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Alcohol use disorders
ALCOHOL AND OTHER DRUG DISORDERS
Alcohol use disorders
Key points
James Bell
C
Drinking history is an essential part of medical history
C
People identified as drinking above recommended levels should be offered brief advice
C
Judgemental or confronting approaches to drinking are unlikely to be effective
C
Hospitalized patients in whom heavy drinking is suspected should be given parenteral thiamine and be monitored for alcohol withdrawal
C
Dependent drinkers and drinkers with alcohol-related disease should be offered advice, follow-up monitoring, and referral if they continue to drink at harmful levels
Abstract Alcohol causes end-organ damage in drinkers, and alcohol dependence is associated with poor self-care, complicating chronic disease management. A drinking history and index of suspicion for alcohol misuse is part of comprehensive medical assessment. Identification of hazardous and harmful drinking, and provision of brief advice and/or referral, should occur in all healthcare episodes. In hospital settings, prevention and management of alcohol withdrawal and Wernicke’s encephalopathy are key priorities. In ambulatory settings, regular monitoring and feedback is effective for managing many alcohol-dependent patients.
Keywords Alcohol; alcohol dependence; alcohol withdrawal; brief intervention; harmful drinking; hazardous drinking; Wernicke eKorsakoff syndrome
relevance. It refers to the changes by which alcohol comes to play a prominent role in an individual’s consciousness and behaviour, and is a predictor of likelihood of withdrawal. In particular, drinkers who exhibit tolerance to alcohol and develop withdrawal symptoms on abstaining appear to have a more adverse prognosis. This paper focuses primarily on four issues of importance to all medical practitioners e identification and brief intervention, management of withdrawal, prevention of WernickeeKorsakoff syndrome, and referral of people not responding to brief advice.
Definitions Hazardous drinking is a pattern of drinking that increases the user’s risk of harmful consequences. Current guidelines recommend not regularly drinking more than the daily unit guidelines of three to four units of alcohol for men (equivalent to a pint and a half of 4% beer) and two to three units of alcohol for women (equivalent to a 175-ml glass of wine). Harmful drinking is defined by NICE (2011) (see Further reading) as a pattern of alcohol consumption causing health problems directly related to alcohol. The most common consequences of harmful drinking relate to acute intoxication, which is estimated to contribute to 1 million alcohol-related attendances at emergency departments in England on Friday and Saturday nights alone. The top 10 presentations are fall, collapse, head injury, assault, accident, feeling generally unwell, gastrointestinal symptoms, cardiac symptoms, psychiatric problems (especially self-harm) and frequent attendance. Not everyone who drinks alcohol progresses to dependence, and not everyone who drinks heavily develops end-organ damage or adverse social consequences. Around 60% of vulnerability to alcohol problems is attributable to genetics. However, from current knowledge, the best advice is ‘universal precautions’ e people should keep their intake within recommended levels. Alcohol use disorder is diagnosed by patients meeting three of the 11 criteria outlined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; Table 1). Alcohol dependence e although this diagnosis has been dropped from DSM-5, it remains important clinically, as the severity of dependence has management and prognostic
Epidemiology Globally, alcohol consumption causes 1.8 million premature deaths each year (3.2% of the total) and is the third leading preventable cause of ill-health in Europe, after smoking and high blood pressure. This substantial burden of disease reflects the popularity of alcohol as a recreational drug. In the UK, as in most developed countries, around 90% of adults consume alcohol, usually without problems. UK survey data suggest that approximately 7.1 million people in England (23% of the population aged 16e64 years) drink hazardously or harmfully, and 1.1 million people are dependent on alcohol. It has been claimed for decades that the relationship between alcohol use and all-cause mortality follows a ‘J-shaped’ curve, with light drinkers having lower risk of death than abstainers. However, recent meta-analysis has challenged this observation.1 A study from London, UK, estimated that alcohol-specific admissions made up only 26% of all alcohol-attributable admissions e admissions for conditions in which alcohol is a contributing factor. Three conditions represented 68% of all alcoholattributable admissions: hypertensive diseases accounted for 35% of all admissions, mental and behavioural disorders caused by alcohol for about 20%, and cardiac arrhythmias for 15%.2 In the UK, the prevalence of alcohol-related violence and injuries is related to the number and density of alcohol outlets and the licensing hours (see Babor, 2003, in the Further reading list). Deprived areas suffer higher levels of alcohol-related mortality, hospital admissions, crime, absence from work, school
James Bell FRACP FAChAM MD is a Consultant Addiction Physician, Kings Health Partners, London, UK. His research interest is the treatment of drug dependence. Competing interests: none declared.
MEDICINE --:-
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Bell J, Alcohol use disorders, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2016.09.001
ALCOHOL AND OTHER DRUG DISORDERS
be for a relapsing, remitting condition in a proportion of more severely affected individuals seeking treatment, follow-up studies suggest quite good outcomes for the treatment of alcohol dependence: 50e60% of men and women with alcohol dependence abstain or show substantial improvements in functioning in the year after treatment.3 In general, the course of alcohol-related problems depends on whether people stop drinking. Neurological damage from alcohol is usually considered irreversible, although cessation of drinking can slow or halt disease progression. The 10-year survival of patients presenting with compensated alcohol-related cirrhosis who remained abstinent or substantially reduced their intake was around 60%, compared with around 30% in those continuing to drink. The respective figures in those with decompensated cirrhosis were 50% and less than 10%.
DSM-5 criteria for alcohol use disorder C C C C C
C
C
C C
C
C
Taking alcohol in larger amounts and for longer than intended Wanting to cut down or quit but not being able to do it Spending a lot of time obtaining alcohol Craving or a strong desire to use alcohol Repeatedly unable to carry out major obligations at work, school, or home due to alcohol use Continued use despite persistent or recurring social or interpersonal problems caused or made worse by alcohol use Stopping or reducing important social, occupational or recreational activities due to alcohol Recurrent use of alcohol in physically hazardous situations Consistent use of alcohol despite acknowledgement of persistent or recurrent physical or psychological difficulties from using alcohol Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal
Diagnosis Most people with alcohol-related problems have jobs and families, and present with general complaints such as insomnia, anxiety, sadness or a range of medical problems.3 Patients, particularly those who drink excessively, are often defensive and understate their intake. History-taking must be undertaken sensitively, with respect for patients’ privacy, dignity and confidentiality (NICE 2011) (see Further reading). The best validated and most widely used screening test to identify people potentially drinking at risk is the Alcohol Use Disorders Identification Text (AUDIT) questionnaire, which takes a little over 1 minute to administer. Questionnaires are not a substitute for a medical assessment e a drinking history, knowledge of the potential adverse health effects of alcohol, and ability to interpret laboratory investigations. Useful biological markers of alcohol misuse include a raised g-glutamyl transferase (GGT) concentration, which has a sensitivity and specificity approaching 60% in men and 50% in women. Raised mean corpuscular volume (MCV) on a full blood count is also a useful, widely available marker. Although not reliable as screening tests in hospitalized patients, GGT and MCV values are commonly available, suggesting that further screening and assessment for alcohol problems be undertaken.
Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Table 1
exclusions, teenage pregnancy and road traffic accidents linked to greater levels of alcohol consumption.
Pathology and pathogenesis Alcohol, and other reinforcing drugs, activates the brain ‘reward pathway’, an array of neural systems involving dopaminergic transmission and endorphin release. These drugs reduce anxiety and cause a sense of well-being and confidence. These reinforcing effects contribute to the popularity of alcohol e and to the risks of persisting use despite harm. With repeated exposure, higher doses are required to achieve the same subjective effects (tolerance), and in some individuals a withdrawal syndrome develops on stopping drinking after prolonged exposure. The chronic administration of alcohol and other drugs produces enduring changes in brain neurotransmitter systems that leave the user vulnerable to relapse after abstinence has been achieved. It has therefore been suggested that alcohol dependence should be viewed as a chronic, relapsing brain disease (see Gunzerath, 2011, in the Further reading list).
Differential diagnosis: alcohol misuse is often occult and can present or contribute to epilepsy, or present as anxiety or depression, or a range of illnesses. The differential diagnosis of alcohol withdrawal is alcohol intoxication, Wernicke’s encephalopathy and other causes of delirium, particularly hepatic encephalopathy, post-ictal state, head injury and effects of other psychoactive drugs.
Course of alcohol dependence Management
Some dependent drinkers neglect themselves and progress to developing poor physical health, mental health problems and social marginalization; these factors predict a poorer prognosis. Recurrent exposure to these patients in emergency departments and hospital contributes to the stigma e doctors and nurses develop pessimistic views about alcohol-related problems. Contrary to prevailing medical pessimism, longitudinal population surveys indicate that many dependent drinkers stop drinking or return to controlled, low-risk drinking (see Dawson, 2005, in the Further reading list). Although the prognosis tends to
MEDICINE --:-
Management of dependence/harmful drinking The medical practitioner’s role is to identify, monitor and give feedback on alcohol use and health consequences in their patients. Such brief intervention has been ranked as the most effective treatment for drinking problems (see Miller, 2002, in the Further reading list). In the UK, all health professionals are advised to implement early Identification and Brief Advice (IBA), using presentation for healthcare as a ‘teachable moment’. A useful structure for such intervention is the FRAMES mnemonic:
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Bell J, Alcohol use disorders, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2016.09.001
ALCOHOL AND OTHER DRUG DISORDERS
vulnerable people (e.g. those who are frail, have cognitive impairment or co-morbidities, lack social support, have learning difficulties or are aged 16 or 17 years).5
Feedback to the patient; Responsibility to be taken by the patient; Advice (on health risks, and how to optimize prognosis); Menu of treatment options; Empathy in conveying the intervention; Self-efficacy on the patients part needs to be emphasized e the patient is not a passive recipient of treatment. Simply providing hazardous drinkers with a leaflet appears no less efficacious than 5 minutes of advice or 20 minutes of counselling.4 In general, interventions should be extensive rather than intensive e follow-up monitoring by general practitioners (or by researchers, as occurs in clinical trials) can improve outcomes of IBA. In one longitudinal study, screening using GGT to identify heavy drinkers, and then the simple, repeated intervention of monitoring GGT concentrations and providing patients with feedback, produced short-term differences in drinking and hospitalization, and long-term reduction in deaths from alcohol-related causes.
WernickeeKorsakoff syndrome This results from a deficiency in vitamin B1 (thiamine) and is characterized by nystagmus and ophthalmoplegia, mental status changes and unsteadiness of stance and gait, the symptoms sometimes being difficult to distinguish from intoxication. However, this triad is seen in only 16% of patients. In developed societies, it is usually observed in heavy drinkers, and autopsy studies indicate that the diagnosis is missed in 75e80% of cases. About 80% of patients with Wernicke’s encephalopathy who survive develop Korsakoff’s syndrome, a disabling disorder characterized by severe memory defects. WernickeeKorsakoff syndrome is a medical emergency. Patients who have signs indicating Wernicke’s encephalopathy should be treated empirically with a minimum of 500 mg thiamine hydrochloride (dissolved in 100 ml normal saline), given by infusion over a period of 30 minutes, three times per day for 2 e3 days. Where there is no response, supplementation can be discontinued. Where an effective response is observed, thiamine 250 mg should be continued intravenously or intramuscularly daily for 3e5 days or until clinical improvement ceases. Doses of thiamine of 100e250 mg/day apparently may not restore vitamin status in the central nervous system or improve clinical signs.
Managing withdrawal Successive episodes of alcohol withdrawal are associated with increased withdrawal severity and cognitive impairment. The priority is to prevent withdrawal: by anticipation, monitoring and early initiation of treatment with long-acting benzodiazepines. Hospitals should have readily accessible protocols for monitoring and managing withdrawal. Benzodiazepines can cause hepatic encephalopathy, and short-acting benzodiazepines are preferred in managing withdrawal in the setting of decompensated cirrhosis. Alcohol withdrawal is characterized by three primary symptom clusters: sympathetic nervous system overactivity e raised pulse, blood pressure, sweating, tremor and temperature Perceptual disturbances e visual, tactile or, more rarely, auditory. Visual disturbances range from vivid dreams or illusions (misperceiving objects in the environment), to frank hallucinations (seeing objects that are not present). Tactile disturbances (formication e the sensation of things crawling on the skin) are not rare cognitive changes e ranging from anxiety to paranoia, and delirium. In addition, alcohol withdrawal is characterized by insomnia and gastrointestinal disturbances (nausea and vomiting). Seizures can occur early in the course of alcohol withdrawal. Many dependent drinkers can stop drinking without experiencing severe withdrawal. However, intercurrent illness (trauma, fever, hypoxia) can contribute to severe withdrawal. Alcohol withdrawal begins within approximately 8 hours of abstinence and peaks in intensity on the second or third day; symptoms usually diminish by the fourth or fifth day. Seizures tend to occur early in the course of withdrawal. All heavy drinkers admitted to hospital should be monitored for the emergence of symptoms and signs indicating withdrawal, many hospitals using a structured withdrawal scale to monitor newly admitted patients. Elective withdrawal management (detoxification) for dependent drinkers should generally be offered on an ambulatory basis. Admission to hospital for medically assisted withdrawal may be required in: people assessed to be at high risk of developing alcohol withdrawal seizures or delirium tremens
MEDICINE --:-
Prognosis and explanation People with alcohol-related disease should be advised that their prognosis depends on ceasing or reducing drinking. Dependent drinkers should be advised to abstain, at least for a period. Most clinicians recommend long-term abstinence for dependent drinkers because of the risk of relapse and rapid reinstatement of dependent drinking. Follow-up People identified as drinking above safe levels should be followed up by their general practitioner. Individuals who do not respond to advice or have been diagnosed with alcohol dependence or alcohol-related disease should be advised of self-help options and referred for specialist assessment. Prevention Doctors should offer drinkers with harmful or dependent drinking prophylactic parenteral thiamine followed by oral thiamine:5 if they are malnourished or at risk of malnourishment or if they have decompensated liver disease and in addition they attend an emergency department or are admitted to hospital with an acute illness or injury.A KEY REFERENCES 1 Stockwell T, Zhao J, Panwar S, Roemer A, Naimi T, Chikritzhs T. Do “moderate” drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality. J Stud Alcohol Drugs 2016; 77: 185e98. 2 Feleke R, Hamm J, De Ponte P. Alcohol attributable admissions in London. London: London Health Observatory, 2010.
3
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Bell J, Alcohol use disorders, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2016.09.001
ALCOHOL AND OTHER DRUG DISORDERS
3 Shuckitt M. Alcohol use disorders. Lancet 2009; 373: 492e501. 4 Kaner E, Bland M, Cassidy S, et al. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. Br Med J 2013; 346: e8501. 5 NICE. Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications. London: NICE, 2010.
Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, Ruan WJ. Recovery from DSM-IV alcohol dependence: United States, 2001 e2002. Addiction 2005; 100: 281e92. Gunzerath L, Hewitt BG, Li TK, Warren KR. Alcohol research: past present and future. Ann N Y Acad Sci 2011; 1216: 1e23. Miller WR, Wilbourne PL. Mesa Grande; a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002; 97: 265e77. NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. 2011. London: NICE, nice.org.uk/guidance/cg115.
FURTHER READING Babor TF, Caetano R, Casswell S, et al. Alcohol: no ordinary commoditydresearch and public policy. Oxford: Oxford University Press, 2003.
MEDICINE --:-
4
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Bell J, Alcohol use disorders, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2016.09.001
Alcohol use disorders
Key points
James Bell
C
Drinking history is an essential part of medical history
C
People identified as drinking above recommended levels should be offered brief advice
C
Judgemental or confronting approaches to drinking are unlikely to be effective
C
Hospitalized patients in whom heavy drinking is suspected should be given parenteral thiamine and be monitored for alcohol withdrawal
C
Dependent drinkers and drinkers with alcohol-related disease should be offered advice, follow-up monitoring, and referral if they continue to drink at harmful levels
Abstract Alcohol causes end-organ damage in drinkers, and alcohol dependence is associated with poor self-care, complicating chronic disease management. A drinking history and index of suspicion for alcohol misuse is part of comprehensive medical assessment. Identification of hazardous and harmful drinking, and provision of brief advice and/or referral, should occur in all healthcare episodes. In hospital settings, prevention and management of alcohol withdrawal and Wernicke’s encephalopathy are key priorities. In ambulatory settings, regular monitoring and feedback is effective for managing many alcohol-dependent patients.
Keywords Alcohol; alcohol dependence; alcohol withdrawal; brief intervention; harmful drinking; hazardous drinking; Wernicke eKorsakoff syndrome
relevance. It refers to the changes by which alcohol comes to play a prominent role in an individual’s consciousness and behaviour, and is a predictor of likelihood of withdrawal. In particular, drinkers who exhibit tolerance to alcohol and develop withdrawal symptoms on abstaining appear to have a more adverse prognosis. This paper focuses primarily on four issues of importance to all medical practitioners e identification and brief intervention, management of withdrawal, prevention of WernickeeKorsakoff syndrome, and referral of people not responding to brief advice.
Definitions Hazardous drinking is a pattern of drinking that increases the user’s risk of harmful consequences. Current guidelines recommend not regularly drinking more than the daily unit guidelines of three to four units of alcohol for men (equivalent to a pint and a half of 4% beer) and two to three units of alcohol for women (equivalent to a 175-ml glass of wine). Harmful drinking is defined by NICE (2011) (see Further reading) as a pattern of alcohol consumption causing health problems directly related to alcohol. The most common consequences of harmful drinking relate to acute intoxication, which is estimated to contribute to 1 million alcohol-related attendances at emergency departments in England on Friday and Saturday nights alone. The top 10 presentations are fall, collapse, head injury, assault, accident, feeling generally unwell, gastrointestinal symptoms, cardiac symptoms, psychiatric problems (especially self-harm) and frequent attendance. Not everyone who drinks alcohol progresses to dependence, and not everyone who drinks heavily develops end-organ damage or adverse social consequences. Around 60% of vulnerability to alcohol problems is attributable to genetics. However, from current knowledge, the best advice is ‘universal precautions’ e people should keep their intake within recommended levels. Alcohol use disorder is diagnosed by patients meeting three of the 11 criteria outlined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; Table 1). Alcohol dependence e although this diagnosis has been dropped from DSM-5, it remains important clinically, as the severity of dependence has management and prognostic
Epidemiology Globally, alcohol consumption causes 1.8 million premature deaths each year (3.2% of the total) and is the third leading preventable cause of ill-health in Europe, after smoking and high blood pressure. This substantial burden of disease reflects the popularity of alcohol as a recreational drug. In the UK, as in most developed countries, around 90% of adults consume alcohol, usually without problems. UK survey data suggest that approximately 7.1 million people in England (23% of the population aged 16e64 years) drink hazardously or harmfully, and 1.1 million people are dependent on alcohol. It has been claimed for decades that the relationship between alcohol use and all-cause mortality follows a ‘J-shaped’ curve, with light drinkers having lower risk of death than abstainers. However, recent meta-analysis has challenged this observation.1 A study from London, UK, estimated that alcohol-specific admissions made up only 26% of all alcohol-attributable admissions e admissions for conditions in which alcohol is a contributing factor. Three conditions represented 68% of all alcoholattributable admissions: hypertensive diseases accounted for 35% of all admissions, mental and behavioural disorders caused by alcohol for about 20%, and cardiac arrhythmias for 15%.2 In the UK, the prevalence of alcohol-related violence and injuries is related to the number and density of alcohol outlets and the licensing hours (see Babor, 2003, in the Further reading list). Deprived areas suffer higher levels of alcohol-related mortality, hospital admissions, crime, absence from work, school
James Bell FRACP FAChAM MD is a Consultant Addiction Physician, Kings Health Partners, London, UK. His research interest is the treatment of drug dependence. Competing interests: none declared.
MEDICINE --:-
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Bell J, Alcohol use disorders, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2016.09.001
ALCOHOL AND OTHER DRUG DISORDERS
be for a relapsing, remitting condition in a proportion of more severely affected individuals seeking treatment, follow-up studies suggest quite good outcomes for the treatment of alcohol dependence: 50e60% of men and women with alcohol dependence abstain or show substantial improvements in functioning in the year after treatment.3 In general, the course of alcohol-related problems depends on whether people stop drinking. Neurological damage from alcohol is usually considered irreversible, although cessation of drinking can slow or halt disease progression. The 10-year survival of patients presenting with compensated alcohol-related cirrhosis who remained abstinent or substantially reduced their intake was around 60%, compared with around 30% in those continuing to drink. The respective figures in those with decompensated cirrhosis were 50% and less than 10%.
DSM-5 criteria for alcohol use disorder C C C C C
C
C
C C
C
C
Taking alcohol in larger amounts and for longer than intended Wanting to cut down or quit but not being able to do it Spending a lot of time obtaining alcohol Craving or a strong desire to use alcohol Repeatedly unable to carry out major obligations at work, school, or home due to alcohol use Continued use despite persistent or recurring social or interpersonal problems caused or made worse by alcohol use Stopping or reducing important social, occupational or recreational activities due to alcohol Recurrent use of alcohol in physically hazardous situations Consistent use of alcohol despite acknowledgement of persistent or recurrent physical or psychological difficulties from using alcohol Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal
Diagnosis Most people with alcohol-related problems have jobs and families, and present with general complaints such as insomnia, anxiety, sadness or a range of medical problems.3 Patients, particularly those who drink excessively, are often defensive and understate their intake. History-taking must be undertaken sensitively, with respect for patients’ privacy, dignity and confidentiality (NICE 2011) (see Further reading). The best validated and most widely used screening test to identify people potentially drinking at risk is the Alcohol Use Disorders Identification Text (AUDIT) questionnaire, which takes a little over 1 minute to administer. Questionnaires are not a substitute for a medical assessment e a drinking history, knowledge of the potential adverse health effects of alcohol, and ability to interpret laboratory investigations. Useful biological markers of alcohol misuse include a raised g-glutamyl transferase (GGT) concentration, which has a sensitivity and specificity approaching 60% in men and 50% in women. Raised mean corpuscular volume (MCV) on a full blood count is also a useful, widely available marker. Although not reliable as screening tests in hospitalized patients, GGT and MCV values are commonly available, suggesting that further screening and assessment for alcohol problems be undertaken.
Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Table 1
exclusions, teenage pregnancy and road traffic accidents linked to greater levels of alcohol consumption.
Pathology and pathogenesis Alcohol, and other reinforcing drugs, activates the brain ‘reward pathway’, an array of neural systems involving dopaminergic transmission and endorphin release. These drugs reduce anxiety and cause a sense of well-being and confidence. These reinforcing effects contribute to the popularity of alcohol e and to the risks of persisting use despite harm. With repeated exposure, higher doses are required to achieve the same subjective effects (tolerance), and in some individuals a withdrawal syndrome develops on stopping drinking after prolonged exposure. The chronic administration of alcohol and other drugs produces enduring changes in brain neurotransmitter systems that leave the user vulnerable to relapse after abstinence has been achieved. It has therefore been suggested that alcohol dependence should be viewed as a chronic, relapsing brain disease (see Gunzerath, 2011, in the Further reading list).
Differential diagnosis: alcohol misuse is often occult and can present or contribute to epilepsy, or present as anxiety or depression, or a range of illnesses. The differential diagnosis of alcohol withdrawal is alcohol intoxication, Wernicke’s encephalopathy and other causes of delirium, particularly hepatic encephalopathy, post-ictal state, head injury and effects of other psychoactive drugs.
Course of alcohol dependence Management
Some dependent drinkers neglect themselves and progress to developing poor physical health, mental health problems and social marginalization; these factors predict a poorer prognosis. Recurrent exposure to these patients in emergency departments and hospital contributes to the stigma e doctors and nurses develop pessimistic views about alcohol-related problems. Contrary to prevailing medical pessimism, longitudinal population surveys indicate that many dependent drinkers stop drinking or return to controlled, low-risk drinking (see Dawson, 2005, in the Further reading list). Although the prognosis tends to
MEDICINE --:-
Management of dependence/harmful drinking The medical practitioner’s role is to identify, monitor and give feedback on alcohol use and health consequences in their patients. Such brief intervention has been ranked as the most effective treatment for drinking problems (see Miller, 2002, in the Further reading list). In the UK, all health professionals are advised to implement early Identification and Brief Advice (IBA), using presentation for healthcare as a ‘teachable moment’. A useful structure for such intervention is the FRAMES mnemonic:
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Bell J, Alcohol use disorders, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2016.09.001
ALCOHOL AND OTHER DRUG DISORDERS
vulnerable people (e.g. those who are frail, have cognitive impairment or co-morbidities, lack social support, have learning difficulties or are aged 16 or 17 years).5
Feedback to the patient; Responsibility to be taken by the patient; Advice (on health risks, and how to optimize prognosis); Menu of treatment options; Empathy in conveying the intervention; Self-efficacy on the patients part needs to be emphasized e the patient is not a passive recipient of treatment. Simply providing hazardous drinkers with a leaflet appears no less efficacious than 5 minutes of advice or 20 minutes of counselling.4 In general, interventions should be extensive rather than intensive e follow-up monitoring by general practitioners (or by researchers, as occurs in clinical trials) can improve outcomes of IBA. In one longitudinal study, screening using GGT to identify heavy drinkers, and then the simple, repeated intervention of monitoring GGT concentrations and providing patients with feedback, produced short-term differences in drinking and hospitalization, and long-term reduction in deaths from alcohol-related causes.
WernickeeKorsakoff syndrome This results from a deficiency in vitamin B1 (thiamine) and is characterized by nystagmus and ophthalmoplegia, mental status changes and unsteadiness of stance and gait, the symptoms sometimes being difficult to distinguish from intoxication. However, this triad is seen in only 16% of patients. In developed societies, it is usually observed in heavy drinkers, and autopsy studies indicate that the diagnosis is missed in 75e80% of cases. About 80% of patients with Wernicke’s encephalopathy who survive develop Korsakoff’s syndrome, a disabling disorder characterized by severe memory defects. WernickeeKorsakoff syndrome is a medical emergency. Patients who have signs indicating Wernicke’s encephalopathy should be treated empirically with a minimum of 500 mg thiamine hydrochloride (dissolved in 100 ml normal saline), given by infusion over a period of 30 minutes, three times per day for 2 e3 days. Where there is no response, supplementation can be discontinued. Where an effective response is observed, thiamine 250 mg should be continued intravenously or intramuscularly daily for 3e5 days or until clinical improvement ceases. Doses of thiamine of 100e250 mg/day apparently may not restore vitamin status in the central nervous system or improve clinical signs.
Managing withdrawal Successive episodes of alcohol withdrawal are associated with increased withdrawal severity and cognitive impairment. The priority is to prevent withdrawal: by anticipation, monitoring and early initiation of treatment with long-acting benzodiazepines. Hospitals should have readily accessible protocols for monitoring and managing withdrawal. Benzodiazepines can cause hepatic encephalopathy, and short-acting benzodiazepines are preferred in managing withdrawal in the setting of decompensated cirrhosis. Alcohol withdrawal is characterized by three primary symptom clusters: sympathetic nervous system overactivity e raised pulse, blood pressure, sweating, tremor and temperature Perceptual disturbances e visual, tactile or, more rarely, auditory. Visual disturbances range from vivid dreams or illusions (misperceiving objects in the environment), to frank hallucinations (seeing objects that are not present). Tactile disturbances (formication e the sensation of things crawling on the skin) are not rare cognitive changes e ranging from anxiety to paranoia, and delirium. In addition, alcohol withdrawal is characterized by insomnia and gastrointestinal disturbances (nausea and vomiting). Seizures can occur early in the course of alcohol withdrawal. Many dependent drinkers can stop drinking without experiencing severe withdrawal. However, intercurrent illness (trauma, fever, hypoxia) can contribute to severe withdrawal. Alcohol withdrawal begins within approximately 8 hours of abstinence and peaks in intensity on the second or third day; symptoms usually diminish by the fourth or fifth day. Seizures tend to occur early in the course of withdrawal. All heavy drinkers admitted to hospital should be monitored for the emergence of symptoms and signs indicating withdrawal, many hospitals using a structured withdrawal scale to monitor newly admitted patients. Elective withdrawal management (detoxification) for dependent drinkers should generally be offered on an ambulatory basis. Admission to hospital for medically assisted withdrawal may be required in: people assessed to be at high risk of developing alcohol withdrawal seizures or delirium tremens
MEDICINE --:-
Prognosis and explanation People with alcohol-related disease should be advised that their prognosis depends on ceasing or reducing drinking. Dependent drinkers should be advised to abstain, at least for a period. Most clinicians recommend long-term abstinence for dependent drinkers because of the risk of relapse and rapid reinstatement of dependent drinking. Follow-up People identified as drinking above safe levels should be followed up by their general practitioner. Individuals who do not respond to advice or have been diagnosed with alcohol dependence or alcohol-related disease should be advised of self-help options and referred for specialist assessment. Prevention Doctors should offer drinkers with harmful or dependent drinking prophylactic parenteral thiamine followed by oral thiamine:5 if they are malnourished or at risk of malnourishment or if they have decompensated liver disease and in addition they attend an emergency department or are admitted to hospital with an acute illness or injury.A KEY REFERENCES 1 Stockwell T, Zhao J, Panwar S, Roemer A, Naimi T, Chikritzhs T. Do “moderate” drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality. J Stud Alcohol Drugs 2016; 77: 185e98. 2 Feleke R, Hamm J, De Ponte P. Alcohol attributable admissions in London. London: London Health Observatory, 2010.
3
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Bell J, Alcohol use disorders, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2016.09.001
ALCOHOL AND OTHER DRUG DISORDERS
3 Shuckitt M. Alcohol use disorders. Lancet 2009; 373: 492e501. 4 Kaner E, Bland M, Cassidy S, et al. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. Br Med J 2013; 346: e8501. 5 NICE. Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications. London: NICE, 2010.
Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, Ruan WJ. Recovery from DSM-IV alcohol dependence: United States, 2001 e2002. Addiction 2005; 100: 281e92. Gunzerath L, Hewitt BG, Li TK, Warren KR. Alcohol research: past present and future. Ann N Y Acad Sci 2011; 1216: 1e23. Miller WR, Wilbourne PL. Mesa Grande; a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002; 97: 265e77. NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. 2011. London: NICE, nice.org.uk/guidance/cg115.
FURTHER READING Babor TF, Caetano R, Casswell S, et al. Alcohol: no ordinary commoditydresearch and public policy. Oxford: Oxford University Press, 2003.
MEDICINE --:-
4
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Bell J, Alcohol use disorders, Medicine (2016), http://dx.doi.org/10.1016/j.mpmed.2016.09.001