National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Chapter 1. Lifestyle
Alcohol
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☰ Table of contents

Recommendations: Alcohol

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

 All people aged ≥15 years Ask about the quantity and frequency of alcohol consumption to detect risky/high-risk drinkers (Box 1)

Useful tools for assessment of physical activity include the UK General Practice Physical Activity Questionnaire (refer to ‘Resources’)		 During the annual health assessment or in response to potential alcohol-related disease IA–IB 7, 47
More frequent assessment is recommended for high-risk groups (Box 3) Opportunistic and as part of annual health assessments I–IIIB 47
Use structured questionnaires such as Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C* or Indigenous Risk Impact Screen (IRIS) to assess drinking (refer to ‘Resources’; note that these tools may require some adaptation to local community needs) As part of an annual health assessment, or opportunistic IA–IB 18,  39,  48
People aged 10-14 years Consider sensitive and age-appropriate alcohol intake screening in children and adolescents between the ages of 10 and 14 (refer to Chapter 4: The health of young people)

Parental or carer involvement may be required and referral should be considered		 As part of an annual health assessment or in response to potential alcohol-related disorders/other risky behavior II 9,  11, 49
People with risky or high-risk drinking levels Review for comorbid physical or mental health disorders and other chronic disease risk factors

Perform comprehensive alcohol assessment such as AUDIT-C and consider brief intervention.

For those with dependence, consider specialist referral where necessary		 As part of an annual health assessment IA 18,  47,  50

Behavioural

 People with hazardous and harmful drinking levels Offer brief interventions for the reduction of alcohol consumption as first-line treatment. Consider using tools such as FLAGS and 5As approach (refer to Box 2 and Chapter 1: Lifestyle, ‘Introduction’)

Note: Brief intervention alone is not sufficient for people with severe alcohol-related problems or alcohol dependence. Strongly consider more extended intervention and/or referral		 Opportunistic and as part of an annual health assessment IA 18,  47,  50
Women who are pregnant, breastfeeding, seeking preconception counselling Advise to abstain from alcohol, explain the risks to the unborn child and emphasise the benefits of not drinking (refer to Box 1 and ‘Resources’)

Advise breastfeeding mothers abstinence from alcohol is the safest option, especially in the first month post-partum. For those choosing to drink, alcohol intake should be limited to no more than two standard drinks per day. Try to breastfeed before drinking. Continue to promote breastfeeding		 Pregnant women – at all antenatal visits, as appropriate

For all others, opportunistic screening as part of an annual health assessment		 IA 18,  19,  22

Environmental

 

 Promote community-led strategies to reduce alcohol supply, including advocacy for:
  • ‘dry communities’ in areas with high numbers of alcohol-related harms
  • restrictions to liquor licensing hours or changes to other licensing conditions
  • better, proactive policing of responsible service of alcohol
  • community development initiatives
  • initiatives to engage young people
  • school or classroom-based  educational sessions
   GPP 39, 51,  52,  53
*Using AUDIT-C, it is recommended that those who reach a cut-off score of equal to or greater than 5 are deemed to be ‘at risk’, those with a score equal to or greater than 6 ‘high risk’, and those with a score equal to or greater than 9 are potentially alcohol dependent.33

Box 1. National Health and Medical Research Council (NHMRC) guidelines for safer alcohol use19
  1. 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.
  2. For healthy men and women, drinking no more than four standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion.
  3. For children and young people under 18 years of age, not drinking alcohol is the safest option.
    • Parents and carers should be advised that children under 15 years of age are at the greatest risk of harm from drinking and that for this age group, not drinking alcohol is especially important.
    • For young people aged 15−17 years, the safest option is to delay the initiation of drinking for as long as possible.
  4. Maternal alcohol consumption can harm the developing fetus or breastfeeding baby.
    • For women who are pregnant or planning a pregnancy, not drinking is the safest option.
    • For women who are breastfeeding, not drinking is the safest option

Box 2. The FLAGS framework for brief intervention18

Feedback
  1. Provide individualised feedback about the risks associated with continued drinking, based on current drinking patterns, problem indicators and health status.
  2. Discuss the potential health problems that can arise from risky alcohol use.

Listen
  1. Listen to the patient’s response.
  2. 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
  1. Give clear advice about the importance of changing current drinking patterns and a recommended level of consumption.
  2. A typical five-minute to 10-minute brief intervention should involve advice on reducing consumption in a persuasive but non-judgemental way.
  3. 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
  1. Discuss the safe drinking limits and assist the patient to set specific goals for changing patterns of consumption.
  2. Instil optimism in the patient that his or her chosen goals can be achieved.
  3. It is in this step, in particular, that motivation-enhancing techniques are used to encourage patients to develop, implement and commit to plans to stop drinking.

Strategies
  1. Ask the patient to suggest some strategies for achieving these goals.
  2. This approach emphasises the individual’s choice to reduce drinking patterns and allows them to choose the approach best suited to their own situation.
  3. 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.

 

Box 3. High-risk groups that require more frequent screening and close attention
  • Adolescents and young adults
  • Pregnant women/those planning pregnancy
  • Illicit drug users/other substance misusers
  • Those with a family history of alcohol dependence
  • People with mental illness
  • Those with medical conditions that may be worsened by alcohol consumption; conditions include:
    • cardiovascular disease (CVD)
    • arrhythmia
    • liver disease
    • diabetes
    • hypertension



Background

Consumption of harmful quantities of alcohol is a leading risk factor contributing to global disease burden and is associated with over 200 diseases and injuries, particularly dependence, liver cirrhosis, cancer and both accidental and non-accidental injury.1 Alcohol consumption is associated with the majority of disease burden from road traffic accidents and with social problems such as aggression and violence, family breakdown and child abuse or neglect.2 Consequentially, alcohol-related harm is not merely a relevant issue for individual drinkers but also affects families and the broader community.1

While alcohol consumption at any level may increase the risk of ill-health and injury (Box 1), there are some reported benefits from low-level consumption for some conditions and in some population subgroups; however, this remains a controversial topic of much debate.3 Habitual low-level daily drinking (one standard drink for women, two standard drinks for men) is associated with reductions in all-cause mortality, diabetes, coronary artery disease and stroke in certain age groups, but this is when comparing regular low-level drinking with heavy episodic (or binge) drinking.4 Low-level drinking has been associated with slightly increased risk of breast cancer;5 however, at high-risk levels, the chance of harm increases exponentially, particularly for all-cause mortality, cardiovascular diseases including non-ischaemic cardiomyopathy, atrial fibrillation, a variety of cancers6 and both ischaemic and haemorrhagic stroke. It is therefore not recommended for healthcare professionals to actively advise low-level alcohol consumption given its strong potential for alcohol dependence even in low-risk individuals.

Surveys in the US have shown alcohol consumption in young people aged 9–18 years is common, with reported use of alcohol increasing ten-fold from 7% of 12-year-olds to 70% of 18-year-olds.7,8 Drinking in adolescence is associated with increased risk of injury and high-risk health behaviours, such as unprotected sex. It is also a risk factor for suicide and for dependency later in life.9 Alcohol use in Australian young people is correlated with the number of licensed outlets in the area.10 The prevalence of drinking in this age group is often underestimated and consequentially undetected,9 emphasising the importance of routinely screening for alcohol consumption in primary care settings. There are currently no validated age-appropriate screening tools. However, recent development of web-based and smart-phone screening and intervention applications may be useful in these age groups.11 It is important to note that hazardous adolescent use of alcohol may be associated with psychosocial and intergenerational trauma.12

Aboriginal and Torres Strait Islander people are less likely than the general Australian population to drink, but the prevalence of harmful drinking and alcohol-related morbidity and mortality is much greater. In 2012–13, 28%13 of Aboriginal and Torres Strait Islander adults had not consumed alcohol in the previous 12 months, compared with 15% of non-Indigenous adults; however, Aboriginal and Torres Strait Islander adults are twice as likely to binge drink compared to non-Indigenous adults (17% versus 8%).14 In 2014–15, 14.7% of Aboriginal and Torres Strait Islander people exceeded the lifetime risk guidelines for alcohol consumption, versus 17.5% of non-Indigenous people.15,16 Within the Aboriginal and Torres Strait Islander population there is a high association between alcohol consumption and contact within the criminal justice system, especially for males; those males who exhibited high-level/risky alcohol consumption are 29% more likely than those with low-level alcohol consumption to have been arrested in the previous five years.16,17

Alcohol crosses the placenta and can cause harm to a developing fetus, therefore current guidelines recommend no level of drinking is safe in the peri-conception period, during pregnancy or when breastfeeding.18,19 Alcohol use in pregnancy is associated with a range of behavioural disorders and fetal alcohol spectrum disorder (refer to Chapter 3: Child health, ‘Fetal alcohol spectrum disorder’). Despite the potential harms from alcohol consumption during pregnancy, survey data suggest it is common.20 In 2014–15, 9.8% of Aboriginal and Torres Strait Islander mothers drank alcohol during pregnancy, although this had decreased substantially from previous surveys (eg 19.6% in 2008). Overall, 56% of Australian women reported drinking during pregnancy, and 26% of these continued to drink after becoming aware of the pregnancy.21 A recent review suggested an inefficiency in current public health methods to tackle alcohol use during pregnancy, and recommended that further research, particularly in the field of public health evaluation of current methods, is required.22


Interventions

The Australian guidelines are currently being revised, but four existing recommendations are outlined in Box 1. There is strong evidence for screening in primary care to identify individuals consuming risky levels of alcohol, using quantity–frequency estimates. Combined with brief intervention, this technique has been associated with decreased alcohol consumption by an average of four standard drinks per week.23,24 Brief interventions have been shown to be effective in patients with unhealthy drinking patterns, but there is little evidence for effectiveness in those with dependence.25 For those patients, more intensive intervention is usually required.

Brief interventions include methods such as those highlighted in the FLAGS (Feedback, Listen, Advice, Goals, Strategy) framework for brief intervention (Box 2); these are most appropriate and effective in nondependent drinkers who are drinking at risky levels.26 Screening and brief intervention has a strong evidence base and in addition to environmental primary prevention measures such as reducing the availability and accessibility of alcohol, is the most effective method for decreasing an individual’s alcohol consumption.18,27 Screening in primary care settings can, importantly, detect those whose current drinking places them at increased risk of morbidity and mortality.28 Barriers for screening and brief interventions include lack of confidence/knowledge from healthcare workers, lack of organisational support and financial incentive, and perceived patient embarrassment/discomfort with discussing alcohol.29 Despite this, studies have shown that patients are generally accepting of their doctor enquiring about alcohol consumption. Furthermore, training may assist health workers with gaining more confidence and knowledge surrounding brief interventions. The FLAGS framework (Box 2) is recommended by The Royal Australian College of General Practitioners (RACGP) as part of the management of problematic drinking.30

Given alcohol-related harm tends to present late, systematic screening is recommended. There remains no clear evidence regarding the optimal frequency of screening for Aboriginal and Torres Strait Islander people. Screening can be performed via a simple patient history as part of routine consultation, or using brief questionnaires as an aid. The recommended and most sensitive of the screening tools is the Alcohol Use Disorders Identification Test (AUDIT) tool (refer to ‘Resources’), which assesses level of drinking, dependency and experience of harm.31,32 The AUDIT-C tool provides a shorter version for circumstances where time is limited. Neither tool has been specifically, nor reliably, validated in the Aboriginal and Torres Strait Islander populations. However, some studies have demonstrated their value33,34 and currently they are the most commonly used tools in this population.35 Using AUDIT-C, it is recommended that those who reach a cut-off score of equal to or greater than 5 are deemed to be ‘at risk’, those with a score equal to or greater than 6 ‘high risk’, and those with a score equal to or greater than 9 are potentially alcohol dependent.33

Alternatively, the Indigenous Risk Impact Screen (IRIS) (refer to ‘Resources’) tool can be used. It comprises 13 questions designed to assist in identifying drug and alcohol problems, along with mental health risks, in Aboriginal and Torres Strait Islander people.36 The IRIS tool has proven to be consistent with other screening tools such as AUDIT and is recommended as a brief screening tool for use with the Aboriginal and Torres
Strait Islander people.28,37

The CAGE tool has been used in many Aboriginal and Torres Strait Islander health settings to screen for hazardous drinking, but has been reported to have very low sensitivity for detecting risky or hazardous drinking.38 According to the Agency for Healthcare Research and Quality in the US, it is not recommended as a screening test for identifying risky or hazardous drinking or for screening for the full spectrum of alcohol misuse.31 Measures such as liver function tests should not be relied on as a primary screen for alcohol dependency and should only be used as adjuncts owing to their low sensitivity and specificity.18

Positive outcomes when tackling risky drinking in Aboriginal and Torres Strait Islander populations are more likely to be attained if screening  and interventions are delivered in a respectful, non-judgemental and culturally appropriate manner.39 Current alcohol screening and intervention techniques need to be adapted for use in Aboriginal and Torres Strait Islander populations, rather than simply transferred; this involves collaboration and partnerships with communities, in the setting of community control.39,40
Effective alcohol management programs (AMPs) have an important role to play in reducing alcohol-related harms, and they do not merely restrict alcohol sales. AMPs are more likely to be successful when they are introduced voluntarily and led by Aboriginal and Torres Strait Islander agencies. They should be fully implemented and comprehensive, and should include a number of activities and resources to support individuals and communities to build capacity and make meaningful changes.41

Community engagement and control, particularly for Aboriginal and Torres Strait Islander peoples, has been shown to be an effective prevention method, along with harm reduction strategies such as community patrols and sobering-up shelters.42 It is important to note that informal communication and counselling methods such as ‘yarning’ are highly valued in Aboriginal and Torres Strait Islander communities.43 Imposed programs to address alcohol consumption, such as having alcohol-managed communities, have not proven effective in tackling problem drinking in Aboriginal in Torres Strait islander populations in Queensland; indeed, there have been unintended effects of binge drinking and cannabis use observed.42,44,45 There is emerging evidence surrounding the benefits of using modern technologies such as text messaging, phone counselling and online resources as health promotion, screening and intervention tools. Young Aboriginal and Torres Strait Islander people have expressed a preference for use of technologies as a contact method for formal help-seeking services.43 Studies in other populations have shown that text message interventions can reduce alcohol consumption in young adults.46
 

Resources
National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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