Diagnosis and management of alcohol use disorders

What screening tools are helpful?

The 10 item AUDIT (alcohol use disorders identification test) questionnaire, which takes about two minutes to complete, was developed by WHO for use in primary care.9 The questionnaire has excellent sensitivity and specificity; has been evaluated in a range of settings, populations, and cultural groups; and is available in all major languages. Shortened forms of the AUDIT questionnaire have been developed for circumstances where time is short.3 These include AUDIT-C (the first three items of AUDIT) and the fast alcohol screening test (FAST), which is based on four AUDIT items. FAST takes about 20 seconds to complete and is useful in primary care and accident and emergency settings.10 A printable version is available from NICE (www.nice.org.uk). The Paddington alcohol test is also an efficient tool for use in the accident and emergency setting.11 AUDIT and its derivatives are superior to CAGE for the detection of hazardous harmful drinking.

Detecting excessive use of alcohol in pregnancy is important for reducing harm to the unborn fetus. Two brief questionnaires, T-ACE and TWEAK, which take only one minute to complete are the tools of choice.3

Biological markers are helpful when the validity of self reports may be questioned, such as in legal proceedings. They can also provide motivational feedback, monitor change, and be indicators of physical complications. Of the commonly requested biological markers (carbohydrate deficient transferrin, γ glutamyl transferase, and mean corpuscular volume), carbohydrate deficient transferrin has marginally better sensitivity and specificity, but it is inferior to and more expensive than self report screening questionnaires.3 A case exists in trauma departments for routinely measuring blood alcohol concentration, because this is the most reliable biological marker of hazardous drinking in young adults.12

What are brief interventions?

Brief interventions range from brief advice—primarily for hazardous drinking—to extended brief interventions for harmful drinking. Brief advice requires minimal training, and it is ideal for delivery in primary care and accident and emergency settings by general practitioners and nurses (box 4).

Extended brief intervention is indicated for harmful drinking and requires basic skills in empathic listening and motivational interviewing. It goes beyond brief advice and aims to provide patients with the tools they need to make changes (box 4).15 Ideally, extended brief interventions should be offered directly after an alcohol related presentation, to take advantage of the “teachable moment.”16 17

A recent Cochrane review of 21 randomised controlled trials showed that brief interventions are effective in routine clinical settings at reducing alcohol consumption in men, with significant reductions maintained at one year follow-up. Their effectiveness is less clear for women.18

How is medically assisted withdrawal managed?

Medically assisted withdrawal is indicated in alcohol dependence. The main aims of a medically assisted withdrawal are to prevent serious complications, such as delirium tremens and seizures; to make the patient comfortable; and to introduce other interventions that promote and maintain abstinence. Whenever possible, withdrawal from alcohol should be part of an overall treatment plan that includes aftercare and takes account of the person’s goals and level of motivation. In general hospitals, however, withdrawal is often unplanned, so an awareness of, and alertness to, the physiological signs and symptoms of withdrawal (box 1) are necessary.

Benzodiazepines are effective at reducing the signs and symptoms of withdrawal and are the drug of choice.19 Longer acting benzodiazepines such as diazepam and chlordiazepoxide, are also effective at preventing seizures, although shorter acting benzodiazepines such as oxazepam, are indicated in clinically significant liver disease to prevent accumulation (box 5).

Wernicke’s encephalopathy

Wernicke’s encephalopathy is a neuropsychiatric complication caused by thiamine deficiency that occurs relatively often in people with chronic alcohol dependence, particularly during alcohol withdrawal. Wernicke’s encephalopathy can be prevented and treated by the timely use of parenteral thiamine supplementation (box 6). It is essential to have a high index of suspicion as the classic triad of confusion, ataxia, and ophthalmoplegia is only present in about 10% of cases, and postmortem evidence suggests that 80% of cases are not diagnosed.19 20 21 Initially Wernicke’s encephalopathy is reversible, but if left untreated it can cause permanent brain damage (Korsakoff’s psychosis), which is characterised by severe short term memory loss and associated functional impairment that requires permanent institutional care.20 21

What psychosocial interventions are effective?

After detoxification, most people with alcohol dependency will need a specialist psychosocial intervention to reduce the risk of relapse. Non-dependent binge drinkers who do not respond to brief intervention may also benefit from more intensive treatment. Systematic reviews have now established that a range of psychosocial interventions are clinically effective, with none being superior overall.3 A recent pragmatic randomised trial in seven UK sites has also reported a saving of £5 for every £1 spent on specialist intervention on an outpatient basis.23 Residential rehabilitation does not have established cost effectiveness, but for some people with severe dependence or complex needs, the period of protected abstinence that it provides may be beneficial, even essential.

Many psychosocial interventions are based on the principles of cognitive behaviour therapy. Such interventions are highly pragmatic and focus on modifying maladaptive beliefs about drinking, learning about high risk situations, and developing problem solving skills and social skills. This family of interventions has the largest research literature on effectiveness.3

Where motivation to change is minimal or changeable, then motivational enhancement therapy is of particular value,14 and it has been shown to be effective in two major multisite randomised controlled trials.23 24

Other effective psychosocial interventions include the community reinforcement approach and contingency management (both of which use positive reinforcers to reward abstinence),3 and 12 step facilitation therapy, which encourages attendance at Alcoholics Anonymous.24 25

What is the role of mutual self help groups?

Alcoholics Anonymous is by far the most extensive worldwide network of mutual self help groups for alcoholics, with more than 100 000 groups worldwide, and 3000 groups in the UK. The voluntary, non-professional, and long term nature of the fellowship does not readily lend itself well to evaluation in randomised controlled trials. However, long term observational studies have established a consistent and strong association between involvement in Alcoholics Anonymous and long term abstinence.26 Furthermore, high quality randomised controlled trials have shown that structured interventions to facilitate engagement with Alcoholics Anonymous, known as 12 step facilitation, are effective at promoting abstinence, mostly as a result of increased involvement in Alcoholics Anonymous.24 25 Other mutual self help groups exist and may also be effective.26 The evidence indicates that systematic encouragement to attend mutual self help groups is a cost effective way to enhance treatment outcomes, and such encouragement should be part of routine practice for people with alcohol dependence.

What is the role of drugs to prevent relapse?

Three drugs are commonly used to prevent relapse into drinking—disulfiram, which produces an unpleasant reaction if alcohol is consumed; and acamprosate and naltrexone, which reduce cravings. Oral disulfiram (Antabuse) is an effective component of strategies to prevent relapse.3 However, it is not risk free, and is contraindicated in people with cardiovascular disease, hypertension, pregnancy, or a history of cerebrovascular accident or psychosis. Acamprosate and naltrexone are much safer than disulfiram, but naltrexone is unlicensed in the UK for alcohol use disorders. Although most randomised controlled trials show a positive effect, the effect size is small and outcomes vary greatly.3 These three drugs should routinely be considered as adjuncts to psychosocial programmes and self help groups, to enhance the effectiveness of treatment.