Technical Paper 3:
Preventing Alcohol-related harm in Australia: a window of opportunity
4.5 - Treatment and early intervention
Table of contents
This paper considers treatment and early intervention as essential components of a preventative approach to the harmful consumption of alcohol. While treatment and prevention are traditionally viewed as separate and sometimes unrelated activities, it is critical that they be embraced as part of a holistic approach to tackling alcohol problems from a public health perspective. While treatments are primarily designed to serve the needs of individuals, there are a number of ways that treatment can also have a positive impact at a whole-of-population level:
- By raising public awareness of alcohol problems
- Influencing national and community agendas
- Involving health professionals in advocacy for prevention
- Providing secondary benefits for families, employers and road users.[13]
In Australia, brief interventions, as yet, are a relatively untapped opportunity, due in part to the need for greater recognition of the role that the primary health workforce can play.[43] Efforts during the 1980s and early 1990s to introduce more systematic screening, early identification and potentially brief or extended responses were variously tried.
These included the Coordinator of Alcohol and Drug Education in Medical Schools (CADEMS) that supported curriculum development for undergraduate medical students, a range of General Practice trials (especially in New South Wales, sometimes in association with other specific interventions including tobacco and even efforts to develop a combined risk-screening instrument for a number of conditions) and studies of the use of screening instruments (especially AUDIT) in hospital settings. Follow-up has been patchy, and even where the uptake and utility under experimental conditions was promising, the longer term effort and cost required to achieve widespread involvement has not been sustained. With a sense of déjà vu, the authors note a recent study of the effectiveness of brief interventions in hospital emergency departments, which suggests that these can potentially reduce subsequent alcohol-related injuries significantly.[75] For assessments and brief interventions to become part of routine practice of doctors, nurses and other health professionals, an approach at the health system level accompanied by funding and promotion is needed. It is unrealistic to expect overstretched health service providers to implement brief interventions without reimbursement or other recognition.
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While this paper especially addresses primary prevention, it is worth noting that there remains a serious lack of accessible and available evidence-based treatment services for later stage alcohol dependence and other alcohol-related disorders across Australia (in private and public as well as in city and remote locations). With a still evolving specialist clinical workforce, there remains a relative vacuum for training and professional development at senior clinical levels, and it is this group that ultimately set the standard and nature of practice in any field. A comment from a senior clinician on the more recent development of Medicare support for private practice GPs and clinical psychologists is pertinent: ‘it means that I get all these patients treated under the mental health items with fundamental alcohol-related problems where alcohol was not properly managed’.
Workplace interventions. Australian workplaces are another setting with great potential for brief interventions with at risk drinkers. There are two main rationales for workplace interventions with regard to the harmful consumption of alcohol: to improve productivity; and to improve workplace safety.[7] In the Australian context, approaches to workplace alcohol issues are influenced by occupational health and safety laws and polices, and devising prevention strategies must be considered in this context. Historically, alcohol problems in the workplace have been dealt with through employee assistance programs (EAPs) and employers’ policies on alcohol and drug use; however, there has been insufficient research to determine the effectiveness of EAPs in responding to and/or preventing alcohol issues in the workplace.[7] Nonetheless, EAPs do provide the potential opportunity for interventions that are known to be effective, such as brief interventions for high-risk drinkers. A recent study of alcohol consumption by Australian workers and the impact on absenteeism has pointed to the need for workplace education to influence young employees’ attitudes and behaviours regarding alcohol use.[76] The study also suggests that there is a need to take a whole-of-workplace approach when designing and implementing prevention strategies that target both ‘problem drinkers’ and workers who drink at short-term risk levels, even infrequently, because the latter have an elevated risk of alcohol-related workplace absenteeism.[76] Others have pointed to the need for addressing structural factors in the workplace as a more sustainable prevention measure, such as reducing stressful working conditions that may lead to health-damaging behaviour such as the harmful consumption of alcohol.[77]
Alcohol problem treatment. Internationally, and particularly in Australia, the evidence base with regard to the treatment of alcohol problems is very well developed and is now at the stage of determining what is best practice rather than attempting to determine if treatment can work.[7] Effective alcohol treatment options include motivational interviewing, brief interventions, social skills training, community reinforcement approach, relapse prevention and some aversion therapies.[7] There is evidence that mutual help programs such as 12-Step Facilitation Therapy, which encourages attendance at Alcoholics Anonymous (AA) meetings, are particularly effective for severely dependent drinkers with low levels of social support.[7] Although popular and widely used, there are also treatments that have little evidence of efficacy, including insight-orientated psychotherapy, confrontation counselling, relaxation training, general ‘alcoholism counselling’, education and milieu therapy.[7] Pharmacotherapies for alcohol dependence include disulfiram, naltrexone and acamprosate. Reviews have found that naltrexone and acamprosate are the safest and most effective of the three pharmacotherapies in the long and intermediate terms, respectively.[7]
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Thiamine supplementation. A unique preventative measure to address the risk of serious brain damage from thiamine deficiency (known as Wernicke-Korsakoff’s syndrome) that can result from heavy consumption of alcohol over many years, along with poor nutrition, is thiamine supplementation. Since 1991, all baking flour in Australia has been supplemented with thiamine as a universal method to increase thiamine levels in the diet of at risk populations.[7] This is included here as an example of a preventative measure that requires ongoing consideration, as there has since been advocacy for the removal of supplements (including thiamine) by the pure food advocates and there is concern that the reach of thiamine in bakers flour might not be the most cost-effective population measure in preventing this condition.[78]
Since the 1980s, sobering-up centres have been established in many parts of Australia, particularly Indigenous communities, as humane forms of care for publicly intoxicated individuals, and as an alternative to individuals being arrested and held in police cells and watch houses.[34]
However, there have been very few evaluations of sobering-up centres, despite their popularity in Australia.[79] In many ways, sobering-up centres function primarily as a broad harm-reduction measure, rather than as a treatment program. As Brady et al. describes them,[80] sobering-up centres are not a detoxification centre, nor are they aimed at long-term rehabilitation; rather, their role is to keep people out of police custody to reduce alcohol-related harm and to offer practical care in a safe environment for a limited time, including protection, shelter and food. Nevertheless, they could provide an opportunity for interventions that can be effective.
Sometimes related to these are night patrols, which are a particularly common alcohol harm-reduction strategy in many Indigenous communities.[7] Night patrols provide transport to safe locations for intoxicated persons, particularly in remote areas.[7] Evaluations of the effectiveness of night patrols, on their own, as an intervention is somewhat equivocal, although they have been rated as being effective in communities in reducing alcohol-related violence and getting intoxicated people off the streets.[7]