Alcohol misuse is associated with considerable morbidity and mortality (100,000 deaths annually), social and legal problems, acts of violence, and accidents. Alcoholism is among the most common psychiatric disorders in the general population: the lifetime prevalence of alcohol dependence, the severe form of alcoholism, is 8 to 14 percent.¹ The ratio of alcohol dependence to alcohol abuse is approximately two to one. The incidence of alcoholism is still more common in men, but it has been increasing in women, and the female to male ratio for alcohol dependence has narrowed to one to two.² Serious drinking often starts in adolescence; approximately 40 percent of alcoholics develop their first symptoms between 15 and 19 years of age.³

Alcoholism often goes undiagnosed; the rate of screening for alcohol consumption in health care settings remains lower than 50 percent.⁴ Some patients also may withhold information because of shame or fear of stigmatization. This can lead to missed information about medical and psychiatric conditions, potential surgical complications, unexpected alcohol withdrawal symptoms, drug interactions, and lost opportunities for prevention, including intervention during pregnancy to prevent damaging effects of alcohol on the fetus. All too often, patients, particularly the elderly, continue to be treated symptomatically for alcohol-related conditions without recognition of the underlying problem (Table 1). There are many reasons why there is a worldwide tendency for physicians to neglect or be unaware of symptoms and signs of alcohol abuse, but inappropriate attitudes, insufficient medical school training in this subject, and subsequent low confidence to treat are key elements.

Etiology

Alcoholism is familial; an important risk factor for developing the disease is to have an alcoholic parent. Although environmental and interpersonal factors are important, a genetic predisposition underlies alcoholism, particularly in the more severe forms of the disease. Heritability of alcoholism (the genetic component of interindividual variation in vulnerability) is 40 to 60 percent.⁵ The major genes that have so far been identified are protective against alcoholism; approximately one half of all Southeast Asians have genetic variants of alcohol metabolizing enzymes such that after drinking only small amounts of alcohol, they experience an unpleasant facial flushing reaction with tachycardia, nausea, and headaches as a result of the accumulation of the toxic metabolite acet aldehyde.

Comorbidity

Nearly all alcoholics have a comorbid psychiatric disorder, most commonly anxiety and mood disorders in women and drug abuse and antisocial personality disorders in men.⁶ Approximately 70 percent of alcoholics are heavy smokers (more than 20 cigarettes per day), compared with 10 percent of the general population.⁷

Medical Sequelae

Profound medical sequelae may develop following heavy, long-term drinking. Apart from fibrosis, cirrhosis, and some neurologic damage, many sequelae are at least partially reversible with abstinence. Alcohol is carcinogenic, particularly in association with smoking. Women tend to be at greater risk of medical complications.⁸ It has been estimated that 6 percent of the children of alcoholic women have fetal alcohol syndrome, which is characterized by growth deficiency, distinctive abnormal facial features, microencephaly and mental retardation, and attention and behavioral problems. There are probably several times as many alcohol-damaged children who have nonspecific symptoms of intellectual impairment and behavioral deficits.⁹ Even drinking seven to 14 drinks per week can cause moderate fetal damage, particularly when five or more drinks are consumed on one occasion.¹⁰

Diagnosis of Problem Drinking and Alcoholism

SYMPTOMS AND SIGNS

Although few of the symptoms and signs of alcohol abuse are diagnostic (Table 1), each should alert the family physician to the possibility of alcohol misuse. Elevated blood test results (Table 2) suggest chronic, heavy drinking.

DEFINITIONS OF ‘SAFE,’ PROBLEM, AND HEAVY DRINKING

An important warning sign is clearly regular, heavy drinking. The ceiling for low-risk alcohol use advocated by the U.S. government is one standard drink per day for women and two standard drinks per day for men (Table 3)¹¹ Because of age-related changes in the body, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends that men and women older than 65 years consume no more than one drink per day.

At-risk alcohol use, or problem drinking, is defined as more than seven drinks per week or more than three drinks per occasion for women; and more than 14 drinks per week or more than four drinks per occasion for men. Heavy drinking is often defined as more than three to four drinks per day for women and more than five to six drinks per day for men.

IDENTIFYING PROBLEM DRINKERS

There are several brief, easy to use and score, screening instruments that are designed to identify problem drinking and alcoholism, and can be self-administered by a patient.¹² The AUDIT¹³ (Alcohol Use Disorders Identification Test) is considered to be the most accurate test for identifying problem drinking (Figure 1).¹⁴The AUDIT is used by the NIAAA in the community for National Alcohol Screening Day. If there is only time for a shorter screening instrument, the Quantity/Frequency Questionnaire¹⁵ devised by the NIAAA may be used (Table 4).¹⁵ Identified problem drinkers can then be further assessed for alcoholism.

The CAGE questionnaire has consistently proved to be the superior instrument for detecting alcohol abuse and alcohol dependence (Table 5).¹⁶ The 10-question Brief Michigan Alcoholism Screening Test (BMAST) and the five-question TWEAK (Tolerance, Worry about drinking, Eye-opener drinks, Amnesia, Cut down on drinking K/C) are also used reliably to detect alcoholism by assessment of the patient's, relatives', and friends' attitudes to their drinking¹² Whichever questionnaire is used, lower thresholds for a positive result should be used for women (Figure 1 and Table 5), because women experience harmful effects at lower levels of alcohol consumption than men.¹⁷

Treatment

The severity of the alcohol problem, comorbid medical and psychosocial problems, and the patient's motivation to change are key elements influencing the family physician's choice of intervention.

TREATMENT OF PROBLEM DRINKING

Brief intervention is a short-term counseling strategy based on motivational enhancement therapy that concentrates on changing patient behavior and increasing patient compliance with therapy (Figure 2).^18,19 It has been shown to be effective for helping socially stable problem drinkers to reduce or stop drinking,^19,20 for motivating alcohol-dependent patients to enter long-term alcohol treatment, and for treating some alcohol-dependent patients for whom the goal is abstinence.²¹ Generally conducted in four or fewer sessions, each lasting from a few minutes to an hour depending on the severity of the patient's alcohol problem, it is designed for health professionals who are not specialists in addiction (Figure 2).^18,19

TREATMENT OF ALCOHOL DEPENDENCE AND ABUSE

A formal diagnosis of alcoholism can have enormous personal implications for a patient, therefore assessment should be detailed (Table 6).¹

Alcohol abuse and dependence have a variable course characterized by periods of remission and relapse. There are three major hurdles to overcome in the treatment of alcoholism: (a) physiologic dependence (symptoms of withdrawal), (b) psychologic dependence (alcohol used as treatment for anxiety, depression, stress), and (c) habit (the central part that alcohol occupies in the framework of daily living).

Alcohol dependence is treated in two stages: withdrawal and detoxification, followed by further interventions to maintain abstinence.

IMMEDIATE TREATMENT: DETOXIFICATION

The severity of withdrawal symptoms increases with each withdrawal episode. Severe withdrawal (grand mal convulsions, delirium tremens) occurs in 2 to 5 percent of heavy drinking, chronic alcoholics fewer than three days after stopping alcohol consumption, and may last for three to seven days. With treatment, mortality is about 1 percent; death is usually caused by cardiovascular collapse or concurrent infection.

Withdrawal severity and indications for pharmacotherapy can be assessed by the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) instrument.²² Use of benzodiazepines greatly reduces the risk of seizure and symptoms of withdrawal. Alcoholics should be admitted to the hospital for detoxification if they are likely to have severe, life-threatening symptoms or have serious medical conditions, suicidal or homicidal tendencies, disruptive family or job situations, or are unable to attend outpatient facilities.²³

SUSTAINED TREATMENT: LONG-TERM MAINTENANCE OF ABSTINENCE

Considerable evidence shows that long-lasting neurobiologic changes in the brains of alcoholics contribute to the persistence of craving. At any stage during recovery, relapse can be triggered by internal factors (depression, anxiety, craving for alcohol) or external factors (environmental triggers, social pressures, negative life events).²³ Psychosocial treatments concentrate on helping patients to understand, anticipate, and prevent relapse.

BEHAVIORAL TREATMENT APPROACHES

Alcoholics Anonymous (AA) and 12-Step Facilitation Therapy

AA and similar self-help groups follow 12 steps that alcoholics should work through during recovery. This free program is particularly supportive for those who are poor, isolated, lonely, or who come from a heavy-drinking social background. Twelve-Step Facilitation (TSF) is a formal treatment approach incorporating AA and similar 12-step programs.²⁴

Cognitive-Behavior Therapy (CBT)

The aim of CBT is to teach patients, by role-play and rehearsal, to recognize and cope with high-risk situations for relapse, and to recognize and cope with craving.²⁵

Motivational Enhancement Therapy (MET)

This counseling method is used to motivate patients to use their own resources to change their behavior.²⁶

Results of a large multisite study, Project MATCH,²⁷ found that there was no difference in the efficacy of CBT, MET, and TSF during the year following treatment, however, MET was found to be most effective in those patients with high levels of anger, and TSF and AA involvement was particularly effective in patients from a heavy drinking social environment.²⁷

PHARMACOTHERAPY

Thirty to 60 percent of alcoholics maintain at least one year of abstinence with psychosocial therapies alone.²⁸ However, more than 20 percent of alcoholics achieve long-term sobriety even without active treatment.¹ More effective therapies are clearly needed, and pharmacotherapeutic agents have recently emerged that can be used as adjuncts to psychosocial treatments.

Anti-craving Medications

The most promising of these medications are the opioid antagonist, naltrexone (Revia), and acamprosate, a glutamate antagonist. These drugs, used separately and in combination, are likely to be the first of many pharmacotherapies targeting multiple neurotransmitters.

Several studies have shown that naltrexone (50 mg once daily) reduces alcohol consumption in male and female alcoholics and is effective, when combined with psychosocial treatment, in reducing relapse rates.^29,30 A recent preliminary study has found that taking naltrexone two hours before an anticipated high-risk situation reduces alcohol consumption in early problem drinkers, particularly women.³¹ Acamprosate, used extensively in Europe and now being tested in the United States, appears to be safe and well tolerated and may almost double the abstinence rate among recovering alcoholics.³²

Aversive Pharmacotherapy

Disulfiram (Antabuse, 250 to 500 mg daily), a drug with a moderate record of adverse effects³³ which has been available since the late 1940s, blocks the metabolism of acet aldehyde and causes an unpleasant flushing reaction if taken with alcohol. Outcomes of patients who take disulfiram are improved when the drug is taken under supervision.³⁴

Pharmacotherapy for Comorbid Conditions

Depression and anxiety can precipitate heavy drinking but can also be a result of alcohol abuse. A careful history is required to identify the primary problem. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor, has been found to be effective in decreasing depressive symptoms and the level of alcohol consumption in depressed alcoholics.³⁵

When to Refer

After a screening questionnaire has identified problem drinking, the physician may question the patient further to determine the severity of alcohol misuse. The physician may try brief intervention and/or suggest AA, or refer the patient to an addiction specialist. The family physician should play a critical holistic role in treatment and prevention, working with the patient and family, even when other specialists may be involved.