Specialised tests include the biomarkers carbohydrate deficient transferrin (CDT) and urinary ethylglucuronide (EtG). Both are readily available from major pathology providers but are costly because they are not covered by Medicare. They would normally be ordered according to directions from authorities such as the family court and professional regulators such as AHPRA.
Abnormal results for biomarkers can be used to raise concerns about alcohol use, especially when GPs suspect the patient may be under-reporting excessive alcohol use during consultations or on self-report measures (such as the AUDIT-C and DSM-5 checklist).
Signs of excessive alcohol consumption may be evident on physical examination. Common indicators of excessive drinking include, but are not limited to:
- signs of intoxication or withdrawal, which may be subtle
- conjunctival injection
- hepatomegaly and other signs of liver disease.
The presence of any of the above physical signs is not diagnostic of or essential to diagnosing AUD. Most patients with AUD have no abnormal physical findings. Only those with more severe AUD show signs of cognitive impairment and poor general presentation. Abnormal findings can be fed back to patients whom GPs suspect may be under-reporting their alcohol intake in order to encourage more open discussion about their drinking.
Pharmacotherapy for relapse prevention
GPs are well placed and trained to offer brief interventions for patients with mild to moderate AUD. For patients with moderate to severe AUD, numerous pharmacotherapy options are available for both abstinence and reduced drinking goals including acamprosate, naltrexone and disulfiram.
Patients who meet the criteria for severe AUD should not be advised to stop drinking abruptly given they likely to be physically dependent on alcohol and are at risk of experiencing potentially life-threatening withdrawal. Such patients would benefit from medicated detoxification that can be offered in primary care or via external referral to the appropriate specialist service. Outpatient withdrawal management uses long-acting benzodiazepines such as diazepam in a tapering dose with daily thiamine for five to seven days. Outpatient detoxification is not indicated in those without social support, or who have significant medical and mental comorbidities, seizure disorders, or a history of complicated withdrawal or failed withdrawal attempts.
Evidence suggests that patients are more likely to achieve their drinking goals if they combine pharmacotherapy with supportive counselling.27 Counselling teaches patients coping skills to manage high-risk situations in which they would typically drink, such as when depressed or bored. Due to the pandemic, counselling services are now typically delivered online via telehealth. Most support groups such as SMART Recovery and Alcoholics Anonymous groups are also being offered online during the COVID-19 pandemic.
Numerous mobile apps also exist to help patients manage their alcohol use and are listed in Box 3.
Alcohol use remains a significant cost and burden to patients and society. Given increased rates of alcohol use since the COVID-19 pandemic in Australia, it is vital that GPs take the time to routinely screen patients for possible alcohol misuse. GPs have the necessary skills to routinely screen, conduct a comprehensive assessment and devise a treatment plan for patients drinking excessively since the pandemic. MT