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31st January 2024

Alcohol misuse

Alcohol Misuse

Definitions

Alcohol misuse refers to the act of high-risk drinking behaviour(s), which often leads to further complications, such as complex psychological and physical health comorbidities as well as alcohol dependence. The 2022 NICE guidance defines alcohol dependence as “craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences”. Dependence (of any psychoactive substance, including alcohol) is one of ten sub-categories in the ICD-10 psychoactive substance use classification, which includes withdrawal syndrome(s). There is some evidence to suggest alcohol dependence has a genetic component.

Current government guidelines suggest adults should consume no more than fourteen units per week of alcohol, spread over a period of approximately three days. However, in deprived neighbourhoods, the average alcohol unit consumption per week is often significantly higher when compared to more affluent areas. Government guidance currently classifies ‘high risk’ drinking as regular consumption of 35 or more units per week for women and 50 or more units per week for men. Alcohol dependence can develop if regular drinking evolves into a continuous behaviour, with signs of dependence usually becoming apparent over the course of one year.

Epidemiology

Statistics highlight that from 2018 to 2019, approximately 600,000 or more adults in England alone were classed as both alcohol dependent and requiring specialist intervention for this, flagged as an increase on previous figures. However, despite the high prevalence of alcohol misuse across England, especially in the Northern region, statistics from 2020 to 2021 identified that over 80% of adults requiring specialist treatment for alcohol dependence had not received any treatment.

One barrier that has been identified in relation to low treatment rates for alcohol dependence is lack of access to the necessary services, for example, exclusion due to a synchronous presentation of acute mental health issues and substance/alcohol misuse. Indeed, there is evidence demonstrating that the prevalence of coexisting mental health issues in this group of people is high, with increased risk of both suicidal ideation and physical health issues. Therefore, many adults requiring specialist treatment for alcohol dependence and associated mental health issues, can be left unable to access help for any of these conditions due to their simultaneous presentation.

Screening tools

There are several tools available that screen for and assess alcohol dependence, which include the Alcohol Use Disorders Identification Tests (AUDIT) and the Severity of Alcohol Dependence Questionnaire (SADQ).

The CAGE questionnaire can also screen for alcohol problems, with the following four questions creating the acronym:

  1. Do you think you should cut down on drinking alcohol?
  2. Have you felt annoyed when your alcohol drinking habits are criticised?
  3. Do you feel guilt regarding your drinking of alcohol?
  4. Do you usually need an ‘eye-opener’ alcoholic drink?

The remainder of the section will focus on summarising some of the conditions that are associated with alcohol misuse and dependence. Purely physical complications of alcohol misuse, such as cancer(s), etc., will not be covered.

References

Delirium tremens

Background

Delirium tremens is a form of severe and acute withdrawal from alcohol and can be considered a medical emergency. The condition develops approximately two to three days after sudden cessation of alcohol altogether or reduction in drinking quantity. Long-term, heavy alcohol intake causes a compensated GABA and NMDA (glutamate) neurotransmitter imbalance. However, when alcohol use is suddenly stopped, glutamate neural pathways become hyper-excitable with unregulated activity, leading to the symptoms of delirium tremens.

Presentation

The usual timeline of symptom development is as follows:

  1. Tremor – can appear only a few hours after drinking is suddenly reduced/stopped.
  2. Hallucinations – usually visual and commence about one day after tremors begin.
  3. Seizures – these tend to be grand mal and can happen at any point from the second day onwards alongside tremor and hallucinations.

Diagnosis

A diagnosis of delirium tremens can be made in a patient presenting with both delirium and symptoms of alcohol withdrawal. Delirium tremens can last up to eight days (three to four on average) with approximately a one to four percent mortality rate.

Differential diagnoses

Alcohol hallucinosis (sometimes referred to as ‘alcohol-induced psychotic disorder’) can present very similarly to delirium tremens, but they are not identical conditions. ICD-10 describes alcohol hallucinosis as characterised by hallucinations, which develop within two weeks of heavy alcohol intake and last for at least 2 or more days. Unlike delirium tremens, impaired cognition should not be a major feature of the condition.

There is little information available about this condition; however, it does seem to be recognised as distinct from delirium tremens and schizophrenia, and dopamine and serotonin receptor involvement have been suggested as likely aetiological factors to consider. Proposed treatments currently also include benzodiazepines, atypical antipsychotics, and abstinence from alcohol (if safely achievable).

Although delirium tremens is a clinical condition, other organic conditions which have similar symptom profiles and should be considered where appropriate, e.g., space-occupying lesions.

Management

The mainstay of treatment for delirium tremens are benzodiazepines; NICE guidance currently lists oral lorazepam as the first line interventional medication to offer, followed by haloperidol or IM lorazepam. Benzodiazepines restore the neurotransmitter imbalance described above by promoting upregulation of GABA receptors, facilitating decreased neural intracellular excitation.

Early intervention can prevent later more severe features such as seizures, and NICE guidance also recommends offering those at high risk of developing the condition a “medically assisted” withdrawal as part of reducing the risk of the condition occurring. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a rating scale (10 items with a maximum score of 67 points) that can rate the severity of withdrawal from alcohol to support necessary treatment and intervention, e.g., administration of chlordiazepoxide if needed. A brief score explanation is as follows:

  • Mild withdrawal = 10 or less points
  • Moderate withdrawal = 11 to 15 points
  • Severe withdrawal = 16 or more points

If Untreated, delirium tremens can lead to autonomic dysfunction, including hyperthermia, arrhythmias and, in severe cases, death. The delirium described may not always be solely due to alcohol cessation/reduction. Other coexisting causes can be present, e.g., electrolyte imbalances, and must also be explored as part of optimal management.

References

Wernicke’s encephalopathy and Korsakoff’s syndrome

Background

These are both syndromes caused by thiamine deficiency as a side effect of long-term excessive alcohol consumption, which impedes the absorption and storage of consumed thiamine. Wernicke’s encephalopathy is an acute neurological disorder, whereas Korsakoff’s is a neuropsychiatric syndrome. If left untreated, Korsakoff’s syndrome can develop in a patient already diagnosed with Wernicke’s. Other conditions which can cause Korsakoff’s syndrome include AIDS and certain cancers; however, alcohol is recognised as the most common cause of the syndrome to date.

Thiamine is required for effective brain cell biochemical metabolism, particularly pyruvate metabolism – a deficiency of thiamine disrupts these necessary metabolic processes, which can cause neuronal atrophy, scar tissue formation and microscopic haemorrhages, resulting in cognitive impairment.

Presentation

The table below demonstrates the symptoms and signs seen in Wernicke’s encephalopathy and Korsakoff’s syndrome:

Wernicke’s encephalopathy Korsakoff’s syndrome
Acute confusion Anterograde and/or retrograde amnesia
Ataxic gait Confabulation
Ophthalmoplegia Visual hallucinations

Source: Adapted from: Vasan S, Kumar A. Wernicke encephalopathy – statpearls – NCBI bookshelf [Internet]. Wernicke encephalopathy. 2022 [cited 2022Dec3]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470344/ and Alzheimer’s Association. Korsakoff syndrome [Internet]. Alzheimer’s Disease and Dementia. 2022 [cited 2022Dec3]. Available from: https://www.alz.org/alzheimers-dementia/what-is-dementia/types-of-dementia/korsakoff-syndrome 

Diagnosis

Both are primarily clinical diagnoses; therefore, a thorough history and examination are required to rule out other causes of the symptoms first. Imaging and lumbar puncture for CSF fluid may help identify alternate diagnoses if clinically indicated but cannot be used to diagnose Wernicke’s.

Differential diagnoses

Other causes of acute confusion hallucinations, and gait disturbance (such as delirium, primary psychiatric disorders, other substance abuse and neurological conditions) could all be differential diagnoses for either of the above presentations and must be considered during the investigation stage.

Management

Established Wernicke’s encephalopathy

Pabrinex (B vitamins including thiamine with ascorbic acid) given intravenously (IV) is required to treat Wernicke’s encephalopathy – oral thiamine is only suitable for long-term maintenance in those who are alcohol-dependent. The BNF current dosing guidelines recommends two to three pairs of Pabrinex three times a day for up to five days as treatment for established Wernicke’s encephalopathy.

Prophylaxis of Wernicke’s encephalopathy

Prophylaxis dose is 1 pair once a day intramuscularly (IM) for 5-7 days. Dose reduction can be used after this period, but oral preparations of thiamine are not suitable as an acute treatment. Literature suggests Korsakoff’s syndrome should also be treated with the same dosing of IV Pabrinex; however, the effects of this condition are often more chronic, and for some, long-term care provision is often needed, alongside standard oral thiamine maintenance. Physiotherapy and support with alcohol abstinence are also often required.

Medications to support abstinence

Those who successfully manage to abstain from alcohol may be offered additional medication to help them remain sober long-term. NICE guidance currently advises use of either acamprosate (1st line), naltrexone (alternative 1st line, not if concomitant opioid use) or, if needed, disulfiram. These treatments are summarised in the table below:

Medication Indication Cautions/contraindications
Acamprosate 1st line for reducing alcohol cravings. It can be taken for up to 6 months or longer if helpful to aid abstinence. Can cause abdominal pain, nausea, and diarrhoea. It should be discontinued if alcohol consumption continues for up to 6 weeks after starting the medication. Cannot be given to those with severe hepatic or renal impairment or those breastfeeding. Advised to avoid in pregnancy unless necessary.
Naltrexone Also 1st line – it is an opioid-receptor antagonist, so stops opioid-based analgesia from working effectively and reduces alcohol cravings. Cannot be given to those who are currently opioid dependents, advised to avoid during breastfeeding and in severe hepatic impairment. Reduced dosing may be needed in renal impairment. Advised to avoid in pregnancy unless necessary.
Disulfiram 2nd line – blocks the metabolism of alcohol after consumption. Usually started 1 day or more after the last alcoholic drink. It reacts with alcohol and causes nausea, flushing and dizziness, which is designed to discourage further alcohol intake. Cannot be used in those with active cardiovascular disease, prior stroke, hypertension, or psychosis. Should be avoided in the first trimester as acetaldehyde (the metabolite of alcohol breakdown) may be a teratogen.

Source: Adapted from: NICE. Disulfiram [Internet]. NICE. 2022 [cited 2022Dec3]. Available from: https://bnf.nice.org.uk/drugs/disulfiram/#indications-and-dose, NICE. Alcohol problem drinking: Acamprosate [Internet]. NICE. 2022 [cited 2022Dec3]. Available from: https://cks.nice.org.uk/topics/alcohol-problem-drinking/prescribing-information/acamprosate/ and NICE. Naltrexone hydrochloride [Internet]. NICE. 2022 [cited 2022Dec3]. Available from: https://bnf.nice.org.uk/drugs/naltrexone-hydrochloride/#drug-action

References 

Dementia secondary to alcohol misuse

Background

There are several subtypes of dementia, characterised by different patterns of cognitive impairment, loss of learned skill and independent functioning. There is some evidence that heavy and sustained alcohol use can result in early-onset dementia presentations and is a potentially modifiable risk factor for dementia.

There are several proposed hypotheses as to the link between heavy alcohol use and dementia, which include the following:

  1. Ethanol is metabolised to acetaldehyde – this substance is known to be neurotoxic.
  2. As previously mentioned, thiamine deficiency secondary to heavy alcohol use can result in Wernicke’s encephalopathy and/or Korsakoff’s syndrome – for some chronic cognitive impairment persists despite treatment.
  3. Heavy alcohol use can increase the risk of developing cardiovascular risk factors such as hypertension, which are themselves associated with an increased risk of developing vascular dementia.
  4. Alcohol intoxication can cause falls with head injury or seizures, both of which have been raised as potential predisposing factors in alcohol-related dementia development.

Presentation

The symptoms of alcohol-related dementia are like symptoms seen in other dementia profiles but include problem-solving issues, cognitive impairment to varying degrees, gait disturbance and low mood/apathy.

Differential diagnoses

Other types of dementia would need to be considered as part of an initial workup. However, a thorough history, including past and present alcohol use, as well as standard first-line investigations for dementia diagnosis as per NICE guidance, e.g., CT head, would be recommended as part of investigation prior to deciding on a diagnosis of alcohol-related dementia.

Management 

It has been proposed that if alcohol consumption is reduced/abstained from and thiamine replacement given alongside other lifestyle measures such as good dietary intake etc, that alcohol-related dementia presentations can improve. Talking therapies such as cognitive behavioural therapy (CBT) and rehabilitation are also important factors in ensuring recovery can continue and progress and reduce the chance of relapse.

References

  • Rehm J, Hasan OS, Black SE, Shield KD, Schwarzinger M. Alcohol use and dementia: A systematic scoping review. Alzheimer’s Research & Therapy. 2019;11(1).
  • Alzheimer’s Society. Alcohol-related ‘dementia’ [Internet]. Alzheimer’s Society. 2021 [cited 2022Dec3]. Available from: https://www.alzheimers.org.uk/about-dementia/types-dementia/alcohol-related-dementia
  • Stringer S, Church L, Keynejad R, Hurn J. Psychiatry P.R.N.: Principles, reality, next steps. Oxford: Oxford University Press; 2020.

Psychiatric disorders secondary to alcohol misuse

Background

Chronic alcohol use can both result in and coexist with several psychiatric disorders (termed ‘dual’ disorders), such as psychosis and mood disorders. Several factors can influence this, including extent of drinking behaviour, existing predisposition to developing psychiatric symptoms, when alcohol was last consumed and the effects of alcohol itself, e.g., disinhibition., and the socioeconomic consequences of chronic, heavy drinking, e.g., relationship issues.

Presentation

These disorders can present very similarly to their independent psychiatric counterparts, making accurate diagnosis and access to necessary treatment difficult. The DSM-IV states that psychiatric symptoms experienced by someone dependent on alcohol must be ongoing and prominent, directly attributable to the effects of alcohol itself and occur within 1 month of withdrawal/last intake of alcohol. However, it should not be solely attributable to signs of withdrawal or intoxication. Therefore, any comorbid presentation attributable to alcohol use would usually resolve or improve without intervention if abstinence was maintained, compared to independent psychiatric disorder presentations.

Diagnosis 

If these disorders arise as a direct result of alcohol misuse, once alcohol use is ceased, symptoms should begin to ease, alongside other measures such as relapse prevention. However, if these disorders have arisen independent from alcohol use, they will need to be assessed and managed as per NICE current guidelines, depending on the condition, alongside sobriety. It can be difficult to differentiate how independently these disorders can arise in a person with alcohol dependence, but where possible, it is important to try and determine this to ensure optimal management of the presentation.

Differential diagnosis

The table below summarises some of the psychiatric disorders that can develop due to/alongside heavy alcohol use:

Condition Summary
Anxiety Specific subtypes often seen in those with alcohol dependency are PTSD, social anxiety and panic disorder. Alcohol-induced presentations tend to have more acute onset and resolution without intervention other than abstinence. Those with independent presentations may find symptoms developed before heavy alcohol intake or persistent even with sobriety.
Depression This can occur as a direct result of alcohol only or, for some, prior to/alongside heavy alcohol use. Compared to those with independent presentations of depression, alcohol-induced depression may be less associated with a family history of depression and suicidal ideation.
Personality disorders There is evidence that people with alcohol dependence are more likely to also have a comorbid personality disorder.
Bipolar It can be difficult to distinguish independent presentations of bipolar disorder with alcohol-induced presentations, because of the effect of alcohol on mood and the similarities between the behaviours exhibited, e.g., pursuing pleasurable activities despite negative associated consequences.
Psychosis As described on page 5, alcohol-induced psychosis can also be termed alcohol hallucinosis.

Source: Adapted from: Shivani R, Goldsmith RJ, Anthenelli RM. Alcoholism and psychiatric disorders: Diagnostic challenges [Internet]. Alcohol Research & Health. National Institute on Alcohol Abuse and Alcoholism; 2002 [cited 2022Dec3]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683829/

Management

As explained before, if these disorders have developed solely because of alcohol use, once the causative factor is removed, symptoms should improve and resolve. Encouragement and support with abstinence and preventing relapse will likely be required, and if symptoms do not improve, investigation into whether a primary psychiatric disorder exists would need to be explored and managed appropriately.

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