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Prevalence, identification and harms of alcohol use disorders

Prevalence, identification and harms of alcohol use disorders

 

Prescriber

By Graham Parsons

November 12, 2018

In the first of a two-part series on the management of alcohol use disorders (AUDs), this article discusses the prevalence of AUDs, the harms associated with alcohol misuse and how to identify and assess patients in the primary care setting.

Alcohol has a significant impact on the health of the population. In the UK there are over 10 million people drinking at levels that increase their risk of health harm. Among those aged 15 to 49 years in England, alcohol is now the leading risk factor for ill health, early mortality and disability and the fifth leading risk factor for ill health across all age groups.1

In part one of this series of articles, I will examine the prevalence, harms and identification of alcohol use disorders (AUDs). Part two will cover the pharmacological management of AUDs but will also briefly review psychosocial elements of treatment, which remain an essential element before, during and after treatment of the AUD.

Prevalence of AUDs

Alcohol dependence affects 4% of people aged between 16 and 65 years in England (6% of men and 2% of women). Of these one million alcohol-dependent people, only 6% receive treatment in any one year.2 Over 24% of the English population (33% of men and 16% of women) consume alcohol in a way that is potentially or actually harmful to their health or well-being. Alcohol misuse is also an increasing problem in children and young people. Over 24,000 children and young people were treated in the NHS for alcohol-related problems in 2008 and 2009.2

In 2016, there were 7327 alcohol-specific deaths in the UK with the highest rates in the 55- to 64-year age group. This rate remains unchanged since 2013 but is higher than that observed 15 years before (11.7 per 100,000 population in 2016 versus 10.6 per 100,000 population in 2001) and, for England, was significantly higher in the most deprived areas when compared to the least deprived areas.3

Physical, mental and social harms associated with alcohol misuse

There are now over one million hospital admissions in the UK relating to alcohol each year, half of which occur in the lowest three socioeconomic deciles. Alcohol-related mortality has also increased, particularly for liver disease, which has seen a 400% increase since 1970.1 Physical co-morbidities are common, including gastrointestinal disorders (in particular liver disease) and neurological and cardiovascular disease. Many people experience long-term consequences that may significantly shorten their life.2 In England, the average age at death of those dying from an alcohol-specific cause is 54.3 years while the average age of death from all causes is 77.6 years. More working years of life are lost in England as a result of alcohol-related deaths than from cancer of the lung, bronchus, trachea, colon, rectum, brain, pancreas, skin, ovary, kidney, stomach, bladder and prostate, combined.1

Drinking alcohol increases the risk of seven types of cancer (mouth and throat, oesophageal, laryngeal, liver, female breast and colorectal cancer) with between 4% to 6% of all new cancers in the UK in 2013 caused by alcohol consumption. The International Agency for Research on Cancer (IARC) has classified alcohol as a group 1 carcinogen noting that even drinking small amounts increases the risk of some cancers. Yet only 12.9% of respondents in a 2016 survey were aware that alcohol increases the risk of cancer.4

Co-morbid mental health disorders commonly include depression, anxiety disorders and drug misuse, some of which may remit with abstinence from alcohol but others may persist and need specific treatment.2 The physical and mental health effects of high-risk drinking are illustrated in Figure 1.

The economic burden of alcohol is substantial, with estimates placing the annual cost to be between 1.3% and 2.7% of annual GDP. Alcohol harms are estimated to cost the NHS around £3.5 billion annually. The public health burden of alcohol is wide ranging, encompassing health, social and economic harms. These can be tangible, direct costs, eg costs to the health, criminal justice and welfare systems, or indirect costs, eg costs of lost productivity due to absenteeism, unemployment, decreased output or lost working years due to premature retirement or death.1 Alcohol-related harms can also be intangible and difficult to cost, including those relating to pain and suffering, poor quality of life or the emotional distress caused as a result of living with a heavy drinker. The spectrum of harm ranges from relatively mild, such as drinkers loitering near residential streets, through to those that are severe, including lifelong disability or death. Many of these harms impact upon other people, including relationship partners, children, relatives, friends, co-workers and strangers.1

The 2016 UK Chief Medical Officers’ (CMO) low-risk drinking guidelines summarise the evidence for the heart health benefits of small amounts of alcohol to the general population, concluding that these are limited.6 The CMO states that “the net benefits from small amounts of alcohol are less than previously thought (with substantial uncertainties around the level of protection) and are significant in only a limited part of the population. That is women over the age of 55, for whom the maximum benefit is gained when drinking around five units a week, with some beneficial effect up to around 14 units a week”. Patients should therefore be advised that there are more effective methods of improving heart health such as exercise and should be discouraged from using alcohol as a positive intervention.

Wernicke-Korsakoff syndrome

Wernicke-Korsakoff syndrome is now considered to be a unitary disorder comprising of the acute condition Wernicke’s encephalopathy, which proceeds in a proportion of cases to the chronic condition Korsakoff syndrome.7 Wernicke’s encephalopathy is a medical emergency and can lead to irreversible brain damage and memory loss if not treated. Research suggests that 17–20% who develop Wernicke’s encephalopathy die and 85% of survivors go on to develop Korsakoff syndrome.8 A presumptive diagnosis of Wernicke’s encephalopathy should be made for any patient with a history of alcohol dependence who shows one or more of the following:2

  • Evidence of opthalmoplegia
  • Ataxia
  • Acute confusion
  • Memory disturbance
  • Unexplained hypotension
  • Hypothermia
  • Unconsciousness
  • Coma.

A high index of suspicion must always be maintained at all times regarding Wernicke’s encephalopathy since it rarely presents with all signs and symptoms, and the consequences of untreated Wernicke’s encephalopathy are significant. Prophylactic treatment is with thiamine (oral or intramuscular) while treatment for Wernicke’s encephalopathy requires intramuscular or intravenous thiamine. These treatments will be covered in part two of this series of articles.

Korsakoff syndrome is characterised by a memory disorder, occurring in clear consciousness, such that the patient appears to be entirely in possession of their faculties. Nevertheless, a severe impairment of current or recent memory is present and the patient often repeatedly asks the same question and fails to recognise people they have not met since the onset of their illness. Korsakoff syndrome mainly affects the consolidation of recent memory traces more than remote memories, which are often filled by ‘false memories’ or confabulations. These confabulations often represent real memories jumbled up and recalled out of temporal sequence. Approximately 25% of people with Korsakoff syndrome will require long-term institutionalisation.9

Defining, categorising and screening for AUDs

AUDs are defined and categorised according to the Alcohol Use Disorders Identification Tool (AUDIT). Produced by the WHO as an evidence-based screening tool, AUDIT allows categorisation of the level of risk associated with alcohol use.5 AUDIT defines alcohol risk into four categories, which are summarised in Table 1. The AUDIT tool remains the gold standard for identifying AUDs and is recommended by NICE for identification and for routine outcome measures.2 The shorter AUDIT-C tool uses the first three questions of the full AUDIT tool. Although its sensitivity and specificity is lower than AUDIT, it provides a practitioner with a quick assessment tool that is easy to administer and starts the conversation about alcohol use.

The severity of alcohol dependence may also be subcategorised into mild, moderate and severe using the Severity of Alcohol Dependence Questionnaire (SADQ). This assessment is important as it also indicates the treatment interventions required. For example, a score of 30 or more (severe dependence) on the SADQ tool indicates that alcohol detoxification treatment should ordinarily be employed in an inpatient or residential setting.5 We will explore the management options in different treatment settings in part two of this series of articles.

Assessing a patient with an AUD in the primary care setting

All patients presenting in primary care should be screened routinely for AUD. This can be done initially using the three-question AUDIT-C tool. Patients scoring 5 or more on AUDIT-C should be further screened using the full AUDIT tool to assess the degree of the AUD and determine appropriate interventions.

Patients scoring 20 or more on AUDIT should be referred to the local specialist alcohol treatment service if they are motivated to engage in treatment. Prior to this, the SADQ tool can be used to assess the severity of the alcohol dependency, which will support appropriate triage by the specialist service. Some local specialist alcohol services may have a pro forma for referral from primary care but if a standard template is unavailable, the following details should be provided to the specialist service as part of the referral process for an alcohol detoxification:

  • Alcohol use – current level of consumption, historical and recent patterns of drinking (a drink diary may be useful for this purpose) and, if possible, additional supporting information regarding drinking from a family member or carer
  • Assessment of the level of dependence using the SADQ tool
  • Other drug use (licit and illicit)
  • Recent blood tests (if available) including full blood count (FBC), liver function tests (LFTs), gamma-glutamyl transferase (GGT), clotting screens, urea and electrolytes (U&Es) and blood-borne virus (BBV) screening (if there is a history of drug misuse or other risk factors for BBVs)
  • Physical health problems
  • Psychological and social problems
  • Cognitive functioning using a validated tool such as the Mini-Mental State Examination (MMSE)
  • Readiness and belief in ability to change.

Patients who are not ready to engage in treatment should be given harm-reduction advice. On all occasions, patients should be warned about the risks of stopping alcohol suddenly and advised not to do so due to the significant risks associated with this, including the onset of delirium tremens, which will be covered in part two of this series. Table 2 outlines harm reduction advice that can be provided to patients at risk from AUDs who are not ready to engage in specialist treatment and Figure 2 summarises the UK CMO guidelines on alcohol consumption.

Summary

Alcohol has a significant impact on the individual and society as a whole. Primary care practitioners have a vital role in screening and educating patients on this risk, which is not limited to alcohol dependence, using validated tools and responding appropriately. Specialist alcohol service providers should support primary care practitioners in this role, especially for patients with alcohol dependence, in whom a comprehensive treatment programme that incorporates pharmacological and psychosocial elements is an essential component of the treatment plan.

Declaration of interests

Graham Parsons has received funding from Martindale Pharma to provide educational talks at conferences and from Indivior to attend a conference.

Graham Parsons is Chief Pharmacist and Pharmacist Independent Prescriber at Turning Point, London

References

  1. Public Health England. The public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies: an evidence review. December 2016. Available from:https://www.gov.uk/government/publications/the-public-health-burden-of-alcohol-evidence-review
  2. National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. CG115. February 2011. Available from:https://www.nice.org.uk/guidance/cg115
  3. Office for National Statistics. Statistical bulletin. Alcohol-specific deaths in the UK: registered in 2016. November 2017. Available from:https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/alcoholrelateddeathsintheunitedkingdom/registeredin2016
  4. Connelly D. Infographic: Drinking alcohol increases cancer risk. Pharm J 23 January 2018. Available from:https://www.pharmaceutical-journal.com/news-and-analysis/infographics/drinking-alcohol-increases-cancer-risk/20204277.article
  5. Babor TF, Higgins-Biddle JC. Brief intervention for hazardous and harmful drinking. A manual for use in primary care. World Health Organization. 2010. Available from:http://www.who.int/iris/handle/10665/67210
  6. Department of Health. UK Chief Medical Officers’ low risk drinking guidelines. August 2016. Available from:https://www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking
  7. Lingford-Hughes AR, et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity. J Psychopharmacol 2012;26(7):899–952. Available from:https://www.bap.org.uk/pdfs/BAP_Guidelines-Addiction.pdf
  8. Victor M, et al, eds. The Wernicke-Korsakoff syndrome and related neurological disorders due to alcoholism and malnutrition, 2nd edn. Philadelphia, PA: FA Davis.
  9. Thompson AD, Marshall EJ. The treatment of patients at risk of developing Wernicke’s encephalopathy in the community. Alcohol Alcoholism 2006;41(2):159–67.
  10. Drinkaware. UK alcohol guidance: CMOs’ low risk drinking guidelines. Available from:https://www.drinkaware.co.uk/alcohol-facts/alcoholic-drinks-units/latest-uk-alcohol-unit-guidance

Prevalence, identification and harms of alcohol use disorders.