. Have you ever noticed or has someone commented that the whites of your eyes or your skin have turned yellow?

    This question is designed to detect signs of alcoholic liver disease, such as alcoholic hepatitis. A change in colour can be a potentially life-threatening indicator. Advise immediate medical attention if this symptom is present.

    4. Have you passed any blood from your back passage?

    This question helps identify bleeding issues that may result from ulceration or oesophageal varices. Ask about the colour and consistency of the blood. Bright red or tar-like (black) blood should prompt medical evaluation.

    5. Do you have a sensation of numbness or pins and needles in your feet or hands?

    This question aims to detect peripheral neuropathy, which can cause pain, loss of sensation, and muscle control issues. If symptoms are present, consider advising a healthcare review.

    6. Have you had a history of head injuries (including non-alcohol related and as a child)?

    A history of head injuries may predispose individuals to alcohol-related brain injury or increase the risk of seizures during withdrawal. Ask for details of any past injuries and associated symptoms.

    7. Have you lost or gained weight unexpectedly recently?

    Unexplained weight changes can signal liver disease (such as ascites) or muscle degeneration. If significant changes are noted, advise the individual to seek medical evaluation.

    8. Have you noticed that you bruise more easily than normal?

    Easily bruising may indicate impaired liver function and reduced production of clotting factors. A positive response should lead to further medical inquiry.

    9. Do you experience or have you experienced a severe, dull pain around the top of your stomach that develops suddenly?

    This question aims to detect acute pancreatitis. Since pain may be referred to other areas, clarify the location and severity. Advise immediate medical attention if symptoms are acute.

    10. Have you or a relative/carer expressed concerns about your memory?

    This question addresses potential cognitive impairment from alcohol. Memory issues may indicate effects on the brain and warrant further evaluation by a healthcare professional.

    11. Are you pregnant or thinking about becoming pregnant?

    The safest approach during pregnancy is to abstain from alcohol to minimise risks to the unborn baby. Advise seeking medical advice and support if the individual is pregnant or planning pregnancy.

    12. When was the last time you had your blood pressure checked or had a blood test?

    This question opens up discussion about recent health monitoring. If the individual has not had recent blood tests (e.g. within the last 3 months), encourage them to consult a healthcare professional for further tests.
Step 2 – Personalised Assessment
  • Comprehensive Alcohol Assessment:
    • Nurse conducts face-to-face assessment within 10 working days.
    • Includes blood tests: Full Blood Count (FBC), U&Es, Liver Function Tests (LFTs).
    • Consider additional testing for **Wernicke’s Encephalopathy (WE)**.
  • Risk Segmentation: Based on **cglgl085 Alcohol Risk Segmentation Guide**:
    • Low Risk: Community-based detox if medically appropriate.
    • Medium Risk: MDT discussion to determine safest treatment option.
    • High Risk: MDT review and inpatient/residential detox if needed.
  • Harm Reduction & Safeguarding:
    • Offer **oral thiamine** for those drinking at harmful/dependent levels.
    • Discuss **Blue Light Project** for non-engaging service users.
Step 3 – Treatment & Detoxification
  • Community-Based Detox (SADQ 16-30):
    • Requires stable home environment and **supportive other** (e.g., family).
    • Use of **Chlordiazepoxide (Librium) or Diazepam**.
    • Monitor using **CIWA-Ar Scale** and adjust medication accordingly.
  • Inpatient/Residential Detox (SADQ 30+ or Complex Needs):
    • Required for those with **severe withdrawal risk** (e.g., history of seizures, DTs).
    • Discuss case at **Alcohol MDT** to determine best facility.
    • Monitor for **Wernicke’s Encephalopathy**, manage with **parenteral thiamine (IM Thiamine).**
  • Step-Down Detox (Hospital to Community):
    • For those started on detox in hospital, **continue treatment in the community**.
    • Ensure discharge plan includes **medication regime & relapse prevention.**
Step 4 – Relapse Prevention & Aftercare
  • Post-Detox Medical Review (2 weeks):
    • Assess for **side effects of relapse prevention medication**.
    • Screen for **anxiety & depression (GAD-7, PHQ-9).**
  • Ongoing Support & Monitoring:
    • **12-week full risk review** including AUDIT & relapse prevention check.
    • **6-monthly medical review** to assess for long-term stability.
  • Medication-Assisted Relapse Prevention (where appropriate):
    • Acamprosate: Neuroprotection & cravings reduction.
    • Naltrexone: Reduces cravings; used post-detox.
    • Disulfiram (Antabuse): Aversion therapy; requires monitoring.
    • Nalmefene: For controlled drinking pathway (mild-moderate dependence).
Step 5 – Disengagement & Re-Engagement
  • If a service user declines detox:
    • Provide **harm reduction advice** and vitamin supplementation.
    • Document on **case management system** and notify GP.
    • Offer **future re-engagement options**.
  • Persistent Disengagement:
    • MDT review to assess **risk escalation and safeguarding concerns**.
    • Use **local re-engagement procedures** and MDT-led outreach.
    • Consider escalation to **Adult Safeguarding** where necessary.
Step 6 – Special Considerations
  • Pregnant Service Users:
    • Enhanced pathway with **multi-disciplinary input**.
    • Consider **Diazepam for detox** (avoid Chlordiazepoxide if possible).
  • Homeless Service Users:
    • Alternative detox settings considered based on individual need.
    • Daily medication collection from pharmacy where possible.
  • Severe Cognitive Impairment (Wernicke-Korsakoff):
    • Ensure **high-dose thiamine supplementation**.
    • Refer to **specialist neurological support** where needed.
  • Driving & Alcohol Use:
    • Service users must notify **DVLA** if alcohol use affects safe driving.
    • Staff should notify authorities if an individual continues to drive under the influence.