Key Facts

Alcohol brief interventions are one of the most cost-effective interventions in primary care. They involve identification of at-risk drinkers and delivery of structured advice to reduce consumption. Screening should be opportunistic and integrated into routine practice.

Epidemiology

• Approximately 25% of adults in England drink above the recommended 14 units/week
• Alcohol-related hospital admissions: >340,000/year in England
• Alcohol-related deaths: approximately 9,600/year in England (24,000 UK-wide)
• Alcohol is a causal factor in >60 medical conditions

Screening and Risk Levels

• AUDIT score 0-7: lower risk; reinforce guidelines
• AUDIT score 8-15: hazardous (increasing risk); brief advice
• AUDIT score 16-19: harmful (higher risk); extended brief intervention + follow-up
• AUDIT score ≥20: possible dependence; assess and refer to specialist alcohol services

Brief Intervention Components (FRAMES)

• Feedback: personal risk assessment based on AUDIT score
• Responsibility: emphasise personal choice and control
• Advice: clear, specific advice to reduce consumption
• Menu: offer a range of strategies for change
• Empathy: warm, reflective, non-judgemental approach
• Self-efficacy: encourage confidence in ability to change

Screening Opportunities

• New patient registration
• NHS Health Check
• Chronic disease review (hypertension, diabetes, liver disease)
• Mental health review
• Pre-conception counselling
• A&E attendance (injury, fall)
• Any consultation where alcohol may be relevant

Signs of Hazardous/Harmful Drinking

• Frequently exceeding 14 units/week
• Binge drinking episodes (>6 units in single session)
• Using alcohol to cope with stress/mood
• Alcohol-related injuries or accidents
• Raised GGT or MCV on routine blood tests

Signs Suggesting Dependence

• Compulsion to drink; inability to control intake
• Withdrawal symptoms (tremor, sweating, anxiety, seizures)
• Tolerance (needing more to achieve same effect)
• Neglect of other activities/responsibilities
• Continued use despite harm

Red Flags

• Physical withdrawal symptoms (tremor, sweating, seizures) — refer for medically assisted withdrawal
• Delirium tremens — medical emergency
• Signs of liver disease (jaundice, ascites, spider naevi) — investigate and refer
• Suicidal ideation associated with alcohol use — psychiatric assessment
• Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia) — IV Pabrinex urgently

Bedside

• AUDIT questionnaire (10 items) or AUDIT-C (3 items) — validated screening tools
• CAGE questionnaire (less sensitive; not recommended as primary screen)
• Unit calculation with patient
• Clinical examination: BMI, BP, signs of liver disease

Bloods

• GGT: most sensitive marker of alcohol excess (rises 3-5× in heavy drinkers)
• MCV: raised in chronic alcohol excess (macrocytosis)
• LFTs: AST, ALT (AST:ALT ratio >2 suggests alcoholic liver disease)
• FBC: macrocytosis, thrombocytopenia
• CDT (carbohydrate-deficient transferrin): sensitive marker of recent heavy drinking

Imaging

• Liver USS: if liver disease suspected (fatty liver, cirrhosis)
• FibroScan (transient elastography): non-invasive assessment of liver fibrosis

Special Tests

• SADQ (Severity of Alcohol Dependence Questionnaire): if dependence suspected
• Alcohol biomarkers (PEth, EtG): specialist use for monitoring abstinence

Brief Intervention Delivery

Simple brief advice (5 minutes — for AUDIT 8-15):

1. Feed back AUDIT score and personal risk
2. Relate to CMO guidelines (14 units/week)
3. Advise specific reduction strategies (drink-free days, smaller measures, lower-strength drinks)
4. Provide written information/leaflet
5. Offer follow-up

Extended brief intervention (15-20 minutes — for AUDIT 16-19):

1. Motivational interviewing techniques
2. Explore ambivalence about change
3. Goal setting (reduction targets or abstinence)
4. Develop personalised action plan
5. Offer follow-up appointment
6. Consider referral to alcohol service

Pharmacological (for dependence — specialist-initiated)

• Medically assisted withdrawal: chlordiazepoxide reducing regimen (e.g. 30mg QDS reducing over 7-10 days)
• Thiamine/Pabrinex: prophylaxis against Wernicke encephalopathy
• Relapse prevention (after detoxification):
  • Acamprosate 666mg TDS (modulates glutamate; helps maintain abstinence)
  • Naltrexone 50mg OD (opioid antagonist; reduces craving and reward)
  • Disulfiram 200mg OD (aversion therapy; causes unpleasant reaction with alcohol)
  • Nalmefene 18mg PRN (for reducing consumption in harmful drinkers; NICE TA325)

Referral Criteria

• AUDIT ≥20: specialist alcohol services
• Physical dependence (withdrawal symptoms): medically assisted withdrawal
• Co-existing mental health problems (dual diagnosis): integrated care
• Severe liver disease: hepatology/gastroenterology
• Pregnancy with alcohol use: specialist obstetric/addiction services
• Failed community detoxification: residential rehabilitation

• Brief intervention: reduces weekly alcohol consumption by 12-20% in hazardous drinkers; NNT of 8
• Harmful drinking: with intervention, 20-30% achieve sustained reduction
• Alcohol dependence: with treatment, 40-60% achieve abstinence at 1 year; relapse rate 40-60%
• Alcohol-related liver disease: fatty liver is reversible with abstinence; cirrhosis is not reversible but abstinence improves survival
• All-cause mortality: moderate reduction in alcohol (even from harmful to hazardous levels) significantly reduces mortality
• Cost-effectiveness: alcohol brief interventions are among the most cost-effective interventions in healthcare (£1 spent saves £26 in health and social costs)

AUDIT-C Scoring (Abbreviated Screening)

Score ≥5: positive screen — complete full AUDIT

UK Units Guide