Assessing Level and History of Alcohol Consumption
The assessment should gather information about the patient’s drinking history, including how the drinking pattern evolved, fluctuated and/or progressed over time. A quantitative alcohol history should be recorded in every case. This comprises the:
A number of studies have shown that in general, reproducible and relatively accurate information can be obtained from a well-taken alcohol history. Based on cumulative population self-reporting, overall alcohol use is frequently under-reported, but interviewing style can influence the accuracy of self-reporting.
Adopt a non-judgmental tone in asking about alcohol use. It is useful for the clinician to use the ‘top-down approach’, suggesting a level of drinking that is higher than expected so the patient is more likely to be comfortable admitting the real level of drinking by bringing the estimation down to the correct level.
Language should be carefully interpreted; the phrase ‘a drink after work’ may mean any number of drinks per drinking day, and any frequency of drinking from once a fortnight to every day. The definition of a standard drink should be clarified in every case using an appropriate visual aid such as that shown in Appendix.
The assessment should include the patient’s reconstruction of a typical drinking day and week, from the time of waking through all the day’s activities. For example, the clinician might ask at what time the first drink is taken, where and with whom. The time spent drinking or the money spent on alcohol can be compared with the patient’s estimate of the amount of alcohol consumed to test the accuracy of that estimation. Consumption can be linked to particular events, behaviours and times. An assessment of a typical day also gives information about the antecedents and consequences of drinking. This information can be incorporated into advice about relapse prevention. The clinician needs to distinguish between daily drinking and binge drinking where the weekly or monthly consumption is concentrated over several days and the patient is abstinent or drinks lightly at other times. The use of drink diaries or calendars may help clarify the patterns.
Several structured methods are available to perform this assessment, although they are not routinely used in clinical practice (for example, the quantity–frequency index and the retrospective diary are both reliable ways of identifying high risk levels and patterns of consumption. The ‘timeline follow-back’ method helps to obtain an accurate, retrospective account of alcohol consumption over a particular period, typically 3 months. These are time consuming but useful approaches to gaining detailed clinical information.
Other drug use, including smoking, use of sedative medications and illicit drugs, should also be assessed.