Alcohol dependence II

Alcohol dependence II




Assessment


All patients should be asked about their alcohol consumption, and specific quantities recorded. Vague responses, such as ‘I only drink socially’, are not acceptable; many alcoholics consider themselves to be very sociable drinkers. As alcohol consumption varies for most people, it is usually easiest to enquire about a typical week and calculate the number of units consumed. Remember that measures poured at home are usually larger than the standard measures provided in bars. The pattern of alcohol consumption is important. Alcoholics typically have a rigid pattern, with regular consumption throughout the day, beginning with an early morning drink to alleviate withdrawal symptoms. The CAGE questionnaire is commonly used as a quick screening tool for alcohol dependence (Fig. 1).


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Fig. 1 The CAGE questionnaire.


If there is evidence of dependence, a detailed history of past and current drinking behaviour and its social, physical and psychological consequences should be obtained. It is important to ask about the patient’s attitude to their drinking: do they consider it to be a problem and if so are they prepared to accept help to stop drinking? Motivation to stop is a vital prerequisite of any treatment package. Those who have no such motivation should be informed of the risks they are taking, and advised about the services available should they wish to seek help in the future.


Assessment of those with symptoms of alcohol dependence should include a full psychiatric history and mental state examination, looking particularly for depression, suicidal thoughts and cognitive impairment. A thorough physical examination will be necessary to search for the many medical complications of alcoholism, and this should be supported by investigations, including full blood count and liver function tests. The mean corpuscular volume (MCV) and serum gamma-glutamyl transpeptidase (GGT) are useful screening tests for alcohol abuse, as both are raised with chronic heavy alcohol consumption. A corroborative history may be useful to complete the assessment, but many alcoholics attempt to hide the full extent of their drinking from their families and may be unwilling to have them involved in the assessment.



Treatment


Treatment of alcohol dependence consists of management of withdrawal from alcohol and prevention of relapse. It is relatively easy to persuade an alcoholic to stop drinking and treat the subsequent withdrawal symptoms; maintaining abstinence from alcohol is the real challenge.



Withdrawal from alcohol


Management of withdrawal from alcohol, or detoxification, may be done in a planned, controlled way, with a patient who recognises that he has an alcohol problem and wishes to stop drinking. In these circumstances the withdrawal can often be managed at home with daily visits from the GP or Community Alcohol Team to monitor progress, and medication to control the symptoms. Hospital admission is only indicated if there is a history of serious problems during previous withdrawals, such as convulsions or delirium tremens.


Many withdrawals are not planned and happen after a period of enforced abstinence from alcohol. This may occur following admission to hospital and should always be considered in a patient who becomes tremulous or confused within a few days of admission. Symptoms of the withdrawal syndrome are summarised in Figure 2. They are usually treated with benzodiazepines (e.g. chlordiazepoxide) which, like alcohol, increase the activity of the neurotransmitter GABA. The drug is given in sufficient doses to control the symptoms, and the dose is then gradually reduced and stopped over the course of a week, by which time the symptoms will have resolved. Parenteral thiamine should be given to all patients to prevent Wernicke’s encephalopathy. Detoxification should be offered to all alcoholics expressing a wish to stop drinking, including those who have been through this process many times in the past.


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Fig. 2 Withdrawal syndrome.

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Jul 12, 2016 | Posted by in PSYCHIATRY | Comments Off on Alcohol dependence II

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