sTANDARD TREATMENT Guidelines

1
Management of
Alcohol Dependence

AUGUST 2017
HEALTH M
AL
Ministry of Health & Family Welfare
NATION

ISSI N
O

Government of India
 HEALTH M
AL

NATION

ISSI N
O
sTANDARD TREATMENT Guidelines
Management of
Alcohol Dependence

AUGUST 2017

Ministry of Health & Family Welfare

Government of India
©2017

Ministry of Health and Family Welfare

Government of India, Nirman Bhawan
New Delhi-110 011

Reproduction of any excerpts from this documents does not require permission from
the publisher so long it is verbatim, is meant for free distribution and the source is
acknowledged.

ISBN: 978-93-82655-21-3

Design by: Macro Graphics Pvt. Ltd. ([Link])

 Table of Contents

Objectives 1

Diagnosis 3

Assessment 5

Screening 5

History taking 5

Physical examination 6

Mental Status Examination (MSE) 6

Investigations 7

Treatment 9

Phases of treatment 9

Clinical Pathway of Management of Alcohol Dependence 17

Quality Standards for Management of Alcohol Dependence 18

How these Guidelines were Developed 25

Background 25

Formation of STG Group on Psychiatry 25

Table of Contents iii

 Objectives

yy The guideline will provide advice on assessment, investigations, short term and long-
term medical management of individuals presenting with alcohol dependence.
yy The guideline will also provide advice on psycho-social interventions for patients
with alcohol dependence.

Objectives 1
 Diagnosis

The diagnosis of alcohol dependence can be done using ICD-10 diagnostic criteria
which are as follows.

Table 1. Diagnostic criteria for alcohol dependence syndrome as specified in the

ICD-10 Classification of Mental and Behavioral Disorders (adapted for
alcohol)
A cluster of physiological, behavioral, and cognitive phenomena in which the use of alcohol
takes on a much higher priority for a given individual than other behaviors that once had
greater value. A central descriptive characteristic of the dependence syndrome is the
desire (often strong, sometimes overpowering) to take alcohol. There may be evidence
that return to alcohol use after a period of abstinence leads to a more rapid reappearance
of other features of the syndrome than occurs with nondependent individuals.
A definite diagnosis of alcohol dependence should usually be made only if three or more of the
following have been present together at some time during the previous year:

(a) A strong desire or sense of compulsion to take alcohol;

(b) Difficulties in controlling alcohol-taking behavior in terms of its onset,

termination, or levels of use;

(c) A physiological withdrawal state when alcohol use has ceased or been reduced,
as evidenced by: the characteristic withdrawal syndrome for alcohol; or use
of alcohol (or a closely related) substance with the intention of relieving or
avoiding withdrawal symptoms;

(d) Evidence of tolerance, such that increased doses of alcohol are required in order
to achieve effects originally produced by lower doses;

Diagnosis 3
 (e) progressive neglect of alternative pleasures or interests because of alcohol use,
increased amount of time necessary to obtain or take alcohol or to recover from
its effects;

(f) persisting with alcohol use despite clear evidence of overtly harmful
consequences, such as harm to the liver through excessive drinking, depressive
mood states consequent to periods of heavy alcohol use, or alcohol-related
impairment of cognitive functioning; efforts should be made to determine that the
user was actually, or could be expected to be, aware of the nature and extent of
the harm.

4 Management of Alcohol Dependence

 Assessment

This includes medical history, physical examination, mental status examination (MSE) and
investigations. Assessment is targeted:
yy To ascertain the diagnosis of alcohol dependence
yy To establish rapport with the patient
yy To assess complications associated with alcohol use (including physical and
psychological)
yy To assess level of motivation
yy To assess support and resources available
yy To assess suitable setting for management
yy To assess need for referral

Screening
As there is a significant time lag between emergence of alcohol dependence and treatment
seeking for the same, it is important for the clinician to enquire about alcohol use from
every patient to catch them early.

History taking
Following information should be obtained during history taking.
yy Socio-demographic details
yy Pattern of alcohol use (Amount, timing, frequency, place, etc)

Assessment 5
 yy Type of alcohol beverage used
yy Duration of use
yy Features of alcohol dependence (craving, tolerance, withdrawal, physical or
psychological symptoms, etc.)
yy Alcohol related complications (physical, psychological, familial, social, vocational,
financial, legal)
yy Past abstinence attempts
yy Level of motivation (coming by self or family or on being referred by another
specialist/employer/ legal agency)
yy Past history of any medical & psychiatric illness, family history

Physical examination
Physical examination should be done to find out
yy Features of alcohol intoxication: unsteady gait, difficulty standing, slurred speech,
nystagmus, decreased level of consciousness (e.g. stupor, coma), flushed face, and
conjunctival injection
yy Features of alcohol withdrawal: Tremors, sweating, nausea, vomiting, tachycardia
or hypertension, psychomotor agitation and generalized seizures.
yy Physical complications: associated with alcohol use. Eg. liver enlargement, pedal
edema

Mental Status Examination (MSE)

yy Assessment of general appearance and behavior, psychomotor activity, speech,
affect, thought, perception, orientation, attention and concentration, memory,
intelligence, abstraction, judgment, insight and level of motivation.

MSE is aimed at identifying the presence of any co-occurring psychiatric disorders and
presence of complicated alcohol withdrawal.

6 Management of Alcohol Dependence

Investigations
yy Haemogram (including hemoglobin, total leucocytes count, differential leukocyte
count, peripheral blood smear)
yy Random blood sugar
yy Liver function tests (serum bilirubin, SGOT, SGPT)
yy Renal function test (serum creatinine, blood urea)

Assessment 7
 Treatment

Phases of treatment
yy Initial short- term management phase (also known as detoxification)
yy Long- term management phase

Short- term management phase

Treatment for alcohol dependence can be carried out in the out-patient as well as in-
patient settings. Some of the indicators for in-patient management are as follows:
yy Presence of severe alcohol dependence (drinks over 30 units of alcohol per day or
regularly drinks between 15 and 30 units of alcohol per day)
yy Presence of or anticipated severe withdrawal or complicated withdrawal
(withdrawal with seizures or delirium)
yy Co-occurring significant physical and psychiatric illness
yy Poor psychosocial support
yy Distance from treatment centre that precludes regular follow up
yy Failure of out-patient detoxification in past
yy Pregnancy, children and adolescents and elderly

Simple alcohol withdrawal

yy There is history of recent cessation of alcohol use that has been heavy and prolonged.
– Alcohol withdrawal typically develops 6 to 8 hours after the cessation of drinking.
– There is presence of clinical features associated with alcohol withdrawal.

Treatment 9
 yy These include tremor of the outstretched hands, tongue or eyelids, sweating,
nausea, retching or vomiting, tachycardia or hypertension, psychomotor agitation,
headache, insomnia, malaise or weakness, transient visual, tactile or auditory
hallucinations or illusions and grand mal convulsions.
yy These clinical features should be clinically significant means due to these symptoms
there is distress and dysfunction to the patient.

Complicated alcohol withdrawal

yy Characterized by presence of seizures or delirium (known as delirium tremens)
along with other features associated with alcohol withdrawal.
yy The alcohol withdrawal seizures typically develop 12 to 24 hours after cessation of
drinking. These are generalized and tonic-clonic in character.
yy Delirium tremens is characterized by disturbance of consciousness, reduced ability
to focus, to sustain, or to shift attention, a change in cognition (such as memory
deficit, disorientation, or language disturbance), and perceptual disturbance, severe
agitation and coarse tremors of limbs and body.

Medications
yy Benzodiazepines are recommended as the first line of treatment of alcohol withdrawal.
yy Long acting benzodiazepines (such as chlordiazepoxide and diazepam) are
preferred over short acting benzodiazepine for this purpose.
yy Short acting benzodiazepines (such as oxazepam and lorazepam) are preferred in
liver damage, in elderly people.

The equivalent dose of different benzodiazepines that are commonly used in management
of alcohol withdrawal are given in table.

Table 2: Approximate therapeutic dose equivalent of different benzodiazepines

commonly used in management of alcohol withdrawal
Benzodiazepine Dose equivalent (mg)
Chlordiazepoxide 25
Diazepam 10
Lorazepam 2
Oxazepam 30

10 Management of Alcohol Dependence

Treatment regimen
I. Benzodiazepines for management of alcohol withdrawal can be administered
using either of the following three administration regimens.

I A. Fixed dose schedule:

yy This involves starting treatment with a standard dose determined by the recent
severity of alcohol dependence and/or typical level of daily alcohol consumption,
followed by reducing the dose to zero usually over 7 to 10 days.

yy The starting dose of benzodiazepine can vary from 15 mg four times a day
(q.d.s.) to 50 mg four times a day (q.d.s.) of chlordiazepoxide dose equivalent
(or 10 mg three times a day to 25 mg three times a day of diazepam dose
equivalent).

yy The same dose is usually maintained over the next two days. The dose reduction is
made at the rate of 20% every day or 25% every alternate day.

I B. Symptom triggered dosing:

yy Benzodiazepine is administered according to the patient’s level of withdrawal
symptoms (ranging from 10-20 mg dose equivalent of diazepam per
administration).

yy Pharmacotherapy continues as long as the patient is displaying withdrawal

symptoms and the administered dose depends on the assessed level of alcohol
withdrawal.

C. Front loading schedule:

yy This involves providing the patient with an initially high dose of medication (30-40
mg dose equivalent of diazepam), and then using either a fixed dose schedule or
symptom triggered dosing approach.

II Thiamine Supplementation:
Along with benzodiazepines, the alcohol withdrawal management includes general
nursing care in form of maintaining hydration and nutritional status.

yy It is recommended to give oral thiamine for minimum of three months.

Treatment 11
 yy All patients in alcohol withdrawal should receive at least 250 mg thiamine by the
parenteral route once a day for the first 3-5 days.
yy Any parenteral administration of glucose during withdrawal management should
not be done without addition of thiamine.

Nursing care
yy Restraints: The critically ill patient experiencing moderate to severe alcohol
withdrawal symptoms may require both chemical and physical restraints
to avoid immediate threat behavior to self and others. Use of bed rails is
advisable.
yy Managing behavioural disturbance: If the patient is confused and disoriented
or hallucinating, a supportive and reassuring approach is to be used and patient
should not be confronted.
yy Managing environment. The patient’s room should be kept quiet everyone
should move around quietly. Interaction should be minimal and questions
limited.
yy Nutritional needs. The patient may be malnourished, causing folate, thiamine,
or vitamin B12 deficiency. If the patient is unable to eat, tube feedings or total
parenteral nutrition (TPN) should be initiated early. If a feeding Ryle’s tube is used
it is taped at the nose and cheek area, with the tubing running toward the head and
behind the bed.
yy Involving family: A complete care plan should involve family members in a
therapeutic alliance to provide optimal symptom relief and formulate acceptable
behavior objectives for the patient.

Motivational Enhancement Therapy (MET)

It utilizes different principles as follows:
yy Expressing empathy through reflective listening
yy Developing discrepancy between clients' goals or values and their current
behavior
yy Avoiding argument and direct confrontation

12 Management of Alcohol Dependence

 yy Adjust to client resistance rather than opposing it directly
yy Supporting self-efficacy and optimism

Management of alcohol withdrawal seizure

yy Effective management of alcohol withdrawal is preventive against emergence of
withdrawal seizures.
yy The alcohol withdrawal seizures can be managed by both short acting
(lorazepam- considered to be more effective by some) and long acting (diazepam)
benzodiazepines.
yy Benzodiazepines can be given either orally or parenterally.

Management of delirium tremens

yy Delirium tremens should be managed in inpatient setting. Safety of the patient
against any physical harm should be ensured.
yy Water and electrolyte balance and nutritional status should be maintained.
yy The benzodiazepines are to be administered through parenteral route in sufficient
dosages with an aim to make the patient clam and sedated.
yy An initial dose of 10 mg diazepam is given intravenously. Further doses of 10 mg
can be repeated every 5-20 min interval. The dose can be increased to 20 mg per
bolus for the subsequent boluses if the first two boluses do not calm the patient
down.
yy Subsequently the patient can be shifted to oral benzodiazepines and the dose can
be gradually tapered down.

Long-term management phase

yy This phase begins after the initial withdrawal management from alcohol has been
achieved
yy The aim is to maintain abstinence from alcohol and to prevent and delay relapse

Medications used in long term management of alcohol dependence are summarized in

Table 3

Treatment 13
Referral to secondary or tertiary care
yy Presence of co-morbid psychiatric condition that cannot be managed at the primary
care or secondary care level
yy Complicated withdrawal like delirium or withdrawal seizures
yy Physical comorbidity of serious nature for which adequate infrastructure and
support may not be available
yy Presence of a co-morbid substance use disorder for which treatment is not available
at primary/secondary hospital setting
yy Non-availability of professionals to administer psycho-social interventions
yy A complete care plan should involve family members to identify treatment options,
appropriate supportive care beyond medication and monitoring may help decrease
morbidity and mortality rates.

Table 3 : Medications used in long term management of alcohol dependence

Medicine Common side-effects and Dose Frequency Duration
contraindications to use
Acamprosate Diarrhea with abdominal pain, nausea, 1332 mg/day TDS One year
vomiting, pruritus Contraindications- (body weight
hypersensitivity reaction, pregnancy and < 50 kg) to
breastfeeding, renal insufficiency (serum 1998 mg/
creatinine more than 120 micromoles day (body
per litre), severe hepatic failure weight> 50
FDA pregnancy category C kg
Disulfiram Drowsiness, fatigue, abdominal pain, 250mg/day OD One year
headache, nausea, diarrhea, allergic
dermatitis, metallic or garlic like after
taste
Contraindications (absolute)-
hypersensitivity reaction , pregnancy
and breast feeding Contraindications
(relative)- cardiovascular problems,
severe personality disorder, suicidal
risk, psychosis
FDA pregnancy category C

14 Management of Alcohol Dependence

Medicine Common side-effects and Dose Frequency Duration
contraindications to use
Naltrexone Nausea, headache, abdominal pain, 50 mg/day OD One year
reduced appetite and tiredness
Contraindications- acute liver failure
(caution is suggested when serum
aminotransferases are four to five times
above normal)
FDA pregnancy category C

Treatment 15
 Clinical Pathway of
Management of Alcohol
Dependence

Individual with alcohol use

Assess for problematic use

Non-dependent use Alcohol dependence

Assess for
Severity of dependence
Severity of withdrawal
Presence of complicated
withdrawal
Severity of withdrawal in past

Severe dependence Mild to moderate dependence

Severe withdrawal Mild to moderate withdrawal
Presence of complicated Absence of complicated withdrawal
withdrawal Poor social support and supervision
Severe withdrawal in past Absence of comorbid use of other
History of complicated withdrawal substances
Presence of Comorbid Personal preference
medical/psychiatric illness

In-patient withdrawal Outpatient Withdrawal

Brief intervention managment management

Clinical Pathway of Management of Alcohol Dependence 17

Quality Standards for Management of
Alcohol Dependence
Standard Statement
Quality Standard 1 All patients reporting to health facility should be screened for
Screening presence of alcohol dependence.
Quality Standard 2 All patients reporting current alcohol use and scoring high on
Assessment the screening tests or having problems due to alcohol use should
be assessed for presence of alcohol dependence and physical
complications associated with long term alcohol use.
Quality Standard 3 All patients with alcohol dependence should be assessed for presence
Investigations of physical complications using laboratory investigations.
Quality Standard 4 All patients with alcohol dependence should bea offered short
Short term management term management (detoxification) in the out-patient, or the
inpatient setting.
Quality Standard 5 All patients with alcohol dependence should be offered long term
Long term management management.

Quality Standard 1: Screening for alcohol dependence

1. Statement All patients reporting to health facility should be screened for
presence of alcohol dependence.
2. Rationale Problematic use of alcohol is a common medical disorder that can go
undetected even among those seeking treatment for some unrelated
medical disorder. Hence, all patients in contact with health care
systems should be screened for presence of alcohol dependence.
3. Quality Measure
3a. Structure Availability of screening instruments (scales) and trained health
professionals at the medical facility.
3b. Process Proportion of patients seeking medical care being screened for
problematic alcohol use.
Numerator- Number of patients screened for problem drinking
amongst those seeking care.
Denominator- Total number of patients seeking medical care.
3c. Outcome Proportion of patients who are likely to have problematic alcohol use.
Numerator- Number of patients who are likely to have problematic
alcohol use.
Denominator- Total number of patients screened for problematic
alcohol use.

18 Management of Alcohol Dependence

Quality Standard 1: Screening for alcohol dependence
4. What Quality Measure Service Provider- Ensure that all patients seeking medical care are
means for each audience screened for problematic alcohol use.
Health Administrator- Ensure that adequate screening facility is
available at the designated facility.
Patient and Community- Patients and caregivers should participate
in the screening process.
5. Data Source Out-patient register In-patient register
6. Definitions Health Facility- Any public health care facility (PHC, CHC, District
Hospitals, Tertiary care Centers/ Teaching Hospitals) or their
equivalent in private sector

Quality Standard 2: Assessment for alcohol dependence

1. Statement All patients reporting current alcohol use and scoring high on the
screening tests or having problems due to alcohol use should be
assessed for presence of alcohol dependence.
2. Rationale Patients with current alcohol use and scoring high on the
screening test or having problems due to alcohol use are likely
to be dependent on alcohol and consequently require medical
intervention.
3. Quality Measure
3a. Structure Availability of trained health professionals at the medical facility.
3b. Process Proportion of patients reporting current alcohol use and scoring high
on screening test or having problems due to alcohol use assessed
thoroughly for presence of alcohol dependence.
Numerator- Total number of patients assessed thoroughly for
presence of alcohol dependence.
Denominator- Total number of patients reporting current alcohol
use and scoring high on screening tests or having problems due to
alcohol use.
3c. Outcome Proportion of patients who have alcohol use in dependent pattern.
Numerator- Total number of patients who have alcohol use in
dependent pattern.
Denominator- Total number of patients assessed for alcohol use in
dependent pattern.

Clinical Pathway of Management of Alcohol Dependence 19

Quality Standard 2: Assessment for alcohol dependence
4. What Quality Service Provider– Ensure that all patients with current alcohol use
Measure means for and scoring high on screening tests or having problems due to alcohol
each audience use seeking medical care are screened for problematic alcohol use.
Health Administrator- Ensure that trained health professionals are
available at the designated facility.
Patient and Community – Patients and caregivers should participate
in the assessment process.
5. Data Source Out-patient register In-patient register
6. Definitions Health Facility- Any public health care facility (PHC, CHC, District
Hospitals, Tertiary care Centers/ Teaching Hospitals) or their
equivalent in private sector

Quality Standard 3: Investigations for alcohol dependence

1. Statement All patients with alcohol dependence should be assessed for presence
of physical complications using laboratory investigations.
2. Rationale Patients with alcohol dependence are likely to experience the physical
complications associated with alcohol use. Also it is important to
exclude the possible medical causes of delirium observed during
alcohol withdrawal. Finally, it is important to monitor for emergence
of side effects associated with medicines used for managing alcohol
dependence. Hence it is important to assess these patients with
appropriate laboratory investigations.
3. Quality Measure
3a. Structure Availability of laboratory facilities at the medical facility.
3b. Process Proportion of patients advised investigations for presence of physical
complications associated with alcohol use, possible medical causes
of delirium observed during alcohol withdrawal and monitoring for
emergence of side effects of medicines used for managing alcohol
dependence.
Numerator- Total number of patients advised investigations.
Denominator- Total number of patients being managed for alcohol
dependence.
3c. Outcome Proportion of patients with deranged biochemical investigation results.
Numerator- Total number of patients who have deranged biochemical
investigation results.
Denominator –Total number of patients investigated.

20 Management of Alcohol Dependence

Quality Standard 3: Investigations for alcohol dependence
4. What Quality Service Provider - Ensure that all patients with alcohol dependence
Measure means for are recommended appropriate laboratory investigations.
each audience Health Administrator- Ensure that adequate laboratory services are
available at the facility.
Patient and Community – Patients and caregivers should participate
in the investigations.
5. Data Source Out-patient register In-patient register Laboratory register
6. Definitions Health Facility- Any public health care facility (PHC, CHC, District
Hospitals, Tertiary care Centers/ Teaching Hospitals) or their
equivalent in private sector

Quality Standard 4: Short term management of alcohol dependence

1. Statement All patients with alcohol dependence should be offered short term
management (detoxification) in the in-patient or the out-patient
setting.
2. Rationale Patients with alcohol dependence are likely to experience
withdrawals when they quit alcohol use. Hence it is important to offer
medical management for alcohol withdrawals. Also it is important to
prevent emergence of complicated alcohol withdrawal and manage
the same whenever they emerge.
3. Quality Measure
3a. Structure Availability of short-term management facilities (in patient and out
patient) at the medical facility.
3b. Process Proportion of patients offered short-term management for alcohol
dependence.
Numerator- Total number of patients offered short-term
management for alcohol dependence.
Denominator- Total number of patients diagnosed with alcohol
dependence.
3c. Outcome Proportion of patients who receive short-term management for
alcohol dependence.
Numerator- Total number of patients who receive short-term
management for alcohol dependence.
Denominator- Total number of patients diagnosed with alcohol
dependence.

Clinical Pathway of Management of Alcohol Dependence 21

Quality Standard 4: Short term management of alcohol dependence
4. What Quality Service Provider –Ensure that all patients with alcohol dependence
Measure means for are offered short-term management.
each audience Health Administrator- Ensure that adequate short-
term management facilities (pharmacological and non
pharmacological; from in-patient and out-patient setting) are
available at the facility.
Patient and Community – Patients and caregivers should participate
in the short-term management.
5. Data Source Out-patient register In-patient register Pharmacy register
6. Definitions Health Facility- Any public health care facility (PHC, CHC, District
Hospitals, Tertiary care Centers/ Teaching Hospitals) or their
equivalent in private sector

Quality Standard 5: Long term management of alcohol dependence

1. Statement All patients with alcohol dependence should be offered long term
management.
2. Rationale Patients with alcohol dependence are likely to relapse even after a
successful short-term management. Hence it is important to offer
long term management to all these patients.
3. Quality Measure
3a. Structure Availability of long-term management facilities at the medical
facility.
3b. Process Proportion of patients offered long-term management for alcohol
dependence.
Numerator- Total number of patients offered long-term management
for alcohol dependence.
Denominator- Total number of patients diagnosed with alcohol
dependence.
3c. Outcome Proportion of patients who receive long-term management for
alcohol dependence.
Numerator- Total number of patients who receive long-term
management for alcohol dependence.
Denominator- Total number of patients diagnosed with alcohol
dependence.

22 Management of Alcohol Dependence

Quality Standard 5: Long term management of alcohol dependence
4. What Quality Service Provider –Ensure that all patients with alcohol dependence
Measure means for are offered long-term management.
each audience Health Administrator- Ensure that adequate long-term management
facilities (pharmacological and non pharmacological) are available at
the facility.
Patient and Community – Patients and caregivers should participate
in the long-term management.
5. Data Source Out-patient register In-patient register Pharmacy register
6. Definitions Health Facility- Any public health care facility (PHC, CHC, District
Hospitals, Tertiary care Centers/ Teaching Hospitals) or their
equivalent in private sector

Clinical Pathway of Management of Alcohol Dependence 23

 How these Guidelines were
Developed

Background
A Task Force was constituted in December 2014 to guide the development of Standard
Treatment Guidelines (STG) in India for application in the National Health Mission. The
Task Force subsequently approved the draft STG development manual of India (Part
1) for development of adapted guidelines. In addition, it approved a list of 14 topics
recommended by a subgroup of the task force appointed to select prioritized topics for
STG development. These 14 topics are from 10 clinical specialties for which the first set of
STGs will be developed. The topic of Management of Alcohol Dependence was included in
this first list and was the dealt with by the Psychiatry clinical subgroup.

Formation of STG Group on Psychiatry

A multidisciplinary group composed of a mix of primary care practitioners, academicians
and practicing psychiatrist was constituted with Dr. Rakesh Chadda as the facilitator of the
group. Following were the members of group-

Coordinator Dr Rakesh Chadda

Professor of Psychiatry AIIMS, New Delhi
drrakeshchadda@[Link]
Experts Prof Rakesh Lal
Professor of Psychiatry Deptt of Psychiatry & National Drug
Dependence Treatment Centre (NDDTC) AIIMS, New Delhi 110029
rakeshlall@[Link]

How these Guidelines were Developed 25

 Prof Debashis Basu
Professor of Psychiatry PGIMER, Chandigarh 160012
db_sm2002@[Link]

Dr Nitin Gupta
Associate Professor Department of Psychiatry Govt Medical College
& Hospital, Chandigrah
nitingupta659@[Link]

Dr Yatan PS Balhara
Asstt. Professor Deptt of Psychiatry & NDDTC AIIMS,
New Delhi 110029
rakeshlall@[Link], ypsbalhara@[Link]

Dr Rachna Bhargava,
Asstt. Professor in Clinical Psychology Deptt of Psychiatry & NDDTC
AIIMS, New Delhi 110029
rachnabhargava@[Link]

Dr Bichitra Nanda Patra,

Asstt Professor Department of Psychiatry, AIIMS, New Delhi 110029
[Link]@[Link]

Dr Sandhya Gupta
Lecturer, College of Nursing AIIMS, New Delhi 110029
drsandhyag407@[Link]

The group was constituted 7 August 2015. All the members signed the declaration of
Interest. First face to face Meeting was held on 17 August 2015 attended by Drs Chadda,
Lal, Balhara, Rachna, Bichitra. Scope decided as guidelines on alcohol dependence
for use in different settings. Uncomplicated cases can be managed as outpatient and
management does not differ across different setting. Complicated cases and those with
co morbid problems need specialist input and can be managed only in secondary or
tertiary care.

26 Management of Alcohol Dependence

First draft got ready on 10th Sept 2015; shared on email amongst the group.

Second Face to Face Meeting was held on 13 Sept 2015. Draft modified as per discussion
and submitted on 6 Oct 2015 to the Internal Harmonization Group of STG Taskforce. The
draft document was reviewed by Internal Harmonization Groupon 24th of October 2015
consisting of Dr. Sangeeta Sharma (IBHAS), Dr. Anil Gurtoo (LHMC), Dr. Om Sai Ramesh
(LHMC), Dr. Babban Jee (ICMR) and Dr. Nikhil Prakash (NHSRC). The comments of internal
harmonization group were received on 8th of Novemeber [Link] Face to Face Meeting
was called on 13 Nov 2015 Attended by Drs Chadda, Lal, Balhara, Rachna, Bichitra. The
Revised draft was prepared and further discussed meeting on third 3 Dec 2015.

Search and Selection of Evidence Based Guidelines

In view of the paucity of time available to develop this guideline, a decision was taken by
the Task Force for the Development of STGs for the National Health Mission that these
STGs would be adopted and/or adapted from existing evidence based guidelines to make
them relevant to our context, resource settings and priorities.

A search was conducted for evidence based guidelines which had been framed using
evidence based methodology and using international guideline development criteria.
Following guidelines were selected for Adapting/Adopting recommendations based
strength of evidence, currency of guidelines and suitability to Indian context.

Table 9: List of available guidelines on management of alcohol dependence and the

guidelines referred to for the purpose of the current guideline
List of the available guidelines Guidelines consulted for the Rationale for considering
current guideline the source guideline
Alcohol use disorders- Diagnosis, Alcohol use disorders- Diagnosis, These guidelines
assessment and management assessment and management are evidence based,
of harmful drinking and alcohol of harmful drinking and alcohol have been created
dependence. NICE clinical dependence. NICE clinical systematically, are
guidelines. National Institute for guidelines. National Institute for some of the most recent
Health and Clinical Excellence, Health and Clinical Excellence, documents on this
UK, 2011. UK, 2011. topic, represent diverse
settings across various
countries including India
and cover various aspects
related to management
of alcohol dependence.

How these Guidelines were Developed 27

List of the available guidelines Guidelines consulted for the Rationale for considering
current guideline the source guideline
Clinical practice guideline for Clinical practice guideline for
Management of Substance Use Management of Substance Use
Disorders (SUD). Department of Disorders (SUD). Department of
Veterans Affairs Department of Veterans Affairs Department of
Defense, USA, 2009. Defense, USA, 2009.
Clinical Practice Guidelines for Clinical Practice Guidelines for
the assessment and management the assessment and management
of substance use disorders. Indian of substance use disorders.
Psychiatric Society, 2014. Indian Psychiatric Society, 2014.
Detoxification and Substance Detoxification and Substance
Abuse Treatment. Treatment Abuse Treatment. Treatment
Improvement Protocol (TIP) Series, Improvement Protocol (TIP)
No. 45. Center for Substance Series, No. 45. Center for
Abuse Treatment. Substance Substance Abuse Treatment.
Abuse and Mental Health Services Substance Abuse and Mental
Administration (US); 2006. Health Services Administration
(US); 2006.
Drug and Alcohol Withdrawal Global strategy to reduce the
Clinical Practice Guidelines – harmful use of alcohol. World
NSW. Mental Health and Drug & Health Organization, 2010.
Alcohol Office, NSW Department
of Health, Australia, 2007.
Global strategy to reduce the Guidelines on treatment of
harmful use of alcohol. World alcohol problems. Australian
Health Organization, 2010. Government Department
of Health and Ageing, The
University of Sydney, Australia,
2009.
Guidelines on treatment of Incorporating Alcohol
alcohol problems. Australian Pharmacotherapies Into Medical
Government Department of Practice. Treatment Improvement
Health and Ageing, The University Protocol (TIP) Series, No. 49.
of Sydney, Australia, 2009. Center for Substance Abuse
Treatment. Substance Abuse
and Mental Health Services
Administration (US); 2009.

28 Management of Alcohol Dependence

List of the available guidelines Guidelines consulted for the Rationale for considering
current guideline the source guideline
Incorporating Alcohol Manual for Long Term
Pharmacotherapies Into Pharmacotherapy. NDDTC,
Medical Practice. Treatment AIIMS, New Delhi, 2013.
Improvement Protocol (TIP)
Series, No. 49. Center for
Substance Abuse Treatment.
Substance Abuse and Mental
Health Services Administration
(US); 2009.
Manual for Long Term Quick reference guide to the
Pharmacotherapy. NDDTC, treatment of alcohol problems.
AIIMS, New Delhi, 2013. Australian Government
Department of Health and
Ageing, The University of Sydney,
Australia, 2009.
mhGAP Intervention Guide Substance Use Disorders.
for mental, neurological and Manual for Physicians. NDDTC,
substance use disorders in AIIMS, New Delhi, 2013.
non-specialized health settings.
Mental Health Gap Action
Programme. World Health
Organization, 2010.
Naltrexone and Alcoholism The Maudsley Prescribing
Treatment. Treatment Guidelines in Psychiatry, 2015.
Improvement Protocol (TIP)
Series, No. 28. Center for
Substance Abuse Treatment.
Center for Substance Abuse
Treatment. Substance Abuse
and Mental Health Services
Administration (US); 1998.
Practice guideline for the
Treatment of Patients With
Substance Use Disorders,
Second Edition. American
Psychiatric Association,
USA, 2006.

How these Guidelines were Developed 29

List of the available guidelines Guidelines consulted for the Rationale for considering
current guideline the source guideline
Quick reference guide to the
treatment of alcohol problems.
Australian Government
Department of Health and
Ageing, The University of Sydney,
Australia, 2009.
Substance Use Disorders. Manual
for Physicians. NDDTC, AIIMS,
New Delhi, 2013.
The Maudsley Prescribing
Guidelines in Psychiatry, 2015.

30 Management of Alcohol Dependence

Note
Note
 HEALTH M
AL
NATION

ISSI N
O

MINISTRY OF HEALTH AND FAMILY WELFARE

Government of India
Nirman Bhawan, New Delhi