Managing unhealthy alcohol use in general practice

Local recommendations

In Singapore, the maximum recommended alcohol intake is two standard drinks per day for men and one standard drink per day for women.(4) Definitions of a standard drink vary internationally. In Singapore, one standard drink is equivalent to 10 g of pure alcohol (Fig. 2) compared to 14 g in the United States. The United Kingdom defines one unit as 8 g of pure alcohol.(5)

Fig. 2

Graphic shows examples of one standard drink in Singapore (10 g pure alcohol)

Another useful way of calculating alcohol intake is by using the following formula:(6) number of standard drinks = amount of drink (in litres) × alcohol by volume (%) × 0.789 (density of ethanol at room temperature). For example, for a 500-mL bottle of beer that is 5% alcohol by volume, the number of standard drinks it contains is: 0.5 × 5 × 0.789 = 1.97 standard drinks.

Screening

Table I shows some screening tools that can be used in primary care. The most widely validated screening instrument is the ten-item Alcohol Use Disorders Identification Test (AUDIT), which was developed by the World Health Organization.(1) The test provides greater specificity but takes longer to administer.

Table I

Screening tools that can be used in primary care.

Clinical history and physical examination

Following a positive screening test, it is important to quantify alcohol use (Fig. 3). A useful tip is to empathetically ask in a non-judgemental way, “bring me through a typical day when you last drank”. Allow the patient to describe the type and brand of alcohol and calculate his/her intake in terms of standard drinks. It is also important to evaluate the frequency of drinking, time of last drink, any binge drinking, and where and with whom they drink. Reasons for drinking, such as stress, low mood, family or relationship problems and peer pressure, should also be elicited.

Fig. 3

Flowchart shows the approach to unhealthy alcohol use. AUDIT-C: Alcohol Use Disorders Identification Test-Concise; SASQ: Single Alcohol Screening Question

It is important to acknowledge the significant impact of physicians’ attitudes, knowledge and perception in eliciting this information. Open and non-judgemental attitudes are vital in encouraging patient disclosure.

A review of the patient’s past medical history, along with a targeted systems review should be done to evaluate for physical and mental health complications of alcohol use disorder. Concurrent substance use, such as cigarettes and recreational drugs, should be screened for.

Clinicians should be mindful of alcohol withdrawal in higher-risk patients, which usually occurs after a drastic reduction in chronic alcohol drinking and within 6–24 hours of the last drink. Symptoms include anxiety, agitation, restlessness, tremors, insomnia, diaphoresis, palpitations, headache and alcohol craving. Patients may also experience nausea, vomiting and loss of appetite. Manifestations of severe withdrawal are hallucinations, seizures and delirium tremens.(14) A thorough physical examination, mental state examination and risk assessment should be performed. If deemed necessary, a suicide risk assessment should be performed in those with severe psychiatric comorbidities.

Special populations

As there is no known safe level of alcohol consumption during pregnancy, alcohol should not be consumed in any quantity by pregnant women or women who are trying to get pregnant. Alcohol is teratogenic and also increases the risk of pregnancy loss.(1) It is important to screen all pregnant women for alcohol consumption and counsel them appropriately.

Laboratory investigations

Investigations are useful to detect complications of alcohol use disorder. These include:

• Full blood count (to look for macrocytosis)
• Liver function tests (aspartate aminotransferase:alanine aminotransferase ratio of 2:1 suggests alcoholic liver disease)
• Gamma-glutamyl transferase (elevated in one-third of heavy drinkers)
• Electrocardiography

Carbohydrate-deficient transferrin is a more specific marker of chronic excessive alcohol use, although it is only available in specialist settings. In the inpatient setting, serum electrolytes (including sodium, potassium, magnesium and phosphate) should be checked, along with amylase, lipase and urine drug testing.

To maintain rapport, efforts should be made to ensure continuity of care, with the same physician seeing the patient at all subsequent visits. Doctors should also keep up to date on the relevant laws related to alcohol use in Singapore (Box 1).(15)

WHEN SHOULD I REFER TO A SPECIALIST?

Patients with mild alcohol use disorder can be safely managed in the community. Brief counselling and interventions, with close follow-up, may be sufficient for most of these patients. There are various resources that can provide further support for motivated individuals or those whose drinking is starting to affect their work or social lives (Table II). These are located in the community and within specialised centres at tertiary hospitals.

Table II

Community resources and helplines.

Patients with moderate to severe alcohol use disorder can be referred to specialist psychiatric clinics for consideration of medication-assisted detoxification therapy. Patients with concurrent psychiatric comorbidities and those with a history of recurrent failed detoxification attempts or delirium tremens should also be referred to specialist clinics. These are primarily based at the National Addictions Management Service (NAMS) within the Institute for Mental Health. NAMS also runs satellite Community Wellness Clinics at Geylang and Queenstown Polyclinics. There are also psychiatrists who run alcohol cessation services within National University Hospital and Changi General Hospital.

Patients with severe physical or psychiatric complications from alcohol use disorder should be referred to the emergency department for stabilisation. Those at high risk of harm to self or others and those with a lack of social support should also be referred for their safety.

TAKE HOME MESSAGES

1. Unhealthy alcohol use is a growing problem in Singapore, with the prevalence of alcohol use disorder and binge drinking steadily increasing in the last decade.

2. The recommended maximum alcohol intake is two standard drinks per day for men and one standard drink per day for women.

3. All at-risk adults should be screened for unhealthy alcohol use, using simple screening tools such as the Single Alcohol Screening Question, CAGE questionnaire or AUDIT-C.

4. Those who screen positive should undergo further assessment for alcohol use disorder, other substance abuse, and medical/psychiatric comorbidities and complications.

5. Laboratory investigations may be helpful as an adjunct to determine the severity of alcohol use disorder.

6. Primary care physicians have an important role in assessing risk and can also provide counselling and intervention. A therapeutic doctor-patient relationship can be fostered if efforts are made to ensure continuity of care.

7. Motivated individuals with alcohol use disorder can be referred to several community resources for more comprehensive management. Those assessed to be at higher risk for alcohol withdrawal syndromes should be referred to specialist psychiatric services for medication-assisted treatment.