Alcohol Misuse

🧭 When to suspect

Problem drinking sits on a spectrum – from increasing-risk (hazardous) use, through harmful drinking, to alcohol dependence. Most people who drink above safe limits are not dependent, and many present without ever mentioning alcohol: with physical problems (deranged LFTs, dyspepsia or gastritis, peripheral neuropathy, falls or unexplained injury), mental health problems (anxiety, depression, insomnia), or social and occupational difficulties (relationship breakdown, money or work problems). Others ask directly for help to cut down, or are brought in by a worried family member.

The two core skills in primary care are to stratify the drinking level – by calculating units and using the AUDIT questionnaire – and to never miss the dangerous complications: alcohol withdrawal (seizures, delirium tremens) and Wernicke's encephalopathy. Management then follows from where the person sits on the spectrum and from their own goal, whether that is moderation or abstinence.

The UK low-risk guideline is to drink no more than 14 units a week, for both men and women, spread over three or more days with several drink-free days (one unit is about 10 ml or 8 g of pure alcohol). Use the AUDIT score to grade risk and direct action.

Raise suspicion particularly in those with a family history of alcohol problems, coexisting depression or anxiety, chronic social stress, or unexplained physical signs such as a raised gamma-GT or macrocytosis. Screen with CAGE or AUDIT-C and follow up with the full AUDIT where indicated.

Source: NICE CG115 · UK Chief Medical Officers' low-risk drinking guidelines