Preventive activities in general practice 7th edition | Early detection of problem drinking

Introduction and user guide

Preventive activities before pregnancy

Genetic counselling and testing

Preventive activities in children and young people

Preventive activities in middle age

Preventive activities in older age

Communicable diseases

Prevention of chronic disease

Prevention of vascular and metabolic disease

Early detection of cancers

Psychosocial

Screening tests of unproven benefit

Appendices

Disclaimer

Early detection of problem drinking

Early detection of problem drinking age range table
Age	0 - 9	10 - 14	15 - 19	20 - 24	25 - 29	30 - 34	35 - 39	40 - 44	45 - 49	50 - 54	55 - 59	60 - 64	65 - 69	70 - 79	>80
			X	X	X	X	X	X	X	X	X	X	X	X	X

Early detection of problem drinking age range table

Age

0 - 9

10 - 14

15 - 19

20 - 24

25 - 29

30 - 34

35 - 39

40 - 44

45 - 49

50 - 54

55 - 59

60 - 64

65 - 69

70 - 79

>80

All patients should be asked about the quantity and frequency of alcohol intake from 15 years of age (A). Those with at risk patterns of alcohol consumption should be offered brief advice to reduce their intake (A).

Early detection of problem drinking: Risk
Who is at higher risk of developing alcohol related complications?	What should be done?	How often?	Level of evidence and references
Low risk
All patients 18 years of age and over	Ask about the quantity and frequency of alcohol intake. Be sensitive in your questioning and avoid using judgmental descriptors (eg. social drinker) Advise if drinking alcohol to drink two drinks per day or less	Every 3-4 years	II B 47,208
Those with lower body weight (<60 kg for men, <50 kg for women) Overweight or obese adults	Advise if drinking alcohol to drink less than two drinks per day
Increased risk
Children and adolescents	Advise that not drinking is the safest option Any drinking should not exceed a maximum of two drinks per day and should be under parental supervision Interventions using brief motivational interviewing targeted at high risk use	Opportunistically	III 47
I B 245
Older people who have a higher risk of falls and are more likely to be taking medication	Advise that there is an increased risk of potential harm from drinking	Opportunistically	III B 246-248
Young adults, who have a higher risk of accidents and injuries	Opportunistically	III C 249
Those with a family history of alcohol dependence	Opportunistically	III C 250-252
Those who are participating or supervising risky activities (eg. driving, boating, extreme sports, diving, using illicit drugs)	Advise that not drinking is the safest option	Opportunistically	Driving I 253 Other areas III 254-257
Women who are pregnant or planning a pregnancy	Opportunistically or at each antenatal visit	I 47,258,259
Those with a physical condition made worse by alcohol such as: pancreatitis hepatitis/chronic liver disease peptic ulcer, hypertension other major organ disease	Advise that not drinking is the safest option but weigh up pros and cons for each individual Advise those with hypertension, or taking antihypertensive medication to limit alcohol intake to no more than two (for men) or one (for women) standard drinks per day	Opportunistically	I 47,260-262
Those with a mental health problem made worse by alcohol such as anxiety or depression		Opportunistically	I 263-265
Those taking medications	Opportunistically	I 266,267

Early detection of problem drinking: Risk

Who is at higher risk of developing alcohol related complications?

What should be done?

How often?

Level of evidence and references

Low risk

All patients 18 years of age and over

Ask about the quantity and frequency of alcohol intake. Be sensitive in your questioning and avoid using judgmental descriptors (eg. social drinker)

Advise if drinking alcohol to drink two drinks per day or less

Every 3-4 years

II B 47,208

Those with lower body weight (<60 kg for men, <50 kg for women)
Overweight or obese adults

Advise if drinking alcohol to drink less than two drinks per day

Increased risk

Children and adolescents

Advise that not drinking is the safest option

Any drinking should not exceed a maximum of two drinks per day and should be under parental supervision

Interventions using brief motivational interviewing targeted at high risk use

Opportunistically

III 47

I B 245

Older people who have a higher risk of falls and are more likely to be taking medication

Advise that there is an increased risk of potential harm from drinking

Opportunistically

III B 246-248

Young adults, who have a higher risk of accidents and injuries

Opportunistically

III C 249

Those with a family history of alcohol dependence

Opportunistically

III C 250-252

Those who are participating or supervising risky activities (eg. driving, boating, extreme sports, diving, using illicit drugs)

Advise that not drinking is the safest option

Opportunistically

Driving I 253

Other areas III 254-257

Women who are pregnant or planning a pregnancy

Opportunistically or at each antenatal visit

I 47,258,259

Those with a physical condition made worse by alcohol such as:

pancreatitis
hepatitis/chronic liver disease
peptic ulcer, hypertension
other major organ disease

Advise that not drinking is the safest option but weigh up pros and cons for each individual

Advise those with hypertension, or taking antihypertensive medication to limit alcohol intake to no more than two (for men) or one (for women) standard drinks per day

Opportunistically

I 47,260-262

Those with a mental health problem made worse by alcohol such as anxiety or depression

Opportunistically

I 263-265

Those taking medications

Opportunistically

I 266,267

Early detection of problem drinking: Intervention
Intervention	Technique	References
Brief intervention	Brief interventions for problem drinking halve the mortality rate in this group. Brief advice in general practice has been demonstrated to have resulted in a reduction in drinking of about six standard drinks per week for men. The impact of brief advice on reduction in consumption for women is less clear. While there is no clear dose response curve for spending more time counselling patients who are drinking at risky levels, the minimum time to achieve some impact is 5–15 minutes. While some have argued that screening of itself constitutes a brief intervention, the impact of interventions of less than 5 minutes is both modest and not significant The key components of brief advice should include the 5As. The AUDIT-C tool can be used (available at www.cqaimh.org/pdf/tool_auditc.pdf)	250–252 268–275
Pharmacotherapy	Both naltrexone and acamprosate can be used in patients with alcohol dependence. Naltrexone: significant effect on the maintenance of abstinence as well as the prevention of heavy drinking better in preventing a lapse from becoming a relapse used as an adjunct to treatment in patients with alcohol dependence common (and usually transient) side effects include: nausea, headache, dizziness, fatigue and insomnia should not be used in patients with acute hepatitis (or where the liver enzymes are three times, or greater, the upper limit of normal Acamprosate: supports abstinence from drinking does not influence or moderate alcohol consumption after the initial drink found to be more effective in preventing lapse can be prescribed as part of a comprehensive alcohol treatment program diarrhoea is a common side effect should not be used in patients with significant renal impairment (creatinine >0.12 mmol/L) not recommended for use in those aged 65 years and over	276-278

Early detection of problem drinking: Intervention

Intervention

Technique

References

Brief intervention

Brief interventions for problem drinking halve the mortality rate in this group. Brief advice in general practice has been demonstrated to have resulted in a reduction in drinking of about six standard drinks per week for men. The impact of brief advice on reduction in consumption for women is less clear. While there is no clear dose response curve for spending more time counselling patients who are drinking at risky levels, the minimum time to achieve some impact is 5–15 minutes. While some have argued that screening of itself constitutes a brief intervention, the impact of interventions of less than 5 minutes is both modest and not significant

The key components of brief advice should include the 5As. The AUDIT-C tool can be used (available at www.cqaimh.org/pdf/tool_auditc.pdf)

250–252
268–275

Pharmacotherapy

Both naltrexone and acamprosate can be used in patients with alcohol dependence.

Naltrexone:

significant effect on the maintenance of abstinence as well as the prevention of heavy drinking
better in preventing a lapse from becoming a relapse
used as an adjunct to treatment in patients with alcohol dependence
common (and usually transient) side effects include: nausea, headache, dizziness, fatigue and insomnia
should not be used in patients with acute hepatitis (or where the liver enzymes are three times, or greater, the upper limit of normal

Acamprosate:

supports abstinence from drinking
does not influence or moderate alcohol consumption after the initial drink
found to be more effective in preventing lapse
can be prescribed as part of a comprehensive alcohol treatment program
diarrhoea is a common side effect
should not be used in patients with significant renal impairment (creatinine >0.12 mmol/L)
not recommended for use in those aged 65 years and over

276-278

Implementation

In the Australian setting, less than one in 3 women and one in 6 men with documented alcohol dependence seek any form of treatment.²⁷⁹ The barriers to identifying and treating patients with risky or problematic drinking are numerous and include: stigma associated with diagnosis, gender (females being less likely to receive treatment), shorter consultations, self perceived skills and skepticism about the benefit of treatment.^280–284 Nevertheless the number needed to treat (return on effort) using brief interventions is one in 8, ie. eight hazardous drinkers needed to be treated to produce one who will reduce drinking to low risk levels.^{250,252,269,270,285}

Implementation is improved through:

screening/routine enquiry of all patients in the target group, especially using nonconfrontational tools such as computerised screening.^286–288 Alternatively, embedding enquiry about drinking in opportunistic assessment of lifestyle or using the AUDIT-C questionnaire^275,289(see Appendix 1 or www.cqaimh.org/pdf/tool_auditc.pdf)
ensuring that there is a supportive organisational practice infrastructure^286,290,291 and adequate training for clinicians^290–292 and practice nurses.^281,290,293

Guidelines for preventive activities in general practice 7th edition

Full index

Introduction and user guide

Preventive activities before pregnancy

Genetic counselling and testing

Preventive activities in children and young people

Preventive activities in middle age

Preventive activities in older age

Communicable diseases

Prevention of chronic disease

Prevention of vascular and metabolic disease

Early detection of cancers

Psychosocial

Oral hygiene

Glaucoma

Urinary incontinence

Osteoporosis

Screening tests of unproven benefit

References

Appendices

Glossary

Acronyms

Acknowledgements

Disclaimer

Early detection of problem drinking

Implementation