Alcohol Misuse

Alcohol misuse means drinking excessively – more than the lower-risk limits of alcohol consumption.

Alcohol consumption is measured in units. A unit of alcohol is 10ml of pure alcohol, which is about:

• half a pint of normal-strength lager
• a single measure (25ml) of spirits

A small glass (125ml) of wine contains about 1.5 units of alcohol.

Lower-risk limits

To keep your risk of alcohol-related harm low, the NHS recommends:

• not regularly drinking more than 14 units of alcohol a week
• if you drink as much as 14 units a week, it's best to spread this evenly over three or more days
• if you're trying to reduce the amount of alcohol you drink, it's a good idea to have several alcohol-free days each week

Regular or frequent drinking means drinking alcohol most weeks. The risk to your health is increased by drinking any amount of alcohol on a regular basis.

Risks of alcohol misuse

Short-term

The short-term risks of alcohol misuse include:

• accidents and injuries requiring hospital treatment, such as a head injury
• violent behaviour and being a victim of violence
• unprotected sex that could potentially lead to unplanned pregnancy or sexually transmitted infections (STIs)
• loss of personal possessions, such as wallets, keys or mobile phones
• alcohol poisoning – this may lead to vomiting, seizures (fits) and falling unconscious

People who binge drink (drink heavily over a short period of time) are more likely to behave recklessly and are at greater risk of being in an accident.

Long-term

Persistent alcohol misuse increases your risk of serious health conditions, including:

• heart disease
• stroke
• liver disease
• liver cancer and bowel cancer
• mouth cancer 
• pancreatitis 

As well as causing serious health problems, long-term alcohol misuse can lead to social problems, such as unemployment, divorce, domestic abuse and homelessness.

If someone loses control over their drinking and has an excessive desire to drink, it's known as dependent drinking (alcoholism).

Dependent drinking usually affects a person's quality of life and relationships, but they may not always find it easy to see or accept this. 

Severely dependent drinkers are often able to tolerate very high levels of alcohol in amounts that would dangerously affect or even kill some people.

A dependent drinker usually experiences physical and psychological withdrawal symptoms if they suddenly cut down or stop drinking, including:

• hand tremors – "the shakes"
• sweating
• seeing things that aren't real (visual hallucinations)
• depression
• anxiety
• difficulty sleeping (insomnia)

This often leads to "relief drinking" to avoid withdrawal symptoms.

Am I drinking too much alcohol?

You could be misusing alcohol if:

• you feel you should cut down on your drinking
• other people have been criticising your drinking
• you feel guilty or bad about your drinking
• you need a drink first thing in the morning to steady your nerves or get rid of a hangover

Someone you know may be misusing alcohol if:

• they regularly exceed the lower-risk daily limit for alcohol
• they're sometimes unable to remember what happened the night before because of their drinking
• they fail to do what was expected of them as a result of their drinking – for example, missing an appointment or work because of being drunk or hungover

Getting help

If you're concerned about your drinking or someone else's, a good first step is to visit your GP. They'll be able to discuss the services and treatments available. 

Your alcohol intake may be assessed using tests, such as:

• the Alcohol Use Disorders Identification Test (PDF, 224kb) – a widely used screening test that can help determine whether you need to change your drinking habits
• the Fast Alcohol Screening Test – a simpler test to check whether your drinking has reached dangerous levels
• the Severity of Alcohol Dependence Questionnaire – this helps identify how severely dependent on alcohol you may be

As well as the NHS, there are a number of charities and support groups across the UK that provide support and advice for people with an alcohol misuse problem.

For example, you may want to contact:

• Alcohol Concern – runs the national drink helpline, Drinkline on 0300 123 1110
• Alcoholics Anonymous – helpline 0845 769 7555
• Al-Anon Family Groups – helpline 020 7403 0888

For a full list of charities and support groups, see our page on alcohol support.

Treating alcohol misuse

How alcohol misuse is treated depends on how much alcohol a person is drinking. Treatment options include:

• counselling – including self-help groups and talking therapies, such as cognitive behavioural therapy (CBT)
• medication
• detoxification – this involves a nurse or doctor supporting you to safely stop drinking; this can be done by helping you slowly cut down over time or by giving you medicines to prevent withdrawal symptoms

There are two main types of medicines to help people stop drinking. The first is to help stop withdrawal symptoms, and is given in reducing doses over a short period of time. The most common of these medicines is chlordiazapoxide (Librium).

The second is a medication to reduce any urge you may have to drink. The most common medications used for this are acamprosate and naltrexone. These are both given at a fixed dose, and you'll usually be on them for 6 to 12 months.

Risks

• Alcohol is a powerful chemical that can have a wide range of adverse effects on almost every part of your body, including your brain, bones and heart.

  Alcohol and its associated risks can have both short-term and long-term effects.

  Short-term effects of alcohol consumption

  The short-term effects of alcohol consumption are outlined below. This information is based on the assumption that you have a normal tolerance to alcohol.

  Dependent drinkers with a higher tolerance to alcohol can often drink much more without experiencing any noticeable effects.

  1-2 units

  After drinking 1-2 units of alcohol, your heart rate speeds up and your blood vessels expand, giving you the warm, sociable and talkative feeling associated with moderate drinking.

  4-6 units

  After drinking 4-6 units of alcohol, your brain and nervous system starts to be affected. It begins to affect the part of your brain associated with judgement and decision making, causing you to be more reckless and uninhibited.

  The alcohol also impairs the cells in your nervous system, making you feel light-headed and adversely affecting your reaction time and co-ordination.

  8-9 units

  After drinking 8-9 units of alcohol, your reaction times will be much slower, your speech will begin to slur and your vision will begin to lose focus.

  Your liver, which filters alcohol out of your body, will be unable to remove all of the alcohol overnight, so it's likely you'll wake with a hangover.

  10-12 units

  After drinking 10-12 units of alcohol, your co-ordination will be highly impaired, placing you at serious risk of having an accident. The high level of alcohol has a depressant effect on both your mind and body, which makes you drowsy.

  This amount of alcohol will begin to reach toxic (poisonous) levels. Your body attempts to quickly pass out the alcohol in your urine. This will leave you feeling badly dehydrated in the morning, which may cause a severe headache.

  The excess amount of alcohol in your system can also upset your digestion, leading to symptoms of nausea, vomiting, diarrhoea and indigestion.

  More than 12 units

  If you drink more than 12 units of alcohol, you're at considerable risk of developing alcohol poisoning, particularly if you're drinking many units over a short period of time.

  It usually takes the liver about an hour to remove one unit of alcohol from the body.

  Alcohol poisoning occurs when excessive amounts of alcohol start to interfere with the body's automatic functions, such as:

  • breathing
  • heart rate
  • gag reflex, which prevents you choking

  Alcohol poisoning can cause a person to fall into a coma and could lead to their death.

  Other risks

  Some of the other risks associated with alcohol misuse include:

  • accidents and injury – more than 1 in 10 visits to accident and emergency (A&E) departments are because of alcohol-related illnesses
  • violence and antisocial behaviour – each year in England more than 1.2 million violent incidents are linked to alcohol misuse
  • unsafe sex – this can lead to unplanned pregnancies and sexually transmitted infections (STIs)
  • loss of personal possessions – many people lose personal possessions, such as their wallet or mobile phone, when they're drunk
  • unplanned time off work or college – this could put your job or education at risk

  Long-term effects of alcohol misuse

  Drinking large amounts of alcohol for many years will take its toll on many of the body's organs and may cause organ damage. Organs known to be damaged by long-term alcohol misuse include the brain and nervous system, heart, liver and pancreas.

  Heavy drinking can also increase your blood pressure and blood cholesterol levels, both of which are major risk factors for heart attacks and strokes.

  Long-term alcohol misuse can weaken your immune system, making you more vulnerable to serious infections. It can also weaken your bones, placing you at greater risk of fracturing or breaking them.

  There are many long-term health risks associated with alcohol misuse. They include:

  • high blood pressure
  • stroke
  • pancreatitis
  • liver disease 
  • liver cancer      
  • mouth cancer
  • head and neck cancer
  • breast cancer
  • bowel cancer  
  • depression
  • dementia 
  • sexual problems, such as impotence or premature ejaculation   
  • infertility 

  As well as having a significant impact on your health, alcohol misuse can also have long-term social implications. For example, it can lead to:

  • family break-up and divorce
  • domestic abuse
  • unemployment
  • homelessness
  • financial problems

  Kindling

  Kindling is a problem that can occur following a number of episodes of withdrawal from alcohol. The severity of a person's withdrawal symptoms may get worse each time they stop drinking, and can cause symptoms such as tremors, agitation and convulsions (seizures).

  Alcohol has a suppressing effect on the brain and central nervous system. Research has shown that when alcohol is removed from the body, it activates brain and nerve cells, resulting in excessive excitability (hyperexcitability). This can lead to behavioural symptoms such as seizures.

  With each alcohol withdrawal episode, the brain and nervous system becomes more sensitised and the resulting side effects become more pronounced.

  This kindling effect can also occur after chemical stimulus to the brain or body, such as anti-convulsant medication. This means a person's alcohol withdrawal programme needs to be carefully planned, with close monitoring of its effects.

Diagnosing

If you visit your GP because you're concerned about your drinking, or if you are treated for an alcohol-related injury or illness, your alcohol misuse may be assessed.

An alcohol assessment usually involves having a number of screening tests that consist of a series of questions.

It's important that you're truthful when answering the questions, so you can receive the appropriate treatment. Your GP or the healthcare professional carrying out the tests will not judge you.

Three commonly used tests are the:

• Alcohol Use Disorders Identification Test (AUDIT)
• Fast Alcohol Screening Test (FAST)
• Severity of Alcohol Dependence Questionnaire (SADQ)

These tests are described below.

Alcohol Use Disorders Identification Test (AUDIT)

The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization (WHO).

It's a widely used screening test that can help people identify whether they might need to think about changing their drinking habits.

AUDIT involves answering 10 questions about your drinking habits to assess the effects it could have on you. Questions include:

• How often do you have a drink containing alcohol?
• How many drinks containing alcohol do you have on a typical day when you are drinking?
• How often during the last year have you found that you were not able to stop drinking once you had started?
• How often during the last year have you had a feeling of guilt or remorse after drinking?

The test is usually carried out under the guidance of a healthcare worker.

After you've completed the test your score will be calculated. If the results show that you're drinking hazardously or harmfully, the healthcare worker will advise you about appropriate treatments and services.

Fast Alcohol Screening Test (FAST)

The Fast Alcohol Screening Test (FAST) is a simpler test that you can use to check whether your drinking has reached hazardous levels.

FAST consists of four questions, listed below. The number after each answer is that answer's score.

1. How often do you drink eight or more units (men) or six or more units (women) on one occasion?

• never (if this is your answer you can stop the test)
• less than monthly (1)
• monthly (2)
• weekly (3)
• daily or almost daily (4)

2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

• never (0)
• less than monthly (1)
• monthly (2)
• weekly (3)
• daily or almost daily (4)

3. How often during the past year have you failed to do what was normally expected of you because you had been drinking?

• never (0)
• less than monthly (1)
• monthly (2)
• weekly (3)
• daily or almost daily (4)

4. In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested that you cut down?

• no (0)
• yes, on one occasion (1)
• yes, on more than one occasion (2)

A FAST score of three or more indicates that you're drinking at a hazardous level.

Severity of Alcohol Dependence Questionnaire (SADQ)

As well as helping to identify a person’s dependence on alcohol, the Severity of Alcohol Dependence Questionnaire (SADQ) can also be used to indicate the severity of dependence.

The SADQ is a 20-item questionnaire that has a maximum score of 60. It focuses on five key areas of alcohol dependence. They are:

• physical withdrawal
• affective withdrawal
• withdrawal relief drinking
• alcohol consumption
• rapidity of reinstatement

The SADQ is often used by healthcare professionals because it’s very quick and simple to use and it doesn’t require any specialist training to carry out or score.

A person with mild alcohol dependence (SADQ score of 15 or less) will not usually need assisted alcohol withdrawal.

Someone with moderate dependence (SADQ score of 16-30) will usually need assisted alcohol withdrawal, which can often be managed in the community.

Someone who is severely alcohol dependent (SADQ score of more than 30) will need assisted alcohol withdrawal. This will usually be carried out in an inpatient or residential setting.

Treatment

The treatment options for alcohol misuse depend on the extent of your drinking and whether you're trying to drink less (moderation) or give up drinking completely (abstinence).