Opportunistic alcohol screening
The Government’s vision to help people live well for longer puts prevention at its heart, citing reduction in alcohol consumption as one of the keys to healthy living. With this in mind, practitioners should feel assured that acting on opportunities to assess their patients’ drinking is a valuable use of consultation time.
NHS health checks and new patient registration are two opportunities for alcohol screening, but opportunities arise during many types of consultation, including during the routine management of any longterm condition.
When conducting an initial assessment of drinking, as well as assessing alcohol misuse, consider:
- the extent of any linked health and social problems,
- presence of depression, anxiety, and/or low self esteem
- risk to self (including unplanned withdrawal, suicidality and neglect),
- risk to others, at home, including to partners, children, or whilst driving or in the workplace
- poor compliance with existing prescribed medications or possible interactions with prescribed medicines, and
- pregnancy or planned pregnancy
There are a variety of alcohol use disorder screening tests to identify higher risk drinking. The standard GMS contract requires that all patients added to the practice list must be asked about their alcohol consumption, with a view to reducing the alcohol-related risks to the patient. This is done using either the four question FAST tool or the three question AUDIT-C tool, both of which are shortened versions of the full AUDIT assessment.
Five key opportunities to discuss alcohol with your patients
Although screening and health checks are important, ask about alcohol at every relevant opportunity. The following are simply examples of presentations which should always prompt questions about alcohol consumption.
Patients needing to lose weight can be educated about the calories contained in all alcoholic drinks, and alcohol's metabolic effects. There is some contentious evidence about the effect of alcohol on insulin sensitivity changing with the amount of alcohol consumed, but the most important message here is to make the link between alcohol and weight gain, which is, of course, associated with increased risk of many diseases including type 2 diabetes. Habitual heavy drinkers are especially at risk of type 2 diabetes due to pancreatic damage.
Our Unit and Calorie calculator provides people with a quick and easy way to look up both the calorie content and units of alcohol in many popular drinks and the Drinkaware: Track and Calculate units app allows the user to track this information over time, and set goals to motivate reduction in consumption.
Raised blood pressure
Take the opportunity to tell patients known to have treated hypertension about the link between blood pressure and alcohol. Regular drinking leads to increased risk of hypertension for both men and women1. You can explain that reducing alcohol can help with blood pressure control, especially alongside weight loss, and this may, for some patients with moderate hypertension, result in medication not being required.
And for patients without a known diagnosis of hypertension, but who are found to have raised blood pressure, it is worth always asking about alcohol consumption and explaining the reason for your question.
Low mood and depression
When a patient requests help for low mood, you might ask ‘Some people have a drink when feeling down. What about you?'. Although alcohol often has a temporary positive effect on mood, the long-term effects of alcohol consumption are linked to depression, anxiety, self-harm and suicide. Alcohol-use disorders at least double the risk of depression. Disinhibition due to alcohol increases the risk of self-harm and suicide, with an approximately seven times higher risk of a suicide attempt immediately after drinking alcohol, and 37 times higher after heavy consumption of alcohol2. Risk of suicidal ideation, suicide attempts and completed suicide are all 2-3 times higher among those with alcohol-use disorders compared with the general population3.
Sleep is a natural line of questioning in patients with mood disturbance, although patients may present with isolated sleep problems. You might ask ‘Many people try alcohol as a way of getting off to sleep. What is your experience?’ Although alcohol is widely considered to help falling asleep, even a couple of drinks can affect sleep quality, because alcohol suppresses the critically important restorative phase, REM sleep4. Additionally, alcohol can cause disturbed sleep due to its effect as a diuretic. So, it is also worth asking patients who drink about having to get up at night to pass urine.
Raised liver enzymes
Blood tests that reveal elevated liver enzyme levels should always prompt an enquiry into the use of alcohol. The first stage of alcoholic liver disease is a fatty liver. Sustained reduction in consumption to within the Chief Medical Officers’ low risk drinking guidelines could resolve this problem with time, if the fatty liver was caused by alcohol. If left unchecked, there is a significant risk of progression to alcoholic hepatitis and cirrhosis.
Patients with chronic viral hepatitis should be advised not to drink any alcohol at all as it increases the risk of the development of hepatocellular carcinoma5.