Alcohol has been a major risk factor for premature mortality in the European Union (EU). The overall level of alcohol-attributable mortality in the EU is high. There are three most important alcohol-related causes of death: cancers, liver cirrhosis and injuries.¹

Alcohol use disorder (AUD) as a problem

In Ireland alcohol consumption is 11.9 litres per capita (2010) which places it in sixth position overall in Europe.² A decline in the age of onset of drinking has also been observed.³ In 2007 the overall cost of harmful use of alcohol in Ireland was estimated to be €3.7 billion, representing 1.9% of gross national product (GNP) that year.⁴

Alcohol in the body

Alcohol absorption rate depends on many factors, such as the amount of food in the stomach and the concentration of the alcohol. 

Blood alcohol concentration (BAC) varies also according to sex, body build, phase of menstrual cycle, previous exposure to alcohol and whether it is taken with drugs that affect absorption.

Alcohol is a known sedative and a mild anaesthetic that can activate the reward system in the brain and produce a sense of wellbeing, relaxation, disinhibition and euphoria. These sensations are accompanied by sweating, tachycardia, flushing and an increase in blood pressure. Increased consumption of alcohol leads to intoxication. 

Over 90% of alcohol is eliminated by the liver. Alcohol is removed from the body at a rate of 15mg/ 100ml/hour, but it varies in different people, at different times, and with the amount of alcohol ingested. 

Patterns of drinking

A standard drink (one unit) in Ireland contains 10g of pure alcohol which corresponds with a half-pint of beer, a small glass of wine or a single measure of spirit (see Figure 1). 

The recommended weekly limit for alcohol is 21 standard drinks for men and 14 standard drinks for women, spread out over the course of the week, with at least two to three alcohol-free days. 

Figure 1. Number of units of alcohol in conventional volume (click to enlarge)

Alcohol-related harm

Excessive alcohol intake has a negative effect on both physical and emotional health.⁶ Comorbid mental health disorders include depression, anxiety disorders and drug misuse. Common physical comorbidities include gastrointestinal disorders (in particular liver disease), neurological and cardiovascular disease. Injuries sustained while under the influence of alcohol are also frequent. 

Sexually transmitted diseases, use of emergency contraception, as well as unplanned pregnancies are more common in those with an AUD.

Detecting harmful drinking and dependence

AUDs should be recognised and addressed as early as possible. Table 1 outlines the different patterns of drinking that present to medical professionals.

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Screening and diagnosing

Screening is directed towards people who are not seeking treatment but who may have an AUD. Screening can be performed routinely or at least in those that present with relevant physical or mental health conditions. 

Screening tools

The Alcohol Use Disorders Identification Test (AUDIT)² was developed by the World Health Organization (WHO) as a method of screening for excessive drinking. A score of eight or more in men, and seven or more in women, indicates a strong likelihood of harmful alcohol consumption. A score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence.⁶

There are also other screening tests available such as FAST (Fast Alcohol Screening Test),⁵ PAT (Paddington Alcohol Test)⁹ and the MAST (Michigan Alcoholism Screening Test).^10,11

Biological markers

Blood tests in persons with AUD show an increase in mean (red) corpuscular volume (MCV), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyltransferase (GGT). In addition AST: ALT > 2:1 suggests alcohol liver damage. In some cases bilirubin, IgA and smooth muscle antibodies may also be altered. Carbohydrate deficient transferrin (CDT) can be useful in detecting chronic alcohol use. 

Urine tests can provide information about alcohol concentration in urine, which can determine if alcohol was consumed recently. Analysis of ethyl glucuronide (EtG) a product of alcohol metabolism, can be detected in urine with 100% sensitivity for over 30 hours post-consumption.¹²

Alcohol dependence syndrome (ADS) according to 10th version of International Classification of Diseases (ICD-10)

In order to diagnose ADS three or more of the following should have occurred together for at least one month, or should have occurred together repeatedly within a 12-month period:

• a desire or sense of compulsion to consume alcohol
• impaired capacity to control drinking
• a physiological withdrawal state when alcohol use is reduced or ceased
• an evidence of tolerance to the effects of alcohol 
• preoccupation with alcohol 
• persistent alcohol use despite evidence of harmful consequences.

Treatment issues, facilitating change

During the initial assessment, an evaluation of alcohol misuse, the severity of dependence and risk should take place together with analysis of the extent of any associated health and social problems and the need for assisted alcohol withdrawal.

Brief intervention

For those that have been identified as drinking harmfully it is recommended to apply a brief intervention based on the FRAMES principle (Feedback, Responsibility, Advice, Menu of options, Empathy, and Self-Efficacy). 

Together with motivational interviewing this should raise the awareness of risks, allow discussion of the barriers to change and outline practical strategies to help the individual reduce alcohol consumption and eventually lead to a set of goals to improve outcomes.¹³

Alcohol detoxification and management of withdrawals

Withdrawal symptoms may vary in severity. Patients may experience tremors, insomnia, headache, nausea, anxiety, restlessness and withdrawal seizures. Delirium tremens (tremor, severe agitation, confusion, autonomic disturbance, vivid hallucinations) occurs usually between three to six days after discontinuation of alcohol.⁷

The National Institute for Clinical Excellence (NICE) guidelines suggests a clinical division of mild, moderate and severe dependence according to the score in Severity of Alcohol Dependence Questionnaire (SADQ). The score in SADQ indicates the treatment option (see Table 2).¹³

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Outpatient treatment of alcohol withdrawal is indicated if dependence with evidence of tolerance and withdrawal is present. Inpatient detoxification is preferred if there is history of epilepsy or withdrawal-related seizures, existing severe alcohol withdrawal, especially with delirium as well as pregnancy, suicide risk and coexisting acute or chronic illnesses requiring inpatient treatment. 

Community patients need to be reviewed at least every other day and the dose may require adjustment depending on presence of withdrawal symptoms or sedation. In the community fixed doses of a benzodiazepine, usually chlordiazepoxide (see Table 3), are recommended as a first-line pharmacological approach. However, symptom-triggered benzodiazepine treatment for alcohol may be associated with a decrease in the quantity of medication and duration of treatment.¹⁵

Thiamine supplementation is essential in malnourished patients for the prevention of Wernicke’s encephalopathy.

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Mental health and AUD

Suicidality

The use of alcohol does not necessarily lead to suicide, but it seems to be one of the major risk factors (see Figure 2). 

Alcohol abuse increases the risk of suicide by exposing a person to social problems such as loss of employment, financial difficulties and interpersonal difficulties. Alcohol also affects problem-solving and inhibits coping strategies.¹⁷

A thorough risk assessment and enquiry about the use of other substances should be performed and appropriate support should be offered.

Figure 2. Alcohol, brain areas and suicidality (click to enlarge)

Depression and anxiety

In patients with comorbid depression or anxiety disorders, NICE guidelines recommend treatment of alcohol misuse first. If symptoms continue after three to four weeks of abstinence, the patient should be reassessed and appropriately treated.¹³

There is evidence supporting the use of antidepressants to reduce alcohol cravings in cases with comorbid depressive¹⁸ and anxiety¹⁹ symptoms.

Relapse prevention

Acamprosate²⁰ or oral naltrexone²¹ in combination with psychological therapy focused specifically on alcohol misuse can be considered to reduce craving. 

Treatment with either can be continued for up to six months and should be reviewed at least monthly. It should be stopped, however, if drinking persists four to six weeks after starting the drug. If the aforementioned is not suitable for the patient (following medical assessment with urea and electrolytes and liver function test) the option of disulfiram¹³ (aversive therapy) should be discussed. 

Patients and their families should be informed about the interaction between disulfiram and alcohol. It should be started at least 24 hours after the last drink and it is advised to contract a family member to enhance compliance. 

Newer medications include nalmefene, an opioid antagonist that has been shown to be effective in reducing alcohol consumption.²² Baclofen has also  been used in managing withdrawal symptoms but so far the evidence is not compelling.²³ Psychological and psychosocial interventions that are utilised in the area are listed in Table 4.

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Summary

The impact of alcohol on the life of the individual, their families and the whole of society is extensive and complex. Skillful and early screening together with brief interventions may empower patients to make positive changes and prevent so many of the costly aspects of alcohol-related harm.

Case studies 

Case study 1: alcohol, depression and suicide

A 35-year-old single, employed male, living alone, complained of a three-month history of low mood, reduced life enjoyment, broken sleep and reduced energy. He admitted that he had been fed up with his life and that he had been contemplating ending it, but had not gathered enough “courage” yet. He had no previous history of depression.

During assessment the patient was asked about alcohol intake. He was adamant that he “does not have a drink problem”, despite the fact that he had been drinking at least three to five pints (about six to 10 units) daily with episodes of bingeing at weekends. These weekend binges were associated with blackouts and more recently with increasing difficulty getting to work. 

He explained that he had been drinking because of loneliness, sadness and low mood following a relationship break-up four months ago. AUDIT score was 21 which indicated high possibility of alcohol dependence. It was discussed with the patient in a non-judgemental manner pointing out the development of loss of control, withdrawal symptoms and tolerance. 

Alcohol-related harm, especially its impact on mental health and coping strategies, was explained. The patient agreed to consider linking in with available support (such as counselling, CBT therapy) in order to work on his mood and stated that would reduce alcohol intake. 

The presence of suicidal thoughts required further evaluation and the risk of suicide was assessed and proved to be increased. The patient was referred for specialist evaluation to determine the need for inpatient detoxification. 

Case study 2: borderline personality disorder and substance misuse (including alcohol)

A 27-year-old mother of two, with a background of child sexual abuse (CSA) and a history of opiate dependence, stable on methadone maintenance therapy for nearly two years, had been drinking heavily every evening for the past one year. 

She had been attending an addiction counsellor but her attendance was erratic and her level of engagement varied. 

She continuously described herself as being worthless and felt guilty for letting her children down (they had been in social care since their birth). She had recurrent thoughts of life not worth living and recognised impulsivity as one of her issues. 

On the days she missed the methadone dispensing time or if she was refused methadone due to intoxication, she would buy illicit methadone to avoid “sickness”. Otherwise her urine analysis was occasionally positive for cocaine, was regularly positive for alcohol and always positive for EtG. She was offered a benzodiazepine detoxification with daily reviews, but she failed to complete it. She was adamant that alcohol helps her to get through the day, saying “it is something to do” and is “the best medication”. 

She was in hospital on a few occasions following suicidal attempts such as serious overdoses, jumping into the river or cutting her wrists. She had been using self-harm as a mechanism to release inner tension since she was 13. 

She was previously offered assessment in a residential treatment centre but failed to attend. She had been therefore managed in community, frequently reminded about alcohol-related harm and the benefits of change. Further detoxifications could be offered depending on her motivation and engagement with a counselling process.

Case study 3: alcohol and violence

A 40-year-old man living with his wife and three children, with frequent severe binge-alcohol use and numerous breaches of the law including public disturbances, assault and drink-driving offences, presented for treatment.

This man had a history of heavy bouts of drinking since his late teens. He used to go out with his peers at weekends. In more recent years he felt he had lost control and he could not stop drinking once he started. 

His wife described him as a “Jekyll and Hyde character”, turning into Hyde when he was drinking. He became physically and verbally abusive. She stated that on a few occasions she was fearful for her safety and she had called the police. He was initially very angry with her, but when sober he felt guilty and was remorseful for his behaviour. 

He agreed to engage in a community programme involving group counselling and individual support  and as such was able to avoid alcohol for the past month. Support and advice were also offered to his wife and children. 

References 

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