Treatment

The long-term goals include abstinence or reduction in use, prevention of relapse and rehabilitation. Treatment can be successful. Approximately 70% of all people achieve a reduction in the number of days drinking and improved health status within 6 months. However, the majority of people have at least one relapse during the first year following treatment. The management of many people with alcohol related takes place within Primary Care. However, people with more serious alcohol misuse and dependency are likely to be referred to Secondary Care [Secondary Alcohol Team].

It should be noted that treatment services may vary between NHS Trusts. Click on the links below for more details:

• Brief interventions
• Detoxification
• Controlled drinking
• Abstinence
• Disulfiram [Antabuse]
• Acamprosate [Campral]
• Naltrexone [Nalorex]
• Antidepressants
• Psychological support and rehabilitation
• Secondary Alcohol Teams
• Motivational Enhancement Therapy
• Hostels
• Emergency hospital admission
• Care plans

Brief interventions

“Brief interventions” includes provision of advice and leaflets and planned review in less severely affected people. It is delivered in Primary Care and has been proven to substantially reduce alcohol consumption in affected individuals.

Where people have significant alcohol related disorders, particularly in the presence of alcohol dependence, treatment may need to be more intensive.

Detoxification

Withdrawal or detoxification from alcohol can often be achieved at home or on an outpatient basis under daily supervision. Relief from the symptoms of withdrawal can be achieved by tapering doses of medication. In the UK Chlordiazepoxide [Librium] is still most widely used and this has superceded the use of Chlormethiazole [Heminevrin].

For the most severe case, those without social support or those who have experienced severe withdrawal symptoms in the past, for example delirium tremens [DTs] or withdrawal fits, a short admission to hospital for detoxification may be more appropriate.

Patients with delirium tremens require emergency treatment in hospital.

Adequate nutrition and vitamin B1 [thiamine] supplements are necessary to replace inadequate stores and prevent the serious consequences of alcohol related nutritional deficiency.

Alcoholic liver disease

It is necessary to stop drinking alcohol to prevent further liver damage.

Liver transplant is occasionally appropriate.

Controlled drinking

When abstinence is not feasible, controlled drinking may be an appropriate goal for those whose alcohol misuse has been detected early and who are not dependent or physically damaged. This can be achieved by setting a limit on drinking, and is facilitated by tactics such as choosing low alcohol drinks and drinking only at certain times of the day.

Maintaining abstinence

Abstinence is especially desirable in established dependence, alcohol related physical disease and failed controlled drinking.

Disulfiram [Antabuse]

This may be used to help prevent drinking. The combination of alcohol and Antabuse causes a potentially dangerous reaction of nausea, vomiting, breathlessness, headache, flushing and tachycardia [rapid heart rate].

The treatment relies on the motivation of the patient to take the tablet each day. In general, Antabuse appears to reduce drinking frequency but without necessarily improving abstinence.

Acamprosate [Campral]

This acts to reduce the craving for alcohol, and in combination with counselling may be helpful in maintaining abstinence. It should be started as soon as possible after abstinence is achieved and continued if the person relapses. Abstinence rates are approximately doubled although the majority of people do return to some form of drinking.

Naltrexone [Nalorex]

This is an opioid [morphine like substance] antagonist that was originally developed to aid abstinence from opiate drugs. It is more effective when compliance is better. Studies have not conclusively proven that Naltrexone consistently decreases drinking behaviour. It is not currently licensed in the UK.

Antidepressants

Antidepressants are useful in people who experience major depression after detoxification. There is some evidence that SSRI antidepressants, for example Citalopram and Fluvoxamine may help to control drinking in people without depression, but this has not been proven to date.

Psychological support and rehabilitation

The facilities for alcohol treatment vary across the country and may be provided by a range of organisations in the community or on a residential basis.

The management of many people with alcohol related disorders takes place within Primary Care. However, people with more serious alcohol misuse and dependency are likely to be referred by the GP to a Secondary Alcohol Team.

The term Secondary Alcohol Team refers to both NHS Hospital based teams and Voluntary Agencies:

NHS

Although specific arrangements may vary between NHS Trusts, Secondary Alcohol Teams may be functionally divided into 2 groups:

• Team that works with less severely disabled patients.
• Team that works with more severely disabled and dependent patients.

Secondary Alcohol Teams

These provide a multidisciplinary approach and the team members may include psychiatrists, psychologists Community Psychiatric Nurses with special training in alcohol related problems, occupational therapists and social workers working in close collaboration with social service departments.

Motivational Enhancement Therapy

Cognitive therapy and behavioural therapy have been shown to be effective treatments for patients dependent on alcohol. Many treatment centres rely on a variety of techniques to help individual patients to control or abstain from their drinking. Examples include education about alcohol, group meetings, individual psychotherapy, social skills and assertiveness training, analysis of the triggers for drinking and planning to avoid relapses and a system of goals and rewards. Therapeutic interventions of this type can achieve reductions of alcohol intake of at least 50% in about half the patients and maintain them for years.

Other agencies concerned with drinking problems

The main providers are Councils on Alcoholism [Sometimes called “Alcohol and Drug Services”]. These are voluntary bodies that coordinate available services in an area and train counsellors. They advise people with alcohol problems and their families and provide social activities for those who have recovered.

Alcoholics Anonymous

This is a spiritual, but non-religious organisation that advocates a strict abstinence policy, provides a social structure to replace drinking and provides support from former alcoholics. The only requirement for membership is a desire to stop drinking.

Al-Anon

This is a parallel organisation to Alcoholics Anonymous providing support for the spouses of excessive drinkers. Al-Ateen provides similar support for their teenage children.

Hostels

These are intended mainly for homeless people with alcohol problems. They provide rehabilitation and counselling. Usually abstinence is a condition of residence.

People with alcohol related disorders may not engage with local support services for a variety of reasons that include:

• Lack of availability of support services.
• Mistrust of professionals.
• Social isolation and alienation of friends and family by the person’s behaviour.

Emergency hospital admission

Hospital admission for people with alcohol related disorders may be indicated in the following circumstances.

Routine admission for detoxification. This may be required for the most severe case, those without social support or those who have experienced severe withdrawal symptoms in the past, for example delirium tremens [DTs] or withdrawal fits.

Routine admission to investigate or treat complications. Conditions that might require admission include:

• Drainage of fluid [ascites] from the abdominal cavity that results from liver damage.
• Injection of oesophageal varices.
• Treatment of nutritional deficiencies.

Emergency admission. This may be required to treat severe, potentially life threatening complications, either physical, including injuries and accidents or mental.

Physical conditions likely to warrant emergency admission include:

• Hepatic Encephalopathy.
• Bleeding oesophageal varices.
• Severe withdrawal symptoms including DTs and withdrawal fits.
• Acute pancreatitis.

Severe mental conditions that may warrant emergency admission include:

• Severe depression.
• Dementia.
• Korsakoff - Wernicke syndrome.

Severe alcohol related mental health conditions might require compulsory admission under the Mental Health Act 1983. However, compulsory admission under the Mental Health Act is not permitted for alcohol related disorders in the absence of severe mental conditions.

Care plans

People with moderate and severe alcohol related mental illness, under the care of the Secondary Alcohol Team are likely to be under the NHS Care Programme Approach (CPA). However, this varies from region to region and people with an alcohol problem in the absence of an additional mental health problem may often be excluded from the CPA.

The care plan is a written document, which brings together information about social care, a medical treatment plan, domestic support, names of the professionals involved in care and actions to be taken in the event of changing circumstances. Copies of the plan are given to the patient/claimant, carer, care co-ordinator and others involved. Plans are of two types depending on the level of support required – standard and enhanced. The plans are reviewed every three to six months, when a revised plan will be completed.

People with moderate alcohol related disability are likely either:

• To be on a Standard care plan.
• Or have 2 Health Care Professionals [in addition to the GP] named on care plan.

People with severe alcohol related disability are likely either:

• To be on an Enhanced care plan.
• Or have More than 2 Health Care Professionals [in addition to GP] named on care plan.
• Or have Care plan meetings more frequently than every 6 months.

Click on the link for details of:

• Accommodation