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Mental Health & Substance Use

Alcohol Use Disorders

A spectrum of conditions resulting from problematic patterns of alcohol consumption, ranging from harmful/hazardous use (causing health/social damage) to alcohol dependence (compulsive use, tolerance, withdrawal).

Also known as: Alcoholism, Alcohol Dependence, Harmful Alcohol Use, Alcohol Abuse

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Referral and warning signs

When to refer

Refer to higher level care / specialist (Mental Health, Addiction Services - HC4/H/RR) for: Patients meeting criteria for Alcohol Dependence. Patients requiring medically supervised detoxification. Patients needing medication-assisted treatment (Naltrexone, Acamprosate). Patients with severe co-occurring medical or psychiatric conditions. Failure of brief interventions for harmful use.

Red flags

  • Signs of severe alcohol withdrawal (seizures, hallucinations, delirium tremens)
  • Signs of severe liver disease (jaundice, ascites, encephalopathy, variceal bleeding)
  • Signs of Wernicke's encephalopathy (confusion, ataxia, ophthalmoplegia)
  • Severe depression or suicidal ideation
  • Continued drinking despite severe consequences
  • Polysubstance use

Signs and symptoms

  • Harmful Use Criteria (UCG): >5 drinks/occasion in last 12m OR >2 drinks/day OR daily drinking, causing physical/mental harm or social/occupational problems.
  • Alcohol Dependence Criteria (≥3 features present - UCG):
  • - Strong desire or compulsion to take alcohol.
  • - Difficulties controlling use (onset, termination, level).
  • - Physiological withdrawal state upon cessation/reduction (see MH012).
  • - Evidence of tolerance (need increased amounts for same effect).
  • - Progressive neglect of alternative pleasures/interests.
  • - Persistent use despite clear evidence of harmful consequences (physical, mental, social).
  • Physical Complications (Chronic Use): Malnutrition (esp. Thiamine deficiency), Liver disease (fatty liver, hepatitis, cirrhosis), Chronic pancreatitis, Peptic ulcer disease, Gastritis, Cardiomyopathy, Hypertension, Peripheral neuropathy, Cerebellar degeneration, Cognitive impairment/dementia (Wernicke-Korsakoff), Increased risk of cancers (mouth, throat, esophagus, liver, breast).
  • Mental/Social Complications: Depression, Anxiety, Psychosis, Sleep disturbance, Relationship problems, Job loss, Financial difficulties, Legal problems (DUI, violence), Accidents/injuries.

Risk factors

  • Genetic predisposition / Family history.
  • Environmental factors (availability, cultural norms, peer pressure).
  • Psychological factors (stress, trauma history, co-occurring mental health disorders like depression/anxiety/personality disorders).
  • Early age of onset of drinking.
  • Male gender (higher rates, but consequences often severe in women).

Diagnosis

Clinical assessment

Based on detailed history of alcohol consumption pattern (quantity, frequency, duration), presence of dependence criteria, evidence of harm (physical, mental, social), and features of withdrawal upon cessation. Use screening tools (e.g., AUDIT, CAGE) to identify risky drinking.

Investigations

  • Screening questionnaires (AUDIT, CAGE).
  • Assess for dependence criteria.
  • Assess for physical complications: LFTs (AST, ALT, GGT - often elevated GGT, AST>ALT ratio ~2:1), CBC (MCV often elevated), PT/INR (if cirrhosis), Electrolytes, Glucose.
  • Assess for mental health comorbidities.
  • Social history assessment.

Diagnostic criteria

Meet criteria for Harmful Use or Alcohol Dependence based on established diagnostic systems (e.g., ICD, DSM) and UCG criteria outlined in signs/symptoms.

Management

Non-pharmacological management

  • Brief Intervention and Counselling: For harmful/hazardous use. Provide feedback on risks, advise reduction/abstinence, discuss strategies.
  • Motivational Interviewing: To enhance motivation for change.
  • Psychosocial Interventions (for Dependence):
  • - Psychoeducation (patient and family).
  • - Counselling / Psychotherapy (CBT, relapse prevention therapy).
  • - Mutual Help Groups: Alcoholics Anonymous (AA) or similar self-help groups.
  • - Family support and therapy.
  • Setting goals (abstinence is usually recommended for dependence, but harm reduction may be initial step).

Pharmacological treatment

  • Management of Acute Intoxication / Withdrawal / Wernicke's: Refer to specific entries (MH011, MH012, TOX013). Includes Thiamine, Benzodiazepines for withdrawal.
  • Medications to Support Abstinence / Reduce Craving (Specialist initiation/supervision - H/RR):
  • - Naltrexone: Reduces rewarding effects, craving. Oral or long-acting injection.
  • - Acamprosate: Reduces protracted withdrawal symptoms, craving. Requires good renal function.
  • - Disulfiram: Creates unpleasant reaction if alcohol consumed (aversive therapy). Requires high motivation, careful patient selection, monitoring.
  • Treat co-occurring medical and psychiatric conditions (e.g., depression, liver disease, nutritional deficiencies - Thiamine 100mg daily PO for at least 2 weeks).
  • Detoxification (managing withdrawal): Should generally occur in inpatient setting due to risks (seizures, DTs). Involves benzodiazepine taper (see MH012).
  • Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Monitor alcohol consumption patterns. Monitor for withdrawal symptoms if cessation attempted. Monitor adherence to treatment (psychosocial, pharmacological). Monitor physical health (liver function, nutrition). Monitor mental health status. Monitor social functioning.

Complications

  • Physical organ damage (liver cirrhosis, pancreatitis, cardiomyopathy etc.)
  • Neurological damage (Wernicke-Korsakoff, neuropathy, dementia)
  • Mental health disorders (depression, anxiety)
  • Alcohol withdrawal syndrome (seizures, DTs)
  • Accidents and injuries
  • Social problems (job loss, relationship breakdown, homelessness)
  • Increased risk of certain cancers
  • Fetal Alcohol Spectrum Disorders (if used during pregnancy)
  • Death (from complications, accidents, suicide)

Prevention

  • Public health policies (pricing, availability, advertising restrictions).
  • Health education on risks of harmful drinking.
  • Screening and brief interventions in primary care.
  • Early identification and treatment of risky drinking patterns.
  • Promoting healthy coping mechanisms for stress.

Patient education

  • Educate on the difference between harmful use and dependence.
  • Explain the short-term and long-term health/social risks of excessive alcohol use.
  • Discuss the concept of withdrawal and its potential dangers.
  • Explain treatment options (psychosocial, medication - if applicable).
  • Emphasize the importance of support systems (family, AA).
  • Provide information on local resources if available.
  • Stress complete abstinence during pregnancy.

Uganda-specific notes

Alcohol use disorders are highly prevalent. Locally brewed beverages ('waragi', etc.) pose additional risks (methanol contamination - see TOX011). Screening and brief intervention should be incorporated into routine care. Thiamine deficiency is common; supplementation is important. Access to specialist treatment (detox units, MAT, rehabilitation) is limited. Community and family support are vital. Stigma is a barrier to seeking help.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.2.5 (Note: Text incorrectly labels section 9.1.1, but content aligns with AUD)

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 1, Section 1.3.12 (Acute/Chronic Poisoning/Withdrawal)

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