Information
Editors
Brief Interventions for Risky Use of Alcohol
Essentials
- Thresholds of high-risk alcohol consumption (alarm thresholds)
- In men:
- 23-24 standard units of alcohol per week or
- regular daily intake of 3 units or
- on any one occasion more than 6-7 units on a weekly basis.
- In women:
- 12-16 standard units of alcohol per week or
- regular daily intake of 2 units or
- on any one occasion 5 or more units on a weekly basis.
- One standard unit consists of e.g. one bottle (33 cl) of medium strength beer, 12 cl of wine or 4 cl of spirits.
- The tolerance of the human body to alcohol declines by age and with illnesses, and hence the threshold of risky use in elderly people is 8 units per week.
- It is often possible to influence the patient's risky drinking by counselling after the problem has been recognized. Brief intervention is a suitable and cost-effective tool for health care personnel Brief Interventions for Heavy Alcohol Users.
- Phosphatidylethanol (PEth) is the most reliable laboratory test to show chronic heavy alcohol intake.
- When a chronic substance use disorder or alcohol dependence is detected, at least 1 month's driving prohibition should be given and therapeutic and follow-up procedures should be started in order to treat the dependence. Consult also relevant local policies and procedures on assessing driving health, and follow them.
Diagnostic criteria for alcohol problem use
- Real damage or impairment of mental or physical health (e.g. depressive episode resulting from heavy use)
- The nature of the damage or impairment is detectable and definable.
- Clear evidence that the intoxicant has caused or contributed to the development of the impairment
- The use of the intoxicant has lasted for at least 1 month or repeatedly for 12 months.
- The disorder does not meet the criteria for any other disorder occurring at the same time.
Dependence syndrome (F10.2)
- At least 3 of the following have been detected at the same time for at least a month or, if uninterrupted episodes are shorter than a month, repeatedly during the previous year:
- Strong or compulsive urge to use alcohol
- Weakened ability to control starting and stopping as well as intake units
- Withdrawal syndrome (F10.3 Withdrawal state and F10.4 Withdrawal state with delirium) when the use of the substance decreases or stops
- Evidence of increased tolerance
- Concentration on alcohol use so that other sources of pleasure and interests are left aside and time is spent on alcohol use and recovering from the effects
- Continuous use of alcohol despite its adverse effects
Recognition of risky drinking
- See article on recognition of alcohol and drug abuse Recognition of Alcohol and Drug Abuse.
- The early phase of risk consumption is not observable in the clinical examination.
- In primary health care, risky drinking can be recognized by asking the patient about his/her alcohol consumption either directly or by using the AUDIT questionnaire Opportunistic Screening for Alcohol Use Disorders in Primary Care(computer program Audit). The sensitivity and specificity of AUDIT are nearly 90%. On the other hand, people often downplay the used amounts or problems caused by the use or deny the use altogether.
- Of the laboratory tests, phosphatidylethanol (PEth) is the most sensitive (98-100%) and most specific (94-100%) to show chronic heavy alcohol intake (daily alcohol intake more than 5 standard units).
- The sensitivity and specificity of other tests (MCV, ALT, AST, GT, CDT) is poor (30-40%), and they should not be used in decision making which may have social, financial or judicial consequences for the patient.
Brief intervention
- The essential elements of a brief intervention comprise questioning, discussion and counselling to help the patient to become aware of the risk consumption. Risk users are motivated to moderate consumption.
- If the patient is not willing to discuss his/her alcohol consumption right then, he/she is informed that he/she may very well contact later on a more suitable time. The patient may also be advised to visit web services that provide tools for self-assessment of drinking habits.
- Follow-up visits increase the effect of a brief intervention Brief Alcohol Interventions in Primary Care Populations. The amount and frequency of the visits are assessed individually according to the patient's need of support.
The principles of a brief intervention: FRAMES
- See e.g. http://iusbirt.org/course1/frames/.
- Feedback - provide individualized information
- Responsibility - emphasize that the patient him-/herself is responsible for the change
- Advice - provide support for the change
- Menu - provide alternative strategies to be used instead of drinking
- Empathy - show understanding and interest
- Self-efficacy - provide encouragement and confidence on the possibility of change.
Subjects to be discussed during the (usually 1-3) sessions
- E.g. the following subjects may be discussed briefly.
- How does the patient feel about his or her drinking?
- Summary of the situation (amount of alcohol consumed weekly, impact on health, alcohol-related problems at home and at work, development of possible tolerance)
- Discussion on the laboratory tests that are done at discretion
- The patient's consumption of alcohol compared with average consumption
- The patient's consumption of alcohol compared with that of other users and his/her friends
- Health impacts of alcohol, increased risk of diseases (obesity, hypertension Effect of Reduced Alcohol Consumption on Blood Pressure, liver disease, headache, hangover, seizures Alcohol as the Cause of Epileptic Seizures, insomnia, sexual problems, accidents Injuries in Problem Drinkers).
- Effects on driving health
- Not only intoxication may weaken the fitness to drive but it may also be weakened by e.g. tiredness caused by hangover, cognitive disorders caused by long-term use of alchohol or epilepsy-like convulsive tonic-clonic seizures (most common 3-5 days after stopping drinking) or exacerbation of other illnesses (e.g. arrhythmia tendency) caused by alcohol use .
Who benefits from brief intervention?
- Risky drinkers (and those approaching the limits of risky drinking) who do not yet have severe problems caused by alcohol abuse or alcohol dependence. They may not yet have noticed their excessive use of alcohol, or looked for help to reduce their drinking.
- The patients are identified by family doctors, in outpatient clinics and at health check-ups when the doctor pays attention to symptoms or laboratory test results that indicate alcohol abuse, and when problem drinking is recognized as a possible cause of symptoms Brief Interventions for Heavy Alcohol Users. Especially health check-ups provide a good opportunity to screen for heavy drinking using a structured questionnaire (AUDIT).
- In case of emergency situations it is not very realistic to try to influence the patient's drinking habits, especially if he/she is intoxicated. It is better to offer a new appointment time. When testing a driver's blood for alcohol, inform the individual where to find professional help.
- A problem drinker who already has clear symptoms of dependence rather seldom benefits from brief intervention. If they cannot reduce alcohol consumption during, for example, 3 months' intervention, they should be forwarded to a unit specialized in alcohol-related diseases.
References
- Neumann J, Beck O, Helander A, et al. Performance of PEth Compared With Other Alcohol Biomarkers in Subjects Presenting For Occupational and Pre-Employment Medical Examination. Alcohol 2020;55(4):401-408. [PubMed]