Last partial update: July 2016 - Please read disclaimer before proceeding
Recognizing problem alcohol consumption
Unfortunately many people with alcohol-use problems do not recongnise their problem or refuse to acknowledge it. And unfortunately doctors are not great at ferreting them out. It is thought that less than 33 per cent of people with an alcohol-use problem are detected by their doctor. This is most unfortunate intervention by GPs has been shown to be successful in reducing harmful alcohol use, especially if it is caught early. The longer the problem goes undetected and untreated, the harder it is to fix. Thus, it is important to be on the look out for the signs of problem alcohol use in any one who consumes alcohol.
AUDIT Questionnaire (The AUDIT questionnaire was developed by the World Health organization)
Question |
Alternative responses to each question. |
Score |
|||||
Points scored for each response. |
0 points |
1 point |
2 points |
3 points |
4 points |
|
|
1. How often do you have a drink containing alcohol? |
Never |
Monthly or less |
Once a week or less |
2 to 4 times a week |
5 times or more a week |
|
|
2. How many standard drinks* do you have on a typical day when you are drinking? |
1 |
2 |
3 or 4 |
5 or 6 |
7 or more |
|
|
3. How often do you have 6 or more standard drinks on one occasion? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
|
|
4. How often during the last year have you found that you were not able to stop drinking once you started? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
|
|
5. How often during the past year have you failed to do what was expected from you because of your drinking? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
|
|
6. How often during the last year have you needed an alcoholic drink in the morning to get you going after a heavy drinking session? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
|
|
7. How often over the past year have you had a feeling of guilt or regret after drinking? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
|
|
8. How often over the past 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 |
|
|
9. Have you or someone else ever been injured because of your drinking? |
No |
|
Yes, but not in the last year |
|
Yes, during the last year |
|
|
10. Has a friend, doctor or other health worker been concerned about your drinking or suggest you cut down? |
No |
|
Yes, but not in the last year |
|
Yes, during the last year |
|
|
Total score out of a possible 40 |
|
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Interpretation of results |
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|
The person is drinking too much or the person has or has previously had problems with drinking. Physical dependence on alcohol is unlikely. |
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|
The person has problems with drinking and is likely to be dependent on alcohol. |
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* A standard drink is defined in section as a drink containing 10g of alcohol. |
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This questionnaire can be accessed via the Royal Australian College of GPs we site at: http://www.racgp.org.au/your-practice/guidelines/redbook/appendices/appendix-3-audit-c/
Any of the factors mentioned below indicate that a problem probably exists.
- Recognition at any time an inability to control drinking.
- Recognition that personal behaviour is significantly altered by drinking. (It is always worth asking a friend or partner what they think.)
- Comments by others (at any time) that a person’s drinking is a problem at home, socially, or at work. This obviously implies that feeling the need to tell a friend / relative to reduce their alcohol consumption implies the person probably does have an alcohol-use problem that needs addressing.
- Failure to fulfill social or work obligations due to alcohol.
- Regular intake at levels that deleteriously affect health.
- The presence of any of the harmful physical or mental effects of alcohol.
- Binge drinking
- ‘Loading dose’ drinking
- Unhealthy drinking habits, such as persistent drinking alone, early drinking, or drinking with others that abuse alcohol.
- Drinking to control nerves.
- Legal problems arising from alcohol use
There are several screening questionnaires used by medical practitioners to help identify people with alcohol problems. One of the most common, the AUDIT questionnaire, appears in the table below.
Alcohol dependence
Alcoholism is a difficult concept and there is much controversy regarding the use of the term. It is perhaps best defined as a disorder that evolves slowly over several years and involves frequent or regular drinking. This abuse often involves problems such as recurrent use of alcohol in hazardous situations, legal problems in relation to alcohol, and failure to fulfill occupational or social obligations.
Over time this dangerous drinking pattern leads to the development of the symptoms of dependency. The first signs of dependency typically occur in the late twenties and early thirties. However, presentation is often delayed till the person reaches their early forties. Dependency is defined as having three or more of the following six ‘dependence symptoms’ at any one time.
1. Compulsion to drink: The need to have a drink i.e. cravings.
2. Loss of control. This is the key feature of dependence and most commonly manifests itself as failure at attempts to reduce alcohol consumption or recurrent binge drinking.
3. Tolerance. This is where more alcohol is needed to be consumed to produce the same effect. Tolerant people can seem to function reasonably on intakes of alcohol that would seriously affect an occasional consumer of alcohol.
4. Alcohol takes priority over all other activities: This usually manifests as inability to perform normal daily activities at work or home.
5. Withdrawal symptoms: This is almost diagnostic of dependence. Symptoms include tremors, agitation, anxiety, excessive perspiration, disorientation and hallucinations. Seizures can also occur.
6. Persistent drinking despite existing evidence of harm from alcohol use: This can mean physical harm or recurrent problems with the law due to alcohol misuse.
Other features of dependence include deteriorating behaviour, impaired performance and skills, insomnia, and recurrent unsuccessful attempts to cut down consumption. Morning anxiety is common before the first drink. Life coping skills diminish and guilt and a sense of helplessness set in. Depression is quite common in people with alcohol dependence.
In Australia, about 5 per cent of males and 2 per cent of females are dependant on alcohol it can occur in people as young as twenty as well as in older people.
What are the benefits of reducing excessive alcohol consumption?
The advantages of reducing alcohol consumption are substantial. Here are some of the more important ones.
- Better sleep
- More energy
- Weight loss and improve physical fitness
- Improved appearance; no facial flushing or prominent facial blood vessels and no blood-shot, tired eyes
- Children are less likely to have alcohol-use problems
- Financially better off; drinking, especially in clubs and pubs, can be a very expensive habit.
- No hangovers; (less wasted Sundays)
- Improved memory
- Improved mood
- Better functioning at work
- Improved relationships at home with less arguments
- Less short-term risk of harm
- Less risk of long-term harm from high blood pressure, liver damage etc
Drinking heavily is relatively common in young people and their ‘indestructible self-image’ means that unfortunately many will view their socializing with a peer group that comsumes harmful amounts of alcohol as more important than worrying about the above. A good approach in such cases is to acknowledge the importance of their peer group and then get them to talk about the above issues, answer their questions, and see if a better balance can be found.
Addressing alcohol abuse
The first issue in dealing with this problem is to ensure that the sufferer realises the problem exists. This comes in the form of either self-awareness or the person involved needs to be told. When a friend or relative has a problem then people need to consider discussing it with them. This is not always easy, and people who do not feel comfortable bringing up the issue should consider discussing the matter with their GP, a drug counselor, or a social worker to decide on the correct strategy.
People should act on problems early as this provides the best opportunity of success. As with any entrenched behavioural pattern, alcoholism is difficult to treat in the chronic stages. Education regarding alcohol and its problems is the cornerstone of treatment for anyone with an alcohol problem. Many people with an alcohol-use problem incorrectly feel that the problem is a minor one that they have control over and can deal with themselves. However, alcohol is a very addictive drug and most alcohol problems have evolved over several years (at least), with its use often interwoven into the social fabric of the person’s life. For these reasons, changing a detrimental usage pattern is rarely easy and almost always needs advice and support from a suitably trained health professional. People who try to reduce their intake without advice or support rarely succeed. Also, there are almost always associated relationship problems that need addressing. Thus, all people who have or think they might have an alcohol-use problem should see their GP or a qualified counselor.
The first stage in dealing with an alcohol-use problem is assessment of the severity of the problem by a GP or a drug and alcohol counselor. Intervention needs to be tailored to the person and there are two broad treatment groups; those with severe problems and / or signs of dependence and those with less longstanding / severe problems. It needs to be emphasized that for any person to be successfully treated, the motivation to change must be present.
Treating people with severe alcohol-use problems / alcohol dependence
People with more severe problems, especially those with signs of alcohol dependence, often need care in a drug and alcohol centre or hospital, usually under the care of a specialist doctor. For those who do not want admission to such a unit, outpatient detoxification is an alternative at many facilities. (People suited to outpatient treatment include those with less severe dependence who are unlikely to have significant withdrawal symptoms or have in the past only had mild withdrawal symptoms. They will still require daily review while going through withdrawal.) People, who have in the past had more severe withdrawal symptoms, especially if they have had a seizure, need to be treated in hospital. Treatments include detoxification and rehabilitation with psychological intervention. Medication is often needed to reduce the severity of withdrawal symptoms (usually diazepam).
Abstinence is the preferred goal as this group has not been able to control their drinking previously and fewer than 10 per cent of dependent drinkers can achieve controlled drinking. Abstinence is the wisest course where the person has significant depression or anxiety, especially if they are medication for their depression, and in people who have suffered significant physical illness as a direct result of their alcohol consumption. The use of either of two anti-craving medications, naltrexone (Revia) or acamprosate (Campral), can significantly increase the proportion of alcohol-dependent people who stay in remission, although they are not a substitute for psychotherapy and should only be used to augment such therapies. (Both medications are under-used in the treatment of alcohol dependence.) Remission rates after two years vary from about 15 per cent in those not using medication to about 30 to 40 per cent in those who do. Medication is usually started after withdrawal is completed and is usually used for at least three months and often considerably longer (up to 12 months).
The option of referral to Alcoholics Anonymous is recommended for all those wishing to stop alcohol use as it is one of only a few treatment options that have been shown to help a considerable number of people with alcohol dependence. However, not everyone will wish to be involved with AA.
Treating people with less severe alcohol-use problems
People with less severe drinking problems make up the majority of people with alcohol problems and those who are reasonably motivated to change can be well treated by their GP, with initial treatment involving breaking the present drinking cycle.
In many people, especially those who are lucky enough to have had their problem diagnosed early, reducing excessive consumption can be achieved by a programme that includes education about alcohol in general and advice in particular regarding how to reduce alcohol intake and stop harmful short-term alcohol use.
Reducing alcohol intake can be achieved by avoiding exposure to drinking situations, such as after work, having at least two alcohol-free days each week (something everyone should do), setting maximum daily alcohol intake levels, reducing the size of alcohol servings (e.g. going from schooners to middies), switching to low-alcohol beverages, ceasing binge and loading drinking, avoiding or limiting time spent with friends that drink heavily, planning other activities at times when heavy drinking previously occurred (e.g. after work), and avoiding abnormal drinking patterns, such as morning drinking and drinking alone. Not drinking to quench thirst and trying to have a non-alcoholic drink first up and then between each alcoholic drink also helps, as can restricting alcohol intake to the main daily meal; although, as this is often a family time, care needs to be taken if the person’s personality is adversely affected by alcohol e.g. becoming irritable or aggressive. Having non-alcohol drinks at the table, such as a jug of iced water, and eating before starting alcohol consumption can help reduce alcohol consumption at meals where this has been a problem. An alcohol-free home policy can also be beneficial, especially if home relationship issues have been a significant problem.
Harm minimisation needs to be emphasized, including avoiding mixing alcohol with driving or swimming, avoiding alcohol related sexual behaviour problems, and avoiding situations where alcohol related violence may occur.
Addressing work, social, and relationship problems that have evolved due to the alcohol problem and encouraging support from family members and friends are important priorities. Professional assessment of the person’s situation from a counselor is a good idea as relationship problems are almost always an issue in households where alcohol use has been a problem. Depression and anxiety are common in people with alcohol-use problems and will sometimes require treatment with medication as well as psychotherapy, especially in people with alcohol dependence. A member of the selective serotonin reuptake inhibitor (SSRI) group of drugs is usually a good first-line choice.
A supporting friend or family member is of great help when trying to reduce alcohol consumption. Most will already be aware of the person’s problem and be only too glad to help.
Avoiding the cycle of regular drinking - An import part of reducing harm from alcohol consumption
Preventing developing regular drinking or breaking the cycle of regular drinking is an important part of reducing risk from alcohol consumption. This can be achieved in two ways
- Having two alcohol free days per week
- Having at least one month per year where no alcohol is consumed. This can be achieved by taking part in community events such as 'Dry July'in NSW or 'FebFast' or Sober October or 'Hello Sunday Morning'.
Relapse
Relapse is quite common, especially in people who have been repeatedly unsuccessful in previous attempt at reducing consumption. (Cravings that accompany withdrawal is a common cause.) This can be helped by trying to anticipate times when excess drinking is more likely and developing a plan for avoiding / overcoming such temptations. Before confronting these situations, going over strategies for overcoming them can help. Common problem times include the following.
- After work (Try to avoid going to the pub / bar after work. Establish a routine of other activities at these times e.g. sport. Getting into the habit of regularly refusing drinks and having non-alcoholic drinks will help at these times. People can justify such actions by saying their doctor has told them to cut down.)
- When socializing with friends who drink heavily (Try to avoid social situations where excessive drinking occurred.)
- When meeting new people. (People who used alcohol to reduce the anxiety associated with meeting new people should try arranging such meetings in an environment where alcohol is not available or difficult to obtain. Having a friend present as a support is also a good idea.)
- At a party or a club. Again, refusing drinks and drinking non-alcoholic drinks is helpful. Also avoid salty ‘party foods’ as they will make you thirsty.
- When relaxing at home, especially watching TV. People should try to avoid having too much free time doing ‘nothing’. There are lots of relaxing activities that don’t usually encourage / allow alcohol use. Walking, playing with childen etc etc.
- When looking after children. (Plan a range of activities in which everyone can participate.)
If relapse does occur, remember that this is not ‘the end of the world’. Breaking a long-standing habit is difficult and it is unrealistic for to expect to have all the answers early on in treatment. Most people have relapses on the way to success and learning from a mistake will make success more likely next time. And, remember, the hardest step is often deciding to address the problem in the first place.
People who do relapse should discuss the setback with their GP / counselor. Being supportive in the difficult times is an important part of their job. It is worth noting that several studies have shown that having a supportive therapeutic relationship with an understanding GP or counselor is one of the best indicators of a favourable outcome in this difficult condition and frequent progress consultations greatly help reduce relapse risk.
The FLAGS program
The FLAGS program for managing patients with alcohol-use problems is one that is commonly use by GPs and is outlined below.
Feedback: Information given about risks of alcohol abuse and safe consumption.
Listen: Listen to the patient’s responses about their alcohol consumption. Part of this process will be identifying the advantages for the patient in reducing their alcohol consumption.
Advice: Give appropriate advice for the patient’s particular situation
Goals: Plan goals for reducing consumption. As well as deciding on overall levels of consumption, this process should also include identifying likely problem times where controlling drinking may be difficult.
Strategies: Devise strategies with the patient that will help achieve these goals.
Additional treatment considerations in older people
- Increased incidence of falls and fractures
- Diet more likely to be inadequate
- Driving ability may be significantly reduced
- Increased risk of side effects / toxic effects of medications, especially sedation, bruising/bleeding due to reduced clotting ability and liver function.
- Increased risk of anxiety, depression, insomnia
- Problems with diabetic control
Further reading
Teenagers, Alcohol and Drugs What your kids really want and need to know about alcohol and drugs. by Paul Dillon. Published by Allen & Unwin, 2009
Further information
Self-help resources
SayWhen - SayWhen provides information and resources to help patients make decisions about their drinking, http://mapi.betterhealth.vic.gov.au/saywhen
Hello Sunday Morning - Hello Sunday Morning encourages people to commit to a period without drinking and to share their experiences on the website, https://www.hellosundaymorning.org
OnTrack Alcohol - OnTrack Alcohol provides an online self-help program to help people cut back on their drinking, https://www.ontrack.org.au/web/ontrack/programs/alcohol
Counselling Online - Counselling Online provides confidential online counselling to people with alcohol and drug concerns who might be unable to attend treatment, might be reluctant to access face-to-face counselling or who may find online counselling more suitable for them, www.counsellingonline.org.au
Alcohol and Drug Information Service in your state.
This service will provide information and/or advice regarding problems. They can also refer you to health professionals that can help you personally regarding alcohol and other drug problems.
ACT Ph 6205 4545; NSW Ph 9361 8000 or 1800 422 599: NT 8981 8030 or 1800422 599; Qld Ph 3236 2414 or 1800 177 833; SA Ph 1300 131 340; Tas 1800 811 994; Vic Ph 9416 1818 or 1800 136 385; WA Ph 9442 5000 or 1800 198 024) Check directory assistance if these numbers have changed.
Australian Drug Information Network www.adin.com.au
Information about alcohol, tobacco and other drugs.
Australian Drug Foundation
www.adf.org.au
Another good general site regarding drug use; easy to access information about most types of drugs.
Family Drug Support 24 hour hotline www.fds.org.au
Ph 1300 368 186 (throughout Australia)
National Health and Medical research Council National Guidelines on Responsible Drinking https://www.nhmrc.gov.au/health-topics/alcohol-guidelines
Brief Intervention: the Drink-less package (University of Sydney) http://sydney.edu.au/medicine/addiction/drinkless/index.php
This site the very helpful and commonly used alcohol reduction program ‘Drink-less’. It can be downloaded free or orders can be taken from the site.
Information for doctors
Specialist advice for doctors regarding drug and alcohol problems (24 hour service)
NSW: Drug and Alcohol Specialist Advisory Service: Ph: 1800 023 687 or (02) 9361 8006
Vic, Tas, NT: Drug and Alcohol Specialist Advisory Service. Ph: 1800 812 804 or (03) 9416 1818
ACT: Alcohol and Drug Program. Ph: (02) 6205 4545
WA: Dept of Health Clinical Advisory Service. Ph 1800 688 847 or (08) 9442 5042
Qld: Alcohol and Drug Information Service. Ph: (07) 3636 7098 or (07) 363607599
NSW Detoxification Clinical Practice Guidelines (for doctors): A Practical Guide to Managing Withdrawal from Psychoactive Substances
www.health.nsw.gov.au/public-health/dph/publications/pdf/detoxification_clinicalpractice_guidelines.pdf
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