Alcohol dependence

Question 1

How common is it?

Answer 1

Present in 6% of men and 2% of women.

Prevalence rates for dependence have been estimated as: Mild 0.69%, Moderate: 0.4%, Severe: 0.1%.

Question 2

Who does it affect?

Answer 2

Adults from most minority ethnic groups are less likely to drink alcohol than the general population.

Question 3

What factors indicate dependence?

Answer 3

A strong desire or sense of compulsion to drink alcohol

Difficulty in controlling drinking in terms of its onset, termination, or level of use

A physiological withdrawal state when drinking has ceased or reduced, or drinking to relieve or avoid such a withdrawal state. These symptoms include tremor, sweating, tachycardia, anxiety, insomnia, and less commonly seizures, disorientation and hallucinations.

Question 4

How does it present?

Answer 4

CAGE:
Cut down (feel the need to)
Annoyance (when people challenge drinking)
Guilt (about drinking)
Eye-opener (need for)

Wernicke’s encephalopathy: Confusion, loss of coordination (ataxia), ophthalmoplegia, nystagmus, memory disturbance, hypothermia, hypotension, and coma.

Question 5

Signs on examination?

Answer 5

Gynecomastia

Spider angiomata

Dupuytren contractures (also may be congenital)

Testicular atrophy

Enlarged or shrunken liver

Enlarged spleen

Question 6

Treatment

Answer 6

Advise them to reduce alcohol consumption, advise them about driving restrictions, heavy machinery and the like, involve family, friends, and carers with the diagnosis and treatment process. Get them involved with groups like alcoholics anonymous. Don’t prescribe NSAIDs or warfarin in people with hepatic varices (which alcohol can cause).

For suspected Wernicke’s encephalopathy admit urgently with parenteral thiamine (pabrinex).

Offer prophylactic oral thiamine to harmful or dependent drinkers if any of the following apply: They are malnourished or at risk of malnourished they have decompensated liver disease; they are in acute withdrawal or medically-assisted alcohol withdrawal is planned.

Refer to psychological treatments, such as CBT, behavioural therapy and social network and environment-based therapy