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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

7.4 Early detection of at-risk drinking

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).6 Those with at-risk patterns of alcohol consumption should be offered brief advice on the risk in drinking (A).90 Motivational interviewing is both a useful and effective counselling strategy to facilitate a decrease of alcohol intake to low-risk drinking (I, B).91–94

Table 7.4.1. Alcohol-related complications: Identifying risk
Who is at risk?What should be done?How often?
Low risk*
All patients aged >15 years Ask about the quantity and frequency of alcohol intake (II, B) 6,95

The alcohol use disorder identification test-consumption (AUDIT-C) tool can be used to assess this (II, B)

Advise if drinking alcohol to drink two drinks or less per day or less and no more than four drinks on any one occasion (II, B)
Every two to four years (III, C)
Increased risk
Children and adolescents Advise children aged <15 years not to drink (III, B) 6,96,97

Advise young people aged 15–17 years to delay drinking as long as possible (III, B)
Opportunistically (III, C)
Older people† Inform that there is an increased risk of potential harm from drinking (III, B)98,99 Opportunistically (III, C)
Young adults, who have a higher risk of accidents and injuries100,101
People with a family history of alcohol dependence 102,103
Individuals who are participating in or supervising risky activities (eg driving, boating, extreme sports, diving, using illicit drugs) Advise that non-drinking is the safest option: driving (I, A), other areas (III, C) 104–106 Opportunistically (III, C)
Women who are pregnant or planning a pregnancy (refer to Chapter 1. Preventive activities prior to pregnancy) Advise that non-drinking is the safest option 107,108 At each antenatal visit (III, C)
People with a physical condition made worse by alcohol:
  • pancreatitis6
  • diabetes109
  • hepatitis/chronic liver disease110,111
  • hypertension6,112
  • sleep disorders6,113
  • sexual dysfunction114,115
  • other major organ disease
Advise that non-drinking is the safest option (II–IV, B)

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 (II, B)
Opportunistically (III, C)
People with a mental health problem made worse by alcohol (eg anxiety and depression)116–118 Assess whether there are possible harmful interactions between their medications and alcohol (II, A) Opportunistically (III, C)
People taking multiple medications119,120 Assess whether there are possible harmful interactions between their medications and alcohol (II, A) Opportunistically (III, C)
*There is some variability between the levels of low-risk drinking in the drinking guidelines for each country. The Australian guidelines, to be updated in 2016, represent the modal (or most common) recommendation.

†Older people who have a higher risk of falls and are more likely to be taking medication.121

AUDIT-C, alcohol use disorder identification test-consumption
Table 7.4.2. What advice, and to whom, should be provided?
What advice should be given to adults who drink alcohol?6 
Advise to limit their drinking to two drinks or less per day, and no more than four drinks on any one occasion (II, B)

Counsel everybody who consumes alcohol about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking (II, B)

Provide simple advice to reduce alcohol consumption to all patients drinking at potentially risky or high-risk levels (I, A)

Advise pregnant women not to drink alcohol (ie there are no safe drinking levels)
Table 7.4.3. Strategies to increase effectiveness 6
InterventionTechnique
Screening Early detection of at-risk drinking may be improved by asking patients about their drinking more frequently. New patient registration, health assessment, chronic disease or mental health assessments and care planning are acceptable times for enquiry 122,123
Brief intervention Screening and brief advice in general practice has been demonstrated to have resulted in a reduction in drinking of about four to six standard drinks per week for men90,124–126

While there is no clear dose-response curve for spending more time counselling subjects who are drinking at risky levels, the minimum time to achieve some impact is between five and 15 minutes. Although some have argued that screening, of itself, constitutes a brief intervention, the impact of interventions of less than five minutes is less clear 126–129

Components of effective interventions include124,130,131:
  • motivational interviewing, especially being more person-centred and eliciting change talk
  • asking about drinking and its consequences
  • personalised feedback about impact on health
  • goal setting
Management of dependence or heavy drinking Brief interventions and routine GP care are likely to be insufficient for patients with alcohol dependence or heavy drinking. Such patients should be referred to a drug and alcohol service132

Implementation

There is some evidence from earlier systematic reviews that for every 10 hazardous drinkers treated using brief interventions, one will reduce drinking to low-risk levels.102,133,134 For more information, refer to the RACGP’s SNAP guide, 2nd edn.82

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