Alcohol

In the UK, roughly 93% of men and 87% of women drink alcohol. Minimal alcohol consumption can of course be pleasurable, socially enjoyable, and associated with health benefits (reduction in deaths from coronary artery disease). There is a tendency to view most people as normal drinkers and a subset as vulnerable to the development of alcohol problems. In fact on a population level, increasing the overall alcohol consumption (e.g. by reducing the real price of alcohol) tends to increase the total number of problem drinkers.

Alcohol consumption in the community is roughly normally distributed with a long ‘tail’ to the right. The distinction between normal and heavy drinking is arbitrary. On both a population and individual level, increased consumption is associated with increased risk of harm of all kinds. However, the fact that normal drinkers heavily outnumber heavy drinkers means that, despite their lower rates of problems, greater numbers of alcohol-related problems occur in normal rather than heavy drinkers. This gives rise to the so-called ‘prevention paradox’—that to significantly reduce overall alcohol related morbidity we must look to reduce problems in normal rather than heavy drinkers. This applies more to problems such as drink driving and drink-related trauma rather than to medical complications of heavy use such as liver cirrhosis.

The term ‘alcoholic’ is often used by patients themselves and is the preferred term of Alcoholics Anonymous. It has unfortunately acquired a pejorative meaning to the general public, and images of the ‘down and out’ or ‘skid row’ alcoholic, drinking strong drink from brown paper bags, have damaged this word’s use in clinical contexts. It is not used in DSM-IV or ICD-10 where the preference is to make the diagnosis of alcohol dependence or harmful use (abuse in DSM-IV).

A history of alcohol use

Alcohol has been used in all societies throughout recorded history, with documentary evidence of brewing and wine making as early as 3000 BC. The intoxicating effects of alcohol were most probably discovered independently in many cultures around the time of the evolution of agriculture, possibly on noting fermentation in fruit. Ancient peoples produced alcoholic beverages from a wide variety of materials including fruits, berries, honey, corn, barley, wheat, sugar cane, and potatoes. The use of alcohol by individuals has been variously regarded, from complete tolerance through to outright prohibition.

Alcohol has always had a place in the lifestyles and formal rituals of many peoples around the world. It was used as an intoxicant in religious rituals, as a celebration, as a gift, as a greeting, and to mark births and deaths. For almost as long as alcohol use is recorded there are recorded attempts at control on its use by the authorities. In AD 92 the Roman emperor Domitian attempted to restrict wine production and its distribution and sale. Similar restrictions were attempted at various times by other leaders, sometimes accompanied by moral disapproval of drinking or drunkenness in particular. In medieval Britain, ale was a staple part of the diet and was consumed in huge quantities, while drunkenness, particularly among the clergy, was frowned upon by the Christian churches. Consumption of wine, however, continued to play a role in Christian worship. After initially preaching moderation, Mohammed later forbade the use of alcohol to followers of his religion, possibly as a way of differentiating his converts from the Christians around them.

The process of natural fermentation of alcohol by yeasts can produce beverages of up to 13% proof: above this concentration the yeast dies. Stronger concentrations of alcohol are produced by the process of distillation which was discovered in the Middle East in 1000 AD. Public consumption of distilled liquor became prevalent in the eighteenth century and the accompanying social problems together with the conservative attitudes of the emerging Protestant clergy led to a developing moral disapproval of alcohol consumption.

In the mid-eighteenth century, as part of a continuing military and trade dispute with France, the British government imposed heavy taxes on French wine imports and encouraged the distillation of cheap domestic spirits—in particular, gin. This change in the drinking practice in the general population from lowto high-strength alcohol produced significant alcohol-related problems in the general public, immortalized in the lithographs of the ‘gin palaces’ by George Cruikshank. In an effort to control the problem the government passed laws to restrict the time and place at which alcohol could be sold and began to levy increasing taxes on distilled spirits. This had the positive effect of reducing consumption but the negative effect of introducing a government interest in continuing consumption. The late eighteenth-century writings of Benjamin Rush describe habitual drunkenness as a ‘disease of the mind’.

Eighteenth-century America saw the development of an increasingly widespread temperance movement (those signing a pledge ‘TA’ for total abstinence becoming known as teetotallers). The temperance movement lobbied for a complete ban on alcohol consumption, and succeeded in 1921 following the passing of the 18th amendment to the US Constitution which provided for prohibition. The period of 11 years until the repeal of prohibition in the 21st amendment did indeed see a reduction in social problems and mortality; however, its unpopularity, widespread flouting of the law, and the flourishing of illegal activity in gangsterism led to its repeal.

Today, in most Western countries, alcohol use is widely tolerated and socially accepted. Interestingly, moral disapproval of drinking during pregnancy and drinking while driving a motor vehicle has resulted in substantial decreases in these activities. Despite improvement in these limited areas, most Western countries have seen an increase in absolute consumption and alcohol-related medical harm compounded by an increasing passion for drug misuse.

Alcohol as a drug

Preparations The active ingredient in alcoholic drinks is ethyl alcohol which makes up a variable percentage of the volume. The flavour of drinks comes from ‘congeners’—the additional organic substances derived from the brewing materials.

Pattern of use Of all drugs, alcohol has the widest range of patterns of use, ranging from yearly light consumption to continuous consumption throughout the waking hours.

Drug actions The effects of alcohol on the CNS were traditionally described as being due to non-specific effects on neuronal cell wall fluidity and permeability. It is now believed that in addition to these general effects there are neurotransmitter-specific effects, including: enhancement of GABA-A transmission (anxiolytic effects), release of dopamine in the mesolimbic system (euphoriant and ‘reward’ effects), and inhibition of NMDA-mediated glutaminergic transmission (amnesic effects). Ethyl alcohol is oxidized by alcohol dehydrogenase (ADH) to acetaldehyde, which in turn is oxidized by acetaldehyde dehydrogenase (ALDH) to carbon dioxide and water. 98% of alcohol metabolism takes place in the liver. Approximately 1 unit (or 8g) of alcohol can be metabolized per hour. Illicitly brewed alcohol may contain methanol, which is broken down to formaldehyde, which has marked toxic effects on the retina.

Acute effects Alcohol is absorbed rapidly from mouth, stomach, and small intestine, and from a single consumption maximum blood levels are obtained in 760min. Absorption is slowed by the presence of food in the stomach and is speeded up by taking effervescent drinks. Alcohol is hydrophilic and is widely distributed throughout the body organs including the brain, placenta, lungs, and kidneys. Blood alcohol concentration (BAC) is consistent throughout the body with the exception of fat and can be estimated from breath samples. In normal drinkers BAC correlates with the subjective and the observable CNS effects of alcohol. Heavy drinkers may have a high BAC with limited outward signs of intoxication due to the development of tolerance. Because of their different body fat distribution, women will have a higher BAC than men following the same oral intake. Initial symptoms of alcohol intoxication are subjective elevation of mood, increased socialization, and disinhibition. Continuing consumption, intended to prolong these effects, can lead to lability of mood, impaired judgement, aggressiveness, slurred speech, unsteady gait, and ataxia.

Societal factors The prevalence of alcohol-related harm increases with the mean population consumption. This mean consumption is increased by increased availability of alcohol, increased societal tolerance of drinking, decreased restrictions on the sale of alcohol, and a decreased ‘real price’ of alcohol. Price is the most influential factor in demand, the real price of a pint of beer or bottle of whisky having dropped considerably since the war. Where societies forbid all alcohol consumption (e.g. prohibition America, Islamic counties), there is a decrease in alcohol-related problems but an increase in the level of personality abnormality in those who continue to drink.

Risk factors Heavy drinking is more common in men, in lower socioeconomic groups, in those with lower educational levels, and in the young. Some professions are also associated with heavy drinking and drink-related harm. These include drinks industry workers (easy availability and effect of heavy drinkers seeking out jobs here); travelling salesmen (boredom, periods away from home, acceptance of drinking on the job); doctors (stress, freedom from direct supervision, reluctance to seek help with incipient problems).

Genetics First-degree relatives of alcoholics have double the risk of alcohol problems themselves. Significantly higher rates in identical compared with fraternal twins (although not 100% concordance). Children of alcoholics have increased risk of development of alcohol problems themselves even when adopted into families without alcohol problems. A metabolically relatively inactive form of ALDH is common in Southeast Asian people, leading to accumulation of acetaldehyde and an unpleasant ‘flushing’ reaction in affected individuals who take alcohol. This may account for the significantly lower rate of alcohol problems found in affected individuals. No causative genes for alcoholism have been identified and it is expected that it will show polygenic inheritance. Problem drinkers contain a significant subgroup of individuals with dissocial personality traits which predisposes to alcoholism, and is itself heritable.

Medical complications Acute toxicity occurs at levels over 300mg% (see b p. 566), with clouding of consciousness and coma, risk of aspiration, hypoglycaemia, and acute renal failure. Associated with a wide range of chronic medical problems

Psychiatric complications Harmful use and dependent use (b p. 566) distinguished by the presence of withdrawals on abstinence; withdrawals may be complicated by seizures and development of an acute confusional state—delirium tremens (b p. 558); acute alcohol-induced amnesia; alcoholic hallucinosis (b p. 568); alcohol-induced delusional disorder (b p. 568); Wernicke–Korsakoff syndrome (b p. 572); pathological jealousy (b p. 569); alcohol-related cognitive impairment and alcoholic dementia (b p. 568); alcohol misuse is also associated with development of, or exacerbation of, anxiety/depressive symptoms and with deliberate self-harm and suicidal behaviour.

Interventions Advice and ‘brief interventions’ regarding safer drinking patterns in those with ‘at risk’ or harmful use (b p. 566); strategies towards encouraging and maintaining abstinence in those with dependency and those with established medical or psychiatric damage; medically managed detoxification (b p. 560); psychological and pharmacological support of abstinence or changed drinking pattern (b pp. 562–5).

Screening for alcohol problems

Diseases related to alcohol abuse are common, significant, and amenable to improvement by early detection and intervention. Screening is therefore indicated. There are low rates of detection in primary care and hospital settings, which may be improved by increased vigilance, increased awareness of alcohol problems, awareness of routes of referral, asking routine alcohol-screening questions (e.g. CAGE—see Box 15.1), paying special attention to at-risk groups. Many patients give reasonably accurate drinking histories if asked, although some may underestimate consumption. A combination of clinical history, screening measure, and a biomarker is the optimal approach to detection.

Disorders suggesting underlying alcohol abuse Hepatitis; cryptogenic (i.e. medically unexplained) cirrhosis; seizures—particularly late onset; gastritis; anaemia; unexplained raised MCV or deranged LFTs; cardiomyopathy; accidents, particularly repeated and poorly explained; TB; head injury; hypertension persisting despite apparently adequate treatment; treatment resistance in other psychiatric conditions; impotence in men.

Breath testing Blood alcohol concentration (BAC) measures recent alcohol consumption, in mg alcohol per 100mL blood (mg%). Correlates well with breath alcohol measured by breathalyser (see Table 15.1). Useful in assessing recent drinking (e.g. in supervised detox regimes) and as an objective measure of intoxication (e.g. in A&E). Discrepancy between high BAC and lack of apparent intoxication suggests tolerance. This measurement is dependent on adequate technique, and reasonable co-operation from the patient.

Blood tests Elevated red cell mean corpuscular volume (MCV), gamma glutamyl transferase (G-GT), and carbohydrate-deficient transferrin (CDT) are markers for excess alcohol consumption. They are best used to monitor consumption in patients at follow-up. Not sensitive/specific enough for routine screening purposes.

• MCV Sensitivity 20–50%, specificity 55–100%. Remains raised for 3–6 months due to 120-day lifespan of RBC. False positive in B12 and folate deficiency.
• G-GT Sensitivity 20–90%, specificity 55–100%. Raised for 2–3wks. Other LFTs are less specific for alcoholic-related liver damage. False positive in liver diseases of other cause, obesity, diabetes, smoking, and medication (e.g. anticonvulsants), and may remain raised in chronic alcoholic liver disease despite abstinence.
• CDT Sensitivity 70%, specificity 95%. Increased levels in response to heavy drinking (7–10 days), 2–3wks to return to normal, can be used to monitor relapse. More expensive than G-GT and not available in all areas.

Urinary tests Urinary ethyl glucoronide (an alcohol metabolite) has been proposed as a measure of alcohol intake, being sensitive to ingestion of 1 or 2 drinks, remaining elevated for several days. It has still to be used routinely, though has been used in forensic settings.

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Hair testing Testing of hair for ethyl glucoronide or fatty acid ethyl esters has been proposed as a method for detecting alcohol use over prior months, though requires further research and validation.

Assessment of the patient with alcohol problems

Patients with a primary alcohol problem, or where it is thought that alcohol consumption is a contributory factor in their presentation, should have a more detailed assessment of their alcohol use, in addition to standard psychiatric history and MSE.

Lifetime pattern of alcohol consumption Age at first alcoholic drink. Age when began to drink regularly. Age when first drinking most weekends. Age when first drinking most days. When did they first begin to drink more than their peers? When (if ever) did they first feel they had an alcohol problem? Pattern of drinking throughout life until present— describe periods of abstinence and more heavy drinking and the reasons for these (including environmental/psychosocial stressors).

Current alcohol consumption Describe a current day’s drinking. When is the first drink taken? What types of drink are taken and in what setting? What is the total number and volume of drinks taken in a day? Some patients find it hard to describe a typical day or easy to overrationalize recent heavy consumption. Ask them to describe the previous day’s drinking, then the day before that, etc., until a pattern emerges. Describe a typical and a ‘heavy’ day’s drinking.

Signs of dependence Do they experience withdrawals in the morning or when unable to obtain alcohol? Have they ever drunk more alcohol as way of relieving withdrawals? Are they having to drink more to get the same intoxicating effect? Do they no longer get ‘drunk’ at all? Do they find it difficult to stop drinking once started? Have they tried and failed to give up, and if so why? Do they have episodes of ‘lost’ memory/‘blackouts’?

Physical/mental health Have they been told of any physical health problems due to drinking? Have they previously been told to stop drinking by a doctor? Any previous or current psychiatric diagnoses?

Problems related to alcohol Have they missed days at work, or had warnings about poor performance, or lost a job as a result of alcohol? Are there relationship difficulties or a relationship breakdown due to drinking? Are there financial problems? Have they been in trouble with the police or do they have outstanding charges against them?

Previous treatment attempts Describe the nature and type of previous treatments. Describe the subsequent return to drinking. Describe any periods of abstinence since the development of the drinking problem. How were they maintained and what ended them?

Family history Drinking problems in parents and extended family. Quality of relationships in past and present. Childhood environment.

Attitude to referral Why have they attended the appointment today? Do they feel they have an alcohol problem and if so will they accept help for it? What sort of help do they want and are there types of treatment

they will not accept? What stage of change are they at (pre-contemplative, contemplative, decision, action)?

Patient goals What (if anything) do they want to change about their drinking? What pattern of drinking do they aspire to?

Physical examination Note general condition; evidence of withdrawals including tremor in hands or protruded tongue; degree of facial capilliarization; stigmata of liver disease (palpable liver edge, jaundice, spider naevi, ascites, palmar erythema); evidence of peripheral neuropathy; ataxia of gait; breath alcohol reading.

Blood testing FBC, LFTs, other blood tests as indicated on history/ examination.

Cognitive testing Although not generally indicated until 4wks of abstinence, it is helpful to get a feel for the patient’s level of cognition, especially if there is a suggestion they may be experiencing delirium, or have significant alcohol-related brain damage.

Giving drinking advice

There are a variety of situations where the doctor will be called on to give ‘safe drinking’ advice: individuals whose histories reveal evolving risky drinking patterns; patients with comorbid psychiatric illness; and individuals with alcohol problems who are attempting controlled drinking rather than abstinence.

There is a wide variety of types of alcoholic drink, each of a different ‘strength’, (i.e. percentage alcohol by volume; see Table 15.2). It is the amount of alcohol taken, rather than the type of drink, which contributes to physical/mental health effects—avoiding spirits or other drinks perceived as ‘strong’ will not protect from health risks if the absolute amount of alcohol is above safe limits.

Sensible drinking Men should drink no more than 21 and women no more than 14 units/wk of alcohol. There should be at least two nondrinking days per week. The amounts should be spread over several days, not drunk all at once. Amounts should not be ‘saved up’ from a light week and drunk on top of the following week’s allowance. The amounts quoted are not ‘safe’ amounts, but represent levels of drinking not associated with significant risks to health. In some situations (e.g. driving, operating machinery) the ‘safe amount’ is zero. Some individuals (e.g. previously alcohol-dependent, chronic medical conditions, pregnant) should not drink at all.

Brief interventions for hazardous and harmful drinking

Low intensity, short interventions, based predominantly at primary care level, to reduce hazardous drinking. Techniques include presenting patients with screening results, identifying risks, giving medical advice, assessing the patient’s goals/commitment and working collaboratively to support the patient.

Techniques of controlled drinking Patients who are seeking advice about avoiding potential alcohol problems and those individuals who are seeking to change from ‘at-risk’ or harmful drinking patterns to controlled

drinking patterns may find a selection of the following strategies helpful:

• Set a weekly and daily alcohol limit and keep to it.
• Do not drink alone.
• Do not drink with individuals who drink heavily themselves.
• Pace drinking, matching the consumption of a light or slow drinker.
• Don’t buy rounds.
• Alternate soft and alcoholic drinks. Drink with a meal.
• Rehearse what to say if offered a drink that you don’t want.
• Plan alternative, enjoyable non-drinking activities to replace drinking periods (e.g. cinema, sports).

Planning treatment in alcohol misuse

Patients presenting with alcohol problems often display marked ambivalence about whether there is even a problem, let alone about the need for change. This reflects both the perceived positive as well as negative roles alcohol plays in their lives and the memory of previous failure or difficulties in attempting change. The aim in counselling such patients is to guide them in making their own decision towards change, or if change is not likely or possible now, to guide them towards harm reduction and considering the possibility of future change.

Motivational interviewing This is a technique aimed at enabling a patient to move through the stages of change (b p. 544) to the point where action can be contemplated. It is based on the principle that: ‘people believe what they hear themselves say’. The interviewer aims to aid the patient in explaining why they should change their behaviour and how this will be achieved.

• Therapist does not take a directive or prescriptive role but expresses interest and concern for the patient’s problems and explores the consequences of their behaviour.
• Uses open-ended questions, reflective listening and summarizing with identification of discrepancy between individual statements.
• Aids the assessment of the pros and cons of current behaviour, avoiding confrontation or direct challenge.
• Emphasizes patient’s own perceptions of degree of risk rather than telling them about risks which they may not believe.
• Encourages personal responsibility and patient’s choice of treatment options.

Planning interventions The initial assessment interview forms the beginning of intervention. Its aims are to gather and impart information, promote the possibility of positive action, and to plan treatment. The ongoing therapeutic relationship aims to maintain purpose, monitor progress, aid self-monitoring and self-awareness. The process of planning treatment should proceed along the following lines:

• Make diagnosis (alcohol dependence, harmful, or at-risk use).
• Assess stage of change (b p. 544).
• Decide with patient the goal of intervention:
• Continue current drinking pattern In some patients there will be no need for change at all. In others there will be a clear history of alcohol problems but the patient presents as ‘pre-contemplative’

regarding change. In these cases give harm-reduction advice and ‘leave the door open’ to further assessment and help rather than alienating the patient.

• Change to safer drinking pattern Many individuals will be able to modify risky or harmful drinking patterns given appropriate advice and help (perhaps monitored by a ‘drinking diary’, which is later reviewed).
• Attempt abstinence from alcohol In some individuals the only safe course is to aim to abstain from alcohol completely.
• For abstinence in a dependent drinker, consider the need for and setting of detox (b p. 560).
• Abstinence vs. controlled drinking The decision to try for controlled drinking rather than abstinence is one for individual patient choice. The doctor should offer suitable advice.
• Factors suggesting possibility of success of controlled drinking: previous prolonged periods of controlled drinking, alcohol misuse primarily in context of other mental disorder which has responded to treatment, otherwise stable lifestyle, absence of drinking problem in family and friends.
• Factors against controlled drinking: previously alcoholdependent, previous failure at controlled drinking, comorbid mental illness, comorbid drug use, established organ damage, risk of job loss/ marriage loss.
• Relapse Alcohol misuse is a chronic illness and many patients will ‘fall off the wagon’ several times before achieving long-standing change. The possibility of relapse should be anticipated with the patient and appropriate strategies should be in place to deal with it (e.g. early review).
• Causes of relapse: ambivalent motivation, insufficient support, novel events, over-confidence, mental illness, environmental stressors.
• Counselling families The family of a patient with alcohol problems may contact you directly to ask for advice regarding their relative.
• Patient’s relatives sometimes request that their relative be detained in hospital ‘to stop them drinking’. The Mental Health Acts in the UK specifically do not allow detention of patients solely for reason of drug or alcohol dependency.
• Aim to encourage and reward moves by the drinker to achieve change in their drinking pattern, while avoiding rewarding and hence reinforcing drinking, but avoiding confrontation or ultimatums.
• Sometimes continued family involvement, despite their best intentions, serves only to support the drinker in their chosen lifestyle. In this case the family may have to be aided to step back (AA call this ‘disengaging with love’).
• Prognostic factors There is 73.6-fold excess mortality cf. age-matched controls. Of 100 45-yr-old patients at 20yrs follow-up: 40% dead, 30% abstinent, 30% problem drinking. Positive factors Motivated to change; supportive family or relationship; in employment; treatable comorbid illness (e.g. anxiety disorder, social phobia); accepting of appropriate treatment goal; AA involvement. Negative factors Ambivalent about change; unstable accommodation or homeless; drinking embedded into lifestyle (e.g. limited pursuits outside alcohol, all friends are drinkers); repeated treatment failures; cognitive impairment.

Management of alcohol withdrawal

Detoxification (detox) is the medical management of withdrawal symptoms in a patient with substance dependence. Alcohol detox involves: psychological support; medication to relieve withdrawal symptoms (usually via a reducing BDZ regime); observation for development of features of complicated withdrawal; nutritional supplementation; and integration with follow-up. Detox may be carried out as inpatient or, with support, in the community. The need to medically manage the complications of alcohol withdrawal can also arise in an unplanned fashion (e.g. in an alcohol-dependent patient in police custody or following emergency surgery). Most of the problems of alcohol use are related to inability to maintain abstinence, rather than to the initial problems of withdrawal.

Detox procedure

• Decide on setting.
• Assess need for BDZ-reducing regime.
• Consider need for other medications.
• Provide verbal and written advice.
• Inform GP of the plans.
• Give the patient a contact in case of emergency.
• Decide on explicit follow-up after detox.

Setting

Outpatient detox

• Treatment of choice for most uncomplicated alcohol-dependent patients, with comparable completion rates to inpatient detoxification and comparable percentage remaining abstinent at 6mths.
• Where there are doubts about compliance or concerns about drinking ‘on top of’ the prescribed drug, the patient should be seen daily in

the morning and breathalysed before dispensing that day’s and the  following morning’s supply of the drug.

Indications for inpatient detox

• Past history of complicated withdrawals (seizures or delirium).
• Current symptoms of confusion or delirium.
• Comorbid mental/physical illness, polydrug misuse, or suicide risk.
• Symptoms of Wernicke–Korsakoff syndrome (b p. 572).
• Severe nausea/vomiting; severe malnutrition.
• Lack of stable home environment.

In planning treatment in alcohol problems, attention should be focused not only on achieving, but also on maintaining change. Many patients find the initial change (e.g. moving to abstinence or controlled drinking) surprisingly easy, but find it difficult to maintain change in the longer term. Alcohol misuse is a chronic illness characterized by relapse and in dependent drinkers there is the tendency for dependent drinking patterns to recur rapidly on abstinence. For this reason, maintenance interventions should support change, and in every patient, relapse should be anticipated and strategies to deal with it should be in place.

Individual counselling In addition to monitoring agreed change, individual counselling can address the following:

• Social skills training (e.g. ‘saying no’).
• Problem-solving skills.
• Relaxation training.
• Anger management.
• Cognitive restructuring.
• Relapse prevention.

In selected patients there may be a role for more formal psychotherapies.

Group support Variety of group methods both within the health service and in the voluntary sector. Variable local provision. Most widespread and best known is AA (see Box 15.2).

Residential abstinence In selected patients, time in a residential facility may offer a period of abstinence which is unachievable ‘outside’, allowing interventions in physical and mental health and a chance to plan social change to permit continued abstinence on discharge. A variety of facilities exist, usually outside health care provision; some offer detoxification, while others will only accept patients following detox. Most residential rehabilitation centres will utilize group therapies, and follow the ‘12-step’ approach, advocated by Alcoholics Anonymous (b p. 563). Residential rehabilitation is used in patients where home environment is unsupportive of abstinence and there has been failure of previous treatment options.

Advice to all patients regarding relapse Returning to drinking is the most common outcome in patients (and some consider relapse as pathognomonic of addiction). The stages of change model (b p. 544) considers relapse to be at the beginning of a further process of change, but with increased knowledge as to future strategies to combat relapse. A relapse can be motivated by over-confidence or forgetting gains. A ‘slip’ does not mean a full-blown relapse is inevitable and all patients should have strategies to deal with relapse discussed and agreed ‘ahead of time’.

Alcoholics Anonymous (AA)

Alcoholics Anonymous (AA) is the best known and the most widespread of the voluntary self-help organizations for problem drinkers. It was founded in 1935 in the USA by Bill Wilson and Dr Bob Smith, themselves both problem drinkers. Currently there are 73 000 groups in the UK and 788 000 groups worldwide. Associated organizations are Al-Anon (for relatives of problem drinkers); Al-Ateen (for teenage children of problem drinkers); and Narcotics Anonymous (NA) (for addicts of illicit drugs).

AA views alcoholism as a lifelong, incurable disease whose symptoms can be arrested by lifelong abstinence. Many other groups will use a variant of the AA model ‘12-step’ programme. AA is a useful and effective intervention in many problem drinkers and all patients should be informed about AA and encouraged to consider attendance.

An AA meeting will generally follow a standard routine: there will be 10–20 people in each group, only first names are used; a rotating chairman will introduce himself with ‘my name is X, and I am an alcoholic’, then will read the AA preamble; a number of speakers are called from the floor who give an account of their stories and recovery if possible, leading to general discussion; the meeting ends with a prayer and is followed by informal discussions and contact between new members and sponsors who may offer emotional and practical support and perhaps a phone number. Open meetings are held where friends, family, and interested professionals can attend. Closed meetings are for AA members only. (See Useful resources for AA contacts in the UK and Ireland b p. 1014.)

The ‘12 steps’

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a power higher than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of the persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory, and when we were wrong promptly to admit it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics and to practise these principles in our affairs.