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How much drinking is too much? Ask, assess, advise and assist

Attending APA 2015

The US National Institute on Alcohol Abuse and Alcoholism (NIAAA) has produced several new evidence-based guides for patients and clinicians. Michael Fleming (North Western University, Chicago, USA), led workshop participants through some of the key elements.

For men, anything more than 14 drinks a week takes you above the low-risk limit. For women, anything more than seven drinks a week is too much. On a single day, 1-2 drinks is probably OK, but 3-4 or more is not a good idea. And above that point the dose response curve between alcohol intake and many forms of harm including violent death, cirrhosis and depression starts to rise steeply.

Compared with binge drinking (now described as episodic heavy drinking), daily use of a lower amount of alcohol may in the end prove more harmful. 


A vital role for psychiatry


In the case of psychiatric patients in the acute phase of treatment, abstaining from all alcohol would be recommended, Dr Fleming said. In the stable phase, modest drinking within the above limits is probably OK.  But for patients with depression, excessive alcohol use is a major contributor to non-response and needs to be addressed with at least a brief intervention. This would involve time-limited counselling based on communication, trust and empathy.  But the evidence is good that such relatively brief encounters can have a powerful impact on drinking behaviour and broader psychiatric health.

In their routine practice, psychiatrists are well equipped to identify and manage alcohol problems. The therapeutic relationship provides the opportunity to have what is a difficult conversation for almost everyone. But the prevalence of AUDs should not be overstated. Seventy percent of Americans either don’t drink at all or drink within safe limits. Twenty percent exceed safe limits but don’t meet the criteria for an AUD. Even so, an AUD diagnosis will be made in only around one in ten people. 

It is worth reinforcing the link between drinking and mental health problems. Cut back your drinking and we are more likely to be able to help. 

For Dr Fleming, the single most important question to ask when screening men is “How many times in the last month have you had more than five drinks in a day?” For women it would be four drinks in a day.

In the majority of cases, the answer will not be worrying, and you can move on to other questions.  But if the answer suggests the possibility of a problem, it is worth using the AUDIT battery of questions.

This tool – the Alcohol Use Disorders Identification Test, to give it the full title – takes about five minutes for the patient to complete and contains items covering alcohol use, absence of control,  guilt about drinking, morning drinking, adverse consequences such as memory loss and injury, and whether others are concerned about your drinking and have advised you to cut down.

The majority of the audience used alcohol screening as part of their routine clinical practice. 




Analysis of liver function is generally not useful in this context.

Testing for ethyl glucuronide (EtG), an alcohol metabolite, can be performed on urine, hair and nails and is highly sensitive –  perhaps too sensitive, since there is a problem with false positives unless the appropriate cut-off is used. Tests for phosphatidylethanol, a phospholipid formed on the red cell membrane, require a fingerprick sample of whole blood and detect drinking over the past thirty or so days with a low risk of false positives.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

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