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.
• The patient needs to accept that there is a problem before therapy can start.
• Detoxification should be discussed.
• Information regarding local Alcoholics Anonymous groups should be offered.

Assessment

It is necessary to decide if the patient has an alcohol problem and, if so, whether the patient is a dependent drinker. The patient has a problem if he or she answers yes to any of the 'CAGE' questions (= C ut down, A nnoyed, G uilty, E ye-opener) and/or scores highly on the Alcohol Use Disorders Identification Test (AUDIT). Specialist advice should be sought if they score more than 15 on AUDIT assessment.

Dependent drinkers are characterised by:

• An overwhelming desire for alcohol.
• Drinking out of control.
• A need for increasing amounts of alcohol.
• Withdrawal symptoms experienced.
• Having little interest in other leisure activities.
• Continuing to drink even when the harm being done is made clear.

These can be formally assessed using a validated tool such as the Severity of Alcohol Dependence Questionnaire (SADQ).^[2]

A comprehensive assessment should be carried out when a person scores 15 or more on the AUDIT. This should address a range of potential needs. A clinical interview should assess:

• Alcohol use (consumption, historical and recent patterns of drinking), using validated clinical tools.
• Level of dependence.
• Alcohol-related problems.
• Other drug misuse (including over-the-counter medication).
• Physical health problems.
• Psychological and social problems.
• Cognitive function - although formal measures of cognitive functioning (eg the Mini Mental State Examination) are usually only performed if impairment persists after a period of abstinence or a significant reduction in alcohol intake.
• Readiness and belief in ability to change.

If possible, information could also be sought from a family member or carer.

Harmful or mildly dependent drinking management

If not a dependent drinker, a brief intervention can be tried. This can produce a 13-34% reduction in weekly drinking.^[3] This can be performed by the doctor, nurse or counsellor and involves:

• Advice on the dangers of excessive or binge drinking.
• Provision of advice leaflets and details on availability of any local organisations.
• Trying to find out what factors make the patient drink and how they could be avoided.
• Agreeing with the patient objectives that can be accomplished. This can include controlled drinking, eg weaker drinks, spacing drinks, alternating alcoholic with non-alcoholic drinks, eating with drinks.

Other psychological therapies to consider offering harmful or mildly dependent drinkers include cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies. These focus specifically on alcohol-related thoughts, behaviour, problems and social networks. If they do not respond, or request a pharmacological intervention, you might consider acamprosate or oral naltrexone in combination with psychological intervention.

Treatment options

Patients can belong to two broad groups, although other scenarios may occur such as a patient presenting whilst under the influence of alcohol, or because of traumatic injury as a result of alcohol:

• Patient wishing to abstain.
• Patient presents in acute alcohol withdrawal:^[4]
  • Treatment may need to begin with detoxification. This may need to occur as an inpatient, depending on severity of symptoms.
  • If disorientation, agitation or seizures occur then refer for inpatient detoxification.
  • However, the majority can be managed in the community and it is worth contacting the local community mental health team, as they may have a set-up for alcohol-dependent patients.^[5]

Detoxification

For people who typically drink over 15 units of alcohol per day, and/or who score 20 or more on the AUDIT, an assessment should be offered for delivery of a community-based assisted withdrawal.^[1] If there are safety concerns (see below) offer inpatient withdrawal.

Inpatient care is recommended for:

• Patients at risk of suicide.^[6]
• Those without social support.
• Patients who have a history of severe withdrawal reactions.

Community detoxification requires:

• Daily supervision to detect complications early, eg DTs, continuous vomiting, deterioration in mental state.
• Multivitamin preparations to prevent Wernicke's encephalopathy.
• Benzodiazepines to prevent withdrawal symptoms (usually chlordiazepoxide).
• Continuing support - primary healthcare team, community alcohol team, residential rehabilitation programmes, voluntary organisations, referral to the specialist mental health team, disulfiram.

Following detox, abstinence is recommended with clear alcohol dependence and/or marked physical damage or controlled drinking ineffective. It is best practised long-term, but some patients may return to controlled drinking after a period of abstinence.

Unrealistic expectations of abstinence may be counterproductive, resulting in relapse. Acamprosate can help to maintain long-term abstinence when combined with counselling.^[7][8] This has been combined with naltrexone in some cases.^[9]

Drugs used in acute withdrawal

Patients should ideally be nursed in quiet surroundings.

Benzodiazepines

Long-acting forms are used to reduce tremor and agitation, eg diazepam or chlordiazepoxide. Some hospitals have alcohol withdrawal assessment charts to determine how much to give, eg the Clinical Institute Withdrawal Assessment for Alcohol scale.^[5] Short-acting benzodiazepines are used for seizures, eg lorazepam intravenously (IV).

Be careful of possible dependence to benzodiazepines - advise short courses at the lowest necessary dose.

Vitamin B complex

This is given as IV Pabrinex® to inpatients for a couple of days and then patients are given oral thiamine and multivitamins.^[10] IV therapy with vitamin B complex is used to treat Wernicke-Korsakoff syndrome.

Beta-blockers

These can be used to reduce autonomic hyperactivity but are rarely used in practice as the long-acting benzodiazepines are usually sufficient.

Treatments used in abstinence or prevention of relapse

After successful withdrawal, acamprosate or oral naltrexone can be considered in combination with an individual psychological intervention.

Calcium acetyl-homotaurinate (acamprosate)

• This blocks gamma-aminobutyric acid (GABA) and reduces N-methyl-D-aspartate (NMDA) receptor glutamate-related excitation.
• It has a possible neuroprotective role in detoxification.
• It does not interact with alcohol and reduces cravings.
• Will usually be given post-detoxification to maintain stabilisation.^[11]

Naltrexone

See separate article Opioid Abuse and Dependence.

• Alcohol causes pleasure by release of endogenous opioids. Naltrexone is a competitive antagonist of the opioid receptor which prevents the endogenous opioid from binding to the receptor, therefore giving reduction in the pleasurable effects from alcohol.
• It is associated with lower relapse rate, fewer drinking days and longer length of abstinence.^[12][13] Therefore, patients are less likely to take large quantities in one go - thus it is used in patients who are binge drinkers.

The length of time spent in treatment of alcohol dependence appears not to be important when comparing brief or extended treatment conditions.^[14]

Other more novel agents

• These agents are not currently licensed for use in alcohol dependence.
• They include selective serotonin re-uptake inhibitors (SSRIs), such as fluoxetine, and anticonvulsants (topiramate).

Psychosocial interventions

• All medications should be used in conjunction with psychological interventions.
• This includes counselling, cognitive-based therapy and self-help groups - for example, Alcoholics Anonymous.
• Social support is also important.^[15] Where possible, families should be involved in the treatment and support of the drinker.

Young people

Children and young people aged 10-17 years who misuse alcohol should be offered individual cognitive behavioural therapy (for those with limited comorbidities).^[1]

Those with significant comorbidities and/or limited social support should be offered multi-component programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multi-systemic therapy).

Clinicians should also bear in mind the effect that a family member's drinking may have on other people in the household.

Comorbidities

Where there is depression or where anxiety disorders exist, clinicians are advised to treat the alcohol misuse first, as this may lead to significant improvement in the depression and anxiety.^[1] If depression or anxiety continues after 3 to 4 weeks of abstinence from alcohol, assess the depression or anxiety and consider referral and treatment.