New Australian guidelines for the treatment of alcohol problems: an overview of recommendations

What is unhealthy alcohol use?

Unhealthy alcohol use is an umbrella term which encompasses alcohol consumption that poses a risk of harm (hazardous or risky use), has caused physical or mental harm (harmful use), or constitutes an alcohol use disorder or alcohol dependence.^{2, 3} In essence, it indicates alcohol use which has reached the point where action to modify it is preferable to no action.

There is a spectrum of alcohol use and unhealthy use (Box 1).⁴ Hazardous (risky) alcohol use, which is a new diagnosis in the International Classification of Diseases, 11th revision (ICD-11), indicates there is a risk of harm in cases where no harm has yet occurred.⁵ Harmful (pattern of) alcohol use is an ICD-11 diagnosis which indicates a pattern of alcohol consumption that has caused physical or mental harm.⁵ Alcohol use disorder is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) of repeated alcohol consumption which has led to symptoms of alcohol dependence and social problems.⁶ Alcohol dependence is defined in the ICD-11 as a disorder of alcohol regulation characterised by a “strong internal drive to use alcohol” and comprising two or more of the following: impaired control over alcohol use (eg, its onset, level or termination); increasing priority of alcohol over other activities and responsibilities; and physiological features such as tolerance or withdrawal.^{4, 5}

Box 1. The spectrum of alcohol use and unhealthy use*

* The term “unhealthy alcohol use” comprises hazardous and harmful use together with alcohol use disorder as defined in DSM-5 and alcohol dependence as defined in ICD-11.

DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th edition; ICD-10 = International Classification of Diseases, 10th revision; ICD-11 = International Classification of Diseases, 11th revision.

Where to screen

Screening can be undertaken while a patient is in the waiting room by means of a paper questionnaire or an electronic device. This saves significant time for all concerned. In some countries, screening is an established part of the health care system and incentives are provided — for example, they form key performance indicators in Scotland. Systematic screening is now recommended by the World Health Organization,³ the United States Preventive Services Task Force⁷ and the full Guidelines for the Treatment of Alcohol Problems⁸ summarised in this supplement. In general practice, screening may be undertaken when the patient attends the practice for the first time and/or periodically (eg, every 2 years) as part of a health check. In addition, self-administered screening is possible through websites and apps.

Screening techniques

A quantitative history of frequency of alcohol consumption (eg, days per week drinking) and quantity of alcohol consumption (eg, number of standard drinks per day) can help detect risky patterns of alcohol use.

In addition, several standardised questionnaires can be used to screen for unhealthy alcohol use. The Alcohol Use Disorders Identification Test (AUDIT) is a screening and brief assessment instrument that comprises ten questions that focus on the previous 12-month period (Box 2):

Box 2. Alcohol Use Disorders Identification Test (AUDIT) questionnaire*

* Responses to questions 1 to 8 are scored (from left to right) 0, 1, 2, 3 or 4; responses to questions 9 and 10 are scored 0, 2 or 4.

The AUDIT and its shorter forms — such as AUDIT-C, which comprises the first three consumption questions, and AUDIT-3, which comprises question 3 only — are widely used.^9-11 On the full AUDIT questionnaire, a score of 8 or more points to hazardous or harmful alcohol consumption and a score of 15 or more points to likely alcohol dependence.⁹ A score of 5 or more on the first three questions (AUDIT-C) indicates likely unhealthy alcohol use. The AUDIT is available in a self-administered electronic format (https://auditscreen.org).

Signs on physical examination

Hypertension is also a common manifestation of unhealthy alcohol use. However, there may be no signs in someone with a lower level of unhealthy alcohol use.

Biological markers

Testing for two types of biological markers can provide useful adjunctive information to screening for unhealthy alcohol use. First, levels of alcohol, or direct metabolites, detected in blood, urine or breath can be measured; second, markers of the pathophysiological effects of alcohol on organs and body systems can be used (Box 3).¹³

Breath and blood alcohol testing is undertaken in several settings, the most common in everyday experience being random breath testing of drivers. It is also undertaken after motor vehicle and industrial accidents, and in therapeutic settings to identify intoxication, monitor adherence to treatment and provide therapeutic feedback. There is some evidence to support alcohol breath testing in occupations where safety is critical. Metabolites of alcohol may be assayed, typically in urine; most commonly, ethyl glucuronide levels are tested, but there is no Medicare rebate for this assay.

Many indirect markers can also be used, which include common liver function tests. Serum γ-glutamyltransferase is the most well known, although its levels are also raised in people with obesity and those taking certain medications. The sensitivity and specificity values of alcohol use biomarkers are shown in Box 3. Carbohydrate deficient transferrin is a sensitive and highly specific marker of unhealthy alcohol use and is also commonly used in regulatory monitoring procedures. However, testing for it is not reimbursed by Medicare.

Responding to screening results

A positive finding on screening can lead to confirmatory questions to identify the level of the patient’s unhealthy alcohol use. If the patient has alcohol use disorder or alcohol dependence, or has experienced significant physical or mental harm, a more comprehensive clinical assessment is indicated. If not, a brief intervention is appropriate⁸ (Box 4).

Box 4. Screening for and responding to unhealthy alcohol use

Assessing alcohol use and its effects

The full AUDIT questionnaire (Box 2) can be used as a convenient assessment framework as it taps directly into these three domains (see above). In doing so, it points to the diagnoses of risky or hazardous alcohol consumption, harmful alcohol consumption (or a mild alcohol use disorder), and alcohol dependence (equivalent to a medium–severe alcohol use disorder).

The extent of the assessment must be balanced with the desire to engage with the patient and retain them in treatment. If the patient feels that a lot of information is being obtained but that there is no clear pathway ahead for them, their motivation may wane. The aim is for the patient to become more confident of the appropriateness of the advice and understand the help available. It is very important to instil a sense of hope and that change is possible. This sense of self-efficacy is an important factor in treatment success.

Assessing physical disease

Any available laboratory test results from such assessment may then be relayed to the patient.

Assessing mental health disorders

Sometimes the mental health disorder is the underlying condition, and sometimes it is a complication of alcohol use (eg, alcohol-induced mood disorder). In other cases, there is no clear cause-and-effect relationship but a bidirectional (vicious circle) relationship. Various copyright-free mental health assessment tools may be employed, such as the Depression, Anxiety and Stress Scale (DASS)¹⁵ and the Kessler Psychological Distress Scale.¹⁶

Assessing social problems

Problems with relationships, work, finances and accommodation may be the reason why someone with unhealthy alcohol use seeks advice and help from health and welfare services. Part of the assessment may focus on these issues and a checklist of common social problems can be employed.¹²

Assessing motivation

The patient’s level of commitment and therefore motivation to change is an important predictor of outcome.^{11, 17} Questions that may be useful include “How interested are you in changing your drinking?” or, to avoid any sense of being judgemental, “How do you feel about your drinking at the moment?”. Contemplative responses such as “I’m thinking about stopping” or action-oriented responses such as “I want to stop now” point to a greater likelihood of engagement and change. Motivation to change should therefore be assessed as it can inform the strategy to engage the patient further in treatment.

Collateral information

Information from family members (where possible and subject to ethical considerations) can be extremely useful, particularly where there is a discrepancy in information — for example, when the patient’s stated alcohol consumption is less than what results of biological tests would suggest. Family members may be concerned about problems related to alcohol use which the patient has not reported.

Other aspects of assessment

Motivational interviewing

Most brief interventions are delivered in the spirit of MI, which uses a collaborative, evocative and compassionate approach, to increase a client’s sense of autonomy and readiness for change.² This client-centred approach facilitates treatment engagement and behaviour change by assisting clients to explore and resolve ambivalence about changing their alcohol use.² Four basic principles of MI are used to enhance a client’s motivation and commitment for change: express empathy; highlight discrepancies; support self-efficacy; and resist the “righting reflex”, which describes a health professional’s urge to tell a client how to solve their problem.²

Screening, feedback and information

Brief screening tools can be used to identify people with problematic alcohol use who may be suitable for a brief intervention. Personalised, informal feedback from the screening tools is typically delivered. This may include information on the frequency, quantity or severity of the individual’s alcohol use and related problems, and how this compares with clinical or population norms. Information on the psychological, social and physical consequences of alcohol use, and advice on harm-minimisation strategies (eg, setting limits) for reducing risk of alcohol-related harm, are also commonly provided. This process provides an important opportunity to increase the individual’s awareness of their alcohol use and enable them to explore and understand its consequences.

Goal setting

People who acknowledge that they may be drinking too much might be willing to set goals for making a change in their alcohol use. These goals need to be specific, realistic, and achievable, and a plan for how they can make changes to meet these goals should be developed. Some people may not perceive change as necessary, so MI and information about the potential consequences of continued alcohol use may help them recognise that their alcohol use is excessive. If an individual is still not receptive to making a change in their alcohol use, it may be useful to focus on how they can make a change in their alcohol-related behaviour to reduce their risk of harm (eg, drink water and eat first).

Referral to treatment

People who are still drinking to excess following a brief intervention can be referred to more intensive psychosocial treatment for alcohol use.³

Effectiveness of brief interventions

Brief interventions that incorporate MI are superior to no treatment for reducing alcohol consumption in adolescents, younger adults and older adults across multiple settings, but the effects are small.^4-12 Brief MI has not consistently been found to be more effective than standard care or alternative psychosocial treatments for reducing alcohol consumption.^{4, 5, 7, 8, 10} For young adults, brief MI is more effective than alternative non-MI psychosocial treatments, but the effects are very small.¹¹ It is not clear whether people with alcohol dependence are more or less likely to benefit from brief MI.^4-12

Brief interventions can be delivered in a variety of settings, including primary care (general practice, emergency departments, general hospital inpatient wards and outpatient clinics), higher education settings, alcohol and other drug treatment services, community counselling and welfare services, justice settings, and workplaces. However, the levels of evidence for the effectiveness of brief interventions in each setting vary, and evidence is strongest in primary care settings (see full Guidelines for the Treatment of Alcohol Problems at https://alcoholtreatmentguidelines.com.au for a more thorough review).¹³

Using brief MI across a variety of settings has the potential to provide large numbers of people with access to treatment for alcohol use. While the effects are small, brief MI interventions delivered at a population level could help reduce the impact of alcohol on the burden of disease and injury in Australia.

Cognitive behaviour therapy

Cognitive behaviour therapy (CBT) should be employed as a first-line psychosocial intervention for alcohol dependence.^{26, 31, 32} It addresses cognitive, affective and situational triggers for drinking and usually involves about 12 weekly sessions. The goal is to help patients feel more confident in their ability to control their drinking by developing effective coping strategies. Clinical benefit is enhanced when CBT is combined with pharmacotherapy or another psychosocial intervention (eg, MI).²⁶

Motivational interviewing

MI, a component of brief interventions, is effective as a standalone intervention in the short term and in patients with less severe alcohol dependence.⁸ It is a style of counselling that focuses on helping the individual explore and resolve ambivalence about change to motivate reduction in drinking. Because of its typically brief duration, it is often employed as a prelude to CBT.

Mindfulness and acceptance-based interventions

Mindfulness and acceptance-based interventions, particularly mindfulness-based relapse prevention and acceptance and commitment therapy have become more commonly employed in mental health. The goal of acceptance and commitment therapy is to foster acceptance of undesirable cognition and affect (eg, craving), and facilitate action tendencies that will lead to improvement in life circumstances. However, there is limited and mostly low quality evidence on the use of these interventions for alcohol dependence, so they should not be offered as first-line treatment.

Residential rehabilitation programs

Residential rehabilitation usually involves patients living and working in a community of other people seeking treatment for substance use and involvement of specialist staff. These programs can be as short as 1 month or as long as 24 or more months. They are designed to help people develop the skills and attitudes to make long term positive changes towards ceasing alcohol and/or drug use and generally include drug withdrawal management. Residential rehabilitation programs may be of benefit for patients with moderate-to-severe alcohol dependence and who need a structured residential treatment setting. While there is evidence showing that residential rehabilitation reduces substance use during the residential program, its long term effectiveness is unknown due to methodological shortcomings in the available research.³³

Assessment of withdrawal

Assessment of withdrawal should include history taking and an examination (Box 3).

Withdrawal setting

In most cases, alcohol withdrawal can be safely completed in the patient’s home (ambulatory withdrawal) if they have sufficient support. However, contraindications to ambulatory withdrawal include: severe complications in a previous withdrawal attempt (eg, seizures, delirium or psychosis); unstable medical or psychiatric problems (eg, suicide risk or recent head injury); concurrent drug use (particularly benzodiazepines); unsuitable home environment or homelessness; drug or alcohol use by others in the home; no suitable support person in the home; and repeated failed attempts at ambulatory withdrawal.

Unsuitable patients should be referred to specialist services for residential withdrawal management. Severe medical conditions (eg, recent seizure or delirium) or psychiatric conditions may warrant hospital admission.

Management of ambulatory alcohol withdrawal

It is important to provide information about alcohol withdrawal to patients and carers, such as the likely short duration of withdrawal and the very high relapse rates without further treatment. Monitoring and supportive counselling should be provided from health workers (eg, general practitioners, drug and alcohol workers, and nurses) and should focus on strategies for coping with withdrawal symptoms, maintaining motivation and reassurance (daily if possible). Linking the patient to a 24-hour telephone counselling service or crisis telephone service can also be of value.

Nutrition and medication

Nutrition advice should include drinking plenty of fluids (2 litres per day minimum) and avoiding heavy meals. Thiamine supplements (300 mg per day for 7 days) should be provided orally if the patient is well or by intramuscular injection if they are nutritionally depleted. For suspected Wernicke encephalopathy, higher thiamine doses are recommended initially (500 mg total dissolved solids by intravenous infusion) with ongoing treatment guided by specialist advice (see the full guidelines at https://alcoholtreatmentguidelines.com.au for additional information).¹³

Benzodiazepines are the preferred medication, supported by Level A evidence, and suppress GABA activity. A typical regimen for oral diazepam is provided in Box 4. Diazepam access should be managed with daily pickup from a pharmacy or clinic, or supervised by a responsible adult, and diazepam use should be limited to a duration of 5 days. If the patient continues to drink or is sedated, doses should be withheld. Medications for symptom management can be administered as required (eg, paracetamol, metoclopramide, hyoscine and loperamide).

Medications not usually recommended for withdrawal include anticonvulsants, chlormethiazole, antipsychotics and antidepressants. Administration of alcohol is not recommended to suppress alcohol withdrawal.

First-line pharmacotherapies: Therapeutic Goods Administration-approved medications

Acamprosate (subsidised by the Pharmaceutical Benefits Scheme [PBS] as an authority item) acts by modulating GABA and glutamate function in the brain, reaching desired levels in the brain after 1–2 weeks. Acamprosate is effective in maintaining abstinence from alcohol and reducing the risk of returning to any drinking with a number needed to treat of 12 over placebo.³⁶ It is contraindicated in patients with a known hypersensitivity to the drug, renal disease or severe hepatic failure. Acamprosate therapy is initiated after resolution of any withdrawal (usually 3–7 days after the last drink). It is well tolerated and usually taken for at least 3–6 months. Mild gastrointestinal adverse effects usually resolve spontaneously within days. Given the pill burden, adherence for prolonged periods is challenging and should be specifically supported.

Naltrexone (subsidised by the PBS as an authority item) is an opioid receptor antagonist that reduces dopamine levels in the nucleus accumbens. The number needed to treat, for reducing the risk of returning to heavy drinking, is 12 over placebo.³⁶ Naltrexone is not suitable for patients on opioid therapy or who require opioid-based analgesia. Naltrexone is contraindicated for patients with acute hepatitis or severe liver failure. Naltrexone therapy is initiated after resolution of any withdrawal (usually 3–7 days after the last drink) and is usually well tolerated.³⁷ Common adverse effects include nausea and headache, which generally subside within days. Naltrexone is usually taken for at least 3–6 months. Due to hepatotoxicity and potential increases in levels of liver enzymes, liver function tests should be performed periodically. Naltrexone should be discontinued 48–72 hours before requirement of opioid analgesia (eg, elective surgery).

Disulfiram (not subsidised by the PBS) works by inhibiting the action of an aldehyde dehydrogenase that is involved in the metabolism of alcohol. This results in the accumulation of the toxin acetaldehyde following consumption of alcohol — subsequently causing flushing, dizziness, nausea and vomiting — and thereby deters drinking. The intensity of the disulfiram–alcohol reaction varies and in rare cases may result in arrhythmias, cardiovascular collapse, respiratory depression, convulsions and death (1 in 15 000 patients). Disulfiram use has been associated with greater rates of abstinence relative to control in open-label studies, especially in direct observed therapy settings.³⁸ Disulfiram is an appropriate medication for patients who are motivated to abstain from alcohol but not those who have a goal of reduced alcohol intake. Treatment should begin about 48 hours after alcohol detoxification. Close supervision of disulfiram intake (eg, by a spouse or carer) to ensure treatment adherence has been associated with greater success. In many patients, two or three doses per week may be sufficient and more practical to schedule with supervision. It should only be prescribed to patients without medical contraindications such as cardiovascular, pulmonary or liver disease. A rare but potentially fatal type of hepatoxicity can occur, so biochemical monitoring in the first 3 months of therapy is important. Alcohol metabolism returns to normal 7–10 days after stopping disulfiram therapy.

Second-line pharmacotherapies: off-label medication

Second-line agents are available for patients unresponsive to first-line medications or with contraindications to their use.

Baclofen is a GABA_B receptor agonist that may assist in achieving abstinence, but evidence remains lower than that for first-line medications.³⁹ It should only be considered in specialist addiction settings for selected patients with contraindications for first-line medications, such as alcoholic liver disease.⁴⁰ Baclofen is associated with adverse effects (including sedation) and safety concerns have been reported (including overdose).^{41, 42} It is usually started at a low dose and judiciously titrated upwards, with weekly controlled dispensing. Treatment should not be abruptly stopped, to avoid baclofen withdrawal syndrome.

Topiramate is an anti-epileptic medication hypothesised to act by antagonising glutamate activity at glutamate receptors and inhibiting dopamine release. Topiramate has promising evidence for reducing heavy drinking³⁶ but has a complex side effect profile and should only be considered in specialist settings with careful monitoring.

Increasing medication adherence

Pharmacotherapy adherence rates for patients with alcohol use disorders are generally low in Australia.^{43, 44} Adherence to pharmacotherapies may be assisted by: eliciting the patient’s concerns about taking medication; using cognitive restructuring techniques to change maladaptive thoughts about taking medication; and using MI techniques to help identify personal costs and benefits of taking medication.

Personalised pharmacotherapy

There is little consensus to direct a personalised approach with confidence.^{45, 46} Naltrexone may be particularly efficacious among those who drink alcohol for the rewarding effect or for those wanting to reduce heavy drinking, whereas acamprosate may be better for those who seek abstinence. Whichever clinical recommendation is made, the effect is maximised with engaged psychological therapies. Pharmacogenomic research has not yielded consistent results, so genetic testing is not currently indicated.

Social context of alcohol problems

Notwithstanding the importance of restoring neurobiological imbalances that can maintain addictive behaviours, it is important to highlight that alcohol-related problems rarely occur in isolation, so the wider social context should be appreciated.⁴⁷ Provision of additional support regarding potential interpersonal and financial problems in addition to referral for any social problems such as housing and child welfare-related issues may be required. Re-establishment of social functioning — including relationships, healthy behaviour (such as exercise and nutrition) and employment — might thus be a significant component of longer term goals.⁴⁷ Addressing these factors, in conjunction with pharmacological assistance, is likely to be key for treatment gains that are sustainable.

Alcoholics Anonymous

AA, the first 12-step model for alcohol problems, was established 85 years ago. It is the world’s best known and most widely accessed form of peer support for alcohol problems and is now available in over 150 countries. Its core program (based around 12 steps) promotes increased self-awareness and heightens a sense of meaning in life. In Australia, there are an estimated 20 000 members of AA and about 1800 AA groups.⁴⁹ Despite the fact that AA has been subjected to the most rigorous research of peer support groups to date, there remains much scepticism about AA’s effectiveness and philosophical approach (eg, its focus on higher power and being powerless around alcohol), with low referral rates reported among clinicians.⁵⁰

Findings of a recent Cochrane review on the effectiveness of peer-led AA and professionally delivered or manualised treatments designed to facilitate AA involvement (12-step facilitation interventions) on the outcomes of people with alcohol use disorder showed that these approaches lead to higher rates of continuous abstinence at 1 year, when compared with conventional psychological treatments such as CBT, and are equally effective at helping people reduce alcohol-related consequences and severity of addiction.⁵¹ Adapting social networks (eg, increasing the number or proportion of non-drinking or pro-recovery peers in one’s network) is one of the key mechanisms through which people benefit.⁵² Participation in AA (especially when facilitated by a peer or clinician) is an effective strategy for increasing the uptake of peer support during and after treatment, and improving or sustaining treatment outcomes.⁵¹ As such, assertive referral practices are encouraged.

SMART Recovery

SMART Recovery and other secular forms of peer support have grown considerably in the past two decades. SMART Recovery was established 25 years ago and operates in 25 countries; it is free and, in Australia, offers about 250 weekly in-person or online meetings. It adopts an MI and CBT framework and is run by trained facilitators (clinicians or peers, and often both). It embraces harm reduction and recognises that greater success is achieved when individuals set realistic and achievable goals.⁵³ While based on an empirically supported theoretical framework, few randomised control trials have been conducted to assess its efficacy.⁵⁴ However, evidence for SMART Recovery is beginning to emerge, with studies suggesting that many people benefit in terms of reduced drinking, improved mental health and well-being, and the strengthening of connections with others.⁵⁵

Online support groups

Online peer support communities — like Counselling Online, Hello Sunday Morning, Sober in the Country and other peer support groups for people with alcohol problems — have also grown in popularity. However, evaluation of their effectiveness to date has been limited to qualitative analysis of blog posts and forum content, with preliminary evidence suggesting that engagement in Hello Sunday Morning’s blog platform is associated with reductions in alcohol consumption, particularly among heavier drinkers.⁵⁶

Peer support for family members

For family members and significant others supporting someone with an alcohol problem, the most widely established form of peer support is the 12-step based Al-Anon program, which is available Australia-wide and operates in more than 115 countries. In Al-Anon, emphasis is placed on attributing alcohol problems to the disease, rather than family members themselves, and accepting that family members have been adversely affected.⁵⁷ There is limited research into the effectiveness of Al-Anon, although a United States study found that ongoing attendance can enhance problem-solving skills, increase wellbeing and functioning, and improve relationships with affected family members.⁵⁸ While other support groups exist for family and significant others in Australia (eg, Family & Friends, a program offered by SMART Recovery) their effectiveness is yet to be established by empirical research.

Consumption goals

Many patients accept the need to reduce drinking but are not ready to abstain. The World Health Organization has defined four drinking risk levels (very high, high, moderate and low) with cut-offs at 60 g/day, 40 g/day and 20 g/day for women and 100 g/day, 60 g/day and 40 g/day for men, respectively.⁵⁹ Sustained reductions of at least two risk levels are associated with meaningful clinical improvement.⁶⁰ However, if drinking continues to exceed current Australian consumption guidelines, health risks remain.

Relapse prevention and management

Relapse to problematic drinking is common. Contributors include: persisting desire to drink, with the belief that consumption can be controlled; negative emotional states, such as frustration, interpersonal conflict, anxiety, depression and anger; positive emotional states (eg, celebration); and direct and indirect social pressure to drink.⁶¹

In relapse prevention and management, patients are taught to develop coping skills and the self-efficacy to implement these skills. Pharmacotherapy for reducing alcohol use or addressing psychological problems, such as anxiety or depression, may be integrated with psychosocial intervention.

Cognitive bias is a feature of alcohol dependence whereby many cues trigger consumption of alcohol.⁶² This process occurs, in part, outside of conscious awareness. These cognitive biases can be dampened through a computerised cognitive training intervention known as cognitive bias modification, where available.⁶²

Aftercare and follow-up

Long term follow-up is an important part of a comprehensive treatment plan. Aftercare refers to contact with a clinician or service following intensive treatment; it acknowledges that, to maintain change, ongoing monitoring and assistance is required. Aftercare is particularly helpful for people with severe dependence, whose likelihood of relapse is greatest. Goals include optimising mental and physical health and improving social functioning. It is important to develop an individual management plan, comparable to escalation planning for other disorders (such as asthma) where early recognition and management can prevent clinical relapse.

Support for people drinking at high or very high risk levels: a harm-reduction approach

Many people will not be receptive to or respond to the variety of treatment approaches aimed at reducing alcohol use.⁶³ An MI approach is recommended but is often unsuccessful. Harm-reduction interventions aim to maintain a therapeutic relationship and reduce alcohol-related harms even when reducing consumption cannot be achieved (see Box 5 for examples). Several options for treatment have been shown to be effective. Dramatic clinical improvements may be seen, but treatment engagement and completion rates are ongoing challenges. There is limited evidence to favour one approach over another, so a patient-centred approach is recommended to optimise engagement.³⁰

Domestic violence

Domestic violence and related injury are more common in women with substance use histories.³ Therefore, when screening for AUDs it is recommended that clinicians screen both women and men as possible victims or perpetrators of domestic abuse. Unsolicited disclosure of domestic abuse is uncommon and screening increases its identification.⁴ All domestic abuse screening should be trauma-informed — recognising how trauma affects people’s lives and behaviour.⁵ Social history-taking can be used to screen women and men for alcohol-related violence and we recommend explicitly asking about violence as it may serve as a catalyst for help-seeking.⁶ It may also be necessary to screen the partners of women with AUDs.⁷

When clinicians are discussing domestic abuse with a patient of the opposite gender, they should (where possible) ask the patient if they would like to talk to someone of the same gender. In cases where domestic abuse is identified, referral to a domestic abuse service, social worker or other specific community service should be made.

Child care

When screening for and managing alcohol-related problems in patients who are parents and caregivers of children, it is recommended that clinicians consider child care responsibilities throughout treatment planning — especially for women, who are more likely to be primary carers. A child protection assessment should be considered for anyone who has an AUD and is living with children.

Contraception

All women who use alcohol and who are of reproductive age should be reviewed for contraception, irrespective of their level of alcohol consumption. An individual woman’s level of sexual activity with males can fluctuate over time, so the potential need for contraception should be discussed and periodically revisited. Evidence supports the use of long acting reversible contraceptives such as intrauterine devices and hormonal implants as these are not user dependent, so these options should be recommended.⁸

Treatment location

Gender-specific options for treatment location should be considered when there are practical considerations that warrant treatment segregation (eg, women with young children, and those with a history of sexual assault or other gender-related trauma). They should also be considered when there are programmatic considerations to be made (eg, consideration of services with integrated domestic violence or parenting programs).

Engagement with Aboriginal and Torres Strait Islander peoples

Engagement is particularly important. It is founded on respect for the patient and their culture, and on understanding of the clinician’s own culture (including any privilege associated with it). Shame or fear of discrimination and legal or child protection consequences may make it hard for individuals to talk about their alcohol use. An unrushed, conversational approach helps build trust and respect. The clinician should make no assumptions about the patient, but endeavour to understand alcohol use and its context.

For patients from remote, traditional communities, clinicians should be aware of local protocols regarding interactions with the opposite gender and respect for older people, and they should seek guidance as needed. In addition, clinicians should be mindful that it can be respectful to avoid eye contact. A conversational style is important as a series of direct questions may seem intrusive or rude, and it may be helpful to start with a scenario to elicit specific information — for example, “Some people get grog shakes when they stop drinking. Some don’t. What’s it like for you?” Approaches that can help improve engagement with Aboriginal and Torres Strait Islander peoples are listed in Box 2.

Asking about alcohol use

To ensure that an accurate assessment of alcohol use is obtained, several factors should be considered. For example, improvised drinking containers, such as empty juice bottles, may be used and kitchen tumblers may hold two or more standard drinks of wine, or several of spirits. Sharing alcohol is also common and some patients may report on how much alcohol the group drank rather than their own use. Intermittent or episodic alcohol use with “dry patches” (periods of not drinking alcohol) is common. If a person only drinks alcohol intermittently, they may think of themselves as a “non-drinker”. A helpful question to ask would be “What about grand finals or sorry business [grieving after a death]?”.

For screening, use a validated tool once per year (eg, the AUDIT-C²⁵). If it is hard to use AUDIT-C, ask how much was consumed during the one to two most recent drinking occasions and approximately when the last four drinking days were.²⁶ The Indigenous Risk Impact Screen (IRIS) screens for alcohol and other drug use disorders plus mental health disorders.²⁷

Further assessment of those drinking above recommended limits

Sensitive assessment of harms, using reflective listening, can help an individual consider the effects of alcohol on their life. The seven areas (or “Seven Ls”) model of the Strong Spirit Strong Mind training program is one aid for this and provides guidance on delivering culturally secure services to Aboriginal communities.²⁸

Assessments of drug use and mental health comorbidities are also helpful. Mental health comorbidities (including complex trauma) are common in people who have AUDs, especially for Aboriginal and Torres Strait Islander peoples. Withdrawal risk should also be assessed. Individuals who drink excessive amounts of alcohol intermittently may experience less (or no) withdrawal symptoms when they stop. It can be helpful to ask about tremors (“grog shakes”) or seizures in the past.

Treatment and intervention

Key considerations for treating Aboriginal or Torres Strait Islander peoples who are alcohol dependent are shown in Box 3. Aim to provide a prompt, integrated and empathic response to the person’s alcohol use. A range of treatment and intervention options can be offered, including both mainstream and culturally adapted or culturally specific care.

Considering comorbidities and other conditions

Alcohol use disorder and polydrug withdrawal

Withdrawal management for individuals with an AUD and polydrug use poses additional challenges because specific clinical guidelines and withdrawal scales are not available. Therapeutic approaches are highly reliant on the substances currently being consumed and the dosages. Planning and undertaking withdrawal from alcohol and polydrug dependence will usually require close monitoring and increased levels of medical and psychological support.⁷ In some situations, patients may only be ready to withdraw from one or two substances.

Nicotine

Nicotine is the most common substance used concurrently by people with an AUD.⁸ Smoking cessation support should always be provided to current smokers as part of overall withdrawal management in all settings. It is important to note that smoking significantly increases the odds of a patient’s relapse to drinking and that smoking cessation is associated with better alcohol treatment outcomes.^{6, 9} Therefore, smoking cessation should be undertaken concurrently with alcohol treatment, and there is some evidence that varenicline¹⁰ or topiramate⁶ may help support reduction of both tobacco and alcohol use. More detailed guidance is available in the full Guidelines for the Treatment of Alcohol Problems¹ and smoking cessation guidelines.¹¹

Opioids and other sedative drugs

In managing patients concurrently using other sedatives (eg, benzodiazepines, opioids), treatment of alcohol withdrawal should be the first treatment priority, with other sedative use kept stabilised until the alcohol withdrawal symptoms have resolved. Longer-acting benzodiazepines are recommended in the treatment of more severe alcohol withdrawal states; for patients who are also concurrently regular benzodiazepine users, higher than usual benzodiazepine doses are required in withdrawal treatment. When providing such treatment for a patient also consuming multiple sedative drugs, alcohol withdrawal is likely to be more severe and will thus require larger benzodiazepine doses.¹² Typically, longer acting benzodiazepines, such as diazepam, are given in a sequential loading dose procedure. Following alcohol withdrawal, it is also recommended that opioid and other medication requirements are reviewed, bearing in mind that inadequate medication after withdrawal could pose risk for relapse.

Alcohol and methadone may have both pharmacodynamic and pharmacokinetic interactions. Chronic exposure to alcohol enhances methadone clearance, so that cessation of alcohol may lead to an increase in methadone levels.^{13, 14} Methadone dosage should be reviewed 1–2 weeks after alcohol withdrawal. Because withdrawal for alcohol and polydrug dependence can be complex, it is recommended that consideration be given to obtaining specialist and/or inpatient treatment.

Stimulants

Stimulants usually do not require additional specific pharmacotherapy treatment, as sudden discontinuation of heavy regular stimulant use is likely to be associated with sedation. However, both alcohol and stimulants are associated with increased cardiovascular risk, so people with heavy use of alcohol and stimulants should always receive screening for cardiovascular effects.¹⁵

Relapse prevention

Prescribing any medication to a patient engaged in polydrug use poses a risk for medication interaction.¹⁶ There is no relapse prevention medication specific for AUD with polydrug use, but specific medication is available for alcohol, nicotine and opioid dependence. For alcohol dependence, disulfiram, naltrexone and acamprosate can be used, while in specialist practice, sometimes off-label medications like baclofen and topiramate are used with caution given the limited evidence. The risk for adverse interaction with these medications is generally low, with the exception of opioids with naltrexone (although naltrexone may be considered after cessation of opioids).¹⁶

Continuing care

The morbidity and mortality associated with AUD and polydrug use necessitates the formulation of a care plan. The plan should include a regular review, collaboration with key supports (eg, family, partner, good friends, carer), and provide collateral information to assist with clinical monitoring.

Screening and assessment

It is not recommended to require a period of abstinence before assessing or treating potential comorbid mental disorders. Differential diagnosis may assist longer term care but should not interfere with engaging the patient or immediate priorities. Assessment sets the scene for the future relationship and needs to be conducted in a compassionate and empathic manner while acknowledging that the patient may strongly believe that alcohol has postitive effects despite its profound negative effects. A standardised screening questionnaire, the Kessler Psychological Distress Scale (K10 or K6),¹⁸ can help identify a wide range of mental disorders in people with an AUD, and is a useful addition to routine assessments. The Alcohol Use Disorders Identification Test (AUDIT)¹⁹ is a suitable screening tool for identifying heavy alcohol consumption and AUDs among people presenting to mental health services. Further, alcohol use is associated with increased risk for suicide, and suicide risk should be assessed and regularly monitored according to established guidelines.²⁰

Providing treatment

Comorbid mental disorders and AUDs should be managed in parallel or in an integrated fashion with evidence-based treatments provided for both problems. We recommend that clinical practice guidelines are consulted for specific mental disorders, and in the absence of guidance or evidence to the contrary, these recommendations should be applied to the care of those with comorbid conditions.

Specific psychological interventions that have strong empirical support for treating mental disorders uncomplicated by comorbidity include cognitive behaviour therapy, behaviour therapy, cognitive therapy, and interpersonal therapy.²⁰ Other psychotherapies may be effective but there is generally insufficient evidence to recommend their use. E-health interventions or the provision of psychological interventions via the internet are an effective channel to deliver evidence-based psychological interventions.^21-25 Portals such as Beacon,²⁶ e-Mental Health in Practice,²⁷ and Head to Health²⁸ provide access. However, care should be taken to coordinate, monitor progress of, and ensure continuity of care, and to maximise engagement.

Specific medications have strong clinical trial evidence for the treatment of mental disorders uncomplicated by comorbidity.^29-32 However, people with comorbid AUDs are often excluded, so there is relatively little evidence about the safety and efficacy of many medications in comorbidity and results need to be applied with caution. Guidance on polypharmacy³³ and off-label prescribing³⁴ are important to consider. Side effect profiles should be considered for the exacerbation of comorbid conditions. Clinicians should also be alert to the possibility of poorer adherence to prescriptions and increased risk of overdose while intoxicated (see the national Comorbidity Guidelines²⁰ for additional resources).

Cardiovascular disease

For patients with AUD, clinicians should have a high index of suspicion for cardiovascular diseases such as hypertension and dysrhythmia (supraventricular tachycardia and atrial fibrillation).^{39, 40} These disorders increase stroke risk. An abstinence-focused treatment plan for alcohol is recommended for patients with cardiac disease to improve clinical outcomes.^{40, 41}

Alcohol-related neurological disorders

Wernicke encephalopathy, cerebellar dysfunction, subdural haematoma, and alcohol-related dementia should be considered as differential diagnoses in patients with altered level of consciousness, falls, cognitive or motor decline, memory loss and AUD.⁴²

Alcohol abstinence, analgesia, a balanced diet, high dose thiamine and a multivitamin supplement containing other B vitamins are recommended for people with alcohol-related neuropathy who present with AUD or neurological symptoms.^{43, 44} People with AUD should be screened for risk of seizures and be provided with benzodiazepines to prevent seizures in the case of alcohol withdrawal.⁴⁵

Infection risk

People with AUD should receive focused education and advice about risks of unprotected sex and acquiring HIV/AIDS and other preventable sexually transmitted infections.^{46, 47} Such interventions should be considered in others who may not meet criteria for AUD, but whose drinking behaviour (eg, binge drinking) may put them at risk of sexually transmitted infections.

Nutritional, gut and liver disease

Liver disease and cirrhosis are the most common medical complications of alcohol.⁴⁸ In patients with AUD, early recognition of liver injury and the risk for liver cirrhosis is critical.⁴⁹ Screening for alcohol-related liver cirrhosis using non-invasive methods such as ultrasonography, transient elastography and/or serological biomarkers is recommended for people with AUD.⁵⁰

Recognition of advanced liver disease and portal hypertension is recommended to ensure the safe use of pharmacotherapies used to aid alcohol abstinence. Patients with cirrhosis should abstain from alcohol⁵¹ and should be referred to a hepatologist for liver disease management and to an addiction physician for treatment. Liver transplant referral should be considered for patients with decompensated liver disease (Model for End-Stage Liver Disease score, > 14) who are abstinent from alcohol for 6 months.⁵²

Alcohol abstinence is required to prevent recurrence of acute alcohol-related pancreatitis. In acute alcohol-related pancreatitis, the use of prophylactic antibiotics is not recommended,⁵³ with management focused on observing for complications such as pancreatic necrosis, managing fluid balance, and maintaining enteral nutrition when possible.

Alcohol and cancer

Alcohol increases the risk of many solid organ cancers including aerodigestive (oropharynx, larynx, oesophagus), liver, colon, rectum and breast, and is attributed as a cause in 5.8% of all cancers.⁵⁴ Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer.⁵⁵