Prevention of and early intervention in alcohol-related disorders

International roundtable discussion on 9 April 2019 in Berlin hosted by the BPtK

Beer, wine, and liquor are consumed in Europe more than anywhere else in the world. Young adults in particular often consume too much alcohol. Alcohol abuse leads to violence and death and increases the mortality rate by raising the incidence of numerous secondary diseases. Greater than ten per cent of all deaths in Europe are caused by alcohol abuse. Some 12 million EU citizens are alcohol-dependent, and around 9 million children in Europe live with alcoholic parents. While there are encouraging examples of initiatives to prevent alcohol abuse in some Member States, there is no effective, Europe-wide strategy in place to manage the consumption and sale of alcohol. Although psychotherapy can contribute significantly to both outpatient and inpatient care for alcoholics, it remains far too rare.

These were the key findings of a roundtable discussion titled "Prevention of and Early Intervention in Alcohol Disorders - Learning from Best-Practice Examples in Europe” held by the Federal Chamber of Psychotherapists (BPtK) in cooperation with the Network for Psychotherapeutic Care in Europe (NPCE) in Berlin on 9 April 2019. Participating in the discussion were experts from Belgium, Bulgaria, France, Ireland, Italy, Lithuania, Austria, Poland, Portugal, Romania, Hungary, Switzerland, Cyprus and Germany.

Opportunities and limitations of a European alcohol control policy

BPtK Vice-President Dr Nikolaus Melcop underlined the need for policies that prevent alcohol abuse effectively and that also facilitate the early detection and treatment of those at risk of suffering from alcohol abuse and those already ill. He contended that alcohol control policy in Germany is lopsidedly focused on education and behavioural prevention. Other EU Member States, he stated, have successfully implemented more effective alcohol control policies, including price controls, advertising bans and distribution restrictions. Yet, according to Dr Melcop, their effectiveness has been compromised by the less proactive measures of neighbouring countries. He argued that this, combined with the very high mobility of EU citizens and the interdependent nature of the EU market, necessitates complementary transnational measures.

It must, for example, be ensured that alcoholic beverages are labelled in a binding, transparent and consumer-friendly manner. Yet, the alcoholic beverage industry’s current proposal concerning ingredient labelling would satisfy neither public health requirements nor consumer protection standards as, according to Dr Melcop, little meaningful information would appear on alcohol products themselves. According to this proposal, consumers would have to go online to access further information. Dr Melcop remarked that it was foreseeable that such proposals for self-regulation would only delay the implementation of effective solutions. Public health, however, must take precedence over economic interests, he asserted.

The EU is explicitly obliged to improve public health and prevent disease. Sentence 4 of Article 168(1) of the Treaty on the Functioning of the European Union (TFEU) states: “The Union shall complement the Member States’ action in reducing drugs-related health damage, including information and prevention.” In addition and in particular, the European Parliament and the Council may, on the basis of Article 168(5) of the TFEU, adopt measures that “have as their direct objective the protection of public health regarding tobacco and the abuse of alcohol”.

In recent years, the European Parliament and the Council have repeatedly mandated the Commission to adopt a new alcohol strategy.

Panel of experts

The roundtable began with a presentation of conditions in particular Member States, as well as research findings and a number of best-practice examples. The participants then developed joint proposals for improving prevention, early detection, and treatment.

Austria (Alfred Uhl)

Alfred Uhl, deputy department head of the Competence Centre for Addiction at the Austrian Public Health Institute presented his country’s highly successful Sucht am Arbeitsplatz (Addiction in the Workplace) programme. He emphasised that the way in which people in Austria conduct themselves with alcohol had improved in recent decades and that consumption had become more moderate. He reported, however, that it was difficult to evaluate methodically the effectiveness of the particular measures taken. Dr Uhl said that it was important to pursue approaches that were non-ideological, patient-oriented, and diversified according to particular needs.

Portugal (Dr Jorge Gravanita and Patrícia António Brilhante)

Although alcohol consumption in Portugal is in line with the European average, a pattern of rising alcohol consumption amongst women and older people is a cause for concern, according to experts Patrícia António Brilhante of the Lisbon Alcoholic Unit ARSLVT and Dr Jorge Gravanita, President of the Portuguese Association of Clinical Psychologists (SPPC). They stressed the importance of including family members of those affected in therapy. Young people, they explained, require adult guidance to develop a healthy attitude toward alcohol consumption and that it is necessary to train psychotherapists in new therapeutic methods and to develop innovative programmes. They also contended that the public in all Member Countries needs to be made more aware of the work performed by psychotherapists in treating addiction and mental suffering in general.

Cyprus (Maria Karekla, PhD)

Maria Karekla from the University of Cyprus also underlined the importance of consuming alcohol in sensible quantities. Alcohol, she asserted, can be part of one’s day-to-day life without it providing any particular stimulus that can lead to its abuse. Dr Karekla stressed the importance of educating and sensitising the public better about the risks. Hospital and outpatient care, she said, are equally important to therapy, as is adequate emergency care.

Italy (Pierangelo Sardi)

“Although alcohol consumption is often downplayed, it is, in fact, responsible for more road accidents than illicit drugs and medicines. It must, therefore, be combated more effectively,” said Pierangelo Sardi, former president of Italy’s national association of psychotherapists. Dr Sardi said that the EU’s Driving under the Influence of Drugs, Alcohol and Medicines (DRUID) project had revealed how important the psychotherapeutic treatment of post-traumatic stress disorders is not only for victims but for perpetrators. He also emphasised that the confidentiality of psychotherapeutic consultations, which is assured by organising the profession into a single chamber, is an important guarantor of treatment.

Romania (Roman Viorel)

Since 2002, Roman Viorel has worked as a board member, project leader, managing director and psychologist at ALIAT, one of Romania’s leading NGOs devoted to fighting alcohol addiction and drug abuse. In addition to offering on-site professional help provided by multi-professional teams, ALIAT offers online counselling and a self-help app. “It’s important to reach out to people wherever they are – both online and in the community – and not wait for someone to come looking for help,” says Viorel. Such legal measures as the government’s zero-tolerance policy against drinking and driving and the country’s ban on drinking alcohol in public places, he said, are helpful.

Poland (Iga Jaracewska)

In Poland, the blood-alcohol content (BAC) limit for driving has been lowered to just 0.02%. Alcohol distribution and advertising are restricted. Iga Jaracewska, who among other things works as a trainer with Poland’s Motivational Interviewing Network of Trainers, proposed that information campaigns about tobacco use be employed as a model for Europe-wide measures against alcohol abuse. She explained that a value-based, non-intimidating approach to such campaigns is important.

Germany (Dr Nikolaus Melcop)

BPtK Vice-President Dr Nikolaus Melcop referred to the successes of campaigns such as Lieber schlau als blau (Better wise than drunk), which is aimed at young people, and Aktionswoche Alkohol (Alcohol Action Week), whose tagline in 2019 was “Alcohol? Less is better”. Overall, however, he felt that politicians in Germany relied too exclusively on people exercising self-control and taking personal responsibility for their actions. He reported that the introduction of effective context-related prevention measures already tried and tested in other countries, e.g. advertising restrictions, has thus far failed, due to insufficient political resonance. According to Dr Melcop, Germany’s addiction assistance system is comparatively well developed, but he said that there is still room for improvement, particularly with respect to prevention and early detection.

Ireland (Vasilis S. Vasiliou, PhD)

Ireland has the second highest rate of binge drinking in the world. Alcohol consumption and excessive drinking are also increasing among the female population. This trend has been countered by legal interventions made in 2018, such as an increase in the alcohol tax and stricter regulations concerning the distribution of alcohol. Dr Vasilis S. Vasiliou, a researcher at University College Cork (UCC), presented two best-practice examples – MiUSE (My Understanding of Substance & Alcohol Use Experiences) and REACT (Responding to Excessive Alcohol Consumption in Third Level) – both of which interactively target behavioural changes among students.

Switzerland (Veronica Isabel Defièbre)

Switzerland’s federally organised system also relies primarily on information and self-regulation. One such example is a campaign against alcohol abuse called “How much is too much?”. Considerable regulatory differences exist amongst the country’s cantons. Hence, for example, more limited opening hours in one canton simply lead people to purchase alcohol in neighbouring cantons with fewer restrictions. Veronica Isabel Defièbre of the Board of the Association of Swiss Psychotherapists (ASP) sees a need for improvement in the support provided to alcoholics in their everyday lives, for example through home visits by social workers, assisted living, and long-term psychotherapeutic treatment for chronic alcoholics.

Country reports

In Belgium, alcoholic products bear illustrated warnings of the dangers of consuming alcohol for pregnant women. The country has implemented an early-detection measure that appears to be worth imitating: Physicians are entitled to refer patients whom they suspect of consuming excessive amounts of alcohol to a one-day consultation and preventive examination. The report’s authors, Dr Salvatore Campanella and Dr Hendrik Kajosch from the Centre Hospitalier Universitaire Brugmann in Brussels, stressed the central importance of changing cultural paradigms. “Drinking has a positive public image and is socially accepted in Belgium. Consuming strong beer, for example, is promoted as a sign of masculinity: ‘If you can’t beer it, you are not strong enough.’”

In Bulgaria, health legislation earmarks one per cent of all state revenues from tobacco and alcohol sales to finance national anti-smoking and alcohol-abuse control programmes. According to Svetlana Nikolova, coordinator of Bulgaria’s national drug, alcohol and gambling helpline team and Dr Svetlana Velkova, a clinical psychologist at Fracarita Bulgaria, a rehab association for addicts, the treatment of alcohol addiction is problematic in many respects in Bulgaria. They report that financial resources are insufficient, that very few alcoholics ever receive psychological counselling, and that staffing shortages prevail. The authors point out the cultural differences that exist with respect to alcohol use. “In Bulgaria, people don’t ask themselves whether they should drink but how much they can drink and stay sober.”

In Lithuania, there has been a ban on alcohol advertising in all media since 2018. Business hours for purchasing alcohol have been shortened and the legal age for purchasing alcohol has been increased from 18 to 20 years. All alcoholic beverage packaging must feature health hazard warnings, e.g. about the link between alcohol consumption and cancer. The country’s BAC limit for driving has been lowered to 0.04%. Clinical psychologist Elena Gaudiesiute remarked: “The opportunity to obtain high-quality assistance through the national health insurance system is a really positive thing. This allows people with little or no income to get the help they need, too”.

France has a well-developed, tiered treatment model, but experts Barak Raz, Dr Dominik Straub and Dr Martine Schmuck from the ROANNE addiction centre in Lyon believe that it is necessary to focus even more on prevention and on involving family members in treatment: “The existing treatment options concentrate on the individual, but often neglect the familial dimension. There is a need for further psychotherapy aimed at combating the suffering and trauma that often occurs in a family across multiple generations”.

According to Dr MátéKapitány-Fövény, Prof. Dr Zsuzsanna Elekes and Dr Zsolt Demetrovics, alcohol consumption in Hungary has deep cultural roots. The country has one of the highest rates of heavy episodic (binge) drinking and the highest rates of cirrhosis in Europe. Meanwhile, the public health insurance scheme does not cover the cost of psychotherapy. When treating alcohol abuse, the majority of health care professionals focus on drug therapy. There is also no political strategy in place, they said. In addition to heavy drinking being socially accepted to a large degree, the country’s media outlets pay no attention to the problem, the report’s authors contended.

Alcohol prices and availability

The participants agreed that moderate alcohol consumption had to be learned and that alcohol should not be readily available. Countries with higher prices and stricter tax regimes have significantly lower per-capita alcohol consumption than those where alcoholic beverages are inexpensive. Higher prices are effective in reducing alcohol addiction.

Systematically strengthening prevention

There are many good examples of how to educate people about the dangers of alcohol consumption and of how young people, in particular, can strengthen their overall mental resilience. Such measures must be implemented across the board at every stage of educational development, from elementary school to university. The universities need to be more involved in the development of such measures.

Identifying risk early and providing comprehensive care

From a therapeutic point of view, there is an urgent need to implement a screening system that would identify those who are at risk of developing an alcohol-related disorder before they do so. Such a system must also care for those already dependent on alcohol according to individual needs (i.e. in a tiered, integrated and coordinated manner) and must include follow-up care for chronic alcoholics. Treatment must not be limited to purely physical detoxification but include withdrawal and weaning therapies, as well as psychotherapeutic (and psychosocial) interventions.

From positive individual examples to a Europe-wide strategy

The discussion also highlighted that the problems and challenges are similar everywhere. In every European country, the consumption of alcohol, a legal drug, has a massive negative impact on public health. Member States offer encouraging examples of how alcohol abuse can be prevented, but there is a lack of a Europe-wide effective policy to control alcohol consumption. It is therefore important that the European Commission, newly formed following the European elections last autumn, accept its mandate to draw up a new alcohol strategy. Such a strategy could provide a framework for a structured dialogue between Member States and could also make available financial resources for the exchange of best practices amongst them. It should also support the Member States in implementing national rules and regulations and, in the medium term, implement proven management approaches across Europe.


Kick-off Speech Dr Nikolaus Melcop

Biographies of the experts

Country Reports and Presentations