1. Advise patients that there is no ‘safe’ limit for alcohol
The maximum recommended limits are 21 units per week for men and 14 units for women. But there are no ‘safe’ limits’ of consumption.
Patients may think they have a ‘low-risk drinking’ lifestyle, so explain that there is no threshold amount of alcohol in terms of its carcinogenic effect.
2. Explain how to calculate alcohol unit measurements
Alcohol units can be calculated by multiplying volume of drink in ml by the alcohol-by-volume in percentage, then dividing by 1000. For example, a 175ml glass of 12% wine is two units and a 25ml measure of a 40% spirit is one unit.
3. Remind patients the blood alcohol levels may still be elevated the morning after drinking
Eating while drinking alcohol slows alcohol absorption and reduces blood alcohol levels. The body metabolises around one unit of alcohol per hour, so blood alcohol levels may still be elevated the morning after drinking.
4. Encourage patients to self-monitor
Recommend that patients use diaries, online drink calculators and smart phone applications to self-monitor their alcohol consumption.
5. Use the AUDIT screening tool to identify alcohol misuse
The Alcohol Use Disorders Identification Test (AUDIT) can be used opportunistically in primary care - at registration, flu-clinics, and antenatal clinics for example. Click here to access the tool.
- A three-question AUDIT-C screen should be done first – a score of 5+ should prompt you to do the full 10-question AUDIT screen.
- An AUDIT score of 8+ requires brief intervention - within the practice or through community alcohol services.
- An AUDIT score of 20+ suggests alcohol dependency and requires referral to specialist alcohol treatment services.
6. Refer patients who are at risk of alcohol withdrawal seizures
Assess anyone who drinks 15 units or more per day, has symptoms of alcohol dependence, or who scores 20 or more on full AUDIT screening, for symptoms of acute withdrawal.
Any patient with acute withdrawal who is at risk of alcohol withdrawal seizures or delirium tremens, or is under 16 years of age, should be referred for inpatient, medically-assisted alcohol detoxification. Also consider inpatient referral for vulnerable patients - those who are frail, have cognitive impairment or learning difficulties, lack social support, have multiple comorbidities, or psychiatric needs.
7. Check liver function
Check liver function in anyone who misuses alcohol or is alcohol dependent - including gamma-glutamyltransferase, and full blood count with mean corpuscular volume. Many patients with alcohol-related liver disease achieve abstinence from alcohol after brief advice. Even in patients with cirrhosis, 75% of those who stop drinking are alive at 10 years. Referral guidance will be published in the 2013 National Liver Strategy.
8. Look out for concomitant mental health and social problems
Identify mental health concerns, since psychiatric co-morbidity is common among patients who misuse alcohol - 10% have severe mental illness and 50-80% have personality disorders. Also assess for other substance misuse and ensure the safeguarding of children and vulnerable adults - signpost to local services to address poverty, unemployment, homelessness and social exclusion.
9. Don’t overlook alcohol misuse in older people
Alcohol misuse is often missed in older people, since it can present with falls, confusion or insomnia which may be attributed to ageing. Contributing factors include bereavement and social isolation. Associated depression often responds well to treatment.
10. Know your local support groups and agencies
There are many charities and support groups. Alcoholics Anonymous and Alcohol Concern offer help with alcohol, drinking and addiction. The British Liver Trust and CORE deal with alcohol-related health problems such as liver damage. Al-Anon and NACOA provide help for young people with alcohol problems. Make leaflets available in your surgery in relevant languages, and recommend relevant websites to patients who want to make lifestyle changes. Continue to support patients who are hesitant about engaging with specialist alcohol services.
Dr Kieran Moriarty is a consultant gastroenterologist at Bolton NHS Foundation Trust and Alcohol Services Lead for the British Society of Gastroenterology. Dr Catherine Woolley-Stafford is a Core Medical Trainee Year 2 at Bolton NHS Foundation Trust.
The British Society of Gastroenterology (BSG), a professional organisation focused on the promotion of standards in gastroenterology and hepatology within the UK. The BSG has produced guidance to aid emerging CCGs in commissioning an effective gastrointestinal and liver disease service.
Further reading
Moriarty KJ. Alcohol Care Teams: reducing acute admissions and improving quality of care. The British Society of Gastroenterology and Bolton NHS Foundation Trust. Quality and Productivity: Proven Case Study. Accessed 10/12/12.
Moriarty KJ, Cassidy P, Dalton D et al. Alcohol-related disease. Meeting the challenge of improved quality of care and better use of resources. A Joint Position Paper on behalf of the British Society of Gastroenterology, Alcohol Health Alliance UK and British Association for Study of the Liver. 2010.
NATIONAL STRATEGY BODIES
British Society of Gastroenterology
British Association for the Study of the Liver
National Institute for Health and Clinical Excellence
