Treatment approaches to alcohol dependence vary according to the extent of the disorder and the circumstances of the patient, writes Garrett McGovern

Alcohol has a particular place in Irish culture. We drink far in excess of most other European countries. In a survey carried out in 2003, Ireland ranked third behind Hungary and Luxembourg for drinking the most alcohol among a group of 26 countries. The writer and journalist John Waters once wrote: “Drinking in Ireland is not simply a convivial pastime, it is a ritualistic alternative to real life, a spiritual placebo, a fumble for eternity, a longing for heaven, a thirst for return to the embrace of the Almighty.”

Ireland may well rank high in the international league table of drinkers but it is estimated that only about 10% of those who drink excessively actually present for formal treatment. There are a number of reasons why this figure is so low, including stigma, fears around anonymity, poor insight and lack of faith in current treatment options. Any sensible national policy around alcohol needs to address the issue of treatment, which has been under resourced for many years.

Approaching the problem in primary care
Family doctors and practice nurses are in a unique position when it comes to treating patients. They often know their patients and families well, and a bond of trust has developed over many years. Screening for alcohol problems should be relatively simple and yet far too few established alcohol problems are picked up in general practice. There are many possible reasons for this. Problem drinking often has an insidious onset and its clinical signs may not be obvious. A routine trip to the primary care clinic with alcohol-related symptoms such as depression or heartburn may not yield the likely cause unless questions around alcohol use are addressed.

Brief interventions are a simple and cost effective early intervention, and are successful in one in 10 drinkers without the need for more formal treatment. A brief intervention is defined as any therapeutic intervention of short duration (one to five sessions) designed to influence patients to think more proactively about their alcohol consumption.

Despite their relative effectiveness, brief interventions are not widely used in general practice. There are a number of brief screening tools which are simple to carry out. These include the CAGE and AUDIT questionnaires, with which many primary care professionals will be familiar. Routine questions about alcohol intake should be asked with the specific intention of ruling in or ruling out a problem, and the way in which the GP or practice nurse couches the question is as important as the question itself. For example, a far more effective question than ‘do you take a drink?’ might be ‘do you drink often?’

If the patient responds that they do drink often then you might ask them how often and do they ever ‘overdo it’? This is important because it can guide you to the context and extent of the patient’s drinking in an less intrusive way. It is then easier to piece together the physical symptoms with the level of drinking and this will reduce the stigma the patient may feel in being quizzed on a sensitive issue.

Classification of alcohol dependence syndrome
Alcohol dependence syndrome (ADS) is defined by The WHO’s ICD-10 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 once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take alcohol. There may be evidence that return to alcohol use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with non-dependent individuals”.

A definite diagnosis of dependence should usually be made only if three or more of the following have been experienced or exhibited at some time during the previous year:

• A strong desire or sense of compulsion to take alcohol
• Difficulties in controlling alcohol-taking behaviour in terms of its onset, termination or levels of use
• A physiological withdrawal state when alcohol use has ceased or been reduced, as evidenced by – the characteristic withdrawal syndrome for alcohol; or use of the alcohol with the intention of relieving or avoiding withdrawal symptoms
• Evidence of tolerance, such that increased doses of alcohol are required to achieve effects originally produced by lower doses
• Progressive neglect of alternative pleasures or interests because of alcohol use, increased amount of time necessary to obtain or take alcohol or to recover from its effects
• Persisting with alcohol despite overtly harmful consequences.

The severity of alcohol dependence questionnaire (SAD-Q) is a very useful way of measuring dependence by asking multiple choice questions on symptoms primarily related to withdrawal. Each answer is weighted according to a Likert-type scale ranging from a zero score for an ‘almost never’ to a three for ‘nearly always’, with a range of other options in between. The score can then be measured according to the following ranges:

• A score of 31 or higher indicates ‘severe alcohol dependence’
• A score of 16-30 indicates ‘moderate dependence’
• A score of below 16 usually indicates ‘mild physical dependency’.

The SAD-Q can be quite useful in guiding the clinician to the extent of an alcohol problem but should be used in conjunction with other assessment and screening tools and, most importantly, clinical judgement.

There are other areas of the assessment and history that are important and relevant to alcohol dependence. As primary care professionals will know many of the patients they treat very well, they will often have detailed information about them already on file. With more constraints being placed on primary care professionals, the time spent with a patient struggling with alcohol needs to be targeted, efficient and goal-orientated. If a healthcare professional feels that the severity and complexities of the case are beyond their level of expertise, then they should refer to a specialist who can provide the appropriate advice and care.

Unfortunately, many primary care professionals do not have a readily available pathway of referral that will meet the needs of every patient. Some barriers to referral include cost, setting (eg. inpatient versus outpatient), treatment views of specialist centres (eg. abstinence versus harm reduction) and patient motivation.

There is no doubt that more money and resources are needed to support community alcohol treatment than are currently provided. There should also be a facility for primary care professionals to talk to specialists in drug and alcohol treatment services should the need arise. Education is important and there are many courses that help to develop better skills in approaching patients misusing alcohol.

The mildly alcohol dependent patient
Often patients who are misusing alcohol at the mild end of the scale are missed as the problem may not seem obvious or the presentation is unrelated to their use of alcohol. Again, a few routine but targeted queries can provide useful information and little more than a brief intervention may be enough to make patients more mindful about their drinking, particularly if their alcohol use is in some way related to their presenting symptoms. Written information (eg. leaflets) or online links can reinforce the importance for patients of being aware of the negative impact that alcohol can have on their health. Formal treatment is often not required for mild cases but any patient expressing a wish for specialist help should be referred appropriately.

The moderately alcohol dependent patient
The greater the severity of an alcohol problem, the less effective brief interventions tend to be and a more intensive approach is often required. This is not to say that brief interventions should be abandoned as they can be an important screening tool for all types of alcohol dependence. Like mild cases, moderate alcohol abuse is often not directly picked up in general practice. Patients will present with other problems and if they want to conceal the extent of their drinking they will do so without too much difficulty, even when faced with abnormal liver function tests or physical signs suggestive of over-drinking (eg. alcohol fetor, hypertension, depression or features of alcohol withdrawal). It is the skill of the primary care professional, in tying together the signs and symptoms of alcohol misuse, that will be a crucial determinant in preventing such a patient from ‘slipping through the net’. Sensitivity is important as patients tend to reject dictatorial advice. The following example illustrates effective responses to queries about depressive symptoms:

Primary care professional: “When do you feel most depressed?”
Patient: “In the morning.” Primary care professional: “
Is this every morning, or would it be worse at any particular time? I’m talking about stress, worries or perhaps after taking alcohol.”
Patient: “Yes, I feel really down after drinking the night before.”
Primary care professional: “Would this happen often?”
Patient: “Recently, yes. I have been drinking more than normal.”

This has led to the discovery of an important component of the patient’s problem. You can now tentatively establish if the patient is becoming more dependent on alcohol and the appropriate advice can be offered. This helps to reduce the stigma to the patient and enhances the therapeutic alliance – key features of an effective outcome.

Best treatment approach
Having established the problem, the next step is deciding what is the best treatment approach for the patient. This should be individualised and take into account psychiatric history, social circumstances, employment, confidentiality and family support. There is little point in referring a working father of three children to an inpatient facility that he is reluctant to attend or if he cannot take time off work. Equally, it will be difficult to treat a patient with complex medical and psychiatric needs who is drinking heavily in the community, and the best option may be inpatient detoxification until their condition has stabilised.

Regardless of the setting there are a number of important evidence-based treatment interventions. The healthcare professional needs to first decide whether they have the expertise and resources to treat the problem. With moderately severe alcohol dependence it is likely that the patient will need to be referred and may need detoxification with chlordiazepoxide. This is to help with alcohol withdrawal symptoms and the dose of the drug is reduced gradually to zero over five to seven days, when the worst symptoms of alcohol withdrawal will have abated. Following this, there are a number of ‘talking therapies’ that are effective in reducing the risk of relapse. These include cognitive behavioural therapy, motivational interviewing, supportive counselling and family therapy. Patients may or may not wish to engage in group sessions and their wishes should be respected.

Abstinence versus sensible drinking
An interesting debate for therapists in the field asks: can patients who drink too much change their drinking pattern and adopt a more sensible relationship with alcohol? Most research supports controlled drinking for those with mild and moderate alcohol dependence, but not for patients with a severe relationship with alcohol. Dependence is often a continuum whereby users can go through different patterns of use, ranging from abstinence to controlled drinking to dependence.

A patient who strives for abstinence often does not reach their intended goal in the short term. In these cases, controlled drinking can be a gateway to a life without alcohol and therapists should work to allow these patients to achieve their goal. Reinforcing abstinence can be counterproductive: patients can feel like ‘failures’ if they are still drinking, albeit more responsibly.

The severely dependent drinker
Severe alcohol dependence is by far the biggest treatment challenge and nearly all cases will need to be referred by the primary care professional for specialist care. It is associated with significant morbidity and mortality, and the outcomes tend to be far poorer than in patients with less severe dependence. Most severely dependent drinkers will require hospital care as their needs will be complex and they will require medically-assisted alcohol withdrawal to reduce the risk of withdrawal seizures and delirium tremens (DTs). About 5% of patients experiencing withdrawal develop DTs ,which carries a mortality rate of 2-15%.

In view of the potentially life-threatening complications of severe alcohol withdrawal, there needs to be a specialist, multidisciplinary and systematic approach to management. Many admissions with severe alcohol withdrawal will reach the emergency room before an addiction treatment facility and staff here should be adequately trained to recognise the features of withdrawal. Elective admissions give the medical staff more time to plan the treatment of severe alcohol dependence.

Managing severe alcohol dependence: key steps

• On establishing severe dependence with a high risk of DTs, a decision should be made to admit the patient to a specialist inpatient facility
• It is important that the assessment includes relevant medical and psychiatric history and any risk of suicidality
• Patients need to be kept under observation for any signs of unplanned withdrawal. The timing from the last alcoholic drink is crucial in this regard
• The role of pharmacotherapy needs to be established and individualised. Not all patients will need medication
• Benzodiazepines are the mainstay of pharmacological treatment for acute alcohol withdrawal, usually oral chlordiazepoxide (Librium). The dosage should be symptom-triggered and individualised. It take into account the level of alcohol dependence, severity of withdrawal and evidence of comorbidities, such as abnormal liver function
• The dose of chlordiazepoxide is reduced gradually over approximately five to seven days but may take longer, depending on the progress of withdrawal symptoms
• The risk of DTs in the acute hospital setting is exceedingly low but in the event that the condition occurs, the dose of chlordiazepoxide will need to be adjusted and other drugs considered, such as lorazepam, olanzapine or haloperidol, to prevent further seizures and to control agitation. Long-term use of anticonvulsants is not indicated
• Wernicke’s encephalopathy (WE) should be considered in any patient presenting in a confused state with evidence of malnutrition. The other two classical signs that complete the triad are ophthalmoplegia and ataxia (although all three signs only appear together in one third of cases)
• A significant number of patients with WE will develop Korsakoff ’s psychosis or syndrome, which is characterised by disordered anterograde memory and other cognitive defects. The treatment of WE is with parenteral thiamine
• Thiamine should be given prophylactically in oral doses of 200mg daily to any patient with decompensated liver disease or who shows evidence of malnutrition.

Other pharmacotherapy
Various drugs have been used to treat alcohol dependence. Acamprosate (Campral) is an analogue of gamma aminobutyric acid (GABA). Its exact mode of action is unknown but it is thought to decrease alcohol consumption by reducing the positive reinforcement linked to alcohol consumption. Disulfiram (Antabuse) is an aversive drug that results in the accumulation of toxic acetaldehyde, by blocking acetaldehyde dehydrogenase when alcohol is consumed. Compliance can be a problem and evidence suggests that the best outcomes are improved when a close family member or friend can supervise consumption of the drug. The opioid antagonist nalmefene (Selincro) is indicated for the reduction of alcohol consumption in alcohol dependent adults with a high drinking risk level without physical withdrawal and who do not require immediate detoxification. It is EU approved, undergoing the pricing/reimbursement process and expected to be available in Ireland in 2014.

Follow-up and relapse prevention
Alcohol dependence comes with a high rate of reinstatement and relapse. Patients who become abstinent or drink within safe limits should maintain the positive long-term changes. The relapse prevention (RP) model developed by Marlatt and Gordon (1985) is a cognitive behavioural approach to managing high-risk social situations that could trigger relapse. There are two key features of this model in terms of relapse risk factors:

• Immediate determinants (eg. high-risk situations, coping skills, outcome expectancies and the abstinence violation effect)
• Covert antecedents (eg. lifestyle imbalances; urges and cravings).

The RP model can be delivered in a variety of settings (eg. one-to-one sessions and group therapy) and can be very effective for long-term stability. There are a number of follow-up options for patients in recovery from alcohol dependence and each should be individually tailored. These may be AA meetings or individual sessions with a counsellor, cognitive behavioural therapist, psychiatrist or primary care professional specialising in drug and alcohol abuse. The number, intensity and frequency of sessions should be decided between the therapist and the patient.

Primary healthcare professionals are excellently positioned to screen patients and provide brief interventions for patients with alcohol problems. In the busy climate of general practice it is unlikely that most clinics have the resources and expertise to provide more intensive treatment.

Alcohol dependence is a chronic relapsing condition with a spectrum of severity. The treatment varies according to the extent of the disorder and the individual circumstances and health status of the patient. Relapse prevention therapy is an important tool to help patients maintain the positive changes and benefits of acute treatment.

Garrett McGovern is a general practitioner specialising in alcohol and substance abuse at the Priority Medical Clinic, Dublin

Continuing education - Brain disease - Alcohol dependence: Management and treatment in primary care