Alcohol and Alcohol Use Disorder

Introduction to Alcohol & Alcohol Use Disorder

Learning Outcomes

  • Understand Alcohol Use Disorder (AUD), its health risks, and prevalence.
  • Learn the diagnosis of AUD.
  • Understand the pharmacology of alcohol consumption.
  • Identify harms to the individual and the world.
  • Explore treatment options for AUD.
  • Examine alcohol policies around the world and their effectiveness.
  • Consider the role of technology in substance treatment.

UK Guidelines for Alcohol Consumption

  • Recommended limit: 14 units per week for both men and women.
  • Include days each week with no alcohol consumption.

Disproportional Alcohol Drinking

  • Most UK adults drink within lower risk levels (≤14 units/week).
  • A quarter of the population consumes over 75% of total alcohol.
  • Less than 2% consume ≥75 units per week.
  • High-need, high-cost alcohol-related attenders represent 9% of alcohol-dependent individuals but account for 59% of NHS hospital admissions.

Alcohol Use Disorder Identification Test (AUDIT)

  • AUDIT: Alcohol screening tool including questions about alcohol consumption, dependence symptoms and related consequences.
    • Asks about frequency of drinking, typical units consumed, frequency of heavy drinking episodes, inability to stop drinking, failure to fulfill normal expectations, morning drinking, guilt/remorse, memory problems, injuries, and concerns from others.
  • Unit Guide:
    • 1 unit: Half-pint of regular beer/lager/cider, small glass of low ABV wine (9%), single measure of spirits (25ml).
    • More than 1 unit: Pint of regular/strong beer/lager/cider, 440ml regular can of cider/lager, 440ml "super" lager, 175ml glass of wine (12%).
  • Scoring System :
    • 0-7: Lower risk
    • 8-15: Increasing risk
    • 16-19: Higher risk
    • 20+: Possible dependence

AUDIT-C

  • A simplified AUDIT version using only the first 3 questions, which can quickly identify risk drinking.
  • If the individual scores 5+ on the AUDIT-C, administer the remaining 7 AUDIT questions to calculate the total score.
  • If the individual scores less than 5, no further action is required.

Risk Categories and Interventions Based on AUDIT Score

  • Score 0-7: Lower risk
    • No intervention is typically needed.
    • Congratulate and reinforce the benefits of lower-risk drinking.
  • Score 8-15: Increasing risk
    • Brief Advice: deliver a brief intervention such as using a 2-sided Brief Advice Tool.
  • Score 16-19: Higher risk
    • Deliver a 5-minute 'Brief Advice' session using a 2-sided tool and/or offer a 20-30 minute follow-up session of Extended Brief Advice.
  • Score 20+: Possible dependence
    • With patient consent, refer to specialist services.
  • Extended Brief Intervention should be offered if the individual does not respond to Brief Advice or wants to discuss further (20-30 minutes of motivational interviewing)

Severity of Alcohol Dependence Questionnaire (SAD-Q)

  • Asks questions of heavy drinking of how often they experienced:
    • Sweaty when waking up.
    • Hands shaking.
    • Whole body shaking violently.
    • Drenched in sweat.
    • Dreading waking up in the morning.
    • Frightened of meeting people.

Stigma Reduction

  • Use person-centered language to reduce stigma.
    • Instead of "addict" or "junkie," use "person with substance use disorder."
    • Instead of "alcoholic" or "drunk," use "person with alcohol use disorder."
    • Instead of "drug abuse," use "substance use" or "medication misuse."
    • Instead of "alcohol abuse," use "person who misuses alcohol."

Alcohol Use Disorder (AUD) Definitions

  • Harmful drinking/high-risk drinking: Alcohol consumption causing health problems directly related to alcohol, including psychological (e.g., depression), accidents, or physical illness (e.g., acute pancreatitis).
  • Alcohol dependence: Characterized by craving, tolerance, preoccupation with alcohol, and continued drinking despite harmful consequences. Associated with increased criminal activity, domestic violence, and higher rates of mental and physical disorders.

Physical and Psychological Elements of AUD

  • Physical elements:
    • Decreased response to alcohol due to continued use (tolerance).
    • Alcohol withdrawal symptoms: tremors, sweating, agitation, and nausea (occurring on cessation or reduction).
  • Psychological elements:
    • Impaired control over drinking.
    • Depression and anxiety.
    • Strong desire for alcohol (craving) and its intoxicating effects.

Prevalence Rates

  • Based on NHS Digital Health Survey for England 2021.
  • Among adults who drank alcohol, the average was 11.6 units/week (14.7 for men, 8.5 for women).

Global Impact of Alcohol Use

  • In 2016, alcohol led to 2.8 million deaths and was the leading risk factor for premature death and disability among those aged 15-49 years.
  • Nearly 9% of all attributable Disability-Adjusted Life Years (DALYs) for men and >2% for women.
  • Around 1 in 20 adults (over 15 years) were estimated to have an AUD.
  • Highest prevalence in the European Region, followed by the Americas.
  • Higher proportion of males than females with AUD.
  • In 2016, around 14% of total deaths among people aged 20-39 years were alcohol-attributable.

Metabolism of Alcohol

  • Ethanol (alcohol consumed) is metabolized in the body through two main enzyme reactions:
    • CH3CH2OH \text{ (Ethanol)} \xrightarrow{\text{ADH enzyme}} CH3CHO \text{ (Acetaldehyde)}
    • CH3CHO \text{ (Acetaldehyde)} \xrightarrow{\text{ALDH enzyme}} CH3COOH \text{ (Acetate)}
  • Acetaldehyde is toxic intermediate.
  • Acetate is further broken down into CO2 + H2O and eliminated through breath, urine, and sweat.

Pharmacology of Alcohol – The Brain

  • GABA: main inhibitory neurotransmitter.
    • Alcohol stimulates GABA receptors, dampening brain activity.
    • Short-term: reduces anxiety.
    • Chronic drinkers: anxiety, tremors, agitation, and seizures upon sudden cessation.
  • Dopamine: neuromodulator signaling reward.
    • Alcohol affects dopamine signaling, underlying habit formation.
    • PET (positron emission tomography) can assess functional consequences of changes in brain dopamine activity.
    • Used to investigate normal brain function and psychiatric/neurological diseases.
    • Used in psychopharmacological research to investigate dopamine drugs and drugs of abuse effects.
    • Studies: Buhler and Mann (2011), Spitta et al. (2023), Ma and Zhu (2014)

Dopamine and Reward Pathway

  • Images shown about dopamine, satisfaction, memory and movement
    • Repeated action makes you want to do the action again.
  • Reward pathways are activated by both natural rewards and addictive drugs.
  • Tolerance occurs when dopamine receptors are maxed out

Health Risks – Short Term

  • Alcohol poisoning and nausea
  • Accidents, falls, and injuries
  • Lowered inhibitions leading to conflicts and risky behaviors
  • Poor sleep
  • Hangover

Health Risks – Long Term

  • Affects almost every part of the body:
    • Increased blood pressure and cholesterol (increased risk of heart attacks and strokes).
    • Weakened immune system.
    • Liver disease.
    • Several types of cancer (liver, mouth, head and neck, bowel, breast).
    • Pancreatitis.
    • Mental health problems.
    • Dementia and other memory problems.
    • Infertility.
    • Fetal alcohol syndrome (alcohol consumption during pregnancy).
  • 29% of people in substance abuse treatment are in treatment for alcohol alone, a 10% increase from 2021.

Wider Harms of Alcohol Use

  • 2.8 million deaths worldwide in 2016.
  • Biggest risk factor for early mortality, ill health, and disability in England for people between 15 and 49 years.
  • Deaths from liver disease have increased by 400% in the UK since the 1970s.
  • Costs the NHS in England £3.5 billion per year, mostly from inpatient and emergency care.
  • Alcohol-related hospital admissions have doubled in the last 10 years to over £1.1 million per year in England.
  • Unmet physical, mental, and social care needs.
  • Drink-driving related injuries and deaths.
  • Alcohol-caused injuries and conflicts (intentional and accidental).
  • Causal relationship between alcohol use and infectious diseases (e.g., TB or HIV).

Treatment Options

  • Brief interventions (5-10 minutes counselling session which covers risks associated with drinking pattern, reduction, emotional issues and support network).
  • Medical advice needed to safely manage withdrawal; medication can be prescribed.
  • Mild cases: detox at home without medication.
  • High risk/severe cases: detox at home with medication or inpatient detox.
  • Alongside/post detox: Self-help groups, counselling, 12-step programs, CBT, Family therapy, drinking diary.

Cognitive Behavioral Therapy (CBT)

  • Successful in addiction treatment by helping individuals identify and change dysfunctional beliefs and behaviours.
  • Often used with other treatments like medication and rehabilitation, but can be used independently.
  • Complements other treatments by addressing negative thoughts and behaviours.
  • Addresses negative thoughts and behaviors associated with addiction.
  • Types include cognitive restructuring, behavioral experiments, exposure therapy.

Alcoholics Anonymous (AA) / 12 Step

  • Controversial research with divergent interpretations.
  • Kelly et al. (2020): AA/TSF interventions usually produced higher rates of continuous abstinence than other established treatments.
  • Non‐manualized AA/TSF performed as well as other established treatments.
  • AA/TSF may perform as well as other clinical interventions for drinking intensity outcomes.
  • Dutra, et al. (2008), Magill and Ray (2009) – meta-analysis on CBT and substance use.

Network Therapy and Social Behavior Network Therapy (SBNT)

  • Network therapy: involves friends and work colleagues in the identified drinker's life.
  • Selected family members and friends are enlisted to provide support and promote change.
  • Network members are part of the therapist's team, not subjects of treatment.
  • SBNT: Combines network therapy, social aspects of community reinforcement, relapse prevention, and approaches with family.
  • SBNT is based on the principle that social support is critical for successful addiction treatment.

Motivational Enhancement Therapy (MET)

  • Directive, person-centred approach to improve an individual’s motivation to change.
  • Addresses ambivalence and low motivation despite acknowledging negative impacts.

Treatment - Medication

  • NICE (National Institute for Health and Care Excellence) recommended medications for alcohol misuse:
    • Acamprosate: Changes levels of GABA with the aim to reduce alcohol craving.
    • Disulfiram (Antabuse): Deters from alcohol consumption by causing an unpleasant physical reaction to alcohol.
    • Naltrexone: Blocks opioid receptors, stopping the effects of alcohol.
    • Nalmefene: Blocks opioid receptors, aims to reduce alcohol craving and should only be taken if receiving support for alcohol reduction and in treatment.

Acamprosate

  • Thought to act on the glutamatergic system as an NMDA receptor partial co-agonist
  • Aims to stabilize brain chemicals damaged by excessive alcohol use.
  • Reduces neuronal hyperexcitability during withdrawal and abstinence.
  • Meta-analysis of 27 RCTs (Jonas et al., 2014) found acamprosate reduced risk of abstinent patients returning to any drinking but did not reduce binge drinking.
  • COMBINE study (Anton et al., 2006) found acamprosate had no significant effect on drinking compared to placebo.

Disulfiram

  • Aldehyde dehydrogenase inhibitor, blocking alcohol metabolism and increasing acetaldehyde concentration (leading to unpleasant side effects).
  • Meta-analysis of 22 RCTs found increased success rates compared to placebo in open-label studies only (Skinner et al., 2014).
  • Effectiveness depends on the patient's anticipation of being sick if alcohol is consumed.
  • Supervised disulfiram ingestion shows significantly better rates compared to non-supervised (Fuller et al., 2014).

Alcohol Research – UKAAT

  • UKAAT – UK Alcohol Treatment Trial
  • RCT comparing social behavior and network therapy with motivational enhancement therapy (MET).
  • Participants: 742 clients with alcohol problems interviewed at 3 and 12 months.
  • Results: Both groups reported substantial reductions in alcohol consumption, dependence, and problems, and better mental health.
  • Conclusion: Social and network therapy did not differ significantly in effectiveness from MET (UKATT research team, 2005).

Alcohol Research – ADAM

  • Alcohol Dependence and Adherence to Medication (ADAM)
  • RCT to determine the effectiveness of Medication Management (MM) with/out Contingency Management (CM) compared to Standard Support (SS) in enhancing adherence to Acamprosate.
  • Participants: 739 with AUD prescribed Acamprosate.
  • Results: SS+MM+CM had higher % of adherence compared to SS alone at 6 months. No significant difference between SS+MM compared to SS alone. SS+MM+CM was cost-effective compared to SS alone.
  • Conclusion: MM enhanced CM is beneficial for supporting Acamprosate adherence (Donoghue et al., 2023).
  • SS: 372 (50%), SS + MM: 182 (25%), SS + MM + CM: 185 (25%)

Alcohol Research – Transdermal Sensors

  • Transdermal Alcohol Sensors (TAS) with/without CM.
  • PhD thesis comprising of two SRs and three studies using TAS.
  • Aim: To investigate the use of TAS within the clinical population by exploring accuracy, acceptability, and feasibility.
  • Conclusion: Findings support the use of TAS within clinical alcohol treatment in the UK.
  • The BACtrack Skyn was accurate over one to two weeks with adults accessing alcohol treatment for AUD. TAS were considered acceptable and feasible to users and staff.
  • The BACtrack Skyn could provide 24/7 monitoring, CM, and motivate/reinforce alcohol reduction and abstinence (Brobbin et al., 2021-2024).

Policy - MUP

  • Minimum unit pricing (MUP) sets a baseline price at which a unit of alcohol can be sold.
  • In Scotland and Wales, MUP is 50p.
    • Wine containing 10 units of alcohol can be sold for no less than £5.
    • Standard strength pint of beer (2.5 units) cannot be sold for under £1.25.
  • Public Health Scotland found that MUP in Scotland has reduced alcohol-specific deaths by 13.4% and averted over 800 hospital admissions every year since its introduction.
  • MUP also had the most impact on those living in the 40% most deprived areas of Scotland, helping to reduce health inequalities.
  • Alcohol Minimum pricing House of Commons Briefing paper 2020 - https://researchbriefings.files.parliament.uk/documents/SN05021/SN05021.pdf
    • https://ahauk.org/what-we-do/our-priorities/minimum-unit-pricing/

Policy - Drink Drive Limits

  • More enforcement needed to stop drink-driving, say UK experts.
  • Reducing blood alcohol limits is welcomed, but Scotland data suggests better enforcement is needed to reduce accidents.
  • In 2014, the limit in Scotland was reduced to 50mg/100ml, but experts found no significant drop in road traffic accidents.

Cue Exposure Therapy (CET) and Virtual Reality (VR)

  • CET: Based on classical conditioning, it is a form of CBT used in treatment, often with fear-based problems.
  • The goal is to extinguish a learned response through repeated exposure to a conditioned stimulus in the absence of the consequence.
  • VRCET study at KCL: VR to develop more realistic CET environments, hoping to produce a greater impact on reducing cocaine craving than previous treatment options.

Summary

  • Long-term heavy drinking can cause physical and mental health harms and is consistently more prevalent in men.
  • GABA and dopamine are altered in the brain when we consume alcohol.
  • There are a range of treatment options available for AUD including psychosocial and medication.
  • A range of policies have been implemented in the UK and globally to address alcohol harms.
  • Consider the role of technology in alcohol treatment and/or research.

Alcohol Support

  • Talk to Frank: www.talktofrank.com
  • Drinkline: 03001231110
  • Lorraine Hewitt House (Brixton, Drug and Alcohol service in London): 02032281500