barcelona . spain - European Association for the Study of the Liver

BARCELONA . SPAIN
76 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 77
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012
ABUSE OR DEPENDENCE ASSESSING THE ALCOHOLIC
PATIENT IN THE CLINIC
Antoni Gual
Barcelona, Spain
E-mail: TGUAL@clinic.ub.es
KEY POINTS
• Alcohol is the most dangerous drug when self inflicted harm and harm to others are considered,
and is the second top risk factor for health in developed countries.
• Europe is the region of the world with the highest alcohol consumption.
• Hazardous and harmful drinking are defined taking the amounts drunk into account, and people
experiencing alcohol related harm do not need to be alcoholics.
• The new DSM V (to be released May 2013), will probably combine Abuse and Dependence in a
single entity called alcohol use disorders (AUD) of graded severity.
• The criteria that define AUD cover four different areas: biological processes, medical harm,
behaviour and social & relational aspects. All of them must be assessed carefully in alcoholic
patients.
• The assessment of AUD must be done in an empathic non judgmental attitude, and must include
a careful examination of drinking patterns, and an evaluation of the bio-medical, behavioural
and social consequences of AUD.
INTRODUCTION
According to recent studies (Nutt, 2010), alcohol is the most dangerous drug when self inflicted harm and
harm to others are considered. Despite this evidence, Europe continues to be the region of the world with
highest alcohol consumption. The World Health Organization (WHO) places alcohol as the second top risk
factor for health in developed countries. 9 % of the disability adjusted life years in Europe are attributable
to alcohol.
Figure 1
There is general agreement in the scientific community that the magnitude of the problems created by
alcoholic beverages to society deserves a public health approach. From the medical point of view, alcohol
is related to no less than sixty diseases, and it is wll known from ancient times that the liver is one of the
most vulnerable targets.
DEFINING HAZARDOUS & HARMFUL DRINKING
Most of the people who drink alcoholic beverages do it at very low risk levels, but a relevant percentage of
the drinkers may be at risk or experience problems because of their drinking. According to WHO hazardous
drinkers are defined as those whose level of consumption or pattern of drinking is likely to result in harm
should present drinking habits persist (Babor et al. 1994). There is no standardized agreement for the
level of alcohol consumption that should be taken for hazardous drinking, and for many conditions any
level of alcohol consumption can carry risk. A working definition of the WHO describes it as a regular
average consumption of 20g-40g of alcohol a day for women and 40g 60g a day for men (Rehm et al. 2004).
Harmful drinking is defined as .a pattern of drinking that causes damage to health, either physical (such
as liver cirrhosis) or mental. Based on the epidemiological data relating alcohol consumption to harm the
WHO defines operatively harmful alcohol consumption as a regular average consumption of more than 40g
alcohol a day for women and more than 60g a day for men (Rehm et al 2004). Episodic heavy drinking is
defined as a drinking occasion that includes consumption of at least 60g of alcohol, and it is considered a
form of hazardous drinking that quite often leads to harm.
Hazardous and harmful drinking are defined taking the amounts drunk into account, and people experiencing
alcohol related harm do not need to be alcoholics. The American Psychiatric Association (APA) uses the
term Alcohol Abuse, which is often used as a synonimous of hazardous and harmful drinking.
DIAGNOSING ALCOHOL DEPENDENCE
The diagnosis of alcohol abuse is mostly based on the amounts drunk and in the presence of harm. Instead,
alcohol dependence is defined takiing into account the drinking patterns of the patient and the type of
relationship the patient has stablished with alcohol. The presence of tolerance, withdrawal signs and the
salience of drinking behaviour over other priorities (family, work, health) are key to stablish a diagnosis.
Both the APA and the WHO have set very similar criteria to diagnose alcohol dependence (Figure 2), and
in both cases the presence of 3 or more criteria during the last 12 months is taken as cut-off to stablish the
diagnosis.
As it can be seen in Figure 1 the criteria used by WHO and APA are pretty similar, and so it is quite likely
that the new versions of ICD and DSM will merge in a common definition.
Figure 2