Effective interventions for alcohol abuse
Dr Stefan Cembrowicz and Dr Anne Lingford-Hughes discuss how GPs can respond to current concern about excessive alcohol consumption and misuse
lDrink diaries and the WHO's five-item AUDIT questionnaire are effective tools
lBreathalysers are useful for identifying high alcohol tolerance
lNaltrexone and acamprosate do not work in isolation – all trials involve some degree of a psychosocial intervention
lFrequent contact with the patient is an important part of detoxification treatment
Many of us feel despondent about treating people with alcohol problems. Are we right to feel this way?
There is little evidence from randomised controlled trials, but there is a wealth of clinical experience that alcohol problems can be successfully treated. So, for example, in a non-treatment seeking, non-dependent patient whose alcohol misuse has come to light opportunistically (such as during a physical check or blood tests) but is not aware of any problems, a brief intervention consisting of feedback, giving advice and alternatives to drinking in an empathic manner can significantly reduce alcohol consumption.
In terms of pharmacotherapy for alcohol dependence, there are no major advances. But it is striking that the number needed to treat for acamprosate or naltrexone is very low, 11, in order to prevent one relapse. This is 10 times less than for many widely used and accepted treatments.
Who should we consider at high risk of alcohol misuse? What categories of patients might surprise us with alcohol misuse in the background?
Patients referred to our specialist service have often been on a series of antidepressants. Clearly their resistant depression may be because their alcohol misuse has not been identified. The combination of an SSRI and a proton pump inhibitor is a good indicator since many patients with alcohol problems are on this.
Other categories include recurrent attenders, those with multiple problems, falls, victims of violence, glucose intolerance, indigestion and hypertension. When new patients register this is an ideal time for them to be screened. Questionnaires are available including a shortened version of the WHO's alcohol use disorders identification (AUDIT) test (see box on page 59).
What are the basic rules for approaching somebody with an alcohol problem?
If the patient presents worried about their consumption, a lot of the work is done – often getting the patient to acknowledge that alcohol is a problem is a major step.
Asking patients to keep a drink diary is a useful, simple intervention. It can surprise and shock the patient about how much alcohol they are drinking and serve as the impetus to change. In addition, a pattern often emerges so that it is easier to identify where behavioural changes might work. Performing routine bloods to check for signs of physical damage (GGT, MCV) are also valuable.
More difficult is where you suspect alcohol misuse but the patient cannot admit either to themselves or to you the level of their consumption. A drink diary and routine bloods are again useful strategies. If these come back deranged, indicate to the patient the disparity between abnormal blood results and their suggested alcohol consumption.
However, it is important not to get into 'finger wagging'. Alcohol misuse and dependence are relapsing remitting conditions and you will need a long-term relationship with the patient to help them overcome their alcohol problems.
It is also important to establish what the patient is concerned about. You may be worried about their impending cirrhosis and the need for a liver transplant; they may be worried about something you think is more trivial. Using their concerns to change their drinking behaviour – rather than lecturing them about dire consequences – is more likely to succeed.
Would breathalysers be useful in GP surgeries?
We use breathalysers very commonly as an instrument of clinical investigation, rather than as a punitive measure. We see it as no different to using a urine dipstick or taking someone's blood pressure. It is a quick way of seeing how much alcohol is in the patient's system.
Even in the alcohol service we are sometimes surprised by how somebody can walk and give a coherent history when the breathalyser reveals they have very high alcohol levels. This shows how tolerant they are and is important clinical information when determining their treatment, particularly the need for pharmacological cover for detoxification. It is important to take the clinical picture into account since the same alcohol level can be associated with intoxication, maintaining the status quo or withdrawal.
Some GPs take part in alcohol detox programmes – what is good practice in this area?
A critical part of alcohol detox is to prepare the patient adequately and make sure they have thought about what will take the place of alcohol in their lives. The more detoxifications people undergo the more symptomatic their withdrawal becomes, with greater anxiety, tremor and so on and the risk of complications such as fits and DTs.
It is very hard to say no to anybody presenting in withdrawal at the end of a busy day but it may be more valuable to give them a few doses of a benzodiazepine, such as chlordiazepoxide, and see them the following day to see if they still want to detox and if they have adequately prepared. Detoxifying in the community requires careful consideration of the person's medical and mental health, domestic support, previous failures, fits and DTs.
While there are a number of different regimens, at our service I prefer daily prescribing wherever possible. Contact with the patient is very important, it is part of their detox. In addition, it avoids giving out large volumes of benzodiazepines and requires commitment from the patient. A study in south Wales used this daily contact during detox to give not only support but also interventions to maintain abstinence. Those who had these interventions did better than those who were just given tablets.
What is the place of acamprosate, naltrexone and disulfiram?
Acamprosate is licensed in the UK to promote and maintain abstinence, but has also recently been shown to reduce the quantity of alcohol drunk if people drink while taking it. There should be explicit goals so that, if the patient lapses or relapses, it can be determined whether the acamprosate is of any benefit – if not in keeping them sober then at least in reducing the amount they are drinking.
Although acamprosate doubles the rate of abstinence (up to 40 per cent) many patients do not benefit. Predictors of efficacy would therefore be very useful, but so far none have been robustly identified.
Naltrexone is unlikely to be licensed in the UK for alcohol dependence, but is prescribed. Research suggests people who lapse or drink alcohol on naltrexone are less likely to fully relapse.
In the US it has been more widely used, though perhaps on less severely alcohol-dependent patients. A recent study of more chronically dependent patients did not show any benefit of naltrexone over placebo.
Naltrexone and acamprosate do not work in isolation – all trials involve some degree of psychosocial intervention.
When the patient has no intention to take any other form of treatment, drugs are unlikely to work and are not appropriate.
There is nothing particularly new about disulfiram except that recent studies in alcohol and cocaine misuse and dependence show it to be promising.
It is worth emphasising that witnessing or supervising consumption is critical to
efficacy: if one compares unsupervised disulfiram with basic support there is no difference in outcome. Giving people disulfiram should be part of a coherent treatment plan.
Stefan Cembrowicz is a GP in Bristol
Anne Lingford-Hughes is honorary consultant for the Bristol Area Specialist Alcohol Service and senior lecturer in biological psychiatry and addiction, University of Bristol
40% of drinking occasions in men are binges (22% in women); comparable figures for France are 10% and 5%
6 units of alcohol is a 'binge' for a woman (8 units for a man)
1 bottle of wine is a binge
70% of people with a family history of alcoholism and a high alcohol tolerance will become alcohol dependent
125ml of wine of 9% strength = one unit of alcohol; most wines are stronger and drunk in larger glasses
3 units is the more likely alcohol content of a glass of wine
70% of presentations in A&E between midnight and 5am are alcohol-related problems
27% of men drink over the recommended limit of 21 units per week
21% of women drink over the recommended limit of 14 units per week (up from 15% in 1992)
6% is the increase in drink-drive related deaths and injuries in 2002 alone
100% is the increase in alcohol
use among children in the past decade
18 is the peak age of onset of alcohol problems
NHS Quality Improvement Scotland overview of treatment of alcohol misuse: www.nhshealthquality.org
The Scottish Intercollegiate Guidelines Network, The Management
of Harmful Drinking and Alcohol Dependence in Primary Care: www.sign.ac.uk
The British Association for Psychopharmacology is preparing evidence-based guidelines on substance abuse, due to be published in September: www.bap.org.uk