Alcohol misuse - A case study
Mary comes into the pharmacy with her two young daughters, to pick up her insulin. She says she has had to start collecting the children from school. Her husband Rob usually fetches them but, last week, a neighbour told Mary that she had seen the children walking home by themselves. Mary says that she suspects Rob is drinking too much. He has always enjoyed a pint but, during the past year, it has become more than that. Sometimes Rob smells of drink when she gets in from work and he often fails to do things he has promised to do. She had put it down to depression because Rob is out of work but now she is really beginning to wonder.
What are the possible symptoms of alcohol misuse?
A person with an alcohol problem may smell of drink and have puffy, blood-shot eyes and a florid complexion, but this is not always the case. A wide range of physical and psychological symptoms can indicate alcohol misuse, including irritability, mood swings, anxiety, insomnia, poor memory or concentration, accidents or injuries and evidence of self-neglect. Social indicators include missed appointments, problems at work (eg, absenteeism and declining work standards) and unemployment. Financial difficulties are also common. Marital problems, domestic violence, child abuse or behavioural disturbance in children are also indicators of alcohol misuse, and partners and children may suffer from depression or anxiety associated with living with a problem drinker. Many of these symptoms, however, are not specific to alcohol and can indicate other conditions. Alcohol misuse is therefore difficult to diagnose, although blood tests can identify heavy drinkers. Despite the uncertainties, pharmacists should be aware of symptoms that could point to alcohol misuse to help ensure it is not overlooked.
What are the sensible limits for alcohol intake?
One unit of alcohol is 8g or 10ml of pure alcohol. Sensible limits for alcohol consumption are that men should not drink more than three to four units of alcohol per day and women should drink no more than two to three units per day. These daily limits apply whether people drink every day or occasionally. A recent MORI poll showed that only 7 per cent of men and 22 per cent of women know the recommended alcohol allowance and binge drinking has been blamed for a large increase in deaths from cirrhosis in the United Kingdom. Women who are pregnant or are trying to conceive should drink no more than one or two units a week, but preferably none. Panel 1 shows the number of units of alcohol in some common drinks.
The World Health Organization (WHO) guidelines (adapted for the UK)1 identify “harmful alcohol use” and dependence as diagnostic features of alcohol misuse. Harmful alcohol use is defined as an intake of over 28 units of alcohol per week for men and over 21 units a week for women or situations where using alcohol has led to physical harm, psychological harm or harmful social consequences (eg, loss of job). Alcohol dependence exists when three or more of the following are present: a strong desire or compunction to consume alcohol, difficulty controlling alcohol consumption, withdrawal symptoms when drinking is stopped, tolerance to large amounts of alcohol and continued consumption despite harmful consequences.
How is alcohol metabolised?
Alcohol is rapidly absorbed from the gastrointestinal tract, mainly from the stomach (20 per cent) and small intestine (80 per cent). It is converted, principally by oxidation, to acetaldehyde. This reaction is catalysed by the enzyme alcohol dehydrogenase. However, some alcohol is metabolised to acetaldehyde by cytochrome P450 in the liver. Acetaldehyde is then converted to acetate (mainly in the liver mitochondria), which is released into the blood and oxidised by peripheral tissues to carbon dioxide, fatty acids and water.
Generally, for equivalent consumption of alcohol, men achieve lower blood-alcohol concentrations than women. This difference is thought to be due to the lower proportion of body fat and the higher proportion of body water in men compared with women. Alcohol is water-soluble and a higher volume of water increases the volume of distribution of alcohol, resulting in lower blood levels. However, following intravenous administration, both men and women achieve similar blood-alcohol levels, indicating that other mechanisms may contribute to the differences in bioavailability after oral intake. For example, some alcohol is metabolised in the gastric mucosa and gastric metabolism occurs more readily in men than in women. Women may attain particularly high blood-alcohol levels (and therefore be more vulnerable to the effects of alcohol) at the time of ovulation or just before menstruation.
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Citation: The Pharmaceutical Journal URI: 10989284
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