Continuing education - Brain disease - Detecting and managing alcohol misuse

Many patients undergoing alcohol withdrawal can do so safely at home under supervision, but some need inpatient admission, writes Grozdana Lalevic

Medical, mental and behavioural problems due to alcohol use are common. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco and hypertension (see Figure 1).1

Figure 1: Global distribution of all alcohol-attributable deaths by disease or injury

More than 80 deaths every month in Ireland are directly attributable to alcohol, and one in four deaths of young men aged 15-39 in Ireland are related to alcohol. Furthermore, there are 1,200 cases of cancer detected each year in Ireland related to alcohol.2

The Global Burden of Disease project showed that the proportion of Irish 15-year-olds (together with British and Danish) who had been drunk three times or more in the past 30 days considerably exceeded the proportion of 15-year-olds elsewhere in Europe.3

There is clear and conclusive evidence that the problems from consumption levels are reflected in both admissions to general hospitals and attendances at emergency departments. Hope et al suggested that 20-50% of all presentations to ED s in Ireland are alcohol-related, with the figure rising to more than 80% at peak weekend periods.4

How much is too much?
Hazardous drinking is consuming more than 17 standard drinks per week for men or 11 standard drinks per week for women. (A standard drink has 10g of pure alcohol.) There is an increased risk of liver disease for those who drink daily, compared with those who drink intermittently or periodically. The liver needs at least two to three alcohol-free days to recover after drinking anything but the smallest amount of alcohol.5

Harmful alcohol use or abuse refers to a pattern of use that is causing damage to health.6 The damage may be physical (eg. hepatitis) or mental (eg. depressive episodes secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse social consequences.

Alcohol dependence is defined as ‘cluster of physiological, behavioural and cognitive phenomena in which the use of alcohol takes on much higher priority for a given individual than other behaviours that once had greater value’.6

A definite diagnosis of dependence should only be made if at least three of the following have been present together in the past year: compulsion to take alcohol; difficulties controlling alcohol taking behaviour; physiological withdrawal state; evidence of tolerance; neglect of alternative interests; and/or persistent use despite harm.

Detection of alcohol misuse
The clinical assessment of alcohol misuse involves finding out the number of standard drinks consumed per week; patterns of drinking; physical and mental health of the patient; and testing blood markers. The following screening questionnaires for detection of alcohol misuse, severity and withdrawal are useful:

People who misuse alcohol often tend to misuse benzodiazepines or other illicit drugs, so it is always worth asking them about other substances.

Table 1: Identification and management of harmful drinking and alcohol dependence

Presentation of alcohol problems in the medical setting
Patients usually present for three major reasons:

1. Wishing to abstain from alcohol and not in alcohol withdrawal or alcohol-dependent
This group of people would have an AUDIT score < 20. The principles underlying most approaches to brief interventions were systemised by Hester and Miller in what is called the FRAMES model:9

2. Alcohol-related medical comorbidities or injuries
This includes patients presenting with accidental or deliberate self-harm.

3. Alcohol dependent or in alcohol withdrawal
Most patients undergoing alcohol withdrawal can do so safely at home with regular supervision by their GP. For people who typically drink over 15 units per day and/or score 20 or more on AUDIT, detox in the community is a possible option. Consider inpatient detox in individuals with: severe alcohol dependence; history of delirium tremens or seizures; poor physical health; pregnancy; major mental illness; cognitive impairment; or multiple failed community detoxifications.

Alcohol withdrawal timeline example

Most of the withdrawal symptoms subside five to seven days after last drink, but craving for alcohol may persist longer.

Drugs used in acute withdrawal
Benzodiazepines are used to prevent/relieve withdrawal symptoms and to prevent delirium and seizures. Most commonly used would be diazepam and chlordiazepoxide. They do not reduce craving and after initial detox, additional interventions may be required. For examples of chlordiazepoxide detox see Table 2.10

Table 2: Examples of chlordiazepoxide detox

Day 1 10-40mg QDS; PRN 10-40mg two-hourly; daily max 250mg in 24 hours

Day 2 10-40mg QDS +/– PRN
Day 3 10-30mg QDS +/– PRN
Day 4 10mg QDS
Day 5 10mg QDS

Day 1: Librium detox example (based on number of units/week):

  • < 100 units/week: 20mg QDS
  • 100-200 units/week: 30mg QDS
  • > 200 units/week: 40mg QDS

Reduce dose in elderly, frail patients or adjust according to body mass. Patients with abnormal liver enzymes but no clinical evidence of liver failure and normal serum bilirubin, albumin and prothrombin time are suitable for chlordiazepoxide. Consider lorazepam or oxazepam to decompensate liver failure11

Vitamin B complex is used for prophylaxis or treatment of Wernicke-Korsakoff’s syndrome (WKS). A presumptive diagnosis of Wernicke’s encephalopathy (WE) should be made for any patient with a history who shows one or more of the following: evidence of ophthalmoplegia, ataxia, acute confusion, memory disturbance, unexplained hypotension, hypothermia, unconsciousness or coma.

Thiamine replacement is still the critical intervention for WKS, and increased vulnerability is associated with genetic susceptibility in association with poor diet.

Recommendations for treatment of WKS and WE:11

Promoting abstinence
Detoxification is usually the first step towards abstinence, followed by appropriate addiction aftercare/support (see below). The four pharmacological treatments available to maintain abstinence include:11

Grozdana Lalevic is a registrar in liaison psychiatry at Cork University Hospital

Table 4: Support services
  • Alcoholics Anonymous (AA) 12-step programme ‘to stay sober and help other alcoholics achieve sobriety’
  • Al-Anon Family Groups provide support to anyone whose life is, or has been, affected by someone else’s drinking(
  • Outpatient/inpatient or day patient addiction treatment
  • Addiction outreach workers in the community

I would like to thank Dr Eugene Cassidy, consultant psychiatrist in liaison psychiatry, Cork University Hospital for his valuable and constructive suggestions, enthusiastic encouragement and useful critiques of this article.


  1. Global status report on alcohol and health, 2004 Accessed on Accessed April 10, 2014
  2. Health Research Board JB. Alcohol: Public Knowledge, Attitudes and Behaviours. Accessed on Accessed March 12, 2014
  3. Room R, Babor T, Rehm J. Alcohol and public health. The Lancet 2005; 365 (9458): 519-530
  4. Hope et al. Alcohol and Injuries in the Accident and Emergency Department: A National perspective Internet pages. Available from: pdf/alcohol_%20and_injuries.pdf?direct=1. Accessed March 22, 2014
  5. Science and Technology Select Committee. Inquiry on alcohol guidelines. http:// guidelines_1.pdf. Accessed on April 26, 2014
  6. The ICD -10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines, 1990. Available at: terminology/ICD10ClinicalDiagnosis.pdf as accessed on April 12, 2014
  7. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test, Guidelines for Use in Primary Care. 2nd Ed. Department of Mental Health and Substance Dependence, World Health Organization
  8. Cassidy EC, O’Sullivan IO, Bradshaw PB, et al. Symptom-triggered benzodiazepine therapy for alcohol withdrawal syndrome in the emergency department: a comparison with the standard fixed dose benzodiazepine regimen. Emergency Medicine J 2012; 29(10): 802-804
  9. Barry JB. Towards a framework for implementing evidence based alcohol Interventions, 2012. Available from
  10. Taylor DT. The Maudsley Prescribing Guidelines. 10th ed. London: Informa Healthcare; 2009
  11. Lingford-Hughes R, Welch S, Nutt DJ. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2004; 18(3): 293-335
  12. National Health Service. Alcohol-use disorders Diagnosis,assessment and management of harmful drinking and alcohol dependence. Available from National Institute for Health and Clinical Excellence, Web site: live/13337/53194/53194.pdf. Accessed March 19, 2014
Continuing education - Brain disease - Detecting and managing alcohol misuse


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