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Clinical guidelines

Guidelines for preventive activities in general practice 8th edition

7.4 Early detection of problem 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 age 15 years (A). Those with at-risk patterns of alcohol consumption should be offered brief advice to reduce their intake348 (A). Provide interventions using brief motivational interviewing targeted at high-risk use (I,B).349-351

The lifetime risk of harm from drinking alcohol increases with the amount consumed. For healthy men and women, drinking no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease or injury. Short-term risks stem from the risks of accidents and injuries occurring immediately after drinking.

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 and over
Ask about the quantity and frequency of alcohol intake (II,B).
Advise if drinking alcohol to drink two drinks per day or less and no more than four drinks on any one occasion (II,B).
Every 2–4 years (III,C)44
Increased risk
  • Children and adolescents
Advise children aged under 15 years not to drink (III,B).
Advise young people aged 15–17 years to delay drinking as long as possible (III,B).
Opportunistically (III,C)44
  • Older people*352-354
Inform that there is an increased risk of potential harm from drinking (III,B). Opportunistically (III,C)
  • Young adults, who have a higher risk of accidents and injuries355
  • People with a family history of alcohol dependence356-358
  • Individuals who are participating or supervising risky activities (e.g. driving, boating, extreme sports, diving, using illicit drugs)
Advise that non-drinking is the safest option: driving (I,A), other areas (III,C). Opportunistically (III,C)359,360,361-364
  • Women who are pregnant or planning a pregnancy
Advise that non-drinking is the safest option (I,A). Opportunistically or at each antenatal visit (III,C)44,365,366
  • People with a physical condition made worse by alcohol:
    • pancreatitis
    • diabetes
    • hepatitis/chronic liver disease
    • peptic ulcer
    • hypertension
    • sleep disorders
    • sexual dysfunction
    • other major organ disease
Advise that non-drinking is the safest option but weigh up pros and cons for each individual (I,A).
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)44,367
  • People with a mental health problem made worse by alcohol (e.g. anxiety and depression)
Assess whether there are possible harmful interactions between their medications and alcohol (II,A). Opportunistically (III,C)368-370
  • People taking medications
Opportunistically (III,C)371,372

* Older people who have a higher risk of falls and are more likely to be taking medication.354

Table 7.4.2 Alcohol-related complications: preventive interventions
InterventionTechnique
Brief intervention
  • Brief interventions for problem drinkers halve the mortality rate in this group.44, 373
  • 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.238,348,356,374,375
  • The impact of brief advice on reduction in consumption for women is less clear.356-358,374,375
  • While there is no clear dose–response curve for spending more time counselling subjects who are drinking at risky levels358,375,376, the minimum time to achieve some impact is between 5 and 15 minutes.238
  • While some have argued that screening of itself constitutes a brief intervention377, the impact of interventions of less than 5 minutes is less clear.356,376,378

Implementation

Strategy

In the Australian setting, fewer than one in three females and one in six males with documented alcohol dependence seek any form of treatment.379 The barriers to identifying and treating patients with risky or problematic drinking are numerous380-385 and include: stigma associated with diagnosis, gender (females less likely to receive treatment), shorter consultations, self-perceived skills and scepticism about the benefit of treatment. Nevertheless, the number needed to treat (return on effort) using brief interventions is one in eight: eight hazardous drinkers need to be treated to produce one who will reduce drinking to low risk levels.238,356,358,374,375,386

Implementation is improved through:

  • screening/routine enquiry of all patients in the target group, especially using non-confrontational tools
    (e.g. computerised screening).387-389 Alternatively, embed enquiry about drinking in opportunistic assessment of lifestyle or use a structured questionnaire, for example the AUDIT-C (Appendix 3).390, 391 (Note that the risk assessment should use the NHMRC guidelines and not other structured questionnaires, e.g. AUDIT-C.)
  • addressing barriers,392,393 for example, ensuring that there is a supportive organisational practice
    infrastructure387,394,395 and adequate training for clinicians394-396 and practice nurses.381,394,397

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