2.1 Clinical history

There is evidence from clinical and epidemiological studies of a relationship between heavy drinking and certain clinical presentations (injuries, physical and psychiatric illnesses, frequent sickness absence) and social problems (see Annex 2). There are some signs at physical examination recognised by experts as linked to heavy drinking, such as injuries (including in the elderly), tremor of the hands and tongue, and excessive capillarisation of the facial skin and conjunctivae.^{16, 17} The exact association between these signs and actual heavy drinking has not been thoroughly investigated. Evidence level 4

Research suggests that most people are not offended by being asked about their alcohol consumption and will give a reliable account if there is no sanction anticipated.^{18, 19} Evidence level 4

Primary care workers should be alerted by certain presentations and physical signs, to the possibility that alcohol is a contributing factor and should ask about alcohol consumption.

2.1.1 THE ACCURACY OF SELF ASSESSMENT

Although evidence is not consistent, patients in research projects tend to report consumption that correlates with blood tests and is fairly close to that reported by their family.²⁰ It is not known if this is true for UK primary care consultations, where the GP may be perceived by the patient as having several roles, and where fears of employment, legal or insurance consequences affect what patients disclose to the GP. Evidence level 2+

Severely dependent drinkers may not want to admit a pattern of drinking, which they prefer to continue, or feel they cannot alter. Shame or guilt may lead some drinkers to minimise their reported consumption.²¹

While most patients are factual about their drinking, the primary care team should recognise that some will under-report their consumption at times.

2.2 Screening for alcohol dependence and those at risk

There is a large volume of good quality evidence indicating that appropriate screening helps the detection and treatment of alcohol problems (see Annex 2 for a list of alerts). This evidence has consistently shown that screening using the Alcohol Use Disorders Identification Test (AUDIT) is effective within primary care, A&E, pre- and antenatal settings. The AUDIT is more sensitive in the detection of hazardous drinking than CAGE (attempts to Cut back on drinking, being Annoyed at criticisms about drinking, feeling Guilty about drinking, and using alcohol as an Eye-opener; positive answers to two or more = probable alcohol dependence), unless CAGE is supplemented with questions on maximum daily and total weekly consumption (CAGE plus two).^{22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33} Evidence level 1++,2++,2+

The scoring procedure for AUDIT can be difficult to memorise, and the questionnaire itself can take five minutes to complete. Abbreviated versions of AUDIT are preferred by many primary care workers, and accuracy is only slightly diminished. These include the Fast Alcohol Screening Test (FAST; see Annex 3), which is a thirty second version of the AUDIT and the Paddington Alcohol Test (PAT; see Annex 4).^{22, 31} TWEAK and T-ACE are abbreviated screening tools found to be particularly appropriate for A&E and obstetric settings.^{25, 26} Evidence level 1++,2++,2+

Abbreviated forms of AUDIT (eg FAST), or CAGE plus two consumption questions, should be used in primary care when alcohol is a possible contributory factor.

In A&E, FAST or PAT should be used for people with an alcohol related injury.

TWEAK and T-ACE (or shortened versions of AUDIT) should be used in antenatal and preconception consultations.

When a patient registers with a GP, a medical history is taken which includes questions on alcohol consumption.³⁴ A screening questionnaire at this point is a useful tool for identifying hazardous drinking.

When new patients register with a GP they should be asked about weekly and daily alcohol consumption, or an appropriate screening tool should be used.

The screening and brief interventions algorithm shown in Box 1 in section 3.1 is based on the UK Alcohol Forum guidelines for the management of alcohol problems in primary care and general psychiatry³⁵ and is a useful tool to aid decision making.

2.3 Biological markers of alcohol problems

2.3.1 MARKERS OF ALCOHOL PROBLEMS

Elevations in mean red blood cell volume (MCV), serum gamma glutamyl transferase (GGT) and carbohydrate deficient transferrin (CDT) are markers of heavy drinking in preceding weeks. The difficulty in assessing their accuracy as diagnostic tests has been that self reported consumption is used as the “gold standard” but sometimes a biological marker may be more accurate than a self report.^{36, 37, 38} Evidence level 2+

False positive results occur with GGT and MCV due to other causes of elevation. False positive MCV can occur as a result of vitamin B12 deficiency, folic acid deficiency, thyroid disease or chronic liver disease. False positives with GGT are due to other causes of liver disease or enzyme induction including some drugs. CDT is normal in mild to moderate liver disease. It may be raised in severe liver disease, but otherwise gives few false positives. If elevated due to alcohol, it remains elevated for several weeks after consumption has reduced. It will not detect a recent relapse. CDT may be a more accurate marker of very recent (past two weeks’) drinking than GGT.^{39, 40} Evidence level 2+

As CDT measurement is not available within Scotland, it is recommended only when there is clinical difficulty in interpreting a normal or an abnormal GGT or other liver test result. King’s College Hospital, London accept serum samples by post for CDT assay.

Biological tests are of less value than self reports for screening with the intention of intervention. They have their greatest role where patients have a reason for minimising (or, less commonly, exaggerating) their consumption, and in monitoring patients’ progress in reducing their drinking.

Even though these tests have limited sensitivity and specificity, if elevated in a given patient, they may help motivate a patient to reduce drinking and they are then useful in monitoring change in consumption.

2.3.2 BLOOD ALCOHOL CONCENTRATION

Blood alcohol concentration (BAC), normally measured by reference to breath alcohol, can contribute to screening⁴¹ and is valuable for monitoring patients during detoxification in the community, as well as following progress thereafter. Breathalysers permit estimates to be made of very recent alcohol consumption and are often used by specialist nurses in the community. A breathalyser is a useful item of equipment in a Health Centre and in A&E. Evidence level 2+

Saliva alcohol tests also give a reliable estimate of BAC.^{42, 43} Evidence level 2+

Biological tests are useful when there is reason to believe that self reporting may be inaccurate.

Biological tests are useful to motivate patients to review their drinking and to consider change.

Biological tests should be used to monitor patients’ progress in reducing their drinking.

A&E departments and health workers regularly dealing with alcohol problems in the community should have access to a breathalyser.

2.4 Presentation in crisis

Patients presenting in crisis may place the primary care team in difficult situations. There is no evidence on how best to approach these encounters. This section discusses some possible common sense solutions.

2.4.1 PATIENT IN CRISIS

Suicidal threats or demands for immediate but undefined “help” require assessment, preferably within the surgery or by the out-of-hours service. Listening to the patient’s concerns may help to alleviate the pressure on the healthcare professional to take additional action. Immediate admission is rarely indicated or possible but, if suicidal ideation persists it may be needed, in which case referral to psychiatric services is appropriate.

2.4.2 DRUNK PATIENTS ON THE TELEPHONE, OR IN PERSON, EXPRESSING THREATS

Physically threatening behaviour should be dealt with by calling the police.⁴⁴ Drunk patients should be listened to politely and with courtesy, as showing frustration may inflame the situation. The patient may respond to being listened to politely and may be gently encouraged to go home. Drunk patients on the telephone can be disruptive to surgery function and also out-of-hours services as they may block the line. Having given due consideration and advice on who to contact when the patient is sober, it may be appropriate to terminate the call. At times, it may be quicker to see these patients.

2.4.3 DOMESTIC ABUSE

The domestic violence/abuse liaison officers at police stations provide advice to victims of domestic abuse and can put them in touch with support systems, whether or not they wish to prosecute their partner. Sometimes the police arrest and charge the aggressor, even if the victim will not give evidence. The victim may need to be removed to a place of safety such as a refuge.

2.4.4 ORGANIC BRAIN DAMAGE

Community management of patients with organic brain damage can be difficult. They often do not attend appointments. The community nursing team may be able to offer advice and support to the patient. A community care assessment by the social work department may be needed. If drinking continues to be problematic, sometimes patients will agree to an arrangement with their family or their social worker such that, at any one time, they only have access to small amounts of their money.