Alcohol Use and

Alcohol Use
Disorders

1
mhGAP-IG base course - field test version 1.00 – May 2012
 In the waiting room…

Mrs Sana - checkup Mr Jad – hypertension Mr Banda – headache

Which of these patients has an alcohol use problem?

How will you find out?
A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
 Introduction

• What do you think about alcohol consumption?

• Is it common in your community?
• Are there benefits of alcohol consumption?
• Are there harms?
• How does your society or community try to balance the
benefits and harms?
• Do you agree with the approach taken by your society or
community?
 Introduction

• What is the effect of alcohol use on health?

• Is it the role of health care providers to ask about alcohol use?

• Do you ask people about their alcohol use?
• What do you do if someone tells you they have an
alcohol use problem
 Health effects of alcohol 1

• Intoxicating effects • Accidents, injuries

• Toxic effects • Liver fibrosis
• Immunosuppressant • brain injury
effects
• Cancer
• Teratogenic effects
• Infections
• Hypertension/stroke
• Fetal alcohol syndrome
• Dependence/addiction
 Health effects of alcohol 2

• Adverse effects on relationships

• Problems in employment
• Domestic violence
• Neglect of social roles including parenting
Effect of alcohol on mortality

8
 Learning objectives

• To be able to identify different patterns of problematic alcohol

use
– hazardous alcohol use
– harmful alcohol use
– Dependence

• To be able to provide brief (motivational) interventions for

people with hazardous/harmful alcohol use

• To be able to manage alcohol dependence and treat alcohol

withdrawal

• To be able to provide regular follow up

 Establish communication and build trust

A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
 Establish communication and build trust

• Alcohol can be a sensitive topic which requires appropriate

sensitivity

• Most people with alcohol use disorders will present with other
conditions and won't say anything about their alcohol use

•Alcohol use can be raised in the context of other risk factors for
health (smoking, inactivity, poor diet).
 Establish communication and build trust

• Address the person's immediate expectations

– What problem or concern has prompted the person to
come to the health service today?
– Listen carefully and with respect

• Manage the person's expectations, if they are unreasonably

high
– Be honest about what you can and cannot do

• Assess the impact of substance use on the person's life

– The healthcare worker should ask everyone about alcohol
use
– How have their home and work life been affected
 Establish communication and build trust

• Look for common ground

– There is a shared interest in improving the person's health
– Do not judge
– Challenge misconceptions but avoid confrontation

• Use good communication skills

– Start by asking open questions
– Remain neutral
– Explain your understanding of the situation to the person
– Always be honest
– Expect that it will take multiple appoints to build trust
 Conduct Assessment

A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up

14
 In the waiting room…

Mrs Sana - checkup Mr Jad – hypertension Mr Banda – headache

Which of these patients has an alcohol use problem?

How will you find out?
 To assess for problematic alcohol use - ask!

• Ask at least one question about alcohol use!

• For example “Do you drink alcohol?”

• If the answer is yes, you need to ask more questions

 Identify the pattern of alcohol use

• Which patterns should be identified?

• Hazardous
• Harmful
• Dependence

• How should they be identified?

• Ask questions of person and carer (with consent)
• Listen and look for further information
• Do a physical examination and request further investigations
 Role of health care

•Onaverage, 1 in 5 primary care and general hospital patients

have either hazardous or harmful alcohol use, or alcohol
dependence

•Yourassessment, management or referral can extend life and

improve quality of life for people with problems due to alcohol

•One question (do you drink…) can promote change

There is hazardous use if the person says yes to any
of the following questions

1. Consumed 5 or more standard drinks on any given

occasion in the last 12 months?
2. Drink on average more than two drinks per day?
3. Drink every day of the week?
4. Do you drink when
• driving or operating machinery?
• considering pregnancy?
• contra-indicated medical condition is present?
• using certain medications, such as sedatives,
analgesics and selected hypertensives?
Assessment involves asking how one drinks
but how much is one drink
 21
mhGAP-IG base course - field test version 1.00 – May 2012
• Record the substance intake in standard
measurements
• 1 unit = 10g alcohol = 1 standard measure spirits, ½
pint beer, 1 glass wine

• 1 unit = volume of alcohol (mls) x ABV (%)

1000

• 1 litre of ANY alcohol contains the ABV % number of

units
 Exercise on Calculation of units
• A 330 ml bottle of Carlsberg Green (4.7% ABV) lager
= 1.55 units
• A 700ml bottle of Malawi (43% ABV) gin
= 30 units
• A 175ml glass of South African (14% ABV) wine
= 2.45 units
• A 3 litre bottle of 8.5% cider
= 25.5 units
• A 30ml sachet of kachasu (42% ABV)

= 1.25 units
 Commonly used local alcohol:
• Kachasu is a locally distilled gin with alcohol
content of around 42%
• Chibuku is made of finger millet and maize and
has an alcohol content of around 8%
• Chikokeyani is a locally brewed beer made
from finger millet with an alcohol content of
around 2.5%
 Patterns of Drinking
Low Risk Drinking: Men <21 units/week
Women <14 units/week

Hazardous Drinking: Men 22-50 units/week

Women 15-35 units/week

Harmful Drinking: Men >50 units/week

Women >35 units/week

Dependent drinking Men >70 units/week

Women >50 units/week
There is hazardous use if the person says yes to any
of the following questions

1. Consumed 5 or more standard drinks on any given

occasion in the last 12 months?
2. Drink on average more than two drinks per day?
3. Drink every day of the week?
4. Do you drink when
• driving or operating machinery?
• considering pregnancy?
• contra-indicated medical condition is present?
• using certain medications, such as sedatives,
analgesics and selected hypertensives?
 What is harmful use?

• Harmful use is a pattern of alcohol use which is causing harm

to health

– a physical or mental health problem caused by alcohol, or

they are pregnant
– often associated with adverse social consequences

– AND

– continued alcohol use despite this health

problem/situation
 What is dependence on alcohol

• Alcohol dependence is a pattern of symptoms that can fit into

different categories:

1. Long term high level of use associated with (a) tolerance

(you need to take more to get the same effect) and (b)
withdrawal symptoms if alcohol is stopped

2. Loss of control over alcohol consumption

3. Reduction in other activities which used to have meaning

 What are the signs of dependence

• Development of tolerance

• Withdrawal symptoms

• Drinking more and longer than was intended

• Continued alcohol use despite problems related to it

• Difficulty in stopping or cutting down

• Craving alcohol
 Dependence vignette

• Adam is a 50 year old man who has come to see you because of
recent abdominal pain

• In talking to him you ask about his alcohol consumption:

– He is drinking 2-3 bottles of wine each day (750ml each). He used
to drink one half a bottle of wine each day in the evening after
work, and a bit more on the weekends, but when he lost his job 2
years ago he started drinking more. He finds he never really gets
drunk but if he doesn’t have any alcohol for more than one day he
gets very uncomfortable.
– He has tried to reduce the amount he is drinking because his wife
is complaining about it but he finds it difficult. He tried to stop a
couple of times but he started drinking again after one day.
– He used to be more active but now he spends most of his time at
home watching television alone or with other friends who also
drink
The CAGE questionnaire is often used to identify
possible dependence

C – Have you ever felt you needed to CUT down or

(reduce) your drinking?
A – Have people ANNOYED you by criticizing your
drinking?
G – Have you ever felt GUILTY (or ashamed) about
drinking?
E – Have you ever felt you needed a drink first thing in
the morning (EYE opener) to steady your nerves or to
get rid of a hangover?
Physical examination and further investigation 1

• You must always do a general medical examination

• Look for the presence of intoxication or withdrawal

• Look for evidence of long-term heavy alcohol

consumption
– Liver disease

• mild – tender, swollen liver

• moderate – small hardened liver

• severe - jaundice, ascites, enlarged spleen

Physical examination and further investigation 2

• Cerebellar or peripheral nerve damage

• poor balance with feet together and eyes

closed
• difficulty walking along a straight line

• intention tremor - difficulty touching a moving

object (i.e. the clinicians finger) without shaking

• peripheral neuropathy - reduced sensation in

the feet
Always note the person's level of sobriety during the
interview

• The person may be intoxicated, sober or in a state or

withdrawal

• If the person is too intoxicated for assessment and

discussion about alcohol, consider making a follow-up
appointment for the assessment
 Video on history taking (alcohol)

• Video
 Role Play 1: Assessment of Mrs Sana

• A 28 year old woman, Mrs Sana, comes to your office for a

check up
• She says she has been feeling well and has no significant
medical history
• You note that she looks tired, but otherwise the physical
examination is normal
• You ask if she is tired and she says that she is, but it's because
she went to bed late last night after a party

• Assess Mrs Sana for alcohol use

 Role Play: Assessment of Mr Jad

• A 45 year old man comes in to his regular check up for

hypertension smelling of alcohol.

• You know him well enough to fully discuss the issue

• Assess Mr Jad for a possible alcohol use disorder

 Plan and start management

A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up

38
Brief interventions for harmful/hazardous use

• Brief interventions involve a variety of low intensity, short

duration activities to reduce or stop drinking
• They usually no more than a few minutes to an hour
• They have been proven to be effective in reducing alcohol use,
particularly when reinforced through repetition at multiple
appointments
• They are designed to increase people's motivation to change
their behaviour
• We will discuss the specific use of brief interventions to treat
harmful/hazardous alcohol use in the coming slides
 Brief interventions

• State the results of the assessment

• Ask about other substance use
• Assess motivation to change
• State the recommendation to cut down or
stop
 Stating the results of the assessment

• When giving the results, you should be honest, but try to be

sensitive and non-judgemental at the same time

• Tell the people when they are drinking at harmful or

hazardous levels

• Tell the people when you believe they are dependent

• This may be difficult for people to hear, but you must be clear
 Asking about other substance use

• Ask for drug use when a person has a possible alcohol use
disorder

• Appear under the influence of drugs

• Signs of drug use
• Requesting prescriptions for sedative medication
• Financial difficulties or involvement in crime
• Difficulties in carrying out usual work or social role
 Assess motivation to change

• Ask the person what they think about their drinking / alcohol
consumption, if they think it is a problem
– e.g. “How concerned are you about your drinking ?”
• Evaluating the balance of the positive and negative effects of
alcohol and challenge any false statements
• Ask if the person feels guilty about the drinking / alcohol
consumption
• Ask if the person has thought about cutting down and quitting
• Ask the person what might be the consequences of cutting
down / stopping
Stages of change
Stating the recommendation to cut down or quit

• Only after asking the person's reasons for drinking,

recommend that the person cuts down or quit alcohol use
– The person may not be ready to change, but they need to
understand your advice clearly

• Explain that you are ready to help whenever the person is

ready to address the drinking
 Role Play: Brief Intervention for Mrs Sana

• Mrs Sana describes himself herself as a social drinker

– She often goes for 2-3 weeks without drinking anything
– She only usually drinks at weekend parties
– She occasionally has 7-9 drinks in one night
– Sometimes she cannot remember how he got home

• Talk to her about this situation and provide advice

• Brief intervention video
 Role Play: Brief Intervention for Mrs Sana

• Mrs Sana describes himself herself as a social drinker

– She often goes for 2-3 weeks without drinking anything
– She only usually drinks at weekend parties
– She occasionally has 7-9 drinks in one night
– Sometimes she cannot remember how he got home

• Talk to her about this situation and provide advice

Management of alcohol dependence

• Give advice to stop drinking

• Manage safe withdrawal from alcohol
• Offer support following detoxification

• Where to manage?
• Primary vs secondary care
 Signs and symptoms of withdrawal 1

• Alcohol withdrawal is a potentially life-

threatening medical condition and can be
complicated by seizures, delirium and
Wernicke’s encephalopathy
• Signs and symptoms typically develop day
2 – 5 after last drink
• Can occur within hours
 Signs and symptoms of withdrawal 2

• Tremor
• Sweating
• Agitation
• Hypertension
• Tachycardia
• Nausea and vomiting
• Insomnia
 Delirium tremens

• Typical onset day 3 after last drink

• May be preceded by withdrawal seizures
• Disorientation, hallucinations, delusions
• Visual hallucinations of small creatures seen at
floor level
 Delirium tremens management

• Should be managed in hospital with reducing

regime of diazepam to gain control of
symptoms

• Thiamine 100mg daily for 5 days

 Oral diazepam Reducing Regime

• Day 1: 10mg 6 hourly with 10mg PRN x 2

• Day 2: 10mg 6 hourly with 10mg PRN x 2
• Day 3: 10mg 8 hourly
• Day 4: 5mg 8 hourly
• Day 5: 5mg 12 hourly
• Day 6: 5mg bedtime
• Thiamine 100mg daily oral for 5 days
• May require up to 120mg diazepam on Day 1
 Wernicke’s encephalopathy

• Confusion
• Ataxia
• Nystagmus
• Ophthalmoplegia –paralysis of eye muscle

• Treatment is thiamine – ideally 100mg iv tds for 5

days
• May progress to Korsakoff’s syndrome – chronic,
permanent short term memory loss
 Unplanned withdrawal

• May be treated with reducing regime of alcohol in

the absence of diazepam

• After any withdrawal follow up with brief

interventions and family and psychosocial support
 Link with other services and supports

A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up

57
 Link with other services and supports

• People with any kind of alcohol use problem may benefit from
– Self-help groups
– Support from family members
– Housing and employment services
– Other available people in the community
• E.g. leaders

•What is available in or near your community?

 Follow up

A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up

59
 Follow Up

• Treating people for alcohol use disorders can be a long

process

• It may take time for people to see their drinking as a problem

• You must be patient

• It is important to schedule regular follow up

 What would you do at follow up?

• Re-assess alcohol use and its impact on people's lives

• Re-assess the impact on people's physical health

• Continue to provide brief interventions

– Re-assess people’s attitude towards alcohol use and offer
advice and services
 Questions

• Would you like to share your experience related to the

material covered thus far?

• Is there anything we discussed that you do not agree with?

• Is there anything we discussed that you do not fully

understand?
 Key messages

• Alcohol use is associated with health and social problems

• All health care providers can make a difference
• Always ask about alcohol use
• Differentiate between harmful, hazardous use and
dependence
• Offer brief interventions for harmful and hazardous use
• If the person is dependent on alcohol, remember that
untreated withdrawal syndrome is a potentially fatal medical
condition and treat