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Alcohol Use Disorders
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Alcohol taken in any amount may be harmful if the time and situation are inappropriate, for example when driving. The risk of sustaining alcohol-related injuries begins to increase with blood ethanol concentrations as low as 20mg / 100mls. It is therefore difficult to identify a level of alcohol consumption that can be considered 'safe'.
However, the Department of Health specifies what is generally regarded as safe drinking limits for the adult population. It should be noted that these levels are higher than those specified by the Royal College of Psychiatrists.
| Safe Drinking(Units per week) | Males | Females |
| Department of Health | 28> | 21 |
| Royal College of Psychiatrists | 21 | 14 |
One Unit of alcohol : 10mls or 8gms absolute alcohol approximately.
- ½ pint (284mls) ordinary strength beer or lager
- 1 glass (125mls) average strength wine
- 1 glass (50mls) of fortified wine; eg. Sherry
- 1 single measure (25mls) spirits.
Women are more sensitive than men to the harm-inducing effects of alcohol.
The legal limit for driving a motor vehicle, (80mg/100 ml) roughly corresponds to the level achieved after 3 units of alcohol have been consumed over the space of a few minutes. However, individuals vary and there are gender differences. It is also important to note that a substantially lower consumption and resultant blood alcohol impairs driving ability and judgement.
Problem Drinking
Problem Drinking It is now recognised that levels of alcohol consumption (and alcohol-related problems) exist within a continuum, ranging from low risk to harmful.
Low risk
- 'Safe drinking', where intake is unlikely to be associated with harm
- Males = 21 units/week
- Females = 14 units/week
Hazardous drinking
- Intake likely to increase risk of developing alcohol related harm
- Males = 22 - 50 units/week
- Females = 15-35 units/week
Harmful drinking ('Alcohol Misuse')
- A pattern of drinking associated with the development of alcohol related harm (physical or psychological).
- Males > 50 units/week
- Females > 35 units/week
Alcohol Dependence Syndrome
Alcohol Dependence
The term dependence refers to certain physiological and psychological phenomena induced by the repeated taking of a substance.
Alcohol dependence syndrome is characterised by the presence of three or more of the following: ·
- A strong desire or compulsion to drink
- Difficulty in controlling the onset or termination of drinking or the levels of alcohol use
- A physiological withdrawal state on cessation of alcohol or its use to avoid withdrawal symptoms
- Increasing tolerance to alcohol (Tolerance is the need to consume more alcohol to achieve the same effect produced originally by smaller amounts)
- Progressive neglect of other interests
- Persisting use of alcohol despite awareness and clear evidence of the harm it is causing.
Alcohol Related Problems
About 27% of men and 11% of women drink over the 'safe' limits.
Cost of alcohol is probably the major determinant of the level of alcohol consumption in society with the prevalence of alcohol related difficulties matching it well. Customs and moral beliefs and formal governmental controls are also important factors.
At the individual level multiple causes determine the levels of consumption, including genetic and personality factors and psychiatric disorders.
The scale of alcohol related problems in the United Kingdom
Each year alcohol use plays a role in up to 40,000 deaths (including 500 young people) and 15 million lost working days. Alcohol related problems account for 25-35% of all general hospital admissions, 33% of domestic accidents, 26% of domestic deaths, 40% of fatal domestic fires, 15-29% of serious accidents in the workplace, 50% of homicides and 80% of domestic violence.
Alcohol related problems can be considered under the following headings:
- Psychiatric disorders
- Physical disorders
- Social disorders
Psychiatric Disorders
Intoxication phenomena
This includes phenomena such as lability of mood, belligerence and memory black outs.
Alcohol withdrawal phenomena
Withdrawal symptoms occur in people who have been drinking heavily for years and who maintain a high intake of alcohol for weeks at a time. They occur when alcohol consumption is abruptly discontinued or substantially reduced. The first symptoms usually appear within 8-12 hours of the last drink and progression to a state of delirium may occur within 2-3 days. The withdrawal symptoms may be:
- Mild such as tremor, nausea, sweating, insomnia, mood disturbances, restless, agitation, anxiety and fear. Other recognised symptoms include tinnitus, cramps and noise sensitivity. Many heavy drinkers continue with drinking to alleviate these symptoms.
- Severe namely:
- Alcohol withdrawal seizures, which can occur in the first 12-48 hours after substantial reduction in alcohol consumption or abrupt discontinuation.
- Delirium Tremens (DT's), which is an acute confusional state usually occurring about 3 days after the last drink and may go on for up to 7 days. It is characterised by disorientation, visual hallucinations (e.g. snakes in the bed), agitation, fearfulness, sweating and tremors. It has a significant mortality rate. It constitutes a medical emergency.
Depression
Alcohol is a CNS depressant and the biological changes induced by it can mimic those seen in depressive disorders. It is also clear that the life of a problem drinker with anxieties and guilt about their behaviour and possible social repercussions all contribute to feelings of depression. In some patients alcohol misuse is a symptom of underlying depressive illness.
Suicide and deliberate self-harm are significant risks in patients with serious alcohol problems particularly when associated with depression or impulsive behaviour.
Anxiety
Alcohol can be used as a means of coping with anxiety. In addition, symptoms of alcohol withdrawal state may mimic an anxiety state.
Alcoholic Hallucinosis
This is usually characterised by auditory hallucinations occurring in clear consciousness. They can occur during heavy drinking or following withdrawal or a sudden reduction in alcohol intake. Sometimes they resemble those in schizophrenia.
Morbid jealousy (Othello Syndrome)
The excessive drinker develops the delusion that his or her partner is unfaithful which may result in domiciliary violence and death of the partner.
Psychotic illnesses
Alcohol problems may be associated with or may precipitate psychotic illnesses such as schizophrenia.
Alcoholic dementia
Specific cognitive deficits are demonstrable in problem drinkers that may or may not be accompanied by non-progressive impairment of intellectual capacity.
Wernicke's encephalopathy and Korsakoff's syndrome
This is caused by thiamine deficiency resulting in haemorrhage in the mammilary bodies of the posterior hypothalamus and nearby midline structures.
- Wernicke's encephalopathy is characterised by ophthalmoplegia, ataxia and a confusional state, which can be reversed to a large extent by administration of thiamine.
- Korsakoff's dysmnestic syndrome is characterised by profound short term memory loss with relative preservation of other intellectual abilities. The gaps in short term memory are filled in by confabulation. Its resolution is less predictable.
Physical & Social Disorders
Physical Disorders
Physical risks to health can be due to intoxication, e.g. accidents or long term physical disorders resulting from heavy alcohol usage. These relate to organ systems as follows:
GI : Hepatitis; hepatic cirrhosis and its complications; pancreatitis; Mallory-Weiss tears;
CVS : Hypertension; alcohol cardiomyopathy
CNS : Seizures, peripheral neuropathy; cerebellar degeneration; dementia; myopathy.
Others: Malnutrition and vitamin deficiency; damage to foetus in pregnant women.
Social disorders
These are multifactorial and relate partly to several of the physical and psychiatric consequences of alcohol misuse, listed above. In addition other factors such as poverty, poor performance at work and difficulties in interpersonal relationships lead to a self perpetuating vicious cycle.
Some of the adverse social consequences of alcohol misuse identified include domestic violence, poor parenting, unemployment, involvement in crime and public disorder and drink driving.
Drinking Assessment
Many individuals are unaware of how much they drink and its potential impact on their health. It is there fore important to obtain an alcohol history from all patients, during the first encounter and periodically thereafter.
While history taking:
- Be aware of clues to heavy drinking, e.g. unexplained trauma, marital violence, history of drink driving, and repeated work absenteeism
- Know those who are at high risk on epidemiological grounds, e.g. doctors, pub and brewery workers, sales executives, seamen, journalists and police officers.
- A quick screening questionnaire such as the CAGE questionnaire is a useful tool:
- Cut down on drinking - do you need to?
- Annoyed by anybody criticising your drinking?
- Guilty about drinking too much?
- Eye opener - do you need a drink first thing in the morning?
The 'AUDIT' questionnaire is a reliable, validated tool developed by the WHO to identify persons whose alcohol consumption has become hazardous or harmful to their health.
If you have any suspicions , you should elicit and record:
Consumption over past 3 months:
- Typical day's drinking
- Frequency
- Maximum / day
Severity of dependence
- Morning drinking to stop shakes and
- Previous failed attempts to control drinking
Alcohol related physical , emotional and social problems.
Consider laboratory investigations:
- Raised gamma-GT, LFT's and MCV.
Treatment of Alcohol Use Disorders
(A flow chart for management)
Early detection of excessive consumption of alcohol is important because treatment of established cases is difficult.
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Key to interventions achieving and maintaining abstinence:
* Detoxification:
This can range from: ·
- Intensive, rapid in-patient programme. The patient stops drinking and receives medication e.g. diazepam to alleviate the suffering of the withdrawal state and to prevent life-threatening withdrawal fits. Thiamine is administered to prevent neurological damage.
- A supervised out-patient detoxification when the dependency and withdrawal problems are expected to be small. Diazepam is used in smaller doses for the withdrawal period.
- Slow, progressive reduction in alcohol consumption
** Psychological:
- Long term counselling and support, e.g. Alcoholics Anonymous
- Cognitive Behaviour Therapy (CBT)
- Relapse prevention.
***Pharmacological:
To help dependent drinkers, pharmacological support is sometimes used, namely:
- Disulfiram
- Acamprosate.
Note: Treatment of co-morbid physical problems, when identified, is part of management plan.
Prevention
In seeking to prevent excessive drinking, two approaches are possible.
- Improve the help and guidance available to the individual as already described.
- Introduce social changes likely to improve drinking patterns in the population as a whole, including
- Putting up the price of alcohol
- Controlling advertising of alcoholic beverages
- Controlling the sale of alcohol
- Health education
The above have varying degrees of success, as would be expected.
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