Assessment and Initial Intervention

Problems caused by alcohol and other drugs affect all areas of medicine and may be overt or less obvious. Alcohol and other drug (AOD) use exists on a continuum from abstinence and non-problematic low level use through risky use to dependence. The majority of people who use drugs will consult a GP in the first instance for both related and non-related issues. Early recognition of, and simple responses to, problematic use can meet with considerable success. Entrenched dependence is likely to require a more intensive response although treatment is still worthwhile and can be very effective.

Despite common perceptions to the contrary, treatment of AOD use is as successful as many highly regarded general medical treatments.

Asking about drugs and alcohol

Open with a general question first, for example:

How is your general health?

What about eating/sleeping/exercise?

Do you smoke?

What about cannabis?

Do you drink alcohol?'

Many people drink alcohol - do you drink?

When you drink how much would you have?

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Standard Drinks

A standard drink contains about 10 grams of pure alcohol. Hotels and restaurants usually serve alcohol in standard drink size glasses. Wine, however, is normally sold in 140 mL or 200 mL glasses. One 200 mL glass of wine contains approximately two standard drinks. Glasses used at home are unlikely to be standard drink size. The labels on alcoholic drink bottles and cans show the number of standard drinks they contain.

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Alternatively, you can use a screening tool, for example, when seeing all new patients or in the context of other chronic problems (e.g. depression or diabetes) or when the presentation may be related to AOD use (e.g. trauma, GIT upset).

Screening tools include:

ASSIST (Alcohol, Smoking & Substance Involvement Screening Test)

AUDIT (Alcohol Use Disorders Identification Test)

The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care (WHO)

If initial assessment indicates potentially problematic use, explore:

• Quantity and pattern of use for each drug to determine level and risk. For example, ask about the use in the last 7 days starting with yesterday and working backwards, then enquire if this is a typical or an unusual week in terms of consumption (if unusual, enquire about a typical week).
• If low risk, low level use no further intervention needed.
• If use is problematic but not dependent consider undertaking a brief intervention (see below).
• If dependent use is present, more intensive intervention is likely to be required. Enquire whether the person wishes to cease/reduce their use and consider likelihood of withdrawal. An opioid-dependent patient may prefer a maintenance program with methadone or buprenorphine. For referral options contact the Alcohol & Drug Information Service on 1300 13 1340.

My dependent patient wants to stop using

Assessment of AOD use and initial intervention

When is it OK to prescribe medications for alcohol dependence

Useful framework

One way to think of problems related to drug use is diagrammatically represented below:

Short term harms are often associated with intoxication problems such as hangovers, alcohol-related violence, drink driving offences etc.

Regular use may result in problems that are health-related (e.g. hypertension, cirrhosis associated with regular alcohol intake) or may affect relationships or finances.

Dependence is where there is loss of control and significant associated problems.

Criteria for Substance Dependence

An individual may experience harms in any one of these areas at any one time or in more than one area at any one time. Similarly, different problems may occur at different times in a person's life.

It can be helpful when talking to an individual patient to look at whether problems associated with use can be considered in each of these areas; it may assist a patient to recognise that, for example, their binge drinking is causing short-term problems such as absences from work with a hangover.

Elements of Brief Intervention

Although the exact composition of a brief intervention may vary, there are common elements and these have been described in a number of ways. One example uses the acronym FRAMES:

• Feedback: provide feedback from your clinical assessment
• Responsibility: emphasise the person's personal responsibility for their drug use and associated behaviour
• Advice: provide clear, practical advice and self-help material
• Menu: offer a range of behaviour change and intervention options
• Empathy: express non-judgmental empathy and support
• Self-efficacy: stress belief in the person's capacity for change

Withdrawal

If withdrawal is likely this will need to be addressed. Mild/moderate withdrawal can be managed in the GP setting if you are available and willing to be involved - specific advice about managing each drug withdrawal syndrome is contained in this website.

My dependent patient wants to stop using

Suitability for GP withdrawal management includes:

• mild to moderate withdrawal predicted and no medical/psychiatric contraindications
• patient wants it and will comply with instructions
• GP able, willing and available (daily review)
• carer support (to look after patient, medication and call for help if deterioration)
• patient has no immediate responsibilities and commitments

Advice and support

Advice and support for you and your patient can be obtained by ringing the Alcohol & Drug Information Service on 1300 13 1340 (24 hours). If needed, clinical advice from the on-call medical staff is available for health professionals.