ICD-10, published by WHO in 1992 categorizes alcohol-related problems under four headings:
- Acute Intoxication due to Use of Alcohol
- Harmful Use
- Dependence Syndrome
- Withdrawal State
The American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders, 4th edition, in 1994 (DSM-IV) combines alcohol and other substance abuse disorders. This manual is also used globally, and there is substantial similarity between ICD-10 and DSM-IV criteria.
Acute intoxication due to use of alcohol: Alcohol consumption results in behavioural changes and other effects by decreasing the activity of the central nervous system (CNS). The manifestation of acute intoxication includes aberrant behaviour and difficulties with ordinary bodily functions such as speech, walking or driving. The extent of CNS depression, the resultant behaviour and bodily effects correspond to the blood alcohol concentration (BAC). It should be noted that impairment in the coordination of movements such as are needed for driving start occurring at BAC 30 mg/dl which is much less than the permissible BAC during driving in many countries.
Harmful use of alcohol: The term harmful use of alcohol is used to describe a situation when there is evidence that alcohol is responsible for impairment in one or more functions of the areas of daily life viz. physical health, mental health, interpersonal or family life, social or occupational functioning or legal problems.
Dependence syndrome due to alcohol: In alcohol dependence, alcohol consumption is regular, frequently during daytime also and is characterized by a compulsive need to drink alcohol. Drinking alcohol gets priority over social, occupational and family obligations. Impairment of social, legal, interpersonal and occupational functioning is marked.
Usually alcohol dependence is associated with concurrent significant medical and neuropsychiatric complications.
Professor Jellinek first considered alcohol dependence as a disease like other diseases and gave the “disease concept of alcoholism” in 1960. It proved to be a stimulus for systematic descriptions of alcohol-related problems. The first description of alcohol dependence syndrome was in 1976 by Edwards and Gross who emphasized the inability to control consumption, salience of drink-seeking behaviour, and narrowing of drinking repertoire as the characteristic besides the phenomena of tolerance and withdrawal. In ICD-10, dependence syndrome is defined as “a cluster of physiological, behavioural and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that once had great value”. The characteristics of alcohol dependence have been described in the form of diagnostic guidelines in ICD-10 for the purpose of easy operationalization.
- A strong desire or sense of compulsion to take the substance
- Impaired capacity to control substance-taking behaviour in terms of its onset, termination or levels of use, as evidenced by: the substance being often taken in larger amounts or over longer period than intended; or a persistent desire or unsuccessful efforts to reduce or control substance use
- A physiological withdrawal state when substance use is reduced or ceased, as evidenced by characteristic withdrawal syndrome for the substance; or by use of the same (or closely-related) substance with the intention or relieving or avoiding withdrawal symptoms
- Evidence of tolerance to the effects of the substance so that there is a need for significantly increased amounts of the substance to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of substance
- Preoccupation with substance use as manifested by important alternative pleasures or interests being given up or reduced because of substance use; or a great deal of time being spent in activities necessary to obtain, take, or recover from effects of the substance
- Persistent substance use despite clear evidence of harmful consequences, as evidenced by continued use when the individual is actually aware of the nature and the extent of the harm
The need to use the well-defined criteria of alcohol dependence cannot be overemphasized in view of the variance in conceptualization across health care settings where a person with alcohol abuse or dependence can present for seeking help. The number of alcohol dependent patients seen at specialized treatment services is only a small part of the total number of such persons in the community. As such, there is a need for early and proper identification of alcohol abuse and dependence at all settings (and within the community) even if an individual presents not with a complaint of alcohol use, but with the consequences of alcohol use.
Withdrawal state from alcohol: Abrupt cessation of rapid decrease in the amount of alcohol consumption by an alcohol-dependent person is most likely to produce a number of characteristic symptoms which are termed as alcohol withdrawal syndrome. These symptoms include tremor of hands and body, sleeplessness, anxiety, nausea, vomiting, agitation, sweating, increased blood pressure, heart rate, body temperature and increased rate of breathing. These symptoms usually start within 8-12 hours of the last drink of alcohol and peak on the second or the third day, and diminish by the fourth or the fifth day. Disturbances of mood, notably anxiety, sadness and irritability, are common after the acute symptoms subside.
Generally, all physical and psychological symptoms and signs of alcohol withdrawal remit in a period of two weeks, even if untreated. In treated case, it can be expected that the symptoms and signs will last for no longer than a week. In a small number of cases, some of the withdrawal symptoms can persist up to 3-6 months. The common symptoms of such protracted withdrawal syndrome in case of alcohol are headache and insomnia.
A severe form of alcohol withdrawal is called delirium tremens (DT). The features of DT include restlessness, hearing and seeing imaginary objects, illusions, intense fear, sleeplessness, increased pulse rate, and sometimes convulsions. DT is not very frequent (5 percent of alcohol dependent persons), but when it occurs, it is often associated with concurrent medical illnesses e.g. liver failure, pneumonia, blood clots in the skull or fractures. It typically begins 48-72 hours after the last drink and subsides within 1-5 days. Death occurs in 20 per cent of untreated case and in 3.5 per cent of the cases despite treatment.
Indicators of Alcohol Use and Related Problems
Epidemiological surveys: The most direct measure of alcohol use and related problems in a community is to conduct epidemiological surveys assessing the magnitude of the problem of alcohol use and alcohol dependence. Such surveys are considered a scientifically accurate measure of individual alcohol use problems, but require large and expensive research studies, which have not been possible in many parts of the world.
Adult per capita consumption of alcohol: Another direct indicator of alcohol use is estimation of adult per capita consumption of alcohol. Even though there are numerous problems with its precise calculation, adult per capita consumption is considered the best available and an adequate indicator of the alcohol-related problems in many countries.
Use of health, police and other official statistics: Another method is to develop indicators of alcohol-related harm from health, police and other official statistics. It appears to be a major challenge as official statistics, particularly in developing countries, rarely records linkage between alcohol and the outcome. However, with some creative solutions, official statistics can provide indications of harm from alcohol. Some creative solutions to the under-reporting in official statistics include:
- Concentrate only on alcohol-specific cases: Certain conditions e.g. alcohol liver cirrhosis or alcoholic gastritis, and directly linked to alcohol abuse. Even though these conditions are under-reported, they do have their place as part of an overall battery of harm indicators
- Identify sub-sets of recorded events or conditions which are known to be highly alcohol-related: To monitor tends, certain conditions which are known to be highly alcohol related, e. g. single vehicle night-time road accidents known to be frequently linked to alcohol use, can be used. Even though the police may not record alcohol for road traffic accidents, they do record the time and conditions of each accident. Such proxy or surrogate measures can also form part of the battery of alcohol-related harm indicators
- Monitor conditions known NOT to be linked to alcohol: Monitor trends in conditions which are known not to be linked with alcohol and comparing these trends in conditions known to be linked to alcohol can indicate whether observed trends are indeed real
- Adjust indicators based on small research studies: Small but detailed research studies can establish the extent of under-reporting in official statistics. From the magnitude of under-reporting an estimate of the true picture of alcohol-related harm can be obtained
- Develop composite indicators. No one indicator can measure the exact magnitude of alcohol-related harm. Thus, assessment of multiple indicators and their possible relationship must be examined. Some of these indicators can be combined into a composite indicator.
Social parameters: Social factors such as welfare payments, disability pension (related to alcohol), work place injury, absenteeism at work, unemployment, offences related to drunkenness, could also serve as indicators of the magnitude of problems related to alcohol use in the community.
A person can benefit greatly from simple introspection on whether the increased alcohol consumption could be affecting his/her life. Four simple questions which comprise the CAGE test can help a person decide whether he/she may have an alcohol problem. If the answer to two or more questions is “yes”, there is a strong likelihood that the person needs help for that alcohol-related problem and must seek it.
The CAGE test:
Cut down: Have you ever felt that you ought to cut down on your drinking?
Annoyed: Have people annoyed you by criticizing your drinking?
Guilty: Have you ever felt bad or guilty about your drinking?
Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Another very simple question which can help you decide if you have a problem with alcohol is to ask yourself: “Do I really NEED a drink?” This question may seem too simple, but if your honest answer is “yes”, it suggests that alcohol is affecting your daily life to the point that you cannot optimally function without it. This is a good indication to seek help for your alcohol-related problem.
The management of people with alcohol-related problems involves two steps: first identification and assessment of people with alcohol-related problems and second, treatment of these people.
People with a problem of excessive alcohol use present themselves in different circumstances and situations for varying degrees and nature of required help.
Clinicians practising in an emergency room or other medical services are often overwhelmed with work and usually confine themselves to treating acute medical conditions even though these conditions are directly linked to consumption of alcohol. Problems related to alcohol use are seldom recognized. Psychiatry services are better aware of problems related to alcohol use, but psychiatrists themselves often do not treat patients for problems related to alcohol. Often there are treatment units attached to psychiatry services, which provide comprehensive services for alcohol-related problems. There are many NGOs who are active in the field of alcohol-related problems. However, the quality of their services is very variable. Police usually look at the law and order situation and if a person is not disturbing the peace, they do not get involved in a person’s problems related to alcohol. The other extreme situation is that police can use physical force on a person suffering from alcohol-related problems over which he or she has ceased to have control.
Thus, an individual with alcohol-related problems presenting to a variety of settings may not complain about his alcohol use problem, but present with complaints related to consequences of alcohol use. In such cases, the alcohol use problem gets overlooked if not specifically looked for.
Step 1: Suspicion
Suspicion of alcohol-related problems can arise based on evidence for problems in the spheres of work, marriage, finances or with the law. Report of excessive use of alcohol, even if is in the form of criticism by the patient’s spouse or any other family member, may indicate a problem. The occurrence of withdrawal features should alert clinicians. Some medical or psychological symptoms or conditions like liver disease, acid peptic symptoms, anxiety, memory lapses, attempted suicide, repeated accidents, and violence are well known to be more commonly associated with alcohol-dependence. Tentative suspicion so aroused must be followed up by specific measures for identification.
Step 2: Screening
The screening for alcohol abuse or dependence can be based on screening instruments (questionnaires) or laboratory tests.
Use of screening instruments for identification and assessment of alcohol-related problems
Screening instruments are used in epidemiological studies where large populations are to be screened for the presence of alcohol-related problems. They are also useful in clinical settings like medical and surgical outpatient departments where detailed history of substance use in every patient is difficult to obtain due to time constraint. For example, while using the CAGE questionnaire described before, the doctor asks just four very simple questions and based on yes/no answers the clinician can judge whether the individual is likely to be suffering from alcohol-related problems. Screening questionnaires like CAGE are considered to be more reliable and feasible to administer than laboratory tests, especially in developing countries and in the community setting.
Numerous screening instruments have been developed for assessing various aspects of alcohol-related problems. The AUDIT is a self-administered questionnaire developed by WHO. Other questionnaires have to be administered either by a physician or by a person trained in the field of alcohol abuse. These questionnaires attempt to obtain information about alcohol and its effects on the life of an individual in a structured objective manner.
Screening Instruments for Alcohol Use Disorder:
- Alcohol Dependence Scale (ADS)
- Alcohol Use Disorder Identification Test (AUDIT)
- The Cage Test
- Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar)
- The Munich Alcoholism Test (MALT)
- Michigan Alcoholism Screening Test (MAST)
- The brief MAST
- Obsessive-Compulsive Drinking Scale (OCDS)
- Readiness To Change Questionnaire (RTCQ)
- Short Michigan Alcoholism Screening Test (sMAST)
- T-ACE Questions TLFB: Alcohol Time Line Follow Back
- TWEAK Questions
- Alcohol Severity Index
Use of laboratory tests for identification and assessment of alcohol-related problems
Biological markers of alcoholism: Biological markers are certain bodily parameters which, when alerted, are linked to specific disorders. These markers can be trait markers or state markers. Trait markers indicate the vulnerability of a person developing a particular disorder. Many trait markers for alcohol-related problems have been identified. State markers indicate an active stage of a disease and are altered only when the disease is active. State markers have been found to be useful to identify patients with alcohol use disorders in epidemiological studies as well as in clinical practise. They are also useful in monitoring abstinence as many of them are indicative of a recent exposure to alcohol. Many of these markers have been found to be more useful when used in combination with screening questionnaires and clinical assessment.
Biological Markers of Alcoholism
- Asparate Aminotransferase (AST) and Alanine Aminotranferase (ALT)
- If raised indicates liver damage from any cause. Useful when combined with other tests.
- Gammaglutamyl Transferase (GGT)
- Most commonly used test. High levels are strongly suggestive of alcohol liver damage, but can also be raised in liver damage due to other causes. Useful test in combination with other tests and also to monitor treatment results or motivating patients to stop excess consumption.
- Mean Corpuscular Volume (MCV)
- Commonly used with GGT. Useful test in combination with other tests.
- Erythrocyte Aldehyde Dehydrogenase (ADH)
- Levels are decreased in long-term abusers of alcohol.
- Carbohydrate Deficient Transferring (CDT)
- Increased levels in long-term abusers of alcohol. Can distinguish recent excessive consumption from abstinence or light drinking.
Step 3: Confirmation
The final confirmation of alcohol dependence in each individual person who is identified on screening tests will have to be made by one or more clinical interviews, exploring the details of alcohol consumption and its effects on different aspects of life. A gentle, persuasive approach on the part of the interviewer is necessary, avoiding confrontation or provocation. The criteria and guidelines such as those of ICD-10 or DSM-IV should be applied in order to arrive at an objective diagnosis. It is possible to train general practitioners and paramedical staff to be able to conduct interviews to assess the patient along these criteria to arrive at the diagnosis of alcohol dependence and other alcohol-related problems.
- Details of alcohol use: its onset, duration, average daily consumption, presence of withdrawal symptoms if not used, over-intoxication with alcohol, abuse of any other drugs, recent changes in pattern of drinking.
- Reasons for initiation and continued drinking
- Health damage due to alcohol: signs of medical consequences of alcohol use
- Behavioural problems associated with alcohol use: depression, memory problems, suspiciousness, interpersonal problems
- Familial, social and legal consequences of alcohol use: as described in a previous section, and currently available social support
- Financial and occupational consequences: includes current financial status and current occupational status
- Previous treatment attempts: reason for seeking help this time, motivation for changes
Barriers in Assessment
- Denial of the problem by the patient as well as ambivalence about the need for external help
- Guilt about alcohol use and use-related behavioural pattern, which leads to withholding information
- Feeling of shame about having been “weak” or a “failure” resulting in poor motivation
- Stigmatization of the patient and the family that hinders active help-seeking process
- Dilemmas about physician’s role and reactions may restrain a person from seeking help
- Apprehension of possible legal and other punitive consequences may deter a person from approaching treatment agencies.
Even a clinician’s personal characteristics may serve as a barrier in the assessment of potential patients. Some important issues are:
- Scientific knowledge about the field of alcohol-related problems, though expanding, is still limited
- Judgemental attitude towards persons with alcohol-related problems affects effective delivery of treatment
- False opinion of therapeutic nihilism in cases of alcohol-related problems leads to half-hearted, non-proactive efforts on the part of the treatment teams
- Fear of inability to manage alcohol-related problems even at the most initial stages of assessment.
- Ensuring privacy and confidentiality
- Remaining non-judgmental and non-moralistic
- Showing non-possessive warmth and concern
- Expressing empathy and optimism
- Readiness to listen and understand before reaching conclusions
- Avoiding ambiguous messages
- Being clear and firm regarding one’s own role, functions, abilities and limitations
- Developing introspective ability by the helper (physician, health worker or any other)