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Clinical guidelines

SNAP Guide

Alcohol

3.4.1 Ask and assess

All patients aged 15 years and older should be asked about the quantity and frequency of their alcohol intake,12,70 with the results logged in the patient record. The Alcohol Use Disorders Identification Test (AUDIT) or abbreviated, three-item AUDIT-C tool (Figure 2) can be utilised for this purpose.71,72

While formal assessment with such a tool is recommended in UK73 and Australian guidelines,74 GPs perceive barriers to its use.75

The AUDIT-C is a brief alcohol screen that reliably identifies patients who are hazardous drinkers or have active alcohol use disorders.

Each AUDIT-C question has a choice of five answers. It is scored on a scale of 0–12.

In men, a score of 4 or more, and in women, a score of 3 or more, is considered positive, optimal for identifying hazardous drinking or active alcohol use disorders. However, when the points are all from Question 1 alone (questions 2 and 3 are zero), it can be assumed that the patient is drinking below recommended limits and it is suggested the provider review the patient’s alcohol intake over recent months to confirm accuracy.76 Generally, the higher the score, the more likely it is that the patient’s drinking is affecting their safety.

Figure 2. The AUDIT-C tool

Audit-C Questionnaire

Patient name:
Date of visit:

  1. How often do you have a drink containing alcohol?
    1. Never
    2. Monthly or less
    3. 2–4 times a month
    4. 2–3 times a week
    5. 4 or more times a week
  2. How many standard drinks containing alcohol do you have on a typical day?
    1. 1 or 2
    2. 3 or 4
    3. 5 or 6
    4. 7 to 9
    5. 10 or more
  3. How often do you have six or more drinks on a single occasion?
    1. Never
    2. Less than monthly
    3. Monthly
    4. Weekly
    5. Daily or almost daily
a = 0 points; b = 1 point; c = 2 points; d = 3 points; e = 4 points

AUDIT-C is based on The Alcohol Use Disorders Identification Test. Reproduced, with the permission of the publisher, from The Alcohol Use Disorders Identification Test: guidelines for use in primary care, AUDIT, second edition. Geneva: World Health Organization; 2000. P 17. Available at http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf [Accessed 22 January 2015].

As some patients may be sensitive to your questions, it is important to be non-judgmental. A careful systematic enquiry is the most valid indicator of the patient’s current level of alcohol consumption and is more reliable than using a number of laboratory tests, including gamma glutamyl transferase (GGT) and mean cell volume (MCV).12

The lifetime risk of harm from drinking alcohol increases with the amount consumed. The risk of an alcohol-related problem increases dramatically with an increase in the number of drinks consumed.77 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.12 Short-term risks stem from the risks of accidents and injuries occurring immediately after drinking.

Alcohol consumption is calculated from the amount of alcoholic beverages, such as beer, cider, wine, spirits and mixed drinks, typically consumed in a day, combined with the number of days per week in which alcohol is usually consumed. Alcohol consumption is most often measured in standard drinks. An Australian standard drink contains 10 g of alcohol, which is equivalent to 12.5 mL of alcohol.12

Figure 3. The Australian standard drink

Reproduced with permission from: National Health and Medical Research Council.
Australian guidelines to reduce health risks from drinking alcohol. Canberra: NHMRC, 2009.
Available at www.nhmrc.gov.au/your-health/alcohol-guidelines [Accessed 3 October 2014].

Table 11. Alcohol: when, how and who to assess

Question

Answer

How often should I screen?

How should I screen?

Ask about the quantity and frequency of alcohol intake. The AUDIT-C tool can be utilised for this.

Every 2–4 years
(III–C)12

Who is at risk?

All patients aged 15 and older.

Every 2–4 years
(III–C)12

Who is at increased risk?

  • Children and adolescents.
  • Children younger than 15 should not drink (III–B).12
  • Young people aged 15–17 should delay drinking as long as possible (III–B).12
  • Older people.78–80
  • Young adults, who have a higher risk of accidents and injuries.81
  • People with a family history of alcohol dependence.82–84

Opportunistically (III–C)12

  • Individuals who are participating or supervising risky activities (eg. driving, boating, extreme sports, diving, using illicit drugs).
  • People with a physical condition made worse by alcohol, including:
    • pancreatitis
    • diabetes
    • hepatitis/chronic liver disease
    • peptic ulcer
    • hypertension
    • sleep disorders
    • sexual dysfunction
    • other major organ disease.
  • People living with a mental health issue made worse by alcohol (eg. anxiety and depression).
  • People taking medications – assess whether there are possible harmful interactions between their medications and alcohol (II–A).70

Opportunistically (III–C)85–95

  • Women who are pregnant or planning a pregnancy.

At preconception and antenatal visits (PP)12,96–98

What are the benefits and risks of preventive actions?

Numerous studies in Australia and the UK have shown that GPs providing brief advice have resulted in a 25–30% reduction in alcohol consumption and a 45% reduction in the number of excessive drinkers.

I–A70

 3.4.2 Advise and assist

Brief interventions to reduce alcohol consumption should be offered to all patients drinking at potentially risky or high-risk levels (A).12 People with at-risk patterns of alcohol consumption should be offered brief advice to reduce their intake,99 while people with high-risk use patterns should be provided with interventions using brief motivational interviewing.12,100,101

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.82,84,99,102,103 Patients are more likely to be responsive to changing their drinking if they see a connection between their drinking and a health problem, if they believe they can change and things will improve if they do.

Table 12. Alcohol: what advice should be provided (and to whom)?

Question

Answer

Level of evidence and strength of recommendation

What advice should be given to adults who drink alcohol?

Advise to drink two drinks per day, or less, and no more than four drinks on any one occasion.

II–B70

Everybody who uses alcohol should be counselled about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking. II–B70
Simple advice to reduce alcohol consumption should be given to all patients drinking at potentially risky or high-risk levels. I–A70
Pregnant women should consider abstaining from alcohol. PP

What advice should be given to children and adolescents?

Advise children younger than 15 not to drink.

Advise young people aged 15–17 to delay drinking as long as possible.

(III–B)12

What advice should be given to:

  • older people
  • young adults who have a higher risk of accidents and injuries81
  • people with a family history of alcohol dependence?82–84

Inform them there is an increased risk of potential harm from drinking.

(III–B)12

What advice should be given to individuals who are participating or supervising risky activities (eg. driving, boating, extreme sports, diving, using illicit drugs)?

Advise that non-drinking is the safest option.

(I-A) driving85–90

(III-C) other areas85–90

What advice should be given to women who are pregnant or planning a pregnancy?

Advise that non-drinking is the safest option.

(I–A)85–90

What advice should be given to individuals with a physical condition made worse by alcohol, including:

  • 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)85–90

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)85–90

Advice to patients and treatment options need to be tailored to patients’ needs and priorities.

Patients drinking at potentially risky or high-risk levels should be assessed according to their readiness to change their drinking pattern. Patients who are not ready should be offered information about the risks associated with their level of alcohol use. Avoid arguing with patients.

Patients who are ready should be provided with brief motivational counselling. Patients should be encouraged to set their own goals. Try to reach an agreement about the number of drinks per day and the number of alcohol-free days. Ask them to assess their own motivation and confidence in making a change.

Try to help patients to identify high-risk situations and encourage them to avoid these. Appropriate social support such as friends or family should be enlisted. Patients should also be given self-help material and information about available support services.

Assessment for assisted alcohol withdrawal

For those who typically score 20 or more on the AUDIT questionnaire or ≥5 on AUDIT–C,104 consider offering:

  • assessment for community-based assisted withdrawal
  • assessment and management in inpatient care if you have safety concerns (refer to criteria below) about a community-based assisted withdrawal.105

Consider inpatient or residential-assisted withdrawal if the person meets one or more of the following criteria:

  • Drinks more than 30 units of alcohol a day.
  • Has a score of more than 30 on the Severity of Alcohol Dependence Questionnaire (SADQ), which is a self-administered 20-item questionnaire designed by the WHO to measure severity of dependence on alcohol (www.drinksafely.info/SADQ).
  • Has a history of epilepsy or withdrawal-related seizures or delirium tremens during previous assisted withdrawal programs.
  • Needs concurrent withdrawal from alcohol and benzodiazepines.
  • Regularly drinks 15–20 units of alcohol a day and has psychiatric or physical comorbidities (eg. chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or a learning disability or cognitive impairment.105

Interventions for moderate and severe alcohol dependence

After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate* or oral naltrexone* in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) that focuses specifically on alcohol misuse. Obtain and document informed consent before prescribing.105

Consider offering interventions to promote abstinence and prevent relapse as part of an intensive and structured community-based intervention for people with moderate and severe alcohol dependence who have:

  • very limited social support (eg. live alone or have very little contact with family or friends)
  • complex physical or psychiatric comorbidities
  • not responded to initial community-based interventions to promote abstinence or moderate drinking.105

* Contraindicated in pregnancy and severe liver or renal disease.

3.4.3 Arrange

Patients who have more severe problems with their alcohol consumption or who fail to respond to brief interventions should be referred to a local drug and alcohol counsellor or service. Patients who drink alcohol at high-risk or potentially risky levels who also have a chronic medical condition and complex needs may benefit from a GP Management Plan and Team Care Arrangement under Medicare’s CDM GP services (formerly Enhanced Primary Care). Refer to Chapter 4 and Chapter 5 for more information about what is available under Medicare, including links to MBS templates.

Table 13. Alcohol: telephone information services

State/territory

Alcohol and Drug Information Service (ADIS) 24-hour hotline

New South Wales

Ph: (02) 9361 8000

Toll free number: 1800 422 599

Western Australia

Ph: (08) 9442 5000

Toll free number: 1800 198 024

Queensland

Ph: (07) 3236 2414

Toll free number: 1800 177 833

South Australia

Ph: (08) 8363 8618

Toll free number: 1300 131 340

Northern Territory

Ph: (08) 8922 8399

Toll free number: 1800 131 350

Tasmania

Ph: (03) 9416 1818

Toll free number: 1800 811 994

Australian Capital Territory

Ph: (02) 6207 9977

Toll free number: 1800 422 599

Victoria

Ph: Alcohol and Drug Direct Line 1800 888 236

Further referral services can be found in Chapter 5. A local directory of services for patients with alcohol services may be compiled for a general practice (refer to Section 4.5.4).

Follow-up

Patients should be reviewed 1–3 months after their first visit in order to monitor progress and review their goals. The practice information system should generate reminders or lists of patients overdue for follow-up (refer to Section 4.5.1). Most relapses in behaviour occur in the first few weeks and patients should be counselled that they should keep trying even if they have relapsed.

References

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