In the first of a new series on addiction, journalist John Windell looks at alcohol dependency, its symptoms, how to get treatment, and what you can do to help.
During her speech for Addiction Awareness Week last October to launch the Forward Trust’s new campaign on substance dependency, Kate Middleton, Duchess of Cambridge, warned: ‘No one chooses to become an addict. It can happen to any of us; none of us are immune.’
Addiction, or dependency, describes the condition of people who have no physical or psychological control when consuming a substance or pursuing certain activities, to the extent that it can cause harm.
The most recent estimates put the number of alcohol-dependent adults in England at just over 600,000, or 13.7 people for every 1000 (Public Health England, 2021). The highest prevalence rates are in the north of England, with a peak of 35 per 1000 in Blackpool. This contrasts with the lowest rate of six per 1000 in Wokingham in Berkshire (Office for Health Improvement and Disparities, 2021).
Excessive alcohol use is linked to a wide range of physical and mental health conditions, such as liver disease, cardiovascular disease, cancers, depression and dementia. It can have a long-term social impact, leading to domestic abuse, unemployment, financial problems and family break-up. It is also linked to accidents and injuries, antisocial behaviour and violence, and homelessness.
Dependency spectrum
As with any chronic condition that can affect a person in so many ways, it’s best to try to diagnose and treat it sooner rather than later. But how do you spot somebody who may have become dependent on alcohol?
‘It can present in a multiplicity of ways,’ says Dr Mike Kelleher, consultant addictions psychiatrist at the South London and Maudsley NHS Trust. ‘But if you’re looking for little telltale signs, it can be as simple as empty bottles and cans around the house, maybe falls and accidents, or frequent unexplained trips to hospital.’
He adds that the physical and mental effects are also clear signs that something may be wrong. ‘It’s worth keeping in mind those deteriorations in mental health and the worsening physical health conditions that we associate with excessive alcohol use. Prolonged alcohol use can cause a large number of chronic conditions, including gastrointestinal, cardiovascular and liver disease. Beyond that there may be social aspects, such as regular interface problems with neighbours, and problems with the police.’
Piers Henriques, spokesperson for the National Association for Children of Alcoholics (NACOA), agrees that there is a spectrum of dependency and that it is open to interpretation.
‘Ultimately, you might want to classify someone once they hit a certain criteria,’ he says. ‘But for me it’s when the habits that people have been falling into become a problem, not just for themselves but also for their families. It starts to impinge on their ability to be a responsible person.’
‘Alcohol doesn’t discriminate. It permeates all sections of society, because it is so embedded in our culture’
Iain Armstrong, alcohol programme manager at the Office for Health Improvement and Disparities, says that the idea of ‘mild dependence’ is not one to overlook. ‘These people may not be doing things that are expected of them because they are giving inordinate priority to the alcohol. They don’t necessarily have physical dependence, which entails drinking increasing amounts to get a similar effect and experiencing withdrawal symptoms if they stop, but nevertheless display dependent patterns of behaviour.
‘It’s also important to recognise that to suffer harm from alcohol, you don’t need to be dependent at all. For example, about one in eight cases of high blood pressure are caused by alcohol use, not all of it dependent use. Regular prolonged consumption can cause cardiovascular disease and stroke, some cancers and mental ill health in non-dependent drinkers.’
Another seldom acknowledged aspect of alcohol dependency is that although it largely goes hand in hand with poverty and deprivation, it can, as Kate Middleton pointed out, affect anybody. ‘Alcohol doesn’t discriminate,’ says Piers. ‘It permeates all sections of society, because alcohol is itself so embedded in our culture.’
Whatever the background of alcohol-dependent people, it’s often the immediate family that experience the consequences most directly.
‘It can mean that children go short of the things they need,’ says Piers. The toll of this can leave them vulnerable. ‘They can look different, behave differently or seem different, which leaves them open to bullying. Children also face unpredictable behaviour and a lack of structure in the home as alcohol takes priority over everything else. One thing I hear over and over again is children not knowing what they are going to face when they get home. Their parents could be elated, happy and manic or unhappy, sad, destructive, angry and abusive. They just don’t know.’
In diagnosing alcohol dependence in all its various guises, health professionals can draw on a wide range of tools and screening tests.
‘Any diagnosis would normally be made by someone who is appropriately trained,’ says Mike. ‘That could be a GP; it could also be a nurse or a psychologist. Something like the AUDIT questionnaire from the World Health Organization [WHO] can also be self-completed.
If you score more than 16, your alcohol intake could be harmful; if you score more than 20, you are possibly dependent.’
The roots of recovery
Once that diagnosis has been made, what are the treatment options and what does recovery look like? ‘Again, there is a whole range of things, depending on what the patient needs and the severity of dependence,’ says Mike. ‘If somebody is drinking heavily every day it can be unsafe for them to stop suddenly. They may need support to cut down alcohol use or they may need a detox.’
A key step is to try to understand why an individual might be drinking. ‘Many have had common adverse childhood experiences,’ says Kelleher. ‘We also know it’s tied to deprivation. Then you have people with low mood. In the short term, alcohol is a wonderful elevator of mood, but in the long term, it makes things worse. People become even more depressed and they have to drink more to get the same effect. So people need psychological therapy support for their underlying anxiety disorder or depression.’
This understanding of why people drink can give an indication of what other interventions might be appropriate, although it remains a very individual matter. ‘A relatively small number will go to residential rehab,’ says Iain, ‘but for most that’s not necessary. It’s also not what they want and not what they need. Many people manage to stop on their own. Others need ongoing support – for example, from the local community alcohol service.’
Charities such as NACOA can also be a vital source of help. ‘Our national helpline is there to provide ongoing support and advice to anybody who needs it,’ says Piers. ‘If we’re the first port of call, we try to signpost to relevant services. So that can be fellowships, other charities such as Childline, community alcohol services or other NHS services. It can be a patchwork of ever-shifting provision across the country.’
The 12-step programme of Alcoholics Anonymous (AA) is another possibility. ‘I’ve seen some phenomenal success stories,’ says Mike, ‘but it’s not for everyone. It’s not the only route to sobriety. But if you speak to 12-step people, they say recovery belongs to you, that it’s whatever you choose it to look like.’
What is alcohol dependency?
‘A disorder of regulation of alcohol use arising from repeated or continuous use of alcohol,’ the WHO says. It is characterised by ‘a strong internal drive to use alcohol, […] impaired ability to control use, increasing priority given to use over other activities and persistence of use despite harm’ (WHO, 2022).
How you can help
Community practitioners (CPs) can have a role to play in helping people take their first steps towards recovering from alcohol dependency.
‘The first thing to do is just inform yourself,’ says Piers. ‘We’re lucky in the UK to have good charities and lots of information from the NHS. Don’t be afraid to make that information available, to hand on a leaflet or give a number to call or suggest a name to Google. Try not to be critical of a parent, or to put any responsibility on to a child or a young person.’
Mike feels that raising concerns directly with people about excessive drinking is a valid approach. ‘I don’t think you can go wrong with asking them if they think it’s an issue. If somebody ends up in hospital after an accident, ask the question, “What role do you think alcohol played in the accident?” Just that can be enough to trigger change. Ask them if you have consent to speak to other people. After that, the logical protocol is to alert the GP and perhaps refer them to community alcohol services. Bring it back to the primary care network.’
While it’s always better to have the individual’s consent, safeguarding legislation is clear about the duty to inform – for example, if alcohol is affecting an individual’s ability to care for themselves or others. People should also be able to self-refer to alcohol services in every local area. CPs should be able to look up and find the details of their local alcohol treatment services.
My personal journey with addiction
Hannah*, RGN & SCPHN, Northern Ireland, gives an honest account with the hope of helping others.
Up until three years ago my life seemed reasonably normal. I was working as a qualified community nurse and had undertaken various levels of study to progress my career and felt proud of my achievements. I had a good working relationship with my colleagues and was viewed as a trusted employee and colleague.
I slowly became aware that my drinking patterns had gradually increased from a relaxing treat at weekends and social occasions, to a ‘well-deserved’ event after work to help cope with family relationships, financial and emotional issues, to something that I needed in order to function. Despite many unsuccessful and half-hearted attempts to reduce my intake, alcohol became a part of daily living.
Addiction eventually took complete hold of every aspect of my life, including my values and beliefs, my thinking and behaviours – which resulted in life-changing events and consequences, and sapped my physical and mental health and my will to live.
Within two months of my 40th birthday, my entire life had become completely unrecognisable, unpredictable and unmanageable and surrounded by an ‘alien’ world of police cells, court appearances, admissions to A&E, and disciplinary and regulatory procedures both within and outside my organisation. I was desperate for help but was incapable of thinking clearly or making decisions.
Following a further admission to A&E, I was admitted voluntarily to a 12-week residential rehabilitation unit. I then found myself among women who shared similar experiences, who all felt desperate, trapped, broken and empty.
Within weeks, my physical health began to improve, my appetite and sleep pattern slowly returned, and through intense therapy, support and education I learned that there was a way to live with addiction.
This allowed me to accept that I had a lifelong addiction to alcohol, my life had become unmanageable as a consequence and that I had no control over it. This involved much soul-searching, pain, tears, uncontrollable emotions and feelings, and the realisation of the power addiction had on every aspect of my life.
Although I had no family contact or access to TV, radio or my mobile phone, I soon found that being removed from everything my addiction had affected allowed me the time to start to heal and find hope. This time also gave my family much-needed rest and peace of mind.
Today I am still healing and learning to live my life with addiction. I have been able to make significant decisions to rebuild and improve family relationships, social circles and my career. I am a member of AA, which I make a priority over any plans or situations. I try to live every day as simply as I can, in order to use the tools and teaching I was given in rehab.
Therapy, support and education showed me that there was a way to live with addiction
As a nurse, mother, wife, daughter, sister and friend I experienced shame, self-loathing, guilt, regret and I felt stigmatised and trapped, but I am also aware that I may have been viewed as weak and wilful with no self-control.
I have regained trust from family and friends, and hope my commitment and hope for my recovery is evident in everything I do. Challenging situations will always threaten my sobriety, but with ongoing support and self-belief, I can manage these without alcohol.
My reason for living has returned, allowing me to show humility and acceptance. I have been able to return to work and be accountable in providing nursing care to the best of my ability. I am now able to appreciate that the most valuable help and insight into addiction is from someone who has lived the experience.
I would urge anyone, in particular those in healthcare, to find the courage to seek help with addiction both within organisations and outside them. My hope for the future is that addiction may become a priority for NHS staff, and resources such as aid with smoking cessation are put in place to provide a safe and non-stigmatising place for staff to seek the help they need.
Resources
- The NHS alcohol support pages are a good starting point for advice on alcohol use nhs.uk/live-well/alcohol-support
- NACOA (nacoa.org.uk) supports children affected by parental drinking. It has a free helpline on 0800 358 3456
- Alcohol Change UK alcoholchange.org.uk
- The Forward Trust charity focuses on drug and alcohol addiction and offers a wide range of support forwardtrust.org.uk
- Adfam – this charity supports family and friends affected by addictive behaviour adfam.org.uk
References:
Alcohol Focus Scotland. (2021) Alcohol facts and figures. See: alcohol-focus-scotland.org.uk/alcohol-information/alcohol-facts-and-figures (accessed 12 April 2022).
NHS Digital. (2020) Around 360,000 admissions to hospital as a result of alcohol in 2018/19. See: https://digital.nhs.uk/news/2020/around-360000-admissions-to-hospital-as-a-result-of-alcohol-in-2018-19 (accessed 27 April 2022).
NICE. (2011) Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. See: nice.org.uk/guidance/cg115/chapter/1-guidance#identification-and-assessment (accessed 12 April 2022).
Northern Ireland Statistics and Research Agency. (2022) Annual 2020 alcohol-specific deaths statistics. See: nisra.gov.uk/news/annual-2020-alcohol-specific-deaths-statistics (accessed 12 April 2022).
Office for Health Improvement & Disparities. (2021) Adult substance misuse treatment statistics 2020 to 2021: report. See: gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2020-to-2021/adult-substance-misuse-treatment-statistics-2020-to-2021-report (accessed 12 April 2022).
Public Health England. (2021) Estimates of alcohol dependent adults in England. See: gov.uk/government/publications/alcohol-dependence-prevalence-in-england (accessed 12 April 2022).
Public Health Wales. (2022). Alcohol. See: https://phw.nhs.wales/topics/alcohol (accessed 12 April 2022).
WHO. (2022) ICD-11 for mortality and morbidity statistics: 6C40.2 alcohol dependence. See: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1580466198 (accessed 12 April 2022).
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