History-taking in assessing alcohol use

Ask all new patients routinely and others (adolescents and adults) opportunistically and periodically about alcohol use, as part of a general screen for disorders of substance use and gambling; these disorders are common (and often co-exist) and patients are reluctant to disclose them, often due to fear of stigma. Without routine screening, the diagnosis of a disorder of alcohol use is often missedQian, 2019.

Screening and assessment of substance use and addictive behaviours outlines history-taking (including use of the ASSIST-Lite tool), examination, and investigations that should be considered in a broad review of substance use and addictive behaviour.

If a person appears intoxicated or has signs of alcohol withdrawal, keep history-taking brief (focusing on asking about withdrawal symptoms as part of identifying dependent use); defer efforts to quantify use until the person is oriented, attentive and coherent.

If alcohol use is identified, ensure a full history is taken to assess:

  • the types of drinks, and quantity and frequency of drinking; use familiar measures (eg cans of beer, glass size) and strengths (for a visual representation of standard drinks in Australia, see the National Health and Medical Research Council Standard drinks guide)
  • the environments, social context and time of day when drinking occurs, and duration of drinking sessions
  • when the last drink occurred
  • measures of alcohol-related harm (for a graphic summarising potential organ damage, see the United States National Institute of Health website). In particular, ask about neurological harms (eg memory blackouts, seizures), features of liver disease or pancreatitis, cardiovascular harms1, drink-driving, and accidental injury
  • social impact (eg impact of drinking on family, parental and occupational capacity) and the extent of the person’s current support network
  • the person’s understanding of their triggers for relapse and remission
  • previous attempts to cut down or stop drinking and the severity of any withdrawal symptoms
  • previous treatment (including duration) for a disorder of alcohol use2
  • collateral history (eg from someone close to the person) of the drinking pattern, time course of change in drinking, landmark events (such as loss of alcohol tolerance, and personality changes3)
  • the age at which excessive alcohol use began and any family history of a disorder of alcohol use4.

Alcohol-specific diagnostic questionnaires may be used as part of assessing the extent and impact of use; for a comprehensive review, see the Guidelines for the Treatment of Alcohol Problems. AUDIT-C is the shortest questionnaire, with only 3 items. The interactive AUDIT questionnaire has 10 items but is quick and easy to administerHaber, 2021.

If a questionnaire is not used, it can be useful to ask ‘In a typical week, how many days might you drink?’ and ‘On an average/lighter/heavier drinking day, how many drinks might you have?’

Ask the patient to describe what happens when they drink and explore any negative consequences (eg accidents, falls, injuries). Allow them to tell their story candidly and listen intently; the 3 goals of history-taking are to gather information, formulate key questions (to help the person make their own connections between their drinking, patterns of relapse and harms) and to build a therapeutic relationship.

A diagnosis of alcohol dependence5 requires recurrent (episodic or continuous) drinking with 2 or more of the following features:
  • impaired control—for example, having more than 4 drinks daily, drinking more often or more intensely, drinking in new contexts or continuing to drink despite previous admissions for withdrawal management
  • ongoing drinking despite evidence of harms—for example, drink-driving charges, alcohol-related organ damage and damage to relationships, work or other important life activities
  • physiological features—tolerance (a reduced effect from drinking a constant amount of alcohol), withdrawal symptoms, or use to prevent or alleviate withdrawal (eg early-morning drinking).

If a person is reported to have had a seizure associated with alcohol use, assess whether the event was:

  • a memory blackout6
  • syncope
  • an episode of excessive shaking
  • a panic attack
  • a witnessed convulsion with loss of consciousness (a seizure).

If a seizure is diagnosed, it is important to know whether it was generalised or focal and whether it occurred at a time of peak intoxication (suggesting alcohol poisoning) or when blood alcohol concentration was falling (suggesting alcohol withdrawal). Causes of generalised seizures include alcohol toxicity, alcohol withdrawal and generalised epilepsy. Focal seizures suggest an intracranial cause such as head trauma causing posttraumatic epilepsy. Seizures that occur or recur late in the alcohol withdrawal period are not typical of withdrawal seizures and require investigation for epilepsy. Many patients with epilepsy who drink heavily have difficulties adhering to their antiepileptic medication regimens. Distinguishing the cause of a seizure is important in determining management, including assessing the impact on fitness to drive.

1 Even moderate consumption of alcohol increases the risk of cardiovascular harms such as hypertension, cardiomyopathy, atrial fibrillation, atrial flutter and strokeWorld Heart Federation, 2022.Return
2 Most people with alcohol dependence are likely to have had years of excessive use and some will have had years of treatment for dependence.Return
3 Personality change correlates strongly with the development of alcohol-related brain damage. Loss of a high level of alcohol tolerance (ie no longer being able to drink large amounts of alcohol without intoxication) correlates strongly with the combination of brain damage and cirrhosisEdwards, 2003Saunders, 2016.Return
4 While onset of alcohol use in adolescence is associated with a family history and poor outcomes in adulthoodEdenberg, 2013Hingson, 2006Pilatti, 2014, onset in older patients may indicate a comorbidity such as severe depression or early dementia.Return
5 For detail on terminology in substance use, including comparison of DSM-5 and ICD-11 classification systems, see Terminology describing the spectrum of substance use.Return
6 Causes of acute alcohol-related memory loss include alcohol intoxication after which memory function returns; chronic alcohol-related memory impairment is most commonly caused by thiamine deficiency.Return