1. 1 Alcohol Health Work Why screen for alcohol ? It is a teachable moment Alcohol and health services. A significant impact on attendances? Alcohol and the body, Alcohol and society. A wide range of problems can be reduced. Screening tools Use whatever suits your environment. Simply asking and giving a leaflet can start the process What is needed for brief advice? A range of interventions available for patients Support, information and education for staff.

2. 2 F EEDBACK about impact on health etc R ESPONSIBILITY for own lifestyle change A DVICE about abstinence M ENU OF ALTERNATIVES for treatment etc E MPATHY during interview ie. non-judgmental S ELF-EFFICACY promotes likelihood of change A BRIEF INTERVENTION F R A M E S

3. 3 Alcohol Health Work BIA Brief Initial Assessment (as per community addiction services) Reason for admission to hospital. Current alcohol use and extent of problem, or patient’s understanding of problem. Alcohol history, esp. previous periods of abstinence, withdrawal symptoms, treatments. Current health, psychiatric & social status + relevant history. Significant social background, ie family, employment and legal history. Risk assessment.

4. 4 What brings you here? Aim of this question is to find out the client's expectation, most pressing problem and possible motivation for attending assessment. Establish the usual daily quantity of alcohol being consumed.

5. 5 What is your daily routine of drinking? Identify daily lifestyle pattern. It is important to establish the last time someone took alcohol/drug in order to indicate expected time of withdrawal symptoms. Note early morning relief drinking – due to withdrawals on waking? Also begin to note salience of drinking – ie impact of alcohol on routine, diet and sleep pattern. If employed, do they drink during work hours or on leaving work?

6. 6 Do you use other drugs or medication? Prescribed medication /smoking /illicit use – note any combinations with alcohol and tendencies to use more in certain circumstances. Establish extent of current substance use. Note if previous substance misuse or smoking has been successfully stopped.

7. 7 How much did you drink in the last 7 days? Identify weekly pattern and factors preceding this assessment. Prompt the client to complete the diary of drug/alcohol use for the last seven days. It can be helpful to start with the day before attending for assessment and working backwards for a week. Note problems remembering amounts & situations. Note types of alcohol drunk for narrowing. It can be important to establish accurate quantities of use i.e. units of alcohol (using the units ready reckoner) – especially where the patient is reluctant to admit the extent of their drinking. Do they drink every day?

8. 8 Brief summary of drinking history First started drinking: any awareness of compulsion to drink to excess? First regular drinking: who with, how was it different to problem drinking? Note any narrowing of repertoire – ie choosing only one type of alcohol. First aware of problems: how & when did they become aware. Establish when misuse began to affect the client’s lifestyle. Note any increase in tolerance. Drinking pattern over the last year: is this is a typical pattern? Have there been any fluctuations? Note pre-session positive change. Can client identify high risk situations and triggers? Note problems remembering amounts & situations. Note types of alcohol drunk for narrowing.

9. 9 Brief summary of drinking history First started drinking: any awareness of compulsion to drink to excess? First regular drinking: who with, how was it different to problem drinking? Note any narrowing of repertoire – ie choosing only one type of alcohol. First aware of problems: how & when did they become aware. Establish when misuse began to affect the client’s lifestyle. Note any increase in tolerance. Drinking pattern over the last year: is this is a typical pattern? Have there been any fluctuations? Note pre-session positive change. Can client identify high risk situations and triggers?

10. 10 Withdrawal symptoms Phase 1: MILD WITHDRAWAL Smell of alcohol on breath, shakes or tremor (usually in the hands), excessive sweating, anxiety and irritability, flushing, sleeplessness. Phase 2: MODERATE WITHDRAWAL Nausea and vomiting, diarrhoea, acute anxiety, agitation, tachycardia, jerky movements, increased sensory perception (ie. easily startled by noises). Sweating - beads of sweat observed, restlessness. Tremors. Insomnia.

11. 11 Withdrawal symptoms Phase 3: SEVERE WITHDRAWAL Delirium tremens (DTs) – not just shakes but visual, auditory or tactile hallucinations (usually sensory, visual and tactile). Convulsions (e.g. ‘Rum fits’), Epileptic seizures. Disorientation to time place and person, confusion, paranoia, restlessness, drenching sweats/ fever, Tachypnoea (rapid breathing). NB Phase 3 is a medical emergency, and can be treated with Diazepam, but admission to A&E may be necessary.

12. 12 Physical & mental health Identify any GP/hospital treatment/medication by prescription. Significant health issues such as liver problems (check LFTs), history of fits, accidents, gastric problems etc. Assess psychological/psychiatric symptoms. Establish whether client has had any experience of depression, anxiety, feeling suspicious recently or in the past. Any changes in mood ? How are these related to substance use? Any treatment for mental health problems in the past or present.

13. 13 Effects on the body Liver cirrhosis & hepatitis Cancer High blood pressure (hypertension) Strokes Pancreatitis Gastritis Fertility Problems Impotence Neurological disorders Mental Health problems depression, suicide

14. 14 Social situation Establish the clients' social network. Are they in a relationship? Do they have any children? Are they caring for those children? How supportive are the relationships? What social roles do they fulfil? Employment and accommodation history can be useful indicators of the impact of alcohol. Establish any family use of alcohol or drugs. How has this affected the family?

15. 15 Have you had times when you have not used substances? Prior treatments, self-detoxes, periods of abstinence. Enquire about attempts to control or abstain from misuse and whether the client sought treatment before. Ask if they have successfully abstained or controlled use in the past and what was helpful to achieve this. Was treatment helpful? What are their expectations of treatment? Longest period of abstinence & most recent are important. What happened prior to relapses? Did drinking pattern return quickly (reinstatement)

16. 16 When referring to Alcohol Dependency Syndrome, it is useful to bear in mind the following relationships. NARROWING NARROWING of repertoire: In Q2 & Q4, note variety of drinking. In Q5, pay attention to changes in type & variety of alcohol drunk. SALIENCE SALIENCE of drinking behaviour: A preoccupation with obtaining the substance (eg. theft), taking the substance, or recovering from its effects. In Q2 is daily routine preoccupied with drinking or obtaining drink? In Q10 to 13 has there been any effect on these aspects of the client’s life? TOLERANCE TOLERANCE to alcohol: In Q5, note increases in consumption over the years. WITHDRAWAL WITHDRAWAL symptoms: Possible symptoms outlined in Q6. RELIEF RELIEF drinking: In Q2, note drinking early morning (or on leaving work), and awareness of anticipating drinking. COMPULSION COMPULSION to drink: Q2 & Q5, Does client get cravings or urges to drink throughout the day? Important social, occupational, or recreational activities given up or reduced because of substance use. Continued substance use despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by the substance. REINSTATEMENT REINSTATEMENT of drinking behaviour: Not just relapse, ie. drinking after abstinence, but a rapid onset of previous heavy drinking. Q5 & Q6, when relapse occurred, did drinking pattern quickly resume? Is there a repeated cycle of this?

17. 17 Feedback & Recommendations Advise them about the known effects of heavy alcohol consumption – leaflets about safer drinking are available and a useful reminder. What next? Individual actions & responsibility How to cut down Advice on safe reduction of drinking How to avoid relapse Advice on recognising stressors & risks Treatment options Menu of where to seek further help Onward referral

18. 18 Benefits of cutting down Reduced risk of injury Reduced risk of high blood pressure Reduced risk of cancer Reduced risks of liver disease Reduced risks of brain damage Sleep better More energy Lose weight No hangovers Improved memory Better physical shape

19. 19 Specific well-defined, not just “to cut down drinking” Measurable how much is your limit ? Attainable it may not be safe to stop abruptly due to withdrawals! Realistic are there factors that may impact on your drinking? Time-limited NOT – “I will start drinking again after three months abstinent” SMART objectives