20th February 2024

Alcohol use and its impact

Epidemiology, aetiology, and pathophysiology

Alcohol use is common in the Western world, with approximately 80% of the UK population drinking alcohol during their lifetime. 20-25% of adults in the UK have also been known to drink over the recommended alcohol limits, with approximately 4% of the population reporting symptoms of alcohol dependence.

The UK Department of Health has stated that both males and females should not drink more than 14 units of alcohol per week. The 14 units of alcohol should also be spread across three days. Binge drinking can be defined as drinking over eight units of alcohol in a single session for males and six units of alcohol for females. One unit of alcohol is defined as 10ml/8g of ethanol. This can be calculated by the formula:This is equivalent towards one standard measure of spirits or half a pint of average-strength beer.

Alcohol use has a multifactorial aetiology that combines social, psychological, and environmental factors. Research into the neurobehavioral effects of alcohol has shown the downregulation of GABA receptors and upregulation of glutamate and noradrenaline receptors. Dopaminergic pathways along the tegmental area and nucleus accumbens mediate the pleasure sensation from taking alcohol. 

Diagnosis of alcohol dependence

Recognition of alcohol dependence is crucial as it is associated with increased morbidities and mortality from direct alcohol use and the co-morbidities it causes. 

NICE recommends using the AUDIT score to screen and identify patients with alcohol issues. Screening should be performed routinely at any opportunity, including patients with physical or mental co-morbidities and those who display stigmata of alcohol misuse (abnormal GGT/MCV; signs of frequent alcohol use including dilated facial capillaries, tremors; high-risk associations including substance misuse). The AUDIT score can help identify hazardous drinking, harmful drinking, and alcohol dependence. 

When alcohol dependence is picked up on the screening tool, clinicians can use the Severity of Alcohol Dependence Questionnaire (SADQ) score to quantify this. Patients should also be assessed for signs and symptoms of alcohol withdrawal with prompt treatment if identified. 

Short and long-term impact of alcohol dependence

Alcohol dependence can be associated with many co-morbidities. Alcohol use is associated with co-morbidities, including accidents and injuries related to alcohol use, self-harm, and accidents. Alcohol withdrawal and Wernicke’s encephalopathy are also acute complications that carry high morbidity and mortality rates. 

There are multiple long-term complications associated with alcohol use, and it affects many organ systems, including:

• Malignancy – There are associations with oral, oesophageal, bowel, stomach, liver and breast cancer. 
• Cardiac – Associated with cardiomyopathy, hypertension, and cardiac arrhythmias.
• Liver and pancreas – Pancreatitis (acute and chronic) are both associated with alcohol use. Alcoholic liver disease (steatosis, hepatitis, and fibrosis/cirrhosis) and its associated complications (ascites, varices, infection, malignancy) are associated with significant morbidity and mortality. 
• Psychiatric – Korsakoff’s syndrome is associated with memory loss, disorientation and confabulation.
• Pregnancy – Foetal alcohol syndrome is associated with alcohol use of over five units per day during pregnancy. This can result in dysmorphic facial features, microcephaly, fetal growth restriction, and the heart, skull, kidneys, brain, and bone malformation. 
• Social – Domestic violence and child abuse can be attributed towards the use of alcohol. 

References

• Bourke, J., & White, P. (2012). Psychological Medicine. In P. Kumar & M. Clark (Eds.), Kumar & Clark’s Clinical Medicine (12 ed.). Spain: Elsevier. 
• Tetrault, J., & O’Connor, P. G. (2021 Jan 20). Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. Accessed on 2022 Mar 22. Available from: https://www.uptodate.com/contents/risky-drinking-and-alcohol-use-disorder-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis?topicRef=108891&source=see_link. 
• National Institute for Health and Care Excellence. (2011 Feb 23). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. Accessed on 2022 Mar 23. Available from: https://www.nice.org.uk/guidance/cg115/resources/alcoholuse-disorders-diagnosis-assessment-and-management-of-harmful-drinking-highrisk-drinking-and-alcohol-dependence-pdf-35109391116229. 
• Drummond, C. (2018). Alcohol-use disorder. Accessed on 2022 Mar 23. Available from: https://bestpractice.bmj.com/topics/en-gb/198.