Alcohol use is prevalent in the UK and it is estimated that 90% of adults consume alcohol. The recommended maximum intake a week is 21 units for men and 14 units for women.
Further information on the scale of the problem is detailed in Alcohol-related Problems.
Identifying patients who drink harmfully
Use non-confrontational questions to begin a discussion about alcohol for example:
- Do you use alcohol?
- In what circumstances do you drink, eg only when socialising?
- What is the most you have ever drunk? How recent was this?
Take a drinking history:
- Quantity consumed in units
- Time of day of the first alcoholic drink
- Drinking pattern (problems characterised by consistent pattern of daily drinking)
- Withdrawal symptoms, eg morning shakes or nausea
In primary care and hospital settings - use the CAGE or AUDIT questions.
Often routine blood results may show coincidental macrocytosis or abnormal liver function tests (LFTs) which should make you suspicious.
- Add notes to any clinical page and create a reflective diary
- Automatically track and log every page you have viewed
- Print and export a summary to use in your appraisal
This involves two main aspects:
- Is their alcohol intake a problem?
- Do they have any illnesses relating to their alcohol intake - this encompasses physical, psychological and social aspects?
Is their alcohol intake a problem?
- Amount of consumption
- Are they dependent on alcohol? Do they need a drink every day? What time to their first drink?
- Has anyone expressed concerns about their alcohol intake?
- Alcohol dependence:
- 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 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
- Auditory and visual hallucinations
- Delirium tremens (the severe end of the spectrum of withdrawal and consists of severe forms of the above symptoms and may be associated with circulatory collapse and ketoacidosis)
Do they have any ill health as a consequence of their alcohol intake?
- History - include features as above
- General demeanour, ethanolic or hepatic foetor
- Signs of acute withdrawal such as coarse tremor and tachycardia
- Signs of liver disease, such as palmar erythema, gynaecomastia, spider naevi and jaundice
- Hepatomegaly (in chronic alcoholic liver disease the liver is shrunken)
- Ascites, gonadal atrophy
- Atrial fibrillation and cardiomyopathy
- Wernicke-Korsakoff (ataxia, confusion, ophthalmoplegia), amnesic problems, peripheral neuropathy and dementia
- 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
- Full blood count, clotting screen, renal and liver function tests:
- Suspect excessive alcohol use if mean corpuscular volume (MCV) raised and 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 patient with suspected alcohol related problem
- Be honest and non-judgemental
- Many patients drink in secret and may not want to discuss the issue
- Patient needs to accept that there is a problem before therapy can start
- Detoxification should be discussed
- Information regarding local alcoholic anonymous groups
This is covered in detail in Alcoholism and Alcohol Abuse - Management.
Further reading & references
- Alcohol Harm Reduction Strategy for England, Cabinet Office UK
- Ashworth M, Gerada C; ABC of mental health. Addiction and dependence--II: Alcohol. BMJ. 1997 Aug 9;315(7104):358-60.
- Ewing JA; Detecting alcoholism. The CAGE questionnaire. JAMA. 1984 Oct 12;252(14):1905-7.
- The AUDIT (Alcohol Use Disorders Identification Test) questionnaire, World Health Organization
- Burge SK, Schneider FD; Alcohol-related problems: recognition and intervention.; Am Fam Physician. 1999 Jan 15;59(2):361-70, 372.
- The management of harmful drinking and alcohol dependence in primary care, Scottish Intercollegiate Guidelines Network - SIGN (2003)
- McIntosh C, Chick J; Alcohol and the nervous system; J Neurol Neurosurg Psychiatry. 2004 Sep;75 Suppl 3:iii16-21.
- Madhotra R, Gilmore IT; Recent developments in the treatment of alcoholic hepatitis. QJM. 2003 Jun;96(6):391-400.
|Original Author: Dr Hayley Willacy||Current Version: Dr Hayley Willacy|
|Last Checked: 20/04/2011||Document ID: 1784 Version: 26||© EMIS|
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