Alcohol dependence is a major problem in the UK. Alcohol dependence affects 4% of people aged between 16 and 65 in England (6% of men and 2% of women). More than 24% of the English population consume alcohol in a way that is potentially or actually harmful to their health or well-being. In 2012 there were 6,490 alcohol-related deaths. This is a 19% increase from 2001 but a 4% decrease from 2011.
In binge drinking - men who report drinking more than eight units of alcohol on their heaviest weekly drinking day, and women who drink more than six units - the proportion of adults in Great Britain who binged at least once a week decreased from 18% in 2005 to 15% in 2013. Young adults were mainly responsible for the decrease in binge drinking, with the proportion of who had binged falling by more than a third since 2005, from 29% to 18%.
In 2012, 43% of school pupils aged 11-15 said they had drunk alcohol at least once. This continies the downward trend since 2003, when 61% of pupils had drunk alcohol..
Approach to the patient with a suspected alcohol-related problem
- 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.
- Information regarding local Alcoholics Anonymous groups should be offered.
It is necessary to decide if the patient has an alcohol problem and, if so, whether the patient is a dependent drinker. The patient has a problem if he or she answers yes to any of the 'CAGE' questions (Cut down, Annoyed, Guilty, Eye-opener) and/or scores highly on the Alcohol Use Disorders Identification Test (AUDIT). Specialist advice should be sought if they score more than 15 on AUDIT assessment.
Dependent drinkers are characterised by:
- An overwhelming desire for alcohol.
- Drinking out of control.
- A need for increasing amounts of alcohol.
- Withdrawal symptoms experienced.
- Having little interest in other leisure activities.
- Continuing to drink even when the harm being done is made clear.
These can be formally assessed using a validated tool such as the Severity of Alcohol Dependence Questionnaire (SADQ).A comprehensive assessment should be carried out when a person scores 15 or more on the AUDIT. This should address a range of potential needs. A clinical interview should assess:
- Alcohol use (consumption, historical and recent patterns of drinking), using validated clinical tools.
- Level of dependence.
- Alcohol-related problems.
- Other drug misuse (including over-the-counter medication).
- Physical health problems.
- Psychological and social problems.
- Cognitive function - although formal measures of cognitive functioning (eg the Mini Mental State Examination) are usually only performed if impairment persists after a period of abstinence or a significant reduction in alcohol intake.
- Readiness and belief in ability to change.
If possible, information could also be sought from a family member or carer.
Harmful or mildly dependent drinking management
If not a dependent drinker, a brief intervention can be tried. This can be effective in reducing alcohol consumption at 6 and 12 months following intervention.This can be performed by the doctor, nurse or counsellor and involves:
- Advice on the dangers of excessive or binge drinking.
- Provision of advice leaflets and details on availability of any local organisations.
- Trying to find out what factors make the patient drink and how they could be avoided.
- Agreeing with the patient objectives that can be accomplished. This can include controlled drinking - eg, weaker drinks, spacing drinks, alternating alcoholic with non-alcoholic drinks, eating with drinks.
Other psychological therapies to consider offering harmful or mildly dependent drinkers include cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies. These focus specifically on alcohol-related thoughts, behaviour, problems and social networks. If patients do not respond, or request a pharmacological intervention, you might consider acamprosate or oral naltrexone in combination with psychological intervention.
Patients can belong to two broad groups, although other scenarios may occur such as a patient presenting whilst under the influence of alcohol, or because of traumatic injury as a result of alcohol:
- Patient wishing to abstain.
- Patient presents in acute alcohol withdrawal:
- Treatment may need to begin with detoxification. This may need to occur as an inpatient, depending on severity of symptoms.
- If disorientation, agitation or seizures occur then refer for inpatient detoxification.
- However, the majority can be managed in the community and it is worth contacting the local community mental health team, as they may have a set-up for alcohol-dependent patients.
For people who typically drink over 15 units of alcohol per day and/or who score 20 or more on the AUDIT, an assessment should be offered for delivery of a community-based assisted withdrawal. If there are safety concerns (see below) offer inpatient withdrawal.
Inpatient care is recommended for:
- Patients at risk of suicide.
- Those without social support.
- Patients who have a history of severe withdrawal reactions.
Community detoxification requires:
- Daily supervision to detect complications early - eg, DTs, continuous vomiting, deterioration in mental state.
- Multivitamin preparations to prevent Wernicke's encephalopathy.
- Benzodiazepines to prevent withdrawal symptoms (usually chlordiazepoxide).
- Continuing support - primary healthcare team, community alcohol team, residential rehabilitation programmes, voluntary organisations, referral to the specialist mental health team, disulfiram.
Following detox, abstinence is recommended with clear alcohol dependence and/or marked physical damage or controlled drinking ineffective. It is best practised long-term but some patients may return to controlled drinking after a period of abstinence.
Unrealistic expectations of abstinence may be counterproductive, resulting in relapse. Acamprosate can help to maintain long-term abstinence when combined with counselling.[8, 9] This has been combined with naltrexone in some cases.
Drugs used in acute withdrawal
Patients should ideally be nursed in quiet surroundings.
Long-acting forms are used to reduce tremor and agitation - eg, diazepam or chlordiazepoxide. Some hospitals have alcohol withdrawal assessment charts to determine how much to give - eg, the Clinical Institute Withdrawal Assessment for Alcohol scale. Short-acting benzodiazepines are used for seizures - eg, lorazepam intravenously (IV).
Be careful of possible dependence on benzodiazepines - advise short courses at the lowest necessary dose.
Vitamin B complex
This is given as IV Pabrinex® to inpatients for a couple of days and then patients are given oral thiamine and multivitamins. IV therapy with vitamin B complex is used to treat Wernicke-Korsakoff syndrome.
These can be used to reduce autonomic hyperactivity but are rarely used in practice as the long-acting benzodiazepines are usually sufficient.
Treatments used in abstinence or prevention of relapse
After successful withdrawal, acamprosate or oral naltrexone can be considered in combination with an individual psychological intervention.
Calcium acetyl-homotaurinate (acamprosate)
- This blocks gamma-aminobutyric acid (GABA) and reduces N-methyl-D-aspartate (NMDA) receptor glutamate-related excitation.
- It has a possible neuroprotective role in detoxification.
- It does not interact with alcohol and reduces cravings.
- Will usually be given post-detoxification to maintain stabilisation.
See also separate article Opioid Misuse and Dependence.
- Alcohol causes pleasure by release of endogenous opioids. Naltrexone is a competitive antagonist of the opioid receptor which prevents the endogenous opioid from binding to the receptor, therefore giving reduction in the pleasurable effects from alcohol.
- It is associated with lower relapse rate, fewer drinking days and longer length of abstinence.[13, 14] Therefore, patients are less likely to take large quantities in one go - thus it is used in patients who are binge drinkers.
This is a newer treatment available as an option for reducing alcohol consumption in people with alcohol dependence, ie those who have an alcohol consumption of more than 60 g per day for men and more than 40 g per day for women, without physical withdrawal symptoms and who do not require immediate detoxification. Nalmefene should only be prescribed in conjunction with continuous psychosocial support and be initiated in patients who continue to have a high drinking risk level two weeks after initial assessment.
The length of time spent in treatment of alcohol dependence appears not to be important when comparing brief or extended treatment conditions.
Other more novel agents
- These agents are not currently licensed for use in alcohol dependence.
- They include selective serotonin re-uptake inhibitors (SSRIs), such as fluoxetine, and anticonvulsants (topiramate).
- All medications should be used in conjunction with psychological interventions.
- This includes counselling, cognitive-based therapy and self-help groups - for example, Alcoholics Anonymous.
- Social support is also important. Where possible, families should be involved in the treatment and support of the drinker.
Children and young people aged 10-17 years who misuse alcohol should be offered individual cognitive behavioural therapy (for those with limited comorbidities).
Those with significant comorbidities and/or limited social support should be offered multicomponent programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy).
Clinicians should also bear in mind the effect that a family member's drinking may have on other people in the household.
Where there is depression or where anxiety disorders exist, clinicians are advised to treat the alcohol misuse first, as this may lead to significant improvement in the depression and anxiety. If depression or anxiety continues after three to four weeks of abstinence from alcohol, assess the depression or anxiety and consider referral and treatment.
Further reading and references
School-based interventions on alcohol; NICE Public Health Intervention Guidance, November 2007
Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence; NICE Clinical Guideline (February 2011)
Statistics on Alcohol - England, 2014; Health and Social Care Information Centre (HSCIC), May 2014
Opinions and Lifestyle Survey, Adult Drinking Habits in Great Britain, 2013; Office for National Statistics
Severity of Alcohol Dependence Questionnaire (SADQ); PHE Alcohol Learning Resources
Bertholet N, Daeppen JB, Wietlisbach V, et al; Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med. 2005 May 9165(9):986-95.
Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications; NICE Clinical Guideline (June 2010)
Blondell RD; Ambulatory detoxification of patients with alcohol dependence. Am Fam Physician. 2005 Feb 171(3):495-502.
Mann K, Lehert P, Morgan MY; The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals: results of a meta-analysis. Alcohol Clin Exp Res. 2004 Jan28(1):51-63.
Mason BJ, Goodman AM, Chabac S, et al; Effect of oral acamprosate on abstinence in patients with alcohol dependence in a double-blind, placebo-controlled trial: the role of patient motivation. J Psychiatr Res. 2006 Aug40(5):383-93. Epub 2006 Mar 20.
Bouza C, Angeles M, Munoz A, et al; Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: a systematic review. Addiction. 2004 Jul99(7):811-28.
McIntosh C, Chick J; Alcohol and the nervous system J Neurol Neurosurg Psychiatry. 2004 Sep
Castro LA, Baltieri DA; The pharmacologic treatment of the alcohol dependence. Rev Bras Psiquiatr. 2004 May26 Suppl 1:S43-6. Epub 2005 Jan 4.
Williams SH; Medications for treating alcohol dependence. Am Fam Physician. 2005 Nov 172(9):1775-80.
Boothby LA, Doering PL; Acamprosate for the treatment of alcohol dependence. Clin Ther. 2005 Jun27(6):695-714.
Nalmefene for reducing alcohol consumption in people with alcohol dependence; NICE Technology Appraisal Guidance, Nov 2014
Moyer A, Finney JW, Swearingen CE, et al; Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction. 2002 Mar97(3):279-92.
No authors listed; Effectiveness of treatment for alcohol problems: findings of the randomised UK alcohol treatment trial (UKATT). BMJ. 2005 Sep 10331(7516):541.
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