The National Health and Medical Research Council (NHMRC) advises that there is no level of alcohol consumption that is completely safe, and the less people drink then the lower their risk of alcohol-related harm. Furthermore, the NHMRC has issued draft guidelines for reducing the health risks from drinking in Australia, and these indicate that healthy men and women should drink no more than: (a) 10 standard drinks per week; and (b) 4 standard drinks on any one day. Men and women who drink in excess of these guidelines should be advised to try and reduce their drinking in order to minimise their risk of alcohol-related harm.
There are also different patterns of alcohol use which may signal increased health risks, and these include:
drinking alcohol every day
repeated episodes of drinking to intoxication
drinking which affects behaviours and contributes to physical or mental harm (e.g., drink driving)
The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item measure that can also be used to inform discussions about drinking, or can be completed by self-report, and can be helpful to identify the level of risk and severity. Questions include:
How often do you have a drink containing alcohol?
How many drinks containing alcohol do you have on a typical day when you are drinking?
How often have you failed to do what was expected of you because of drinking?
If the individual scores 8-12 on the AUDIT then they may be classified as hazardous or risky drinkers, while scores of 13+ may signal high risk of harmful drinking or alcohol dependence.
Screening and initial assessment
In the aftermath of disaster, individuals may not be fully aware that their alcohol use has changed or increased their risk of consequences, and screening (or routine questioning) in frontline services should be considered to identify people who might benefit from an intervention. The World Health Organisation has developed the AUDIT for such purposes, and the first three consumption questions (called the AUDIT-C) may be useful when time and resources for screening are limited.
However, where resources are permitting, then initial assessments may also consider the range of problems that have been caused by drinking, as well as the severity of alcohol dependence. The Alcohol Problems Questionnaire (APQ) and the Severity of Alcohol Dependence Questionnaire (SADQ) may be used for such purposes. (see below).
Depending on the level of risk or severity of problems, there are different types of strategies that may then be considered.
Individuals who are identified as hazardous or harmful drinkers may benefit from a brief intervention, which have a long history in addressing alcohol misuse, and have been shown to be beneficial in reducing drinking behaviour. These brief alcohol interventions can range from 1-4 sessions, but may be a short as 5 minutes in a single session, and can be organised around elements of the FLAGS (feedback, listen, advice, goals, strategies) model: Referral to specialist treatment and support services Individuals who are identified as harmful drinkers, and particularly those who are alcohol dependent, may require and benefit from referral or engagement with specialist alcohol treatment. There are different types of services which may include counselling, residential or non-residential withdrawal services, as well as intensive structured programs that may be offered on a residential or non-residential basis. Specialist alcohol treatment services are likely to provide many of the following:
Individuals who are identified as hazardous or harmful drinkers may benefit from a brief intervention, which have a long history in addressing alcohol misuse, and have been shown to be beneficial in reducing drinking behaviour. These brief alcohol interventions can range from 1-4 sessions, but may be a short as 5 minutes in a single session, and can be organised around elements of the FLAGS (feedback, listen, advice, goals, strategies) model:
Referral to specialist treatment and support services
Individuals who are identified as harmful drinkers, and particularly those who are alcohol dependent, may require and benefit from referral or engagement with specialist alcohol treatment. There are different types of services which may include counselling, residential or non-residential withdrawal services, as well as intensive structured programs that may be offered on a residential or non-residential basis. Specialist alcohol treatment services are likely to provide many of the following:
Administer the AUDIT screening measure, including the brief AUDIT-C?
Assess impact of alcohol use on individual/individual’s health or social functioning?
Provide feedback on AUDIT?
Provide brief advice to reduce drinking?
Provide appropriate referrals for specialist alcohol treatment?
Become familiarised and prepared to administer the following scales:
Conduct supplementary assessments of the following:
See the AUDIT, APQ and SADQ-C forms, available from the Australian Guidelines for the Treatment of Alcohol Use Problems.
Become familiarised with the draft Australian guidelines to reduce health risks from drinking. This includes background rationale regarding immediate and cumulative effects of alcohol that can help justify advice to reduce drinking, as well as the draft guidelines for drinking. These indicate that healthy men and women should drink no more than: (a) 10 standard drinks per week; and (b) 4 standard drinks on any one day.
(OPTIONAL) Suggest a period of monitoring alcohol use, while emphasising that people are often unaware of their level or changes in alcohol use, and that monitoring itself can help to reduce consumption due to increased awareness. Completing a monitoring form can help track use, in particular during difficult times when individuals often have to focus on many things relating to disaster recovery. Monitoring also supports the individual to learn more about when, where, and why they use their substance of choice, and provides direction to more targeted strategies specific to their circumstances.
See the substance use monitoring form (see Resources Step 6 section).
(OPTIONAL) Identify troublesome and trouble-free drinking situations. Information about this can be found in the alcohol use monitoring form. The individual can aim to increase their involvement in trouble-free drinking use situations and reduce involvement in troublesome situations.
Become familiarised with approaches to delivering brief alcohol advice, including those based on the FLAGS model (TABLE 4.1, PG. 42 from the Australian Guidelines for the Treatment of Alcohol Problems).
Become familiar with more detailed resources for delivering brief alcohol interventions, many of which have been developed for use in general practice settings, and include scripts for introducing the subject and providing advice.
(OPTIONAL) Propose delay and distraction strategies that may to help to reduce alcohol consumption:
(OPTIONAL) Become familiar with linked materials presented below that include education brochures, self-help booklets, and training resources. These include online resources which address:
Become familiarised with the nature of alcohol treatment services in your region. These services are typically organised and may vary across State and Territories,
Alcohol and Drug Information Services (ADIS) also exist in in each state and territory, and can be contacted to identify appropriate services for referral, https://www.turningpoint.org.au/treatment/clients/phone-online-services#.
Motivational interviewing: Use these techniques to link increased stress levels to increased use. Consider exploring, in detail, the individual’s typical day. The function of this strategy is to help the individual talk about the behaviour in detail within a non-pathological framework, and to assess their readiness to change. This strategy is good for eliciting the context of the dysfunctional behaviour, and minimizing resistance when discussing the negative consequences of the behaviour.
Summarise the pros and cons of both continued alcohol use and reduction. Use open questions and reflective listening. Explore any concern that is raised. Once the individual has agreed on the need for change, develop alcohol use goals. Note that these goals may work toward cutting down OR stopping completely. In brief interventions, any reduction in use is considered positive and the aim is not to get the individual to work towards Australian Guidelines in the short term. The individual may choose any goal that is focussed on a reduction in use at that time.
The individual may already have other functional coping strategies. Encourage them to consider how they may be applied to managing substance use as substance reduction goals are developed.
Cognitive strategies: Review the alcohol use monitoring sheet and the assessment with the individual and explore their ideas about the positives of their drinking. The individual/individual may already have been able to identify the ‘other side of the coin’ for these positives. Reinforce these ideas that the individual/individual had. If you wish to make suggestions that seem very apparent, ask the individual/individual first before making the suggestion.
This activity is designed for the individual/individual to reflect on afterwards, not for them to come to any ‘correct’ conclusion in front of the practitioner.
There are two main cognitions to focus on:
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