THE management of alcohol disorders in Australia is “about 20–30 years” behind the mental health sector in terms of diagnosis and destigmatisation, according to one expert.
Professor Paul Haber, Clinical Director of Drug Health Services, Sydney Local Health District, and professor of Addiction Medicine at the University of Sydney’s Central Clinical School, told InSight+ that there was “a long journey ahead to bring our treatment of alcohol problems into the light”.
“If you think about how [the mental health sector has] gone about destigmatising, enhancing, promoting and developing mental health care, they’ve gone a long way in the past 20–30 years,” Professor Haber said in an exclusive podcast.
“We’re about 20 or 30 years behind them. When I graduated, you wouldn’t have considered that mental health care would be so mainstream and so effective.
“That provides the signposts for us that we can achieve similarly excellent progress in the future if we put our minds to it.”
Professor Haber and Benjamin Riordan, a Postdoctoral Researcher in Addiction Medicine at the University of Sydney and the Centre for Alcohol Policy Research at La Trobe University, are coordinating editors of an MJA Supplement published today called New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.
“There is recognition in the new guidelines that certain population groups have not been carefully considered in previous versions of the guidelines,” Professor Haber told InSight+. “By including them we become more comprehensive in the work we do, and there are other refinements across the board.”
The Supplement has five sections:
- Guidelines for the treatment of alcohol problems: an introduction – by Benjamin Riordan, Postdoctoral Researcher in Addiction Medicine at the University of Sydney and the Centre for Alcohol Policy Research at La Trobe University, and colleagues;
- Screening and assessment for unhealthy alcohol use – by Professor John Saunders, a consultant physician in internal medicine and addiction medicine, and colleagues;
- Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up – by Professor Leanne Hides, Chair of Alcohol, Drugs and Mental Health at the University of Queensland, and colleagues;
- Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations – by Associate Professor Carolyn Day, from the University of Sydney, and colleagues; and
- Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities – by Associate Professor Michael McDonough, Director of Outpatient Services at Drug and Alcohol Services SA, and colleagues.
Professor Haber told InSight+ that the latest data about Australians’ drinking habits contained a paradox.
“[Data from the National Drug Strategy Household Survey] suggest that while young people drink the most, they are probably drinking a bit less than they were a few years ago. And while old people drink the least, they drink more often than young people, but in lower amounts, and they are starting to drink more,” he said.
“So, what we have is a total population that, according to the Australian Bureau of Statistics, is drinking a bit less than it was 5 years ago. But the total amount of harms and the total number of people being admitted to hospital is not getting less.
“One possible explanation is that the people who drink dangerously and harmfully are continuing to do so,” he said. “And that the reduction in overall consumption comes from low risk drinkers, reducing a little bit less, so that they were never going to get into trouble from their alcohol anyway – so it has no favorable impact on harms.
“If you take the average of the whole community, it doesn’t necessarily reflect what’s happening under the surface.”
In an editorial accompanying the Supplement, Professor Haber, Mr Riordan and Associate Professor Kirsten Morley, from the University of Sydney, wrote that scaling up the treatment of alcohol problems would lead to considerable health benefits across the nation.
Unhealthy alcohol use “is linked to about 150 000 hospital admissions and 6000 deaths per annum, and remains the most common substance use problem seen in specialist treatment services”, they wrote.
“Therefore, identifying and effectively managing alcohol problems remains critical.
“Alcohol problems are not distributed equally through the population, being more common among those with a family history, in men, among those living outside the metropolitan areas, and among individuals and populations exposed to high levels of trauma and stress, especially adverse childhood experiences.
“Routine clinical assessment typically detects severe cases but misses out on the less severely affected. It is the treatment of less severe cases that has the greatest potential to prevent life‐threatening complications.
“Treatment of alcohol use disorders can be undertaken in primary care settings. Brief interventions are easily offered in primary care or other health care settings and can be effectively delivered online.
“Improving the efficacy and implementation of comprehensive and effective treatment is a priority and has the potential to save lives and return value to the community,” Haber and colleagues wrote.
Professor Haber told InSight+ that the stigma of and reluctance to admit to having a problem with alcohol remained the most obvious reasons for an average delay from a problem developing to treatment of 18 years.
“Stigma is one issue. The other is recognition of the spectrum of alcohol problems is still not great,” he said.
“People still have in their mind what we would call a ‘skid row alcoholic’ as a concept. That severe end of the spectrum would only reflect perhaps 10% of the range of alcohol problems that one sees.”
Do doctors ask patients questions about their alcohol use often enough?
“We’re not asking the question enough in practice, there is also the problem of what we do if we get the answer that we didn’t want to hear,” Professor Haber said.
“It’s one of the reasons why people don’t ask – they’re a bit unsure about what to do next, if the patient confesses that there is a problem.
“Increasing understanding about how to respond to alcohol problems, whether it’s in primary care or in any other clinical setting, is one of our challenges. We hope that we’ve provided some of the answers to that in the guideline documents and the associated website.
“On the one hand, this is a disorder that tends to be stigmatised, underdiagnosed and undertreated,” he said.
“There are a lot of challenges ahead of us to get our systems up to the standard we would like them to be.
“But on a positive note, we see patients who are in a very poor state, and when they completely stop drinking, and when they engage in health care, the positive transformation that they can undergo is almost unbelievable.
“We can take people from literally death’s door back to a functioning, happy and successful life. That’s the blue sky in this whole field, which is that it is not hopeless.”
The full guidelines for the treatment of alcohol problems are available here.