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Alcohol dependence
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Module 196: December 2013
Treatment approaches to alcohol dependence vary according to the extent of the disorder and the
individual circumstances and health status of the patient
(This module was facilitated by Dr Garrett McGovern)
Alcohol has a particular place in Irish culture. As
a nation we drink far in excess of most of our European
counterparts. In a survey carried out in 2003, Ireland
ranked third behind Hungary and Luxembourg for drinking
most alcohol among a group of 26 countries. The writer and
journalist John Waters once wrote: “Drinking in Ireland is
not simply a convivial pastime, it is a ritualistic alternative
to real life, a spiritual placebo, a fumble for eternity, a
longing for heaven, a thirst for return to the embrace of the
Almighty.”
Ireland may well rank high up in the international league
table of drinkers but it is estimated that only about 10%
of those who drink excessively actually present for formal
treatment. There are a number of reasons why this figure
is so low including stigma, fears around anonymity, poor
insight and lack of faith in current treatment options. Any
sensible national policy around alcohol needs to address
the issue of treatment, which has been under resourced for
many years.
Approaching the problem in general practice
Family doctors are in a unique position when it comes
to treating patients. They often know their patients and
families well, and a bond of trust has developed over many
years. Screening for alcohol problems should be relatively
simple and yet far too few established alcohol problems are
picked up in general practice. There are many possible reasons for this. Problem drinking often has an insidious onset
and its clinical signs may not be obvious. A routine trip to
the GP with alcohol-related symptoms such as depression
or heartburn may not yield the likely cause unless questions
around alcohol use are addressed.
Brief interventions are a simple and cost effective early
intervention, and are successful in one in 10 drinkers without the need for more formal treatment. A brief intervention
is defined as any therapeutic intervention of short duration (one to five sessions) designed to influence patients
to think more proactively about their alcohol consumption.
Despite their relative effectiveness, brief interventions are
not widely used in general practice. There are a number of
brief screening tools which are simple to carry out. These
include the CAGE and AUDIT questionnaires, with which
many GPs will be familiar. Routine questions about alcohol
intake should be asked with the specific intention of ruling
in or ruling out a problem, and the way in which the GP
couches the question is as important as the question itself.
For example, a far more effective question than ‘do you take
a drink?’ might be ‘do you drink often?’
If the patient responds that they do drink often then you
might ask them how often and do they ever ‘overdo it’? This
is important because it can guide the GP to the context and
extent of the patient’s drinking in an less intrusive way.
It is then easier to piece together the physical symptoms
with the level of drinking and this will reduce the stigma
the patient may feel in being quizzed on a sensitive issue.
Classification of alcohol dependence syndrome
Alcohol dependence syndrome (ADS) is defined by The
World Health Organization’s ICD-10 as “a cluster of physiological, behavioural and cognitive phenomena in which the
use of alcohol takes on a much higher priority for a given
individual than other behaviours that once had greater
value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes
overpowering) to take alcohol. There may be evidence that
return to alcohol use after a period of abstinence leads to a
more rapid reappearance of other features of the syndrome
than occurs with non-dependent individuals”.
A definite diagnosis of dependence should usually be
made only if three or more of the following have been experienced or exhibited at some time during the previous year:
• A strong desire or sense of compulsion to take alcohol
• Difficulties in controlling alcohol-taking behaviour in
terms of its onset, termination or levels of use
• A physiological withdrawal state when alcohol use
has ceased or been reduced, as evidenced by – the
This healthcare professional education is sponsored by Lundbeck Ireland Ltd.
Lundbeck had no editorial oversight of the final content.
DISTANCE LEARNING Managing alcohol dependence in general practice
Table 1. Advantages of GP involvement
in management of alcohol dependence
• O
ften has extensive knowledge of patient’s medical
history
• Empathic approach
• Can provide support for family in crisis
• Excellently-positioned to screen for alcohol problems
• Can provide brief interventions
• W
ith resources and expertise, can play a significant role
in providing treatment
• Can provide treatment for medical complications or
refer to specialist services where indicated
characteristic withdrawal syndrome for alcohol; or use
of the alcohol with the intention of relieving or avoiding
withdrawal symptoms
• E vidence of tolerance, such that increased doses of
alcohol are required in order to achieve effects originally
produced by lower doses
• Progressive neglect of alternative pleasures or interests
because of alcohol use, increased amount of time necessary to obtain or take alcohol or to recover from its effects
• Persisting with alcohol use despite clear evidence of
overtly harmful consequences.
The severity of alcohol dependence questionnaire (SAD-Q)
is a very useful way of measuring dependence by asking
multiple choice questions on symptoms primarily related to
withdrawal. Each answer is weighted according to a Likerttype scale ranging from a zero score for an ‘almost never’
to a three for ‘nearly always’, with a range of other options
in between. The score can then be measured according to
the following ranges:
• A score of 31 or higher indicates ‘severe alcohol
dependence’
• A score of 16-30 indicates ‘moderate dependence’
• A score of below 16 usually indicates ‘mild physical
dependency’.
The SAD-Q can be quite useful in guiding the clinician
to the extent of an alcohol problem but should be used in
conjunction with other assessment and screening tools and,
most importantly, clinical judgement.
There are other areas of the assessment and history that
are important and relevant to alcohol dependence. As GPs
will know many of the patients they treat very well, they will
often have detailed information about them already on file.
With increasing constraints being placed on GPs, the time
spent with a patient struggling with alcohol needs to be
targeted, efficient and goal-orientated. If a GP feels that the
level of severity and complexities of the case are beyond his
or her level of expertise, then they should refer to a specialist who can provide the appropriate advice and care.
Unfortunately, many GPs do not have a readily available pathway of referral that will meet the needs of every
patient. There are a number of barriers to referral including
cost, setting (eg. inpatient versus outpatient), the treatment
philosophy of specialist centres (eg. abstinence versus
FORUM December 2013
harm reduction) and levels of patient motivation. Often the
GP is left in a position where they treat the problem with
inadequate or absent resources. This is a very difficult and
tricky position for the GP who has the ultimate responsibility of providing care. There is no doubt that more money
and resources are needed to support community alcohol
treatment than are currently provided. There should also
be a facility for GPs to talk to specialists in drug and alcohol treatment services should the need arise. Education
is important and there are many courses provided by the
various colleges (ICGP, CPsychI) that can provide GPs with
better skills in approaching patients misusing alcohol.
The mildly alcohol dependent patient
Often patients who are misusing alcohol at the mild end
of the scale are missed as the problem may not seem obvious or the presentation is unrelated to their use of alcohol.
Again, a few routine but targeted queries can provide the
GP with useful information and little more than a brief
intervention may be enough to make patients more mindful about their drinking, particularly if their alcohol use is
in some way related to their presenting symptoms. Written
information in the form of leaflets or online links can reinforce the importance for patients of being more aware of the
negative impact that alcohol can have on their mental and
physical health. Formal treatment is often not required for
mild cases but any patient expressing a wish for specialist
help should be referred appropriately.
The moderately alcohol dependent patient
The greater the severity of an alcohol problem, the less
effective brief interventions tend to be and a more intensive approach is often required. This is not to say that
brief interventions should be abandoned as they can be an
important screening tool for all types of alcohol dependence. Like mild cases, moderate alcohol abuse is often not
directly picked up in general practice. Patients will present
with other problems and if they want to conceal the extent
of their drinking they will do so without too much difficulty, even when faced with abnormal liver function tests or
physical signs suggestive of over-drinking (eg. alcohol fetor,
hypertension, depression or features of alcohol withdrawal).
It is the skill of the GP, in tying together the signs and
symptoms of alcohol misuse, that will be a crucial determinant in preventing such a patient from ‘slipping through the
net’. A sensitive approach is important as patients tend to
respond poorly when the advice is dictatorial.
The following example illustrates effective responses to
queries about depressive symptoms:
GP: “When do you feel most depressed?”
Patient: “In the morning doctor.”
GP: “Would this be every morning or would it be
worse at any particular time? I’m talking about
stresses, worries or perhaps after taking alcohol.”
Patient: “Yes, I feel really down after I have been drinking
the night before.”
GP: “Would this happen often?”
Patient: “Recently, yes. I have been drinking a lot more
than normal.”
DISTANCE LEARNING Managing alcohol dependence in general practice
This has led the GP to an important component, if not
the cause, of this patient’s problem. The doctor has tread
carefully and established that the patient is becoming more
dependent on alcohol. This has been a crucial intervention because the GP can now offer the appropriate advice
having established the role of alcohol in the context of the
patient’s depressive symptoms. This also helps to reduce
the stigma to the patient and enhances the therapeutic alliance – key features of an effective outcome.
Best treatment approach
Having established the problem, the next step for the
GP is deciding what is the best treatment approach that
will meet the needs of the patient? Treatment should
always be individualised and take into account other
issues such as psychiatric history, social circumstances,
employment, confidentiality and family support. For
example, there is little point in referring a working
father of three children to an inpatient facility that he
is reluctant to attend or if he cannot take time off work.
Equally, it will be difficult to treat a patient with complex
medical and psychiatric needs who is drinking heavily
in the community, and the best option may be inpatient
detoxification, even for a short period of time until their
condition has stabilised.
Regardless of the setting there are a number of important
evidence-based treatment interventions. GPs need to first
decide whether they have the expertise and resources to
treat the problem. With moderately severe alcohol dependence it is likely that the patient will need to be referred
and may need detoxification with chlordiazepoxide. This
is to help with alcohol withdrawal symptoms and the dose
of the drug is reduced gradually to zero over five to seven
days, when the worst symptoms of alcohol withdrawal will
have abated. Following this, there are a number of ‘talking
therapies’ that are effective in reducing the risk of relapse.
These include cognitive behavioural therapy, motivational
interviewing, supportive counselling and family therapy.
Patients may or may not wish to engage in group sessions
and their wishes should be respected.
Abstinence versus sensible drinking
This is an interesting debate that has raged for decades
and has polarised therapists working in the field. The question arises: can patients who drink too much change their
drinking pattern and adopt a more sensible relationship
with alcohol? The research would tend to support controlled
drinking for most users with mild and moderate alcohol
dependence, but the message tends to be lost on those
patients with a pervasive and severe relationship with alcohol. It should also be remembered that alcohol dependence
is often a continuum whereby users can go through different patterns of use, ranging from abstinence to controlled
drinking to dependence.
The approach should therefore adapt to patients at a particular point in time. For example, a patient who strives
for abstinence often does not reach their intended goal in
the short term. In these cases, controlled drinking can be
a gateway to a life without alcohol and therapists should
work with these patients to allow them to achieve their goal.
Reinforcing abstinence can be counterproductive, as these
FORUM December 2013
patients can feel like ‘failures’ because they are still drinking, albeit in a much more responsible way.
The severely dependent drinker
Severe alcohol dependence is by far the biggest treatment challenge for any clinician and nearly all these cases
will need to be referred by the GP for specialist care. It
is associated with significant morbidity and mortality, and
the outcomes tend to be far poorer than in patients with
less severe forms of dependence. Except in rare cases, the
severely dependent drinker will require hospital admission as their needs will be complex and they will require
medically-assisted alcohol withdrawal to reduce the risk of
withdrawal seizures and delirium tremens (DTs). About 5%
of patients who experience alcohol withdrawal develop DTs
,which carries a mortality rate of 2-15%.
In view of the potentially life-threatening complications
of severe alcohol withdrawal, there needs to be a specialist,
multidisciplinary and systematic approach to management.
Many admissions with severe alcohol withdrawal will reach
the emergency room before an addiction treatment facility
and staff at these centres should be adequately trained to
recognise the features of withdrawal. Elective admissions
give the medical staff more time to plan management and
are a more ideal way of treating severe alcohol dependence.
Managing severe alcohol dependence: key steps
• Having established severe alcohol dependence, with a
high risk of DTs, a decision should be made to admit the
patient to a specialist inpatient facility
• It is important that the assessment includes relevant
medical and psychiatric history and any risk of suicidality
• Patients need to be kept under observation for any signs
of unplanned withdrawal. The timing from the last alcoholic drink is crucial in this regard
• The role of pharmacotherapy needs to be established and
individualised. Not all patients admitted to hospital will
need medication
• Benzodiazepines are the mainstay of pharmacological
treatment for acute alcohol withdrawal, usually oral chlordiazepoxide (Librium). The dose of medication should be
symptom-triggered and individualised. It should take
into account the level of alcohol dependence, the severity of withdrawal and evidence of co-morbidities, such as
abnormal liver function
• The dose of chlordiazepoxide is reduced gradually over
approximately five to seven days but may take longer,
depending on the progress of withdrawal symptoms
• The risk of DTs in the acute hospital setting is exceedingly
low but in the event that the condition occurs, the dose of
chlordiazepoxide will need to be adjusted and other drugs
considered such as lorazepam, olanzapine or haloperidol
to prevent further seizures and to control agitation. Longterm use of anticonvulsants is not indicated
• Wernicke’s encephalopathy (WE) should be considered in
any patient presenting in a confused state with evidence
of malnutrition. The other two classical signs that complete the triad are ophthalmoplegia and ataxia (although
all three signs only appear together in one third of cases)
• In patients with acute Wernicke’s encephalopathy, a
DISTANCE LEARNING Managing alcohol dependence in general practice
Table 2. Treatment interventions in mild, moderate and severe alcohol dependence
Treatment intervention
Mild alcohol dependence
Moderate alcohol dependence
Severe alcohol dependence
Brief interventions
Effective
Mildly effective
Relatively ineffective
Chlordiazepoxide
Not required
May be required
Essential
Unlikely to be required
Required and effective
Required in relapse prevention
Thiamine
Not indicated
May be indicated
Indicated and essential
Acamprosate
Not required
May be used and moderately
effective
Relatively ineffective
Psychotherapy
significant number will develop Korsakoff’s psychosis or
syndrome, which is characterised by disordered anterograde memory and other cognitive defects. The treatment
of WE is with parenteral thiamine
• Thiamine should be given prophylactically in oral doses
of 200mg daily to any patient with decompensated liver
disease or who shows evidence of malnutrition.
Other pharmacotherapy
There are a number of drugs that have been used to treat
alcohol dependence and an overview is provided here.
Acamprosate (Campral) is an analogue of gamma aminobutyric acid (GABA). Its exact mode of action is unknown
but it is thought to decrease alcohol consumption by reducing the positive reinforcement associated with alcohol
consumption. Disulfiram (Antabuse) is an aversive drug
that results in the accumulation of toxic acetaldehyde, by
blocking acetaldehyde dehydrogenase, when alcohol is
consumed. Compliance can be a problem and the evidence
suggests that the best outcomes are improved when a close
family member or friend can supervise consumption of the
drug. A recent therapy, the opioid antagonist nalmefene
(Selincro) is indicated for the reduction of alcohol consumption in adult patients with alcohol dependence who
have a high drinking risk level without physical withdrawal
and who do not require immediate detoxification. It has EU
approval and is going through the pricing/reimbursement
process and is expected to be available in Ireland in 2014.
Follow-up and relapse prevention
Alcohol dependence comes with a high rate of reinstatement and relapse. Patients who become abstinent or drink
within safe limits should maintain the positive changes in
the long-term. The relapse prevention (RP) model developed
by Marlatt and Gordon in 1985 is a cognitive behavioural
approach to managing high-risk social situations that could
be a trigger to lapse and relapse. There are two key features
of this model in terms of relapse risk factors:
• I mmediate determinants (eg. high-risk situations, a
person’s coping skills, outcome expectancies and the
abstinence violation effect)
• Covert antecedents (eg. lifestyle imbalances and urges
and cravings).
FORUM December 2013
The RP model can be delivered in a variety of settings
(including one-to-one sessions and group therapy) and can
be very effective in maintaining long-term stability. There
are a number of follow-up options for patients in recovery from alcohol dependence and each should be tailored
to meet individual needs. These may be AA meetings or
individual sessions with a counsellor, cognitive behavioural
therapist, psychiatrist or GP specialising in drug and alcohol abuse. The number, intensity and frequency of sessions
should be decided between the therapist and the patient.
Summary and conclusions
GPs are excellently positioned to screen patients and
provide brief interventions for patients encountering alcohol problems. In the busy climate of general practice it is
unlikely that most GPs have the resources and expertise to
provide more intensive treatment.
Alcohol dependence is a chronic relapsing condition with
a spectrum of severity. The treatment varies according to
the extent of the disorder and the individual circumstances
and health status of the patient. Relapse prevention therapy
is an important tool to help patients maintain the positive
changes and benefits of acute treatment.
Garrett McGovern is a GP specialising in alcohol and
substance abuse at the Priority Medical Clinic, Dublin
References on request
ICGP LIBRARY
& information service
Some suggestions for additional resources:
GUIDELINES
• ICGP Quick Reference Guide – Helping Patients with Alcohol Problems: A Guide for Primary
Care Staff (2009) www.icgp.ie/library_catalogue/index.cfm/id/39053/event/catalogue.item.view.html
•N
ICE Clinical Guideline 115 – Alcohol dependence and harmful alcohol use (February 2011)
guidance.nice.org.uk/CG115
•H
SE guidelines on alcohol levels and at-risk drinking. www.hse.ie/eng/health/az/A/Alcohol-misuse/
GENERAL
• ICGP position paper on prevention of alcohol related problems in Ireland (2012).
www.icgp.ie/library_catalogue/index.cfm/id/134019/event/catalogue.item.view.html
•H
SE – A Guiding Framework for Education and Training in Screening and Brief Intervention
for Problem Alcohol Use (2012).
www.hse.ie/eng/services/Publications/topics/alcohol/interventionforproblemalcoholabuse.pdf
• ICAP Blue Book: Practical Guides for Alcohol Policy and Prevention Approaches.
www.icap.org/PolicyTools/ICAPBlueBook/
•D
ealing with alcohol problems – CAMH Knowledge Exchange – Toronto Canada (2010).
knowledgex.camh.net/primary_care/toolkits/addiction_toolkit/alcohol/Pages/default.aspx