Identifying hazardous and harmful alcohol consumption 

There are several individual and social consequences brought about by harmful alcohol consumption: death, disability (due to accidents and the diseases it causes), lack of productivity at work, and family violence and crime, among others. Therefore, it is necessary to detect both hazardous and harmful consumption, with Primary Health Care being the best environment to enable the identification of these situations, alongside intervention targeted according to the level of complexity and severity of the problem. With regard to cases of addiction that fall within a certain established criteria, they should be appropriately referred to Secondary Health Care.

As the majority of patients who have a hazardous and harmful consumption are not known by their doctors (Rush et al. 2003), it is necessary to detect the issue in certain patient groups or specific clinical situations or social needs. The selection of these groups can be made based on epidemiological relevance in relation to consumption, or based on the risks to health that alcohol poses, such as pregnant women, teenagers or young adults.

In order to implement these alcohol consumption detection habits in Primary Health Care and to optimize results, issues related to alcohol may be included in general health tests or in questions related to habits and lifestyles, such as exercise, eating habits and smoking habits.
The hazardous and harmful consumption of alcohol can be identified through detection devices, like short questionnaires that can be self-completed, or whose questions can be asked by a health professional.

Research has shown that some surveys detect about twice as many heavy drinkers as those found in routine doctor visits, and three times more than those revealed by some laboratory tests (Kaner et al. 1999).

Identifying the type of consumption is crucial, as it has been demonstrated that when excessive consumers are subject to Brief Interventions or accept a treatment plan, they will reduce consumption levels, this becoming more effective the sooner clinical intervention is initiated (Bien et al. 1993).




AUDIT (Alcohol Use Disorders Identification Test) 

This questionnaire was constructed so as to be appropriate to Primary Health Care, allowing the detection of varying levels of consumption, from hazardous to harmful consumption and even addiction.

The use of the original AUDIT found a sensitivity of 97% and a specificity of 78% for hazardous consumption and a sensitivity of 85% and a specificity of 85% for harmful use when a cut-off point of eight or above was used (Saunders et al. 1993).

A variety of subpopulations was studied involving Primary Health Care patients (Piccinelli et al. 1993) in emergency rooms (Cherpitel et al. 1995), consumers of illicit substances (Skipsey et al. 1997), unemployed (Claussen et al. 1993), university students (Fleming et al. 1991), hospitalized elderly patients (Powell et al. 1994) and people of low socio-economic stratum (Isaacson et al. 1994). The AUDIT showed good discrimination in a variety of contexts, but is better suited for detecting hazardous and harmful drinkers and is mainly directed to Primary Health Care.

Some studies considered the relationship between AUDIT scores and indicators of future alcohol related problems (Claussen et al. 1993).
AUDIT C (Aertgeerts et al. 2001) includes only the first three quantification questions of AUDIT.

Gordon (Gordon, et al. 2001) used C AUDIT to identify hazardous level consumption in Primary Health Care. In general, AUDIT C has a sensitivity ranging from 54 to 98% and a specificity ranging from 57 to 93%.

Gual et al. compared AUDIT C with the clinical diagnosis of hazardous consumption carried out by doctors following patients in Primary Health Care units. For men, the best cut-off score was 5 (sensitivity 92.4%, specificity 74.3%) and in women, the best cut-off score was 4 (sensitivity 90.9% and specificity 68 4%).

There is no evidence confirming that the identification of consumers at risk or with a harmful consumption pattern leads to adverse side effects, such as discomfort or dissatisfaction of patients.



Brief intervention in hazardous and harmful consumption of alcohol 

There are several meta-analysis and/or systematic reviews about research of the effectiveness of brief interventions, which use distinct objectives and methods (Moyer et al. 2002; Whitlock et al. 2004; Cuijpers et al 2004; Bertholet et al. 2005; Kanner et al. 2007). They all came to conclusions that favour the effectiveness of brief interventions in reducing alcohol consumption to low risk levels among individuals with hazardous and harmful alcohol consumption following early detection.

Primary care professionals can offer patients identified as being at risk or with harmful alcohol consumption a brief intervention that can be described as based on five steps (the English 5As): assessment of alcohol consumption, using a brief assessment tool followed by a clinical evaluation; counselling patients to make them reduce alcohol consumption; agree and establish individual goals to reduce consumption or to initiate abstinence (if indicated); assist patients in developing motivation and to have the necessary support to undergo behavioural changes; and ensure the follow-up and the referral of dependent patients to specialized treatment (U.S. Preventive Services Task Force 2004).

These Brief Intervention models based on motivational interviewing last an average of 5 to 10 minutes and may be carried out in 3 or 4 sessions, which are intended to modify the risk behaviour of an individual towards reducing his/her levels of alcohol consumption.

If the patient is making progress, the frequency of the intervention, by means of a visit, should be every 6 months or on a yearly basis. However, if the patient has difficulty in meeting the goals he/she has set for him/herself, the intervention should be reassessed and the possibility of referral should be considered.

Compared with a control group, Brief Interventions can prevent one in every three deaths arising from problems related to the consumption of alcohol (Cuijpers et al 2004).



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General and Family Medicine and the Approach to Alcohol Consumption Detection and Brief Interventions in the context of Primary Health Care

PhD SUMMARY 

Portugal is the country with the highest continued consumption of alcoholic beverages per capita in Europe and the world, which causes Alcohol Related Problems (ARP) and has an important impact on public health.

Several studies reveal that there is a dose-response relationship between alcohol consumption and the frequency and severity of various diseases. Thus, higher levels of consumption correspond to higher mortality and morbidity rates.

Following the detection of consumption, various studies suggest that early detection and brief interventions, in the form of family doctors giving advice about alcohol consumption and the provision of information in clinical practice are, in terms of evidence, the most efficient approach to hazardous and harmful consumption at the level of Primary Health Care.

The doctoral thesis followed an action-research approach and aimed to evaluate the effectiveness of early detection and brief interventions in dealing with patients identified as alcohol consumers at hazardous and harmful levels, and confirm if the training of doctors in Brief Interventions to address alcohol-related problems (ARP) contributes, in some way, to change their attitudes with regard to alcohol consumers at hazardous and harmful levels.

The work had two distinct phases. One phase involved characterizing and measuring a questionnaire of perception of attitudes in a random sample of physicians. The other phase had two components: firstly the perception of the attitudes of family physicians in relation to the alcohol consumption of their patients and, secondly, detection and assessment of the level of alcohol consumption by patients through the application of the AUDIT.

There were some changes in the attitudes of physicians in the experimental group, particularly with regard to motivation, self-esteem and satisfaction when compared with physicians in the control group.

We observed that 21% of patients showed evidence of hazardous consumption (AUDIT C). Patients with hazardous and harmful consumption of alcohol who were followed by a doctor in the experimental group (compared to being followed by a doctor of the control group) were more prone to reducing their consumption levels. Regarding the relationship between doctors and patients, results also indicate that a better attitude on the part of doctors towards patients with ARP may influence the reduction of alcohol consumption by these patients at the start and end of the study.

 

Cristina Ribeiro
Lecturer at the General and Family Medicine Unit
Institute of Preventive Medicine
Faculty of Medicine of the University of Lisbon
cristina.mpr@sapo.pt

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