Elsevier

The Lancet

Volume 373, Issue 9662, 7–13 February 2009, Pages 492-501
The Lancet

Seminar
Alcohol-use disorders

https://doi.org/10.1016/S0140-6736(09)60009-XGet rights and content

Summary

Alcohol dependence and alcohol abuse or harmful use cause substantial morbidity and mortality. Alcohol-use disorders are associated with depressive episodes, severe anxiety, insomnia, suicide, and abuse of other drugs. Continued heavy alcohol use also shortens the onset of heart disease, stroke, cancers, and liver cirrhosis, by affecting the cardiovascular, gastrointestinal, and immune systems. Heavy drinking can also cause mild anterograde amnesias, temporary cognitive deficits, sleep problems, and peripheral neuropathy; cause gastrointestinal problems; decrease bone density and production of blood cells; and cause fetal alcohol syndrome. Alcohol-use disorders complicate assessment and treatment of other medical and psychiatric problems. Standard criteria for alcohol dependence—the more severe disorder—can be used to reliably identify people for whom drinking causes major physiological consequences and persistent impairment of quality of life and ability to function. Clinicians should routinely screen for alcohol disorders, using clinical interviews, questionnaires, blood tests, or a combination of these methods. Causes include environmental factors and specific genes that affect the risk of alcohol-use disorders, including genes for enzymes that metabolise alcohol, such as alcohol dehydrogenase and aldehyde dehydrogenase; those associated with disinhibition; and those that confer a low sensitivity to alcohol. Treatment can include motivational interviewing to help people to evaluate their situations, brief interventions to facilitate more healthy behaviours, detoxification to address withdrawal symptoms, cognitive-behavioural therapies to avoid relapses, and judicious use of drugs to diminish cravings or discourage relapses.

Introduction

The alcohol-use disorders consist of alcohol dependence, alcohol abuse,1 and dependence or harmful use.2 These are common and potentially lethal disorders that mimic and exacerbate a wide range of additional medical and psychiatric conditions, and thereby shorten the lifespans of affected people by more than a decade.3 However, most people with alcohol-use disorders are hard to identity, since they are likely to have jobs and families, and present with general complaints such as malaise, insomnia, anxiety, sadness, or a range of medical problems.

Both primary-care physicians and specialists can help to screen for these disorders, institute brief interventions, and refer patients for more intensive care if needed. This paper presents a selective update of clinical developments regarding alcohol-use disorders that are relevant to practising physicians, and focus on skills that they already have or can easily acquire.

Section snippets

Epidemiology

Alcohol-use disorders are common in all developed countries, and are more prevalent in men than women, with lower, but still substantial rates in developing countries.3, 4, 5 Although rates of these disorders are lower in Mediterranean countries (eg, Greece, Italy, and Israel), and higher in northern and eastern Europe (eg, Russia and Scandinavia), they are responsible for a large proportion of the health-care burden in almost all populations.3, 4, 5

As many as 80% of men and 60% of women in

Criteria for screening and diagnosis

Clinicians should screen for unhealthy drinking (eg, more than three or four standard drinks per day), just as they counsel their patients for other risky behaviours such as being 10% overweight. A standard drink is defined as 8 g of ethanol in the UK and about 10 g in the USA. Both the US-based 4th Diagnostic and Statistical Manual (DSM-IV)1 and the 10th International Classification of Diseases (ICD10)2 describe alcohol dependence as the more severe condition, associated with major

Causes and origins

About 40–60% of the risk of alcohol-use disorders is explained by genes and the rest through gene–environment associations.43, 44 The environment includes the availability of alcohol, attitudes towards drinking and drunkenness, peer pressures, levels of stress and related coping strategies, models of drinking, and laws and regulatory frameworks.43, 44

Recent advances in our understanding of genes that operate through intermediate characteristics (or phenotypes) to affect the risk of alcohol-use

Treatment

Despite perceptions to the contrary, efforts to help patients decrease heavy drinking commonly result in changes in behaviours, and most patients with alcohol-use disorders do well after treatment.87, 88 About 50–60% of men and women with alcohol dependence abstain or show substantial improvements in functioning the year after treatment, and such outcomes are excellent predictors of their status at 3–5 years.26, 36, 37, 39, 89 Although anyone in treatment might do well, better outcomes are

Rehabilitation

The goals of rehabilitation for alcohol-use disorders are the same as for any chronic relapsing disorder: to help to keep motivation high, change attitudes toward recovery, and diminish the risk of relapse.3 Cognitive-behavioural steps can help people to change how they think about alcohol and its role in their lives (the cognitive component); learn new behaviours for development and maintenance of abstinence or diminished drinking; and avoid relapses.

The Alcoholics Anonymous programme offers

Conclusions

The criteria for alcohol dependence are reliable, patients face substantial morbidity and mortality, and resources are available to identify patients with unhealthy drinking or alcohol-use disorders, and to offer treatment. Treatment can include motivational interviewing to help people to evaluate their situations, brief interventions to facilitate more healthy behaviours, cognitive-behavioural therapies, and the judicious use of drugs to improve outcomes for alcohol-use disorders.

Search strategy and selection criteria

This Seminar was based on a comprehensive survey of PubMed between January, 2000, and March, 2007, excluding papers not published in English. The search terms used was “alcoholism”, in combination with “criteria”, “course” “treatment”, and “etiology”.

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