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

• Do you use alcohol?
• In what circumstances do you drink, e.g. only when socialising?
• What is the most you have ever drunk? How recent was this?

Take a drinking history:¹

• 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

In primary care and hospital settings - use the CAGE or AUDIT questions.^2,3

Often routine blood results may show coincidental macrocytosis or abnormal liver function tests (LFTs) which should make you suspicious.⁴

Assessment

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:⁵
  • 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, e.g. 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
  • Seizures
  • 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)⁶

Do they have any ill health as a consequence of their alcohol intake?

• History - include features as above
• Examination:
  • General demeanour, ethanolic or hepatic foetor
  • Malnourishment
  • Signs of acute withdrawal such as coarse tremor and tachycardia
  • Signs of liver disease, such as palmar erythema, gynaecomastia, spider naevi and jaundice⁷
  • 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

Investigations

• 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

Management

This is covered in detail in Alcoholism and Alcohol Abuse - Management.

Document references

1. Ashworth M, Gerada C; ABC of mental health. Addiction and dependence--II: Alcohol. BMJ. 1997 Aug 9;315(7104):358-60.
2. Ewing JA; Detecting alcoholism. The CAGE questionnaire. JAMA. 1984 Oct 12;252(14):1905-7. [abstract]
3. The AUDIT (Alcohol Use Disorders Identification Test) questionnaire, World Health Organisation
4. Burge SK, Schneider FD; Alcohol-related problems: recognition and intervention.; Am Fam Physician. 1999 Jan 15;59(2):361-70, 372. [abstract]
5. The management of harmful drinking and alcohol dependence in primary care, Scottish Intercollegiate Guidelines Network (SIGN), 2003
6. McIntosh C, Chick J; Alcohol and the nervous system.; J Neurol Neurosurg Psychiatry. 2004 Sep;75 Suppl 3:iii16-21.
7. Madhotra R, Gilmore IT; Recent developments in the treatment of alcoholic hepatitis. QJM. 2003 Jun;96(6):391-400. [abstract]

Internet and further reading

• Alcohol Harm Reduction Strategy for England - Cabinet Office UK

Acknowledgements