Alcohol and other substances: when to seek help

Drinking is a continuum, and a person can move from one level to another in either direction.⁸ Three situations are usually distinguished:

• Risky (hazardous) drinking: a pattern that carries a risk of health consequences if it continues, but without visible problems yet. Heavy episodic drinking, a lot of alcohol on a single occasion, counts as risky drinking.⁸
• Harmful drinking: a pattern that already causes physical or psychological health problems, such as depression, accidents or pancreatitis.²
• Dependence: characterised by craving, tolerance, preoccupation with alcohol and continued drinking despite harmful consequences; it varies in severity.²

The World Health Organization stresses that no form of alcohol consumption is risk-free, although most harm comes from heavy drinking, whether episodic or continuous; alcohol is linked to liver and heart disease, several cancers and conditions such as depression and anxiety.⁵ With other substances, such as cannabis, cocaine or medicines used outside a prescription, the logic is similar: what matters is the pattern, loss of control and the impact on life.

Some signs deserve attention, in yourself or in someone close; with other substances, the signs are similar:^2,8

• drinking more, or more often, than intended;
• feeling such a strong urge to drink that it cannot be controlled;
• needing larger amounts for the same effect;
• spending long periods drinking or under the influence, or constantly thinking about the next drink;
• drinking interfering with work, study or home life, or causing emotional problems;
• drinking in situations where you could get hurt, such as before driving;
• carrying on despite consequences for health, such as liver disease or depression.

People who drink too much often play the problem down, and stigma makes it harder to ask for help; an honest, non-judgemental conversation is the starting point.¹

Closely, and in both directions. Alcohol use disorder often coexists with other psychiatric disorders, and the relationship varies: alcohol can cause or worsen symptoms, other disorders can lead to heavier drinking, and both may share genetic and environmental factors.⁶ When the two coexist, this is called a dual diagnosis.

In clinical practice, NICE recommends treating harmful drinking first in people who also have depression or anxiety, as this may bring a significant improvement in those symptoms; if depression or anxiety persist after three to four weeks without alcohol, they are assessed and treated in their own right.¹ Antidepressants should not be used routinely to treat alcohol misuse alone.¹ See also Depression and Anxiety.

As for sleep, drinking a lot before bed may help people fall asleep, but it disrupts the second half of the night and lowers sleep quality. With long-term drinking, sleep problems can persist into abstinence and contribute to relapse.⁷ The Insomnia page describes treatments that do not rely on alcohol.

An assessment is worthwhile when:

• you have tried to cut down or stop and could not;
• drinking or drug use is causing problems with health, work or relationships;
• you use alcohol or other substances to ease anxiety, low mood or insomnia, or these symptoms come with the drinking or drug use;
• you drink heavily every day and want to stop, because stopping should then be planned with a doctor;³
• someone close to you is worried about you.

Family members may also need support and information, including support groups for families.¹ Confusion, hallucinations or seizures after stopping drinking are a medical emergency.³

In people who are dependent on alcohol, a sudden reduction in drinking can cause a severe withdrawal syndrome.³ In its most severe forms, seizures or delirium tremens, a state of confusion with agitation and hallucinations, may occur and require hospital admission.³

For this reason, NICE advises people who are dependent and not in hospital to avoid a sudden reduction in drinking and to contact specialist support.³ Detoxification (assisted withdrawal) is done with medical supervision, usually in the community and, when there are added risks, such as previous seizures or delirium tremens, serious associated illness or very heavy drinking, as an inpatient.¹ Medication used at this stage, such as benzodiazepines, is prescribed and monitored by a doctor, and thiamine (vitamin B1) may be needed to prevent a neurological complication, Wernicke’s encephalopathy.³

The assessment looks at the pattern and amount of use, the severity of dependence, the risk of withdrawal, the physical, psychological and social consequences, and any other disorders.¹ Validated questionnaires are used, such as the AUDIT, which the Portuguese Directorate-General of Health recommends for early detection of excessive drinking in primary care.^1,8 Depending on the case, blood tests may be requested, for example of liver function.¹

The goal of treatment is agreed with the person. In dependence, and when there is significant psychiatric or physical illness, abstinence is usually the most appropriate goal; in harmful drinking or mild dependence, without other relevant problems, moderate drinking may be considered.¹

In psychiatry, the assessment takes place in a consultation, in person in Lisbon or by online consultation, in Portuguese, English or Spanish.

Treatment begins with a motivational intervention, which helps people recognise problems, resolve ambivalence and believe in their ability to change, in a supportive rather than confrontational way.¹ The options then include:

• Psychological interventions focused on drinking, such as cognitive behavioural and behavioural therapies, social network and environment-based therapies and, when a partner is willing, behavioural couples therapy.¹
• Medication to prevent relapse, after withdrawal, in moderate to severe dependence: acamprosate or oral naltrexone, combined with a psychological intervention; disulfiram is an alternative in specific situations, with close supervision.¹ A medical assessment with blood tests is done beforehand.¹
• Other substances: for drug misuse, NICE recommends psychosocial interventions such as contingency management and behavioural couples therapy, and treatment of associated mental health problems; self-help groups can be a useful addition.⁴

The plan is individual, reviewed over time, and involves the family when the person agrees.¹ When a goal of abstinence is not yet accepted, a harm reduction programme can be a first step.¹

In Portugal, specialist public services are run by the Instituto para os Comportamentos Aditivos e as Dependências (ICAD, I.P.), created in 2023 as the successor to the former SICAD.¹¹ ICAD offers:

• the 1414 helpline (Linha 1414), an anonymous, free and confidential advice, information and referral service on alcohol, other substances and addictive behaviours, which does not book appointments but helps people get in touch with services;⁹
• an online pre-registration form for referral to a specialist team;⁹
• a network of support services, such as Integrated Response Centres and Alcohol Units, searchable by district and municipality.¹⁰

The family doctor can provide early detection and a brief intervention, and refer to specialist care when there are signs of dependence.⁸ For non-urgent clinical advice, SNS 24 can help; a psychiatric consultation also assesses the anxiety, depression or insomnia that often accompany substance use.