The English National Institute for Health and Clinical Excellence (NICE) published a clinical guideline in the year 2011 on alcohol-use disorders to improve treatment in England, Wales and Northern Ireland for alcohol dependence and harmful use (NICE, 2011). Clinical guidance on these topics already exists in Scotland (Scottish Intercollegiate Guidelines Network, 2003). The NICE guidance has been developed by the National Collaborating Centre for Mental Health (NCCMH) for use in primary, secondary, community and social care. It is the third part of a series of NICE publications on managing the harms associated with alcohol misuse. The other documents in the series are a public health guideline on alcohol problems (NICE, 2010), and clinical guidance on managing alcohol-use disorders which concentrates on alcohol-related problems seen in the acute general hospital (National Clinical Guidelines Centre, 2010).
Like other NICE guidelines, the guidance begins by outlining two main ‘principles of care’ on which its clinical recommendations are based. The first is ‘building a trusting relationship and providing information’ (2011, p. 14). This includes the importance of respecting the dignity and privacy of patients and acknowledging ‘ … that stigma and discrimination is often associated with alcohol misuse and that minimising the problem may be part of the service user’s presentation’ for treatment (2011, p. 14). The second principle, ‘working with and supporting families and carers’, encourages families to be involved in treatment, providing them with information and identifying and meeting their needs (2011, p. 14). In the latter principle, NICE reflects a consensus among those working in the field of addiction that social and environmental factors influence drinking and recovery (Edwards and Gross, 1976; Leshner, 1997; Volkow and Li, 2005).
The evidence base reported in the full NICE guideline by the NCCMH illustrates further the importance attached to the social dimensions of dependence. It states, for example, that all degrees of alcohol misuse can ‘ … stem from a range of environmental and social factors’ (NCCMH 2011, p. 78); this includes the affordability of alcohol, high levels of alcohol consumption in the population and cultural attitudes surrounding alcohol (NCCMH, 2011, p. 25) The document notes that negative life events can lead to alcohol problems, but also provide the impetus for individuals, including those who are dependent on alcohol, to stop drinking—though positive life events also support recovery (NCCMH, 2011, p. 78). The full guideline states that obstacles to treatment include ‘ … internal and external stigma … ’and ‘ … an apprehension towards discussing alcohol-related issues with healthcare professionals … ’(NCCMH, 2011, p. 79). Factors that can help facilitate treatment and recovery are identified as including supportive social networks (NCCMH, 2011, p. 79); those with less social stability and contacts not associated with alcohol do not fare as well in recovery as individuals with such support (NCCMH, 2011, p. 26f). This emphasizes, in part, why the family and friends of those with dependency problems ‘require information and support from healthcare professionals’ (NCCMH, 2011, p. 80).
The NICE guidance is likely to have a positive influence on the treatment of alcohol dependence. The guidance will help to target the limited funding that is available for alcohol treatment, but it is likely that it will still encounter considerable financial constraints. Treatment for alcohol problems continues to fare poorly in the funding stakes compared, for example, to illegal drug use (Prime Minister’s Strategy Unit, 2004; Department of Health, National Audit Office, 2008, p. 7). Yet evidence of the cost effectiveness of alcohol treatment supports efforts to improve its provision (UKATT, 2005; Raistrick et al., 2006). The success of the guidance will also be impeded by the reluctance of many living with alcohol dependence to enter treatment (Drummond et al., 2005; NICE, 2011). This is partly due, as NICE acknowledges, to the social stigma that surrounds the condition (Turning Point, 2003; WHO, 2004; NICE, 2011; Schomerus et al., 2011a). In addition, the efforts of NICE to improve the therapeutic support available for alcohol dependence may be compromised if the guidance is not supported adequately by public policy. Indeed, the failure of policy to attend to the particular challenges associated with the alcohol dependence may hamper efforts to improve treatment. It will be argued here that policy risks increasing the stigma that surrounds dependence and eroding the trust needed to encourage dependent drinkers to seek treatment.