Welcome to Alcohol misuse: reducing the risks – an interactive workshop designed to assist general practitioners and their practice staff to effectively identify patients drinking alcohol at risky levels, and to help them reduce their alcohol intake and risk to health.

How much alcohol does a standard drink contain, as set out in the Australian alcohol guidelines?

QUIZ

Question 1

A. 0.01 gB. 0.1 gC. 1.0 gD. 10 g.

What constitutes a standard drink as set out in the Australian alcohol guidelines?

Question 2

A. One average glass (130–150 mL) of wineB. One 425 mL glass of regular beerC. One shot/nip (30 mL) of spiritsD. One can of full strength beer.

What is the low risk recommended limit for women?

Question 3

A. 2 standard drinks or less in any one day B. 2 standard drinks in an average weekC. 4 standard drinks on an average dayD. 4 standard drinks in an average week.

What is the low risk recommended limit for men?

Question 4

A. 2 standard drinks or less in any one day B. 2 standard drinks in an average weekC. 4 standard drinks on an average dayD. 4 standard drinks in an average week.

Not all Australians drink within the recommended limits.

What percentage of total alcohol consumption in Australia is consumed at levels that put the drinker at risk of acute or chronic harm?

Question 5

A. 22%B. 48%C. 67%D. 83%.

Alcohol is absorbed into the bloodstream through the stomach and small intestine, and then metabolised by the liver.What percentage of alcohol in the body is metabolised by the liver?

Question 6a

A. About 60%B. About 80%C. About 70%D. About 90%.

Question 6b

How long does it take the liver to metabolise one standard drink?

A. About half an hourB. About 20 minutesC. About 3 hoursD. About 1 hour.

Question 7

Drinking alcohol can affect which of the following body systems?

A. Cardiovascular system, nervous system, gastrointestinal systemB. Endocrine system and the liverC. Cardiovascular system, gastrointestinal system and the liverD. All of the above.

What are the short term harms that can occur from one heavy binge drinking occasion?

Question 8a

A. Alcohol dependenceB. Risk of traumaC. Risk of trauma, stress, sleep disordersD. A and B.

There are many other short term harms that can occur from alcohol. Name three other possible short term harms from alcohol.

Question 8b

What are the long term harms that can occur from regular and repeated drinking of alcohol over months or years?

Question 9

A. Alcohol dependence, mental health problems, brain damageB. Heart disease, strokeC. A, B and DD. Diabetes, liver disease, cancer.

Alcohol is a risk factor for some types of cancer. These include:

Question 10

A. Mouth, pharynx, larynxB. Mouth, larynx, pharynx, oesophagus, liver, breastC. Mouth, oesophagus, liverD. Mouth, pharynx, larynx, oesophagus, liver.

Excessive drinking of alcohol can increase the risk of which of the following:

Question 11

A. High blood pressureB. High blood pressure, raised cholesterol and triglyceridesC. High blood pressure, raised triglycerides and body weightD. All of the above.

Heavy alcohol use and binge drinking is one of the main risk factors for stroke. What are the other main risk factors for stroke?

Question 12

A. Previous stroke or transient ischaemic attack (TIA)B. High blood pressure, increasing ageC. Coronary heart disease, peripheral vascular diseaseD. All of the above.

Cardiovascular disease (stroke, heart disease and blood vessel disease) causes the highest number of premature deaths and disability among Australians (45 670 deaths in 2006), but many risk factors are preventable.

List seven preventable risk factors for cardiovascular disease.

Question 13

Recognising early warning signs or ‘red flags’ indicating alcohol problems is key to implementing interventions and reducing the risk to health.

List as many early warning signs or ‘red flags’ for detecting alcohol problems in general practice.

Question 14

GP intervention can make a difference in risky drinking behaviour; 3–5 minutes of behavioural counselling (using the ‘5As’ approach) has which of the following outcomes?

Question 15

A. 25–30% reduction in alcohol consumption for every 1 in 10 patientsB. 10% reduction in alcohol consumption for every 1 in 10 patientsC. 10% reduction in alcohol consumption for every 1 in 20 patientsD. 25–30% reduction in alcohol consumption for every 1 in 20 patients.

SLIDE PRESENTATION

A general practice approach to alcohol misuse

Alcohol in the community

• Individuals who have hazardous or harmful drinking patterns are not only at risk of damage to their health, but face considerable social harms

• Regular use of alcohol can lead to family and financial problems, crime and violence.

Red flag conditions

• Red flag conditions (health and social indicators) alert GPs to the possibility of alcohol related harm.

Common red flag conditions

• Accidents/trauma, including injuries from falls and drink driving • Psychological/psychiatric problems, eg. depression and stress• Family/relationship problems, including marital difficulties• Employment problems, eg. periods off work and difficulties at work• Involvement in crime (risky behaviour)• Sleep problems such as insomnia• Alcohol related health problems such as sexual dysfunction and

gastrointestinal complaints.

Alcohol misuse: reducing the risks to your patients’ health

• Identify a patient’s life stage.

Alcohol misuse: reducing the risks to your patients’ health

• Determine a patient’s readiness for change• Apply motivational interviewing techniques.

Stages of change model

Precontemplation Contemplation Preparation Action Maintenance

No thoughts about changing behaviour

Thoughts about the need to change, but no action taken yet

Ready to take action to change

Attempts made to change behaviour and avoid environmental triggers

Behaviour has been changed and the person is adjusting to these changes and working to preventing relapse

National Prescribing Service 2002

Case studies

Case study: Peter• Aged 14 years; lives in a small country town; and is a keen

football player• Changed schools 6 months ago and trying to make new friends• Has been skipping classes, staying out after footy training, and

racing cars • Finds it difficult to get out of bed, is pale and experiencing loss

of appetite• Evidence of drinking (empty rum and coke cans in his room).

Case study: Peter

What are the key influences at this point in time on Peter’s drinking?

Case study: Peter

Key influences on Peter’s drinking are:• he may be under peer pressure from new friends to try drinking• underage drinking is an increasing problem• small country towns are socially isolated, with fewer recreational

activities available• sport clubs have a strong drinking culture.

Case study: Peter

What stage of change is Peter in?A. PrecontemplationB. ContemplationC. PreparationD. ActionE. Maintenance.

Case study: Peter

What intervention strategies would you consider with Peter at this stage, and how would you involve Peter’s mother?

Case study: Peter

Intervention strategies will depend on Peter’s willingness to engage:• motivational interviewing techniques and gaining Peter’s

confidence • suggest ways to deal with peer pressure from his new friends• include Peter’s mother in the discussions.

Case study: Kylie

• 19 year old university student• Works part time in a supermarket delicatessen• Requests a repeat script of ‘the pill’• On examination, Kylie is ‘shaky’ and has cuts and bruises on her legs• Kylie regularly goes clubbing, drinks well over the recommended

limit, and feels sick the following day.

Case study: Kylie

How would you describe the pattern of Kylie’s drinking?

Case study: Kylie

Kylie’s drinking pattern includes:• she appears to be a teenage binge drinker• there is evidence of trauma from intoxication• possibility of other high risk behaviours (eg. drug use and unsafe sex)• likely to experience ‘blackouts’• potentially at risk of serious injury to herself.

Case study: Kylie

What stage of change is Kylie in?A. PrecontemplationB. ContemplationC. PreparationD. ActionE. Maintenance.

Case study: Kylie

What intervention strategies would you consider with Kylie at this stage?

Case study: Kylie

As Kylie is a regular patient requiring the oral contraceptive pill, her GP has a potentially important role to play here.• Brief motivational interviewing techniques, exploring advantages

and disadvantages of drinking• Simple advice and education about alcohol consumption• Warnings about drinking and driving, and operating machinery• Harm reduction approach.

Case study: Amanda

• 24 year old busy executive• Recently started a new job in a competitive male environment• Complains of stomach ache; is stressed and agitated• Feels the need to go out after work for drinks with colleagues• Usually drinks 2–3 glasses of red wine most nights to relax.

Case study: Amanda

What are factors influencing Amanda’s drinking?

Case study: Amanda

Factors influencing Amanda’s drinking• Young adult hoping to do well in her career• Under peer pressure from work colleagues to fit in• Amanda’s drinking level has started to become a concern• Short term harm from drinking needs to be considered.

Case study: Amanda

What stage of change is Amanda in?A. PrecontemplationB. ContemplationC. PreparationD. ActionE. Maintenance.

Case study: Amanda

• Investigations fail to demonstrate an obvious cause for the stomach ache

• A gastroenterologist feels that the pain may be of psychologicalorigin.

Amanda has now returned to see you. What intervention strategies, regarding alcohol use, would you consider with Amanda at this stage?

Case study: Amanda

Intervention strategies for Amanda• Detailed alcohol use history• Brief motivational interviewing techniques for ‘safe’ levels of alcohol

consumption and lifestyle change• Simple harm reduction strategies• Further psychological assistance.

Case study: Graham

• Aged 32 years; regular heavy drinker• Family history of alcohol related problems. Graham’s father has

hypertension and ischaemic heart disease; grandmother has diabetes• His partner is expecting their first baby and he needs to stop drinking• He is finding it hard to ‘stay off the booze’.

Case study: Graham

How would you describe Graham’s drinking?

Case study: Graham

Graham:• is a regular heavy drinker at risk of alcohol dependence• now has a reason to change his lifestyle, with a baby on the way• is aware of his family history of alcohol related problems• is ready to ask for help.

Case study: Graham

What stage of change is Graham in?A. PrecontemplationB. ContemplationC. PreparationD. ActionE. Maintenance.

Case study: Graham

What intervention strategies would you consider with Graham at this stage?

Case study: Graham

Intervention strategies will depend on Graham’s assessment for alcohol dependence.• Medical detoxification may be required• Drug intervention with acamprosate or naltrexone could be considered• Referral to local alcohol and drug services.

Case study: Dave

• Aged 33 years; recently lost driving licence and job as a van driver• Drinking and driving is a familiar pattern • Had trouble sleeping; is anxious and depressed• Sometimes needs an early morning drink to get out of bed.

Case study: Dave

Why has Dave presented for help with his drinking?

Case study: Dave

Dave’s drinking• Legal and employment problems, and sleep disorders are indicators of

alcohol related harm• He is dependent on alcohol to function• He has not tried to change his behaviour.

Case study: Dave

What stage of change is Dave in?A. PrecontemplationB. ContemplationC. PreparationD. ActionE. Maintenance.

Case study: Dave

What intervention strategies would you consider with Dave at this stage?

Case study: Dave

Intervention strategies will require detoxification and referral to a drug and alcohol physician.• Medical tests to assess the extent of alcohol damage• Needs to become motivated before considering treatment for alcohol dependence• Education about alcohol related harm• May benefit from self help groups such as Alcoholics Anonymous• Alcohol withdrawal under medical supervision• Relapse prevention.

Using the 5As in risky drinking behaviour

A 1-minute intervention using the 5A framework for hazardous drinkers

Ask

Do you drink?How much on a typical day?How many days per week?

Assess

Concern about drinkingInterest in cutting downBarriers to cutting down*

Advise

Provide brief, personalised, nonjudgmental and clear advice to cut downHighlight other benefits of cutting down

Assist

Enlist supportArrange

Offer relevant pamphlets on safe drinking levels and ideas to help reduce intakeFollow up soon after

* Look for ‘red flag’ conditions (RACGP 2006)

Jan’s case study puts the 5As into practice

Using the 5As in risky drinking behaviour

• What are the benefits of reduced drinking?• What are the strategies available to GPs to help their patients

overcome alcohol misuse?

Case study: Monica

• Aged 29 years and presents to you for the first time• She finds it difficult to lose weight and asks for your help.

Case study: Monica

At this point, discuss how you would continue the consultation – ‘ASK’.

Case study: Monica

ASK Monica if:• she has tried diet and exercise• she is experiencing any difficulties with diet and exercising• there is anything else that may be contributing to her difficulty in losing

weight, eg. how much alcohol does she drink per day or week?

Case study: Monica

Discuss how you would continue the consultation – ‘ASSESS’.

Case study: Monica

ASSESS Monica’s readiness to change.• Monica has not been aware that her drinking may be contributing to

her difficulty in losing weight• Monica is on the low risk limit for female drinkers (14 standard drinks

per week)• Consider if Monica has other health problems that may be helped by

reducing her alcohol intake• A routine health assessment could be performed: diet, exercise,

smoking status, alcohol intake, blood pressure, weight, BMI, waist circumference.

Case study: Monica

Discuss how you would continue the consultation – ‘ADVISE’.

Case study: Monica

ADVISE Monica:• alcohol is contributing to her difficulty in losing weight• reduce the amount of alcohol she is drinking as part of a

lifestyle change.

Case study: Monica

• Monica wants to reduce her drinking which is positive• Monica is determined to stick to her diet, despite not losing weight• By changing her lifestyle, Monica could also reduce her risk for

diabetes and heart disease.

Case study: Monica

Discuss how you would continue the consultation – ‘ASSIST’.

Case study: Monica

ASSIST Monica by suggesting she:• reduces the number of times she goes out during the week• makes her second drink a nonalcoholic drink• tries drinks with less sugar content, such as red wine or dry

white wine• limits alcoholic drinks to two in an evening.

Case study: Monica

Discuss how you would continue the consultation – ‘ARRANGE’.

Case study: Monica

ARRANGE for Monica:• lifestyle risk factor counselling • an appointment with the practice nurse to join the healthy

lifestyle clinic• useful patient information, including websites and guidelines• follow up visit in 4 weeks.

Case study: Michael

• Aged 71 years, and has been a patient at the practice for the past 10 years

• Presents due to heartburn and lack of sleep • Clinical history includes precious depression, and medication for

hypertension and reflux oesphagitis.

Case study: Michael

Discuss special considerations you would take into account for an elderly patient.

Case study: Michael

Special considerations• The elderly population has an increased prevalence of comorbid

conditions• In patients over 65 years an awareness is needed for symptoms of

dementia and depression• Polypharmacy is more likely in this population.

Case study: Michael

• Appears to be well controlled on proton pump inhibitor medication• Eats regular meals and follows the diet sheet from the nurse• Is sad and anxious about his daughter and grandchildren moving

away• Not taking any medication to help him sleep, but has a drink of

whisky.

Case study: Michael

Discuss special considerations you would take into account for alcohol use in the elderly population.

Case study: Michael

Special considerations for the elderly population• Alcohol use in the elderly population can be easily missed • GPs are in an ideal position to intervene because of their high level of

contact with the elderly• With a higher level of comorbidity and polpharmacy, intervention can

have a positive impact on outcome.

Case study: Michael

Discuss the effects of alcohol with aging.

Case study: Michael

Effects of alcohol with aging• There is a reduction in the level of gastric alcohol dehydrogenase, so

there are higher blood alcohol levels for the same amount of alcohol consumed

• Higher plasma concentration due to smaller volume of distribution• Renal impairment can slow removal of alcohol from the body• Physical inactivity, bone density loss and nutritional deficiencies

worsen effects of alcohol• Complications due to other illnesses and polypharmacy.

Case study: Michael

• Whisky may be interfering with blood pressure medications and reflux, aggravating the heartburn and causing discomfort.

Case study: Michael

Discuss the support strategies you would suggest for Michael.

Case study: Michael

• Try and cut out the night time drinks before bed• Counselling support from local aged care team• With Michael’s past history of depression, support from a psychologist

and alcohol counsellor• Opportunities to build social networks

Conclusion

GPs and practice nurses have an opportunity to significantly lessen the burden of alcohol misuse, and support their patients in adopting a healthy lifestyle, by regular physical exercise, healthy eating, and the avoidance of smoking and excess alcohol.