Treatment of alcohol abuse

Current Care Summary
15.4.2010
Working group appointed by the Finnish Society of Addiction Medicine

Current Care Guideline in Finnish «Alkoholiongelmaisen hoito»1

Update on Current Care guidelines: Treatment of alcohol abuse

Brief intervention is an effective form of treatment for excessive alcohol consumption prior to the development of dependency. Motivational interviewing and cognitive therapy are likely to increase the effectiveness of treatment. Another effective method is the Twelve-Step Facilitation treatment programme. Supervised disulfiram medication significantly improves the results achieved with psychosocial therapies alone. Naltrexone increases the number of non-drinking days and reduces relapses compared with a placebo, especially if the medication is combined with psychosocial treatment which is based on cognitive behaviour therapy. Compared with a placebo, acamprosate improves the treatment results achieved with psychosocial therapies alone.

Excessive (hazardous, harmful and heavy consumption) alcohol consumption and associated diseases

All-cause mortality is significantly higher in men who on the average consume more than 40 g of absolute alcohol per day, and in women who consume more than 20 g per day, than in non-drinkers. One unit of alcohol approximately equals to 12 g of alcohol (1 bottle of medium strength beer, 12 cl of wine or 4 cl of spirits). The relative risk is higher in women than in men at all levels of consumption.

Alcohol consumption significantly increases the risk of liver cirrhosis, neoplasms of the upper respiratory and digestive tracts and haemorrhagic stroke. Weaker but significant associations have been found for hepatic, colorectal and breast cancers, chronic pancreatitis and essential hypertension.

Abstinence from alcohol is recommended during pregnancy; binge drinking is associated with a particular risk (A).

Patient history and laboratory investigations

A supportive and open approach is important during the appointment. The most useful structured questionnaire for the early detection of excessive alcohol consumption appears to be the 10-item AUDIT questionnaire (B). The shorter version AUDIT-C (three first questions) appears to be sensitive enough to detect excessive alcohol consumption (C).

In collaboration with the patient, laboratory tests may also be used to identify a drinking problem. These tests are sensitive markers of alcoholism but their significance in the early identification of excessive alcohol consumption is modest (A).

Diagnosis of chronic alcohol abuse must never be based on a single abnormal laboratory test result but must always include the patient history (A).

Brief intervention

Brief intervention should be based on emphasising the high prevalence of excessive alcohol consumption and on active questioning regarding the patient’s drinking habits. The crucial task of brief intervention is to furnish the patient with motivation. Laboratory tests may be used to support brief intervention.

Brief intervention is an effective treatment form for excessive alcohol consumption before the development of dependency (A).

Psychosocial treatment and rehabilitation

Psychosocial treatment is more effective than no treatment (A).

Motivational interviewing (A) and cognitive therapy (B) are likely to increase the effectiveness of the treatment.

The Twelve-Step Facilitation treatment program is as effective as community reinforcement approach (CRA) or cognitive therapy with additional medication with disulfiram (B).

So far no such criteria have been identified that could be used to provide the best individual treatment form for an individual person with alcohol problems. Treatment results of psychosocial therapy appear to fluctuate according to the therapist (B). A successful therapeutic alliance is associated with good treatment results (A).

Clinical treatment of excessive alcohol consumption

Acute alcohol intoxication

Serious ethanol poisoning requires always hospitalisation (D).

Withdrawal symptoms

Benzodiazepines are the most effective drugs in the treatment of withdrawal symptoms and delirium tremens (A). In outpatient detoxification programmes, mild to moderate withdrawal symptoms can be treated with supervised, decreasing doses of chlordiazepoxide, administered over 3–5 days.

Pharmacotherapy in alcohol dependence

Psychosocial therapies form the cornerstone of the treatment in alcohol dependence, but the results may be further enhanced with drug therapies (statistically significantly).

Supervised disulfiram medication significantly improves the results achieved with psychosocial therapies alone (A).

Naltrexone increases the number of non-drinking days and reduces relapses compared with placebo, especially if the medication is combined with psychosocial treatment which is based on cognitive behaviour therapy (A). Compared with placebo, acamprosate (requires a special licence in Finland) improves the treatment results achieved with psychosocial therapies alone (A).

Prevention and treatment of polysubstance abuse

The prescription, without a clear psychiatric indication, of any medication that may cause dependence should be avoided in a patient with alcohol problems. In urgent situations, benzodiazepines should normally not be prescribed, and their long-term use should be reserved for special cases.

Benzodiazepine derivatives appear to differ as to their dependence-inducing properties. Fast acting and quickly eliminated benzodiazepines should be avoided during treatment.

Working group appointed by the Finnish Society of Addiction Medicine

Hannu Alho

Mauri Aalto

Kari Eskola

Antti Holopainen

Juhani Juntunen

Olli Kampman

Rauno Mäkelä

Solja Niemelä

Kari Poikolainen

Kaija Seppä

Helena Vorma