Management of alcohol misuse
On the last page we saw what hazardous, harmful and dependent drinking behaviours were and what consequences they can have on the body. Individuals drinking in these ways should be offered help with their problem. To help identify who might benefit from support, primary care teams often use screening questions to identify who may need help and then might signpost the patient to the GP for further input. These are the CAGE questions and/or the AUDIT tool (Alcohol Use Disorders Identification Test).
The three main components of managing alcohol misuse are psychological therapy, group based therapy and sometimes pharmacotherapy. How these are delivered varies across the country but might range from sole action from the patient's GP to community groups or specialist addiction services.
Psychological Therapies
The most basic form of psychological help is brief intervention. This comprises an assessment of recent intake and then provision of information about hazardous/harmful drinking, clear specific advice on options supported by literature and contact details of local support agencies. This is often available from your local alcohol service in the form of a leaflet.
There are many barriers to change of course and simply confronting and challenging patients who may not share your own views about their drinking is useless: it creates frustration for both parties. Motivational Interviewing can be very helpful in avoiding such problems. In motivational interviewing, the clinician allows the patient to arrive at their own decision about changing harmful habits. One method used in motivational interviewing is to ask about the pros and cons about their current drinking levels, about reducing and about stopping. First the clinician asks about the pros in each category and then asks 'what's not so good' about those options too. Talking about them in this way makes it clear there are options (or a menu) available to the patient.
Brief Intervention through motivational interviewing has five essential components, known as FRAMES (Hester & Miller, 1995):
Pharmacotherapy
Disulfiram (Antabuse) - inhibits hepatic alcohol-dehydrogenase and so causes a rapid build of of aldehyde. This produces a flushing reaction and often nausea, vomiting, tachycardia and hypotension. The combination of disulfiram with alcohol can be severe and it must be used with caution.
Naltrexone - is an opiate receptor antagonist and has shown to have a significant albeit modest effect on drinking behaviour. The drug is contraindicated in current opiate users, for obvious reasons.
Acamprosate (calcium acettlyhomotaurinate) is a glutamate antagonist and has a significant but modest effect on behaviour. The benefits increase with time and so is usually given in 12-18 month courses.
Selincro (nalmefene) - has recently been approved by NICE for use to reduce harmful drinking/dependence. Studies have suggested it's effect when used in combination with counselling could be significant.
It is often local policy NOT to prescribe such agents without the input from a specialist alcohol service.
Self-help Groups
Alcoholics Anonymous is the most famous self help group in the world. They provide a 12-step recovery programme with abstinence as the goal. Al-Anon is a parallel organisation for the relatives/partners of people struggling with alcohol abuse. These groups offer an opportunity for mutual support and sharing of experiences which can have profound impacts.
Community-Based Services
Usually involve a Specialist Community Psychiatric Nurse (CPN) with skills in assessment and management of alcohol misuse and withdrawal and relapse prevention techniques, counsellors and often a physician with an interest in the area.
Specialist Addiction Services
Are run by the NHS and are usually headed by a consultant psychiatrist, clinical psychologists, specialist nurses, occupational therapists and counsellors. They can co-odrinate detox treatments on an inpatient or outpatient basis.
For more information and other educational resources about alcohol and alcohol related liver disease go to:
The three main components of managing alcohol misuse are psychological therapy, group based therapy and sometimes pharmacotherapy. How these are delivered varies across the country but might range from sole action from the patient's GP to community groups or specialist addiction services.
Psychological Therapies
The most basic form of psychological help is brief intervention. This comprises an assessment of recent intake and then provision of information about hazardous/harmful drinking, clear specific advice on options supported by literature and contact details of local support agencies. This is often available from your local alcohol service in the form of a leaflet.
There are many barriers to change of course and simply confronting and challenging patients who may not share your own views about their drinking is useless: it creates frustration for both parties. Motivational Interviewing can be very helpful in avoiding such problems. In motivational interviewing, the clinician allows the patient to arrive at their own decision about changing harmful habits. One method used in motivational interviewing is to ask about the pros and cons about their current drinking levels, about reducing and about stopping. First the clinician asks about the pros in each category and then asks 'what's not so good' about those options too. Talking about them in this way makes it clear there are options (or a menu) available to the patient.
Brief Intervention through motivational interviewing has five essential components, known as FRAMES (Hester & Miller, 1995):
- Feedback about the risk of personal harm
- Stress personal Responsibility for making the change
- Advice to cut down or stop drinking
- provide a Menu of alternative strategies
- Empathy
- Self efficacy: a style that leaves the patient motivated at the end
Pharmacotherapy
Disulfiram (Antabuse) - inhibits hepatic alcohol-dehydrogenase and so causes a rapid build of of aldehyde. This produces a flushing reaction and often nausea, vomiting, tachycardia and hypotension. The combination of disulfiram with alcohol can be severe and it must be used with caution.
Naltrexone - is an opiate receptor antagonist and has shown to have a significant albeit modest effect on drinking behaviour. The drug is contraindicated in current opiate users, for obvious reasons.
Acamprosate (calcium acettlyhomotaurinate) is a glutamate antagonist and has a significant but modest effect on behaviour. The benefits increase with time and so is usually given in 12-18 month courses.
Selincro (nalmefene) - has recently been approved by NICE for use to reduce harmful drinking/dependence. Studies have suggested it's effect when used in combination with counselling could be significant.
It is often local policy NOT to prescribe such agents without the input from a specialist alcohol service.
Self-help Groups
Alcoholics Anonymous is the most famous self help group in the world. They provide a 12-step recovery programme with abstinence as the goal. Al-Anon is a parallel organisation for the relatives/partners of people struggling with alcohol abuse. These groups offer an opportunity for mutual support and sharing of experiences which can have profound impacts.
Community-Based Services
Usually involve a Specialist Community Psychiatric Nurse (CPN) with skills in assessment and management of alcohol misuse and withdrawal and relapse prevention techniques, counsellors and often a physician with an interest in the area.
Specialist Addiction Services
Are run by the NHS and are usually headed by a consultant psychiatrist, clinical psychologists, specialist nurses, occupational therapists and counsellors. They can co-odrinate detox treatments on an inpatient or outpatient basis.
For more information and other educational resources about alcohol and alcohol related liver disease go to:
- e-GP (modules about alcohol issues and brief advice/intervention)
- BMJ Learning has a great module on alcoholic liver disease.
- RCGP Certificate in the Management of Alcohol Problems in Primary Care.
- Patient.co.uk - Approach to managing alcohol abuse.
References
Hester RK, Miller WR. Handbook of Alcoholism Treatment Approaches (2nd Edition). 1995.
Royal College of General Practitioners. RCGP Guide to The Management of Substance Misuse in Primary Care (2nd Edition) 2013. pp.231-232.
Hester RK, Miller WR. Handbook of Alcoholism Treatment Approaches (2nd Edition). 1995.
Royal College of General Practitioners. RCGP Guide to The Management of Substance Misuse in Primary Care (2nd Edition) 2013. pp.231-232.