By Dr David Ryder MAPS
Centre for Public Health, Edith Cowan University

Alcohol is a most popular beverage in Australia, used to celebrate good times, commiserate over bad times, as a companion to good food, and to relax and 'kick in' to weekends. In 2004, 84.6 per cent of the Australian population aged 14 and over consumed alcohol, spending an average of $717 per person, consuming 95 litres of beer, 19 litres of wine and 1.3 litres of pure alcohol from spirits (Australian Institute of Health and Welfare [AIHW], 2005). But such consumption is not cost-free. In Australia it is responsible for approximately 4,000 deaths per year, for a total of 21,147 years of life lost (AIHW, 1999). In 1998, it cost the Australian economy $7,560 million (Collins & Lapsley, 2002). But what, it may be asked, has this got to do with psychologists?

The purpose of this article is to argue that the provision of screening and brief interventions by psychologists would significantly contribute to public health by minimising alcohol-related harm. The article will discuss alcohol-related harm, recommend psychologists screen for alcohol-related problems within their caseloads, describe how brief intervention can be applied and conclude with a discussion of the effectiveness of brief intervention.

Alcohol-related harm

Common assumptions are that alcohol-related harm arises from the consumption of dependent drinkers, that the most appropriate treatment approach is to provide specialist services through government and non-government services, and the role of psychologists not employed in these specialist services is to refer clients to such services. More recently it has been suggested that community-based services take an active role in addressing these issues (Moyer et al, 2002; Shand et al, 2003). Health professionals, especially general practitioners, have been identified as important players (Shand et al, 2003) and more recently it has been recommended that psychologists take a role (Rickwood et al, 2005). To understand this, the nature of alcohol-related harm first needs to be considered.

Alcohol-related problems derive from three styles of drinking - intoxication, regular, and dependent use (Ryder et al, 2006). While it may be of concern to the individual drinker, dependent use of alcohol is responsible for a relatively small proportion of harm. Intoxication problems (including road traffic accidents, assaults and industrial injury) and regular use problems (which include damage to nearly all major organs of the body) are responsible for most harm (Ryder et al, 2006). The question arises - where do individuals go as a consequence of such problems? Services addressing alcohol-related problems attract severely dependent drinkers, while the much larger population of intoxication and regular use drinkers are missed. So where do these drinkers go? The answer is they appear in community agencies, including hospitals, doctors' surgeries, and psychologists' practices, but often with the alcohol issues being missed.

Screening: identifying at-risk drinkers

So how can we better intervene? Firstly, cases need to be identified from within the psychologist's caseload. This can be achieved by screening all clients, the most suitable instrument being the Alcohol Use Disorders Identification Test (AUDIT) (Shand et al, 2003). The AUDIT comprises 10 questions and was developed by the World Health Organisation (1992) - see Table 1. It is self-completed by clients, takes less than 5 minutes and can be included as part of routine data collection. It takes seconds to score and calculate who is an at-risk drinker. The questions are behaviourally specific, making them useful when raising the issue of drinking in the consulting room.

Brief intervention

The issue of drinking then needs to be raised with at-risk drinkers. Except for those who are severely dependent upon alcohol, relatively brief intervention is sufficient for change to occur (Moyer et al, 2002). Brief intervention can range from a few minutes to three one-hour sessions. There is no set way for the intervention to be structured, though there are guidelines. The intervention includes an assessment of drinking and negotiation of drinking goals. In most cases abstinence is not required, with clients guided towards continuing to drink at lower risk. Low-risk drinking has been described by the National Health and Medical Research Council (NHMRC) (2001), and includes no more than four standard drinks per day for men and two for women on a regular basis, with alcohol-free days interspersed throughout the week. For advice on drinking in specific situations, see the NHMRC Guidelines. Counselling is likely to use motivational interviewing principles, an approach to counselling that assists clients to deal with the ambivalence that often surrounds their drinking (Miller and Rollnick, 2002). Adaptations of this approach have been shown to be effective with drinkers and for other problems seen by psychologists (Burke et al, 2002). Follow-up is included and self-help manuals are available for use as adjuncts to brief intervention (Shand et al, 2003).

Is brief intervention effective?

Brief intervention has been shown to be effective in community settings, outside of specialist alcohol treatment services, and if clients have a low to moderate dependence upon alcohol (Moyer et al, 2002) - precisely the sorts of settings psychologists work in and types of clients they are likely to see. The challenge is there - the psychology profession can make a significant contribution in minimising the harm from this most popular but also most hazardous of drugs. g

For further information, contact the author david.ryder@ecu.edu.au.

Table 1: Alcohol Use Disorders Identification Test (AUDIT) screening instrument

1. How often do you have a drink containing alcohol?
Never (0)
Monthly or less (1)
2-4 times a month (2)
2-3 times a week (3)
4 or more times a week (4)

2. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 (0)
3 or 4 (1)
5 or 6 (2)
7 to 9 (3)
10 or more (4)

3. How often do you have six or more drinks on one occasion?
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)

4. How often during the last year have you found that you were not able to stop drinking once you had started?
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)

5. How often during the last year have you failed to do what was normally expected from you because of drinking?
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)

7. How often during the last year have you had a feeling of guilt or remorse after drinking?
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)

9. Have you or someone else been injured as a result of your drinking?
No (0)
Yes, but not in the last year (2)
Yes, during the last year (4)

10. Has a relative or friend, or a doctor or other health worker, been concerned about your drinking or suggested you cut down?
No (0)
Yes, but not in the last year (2)
Yes, during the last year (4)

Scoring

Each question will receive a score from zero to four. For the last two questions, 'No' scores zero, 'Yes, but not in the last year' scores two, and 'Yes, during the last year' scores four. The scores for each question are then totalled, with a score over eight indicating risky drinking patterns.

References

Australian Institute of Health and Welfare (1999). National Drug Strategy Household Survey, 1998: First results. Canberra: Author.

Australian Institute of Health and Welfare (2005). National Drug Strategy Household Survey, 2004: First results. Canberra: Author.

Burke, B.L., Arkowitz, H. & Dunn, C. (2002). The efficacy of motivational interviewing and its adaptations. In: W.R. Miller, & S. Rollnick,
(Eds). (2002). Motivational interviewing: Preparing people for change (2nd Edition). New York: Guilford Press.

Collins, D. & Lapsley, H. (2002). Counting the cost: Estimates of the social costs of drug abuse in Australia in 1998-9. NDS Monograph Series, No. 49. Retrieved 30th October 2006 from: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-publicat-mono.htm/$FILE/mono49.pdf.

Miller, W. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd Edition). New York: Guilford Press.

Moyer, A., Finney, J.W., Swearingham, C.E. & Vergun, P. (2002). Brief interventions for alcohol problems: A meta-analytic review of controlled investigations in treatment-seeking and non treatment-seeking populations. Addiction, 97(3), 279-292.

National Health and Medical Research Council (2001). Australian Alcohol Guidelines: Health Risks and Benefits. Canberra: Australian Government Publishing Service. Retrieved 30th October 2006 from: http://www.nhmrc.gov.au/publications/_files/ds9.pdf.

Rickwood, D., Crowley, M., Dyer, K., Magor-Blatch, L., Melrose, J., Mentha, H. & Ryder, D. (2005). Perspectives in psychology: Substance use. Melbourne:
Australian Psychological Society.

Ryder, D., Walker, N. & Salmon, A. (2006). Drug use and drug related harm: A delicate balance (2nd Edition). Melbourne: IP Communications.

Shand, F., Gates, J., Fawcett, J. and Mattick, R. (2003). Guidelines for the treatment of alcohol problems. Sydney: National Drug and Alcohol Research Centre.

World Health Organisation (1992). The Alcohol Use Disorders Identification Test: Guidelines for use in primary health care. World Health Organisation.