Alcohol identifying and supporting patients who drink excessively

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More than 1 in 4 adults are currently drinking above the lower risk limits recommended by Government. As a GP for every 1,000 adults on your practice list, there are likely to be , around 260 drinking either at increasing risk or at higher risk levels. These people could benefit from very simple interventions. This factsheet has been designed for you as an easy-reference tool, to capture levels of risk, potential impact on health, ways to identify patients drinking at increasing or higher risk levels and brief, easy advice to share with them within their regular appointment.

The facts
Between 15,000 and 22,000 premature deaths in England and Wales each year are associated with alcohol misuse1 There are around 10 million people drinking above the Governments recommended limits2 NHS admissions for alcohol-related illness have almost doubled since 19972 The number of alcohol-related deaths in the UK has more than doubled from 4,144 in 1991 to 8,386 in 20052 Alcohol is causally related to cancers of the oral cavity and pharynx, larynx, oesophagus and liver. It is also linked to rectal and breast cancer Alcohol misuse is calculated to cost the health service 1.7bn per annum3

Your patients drinking are they putting themselves at risk?

In order to recommend the most suitable advice and/or treatment for patients who drink alcohol excessively, it is important to identify those individuals whose drinking might be putting their health at risk by determining whether patients are drinking at lower, increasing or higher risk levels.

1 HM Government (2007) Safe. Sensible. Social. The next steps in the National Alcohol Strategy. Department of Health 2 Office of National Statistics (2007) Omnibus Survey Report No. 34: Drinking: adults behaviour and knowledge in 2007 3 Strategy Unit Alcohol Harm Reduction project Interim Analytical Report, 2003

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Defining lower, increasing and higher risk drinking

Drinking at lower risk
The Governments new campaign to raise awareness of unit guidelines will refer to drinking within the recommended limits as lower risk drinking. (Research has shown this terminology to be less judgemental and more accurate than the term sensible drinking. This terminology is also used in other countries.) The NHS recommends for lower risk drinking that: men should not regularly drink more than 3-4 units of alcohol daily women should not regularly drink more than 2-3 units of alcohol daily Pregnant women or women trying to conceive should avoid drinking alcohol. If they do choose to drink, to protect the baby they should not drink more than 1-2 units of alcohol once or twice a week and should not get drunk. If men or women do drink heavily in one session, build in at least 48 hours alcohol-free after this to allow time for body tissue to recover. Awareness of personal circumstances: Lower risk drinking involves a personal assessment of risks and responsibilities of drinking at the time e.g. it is sensible not to drink when taking certain medications, when driving or operating machinery. It can be advisable for some patients to drink much less than the recommended limits because of their own personal circumstances. For example, for some people, mental health problems may be aggravated by alcohol so they may choose to avoid drinking completely at certain times, as may those driving, swimming or in sole charge of young children in some circumstances. Advice to patients: No corrective action required. Up to the lower risk drinking limits for regular consumption, an adults risk of alcohol- related illness is statistically low. It may be useful to inform the patient what the lower risk drinking limits are, to congratulate them and encourage them to maintain this pattern.

Drinking at increasing risk

For patients drinking above the limits for lower risk drinking, the risk of long-term health harms starts to become more substantial and the risk increases progressively the more these limits are exceeded. So, men and women who regularly drink above the recommended lower risk levels substantially increase their risk of harm now or in the future, and need to reduce their consumption to reduce this risk. Those drinking at the highest levels higher risk drinking (see below) are at particularly high risk already of experiencing harm or alcohol dependence and as they may need a different response (described below), an intermediary category of risk is increasing risk drinking. Increasing risk drinking, broadly equivalent to hazardous drinking, applies to those drinking more than lower risk levels but less than higher risk levels. This includes: men who regularly drink more than lower risk levels (more than 3-4 units a day) but are not regularly drinking at higher risk levels (over 8 units a day or over 50 units a week). women who regularly drink more than lower risk levels (more than 2-3 units a day) but are not regularly drinking at higher risk levels (over 6 units a day or over 35 units a week). Reducing regular drinking levels now can actually ward off the real risks of harm that will otherwise develop over time. Health risks: Problems that are reported in some of those drinking at increasing risk levels include health problems such as lack of energy, low mood or anxiety/stress, insomnia, impotence, injuries and high blood pressure, but many more serious problems can occur if drinking continues at this level over time. Advice to patients: Simple structured advice on: lower risk drinking levels; risks of drinking above these; potential benefits of cutting down; and suggestions on ways to cut back (with added support or referral on for a minority who are found not to respond).

Drinking at higher risk

Higher risk drinking is also referred to as harmful drinking. It is drinking at a level that is the highest risk of harm and most likely either to be causing current health harms or signs of alcohol dependence or both. Drinking at higher risk is defined as: men who regularly drink over 8 units a day (or over 50 units a week) women who regularly drink over 6 units a day (or over 35 units a week) Men and women are 13 times more likely to suffer liver cirrhosis if they regularly drink around higher risk levels, as shown in the table opposite.

Risks of ill health to those drinking at higher risk levels

Condition
Hypertension Breast cancer (women) Coronary heart disease (CHD) in middle age Mouth cancer Liver cirrhosis

Men
Four times (4.1 times) 1.7 times 5.4 times 13.0 times

Women
Double (2.0 times) 1.6 times 1.3 times 5.4 times 13.0 times

Men drinking 60g+/day and women 40g+/day; relative risk compared with zero drinking except for CHD (which is compared to occasional or very light drinkers) Source: P Anderson (2008) The scale of alcohol-related harm (Unpublished, DH) .

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Drinking at higher risk (continued)

Characteristics of patients whose drinking puts them at higher risk of health harms: A regular pattern of higher risk drinking is more common amongst adults aged over 35 than for other age groups People drinking at higher risk levels can be found across all sociodemographic groups In terms of drinking habits and attitudes: Days off alcohol are likely to be the exception rather than the rule They can be outspoken and seemingly proud of their drinking, especially if they feel criticised for it They often believe their drinking is typical of their peers They may underestimate their alcohol consumption, since drinking alcohol is an integral part of their daily lives (for example, they may not register lunchtime drinks or the first few drinks after work) Other cancers including breast cancer Mental illness including memory loss Alcohol Dependence Syndrome.

Health risks
These patients are more likely to suffer from problems related to their alcohol consumption such as: Liver cirrhosis and other forms of alcoholrelated liver disease Hypertension and haemorrhagic stroke Cancers of the mouth, larynx, pharynx and oesophagus

Advice for patients: Simple structured advice on: lower risk drinking levels, risks of drinking above these, potential benefits of cutting down and suggestions on ways to cut back. There is a greater chance in this group that additional support may be needed by some patients, where more extended advice and follow-up may be helpful and/or referral to specialist alcohol services, particularly if alcohol dependence is identified.
Referral to the Drinkline patient helpline may be helpful, Tel: 0800 917 82 82.

Drinking at increasing and higher risk levelsthe facts

For men and women living in the most deprived areas, alcohol-related death rates are over five and three times higher respectively compared with those living in the least deprived areas1 It has recently been estimated that alcohol-related harm costs England 20 billion each year2

Alcohol health risks how much is too much?

who regularly* drink:

Men

who regularly* drink:

Women

8 Units
(over 50 units per week)

over

per day

HIGHER RISK

6 Units
(over 35 units per week)

over

per day

3-4 Units
per day

over

INCREASING RISK

2-3 Units
per day

over

no more than
1 J.Wood et al (2006) Where Health Means Wealth: Illustrating Inequality in the North West. North West Public Health Observatory 2 HM Government (2007) Safe. Sensible. Social. The next steps in the National Alcohol Strategy. Department of Health

3-4 Units
per day

no more than
LOWER RISK

2-3 Units
per day

*Regularly here means every day or most days of the week (not just drinking at these levels once a week)

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Alcohol case identification

There are a number of very quick, validated questionnaires to identify patients whose drinking is putting their health at risk, particularly as their level of consumption and level of risk may not otherwise be apparent in your contact with them Short questionnaires are the most efficient way of identifying these individuals (see below); whilst biochemical markers are relatively intrusive, expensive and less accurate for identifying such risk (e.g. GGT, MCV and CDT) Most identified cases who are drinking above lower risk levels will be drinking at increasing risk, with only a much smaller number drinking at higher risk Once identified, almost all the cases can be provided with simple, structured advice that will help them cut down, lower their risk and improve their health (but some, particularly the more resistant to change or the more dependent in the higher risk group, may need further support or referral on for more specialist advice) see page 6
For more information about case identification and brief advice, you can access www.nhs.uk/alcoholstakeholders

Identification using AUDIT or other screening tests

The Alcohol Use Disorders Identification Test (AUDIT) is an alcohol risk screening questionnaire that can be used very quickly to assist you and your patients to identify how much they are drinking and whether there is evidence of them drinking at increasing or higher risk (including dependent) levels. Tools for using the AUDIT form very quickly, are available at www.nhs.uk/alcoholstakeholders. They include visual aids to help patients work out alcohol units easily. Other quick screening tools exist (such as FAST, available on www.sips.iop.kel.ac.uk) but the AUDIT is the most validated tool. As an example, we have copied the one page full AUDIT on page 5. Its supporting unit calculator can be found at www.nhs.uk/alcoholstakeholders In many cases, only the first three questions need to be asked about levels of typical and heavy alcohol consumption. If the score is less than 5, lower risk drinking can normally be assumed and a statistically low risk of harm. A patient scoring 5 or more can be offered a brief intervention as they are considered as likely to be drinking above lower risk levels. The unit calculator and other materials available from the stakeholder website will make it easy for the patient to double-check exactly how much they drink on a regular daily basis. If all the 10 questions of the AUDIT are completed by the patient, the scores (see bottom of table overleaf) can actually give a good idea whether the patient may fall into the higher risk category and it will even identify those who are more likely to be dependent, alerting you to patients that might need more support at some point.

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AUDIT questionnaire example

0
How often do you have a drink that contains alcohol? How many units do you have on a typical day when you are drinking? In the last 6 months, how often have you had more than 6 units on any one occasion if female, or more than 8 units if male? How often in the last year have you found you were not able to stop drinking once you had started? How often in the last year have you failed to do what was expected of you because of drinking? How often in the last year have you needed an alcoholic drink in the morning to get you going? How often in the last year have you had a feeling of guilt or regret after drinking? How often in the last year have you not been able to remember what happened when drinking the night before? Have you or someone else been injured as a result of your drinking? Has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down?

1 Monthly or less 3-4

2 2-4 times per month 5-6

3 2-3 times per week 7-9

4 4+ times per week 10+

Score

Never 1-2

Never

Less than monthly

Monthly

Weekly

Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Yes, during the last year Yes, during the last year

Never

Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly

Monthly

Weekly

Never

Monthly

Weekly

Never

Monthly

Weekly

Never

Monthly

Weekly

Never

Monthly

Weekly

No

Yes, but not in the last year Yes, but not in the last year

No

Scoring: 0-7=lower risk drinking, 8-15 = increasing risk drinking, 16-19 = higher risk drinking and 20+ = possible dependence
For further information on alcohol screening, log on to www.nhs.uk/alcoholstakeholders
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Brief advice for patients

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If patients have been identified as drinking to increasing or higher risk levels, brief structured advice can be provided. Research has found that brief interventions produce clinically significant effects on drinking behaviour and related problems in non-alcohol dependent individuals who consume alcohol at increasing or higher risk levels.
The easy and quick advice commonly consists of key stages including: assessment of level of use/risk simple feedback of lower risk advice and how their own drinking relates to that goal setting and some suggested simple material or techniques to succeed The type of advice that should be offered during a brief intervention includes:1 information about the nature and effects of alcohol and its potential for harm personalised feedback on potential harm emphasis on the individuals personal responsibility for change attempts to increase the patients confidence in being able to reduce their alcohol consumption (self-efficacy) goal-setting (for example, start dates and daily or weekly targets for drinking) written self-help material for the individual to take away, containing more detailed information on consequences of excessive drinking and tips for cutting down (this can be in a variety of media, including electronic, such as the internet) signposting individuals to having a wider general health check, where indicated arrangements for follow-up monitoring if necessary information on where to get further help if necessary if concerned that a patient is dependent, consider referral for specialist support or direct them to Drinkline, the patient helpline, tel: 0800 917 82 82.

To receive free copies of patient materials, including a self help leaflet and quick-reference self-help fold-out z-card, go to www.nhs.uk/alcoholstakeholders

1 BMA Board of Science (2008) Alcohol misuse: tackling the UK epidemic British Medical Association, London

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