The term Alcoholism has lost much of its
meaning. It lacks scientific precision and is of little
relevance.The term ALCOHOL DEPENDENCE is
preferred and has been used
by the World Health organisation.
ALCOHOL DEPENDENCE SYNDROME
For most people who drink, alcohol is a pleasant accompaniment to social
activities. Moderate alcohol use is not harmful for most adults. Nonetheless, a
large number of people get into serious trouble because of their drinking. The
consequences of alcohol misuse are serious—in many cases, life threatening.
Heavy drinking can increase the risk for certain cancers, especially those of
the liver, oesophagus, throat, and larynx. Heavy drinking can also cause liver
cirrhosis, immune system problems, brain damage, and harm to the foetus during
pregnancy. In addition, drinking increases the risk of death from car crashes
as well as recreational and on-the-job injuries. Furthermore, both homicides
and suicides are more likely to be committed by persons who have been drinking.
Alcohol dependence results in behavioural responses
that include a compulsion to take alcohol on a continuous or periodic basis in
order to experience its psychic effects, and sometimes to avoid the discomfort
of its absence. Tolerance may develop and the person may consume greater
amounts to achieve the same psychic state. A person may be dependent on alcohol
alone or other drugs. The continuous alcohol use may lead to physical
complications such as liver cirrhosis, epilepsy or gastritis and psychiatric
problems such as alcoholic psychosis and dementia.
Alcohol dependence. Dependence is present when of the following are
present:
— A strong desire or compulsion to use alcohol (Craving)
— Difficulty controlling alcohol use
— Withdrawal symptoms (e.g. anxiety, tremors, sweating) even when drinking
is ceased
— Tolerance (e.g. drinks large amounts of alcohol without appearing
intoxicated)
— Continued alcohol use despite harmful consequences.
•
Harmful
alcohol use:
— heavy alcohol use (
eg over 28 units per week for men, over 21 units per week for women)
— overuse of alcohol
has caused physical harm (eg liver disease, gastrointestinal bleeding),
psychological harm (eg depression or anxiety due to alcohol), or has led to harmful
social consequences (eg loss of job).
The
phrase that a person is "having a problem
with drinking" is more acceptable in the
initial phase of investigation and
treatment. Basically it implies that
drinking is out of
control either continuously or intermittently. As a
result of this the person either causes damage to (a)
themselves or (b) other people. This damage may be (i)
physical (ii) psychological (iii) social.
Alcohol abuse differs from alcoholism in
that it does not include an extremely strong craving for alcohol, loss of
control over drinking, or physical dependence. Alcohol abuse is defined as a
pattern of drinking that results in one or more of the following situations
within a 12-month period:
• Failure to fulfill major work, school, or
home responsibilities;
• Drinking in situations that are physically
dangerous, such as while driving a car or operating machinery;
• Having recurring alcohol-related legal
problems, such as being arrested for driving under the influence of alcohol or
for physically hurting someone while drunk; and
• Continued drinking despite having ongoing
relationship problems that are caused or worsened by the drinking.
Although alcohol abuse is basically
different from alcoholism, many effects of alcohol abuse are also experienced
by alcoholics.
This
can be defined in terms of volume of equivalent absolute alcohol, but it
has been customary to use the term UNIT which is approximately equal
to 10 mls of absolute alcohol which
is equal to 8.0 g of absolute alcohol.
|
ALCOHOL CONTENT OF SOME
DRINKS |
|
|
BEER |
1
pint - 250 ml =2 units |
|
STRONG
LAGER |
1
pint
= 3 units |
|
WINES |
1
bottle - 90 ml = 6
units 1 glass - 15 ml = 1- 1.5 units |
|
FORTIFIED
WINES Sherry,
Port, etc. |
1
bottle -
125 ml = 15 unit 1
large glass- 16ml = 2
units 1
small glass- 8 ml =
1 unit |
|
SPIRITS Whiskey,
Gin, Vodka Brandy |
1
bottle -
290 ml = 30 units |
|
1
double - 18
ml =2 units |
|
|
1
single -
9 ml = 1
unit |
|
The Royal Colleges
of Physicians, General Practitioners
and Psychiatrists have agreed recommended
levels. Men should not drink more
than 28 Units per week and women
not more than 21 Units. A further
recommendation is that every person should have at least two
drink free days per week. Where
men drink over 50 Units and women over
35 over any period of time there is
definite evidence of physical damage. Women
achieve higher blood alcohol levels per Unit of alcohol because
on average they weigh 20% less than men and their total body
fluid is less. There may
also be increased tissue susceptibility.
Alcohol is rapidly absorbed
from an empty stomach reaching peak levels in half an
hour. Food delays absorption and flattens the absolute curve. 10
mls
(1 Unit) of alcohol can cause a rise in blood
alcohol levels between 15 and 20 mgs per 100 ml. Alcohol is removed from blood
and excreted at the rate of about 15 mgs per hour (e.g. a patient drinking 12
pints in 4 hours would have an average alcohol level of 24 units*15=360
mg-60mg= 300mg per 100ml). Alcohol is a CNS depressant. Depression of
higher functions
like inhibitions are the first factors affected giving a sense of
inflated self-confidence. Motor performance is affected
very early and has been demonstrated to affect driving skills at levels
as low as 30 mgs per 100 ml. ( legal limit = 80 mgs per 100
ml = 37 mmols per litre of breath alcohol).
EPIDEMIOLOGY
Formerly
a number of indirect methods were used to find out how many
people were drinking and how much.
Such things as mortality statistics from
cirrhosis of the liver, and per capita consumption of alcohol
were used in complicated
calculations. More recently with more open discussion
about alcohol consumption surveys gave a more
accurate picture of what people drank. In the
United Kingdom about 90% of the adult population drink alcohol. The
majority in a sensible and enjoyable way or think
they do so until proved otherwise by comparing
with wider norms. There is evidence that
about 30 % of the male population drink more than they ought
to over prolonged periods and 20% of men drink more over short
periods (the "wild oat" phase of drinking). In women under 10%
drink too much over prolonged periods and 20% drink too much over short
periods. Clearly with high numbers like that treatment
must be from an educational
standpoint. Fortunately only relatively few of
these will need treatment in the specialist sense.
Surveys have also
shown there is a wide variation in drinking patterns throughout the
country. This is also reflected in those
who are seeking treatment. Nevertheless estimates have been made
that between 0.5% and 3% of the population need treatment in the
specialist sense. The male to female ratio
has been falling and currently stands at about one male
to two females. Surveys in general hospitals show that in excess of
20% of hospital beds are taken up with alcohol related
diseases.
It
has been clear for some time that alcoholism runs in
families but it has not been clear if
this is genetic or a result of family behaviour patterns. Twin
studies have shown that there is a probable genetic factor
and specific genetic studies seem to be
implicate specific genes.
There
has been a long search for personality
factors. No alcoholic personality has been successfully
defined and demonstrated. It is tempting to blame a dependent
personality but the evidence is lacking. It is clear that many personality
disorders have drinking problems.
CULTURAL AND
ENVIRONMENTAL FACTOR
There
is clear evidence that some races
have higher incidence of alcoholism than others.
The Irish in whatever country they are living have often been compared
with the Jewish community. In certain religions alcohol is taboo but this
does not stop drinking problems from arising. It is clear that
price, in terms of relative cost, availability
and social acceptability of drinking are
strong
aetological
factors. It is clear that certain occupations drink more heavily
than others. For example:
a. Those who work
with alcohol, e.g. barmen and waiters.
b. Those who
entertain with alcohol, e.g. company
executives, commercial travellers.
c. Thosw
working in heavy industry, e.g. miners and steelworkers.
d. Those
working unsocial hours, e.g. armed services, police,
night workers, doctors.
PSYCHIATRIC
DISORDERS.
Alcohol
can produce depression. Most of those
depressive factors are through the result of
the direct action of alcohol on the body
or the problems that have been
produced in that patient's life. Some
who are depressed may drink excessively as an
attempt to relieve their depressive symptoms. The
same may be said for anxieties and phobias. We are now seeing
higher numbers of schizophrenics who are drinking heavily
complicating their condition. The relationship between
the personality disorder and heavy drinking has already
been mentioned. Alcohol does not only cause
sexual problems but there are a
whole gamut of sexual problems from dysfunction to
paraphilia and frank deviant sexual behaviour that may associated
with heavy drinking. Women and, to a lesser extent, men who
were sexually abused in childhood may develop sexual problems and
drink excessively in order to have some sort of sexual
relationships or suppress their desires.
SCREENING TESTS
(QUESTIONNAIRES)
These
are short questionnaires which are designed to identify
people with a drinking problem by inviting
them to answer a series of questions.
The most well known are:
1. M.A.S.T. (Michigan
Alcohol Screening Jest)
2. CAGE
C = Cutting
down was tried (tried before to cut down
his drinking but failed)
A = Annoyed by
criticism of others for drinking (upset
by comments of family about his drinking)
G = Guilt
feeling over drinking (Feels he drinks
too much)
E = "Eye
opener", i.e. morning drinking is usual. (drinks first thing in the morning)
These
questionnaires may have their uses but are no substitute for a good
alcohol history.
TAKING AN
ALCOHOL HISTORY
This
can be done with a history
of smoking and other social
activities. It must be done without embarrassment and in detail
first establishing if the patient drinks at all and when this is, so that it is
possible to construct a mini-drinking diary for each week so that Units
can be added up for each part of the day and for a typical week. Bout
drinkers have to be questioned about frequency of drinking bouts and the
amount they drink.
LABORATORY
SCREENING TESTS
M.C.V.
(Mean Corpuscular Volume) is increased
Abnormal
liver function tests [Gamma G.T
(Gamma glutamyl transpeptidase) is high due to liver cell
damage]
Blood
alcohol levels help to screen patients and can be used in diagnosis.
RELATED
DISABILITIES
A) Physical
Disabilities
Heavy drinkers
tend to be unhealthy in a number of
non-specific ways, by neglecting their health. Thus they tend
to have weight problems and its associated disorders, their diet is
poor, smoking is heavy with higher incidences of respiratory and cardio-vascular
disease. Life expectation is shortened in
this way, to say nothing of specific alcohol related diseases
and increased susceptibility to accident and violent attacks.
1) Haematological
Disorders
Alcoholism is
the most common cause of macrocytosis (raised
MCV) and in the absence of other specific
causes is almost diagnostic of alcoholism. Thrombocytopenia and
anaemia may also occur.
2) Liver
Disease
The
progression is acoholic hepatitis progressing
to fatty infiltration (both of these are
reversible if drinking is stopped), but
prolonged heavy drinking can lead to alcoholic
cirrhosis with
signs of
liver disease, acute
hepato-encenhalopathy and hepatoma may be terminal
events. Diagnosis of each stage is made
on clinical and biochemical grounds.
3) Peptic
ulceration - the incidence is doubled in alcoholics.
4) Gastritis
- this is a common complication of alcohol abuse and can lead to acute gastric
erosion.
5) Pancreatitis
- both acute and chronic may be associated with alcoholism.
6. Neurological
Disorders
The most
common is epilepsy of late onset (over 25 years
of age). This may be the result of alcoholic withdrawal or can be due to brain
damage.
Peripheral
neuropathy is probably due to thiamine deficiency (Dry
Beriberi) and to some extent may be
dependent on the nutritious state of the patient.
Both
Wernicke's Encephalopathy with evidence of cranial nerve damage and
Korsakoff'syndrome with evidence of global brain dysfunction may
accrue together. Over time with abstinence
from alcohol and high doses of
thiamine some cases may well gradually recover
while others remain static and permanently disabled.
Cerebellar degeneration may be seen in chronic alcoholism.
7. Heart
Disease. Alcoholic cardiomyopathy is probably the other part
of thiamine deficiency (Wet Beriberi).
Arrhythmias may also be more commonly seen in heavy drinkers.
B)
Psychological Disorders
1. Anxiety
Anxiety
may not only be an
aetiological factor. The consumption of alcohol
to a certain extent may cover anxiety symptoms resulting in
an increased consumption of alcohol to alleviate
anxiety. As the effects of alcohol begins to wear
off so more pronounced rebound anxiety
becomes apparent. Alcohol may also
be associated with phobic
disorders, especially phobia where attempts have
been made to suppress the specific anxiety with alcohol.
2. Depression
Alcohol
is a CNS depressant and
can in itself produce depressing effects. This
says nothing of the social problems, deterioration in relationships and
general ill-health that can produce reactive depressing
effects. Depression and anxiety may be seen in the wives of alcoholics.
3. Attempted
Suicide and Suicide
16% of females
who attempt suicide are heavy drinkers but of males who commit
suicide 40% are heavy drinkers. 25% of
alcoholics below the age of 40 make suicide attempts.
Alcoholics have a high suicide rate
(x80 of the general population). One third to one
half of all suicides go through a heavy drinking phase before killing
themselves.
4. Schizophrenia
A type of
schizophrenia may be precipitated and seen only when a patient
is in a heavy drinking bout. More
schizophrenics are now being seen with drinking problems and it is estimated
that 17% of male schizohrenics have drinking 'problems.
5. Personality
Deterioration
As
many alcoholics have personality problems before their
drinking becomes heavy it is difficult to qualify how much is due to
alcoholism.
6. Morbid
jealousy
Alcohol is
one of the chief precipitants of this disorder.
7. Delirium
Tremens
This is is really a
toxic confusional state which can occur after hours of
withdrawal from alcohol. It is characterised by visual
hallucinations, delusions and may be
accompanied by gross autonomic
disturbance, including
tachycardia, hypertension and even pyrexia. There may be
hypoglycaemia and electrolyte disturbance including
hypomagnesaemia. Potassium depletion is dangerous in
dehydration. All this may be seen in a
patient with marked anxiety tremor and
confusion. Delirium Tremens is a dangerous
condition and mortalities of 20-30% used to be
reported before good supportive treatment was
given. There is always the danger that the
confusional state is partly due to a respiratory
or urinar tract infection, other infections
are also possible. Diagnosis of physical
condition and management is made much more difficult due to the patients
confused and restless state.
8. Amnesia
This may just be
due to high blood alcohol levels which cause of consciousness but
prolonged periods of amnesia may accrue wich may
cover a whole drinking bout and do not
reflect persistently high blood
alcohol levels and other mechanisms are
clearly responsible. Alcoholics call these episodes
"black outs" but there must be a distinction from an amnesic
episode and an epileptic fit. Amnesia is no defence in law
but frequent attempts will be made by patients and even their solicitors
to angle a Court report in this direction.
9. Intellectual
impairment
There
is now both psychological and CT Scan
evidence that alcoholism can produce reduced cognitive capacity.
There is a remarkable improvement
in some patients with prolonged abstinence.
10. Sexual
Problems
Classically
alcoholism produces erectile dysfunction in males and once
this is fully developed may
not improve with abstinence. This is to be
distinguished from inability to get a good erection
with drink - "brewers droop".
Alcohol may remove sexual inhibitions and
can initially improve sexual performance of
both males and females but as a
long term effect causes problems in both sexes.
C) Social
Problems
1. Family Problems
There
is no doubt that alcoholism has a disastrous effect on
marriage. Up to of alcoholics are divorced or separated Up to 25%
are not married by the age of 40. Marital violence is
frequently precipitated by heavy drinking. Violence and
neglect of children may also be seen
in heavy drinking families. Threatened divorce is
a frequent reason for seeking treatment.
2. Employment
Problems
Heavy
drinking is one of the
principle causes of work absenteeism. Resignation
or dismissal is a frequent sequel. A descending
spiral of work record may be seen with inferior jobs being
accepted. Dismissal, or threat of dismissal, is a
frequent reason for seeking treatment.
3. Financial
Problems
It is
amazing the amount of money alcoholics can get through and the
debts they can run up, to say nothing of the
family deprivation this causes.
4. Accommodation
Problems
This
readily follows dismissal from work, family
problems, separation and financial difficulties. Alternatively, alcoholics may
be seen living in a family situation where they have completely
lost their respect, dignity and role where
only financial restraints and
stubbornness prevents them leaving. More
alcoholics are now being seen who live in bed and
breakfast accommodation. The last stage is
to be of no fixed abode and vagrant.
5. Problems with
the law
The percentage of
alcoholics presenting with a criminal record varies with the
type of clientele. Most cases are alcohol
related like drunk and disorderly. There
is a high degree of recidivism. Violent
offences are frequently associated with heavy drinking. This goes
right through the spectrum of offences, including murder.
THE TREATMENT OF ALCOHOLISM
Essential
information for patient and family
•
Alcohol
dependence is an illness with serious consequences.
•
Ceasing
or reducing alcohol use will bring mental and physical benefits.
•
Drinking
during pregnancy may harm the baby.
•
For
most patients with alcohol dependence, physical complications of alcohol abuse or
psychiatric disorder, abstinence from alcohol is the preferred goal. Sometimes, abstinence
is also necessary for social crises, to regain control over drinking or because
of failed attempts at reducing drinking. Because abrupt abstinence can cause withdrawal
symptoms, medical supervision is necessary.
•
In
some cases of harmful alcohol use without dependence, or where the patient is unwilling
to quit, controlled or reduced drinking is a reasonable goal.
•
Relapses
are common. Controlling or ceasing drinking often requires several attempts. Outcome
depends on the motivation and confidence of the patient.
Advice and support
to patient and family15
• For all patients:
— Discuss costs and benefits of
drinking from the patient's perspective.
— Feedback information about health
risks, including the results of GGT and MCV
— Emphasize personal responsibility
for change.
— Give clear advice to change.
— Assess and manage physical health
problems and nutritional deficiencies (e.g. vitamin B).
— Consider options for
problem-solving or targeted counselling to deal with life problems related to
alcohol use.
— If there is no evidence of
physical harm due to drinking, or if the patient is unwilling to quit, a
controlled drinking programme is a reasonable goal:
— Negotiate a clear goal for decreased use (e.g.
no more than two drinks per day, with two alcohol-free days per week).
— Discuss strategies to avoid or
cope with high-risk situations (e.g. social situations and stressful events).
— Introduce self-monitoring
procedures (eg a drinking diary) and safer drinking behaviour (e.g. time restrictions,
deceleration of drinking).
•
For patients with
physical illness and/or dependency or failed attempts at controlled drinking,
an abstinence programme is indicated.
• For patients willing to stop now:
— Set a definite day to quit.
— Discuss symptoms and management of
alcohol withdrawal.
— Discuss strategies to avoid or
cope with high-risk situations (eg social situations and stressful events).
— Make specific plans to avoid
drinking (eg ways to face stressful events without alcohol, ways to respond to
friends who still drink).
— Help patients to identify family
members or friends who will support ceasing alcohol use.
— Consider options for support after
withdrawal.
• For patients not willing to stop or
reduce now, a harm-reduction programme is indicated:
— Do not reject or blame.
— Clearly point out medical and
social problems caused by alcohol.
— Consider thiamine preparations.
— Make a future appointment to
re-assess health and alcohol use.
• For patients who do not succeed, or
who relapse:
— Identify and give credit for any
success.
— Discuss the situations that led to
relapse.
— Return to earlier steps above.
q Self-help organizations (eg
Alcoholics Anonymous) voluntary and non-statutory agencies are often helpful.
Medication
• For patients with mild withdrawal symptoms, frequent
monitoring, support, reassurance, adequate hydration and nutrition are
sufficient treatment without
medication.
• Patients with a moderate withdrawal syndrome require
benzodiazepines in addition. Most can be detoxified, with a good outcome, as
outpatients or at home. Community detoxification
should only be undertaken by practitioners with appropriate training and
supervision.
• Patients at risk of a complicated withdrawal syndrome
(e.g. with a history of fits or delirium tremens, history of very heavy use and
high tolerance, significant polydrug use, severe comorbid medical or
psychiatric disorder) who lack social support or are a significant suicide risk
require inpatient detoxification.
• Chlordiazepoxide (Librium) 10 mg, is recommended. The
initial dose should be titrated against withdrawal symptoms, within a range of
5–40 mg four times a day. (See BNF section 4.10.) This requires close, skilled
supervision.
• The following regimen is commonly used, although the
dose level and length of treatment will depend on the severity of alcohol
dependence and individual patient factors (eg weight, sex and liver function):
Days 1 and 2: 20–30
mg QDS
Days 3 and 4: 15 mg
QDS
Day 5: 10 mg QDS
Day 6: 10 mg BD
Day 7: 10 mg nocte
• Chlormethiazole is not recommended for craving or
detoxification under any circumstances.19
• Dispensing should be daily or involve the support of
family members to prevent the risk of misuse or overdose. Confirm abstinence by
checking the breath for alcohol, or using a saliva test or breathalyser for the
first three to five days.
• Thiamine (150 mg per day in divided doses) should be
given orally for one month. As oral thiamine is poorly absorbed, transfer patient immediately to
clinic with appropriate resuscitation facilities for parenteral supplementation
if any one of the following is present: ataxia, confusion, memory
disturbance, delirium tremens, hypothermia and hypotension, opthalmoplegia or
unconsciousness.
• Daily supervision is essential in the first few days,
then advisable thereafter, to adjust dose of medication, assess whether the
patient has returned to drinking, check for serious withdrawal symptoms and maintain
support.
• Anxiety and depression often co-occur with alcohol
misuse. The patient may have been using alcohol to self-medicate. If symptoms
of anxiety or depression increase or remain after a period of abstinence of
more than a month. Selective serotonin re-uptake inhibitor (SSRI)
anti-depressants are preferred to tricyclics because of the risk of tricyclic–alcohol
interactions (fluoxetine, paroxetine and citalopram do not interact with alcohol).
(See BNF section 4.3.3.) For anxiety, benzodiazepines should be avoided because
of their high potential for abuse.21 (See BNF section 4.1.2.)
• Acamprosate may help to maintain abstinence from
alcohol in some cases, but routine use is not currently recommended.
Referral
Consider referral:
• to non-statutory Alcohol Advice and Counselling
Agency, if available, and if no psychiatric illness is present
• to a specialist NHS alcohol service if the patient has
alcohol dependence and requires an abstinence-based group programme or has an
associated psychiatric disorder, or if there are no appropriately trained
practitioners available in primary care
• for general hospital inpatient detoxification if the
patient does not meet the criteria for community detoxification (see above)
• to targeted counselling, if available, to deal with
the social consequences of drinking (eg relationship counselling)
• non-urgently to secondary mental health services if
there is a severe mental illness (see relevant disorder), or if symptoms of
mental illness persist after detoxification and abstinence.
If available,
specific, social skills training and community-based treatment packages both may be
effective in reducing drinking.
Resources for
patients and their families
Information
Leaflets on: Problem-solving, Responsible
drinking guidelines and How to cut down on your drinking
Al — Anon Family
Groups UK and Eire 020 7403 0888 (24-hr helpline)
(Understanding and
support for families and friends of alcoholics whether still drinking or not)
Alateen (For young people aged 12–20
affected by others' drinking)
Alcoholics
Anonymous 0700 0780977 (24-hr helpline)
(Helpline and
support groups for men and women trying to achieve and maintain sobriety and
help other alcoholics to get sober)
Drinkline National
Alcohol Helpline 0345 320202 (UK-wide; charges at local rates)
Secular
Organisations for Sobriety (SOS) 0700 78 1230
(A non-religious
self-help group)
Northern Ireland
Community Addiction Service 02890 664 434
Scottish Council on
Alcohol 0141 333 8677
Health Education
Authority 020 7222 5300
Health Education
Board for Scotland 0131 536 5500
(Provide leaflets to support brief
interventions for people at risk of becoming dependent on alcohol).