Clinical Evidence Handbook

A Publication of BMJ Publishing Group

Alcohol Misuse

Am Fam Physician. 2009 Apr 15;79(8):692-694.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 645.

Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the World Health Organization (WHO) as one of the top five risk factors for disease burden.

  • Without treatment, approximately 16 percent of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption.

    This review covers interventions in hazardous or harmful, but not dependent, alcohol users.

  • Hazardous alcohol consumption is defined as a pattern of alcohol consumption that increases the person's risk of alcohol-related harm, but that is not currently causing alcohol-related harm.

  • Harmful alcohol consumption is a pattern of consumption likely to have already caused alcohol-related harm.

Single-or multiple-session brief intervention reduces alcohol consumption over one year in hazardous drinkers treated in the primary care setting, but we do not know how it affects mortality.

Brief intervention (single-or multiple-session) is also effective at reducing alcohol consumption in persons treated in the emergency department, although the evidence is not as strong.

Adding universal screening to brief intervention enhances its benefits when given in primary care.

  • We do not know the effects of universal screening in emergency departments because we found no data.

  • We do not know the effects of targeted screening because we found no data assessing its use in primary or emergency care.

Clinical Questions

What are the effects of interventions in hazardous or harmful drinkers in the primary care setting?

Beneficial

Brief intervention (single-or multiple-session; more effective than usual care)

Likely to be beneficial

Adding universal screening to brief interventions (more effective than brief intervention alone)

Unknown effectiveness

Adding targeted screening to brief intervention

What are the effects of interventions in hazardous or harmful drinkers in the emergency department setting?

Likely to be beneficial

Single-session brief intervention (more effective than usual care in persons presenting to emergency departments with injuries related to alcohol consumption)

Unknown effectiveness

Targeted screening plus brief intervention

Universal screening plus brief intervention

Clinical Questions

View Table

Clinical Questions

What are the effects of interventions in hazardous or harmful drinkers in the primary care setting?

Beneficial

Brief intervention (single-or multiple-session; more effective than usual care)

Likely to be beneficial

Adding universal screening to brief interventions (more effective than brief intervention alone)

Unknown effectiveness

Adding targeted screening to brief intervention

What are the effects of interventions in hazardous or harmful drinkers in the emergency department setting?

Likely to be beneficial

Single-session brief intervention (more effective than usual care in persons presenting to emergency departments with injuries related to alcohol consumption)

Unknown effectiveness

Targeted screening plus brief intervention

Universal screening plus brief intervention

Definition

This review covers interventions in hazardous and harmful alcohol users 18 years and older who are being treated in primary care or in emergency departments. In defining hazardous and harmful alcohol consumption, we have used the WHO categorization of alcohol use disorders. Dependent drinkers (who have more serious alcohol misuse problems than harmful or hazardous drinkers) are not covered in this review.

It is important to note that threshold levels of hazardous and harmful consumption often vary by country and culture. Hazardous alcohol consumption is defined as a pattern of alcohol consumption that increases the person's risk of alcohol-related harm, but that is not currently causing alcohol-related harm. The quantity and frequency of alcohol consumption that constitutes hazardous use is usually specified using threshold levels of consumption. In the United Kingdom, these levels are specified as in excess of 14 standard drinks for women and 21 standards drinks for men in any week, where a standard drink constitutes 10 mL by volume or 8 g by weight of pure ethanol. Harmful alcohol use is a pattern of consumption likely to have already led to alcohol-related harm. In the International Classification of Diseases, 10th revision, alcohol consumption is defined as harmful if there is clear evidence that alcohol is responsible for physical or psychological harm, the nature of the harm is identifiable, alcohol consumption has persisted for at least one month within the previous 12 months, and the person does not meet the criteria for alcohol dependence. Harmful alcohol use is also conceptualized in terms of a pattern of alcohol consumption in excess of specified limits, which currently in the United Kingdom is 35 standard drinks for women and 50 standard drinks for men in any week.

Hazardous and harmful alcohol users are unlikely to seek treatment specifically for alcohol-related problems. However, they may come to the attention of health services through opportunistic screening for alcohol use, or, in persons with harmful levels of alcohol consumption, because they exhibit alcohol-related harm at presentation. Alcohol-related harm may be acute (e.g., alcohol-related accidents, alcohol poisoning, acute pancreatitis) or chronic (e.g., hypertension, cirrhosis, depression and anxiety, fetal alcohol syndrome, fetal alcohol effects).

Diagnosis. Clinical presentations in primary and emergency care that are associated with excessive alcohol use include hypertension, accidental injury, hand tremors, duodenal ulcers, gastrointestinal tract bleeding, cognitive impairments, anxiety, and depression. There are several short, paper-based screening instruments available for use in primary care populations. The Alcohol Use Disorder Identification Test (AUDIT) is a 10-item questionnaire that addresses quantity and frequency of alcohol use, alcohol-related problems, and symptoms of mild alcohol dependence. It has high levels of sensitivity (92 percent) and specificity (94 percent). A score of 8 points or more is indicative of hazardous alcohol use, and a score of 13 points or more is indicative of harmful alcohol use. Several shortened versions of the AUDIT exist. AUDIT-C includes the first three questions of AUDIT, and measures the quantity and frequency of alcohol consumption; it also has acceptable levels of sensitivity and specificity in primary-care populations (sensitivity is 78 percent for men, 50 percent for women; specificity is 75 percent for men, 93 percent for women). The Fast Alcohol Screening Test (FAST) is a short AUDIT derivative specifically developed for use in emergency departments. It identifies 90 percent of the hazardous alcohol users identified by the 10-item AUDIT questionnaire. Other short screening instruments include the Michigan Alcohol Screening Test (MAST), CAGE (Cutting down on drinking, Annoyance with criticism, Guilt about drinking, and need for an Eye-opener) questionnaire, and the Paddington Alcohol Test (PAT).

A number of biologic markers of alcohol use can be used in the diagnosis of hazardous or harmful use. These include elevations in mean red blood cell volume, serum γ-glutamyltransferase level, and carbohydrate-deficient transferrin level. Although the results of biochemical tests may be useful as motivating factors in addressing a patient's alcohol consumption, they are less sensitive and specific than screening questionnaires in identifying hazardous and harmful alcohol use.

Incidence

Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked as one of the top five risk factors for disease burden by WHO. Based on data from 28 countries in Europe between 1992 and 1996, the prevalence of hazardous alcohol consumption was estimated at 5 to 41 percent for men and 1 to 21 percent for women. Research in England in 2005 estimated that 7.1 million persons, or 23 percent of the adult population (32 percent of men and 15 percent of women), could be categorized as hazardous or harmful alcohol users. The prevalence of hazardous and harmful consumption was highest in persons 16 to 24 years of age. Although the prevalence has remained relatively stable in men, it increased by 50 percent in women between 1984 and 2006. In England annually, 150,000 hospital admissions result from acute or chronic alcohol use, and alcohol use is implicated in 33,000 deaths.

Etiology

The causes of hazardous and harmful alcohol consumption are uncertain and complex. There is some evidence that genetic susceptibility may play a role, particularly in terms of a person's response to alcohol consumption. Other approaches address issues of psychological predisposition—particularly the roles of learning theories, expectancies, and self-efficacy. Another approach emphasizes the role of market forces and social norms in increasing the availability of alcohol and the acceptability of its use within society. Integrated models that address the complex interplay between genetic, physiologic, psychological, and social factors are probably the most reliable approaches to understanding the etiology of alcohol-use disorders.

Prognosis

Some hazardous and harmful alcohol users reduce their consumption to “safe” levels without intervention, and others move in and out of different consumption patterns throughout their lives. Approximately 16 percent of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption. Harmful alcohol consumption is associated with damage to the liver, increased blood pressure, increased risk of hemorrhagic stroke, cardiomyopathy and arrhythmias, cancer of the esophagus, gastrointestinal bleeding, and pancreatitis.

Psychiatric comorbidities include increased risk of depression, anxiety, suicide, and parasuicide. Alcohol use accounts for 1,700 accidental deaths per year and, in older persons, may be associated with an increased risk of falls. Alcohol use also contributes to the early onset of age-related cognitive deficits, dementia, and Parkinson disease. From a social perspective, increased alcohol use is associated with increased rates of relationship breakdown, domestic violence, child neglect, and negative impact on neonates (e.g., fetal alcohol syndrome).

Author disclosure: Nothing to disclose.

Adapted with permission from Coulton S. Alcohol misuse. Clin Evid Handbook. December 2008:331–333. Please visit http://www.clinicalevidence.bmj.com for full text and references.


search date: November 2006

This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required). Those who receive a complimentary print copy of the Clinical Evidence Handbook from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.


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