1. Assessment tools: Alcohol

2. Why screen for substance use? (NICE, 2010) Systematic reviews explored by NICE indicated that early intervention in alcohol use reduces alcohol related mortality, morbidity, and social consequences of harmful use. Also, they support evidence that integrating screening and advice into general lifestyle discussions may increase the acceptability of screening and brief intervention.

3. Screening and assessing for alcohol misuse Let’s look at some resources available for non- substance use specialist health and social care practitioners to carry out brief screening and assessment for hazardous or harmful alcohol use.

4. Measuring alcohol use and ‘units’ Units are a simple way to measure the amount of alcohol in a drink. UK Government guidelines advise drinking no more than 14 units each week to avoid increased risks to health (DH 2016). One unit is 8g or 10mls of pure alcohol. One unit is the amount most adults can process in one hour. So, if you drink one unit per hour, your alcohol level is (theoretically) going to remain stable. However, people tend to process alcohol at different rates – so the 1 unit/hour is not a strict rule! How much alcohol in a drink depends on the concentration of the alcohol. So a ‘short’ is more concentrated than, say, a pint of beer. It is not the amount of liquid drunk, but the amount of alcohol in the drink. This can be easily calculated using the alcohol volume and liquid amount given on the label. However, it is easier to use a ‘rough guide’.

5. Rough guide to units (NHS Choices, 2015) Wine –1 small pub standard glass = 1.5 units –1 large pub standard glass = 3 units Beer –Half pint low strength beer = 1 unit –Pint of higher strength beer = 3 units Spirits –1 pub measure of whisky/vodka etc = 1 unit –Typical home measure of whisky/vodka etc > 2 units* * home measured alcohol is typically much bigger than measured amounts in a pub or club.

6. Calculating units To calculate units contained in a drink, just follow the formula –Strength (ABV%) x Volume (ml) ÷ 1000 = units. Find a can of beer or bottle of wine in your house or in a shop. Check the amount in the container (i.e. 568ml) and the alcohol volume (i.e. ABV 5.2%). Here’s a worked example below: 5.2 (%) x 568 (ml) ÷ 1,000 = 2.95 units There are online calorie counters which might be easier and you can do them on your phone. Try the Alcohol Concern unit calculator. It will also estimate the calories in each drink. http://www.alcoholconcern.org.uk/help-and-advice/help-and-advice-with-your-drinking/unit- calculator/?gclid=Cj0KEQjw04qvBRC6vfKG2Pi0_8gBEiQAAJq0vSWu8E_eYmBlBsrufiLHZSS 9gDULT83b1dYqJuYLGLgaAjul8P8HAQ

7. Screening tools: alcohol (NICE 2010) The main recommended screening tool for alcohol in most non- specialist settings is the Alcohol Use Disorders Identification Test (AUDIT). AUDIT is helpful to non-substance specialist practitioners in that it can help them to evaluate if someone would benefit from reducing their alcohol consumption. AUDIT is a 10 item questionnaire and is scored according to the answers given. The scores indicate the following: –1-7 = low-risk drinking –8-15= hazardous drinking –16-19= harmful drinking –20+ = possible dependence.

8. AUDIT: its use Babor et al (2001) recommend that AUDIT screening is used following explanation of the reasons for its use and with key terms explained. For instance, examples of a typical ‘unit’ of alcohol should be explained. Also, after questions 1 or 3, there may be no need to continue if the person has answered minimally to their use. Find a copy and user manual at Public Health England’s website: http://www.alcohollearningcentre.org.uk/Topics/Browse/BriefAdvice/?pa rent=4444&child=4896

9. AUDIT: critique Go to the Public Health England link on a previous slide and complete the AUDIT tool yourself. How easy were the questions? How easy would they be to use in an assessment with one of your service users? How might you adapt it to make it easier to use?

10. AUDIT: what next? Babor et al. (2001) recommend the following action dependent on the person’s score:  0-7Alcohol education.  8-15Simple advice on healthier alcohol use.  16-19Simple advice plus brief intervention and continued monitoring.  20-40Referral to specialist for diagnostic evaluation and treatment.

11. FAST (fast alcohol screening test) The Fast Alcohol Screening Test (FAST) is a simpler test that you can use to check whether drinking has reached hazardous levels. A FAST score of three or more indicates that you're drinking at a hazardous level. Go to the FAST test and try it for yourself.FAST test How would you use this in your practice?

12. Screening vulnerable groups NICE (2010) recommend that some groups may be more vulnerable to alcohol or screening errors. Their screening may require either more careful or an adapted assessment depending on their needs. Women who are pregnant or considering pregnancy –Women who are, or very likely to become, pregnant should be advised not to drink at all at this time. See the resource on ‘Specific issues in pregnancy’ for more on this.

13. Screening vulnerable groups (cont.) Younger people –People under the age of 16 are more vulnerable to the effects of alcohol, both physically and behaviourally. Therefore their risks are higher. A lower score on a screening test does not mean their drinking is not harmful. –Gillick and Fraser principles apply to anyone under 16. Practitioners should encourage inclusion of parents or guardians when assessing risk from substances. –For more on this, see the resource Working with young people and families.Working with young people and families

14. Screening vulnerable groups (cont.) People over 65 years of age –Older people are more vulnerable to the effects of substances than younger adults, both physically and psychologically. They are more at risk from chronic alcohol related health problems and at risk from acute problems such as falls. –They are also more likely to have co-morbid conditions which increase their risk of harm from alcohol use, such as diabetes, heart disease, liver disease. –They may also be on medications which interact negatively with alcohol. –See Physical and psychological harms – chronic for more on this.Physical and psychological harms – chronic

15. Screening vulnerable groups (cont.) People from minority ethnic backgrounds –A concern here is that assessment using language-based screening tools may not be appropriate for people whose first language is not English. –It is recommended that practitioners use professional judgement to determine the most appropriate approach to screening for these population groups.

16. Screening vulnerable groups (cont.) People with learning disability –Similar concerns arise here for people who may not have mental capacity to consent to assessment, or may have difficulty understanding assessment tool questions. –Again, recommendations are for professional judgement to be made regarding the most appropriate approach to screening for people with a learning disability.

17. Assessment tools for established alcohol harm The following are the tools recommended by NICE for assessing risky use once harm has been established. These may be used by more specialist practitioners or where a more detailed assessment is necessary. This need indicates a need for referral or consultation with specialist colleagues. Severity of Alcohol Dependence Questionnaire (SADQ) or Leeds Dependence Questionnaire (LDQ) for severity of dependence Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) for severity of withdrawal. Alcohol Problems Questionnaire (APQ) for the nature and extent of the problems arising from alcohol misuse.

18. References Babor, T., Higgins-Biddle, J., Saunders, J., Monteiro, M. (2001) The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care. World Health Organization. Department of Health (2016) UK Chief Medical Officers’ Alcohol Guidelines Review. Summary of the proposed new guidelines. Available online at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489795 /summary.pdf https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489795 /summary.pdf NHS Choices (2015) Alcohol Units. Available at: http://www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx#table http://www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx#table NHS Health Scotland (2015) Delivering an ABI: Process, screening tools and guidance notes. Edinburgh, NHS Health Scotland. NICE (2010) Alcohol-use disorders: preventing harmful drinking. National Institute of Clinical Excellence Public Health Guidance 24.