In any discussion of alcohol-related problems, it is important to distinguish between use, misuse and dependence:

• Use – any ingestion of alcohol
• Misuse – a general term for any level of risk, ranging from increased risk to alcohol dependence
• Dependence – alcohol dependence is a particular form of misuse and, rather than being defined by intake, it is typified by an increased desire to use alcohol and difficulty in controlling its use, despite negative consequences. There is also a risk of alcohol withdrawal on stopping.

The NHS has developed terms to categorise levels of alcohol consumption to be used with patients. It is generally thought that these terms are easier for people to understand, and to accept, if they are to change their behaviour:

• Lower risk refers to drinking that is within the guidelines and is not likely to result in alcohol-related problems
• Increasing risk refers to regularly drinking more than two to three units a day for women and more than three
  to four units a day for men
• Higher risk refers to regularly drinking more than six units per day or 35 units per week for women or more than eight units per day or 50 units per week for men. Binge drinking is defined as drinking more than six units for women and more than eight units for men, i.e. twice the daily limit, on a regular basis.

Alcohol misuse with an increasing or higher risk can also be referred to as hazardous, harmful or dependent:

Hazardous drinking

This usually refers to someone who is regularly drinking above the recommended safe levels or has occasional high levels of alcohol intake associated with a risk of negative consequences for the drinker. These consequences may be damaging to physical and/or mental health, or they may include social consequences for the drinker or others.

People drinking these amounts may not have started to experience significant physical health consequences as a result of their drinking. However, if they continue to drink at this level, their risk of experiencing serious negative effects increases. This group of people are considered most appropriate for, and receptive to, brief advice and information.

Harmful drinking

The NHS clinical knowledge summaries describe harmful drinking (higher risk) as the level at which alcohol-related problems appear as either physical or mental health issues, such as liver damage or depressive episodes.

While brief advice may initially be offered to people drinking at harmful levels, there is little evidence that people drinking at this level will respond to such minimal intervention. Instead, they may benefit from a more structured intervention, ideally by someone with knowledge and experience of working with people with alcohol issues.

Dependent drinking

Dependence is characterised by an increased need to drink alcohol and difficulty in controlling its use, despite negative consequences. There are different levels of dependence, so it is important to diagnose the person accurately to ensure that any treatment pathway accurately meets their needs. 

A diagnosis of dependence is made when three or more of the International Classification of Disease (ICD-10) criteria for dependence are met.

The fact that someone is able to hold down a job, control their drinking when they need to, or not need a drink first thing in the morning does not necessarily mean that they are not a dependent drinker or alcoholic.

Whenever possible, rather than labelling a patient as a binge drinker or an alcoholic, it is best to describe their drinking behaviour as falling into the increasing risk category. This will allow them to focus on changing their drinking behaviour without feeling defensive about the terms being applied to them.

Now you've completed part one of this alcohol misuse module, move onto part two:

Part two: Alcohol as a drug.