BMJ 2005;330:139-141 (15 January), doi:10.1136/bmj.330.4!3.

139
Clinical review
ABC of alcohol
Treatment for alcohol related problems
Bruce Ritson
Introduction
When hazardous or harmful drinking is first identified in primary

care or the hospital setting, patients
should be offered brief

intervention. This consists of 10 minutes of discussion and

explanation,
provision of a self-help booklet, and the offer

of a further appointment in one or to eeks. !ts cost
effectiveness

has been proved, although time may have to be set aside rather

than trying to undertake
intervention ithin normal practice.

Training and employing a member of staff for the purpose is

orth consideration.

Motivational interviewing
The value of motivational intervieing is proved. This essentially

is an empathic, non-
confrontational approach in hich the doctor

helps the patient identify his or her on reasons for
change

and strategies for achieving realistic goals. "ssential components

include sustaining
commitment over time, involving the family

hen possible, acknoledging achievements, and
dealing promptly

ith lapses. # patient$s motivation to change his or her ay

of life fluctuates
according to mood and circumstance, and patient

and doctor can feel deflated by early setbacks.

Motivational interviewing
1
%eople believe hat they hear themselves say
Empathic interviewing style
& 'pen ended (uestions
& )eflective listening
& *et on their +avelength+
Feedback about risk
& #gree factual information about personal harm or impairment
& ,alance sheet of pros and cons of changing-not changing
Roll with resistance
& #void confrontation
& #rguments about terms such as alcoholic are usually fruitless, particularly in the early stages
Support self efficacy
& %atient takes responsibility for achieving goals
& .hoosing from menu of options
& "ncourage belief that change is possible
Reinforce self motivating statements
& )ecognition of harm caused
& /esire to change
& 0easibility of change
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Motivational interviewing
The primary care team is ideally suited to provide long term

support. ,arriers to change need to be
identified3 some patients

ill have fe barriers4 others ill have serious impediments

that need to be
dealt ith.

"ependence and deto#ification
5ome patients ill find it hard to cut don or stop drinking

because they experience ithdraal
symptoms. #t first, these

may not be recognised for hat they are. %atients may describe

feeling
nervous ithout a drink or not being able to function

effectively until the first drink of the day. 'ther
features

in patients ho are physically dependent ill provide supportive

evidence. They vary in
severity.

$lcohol withdrawal syndrome
6
.ommon features on stopping or reducing alcohol3
& #nxiety and agitation
& Tachycardia
& 5eating
& Tremor of extended hands, tongue, and eyelids
& 7ausea and vomiting
& !nsomnia
& Withdraal fits
& .onfusion
& 8allucinations
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$lcohol withdrawal syndrome
9ild symptoms can be dealt ith by rest, relaxation, and reassurance.

#n explanation that
ithdraal symptoms are evidence that the

brain has adapted to living in an alcoholic environment
and

ill take time to ad:ust to one that is alcohol free is helpful.

%atients find it reassuring to kno
that symptoms, hoever unpleasant,

ill pass in a fe days. This approach is often enough hen

patients are alcohol free at intervie and report drinking ;

1< units a day in men and ; 10 units a day
in omen ithout

recent ithdraal symptoms or recent drinking to relieve alcohol

ithdraal.

When dependence is more advanced, the discomfort of ithdraal

may necessitate medical
detoxification. !n most cases, this

can be done at home, but patients hose symptoms are very severe

and ho have other prominent physical, psychological, and social

factors, need referral for specialist
treatment in hospital.

Factors indicating need for specialist or hospital referral
& .onfusion
& 8allucinations
& "pilepsy or history of fits
& )isk of suicide
& 0ailed home detoxification
& %oor nutrition
& =nsupportive home environment
& #cute physical or psychiatric illness
& #ny symptoms of encephalopathy
>
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Factors indicating need for specialist or hospital referral
"rug treatment
,enzodiazepines are the drug of choice for managing ithdraal

symptoms. )emember that they
can induce temporary difficulties

in cognition and recall. They are addictive if taken over time,

and
detoxification ith benzodiazepines should not be continued

for more than seven days. !t is sensible
to start ith a high

daily dose, such as 160 mg chlordiazepoxide or 60 mg diazepam

on the first day,
and then reduce the dose. #fter the third

day, the dose should have been reduced by at least 6<?.
/etails

of the drug regimen should be ad:usted to the patient$s condition.
This article is adapted from the %th edition of the ABC of Alcohol&

which will be available
in February
'ther support
/rug treatment is only one part of the treatment for ithdraal.

%atients and families should receive
a careful explanation and

should be advised to stay off ork, not drive, rest, and drink

plenty of
fluids @fruit :uice rather than stimulants such as

coffeeA. The need to abstain from all alcohol should
be made

clear. !deally, a community nurse or general practitioner should

visit daily to monitor
progress, revie drugs, assess mental

state, and vital signs, and, if possible, breathalyse for alcohol.

Withdraal symptoms usually resolve in B-C days, after hich

time patients feel much better and
optimistic about the future.

They may believe they can no handle alcohol, but it needs to

be made
clear to patients and carers that on no account should

drinking @hoever littleA be resumed. The
visiting health professional

is ell placed to establish a therapeutic alliance for the future

and
reinforce the need for continued abstinence.
B
iew larger version @6>DA3
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"eto#ification regimen

itamins
7o clear evidence shos that oral vitamins are needed for ell

nourished people ith moderate
alcohol dependence. !n patients

ho are undernourished and have a history of fre(uent relapse

and
self neglect, hoever, 600->00 mg thiamine a day over three

months or longer ill help minimise the
risk of damage to the

brain and peripheral nervous system. 'ral vitamins are absorbed

poorly during
the early stages of detoxification, so parenteral

thiamine may be needed. !f the patient is suspected to
have

or be developing Wernicke$s encephalopathy, urgent treatment

in hospital ith parenteral
thiamine is needed.

<
"eto#ification(daily check
& Tremor
& %ulse
& Temperature
& ,lood pressure
& Eevel of consciousness
& 'rientation
& /ehydration
& "vidence of continued drinking
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"eto#ification(daily check
'ther drugs are rarely necessary. #ntacids ill help relieve

stomach pains. #nticonvulsants are of
little value in preventing

ithdraal fits, and the management of alcohol dependent people

ith
established epilepsy is best supervised by a specialist

clinic. #ntidepressants are not indicated at this
stage in treatment,

and antipsychotics are needed rarely.
)ernicke*s encephalopathy
5igns may include3
& .onfusion
& #taxia, especially truncal ataxia
& 'phthalmoplegia
& 7ystagmus
& .oma
& 8ypotension
& 8ypothermia
& =nexplained neurological signs during ithdraal
)l(uires urgent specialist assessment and treatment ith parenteral thiamineFeg %abrinex
intramuscular
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)ernicke*s encephalopathy
C
+reventing relapse
The drinker ill need to devise strategies to cope ith life

ithout recourse to alcohol or ith
controlled drinking. 5ome

people ill find it relatively easy to change this habit4 this

is often most
true of those ho identified the problem early

and have not developed severe physical, social, and
psychological

problems.

Triggers to relapse
"nvironment & #vailability
& %ub atmosphere
.ustom & #lays drink at certain times, occasions, and situations
!nterpersonal & 5tress
& .onflicts
!ntrapsychic & "xpectations
& #nxiety
& 5ocial phobias
& /epression or elation @celebrationA
'verconfidence & 0eeling good
+! have got over my drinking problem+
+! can take some alcohol again+
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Triggers to relapse
# drinking diary and a balance sheet of the good and bad conse(uences

of continued drinking, hich
are often used in the initial assessment,

are useful tools throughout follo up, and they can be used

to
set goals and monitor progress. %atients are encouraged to

set their on goals and identify ays of
dealing ith triggers

to relapse. !f possible, involve the family in the plan and

encourage persistence,
even in the face of relapses. 5ometimes

ma:or barriers to change that are not responding to
motivational

approaches ill be obvious, and more specialist help ill be

re(uired.

9any problem drinkers risk becoming dependent on benzodiazepines,

hich have been initiated
over a series of failed detoxification

episodes.

G
+harmacotherapy

"isulfiram
/isulfiram is a ell established drug that acts as a deterrent

to drinking by blocking the metabolism
of alcohol and thus flooding

the body ith the toxic substance acetaldehyde. This produces

flushing,
palpitations, nausea, faintness, and in some cases

collapse. Hery rarely the conse(uences are serious
or even fatal.

%roblems most often occur hen high doses are taken. #n initial

dose of 600 mg a day, if tolerated,
can be increased after a

fe days to B00 mg4 eventually a supervised dose of B00 mg to

or three
times a eek is usually enough. /isulfiram should not

be given to patients ith serious active liver
disease or cardiovascular

disorders, to pregnant omen, or patients ho are suicidal or

cognitively
impaired. The action should be explained carefully

to patients and their families. %atients should
carry explanatory

leaflets and a card explaining the actions of the drug.

St Martin, patron saint of alcoholics

and alcoholism
The efficacy of disulfiram has been shon only hen its use

is supervisedFfor instance, by relatives
or by clinic,

primary care, or occupational health staff. /isulfiram interferes

ith the metabolism of
other drugs, most notably tricyclic antidepressants,

monoamine oxidase inhibitors, heparin, and some
anticonvulsants.

/rosiness is noted by some users. 8epatotoxicity is a recognised

risk, and regular
monitoring of liver function in the early

months of treatment is advisable.

$camprosate
#camprosate has proved helpful as an ad:unct to psychological

therapies. !t should be started as soon
as abstinence is achieved

and can be continued during a relapse. !f the patient makes

good progress,
it can be continued for one year. The dose is

CCC mg three times daily for patients aged 1I-C< years
ho eigh

C0 kg or more. %atients ho eigh less than C0 kg should take

CCC mg at breakfast, >>>
mg at midday, and >>> mg at night.

5ide effects are rare and are mostly mild gastric upsets.
I
7altrexone also improves outcome and reduces the severity of

relapse, but it is not yet licensed for
regular use in the =nited

Dingdom.

Referral
& 9ake sure the patient knos hy he or she is being referred and give a follo up appointment to
revie progress
& !t is good practice to get to kno the specialist resources available in your area as they vary
considerably
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Referral
Referral
)eferral to another agency should be timed carefully. )eferral

should not be too early because the
patient may feel re:ected4

neither should it be too late, hen the patient and family have

become
despondent or further damage has occurred. #t the time

of referral, a further follo up appointment
should be made

to find out hether the patient attended and ho they got on.

The dropout rate at the
point of referral is high.

0or people ith established alcohol dependency, #lcoholics #nonymous

is a valuable resource. !t is
best to make a personal introduction

if possible.

"rug treatments should always be accompanied by psychological

support and therapy aimed at
attaining a longer term change

of lifestyle that is essentially drug free
Further reading
& "dards *, 9arshall "J, .ook ..8. The treatment of drinking problems. .ambridge3
.ambridge =niversity %ress, 600>
& 0reemantle 7, %aram:it *, *odfrey ., Eong #, )ichards ., 5heldon T, et al. ,rief interventions
and alcohol use3 are brief interventions effective in reducing harm associated ith alcohol
K
consumptionL Effective Health Care 1KK>4G3 1-1>
& 0uller )D, *ordis ". /oes disulfiram have a role in alcoholism treatment todayL Addiction
600B4KK3 61-B1.ross)ef2 1!5!2 19edline2
& *arbutt J, West 5, .arey T, Eohr ", .res 0. %harmacological treatment of alcohol dependence3
a revie of the evidence. JAMA 1KKK46I13 1>1I-6<1#bstract- 0ree 0ull Text2
& 9iller W, Wilbourne %. 9esa grande3 a methodological analysis of treatments for alcohol use
disorders. Addiction 60064KG3 6C<-GG1.ross)ef2 1!5!2 19edline2
& 5lattery J, .hick J, .ochrane 9, .raig J, *odfrey ., Dohli 8, et al. Prevention of relapse in
alcohol dependence. 785 5cotland3 8ealth Technology ,oard for 5cotland, 6006
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