These recommendations are in line with the public health guidance Alcohol-use disorders: preventing the development of hazardous and harmful drinking published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010c], and guidelines published by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003]. They are largely based on expert and consensus opinion.

• There is evidence that the assessment process alone may be an effective intervention at reducing the level of alcohol consumption in people drinking above the recommended limits, by changing an individual's perception of their problem and their commitment to treatment [DH, 2006].

These recommendations are in line with the public health guidance Alcohol-use disorders: preventing the development of hazardous and harmful drinking, published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010c], and with guidelines published by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003].

• 'Brief intervention' is an umbrella term covering a range of therapeutic activities with the aim of alerting people who are drinking too much, and getting them to cut down before they come to any significant harm. The primary healthcare professional is key to the recognition and implementation of any intervention that is needed to help reduce alcohol consumption. A brief intervention:
• Is usually carried out immediately after the opportunistic detection of hazardous or harmful drinking, or at another suitable moment when the time becomes available.
• Should be given with an empathetic manner, to increase a person's confidence to make a change in their alcohol consumption. There should be a discussion of the personal risks related to their level of alcohol consumption, and practical advice on how to reduce their alcohol intake.
• NICE recommends using FRAMES as the basis of brief advice. FRAMES is 'an acronym summarising the components of a brief intervention, which are Feedback (on the client's risk of having alcohol problems), Responsibility (change is the client's responsibility), Advice (provision of clear advice when requested), Menu (what are the options for change?), Empathy (an approach that is warm, reflective and understanding), and Self-efficacy (optimism about the behaviour change)' [NICE, 2010c].
• There is a large amount of evidence to support the use of brief intervention to reduce alcohol consumption in a primary care setting [Babor and Grant, 1992; Raistrick et al, 2006]. A recent Cochrane systematic review has shown that brief intervention consistently produces reductions in alcohol consumption. It is ranked as number one in the Mesa Grande ranking of evidence-based alcohol interventions.
• There is evidence to show that self-help manuals provide an additional benefit to simple advice and are cost effective at reducing alcohol consumption, improving physical health, and reducing alcohol-related problems when aimed at people with hazardous and harmful drinking. Also, in people with low levels of dependence, self-help manuals appear to be as effective as one-to-one or group therapy.
• The benefits of brief interventions are currently being addressed by a pragmatic multicentre randomized trial (Screening and brief Interventions for hazardous and harmful alcohol use in Primary care [SIPs trial]) [Kaner et al, 2009].
• In addition to the individual's benefit from brief intervention, the public health impact of the widespread implementation of simple brief interventions is likely to be very large [NICE, 2010c].

Recommendations on extended brief interventions are based on the public health guidance Alcohol-use disorders: preventing the development of hazardous and harmful drinking, published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010c], and from a review from the NHS National Treatment Agency for Substance Misuse [Raistrick et al, 2006].

• The current available evidence consistently shows no additional benefit from extended brief intervention above the simple 5-minute advice approach. The optimum intensity of extended intervention, and its applicability for different types of alcohol problems and different circumstances, remains unclear. Nevertheless, additional advice should be offered to harmful drinkers on pragmatic grounds.

These recommendations are based on the clinical guidelines Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications, published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010a], and are consistent with guidelines published by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2003].

• People who drink harmful amounts of alcohol are often malnourished and deficient in vitamins. In particular, thiamine deficiency is common due to poor diet, poor absorption of nutrients (caused by gastritis), and a high demand for the vitamin (it is a coenzyme in alcohol metabolism).
• Lower doses of oral thiamine (10–25 mg) are recommended for harmful drinkers who may have mild chronic deficiency [BNF 59, 2010]. However, as tablets are most readily available at a dose of 50 mg, and it is very unlikely thiamine will cause harm at higher doses, CKS recommends that 50 mg should be taken daily.

These recommendations are in line with those made by the National Treatment Agency for Substance Misuse [Raistrick et al, 2006] and the Scottish Intercollegiate Guidelines Network (SIGN) [Raistrick et al, 2006], and are largely based on expert and consensus opinion. Drinking targets are 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].

• Treatment goals (whether to aim for lifelong abstinence or responsible drinking at non-harmful levels) are contentious, but increasingly in the UK drinking in moderation is seen as an acceptable target for most hazardous and many harmful drinkers:
• The target selected is essentially a clinical choice and depends on the individual's characteristics and wishes.
• A persons acceptance of the goal is an important indicator of how likely it is to be achieved.
• Many hazardous and harmful drinkers are likely to be deterred by the prospect of lifelong abstinence, and this may put them off seeking help in the first place.
• The decision to aim for abstinence or drinking in moderation should be negotiated with the person, with defined drinking targets where appropriate (usually in line with national recommendations; see Safer drinking limits). The most suitable course of action will depend on individual circumstances [SIGN, 2003; Raistrick et al, 2006].
• Moderation is a reasonable goal for most hazardous drinkers. However, if drinking is heavy, a period of abstinence may be advisable before attempting moderation.
• People who have physical or mental conditions that would be worsened by continued alcohol use (for example liver damage or severe depression) should aim for abstinence. Abstinence may also be necessary if the person is using particular medication that interacts with alcohol, or if they are pregnant or are planning a pregnancy.

This recommendation is based on the Scottish Intercollegiate Guidelines Network (SIGN) national guideline on The management of harmful drinking and alcohol dependence in primary care, which is pragmatic advice based on good clinical practice [SIGN, 2003]. It is consistent with the public health guidance Alcohol-use disorders: preventing the development of hazardous and harmful drinking published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010c].

• NICE recommends that 'where there is an ongoing relationship with the patient or client, (the healthcare professional should) routinely monitor their progress in reducing their alcohol consumption to a low-risk level' [NICE, 2010c].
• Many people who are drinking at hazardous levels will reduce their consumption following influences from society, friends, and spouses, resulting in no complications from alcohol and no further need for follow up. Nevertheless, people with alcohol-related problems and/or dependence have a worse prognosis and their complications make follow up necessary, and an essential part of treatment success.
• Many people may develop new problems when tackling their alcohol consumption. Relationships, work commitments, and family problems may surface and do not necessarily resolve automatically with a reduction in alcohol. These issues will need attention and management in their own right.

Recommendations for referral are based on the public health guidance Alcohol-use disorders: preventing the development of hazardous and harmful drinking, published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010c], and The management of harmful drinking and alcohol dependence in primary care, published by the Scottish Intercollegiate Guidelines Network (SIGN) national guideline [SIGN, 2003].

• NICE states that 'those who are moderately or severely alcohol dependent are likely to need specialist help'. Referral is also recommended for people who have experienced physical harm from alcohol (for example liver damage) [NICE, 2010a] or mental health problems [SIGN, 2003] (see Scenario: Dependence on alcohol).