Recovery From Alcohol addiction
Dr Rob Hicks discusses the role of GPs in identifying and managing patients addicted to alcohol
The goals of management are to achieve and maintain either a reduction in alcohol consumption or total abstinence. All patients should be made aware of the safe drinking levels and the possible health risks of exceeding them. The current recommended safe levels of alcohol consumption are up to 21 units per week for men and up to 14 units per week for women. (One unit is equivalent to a glass of wine or half a pint of beer or lager or a pub measure of a spirit.)
When To Treat?
Above these levels, then the patient is putting themselves at risk. It is common for many to deny they have a problem. When this is the case the patient should be followed up, either opportunistically or with a confirmed review appointment, where health risks are emphasised, and help and encouragement to address the problem is offered. For those who acknowledge they have a problem and are receptive to the idea of addressing it, the decision has to be made as to whether a reduction in their consumption or abstinence is advisable. The absolute indications for advising abstinence are: alcohol-related organ damage, severe dependence (morning drinking to stop the shakes), or significant psychiatric disorders. Relative indications are: epilepsy, social factors (work / home/ legal), and other physical problems5 (see Table 2). If a reduction in consumption is appropriate, then regular review is important for monitoring and as a means of patient support. It should include self-monitoring of intake, re-enforcement of the benefits to the patient, and exploring and addressing the patientÕs concerns. It is valuable for the patient to be taught how to predict and deal with situations that may encourage more drinking.
Where local alcohol services are available, for example support groups, then their use should be encouraged. Monitoring LFTs, GGT and MCV is helpful in demonstrating that the patient is being honest and encourages the patient by showing improvement and reduction of damage.
In preparing the patient it is important to explain the process of withdrawal, the likely symptoms, and that relapses will not be met with disappointment or anger but that they are common. Moreover, that support for the next attempt will be available. They must be sober when they agree and make a commitment.
Many patients can undergo a withdrawal programme in the community provided there are no contraindications to this (see Table 3). It is probably best not to start the withdrawal process on a Friday. The first few days are hard and patients need to feel support is easily accessible. The chances of temptation getting in the way of a good start are also high during this time of the week.
For someone who is sober, has not suffered withdrawal symptoms, or has not needed to drink to prevent the symptoms of withdrawal, then medication is probably not needed.
This is also likely to be the case if someone has been drinking less than 15 units a day6. When medication is necessary then chlordiazepoxide should be used in a reducing dose. Starting with 10 mg capsules, 8-12 are taken in the first 24 hours, and over one week reduced to zero. To facilitate monitoring of the patient it is sometimes advisable not to issue the full supply in a single prescription. Three weeks treatment with vitamin B complex of thiamine should also be given at a dose of 50 mg twice daily.
Drugs such as chlormethiazole (Heminevrin) should be avoided in community withdrawal programmes because of the risk of respiratory failure if combined with alcohol.