Alcoholism and Alcohol Abuse - Management

More than 90% of adults in the UK population drink alcohol.

Alcohol dependence is a major problem in the UK.

Pharmacological therapy can help patients to abstain from alcohol and also reduce cravings.

• 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 Alcoholics Anonymous groups.

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.¹ 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 are experienced.
• Has little interest in other leisure activities.
• Continues drinking even when the harm being done is made clear.

Patients can belong to two broad groups:

1. Patient wishing to abstain
2. Patient presents in acute alcohol withdrawal:
   • 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.²

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 suicide³
• 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 practised 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.^4,5 This has been combined with naltrexone in some cases.⁶

Patients should ideally be nursed in quiet surroundings.

Benzodiazepines

Long-acting forms are used to reduce tremor and agitation e.g. diazepam or chlordiazepoxide. Some hospitals have alcohol withdrawal assessment charts to determine how much to give e.g. clinical institute withdrawal assessment for alcohol scale.^2,7
Short-acting benzodiazepines are used for seizures e.g. lorazepam intravenously.
Be careful of possible dependence to benzodiazepines - advise short courses at 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.⁷
Intravenous 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.

Disulfiram (Antabuse)

• Irreversibly and specifically blocks aldehyde dehydrogenase - a crucial enzyme involved in the metabolism of alcohol.
• This leads to a build-up of acetaldehyde which results in an unpleasant reaction, thereby the patient will be unkeen to take alcohol.
• The unpleasant reaction includes: flushing, headaches, palpitations, nausea, vomiting.
• However, if a high dose of alcohol is taken then there is a risk of arrhythmias, MI, respiratory depression and hypotension and collapse - making its use less attractive.
• Thus its use should be restricted in patients who are well motivated and can be supervised e.g. colleague or partner.
• Patients also need to be aware of taking substances that inadvertently contain alcohol e.g. mouthwash.
• Furthermore, there is no clear evidence that disulfiram actually increases abstinence or relapse rates.^8,9,10
• Hepatotoxicity is a rare but fatal side-effect. Advise check LFTs at two weeks and then at three and six months.

Calcium acetyl-homotaurinate: (Acamprosate)

• Blocks GABA and reduces NMDA receptor glutamate related excitation
• Possible neuroprotective role in detoxification
• Does not interact with alcohol and reduces cravings
• Usually given post detoxification to maintain stabilisation⁸

Naltrexone

• See Opioid Abuse and Dependence record.
• 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.
• Associated with lower relapse rate, drinking days and length of abstinence.^9,10
• Therefore, patients are less likely to take large quantities in one go - thus used in binge drinkers.

The length of time spent in treatment of alcohol dependence appears not to be important when comparing brief or extended treatment conditions.¹¹

Other more novel agents

• These agents are not currently licensed for use in alcohol dependence
• Include SSRIs such as fluoxetine and anticonvulsants (topiramate)

Psychosocial interventions

• All medications should be used in conjunction with psychological interventions.¹²
• This includes counselling, cognitive-based therapy and self-help groups e.g. Alcoholics Anonymous.
• Social support is also important.¹³

• Early referral of patients with liver, cardiac or neurological dysfunction.
• Treatment and prevention of malnourished states.
• Treatment of depression which may co-exist.