• A cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol, tolerance to its effects, and difficulties controlling its use. Someone who is alcohol-dependent may persist in drinking, despite harmful consequences, such as physical or mental health problems.

• In severely dependent patients who have been drinking excessively for a prolonged period of time, an abrupt reduction in alcohol intake may result in the development of an alcohol withdrawal syndrome, which, in the absence of medical management, can lead to seizures, delirium tremens, and death.

Assisted alcohol withdrawal

• Chlordiaxepoxide or diazepam

• Carbamazepine

• Clomethiazole

Delirium tremens

Medical emergency that requires inpatient care

• Agitation

• Confusion

• Paranoia

• Visual/auditory hallucinations

Management options

• Oral lorazepam

• Parenteral lorazepam

• Haloperidol

Mild alcohol dependance

• CBT

• Acamprosate: maintenance of abstinence 

• Naltrexone: opioid-receptor antagonist. maintenance of abstinence in formerly opioid or alcohol-dependent patients

• Disulfiram: reactions may occur following exposure to small amounts of alcohol. More contra-indications. Disulfiram can be used in the treatment of alcohol dependence and works by producing an acute sensitivity to alcohol by causing an accumulation for acetaldehyde when alcohol is consumed.

• Nalmefene: recommended for the reduction of alcohol consumption in patients with alcohol dependence who have a high drinking risk level, without physical withdrawal symptoms, and who do not require immediate detoxification 

Resources

• Alcohol dependence (BNF)

• Alcoholic liver disease

According to the National Institute for Health and Care Excellence (NICE), most people with alcohol dependence should be provided with withdrawal treatment in community-based settings where possible; the duration and intensity of which should vary with the severity and complexity of the person’s problems.

Medication is used to replace alcohol during withdrawal, to prevent delirium tremens and fits. Chlordiazepoxide is the drug of choice and the preferred benzodiazepine for community-based detoxification. It has a long half-life, and there is less likelihood of diversion for illicit use. Diazepam, although an alternative, can be used as a drug of abuse.

Chlormethiazole can be used as a second-line drug in inpatients; but is not recommended for outpatient detoxification.

Haloperidol is usually reserved for acute hallucinosis. It should be used cautiously and reviewed regularly under inpatient specialist supervision.

Multivitamins, including thiamine, are used in the management or prevention of Wernicke’s encephalopathy and Korsakoff’s syndrome. Acamprosate or oral naltrexone can be offered after successful withdrawal.

Resource:

NICE. Alcohol-Use Disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. CG115. 2011.

Chronic pancreatitis may follow episodes of acute pancreatitis or may occur without an identifiable attack. The most common aetiological agent is alcohol but in some patients no satisfactory explanation is available.

Clinical features include abdominal pain, anorexia and weight loss.

Features of exocrine insufficiency include:

• Steatorrhoea

• Hypocalcaemia

• Fat malabsorption

• Protein catabolism (due to deficiency of pancreatic proteases)

Features of endocrine insufficiency include impaired glucose tolerance and diabetes mellitus.

Chronic pancreatitis may burn out after many years as the gland atrophies and malabsorption and diabetes develop. Overall, about 25–30% die within 10 years. Pancreatic cancer develops in approximately 4% of patients with a 20-year-history of chronic pancreatitis.

Alcoholic liver cirrhosis

A 45-year-old man, known to drink around 50 units of alcohol per week, presents with fatigue, weight loss, diarrhoea, right-upper abdominal pain and jaundice.

Which of the following is a RISK FACTOR for developing alcoholic liver cirrhosis? 

A. Male

B. Low fat diet

C. BMI of 22 kg/m2

D. Caucasian

E. Genetic predisposition

The threshold beyond which alcoholic liver disease may occur is 35 units of alcohol per week for women and 50 units of alcohol per week for men. Only the amount of alcohol, and not the nature of the beverage, is important.

The exact mechanism of alcoholic hepatitis and cirrhosis is not known. Genetic factors may be important as only 10–20% of heavy drinkers develop cirrhosis, and 33% of heavy drinkers have no hepatic consequences. Whilst binge drinking is associated with increased violence and accidents, its role as a risk factor for cirrhosis is still unclear.

Other risk factors for the development of alcoholic liver cirrhosis include:

• Daily drinking

• Increased duration of alcohol use

• Female

• Poor nutrition

• Coexistence of viral infection (hepatitis B or C)

• High fat diet

Resource:

• RCGP. Curriculum Topic Guides: smoking, alcohol and substance misuse. 2019