Alcoholism and alcohol misuse - recognition and assessment

The harmful use of alcohol is a causal factor in more than 200 disease and injury conditions. Overall, 5.1% of the global burden of disease and injury is attributable to alcohol, as measured in disability-adjusted life years (DALYs). Beyond health consequences, the harmful use of alcohol brings significant social and economic losses to individuals and society at large. Alcohol consumption causes death and disability relatively early in life. In people aged 20–39 years, approximately 13.5% of total deaths are attributable to alcohol. There is a causal relationship between harmful use of alcohol and a range of mental and behavioural disorders, other noncommunicable conditions and injuries.¹

Epidemiology

Statistics on Alcohol, England 2021, reported:²

• 280,000 estimated admissions to hospital in 2019/20 where the main reason was attributable to alcohol. 2% higher than 2018/19 and 8% higher than 2016/17.

• More men than women were admitted where the main reason was attributable to alcohol. 65% of the patients were male.

• 167,000 prescription items dispensed in 2020/21 to treat alcohol dependence. 1% higher than 2019/20 but 15% lower than 2014/15.

The prevalence of alcohol binge drinking continues to rise, particularly among those aged 18 to 24. It is also frequent in individuals aged 65 and older.³

Recommended alcohol limits

The recommended levels of alcohol intake in the UK are:⁴

• All adults: to keep health risks to a low level, it is safest not to drink more than 14 units per week. For adults who drink as much as 14 units per week, it is best to spread this evenly over 3 days or more.

• Young people: an alcohol-free childhood is the healthiest and safest option.

• Pregnant women: the safest approach for women who are pregnant, or planning a pregnancy, is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk. The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.

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

Identifying patients who drink harmfully⁵

Routinely carry out alcohol screening as an integral part of practice in primary care. Incidental findings that raise suspicion of problem drinking may include:

• Abnormal blood tests such as a raised gamma-glutamyl transferase (GGT) and mean corpuscular volume (MCV).

• Signs of an alcohol problem, eg, dilated facial capillaries, bloodshot eyes, or hand tremor.

• Symptoms suggestive of a possible alcohol problem, eg complications and comorbid diseases associated with an alcohol problem, or an individual's behaviour (eg, use of illicit drugs, smelling of alcohol in consultations, numerous accidents, or requesting numerous sick notes).

See also the article on Effects of Alcohol Abuse.

Tailor discussions on alcohol and screening according to the person's needs. Take into account that stigma and discrimination are often associated with alcohol misuse, and that minimising the problem may be part of the presentation.

Use AUDIT (Alcohol Use Disorders Identification Test) to routinely assess the nature and severity of alcohol misuse. Use clinical judgement to decide whether AUDIT cut-offs should be revised downwards to increase sensitivity when screening women (including those who are, or plan to become, pregnant), people aged 65 years and older, and people from some black and minority ethnic groups.

Be aware of symptoms of alcohol withdrawal.

Blood tests should not be used routinely to detect whether a person has been misusing alcohol. However, they may help identify physical health needs relating to alcohol use.

Is their alcohol intake a problem?

• 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}

Do they have any ill health as a consequence of their alcohol intake?

• 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.

Investigations

• 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 (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.

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.

• Provide information regarding local Alcoholics Anonymous groups.

Alcoholism treatment and management

See the separate Alcoholism and Alcohol Misuse - Management article.