Which of the following statements is true about the global use of alcohol?

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Alcohol Research & Health, Vol. 24, No. 4, 2000: Covers a range of topics, including prevalence of alcohol and tobacco use; behavioral, sociocultural, and genetic risk factors for smoking and drinking; the effects of tobacco use during and after pregnancy on exposed children; and preventing alcohol and tobacco use through life skills training in high school students.

This guideline is concerned with the identification, assessment and management of alcohol dependence and harmful alcohol use in people aged 10 years and older. In 2008, alcoholic beverages were consumed by 87% of the population in England, which is equivalent to 36 million people (adults aged 16 years or over) (). Drinking alcohol is widely socially accepted and associated with relaxation and pleasure, and some people drink alcohol without experiencing harmful effects. However, a growing number of people experience physical, social and psychological harmful effects of alcohol. Twenty-four per cent of the adult population in England, including 33% of men and 16% of women, consumes alcohol in a way that is potentially or actually harmful to their health or well-being (). Four per cent of adults in England are alcohol dependent (6% men; 2% women), which involves a significant degree of addiction to alcohol, making it difficult for them to reduce their drinking or abstain despite increasingly serious harm (). Alcohol dependence and harmful alcohol use are recognised as mental health disorders by the World Health Organization (; see ). Although not an official diagnostic term, ‘alcohol misuse’ will be used as a collective term to encompass alcohol dependence and harmful alcohol use throughout this guideline.

The physical harm related to alcohol is a consequence of its toxic and dependence-producing properties. Ethanol (or ethyl alcohol) in alcoholic beverages is produced by the fermentation of sugar by yeast. It is a small molecule that is rapidly absorbed in the gut and is distributed to, and has effects in, every part of the body. Most organs in the body can be affected by the toxic effects of alcohol, resulting in more than 60 different diseases. The risks of developing these diseases are related to the amount of alcohol consumed over time, with different diseases having different levels of risk. For example, the risk of developing breast cancer increases in a linear way, in which even small amounts of alcohol increase risk. With alcoholic liver disease the risk is curvilinear, with harm increasing more steeply with increasing alcohol consumption. In the case of cardiovascular disease a modest beneficial effect has been reported with moderate amounts of alcohol, although recent research suggests this effect may have been overestimated (). During pregnancy alcohol can cause harm to the foetus, which can cause prematurity, stillbirth and the developmental disorder fetal alcohol syndrome.

Alcohol is rapidly absorbed in the gut and reaches the brain soon after drinking. This quickly leads to changes in coordination that increase the risk of accidents and injuries, particularly when driving a vehicle or operating machinery, and when combined with other sedative drugs (for example, benzodiazepines). Its adverse effects on mood and judgement can increase the risk of violence and violent crime. Heavy chronic alcohol consumption increases the risk of mental health disorders including depression, anxiety, psychosis, impairments of memory and learning, alcohol dependence and an increased risk of suicide. Both acute and chronic heavy drinking can contribute to a wide range of social problems including domestic violence and marital breakdown, child abuse and neglect, absenteeism and job loss (; ; ).

The physical harm related to alcohol has been increasing in the UK in the past three decades. Deaths from alcoholic liver disease have doubled since 1980 () compared with a decrease in many other European countries. Alcohol related hospital admissions increased by 85% between 2002/03 and 2008/09, accounting for 945,000 admissions with a primary or secondary diagnosis wholly or partly related to alcohol in 2006/07 and comprising 7% of all hospital admissions ().

Alcohol is a psychoactive substance with properties known to cause dependence (or addiction). If compared within the framework of the 1971 Convention on Psychotropic Substances, alcohol would qualify as a dependence-producing substance warranting international control (; ). Alcohol shares some of its dependence-producing mechanisms with other psychoactive addictive drugs. Although a smaller proportion of the population who consume alcohol become dependent than is the case with some illegal drugs such as cocaine, it is nevertheless a significant problem due to much the larger number of people who consume alcohol ().

Alcohol presents particularly serious consequences in young people due to a higher level of vulnerability to the adverse effects of alcohol (see on special populations).

Heavy drinking in adolescence can affect brain development and has a higher risk of organ damage in the developing body (). Alcohol consumption before the age of 13 years, for example, is associated with a four-fold increased risk of alcohol dependence in adulthood (; ).

Other groups who are also at higher risk of alcohol-related harm include: the elderly, those with pre-existing illnesses or who are taking a range of medicines that interact with alcohol, and the socially disadvantaged (; ). A given amount of alcohol will also be more harmful in women compared with men due to differences in body mass and composition, hence the government's recommended sensible-drinking guidelines are lower for women than men. Nevertheless, or perhaps as a consequence, women tend to seek help for alcohol misuse earlier in their drinking career than do men ().

2.2. DEFINITIONS

The definition of harmful alcohol use in this guideline is that of WHOs International Classification of Diseases, 10th Revision (The ICD–10 Classification of Mental and Behavioural Disorders) (ICD–10; ):

a pattern of psychoactive substance use that is causing damage to health. The damage may be physical (e.g. hepatitis) or mental (e.g. depressive episodes secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse social consequences; social consequences in themselves, however, are not sufficient to justify a diagnosis of harmful use.

The term was introduced in ICD–10 and replaced ‘non-dependent use’ as a diagnostic term. The closest equivalent in other diagnostic systems (for example, the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association [], currently in its fourth edition [DSM–IV]) is ‘alcohol abuse’, which usually includes social consequences.

The term ‘hazardous use’ appeared in the draft version of ICD–10 to indicate a pattern of substance use that increases the risk of harmful consequences for the user. This is not a current diagnostic term within ICD–10. Nevertheless it continues to be used by WHO in its public health programme ( and ).

In ICD–10 the ‘dependence syndrome’ is defined as:

a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.

In more common language and in earlier disease-classification systems this has been referred to as ‘alcoholism’. However, the term ‘alcohol dependence’ is preferred because it is more precise, and more reliably defined and measured using the criteria of ICD–10 (Text Box 1).

Text Box 1

ICD–10 diagnostic guidelines for the dependence syndrome (WHO, 1992).

Alcohol dependence is also a category of mental disorder in DSM–IV (), although the criteria are slightly different from those used by ICD–10. For example a strong desire or compulsion to use substances is not included in DSM–IV, whereas more criteria relate to harmful consequences of use. It should be noted that DSM is currently under revision, but the final version of DSM–V will not be published until 2013 ().

Although alcohol dependence is defined in ICD–10 and DSM–IV in categorical terms for diagnostic and statistical purposes as being either present or absent, in reality dependence exists on a continuum of severity. Therefore, it is helpful from a clinical perspective to subdivide dependence into categories of mild, moderate and severe. People with mild dependence (those scoring 15 or less on the Severity of Alcohol Dependence Questionnaire [SADQ]) usually do not need assisted alcohol withdrawal. People with moderate dependence (with an SADQ score of between 15 and 30) usually need assisted alcohol withdrawal, which can typically be managed in a community setting unless there are other risks. People who are severely alcohol dependent (with an SADQ score of 31 or more) will need assisted alcohol withdrawal, typically in an inpatient or residential setting. In this guideline these definitions of severity are used to guide the selection of appropriate interventions.

2.3. EPIDEMIOLOGY OF ALCOHOL

2.3.1. Prevalence

Alcohol was consumed by 87% of the UK population in the past year (). Amongst those who are current abstainers, some have never consumed alcohol for religious, cultural or other reasons, and some have consumed alcohol but not in the past year. This latter group includes people who have been harmful drinkers or alcohol dependent in the past and who have stopped because of experiencing the harmful effects of alcohol.

Amongst those who currently consume alcohol there is a wide spectrum of alcohol consumption, from the majority who are moderate drinkers through to a smaller number of people who regularly consume a litre of spirits per day or more and who will typically be severely alcohol dependent. However, it is important to note that most of the alcohol consumed by the population is drunk by a minority of heavy drinkers.

The Department of Health has introduced definitions that relate to different levels of drinking risk. One UK unit of alcohol is defined as 8 g (or 10 ml) of pure ethanol. The Department of Health recommends that adult men should not regularly drink more than four units of alcohol per day and women no more than three units (). This definition implies the need for alcohol free or lower alcohol consumption days. Below this level alcohol consumption is regarded a ‘low risk’ in terms of health or social harms. The government's advice on alcohol in pregnancy is to abstain (). The Royal College of Psychiatrists' advice is to drink less than 21 units of alcohol per week in men and 14 units in women, which is consistent with government advice if alcohol-free days are included in the weekly drinking pattern (). Those people who drink above these levels but have not yet experienced alcohol-related harm are regarded as hazardous drinkers: that is, their drinking is at a level which increases the risk of harm in the future. These recommendations are based on longitudinal research on the impact of different levels of alcohol consumption on mortality. Above 50 units of alcohol per day in men and 35 units in women is regarded as ‘definitely harmful’ (). Those drinking more than eight units per day in men and six units in women are regarded by the government as ‘binge drinkers’ (). Again these definitions are based on longitudinal research on the effects of alcohol consumption on adverse consequences including accidents, injuries and other forms of harm.

Most of the data on the English population's drinking patterns comes from the General Household Survey, the Health Survey for England and the Psychiatric Morbidity Survey (; ; ). In terms of hazardous drinking, in 2008, 21% of adult men were drinking between 22 and 50 units per week, and 15% of adult women were drinking between 15 and 35 units; a further 7% of men and 5% of women were harmful drinkers, drinking above 50 and 35 units per week, respectively. In addition, 21% of adult men and 14% of women met the government's criteria for binge drinking. There were regional variations in the prevalence of these drinking patterns. Hazardous drinking among men varied from 24% in the West Midlands to 32% in Yorkshire and Humber, and in women from 15% in the East of England to 25% in the North East. Harmful drinking in men varied from 5% in the East Midlands to 11% in Yorkshire and Humber, and in women from 2% in the East of England to 7% in Yorkshire and Humber. Binge drinking among men varied from 19% in the West Midlands to 29% in Yorkshire and Humber and among women from 11% in East of England to 21% in Yorkshire and Humber ().

There is a lack of reliable data on the prevalence of alcohol dependence because UK general-population surveys do not include questionnaires that provide an ICD–10 diagnosis of alcohol dependence (for example, the WHO Composite International Diagnostic Interview [CIDI]). Instead the most reliable estimate of alcohol dependence comes from the Psychiatric Morbidity Survey, which used a WHO measure of alcohol-use disorders: the Alcohol Use Disorders Identification Test (AUDIT; ). A score of 16 or more on this questionnaire is indicative of possible alcohol dependence (). The Alcohol Needs Assessment Research Project (ANARP) in England found the prevalence of alcohol dependence to be 4% in 16- to 64-year-old adults: 6% of men and 2% of women (). This equates to a population of 1.1 million people in England with alcohol dependence in 2000. This population increased to 1.6 million in 2007 (). There was considerable regional variation in the prevalence of alcohol dependence, from 2% in the East Midlands to 5% in the North West. The prevalence of hazardous and harmful drinking and dependence is highest in 16- to 24-year-olds and decreases steadily with age. Hazardous and harmful drinking is 1.6 times greater in the white population than in the black and minority ethnic population. However, alcohol dependence is approximately equally prevalent in these two populations (see on special populations).

Whilst the government and Royal Colleges' definitions of harmful drinking and risk levels of alcohol consumption provide useful benchmarks to estimate the prevalence of alcohol-use disorders in the general population and monitor trends over time, they have a number of limitations. This is particularly apparent when examining an individual's risk of alcohol-related harm at a given level of alcohol consumption.

According to WHO, alcohol is implicated as a risk factor in over 60 health disorders including high blood pressure, stroke, coronary heart disease, liver cirrhosis and various cancers. The extent to which these disorders are attributable to alcohol varies. This is known as the alcohol-attributable fraction (AAF). The AAF for alcoholic liver disease and alcohol poisoning is 1 (or 100% alcohol attributable) (). For other diseases such as cancer and heart disease the AAF is less than 1 (that is, partly attributable to alcohol) or 0 (that is, not attributable to alcohol). Further, the AAF varies with age and gender. Also, as noted earlier, the risk with increasing levels of alcohol consumption is different for different health disorders. Risk of a given level of alcohol consumption is also related to gender, body weight, nutritional status, concurrent use of a range of medications, mental health status, contextual factors and social deprivation, amongst other factors. Therefore it is impossible to define a level at which alcohol is universally without risk of harm.

2.3.2. Mental health

Alcohol is strongly associated with a wide range of mental health problems. Depression, anxiety, drug misuse, nicotine dependence and self-harm are commonly associated with excessive alcohol consumption. Up to 41% of suicides are attributable to alcohol and 23% of people who engage in deliberate self-harm are alcohol dependent (; ). Amongst adults admitted to inpatient mental health services, hazardous and harmful alcohol use increased the risk of a suicidal presentation by a factor of three, and alcohol dependence increased the risk by a factor of eight (). In the same study 49% of patients admitted were hazardous and harmful drinkers, including 53% of men and 44% of women, and 22% of the total population were alcohol dependent (). These prevalence rates are considerably higher than the general population, particularly in women.

A UK study found 26% of community mental health team patients were hazardous or harmful drinkers and 9% were alcohol dependent (). In the same study examining patients attending specialist alcohol treatment services, overall 85% had a psychiatric disorder in addition to alcohol dependence. Eighty-one per cent had an affective and/or anxiety disorder (severe depression, 34%; mild depression, 47%; anxiety, 32%), 53% had a personality disorder and 19% had a psychotic disorder.

2.3.3. Social problems

Alcohol is implicated in relationship breakdown, domestic violence and poor parenting, including child neglect and abuse. It is estimated that over 1 million children are affected by parental alcohol misuse and up to 60% of child protection cases involve alcohol (). Alcohol also contributes to unsafe sex and unplanned pregnancy, financial problems and homelessness. Up to half of homeless people are alcohol dependent ().

In terms of productivity, alcohol contributes to absenteeism, accidents in the workplace and decline in work performance. Up to 17 million working days are lost annually in the UK due to alcohol-related absences and 58,000 working years are lost annually due to premature deaths related to alcohol (). Alcohol misuse can also lead to job loss and over 38,000 people of working age in England were claiming Incapacity Benefit with a diagnosis of ‘alcoholism’ – nearly 2% of all claimants ().

2.3.4. Criminality

There were 986,000 violent incidents in England and Wales in 2009/10 where the victim believed the offender to be under the influence of alcohol, accounting for 50% of all violent crimes (). Nearly half of all offences of criminal damage are alcohol related and alcohol is implicated in domestic violence, sexual assaults, burglary, theft, robbery and murder (). In 2008, it was estimated that 13,020 reported road casualties (6% of all road casualties) occurred when someone was driving whilst over the legal alcohol limit. The provisional number of people estimated to have been killed in drink-driving accidents was 430 in 2008 (17% of all road fatalities) ().

Approximately two thirds of male prisoners and over one third of female prisoners are hazardous or harmful drinkers, and up to 70% of probation clients are hazardous or harmful drinkers ().

2.3.5. Public health impact

WHO has estimated the global burden of disease due to alcohol using AAFs, as described above, and found that alcohol accounts for 4% of all disease burden worldwide (). Alcohol is the third leading cause of disability in the developed world after smoking and hypertension. Using the same methodology, nearly 15,000 deaths in England are caused by alcohol per annum – 3% of all deaths (). Men had more than double the risk of alcohol attributable deaths compared with women, and deaths of 16- to 24–year-olds are 20 times more likely to be the result of alcohol compared with deaths of those aged 75 years and over (23% of all deaths in 16- to 24-year-olds), mostly due to acute effects of alcohol: intentional self-harm and road traffic accidents. In those over 35 years old, alcohol-related deaths are more commonly due to chronic physical illness from alcohol, for example alcoholic liver disease, malignant cancers of the oesophagus and breast, and hypertension.

The health consequences of alcohol, including deaths from alcoholic liver disease, have been increasing in the UK compared with a reduction in many other European countries (). Further, the age at which deaths from alcoholic liver disease occur has been falling in the UK, which is partly attributable to increasing alcohol consumption in young people ().

Alcohol-related hospital admissions increased by 85% between 2002/03 and 2008/09. For conditions directly attributable to alcohol, admissions increased by 81% between 2002/03 and 2008/09. In 2008/09, there were 945,000 hospital admissions in England where alcohol was either a primary or secondary diagnosis (). Alcohol related admissions increase steeply with age, peaking in the 60- to 64-year-old age group ().

Data on alcohol-related attendances at accident and emergency departments are not routinely collected nationally in England. However, a 24-hour weekend survey of 36 accident and emergency departments found that 40% of attendances were alcohol related and at peak times (midnight to 5 a.m. at weekends) this rises to 70% (). Harmful and dependent drinkers are much more likely to be frequent accident and emergency department attenders, attending on average five times per annum. Between 20 and 30% of medical admissions, and one third of primary care attendances, are alcohol related (; ; ). Further, people who are alcohol dependent are twice as likely as moderate drinkers to visit their general practitioner (GP) ().

2.4. AETIOLOGY

There is no single factor that accounts for the variation in individual risk of developing alcohol-use disorders. The evidence suggests that harmful alcohol use and alcohol dependence have a wide range of causal factors, some of which interact with each other to increase risk.

2.4.1. Family history

It is well established that alcohol dependence runs in families. In general, offspring of parents with alcohol dependence are four times more likely to develop alcohol dependence. Evidence from genetic studies, particularly those in twins, has clearly demonstrated a genetic component to the risk of alcohol dependence. A meta-analysis of 9,897 twin pairs from Australian and US studies found the heritability of alcohol dependence to be in excess of 50% (). However, a meta-analysis of 50 family, twin and adoption studies showed the heritability of alcohol misuse to be at most 30 to 36% (). Whatever the true heritability, these studies indicate that genetic factors may explain only part of the aetiology of alcohol dependence. The remaining variation is accounted for by environmental factors and their interaction with genetic factors. While no single gene for alcohol dependence has so far been identified, a range of genes that determine brain function have been implicated ().

2.4.2. Psychological factors

There is good evidence that a range of psychological factors contribute to the risk of developing alcohol-use disorders. Various learning theories have provided evidence of an important role of learning in alcohol dependence. Conditioning theories provide an explanation for the development of alcohol dependence. Alcohol, being a psychoactive drug, has reinforcing properties, for example through its pleasurable effects and its ability to relieve negative mood states such as anxiety. Conditioning can also explain why people become particularly sensitive to stimuli or cues associated with alcohol consumption, for example the sight and smell of a favourite drink, such that these cues can trigger craving for and continued use of alcohol, including relapse after a period of abstinence ().

Social learning theory also provides some explanations of increased risk of excessive drinking and the development of alcohol dependence. People can learn from families and peer groups through a process of modelling patterns of drinking and expectancies (beliefs) about the effects of alcohol. Teenagers with higher positive expectancies (for example, that drinking is pleasurable and desirable) are more likely to start drinking at an earlier age and to drink more heavily (; ).

2.4.3. Personality factors

The idea that a particular ‘addictive personality’ leads to the development of alcohol dependence is popular with some addiction counsellors, but does not have strong support from research. Often with patients in treatment for alcohol dependence, it is difficult to disentangle the effects of alcohol on the expression of personality and behaviour from those personality factors that preceded alcohol dependence. Nevertheless, people who are alcohol dependent have a 21-fold higher risk of also having antisocial personality disorder (ASPD; ), and people with ASPD have a higher risk of severe alcohol dependence (). Recent evidence points to the importance of disinhibition traits, such as novelty and sensation seeking, and poor impulse control, as factors related to increased risk of both alcohol and drug dependence, which may have a basis in abnormal brain function in the pre-frontal cortex (; ).

2.4.4. Psychiatric comorbidity

As noted earlier, people who are alcohol dependent have higher rates of comorbidity with other psychiatric disorders, particularly depression, anxiety, post-traumatic stress disorder (PTSD), psychosis and drug misuse, than people in the general population. Alcohol can, temporarily at least, reduce the symptoms of anxiety and depression, leading to the theory that alcohol use in this situation is a form of ‘self-medication’. This theory, however, lacks clear experimental support, and the longer-term effects of alcohol worsen these disorders.

2.4.5. Stress, adverse life events and abuse

There is clear evidence that adverse life events can trigger excessive drinking and may predispose to the development of alcohol dependence. This is particularly apparent in alcohol dependence developing later in life following, for example, a bereavement or job loss. Stressful life situations or events can also trigger heavy drinking. People who are alcohol dependent also report much higher levels of childhood abuse and neglect, particularly sexual abuse. One UK study found 54% of female and 24% of male alcohol dependent patients identified themselves as victims of sexual abuse, mostly before the age of 16 years (). Further, they were more likely to have a family history of alcohol misuse, and began drinking and developed alcohol dependence earlier than those without such a history.

2.4.6. Other environmental and cultural factors

There is a wide range of other environmental factors that predispose to the development of alcohol-use disorders (). These include the affordability and availability of alcohol, high consumption rates in the general population, occupational risk factors (such as working in the alcohol or hospitality industries), social pressure to drink, and religious- and culturally-related attitudes towards alcohol.

2.5. COURSE OF HARMFUL ALCOHOL USE AND DEPENDENCE

Harmful alcohol use and dependence are relatively uncommon before the age of 15 years, but increase steeply to reach a peak in the early 20s, this being the period when alcohol use-disorders are most likely to begin. One US general population study found the prevalence of alcohol dependence to be 2% in 12- to 17-year-olds, rising to 12% in 18- to 20–year-olds (). Thereafter, the prevalence of alcohol-use disorders declines steadily with age. The same US study found the prevalence of dependence was 4% in 30- to 34-year-olds and 1.5% in 50- to 54-year-olds. A similar UK study found the prevalence of alcohol dependence to be 6% in 16- to 19-year-olds, 8.2% in 20- to 24–year-olds, 3.6% in 30- to 34-year-olds and 2.3% in 50- to 54–year-olds (). Therefore, it is clear that there is substantial remission from alcohol-use disorders over time. Much of this remission takes place without contact with alcohol treatment services ().

However, it is also known that people who develop alcohol dependence at a younger age tend to have a more chronic course (). Further, while a large proportion of those who meet the criteria for alcohol dependence in their 20s will remit over the following two decades, those who remain alcohol dependent in their 40s will tend to have a more chronic course. This is the typical age group of people entering specialist alcohol treatment. Most studies examining the outcome of people attending alcohol treatment find that 70 to 80% will relapse in the year following treatment, with the highest rate of relapse taking place in the first 3 months after completing treatment (; ). Those who remain abstinent from alcohol for the first year after treatment have a relatively low risk of relapse thereafter (). Factors associated with a worse outcome include having less social stability and support (for example, those without jobs, families or stable housing), lacking a social network of non-drinkers, a family history of alcohol dependence, psychiatric comorbidity, multiple previous treatment episodes and history of disengagement from treatment.

In contrast with the relatively positive prognosis in younger people who are alcohol dependent in the general population, the longer term prognosis of alcohol dependence for people entering specialist treatment is comparatively poor. Over a 10-year period about one third have continuing alcohol problems, a third show some improvement and a third have a good outcome (either abstinence or moderate drinking) (). The mortality rate is high in this population, nearly four times the age-adjusted rate for people without alcohol dependence. Those who are more severely alcohol dependent are less likely to achieve lasting stable moderate drinking and have a higher mortality than those who are less dependent (). It is important to note that most of the excess mortality is largely accounted for by lung cancer and heart disease, which are strongly related to continued tobacco smoking.

2.6. PHARMACOLOGY OF ALCOHOL

Following ingestion, alcohol is rapidly absorbed by the gut and enters the bloodstream with a peak in blood alcohol concentration after 30 to 60 minutes. Alcohol is then distributed around every part of the body. It readily crosses the blood–brain barrier to enter the brain where it causes subjective or psychoactive and behavioural effects, and, following high levels of chronic alcohol intake, it can cause cognitive impairment and brain damage.

Alcohol is excreted in urine, sweat and breath, but the main method of elimination from the body is by metabolism in the liver where it is converted to acetaldehyde and acetate. These metabolites are then excreted from the body, primarily in urine. The rate at which alcohol is metabolised and the extent to which an individual is affected by a given dose of alcohol is highly variable from one individual to another. These individual differences affect drinking behaviour and the potential for alcohol-related harm and alcohol dependence. Also, the effects of alcohol vary in the same individual over time depending on several factors including whether food has been consumed, rate of drinking, nutritional status, environmental context and concurrent use of other psychoactive drugs. Therefore, it is very difficult to predict the effects of a given amount of alcohol both between individuals and within individuals over time. For instance, the impact on the liver varies clinically so that some experience liver failure early on in their drinking career, whilst in others drinking heavily liver function is relatively normal.

Alcohol is a toxic substance and its toxicity is related to the quantity and duration of alcohol consumption. It can have toxic effects on every organ in the body. In the brain, in a single drinking episode, increasing levels of alcohol lead initially to stimulation (experienced as pleasure), excitement and talkativeness. At increasing concentrations alcohol causes sedation leading to sensations of relaxation, then later to slurred speech, unsteadiness, loss of coordination, incontinence, coma and ultimately death through alcohol poisoning, due to the sedation of the vital brain functions on breathing and circulation.

The dependence-producing properties of alcohol have been studied extensively in the last 20 years. Alcohol affects a wide range of neurotransmitter systems in the brain, leading to the features of alcohol dependence. The main neurotransmitter systems affected by alcohol are gamma-aminobutyric acid (GABA), glutamate, dopamine and opioid (). The action of alcohol on GABA is similar to the effects of other sedatives such as benzodiazepines and is responsible for alcohol's sedating and anxiolytic properties (). Glutamate is a major neurotransmitter responsible for brain stimulation, and alcohol affects glutamate through its inhibitory action on N-methyl D-aspartate (NMDA)-type glutamate receptors, producing amnesia (for example, blackouts) and sedation ().

Chronic alcohol consumption leads to the development of tolerance through a process of neuroadaptation: receptors in the brain gradually adapt to the effects of alcohol, to compensate for stimulation or sedation. This is experienced by the individual as the same amount of alcohol having less effect over time. This can lead to an individual increasing alcohol consumption to achieve the desired psychoactive effects. The key neurotransmitters involved in tolerance are GABA and glutamate, with chronic alcohol intake associated with reduced GABA inhibitory function and increased NMDA-glutamatergic activity ( and ). This GABA–glutamate imbalance is acceptable in the presence of alcohol, which increases GABA and reduces NMDA-glutamate activity. However, when the alcohol-dependent individual stops drinking, the imbalance between these neurotransmitter systems results in the brain becoming overactive after a few hours leading to unpleasant withdrawal symptoms such as anxiety, sweating, craving, seizures and hallucinations. This can be life threatening in severe cases and requires urgent medical treatment. Repeated withdrawal is also thought to underlie the toxic effect of alcohol on neurons, leading to cognitive impairment and brain damage (). The effects of alcohol withdrawal can take up to between 3 months and 1 year to fully recover from (referred to as the protracted withdrawal syndrome). Even then, the brain remains abnormally sensitive to alcohol and, when drinking is resumed, tolerance and withdrawal can return within a few days (known as reinstatement) (). This makes it extremely difficult for a person who has developed alcohol dependence to return to sustained moderate drinking.

The brain's endogenous opioid system is also affected by alcohol (). Alcohol stimulates endogenous opioids, which are thought to be related to the pleasurable, reinforcing effects of alcohol. Opioids in turn stimulate the dopamine system in the brain, which is thought to be responsible for appetite for a range of appetitive behaviours including regulation of appetite for food, sex and psychoactive drugs. The dopamine system is also activated by stimulant drugs such as amphetamines and cocaine, and it is through this process that the individual seeks more drugs or alcohol (; ). There is evidence that drugs which block the opioid neurotransmitters, such as naltrexone, can reduce the reinforcing or pleasurable properties of alcohol and so reduce relapse in alcohol-dependent patients ().

2.7. IDENTIFICATION AND DIAGNOSIS

People with alcohol-use disorders commonly present to health, social and criminal justice agencies, often with problems associated with their alcohol use, but they less often seek help for the alcohol problem itself. Further, alcohol-use disorders are seldom identified by health and social care professionals. One recent study found that UK GPs routinely identify only a small proportion of people with alcohol-use disorders who present to primary care (less than 2% of hazardous or harmful drinkers and less than 5% of alcohol-dependent drinkers) (). This has important implications for the prevention and treatment of alcohol-use disorders. Failure to identify alcohol-use disorders means that many people do not get access to alcohol interventions until the problems are more chronic and difficult to treat. Further, failure to address an underlying alcohol problem may undermine the effectiveness of treatment for the presenting health problem (for example, depression or high blood pressure).

Screening and brief intervention delivered by a non-specialist practitioner is a cost-effective approach for hazardous and harmful drinkers (). However, for people who are alcohol dependent, brief interventions are less effective and referral to a specialist service is likely to be necessary (). It is important, therefore, that health and social care professionals are able to identify and appropriately refer harmful drinkers who do not respond to brief interventions, and those who are alcohol dependent, to appropriate specialist services. In acute hospitals, psychiatry liaison teams or specialist addiction liaison psychiatry staff can provide a useful in-reach service including the provision of staff training in alcohol identification and brief interventions, advice on management of alcohol withdrawal and referral to specialist alcohol services in the community (). Addiction psychiatrists also have an important role in liaison with general psychiatrists in the optimal management of people with alcohol and mental health comorbidity ().

Around one third of people presenting to specialist alcohol services in England are self-referred and approximately one third are referred by non-specialist health or social care professionals (). The majority of the remainder are referred by other specialist addiction services or criminal justice services. At the point of entry to treatment it is essential that patients are appropriately diagnosed and assessed in order to decide on the most appropriate treatment and management, assess the level of risk, such as self-harm and risk to others, and identify co-occurring problems that may need particular attention, for example psychiatric comorbidity, physical illness, problems with housing, vulnerability and pregnancy (). Therefore assessment should not be narrowly focused on alcohol consumption, but should include all areas of physical, psychological and social functioning.

Because alcohol dependence is associated with a higher level of problems and a more chronic course, and requires a higher level of medical and psychiatric intervention, it is essential that practitioners in specialist alcohol services are able to appropriately diagnose and assess alcohol dependence.

2.8. THE ROLE OF TREATMENT AND MANAGEMENT

As noted above, many people will recover from alcohol-use disorders without specialist treatment and many will reduce their alcohol intake following a change in circumstances, such as parenthood, marriage or taking on a responsible job. Hazardous and harmful drinkers may respond to a brief intervention provided in primary care without requiring access to specialist treatment (). For others, their alcohol problems are overcome with the help of a mutual aid organisation, such as Alcoholics Anonymous (AA; see ). Nevertheless, many will require access to specialist treatment by virtue of having more severe or chronic alcohol problems, or a higher level of complications of their drinking (for example, social isolation, psychiatric comorbidity and severe alcohol withdrawal).

The primary role of specialist treatment is to assist the individual to reduce or stop drinking alcohol in a safe manner (). At the initial stages of engagement with specialist services, service users may be ambivalent about changing their drinking behaviour or dealing with their problems. At this stage, work on enhancing the service user's motivation towards making changes and engagement with treatment will be particularly important.

For most people who are alcohol dependent the most appropriate goal in terms of alcohol consumption should be to aim for complete abstinence. With an increasing level of alcohol dependence a return to moderate or ‘controlled’ drinking becomes increasingly difficult (; ). Further, for people with significant psychiatric or physical comorbidity (for example, depressive disorder or alcoholic liver disease), abstinence is the appropriate goal. However, hazardous and harmful drinkers, and those with a low level of alcohol dependence, may be able to achieve a goal of moderate alcohol consumption (). Where a client has a goal of moderation but the clinician believes there are considerable risks in doing so, the clinician should provide strong advice that abstinence is most appropriate but should not deny the client treatment if the advice is unheeded ().

For people who are alcohol dependent, the next stage of treatment may require medically-assisted alcohol withdrawal, if necessary with medication to control the symptoms and complications of withdrawal. For people with severe alcohol dependence and/or significant physical or psychiatric comorbidity, this may require assisted alcohol withdrawal in an inpatient or residential setting, such as a specialist NHS inpatient addiction treatment unit (). For the majority, however, alcohol withdrawal can be managed in the community either as part of shared care with the patient's GP or in an outpatient or home-based assisted alcohol withdrawal programme, with appropriate professional and family support (). Treatment of alcohol withdrawal is, however, only the beginning of rehabilitation and, for many, a necessary precursor to a longer-term treatment process. Withdrawal management should therefore not be seen as a standalone treatment.

People who are alcohol dependent and who have recently stopped drinking are vulnerable to relapse, and often have many unresolved co-occurring problems that predispose to relapse (for example, psychiatric comorbidity and social problems) (). In this phase, the primary role of treatment is the prevention of relapse. This should include interventions aimed primarily at the drinking behaviour, including psychosocial and pharmacological interventions, and interventions aimed at dealing with co-occurring problems. Interventions aimed at preventing relapse include individual therapy (for example, motivational enhancement therapy [MET], cognitive behavioural therapy [CBT]), group and family based therapies, community-based and residential rehabilitation programmes, medications to attenuate drinking or promote abstinence (for example, naltrexone, acamprosate or disulfiram) and interventions promoting social support and integration (for example, social behaviour and network therapy [SBNT] or 12-step facilitation [TSF]) ().

Although psychiatric comorbidity is common in people seeking help for alcohol-use disorders, this will usually resolve within a few weeks of abstinence from alcohol without formal psychiatric intervention (). However, a proportion of people with psychiatric comorbidity, usually those in whom the mental disorder preceded alcohol dependence, will require psychosocial or pharmacological interventions specifically for the comorbidity following assisted withdrawal. Self-harm and suicide are relatively common in people who are alcohol dependent (). Therefore, treatment staff need to be trained to identify, monitor and if necessary treat or refer to an appropriate mental health specialist those patients with comorbidity which persists beyond the withdrawal period, and/or are at risk of self-harm or suicide. Patients with complex psychological issues related to trauma, sexual abuse or bereavement will require specific interventions delivered by appropriately trained personnel ().

Often, people who are alcohol dependent (particularly in the immediate post-withdrawal period) find it difficult to cope with typical life challenges such as managing their finances or dealing with relationships. They will therefore require additional support directed at these areas of social functioning. Specific social problems such as homelessness, isolation, marital breakdown, child care issues including parenting problems, child abuse and neglect will require referral to, and liaison with, appropriate social care services (). A proportion of service users entering specialist treatment are involved with the criminal justice system and some may be entering treatment as a condition of a court order. Therefore, appropriate liaison with criminal justice services is essential for this group.

People who are alcohol dependent are often unable to take care of their health during drinking periods and are at high risk of developing a wide range of health problems because of their drinking (). Treatment staff therefore need to be able to identify and assess physical health consequences of alcohol use, and refer patients to appropriate medical services.

In the later stages of treatment, the focus will be more on reintegration into society and restoration of normal function, including establishing a healthy lifestyle, finding stable housing, re-entering employment, re-establishing contact with their families, and forming appropriate and fulfilling relationships (). All of these factors are important in promoting longer term stable recovery.

2.9. CURRENT CARE IN THE NATIONAL HEALTH SERVICE

A recent alcohol needs assessment in England identified nearly 700 agencies providing specialist alcohol treatment, with an estimated workforce of 4,250 and an annual spend of between £186 million and £217 million (; ). The majority of agencies (70%) were community based and the remainder were residential, including inpatient units in the NHS, and residential rehabilitation programmes mainly provided by the non-statutory or private sector. Overall, approximately half of all alcohol services are provided by the non-statutory sector but are typically funded by the NHS or local authorities. Approximately one third of specialist alcohol services exclusively provide treatment for people with alcohol problems, but the majority (58%) provide services for both drug and alcohol misuse.

In terms of services provided by community specialist agencies, the majority (63%) provide structured psychological interventions either on an individual basis or as part of a structured community programme (). There is considerable variation in the availability and access to specialist alcohol services both in community settings and in inpatient settings where provision of specialist psychiatric liaison services with responsibility for alcohol misuse is also very variable. Only 30% provide some form of assisted alcohol-withdrawal programme, and less than 20% provide medications for relapse prevention. Of the residential programmes, 45% provide inpatient medically-assisted alcohol withdrawal and 60% provide residential rehabilitation with some overlap between the two treatment modalities. The alcohol withdrawal programmes are typically of 2 to 3 weeks duration and the rehabilitation programmes are typically of 3 to 6 months duration.

It is estimated that approximately 63,000 people entered specialist treatment for alcohol-use disorders in 2003–04 (). The recently established National Alcohol Treatment Monitoring System (NATMS) reported 104,000 people entering 1,464 agencies in 2008–09, of whom 70,000 were new presentations (). However, it is not possible to identify what proportion of services is being provided by primary care under the enhanced care provision as opposed to specialist alcohol agencies.

The 2004 ANARP found that only one out of 18 people who were alcohol dependent in the general population accessed treatment per annum. Access varied considerably from one in 12 in the North West to one in 102 in the North East of England ().

Although not directly comparable because of different methodology, a low level of access to treatment is regarded as one in ten (). A recent Scottish national alcohol needs-assessment using the same methods as ANARP found treatment access to be higher than in England, with one in 12 accessing treatment per annum. This level of access may have improved in England since 2004 based on the NATMS data. However, the reported that the spending on specialist alcohol services by Primary Care Trusts was not based on a clear understanding of the level of need in different parts of England. There is therefore some further progress needed to make alcohol treatment accessible throughout England.

2.10. SERVICE USER ORGANISATIONS

There are several organisations available in England to provide mutual aid for service users and their families. The largest and longest established such organisation is Alcoholics Anonymous. Founded in the US in the 1930s, AA is based on a ‘12-step’ programme, and the ‘12 traditions’ of AA. The programme includes acceptance that one is powerless over alcohol, acceptance of the role of a higher power and the role of the support of other members. AA is self-financing and the seventh tradition is that AA groups should decline outside contributions. In 2010, AA membership worldwide was reported as nearly 2 million (). While AA might not suit all people who misuse alcohol, its advantages include its wide availability and open access.

Allied to AA are Al-anon and Alateen, jointly known as Al-anon Family Groups. Al-anon uses the same 12 steps as AA with some modifications and is focused on meeting the needs of friends and family members of alcoholics. Again, meetings are widely available and provide helpful support beyond what can be provided by specialist treatment services.

Another organisation developing England is Self-Management and Recovery Training (SMART). Its development is being supported by Alcohol Concern, a leading UK alcohol charity, and the Department of Health. SMART is another mutual aid organisation but is based more on cognitive behavioural principles and provides an alternative or adjunct to AA.

2.11. IMPACT ON FAMILIES

The adverse effects of alcohol dependence on family members are considerable. Marriages where one or both partners have an alcohol problem are twice as likely to end in divorce as those in which alcohol is not a problem. Nearly a million children live with one or more parents who misuse alcohol and 6% of adults report having grown up in such a family. Alcohol is implicated in a high proportion of cases of child neglect and abuse, and heavy drinking was identified as a factor in 50% of child protection cases ().

Partners of people with harmful alcohol use and dependence experience higher rates of domestic violence than where alcohol misuse is not a feature. Some 70% of men who assault their partners do so under the influence of alcohol (). Family members of people who are alcohol dependent have high rates of psychiatric morbidity, and growing up with someone who misuses alcohol increases the likelihood of teenagers taking up alcohol early and developing alcohol problems themselves ().

All of this points to the importance of addressing the needs of family members of people who misuse alcohol. This includes the need for specialist treatment services to assess the impact of the individual's drinking on family members and the need to ensure the safety of children living with people who misuse alcohol.

2.12. SPECIAL POPULATIONS

There are several special populations which require separate consideration because they have particular needs that are often not well met by mainstream services, or require particular considerations in commissioning or delivering care, or who require modification of general treatment guidelines. This section provides an overview of the issues for each special population. Specific guidance applying to special populations will be referred to in the appropriate section in subsequent chapters.

2.12.1. Children and young people

While drinking and alcohol-use disorders are relatively rare under the age of 10 years, the prevalence increases steeply from the teens to peak in the early 20s. The UK has the highest rate of underage drinking in Western Europe (). This is of particular concern because alcohol presents particularly serious consequences in young people due to a higher level of vulnerability to the adverse effects of alcohol. Heavy drinking in adolescence can affect brain development and has a higher risk of organ damage in the developing body ().

The number of adolescents consuming alcohol has shown a reduction from 60 to 65% between 1988 and 1998 to 54% in 2007, but the amount consumed by those drinking doubled over the same period to 12.7 units per week (). Regular alcohol consumption in adolescence is associated with increased accidents, risky behaviour (including unprotected sex, antisocial behaviour and violence) and decreased family, social and educational functioning. There is evidence of an association between hazardous alcohol consumption in adolescence and increased level of alcohol dependence in early and later adulthood (). For example, alcohol consumption before the age of 13 years is associated with a four-fold increased risk of alcohol dependence in adulthood. Adolescents with early signs of alcohol misuse who are not seeking treatment are a critical group to target interventions towards. Adolescent alcohol-related attendances at accident and emergency departments saw a tenfold increase in the UK since 1990 and a recent audit estimates that 65,000 alcohol-related adolescent attendances occur annually.

Comorbid psychiatric disorders are considered to be ‘the rule, not the exception’ for young people with alcohol-use disorders (). Data from the US National Comorbidity study demonstrated that the majority of lifetime disorders in their sample were comorbid disorders (). This common occurrence of alcohol-use disorders and other substance-use disorders along with other psychiatric disorders notes the importance of a comprehensive assessment and management of all disorders. Disruptive behaviour disorders are the most common comorbid psychiatric disorders among young people with substance-use disorders. Those with conduct disorder and substance-use disorders are more difficult to treat, have a higher treatment dropout rate and have a worse prognosis. This strong association between conduct disorder and substance-use disorders is considered to be reciprocal, with each exacerbating the expression of the other. Conduct disorder usually precedes or coincides with the onset of substance-use disorders, with conduct disorder severity found to predict substance-use severity. Significantly higher rates of attention deficit hyperactivity disorder (ADHD) have been reported in young people with substance-use disorders; data from untreated adults with ADHD indicate a higher risk of developing substance-use disorders and at an earlier age compared with treated controls as well as a more prolonged course of substance-use disorders. However, those young people with ADHD and co-occurring conduct or bipolar disorders are at highest risk of development of substance-use disorders.

High rates of depression and anxiety have been reported in adolescents with alcohol-use disorders, with increased rates of suicidality. Among clinical populations for alcohol-use disorders there was an increased rate of anxiety symptoms and disorder, PTSD and social phobias ( and ). For young people the presentation may be different because dependence is not common, with binge drinking being the pattern seen more often, frequently alongside polydrug use. Criminality and offending behaviour are often closely related to alcohol misuse in children and adolescents. Liaison with criminal justice services is necessary to ensure that appropriate co-ordination of care and effective communication and information-sharing protocols are in place.

In addition to the problems presented by comorbid disorders, the concept of dependence and criteria for diagnosis (DSM–IV or ICD–10) has limitations when applied to adolescents because of the low prevalence of withdrawal symptoms and the low specificity of tolerance in this age group (). The adolescent therefore may continue drinking despite problems, which manifest as difficulties with school attendance, co-morbid behavioural difficulties, peer affiliation and arguments at home.

As has been noted previously, relationships with parents, carers and the children in their care are often damaged by alcohol misuse (). The prevalence of alcohol-use disorders in the victims and perpetrators of domestic violence provides an important rationale for the exploration of these issues. Sexual abuse has been found to be prevalent in alcohol dependent drinkers seeking treatment and may be a particular concern with young people with alcohol misuse problems (). For young people, both their own alcohol misuse and that of their parents or carers may be a safeguarding concern. The Children Act 2004 places a statutory duty on services providing assessments to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. Services that are involved with those who misuse alcohol fit into a wider context of safeguarding young people from harm and need to work to ensure that the rights of children, young people and their parents are respected. Local protocols between alcohol treatment services and local safeguarding and family services determine the specific actions to be taken ().

2.12.2. Current service provision for children and young people

In the UK, most treatment is community based and provided as part of a range of services and models. These can be services provided by child and adolescent mental health services (CAMHS) in Tier 2 and Tier 3 services, specific CAMHS addiction services and other commissioned specialist services that are formed by a range of practitioners (generally Tier 2 and Tier 3 collaborating from the youth offending teams, looked-after teams and voluntary sector). Much of the focus is on engagement, health promotion and retention in services. In addition, in the UK, services that offer treatment tend to prioritise drug misuse such as opiate or cannabis misuse and not alcohol. Given the comorbidity noted above, many adolescents having treatment for alcohol-use disorders are often seen in specialist services, such as Youth Offending Teams, or specialist services for young people with conduct disorders, such as the newly-developed multisystemic therapy teams (), although identification and treatment of their dependence and/or harmful use may not be fully explored. In the US, adolescents with substance-use disorders receive treatment in a variety of settings including community, residential and criminal justice settings, and home-based treatment. However, there is little research evaluating the differences between these settings. As a consequence there is little clear evidence to determine the most appropriate treatment environments. The recommend that factors affecting the choice of setting should include: the need to provide a safe environment; motivation of the adolescent and his/her family to cooperate with treatment; the need for structure and limit-setting; the presence of additional medical or psychiatric conditions and the associated risks; the availability of specific types of treatment settings for adolescents; preferences for treatment in a particular setting; and treatment failure in a less restrictive/intensive setting in the past.

2.12.3. Older people

The prevalence of alcohol-use disorders declines with increasing age, but the rate of detection by health professionals may be underestimated in older people because of a lack of clinical suspicion or misdiagnosis (). Nevertheless, the proportion of older people drinking above the government's recommended levels has recently been increasing in the UK. The proportion of men aged 65 to 74 years who drank more than four units per day in the past week increased from 18 to 30% between 1998 and 2008 (). In women of the same age, the increase in drinking more than three units per day was from 6 to 14%. Also, as noted earlier, alcohol-related admissions to hospital increase steeply with age although the prevalence of heavy drinking is lower in this group. This may partly reflect the cumulative effects of lifetime alcohol consumption as well as the general increasing risk of hospital admission with advancing age.

Further, it is important to note that due to age-related changes in metabolism, intercurrent ill health, changing life circumstances and interactions with medications, sensible drinking guidelines for younger adults may not be applicable to older people (). Equivalent levels of alcohol consumption will give rise to a higher blood alcohol concentration in older people compared with younger people (). The US National Institute of Alcohol Abuse and Alcoholism (NIAAA) has therefore recommended people over the age of 65 years should drink no more than one drink (1.5 UK units) per day and no more than seven drinks (10.5 UK units) per week. There are no similar recommendations for older people in the UK. A related issue is that standard alcohol screening tools such as the AUDIT may require a lower threshold to be applied in older people ().

Older people are at least as likely as younger people to benefit from alcohol treatment (). Clinicians therefore need to be vigilant to identify and treat older people who misuse alcohol. As older people are more likely to have comorbid physical and mental health problems and be socially isolated, a lower threshold for admission for assisted alcohol withdrawal may be required (). Further, in view of changes in metabolism, potential drug interactions and physical comorbidity, dosages for medications to treat alcohol withdrawal and prevent relapse may need to be reduced in older people (). These issues are dealt with in more detail in the relevant chapters.

2.12.4. Homeless people

There is a high prevalence of alcohol misuse (as well as mental and physical health, and social problems) amongst people who are homeless. The prevalence of alcohol-use disorders in this population has been reported to be between 38 and 50% in the UK (; ). In the US, studies of this population typically report prevalence rates of 20 to 45%, depending on sampling methods and definitions ().

Homeless people who misuse alcohol have particular difficulties in engaging mainstream alcohol services, often due to difficulties in attending planned appointments.

Homelessness is associated with a poorer clinical outcome, although this may also be due to the higher levels of comorbidity and social isolation in this population rather than the homelessness per se. Hence services need to be tailored to maximise engagement with this population.

This has led to the development of specific alcohol services for homeless drinkers, including assertive outreach and ‘wet’ hostels. In wet hostels, residents are able to continue drinking, but do so in an environment that aims to minimise the harm associated with drinking and address other issues including homelessness (; ). Such hostels tend to be located in urban centres where there is a higher concentration of homeless drinkers. Assertive outreach and ‘crisis’ centres have been developed to attract homeless people who misuse alcohol into treatment (). Further, a lower threshold for admission for assisted alcohol withdrawal and residential rehabilitation will often be required with this population.

2.12.5. People from ethnic minority groups

It is often asserted that people from ethnic minority groups are under-represented in specialist alcohol treatment services (). The reality is that the situation is likely to be more complex and depends on which specific ethnic group and the prevalence of alcohol misuse in that group (). Based on the Psychiatric Morbidity Survey, the ANARP study found that people from ethnic minority groups as a whole had a lower prevalence of hazardous and harmful drinking compared with the white population (ratio of 1:1.7) whereas alcohol dependence was approximately equal in prevalence (ratio of 1:1.1) (). However this study was unable to compare different ethnic minority groups. Nevertheless, because people from ethnic minority groups have approximately the same prevalence of alcohol dependence as the white population, if access to treatment is equal one would expect the population in treatment to have approximately the same proportion of people for ethnic minorities. The ethnic minority population in England was 13% in the 2001 census. The NATMS found that in 2008–09 the proportion of people from ethnic minorities with alcohol dependence is 9%, suggesting some under-representation (). However, it is not clear what proportion of NATMS attenders were hazardous/harmful or dependent drinkers, which may account for the difference in proportions.

found that cirrhosis mortality rates are higher than the national average for men from the Asian subcontinent and Ireland, but lower than average for men of African–Caribbean origin. Cirrhosis mortality was lower in Asian and African–Caribbean women but higher in Irish women. However, because there were few total deaths in ethnic minority groups this may lead to large errors in estimating prevalence in this population. Studies in England have tended to find over-representation of Indian-, Scottish- and Irish-born people and under-representation in those of African–Caribbean or Pakistani origin (). This may partly be due to differences in prevalence rates of alcohol misuse, but differences in culturally-related beliefs and help-seeking as well as availability of interpreters or treatment personnel from appropriate ethnic minority groups may also account for some of these differences (). There are relatively few specific specialist alcohol services for people from ethnic minority groups, although some examples of good practice exist ().

2.12.6. Women

identified three main factors that may account for a historical under-representation of women in specialist alcohol services. Women tend to perceive their problems differently from men, with a greater tendency not to identify themselves as ‘alcoholic’. They are more likely to experience stigma in relation to their drinking than men and have concerns about their children being taken into care. Also, women regard the services as less suited to their needs than men do. Few services tend to provide childcare facilities or women-only services. Nevertheless, more women are now accessing treatment. The ANARP study found that, taking account of the lower prevalence of alcohol dependence in women compared with men (ratio of 1:3), they were 1.6 times more likely to access treatment (). Women are also more likely to seek help for alcohol misuse than men in the US (). This may indicate that some of the barriers identified by may have been overcome. However, services need to be sensitive to the particular needs of women. There is also a need to develop services for pregnant women. This is the subject of a separate NICE guideline on complex pregnancies ().

2.13. ECONOMIC IMPACT

Alcohol misuse and the related problems present a considerable cost to society. Estimates of the economic costs attempt to assess in monetary terms the damage that results from the misuse of alcohol. These costs include expenditures on alcohol-related problems and opportunities that are lost because of alcohol ().

Many challenges exist in estimating the costs required for cost-of-illness studies in health; there are two such challenges that are particularly relevant to alcohol misuse. First, researchers attempt to identify costs that are caused by and not merely associated with alcohol misuse, yet it is often hard to establish causation (; ). Second, many costs resulting from alcohol misuse cannot be measured directly. This is especially true of costs that involve placing a value on lost productivity. Researchers use mathematical and statistical methods to estimate such costs, yet recognise that this is imprecise. Moreover, costs of pain and suffering of both people who misuse alcohol and people affected by them cannot be estimated in a reliable way, and are therefore not considered in most cost studies. These challenges highlight the fact that although the economic cost of alcohol misuse can be estimated, it cannot be measured precisely. Nevertheless, estimates of the cost provide an idea of the dimensions of the problem and the breakdown of costs suggests which categories are most costly ().

The first category of costs is that of treating the medical consequences of alcohol misuse and treating alcohol misuse. The second category of health-related costs includes losses in productivity by workers who misuse alcohol. The third category of health-related costs is the loss to society because of premature deaths due to alcohol misuse. In addition to the health-related costs of alcohol misuse are costs involving the criminal justice system, social care, property losses from alcohol-related motor vehicle crashes and fires, and lost productivity of the victims of alcohol-related crime and individuals imprisoned as a consequence of alcohol-related crime ().

The UK Cabinet Office recently estimated that the cost of alcohol to society was £25.1 billion per annum (). A recent report by the Department of Health estimated an annual cost of £2.7 billion attributable to alcohol harm to the NHS in England (). Hospital inpatient and day visits accounted for 44% of these total costs, whilst accident and emergency department visits and ambulance services accounted for 38%. However, crime and disorder costs amount to £7.3 billion per annum, including costs for policing, drink driving, courts and the criminal justice system, and costs to services both in anticipation and in dealing with the consequences of alcohol-related crime (). The estimated costs in the workplace amount to some £6.4 billion through lost productivity, absenteeism, alcohol-related sickness and premature deaths ().

For the European Union, the US and Canada, social costs of alcohol were estimated to be around €270 billion (2003 prices; ), US$185 billion (1998 prices; ), and CA$14.6 billion (2002 prices; ), respectively.

1

Several terms including ‘alcoholism’, ‘alcohol addiction’, ‘alcohol abuse’ and ‘problem drinking’ have been used in the past to describe disorders related to alcohol consumption. However, ‘alcohol dependence’ and ‘harmful alcohol use’ are used throughout this guideline to be consistent with WHO's International Classification of Mental Disorders, 10th Revision ().

2

Defined as scoring 8 or more on the Alcohol Use Disorders Identification Test (AUDIT).

3

Defined as scoring 16 or more on the AUDIT.

4

The UK unit definition differs from definitions of standard drinks in some other countries. For example, a UK unit contains two thirds of the quantity of ethanol that a US ‘standard drink’ has.

Which of the following is true with respect to global health and alcohol use?

What are the true effects of alcohol?

What is the present status of alcohol use?

What percentage of the world's population suffers from an alcohol addiction *?