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Alcohol consumption: the risks and the treatment

Rachel Harrison
BSc(Hons)
Medical Student

Nick Sheron
MD FRCP
Consultant Hepatologist
Liver Unit
University of Southampton
Medical School and Southampton University Hospitals Trust

Historically the UK has been a heavy drinking nation. Alcohol use has followed cycles of increased usage, alcohol-related harm and levels of public drunkenness. In the mid-1750s Hogarth depicted the consequences of an estimated eight million gallons of cheap gin imported from the Netherlands. One quarter of London houses were "gin houses", which led to the 1751 Gin Act. Alcohol consumption and harm peaked again at the start of the 20th century, until the combined effects of legislation and two world wars reduced the levels of consumption.
Alcohol is now relatively cheaper than at any time in the last 100 years, and increased levels of consumption are once again leading to very high levels of alcohol-related harm (see Figure 1). Alcohol misuse costs around £20bn a year through alcohol-related disorders and disease, crime and antisocial behaviour, loss of productivity in the workplace and social harm, including domestic violence.(1) More worryingly, it is predicted that these figures will continue to grow following current trends.
Ninety percent of UK adults drink regularly. Over 27% of men and 17% of women consume more than the recommended alcohol intake (21 units a week for men and 14 units a week for women; see Box 1). Five percent of men and 3% of women will drink over 50 or 35 units a week - the level at which alcohol becomes a serious health risk.(1)

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Patterns of drinking
The UK is unique in Europe as being the only country with increasing alcohol intake and deaths from alcoholic liver disease. The World Health Organization specifies three areas of alcohol use disorders:(2)

  • Hazardous drinking - drinking above recognised sensible levels but not yet experiencing harm.
  • Harmful drinking - people drinking above sensible levels and experiencing harm.
  • Alcohol dependence - people drinking above sensible levels and experiencing harm and symptoms of alcohol dependence.

Two patterns of drinking are particularly likely to lead to harm:(2)

  • Binge drinking - drinking over twice the daily guideline in one day, implying heavy or risky consumption of alcohol in a single session with the aim of getting drunk.
  • Chronic drinking - sustained drinking, which causes or is likely to cause risk of harm.

Who is at risk?
As previously mentioned, a lot of the risks associated with alcohol depend on the individual's drinking pattern. Young adults, aged 18-24 years, who are binge drinking on a regular basis are more likely to have complications such as accidents, injuries and assaults. They are also at risk of sexually transmitted infections, unwanted pregnancies and sexual assaults. Increasing awareness within schools and higher education may help to reduce the levels of harm and prevent the establishment of future heavy drinking. However, more important is the influence of parents and peers - one of the main targets of the £800m that the drinks industry spends on advertising and marketing every year.
Alcohol is a highly addictive drug, and a substantial minority of drinkers will develop a dependency as severe as heroin or cocaine addiction. Alcohol dependency is characterised by tolerance to the effects of alcohol and a physiological withdrawal state when alcohol use is reduced or ceased. It involves continued use despite evidence of harm to self, neglect of normal daily activities due to alcohol, and a strong desire to drink. Recognising alcohol dependency requires more specialist intervention  - with a treatment goal of lifelong abstinence.
Some people enjoy a few drinks at the end of a long day at work and perhaps a few more at weekends. Over the years one glass of wine a night becomes two or three, or more. More than half of our patients with alcohol-related liver diseases fall into this category of the "heavy social drinker". They may never get obviously drunk, and they are not "alcoholics", but they are drinking enough over 10-20 years to severely damage their health. It is this group that primary care may be particularly effective in targeting with the measures discussed here.

What are the risks?
A moderate amount of alcohol, up to 14-21 units a week, probably does little in the way of harm and may have some health benefits by lowering the risk of death from coronary heart disease for people over the age of 40.(1) Above this level alcohol is clearly harmful to the health, increasing the incidence of high blood pressure, stroke, alcoholic liver disease, pancreatitis and cancer.
Alcohol consumption is associated with raised blood pressure - 300 deaths a year are due to hypertension related to alcohol consumption. Hypertension is also a risk factor for cerebrovascular accidents, of which 1,200 deaths a year are associated with alcohol use.(2) Alcohol consumption and cancers in the oral cavity, pharynx, larynx and oesophagus, liver, pancreas, colon, rectum and breast are closely dependent. It is estimated that 5,000 deaths a year from cancer are attributable to alcohol.(2) Alcohol is known to contribute to anxiety and depression - 15-25% of suicides and 65% of suicide attempts are related to alcohol.(2)
Half of all liver diseases are caused by alcohol.(3) Liver disease from alcohol consumption forms a spectrum from the relatively benign fatty liver to alcoholic hepatitis and liver cirrhosis. Eighty percent of all heavy drinkers (more than 50 units a week for men or more than 35 units a week for women) will develop fatty liver, but only 20% will progress to cirrhosis within a 10-year period (see Figure 2). Alcohol-related liver disease causes 4,500 deaths a year.(2)

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The key message is that it is never too late to stop drinking. Even with the most severe degrees of cirrhosis, enormous clinical improvements are possible. The skill of a good liver unit lies first in keeping patients alive to enable them to stop drinking, and secondly in motivating as many patients to stop drinking as possible. In our unit the long-term abstinence rate is around 50%, and with specific nurse-led intervention and follow-up we are able to increase this to 60-70%.

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What can nurses do?
There is no mystery to dealing with alcohol-related problems or, preferably, potential problems. The majority of patients seen in primary care are perfectly capable of moderating their drinking back to safe levels - they just require a little guidance. The overwhelming experience in our liver clinic is that it is far easier to get someone to reduce his or her alcohol intake than it is, for example, to reduce his or her weight.
Brief interventions are highly effective. They involve five to 10 minutes of structured advice about alcohol over one to five sessions (see Box 3). At least half of the subjects will respond positively, with overall numbers needed to treat less than those for smoking cessation advice.(4) If consistently implemented, primary care-based interventions could reduce levels of drinking from hazardous and harmful to low risk for 250,000 men and 67,500 women each year.(2) Probably the single most important factor is to get specific training in these interventions, and then to do what you can in terms of simple advice.
The question then becomes who to intervene with and when. The most effective way to determine this is through the use of a simple screening test on all subjects. The fast alcohol screening test (FAST), for example, uses a single question on most subjects, with a maximum of four questions, but is able to detect hazardous levels of drinking in 95% of cases (see Box 2).(5) In contrast, the standard method of taking a typical "alcohol history" is clumsy, long-winded and often inaccurate.
Nurses have been described as an underutilised resource for screening and brief interventions in primary care. Their involvement in alcohol intervention remains low despite primary care nurses demonstrating an ability to reduce excessive drinking.(6)

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Conclusion
The number of people that are abusing alcohol is on the increase. The cost is socially and economically growing, and most importantly to healthcare professionals, morbidity and mortality due to excess alcohol consumption is a very real problem. But this can be identified at an earlier stage, and a high proportion of alcohol-related illness and death could be prevented. Not all dependent drinkers will develop severe
complications; therefore screening and brief interventions are important in identifying those at risk.
These strategies have been proven to be cost-effective and successful at reducing heavy drinking. Trained nurses with appropriate support should be able to implement these strategies within primary care.

References

  1. Cabinet Office. Alcohol harm reduction strategy for England 2004. London: The Prime Minister's Strategy Unit; 2004.
  2. Department of Health. Alcohol misuse interventions: guidance on developing a local programme of improvement. Available from http://www.dh.gov.uk/publications
  3. Sheron N. Alcoholic liver disease. In: O'Grady J, Lake J, Howdle P, editors. Principles of clinical hepatology. London: Mosby; 2000.
  4. Verrill C, Sheron N. Alcohol related harm - a growing crisis: time for action. Clin Med 2005;5:154-7.
  5. De Silva AN, Sheron N. Alcohol related liver problems - strategies for primary care. Clin Focus Prim Care 2005;1(2):61-4.
  6. Kaner E, Lock C, Heather N, McNamee P, Bond S. Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial. Patient Educ Counselling 2003;51:277-84.

Resources
Alcoholics Anonymous UK
W:www.
alcoholics-anonymous.org.uk
Alcohol Concern
W:alcoholconcern.org.uk
Addaction
W:addaction.org.uk