Alcoholism and Alcohol Misuse - Recognition and Assessment

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also: Recommended Safe Limits of Alcohol written for patients

Alcohol use is prevalent in the UK although there has been a reduction in recent years. Government statistics reported that in England in 2014, 58% of the population reported drinking alcohol in the previous week[1].

The recommended levels of alcohol intake in the UK are 14 units per week for men and women and the thinking behind this is that binge drinking is more harmful than regular intake throughout the week. The recommendations relating to daily consumption of pure alcohol in the UK are no more than 20 g (2.5 units)[2].

Further information on the scale of the problem is detailed in the separate Alcohol-related Problems article.

Key point: always ask about alcohol use in all settings and have a high index of suspicion.

Use non-confrontational questions to begin a discussion about alcohol - for example:

  • Do you use alcohol?
  • In what circumstances do you drink - eg, only when socialising?
  • What is the most you have ever drunk? How recent was this?

In primary care and hospital settings - use the CAGE or AUDIT questionnaires[3, 4].

Often routine blood results may show coincidental macrocytosis or abnormal LFTs which should make you suspicious[5].

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This involves two main aspects:

  • Is their alcohol intake a problem?
  • Do they have any illnesses relating to their alcohol intake - this encompasses physical, psychological and social aspects?
  • Amount of consumption.
  • Are they dependent on alcohol? Do they need a drink every day? What time is their first drink?
  • Has anyone expressed concerns about their alcohol intake?
  • Alcohol dependence[6]:
    • Strong desire to drink.
    • Difficulty controlling alcohol intake.
    • Physiological withdrawal when intake is reduced.
    • Tolerance, such that increasing amounts are required to produce the same effect.
    • Harm resulting from alcohol use - eg, work, relationships.
  • Alcohol withdrawal:
    • Symptoms begin within a few hours of not having a drink and can last beyond 48 hours.
    • Hyperactivity, anxiety and coarse peripheral tremor.
    • Mild pyrexia, tachycardia and hypertension.
    • Sweating, nausea and retching.
    • Seizures.
    • Auditory and visual hallucinations.
    • Delirium tremens (the severe end of the spectrum of withdrawal, consisting of severe forms of the above symptoms, and may be associated with circulatory collapse and ketoacidosis)[7, 8].
  • History - include features as above.
  • Examination:
    • General demeanour; ethanolic or hepatic fetor.
    • Malnourishment.
    • Signs of acute withdrawal such as coarse tremor and tachycardia.
    • Signs of liver disease, such as palmar erythema, gynaecomastia, spider naevi and jaundice[9].     
    • Hepatomegaly (in chronic alcoholic liver disease the liver is shrunken).
    • Ascites; gonadal atrophy.
    • Atrial fibrillation and cardiomyopathy.
    • Wernicke-Korsakoff syndrome (ataxia, confusion, ophthalmoplegia), amnesic problems, peripheral neuropathy and dementia.
  • Alcohol level is useful in acute comatose state:
    • Alcohol level >300 mg/100 ml extreme intoxication (drowsiness and then coma).
    • Levels > 400 mg/100 ml may be fatal.
  • FBC, clotting screen, renal testing and LFTs:
    • Suspect excessive alcohol use if mean corpuscular volume (MCV) is raised and platelet count may be decreased or elevated liver enzymes. (Gamma-GT is the best indicator of excessive alcohol consumption.)
    • Chronic alcohol consumption may also be associated with dyslipidaemia, notably hypertriglyceridaemia.
    • Also check fasting glucose, as chronic pancreatitis can lead to diabetes mellitus.
  • Be honest and non-judgemental.
  • Many patients drink in secret and may not want to discuss the issue.
  • The patient needs to accept that there is a problem before therapy can start.
  • Detoxification should be discussed.
  • Provide information regarding local Alcoholics Anonymous groups.

See separate Alcoholism and Alcohol Misuse - Management article.

Further reading & references

  • Dhalla S, Kopec JA; The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clin Invest Med. 2007;30(1):33-41.
  1. Statistics on Alcohol - England, 2016; NHS Digital
  2. Alcohol Guidelines Review – Report from the Guidelines development group to the UK Chief Medical Officers; Department of Health, January 2016
  3. Elwy AR, Horton NJ, Saitz R; Physicians' attitudes toward unhealthy alcohol use and self-efficacy for screening and counseling as predictors of their counseling and primary care patients' drinking outcomes. Subst Abuse Treat Prev Policy. 2013 May 30;8(1):17. doi: 10.1186/1747-597X-8-17.
  4. Bowring AL, Gouillou M, Hellard M, et al; Comparing short versions of the AUDIT in a community-based survey of young people. BMC Public Health. 2013 Apr 4;13(1):301.
  5. Topic A, Djukic M; Diagnostic characteristics and application of alcohol biomarkers. Clin Lab. 2013;59(3-4):233-45.
  6. Alcohol Dependence and Harmful Alcohol Use; The British Psychological Society & The Royal College of Psychiatrists, 2011
  7. Bilbault P, Levy J, Vinzio S, et al; Abrupt alcohol withdrawal: another cause of ketoacidosis often forgotten. Eur J Emerg Med. 2008 Apr;15(2):100-1. doi: 10.1097/MEJ.0b013e328285d895.
  8. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence; NICE Clinical Guideline (February 2011)
  9. Karsan HA, Parekh S; Management of alcoholic hepatitis: Current concepts. World J Hepatol. 2012 Dec 27;4(12):335-41. doi: 10.4254/wjh.v4.i12.335.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Gurvinder Rull
Current Version:
Peer Reviewer:
Dr Laurence Knott
Document ID:
1784 (v28)
Last Checked:
Next Review:

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