Supporting a Person Drinking at High- or Very-High-Risk Levels: a Harm Reduction Approach

Many people will not be receptive or respond to the variety of treatment approaches aimed at reducing their alcohol use and continue to drink at high- or very-high-risk levels, and experience ongoing alcohol-related harms. The principles of clinical harm-reduction interventions recognise that some people will continue to use alcohol and/or other drugs, and aim to work with these people to nevertheless reduce alcohol-related harms. Priority is placed on immediate and achievable goals, underpinned by values of pragmatism and humanism. Such goals may include achieving a greater number of abstinence days and reducing alcohol consumption on drinking days. 

It is critical to undertake a comprehensive risk and medical assessment and design a strategy that reduces identified risks. 

Examples of clinical harm-reduction interventions or strategies include: 

• Recognising that a person’s motivation to change their drinking patterns is not always fixed, and can be influenced by health professionals, families and friends, and changes in circumstances. Building a good therapeutic alliance by attending to their wants and needs can forge the way for subsequent willingness to cut down or stop their drinking. For example, an alcohol-related hospitalisation can act as a ‘window of opportunity’ to engage the patient in treatment for their alcohol use.  
• Maintaining engagement, and an underlying sense of hope for the patient, is important. Strategies to enhance patient engagement may include the clinician attending to barriers posed by the patient’s memory or other cognitive disorders, language and/ or cultural issues, or physical disabilities. For example, consider using translation services, appointment reminder systems and strategies to enhance medication adherence. 
• Continue to encourage a reduction or cessation of alcohol intake, and regular discussion of available interventions to this end, including psychosocial interventions, self-help groups, and pharmacotherapies (such as naltrexone). 
• Provide regular feedback to the patient about the effects of their alcohol use upon their lives, and include feedback from biological testing (such as liver function tests) or psychological testing (including cognitive function testing). 
• Minimise the harms associated with polydrug use by advising against and offering treatment for other drug problems. 
• Monitor prescribed and complementary use of medications to avoid predictable drug–alcohol interactions (for example, alcohol and paracetamol, benzodiazepines, anti-coagulants, non-steroidal anti-inflammatory drugs). Alcohol and drug interactions are discussed in Chapter 10. Identify and respond to problems of poor medication adherence among people who drink heavily. 
• Define any specific medical and psychiatric conditions and attend to them systematically with relevant specialist medical teams that communicate regularly. Medical treatment can be of great value in reducing morbidity and mortality associated with continuing alcohol intake. More common medical complications of long-term heavy alcohol use include hypertension, cardiac damage, cerebral atrophy, cerebellar damage, peripheral neuropathy, cirrhosis, coagulopathies, peptic ulcer disease, myopathy and malignancies (breast, liver, oesophagus, colon). These are discussed in Chapter 4 and Chapter 22. 
• Offer treatment to minimise the consequences of specific medical complications, such as: 
  • thiamine supplements to prevent further central nervous system and peripheral nerve damage 
  • antihypertensives for those whose blood pressure fails to normalise on reduction of alcohol consumption 
  • beta-blocker or variceal banding for portal hypertension 
  • appropriate nutritional management for advanced liver disease and other organ damage  
  • falls prevention management for patients with cerebellar damage and/or peripheral neuropathy. 
• Engage psychosocial supports (meals-on-wheels, welfare, employment support, community and religious networks, financial or relationship counselling) to reduce family, personal and societal harms. 
• Empower family and close friends to reduce availability of alcohol and to encourage further engagement with clinicians able to help with alcohol problems. 
• Consider any medico-legal or ethical obligations, including driving assessment, child protection, welfare, guardianship and employment issues for patients in certain trades or professions. These are often complex and specialist advice should be obtained.  
• However, limited evidence is available about the outcomes of the harm-reduction oriented interventions described above. 
• General practitioners and other health professionals are particularly well placed to maintain long-term contact and promote clinical harm-reduction interventions with people who continue to drink excessively. 
• Assertive outreach and involuntary models of care may be considered subject to local availability. A general principle for assertive followup is to utilize the least restrictive approach that is effective and in many cases, regular scheduled followup is an effective approach. These are described in Chapter 5 and earlier in this Chapter. 
• Finally, a managed alcohol program (MAP) is under investigation in Australia and has been shown to reduce alcohol related morbidity in Canadian studies. No such programs are currently operating.