Alcohol History Taking

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Taking an alcohol history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking an alcohol history in an OSCE setting.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain the purpose of the consultation and gain consent:

  • “I’ve been asked to come and speak to you today regarding your alcohol intake. Is that okay with you?”
  • “I appreciate that some of these questions may be difficult, but it is important that you are honest. If you would like to stop at any time, let me know.”

Screening tools

There are two major brief screening tools used in practice to identify signs of hazardous drinking and dependence:

  • CAGE questionnaire: a brief, easy to use screening test consisting of only four questions.
  • AUDIT-C: a shortened version of the AUDIT screening tool, consisting of three questions.

CAGE

The CAGE questionnaire is often used in general history taking to briefly screen for problematic alcohol issues.

The CAGE questions should not be preceded by any questions about alcohol intake as its sensitivity is dramatically enhanced by an open-ended introduction.2

CAGE introduction

“I’m going to ask some general questions about your alcohol use and how it affects you.”

CAGE questions

Ask the CAGE questions:

  • Have you ever felt that you should Cut down on your drinking?
  • Have people Annoyed you by criticising your drinking?
  • Have you ever felt bad or Guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (known as an Eye-opener)?

Interpretation

The patient should be given 1 point for each question they answer yes to.

A score of over 2 suggests problematic drinking.

AUDIT-C

AUDIT-C introduction

“Now I am going to ask you some questions about your use of alcoholic drinks during this past year.”

AUDIT-C questions

How often do you have a drink containing alcohol?

  • Never – 0 points
  • Monthly or less – 1 point
  • 2 to 4 times a month – 2 points
  • 2 to 3 times a week – 3 points
  • 4 or more times a week – 4 points

How many units of alcohol do you drink on a typical day when you are drinking?

  • 1 or 2 drinks – 0 points
  • 3 or 4 drinks – 1 point
  • 5 or 6 drinks – 2 points
  • 7 to 9 drinks – 3 points
  • 10 or more drinks – 4 points

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

  • Never – 0 points
  • Less than monthly – 1 point
  • Monthly – 2 points
  • Weekly – 3 points
  • Daily or almost daily – 4 points

Interpretation

If a patient scores 3 or more out of 12, the full AUDIT questionnaire should be asked.


Alcohol intake

Origin of the drinking problem

Ask the patient when they first noticed an increase in their alcohol intake and try to identify any factors that played a role in this:

  • “When did you first notice an increase in the amount of alcohol you were drinking?”
  • “Was there anything going on at the time that played a role in this?”

Current drinking pattern

Assess the patient’s current drinking pattern:

  • “How often do you drink alcohol?”
  • “Do you drink alcohol every day?”
  • “Do you drink alcohol every week?”
  • “Do you drink alcohol at a particular time of the day?”

Quantification of alcohol intake

Quantify the patient’s alcohol intake:

  • “How much do you drink on an average day?”
  • “How much do you drink in an average week?”
  • “What kind of alcoholic drinks do you drink?”
  • “Is there anything that makes you drink more or less in a day?”
  • “How much do you spend on alcohol each week?”

It may be useful to write down alcohol intake on a piece of paper (Monday – Sunday with approximate timings and drinks had). This ensures a history which is as comprehensive as possible and accounts for varied intake across the week.

Drinking behaviours

Ask about the patient’s drinking behaviours:

  • “Where do you drink?”
  • “Who do you drink with?”

Previous attempts at abstinence

Ask if the patient has previously attempted to stop drinking:

  • “Have you ever tried to stop drinking before?”
  • “What happened when you tried?”
  • “Did you have any support?”
  • “Why do you think it was unsuccessful?”

Impact of alcohol

Dependence

Screen for evidence of alcohol dependence including biological and psychological signs.

Biological signs of dependence

Screen for biological signs of dependence:

  • “If you stop drinking, do you…get the shakes/sweat a lot/feel sick/notice any physical changes?”
  • “Do you have to drink more than you used to, to get the same effects?”

Psychological signs of dependence

Screen for psychological signs of dependence:

  • “Do you feel a compulsion/need to drink?”
  • “How important is drinking to you?”
  • “If you stop drinking, do you notice that you…feel down/angry/anxious?”

Effects on day to day life

Relationships

Ask if alcohol has impacted the patient’s relationships with others:

  • “Has alcohol impacted any of your personal relationships?”
  • “How has it affected them?”

Occupation

Ask if alcohol has impacted the patient’s job:

  • “Has alcohol had any impact on your job or ability to work?”

Diet

Ask what the patient’s diet looks like on an average day and if they feel alcohol is negatively affecting it:

  • “What does your diet look like on an average day?”
  • “Do you feel that alcohol impacts the way in which you eat?”

Alcohol-related crime

Ask if the patient has ever had involvement of the police for alcohol-related issues:

  • “Have you ever committed a crime or had the police involved as a result of your drinking?”

Psychological assessment

Perform a brief assessment of the patient’s current mood to identify signs of depression:

  • “During the past month have you felt low, depressed or hopeless?”
  • “Have you recently had little interest or pleasure in doing things?”

Screen for thoughts of self-harm or suicide:

  • “Have you had any thoughts of hurting yourself?”
  • “Have you ever thought of ending your life?”

Screen for thoughts of harming others:

  • “Do you ever have thoughts of harming others?”

Past medical history

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Ask if the patient has previously undergone any surgery or procedures (e.g. banding of oesophageal varices):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure and why was it performed?”

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

Alcohol-related medical conditions

Alcohol-related medical conditions include:

  • Alcoholic hepatitis
  • Liver cirrhosis
  • Epistaxis
  • Upper gastrointestinal bleeding
  • Pancreatitis
  • Dilated cardiomyopathy

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.

Identify medications whose side effects are potentiated by alcohol (e.g. benzodiazepines).

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”

Social history

Explore the patient’s social history to understand their social context.

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network (if children at home, consider if social services need to be involved)
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
  • if they have any carer input (e.g. twice daily carer visits)

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.

Gambling

Ask the patient if they gamble and if they feel this is a problem.

Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have substance misuse issues.1

Problematic gambling can be assessed via the Problem Gambling Severity Index (PGSI).


Closing the consultation

Thank the patient for their time.

Offer leaflets about alcohol dependence and the negative health impact of alcohol.

Offer referral to an alcohol rehabilitation service if appropriate.

Dispose of PPE appropriately and wash your hands.


References

  1. Ewing, JA (1984), Detecting alcoholism: The CAGE questionnaire, JAMA, 1984 Oct 12;252(14):1905-7. Available from: [LINK].
  2. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG; The Alcohol Use Disorders Identification Test, Guidelines for Use in Primary Care, Second Edition, Department of Mental Health and Substance Dependence, World Health Organization. Available from: [LINK].

 

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