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The government’s new alcohol guidelines, out to consultation until April, advise stricter safe drinking limits and are clearer on the risks of misuse.
There were more than 6,500 alcohol-related deaths in England in 2013, a 1% increase from 2012 and a 10% increase from 2003.1
Hazardous and harmful drinking refers to a consumption pattern whereby the person drinking this level of alcohol is at psychological and physical risk.
Harmful drinking is the more severe end of the category, whereby an individual is likely to experience harmful health effects from the alcohol consumed.
The most recent data for harmful and hazardous drinkers is from 2007, when 3.8% of the UK population could have their alcohol intake categorised as harmful.
The highest prevalence of hazardous and harmful drinking was in men aged 25-34 years and women aged 16-24 years.2
The government’s recently published new guidelines for safe drinking of alcohol are stricter than previous guidance.3 They have been set to reduce the risk of cancer, following new evidence which has shown that the risk of developing cancer, especially breast cancer, correlates with the level of alcohol regularly drunk.
Importantly, new research findings also show that a small protective effect of alcohol for heart disease only applies to women aged 55 years and above taking small amounts of alcohol per week.
Recommended safe drinking levels for men equate to those for women, at not more than 14 units of alcohol per week. Spreading the total amount of alcohol across the week is recommended, along with trying to keep some days per week alcohol-free.
The guidelines also offer some simple steps to share with patients to help reduce alcohol intake and limit the short-term risks from drinking, such as accidents.
The advice is to drink slowly, to alternate alcoholic drinks with soft drinks, to limit the amount of overall alcohol taken in one session and to avoid binge drinking.
The government also now recommends that pregnant women avoid alcohol completely.
Risk factors and red flags
The age at which drinking starts is significant, because 40% of youngsters who start drinking regularly before the age of 14 years 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.
Risk factors include:
- Increased alcohol use with features of tolerance
- Narrowed drinking repertoire
- Guilt about use of alcohol
- Withdrawal features in the absence of alcohol
All patients should have their alcohol use quantified at least once a year, with a brief discussion about safe alcohol intake. The CAGE questionnaire (see box) provides a useful screen for suspected dependence. The alcohol use disorders identification test (AUDIT) screening tool is the gold standard, but is more time consuming.
Management of abuse
Brief intervention strategies (BIS) have been shown to be effective in reducing alcohol use in excessive drinkers, and take only minutes.4
Many patients will benefit from the help of more specialised support services, such as Alcoholics Anonymous or other community groups. The FRAMES template (Feedback, Responsibility, Advice, Menu of options, Empathetic interviewing, Self-efficacy) offers a useful prompt for BIS. It involves the discussion of drinking habits and strategies for reducing intake.
Many require more specialist treatment to help manage their often complex needs.5 Dependent drinkers are at risk of complications such as delirium tremens (DTs) if intake is reduced too quickly. Specialist support is essential.
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 has a 15% mortality.
Wernicke-Korsakoff syndrome carries a high mortality and is associated with thiamine deficiency. All patients using alcohol excessively should be considered for vitamin B supplements with thiamine.
|Key learning points|
- Dr Anna Cumisky is a GP in Bath
- Health & Social Care Information Centre. Statistics on Alcohol, England 2015. www.hscic.gov.uk/catalogue/PUB17712/alc-eng-2015-rep.pdf
- Health & Social Care Information Centre. Adult psychiatric morbidity in England 2007 – results of a household survey. www..hscic.gov.uk/pubs/psychiatricmorbidity07
- DH. Open consultation. Health risks from alcohol: new guidelines. January 2016. www.gov.uk/government/consultations/health-risks-from-alcohol-new-guidelines
- NICE. Alcohol-use disorders: prevention. PH24. London, NICE, June 2010
- NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. CG115. London, NICE, February 2011