Dr Graham Roberts Alcohol identification and brief advice

Aim The aim of identification and administration of brief advice in relation to alcohol use is to identify those drinking at increasing and higher risk levels and implement brief advice in a structured way so as to reduce levels of alcohol consumption to lower risk. IBA does not aim to manage dependant drinkers. A key element is understanding alcohol units.

Alcohol units To discuss alcohol consumption meaningfully, it is vital that both the giver and recipient of advice understand alcohol units 1 unit is equivalent to 10 ml ( 8 g ) of ethyl alcohol The formula for calculating units is ( volume in ml/1000 ) x abv % Compared to 20 years ago, glass sizes tend to be bigger and alcoholic drinks contain a greater percentage of alcohol by volume

Units in real terms Wine : 125 ml of 8% wine = 1 unit More typically however, a glass of wine will be 175 ml of 14% wine = 2 -3 units 1 bottle of wine = 9 – 10 units

Beer, lager and cider : ½ pint of 3. 5% beer, lager or cider = 1 unit 1 pint of 5% beer, lager or cider = 3 units

Spirits : 25 ml of 40% spirits = 1 unit Alcopops : 1 alcopop = 1. 5 units

Recommended limits Adult women should not regularly exceed 2 – 3 units per day Adult men should not regularly exceed 3 – 4 units per day ‘Higher risk drinking’ is defined as regularly drinking > 6 units per day for women ( > 35 units per week ) and > 8 units per day for men ( > 50 units per week )

Metabolism of alcohol Alcohol levels peak in the blood approximately 1 hour after consumption 2. Most alcohol is metabolised in the liver to acetaldehyde ( a process which uses thiamine ), at a rate of approximately 1 unit per hour. 3. A small proportion is excreted in breath, sweat and urine. 1.

Risk To clarify the terms used in relation to alcohol consumption and it’s risks, the DOH now recommends the terms Lower risk Increasing risk Higher risk

Lower risk This term implies that no level of alcohol consumption is without risk

Increasing risk This relates to Females regularly drinking > 2 – 3 units per day Males regularly drinking > 3 – 4 units per day

Higher risk refers to Women regularly drinking > 6 units per day ( > 35 units per week ) Men regularly drinking > 8 units per day ( > 50 units per week )

Binge drinking The term ‘binge drinking’ is more a media term but refers to drinking > 2 x the recommended daily maximum ( > 6 units for a woman, > 8 units for a man )

Alcohol dependance affects around 3% of the population and is typified by : Increasing drive to use alcohol Difficulty in controlling it’s use Often despite negative consequences that begin to build up Physical symptoms of withdrawal – shaking hands, sweating, nausea, anxiety Identification and brief advice does not aim to target this group ( rather aims to target those at increasing and higher risk ) but we should be aware of how to identify them and signpost them to more appropriate sources of help.

Data from the National Household Survey 2006

Effects of drinking alcohol The effects of alcohol use can be classified into Physical Mental Social There also legal implications of excessive drinking

Alcohol identification and brief advice Benefits : There is much evidence to show that early identification of problem drinking and delivery of brief advice can be very effective in reducing people’s drinking to lower risk levels. The evidence shows that 1: 8 people who receive such advice will reduce their drinking to lower risk levels. This compares to 1: 20 smokers who stop following brief advice ( 1: 10 when NRT products are used ).

IBA pathway 1. Initial screening test – Audit-C 2. Full screening tool – Audit 3. Implementation of brief advice 4. ( referral for specialist treatment if necessary )

Tools to identify alcohol misuse Screening : Audit-C ( Audit-consumption ) is derived from the first 3 questions of the full Audit questionnaire. It is quick to administer and will indicate if an individual is drinking at increasing or higher risk levels. A score of 5+ indicates increasing or higher risk drinking.

Audit-C Scoring system Questions 0 1 2 3 4 How often do you have a drink containing alcohol? Never Monthly or less 2 -4 times per month 2 -3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1 -2 3 -4 5 -6 7 -9 10+ Never Less than monthly Weekly Daily or almost daily How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Monthly Your score SCORE Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive.

Assessment : Full AUDIT questionnaire. As a screening tool it has a high sensitivity ( 92% ) and specificity ( 94% ). N. B. M-SASQ = Sensitivity (91. 8); Specificity (70. 8) There are 10 questions and the results will accurately classify persons into low, increasing and high risk groups. Low risk score <7 Increasing risk score 8 -15 High risk score 16 -19 Possible dependance score 20 -40

Audit Scoring system Questions 0 1 2 3 4 Never Monthly or less 2 - 4 times per month 2 - 3 times per week 4+ times per week 1 -2 3 -4 5 -6 7 -9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? Your score Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence SCORE Have you or somebody else been injured as a result of your drinking? No Yes, but not in the last year Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in the last year Yes, during the last year

Brief intervention - FRAMES ( Sanchez and Miller, 1993 ) Brief intervention has six essential elements : FEEDBACK : provide feedback on the patients risk for alcohol problems RESPONSIBILITY : highlight that the individual is responsible for change ADVICE : advise reduction or give explicit direction to change MENU : provide a variety of options for change EMPATHY : emphasise a warm, reflective and understanding approach SELF-EFFICACY : encourage optimism about changing behaviour

Feedback for lower risk drinkers Provide feedback about results of the test Educate that exceeding recommended levels of alcohol intake is associated with alcoholrelated health problems like accidents, injuries, high blood pressure, liver disease, cancer and heart disease Congratulate patients for their adherence to the guidelines

Structured feedback tools Clinical trials from early intervention programmes indicate that brief advice, using a patient education leaflet ( structured advice tool ), is effective and consequently the intervention tool of choice. Feedback and advice should be structured according to the patient’s readiness to change.

The stages of change

Structured advice tool

Single Sided Advice.

Feedback 1. 2. 3. 4. 5. Give feedback on the common effects of drinking Give feedback on other people’s drinking habits Give feedback on the benefits of reduction Give a menu of options to encourage a goal Give advice on units and limits

Empathy & responsibility Be empathic and non-judgemental : patients are often unaware of the risks of drinking excessively and drinking at increasing or higher risk levels is often not a permanent condition but a pattern into which people fall for a period of time. Condemnation may jeopardise the relationship resulting in advice being rejected and defeating the object of the intervention

Be authoritative, advise reduction Be clear and objective, don’t undermine the recommended limits by admitting that you exceed them or regard them as arbitrary.

Deflect denial Some patients may not be ready for change. They may deny that they drink too much and become defensive at the suggestion that they cut down. Do not get drawn into confrontation, aim to motivate them by giving factual information and expressing genuine concern.

Highlight that the individual is responsible for change It is vital that the patient is in charge of goal setting and provides some suggestions as to how they can cut down. Engage them in a conversation about what is best for them, it is inappropriate to dictate to them and tell them what to do.

Follow up After administering brief advice it is important to create a plan for follow up

Dependant drinking IBA is not designed for persons drinking at dependant levels. The following characteristics should prompt referral to more specialist alcohol services : Alcohol related harm : Accidents, trips, falls Increasing or higher risk drinkers wanting more help Audit score of 20+ Severe alcohol related problems such as loss of job or family Symptoms of dependance

Wernicke – Korsakoff syndrome Caused by thiamine ( vitamin B 1 ) deficiency Wernicke’s encephalopathy is the acute or subacute mainfestation of the syndrome and Korsakoff’s psychosis is the chronic form In alcohol dependant individuals, Wernicke’s encephalopathy may be precipitated by alcohol withdrawal or by intercurrent illness. The encephalopathy has an abrupt onset with a classic triad of mental confusion, ataxia and ocular abnormalities. However the symptoms or signs may only be present in part and it is important to have a high index of suspicion. The acute stage has a 17 – 20% death rate and is hence a medical emergency treated with high dose parenteral thiamine.

Korsakoff’s syndrome may emerge as a chronic disorder following an episode of Wernicke’s encephalopathy or insidiously with no clear prior history. The main deficit is in recent memory. New learning is also impaired. They often have little insight. It is likely to be underdiagnosed in clinical practice with overlap with ‘alcoholic dementia’. It is irreversible

Prevention Dependant drinkers should be treated with thiamine and vit B Co-strong supplements as a preventative measure.