Alcohol addiction

Dr Rob Hicks discusses the role of GPs in identifying and managing patients addicted to alcohol

Most of us at some time in our lives have enjoyed a little more of our favourite tipple than we should have consumed. Alcohol plays a large part in social culture in this country and is readily available. However, over the last ten years many of us in general practice have seen a rise in the number of people with alcohol-related problems. It is important, therefore, that we are able to identify and help those who are being harmed.

Prevalence

Alcohol dependency is estimated to affect nearly one in 20 people (aged 16-64) in the UK1. Although many consider the problem to be one of the older age-group, it is men between the ages of 20-24 who are most at risk¹.

In 1994, the UK alcoholic drinks market was worth £25.8 billion². Consequent to the amount of alcohol consumed are the many physical, psychological, and social problems that alcohol dependency brings. Accidents both in and out the home, gastritis, acute pancreatitis, gout, cardiac arrhythmias and impotence, are all common problems suffered by those who become intoxicated. Sadly 40 per cent of domestic violence³ and one in seven deaths on the road are alcohol related⁴. Some of the common problems caused by chronic heavy drinking include liver cirrhosis, cardiomyopathy, neuropathy, Korsakoff's psychosis and depression.

Those at risk

The primary care team is well situated to identify those with alcohol-related problems and many clues may become apparent. Information can be gathered directly from the patient in the consultation, or through observation or knowledge of the patient by other members of the practice. Often it is family members who raise concerns or on home visits clues such as empty bottles are noted. Binge drinking is more common in the UK and is associated with the problems of intoxication listed earlier. In addition to the physical damage binge drinking causes, problems with relationships, work absenteeism, and the law are common and may bring the problem out into the open. In contrast, the chronic heavy drinker may go unnoticed until blood tests reveal raised MCV, LFTs, and GGT. It is common for patients to under-report the amount they drink, however, a good relationship with the patient and an empathic rather than confrontational approach reaps rewards. The CAGE test is the simplest and most widely used screening questionnaire (see Table 1) having a 60-85 per cent sensitivity and helps establish the severity of the problem.

Management

The goals of management are to achieve and maintain either a reduction in alcohol consumption or total abstinence. All patients should be made aware of the safe drinking levels and the possible health risks of exceeding them. The current recommended safe levels of alcohol consumption are up to 21 units per week for men and up to 14 units per week for women. (One unit is equivalent to a glass of wine or half a pint of beer or lager or a pub measure of a spirit.)

Above these levels, then the patient is putting themselves at risk. It is common for many to deny they have a problem. When this is the case the patient should be followed up, either opportunistically or with a confirmed review appointment, where health risks are emphasised, and help and encouragement to address the problem is offered. For those who acknowledge they have a problem and are receptive to the idea of addressing it, the decision has to be made as to whether a reduction in their consumption or abstinence is advisable. The absolute indications for advising abstinence are: alcohol-related organ damage, severe dependence (morning drinking to stop the shakes), or significant psychiatric disorders. Relative indications are: epilepsy, social factors (work / home/ legal), and other physical problems⁵ (see Table 2). If a reduction in consumption is appropriate, then regular review is important for monitoring and as a means of patient support. It should include self-monitoring of intake, re-enforcement of the benefits to the patient, and exploring and addressing the patientÕs concerns. It is valuable for the patient to be taught how to predict and deal with situations that may encourage more drinking.

Where local alcohol services are available, for example support groups, then their use should be encouraged. Monitoring LFTs, GGT and MCV is helpful in demonstrating that the patient is being honest and encourages the patient by showing improvement and reduction of damage.

Withdrawal

In preparing the patient it is important to explain the process of withdrawal, the likely symptoms, and that relapses will not be met with disappointment or anger but that they are common. Moreover, that support for the next attempt will be available. They must be sober when they agree and make a commitment.

Many patients can undergo a withdrawal programme in the community provided there are no contraindications to this (see Table 3). It is probably best not to start the withdrawal process on a Friday. The first few days are hard and patients need to feel support is easily accessible. The chances of temptation getting in the way of a good start are also high during this time of the week.

For someone who is sober, has not suffered withdrawal symptoms, or has not needed to drink to prevent the symptoms of withdrawal, then medication is probably not needed.

This is also likely to be the case if someone has been drinking less than 15 units a day⁶. When medication is necessary then chlordiazepoxide should be used in a reducing dose. Starting with 10 mg capsules, 8-12 are taken in the first 24 hours, and over one week reduced to zero. To facilitate monitoring of the patient it is sometimes advisable not to issue the full supply in a single prescription. Three weeks treatment with vitamin B complex of thiamine should also be given at a dose of 50 mg twice daily.

Drugs such as chlormethiazole (Heminevrin) should be avoided in community withdrawal programmes because of the risk of respiratory failure if combined with alcohol.

Maintaining abstinence

Often the most difficult thing to do once someone has stopped drinking is to maintain abstinence. Support from family and friends is essential throughout the process but particularly once the drinking has stopped. Continual reminders of why abstaining is best and protection from temptation are needed because the all too common 'go on, one won't hurt you' scenario destroys weeks, months, sometimes years of hard work.

Groups such as Alcoholics Anonymous (AA) provide encouragement to many and are available throughout the UK. Other organisations are also available locally and GPs should be able to point patients in the right direction.

The drug disulfiram (Antabuse) works as a deterrent when taken. The potential systemic reaction of facial flushing, throbbing headache, palpitations, hypotension, tachycardia, nausea and vomiting, when combined with alcohol puts enough fear into the patient to keep them from drinking. More recently, the first licensed drug to actually reduce craving and desire for alcohol has become available. Acamprosate (Campral EC) is being used at specialist alcohol centres and is believed to work by stimulating the GABAnergic inhibitory transmission and antagonising excitatory amino acids, which may underlie some aspects of CNS vulnerability to relapse. It is recommended that acamprosate is used in combination with specialist alcohol counselling.

Conclusion

As GPs we have a real challenge on our hands in trying to halt the increasing number of preventable alcohol-related problems. By taking a non-judgemental and supportive approach to the problem and engaging the help of specialist colleagues we should succeed.

Rob Hicks is a general practitioner, London

References

1 H Melzer. The prevalence of psychiatric morbidity among adults aged 16 -64, living in private households, in Great Britain. OPCS Survey 1995
2 Health Update, Health Education Authority 1997
3 British Medical Association. BMA Guide to alcohol and accidents. London; BMA; 1989
4 Department of Health. Health and Personal Social Services Statistics for England 1989
5 Guidelines - summarising clinical guidelines for primary care, 1999
6 UK Alcohol Forum - Guidelines for the Management of Alcohol Problems in Primary Care and general Psychiatry, 1997