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Lifescripts methodology card: alcohol

Helping patients reduce health risks from alcohol.

Lifescripts methodology card: helping patients reduce health risks from alcohol (PDF 102 KB)

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Ask, assess, advise, assist, arrange
Evidence for the management of alcohol use

Ask, assess, advise, assist, arrange

Ask

Less intensive (1-5 mins)

Identify patients who can benefit from alcohol assessment and advice on low-risk drinking¹

• Waiting room checklist and poster
• Patient record prompts: check alcohol patterns at least every two years
• Prompts by practice staff

Ask: 'How do you feel about your drinking at the moment?'

More intensive (5-15 mins)

Identify patients who can benefit from alcohol assessment and advice on low-risk drinking¹

• Waiting room checklist and poster
• Patient record prompts: check alcohol patterns at least every two years
• Prompts by practice staff

Ask: 'How do you feel about your drinking at the moment?' Top of page

Assess

Less intensive (1-5 mins)

Assess readiness to reduce drinking

• Assess:
  • level of drinking (using AUDIT C), risk of harm (of illness or injury) and dependence - if a score of 5 or more, consider more intensive intervention
  • interest and confidence in cutting or stopping

Ask: 'Are you willing to try cutting your alcohol consumption?'

• Assess barriers to change (e.g. 'What would be the hardest thing about cutting down?')
• Record alcohol patterns in patient's record

More intensive (5-15 mins)

Assess risk level and readiness to reduce drinking

• Alcohol assessment tool:
  • level of drinking, risk of harm (or illness or injury) and dependence
  • interest and confidence in cutting down or stopping
• Assess pattern
• Assess psychological triggers e.g. social pressure, negative emotions (boredom, anger, worry/ anxiety, depressed)
• Take drinking history

Ask: 'What situations create pressure to drink?' 'What makes it difficult to stick to your drinking goals?'

• Identify individual barriers to cutting down/ stopping
• Assess mental health status
• Record alcohol problems in patient's record Top of page

Is the person ready to attempt change?

If yes, ready to attempt change, continue with the 5As approach

If no, not ready

• Advise on benefits of change
• Offer information and resources
• Assess interest in changing at later date

Advise

Less intensive (1-5 mins)

Advise on benefits of change

• Provide brief, non-judgemental advice about positive benefits of cutting down

More intensive (5-15 mins)

Provide tailored advice

• Give feedback on current drinking
• Provide brief, non-judgemental advice to cut down/ stop
• Discuss individual benefits of low-risk drinking
• Set date for change Top of page

Assist

Less intensive (1-5 mins)

Offer resources and support

• Offer alcohol information/ resources
• Consider referral
• Encourage social support

More intensive (5-15 mins)

Write prescription for change

• Jointly devise strategies for support
• Individualise the prescription (incl. goal setting)
• Make an individual plan to deal with common challenges e.g. patterns, social pressure, mood, stress, drinking triggers, withdrawal and high-risk situations
• Offer information and resources
• Consider referral
• Encourage social support
• Prescribe medication where appropriate (dependent drinkers)²

Arrange

Less intensive (1-5 mins)

Arrange follow-up

• Negotiate a separate consultation about alcohol
• Organise follow-up review

More intensive (5-15 mins)

Arrange referral and follow-up

• Recruit support (e.g. partner or family)
• Organise follow-up in 2-4 weeks for review
• Negotiate a separate consultation about cutting down/ stopping
• Where appropriate refer to addiction medicine specialist, psychiatrist, drug and alcohol counsellor Top of page

Evidence for the management of alcohol use *

No level of drinking alcohol can be guaranteed to be completely 'safe' or 'no risk'¹. Lifetime risk of harm and risk of alcohol-related injury on a single occasion increases with the amount consumed.

Drinking behaviour in Australia

AIHW 2007 Household Survey data² indicated that:

• Risky drinking is most prevalent among 20–29 years age group.
• 2 or less standard drinks — 51% of male and 46% of female daily or weekly drinkers consumed two or less drinks per day
• 4-5 standard drinks - 42% of males and 21% of females drank four or five drinks on one occasion at least monthly
• 6 or more standard drinks — 27% of males and 11% of females drank more than six drinks on one occasion at least monthly

General practice will more commonly encounter non-dependent risky drinkers than alcohol dependent drinkers.

How have NHMRC alcohol guidelines changed?

• Risk: the 2009 NHMRC guidelines are predicated on calculations of cumulative risk of alcohol-related disease or injury over the lifetime. The categories of risk (low-risk, risky and high-risk) from the 2001 guidelines are no longer used. This will require clinicians to exercise greater judgement about what constitutes risk for a given patient.
• Gender: at 2 or less standard drinks per day, no distinction between men and women is drawn. At higher levels, risk of alcohol-related disease increases more quickly for women and risk of alcohol-related injury increases more quickly for men.

Australian recommended levels of alcohol consumption

The NHMRC 2009 alcohol guidelines¹ recommend:

• for healthy men and women, drinking no more than:
  • two standard drinks on any day reduces lifetime risk of harm from alcohol-related disease or injury
  • four standard drinks on a single occasion reduces risk of alcohol-related injury arising from that occasion
    
    
• for young people under 18 years, not drinking alcohol is the safest option:
  • children under 15 years are at greatest risk of harm from drinking. For this age group, not drinking alcohol is especially important.
  • for young people aged 15-17 years, the safest option is to delay initiation of drinking for as long as possible
    
    
• for women who are pregnant, considering pregnancy or breastfeeding:
  • not drinking is the safest option
  • risks are likely to be low if a woman has consumed only small amounts of alcohol (i.e. 1 or 2 drinks per week) before she knew she was pregnant or during pregnancy. Top of page

Use of AUDIT C, AUDIT-10 and AUDIT

Lifescripts uses the Alcohol Use Disorders Identification Test (AUDIT) C tool to detect risky drinking. Although changes to NHMRC guidelines make interpretation more difficult, it remains the most recognised tool available.

Clinicians need to interpret level of risk identified by the tool, noting:

• 2 or less standard drinks per day indicates low risk of disease or injury
• 4 or more standard drinks per day indicates increased risk of disease or injury
• 6 or more drinks per day indicates further investigation is required. Consider using a more thorough assessment (AUDIT-10 or AUDIT).

A score of 5 or more indicates further assessment is required. Clinicians should be aware that AUDIT is a screening tool only and should not replace the consideration of physical, mental and social complications, symptoms of dependence, and misuse of other substances.

Risky drinking — early intervention is effective

The most effective strategy to reduce alcohol-related harm (i.e. disease or injury) is early intervention for people who drink at risky levels, to prevent heavy regular or dependent drinking. Brief interventions from a GP can be effective in correcting risky drinking in non-dependent drinkers, particularly men⁵. If a person is alcohol dependent, withdrawal may be difficult or complicated.

Alcohol dependence — more help needed

It is important to identify patients who meet criteria for alcohol dependence. If you suspect dependence, use AUDIT.

GPs can help people who are alcohol dependent, but effective interventions take more time and relapse is common. Detoxification in the community, supervised by a GP, can be a safe option. Alcohol abstinence — rather than moderate drinking — is usually the most appropriate goal, as these patients have difficulty controlling their alcohol consumption.

Consider referral to a clinician with expertise in addiction medicine, community health and NGO treatment agencies, and/or telephone support services. Top of page

Pharmacotherapies for alcohol dependence

Pharmacotherapies should only be used in general practice as part of a comprehensive treatment program when the patient has been diagnosed as alcohol dependent and has completed withdrawal from alcohol use. Pharmacotherapies are not primarily designed to reduce consumption. Consult product literature regarding prescribing cautions and discuss side effects before prescribing.

• Naltrexone and acamprosate are generally well tolerated and can be used even if the person continues to drink.
• Disulfiram is not used as first-line therapy. It is risky for some patients, especially if alcohol is used. Seek specialist advice.

Evidence for the benefits of low-risk alcohol use

Evidence for the benefits of low alcohol consumption remains inconclusive and controversial. Although there is evidence of health benefits for older adults of very low alcohol consumption, these benefits can be obtained through means such as exercise or diet¹.

Recommended reading

• National Health & Medical Research Council. Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Commonwealth of Australia; Canberra: 2009.
• Holmwood C. Alcohol-related problems in Australia: is there a role for general practice? Med J Aust 2002; 177: 102–103.
• Roche A, Freeman T. Brief intervention: good in theory but weak in practice. Drug Alcohol Rev 2004; 23: 11–18.

Useful resources

• www.alcohol.gov.au
• therightmix.gov.au
• www.adin.com.au Top of page

References

See www.health.gov.au/lifescripts

¹ See national alcohol guidelines.
² Note contraindications, adverse effects and drug interactions.
* References in this section are listed in risk factor area evidence references from the practice manual.

Page last reviewed: 18 March 2011