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Alcohol use disorder

Alcohol use disorder ( ALD ) is defined by the use of large and escalating amounts of alcohol over a period of time with unsuccessful efforts to cut down ; much time spent recovering , obtaining , or using alcohol ; recurrent alcohol use when is physically hazardous ; and craving and withdrawal American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders ( DSM -5 ) 2013DSM classifies AUD as mild moderate or severe

 

How common –Data can vary based on definitions and criteria used , where is the data sourced and guidelines Alcohol use disorder ( AUDs ) are among the most prevalent mental disorders worldwide McManus et al in 2009 reported that some 24 % of the adult population in England ( 33 % men and 16 % women ) consume alcohol in a way that is potentially or actually harmful to their health or well being A survey in England in the year 2000 ( Singleton N et al ) estimated the prevalence of alcohol dependence to be 5.9 % CKS quotes that alcohol use disorder ( ALD ) is a common psychiatric problem with a lifetime prevalence estimated to between 7 % and 12.5 % in most Western countries Men generally consume more alcohol than women Alcohol use declines with age A link is well known between alcohol use and both mood disorders and other substance misuse Primary care has an important role in recognition and management of AUD but a recent BJGP study ( 2020 ) has found that only 23 % of GPs routinely screen for alcohol abuse.

 

Why important – An important risk factor for illness , disability and mortality Listed as top 5 causes of disease burden by WHO in 2009 and the 2nd highest cause of disability when expressed in terms of years lost to disability AUDs impair productivity and interpersonal functioning and place psychological and financial burdens on those who misuse alcohol , on their families , friends and co-workers ( Rehm J et al 2009 ) CKS quotes that alcohol plays a part in 25 % of 33 % of known cases of child abuse Well established link between AUDs and other substance misuse disorders , major depressive and bipolar disorders and antisocial and borderline PDs across time frames and severity levels More people die from alcohol related conditions than from breast or cervical cancer or MRSA combined ( Cancer research UK 2004 ) In contrast to some other European countries deaths from alcoholic liver disease and alcohol related hospital admissions have increased substantially in the UK According to WHO 5.3 % of all global deaths in 2016 were attributable to alcohol consumption.

 

Why is alcohol harmful –Ethanol ( or ethyl alcohol ) is rapidly absorbed in the gut and distributed to , and affects all body parts ( permeates all body tissues ) Most of alcohol detoxification happens in liver , it is metabolised to acetaldehyde primarily by alcohol dehydrogenase and the cytochrome P450 2E1 Toxic affects of alcohol can result in more than 60 different diseases Alcohol abuse disrupts multiple cellular mechanisms , leading to altered organ function and disease Tissue and organ injury due to various processes as
♦ oxidative stress ♦ inflammation ♦ acetaldehyde generation ♦ adduct formation ♦ decreased barrier function ♦ impaired anabolic signaling ♦ upregulation of catabolic processes ♦ fibroblast activation ♦ mitochondrial injury ♦ cell membrane perturbations Alcohol disrupts the HPA ( hypothalamo- pituitary-adrenal ) axis and this has been implicated in the pathophysiology of pseudo-Cushing’s syndrome ♦ addiction ♦ dependence and relapse of recovering alcoholics.

 

Assessment – Before asking how much we should know what is permitted , what is within normal limits and a unit ( use the websites as drinkware.co.uk or drinkcoach for reference )
 1 unit of alcohol is 10 ml or 8g of pure alcohol No of units can be calculated easily 
% alcohol by volume x volume ( mls ) / 1000 = number of units for e.g 1/2 pint beer at 4.2 % is
4.2 x 280 mls = 1.76 / 1000 ie 1.2 units In the UK currently maximum permitted weekly limits is 14 units for women and men ( NHS ) This was following a study which reported that people who drank more than 12.5 units ( 100 g ) of alcohol a week were likely to die sooner than those who drank no more than this amount In the US
○ Moderate drink – upto 1 drink ( standard drink has 14g alcohol ) a day for women or 2 standard drinks a day for men
○ Binge drinking -more than 4 standard drinks for women or more than 5 standard drink for men in a single occasion
○ Heavy alcohol -binge drinking 5 or more dats in the past month

 

History taking

 

Why has the patient sought help for e.g
○ health , social , legal issues
○ persuaded by friends , family , probation
○ what do they hope to get from the services
○ impact of alcohol / substance misuse on their life
 Condition of presentation ie 
○ emergency / crisis appt 
○ with a friend / social worker
○ temporary resident
 Current drug use
○ alcohol – types , strengths , amount , frequency
○ duration
○ are they taking any prescribed drugs for e.g methadone
○ is alcohol the primary drug of abuse or they abuse other drugs
 Past drug history○ age when they started using alcohol
○ when did this become a problem
○ have they been abstinent and if so for how long
 Previous treatments
○ what when and for how long
○ in-patient , in community , hospital admission 
○ contact with other agencies
○ period of abstinence , why relapsed
 Physical health problems
○ any acute or chronic medical health problems
○ any complications they have suffered due to alcohol abuse as varices , cirrhosis , pancreatitis
○ are they taking any prescribed medications
 Mental and psychological health issues
○ depressed or psychotic
○ h/o psychiatric illness , contact with mental health agencies
○ h/o overdose – accidental or deliberate
 Social and forensic history
○ personal relationships , partner , family , friends , children 
○ occupation
○ accommodation – homeless / secure
○ level of education
○ financial situation
○ contact with criminal justice system
○ outstanding charges
○ been to prison -if when and for how long
○ are they on probation
○ on benefits / debts / how do they finance alcohol purchase

 

Further assessment – The ICD 10 definition of alcohol use disorder along with validated screening tools are useful practical tools in assessment of people presenting with possible AUD. Specific definitions/ codes are available for what is withdrawal , intoxication etc but we are focused here on assessment of a patient with possible AUD who is presenting to get help .

Consider using ” alcohol use disorder ” as other terms like alcohol addiction are not in favor as they appear to be patronizing.

 

Screening and brief advice to reduce heavy drinking are the two key elements that a primary care professional can achieve effectively. This is based on evidence from RCTs that brief advice in primary care setting reduces alcohol consumption among at-risk drinkers and those with mild alcohol related problems .

 

Use a validated screening questionnaire to identify those individuals who are drinking heavily

Render a brief advice on harmful effects of alcohol and what help is available.For harmful affects of alcohol you can consider using the Drinkaware website- Health affects and alcohol.

 

With quite a ground to cover in a limited time , in a non specialized setting – the 5A concept easily summarizes the essential framework of initiating help for your client ( Anderson, Peter et al. “Managing Alcohol Use Disorder in Primary Health Care.”Current psychiatry reports 2017 )

 

use a brief screening tool to assess alcohol consumption followed by a clinical assessment as needed , advice to reduce alcohol consumption to lower levels , agree on individual goals for reducing alcohol use or abstinence ( if indicated ), assist patients in acquiring the motivations , self-help skills or support needed for behavior change ( ie inform of local CDAT setup , links , tel etc ) arrange follow up support and repeated counseling , including referral of 
dependent drinker to specialty treatment.

 

Several screening tools are available widely , consider using the AUDIT ( Alcohol Use Disorders Identification Test ) as this has been available for over 2 decades and has been validated for use in primary care , is brief , rapid , flexible , consistent with ICD-10 definitions and focuses on recent alcohol use. Key component of Brief advice tool are often explained as FRAMES ( find it under links )

 

Blood tests – no specific guidance is available which bloods should be ordered / or even asked for in primary care on initial presentation Specialist clinics can use tools as The Southampton Traffic Light Calculator to screen those who are suspected to present with ALD CKS mentions that incidental findings that raise suspicion of problem drinking may include a raised GGT and MCV Thiamine – CKS suggests to use 50-100 mg / day in mild deficiency and 2-300 mg / day in severe deficiency

 

Person is at high risk of developing alcohol withdrawal seizure or delirium tremens , Clinical features suggest Wernicke’s encephalopathy- admit

Suspected complications or severe 
mental health problems-refer

 

Do not offer unsupervised alcohol detoxification on your own -danger in prescribing benzodiazepine or chlordiazepoxide to someone who may continue to drink and may suffer with synergestic sedation. A community detoxification service will fully assess the patient , establish where to offer detoxification , use equipment as breathalyzer and monitor treatment. They specialize in this field and can provide a range of other support services.

 

Disulfiram – disrupts normal alcohol metabolism it irreversibly inhibits the mitochondrial enzyme aldehyde degydrogenase ( ALDH ) which leads to greater accumulation of acetaldehyde –> person consumes alcohol while taking disulfiram -causes an unpleasant physiological reactions as nausea , vomiting , flushing , rapid heartbeat and falling BP this unpleasant reaction acts as a deterrent and even small amount of alcohol consumed with disulfiram produces mild reactions has positive outcomes when taken under supervision this would mostly be issued by drs specialising in drug addiction ( check local formulary restrictions ) although some prescribing is done by GPs

 

Acamprostate – homotaurine analogue active at both GABA and glutamate receptors- does not produce sedation or tolerance exact mechanism how it works is not known although it is believed that it normalizes the balance between excitatory and inhibitory pathways that become adapted to chronic alcohol use and alleviate psychological and physiological discomfort that follows withdrawal

 

Naltrexone- license granted for use in the UK only in he last few yrs Opioid receptor antagonist reduces euphoric effects of drinking number of potential side effects

PATIENT INFORMATION

Drinkaware – a very comprehensive useful site from explaining the harms of excessive drinking to finding help https://www.drinkaware.co.uk/advice/support-services/alcohol-support-services

American Addiction Centershttps://www.alcohol.org/helping-an-alcoholic/

NHS in England finding a local addiction service https://www.nhs.uk/service-search/other-services/Alcohol%20addiction/LocationSearch/1805

A useful one-stop  collection of all alcohol related services from Mind including the popular AA https://www.mind.org.uk/information-support/guides-to-support-and-services/addiction-and-dependency/addiction-and-dependency-resources/

Another useful compilation -Alcohol rehab guide https://www.alcoholrehabguide.org/resources/

 

References

  1. Wackernah, Robin C et al. “Alcohol use disorder: pathophysiology, effects, and pharmacologic options for treatment.” Substance abuse and rehabilitation vol. 5 1-12. 23 Jan. 2014, doi:10.2147/SAR.S37907
  2. Latanioti MSchuster JRosselet Amoussou J, et al
    Epidemiology of at-risk alcohol use and associated comorbidities of interest among community-dwelling older adults: a protocol for a systematic review
  3. WHOAlcohol epidemiology, monitoring, and information system https://www.who.int/substance_abuse/activities/gad/en/
  4. Mellinger, J.L. (2019), Epidemiology of Alcohol Use and Alcoholic Liver Disease. Clinical Liver Disease, 13: 136-139. doi:10.1002/cld.806
  5. Grant, Bridget F et al. “Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III.” JAMA psychiatry vol. 72,8 (2015): 757-66. doi:10.1001/jamapsychiatry.2015.0584
  6. Anderson, Peter et al. “Managing Alcohol Use Disorder in Primary Health Care.” Current psychiatry reports vol. 19,11 79. 14 Sep. 2017, doi:10.1007/s11920-017-0837-z
  7. Spithoff, Sheryl, and Meldon Kahan. “Primary care management of alcohol use disorder and at-risk drinking: Part 2: counsel, prescribe, connect.” Canadian family physician Medecin de famille canadien vol. 61,6 (2015): 515-21.
  8. Management of alcohol use disorders in primary care Iain D Smithand Caroline Woolston Prescriber December 2015 https://www.practicaldiabetes.com/wp-content/uploads/sites/28/2015/12/Management-of-alcohol-use-disorders-in-primary-care.pdf#page=1&zoom=auto,-159,786
  9. Rombouts, S.A., Conigrave, J., Louie, E. et al. Evidence-based models of care for the treatment of alcohol use disorder in primary health care settings: protocol for systematic review. Syst Rev 8, 275 (2019). https://doi.org/10.1186/s13643-019-1157-7
  10. WHO Screening and brief intervention for alcohol problems in primary health care https://www.who.int/substance_abuse/activities/sbi/en/
  11. Alcohol Screening Audit Tool via https://www.gmmh.nhs.uk/download.cfm?doc=docm93jijm4n639.pdf&ver=1017
  12. CKS Alcohol problem drinking https://cks.nice.org.uk/topics/alcohol-problem-drinking/
  13. Drinkware website  https://www.drinkaware.co.uk/
  14. Molina, Patricia E et al. “Alcohol abuse: critical pathophysiological processes and contribution to disease burden.” Physiology (Bethesda, Md.) vol. 29,3 (2014): 203-15. doi:10.1152/physiol.00055.2013
  15. Wackernah, Robin C et al. “Alcohol use disorder: pathophysiology, effects, and pharmacologic options for treatment.” Substance abuse and rehabilitation vol. 5 1-12. 23 Jan. 2014, doi:10.2147/SAR.S37907
  16. Delivering ‘Identification and Brief Advice’ (IBA) for alcohol users A guide for delivering alcohol brief interventions and referral in Hammersmith and Fulham http://www.alcoholacademy.net/uploads/IBA%20Sept%20H&F%202.pdf
  17. NICE Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence Clinical guideline [CG115]Published date: 
  18. Care of drug users in general practice A harm reduction approach Second edition Edited by Berry Beaumont Foreward by David Haslam Radcliffe Publishing 2004

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