Key learning points:
– Recognising influential factor to problematic/dependent drinking
– Common treatments for alcohol dependency
– Understanding where treatment for alcohol can be provided in the health system
Alcohol has been an increasing problem in health care for the UK. There are increasing consumption rates that have led to growing presentations of health problems in the UK for primary care. In England during 2008 there were 6,769 deaths directly related to alcohol (an increase of 24% from 2001). Of these alcohol related deaths, the majority (4,400) died from alcoholic liver disease. In the field of substance misuse this is also a growing problem. As patients stabilise on methadone, alcohol increases to dependent patterns.1
Problematic drinking can be in the region of 50-80 units a week. Dependent drinking patterns indicate that alcohol is consumed everyday and this is on a basis of 50-120 units a week and more. To stop the consumption of alcohol for one day would lead to a person experiencing alcohol withdrawals, including: shaking, feeling cold and hallucinations.
Factors influencing problematic/dependent drinking
There are many factors that can lead to a person developing a dependent alcohol pattern but one of the main factors for people who present for help in primary care is untreated depression. When asked how the alcohol is used in their daily lives, many of the patients would say it is used as a process of self medication to help them through when they have a low mood, some evidence shows this is a common factor.2
Depression is often a factor that initiates a level of increased alcohol consumption, and there are many examples of this, with social isolation, lack of support and stress being the main factors effecting depression.3,4 The co-morbidities of alcohol dependence and depression are problems that clinicians in the field of alcohol treatment often encounter.
There is much debate on whether to treat people who have dependent drinking patterns for depression early in their treatment cycle. It is always preferable to treat someone for depression when there is little or controlled alcohol consumption, as this makes it easier to see the response to treatment. In terms of prescribing medication it is always preferable to try and detoxify the patient off alcohol, otherwise the benefits of medication are minimal at best. National clinical guidelines on prescribing for depression advocates that for dependent drinkers, the move to abstinence or alcohol free periods is more effective in lifting moods than prescribing an anti-depressant and this should be the first step in any treatment plan. Indeed, if the patient’s mood does not improve this would make the rationale for prescribing an anti-depressant clearer. Other influencing factors are anxiety disorders and mental health problems such as bi-polar conditions. In much the same way people used alcohol to self medicate and manage the symptoms of their mental health problems. However, this can be met with mixed results.
Signs and symptoms
The signs and symptoms of dependent drinking are usually physical in presentation. This can be with patients presenting with gastric problems, increased water retention in the abdomen area (ascites), increased blood pressure (linked to portal hypertension), increased bruising of the skin (linked to a lack of vitamin K). Often in general practice in Islington drug and alcohol services when a patient presents with any of these problems questions are asked around alcohol consumption per week.
Basic questions can be used, for example, how much are you drinking daily? Do you think drinking is a concern for you? Some professionals use more formal but quick assessment tools such as the ‘fast tool’. But generally the same questions are asked in this assessment tool as well.
Assessment and treatment
Much of the assessment and treatment for problematic and dependent alcohol consumption5 can be provided in primary care settings with specialist support from an alcohol specialist nurse.
Starting the assessment process is the first step in gathering information to plan appropriate treatment. From an assessment, the history a person gives will indicate whether they have been drinking at problematic or dependent levels. If this is indicated the next step would be to plan treatment in primary care with the first plan being to work on lowering alcohol consumption and moving the patient towards a more controlled pattern of drinking within the first stages.
In primary care the alcohol specialist nurse would work with the patient to recognise their pattern and problematic/dependent drinking by completing a regular drink diary, and then to work through triggers and factors to reduce alcohol use. The approaches used are usually motivational interviewing (MI) or cognitive behavioural therapy (CBT).3,4 These psychological interventions are used to increase a person’s insight and ability to rationalise their behaviour towards alcohol in order to make better decisions in the future.
The main way this works is to look at triggers/factors that can influence drinking. This can be done when someone has completed a drink diary and then the clinician can ask what initiated the start of a drinking episode. Questions that are open and need a response from the patient are used, for example, what was the benefit of alcohol consumption, what were the negatives of the alcohol consumption, did the person feel alcohol was a good idea and was a beneficial way of dealing with the situation? This type of questioning can open a person to engage with clinical staff and the information they provide can inform the clinician of their drinking pattern and its triggers. This information can be used for the person/patient to reflect on their responses, which is an integral part of MI.
For example if a person/patient started drinking after an argument with their partner, once establishing this is the trigger they can then reflect on the emotions the ‘argument with their partner’ caused them to feel. Once the patient has established the trigger the healthcare professional can then ask: "is it excessive and can anything be done to curb this?" This will hopefully prompt the patient to start reflecting on the situation using MI questioning. This line of questioning will push the patients’ thinking so they are able to think and talk through possible solutions. If they can think and verbalise the solutions then it is a question of acting on this and changing their behavioural responses to stress or anger.
Using these approaches can reduce alcohol consumption and often patients will be able to do this. However, some patients may want to stop and have a period of time where they are alcohol free.
There is a significant cohort of patients that will ask to detoxify off alcohol and this patient group is assessed for their suitability to detoxify via the community, meaning they can visit the surgery to obtain medication and detoxification rather than be admitted for an in-patient detoxification bed. The criteria for this cohort of patients is given to patients who are:
– Not severely dependent and his/her alcohol consumption is fewer than 200 units/week.
– Aged 18-65.
– Not confused, nor have hallucinations.
– Have no history of uncontrolled or unexplained seizures while on medication.
– Have no acute physical illness including history of reduced respiratory function, cardiac failure or severe liver damage.
– Not pregnant or breast feeding.
– Not physically compromised.
– Not dependent on benzodiazepines or chaotically misusing
– Have no presenting signs of Wernicke-Korsakoff’s syndrome.
– Have not suffered from unstable or severe psychiatric illness including a risk of suicide, frequent self harm or impaired cognitive function.
– Have no history of uncompleted medication assisted withdrawal or are likely to disengage with services for monitoring during withdrawal.
– Have a supportive home environment.
All patients who meet the above criteria can be considered for a detoxification off alcohol in primary care. For patients who fail to meet this criteria but still request for their mode of treatment to be alcohol free, an in-patient detoxification would be considered, as they would be either using other illicit drugs, be prone to alcohol withdrawal fits with little home or family support.
In terms of medications used for detoxing patients off alcohol, benzodiazepines are effective against alcohol withdrawal symptoms particularly withdrawal seizures, when compared to a placebo. Chlordiazepoxide is the first preferred choice of benzodiazepine for alcohol detoxification management.2 Benzodiazepines such as diazepam and lorazepam have a rapid onset of action but have a higher potential for dependency than those with a slower onset of action such as chlordiazepoxide. Clomethiazole should only be used in the hospital setting. This is related to the risk of dependency and the increased harmful effect if the individual is likely to continue drinking alcohol. Therefore chlordiazepoxide is encouraged to be used as the alcohol detoxification medication nationally.1 In the UK the alcohol guidelines advocate for the use of chlordiazepoxide in all community detoxifications. This is seen as the safest and best tolerated detoxification medication to use in the community.
The nurse specialist will discuss the side effects of medication use and possible complications of the symptoms of alcohol withdrawal. The individual will be advised to take time off from work and childcare responsibilities during the course of the medication regime if appropriate. The patient is then advised to stop drinking alcohol at least 12 hours prior to the commencement of the medication regime.
The individual is monitored at least twice during the first week of the detoxification programme by a specialist nurse or GP. The primary care nurse specialist determines the frequency of monitoring and whether it is face-to-face contact or telephone support. Breathalyser tests to detect breath alcohol level will be taken and blood pressure and pulse rate will be measured. The nurse specialist may decide to use a urine drug-screening test to monitor illicit drugs used during the medication regime. Any positive reading for alcohol from the alcometer during the detoxification programme should lead to the discontinuance of the medication regime.
The specialist nurse/GP will plan a follow-up treatment prior to the commencement of the community alcohol detoxification regime. The early start of the treatment is useful to prevent a relapse into drinking following the completion of alcohol detoxification. Medical treatments may be offered to individuals who express concerns about the likelihood of relapse. For patients who suffer from mental health problems such as schizophrenia and bi-polar disorder, they need a service that offers psychiatric provision and a high degree of monitoring. These are usually called complex needs services and are highly specialised.
Secondary care service/specialist care
Complex need services accept patients through referral only from professionals in other services such as primary care based services or drop-in services. Any patient with an alcohol problem, regardless of the level of complexity, is seen. The complex needs services have a range of highly qualified staff including psychiatrists, psychologists, care managers and alcohol workers/nurses from differing professional backgrounds. Treatment provided include psychosocial treatments for alcohol misuse, access to in-patient detoxification and medications to promote abstinence and importantly, assessment and management of patients with co-morbid mental health problems. The treatment is provided mainly at the service’s base separate from other services such as primary care.
Psychiatric assessments for undiagnosed dependent drinker has often been an unmet need for this population. Therefore, having a specialist service that has psychiatric services can accommodate this population. Also on offer is psychology for mental health problems, what was often an unmet need in the dependent drinking community.
Therefore, patients with complex mental health problems and problematic/dependent alcohol consumption are best treated in a professional multi-disciplinary team where comprehensive care can be given. Also as the patient risk profile is greater specialist services can monitor the patient more closely.
This is an introduction into what are the main factors influencing problematic and dependent alcohol patterns and also what can be done in terms of treatment. Much of the treatment for patients can be provided in primary care and within inner cities this should always be the first place treatment.
However, if the patient has a more complex profile such as mental health diagnosis (other than moderate depression) then a referral to specialist service should be sought. This has a high professional multi-disciplinary team to treat often clinically complex patients.
1. National Treatment Agency for Substance Misuse. Drug Misuse and Dependence- UK Guidelines on Clinical Management. 2007. National Treatment Agency for Substance Misuse.
2. Raistrick D, Heather N, Godfrey C. Review of the Effectiveness of Treat¬ment for Alcohol Problems. National Treatment Agency for Substance Misuse, London. 2006. www.nta.nhs.uk/ review-effectiveness-alcohol. aspx (accessed 22 February 2013)
3. Fernandez J. Alcohol Guidelines for Primary Care. 2004. NHS Islington Primary Care Trust, London.
4. Fernandez J, Jones MM Detoxification of metha¬done maintained patients. 2010. Drug and Alcohol Today 10(4)
5. Barratt M. Treatment Plan for Islington Services in Substance Misuse. 2009. NHS Islington, London (internal paper).
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