Dr Graham Roberts

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.

To discuss alcohol consumption meaningfully, it is vital that both the giver and recipient of advice understand alcohol units 1 unit is equivalent to 10ml ( 8g ) 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

Wine : 125 ml of 8% wine = 1 unit More typically however, a glass of wine will be 175ml 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 : 25ml of 40% spirits = 1 unit Alcopops : 1 alcopop = 1.5 units

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 )

1. 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.

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

This term implies that no level of alcohol consumption is without 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 )

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.

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

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 ).

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

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.

Questions Scoring system Your score How often do you have a drink containing alcohol? Never Monthly or less times per month times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 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 MonthlyWeekly Daily or almost daily 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 riskscore<7 Increasing riskscore8-15 High riskscore16-19 Possible dependancescore20-40

Questions Scoring system Your score How often do you have a drink containing alcohol? Never Monthly or less times per month times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 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 MonthlyWeekly 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 MonthlyWeekly 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 MonthlyWeekly 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 MonthlyWeekly 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 MonthlyWeekly 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 MonthlyWeekly Daily or almost daily Have you or somebody else been injured as a result of your drinking? No Yes, but not in the last year Yes, during 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 SCORE Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence

( 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

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

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.

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

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

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.

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.

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

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

 Caused by thiamine ( vitamin B1 ) 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

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