National Guide

Chapter 2 | Healthy living and health risks

Alcohol







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      6. Alcohol

Healthy living and health risks | Alcohol

Dr Marguerite Tracy   

Key messages

  • In Australia, alcohol is the leading cause of loss of healthy life for all people aged 15–44 years.1
  • There are no clear physical health benefits from alcohol, including at low levels of consumption.2
  • The amount of and regularity with which alcohol is consumed vary across individuals and communities. Assuming a regular pattern of alcohol use may underestimate alcohol use in some communities of Aboriginal and Torres Strait Islander people.3
  • Current Australian guidelines (2020) for harm minimisation from alcohol make recommendations for three distinct groups of people (adults; children and people aged under 18 years; and women who are pregnant or breastfeeding),2 including:
    • a maximum of four standard drinks per drinking day
    • no more than 10 standard drinks across the week (previously 14 drinks per week)
    • there is no safe level of drinking during preconception, pregnancy and breastfeeding
    • no alcohol for those aged under 18 years.
  • Opportunistic screening for hazardous or harmful alcohol use and alcohol dependence is recommended using validated screening tools such as the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) and Indigenous Risk Impact Screen (IRIS).4
  • Brief intervention and further support are the next steps when screening identifies a person who is drinking alcohol with a high risk of harms.5
  • Highlighting the benefits of not consuming alcohol may be more helpful for some people than emphasising the negative consequences of consuming alcohol.
Type of preventive activity - Immunisation
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All people Check vaccination eligibility for hepatitis B and A according to the Australian immunisation handbook

Recommend vaccination for eligible people		 Opportunistically Strong National guideline6 Immunisation is a harm reduction strategy for reducing harms from alcohol use; infection with hepatitis viruses can hasten alcohol-related liver disease
Type of preventive activity - Screening
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Adults aged over 18 years Ask about alcohol use and use a validated screening tool (eg AUDIT-C or IRIS) that detects hazardous, harmful alcohol use and2 dependence (see Box 1) Opportunistically Strong National guidelines 2,5,7

Aboriginal and Torres Strait Islander-specific resource7		 Identification of harmful alcohol use and dependence are essential to minimise the harms of alcohol use
Type of preventive activity - Behavioural
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Children aged 12–17 years Discuss alcohol use with young people and use a validated tool, such as HEEADSSS (Home, Education/Employment, Eating/Exercise, Activities, Drugs and alcohol, Sexuality, Suicide and depression, Safety) assessment8

If appropriate, use CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) as a further assessment for risk of harms (see Box 2)

Advise not to drink alcohol to reduce the risk of injury and other harms		 Opportunistically Good practice point National guidelines2,5
Aboriginal and Torres Strait Islander-specific resource7		 Although US guidelines report insufficient evidence for whole-population screening for those aged 12–17 years, sensitive and appropriate exploration using a tool such as HEEADSSS may identify early issues with alcohol use, providing opportunities for intervention
Adults aged over 18 years Provide information on how to reduce the risk of harm from alcohol-related disease or injury (see Box 3), including the risk of prenatal exposure to alcohol during pregnancy Opportunistically Good practice point National guidelines2,5
Aboriginal and Torres Strait Islander-specific resource7		 Drinking alcohol has a risk of associated physical harms. Recommending and reinforcing levels of alcohol consumption within guidelines minimises those harms

Promoting the national guidelines for alcohol consumption creates awareness of the potential hazards of alcohol consumption
Women considering pregnancy, pregnant and who are breastfeeding Recommend abstinence from alcohol (see Box 3) Opportunistically Strong National guideline2
Aboriginal and Torres Strait Islander-specific resource7		 Prenatal exposure to alcohol is associated with a range of harms, including fetal alcohol spectrum disorder, low birth weight and pregnancy loss
For those identified at risk of harm from alcohol Provide a brief intervention to individuals who are drinking above National Health and Medical Research Council (NHMRC)-recommended guidelines (eg using the FLAGS [Feedback, Listen, Advice, Goals, Strategies] framework; see Box 4) Opportunistically, following screening Strong National guideline2
Aboriginal and Torres Strait Islander-specific resource7		 A brief intervention alone is not sufficient for people with severe alcohol-related problems or alcohol dependence

Strongly consider more extended intervention and/or referral
Children aged 12–17 years and their carers Recommend abstinence from alcohol (see Box 3) Opportunistically Good practice point National guideline2
Aboriginal and Torres Strait Islander-specific resource7
Single study9		 Drinking alcohol has a risk of associated physical harms, and binge drinking is an antecedent to depression in adolescent females. Recommending and reinforcing the message that alcohol consumption should be delayed as long as possible minimises those harms

Promoting the national guidelines for alcohol consumption creates awareness of the potential hazards of alcohol consumption; however, there is not strong evidence that it reduces alcohol consumption
Type of preventive activity - Environmental
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All people Support people and their community to be involved in decisions regarding access and use of alcohol where they live Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific consensus statement10

Aboriginal and Torres Strait Islander-specific individual study 11		 Policy and practice regarding alcohol access and use should involve community. Significant harms have arisen when policy has been implemented without this consultation
All people Provide access to culturally safe screening, assessment and care Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific individual studies12–14 Providing culturally safe environments for people seeking assessment and treatment in primary care may improve access and adherence to treatment
  • Use simple messaging around the benefits of not drinking alcohol and the potential harms of drinking alcohol.
  • Visual aids can be useful in communicating risks from consuming alcohol, such as the University of Sydney Alcohol Awareness kit and alcohol booklet.
  • Remember to ask about sharing of alcohol and dry periods when you are assessing drinking. Because some people will only be episodic drinkers, and may not consider themselves a ‘drinker’, check about drinking during special occasions in the past year.
  • Be sensitive to internalised shame around drinking.
  • Staff training and support, and service-wide action to improve alcohol care, may assist with the implementation of screening.

Clinical guidelines

Other resources for health professionals

Professional development

Tools

Box 1. AUDIT-C screening questionnaire and scoring
Reproduced from Bradley et al.4
AUDIT-C screening questionnaire
1. How often do you have a drink containing alcohol?
  • Never (0 points)
  • Monthly or less (1 point)
  • Two to four times a month (2 points)
  • Two to three times a week (3 points)
  • Four or more times a week (4 points)
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
  • One or two (0 points)
  • Three or four (1 point)
  • Five or six (2 points)
  • Seven to nine (3 points)
  • 10 or more (4 points)
3. How often do you have six or more drinks on one occasion?
  • Never (0 points)
  • Less than monthly (1 point)
  • Monthly (2 points)
  • Weekly (3 points)
  • Daily or almost daily (4 points)
The AUDIT-C, a WHO-approved instrument, is scored on a scale of 0–12, with a score of 0 reflecting no alcohol use. Scores of 4 or more in men and 3 or more in women are considered positive for identifying hazardous drinking or active alcohol use disorders. Generally, the higher the AUDIT-C score, the more likely it is that the patient's drinking is affecting their health and safety.

Box 2. The CRAFFT questions
Reproduced from Knight et al.17

C

Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

R

Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

A

. Do you ever use alcohol or drugs while you are by yourself, or ALONE?

F

Do you ever FORGET things you did while using alcohol or drugs?

F

Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

T

Have you ever gotten into TROUBLE while you were using alcohol or drugs?

Box 3. Guidelines to reduce health risks from alcohol
Reproduced from the 2020 Australian guidelines to reduce health risks from drinking alcohol.2

The Australian (2020) guidelines for reducing harms from alcohol are as follows:

Guideline 1: For adults

  • To reduce the risk of harm from alcohol-related disease or injury, healthy men and women should drink no more than 10 standard drinks a week and no more than four standard drinks on any one day. (One standard drink contains 10 g of pure alcohol.)

  • The less you drink, the lower your risk of harm from alcohol.

Guideline 2: For children and people aged under 18 years

  • To reduce the risk of injury and other harms to health, children and people aged under 18 years should not drink alcohol.

Guideline 3: For women who are pregnant or breastfeeding

  • To prevent harm from alcohol to their unborn child, women who are pregnant or planning a pregnancy should not drink alcohol.

  • For women who are breastfeeding, not drinking alcohol is safest for their baby.

Box 4. FLAGS framework for alcohol brief intervention
Adapted from Haber and Riordan.5

Feedback 

  • Provide individualised feedback on any harms experienced and the risks associated with continued drinking, based on current drinking patterns, problem indicators and health status

  • Discuss the potential health problems that can arise from risky alcohol use

Listen

  • Listen to the patient’s response

  • This should spark a discussion of the patient’s consumption level and how it relates to general population consumption and any false beliefs held by the patient

Advice

  • Give clear advice about the importance of changing current drinking patterns and a recommended level of consumption

  • A typical 5- to 10-minute brief intervention should involve advice on reducing consumption in a persuasive but non-judgmental way

  • Advice can be supported by self-help materials, which provide information about the potential harms of risky alcohol consumption and can provide additional motivation to change

Goals 

  • Discuss the safe drinking limits and assist the patient to set specific goals for changing patterns of consumption

  • Instil optimism in the patient that their chosen goals can be achieved

  • Use motivation-enhancing techniques to encourage patients to develop, implement and commit to plans to stop drinking

Strategies

  • Ask the patient to suggest some strategies for achieving their goals. This approach emphasises the individual’s choice to reduce drinking and allows them to choose the approach best suited to their own situation. The individual might consider setting a specific limit on alcohol consumption, learning to recognise the antecedents of drinking and developing skills to avoid drinking in high-risk situations, pacing one’s drinking and learning to cope with everyday problems that lead to drinking

Background

Aboriginal and Torres Strait Islander people experience ongoing burden and trauma due to colonisation that places the community at increased risk of harms due to substance use, including alcohol.18,19 The culture and ways of being, doing and knowing of Aboriginal and Torres Strait Islander peoples are a source of strength that can be integrated into the prevention and treatment of harms from alcohol use for the whole population.12

There are no clear physical health benefits from alcohol, including at low levels of consumption.2 Many people experience some social benefits with the use of alcohol, such as increased engagement in social settings. However, alcohol has well-recognised physical and other harms. Harms can affect individuals, families, unborn children and the community. Those harms can be due to acute intoxication, such as traffic-related accidents, family and domestic violence and other trauma, and less immediate consequences, including harmful use or dependance,20 fetal alcohol spectrum disorder (FASD), an increase in non-communicable chronic diseases and several cancers (breast, colon and rectum, pancreas, liver, oesophagus, mouth and throat and pharynx).21,22

Alcohol use is responsible for 4.5% of the total burden of disease in Australia.19 The global burden of disease is estimated at 5.1%, and alcohol contributes to over three million deaths annually worldwide.23 In Australia, alcohol is the leading cause of loss of healthy life for all people aged 15–44 years.1 Alcohol use contributes 10.5% of the total burden of disease for Aboriginal and Torres Strait Islander people (2018 data).24

Most survey data report that Aboriginal and Torres Strait Islander people are less likely to drink alcohol compared with the rest of the population.2 However, a recent study, using novel methods of asking Aboriginal and Torres Strait Islander people about alcohol,3 reported different rates of use to those from previous surveys. Most surveys assume a regular pattern of alcohol use and therefore underestimate alcohol use in some communities of Aboriginal and Torres Strait Islander people.3 The app-based survey tool found the prevalence of alcohol use in the past year was approximately 77.0%, equivalent to the general population at 76.7%.2,3 Drinking more than four standard drinks on one occasion is somewhat higher in Aboriginal and Torres Strait Islander populations (33.7%) compared with the general population (25.5%).25,26 It is important to note the amount of and regularity with which alcohol is consumed vary across individuals and communities.

Since the last edition (2018) of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, new Australian guidelines for harm minimisation from alcohol have been published.2 The guidelines make recommendations for three distinct groups of people: adults; children and people aged under 18 years; and women who are pregnant or breastfeeding (see Box 3).

Definitions

Levels of harms from alcohol and diagnoses related to alcohol (and other substance use) are outlined in the Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5)27 and the International classification of diseases 11th revision (ICD-11)20 and presented in Box 5.

Box 5. Definitions of harms from alcohol use and for problematic alcohol use
Hazardous use is the repeated use of alcohol that carries the risk of future harms, no current dependence or harms being experienced.20 This is not a diagnosis and is usually applied where a person is drinking alcohol above the limits set out in the national guideline (Box 3).

Harmful use describes the repeated consumption of alcohol that causes harm but does not meet the criteria for dependence.20

Dependence describes the consumption of alcohol that affects a person’s ability to function in other areas of their life, showing features of tolerance and/or withdrawal and issues controlling their use of alcohol.20

Substance use disorder (SUD) and, in this case, alcohol use disorder (AUD) are diagnostic terms used to describe dependence or the harmful use of alcohol. The criteria for SUD/AUD are outlined in DSM-527 and ICD-11.20 SUD/AUD is also referred to in the academic and some other literature as problem alcohol use.28

General approaches to preventing harms from alcohol

As with all areas of healthcare for Aboriginal and Torres Strait Islander people, there are aspects of providing care that increase engagement and improve health outcomes. This is particularly true when discussing alcohol use due to stigma and shame that may be caused or reinforced by negative discrimination and stereotyping.5,29

Guidelines have been established to support services in assisting Aboriginal and Torres Strait Islander people with alcohol (and other drug) treatments and implementing prevention strategies.30 The model developed in the guidelines has been evaluated as feasible to implement in alcohol and other drug services and may serve as a useful guide for primary care and other services more generally.14

The six areas specified in the model are:

  • a welcoming environment
  • service delivery that is culturally informed, flexible and, where possible, provides immediate assistance
  • community consultation and engagement
  • engagement with Aboriginal and Torres Strait Islander organisations and workers
  • culturally capable staff
  • maintaining organisational responsibilities, such as including Aboriginal and Torres Strait Islander staff, and making and maintaining the changes involved in the implementation of the guidelines.14

Even if the whole model cannot be implemented, improving cultural safety can start with a yarn; for example, asking the person about their Country may put them at ease before asking about alcohol use.12,31

Primary prevention

Promoting the NHMRC Australian guidelines to reduce health risks from drinking alcohol creates awareness of the potential hazards of alcohol consumption; however, there is not strong evidence that it reduces alcohol consumption.32,33 Broad community-based changes, such as reduced opening hours for the sale of alcohol and pricing, are measures that may reduce the risk of hazardous alcohol use. Advocating for and supporting changes that reduce risks from alcohol, particularly changes that are led by the community, is an important role for clinicians.

As mentioned, Aboriginal and Torres Strait Islander health workers/health practitioners and other Aboriginal and Torres Strait Islander staff have an important role in engaging patients in preventive healthcare. It is important to ensure all staff are aware of the Australian guidelines to reduce health risks from drinking alcohol and provide consistent messaging around the safest possible use of alcohol,2 such as reinforcing the benefits of not drinking alcohol.

Immunisation against hepatitis viruses can protect the liver against infections that may hasten alcohol-related liver disease.34 Vaccinations are available for hepatitis B (and hepatitis A in some jurisdictions) as per the National Immunisation Program schedule.6 In addition, for those with risk factors (eg people who have ever injected drugs, had an organ transplant before 1990, have tattoos or piercings, or are in custodial settings), hepatitis C screening and treatment should be offered.35

Primary prevention is also possible in the setting of preconception, antenatal and postnatal care. Education has been shown to reduce alcohol consumption in one community of pregnant women, with a subsequent reduction in diagnoses of fetal alcohol spectrum disorder.36 Reframing messages of harms of alcohol in pregnancy to reducing alcohol to make the child healthy, as well as correcting misconceptions about alcohol use in pregnancy, provide more positive approaches.34

Secondary prevention

Screening and brief interventions are the first-line tools for the secondary prevention of alcohol use harms and are suitable for use in many settings, particularly primary care. Brief interventions have been shown to be effective in reducing alcohol use, although there are no specific data for efficacy in Aboriginal and Torres Strait Islander people to date.37 In addition, encouraging the use of positive framing of the benefits of not consuming alcohol may be more helpful for some people than emphasising the negative consequences of consuming alcohol.

Screening

There are several screening tools that are frequently used with Aboriginal and Torres Strait Islander people. AUDIT-C is a three-question tool about alcohol use to identify ‘heavy drinkers’ and those at risk from drinking alcohol that it is widely used in various forms22,38–40 and has been validated for use in primary care settings (Box 1).4,41 Current recommended cut-off total AUDIT-C scores in primary care for Aboriginal and Torres Strait Islander people are ≥3 for women and ≥4 for men.

Other screening tools exist, such as IRIS, which screens for alcohol, other drug issues and mental health conditions. IRIS is designed and has been validated for use with Aboriginal and Torres Strait Islander people.42

Resources are available that describe a standard drink (10 g alcohol), keeping in mind that in some Aboriginal and Torres Strait Islander communities alcohol is often shared and up to 40% is consumed from other containers, such as drink bottles, requiring a detailed history to accurately assess drinking.3 The clinician should calculate the amount of alcohol consumed in standard drink units based on the drink consumed, the type and the fullness of the container used.3 In addition, drinking patterns may include long periods of abstinence followed by episode/s of heavy drinking.3

Young people

As mentioned, AUDIT-C and IRIS screening tools for alcohol have been validated for use in Aboriginal and Torres Strait Islander people aged >18 years. A systematic review and meta-analysis has found the CRAFFT screener17 (see Box 2) is a sensitive (0.97) tool for screening for at-risk outcomes from alcohol for young people aged 12–18 years in primary care.43 To initiate general discussion with young people, the HEEADSSS tool and its later versions (with additions of eating, safety and screen use) include a discussion of alcohol use and may assist in assessing for potential harms.8 HEEADSSS is not an alcohol-specific screening tool.

The Australian alcohol guidelines recommend not drinking as safest for those aged under 18 years. Neurocognitive, psychological and other harms seen in adult drinkers, such as drink driving and injury, are well-recognised sequelae of harmful alcohol use in young people.44–46

Brief interventions

When screening identifies a person who is drinking alcohol with a high risk of harms, the next step is a structured 5- to 15-minute conversation known as a brief intervention. Brief interventions have been found to be effective in reducing the consumption of alcohol where people are not dependent on alcohol but are drinking at hazardous and harmful levels.5 Brief interventions use motivational interviewing techniques that involve exploring alcohol use, discussing what the person likes and does not like about drinking alcohol, some of the risks of alcohol use and exploring the person’s readiness to change their drinking behaviour.5 The FLAGS framework is an example of how a brief intervention can be structured (see Box 2)).5 Brief interventions are not a standalone treatment for individuals with more severe AUDs such as dependence, but may help the person engage with further treatment or care.47

Treatment for alcohol dependence in Aboriginal and Torres Strait Islander people is beyond the scope of this guide; however, the general principles of the benefits of culturally secure treatment apply29 and useful evidence-based resources are freely available online.5

In addition, support for families and the community of a person with AUD can help the person with the issue to manage this. Social and emotional wellbeing support are important for Aboriginal and Torres Strait Islander people to heal from issues due to drinking alcohol or from traumas that may be contributing to problematic alcohol consumption.29,48–51 Some examples may include reconnecting to Country, holistic care supporting other physical, mental and social needs and involving family where the person would like this. 18,29,49,52–54

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