Alcoholism and alcohol dependence

Alcoholism is 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.

Epidemiology^{1 2}

Alcoholism, also known as alcohol dependence and alcohol abuse, is a major problem in the UK. Alcoholism affects 4% of people aged between 16 and 65 in England (6% of men and 2% of women).

In England, 31% of men and 16% of women drink alcohol at levels above the low risk drinking guidelines. In primary care, the prevalence of alcohol-use disorders ranges from 20% to 36%.

Alcohol-use disorder (see 'Definitions' below) is a common psychiatric disorder with lifetime prevalence estimates of 7% to 12.5% in most Western countries. Men outnumber women by a ratio of more than 2:1, although the disorder is probably under-reported in females.

In the UK, alcohol misuse is the biggest risk factor for early death, ill health and disability for those aged 15-49 years. It is the fifth most important factor when considered for all ages.

Up to 17 million working days are lost annually through absences caused by drinking. Up to 20 million are lost through loss of employment or reduced employment opportunities.

Definitions¹

Problem drinking is defined as regular consumption of alcohol above recommended levels. The UK Department of Health Low Risk Drinking Guidelines state that:

• Men and women who drink regularly or frequently (ie most weeks) are safest not to regularly drink more than 14 units of alcohol per week.

• People who drink as much as 14 units per week should spread this evenly over three days or more.

• During pregnancy, the safest approach is not to drink alcohol at all.

The National Institute for Health and Care Excellence (NICE) states that:

• Harmful drinking is defined as a pattern of alcohol consumption causing health problems directly related to alcohol. This could include psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis.

• Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences (for example, liver disease or depression caused by drinking).

• The term 'alcohol use disorders' encompasses both of these terms.

The presence of an alcohol use disorder is defined by DSM-V as a person answering 'yes' to two or more of the following questions: In the past year, have you:

• Had times when you ended up drinking more, or longer, than you intended?

• More than once wanted to cut down or stop drinking, or tried to, but couldn't?

• Spent a lot of time drinking? Or being sick or getting over other after effects?

• Wanted a drink so badly you couldn't think of anything else?

• Found that drinking - or being sick from drinking - often interfered with taking care of your home or family? Or caused job troubles? Or school problems?

• Continued to drink even though it was causing trouble with your family or friends?

• Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?

• More than once found yourself in situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?

• Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?

• Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?

• Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there?

The severity of the alcohol use disorder is defined as:

• Mild - the presence of 2 to 3 symptoms.

• Moderate - the presence of 4 to 5 symptoms.

• Severe - the presence of 6 or more symptoms.

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.

Assessment²

The patient should be considered as having an alcohol problem if he or she answers yes to any of the 'CAGE' questions (Cut down, Annoyed, Guilty, Eye-opener).

Any patient with a score of more than 15 on AUDIT assessment should be referred to specialist The nature and severity of alcohol misuse can be assessed using the Alcohol Use Disorders Identification Test (AUDIT) questionnaire.

A comprehensive assessment in specialist services should cover the following areas:

• Alcohol use, including:

  • Consumption: historical and recent patterns of drinking (using, for example, a retrospective drinking diary), and if possible, additional information (for example, from a family member or carer).

  • Dependence (using, for example, SADQ or Leeds Dependence Questionnaire [LDQ]).

  • Alcohol-related problems - eg, using the Alcohol Problems Questionnaire.

• Other drug misuse, including over-the-counter medication.

• Physical health problems.

• Psychological and social problems.

• Cognitive function - eg, using the Mini Mental State Examination.

• Readiness and belief in ability to change.

If possible, information should also be sought from a family member or carer.

Treatment options²

Interventions for harmful drinking (high-risk drinking) and mild alcohol dependence

A psychological intervention (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) should be offered, focused specifically on alcohol-related cognitions, behaviour, problems and social networks.

Assessment for assisted alcohol withdrawal

For service users who typically drink over 15 units of alcohol per day, and/or who score 20 or more on the AUDIT, the following options should be considered:

• An assessment for and delivery of a community-based assisted withdrawal; or

• Assessment and management in specialist alcohol services if there are safety concerns about a community-based assisted withdrawal.

Interventions for moderate and severe alcohol dependence

After a successful withdrawal for people with moderate and severe alcohol dependence, acamprosate or oral naltrexone should be considered, in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies), focused specifically on alcohol misuse.

Assessment and interventions for children and young people who misuse alcohol

For children and young people aged 10-17 years who misuse alcohol, the following should be offered:

• Individual cognitive behavioural therapy for those with limited comorbidities and good social support.

• Multicomponent programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multi-systemic therapy) for those with significant comorbidities and/or limited social support.

Interventions for conditions comorbid with alcohol misuse

• For people who misuse alcohol and have comorbid depression or anxiety disorders, treat the alcohol misuse first as this may lead to significant improvement in the depression and anxiety.

• If depression or anxiety continues after 3-4 weeks of abstinence from alcohol, undertake an assessment of the depression or anxiety and consider referral and treatment.

Pharmacological treatments used for alcohol dependence³

All medications should be used in conjunction with psychological interventions. Social support is also important. Where possible, families should be involved in treatment and support.

Acamprosate calcium or oral naltrexone hydrochloride in combination with a psychological intervention are recommended for relapse prevention in patients with moderate and severe alcohol dependence, to start after successful assisted withdrawal.

Disulfiram is an alternative for patients in whom acamprosate calcium and oral naltrexone hydrochloride are not suitable, or if the patient prefers disulfiram and understands the risks of taking the drug.

Nalmefene is recommended by NICE as an option for reducing alcohol consumption, for people with alcohol dependence⁴ :

• Who have a high drinking risk level (defined as alcohol consumption of more than 60 g per day for men and more than 40 g per day for women, according to the World Health Organization's drinking risk levels) without physical withdrawal symptoms; and

• Who do not require immediate detoxification.

Nalmefene should only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption and should only be initiated in patients who continue to have a high drinking risk level two weeks after initial assessment.

Acute alcohol withdrawal⁵

See also the separate Acute Alcohol Withdrawal and Delirium Tremens article.

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 withdrawal² .

For people in acute alcohol withdrawal with, or who are assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, admission to hospital for medically assisted alcohol withdrawal should be offered.

For young people under 16 years who are in acute alcohol withdrawal, admission to hospital for physical and psychosocial assessment should be offered, in addition to medically assisted alcohol withdrawal.

For certain vulnerable people who are in acute alcohol withdrawal (eg, frail, cognitive impairment or multiple comorbidities, lack social support, have learning difficulties or are 16 or 17 years), a lower threshold for admission to hospital for medically assisted alcohol withdrawal should be considered.

For people who are alcohol-dependent but not admitted to hospital, offer advice to avoid a sudden reduction in alcohol intake and information about how to contact local alcohol support services. A sudden reduction in alcohol intake can result in severe withdrawal in dependent drinkers.

Assessment and monitoring

People in acute alcohol withdrawal should be assessed immediately on admission to hospital by a healthcare professional skilled in the management of alcohol withdrawal.

Locally specified protocols should be used to assess and monitor patients in acute alcohol withdrawal.

A tool - eg, Clinical Institute Withdrawal Assessment - Alcohol, revised (CIWA-Ar) scale - should be considered as an adjunct to clinical judgement.

Treatment for acute alcohol withdrawal

Offer pharmacotherapy to treat the symptoms of acute alcohol withdrawal as follows:
Consider offering a long-acting benzodiazepine (eg, diazepam) or carbamazepine.

Clomethiazole may be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, and only in inpatient settings.

A symptom-triggered regimen for drug treatment should be used for people in acute alcohol withdrawal who are in hospital or in other settings where 24-hour assessment and monitoring are available.

If there are safety concerns (eg, suicide risk, no social support, history of severe withdrawal reactions) then inpatient withdrawal is required.

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.