These recommendations are consistent with those made by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003]. With the exception of the use of acamprosate in reducing alcohol intake, they are largely based on expert and consensus opinion formed from clinical experience with alcohol-dependent people. Ongoing management of dependent drinkers who have undergone withdrawal is beyond the scope of current guidelines from the National Institute for Health and Clinical Excellence (NICE) concerning alcohol misuse [NICE, 2010a; NICE, 2010c]. However, this issue will be addressed in the forthcoming NICE clinical guideline Alcohol-use disorders: diagnosis and clinical management of harmful drinking and alcohol dependence, due to be published in January 2011 [NICE, 2010e].

Follow up and monitoring

• It is important to follow people up immediately after detoxification, as they often find the post-detoxification period difficult. They are often having to address problems that have occurred as a result of their drinking, and may be struggling to meet the expectations of friends and relatives.
• Maintaining contact over the long term with people previously treated by specialist services for alcohol dependence is an important factor in maintaining abstinence.
• Low-intensity monitoring over 1–3 years has been shown to reduce the severity of relapses (possibly through earlier referral to specialist services when needed).
• Depending on the definition used, as many as 70% of people receiving treatment for an alcohol problem will have relapsed at the 6-month follow up. At 12 months, less than 30% of people will still be in contact with a specialist service, but evidence suggests this can be increased to 80% if follow up is given by trained staff [Raistrick et al, 2006].
• The literature suggests that observations at the 3-month follow-up are a good guide to how effective a treatment is for a particular person (changes tend to occur in the first 3 months), and at 12 months it will give you a better guide to the overall benefit of treatment.

Intensive treatments

• Intensive treatments are usually undertaken by specialists and are appropriate for people with moderate to severe alcohol dependence.
• Most of the therapies are based on cognitive behavioural therapy, which is flexible, performance based (the person is given a 'to do list'), and best carried out in the community under specialist supervision.
• For evidence on the effectiveness of intensive treatments relative to each other, see The Mesa Grande project.

Acamprosate

• Acamprosate is an anti-craving drug and is useful for reducing the quantity of alcohol consumed or for maintaining abstinence, and there is evidence from randomized controlled trials that acamprosate is effective for this purpose [Bouza et al, 2004]. It is usually initiated by specialist services within a few days of successful alcohol detoxification, and its use may be continued in primary care.

Self-help manuals

• Self-help manuals have been shown in controlled trials to be effective at reducing alcohol intake (and are ranked joint fourth in the Mesa Grande), but only if the person has a low level of alcohol dependence. They are unlikely to be effective if the person is more severely dependent.

Mutual-aid groups

• The evidence to support the effectiveness of mutual-aid groups is limited by methodological difficulties, in part caused by the need for anonymity of the attendees. Alcoholics Anonymous has claimed a success rate of 65% of people remaining abstinent after 1 year, but this only applies to committed attendees, and does not take into account the high drop-out rate that is observed.

Disulfiram

• Disulfiram (Antabuse^®) is a sensitizing drug, which provokes an unpleasant reaction when alcohol is consumed concomitantly, including tachycardia, headache, flushing, nausea, and vomiting. Knowledge of this reaction deters the person from drinking alcohol. It is important to warn the person about the need for abstinence and the dangers of continuing drinking whilst taking the drug [SIGN, 2003].
• Disulfiram is sometimes indicated as an adjuvant in the treatment of chronic alcohol dependence, but should only be initiated in a hospital or specialized clinic, and by physicians experienced in its use [ABPI Medicines Compendium, 2008].
• Treatment with disulfiram requires commitment from the person receiving it, and an agreement should be undertaken to continue using the drug even when there is ambivalence. To facilitate this, the taking of the drug should be supervised by a spouse, work representative, or healthcare professional [SIGN, 2003].
• The evidence for the efficacy of disulfiram is limited to supervised use. It is effective at reducing the number of drinking days and the quantity of alcohol used in people who are adherent, even if they continue to drink. However, surprisingly, there is a lack of evidence that disulfiram increases the proportion of people who maintain total abstinence [Hughes and Cook, 1997]. It is rated as number 22 in the Mesa Grande comparison of interventions [Raistrick et al, 2006].

Naltrexone

• Naltrexone is an opioid antagonist that acts as an anti-craving drug in people who are dependent on alcohol. There is evidence that it increases the rates of abstinence, and decreases relapse rates in alcohol-dependent people who are in abstinence-orientated programmes [Schaffer and Naranjo, 1998; Garbutt et al, 1999]. In this regard, it compares favourably with acamprosate, and it is rated as number six in the Mesa Grande comparison of alcohol interventions.
• At present, naltrexone is not licensed for the purpose of preventing relapse in alcohol-dependent people, and it should be reserved for use in specialist centres rather than used in primary care [SIGN, 2003].