With rising prevalence of risky drinking – and reports of people using alcohol as a replacement for OTC codeine – could pharmacists play a role in alcohol screening?
The number of older Australians has increased substantially in recent years, accompanied by unprecedented changes in their alcohol consumption patterns, say Professor Ann M Roche and Victoria Kostadinov from the National Centre for Education and Training on Addiction, Flinders University, Adelaide, this week in the MJA.
Their analyses of data from the National Drug Strategy Household Surveys for 2004, 2007, 2010, 2013 and 2016 found that while most Australians aged 50 years or more drank alcohol at low-risk levels (61.0–63.7%), between 2004 and 2016 the proportions of risky (from 13.4% to 13.5%) and high-risk drinkers (from 2.1% to 3.1%) increased.
“The rising prevalence of risky drinking therefore cannot be attributed solely to increasing numbers of older people,” say Prof Roche and Mrs Kostadinov.
“Although the increase in the proportions of risky and high-risk drinkers are small, they nevertheless correspond to an additional 400,000 people drinking at potentially problematic levels.”
They point out that older people are vulnerable to a range of alcohol‐related adverse effects, including falls and other injuries, diabetes, cardiovascular disease, cancer, mental health problems, obesity, liver disease, and early onset dementia and other brain injury.
“Primary health care is an ideal setting in which to detect and intervene in risky drinking, and routine screening for problematic alcohol use by older patients is warranted,” say Prof Roche and Mrs Kostadinov.
“Brief interventions by clinicians (short, opportunistic counselling and information sessions that motivate behavioural change) can effectively reduce rates of risky drinking, and are viable treatment options for the majority of older drinkers who do not require formal substance use interventions.”
Research from 2016 found pharmacy-based screening and brief interventions for alcohol-related problems appeared to be acceptable to consumers and feasible for pharmacy staff to deliver.
A study by health researchers from Curtin University in WA recruited five Australian pharmacies and trained staff to deliver screening and brief interventions.
Fifty consumer participants were screened – 10 from each pharmacy.
Responses to the screening and intervention process were “generally favourable”: for example, 75% agreed that it was either appropriate or very appropriate to be asked about their alcohol consumption.
Of 11 participants who were contactable three months later, three of the five non-low-risk drinkers had reduced their level of risk over the three months.
Ten pharmacists who were interviewed about their experience were generally positive about the intervention, citing reasons such as flexibility, ease of use, perceived positive impact, and an enhanced role of community pharmacists.
I’ve had people tell me since they couldn’t buy codeine combinations over the counter they have a few extra drinks at night.—Nick Logan, Nick Logan Pharmacist Advice
The extensive distribution of community pharmacies presents a unique opportunity for pharmacists to discuss alcohol-related illness with patients, provide information and facilitate referrals, the researchers concluded.
PSA National Vice President and pharmacy owner Dr Shane Jackson says pharmacists can and should play a role in helping to reduce drinking levels among patients.
“Pharmacists that I know would frequently discuss alcohol consumption with patients who come into the pharmacy, or when doing a Medscheck or Home Medicines Review,” says Dr Jackson.
“It’s an opportunity to inform or discuss safe drinking levels with people. There is quite a lot of good evidence about brief interventions for alcohol reduction and pharmacies are one of those places where those brief interventions can take place.”
Sydney pharmacy owner Nick Logan says there is potential for pharmacists to do alcohol screening but there should be appropriate evidence-based training provided first.
“I manage a few alcoholics who come and talk to me all the time. We show them empathy and support but we don’t engage with them [about their alcohol use] at this time,” Mr Logan tells AJP.
He says the latest research from the MJA is “really relevant”.
“I think alcohol is seen differently among the generations and the baby boomers were much more likely to be binge drinkers at some stage.”
He’s also noticed a concerning trend among people experiencing pain following the codeine upschedule.
“I’ve had people tell me since they couldn’t buy codeine combinations over the counter they have a few extra drinks at night,” he says.
“For centuries, alcohol has been used as an analgesic and I think it probably come into play more [recently]. It’s hard to gauge the numbers but I’m absolutely sure that more people are using it as an analgesic.”
This is something that pharmacist and pain expert Joyce McSwan signalled back in early 2018 when the upschedule occurred.
“One of the things that pharmacists really need to watch out for – and this something I really fear may happen with codeine being upscheduled – is alcohol consumption,” Ms McSwan told AJP.
“It’s quick, it’s easy, you don’t need to go to the doctor to get it and it provides that dopamine hit.
“I find that so many of my patients have undisclosed alcohol use. They take it to relax, and another couple of drinks helps them sleep.
“The question, ‘are you drinking more for pain?’ or ‘do you drink it to relax and help you cope a bit?’ is a really important conversation.”
While Mr Logan is wary of just how much a pharmacist could do to change the behaviours of someone dealing with full-blown alcoholism, he believes pharmacists could play a role in providing support.
“I’ve asked as many ex alcoholics about it and they said that with alcoholics, you have to hit rock bottom before you turn around.
“Having said that, probably the first step of the journey is people admitting they have a problem. So having screening in pharmacy and having that as a pathway to them being taken care of could be a good idea.
“I think the future for pharmacy is that we will be a triage centre for people who are depressed, or alcoholic, or need to quit smoking, and those ones we can’t help directly we would refer,” he says.
“For people who were drinking too much – because you can die from alcohol withdrawal – there’s risk involved.”
He says before rolling out any intervention, “we would want some expertise from someone in the drug and alcohol sector, an expert involved to design an intervention that was professional and efficient and evidence based.
“[But] we have such good relationships with our customers – the average Australia goes to a pharmacy 14 times a year – there’s no better place to set up a screening or a referral or triage facility for people who need to do something about it.
“The future of community pharmacy as a health profession will be somewhere where you have professional services such as this,” says Mr Logan.
If you are experiencing a personal crisis help is available, please contact Lifeline on 13 11 14. ReachOut Forums also provide a supportive, safe and anonymous space for people to discuss issues with addiction and alcohol abuse.