The basics - Alcohol abuse

Problem drinking is increasing and early detection is vital for successful intervention, says Dr Anna Cumisky.

Dependent drinkers tend to feel an uncomfortable urge to drink
Dependent drinkers tend to feel an uncomfortable urge to drink

According to government data, there were just over 9,000 alcohol-related deaths in 2008.1

Problem drinking refers to a situation where day-to-day life is affected by alcohol. This may involve difficulties with personal health, work and social life and relationships. About 1-2 per cent of the UK population is in this category.

Dependent drinkers tend to feel an uncontrollable urge to drink and may display withdrawal symptoms when sober. This leads to chronic or episodic intoxication. Tolerance exacerbates the problem leading to greater use.

Drinkers may consume alcohol at a high level for some time before complications develop, and early identification of a problem with appropriate intervention is the ideal approach.

Risk factors and red flags
The age at which drinking starts is significant, as 40 per cent of youngsters who start drinking regularly before age 14 develop a drinking problem later in life. Alcohol may affect the developing adolescent brain, leading to a persistent urge to drink. A strong family history of excessive alcohol use predisposes an individual to alcoholism, probably due to both genetic and acquired factors. People who have been abused at a young age, the unemployed and the homeless are all at increased risk.

Red flags include: increased use with features of tolerance; narrowing of drinking repertoire; guilt about use of alcohol; and withdrawal features in absence of alcohol.

Detecting dependence
All patients should have their alcohol use quantified at least once a year with a brief discussion about safe alcohol intake.

The CAGE questionnaire provides a useful screen for suspected alcohol dependence, and consists of four questions: Have you ever felt that you need to Cut down your drinking; have people Annoyed you by criticising your drinking; have you ever felt Guilty about your drinking; have you ever needed an Eye-opener to steady your nerves in the morning or clear a hangover?

The alcohol use disorders identification test (AUDIT) screening tool is regarded as the gold standard but is more time consuming. A comparison of CAGE and AUDIT found that AUDIT detected more than 50 per cent more cases of problem drinking. AUDIT is designed to detect problem, as well as hazardous, drinkers.

All CAGE positive candidates were also AUDIT positive. This may suggest a benefit for using AUDIT in practice.

Other features of problem drinking not covered should be discussed, including concentration on a single type of drink, and increased tolerance to alcohol.

Management of abuse
Ideally, education regarding safe limits, alcohol units and drinking patterns should be routine in all consultations from adolescence onwards. Quantifying alcohol use at new patient checks and annual chronic disease checks can be useful.

Brief intervention strategies (BIS) have been shown to be effective in reducing alcohol use in excessive drinkers, and take only minutes to employ.2 The FRAMES template (Feedback, Responsibility, Advice, Menu of options, Empathetic interviewing, Self-efficacy) provides a useful prompt of BIS. It involves the discussion of drinking habits, and strategies for reducing alcohol intake.

Dependent drinkers are at risk of complications such as delirium tremens (DTs) if alcohol use is reduced too suddenly.

Specialist support is essential for a gradual approach. Organisations including Alcoholics Anonymous offer this sort of service. NHS hospitals do not usually admit patients purely for detoxification, but high risk patients such as those with substantial comorbidity may require secondary care.

Complications
The onset of DTs is a serious complication. Following a prodromal period of 24-36 hours, a gross tremor develops with delirium and hallucinations. Patients should be admitted as a medical emergency, because DTs have a 15 per cent mortality.

Wernicke-Korsakoff syndrome carries a high mortality and is associated with thiamine deficiency.

All patients using alcohol excessively should be considered for B vitamin supplements with thiamine.

Key Points
  • Alcohol-related illness costs £2.7 billion a year.
  • The CAGE questionnaire and AUDIT are useful screening tools.
  • Detection at an early stage is essential.
  • Brief intervention strategies are useful.
  • DTs have a 15 per cent mortality.

Dr Cumisky is a locum GP in Bath

REFERENCES

1. Office for National Statistics www.statistics.gov.uk/CCI/nugget.asp?ID=1091

2. Ballesteros J, Duffy JC, Querejeta I et al. Alcohol Clin Exp Res 2004; 28: 608-18.

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