Health Technology Board for Scotland Health Technology Assessment of Prevention of Relapse in Alcohol Dependence Consultation Assessment Report Authors: Slattery J, Chick J, Cochrane M, Craig J, Godfrey C, Macpherson K, Parrott S With significant contributions from a broad range of Scottish and UK experts (see Appendix 1) Version: 26 July 2002 Consultation comments should be sent by 17 September 2002 to: Ms Susan Quinn, Medical Writer Phone +44 (0)141 225 6999 Email [email protected] (See section 2.3 for further details) i CONTENTS 1 EXECUTIVE SUMMARY............................................................................................... 1 1.1 Background ........................................................................................................ 1 1.2 Objectives of this Health Technology Assessment............................................ 1 1.3 Health Technology Assessment Evidence ......................................................... 2 1.4 Clinical Effectiveness......................................................................................... 2 1.5 Patient issues...................................................................................................... 4 1.6 Economic Evaluation......................................................................................... 5 1.7 Organisational Issues.......................................................................................... 6 1.8 Draft Recommendations..................................................................................... 7 1.9 Consultation....................................................................................................... 8 2 INTRODUCTION AND OBJECTIVES .......................................................................... 9 2.1 Introduction........................................................................................................ 9 2.2 Objectives......................................................................................................... 10 2.3 Current stage of assessment: Open consultation.............................................. 10 3 BACKGROUND............................................................................................................. 13 3.1 Alcohol misuse in Scotland.............................................................................. 13 3.2 Treatment strategy and settings ........................................................................ 14 3.3 Health Consequences of High Levels of Drinking........................................... 15 3.4 Social and Economic Consequences of Problem Drinking.............................. 16 3.5 The Prevalence of Alcohol Dependence .......................................................... 16 3.6 Special Subgroups............................................................................................ 18 3.6.1 Comorbidity..................................................................................................... 18 3.6.2 Dual Substance Dependence ............................................................................ 18 3.6.3 Alcohol Problems in Offenders........................................................................ 19 3.6.4 Homelessness and Alcohol Problems .............................................................. 19 3.6.5 Alcohol vs Drug Misuse................................................................................... 19 3.7 Organisation of NHSScotland .......................................................................... 20 3.8 Structure and aims of current services ............................................................. 21 3.8.1 Defining Success.............................................................................................. 22 3.9 The Draft Alcohol Problems Support and Treatment Services Framework .... 22 3.10 HTBS surveys of Scottish services .................................................................. 23 3.11 Psychosocial Interventions ............................................................................... 23 3.12 Psychosocial Interventions within NHSScotland............................................. 25 3.13 Psychosocial Interventions in Non NHS Services ........................................... 27 3.13.1 Alcoholics Anonymous.................................................................................... 28 3.14 Pharmacological Interventions ......................................................................... 29 3.14.1 Disulfiram......................................................................................................... 29 3.14.2 Acamprosate..................................................................................................... 30 3.14.3 Naltrexone ........................................................................................................ 30 3.15 Pharmacological Interventions in NHS Specialist Services in Scotland.......... 31 3.15.1 Disulfiram......................................................................................................... 32 3.15.2 Acamprosate..................................................................................................... 33 3.15.3 Naltrexone ........................................................................................................ 34 3.16 The Care Pathway............................................................................................ 34 3.17 Default, non-adherence and recurrent relapse.................................................. 35 3.18 Services available for alcohol related problems............................................... 35 3.18.1 NHS Specialist Services................................................................................... 36 3.18.2 Inpatient services.............................................................................................. 36 3.18.3 Outpatient services ........................................................................................... 38 3.18.4 NHS Generalist Services.................................................................................. 39 - - ii 3.18.5 Non NHS Services ........................................................................................... 40 3.18.6 Social Work Services....................................................................................... 42 3.18.7 Non-statutory facilities..................................................................................... 42 3.18.8 Private Care...................................................................................................... 43 3.18.9 Services for Alcohol Dependent Offenders ..................................................... 44 3.19 Demand vs Service Distribution...................................................................... 44 3.20 Long-term health expectation in alcohol dependence...................................... 44 3.20.1 Effects of chronic and acute exposure to alcohol............................................. 44 3.20.2 The Australian National Alcohol Indicators Project........................................ 45 3.20.3 Categorisation of drinking by associated risk .................................................. 47 3.20.4 Concordance between epidemiological studies................................................ 47 3.20.5 Suicide.............................................................................................................. 49 3.20.6 Alcoholic cardiomyopathy and polyneuropathy.............................................. 49 3.20.7 Alcoholic psychosis.......................................................................................... 49 3.20.8 Alcohol associated diseases accounted in the HTBS model............................ 50 3.20.9 Disease incidence ............................................................................................. 50 3.20.9.1 Cancer....................................................................................................... 51 3.20.9.2 Stroke ....................................................................................................... 51 3.20.9.3 Liver disease and cirrhosis ....................................................................... 51 3.20.10 Mortality in harmful drinkers....................................................................... 52 3.21 Mortality in the Scottish population................................................................. 54 3.21.1 Calculation of life-time probabilities of severe alcohol related disease........... 54 3.21.1.1 Method ..................................................................................................... 54 3.21.1.2 Men........................................................................................................... 54 3.21.1.3 Women..................................................................................................... 55 4 SOURCES OF EVIDENCE............................................................................................ 57 5 CLINICAL EFFECTIVENESS ...................................................................................... 59 5.1 Summary.......................................................................................................... 59 5.2 Literature search............................................................................................... 61 5.3 Issues related to assessment of relapse prevention interventions..................... 62 5.4 Previous Health Technology Assessments and Comprehensive