Document Sample
binder1 Powered By Docstoc
					Ongoing Medical Training                                                        12/04/2005

Title: Effective interventions in the handling of alcohol problems

Title: Effective interventions in the handling of alcohol problems

1. Introduction

From a population perspective, the majority of the problems related with alcohol appear

in individuals whose alcohol consumption is risky or harmful, according to the

terminology of the World Health Organization (WHO)1. Risky consumption is deemed

to be that which may be prejudicial to health, which has been quantified for men as

being more than 280g of alcohol per week and for women more than 168g.

Furthermore, the risk of becoming dependent on alcohol begins with moderate values of

consumption and increases linearly as the quantity consumed increases, in general, and

with the consumption of large quantities of alcohol in short intervals2.

       As shown in table 1, consumption of alcoholic drinks is habitual in Spain, where

the progressive incorporation of women in the regular consumption of alcohol has also

been confirmed3,4. In European countries it is estimated that around 25% of men and

10% of women are risky drinkers, that the prevalence of serious intoxications is around

10-30% of all alcohol-drinking occasions and that alcohol dependence stands at

between 3% and 5%.

       According to the last report from the WHO, in the year 2002 problems related to

alcohol consumption contributed some 4% to the morbidity total, and as up to at least

9% in European countries. Furthermore, alcohol occupies third place, behind tobacco

and hypertension, in the list of risk factors for health in developed countries and fifth

place worldwide5. Moreover, 40% of accidents are attributed to alcohol, a third of all

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems

work-related accidents, 38% of all neuropsychiatric illnesses or disorders and 7-8% of

other illnesses, such as diabetes mellitus, hepatic cirrhosis and cardiovascular

conditions. Alcohol dependence also appears in fourth place among the most serious

illnesses after cardiac disorders, depression and cerebral thrombosis. Alcohol causes 1

in every 10 premature deaths in Europe.

       Alcohol does not only harm those who consume it but also those around them,

including children, family members and the victims of violent acts and accidents, which

entails high costs to society, which in the year 1998 were estimated for the whole of the

Spanish nation at a total of 3,829 million euros6 (two thirds were indirect costs)

       Furthermore, the use of alcohol can complicate the treatment of many other

medical problems, interfere with prescribed medicines and cause adverse side effects.

Alcohol and primary care

In European countries the prevalence of the risky drinker in primary care (PC) oscillates

between 2.1% and 41 % in men, and between 0.8% and 21% in women7. It is therefore

essential to promote the detection and intervention in excessive drinkers from PC, with

the objective of preventing and minimizing the apparition of negative consequences,

including alcoholism, associated with the excessive consumption of alcohol.

       Despite the fact that many studies have shown that excessive drinkers can reduce

and suppress their alcohol consumption with the aid of their GP, what is certain is that

many PC professionals resist screening and giving advice to their patients about the

consumption of alcohol. Among the reasons mentioned are lack of time, lack of

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems

training, fear of confrontation, the perception of the incompatibility of preventive

actions with their everyday clinical practice and the perception that alcoholics will not

respond to their interventions8-14.

        PC, the gateway to the healthcare system, is the ideal place to carry out

secondary prevention activities, and for this reason it must be made a priority of any

healthcare strategy to try to overcome this resistance to tackling alcohol problems.

2. Units of measurement, typologies and patterns of consumption

The risk when consuming alcohol increases in proportion to the quantity and frequency

of the consumption. Presently there are simple systems of measurement that permit us

to establish the limits of risk.

Standard drink unit (SDU)

The WHO has proposed the following operative definition of the SDU:

    − 330 ml of beer

    − 40 ml of spirits (whisky, gin, vodka, etc)

    − 140 ml of wine

    − 90 ml of sherry

    − 70 ml of liqueur or aperitif

    In general it can be said that one consumption of a drink with a low alcoholic

    content (wine, beer and cava) is approximately equal to 1 SDU, whereas one

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems

   consumption of a high proof drink (spirits, etc) is the equivalent of 2. The SDU in

   Spain contains an average of 10g of pure alcohol15. This method, while a little

   imprecise, is adequate for use in any socio-sanitary setting, but only in contexts

   where the professionals are subjected to great pressure of people attending.

   Typologies and patterns of alcohol consumption

   Patterns of alcohol consumption can be classified as follows: 1) low risk

   consumption, 2) risky consumption, 3) harmful consumption, 4) severe

   intoxication and 5) alcohol dependence syndrome.

       Low risk consumption is less than 3 drinks per day (21 per week) for men and

   2 drinks per day (14 per week) for women. Abstinence from alcohol is

   recommended for children under 16 and for women during pregnancy and maternal

   lactation. It is also recommended for people who carry out risky activities or handle

   dangerous materials, suffer certain physical or mental illnesses and those who take

   medicines or psychotropic substances the effects of which could be modified when

   mixed with alcohol.

       Risky alcohol consumption is a consumption pattern which if maintained may

   end up causing harm to the physical or mental health of the individual, without them

   necessarily having medical or psychiatric problems at the present moment. The

   level of risk is associated with the degree of consumption, but also with other factors

   of personal, familiar or environmental vulnerability. At the present time the WHO

   has established the criteria for risky drinking in men at > 28SDU/week, and in

   women at ≥17 SDU/week. Furthermore, consumption of more than 6 SDU (5 SDU

   in the case of women) on a single occasion is also considered risky drinking, as well

Ongoing Medical Training                                                         12/04/2005

Title: Effective interventions in the handling of alcohol problems

   as any kind of ingestion of alcohol occurring in situations where life may be

   endangered: operating dangerous machinery, working at heights, driving etc.

       Harmful consumption of alcohol is a pattern of consumption which is already

   currently harming the health, whether physical or mental, of the individual. The

   diagnosis of harmful consumption requires the damage to have already been done.

       Severe Alcoholic Intoxication (SAI) is defined as a clinical syndrome produced

   by the rapid consumption of alcoholic drinks in quantities greater than the individual

   tolerance level of the person. It is a more or less brief state of alteration in

   psychological functioning and psychomotor performance and the alterations are

   proportional to the doses consumed. Depending on the quantity ingested and the

   tolerance level, the effects may range from a slight disinhibition to coma, respiratory

   depression and death. In general, any episode of consumption of more than 60 g of

   alcohol (6 SDU) can be considered intoxication.

       The International Classification of Diseases16 defines Alcohol Dependence

   Syndrome (ADS) as a collection of physiological, behavioural and cognitive

   phenomena in which the use of alcohol becomes a priority for the individual above

   all other conducts which before had great value for him. The criteria for the

   identification of ADS are qualitative, in contrast to those that we have described so

   far, which were quantitative (see table 2). The gravity of the alcoholism will depend

   on the presence and the gravity of the withdrawal symptoms, the level of

   consumption and the associated psychiatric, psychosocial and organic pathology.

       Faced with the diversity of consumption patterns that may be encountered in the

   consulting room, it is recommendable that the professionals have at their disposal

Ongoing Medical Training                                                        12/04/2005

Title: Effective interventions in the handling of alcohol problems

   useful screening instruments and strategies of differential diagnosis which would

   enable them to take decisions and adequately tackle any situation.

   3. The detection of excessive alcohol consumption

   The detection of alcohol problems in their early stages, such as risky consumption,

   is becoming more and more important in primary care, and it is necessary to have

   instruments that fit in with the routine of attention and the complex situations that

   may arise from it (visits to old people, evaluation of patients of a low cultural level,

   etc.) Generally speaking, to screen for risky or harmful consumption it is advisable

   to evaluate the quantity, the frequency and the intensity (pattern) of consumption of

   alcoholic drinks by means of instruments specifically designed for the task, such as

   the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT-C17

       The Alcohol Use Disorders Identification Test (AUDIT) is a questionnaire

   which can be self-administered, consisting of just 10 questions. With the exception

   of items 9 and 10 which are scored 0-2-4 the rest have 5 answer options, scored

   from 0-4. It explores the quantity and the frequency of consumption, the presence

   of disorders related to alcohol and the symptomology of dependence and finally, the

   negative consequences of alcohol consumption18,19. The questionnaire has

   demonstrated its validity and reliability (table 3) for the early detection both of risky

   consumptions and of alcohol dependence20,21. In our context it has been validated

   for the detection of risky consumption22: the cut off point is 9 in the case of men

   (sensitivity of 90% and specificity of 81%) and this cannot be established for

   women, In another study23, the sensitivity of AUDIT to detect risky drinkers was

Ongoing Medical Training                                                        12/04/2005

Title: Effective interventions in the handling of alcohol problems

   89% and the specificity 93%. Its sensitivity was less in women (60 as opposed to

   78%) and in patients under 60 years old (86 as opposed to 100%).

       The AUDIT-C24, which includes the first 3 questions of AUDIT, has shown

   itself to have highly adequate values of specificity and sensitivity in its validations

   of the masculine population and the general population. In our context it has been

   validated in primary care, and the results obtained for men and women confirm its

   usefulness for screening at-risk consumers25. Also the Systemized Interrogation of

   Alcoholic Consumption (SIAC), composed of only 3 items which explore the

   quantity and the frequency of consumption, with some fairly acceptable values for

   sensitivity and specificity26.

       The patients who have a positive score in the questionnaires for the detection of

   risky consumption have to be evaluated in depth in order to determine if they have

   problems associated with alcohol and the nature, extent and gravity of these

   problems. There are many screening instruments for alcohol dependence, such as

   the MAST27, but at the present time the most frequently used ones are CAGE28 and

   the AUDIT.

       The biological markers (VCM, GGT, CDT)29,30 have shown a limited usefulness

   for the detection of risky alcohol consumption, and for this reason they should not

   be used for habitual screening in primary care. Nevertheless, having biochemical

   markers at one’s disposal may make more objective those situations in which the

   patient denies or minimizes their symptoms and alcohol consumption. If they are

   combined together or associated with other diagnostic tools (multiple screening),

Ongoing Medical Training                                                      12/04/2005

Title: Effective interventions in the handling of alcohol problems

   they are especially useful for the diagnostic confirmation of alcoholism and for the

   control and monitoring of the patient in treatment.

   4. Intervention in alcohol problems from primary health

   The tackling of alcohol problems from PC must be framed within a model of

   continuous intervention in which other professionals participate and in which the

   strategy is adopted according to the consumption pattern and the presence or

   otherwise of related problems. Any occasion within the clinical practice of PC (for

   example, a check-up, referral to a specialist) could be used to ask the patients about

   their alcohol consumption. Generally speaking, the intervention must be aimed at

   achieving a reduction in the consumption to within the limits of “low risk” when a

   risky or harmful consumption is detected on the part of the patient, and towards

   abstinence if there is a problem of dependence. In table 4 there is a summary of the

   types of intervention and the role of the PC professional according to the different

   consumption patterns.

       PC can take responsibility for the management of risky consumption and

   harmful consumption. The treatment of dependence syndrome can also be carried

   out from PC when the patient doesn’t accept referral to a specialist centre but wishes

   to give up alcohol consumption, when there are no serious complications or when he

   is well disposed to treatment etc.

       As a general rule, it must be considered that the dependent patient will benefit

   most from treatment in a specialist centre, although PC doctors who have received

Ongoing Medical Training                                                        12/04/2005

Title: Effective interventions in the handling of alcohol problems

   special training can successfully initiate treatment of patients without prior

   therapeutic history and without psychiatric comorbidity.

   Intervention in risky or harmful consumption

   If risky or harmful consumption is detected without associated symptoms of

   dependence, the professional may carry out a brief intervention (BI), which has been

   proven to be extremely useful in raising patients’ self-awareness and achieving that

   the person decides to reduce consumption of alcohol. BIs that are carried out in PC

   with patients who do not attend for alcohol-related problems are known as

   “opportunist” and are shorter, less structured, and less rigorous than those carried

   out by specialists31. However, in the bibliography there is little consensus as to their

   length32 and structure.

       More than 10,000 people have participated in random and controlled studies of

BIs33 and there are many meta-analyses which demonstrate their efficaciousness and

effectiveness in PC for reducing alcoholism in patients with risky or harmful

consumption 34,35.

       In the meta-analysis of Moyer et al34, when comparing the BIs (no more than 4

sessions) with the control condition for individuals who were not seeking treatment, a

significant reduction was found in the alcohol consumption (standard difference of

averages between groups [d] = 0.26; trust interval [TI] of 95%, 0.20-0.32), equivalent to

an improvement of 13% in the intervention group. Moreover, in the same study a

significant reduction was found in alcohol-related problems (d = 0.24; TI of 95%, 0.18-

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems

0.30) after 6 and 12 months of follow-up. Equivalent to an improvement of 12%.

Furthermore, men and women benefited equally form the BI and there was evidence of

its greater usefulness in individuals with light alcohol problems.

       In the metaanalysis of Ballesteros 35, the BIs also worked better (odds ratio =

[OR] = 1.54; TI of 95 %, 1.26-1.89); number necessary for treatment [NNT] = 12; TI of

95%, 8-20) and the results were similar between men and women (OR = 2.32; TI of

95%, 1.78-2.93, and OR = 2.31; TI of 95%, 1.60-3.17, respectively). There was no

evidence found in favour of a dose-response relation, as it does not appear that longer

interventions are more effective.

       There are 2 studies that have shown evidence of long term effects of BIs. In the

study by Fleming36 the intervention group reduced significantly its weekly alcohol

consumption and the frequency of excessive consumption compared with the group

control. The effect was maintained for 4 years and the intervention group experienced

fewer days of hospitalization and fewer visits to casualty.

       In the study by Wutzke 37, after 9 months the intervention group had reduced by

36% its consumption, while the control group had only reduced it by 15%. This effect

was not maintained in the follow-up at 10 years.

The use of the motivational interview38 can improve the effectiveness of BIs, although

little is known about how this works and for which type of patients this is most useful.

       In our context, in the metaanalysis of Ballesteros 39, 4 out of 5 studies supported

the efficaciousness of BIs in the reduction of alcohol consumption (d = 0.46, TI of 95%.

-0.29 to -0.63; p< 0.0005) and 1 in 4 studies supported the efficaciousness of BIs in the

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems

reduction of the prevalence of risky drinkers (OR = 1.55; TI of 95%, 1.06-2.26; p =


         BIs have been shown to be efficacious and effective in the reduction of

consumption, in the improvement of health and in the reduction of healthcare costs, and

the variable follow-up is vital for its long-term effectiveness. BIs are effective when

they are applied by nursing staff or other trained professionals, and besides, they are


         The content and style of BIs41 are described in figure 1. The professional must

provide the patient with feedback on his state of health and clear advice on how to

change, if this is required, evaluate his awareness of the problem, negotiate with him the

objectives and strategies for achieving them and monitor his development and progress.

All this must be done while at the same time making the patient responsible for the

change, promoting his autoefficacy and relating to him in an empathic style.

         Generally speaking, in order for a person to propose to himself and succeed in a

reduction in his alcohol consumption, he must have an incentive to do so, he must feel

that his consumption is harming him, that reducing consumption will be beneficial and

cost little and, besides, he must feel himself capable of carrying it out. To make a

patient aware that his alcohol consumption is could be a problem and to motivate him to

reduce it is not easy, but both requisites can be achieved and promoted by the

professional making use of motivational strategies.

         In order to conduct BIs adequately the professional must be motivated to

implement them, must have good communication skills, and must have received basic

training on the model of beliefs of health42, the model of the stages of change43 and the

motivational interview38.

Ongoing Medical Training                                                         12/04/2005

Title: Effective interventions in the handling of alcohol problems

       The model by Prochaska and Di Clemente proposes that the changing of any

conduct comes about in stages and that these form a wheel or a spiral through which the

professional must accompany the patients so that they can advance through it. The

phases that they describe are: a) pre-contemplation, in which the person does not

propose to change anything; b) contemplation, in which the person begins to consider

that alcohol causes him more problems than benefits; c) Preparation, in which the

person begins to prepare himself to carry out the change; d) Action, when the person is

already committed to the decision and begins to act, and e) Maintenance, when the

person has to begin to learn how to maintain in the future these goals that he has

achieved up to this point.

       In this process, however, the person can relapse into the original behaviour and

enter once again into the wheel of change, or hold their conduct in stable remission


       Every one of these stages is characterized by psychological processes which the

professional must know how to recognize and manage in order to help the patient to

advance along the wheel of change and achieve stable remission. The motivational

interview has systemized what the professional has to do in every moment according to

the stage at which the patient finds himself (table 5). Obviously, in order for the

motivational interview to be effective, the therapist must be able initially to identify the

stage of change which the patient has reached. If not, the most probable outcome would

be that his intervention would generate resistance and a defensive attitude on the part of

the patient, and would not be effective.

       The motivational interview is a style of direct attention, focussed on the patient,

which seeks to provoke a change in behaviour, helping him to explore and resolve

Ongoing Medical Training                                                          12/04/2005

Title: Effective interventions in the handling of alcohol problems

ambivalences. It is a collaborative way to get near to the patient, and applied

progressively according to the stage of change of the patient.

       The basic principles of the motivational interview are: a) express empathy; b)

create discrepancies; c) turn resistance around and d) promote self-sufficiency.

       Among the most effective strategies for stimulating motivation are the

following; a) ask open questions about what is worrying the patient, b) exercise

reflective listening, that is to say, try to understand the meaning for the patient of what

he wants to tell us; c) underline and support the positive aspects that the patient

spontaneously puts into words, d) give summaries of the most crucial aspects referred

to in each moment, e) favour and elicit self-motivational affirmations on the part of

the patient.

Intervention in alcohol dependence

If the professional detects a harmful consumption and symptoms of alcohol

dependence syndrome ADS, it is advisable that he assess whether there are criteria for

the diagnosis of alcoholism.

       The treatment of alcoholism can be initiated in PC, and it is advisable that PC

monitor, to a point, even those patients that required referral to a specialist centre.

Shared treatment may be chosen in the following situations:

    − The patient is abstaining and stabilized and undergoing psychotherapeutic

        treatment in a specialized centre.

    − The patient refuses treatment in a specialized centre and wishes to be treated in


Ongoing Medical Training                                                      12/04/2005

Title: Effective interventions in the handling of alcohol problems

   − At the beginning of uncomplicated treatment and those undergoing home


   − In patients with associated organic pathology receiving treatment in PC

   Patients with ADS will be referred to a specialized centre when; a) PC cannot

   undertake the treatment; b) previous attempts at treatment have been made without

   success; and c) the patient presents serious complications.

       Faced with a patient with a physical dependence on alcohol the first intervention

   will be aimed at exploring the presence or otherwise of withdrawal symptoms

   (which may appear between 6 and 24 hours after the last drink), as well as the

   presence of organic pathology. Its gravity will depend on the consumption pattern

   (quantity, frequency and duration), but in the majority of cases abstinence will not

   be very severe and will remit on its own after 5 days. In some patients, however, it

   may be very serious and can appear in the first 48 -72 hours. Convulsions may start

   between 12-48 hours after the last drink, and delirium tremens between 48 and 96

   hours. The severity of the withdrawal symptoms can be evaluated with specific

   scales, such as the CIWA-Ar44, and it must be pointed out that the existence of a

   significant group of clinical withdrawal symptoms constitutes a criterion for referral

   to the emergency department.


   In cases of physical dependency, tranquilizers are usually administered, such as

   clormetiazol or the benzodiacepines, during short periods to relieve withdrawal

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems

   symptoms and avoid relapses33. Detoxification will consist of the administration, in

   decreasing dose, of a pharmaceutical to depress the central nervous system (CNS)

   which has crossed tolerance to alcohol together with vitaminotherapy. Among the

   important characteristics for the use of both are: a) significant sedative, hypnotic

   and anti-convulsive action; b) significant central depressor action; c) strong

   addictive potential, and d) hepatic metabolism. In table 6 is an orientative

   reproduction of 2 courses for prevention of withdrawal syndrome with diazepam

   and clormetiazol. For each pharmaceutical a course of minimums is described, in

   patients with little risk of suffering withdrawal symptoms and a more intensive

   course for patients with elevated alcohol consumptions. It is important that the

   course of detoxification is never prolonged for more than two weeks, given the

   addictive potential of both pharmaceuticals.

       A large number of patients will not require this treatment, but a course of

   treatment for prevention of withdrawal syndrome will be instigated if the patient

   meets one or more of the following criteria:

   − Previous history of delirium tremens or comitial crises due to abstinence

   − Presence of morning withdrawal symptoms

   − Habitual consumption of alcohol when not eating

   − Subjective feeling of the patient of not being able to give up alcohol without

       pharmacological aid

   − Presence of withdrawal symptoms, even slight, during the examination

   − Gravely compromised organic state (e.g. uncompensated cirrhosis, etc)

Ongoing Medical Training                                                         12/04/2005

Title: Effective interventions in the handling of alcohol problems

       A course of detoxification will not be required in the following situations:

           − Intermittent drinkers or patients who have not had any alcoholic drink or

               taken any pharmaceutical with crossed tolerance to alcohol during the

               last 72 hours and who show no withdrawal symptoms

           − Patients who do not wish to abstain completely from alcohol.

       In the event that detoxification is required, we will examine whether it is

       appropriate to refer the patient to a specialist centre or if it can be undertaken by

       PA. Liable for referral to a specialized centre or to emergency services will be

       patients who show:

           − Risk of withdrawal symptoms, moderate to severe

           − Compromised organic state

           − Lack of family support or a very conflictive family situation

           − Comorbid psychiatric pathology

           − Regular consumption of other addictive substance, with the exception of

               tobacco and caffeine

       Out-patients’ detoxification within the setting of PC can be considered if the

following conditions occur:

           − A quantity of pure alcohol ingested which is less than 25 SDU/day

           − Absence of serious complications (previous history of delirium,

               comorbid psychopathology, compromised organic state, etc.)

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems

           − Pledge by the patient not to drink during the course of the detoxification,

               not to leave the family home and not to engage in risky activities

           − Presence of a family member free of problems of addiction who

               undertakes responsibility for administering medication and supervising

               the treatment.

           − Suppression of alcoholic drinks in the family home for as long as the

               detoxification lasts

           − Telephone contact or visit every 2-3 days.


Once the detoxification has been carried out, the rehabilitation phase will begin in

which the patient must learn to live without consuming alcohol, and for this it would be

ideal to combine a psychological approach with a pharmacological one. In this phase,

the administration of pharmaceuticals to prevent relapse, such as acamprosate,

naltrexone, topiromate, disulfiram and calcium cyanamide, has been shown to be very

useful.45 While acamprosate (Campral®, Zulex®,), naltrexone (Antaxone®, Celupan®,

Revia®) and topiromate (Topamax®) produce a decrease in the desire to drink (anti-

craving substances), disulfiram (Antabus®) and calcium cyanamide (Colme®) base

their effectiveness on the discouraging reaction that the person experiences if they drink

alcohol after having taken these medications (antidipsotropic substances).

       Acamprosate is a pharmaceutical with structural similarities to

gammaaminobutiric acid (GABA) which stimulates the GABA receptors and

Ongoing Medical Training                                                           12/04/2005

Title: Effective interventions in the handling of alcohol problems

GABAergic transmission (decreased by chronic exposure to alcohol) and modulates the

excitatory action of the NMDA-glutamate system. It also acts upon the calcium

channels, reducing hyper-excitability, induced by the suppression of alcohol, of the

CNS. It has been shown to be effective to improve the rates of abstinence at 6 and 12

months in alcoholic patients, once they have been through detoxification (OR = 1.88; TI

of 95%, 1.57-2.25)46. Its effect persists once the treatment has finished. It is

administered in doses of 2g daily, administered in two tablets every 8 hours or 3 tablets

every 12 hours (2g/day).

        Naltrexone is an opiaceous antagonist that acts by impeding the release of

dopamine induced by alcohol and, therefore, reducing the stimulating and strengthening

effects associated with its consumption. It decreases the levels of craving and the loss

of control, thus helping the patients to maintain abstinence and reduce alcohol

consumption. In a meta-analysis of double blind clinical studies, lasting 3 months,

naltrexone has shown itself to be effective for significantly reducing the rate of relapses

of alcoholic patients (OR = 0.62; TI of 95%, 0.52-0.75)46 but not in the rate of

abstinence (OR = 1.26; TI of 95%, 0.97-1.64)46 . Its effect disappears once the

medication is withdrawn. It is administered in a single dose of 50mg per day in one

single tablet (50mg/day [1-0-0]). Recently the efficaciousness was demonstrated,

comparing with a placebo, of the administration of naltrexone in delayed release in

doses of 190 and 380 mg in patients who were still drinking when the treatment


        In a multicentric study, in which naltrexone was compared with acamprosate, it

was found that the group treated with naltrexone had a more favourable evolution in the

following variables; rate of relapse (OR = 2.90; TI of 95%, 1.53-5.48; p = 0.001),, rate

Ongoing Medical Training                                                         12/04/2005

Title: Effective interventions in the handling of alcohol problems

of abstinence (OR = 0.32; TI of 95%, 0.16-0-63; p = 0.001), time until the first relapse,

number of consumptions per day, craving levels and retention in treatment46.

       Topiramate is an antiepileptic (similar structure to acetazalomide) with

neuroprotective properties. It has been used for the treatment of alcoholism because of

its double action as facilitator of the inhibitor impulses mediated by GABA and as an

inhibitor of the gulamatergic system. Its effectiveness has recently been demonstrated

against a placebo in the treatment of alcohol dependence, significantly reducing alcohol

consumption (OR = 3.10, TI of 95%, -4.88 to -1.31; p = 0.0009) and craving levels

(p<0.001)48. It is used in doses between 150 and 300 mg/day and it is applied

progressively with the dose increasing.

       Disulfiram acts as an inhibitor of the metabolism of acetaldehyde

dehydrogenase, a metabolite of alcohol. The elevated concentrations of the metabolite

produce an unpleasant reaction which is used to create an aversion to the consumption

of alcohol. Clinical studies have shown that it is only effective if its administration is

supervised (a high level of compliance) and the dose is carefully adjusted49. It is useful

in patients who are ambivalent about the decision to abstain from drinking. The

recommended doses are of 250mg per day, in one single dose (250mg/day [1-0-0]).

Calcium cyanamide has similar effects to disulfiram, with the disadvantage that its half

life is shorter and it requires a minimum of two doses per day (10-15 drops / 12 hours).

       The prescription of pharmaceuticals, however, will have to be applied within the

frame of an integral psychosocial approach that includes individual monitoring with

psychotherapy and/or brief counselling, group therapy and, if possible, family support.

In this frame, one of the essential elements for facilitating a favourable evolution will be

the creation of a solid therapeutic alliance between doctor and patient.

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems

       Berglund 33 in their revision on psychosocial treatments for alcoholism conclude

that they are effective (s = 0.37; TI of 95%, 0.18-0.57), but that interventions must

differ according to the seriousness of the dependence. For patients with light or

moderate alcoholism the duration and the intensity of the treatment seem to be variables

of little importance, and they may benefit more from a brief handling than from

treatments that are overly prolonged. The study by Holder 50 showed that brief

psychotherapy is cost-effective and that the highest values of cost-effectiveness are

achieved when patients with unfavourable prognoses are offered longer treatments

(cognitive-behavioural therapy, etc.) In general, specific treatments, more conceptually

structured and focussed on the conduct of drinking (motivational interview, cognitive-

behavioural therapy, AA, etc), have been shown to be more effective than the less

structured approaches (counselling, psychosocial support, etc.) No differences have

been found in the effectiveness of the different specific treatments and there is not too

much evidence regarding their effectiveness in the long term.

Ongoing Medical Training                                                     12/04/2005

Title: Effective interventions in the handling of alcohol problems

Tabla 1. Prevalence of consumption of alcoholic drinks

                                           Age group        Men      Women      Total

Consumption in the last 30 days

                                          15-29 years       85,4      76,6      81,1

                                          15-64 years        76       59,2      67,7

Risky consumption*

                                          15-29 years       12,1      13,3      12,7

                                          15-64 years       11,1      7,8        9,5

   men ≥280 gr. alcohol/ week and women > 168 gr. Alcohol/ week.

Ongoing Medical Training                                                      12/04/2005

Title: Effective interventions in the handling of alcohol problems

Table 2. CIE-10 Criteria for the diagnosis of ADS

The diagnosis of dependence must only be done using this classification if 3 or more of

the following elements have been present in the last 12 months, or on a continual basis:

1. Intense desire or experience of compulsion to consume alcohol

2. Diminished capacity to control the consumption of alcohol, on some occasions to

control the beginning of consumption and on others to stop it and to control the quantity


3. Withdrawal symptoms after reducing or ceasing consumption of alcohol, which must

be accompanied by withdrawal syndrome or by the ingestion of alcohol (or a similar

substance) with the aim of mitigating or avoiding withdrawal symptoms.

4. Tolerance to alcohol defined as a progressive increase in doses in order to achieve the

same effects as were originally achieved with smaller doses

5. Progressive abandoning of other sources of pleasure or amusement, increase in the

time needed to obtain and ingest alcohol, or to recover from its effects.

6. Persistence in the consumption of the substance, despite its evident harmful

consequences (liver damage, depressed mental state, etc.)

The severity of the alcoholism will depend on the presence and the gravity of the

withdrawal syndrome and associated organic pathology. The severity will condition the

therapeutic approach.

Ongoing Medical Training                                                      12/04/2005

Title: Effective interventions in the handling of alcohol problems

Table 3. . Instruments for the screening of risky or harmful drinking

Name                  Cut-off point        Sensitivity          Specificity

AUDIT                 ≥8                   51%-59%              91%-96%

AUDIT-C               ≥ 5 men              92%                  74%

                      ≥ 4 women            91%                  68%

ISCA                  > 28 men             70%-81%              82%-99%

                      > 17 women           50%-72,7%            97%-100%

Ongoing Medical Training                                                        12/04/2005

Title: Effective interventions in the handling of alcohol problems

Table 4. Patterns of consumption and types of intervention

Pattern     of Criteria                           Intervention       Role of Primary Care

consumption     Man              Woman

Low risk        ≤280g/week       ≤168g/ week*     Primary            Education for Health

                (≤28 UBE)        (<17 UBE)

Risky*          >280g            >168g            Brief              Identification,

                                                  Intervention       evaluation, brief
                (>28 SDU         (≥17 SDU)
                                                                     advice, follow-up
Harmful         Presence of disorder

Dependence      ICD-10                            Specialized        Identification,

                                                  treatment          evaluation, referral

                                                                     and follow-up

*Any consumption in pregnant women, under 16s and people who perform activities,

have illnesses or are undergoing treatments where the consumption of alcohol is advised


Ongoing Medical Training                                                 12/04/2005

Title: Effective interventions in the handling of alcohol problems

Figure 1. Model of brief interventions*

 Communicate                                                          Promote
   empathy                                                           autoefficacy
                       Give feedback on the state of health
                                   and the risks.
                          Evaluate the stage of change.
                       Give advice, if the patient requires it.
                        Negotiate objectives and strategies.
                                Monitor progress


*Source: Modified from

Ongoing Medical Training                                                      12/04/2005

Title: Effective interventions in the handling of alcohol problems

Table 5. Objectives of the intervention of the professional according to the stage of


         Estadio         Principal element          Objective of the professional

 Precontemplation       Unawareness            Promote awareness

 Contemplation          Ambivalence            Explore concerns
                                               Promote internal discrepancy

 Preparation            Ambivalence            Offer information and neutral advice.
                                               Give options.

 Action                 Commitment             Strengthen commitment and
                                               autoefficacy towards change

 Maintenance            Stability              Support. Prevention of relapses

 Relapse                  Desperation          Avoid criticism and demoralization,
                                               increase self-esteem, renew commitment

Ongoing Medical Training                                                    12/04/2005

Title: Effective interventions in the handling of alcohol problems

Table 6. Pharmacological stages of detoxification

      Day       Clormetiazol, 192 mg capsules              Diazepam, 5 mg tablets

                 Low risk           High risk           Low risk          High risk

      1            2/2/2               4/4/4              1/1/1             4/4/4

      2            2/2/2               2/4/4              1/0/1             4/3/4

      3            1/2/2               2/3/4              0/0/1             3/3/4

      4            1/1/1               2/2/4                                3/3/3

      5            1/0/1               2/2/3                                3/2/3

      6            0/0/1               2/1/3                                2/2/3

      7            0/0/0               1/1/3                                2/1/3

      8            0/0/0               1/0/2                                1/1/3

      9            0/0/0               0/0/2                                1/1/2

      10           0/0/0               0/0/1                                1/1/1

      11           0/0/0               0/0/0                                1/0/1

      12                                                                    0/0/1

Ongoing Medical Training                                                       12/04/2005

Title: Effective interventions in the handling of alcohol problems


   1. International Guide for Monitoring Alcohol consumption and Related Harm.

       Department of Mental Health and Substance Dependence. Geneva: World

       Health Organization; 2000.

   2. Caetano R, Cunradi C. Alcohol dependence: a public health perspective.

       Addiction 2002 Jun;97(6):633-645.

   3. Survey on drugs in the school-going population, 2000. Madrid: Spanish

       Observatory on Drugs, Report nº5, July 2002.

   4. Household survey on Drug Consumption, 2001. Madrid: Spanish Observatory

       on Drugs, Report nº6, Nov 2003.

   5. The World Health Report 2002. Reducing risks, promoting healthy life. Geneva;

       World Health Organization; 2003.

   6. Portella E, Ridao M, Carrillo E, Ribas E, Ribó C y Salvat M. Alcohol and its

       abuse: socioeconomic impact. Ed. Médica Panamericana. Madrid. 1998.

   7. Alcohol in the European Region –consumption, harm and policies. Copenhagen,

       Denmark: World Health Organization Regional Office for Europe; 2001.

   8. Roche AM, Richard GP. Doctors’ willingness to intervene in patients’ drug and

       alcohol problems. Soc Sci Med 1991;33:1053-61.

   9. Roche AM, Guray C, Saunders JB. General practitioners’ experiences of

       patients with drug and alcohol problems. British Journal of Addiction


   10. Richmond RL, Mendelsohn CP. Physicians’ views of program incorporating

       stages of change to reduce smoking and excessive alcohol consumption. Am J

       Health Promot 1998;12:254-257.

Ongoing Medical Training                                                      12/04/2005

Title: Effective interventions in the handling of alcohol problems

   11. McAvoy BR, Kaner EF, Lock CA, Heather N, Givarry E. Our healthier Nation:

       are general practitioners wiling and able to deliver? A survey of attitudes to and

       involvement in health promotion and lifestyle counselling. British Journal of

       General Practice 1999;49:187-190.

   12. Kaner EF, Heather N, McAvoy BR, Lock CA, Gilvarry E. Intervention for

       excessive alcohol consumption in primary health care: attitudes and practices of

       English general practitioners. Alcohol Alcohol 1999;34:559-566.

   13. Cornuz J, Ghali WA, Di Carlantonio D, Pecoud A, Paccaud F. Physicians’

       attitudes towards prevention: importance of intervention-specific barriers and

       physicians’ health habits. Fam Pract 2000;17:535-40.

   14. Aalto M, Pekuri P, Seppa K. Primary health care nurses’ and physicians’

       attitudes knowledge and beliefs regarding brief intervention and heavy drinkers.

       Addiction 2001;96:305-311.

   15. Gual A, Martos AR, Lligoña A, Llopis JJ. Does the concept of a standard drink

       apply to viticultural societies? Alcohol and Alcoholism 1999;34(2):153-160.

   16. World Health Organization. Mental and behavioural disorders CIE-10. Madrid:

       Meditor; 1992.

   17. Fiellin DA, Reid MC, O’Connor PG. Screening for Alcohol Problems in

       Primary Care. A Systematic Review. Archives of Internal Medicine 2000;


   18. Saunders, J.B. & Aasland, O.G. (1987). WHO Collaborative Project on the

       identification and treatment of persons with harmful alcohol consumption.

       Report on phase I: development of a screening instrument. Geneva: World

       Health Organization.

Ongoing Medical Training                                                     12/04/2005

Title: Effective interventions in the handling of alcohol problems

   19. Babor, M.J., de la Fuente, J.K, Saunders, J. & Grant, M. (1992). AUDIT: The

       Alcohol Use Disorders Identification Test: Guidelines for use in primary health

       care. Geneva, Switzerland: World Health Organization.

   20. Saunders JB, Aasland OG, Babor TF, de la Fuente JR ,Grant M. Development of

       the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative

       Project on Early Detection of Persons with Harmful Alcohol Consumption-II.

       Addiction 1993;88:791-804.

   21. Bohn MJ, Babor TF, Kranzler HR. The Alcohol Use Disorders Identification

       Test (AUDIT): validation of a screening instrument for use in medical settings.

       Journal of Studies on Alcohol 1995;56(4):423-432.

   22. Contel M, Gual A, Colom J. Test for the identification of disorders due to

       alcohol use (AUDIT): translation and validation of AUDIT into Catalan and

       Spanish. Addictions 1999;11(4):337-347.

   23. Rubio G, Bermejo J, Caballero MC, Santo-Domingo J. Validation of the test for

       the identification of disorders due to alcohol use (AUDIT) in primary care.

       Revista Clínica Española 1998;198(1):11-14.

   24. Bush K, Kivlahan DR, McDonell MS, Fihn SD, Bradley KA. The AUDIT

       Alcohol Consumption Questions (AUDIT-C): An Effective Brief Screening Test

       for Problem Drinking. Archives of Internal Medicine 1998;158(14):1789-1795.

   25. Gual A, Segura L, Contel M, Heather N, Colom J. Audit-3 and audit-4:

       effectiveness of two short forms of the alcohol use disorders identification test.

       Alcohol Alcohol 2002;37(6):591-596.

Ongoing Medical Training                                                         12/04/2005

Title: Effective interventions in the handling of alcohol problems

   26. Gual A, Contel M, Segura L, Riba A, Colom J. ISCA (Systemized Interrogation

       on Alcohol Consumptions), a new tool for the early identifiaction of at-risk

       drinkers. Medicina Clínica (Barc) 2001;117: 685-689.

   27. Selzer, M.L. (1971). The Michigan Alcoholism Screening Test: The quest for a

       new diagnostic instrument. American Journal of Psychiatry, 127,1653-1658.

   28. Mayfield D, Mcleod G, Hall P. The CAGE questionnaire: Validation of a new

       alcoholism instrument. American Journal of Psychiatry 1974;131:1121-1123.

   29. Meerkerk GJ, Njoo KH, Bongers IMB, Trienekens P, Oers JAM. Comparing the

       diagnostic    accuracy    of    carbothidrate-deficient   transferring,     gamma-

       glutamyltransferase, and mean cell volume in a general practice population.

       Alcohol Clin Exp Res 1999;23:1052-1059.

   30. Harasymiw J, Bean P. The combined use of the early detection of alcohol

       consumption (EDAC) test and carbohydrate-deficient transferring to identify

       heavy drinking behaviour in males. Alcohol & Alcoholism 2001;36(4):349-353.

   31. Heather N. Interpreting the evidence on brief interventions for excessive

       drinkers: the need for caution Alcohol and Alcoholism 30, 287-296.

   32. Babor TF, Grant M. A randomized clinical trial of brief intervention in primary

       health care: summary of a WHO project. Addiction 1994; 89;657-678.

   33. Berglund M, Thelander S, Salaspuro M, Franck J, Andreasson S, Ojehagen A.

       Treatment of alcohol abuse: an evidence-based review. Alcohol Clin Exp Res.

       2003 Oct;27(10):1645-56.

   34. Moyer A, Finney JW, Swearingen CE. Brief Interventions for alcohol problems:

       a meta-analytic review of controlled investigations in treatment-seeking and

       non-treatment-seeking populations. Addiction 2002; 97; 279-292.

Ongoing Medical Training                                                    12/04/2005

Title: Effective interventions in the handling of alcohol problems

   35. Ballesteros J, Duffy JC, Querejeta I, Arino J, Gonzalez-Pinto A. Efficacy of

       brief interventions for hazardous drinkers in primary care: systematic review and

       meta-analyses.Alcohol Clin Exp Res. 2004 Apr;28(4):608-18.

   36. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL.

       Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Benefit-

       Cost Analysis. Alcohol Clin Exp Res, 2002; 26;36-43.

   37. Wutzke SE, Conigrave KM, Saunders JB, Hall WD. The long term effectiveness

       of brief interventions for unsafe alcohol consumption: a 10-year follow up.

       Addiction 2002;97, 665-675.

   38. Miller WR, Rollnick S. The Motivational Interview. Barcelona: Ed. Paidós;


   39. Ballesteros J, Ariño J, González-Pinto, A Querejeta L. Efficacy of medical

       advice for the reduction of alcohol consumption. Meta-analysis of Spanish

       studies in primary care. Gac Sanit 2003;17(2):116-122.

   40. Anderson P. The risk of alcohol. What general practice can do. Nijmegen, 2003.

   41. AlcoholCME. A combined Approach to Brief Interventions. [Online]. 2004.

       Available from:

   42. Rosenstock IM. Historical origins of the Health Belief Model. Health Education

       Monographs 1974;2:328-332.

   43. Prochaska JO, DiClemente CC. Towards a comprehensive model of change. In:

       Miller, WR and Heather, N (Eds) Treating addictive behaviours: processes of

       change. New York: Plenum; 1986.

Ongoing Medical Training                                                  12/04/2005

Title: Effective interventions in the handling of alcohol problems

   44. Sullivan JT, Skykora K, Schneiderman J. Assessment of alcohol withdrawal: the

       revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar).

       British Journal on Addiction 1989;84:1353-1357.

   45. Gual A, Lligoña A, Mondón S. Treatment of alcohol dependence. Specific

       programmes of dehabituation. In: Rodríguez-Martos A (dir.). Training course on

       Prevention and Treatment of Alcoholism. Barcelona: Ediciones DOYMA; 1999.

   46. Bouza C, Magro A, Munoz A, Amate JM. Efficacy and safety of naltrexone and

       acamprosate in the treatment of alcohol dependence: a systematic review.

       Addiction. 2004 Jul;99(7):811-28. Review.

   47. Garbutt JC, Kranzler HR, O'Malley SS, Gastfriend DR, Pettinati HM, Silverman

       BL, Loewy JW, Ehrich EW; Vivitrex Study Group. Efficacy and tolerability of

       long-acting injectable naltrexone for alcohol dependence: a randomized

       controlled trial.JAMA. 2005 Apr 6;293(13):1617-25.

   48. Johnson BA. Progress in the development of Topiramate for Treating Alcohol

       Dependence: From a Hipótesis to a Proof-of-Concept Study. Alcohol Clin Exp

       Res 2004, 28(8);1134-44.

   49. Kranzler HR. Pharmacotherapy of alcoholism: gaps in knowledge and

       opportunities for research. Alcohol and Alcoholism 2000. 35: 537-547

   50. Holder HD, Cisler RA, Longabaugh R, Stout RL, Treno AJ, Zweben A. Alcohol

       Treatment and medical costs from Project MATCH. Addiction 2000;95; 999-



Shared By: