Top tips: alcohol dependency

Alcohol is the leading risk factor for ill health, early mortality, and disability among people aged 15 to 49 years in England.¹ Alcohol-related mortality is also on the rise, particularly for liver disease, which has seen a 400% increase since 1970.¹ In England, around 65 people per day die from alcohol-related causes and many working years of life are lost because of alcohol-related deaths; the average age at death of those dying from an alcohol-related cause is 54.3 years, whereas the average age of death from all causes is 77.6 years.¹

Alcohol misuse does not only harm those who drink. In the year ending March 2017, victims of violent crime believed that the perpetrator(s) were under the influence of alcohol in 40% of all violent incidents.²

The Driver and Vehicle Licensing Agency definition of alcohol dependence is consistent with the World Health Organization (WHO) International Classification of Diseases (ICD):³

‘A cluster of behavioural, cognitive, and physiological phenomena that develop after repeated alcohol use, including:

• a strong desire to take alcohol
• difficulties in controlling its use
• persistent use in spite of harmful consequences
• and with evidence of increased tolerance and sometimes a physical withdrawal state.’

Note that withdrawal symptoms are not a requisite for alcohol dependency and there is a wide range of dependence from mild (sometimes just a psychological dependence) to severe (physical as well as psychological dependence).⁴ The ICD-10 definition also stipulates that three or more of the above manifestations should have occurred together for at least 1 month (or, if persisting for periods of less than 1 month, should have occurred together repeatedly within a 12-month period).⁵

In England, estimates suggest that there are nearly 600,000 dependent drinkers, of whom less than 100,000 are currently accessing treatment, which presents a challenge to primary care to detect, engage, and encourage referral.^6,7

GPs should not be afraid of detecting or managing alcohol dependency. For many people, there is much that can be done through either harm reduction or journeying towards abstinence but this is not usually the remit of the GP. Alcohol dependency is rarely an emergency—it is often a chronic condition that has been going on for years. The main role of primary care clinicians is to make the patient aware that their drinking could be harmful and to signpost them to avenues of help, in a firm but caring way.

1. Take opportunities to discuss patients’ drinking habits

While there is a myriad of both social and clinical presentations that might suggest heavy drinking, when a patient presents with raised blood pressure (BP) or low mood, GPs have a golden opportunity to talk to them about their drinking.

In the author’s view, it is inexcusable not to take a drinking history from someone who presents with raised BP or a low mood/anxiety problem. It can be useful both as a lead-in to taking an alcohol history and as a trigger to stimulate behavioural change for someone to tackle their heavy drinking.

Any system of the body can be affected so there is a wide range of co-existing physical health problems, including:⁸

• minor
  • dyspepsia/gastro-oesophageal reflux disorder (GORD)
  • gout
  • psoriasis
  • insomnia
• major
  • liver problems
  • pancreatitis
  • neuropathy
  • myopathy
  • nutritional deficiencies.

It is important to be alert for any condition that may be alcohol related, for example, an emergency department attendance for someone who has sustained an injury while intoxicated can lead to a learning opportunity or one where the person is willing to discuss their drinking.

Don’t forget that heavy drinking may present as a social problem, which very often leads to withdrawal from family life, domestic arguments, relationship difficulties, or domestic violence. Part of the DSM-5 criteria for dependence includes:^9,10

• ’a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects
• ’recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home
• ’continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol
• ’important social, occupational, or recreational activities are given up or reduced because of alcohol use.’

2. Choose the right tool to assess alcohol dependency

There are many different tools that detect and assess alcohol problems so it is important to choose the right one. Screening tools can be used to detect alcohol problems and are generally far more effective than any blood tests. Screening is more important for the lower end of the spectrum of alcohol problems since dependency is often (but not always) obvious. The severity of a person’s alcohol dependence informs the management strategy and setting (see Figure 1).

First, however, it is important to have an idea of units:

• units = volume in litres × alcohol by volume (ABV)
• examples:
  • 1 litre of 5% lager = 5 units
  • 0.75 litres of 12% wine = 9 units.

Forget liver blood tests (LBTs) as up to 50% of people with cirrhosis can have normal results.¹¹ The best tool to use is a validated set of questions, such as the Alcohol use disorders identification test (AUDIT).¹² AUDIT was developed by WHO and is one of the most widely used alcohol screening tests.¹³ It is used to assess whether or not a person has a problem with alcohol dependence, and consists of 10 questions which assess three domains: alcohol consumption (questions 1–3), alcohol dependence (questions 4–6), and alcohol-related problems (questions 7–10). It helps to distinguish between hazardous drinking, harmful drinking, and possible alcohol dependence.¹³

The Severity of Alcohol Dependence Questionnaire (SADQ) provides a measure of the severity of a person’s alcohol dependence.^14,15 SADQ is a 20-item questionnaire, divided into five sections corresponding to physical withdrawal symptoms, affective symptoms of withdrawal, craving and withdrawal relief drinking, typical daily consumption, and reinstatement of withdrawal symptoms after a period of abstinence. It has been validated in inpatient, outpatient, and community settings.¹⁶

Biological markers available in the UK are neither sensitive nor specific enough to diagnose alcohol use disorder, but might be useful to monitor progress.^17,18 Although LBTs are generally of little help, a high aspartate transaminase/alanine transaminase (AST/ALT) ratio can point towards a degree of fibrosis and together with a history of heavy drinking may warrant further investigation, for example, with transient elastography (‘fibroscan’) if available. This itself can be a useful wake-up call to stimulate positive behavioural change.¹⁹ NICE recommends screening for cirrhosis using transient elastography in patients who have been drinking at harmful levels (in excess of 50 units per week and 35 units per week for men and women, respectively) for several months.²⁰

Using a breathalyser (it is worth having one per practice—a reasonable one costs about £500) to get a real-time reading of breath alcohol concentration (BrAC) can be useful in some circumstances. Readings are usually between 0 and 120 mcg/100 ml (1 unit = 10 mcg/100 ml); the drink-drive limit is 35 mcg/100 ml. Breathalysing the patient can help to verify whether the AUDIT/SADQ are in the right range (effectively acting as a lie detector); for example, if a patient has a low AUDIT score and appears sober but has a high BrAC or you can smell alcohol, it suggests significantly understated alcohol use.

If BrAC is negative with no signs of withdrawal it is unlikely that the patient has any significant physical dependency. However, if they are agitated with signs of withdrawal but still have a moderately high BrAC or you can smell alcohol, then this is suggestive of a severe physical dependency.

3. Provide brief advice

Brief interventions can be effective in reducing drinking in hazardous and harmful drinkers.²¹ People who are physically dependent on alcohol may require a medication-assisted withdrawal; however, there is evidence that brief interventions can reduce alcohol consumption in people with hazardous and harmful drinking habits.²²

Practise brief advice and make sure it is just that—brief. Have leaflets to hand to reinforce the message with details of where patients can go to get further help.

Brief advice should not be a lecture, but an opportunistic moment to try to relate someone’s drinking to a negative impact it is having on their health. This is all about having a ready tool to use in the vanishingly short time available, so it needs to be able to trip off the tongue to stand a chance of hitting home. Find your own form of words, perhaps posing a question to the patient, such as:

• have you considered how your drinking may be affecting your health? or
• the amount you’re drinking may be putting your health at risk … what do you think about that? or
• what benefits do you think reducing the amount of alcohol you drink would have for you?

Brief advice is best accompanied by a decent patient information leaflet to take away and reflect on, such as the one developed by the Screening and Intervention Programme for Sensible Drinking (SIPS) on Brief advice about alcohol risk (see www.sips.iop.kcl.ac.uk/documents/gnr/sipsBA.pdf).²³

4. Be aware of co-existing mental health problems

There is a huge overlap between dependent drinking and mental health problems and often it is a ‘chicken and egg’ scenario—some people start drinking because of their mental health, whereas others experience significant negative effects on their mental health as a result of their chronic drinking. Bear in mind that problematic alcohol use is very often a manifestation of trauma that the patient has experienced at some point in their life.

In the short term, alcohol can induce euphoria, act as a social lubricant, relieve stress, and relax inhibitions,²⁴ whereas in the long term it is a depressant and can increase both anxiety and depression (anxiety tends to kick in as the alcohol wears off) so those who drink to self-medicate can become trapped in a vicious circle.²⁵ There is a well-established link between alcohol use and self-harm and, more importantly, suicide. The 20-year National confidential inquiry into suicide and homicide by people with mental illness showed that between 2005 and 2015, almost one-half (47%) of people who died by suicide had a history of alcohol misuse.²⁶ Of the 1 million people aged between 16 and 65 years who are alcohol dependent in England, only about 6% per year receive treatment.²⁷ Note that dependent drinkers can also be more prone to psychosis including schizophrenia.²⁸

NICE recommends that if depression or anxiety continues after 3 to 4 weeks of abstinence from alcohol, the patient’s depression or anxiety should be assessed and referral and treatment should be considered in line with the relevant NICE guideline for that particular disorder.²⁷

It is generally best to avoid prescribing antidepressants in people who are alcohol dependent.⁴ Most people who stop drinking or reduce their consumption see improvements in their mood and/or anxiety.²⁹ A pragmatic solution is only to prescribe antidepressants if symptoms persist for more than 6 weeks after a reduction in alcohol consumption. Another advantage of reducing drinking or better still, stopping altogether, is that it helps determine whether someone is miserable as a result of their drinking or ill with depression.

NICE recommends that psychological interventions (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) should be offered to harmful drinkers and people with mild alcohol dependence; however, referral pathways vary so check the criteria in your area.^21,27

In a 10-minute consultation it is unlikely that there will be sufficient time to provide much detail on alcoholic dementia or, better still, the umbrella term of alcohol-related brain damage (ARBD). ARBD describes the spectrum of cognitive impairment that can result from long-term (more than 5 years’) excessive alcohol consumption (more than 52 units per week for men, more than 42 units per week for women). For more detail, refer to the Royal College of Psychiatrists’ report: Our invisible addicts (see: www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr211.pdf).³⁰ Suffice to say that this is underdiagnosed in primary care and requires an index of suspicion to detect.

Important things to consider in all dependent drinkers, but particularly those with ARBD, are:

• Is the patient’s home fitted with a smoke alarm? The risk of dying in a fire is greater in those under the influence of alcohol, but may be reduced if they can be alerted quickly and effectively³¹
• Is the patient taking oral thiamine? Thiamine deficiency is common in patients who are dependent on alcohol (the deficiency can be caused by alcohol damage to the liver where thiamine is processed) and can become more serious if they suddenly stop drinking (e.g. if they run out of money). Parenteral thiamine can be given safely in primary care and should be offered to:³²
  • people with suspected Wernicke’s encephalopathy
  • harmful or dependent drinkers who:
    • are malnourished or at risk of malnourishment
    • have decompensated liver disease.

5. Refer the patient to an assisted withdrawal service

A detox (medicated assisted withdrawal) is simply one step on the pathway, allowing someone with dependency to safely and comfortably stop drinking. It is only worth attempting a detox if the patient has a realistic plan to remain abstinent for a period (3 months at the very least) before they decide whether to try controlled drinking or aim for long-term abstinence. The most crucial part of detox is deciding carefully who and when to detox and making sure they have the right preparation and aftercare—this decision would normally be made by a specialist; the role of the GP is to encourage people who are dependent on alcohol to consider whether they are ready for abstinence and to see the specialist service.

Assisted alcohol withdrawal is not usually provided in primary care; patients should be referred to community-based, outpatient-based, or intensive assisted withdrawal services depending on the severity of their dependence.²⁷ For the few who undergo detoxification within primary care, it is essential to have ongoing psychosocial support arranged, preferably before commencing the detoxification.

Alcohol withdrawal is a standalone intervention but it takes place in the context of the treatment journey. Preparation and immediate aftercare are important and clinicians should be vigilant to complications and unmasking of co-morbid conditions. In most cases, alcohol withdrawal is straightforward with careful medical management but in some cases, referral or secondary care support will be required.²⁷

It is especially important to resist requests from well-meaning carers for an urgent detox because the individual is withdrawing or suddenly wants to stop drinking. People who are alcohol dependent should be advised not to suddenly stop drinking due to the risk of seizures or other severe withdrawal problems.³² Gently and firmly advise them to have regular drinks sufficient to ease shakes and sweats, while encouraging timely referral to alcohol services to consider a well-planned detox that will have a far greater chance of success.

6. Prevent relapse through therapy

Relapse is a common event so it is vitally important to maximise the chances of success by tailoring the most appropriate relapse prevention therapy to an individual’s specific situation. Psychosocial interventions are the most important and generally fall within the remit of the alcohol service who arranged a detox. Psychological interventions involve individual treatments, group treatments, psychoeducational interventions, help to attend self-help groups, family and carer support and involvement, and case management.²⁷ These interventions are designed to help people remain abstinent through:

• changing knowledge, attitudes, and behaviour
• developing skills to recognise and deal with dangerous situations and cravings
• reinforcement of non-drinking behaviour (family support, groups)
• developing alternative interests (home, work, education, leisure)
• changing the social environment; no drink at home, informing the local off licence or convenience store of intentions
• rewards for successfully managing abstinence.

Pharmacological therapy can be considered in combination with psychological intervention after successful alcohol withdrawal.²⁷ NICE recommends considering acamprosate or oral naltrexone as first-line treatment options.²⁷ These therapies promote abstinence, reducing the chance of a motivated individual to start drinking again. They are relatively safe to prescribe in primary care with few side-effects and monitoring is only required to check for relapse to previous levels of drinking.

Disulfiram can be considered for people have a goal of abstinence but for whom acamprosate and oral naltrexone are not suitable, and for those who prefer disulfiram and understand the relative risks of taking the drug. Disulfiram is an alcohol-sensitising drug but carries the risk of a severe reaction if someone drinks while taking it—regular supervision is required.²⁷ Refer to the British National Formulary for details about cautions and contraindications.³³

7. Ensure appropriate safeguarding measures are in place

‘Toxic trio’ describes the issues of domestic abuse, mental ill-health, and substance misuse, which are common features of families where harm to children has occurred (see Figure 2). Estimates suggest that around 3 million children in the UK are affected in some way by one or other parent’s alcohol misuse.³⁴ Between 2011 and 2014, parental alcohol misuse was recorded as a factor in 37% of cases where a child was seriously hurt or killed.³⁵

Dependent drinkers are more likely to be violent towards others in the home including spouses, children, or parents. Mechanisms need to be in place to ensure the safeguarding of children and vulnerable adults who may be affected by people who are dependent on alcohol.³⁵ It is important to identify any children or grandchildren that a dependent drinker may be looking after and alert the relevant safeguarding authorities if they are believed to be at risk of harm.³⁶

Some perpetrators of domestic violence control others by encouraging them to be dependent on alcohol, so the patient themselves may be the one who is most at risk.

8. Assess the patient’s fitness to drive

For some people, driving is not only a matter of their independence, but their livelihood and some are fearful of losing their licence if it is confirmed that they have an alcohol problem. While GPs are not law enforcement officers, they do have a duty not only to help the patient but to safeguard others. Try to discuss driving with the patient and encourage them to contact the DVLA themselves. Anyone can alert the DVLA and raising a concern does not mean that the person loses their licence. If, as a GP, you raise a concern with a patient and ask them to contact the DVLA but do not receive a form back to complete, then it is safe to assume the patient has not contacted the DVLA and you may need to consider taking action.

Where there are signs of persistent driving with an alcohol misuse problem, the DVLA guidance is clear—the person should not drive for at least 6 months (1 year in the case of bus or lorry drivers). If alcohol dependence is confirmed, their licence will be refused or revoked until after at least 1 year free of alcohol problems (3 years for bus or lorry drivers) (see Table 1).³

There are situations where it is necessary to break confidentiality and call either the DVLA or the police (or both), for example, when a patient is clearly driving (or intending to drive) while intoxicated. The General Medical Council published Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA, which provides guidance about the role of doctors in disclosing this information.³⁷  If there was a fatality involving a drunk driver, the coroner could reasonably ask a GP why the DVLA or police were not informed.

The DVLA’s medical advisers can be contacted on 01792 782 337 or at medadviser@dvla.gsi.gov.uk, and the Driver and Vehicle Agency (Northern Ireland) on 0800 200 7861.

Table 1: Assessing fitness to drive in people who persistently misuse alcohol and people with confirmed alcohol dependence³

	Group 1: car and motorcycle	Group 2: bus and lorry
Persistent alcohol misuse confirmed by medical enquiry and/or evidence of otherwise unexplained abnormal blood markers	✘Must not drive and must  notify the DVLA. Licence will be refused or  revoked until after: a minimum of 6 months of controlled drinking or abstinence, and normalisation of blood parameters.	✘Must not drive and must  notify the DVLA. Licence will be refused or  revoked until after: a minimum of 1 year of controlled drinking or abstinence, and normalisation of blood parameters.
Dependence confirmed by medical enquiry Also refer to alcohol-related  seizure guidance (see www.gov.uk/guidance/drug-or-alcohol-misuse-or-dependence-assessing-fitness-to-drive#alcohol-related-seizure)	✘- Must not drive and must notify the  DVLA. Licence will be refused or revoked until after a minimum of 1 year free of alcohol problems. Abstinence is required, with normalised blood parameters if relevant.	✘- Must not drive and must notify the DVLA. Licence will be refused or revoked in all cases of any history of alcohol dependence  within the past 3 years. Abstinence is required, with normalised blood parameters if relevant.
	For both driving groups: licensing will require satisfactory medical reports from a doctor the DVLA may need to arrange independent medical examination and blood tests referral to and the support of a consultant specialist may be necessary.
Driver and Vehicle Licensing Agency. Drug or alcohol misuse or dependence: assessing fitness to drive. DVLA, 2018.  Available at: www.gov.uk/guidance/drug-or-alcohol-misuse-or-dependence-assessing-fitness-to-drive Contains public sector information licensed under the Open Government Licence v3.0 (www.nationalarchives.gov.uk/doc/open-government-licence/version/3/)

9. Be firm but caring with patients presenting in crisis

Crises are common because dependent drinkers, especially those with a long history, have often wrecked their social networks and exasperated those who are closest to them. At the risk of generalising, it is important to maintain a firm but caring approach.

Don’t see the patient there and then if they are clearly intoxicated (see also tip 8 regarding fitness to drive if they have driven to the surgery). The important thing is to recognise this before the patient gets into the consultation room, otherwise you risk a long battle trying to extract them. Try lines like: ‘I’d really like to see you, but that can’t happen today because you’ve had too much to drink. Let’s make you another appointment.’ This doesn’t break confidentiality because their behaviour is already in the public domain.

A breathalyser can be really useful here (as mentioned in tip 2) but if there are any obvious speech or motor signs of intoxication it is not necessary. The same principle applies to telephone consultations, although it can be difficult to safety net the calls when self-harm or suicide are threatened. Often it is worth giving simple, firm advice to a third person who may be present, but if not, give simple harm-reduction advice and offer to see them when they are sober.

One mental health scenario that is a potential emergency is when a patient has suddenly stopped drinking within the last 2–3 days and presents with a symptoms of (even mild) confusion or delirium that is new but with no evidence of recent drinking. They must be urgently assessed at hospital as they may have incipient Wernicke’s encephalopathy or onset of a delirium tremens, both of which have a high mortality rate if untreated. If necessary, they may need to be admitted against their will under common law or the mental capacity act.

10. Signpost support services, including those for carers and relatives

Apart from national helplines and agencies such as Alcoholics Anonymous (AA), the services available will be different in each locality. Find out what services are available in your area, for example, the meeting times and places of the local AA group, and have the details to hand to share with patients. Make sure you also have leaflets that clearly describe how someone can self-refer to the local alcohol service.

Sick notes are a common request from people who misuse alcohol. Consider linking any sick notes to getting help—you can vary the length of time given based on whether or not they have engaged with the specialist alcohol service.

It is also important to signpost information about the resources and support available for the relatives/carers of dependent drinkers. A selection of resources for people with drug and alcohol problems and their relatives/carers are listed in Box 1.

Dr Stephen Willott

GP and Clinical Lead for Alcohol and Drug Misuse, NHS Nottingham City

References