With any dependence or addiction, the person feels they cannot control what they do, and that they can't function without something. Alcohol is a classic cause of dependence (or addiction) but is almost the same for many other substances or behaviours.

Features of the Dependence Syndrome (about alcohol)

• a strong desire to drink
• difficulties in controlling the amount you drink
• drinking despite being aware of the harm its doing to you and others around you
• drinking becoming more important to you than other activities and obligations,
• increased tolerance (ie being able to drink more than other people without getting 'drunk')
• sometimes getting physical withdrawal symptoms (like sweats and shakes) if you don't drink
• drinking to relieve or avoid withdrawal symptoms
• developing a daily drinking routine
• very quickly slipping back to drinking heavily if you start again after stopping for a while

Alcohol drinking problems can be put into 3 groups:

1. Hazardous drinking

• The "official" sensible adult weekly limits are 21 units for men and 14 units for women (see next question)
• Hazardous drinking is where someone is drinking above the "sensible limits" but has no major alcohol-related problems
• This can include binge drinking, where someone stays within the weekly limit but has it all in one day e.g. more than 8 units in a day for men or 6 units a day for women

2. Harmful drinking

• Someone is drinking above the sensible weekly limits (as above) and has some alcohol-related problems e.g. dependence and can get alcohol withdrawal symptoms sometimes, but these may only be mild.

3. Alcohol dependence (alcoholism)

• This is where someone is drinking and has the same symptoms as other dependences:
• Continual desire to drink
• Return to drinking after abstinence, even with a single drink
• Severe alcohol withdrawal symptoms
• Continued drinking despite knowing of the harm it is causing

The Department of Health in the UK in 2006 said that 23% adults (1 in 4) drink at hazardous levels (33% of men and 16% of women), and that dependence is thought to be present in at least 4% adults (1 in 25), made up from 6% (1 in 16) of men and 2% (1 in 50) of women. A further report, in 2009, found that:

• Among adults aged over 16, just over two-thirds of men (69%) and half of women (55%) reported drinking an alcoholic drink on at least one day in the week before they were interviewed. A tenth of men and 6% of women reported drinking every day in the previous week.
• Over a third of men (37%) drank over four units on at least one day in the week prior to interview and 29% of women drank more than three units at least one day in the week prior to interview (that is, more than the daily maximum levels recommended by the government). One in five men (20%) reported drinking over eight units and one in eight (13%) of women reported drinking over six units on at least one day in the week prior to interview.
• Average weekly alcohol intake was 16.4 units for men and 8.0 units for women.
• Just over one in four (26%) men reported drinking more than 21 units in an average week. For women, one in six (18%) reported drinking more than 14 units in an average week.  

There is a UK 2011 report on the truth behind the headlines report called "What's your poison? A sober analysis of alcohol and health in the media", which is well worth reading.

In February 2013 the UK Department of Health launched a "Change4life" campaign and their website has a review called "Drinkers can underestimate alcohol habits" by as much as 40%.

You can also use the NHS tool for calculating on-line your alcohol consumption.

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You can work out someone's alcohol intake using the NHS on-line alcohol unit calculator. If you don't want to use this see the advice below.  

How much alcohol you can safely drink will depend on your age, sex and state of health. The official UK limits are as follows:

Men age 18-65 = 3-4 units per day with at least 2-3 alcohol free days per week. No more than 21 units per week.

Women aged 18-65 = 2-3 units per day with at least 2-3 alcohol free days per week. No more than 14 units per week.

If you are either younger or older than 18-65 yrs of age or if you have significant health problems (particularly affecting the liver or heart) you should drink less than these limits.

If you are pregnant the British Medical Association recommends stopping drinking altogether. Alcohol is the commonest cause of preventable brain damage in babies.

It is now clear that 4 or more units of alcohol a day for men and 3 or more units a day for women carries a cumulative risk of harm i.e. the longer you drink above these levels, the more damage you cause.   

One unit of alcohol in UK contains 8g of pure alcohol [NB beware as the "one unit" contains more alcohol in Australia and USA). There is around one UK unit of alcohol in the following:

• Half pint of standard beer, lager or cider
• Small pub measure of spirits (25ml)
• Standard pub measure of fortified wine e.g. sherry (50ml)

Some UK examples include:

• Pub measure of spirits = 1.5 units
• Standard pub measure of wine (125ml) = 1.5 units
• Can of standard beer or lager = 2 units
• Can of strong beer or lager = 3 units
• Pint of standard lager, beer or bitter = 2.3 units
• Pint of strong lager, beer or bitter = 2.8 units
• Small glass of wine = 1.5 units
• Large glass of wine = 3 units
• Alcopops = 1.4 units
• Glass of spirits (25ml) = 1 units
• Bottle of wine = 9-10 units
• 1L bottle of standard cider = 4 units
• 1L bottle of strong cider = 9 units
• Bottle spirits (700ml) = 27-28 units

To work out the number of units of alcohol in a drink:

• Write down the "volume of alcohol" (i.e. alcohol content) as stated on the bottle, can or label (e.g. wine is usually around 8-10%, beer 3-4%)
• Work out how many millilitres (ml) you have drunk (a pint is 568mls, a can of Coke is 330ml, a larger can is usually 440ml or 500ml)
• Multiply the two together and divide by 1000

Alcohol content in % x mls    = units of alcohol
          1000

Example 1:

An ordinary beer at 3.5% alcohol:  
A pint of it would be 568ml
3.5 x 568 = 1988
1988 divided by 1000 = 2 units (or 1.988 units to be exact)

Example 2:

A strong cider at 6% alcohol:
A large can of it would be 500ml
6 x 500 = 3000
3000 divided by 1000 = 3 units

Example 3:

A Smirnoff Ice at 4% alcohol:
A bottle would be 275ml
4 x 275 = 1100
1100 divided by 1000 = 1.1 units

A report in June 2011 from the Royal College of Psychiatrists (published in the British Medical Journal 2011;342:d3950) has suggested lower safe drinking limits for people aged over 65 years. The report recommends up to 1.5 units a day for men and 1 unit a day for women. "Binge drinking" is set at 4.5 units or more in men and 3 units or more in women in a single session. The report, called ‘Our Invisible Addicts’, says that the changes from aging (e.g. changes to the body with age and how the liver breaks down alcohol) mean that the current safe limits are too high for elderly people. You can read the report by clicking here.

It is also recommended to have 2 drink-free days a week, because if you can't have at least one drink-free day a week then you do have a problem.

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Alcohol dependence means drinking harmful amounts of alcohol and not being able to stop. Apart from alcohol intake itself, there are some key symptoms:

• Physical signs e.g. flushed or red cheeks with veins showing, bloodshot eyes, tremor or a shake of the hand (especially if not having had a drink for a few hours)

• Symptoms such as smelling of alcohol, having accidents or mishaps, frequent sick notes or unexplained illnesses

• Abnormal blood tests, especially of the liver e.g. raised GGT (gamma-glutamyl transferase) shows the liver is having to work hard to get rid of the alcohol and is getting damaged

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Strictly speaking not really. However, alcohol dependence can be the result of taking alcohol to help symptoms of e.g. anxiety or insomnia. However, if no one knows someone is drinking a lot then the symptoms can be mistaken for many other things. People who have a problem with alcohol may find this hard to admit to themselves or others. They may then conceal, minimise or deny their drinking. If alcohol consumption is not known about, then the symptoms can be mistaken for:

• Psychosis - where people seem to be suffering from voices and delusions

• Alcohol-induced anxiety disorders

• Diabetic ketoacidosis (something dangerous that can happen in diabetes, and has symptoms of vomiting, dehydration, confusion, coma and breathlessness)

• Hypoglycaemia (low blood sugar, as in diabetes)

• Panic disorder

• Dysthymia (a long-term low level depression)

• Prescription drug abuse (e.g. pain killers)

• Non-prescription substance misuse (e.g. opiates)

• Liver failure (caused by something else)

• Primary insomnia (where there is no real known cause)

• Social anxiety or phobia

• Brain trauma, damage or injury (e.g. after a fall, road accident)

• Meningitis (an infection of the brain, which needs treating straight away)

• Pancreatitis (where the pancreas being inflamed, which is really very painful, and usually caused by gall stones, alcohol or rarely by a scorpion bite)

• Neurological causes e.g. multiple sclerosis

• Pneumonia and chest infections

• Stroke (where part of the brain gets no blood for a while and is damaged)

Just to confuse matters further, sometimes people have more than one condition. This is called co-morbidity. It can happen by chance (for example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people gets anxiety as well). However, if you're depressed, you're actually more likely to be anxious. The fact that having one condition can put you at greater risk of having others can make diagnosis more difficult.

If someone is drinking heavily they are more likely to also have the following conditions:

• Malnutrition (lack of food or not absorbing the vitamins in it)

• Brain problems e.g. caused by lack of Vitamin B1, stroke, dementia

• Nerve problems - causing tingling, numbness or pain in the hands and feet

• Heart disease e.g. odd beats, high blood pressure, swelling of the heart

• Liver disease (caused by the alcohol or other causes)

• Blood problems e.g. anaemia,

• Some cancers (esp. oesophagus, colon, rectum, breast)

• Gut problems e.g. stomach ulcers and inflammation, inflamed pancreas (pancreatitis), bleeding from the gut

• Lungs - pneumonia, tuberculosis

• Osteoporosis (thin bones) causing fractures

• Fits 

• Obesity, especially in women (and not just from alcohol)

Additionally almost all mental health problems are more common. Of people with alcohol dependence:

• Up to 15% have a severe mental illness e.g. psychosis or bipolar mood disorder (1 in 50 people, 2%)

• Up to 80% have a mental health disorder such as depression (1 in 4 people, 28%), Generalised Anxiety Disorder (up to 1 in 2 people, 50%) e.g. panic disorder (1 in 25 people, 4%), Post-Traumatic Stress Disorder (PTSD) (1 in 12 people, 8%) and maybe 25% with social phobia

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There is no single cause of alcohol dependence. Alcohol changes how we feel, either mentally or physically. Some people don't like this; some people do and have a desire to repeat it.

However, the risk is higher in some people than others but risk is not destiny. Knowing if you are at greater risk of becoming alcoholic means you can take steps to stop yourself from getting problems with alcohol - like being aware of how much and how often you drink, why and when you drink and making sure you stick to recommended limits and have alcohol free days.

What is important to remember is that developing an alcohol use disorder is not all down to personal choice (although part of it is). On the other hand, taking control of your drinking and recovering from alcohol use disorder is primarily up to the individual. Finding help through treatment services and peer support groups like AA and NA can really improve your chances of success though.  

One of the things that increases someone's risk of becoming alcohol dependent is their genetics, alcoholism runs in families.  You are more likely to be alcohol dependent if you have an alcohol dependent parent, especially if you are female (Sørensen, 2011) even if you are adopted away at birth. This is probably due to something about the way the body handles alcohol.

The family environment is also very important though.  Children in households where at least one parent misuses alcohol not only learn by example to use alcohol for recreation and for coping; they are also more likely to witness domestic violence or suffer abuse or neglect themselves. Known risk factors include a lack of parent support, poor communication, harsh or inconsistent discipline, and physical or mental trauma.

The statistics speak for themselves. 1 in 9 (11%) men with no alcoholic parent becomes alcoholic. 1 in 3 (33%) men become alcoholic if they have at least one alcoholic parent

In adult life the risk of alcohol dependence is increased by:

• things which cause stress
• things which make it difficult to cope with stress and
• access to alcohol

such as:

• Unemployment, losing a job
• Stressful job, job where people drink heavily (eg running a pub)
• Staying with the same friends who use alcohol or drugs (4 times the risk)
• Financial problems
• Poor education
• Poverty
• Social isolation (Bereavement, Divorce, re-locating)
• Chronic disease, chronic pain
• Mental health problems - about 4 times more likely (1 in 10 people compared to 1 in 45)

Sometimes people start drinking to try to manage the symptoms of something else eg pain, anxiety, grief, insomnia, chronic anxiety, Attention Deficit Hyperactivity Disorder (ADHD) (e.g. to help sleep), depression, or social anxiety or phobia.

Personality traits such as low self-esteem, high personal expectations, low frustration levels, being impulsive, being a risk taker can increase the chances of alcohol use disorders.

Other things which contribute include

• Gender - alcoholism is 2-5 times more common in men than in women, although the number of women alcoholics is rising
• Culture e.g. if alcohol is seen as routine it is more likely than in societies where alcohol is frowned upon or banned
• Advertising (e.g. the alleged glamour of drink and drinking being seen as the cultural normal, social drinking)
• Peer pressure in some vulnerable people, including partners
• Availability - if it's cheap and readily available this increases the risk
• Preference for sweet tastes (Kranzler 2001)
• Having a parent with AUD, increases risk in sons and daughters, especially the latter (Sørensen, 2011)
• Having a mental health problem – about 4 times more likely (9.6% vs 2.2%)   

Once heavy drinking begins changes occur in the brain that make it more likely to carry on.

Firstly alcohol is a ‘sedative' drug, so it increases the activity of the GABA system in the brain. The brain will try to stay 'in balance', so as more sedative drug (alcohol) goes in, it adapts by increasing activity in the natural ‘accelerator' system (glutamate).  This means that if the alcohol intake stops, the brain will be out of balance with too much ‘accelerator', causing withdrawal symptoms including agitation, anxiety and even fits and hallucinations.

Secondly the brain learns certain behaviours so well that it can perform them without conscious thought; this saves it time and energy. It learns best behaviours that activate the ‘reward system' (this system uses a chemical called dopamine). Alcohol does this; so drinking behaviors are learnt sufficiently well that they can occur before the person has thought about them. What makes this even harder to control is that fact that repeated alcohol use may damage the ‘impulse control' systems needed to override these behaviours.

Thirdly the brain learns to link the ‘reward' it gets form alcohol with times, places and emotional states that have usually been around when the person drinks. When someone is trying to stop the brain will still expect a drink when these ‘triggers' occur. This leads to a really strong 'compulsion' or ‘craving' for alcohol and can even activate physical withdrawal symptoms. This makes it even harder for people to stop drinking.

But remember that a risk is not destiny. Knowing if you are at greater risk of becoming alcoholic means you can take steps to stop yourself from getting problems with alcohol. Or you can help someone else try not to have problems with alcohol. Getting an alcohol problem isn't necessarily always only the person's fault but it largely rests on their shoulders. 

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Long-term high intake of alcohol can lead to any of the following:

• Death: The Alcohol Harm Reduction Strategy 2006 estimated that 20,000 deaths a year are premature in some way due to alcohol, and (in 2007) 6541 deaths were directly due to alcohol misuse

• These include deaths in road incidents (not accidents, because they are avoidable). This does not only apply to drivers. Pedestrian and cyclists are also more likely to be injured or killed in a road accident if they have been drinking. Additionally, when the accident occurs, anyone else in the way may be hurt, whether they have been drinking of not.

• Accidents at work and elsewhere - up to 3 in 4 visits to A&E in UK at peak times may be due to alcohol misuse

• Weight gain - (a glass of wine has same calories as a bag of crisps, one beer the same as a jam doughnut) or weight loss - where the person's only intake of food is alcohol

• Liver damage - this starts to occur in about 9 in 10 (90%) alcoholics, alcoholic hepatitis occurs in nearly 1 in 2 (40%) of heavy drinkers and is a start on the way to cirrhosis of the liver (which can occur in 8-30%). 20 units a day for 5 years will cause major liver damage. It has been said that if you can have two drink-free days a week your liver won't develope cirrhosis (because it has time to recover on the drink-free days). 

• Brain damage - e.g. seizures or fits, stroke, alcohol-related Dementia " target="_blank">dementia and brain inflammation due to lack of thiamine (Wernicke's encephalopathy). This can lead to confusion, loss of balance, poor co-ordination, eye problems e.g. nystagmus and even death. Most of those who survive this have permanent loss of the ability to make new memories (called Korsakoff's syndrome). Alcohol also damages the part of the brain that controls balance (the cerebellum), which can lead to unsteadiness and poor coordination.

• Nerve damage - a syndrome called ‘peripheral neuropathy' where tingling, numbness and pain starts in the hand and feet and gradually extends up the arms and legs like a ‘glove and stocking' .

• Gut - risk of major bleeds from the gut, and stomach ulcers. Poor food absorption can occur so the person can become low on vitamins.

• Pancreatitis - inflammation of pancreas, this can lead to severe pain, death, or long term problems such as diabetes and malabsorption of food

• Heart disease - raised blood pressure, stroke, heart irregularities and heart attacks

• Cancer - 3% of cancers are thought to be alcohol-related, especially cancer of liver, stomach, bowels, breast, lung and pancreas, plus throat and mouth areas

• Sexual problems e.g. impotence, premature ejaculation

• Infections - especially of the chest

• Bones - osteoporosis causing thinning of the bones with increased risk of fractures

• Skin - worsening of skin diseases like psoriasis and eczema.

• Other physical problems like gout, falls, malnutrition and dehydration

• Mental health problems (in up to 80% people) - depression, anxiety, plus suicide, personality changes, hallucinations, loss of memory, loss of social skills

• Insomnia and sleep problems e.g. waking up a lot to go to the loo, getting dehydrated, headache, and alcohol upsets your normal sleep "architecture" (the so-call REM and non-REM sleep) which makes it less refreshing so you actually feel more tired

• Problems when stopping - see above

• Loss of driving license - if you continue to drink the DVLA must be told. If you don't then any health care professional you deal with has a duty to contact the DVLA. You may have your license revoked for six months or longer, especially if you drive HGVs.

• Social problems - 30% divorces, 40% cases of domestic violence and 20% of child abuse is associated with excess alcohol. Plus time off work, loss of jobs, losing things when drunk, making poor decisions e.g. unsafe or risky sexual behaviour, getting into fights or arguments

• Risk to any unborn child - slow growth, miscarriage, malformations, brain damage especially at 5 or more units a day

• Delayed puberty in younger people, plus slower bone growth in adolescents

• Alcohol can be a "gateway" drug to illicit substances

Having said this, around 1 in 5 people with a mild to moderate alcohol problem can sort themselves out without professional help and be dry or well controlled over the next 30 years (Moyer 2002) if they want to.

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If you stop suddenly, then you can get withdrawal symptoms. There are many serious withdrawal effects that need treatment as they can be life-threatening. See the link to alcohol withdrawal symptoms for a full list.

Other withdrawal symptoms can include:

• Depression

• Feeling nervous or anxious

• Difficulty sleeping

• Fatigue, alcohol craving, restlessness, confusion, sweating, muscular weakness

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The lists here include most of the main options for alcohol dependence but does not say what works and doesn't. Many may be used in combination. Most herbal and "Alternative Therapies" have not really been tested in the same way rigorous that medicines have. Probably the most important thing is consistently putting advice into practice. 

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment. 

Self-help

• Aiming for a realistic moderation, not necessarily abstention (unless you are pregnant, or have liver damage, in which case carrying on drinking will only lead to more damage)

• Avoiding high risk situations for drinking (eg going to the pub)

• Recognising prompts or cues for drinking (e.g. stress, being alone) and planning other ways to cope or avoid them

• Eating healthily to make sure you have enough thiamine (or taking thiamine tablets)

• Eating before drinking

• Drinking a soft drink for every alcoholic one, or having lower strength alcohol drinks

• Trying alternative activities to reduce drinking e.g. exercise, reading

• Don't take medicines called NSAIDs (usually used for pain and arthritis e.g. ibuprofen, aspirin, diclofenac), as this can make stomach damage worse

• Taking any medicines regularly and reliably

• Sorting out sources of stress eg Citizens' Advice, for e.g. money problems

• Alternative therapies have been tried. If they help you we wouldn't knock them, although they haven't been tested in the same way as medicines. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links), and homeopathy (click for a review of the 25 studies in mental health by Davidson 2011).

Help from others

• e.g. family, children, parents, and friends encouraging and helping you to cut down (gradually if you are dependent) and supporting you to try again if you lapse. Remember though that change is down to you and no-one else, however well intentioned, can do this for you.

• Peer pressure, help and moral support, especially if you relapse

More Specific treatments

• Self-help manuals - can be helpful at lower levels of consumption and may help with counseling

• Keeping a drinking diary so you have a better idea how much you are really drinking and working out the units. This can come as quite a shock, if you are truthful!

• A chat with your GP or health worker, called a Brief Intervention. If you are honest they can give you an idea how much harm you have already caused to your body, what is likely to get better if you stop and what may happen if you continue. They can also advise on safe ways to cut down and direct you to helpful services if necessary.

• Use of Alcoholics Anonymous and other mutual and self-help groups. AA use a 12-step programme to help you get control of your life and drinking, learn to deal with the errors of the past and live a new life

• Alcohol related counseling Extended brief interventions, if a brief one isn't enough:

  • Motivational interviewing, or Motivational Enhancement Therapy (MET is a type of talking therapy which helps to build and maintain motivation to stop drinking),

  • Cognitive Behavioural Therapy - a type of talking therapy that helps you in a problem-orientated way. It seems to be useful in the short-term 

  • Family therapy - to learn about alcohol dependence as a family and learn how to work together to help cutting down

  • Social behaviour and network therapy (SBNT), which may help

  • CRAFT (Community Reinforcement And Family Training)

• Counseling for other issues eg bereavement, past trauma which may help may be helpful long-term (although trauma focused therapy may be too much to cope with emotionally until you have been abstinent for a while)

• Alcohol detoxification - this is only necessary for those who are truly physically dependent. Also it does not treat the addiction - only the physical dependence - ie it doesn't stop someone wanting to drink, only the withdrawal symptoms.

After stopping it is easy to start to believe that you have got your control back and it is safe to have ‘the odd one or two'; but as many as 2 in 3 people relapse over the next 6 months after stopping.

Medicines

There are two sorts medicines to help alcohol dependence.

• One group helps people with severe dependence stop alcohol safely, and another group can help you keep off or manage your alcohol.

• Also if you have other physical or mental health problems e.g. anxiety, depression, Attention Deficit Hyperactivity Disorder (ADHD), Insomnia, then they need to be helped

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include: 

• side effects (which ones are important to you)
• any physical or mental health problems you may have which could make particular drugs more or less risky for you 
• local policies or agreements (such as what that GP surgery uses, in your area etc)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better to get best out of a medicine you are familiar with)
• relative costs for similar medicines
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms. They are listed in the British National Formulary (www.bnf.org/bnf/). To be listed in the BNF there needs to be good evidence that the medicine works and that the producers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

Main medicines: (BNF Listed)

• Acamprosate (Campral®) - to reduce craving and reward, can be started as the person stops alcohol

• Disulfiram (Antabuse®) - to make it unpleasant to drink, and called an adversive treatment

• Nalmefene (Selincro®) - this is a little bit similar to naltrexone and became available in March 2013

• Naltrexone (Adepend®) - to help reduce the reward from drinking and the craving (Adepend is the licensed version)

• Thiamine - to help correct a lack of the essential vitamin thiamine

• Vitamin B & C strong - to help a lack of thiamine and other vitamins

• Pabrinex can sometimes be useful if the person isn't fully stopping or withdrawing from alcohol but is just stopping for a few days. This might happen if they were in hospital after an accident or are having some surgery. It might be well worth having some Pabrinex to reduce the risk of harm to the brain from alcohol dependence.

Others:

• Baclofen - an old drug with a new role which may help but is unproven at the moment

• Hypnotics - for when not being able to sleep might be a prompt to drink

• Antidepressants - to help with any depression that may occur

• Anxiolytics - where anxiety is a main cause of drinking alcohol, especially social anxiety  

Alcohol withdrawal

There are medicines to help you stop drinking safely and to help the symptoms of alcohol withdrawal. Click here for the main medicines for alcohol withdrawal.

There are medicines or vitamins to help either treat alcohol dependence or the consequences of this. If someone is drinking too much because they are depressed, have long-term anxiety or other problems, then obviously treating these other causes as well will help the person overall. However, treating these with medicines and other therapies doesn't usually work unless you have stopped drinking first.

Sometimes the symptoms caused by a lack of these vitamins can be so severe that they look like being intoxicated.

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Download a handy summary chart comparing the main medications for alcohol dependence e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

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It is very difficult to say what are the most effective treatments, because everyone is different. However, a review has tried to put the various treatments in order. The top 10 are listed here, plus a couple of other ones, although this paper was from 2002 and there has been quite a lot published since then. The most effective treatments (based on evidence available) were, in order:

We haven't got the data yet for nalmefene, but guess it will be up near naltrexone.

Before you move on, the "Mesa Grande" score is based on the number of studies that have been done. One problem with this is that research is expensive to do. So, most research is done by companies with something to sell, eg medications, because they have the money to invest in research. This may mean that some treatments look better on the scale, not because they are more effective, but because there has been more research done on them. For example Alcoholics Anonymous (AA) scores badly because of the lack of studies, although it is clearly better than this in people who want to change and stick with it. It may be that 2 in 3 (65%) people going to AA have stopped drinking after a year, but have to be committed to stopping and go to every meeting. It doesn't seem to work if someone is forced to go.  

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Medicines can only help if you are motivated. Talking Therapies can help you to be more motivated but also sort out a whole load of other issues. Medicines alone are unlikely to be successful.

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

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This will depend on the medicine: 

• Acamprosate - it is recommended to take acamprosate for a year. It may help to take it longer than that.

• Nalmefene - is aimed at helping people reduce their alcohol intake. It seems to help for at least 6 months and probably up to 12 months if needed.  

• Naltrexone - is part of the overall treatment and so there is no set answer to this. You should probably take it for at least 3 months to start with, possibly even longer, and some people take it for over a year for alcohol dependence.

• Disulfiram - this is up to you and your doctor or key worker to decide. Many people take disulfiram for many years. Probably about 6 months is the minimum.

• Thiamine - this should be discussed with your doctor as different people respond differently. You will probably need to take it for at least 2-3 weeks to start with make sure your body stores build up again. It may be better if you take it for a lot longer. You should take it all the time while you are drinking, then for at least a month after you have stopped.

• Vitamin B compound tablets - you will probably need to take Vitamin B Co Strong for at least 2-3 weeks to start with make sure your body stores are built up again. You may then need to take Vitamin B Co for a lot longer after this to keep your vitamin levels healthy.

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Before starting it is sometimes a good idea to set out your aims of success in advance and be realistic with these.

We would mention that there is sometimes a danger or risk that switching medicines too quickly means you don't get the best out of one medicine and perhaps then search for the "magic bullet", expecting a miracle. No one develops alcohol dependence in a few days, rather over several or many years, so it is unfair to expect an improvement overnight

• Acamprosate - this should be started as soon as possible after you have stopped drinking alcohol. It will start to have an effect after about a week or so. The effect should build steadily over the next few months.

• Nalmefene - this starts to work in about 1-2 hours and the effect can last for about 12 hours

• Naltrexone - this starts to work in about an hour, the peak is after about an hour and the effect can last for 2-3 days.

• Disulfiram - the effect starts very quickly e.g. within a few hours. Because of this, you should not take disulfiram if you have had alcohol within the last 24 hours, or you may get an unpleasant reaction. The effect can last for up to two weeks after the last dose.

• Thiamine - in Wernicke's Encephalopathy (see question above), thiamine injection (as Pabrinex®) can start to have an effect in a few hours. The tablets are slower to work because not very much is absorbed into the body.

• Vitamin B Compound Strong - some of the effects of vitamin B co strong appear soon after taking it. However, the most important action to help the symptoms of vitamin deficiency may take weeks or even months of regular vitamin B co to become fully effective.

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called "polypharmacy") sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE. NICE is the National Institute for Health and Clinical Excellence. NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound (although sometimes controversial) guidance. They are, however, only "guidelines", so are not rigid instructions.
When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website: 

• Full guidelines (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals

• User-friendly summary for service users, carers and the general public

These are then reviewed every few years.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE has issued several clinical guidelines:

  • Physical complications of alcohol-use disorders (2010)

  • Public health guidance on preventing harmful drinking (2010)

  • Alcohol dependence and harmful alcohol use, advice on the diagnosis, assessment and management of harmful alcohol drinking in adults and young people aged 10-17 (February 2011)

• Scottish Intercollegiate Guidelines Network (SIGN) guidelines for the Management of harmful drinking and alcohol dependence (December 2004)

• Northern Ireland Department of Health, Social Services and Public Safety has guidelines, but not for alcohol dependence

• Department of Health "Review of the effectiveness of treatment for alcohol problems"

• BAP Guidelines on substance misuse, addiction and co-morbidity (2005) (for healthcare professionals)

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based more on their own experiences and what the published papers say rather than just what the published studies say).

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Use the resources below to find out more information about alcohol dependence. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

http://www.actiononaddiction.org.uk/

http://www.downyourdrink.org.uk/

http://www.alcoholics-anonymous.org.uk/

http://www.alcoholconcern.org.uk/

http://www.citizensadvice.org.uk/

http://www.knowyourlimits.info/, a really useful site from the Northern Ireland Public Health Agency

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

Information about local mental health trusts is available on the NHS Choices website.

The British Association for Psychopharmacology has a BAP public area, which has loads of interesting articles, some mentioning alcohol dependence.

The Big White Wall is a 16+ safe, anonymous web-based service for people experiencing emotional or psychological distress provided entirely online. Professionally staffed 24/7 it offers a wide range of services for improving mental wellbeing including tests, peer support, individual and group therapies, articles, tips and creative self expression. Simply click on the link to learn more, or to join for £2.00 a week.

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