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Clinical guidelines

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

Alcohol

Author Dr Penny Abbott
Expert reviewer Associate Professor Kate Conigrave

Background

Any level of drinking alcohol can increase the risk of ill health and injury. Alcohol is responsible for a considerable burden of death, disease and injury in Australia. Drinking is a major factor in much of the injury resulting from road crashes and other accidents, and in social problems such as violence, family breakdown, child abuse and neglect. As such, alcohol related harm is not restricted to individual drinkers but has relevance for families, bystanders and the broader community.93 Although most surveys show that Aboriginal and Torres Strait Islander people are less likely than the general population to drink, the prevalence of harmful drinking and alcohol attributable injury and disease in the Aboriginal and Torres Strait Islander population is about twice that of the non-Indigenous population.94 The rate of alcohol attributable death among Aboriginal and Torres Strait Islander people is similarly twice that of the non-Indigenous population.95 There is a strong association between alcohol use and associated harms such as suicide and violence.96 Alcohol causes and exacerbates common mental health conditions such as anxiety, depression and insomnia.94

The current Australian guidelines for healthy men and women recommend that drinking no more than two standard drinks on any one day reduces the lifetime risk of harm from alcohol related disease or injury.93 Every drink above this level continues to increase the lifetime risk of both disease and injury; drinking less frequently over a lifetime (eg. drinking weekly rather than daily), and drinking less on each drinking occasion, reduces this risk.93 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. Not drinking is the safest option for pregnant or breastfeeding women and for children and adolescents under 18 years of age.93

There is clear evidence to support the effectiveness of primary care screening in detecting at-risk levels of alcohol consumption using quantity-frequency estimates.97 Given the late presentation of alcohol problems in many Aboriginal and Torres Strait Islander people, active screening and detection is recommended.97 The appropriate frequency of alcohol screening in Aboriginal and Torres Strait Islander settings is uncertain, with no clear evidence base to draw on. Screening can be done by a drinking history taken as part of the routine interview. Brief questionnaires are also available as an aid to systematic screening and can be incorporated into adult health assessments. The AUDIT tool, comprising 10 questions that cover level of consumption, evidence of dependence and experience of harms, is the most sensitive of the currently available screening tools (see Resources). There is high level evidence to support its use in the general population, although it has not been validated specifically in the Aboriginal and Torres Strait Islander community.97,98 A shorter version, AUDIT-Consumption (AUDIT-C), comprises the first three questions of AUDIT and may also be used for practical purposes when time is limited. These questions assess alcohol consumption, asking: ‘How often do you have a drink containing alcohol?’, ‘How many drinks containing alcohol do you have on a typical day when you are drinking?’ and ‘How often do you have six or more drinks on one occasion?’98,100 Another structured questionnaire, the Indigenous Risk Impact Screen (IRIS), is a 13-item structured questionnaire that can be used to help in identification of alcohol and drug problems and mental health risks for Aboriginal and Torres Strait Islander people (see Resources).94,101–103 

Several barriers to successful integration of these tools in Aboriginal and Torres Strait Islander settings have been identified104,105 and screening tool questions may require rephrasing to allow for cultural differences.94,102 Nevertheless it is likely they will assist in the earlier detection of alcohol problems in Aboriginal and Torres Strait Islander people.94,105 Indirect biological markers (such as liver function tests) should only be used as an adjunct to other screening measures as they have lower sensitivity and specificity in detecting people risk of alcohol related harm than structured questionnaire approaches.97

Brief interventions for problem drinking can decrease alcohol misuse and alcohol related harm.105 Brief interventions are particularly effective in non-dependent drinkers who are drinking at risky levels, but are also useful in dependent drinkers as a precursor to engaging them in more intensive treatments.99,105 These treatments include measures that can be provided by primary healthcare services, including psychosocial counselling, and where suitable, home detoxification and use of relapse prevention medications. Other drinkers may benefit from referral to specialist services.97 

Positive outcomes in the management of problem and dependent drinking are likely in Aboriginal and Torres Strait Islander settings if they are delivered in a respectful and non-judgemental manner.94,104,106,107 Training is available to increase skills in providing appropriate brief intervention.

Aboriginal and Torres Strait Islander people are acutely aware of the costs of alcohol and there are several examples of active community engagement in responding to alcohol misuse.9,4 This includes primary prevention activities such as school and family education programs and programs aimed at fostering self esteem and cultural connectedness in youth.94,108 Environmental strategies such as reducing access to alcohol have also been used in some communities with evidence of effect in decreasing alcohol related harm.108

Recommendations: Alcohol
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All people aged ≥15 years Ask about the quantity and frequency of alcohol consumption to detect hazardous drinkers (see Table 1.5) As part of an annual health assessment 1B97–99
Focus particularly on the following high risk groups:
  • adolescents and young adults
  • women who are pregnant or planning a pregnancy
  • illicit drug users
  • those with a family history of alcohol dependence
  • people with medical conditions made worse by alcohol (chronic liver disease, hypertension, other major organ disease)
  • people suffering from mental illness made worse by alcohol such as anxiety and depression
Opportunistic I–IIIB99,109
Consider the use of structured questionnaires such as AUDIT, AUDIT-C or IRIS to assess drinking (see Resources – these tools may require some adaptation to local community needs) As part of an annual health assessment 1B94,97–105
People aged 10–14 years Consider sensitive and age appropriate alcohol intake screening in aged 10–14 years (see Chapter 3: The health of young people)
Parental or carer involvement may be required and referral should be considered
As part of an annual health assessment IIIB98,109,110
People with hazardous and harmful drinking levels Review for comorbid disease and other chronic disease risk factors As part of an annual health assessment 1A97,111
Behavioural People with hazardous and harmful drinking levels Offer brief interventions. Consider using tools such as FLAGS and 5As approach (see Table 1.1 and 1.6 and Chapter 1: Lifestyle, introduction)
Brief interventions alone are not sufficient for people with severe alcohol related problems or alcohol dependence who require referral or extended intervention. (Treatment specific guidelines should be consulted in these circumstances)
Opportunistic and as part of an annual health assessment IA97–99
Women who are pregnant, breastfeeding, seeking pre-conception counselling Advise to abstain from alcohol, emphasising the risks to the unborn child
Advise breastfeeding mothers that not drinking is the safest option, especially in the first month postpartum. For those choosing to drink, alcohol intake should be limited to no more than two standard drinks per day. Continue to promote
breastfeeding
Pregnant women: At first and subsequent antenatal visits as appropriate
For all others opportunistic and as part of an annual health assessment
IA93
Environmental Promote community led strategies to reduce alcohol supply including:
  • advocacy for ‘dry communities’
  • restrictions to liquor licensing hours
  • better policing of responsible service of alcohol
  • community development initiatives
  GPP108,112,113
Table 1.5. National Health and Medical Research Council guidelines for safer alcohol use
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
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
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
Maternal alcohol consumption can harm the developing fetus or breastfed 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
Source: NHMRC 200993
Table 1.6. The FLAGS framework for brief intervention
Feedback
  • Provide individualised feedback about 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 5–10 minute brief intervention should involve advice on reducing consumption in a persuasive but non judgemental 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 his or her chosen goals can be achieved
  • 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
  • Ask the patient to suggest some strategies for achieving these goals
  • This approach emphasises the individual’s choice to reduce drinking patterns and allow 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
Source: Haber P, Lintzeris N, Proude E, Lopatko O 200997

Resources

Quick reference guide to the treatment of alcohol problems: companion document to the guidelines for the treatment of alcohol problems (Australian Government)
www.alcohol.gov.au/ internet/alcohol/publishing.nsf/Content/treat-quick

Guidelines for safer alcohol use (NHMRC)
www.health.gov.au/ internet/alcohol/publishing.nsf/Content/standard

AUDIT tool (Northern Territory Government)
www.health.nt.gov.au/ library/scripts/objectifyMedia.aspx?file=pdf/63/68.pdf&siteID=1&str_title=Alcohol%20Screen%20(AUDIT)%20Tool.pdf

AUDIT-C tool
www.cqaimh.org/ pdf/tool_auditc.pdf

IRIS tool (Queensland Government)
www.health.qld.gov.au/ atod/prevention/iris.asp

Talking about alcohol with Aboriginal and Torres Strait Islander patients flipchart (the flipchart includes tear off prescription pads)
www.alcohol.gov.au

Standard drink definition and calculator
www.health.gov.au/ internet/alcohol/publishing.nsf/Content/standard.

References

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