The new SIGN guideline will help GPs identify and treat patients at risk from harmful drinking and help standardise management, says Dr Alan Clubb

Harmful drinking and alcohol dependence are increasing. In Scotland, the number of deaths attributable to alcohol misuse doubled between 1990 and 1999.1

Alcohol-dependent patients create considerable work in primary and secondary care, consulting their GP twice as often as the average patient.2 Despite this, there is little standardisation in the management of alcohol dependent patients in primary care.3

The SIGN guideline The Management of Harmful Drinking and Alcohol Dependence in Primary Care was developed to aid the primary healthcare team, including GPs, community psychiatric nurses and practice nurses, in improving management of alcohol-related problems.

Defining problem drinking

Hazardous drinking is defined as the regular consumption of 5 units of alcohol per day for men and 3 units per day for women. A unit is equivalent to half a pint of 3.5% beer or lager, or a pub measure of 25 ml of spirits. A small (125 ml) glass of 12% wine equates to 1.5 units.

The definition of harmful drinking is that actual damage has been caused to the physical or mental health of the patient.4

Alcohol dependence is defined as "a cluster of physiological, behavioural, and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that previously had greater value”.4

A diagnosis of alcohol dependence usually requires three or more of the characteristics listed in Box 1 (below) to have been present in the past year.

Box 1: Diagnosing alcohol dependence
A diagnosis of alcohol dependence usually requires three or more of the following to have been present in the past year:
  • A strong desire or sense of compulsion to take alcohol
  • Difficulty in controlling drinking in terms of its onset, termination or level of use
  • A physiological withdrawal state when drinking has ceased or been reduced (e.g. tremor, sweating, rapid heart rate, anxiety, insomnia, or less commonly seizures, disorientation or hallucinations) or drinking to relieve or avoid withdrawal symptoms
  • Evidence of tolerance, such that increased doses of alcohol are required in order to achieve effects originally produced by lower doses (clear examples of this are found in drinkers who may take daily doses sufficient to incapacitate or kill non-tolerant users)
  • Progressive neglect of alternative pleasures or interests because of drinking and increased amount of time necessary to obtain or take alcohol or to recover from its effects (salience of drinking)
  • Persisting with alcohol use despite awareness of overtly harmful consequences, such as harm to the liver, depressive mood states consequent to periods of heavy drinking, or alcohol-related impairment of cognitive functioning

Detection and assessment of problem drinkers

Primary care professionals should be alert to the possibility of alcohol-related problems by certain presentations and physical signs (Box 2, below). They should ask the patient about his or her alcohol consumption; most people are not offended by such a question and most will give a reliable account.5 However, some will under-report at times.

Box 2: Presentations that should raise the suspicion of alcohol as a cause

Social

  • Marital disharmony and domestic violence
  • Neglect of children
  • Criminal behaviour such as driving offences, breach of the peace, shoplifting
  • Misuse of the emergency telephone services
  • Unsafe sex
  • Financial problems

Occupational

  • Repeated absenteeism, especially around weekends
  • Impaired work performance and accidents
  • Poor employment record

Psychiatric

  • Amnesia, memory disorders and dementia
  • Anxiety and panic disorders
  • Depressive illness
  • Morbid
  • Alcoholic hallucinosis
  • Treatment resistance in other psychiatric illnesses and as a factor in relapse
  • Repeated self-harming

Physical

  • Multiple acute presentations to A&E with trauma and head injury
  • Dyspepsia, gastritis, haematemesis
  • Diarrhoea and malabsorption
  • Acute and chronic pancreatitis
  • Liver abnormalities from deranged liver function tests, through hepatitis, to fatty liver and cirrhosis
  • Cardiac arrhythmias
  • Hypertension and stroke
  • Cardiomyopathy
  • Peripheral neuropathy, cerebellar ataxia
  • Impotence and problems with libido
  • Withdrawal seizures and fits starting in middle age
  • Falls and collapses in the elderly
  • Blood dyscrasias such as low platelet count and white cell count (neutrophils)
  • Acne rosacea, discoid eczema, psoriasis, multiple bruising
  • Cancers of the mouth, pharynx, larynx, oesophagus, breast and colon
  • Acute and chronic myopathies
  • Unexplained infertility
  • Gout

To identify problem drinkers, the guideline recommends abbreviated forms of AUDIT (Alcohol Use Disorders Identification Test), for example FAST (Fast Alcohol Screening Test), or ‘CAGE plus two’ (attempts to Cut back on drinking, being Annoyed at criticisms about drinking, feeling Guilty about drinking, and using alcohol as an Eye-opener plus two questions about consumption).6,7

For the continuing management of problem drinkers, all members of the primary healthcare team should ask the patient about their consumption.

Self-reported consumption has been used as the gold standard. Raised levels of carbohydrate deficient transferrin (CDT), mean red cell volume (MCV), serum gamma glutamyl transferase (GGT) are markers of heavy drinking in preceding weeks.8 These biochemical markers are useful in monitoring consumption when the healthcare professional believes that the patient’s self-reported consumption is false.

False positives may occur with MCV and GGT. However, CDT gives fewer false positives than MCV and GGT.9 When reviewing CDT results it is important to remember that the result is normal in mild to moderate liver disease and elevated in severe liver disease. The guideline suggests that breathalysers may have a role in monitoring recent consumption in problem drinkers.

Brief interventions

Brief verbal interventions by the primary healthcare team for hazardous and harmful drinking can reduce total alcohol consumption and binge drinking for up to a year.10 Even very brief 5-10 minute interventions may be as effective as more extended consultations of 20-45 minutes.

The guideline recommends a tool such as FRAMES.11 FRAMES (Box 3, below) captures the essence of the interventions commonly known as ‘brief interventions’ and ‘motivational interviewing’.

The message can be further reinforced by giving the patient a leaflet on problem drinking.12

Severely affected patients are not helped by brief interventions and it is important to give time to these patients to maximise the chances of treatment success.13

Box 3: The FRAMES intervention
  • Feedback: about personal risk or impairment
  • Responsibility: emphasis on personal responsibility for change
  • Advice: to cut down or abstain if indicated because of severe dependence or harm
  • Menu: of alternative options for changing drinking pattern and, jointly with the patient, setting a target; intermediate goals of reduction can be a start
  • Empathic interviewing: listening reflectively without cajoling or confronting; exploring with patients the reasons for change as they see their situation.
  • Self-efficacy: an interviewing style that enhances people’s belief in their ability to change

Detoxification

Detoxification, the planned withdrawal of alcohol, carries some risk and requires careful clinical management. Community-led detoxification has been shown to be as effective as inpatient detoxification and works for three out of four patients,14 but may not be suitable for all patients (Box 4, below).15 Elderly patients can be managed in the community if there is no acute or chronic physical illness.16

Box 4: Patients for whom community detoxification is unsuitable
Hospital detoxification is advised if the patient:
  • Is confused or has hallucinations
  • Has a history of previously complicated withdrawal
  • Has epilepsy or a history of fits
  • Is undernourished
  • Has severe vomiting or diarrhoea
  • Is at risk of suicide
  • Has severe dependence and is unwilling to be seen daily
  • Has had a previously failed home-assisted withdrawal
  • Has uncontrollable withdrawal symptoms
  • Has an acute physical or psychiatric illness
  • Has multiple substance misuse
  • Has a home environment unsupportive of abstinence

Medication to help support the withdrawal of alcohol is usually not required if:

  • the patient’s self-reported consumption is less than 15 units of alcohol per day for men and less than 10 units of alcohol per day for women and he or she reports neither recent withdrawal symptoms nor recent drinking to prevent withdrawal symptoms
  • a breath test shows no alcohol and there are no withdrawal signs or symptoms.

Chlordiazepoxide is the benzodiazepine of choice for detoxification in the community. A recommended dosage schedule is given in Table 1 (below). Chlordiazepoxide is preferred to diazepam as it is less prone to abuse in the community setting.

Table 1: Recommended dosage schedule for chlordiazepoxide 10 mg
  First thing 12 noon 6 pm Bedtime
Day 1 - 3 3 3
Day 2 2 2 2 3
Day 3 2 1 1 2
Day 4 1 1 - 2
Day 5 - 1 - 1

Clomethiazole has no place in community detoxification, because there have been well-documented fatal interactions with alcohol.17

For patients with a chronic alcohol problem whose diet may be deficient, oral thiamine should be prescribed at a daily dose of 200-300 mg. It should be given in divided doses to maximise absorption.18

Patients with signs of Wernicke-Korsakov syndrome should be given combined B complex and C vitamins by the intramuscular route, but only if resuscitation facilities are available.

Referral and follow up

Specialist services are effective in preventing relapse if they offer behavioural self-control training, motivational enhancement therapy, family therapy/community reinforcement approach and/or coping/communication skills training.19

Patients with alcohol-related physical disorders have been shown to benefit from close links between their alcohol treatment services and primary care.20 The guideline recommends that primary care should maintain contact with all patients who have been referred to specialist services.

Alcohol-dependent patients should be advised to attend Alcoholics Anonymous or other lay services that use motivational interviewing and coping skills training. The guideline contains a summary of the management approach for harmful drinking and alcohol dependence in primary care (Figure 1, below).

Figure 1: Management of harmful drinking and alcohol dependence in primary care

Medication to prevent relapse

There is evidence to support the use of both disulfiram (under supervision) and acamprosate. However, evidence is still lacking to justify co-prescribing.

Acamprosate and disulfiram should usually be initiated by a specialist service. However, if no specialist service is available, GPs may need to offer these medications, monitoring efficacy and providing links to support organisations.

Acamprosate reduces the craving for alcohol, but is not effective in all patients and it would be prudent to review therapy regularly and withdraw if it is ineffective. Patients taking disulfiram must be made aware of the dangers of alcohol ingestion while taking the medication. Evidence of efficacy is only available in patients who are supervised while taking the medication.

Patients with anxiety or depression

Alcohol-dependent patients with anxiety or depression should be treated for their alcohol problem first. If the patient’s depressive symptoms continue for more than 2 weeks following treatment for alcohol dependence, treatment with an SSRI should be considered or referral to a counselling or specialist psychological service along with relapse prevention therapy.

Advising families

The patient’s family may need help from the primary healthcare team to use behavioural methods to reinforce a reduction in drinking and increase the likelihood of the drinker seeking help.The guideline includes a section on information for discussion with patients and carers.

Guideline methodology

Literature searches covering the years 1995-2001 were conducted using Medline, Embase, Healthstar, Cinahl, PsychINFO, Alcohol and Alcoholism and the Cochrane Library. Internet searches were conducted on other guideline networks and supplementary material was supplied by members of the guideline development group. The Medline version of the search can be found on the SIGN website: www.sign.ac.uk.

Conclusion

The guideline contains helpful information that should help to standardise the management of problem drinkers.

SIGN 74. The Management of Harmful Drinking and Alcohol Dependence in Primary Care can be downloaded free of charge from the SIGN website: www.sign.ac.uk

References

  1. Scottish Executive Health Department. Plan for Action on Alcohol Problems. Edinburgh: Scottish Executive, 2002.
  2. Morgan MY, Ritson EB. Alcohol and Health: a handbook for students and medical practitioners (4th edn). London: Medical Council on Alcohol, 2003.
  3. Deehan A,Templeton L,Taylor C, Drummond C, Strang J. How do general practitioners manage alcohol misuse in patients? Results from a national survey of GPs in England and Wales. Drug Alcohol Rev 1998: 17(3): 259-66.
  4. World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 10th Edition. Geneva: WHO, 1992.
  5. Wallace PG, Haines AP. General practitioner and health promotion: what patients think. Br Med J (Clinical Res Ed) 1984; 289(6444): 534-6.
  6. Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem drinking comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med 1998; 13(6): 379-88.
  7. Hodgson R, Alwyn T, John B,Thom B, Smith A.The FAST Alcohol Screening Test. Alcohol Alcohol 2002; 37(1): 61-6.
  8. Conigrave KM, Degenhardt LJ,Whitfield JB et al. CDT,GGT, and AST as markers of alcohol use: the WHO/ISBRA collaborative project. Alcohol Clin Exp Res 2002; 26(3): 332-9.
  9. Anton RF, Stout RL, Roberts JS, Allen JP.The effect of drinking intensity and frequency on serum carbohydrate-deficient transferrin and gammaglutamyl transferase levels in outpatient alcoholics. Alcohol Clin Exp Res 1998; 22(7): 1456-62.
  10. Wilk AI, Jenson NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med 1997; 12(5): 274-83.
  11. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993; 88(3): 315-35.
  12. Mullen PD, Simons-Morton DG, Ramirez G et al. A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors. Patient Educ Couns 1997; 32(3): 157-73.
  13. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a metaanalytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 2002; 97(3): 279-92.
  14. Hayashida M, Alterman AI, McLellan AT et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. N Engl J Med 1989; 320(6): 358-65.
  15. UK Alcohol Forum. Guidelines for the management of alcohol problems in primary care and general psychiatry. London: The Alcohol Forum, 2001. www.ukalcoholforum.org/pages/guidelinesset.htm
  16. Wetterling T, Driessen M, Kanitz RD, Junghanns K.The severity of alcohol withdrawal is not age dependent. Alcohol Alcohol 2001; 36(1): 75-8.
  17. McInnes GT. Chlormethiazole and alcohol: a lethal cocktail. Br Med J (Clin Res Ed) 1987; 294(6572): 592.
  18. British Medical Association, Royal Pharmaceutical Society of Great Britain. British National Formulary. London: BMA, 2003.
  19. Slattery J, Chick J, Cochrane M et al. Prevention of relapse in alcohol dependence. Glasgow: Health Technology Board for Scotland, 2003. Health Technology Assessment Report 3. http://80.75.66.189/nhsqis
  20. Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addiction treatment: a randomised controlled trial. JAMA 2001; 286(14): 1715-23.

See also ‘SIGN notes for discussion with patients’ on management of harmful drinking.

Guidelines in Practice, November 2003, Volume 6(11)
© 2003 MGP Ltd
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