A moderate alcohol intake is, for most people, acceptable and enjoyable. However, those who drink to excess, or are particularly vulnerable to the unwanted effects of alcohol, may experience a wide range of medical and psychiatric problems.

Alcohol misuse may be defined in terms of:

• Quantity of alcohol intake.
• Presence of dependency.
• Alcohol-related disability, whether physical, mental or social.

There is no agreed definition of ìalcoholismî; patients with obvious drink problems often seek to avoid the issue by engaging in fruitless discussions about whether they are or are not ìan alcoholicî. The words are used here as a useful shorthand only.

SAFE LIMITS OF DRINKING Quantities: the limits of 21 units per week for men and 14 for women suggested by the Royal College of Physicians have been widely influential. A ìunitî is one drink (half a pint of ordinary strength beer, one glass of wine, a single measure of spirits) and contains 8ñ10 g alcohol.

Pattern: ìbinge drinkingî can cause problems (for example accidents, especially head injury, acute alcoholic poisoning, and involvement in criminal activity such as assault and vandalism) over and above those found with the steady daily intake of equivalent amounts of alcohol.

Hence, a person would certainly be drinking in an unsafe pattern if they drank only once per week, but consumed all their ìweekly allowanceî on that single occasion.

FREQUENCY Up to 5% of people in England and Wales have a serious drinking problem. About 25% of men and 15% of women drink more than the recommended limits given above.

Alcohol misuse is often concealed. Its extent within a given population can be estimated by:

• Alcohol sales per capita.
• Alcohol-related hospital admissions.
• Drunkenness convictions.
• Mortality from cirrhosis of the liver.

EPIDEMIOLOGY

• Nationality: wine-producing countries like France and Italy have high rates of alcohol-related problems, especially cirrhosis. Northern European countries have lower rates of total consumption, so lower rates of cirrhosis, but higher rates of binge drinking with its attendant behavioural problems. Muslim and Jewish societies, with their religious constraints on drinking, have lower rates. Scotland and Ireland have higher rates than England and Wales.

• Occupation: groups at high risk include publicans, seamen, journalists and doctors.

• Age: most cases present in middle age, but a growing number of young adults are seeking treatment, and concealed alcohol misuse is increasingly recognised as a problem in old age.

• Sex: men are more often affected than women but the prevalence among women is increasing, with changing behavioural norms (so called ìladdetteî culture).

CAUSES

• Genetics: there is evidence of a genetic component to alcoholism; a 2ñ3-fold increase in alcoholism in the relatives of alcoholics, especially male ones; a higher concordance between monozygotic than dizygotic twins; and a high rate in children of alcoholic parents who were adopted into non-alcoholic homes in infancy. Sociopathic personality disorder is over-represented among the male relatives of alcoholics, and depressive illness among female relatives.

• Psychological factors: psychosocial stress is often the precipitant for heavy drinking, alcohol being a powerful temporary anxiolytic and euphoriant. Any psychiatric disorder may lead to self-medication with alcohol.

• Social and cultural factors: drinking problems are more common in settings where alcohol is cheap and easily available, and drinking is encouraged socially.

• Economic: the greater the per capita consumption of alcohol in a society, the larger is the number of people with alcohol problems, and per capita consumption is inversely related to price. This means that a nationís alcohol taxation policy affects its rate of alcohol-related problems: a good historical example is the increase in alcohol problems in the 18th century, after government encouraged the production of cheap home-produced gin to supplant French brandy. A current example is the association between the fall in the real price of alcohol in the UK with a rise in alcohol problems.

EFFECTS OF ALCOHOL Small quantities promote sociability and well-being, and may bring certain health benefits; people who take one or two drinks per day have been held to suffer less coronary heart disease and have a lower all-cause mortality rate than non-drinkers. However, the epidemiological evidence for this possibly attractive proposition remains conflicting. Higher consumption, whether on a long-term regular basis or in the form of acute drunkenness, can cause many damaging effects.

Damage may result from direct toxicity of ethanol, or from associated phenomena including vitamin B deficiency, hypoglycaemia, dehydration, alcohol withdrawal, toxic congeners (other substances present in alcoholic drinks) and trauma sustained during intoxication.

ACUTE INTOXICATION Blood alcohol levels around 50 mg/ 100ml cause increased well-being, reduced inhibitions and reduced efficiency (seldom recognised by the subject).

Heavier intoxication causes obvious cognitive impairment, ataxia, slurred speech and vomiting, with subsequent amnesia.

Coma usually supervenes when blood alcohol reaches about 2-300 mg/ 100ml.

Coma in heavy drinkers may also result from head injury, drug overdose, a recent fit, hypothermia or hypoglycaemia: this is a well known clinical pitfall in casualty and in acute psychiatric presentations. The patient may well be a known alcoholic or obviously drunk: but may also have other pathology.

Blood alcohol levels over 400 mg/ 100ml may be fatal. Milder degrees of intoxication can lead to death indirectly through accidents or inhalation of vomit.

ìPathological intoxicationî (mania-a potu) is abnormal behaviour following only modest alcohol intake, usually described in brain-damaged people, though there is doubt as to the validity of this concept. It is sometimes attempted to be used as the basis of a somewhat optimistic defence to criminal charges.

NEUROPSYCHIATRIC COMPLICATIONS

• Delirium tremens (DTs): an indication of physical dependence, can be precipitated by abrupt withdrawal of alcohol in a heavy drinker, for example the end of a drinking bout, efforts to give up drinking without professional advice, intercurrent illness, hospital admission, or arrest/imprisonment. Confusion, fever, visual or tactile hallucinations and fits may occur.
  

• Wernickeís encephalopathy is an acute syndrome thought to result from deficiency of B1 (thiamine). Haemorrhages occur in the mammillary bodies, thalamus and hypothalamus. Acute confusion is accompanied by nystagmus, diplopia, ataxia and peripheral neuritis. The condition may be fatal unless promptly treated with thiamine.

• Korsakovís syndrome, a more chronic disorder, is also believed to result from thiamine deficiency. It may be a sequel of delirium tremens or Wernickeís encephalopathy. Haemorrhage, necrosis and gliosis are present in the mammillary bodies and hippocampus. A gross defect of short-term memory leads to disorientation, for which some patients attempt to compensate by confabulation. Peripheral neuropathy often co-exists.

• Alcoholic dementia comprises global impairment of mental functioning, often accompanied by personality changes of the frontal lobe type. Brain scan shows cerebral atrophy.
  

• Epilepsy may be caused by direct toxicity of alcohol, especially if there is pre-existing brain damage; alcohol withdrawal; overhydration; or hypoglycaemia.

• Peripheral neuropathy results from thiamine deficiency, and affects motor, sensory and autonomic nerves. Presenting symptoms include impotence, or burning pain in the feet.

• Other neurological complications include cerebellar degeneration, central pontine myelinosis, degeneration of the corpus callosum, retrobulbar neuritis, and subdural haematoma following falls.

• Alcoholic hallucinosis often starts during a phase of abstinence and recovers spontaneously after a few months. Auditory hallucinations, usually voices, develop in clear consciousness. If insight is lacking, the voices may form the basis of a delusional system.

• Alcoholic paranoia is the development of paranoid delusions in the absence of hallucinations. Morbid jealousy (Ch 8) of the sexual partner is a frequent theme, in which case dangerousness (Ch 21) must be assessed because of the risk of assault or even homicide.

• Alcoholic hallucinosis and alcoholic paranoia can be helped by antipsychotic drugs, though abstinence is crucial.

PHYSICAL COMPLICATIONS The mortality rate in alcoholics is about three times the general population rate.

• Liver damage includes acute hepatitis, fatty infiltration, and cirrhosis. In men, cirrhosis seldom develops until heavy drinking has continued for at least five years, but women are more vulnerable. Cirrhosis has a high mortality rate even in those who become totally abstinent.

• In pregnancy, heavy drinking may cause abortion, stillbirth, or the ìfoetal alcohol syndromeî comprising microcephaly and other deformities, and learning disability.

• Other physical consequences include peptic ulcer, pancreatitis, gastritis, cardiomyopathy, myopathy, gout, vitamin deficiencies, drug interactions (the effect of psychotropic drugs may be either enhanced or reduced) and raised susceptibility to infections, including tuberculosis, and malignancies.

• Accidents, including road accidents, and accidental deaths are common. Suicide is the cause of death in about 15% of alcoholics, and 50% of non-fatal self-poisonings are combined with alcohol.

SOCIAL CONSEQUENCES

• Family disruption: marital breakdown, and violence towards partners and children.

• Working efficiency is reduced, often leading to demotion or unemployment.

• Crime: many alcoholics steal to get money for drink, and intoxication may precipitate violence. About 50% of violent crimes are committed when the offender is drunk, and about 50% of men in prison have a drinking problem.

• Drunken driving: 80 mg/ 100ml is the legal upper limit of blood alcohol for drivers in the UK.

COURSE OF ALCOHOL ABUSE The traditional view, which may well apply to some of the most severely affected, is of a relentlessly progressive disorder.

Alcohol problems commonly begin when social drinking becomes heavier for psychological reasons, such as living in a hard-drinking environment, or stressful work or family circumstances.

This stage of psychological dependence is followed in some cases by development of physical dependence, manifest by loss of control over the amount consumed, and withdrawal symptoms (tremor, sweating, anxiety, craving) if alcohol is unavailable for a few hours. Intake increases further to combat withdrawal symptoms.

Alcohol tolerance increases initially, decreasing again when the condition becomes advanced. Drinking gains priority over other activities, and the various physical, psychiatric and social problems ensue.

Other patterns include repeated relapses and remissions according to current circumstances and/or changes in mood. As with other kinds of substance misuse, some people drink heavily in early adulthood but ìgrow outî of their habit later on.

Many drinkers deny their problem, concealing the extent of their drinking and hiding bottles at home or at work.

Heavy smoking, dependence on other drugs, and heavy gambling may be associated.

Vagrant (skid row) alcoholics are those without families, homes or jobs, often handicapped by low intelligence or chronic mental illness, who live rough in city centres drinking cheap forms of alcohol.

RECOGNITION Patients with undetected drinking problems commonly present in primary care or hospital settings because of the physical or psychiatric complications of alcohol. Patients with, for example, depressive illness or peptic ulcer will not improve if treatment is directed to these diagnoses without attention to the underlying alcohol misuse. Ways of improving recognition include:

• Taking a drinking history as a routine part of medical or nursing assessment.

• Screening questionnaires such as CAGE:
• Have you ever felt you ought to Cut down on your drinking?
• Have people Annoyed you by criticising your drinking?
• Have you ever felt Guilty about your drinking?
• Have you ever had a drink first thing in the morning (an ìEye-openerî) to steady your nerves or get rid of a hangover?
• Two or more positive replies indicate a possible drinking problem, but must be followed up by direct inquiry. Brief counselling by trained nurses is effective in persuading general medical patients identified in this way to reduce their drinking.
  

• Laboratory tests: a raised blood level of liver enzymes, the most sensitive being gamma glutamyltranspeptidase (gamma GT) (over 40 iu/litre), and/or macrocytosis (mean corpuscular volume, MCV, over 96 fl), are suggestive of high alcohol intake. However, both tests may also give abnormal results in other illnesses unrelated to alcohol, so they are not in themselves diagnostic.

TREATMENT Alcohol misuse cannot be regarded as a disease to be ìcuredî by doctors. The responsibility for change in behaviour rests with the drinker, the professionalís role being to facilitate this change.

There is limited point in attempting to treat those who deny their problem, or do not want to overcome it. Some who are well motivated stop drinking of their own accord, others need professional help, but the strength of motivation is the most powerful predictor of treatment success.

Intervention is probably most effective at an early stage, but most alcohol misusers do not seek help till they are forced to do so and their condition is advanced. Once heavy drinking has become established and physical dependence is present, results of treatment are poor.

Total abstinence is the traditional goal, especially for those with physical dependence or physical complications. Controlled drinking is a realistic aim for some milder cases.

Treatment methods include:

• Detoxification, using medical treatment as outlined above for delirium tremens, is necessary to permit safe cessation of drinking in those who are chemically dependent (as evidenced by a physical withdrawal syndrome). It may be done safely at home or in a hostel if there is adequate supervision. A typical regime would be chlordiazepoxide 40-60 mg qds, reducing gradually to zero over five days. Chlormethiazole (Hemineverin) was formerly the standard treatment, but is no longer recommended.

• Psychological and social approaches: systematic reviews indicate that most brief approaches are effective in reducing consumption, but that longer-term psychological treatments (including dynamic, behavioural or supportive psychotherapy, individual or group, on an inpatient or outpatient basis) have no additional benefit. The trend is firmly toward inexpensive community treatments with input from health, social and probation services. However, inpatient alcoholic units still exist, offering intensive group psychotherapy over several weeks or months. Long-term residence in a ìdryî hostel offers support for some severely damaged ex-drinkers.

• Alcoholics Anonymous (AA) is a voluntary organisation which offers self-help group therapy at evening meetings and also runs groups for partners and children. The goal of lifetime total abstinence is central to AAís approach. Some people derive great benefit from AA, and continue frequent attendance at meetings for many years to make sure they remain ìdryî. For others, however, the AA approach makes them feel so guilty if they return to drinking that they are more likely to continue doing so.

• Motivational interviewing uses a model which can also be applied to other addictive behaviours, describing a ìcycle of changeî:

• Drugs: disulfiram (ìAntabuseî tablets or implant) blocks the action of acetaldehyde dehydrogenase, causing accumulation of acetaldehyde if alcohol is taken. Drinking therefore becomes both unpleasant and dangerous, with the risk of cardiac arrhythmias or extreme hypotension. Disulfiram can be effective if supervised by family or staff.
  

• Many other drugs have been tried including lithium, fluoxetine and naltrexone, however none of these has become established. Recently, acamprosate has been introduced; it has been suggested as a useful adjunct to psychological treatments, but evidence is not yet conclusive.

PROGNOSIS It is very difficult to give a numerical overall prognosis, as the condition is not exclusively a medical one. Prognosis is poorer for those severely affected, especially with attendant physical health problems, or loss of family, job and home, or with forensic problems. Prognosis will be better for younger, healthier patients without such complications, especially if they are identified earlier and engage well with treatment.

PREVENTION There is evidence that a reduction in national per capita alcohol consumption, and hence a reduction in the number of people with alcohol-related problems, could be achieved by increasing the price of alcohol.

Other measures which may be presumed to be helpful include: education about the dangers of alcohol, increasing the availability of non-alcoholic drinks at business and social functions, banning advertisements for drink, tougher drink-drive laws, and placing moderate (but not extreme) restrictions on availability in shops and catering establishments.

However, some of these suggestions run counter to civil liberty arguments, and perhaps more to the point, to powerful vested interests of tradespeople.

FURTHER READING

Edwards G, Marshall EJ, Cook CCH. The treatment of drinking problems. Cambridge: Cambridge University Press, 2003.