What you need to know about alcohol dependence
Consultant psychiatrist and addiction specialist Dr Anupam Agnihotri answers GP Dr Sabby Kant’s questions on screening tools, brief interventions and prescribing for those with impaired liver function
Consultant psychiatrist and addiction specialist Dr Anupam Agnihotri answers GP Dr Sabby Kant's questions on screening tools, brief interventions and prescribing for those with impaired liver function
1. How do you define alcohol dependence and binge drinking?
About 15% of hospital inpatients have a disorder that is directly related to excess alcohol consumption, and a further 15% may drink above the safe limits or have other alcohol-related problems. In general practice settings, up to one patient in six may have evidence of an alcohol use disorder.
Alcohol dependence is the clinical term used to describe a person who has become addicted to alcohol. It represents a cluster of psychological, behavioural and cognitive symptoms fuelled by an inner drive to carry out a repetitive pattern of drinking alcohol.
Dependent drinkers have typically lost control of their drinking and may experience withdrawal symptoms on cessation of intake. They will usually need support and treatment to achieve the goal of abstinence.
A diagnosis of current alcohol dependence is made if three or more of the following have occurred repeatedly within past year:
• impaired control – subjective awareness of an impaired capacity to control drinking
• cravings/compulsion – awareness of strong desire or sense of compulsion to drink
• drinking taking over life – preoccupation with drinking to neglect of other responsibilities or interests
• tolerance – increased amount of alcohol is required to achieve the desired effect
• withdrawal symptoms on cessation or reduction of alcohol intake or using alcohol to relieve or prevent these
• persistent use, despite clear evidence of overtly harmful consequences.
On the other hand, binge-drinking is a pattern of harmful alcohol use where an individual drinks above recommended limits for a period of time, which is spaced with intervening periods of sobriety. This type of patient usually requires brief intervention with a view to harm minimisation.
2. How can the primary care team best identify those who misuse alcohol?
A screening tool such as the CAGE questionnaire can be useful in primary care.
The questions are:
• Cut down: Have you ever felt you ought to cut down on your drinking?
• Annoyance: Have other people annoyed you by criticising your drinking?
• Guilt: Have you ever felt guilty about your drinking?
• Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Two or more replies of yes identify alcohol misuse. You can use these questions for any patients presenting with psychological symptoms such as disturbed sleep, anxiety and depression.
A review of CAGE's sensitivity and specificity for alcohol misuse and dependence screening in a general population suggested it was 71% and 90% respectively.
3. Can you give some practical advice as to how to rate alcohol units in today's most common drinks?
A unit contains 8g of ethanol and a standard 285ml bottle of 5% beer contains one unit of alcohol. One unit of a 12% wine is contained in 80ml – a standard glass of wine in the UK is now 175ml, which is two units. A 500ml can of strong 8 or 9% lager can deliver up to four units of alcohol.
Remember home-poured drinks may be 50% larger than the standard drink size.
The simple formula to calculate units is to multiply volume in ml by % of alcohol and divide by 1,000 – for example 500ml of 5% beer is 2.5 units.
4. Can you summarise the clinical features of alcohol misuse?
Any patient presenting with symptoms of anxiety, depression, sleep disturbance, poor concentration and stress should be asked about their alcohol consumption. If there is a doubt about the amount and the pattern of alcohol consumption then recommend they keep a drink diary to review at their next appointment. A suitable diary is available at www.drinkaware.co.uk.
A diagnosis of dependent syndrome is made by identifying repeated withdrawal symptoms, signs of tolerance, narrowing of personal repertoire, inability to control initiation and stopping of alcohol intake and continuing use despite clear evidence of harm from alcohol use.
Other signs to look for include stale smell of alcohol, obesity, poor nutrition, poor self-care, signs of new and old injuries, and signs of alcohol withdrawal such as tremors, sweating, anxiety and increased pulse and high blood pressure.
There are also the facial stigma of alcohol dependence such as conjunctival injection, telengiectsia, rhinophyma, parotid enlargement, facial erythema, periorbital puffiness, acne and Cushing's syndrome.
5. What about the biochemical features?
In a full blood count, an elevated increased MCV is present in 20-30% of heavy drinkers in the community and 50-75% of heavy drinkers as inpatients.
Gamma glutamyltransferase (GGT) is elevated in 30-50% of heavy drinkers in the community and 50-80% of inpatients.
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are quite insensitive. Only 20% of those drinking 60g of alcohol a day have elevated results.
Raised levels tend to reflect histological changes/impairments of hepatocyte cell membrane integrity. An AST/ALT ratio of more than two is indicative of alcoholic hepatitis.
Other biochemical features include:
• increased serum uric acid
• increased HDL cholesterol
• increased carbohydrate-deficient transferrin (CDT).
6. What are the possible therapeutic pitfalls the prescribing GP should be aware of in patients with alcoholic liver disease?
In treating patients with alcoholic liver disease, drug-prescribing should be kept to a minimum. The prescriber should be mindful of:
• impaired drug metabolism and possibility of drug overdose
• hypoproteinemia resulting in reduced protein binding and increased availability, resulting in drug toxicity
• reduced clotting and prolonged prothrombin time resulting in increased bleeding risk, due to side-effects of drugs such as NSAIDS and anticoagulants
• hepatic encephalopathy, which may be precipitated by drugs that impair cerebral functions (such as all sedatives, opioid analgesics), diuretics (resulting in hypokalaemia) and drugs causing constipation
• drugs giving rise to fluid retention such as NSAIDs and steroids, which may exacerbate oedema and ascites.
7. What brief counselling techniques can we try in primary care?
The components of an early and brief intervention can be summarised by the mnemonic FLAGS:
• Feedback: give patients brief feedback on alcohol score and biochemical results, plus discuss any alcohol-related harms that they may have experienced.
• Listen: allow patients to respond and gauge their readiness to change. This may include any past attempts to address drinking.
• Advise: provide clear and unequivocal advice to change. This can include describing benefits such as improved fitness and sleep and reduced expenditure on alcohol.
• Goals: negotiate goals with the patient. Suggest reducing drinking to within recommended limit. If the patient does not accept this goal, try another compromise goal.
• Strategies: discuss practical strategies to reduce drinking, such as switching to low-alcohol beer, alternating alcoholic with non-alcoholic drinks, reducing drink size, planning an alternative focus for socialising or identifying high-risk situations and practical ways to deal with these.
This basic model can be adapted to different patients. For example, in those not yet motivated to change their drinking, the principals of motivational interviewing can be incorporated into feedback of harm.
Ask the patient to weigh up good and bad aspects of drinking with a view to building their own strength and resources for change. This approach will also enhance therapeutic alliance, raise hopes and expectations and maximise the effectiveness of your therapeutic technique.
8. What are the pharmacological options?
Home or ambulatory detoxification can be attempted if:
• the patient has mild to moderate alcohol dependence, can be reviewed daily and lives with a supportive partner or family
• there is low risk of complication – for example, no history of past severe withdrawal or delirium tremors, past history of seizure or epilepsy, multiple medications
• there is no evidence of multiple psychoactive substance abuse
• there is no concurrent medical or psychiatric problem including suicidal ideation that may place patient at risk
• the patient is not vomiting or malnourished.
Benzodiazepines are the most common group of drugs to reduce withdrawal symptoms. Whenever possible the patient is reviewed daily and then given that day's medication.
The most commonly used benzodiazepine is oral chlordiazepoxide - starting at 15-20mg every six hours, slowly reduced it over next week to 10 days before stopping. The equivalent dose for diazepam would be 5-20mg three to four times a day depending on the severity of withdrawal symptoms.
Patients should also take oral thiamine 100mg daily and multivitamins.
If alcohol withdrawal scale or the CIWA scores (? first mention of this) rise rapidly, or if patient develops withdrawal seizures, agitation that is difficult to control or hallucination, they should be immediately transferred to the hospital.
Medications used for relapse prevention following a successful detox are:
• the opioid antagonist naltrexone as an anticraving agent
• acamprosate (Campral) as an anticraving agent
• disulfiram (Antabuse) as aversive therapy.
Acamprosate and disulfiram are both licensed for the treatment of alcohol dependence but should only be initiated and prescribed in secondary care. These medications are usually initiated and monitored by specialist services.
9. I often get asked about ‘detoxification' – what types of programmes are there available and what exactly does a detoxification program entail?
Depending on severity of alcohol dependence and presence of medical or psychiatric comorbidity, alcohol dependence can be treated in the community or in the hospital as described above in question 8.
Complementing medical treatment with motivation enhancement and relapse prevention therapies and treatment of co-morbidity would improve the outcome.
In specialist alcohol treatment and rehabilitation units, regular participation in group and counselling programmes during and after the treatment forms an important part of management and aftercare. These programmes are based on 12-steps-to-recovery model and complement the biopsychsocial approach enhance the outcome treatment and achieve a goal of abstinence.
Dr Anupam Agnihotri is a consultant psychiatrist and addiction specialist at The Priory Hospital, Glasgow
Competing interests: none declaredCT abdominal scan showing fatty liver (purple) in alcohol-dependent patient CT abdominal scan showing fatty liver (purple) in alcohol-dependent patient alcohol take home points What I will do now
Dr Sabby Kant considers the responses to his questions
The simple CAGE questionnaire is useful and I like the handy formula of calculating alcohol units, particularly as the amount of alcohol in today's drinks is so variable.
It is a useful reminder that blood tests provide a low specificity and thus can wrongly reassure drinkers that all is well if bloods tests are normal.
The FLAGS provides a useful structure for GPs to provide brief counselling. I'm pleased that the author emphasises the importance of using the techniques of motivational interviewing, a key method towards affecting a change in behaviour – an effective proven method sadly not familiar to many GPs.
Dr Sabby Kant is a GP in Hillingdon, west London