Women and alcohol

Addiction specialist Kate Conigrave believes health professionals should remove the stigma from the conversation around alcohol by making it a routine part of screening for every female patient.

The reasons for doing so are compelling. Alcohol is the most widely used drug in Australia and is the sixth leading risk factor for disease. Additionally, an Australian study, published in January this year, revealed that one in five women aged 40-65 report consuming at risky levels.

“I’m aware of the many pressures on GPs but making this conversation routine is helpful,” says Prof Conigrave, a Public Health Physician at the Royal Prince Alfred Hospital in Sydney. “Ask in a plain way – start with ‘how often do you have a drink?’. Then you can find out how much they usually have when they drink. If you suspect they’re heavy drinkers, you can ask more questions. Try to make it clear to patients that you are comfortable with their responses.”

“Women need to know this stuff”

Alcohol has become so ingrained in the culture that women are often unaware of the impacts of alcohol on their health, both in the short-term and in the long-term. Professor Conigrave, who chaired the committee that released Australia’s revised alcohol guidelines in 2020, says many people are confused about what constitutes a standard drink.

“I encourage my colleagues and patients to measure 100ml which is a standard glass of wine,” she says. “A lot of people think they are only having two standard drinks a day, but if they are pouring their wine into largish glasses, then two or three drinks might actually add up to 750ml of wine (more than 7 standard drinks).”

The increased risk of breast cancer is sufficient reason to have the conversation about alcohol. “Every extra standard drink per day increases a woman’s risk of breast cancer ,” she warns. “Women need to know this stuff.”

Red flags

Two of the common side effects of drinking above the recommended guidelines – and flags for health professionals – are sleep difficulties and anxiety.

“There are also the common things like, is the blood pressure up, is the mood down?” she says. “If they have other conditions that might affect the liver, if they’re overweight, or have diabetes, they would also be extra reasons for me to check on alcohol.

“And, of course, pregnancy, just checking that they’re aware that if they’re open to having babies, that it’s best to stop drinking before conception.”

Screening questions

In practice, there are three screening questions for patients that cover frequency, quantity, and frequency of drinking to intoxication. “I typically weave them into a conversation rather than deliver them staccato-like,” she explains. “If someone is drinking six or more glasses of alcohol on a regular basis, then you need to screen for dependence.

“Questions clinicians might consider would be, ‘what are you like before the first drink of the day? Do you get the shakes? How easy is it for you to stop after one or two glasses?”

Patients not telling the truth is, says Prof Conigrave, less of a problem than many clinicians believe. And taking a history is not difficult. “It’s practice,” she explains. “Assessing someone for alcohol dependence would be asking about loss of control, tolerance, withdrawal, or whether the alcohol might be having a higher priority than other things in life. If the patient meets two or more of those criteria, they’re likely to be dependent on alcohol.”

‘FLAGS’

For non-dependent drinking, there is the acronym, ‘FLAGS.’ Professor Conigrave says most health professionals will already be aware of these pointers in discussing alcohol with patients.

• Feedback – about any harms that alcohol may be causing or could cause or exacerbate (like injuries or sleep problems)
• Listening – are they open to a conversation around change? This can guide the clinician’s emphasis – for example, to increasing motivation.
• Advice – “not too much advice is my tip”. If they were able to get down to drinking within the guidelines, share how this could improve their quality of life or reduce their health risks down the track.
• Goals – are they interested in stopping? Or cutting down?
• Strategies – practical steps on how they can achieve their goals. If they’re using alcohol for stress, explore how that link can be broken.

The GP perspective

Jean Hailes GP Fiona Jane says health professionals often avoid the conversation around drinking and research shows they believe it has potential to damage the doctor/patient relationship. Patients too can find the questions confrontational and judgemental. However, she agrees health professionals should be raising the issue more frequently.

Opportunities for discussion

“I think it’s about raising the topic in the right context,” she says. “A good time to raise it is when a new patient comes and you are gathering information about her – weight, smoking, nutrition – you can also ask about alcohol consumption.

“I don’t ever react to the amount of alcohol they admit to drinking remembering it’s common for people to underestimate this,” says Dr Jane.

Unless the patient has come in to discuss alcohol, Dr Jane finds it’s usually more prudent to absorb the information and address it when a good therapeutic relationship has been established.

Other opportunistic moments to raise the issue of alcohol, she believes, are during mental health care assessments and during routine health checks. “I think it’s important not to be judgemental,” she says. “It’s important to remove all moral context from the discussion and then work with the patient to discover if they might want to change the amount they drink.

A GP can prescribe alcohol relapse prevention medicines. Professor Conigrave says they’re typically started after a patient has stopped drinking and finished any withdrawal, but needs a little support to stay ‘dry’.

She also says it’s important for health professionals to manage their own distress if the patient refuses to change her drinking habits. “We love fixing things,” she says. “But when we have done everything we can, there’s no point in beating yourself up.”

She believes, however, that a conversation around alcohol is well worth having, especially since it serves to highlight the potential harms of drinking. “There is awareness around those harms when new guidelines are released but rarely in between those times.”