This site is intended for health professionals only

Cheers! A guide to managing alcohol problems

Hazel Watson
MN PhD RGN RMN RNT
Professor of Nursing
Caledonian Nursing and Midwifery Research Centre
Glasgow Caledonian University
Glasgow
E:h.e.watson@gcal.ac.uk

Alcohol can induce feelings of wellbeing, making us feel more relaxed and sociable. Not only is it associated with positive social effects, there is also evidence that, at a reasonable level, alcohol can be beneficial to physical wellbeing.(1) However, it is also the most commonly abused substance in the world and, when alcohol is used inappropriately, it can give rise to health, emotional and social problems. When mixed with human emotion, it can increase feelings of despair to the point of suicide.
In the UK nearly one in three adults in England (39% of men and 22% of women) regularly consume alcohol at levels that exceed the recommended "sensible drinking limits" on at least one occasion per week,(2) and one in four men and one in eight women experience serious alcohol-related health problems during their lives.(3)
Excessive alcohol consumption is a risk factor in disorders of every one of the body's systems. Because of the widespread consequences, patients with alcohol-related health problems receive treatment in accident and emergency departments and general hospital wards as well as from the specialist alcohol services. Excessive drinkers present to GPs twice as often as average patients.(4,5) Community nurses and those working in association with any of the above services are therefore highly likely to encounter people with alcohol problems.
Early alcohol-related problems include accidents associated with intoxication, which may range from relatively minor cuts and bruises to major road traffic accidents. Gastritis, hypertension and insomnia are also considered to be early symptoms, which can alert the perceptive health professional to the possibility of an underlying alcohol problem and the need to probe further. Alcohol is also implicated in the development of many serious diseases, such as hypertension, stroke, oral and oesophageal cancer, and liver problems. Distinctions can be drawn between those problems caused by intoxication and those by regular heavy drinking (Table 1).

[[NIP11_table1_44]]

Screening
Accurate assessment of alcohol consumption is the key to detection of problem drinking. Without this ­assessment, health professionals may fail to recognise problem drinkers, and opportunities for providing appropriate information may be missed. Descriptive statements, such as "social" or "heavy drinker", are not helpful as they are subjective and open to interpretation in different ways by different people. On the other hand, the use of an accepted system, which measures consumption in standard units of alcohol, has the advantage of providing an objective estimation that can be recorded and compared with future reports of consumption.
One standard unit of alcohol contains 8g of ethanol and is equivalent to the following measures:

  • Half a pint of lager or light beer (3.5% alcohol content by volume).
  • A measure of spirits (one-sixth gill/25ml).
  • 50ml of fortified wines (for example, sherry and ­vermouth).
  • 125ml of table wine.

When assessing alcohol consumption it is useful to note not only how much alcohol an individual consumes, but also the pattern of consumption. This is important because it influences the nature of the advice to be given. Binge drinkers, whose drinking is concentrated on one or two days a week, are likely to experience different problems from those who drink as much but in smaller amounts on a more regular basis. For this reason, quantity/frequency measures, calculated by multiplying the average amount of alcohol consumed by the number of drinking days a week, are not advised.
The use of a drinking diary provides a record of alcohol consumption over a specific period of time, thus incorporating both the pattern and level of consumption (see Figure 1). This should be recorded retrospectively for the week immediately before the assessment and is achieved by asking the patient/client how much he/she drank on that particular day, the day before, the day before that, and so on. It is likely that prompts will be required, such as: " Try to remember where you were and who you were with …" The responses should be recorded on the chart and kept in the patient/client's notes. An additional reason for making a detailed record of alcohol consumption is that it can influence the nature of the advice for those individuals whose drinking exceeds the limits for moderate, or responsible, drinking. Helping them to consider their levels, triggers and patterns of drinking by reflecting on the previous week can, in itself, be an effective intervention that results in their cutting down. In the case of moderate drinkers, a drinking diary can help them see that they are consuming levels that exceed the sensible drinking guidelines, although they may, as yet, be ­experiencing few alcohol-related problems.

[[NIP11_fig1_45]]

The Alcohol Use Disorders Identification Test (AUDIT), a 10-question assessment tool, has been developed by the World Health Organization and can distinguish early problem drinkers who are amenable to relatively simple advice in the form of a "brief intervention" from those with signs of dependence, for whom referral to specialist services is appropriate (see "Resources" section).
For an alcohol assessment to be meaningful, nurses need to know what levels of consumption are associated with increased risk. There has been some debate about this in recent years. The Royal College of Physicians, Royal College of Psychiatrists, Royal College of General Practitioners and British Medical Association have all recommended that men should drink less than 21 units a week and women less than 14 units a week.
The Department of Health's advice is that health risks increase for men who drink more than three to four units a day, and for women who drink more than two to three units a day. This is open to interpretation - should it be seen as a change to daily rather than weekly limits, or alternatively as an increase in the weekly limits? Certainly, the Department's advice to consider day-to-day consumption is commendable as it avoids the possibility of construing the consumption of 14 or 21 units in one day as either safe or sensible. The weight of medical and scientific authority, however, supports the view that, for most people, relative risk increases with an increase in alcohol consumption, as shown in Table 2, with the proviso that drinking should not be confined to only one or two days in the week.

[[NIP11_table2_46]]

Screening for alcohol problems should become a routine part of assessment of lifestyle factors such as diet and smoking, and questions should be asked in a matter-of-fact and nonjudgemental manner. Health professionals ought to consider their own attitudes to drinking, which should not be allowed to influence their approach.

Brief interventions
There is now convincing evidence of the effectiveness of brief interventions for people whose drinking places them at risk of developing alcohol-related health problems.(6,7) Brief, sometimes referred to as "minimal", interventions are defined as interventions for problem drinkers whose level of alcohol consumption places them at risk of problems associated with their drinking but who have few, if any, symptoms of alcohol dependence.
These strategies are within the scope of healthcare professionals who have not received specialist training in substance abuse, such as nurses and doctors who work in primary and acute care settings, and community ­pharmacists. Such interventions comprise:

  • Giving patients information about the links between their drinking and any identified health or social problems.
  • Teaching them how to calculate how much they drink.
  • Giving information about moderate drinking ­limits and health risks associated with increasing levels of consumption.
  • Giving information about how to cut down their consumption.
  • Discouraging binge drinking.
  • Giving advice about spreading drinking ­throughout the week.
  • Pointing out that everyone should have at least one alcohol-free day each week.

This can take as little as 5-10 minutes. The advice may be given verbally and can be supplemented with relevant reading material, such as that produced by Health Education Authorities/Boards and Drinkwise.
People are more likely to change habits if they recognise that there are benefits in doing so. For this reason it is helpful to encourage at-risk drinkers to draw up a "balance sheet" of what are, for them, the positive and negative effects of drinking. This helps the individual to focus on the effects of their drinking and to decide for themselves that they should change.
Studies have indicated that, a year after receiving such advice, problem drinkers reported statistically significant reductions in the amount of alcohol they drank.(8-10) They also had a significant reduction in the number of alcohol- related health problems and an improvement in liver function tests. There is evidence that such improvements are sustained over a four-year period and are accompanied by reduced hospital re­admission rates, indicating that early detection of problem drinking followed by such interventions are cost-effective alternatives to more intensive forms of treatment.
Another interesting feature of this research is that reductions in mean drinking levels occurred in the control group as well as in the treatment groups. One possible reason may be that the detailed enquiry into drinking behaviour acted in itself as an intervention, raising awareness of potentially harmful levels of alcohol consumption. This suggests that simply asking people about alcohol consumption may act as an intervention in its own right. It could be that talking in detail about the amount they drink - at a time when, being unwell and therefore perhaps more sensitive to health-related issues - is sufficient to encourage them to consider the implications of their drinking on their health.
 
Alcohol dependence
Individuals who have a long history of regular drinking are likely to become dependent drinkers. They may present with signs of physical dependence, such as tremor that is relieved by drinking in the morning, an increased tolerance of alcohol (in which they need to consume increasing amounts to gain the same effects), a strong compulsion to drink, and diminished control over their drinking. If access to alcohol ceases abruptly, people who are dependent on it are likely to ­experience physical and psychological symptoms of withdrawal. Severe withdrawal can be life-threatening, so patients who are drinking at harmful levels, or clearly in a dependent way, should be referred to specialist alcohol services.
Severely dependent individuals are likely to undergo detoxification in hospital, but most alcohol withdrawal can be managed at home. Orally administered diazepam 5mg or chlordiazepoxide 20mg, four-hourly in the first 24 hours, is usually prescribed before the onset of withdrawal symptoms. The first dose should not, however, be administered until the breath alcohol test registers zero. The drug regimen should be closely supervised and tailored to reduce over five to six days.
 
Relapse prevention
Many people find self-help groups, such as Alcoholics Anonymous or local Councils on Alcohol (phone numbers in local directories), of value in helping to prevent relapse. The specialist NHS alcohol services offer a range of psychosocial interventions based on enhancing and maintaining motivation to change, identifying cues and triggers that lead to drinking, and rehearsing coping strategies. Some pharmacological preparations have been shown to be useful in complementing psychosocial therapies. These include disulfiram and acamprosate.
Disulfiram affects the metabolism of ethyl alcohol so that, if alcohol is consumed when taking disulfiram, potentially toxic levels of acetaldehyde are produced, leading to facial flushing, tachycardia, hypotension, nausea, dyspnoea and blurred vision. These unpleasant effects have been shown to act as a deterrent and can help people to remain abstinent, but it is most effective when its administration is supervised by a third party. It can be of particular value in helping people to resist alcohol at special occasions when risk increases. The effects vary in severity with the amount of alcohol consumed, and large quantities can lead to life-threatening symptoms. Patients who are prescribed disulfiram should be made aware of the dangers of eating foods and other substances, such as medicines, which may contain alcohol. Contraindications include severe short-term memory impairment, cardiovascular disease, liver disease, pregnancy, lactation and nonalcohol-related psychotic symptoms.
Acamprosate reduces the sensation of craving for alcohol and is therefore useful in maintaining abstinence. It does not interact with alcohol, so can be continued during relapse. Its most commonly reported side-effect is diarrhoea. It is absolutely contraindicated in renal insufficiency, liver failure, pregnancy and lactation.

Conclusion
Alcohol-related health problems constitute a major source of morbidity and mortality. However, the progression from low-risk drinking to alcohol dependence is by no means inevitable. Consequently, there are opportunities for nurses to detect potential problem drinkers as well as becoming involved in the management and treatment of those with more entrenched problems.
The Nursing Council on Alcohol has been set up to provide appropriate support, advice and information to nurses about the prevention and management of alcohol-related problems, irrespective of their place of work, thereby reducing alcohol-related harm. If you are interested in finding out more about what nurses can do to help problem drinkers, or prevent alcohol-related harm in the first place, or for more information on the Nursing Council on Alcohol, you can write or email the author or access the website - www.show.scot.nhs.uk/nca 

References

  1. Klatsky AL. Is drinking healthy? In: Peele S, Grant M, editors. Alcohol and pleasure: a health perspective. Washington DC: International Center for Alcohol Policies; 1999. p. 141-56.
  2. Office of National Statistics. Living in Britain: results from the 2001 general household survey. London:The Stationery Office; 2003.
  3. Alcohol Concern. Britain's ruin. London: Alcohol Concern; 2000.
  4. Hartz C, et al. Alcohol and health: a handbook for nurses, midwives and health visitors. London: The Medical Council on Alcoholism; 1990.
  5. Deehan A, Templeton L, Taylor C, Drummond C, Strang J. Are practice nurses an unexplored resource in the identification and management of ­alcohol misuse? Results from a study of practice nurses in England and Wales in 1995. J Adv Nurs 1998;28:592-7.
  6. World Health Organization Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. Am J Public Health 1996;86:948-55.
  7. Fleming M, Manwell LB. Brief ­interventions in primary care settings. Alcohol Res Health 1999;23:128-37.
  8. Monteiro MG, Gomel M. World Health Organisation on brief ­interventions for alcohol-related ­problems in primary health care settings. J Substance Misuse Nurs Health Soc Care 1998;3(1):5-9.
  9. Watson HE. A study of minimal interventions for problem drinkers in acute care settings. Int J Nurs Stud 1999;36:425-34.
  10. Heather N. Brief interventions. In: Heather N, Peters TJ, Stockwell T, editors. International handbook of ­alcohol dependence and problems. New York: Wiley; 2001. ch. 31.

Resources
The Nursing Council on Alcohol
W:www.show.scot.nhs.uk/nca

The UK Alcohol Forum Booklet
Guidelines for the management of alcohol problems in primary care and general psychiatry
Available at: W:www.ukalcoholforum.org

Drinkwise
W:www.drinkwise.co.uk

Alcoholics Anonymous UK
W:www.aa-uk. org.uk