Reducing Alcohol Intake

More than 90% of adults in the UK population drink alcohol. Average weekly consumption for men increased from 15.7 in 1992 to 17.0 units in 2002.¹ The increase for women was 5.5 to 7.6 units during the same period.
Twenty seven per cent of men and 17% of women aged 16 and over drank on average more than 21 and 14 units respectively in 2002.
There is currently inconclusive evidence for the effectiveness of primary care lifestyle advice in reducing heavy drinking.²

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 e.g. morning shakes or nausea

Next use CAGE questionnaire:

Need to decide if patient has an alcohol problem and if so whether the patient is a dependent drinker.

Non-dependent drinkers

Patient has a problem if answers yes to any of the CAGE questions and/or

• Drinks >21 units/week if male
• Or >14 units/week if a woman

If not a dependent drinker, you can use a brief intervention, which can produce a 13-34% reduction in weekly drinking, which means 2.9 to 8.7 fewer mean drinks per week.⁴ This can be performed by the doctor, nurse or counsellor and involves:

• Advice on dangers of excessive or binge drinking
• Provision of advice leaflets and 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, e.g. weaker drinks, spacing drinks, alternating alcoholic with non-alcoholic drinks, eating with drinks.

Dependent drinkers

These are characterised by:

• Overwhelming desire for alcohol
• Drinking out of control
• Need for increasing amounts of alcohol
• Withdrawal symptoms
• Has little interest in other leisure activities
• Continues drinking even when the harm being done is made clear

Alcohol dependence normally needs controlled detoxification with help of an attenuation therapy (e.g. benzodiazepines) to avoid withdrawal symptoms/complications. Can be performed in the community but in-patient care recommended for:

• Patients at risk of suicide⁵
• Those without social support
• Patients who have a history of severe withdrawal reactions

Community detoxification requires:

• Daily supervision to detect complications early (e.g. 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 specialist mental health team, disulfiram

Following detox abstinence is recommended with clear alcohol dependence and/or marked physical damage or controlled drinking ineffective.
Best if long-term, but some patients may return to controlled drinking after a period of abstinence.
Unrealistic expectations of abstinence may be counter-productive resulting in relapse. Acamprosate can help to maintain long term abstinence when combined with counselling.^6,7 This has been combined with naltrexone in some cases.⁸