Nurse clinical lecturer and specialist in mental health Liz Burns outlines her five top tips for identifying potentially risky drinking and supporting patients to cut down
With the beginning of a new year, many people will have been taking the opportunity to reset their relationship with alcohol. Alcohol Change UK’s Dry January campaign is now in its 11th year, setting out to encourage people to have conversations that lead to healthier relationships with alcohol – not just in January but all year round.
In England, 10.4 million people consume alcohol at levels above the Chief Medical Officer’s low-risk guideline: 8.5 million drinking at increasing-risk of health harm and 1.9 million drinking at higher-risk. Many could benefit from an alcohol brief intervention, commonly referred to as alcohol screening and brief intervention, or alcohol identification and brief advice.
As a nurse working in the community, here are five top tips to help you to identify and support people drinking above low-risk levels in a brief opportunistic conversation.
1 Use a handy unit calculator
Calculating how many units of alcohol a person drinks in a single session and over a typical week can be made easier with an online unit calculator. The number of units in an alcoholic drink depends on both its size and strength, measured as alcohol by volume (ABV, usually labelled as a percentage). One alcoholic drink is rarely one unit of alcohol, so without a unit calculator it is difficult for people to accurately keep track of how much they are drinking.
You can work out how many units there are in any drink by multiplying the size of the drink (in ml) by its ABV and dividing the result by 1,000:
Strength (ABV) x volume (ml) ÷ 1,000 = alcohol units.
For busy day-to-day practice, try Alcohol Change UK’s interactive online tool (that also counts calories too).
2 Adopt non-judgmental, risk-based terminology
Using risk-based terminology to define drinking patterns across a continuum or scale can help explain how the risk of alcohol-related harm varies according to how much a person drinks. The three main categories are lower-risk, increasing-risk, and higher-risk drinking. Using such risk-based language in a conversation can also help reduce social stigma associated with talking about alcohol use, conveying a non-judgmental and empathic approach to making every contact count in the community.
The risks associated with alcohol use span over 200 illnesses and a range of accidents and injuries. It is a causal factor in more than 60 medical conditions including: mouth, throat, stomach, liver and breast cancers; high blood pressure; liver disease; and depression.
For people who do drink alcohol, consuming no more than 14 units of alcohol within one week, spread evenly across three days or more, lowers a person’s risk of harming their health.
If pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all.
3 Ask everybody about their alcohol use
One reason why it is important to ask everybody about their alcohol use is to normalise the conversation, indicating that you are asking people routinely and not singling anyone out. A good way to introduce the topic is by explaining, ‘I usually ask some questions about alcohol use here. Are you OK to go through some now with me?’
Since the majority of people drinking above low-risk levels will not have any obvious signs or symptoms, another benefit of asking everybody is to promote early identification and intervention.
Those drinking hazardously, where there is an increased risk of harm, make up the largest number of people drinking above the low-risk guideline (8.5 million people): women drinking 15-34 units per week and men drinking 15-49 units per week.
At higher-risk levels, women start to drink harmfully when they exceed 35 units per week and men more than 50 units per week. While all hazardous and harmful drinkers do not become alcohol dependent, alcohol dependence is more likely at higher-risk levels. An estimated 1.6 million adults have some level of alcohol dependence with symptoms that can be mild, moderate or severe.
4 Use an evidence-based alcohol screening questionnaire
The Alcohol Use Disorder Identification Test (AUDIT) is referred to as the gold standard screening questionnaire. Made up of 10 questions, AUDIT gives an indication of the person’s current risk drinking level out of a maximum possible score of 40.
There are a number of evidence-based questionnaires available other than AUDIT to help identify increasing-risk (AUDIT score 8-15), higher-risk (AUDIT score 16-19) or possible dependent drinking levels (AUDIT score 20-40). As a structured tool, such short alcohol screening tests guide you when to offer simple, structured brief advice and when to support a referral for a specialist alcohol assessment. Since they all include a set of questions asking about current alcohol intake, having a unit calculator to hand comes in use whatever your chosen alcohol screening questionnaire.
5 Support straightforward access to specialist alcohol assessment and treatment
A referral for a specialist alcohol assessment should be supported for those drinking harmfully who are already experiencing alcohol-related problems or other health needs, and anyone with possible alcohol dependence. Alcohol dependence can become more severe over time and the type of specialist treatment and support varies according to how severe it is.
Alcohol withdrawal symptoms can include poor sleep, anxiety, feeling shaky and sweaty, to more serious, life-threatening problems such as fits (seizures) and delirium tremens (hallucinations, confusion). Stopping or reducing drinking suddenly should not be advised in such a case without specialist assessment, treatment and support planning for these reasons.
Enabling community access to local alcohol services involves a non-judgmental, supportive discussion. Provide information that matters to the person such as the different types of treatment and support available depending on their goal, and where they can be seen for a first appointment. Signposting people to their GP is a good place to start, or find out what organisations provide local alcohol treatment services in your area so that you can share information with people promptly and directly.
Liz Burns is senior lecturer in mental health nursing at the University of Salford
