Preventing Alcohol-related Harm in Australia - Department of Health

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4.5 Treatment and early interventionThis paper considers treatment and earlyintervention as essential components ofa preventative approach to the harmfulconsumption of alcohol. While treatment andprevention are traditionally viewed as separateand sometimes unrelated activities, it is criticalthat they be embraced as part of a holisticapproach to tackling alcohol problems froma public health perspective. While treatmentsare primarily designed to serve the needs ofindividuals, there are a number of ways thattreatment can also have a positive impactat a whole-of-population level:nnnnBy raising public awarenessof alcohol problemsInfluencing national andcommunity agendasInvolving health professionals inadvocacy for preventionProviding secondary benefits for families,employers and road users.[13]Brief interventions in primary health settings. Forearly-stage alcohol problems, brief interventionsare consistently identified as a key ingredient ina comprehensive alcohol-prevention strategybecause they are regarded as relativelyinexpensive, they take very little time andthey can be implemented by a wide rangeof health and welfare professionals.[7] Theirbenefit as preventative measures arises fromthe relative effectiveness in treating early-stageproblem drinking, obviating the need for latermore intense and costly treatment.[43] Briefinterventions are designed to motivate high-riskdrinkers to moderate their alcohol consumption,and typically involve one to three sessions beforeor soon after the onset of problem drinking.[13]In Australia, brief interventions, as yet, are arelatively untapped opportunity, due in partto the need for greater recognition of the rolethat the primary health workforce can play.[43] Efforts during the 1980s and early 1990s tointroduce more systematic screening, earlyidentification and potentially brief or extendedresponses were variously tried.These included the Coordinator of Alcohol andDrug Education in Medical Schools (CADEMS)that supported curriculum development forundergraduate medical students, a rangeof General Practice trials (especially in NewSouth Wales, sometimes in association withother specific interventions including tobaccoand even efforts to develop a combined riskscreeninginstrument for a number of conditions)and studies of the use of screening instruments(especially AUDIT) in hospital settings. Follow-uphas been patchy, and even where the uptakeand utility under experimental conditions waspromising, the longer term effort and costrequired to achieve widespread involvement hasnot been sustained. With a sense of déjà vu, theauthors note a recent study of the effectivenessof brief interventions in hospital emergencydepartments, which suggests that these canpotentially reduce subsequent alcohol-relatedinjuries significantly.[75] For assessments andbrief interventions to become part of routinepractice of doctors, nurses and other healthprofessionals, an approach at the healthsystem level accompanied by fundingand promotion is needed. It is unrealisticto expect overstretched health serviceproviders to implement brief interventionswithout reimbursement or other recognition.While this paper especially addresses primaryprevention, it is worth noting that there remainsa serious lack of accessible and availableevidence-based treatment services for laterstage alcohol dependence and other alcoholrelateddisorders across Australia (in private andpublic as well as in city and remote locations).With a still evolving specialist clinical workforce,there remains a relative vacuum for trainingand professional development at senior clinicallevels, and it is this group that ultimately set thestandard and nature of practice in any field.A comment from a senior clinician on the morerecent development of Medicare support forprivate practice GPs and clinical psychologistsis pertinent: ‘it means that I get all these patientstreated under the mental health items withfundamental alcohol-related problemswhere alcohol was not properly managed’.28
Workplace interventions. Australian workplacesare another setting with great potential for briefinterventions with at risk drinkers. There are twomain rationales for workplace interventionswith regard to the harmful consumptionof alcohol: to improve productivity; and toimprove workplace safety.[7] In the Australiancontext, approaches to workplace alcoholissues are influenced by occupational healthand safety laws and polices, and devisingprevention strategies must be considered inthis context. Historically, alcohol problems inthe workplace have been dealt with throughemployee assistance programs (EAPs) andemployers’ policies on alcohol and drug use;however, there has been insufficient researchto determine the effectiveness of EAPs inresponding to and/or preventing alcoholissues in the workplace.[7] Nonetheless, EAPsdo provide the potential opportunity forinterventions that are known to be effective,such as brief interventions for high-risk drinkers.A recent study of alcohol consumptionby Australian workers and the impact onabsenteeism has pointed to the need forworkplace education to influence youngemployees’ attitudes and behaviours regardingalcohol use.[76] The study also suggests thatthere is a need to take a whole-of-workplaceapproach when designing and implementingprevention strategies that target both ‘problemdrinkers’ and workers who drink at short-termrisk levels, even infrequently, because thelatter have an elevated risk of alcohol-relatedworkplace absenteeism.[76] Others havepointed to the need for addressing structuralfactors in the workplace as a more sustainableprevention measure, such as reducing stressfulworking conditions that may lead to healthdamagingbehaviour such as the harmfulconsumption of alcohol.[77]Alcohol problem treatment. Internationally, andparticularly in Australia, the evidence base withregard to the treatment of alcohol problems isvery well developed and is now at the stageof determining what is best practice ratherthan attempting to determine if treatmentcan work.[7] Effective alcohol treatmentoptions include motivational interviewing, briefinterventions, social skills training, communityreinforcement approach, relapse preventionand some aversion therapies.[7] There isevidence that mutual help programs such as12-Step Facilitation Therapy, which encouragesattendance at Alcoholics Anonymous (AA)meetings, are particularly effective for severelydependent drinkers with low levels of socialsupport.[7] Although popular and widelyused, there are also treatments that have littleevidence of efficacy, including insight-orientatedpsychotherapy, confrontation counselling,relaxation training, general ‘alcoholismcounselling’, education and milieu therapy.[7]Pharmacotherapies for alcohol dependenceinclude disulfiram, naltrexone and acamprosate.Reviews have found that naltrexone andacamprosate are the safest and most effectiveof the three pharmacotherapies in the longand intermediate terms, respectively.[7]Thiamine supplementation. A uniquepreventative measure to address the risk ofserious brain damage from thiamine deficiency(known as Wernicke-Korsakoff’s syndrome)that can result from heavy consumption ofalcohol over many years, along with poornutrition, is thiamine supplementation. Since1991, all baking flour in Australia has beensupplemented with thiamine as a universalmethod to increase thiamine levels in the dietof at risk populations.[7] This is included hereas an example of a preventative measurethat requires ongoing consideration, as therehas since been advocacy for the removal ofsupplements (including thiamine) by the purefood advocates and there is concern that thereach of thiamine in bakers flour might not bethe most cost-effective population measure inpreventing this condition.[78]Since the 1980s, sobering-up centres havebeen established in many parts of Australia,particularly Indigenous communities, ashumane forms of care for publicly intoxicatedindividuals, and as an alternative to individualsbeing arrested and held in police cells andwatch houses.[34]29
Page 1: Preventative Health TaskforceNation
Page 4 and 5: Contents1 Introduction: changing th
Page 6 and 7: 1. Introduction:changing thedrinkin
Page 8 and 9: ModifiableDeterminants:Cultural Pla
Page 10 and 11: 2. Key trends in alcoholconsumption
Page 12 and 13: Figure 3: Drinking at risky/high ri
Page 14 and 15: 2.4 Alcohol prices andconsumer spen
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Page 18 and 19: Families and childrenIt is a realit
Page 20 and 21: Young AustraliansRates of risky dri
Page 22 and 23: Table 5: Key to the rating scales s
Page 24 and 25: 4.2 Regulating the physicalavailabi
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Page 28 and 29: While increasing the price through
Page 30 and 31: These changes have resulted in majo
Page 35 and 36: number of RSA training programs hav
Page 37 and 38: Table 8: Alcohol advertising in Aus
Page 39 and 40: nThe effectiveness of the current s
Page 41 and 42: 5. Policy imperatives5.1 The state
Page 43 and 44: Table 10: Cost-effectiveness (avera
Page 45 and 46: There are some specific challenges
Page 47 and 48: thousands of Australians at the ear
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Page 51 and 52: 63. Gruenewald P, Freisthler B and

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