Protocole pour la prise en charge thérapeutique des sujets usagers de l’alcool

Objectives

The protocol frames alcohol misuse as a public-health and addiction concern affecting all socio-professional groups, distinguishing non-use, use and misuse, including risky use, harmful use and dependence.[1]Its overall therapeutic aim is to deliver integrated medical, psychological, social and reintegration support for people with alcohol-related problems.[2]Long-term treatment seeks abstinence, relapse prevention, occupational reintegration and improved quality of life; reduced consumption is an exceptional objective for non-dependent patients.[3]

• Identify alcohol-related problems through systematic screening and clinical assessment, using a standard drink equivalent of 10 grams of pure alcohol.[1]
• Assess consumption, dependence, physical and psychiatric complications, co-existing addictions, social circumstances, motivation and quality of life in order to shape an individual therapeutic plan.[4]
• Support medically safe withdrawal, address misuse or dependence, and maintain long-term follow-up to sustain abstinence and prevent relapse.[5][3]
• Combine medical treatment with psychotherapeutic, social and reintegration interventions, including motivational, cognitive-behavioural, psychoanalytic and group approaches where appropriate.[2]
• Prioritise treatment accompanying withdrawal and use mean corpuscular volume and gamma-glutamyl transferase as part of investigation when indicated.[2]

Implementation

The protocol uses a stepped, integrated care model organised by clinical severity and health-system level.[5][6]First-contact facilities provide reception, screening, information and referral; general and regional hospitals assess alcohol use, motivation and complications, provide brief intervention for uncomplicated risky or harmful use, and refer dependence or complications for higher-level care.[6]University hospitals and specialised services add clinical and paraclinical assessment, management of complications, motivational interviewing and individual or group psychotherapy.[6]

• Screen people through clinical interview, family information where relevant, questionnaires, observation and examination.[6][7]Use DETA, the World Health Organization Alcohol Use Disorders Identification Test, and FACE questionnaires to support identification of problematic use or dependence.[5][8][9][10]
• Interpret DETA results as suggesting a possible alcohol problem with two positive responses and a need to seek help with three or more positive responses.[8]Use FACE thresholds to identify hazardous use or possible dependence, with intermediate scores supporting a brief intervention to reduce consumption.[8][9]Use Alcohol Use Disorders Identification Test scoring to identify current misuse and probable dependence.[10]
• Assess chronic alcohol use clinically before relying on biological testing, covering reported consumption, associated risks and daily-life impact, physical illness, psychiatric co-morbidity, social difficulties, other addictions, severity, motivation and quality of life.[4]Complement this assessment, when indicated, with gamma-glutamyl transferase and mean corpuscular volume, followed by carbohydrate-deficient transferrin.[4][7]
• Match the treatment setting to withdrawal risk, patient cooperation and self-management capacity, socio-family circumstances, potential need for hospitalisation, and co-morbid conditions.[3]Provide outpatient withdrawal care for patients at low risk of complications and inpatient care where there is a history of seizures or delirium tremens, risk of harm, combined substance dependence, serious physical or psychiatric illness, unsuccessful outpatient treatment, or a need for separation from the family environment.[3]
• Provide withdrawal where frequent clinical assessment is possible, with an average hospital stay of two weeks determined case by case according to treatment needs.[3]Use the Cushman scale to prevent or guide initial management of delirium tremens, assessing vital signs, tremor, sweating, agitation and sensory disturbance; the scale differentiates moderate, moderate-to-severe and severe withdrawal.[10]
• Deliver accessible, non-judgemental information to patients and families, establish a trusting therapeutic relationship, and provide supervised withdrawal and stable longer-term support where needed.[3][11]
• Use vitamin B1, correction of fluid and electrolyte disturbances, and benzodiazepines during withdrawal where clinically indicated; diazepam is the reference benzodiazepine and oxazepam is preferred in liver disease.[11]Use other medicines for withdrawal or psychotic symptoms as indicated.[11]
• Support relapse prevention with acamprosate or naltrexone where appropriate, and reserve disulfiram for selected, well-informed, motivated patients with a stable socio-family environment.[12]Reinforce withdrawal benefits and address difficulties through motivational psychotherapy and responses adapted to the patient’s stage of motivation.[12]
• Assign nurses and midwives responsibility for frontline screening, advice and referral; enable doctors and dentists to assess use and motivation, identify complications, provide brief intervention or withdrawal care, and refer patients when necessary.[7]Involve relevant medical specialists in joint follow-up and complication management, and use social workers and specialised educators for social and reintegration support.[2][7]
• Maintain clinical controls and follow-up after brief intervention, withdrawal treatment and psychotherapy, escalating referral where treatment fails or complications require specialist care.[6][7]The protocol does not specify programme-level reporting systems, formal performance indicators, budgets, financing arrangements or a wider governance and accountability framework.[3][11][12][2][6][7]

Monitoring & Evaluation

Evaluation is principally clinical and patient-level, covering screening, diagnostic assessment, withdrawal severity, complications, treatment response and long-term follow-up. The protocol does not establish a formal programme-level indicator set, reporting system, population surveillance mechanism or accountability framework beyond clinical assessment, controls, referral and continuing care.[5][6][7]

• Screen for problematic alcohol use through patient and family interviews, clinical examination and structured questionnaires, including DETA, the Alcohol Use Disorders Identification Test (AUDIT) and FACE.[5][6][7]
• Assess chronic alcohol use by examining consumption quantity and frequency, alcohol-related risks and daily-life effects, dependence severity, motivation, quality of life, physical complications, psychiatric co-morbidities, social difficulties and other addictions.[4]
• Complement clinical assessment with biological investigation where appropriate, using gamma-glutamyl transferase and mean corpuscular volume initially, followed by carbohydrate-deficient transferrin when indicated.[4]
• Use DETA results to identify a possible alcohol problem after two positive responses and a need to seek help after three or more positive responses.[8]
• Interpret FACE scores of at least 4 for women or 5 for men as hazardous consumption, and scores of at least 9 for either sex as possible dependence; provide a brief consumption-reduction intervention for intermediate scores.[8][9]
• Interpret AUDIT scores of at least 8 in men or 7 in women as current alcohol misuse, and scores above 12 in men or above 11 in women as alcohol dependence.[10]
• Monitor withdrawal frequently in a setting that permits regular clinical assessment, particularly where there is a risk of complications.[3]
• Apply the Cushman scale to prevent or guide the initial management of delirium tremens, assessing pulse, systolic blood pressure, respiratory rate, tremor, sweating, agitation and sensory disturbances.[11][10]
• Classify Cushman scores below 7 as clinically moderate, scores from 7 to 14 as moderate withdrawal, and scores above 14 as severe withdrawal; the stated criteria apply in the absence of fever, with an age-related blood-pressure adjustment after age 50.[10]
• Maintain clinical controls and follow-up after brief intervention, withdrawal management and psychotherapy, and refer patients to a higher care level when treatment fails or complications require escalation.[6][7]
• Support long-term follow-up through a stable therapeutic relationship, continued therapist availability, referral to relevant services and consideration of medication to maintain abstinence.[11]

Costing & Financing

Costing information is very limited. Addiction-targeted treatments are characterised as longer and more expensive than withdrawal treatment, and their effects may be strengthened when combined with psychotherapy, particularly cognitive-behavioural therapy.[2]No monetary amounts, budgets, funding allocations, financing sources, funding gaps, resource-mobilisation arrangements, currencies or quantitative economic assumptions are specified.[1][3][8]

• Require resources for multi-level care, including first-contact screening and referral, hospital and specialist assessment, ambulatory or inpatient withdrawal management, psychotherapy, social support and reintegration interventions.[2][6][7]
• Provide medicines and diagnostic inputs including benzodiazepines, neuroleptics, anti-addiction medicines, vitamin B1, gamma-glutamyl transferase, mean corpuscular volume and carbohydrate-deficient transferrin reagents, without specifying their costs or financing.[7]
• Allow withdrawal hospitalisation to last on average two weeks, while determining the actual duration case by case according to the treatment stages needed.[3]