There are a number of different types of alcohol abuse, and a wide range of physical, social and psychological problems are associated with excessive drinking. Until recently, much attention was devoted to the syndrome of alcohol dependence. In fact, doctors should be concerned with the health problems caused by alcohol abuse whether or not such abuse is related to actual physiological dependence on alcohol. The term alcoholism is a confusing one with off-putting connotations of vagrancy, ‘meths’ drinking and social disintegration. It has been replaced by the term alcohol dependence syndrome, which has seven essential elements:
1 A compulsive need to drink.
2 A stereotyped pattern of drinking. Whereas ordinary drinkers vary their daily pattern, addicted drinkers drink at regular intervals to avoid or relieve withdrawal symptoms.
3 Drinking takes primacy over other activities.
4 Tolerance to alcohol is altered. The dependent drinker is ordinarily unaffected by blood alcohol levels that would incapacitate a normal drinker. Increasing tolerance is an important sign of increasing dependence. In the later stages of dependence, tolerance falls.
5 Repeated withdrawal symptoms. These occur some 8- 12 hours after cessation of drinking or after a sharp fall in blood alcohol in people who have been drinking heavily for many years. Symptoms characteristically appear on waking as a result of the fall in the blood alcohol level during sleep.
6 Relief drinking. Many dependent drinkers take a drink early in the morning to stave off withdrawal symptoms. In most cultures, early morning drinking is diagnostic of alcohol dependence.
7 Reinstatement after abstinence. Severely dependent drinkers who drink again after a period of abstinence are likely to relapse quickly and return to their old addictive pattern.
The problem drinker is one who causes or experiences physical, psychological and/or social harm as a consequence of drinking alcohol. Many problem drinkers, while heavy drinkers, are not physiologically addicted to alcohol. Heavy drinkers are those who drink significantly more in terms of quantity and/or frequency than the average drinker. Binge drinkers are those who drink excessively in short bouts, usually 24-48 hours long, separated by often quite lengthy periods of abstinence. Their overall monthly or weekly alcohol intake may be relatively modest. The interrelationship between these types of drinking is shown in Fig. 19.2.
Extent of the problem
A conservative estimate is that there are at least 300000 people in the UK with alcohol-related problems. A survey on drinking in England and Wales found that 5% of men and 2% of women reported alcohol-related problems. People with serious drinking problems have an increased risk of dying that is between two and three times greater than that of members of the general population of the same age and sex. Approximately one in five male admissions to acute medical wards are directly or indirectly due to alcohol. Between 33 and 40% of accident and emergency attenders have blood alcohol concentrations above the present UK legal limit for driving. Up to one in five seemingly healthy men attending health screening programmes are found to have biochemical evidence of heavy alcohol consumption, though they are a selected population coming mainly from the upper social classes. Of the 2000 patients on the practice list of the average general practitioner, about 100 will be heavy drinkers, 40 will be problem drinkers and 10 will be physically dependent on alcohol.
Over the past 40 years, the alcohol consumption of the average British adult has increased considerably (from 5.2 litres of absolute alcohol per year in 1950 to 8.5 litres in 1991). There has been a downward trend since 1989. Over a similar period, admissions to psychiatric hospitals for treatment of alcohol problems have increased more than 25-fold, cirrhosis rates have doubled, and drunkenness offences have risen from 60000 to over 100000 per year.
Many doctors still fail to recognize the heavy drinker and even the problem drinker. Greater awareness is urgently needed to allow intervention at a stage when something can still be achieved, and to provide better statistics. Alcohol abuse should be suspected in any patient presenting one or more physical problems commonly associated with excessive drinking (see Chapter 3, p. 173). Alcohol abuse may also be associated with a number of psychological symptoms and social problems (Table 19.25). Certain features in the history should also raise suspicion, most notably:
• Absenteeism from work
• Frequent attendances for unexplained dyspepsia or gastrointestinal bleeds
• Hospital admissions for accidents of all kinds
• Fits, ‘turns’ or falls
Certain signs may be helpful, if present, in detecting alcohol abuse in patients. These include:
• Plethoric face with/without telangiectases
• Bloodshot conjunctivae
• Smell of stale alcohol
• Facial appearance resembling Cushing’s syndrome
• Marked tremor
• Signs of alcohol-related diseases
The patient’s frequency of drinking and quantity drunk on typical occasions should be established. Patients can assess their alcohol consumption on the basis of units of alcohol. One standard unit of alcohol is equivalent to 8 g of absolute alcohol .
The following are useful guidelines:
1 Drinking up to 20 units of alcohol a week for men and 13 units for women carries no long-term health risk.
2 There is unlikely to be any long-term health damage between 21 and 36 units (men) and 14 and 24 units (women) provided that the drinking is spread throughout the week.
3 Beyond 36 units a week in men and 24 units a week in women, damage to health becomes increasingly likely.
4 Drinking above 50 units a week in men (35 units in women) is currently regarded as a definitive health hazard.
A number of questionnaires, such as the CAGE questionnaire (Table 19.26), have been developed to help identify patients with alcohol-related problems. Two or more positive replies to the CAGE questionnaire are said to identify problem drinkers.
patients with alcohol-related problems. Two or more positive replies to the CAGE questionnaire are said to identify problem drinkers.
It is important to remember that there are a number of key ‘at-risk’ factors involved, which include:
MARITAL DIFFICULTIES. These may conceal heavy drinking or may be used to justify it.
WORK PROBLEMS. Alcohol abusers have twice as manydays off work as more sober colleagues.
AN AFFECTED RELATIVE. Twenty-five per cent of the male relatives of alcohol abusers have similar problems.
HIGH-RISK OCCUPATIONS. Examples of these include company directors, salesmen, doctors, journalists, publicans and seamen.
ASSOCIATED PHYSICAL AND MENTAL CONDITIONS, for example, depression.
A number of laboratory tests are helpful in the identification of excess chronic alcohol consumption:
BLOOD ALCOHOL. This is useful in anyone suspected of, but who denies drinking; most people have no detectable alcohol in their blood in the middle of the day.
URINARY ALCOHOL. A value exceeding 120 mg dl” is suggestive of chronic alcohol abuse, and a value over 200 mg dl-I (44 mmollitre-1) is said to be diagnostic.
y-GLUTAMYL TRANSPEPTIDASE (y-GT). Elevated serum y-GT activity is observed in about 75% of patients hospitalized for alcohol abuse; in outpatients and heavy drinkers, the prevalence reaches 90%. Acute alcohol consumption does not lead to abnormal levels but regular, moderate drinkers often have a slight elevation of the y-GT. Levels return to normal with abstention from alcohol.
MEAN CORPUSCULAR VOLUME (MCV) of more than 96 fl is found in about 60% of alcohol abusers.
The response to abstinence is a return to normal over a period of about 2 months.