Alcohol & Drugs

Alcohol use among males, impact of alcohol on health, theories of AOD use—harm minimisation, Schaeffer’s model, Zinberg’s model, managing withdrawal, brief intervention approach, motivational interviewing approach, harm reduction therapy, child aware practice


This page has three sections:

  1. Background Material that provides the context for the topic

  2. A suggested Practice Approach

  3. A list of Supporting Material / References

Feedback welcome!


Background Material


Alcohol Use Among Australian Males

Quinn, B., Swami, N., Terhaag, S., & Daraganova, G. (2020). Alcohol use among Australian males. Ten to Men: The Australian Longitudinal Study on Male Health. Retrieved from https://tentomen.org.au/sites/default/files/publication-documents/2020_ttm_insights_report_chapter_2.pdf


Key Messages

  • Around one-fifth of Australian boys aged 10–14 years have consumed alcohol. Those who have are more likely to also have friends who have drunk alcohol in the past year.

  • Young men (15–17 years old) who have drunk more than a sip or taste of alcohol underage are more likely to engage in frequent and riskier alcohol consumption patterns from the age of 18.

  • The majority of adult Australian men have recently drunk alcohol (88%), of which only a minority – one-third – drink at moderate-to-high risk levels.

  • Younger adult males typically drink at riskier levels than their older counterparts

  • Many adult males engaging in moderate-to-high-risk alcohol consumption do not transition to low-risk patterns over time.

  • Compared to females, males are more commonly affected by alcohol-related harms due, at least in part, to typically higher rates of alcohol use.

Impact of Alcohol on Health

It is well-established that the use of alcohol is associated with copious personal and interpersonal harms, including a range of diverse health-related consequences. Specific harms – resulting particularly from more frequent and heavy alcohol use patterns – include

  • numerous types of cancer (e.g. cancers of the liver, oral cavity, oesophagus, rectum and colon),

  • infertility,

  • mental health issues,

  • violence,

  • damage to bodily organs such as the brain and liver, and

  • incurring injuries while intoxicated.

The December 2020 report from the Sax Institute (What the 45 and Up Study showed us in 2020) stated: “Seven types of cancer were linked to alcohol consumption – namely liver, oesophagus, mouth, pharynx, larynx, bowel and breast cancers. Consumption of more than 14 drinks a week raised the absolute cumulative risk of these cancers by 4.4% in men and 5.4% in women, compared with drinking less than one drink per week."


"The strongest association was with liver cancer: people consuming 7-14 drinks a week had a 48% increase in the relative risk of liver cancer compared with less than one drink a week."


"The authors point out that although Australians are familiar with the message that smoking and exposure to UV rays can cause cancer, they are much less likely to realise the link with alcohol.” (Sarich et al., 2020)


It is estimated that 4.5% of the total burden of disease and injury in Australia is attributable to the consumption of alcohol. The estimated ‘societal’ consequences of alcohol consumption in Australia are also substantial. In 2010 alone, the cumulative amount of alcohol-related costs to the country’s criminal justice and health care systems, Australian productivity and traffic accidents was estimated to be around $14.4 billion.


Practice approach with Adolescents

A growing body of research suggests that any alcohol use by young people is problematic. Underage drinking by young men was associated with more frequent alcohol consumption following the age of 18. Recent research has indicated that harm minimisation policies targeting adolescents may be less effective at reducing alcohol-related problems compared to stricter zero tolerance approaches. Australian policy guidelines suggest there is no level of safe alcohol use for Australians aged less than 18 years.


In 2021 Quinn released findings from the Growing Up in Australia study on the results of allowing teens to drink at home. This reinforced the above situation, i.e. children and people under 18 years of age should not drink alcohol, even in environments or circumstances that might be considered ‘low risk’ such as drinking at home. The key findings of Quinn’s research were:

  • In 2016, around 28% of teens aged 16–17 were allowed to drink alcohol at home. Approximately 18% of teens of this age were permitted to take alcohol to parties or social events.

  • Overall, alcohol use was significantly more common among 16- to17-year-olds who were permitted to drink at home, compared to those not allowed to drink at home. Around three-quarters (77%) of teens with permission to drink at home had drunk alcohol in the past month, compared to 63% of teens without permission.

  • Teens allowed to drink at home were more likely to have experienced alcohol-related harm compared to those without permission (23% vs 17%, respectively). Alcohol use can lead to numerous types of harms, including negative physical, mental, financial and social outcomes such as:

  • trouble at school or work the day after drinking

  • arguments with family members

  • alcohol-related injuries or accidents

  • violence or involvement in a fight due to alcohol

  • having sex with someone due to alcohol and regretting it later.

  • More frequent parental alcohol consumption was associated with a greater likelihood of teens being allowed to drink at home. Other factors likely to increase the likelihood of teens being allow to drink at home include:

  1. Living in more sociao-economically disadvantaged neighbourhoods

  2. Residing in inner or out regional areas compared to major cities in Australia

  3. Being an only child

  4. Having a younger primary parent/carer

  5. Having a less educated primary parent

  6. Residing with one biological parent and one step-parent (compared to two biological parents).

Factors not significantly associated with permitting teens to drink at home included: sex of adolescent and primary parent, Indigenous status of adolescent, language background, and level of parental monitoring.

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From Topic 2: Introduction to AOD (alcohol and other drugs) interventions (Department of Health, 2004, https://www1.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-front9-wk-toc~drugtreat-pubs-front9-wk-secb~drugtreat-pubs-front9-wk-secb-2)



A number of approaches underpin alcohol and other drug work: harm minimisation, Schaeffer’s model, youth-focused systems model and Zinberg’s interaction model.


Harm minimisation


Harm minimisation focuses on the range of factors that are contributing to the harm associated with AOD use (and not just on the AOD use alone). Harm minimisation strategies can be categorised into three areas:

  1. Harm reduction: reducing the harm from drugs for both individuals and communities without necessarily stopping drug use, e.g. needle syringe services, methadone maintenance, brief interventions, and peer education.

  2. Supply reduction: reducing the production and supply of illicit drugs, e.g. legislation and law enforcement.

  3. Demand reduction: preventing the uptake of harmful drug use, e.g. community development projects and media campaigns.

The harm minimisation approach rests on the assumption that we cannot stop all people from using illicit substances. It is based on the following premises:

  • Drug use, both licit and illicit, is an inevitable part of society

  • Drug use occurs across a continuum, ranging from occasional use to dependent use

  • A range of harms are associated with different types and patterns of AOD use

  • A range of approaches can be used to respond to these harms.

Harm minimisation is not restricted to reducing individual levels of harm. It takes a systems approach and considers potential harm to the community as a whole as well as the individual. It is designed reduce the harm associated with use, without necessarily reducing use. Some examples of harm reduction strategies include: labelling on cigarette packets, limits and controls on gambling, needle and syringe exchange programs, safe injecting rooms, peer education programs, methadone maintenance programs, labelling on alcoholic beverages.


Schaeffer's model


Schaeffer's model reminds us that not all AOD use is inherently problematic. We need to be able to distinguish between different patterns of AOD use and intervene appropriately depending on the type of use identified.

  • Experimental use – Drug use is motivated by curiosity or desire to experience new feelings or moods. It normally involves single or short-term use.

  • Social/recreational use – Drugs are used on specific social occasions by experienced users who know what drug suits them and in what circumstances.

  • Circumstantial/situational use – Drugs are used when specific tasks have to be performed and special degrees of alertness, calm, endurance or freedom from pain are sought. (e.g. truck driving, shift work or studying for exams).

  • Intensive use – This drug use is similar to the previous category, but more intensive. It is often related to an individual's need to achieve relief or to achieve a high level of performance. It can also involve binge AOD use, where there is excessive use of a substance at one time.

  • Compulsive/dependent use – Drug use leads to psychological and physiological dependence where the user cannot at will discontinue use without experiencing significant mental or physical distress. Drug use is central to the user's day-to-day life. When a person is physically dependent they develop withdrawal symptoms when the drug is not taken. Psychological dependence occurs when the drug is central to a person's thoughts, emotions and activities. Drug users in this category have a strong urge to use despite being aware of the harmful effects.

Even though not all use is problematic, there may still be harms and consequences associated with any pattern of AOD use.


Youth-focused systems model

The youth-focused systems approach helps consider a broad range of factors that impact on AOD use, i.e. the context.Other aspects of the system, even in a one-on-one context, may influence the outcomes that you are trying to achieve.


Zinberg’s interaction model

Zinberg’s interaction model provides a simpler version of the youth-focused system approach. The model identifies three factors:

  1. The properties of drug(s) consumed: feelings or moods generated versus negative impact

  2. The individual characteristics of the user: · personality and intelligence; gender; cultural background; physical and mental health; social skills and self-esteem; sexual behaviour/sexuality; alcohol and drug use; criminal involvement; living situation/homelessness; values and beliefs.

  3. The environmental factors:

  • Local community factors: population density; housing conditions; urban/rural area; neighbourhood violence and crime; cultural norms, identity and ethnic pride; opportunities for social development; recreational and support services; demographic and economic factors; connectedness or isolation.

  • School and peer factors: peer connectedness; school climate and culture; school attendance; opportunities for social connection; norms and values of peers and school; friendships and interests; educational approach/methods; school discipline and structure.

  • Family factors: abuse and neglect; family dysfunction; patterns of communication; family income/employment; parents' mental and physical health; consistency of connection; family values, beliefs and role models; family discipline and structure; extended/nuclear family; family size.

  • Societal and political issues: laws of society; socio-economic climate; availability of services; social values and norms; social/cultural practices and traditions; popular culture (e.g. movies and music); government ideology and policies; role of media and advertising.

From Management of Withdrawal from Alcohol and Other Drugs (Sax Institute, 2019). https://www.saxinstitute.org.au/publications/evidence-check-library/management-of-withdrawal-from-alcohol-and-other-drugs/


Principles


Withdrawal management involves a combination of psychosocial, physical and pharmacological interventions and effective withdrawal management requires integration of these approaches.


Withdrawal services should be seen as part of a continuum of care and should be integrated into a broader care plan that addresses the individual’s substance use, health and social issues.


Delayed access to withdrawal treatment is associated with poorer outcomes, and a greater emphasis upon earlier engagement is required.


Principles of motivational enhancement, cognitive behavioural approaches to coping with cravings and withdrawal symptoms, case management and care planning, including assertive approaches to post-withdrawal engagement, should be considered as standard care across drug classes.


There is considerable evidence that exercise can assist with important symptoms in withdrawal management (e.g. sleep, anxiety, reduced cravings), and as such should be incorporated into withdrawal management services, on an individualised basis. There may be some patients who benefit from acupuncture.


Patients tend to have better outcomes when psychoeducation information is available in an accessible form.


For Aboriginal people and LGBTI people, the limited evidence available indicates that services tailored specifically for the population (LGBTI), or which incorporate cultural factors e.g. remaining close to country and family (for Aboriginal people) are more likely to engage these populations in treatment. Further research is required.


All services should have clinical pathways that ensure that patients have access to the range of withdrawal settings, i.e. ambulatory, residential and in-patient settings. Historically, NSW withdrawal services have emphasised residential or hospital-based approaches.


Practice Approach


In a recent webinar Hinkley, Tidyman and Yeoman (2021) made the following points about engaging with people whose alcohol use is problematic. They suggested a person-centred and relational approach was central. This is accomplished by listening to the person’s story and being curious, but not judgemental. It acknowledges that social workers are not experts in the person’s life, and people who front an agency to discuss alcohol (and drug) issues are not the same. One approach suggested is to preface any conversation with a comment such as, “Look, I feel a little bit uncomfortable asking these questions. However, I need to ask them, because this is either part of my role.” Then adopt an open and honest approach, “So, are you drinking? Has your drug use changed? What does it look like now? Describe it to me. Describe what it looks like to your partner. Is it interfering with finance?”


Two approaches are described in this section: Brief Intervention and Harm Reduction (Minimisation) Therapy (incorporating Motivational Interviewing).


Brief Intervention - Alcohol

This material comes from research by Farrugia and Hinkley (2021). It is a harm minimisation approach that can support people as they continue drinking, moderate their drinking, or choose abstinence.


The following guiding questions are adapted from brief motivational strategies in a medical setting:

  1. Opening strategy: Talk generally about lifestyle, stresses, and question ‘Where does alcohol use fit in to this broad life picture?’

  2. Further unpack a typical day and where alcohol may or may not fit in.

  3. Suggest the person complete a screening instrument like AUDIT (see link in Supporting Material section below). The remainder of the intervention could be guided by the AUDIT scores:

  4. 0–7 Brief Intervention: alcohol education

  5. 8–15 Brief Intervention: simple advice

  6. 6–19 Brief Intervention: simple advice plus brief counselling and continued monitoring

  7. 20–40 Referral to specialist for diagnostic evaluation and treatment. The article by Farrugia and Hinkley (see Supporting Material) has links to Australian State Services to assist in addressing excessive alcohol consumption. It also has a list of further resources at the end of the article dealing with alcohol and child aware practice, working with mothers, an online training organisation—Turning Point, avoiding stigmatising language—The Power of Words, case studies, and a link to the Drug and Alcohol Clinical Advisory Service.

  8. Provide information about alcohol consumption and alcohol-related harms based on the readiness of the patient to receive information. Provide information in a neutral and non-personal way and with the use of open questions.

  9. Have a ‘future’ and ‘present’ conversation that asks, ‘How would you like things to be different in the future?’ and unpacks what the barriers in the present are to making this change.

  10. Explore concerns (if there are any) about alcohol or about changing the type or level of alcohol consumption.

  11. Help with decision making and goal setting if a client wishes to make changes.

Brief interventions can be efficient as they require minimal time and can be delivered in as little as 15 minutes on each occasion. They have been shown to be effective when they are delivered multiple times over a six-month period or longer.


These additional discussion points could be included in a brief intervention:

  • Discuss what a standard drink is, how many drinks are considered risky and other aspects of safe alcohol consumption.

  • Goal setting could include supporting the client to move towards reducing their consumption to align with current safe-drinking recommendations.

  • Explore results from a screening instrument like AUDIT. Often people are unaware of the extent of some of their behaviours and tend to underestimate behaviours such as alcohol consumption that can cause harm.

  • Screening results can be coupled with individualised feedback about risks associated with continued drinking and potential health problems.

  • Provide self-help materials, such as printed information or reputable websites, which provide information about potential harms.

  • Support the client to develop strategies that work for them and their situation. Options could include specific limits to alcohol consumption, recognising the antecedents of drinking, or developing skills to avoid or minimise drinking in high-risk situations.

Motivational Interviewing


The Motivational Interviewing approach, accessed via the Contents section of this website, is the recommended approach when working with people misusing substances. But users of this approach should keep in mind the different patterns of drug use that have been highlighted in the Background Material section above: experimental, social/recreational, circumstantial/situational, intensive, and compulsive/dependent use.


Harm Reduction (Minimisation) Therapy


Vakharia and Little (2016) incorporate motivational interviewing into their suggested harm reduction therapy (HRT) approach. The suggest social workers use a number of strategies prior to using motivational interviewing. Their focus is to increase client engagement and lower their reluctance to change by welcoming people as they are and offering help that meets their basic needs. Vakharia and Little suggest three areas are critical to successful implementation of HRT: creating a therapeutic alliance, conducting a comprehensive biopsychosocial assessment and establishing a hierarchy of needs prior to using strategies suggested in the motivational interviewing approach.


1. Creating a Therapeutic Alliance


The first weeks of substance-use treatment are critical: 15-28% do not return for the second session, and 30% drop out in the first month. Empathy and client-centeredness are important in retaining clients and can be encouraged by:

  • Lowering thresholds for treatment entry: Make explicit from the first contact that the client can come to treatment whether they have decided to commit to abstinence or not.

  • Conveying a neutral stance towards substance use: Accept the person’s capacity to make choices for themselves, i.e. neither condemn or condone substance use. People use drugs for reasons that need to be understood.

  • View individuals as having a relationship with drugs rather than an addiction to them: Recognise this relationship can range from helpful to harmful; this affirms client autonomy and choice and captures the complexity of a person’s use. It demonstrates respect for the client’s self-assessment and puts the client in charge of prioritising problems.

  • Ensuring that the client feels like a collaborative partner in her or his treatment.

HRT still addresses harmful behaviour (to the person and/or to others), but HRT scrutinises this behaviour to ensure it is truly harmful and not just uncomfortable to staff.


2. Conducting a Comprehensive Biopsychosocial-spiritual Assessment


Substance use (whether problematic or not) is drug specific, individual specific, and context specific. Zinberg’s research found that both positive and negative drug experiences emerge out of an interaction among the drug (the type of drug, how it is consumed, how much, and how often), the set (the mindset of the person using), and the setting in which the drug is consumed (where, with whom, and the social context). Users can have different experiences with same drug on different occasions of use. An important goal of a BPSS assessment is to identify what the client may have to give up or adjust to reach their substance-related goals. Areas that could be covered in a BPSS assessment include the following.

Drug

  • Type of drug(s) used: including frequency, amounts, methods and patterns of use

  • Level of abuse or dependence, including the continuum of use, abuse (including negative consequences, dependence and user’s level of control

  • Prescribed medications: Current and past prescribed medicines, including patterns of compliance

Set

  • Motivation and expectation: what the client hopes and expects to get out of the use of a drug

  • Client’s stated goal(s): Including type(s) of treatment desired as well as types of treatment rejected. Goals may not be related to substance use at all

  • Stage of change: Where the client fits in a motivational schema

  • Self-efficacy: The client’s degree of confidence in his ability to control or to make changes in his life, including drug use

  • Treatment history: A history of the client’s attempts to stop or reduce substance use, with and without help

  • Psychiatric and medical problems: Psychosocial history, medical history, DSM diagnosis, observation, and client’s subjective statement about how drug use impacts emotional problems, medical or mental disorders

  • Developmental grid: Outline of key events and personality traits that will be used to guide treatment

Setting

  • Setting of use: Where and with whom a person uses

  • Therapist’s concerns: these may be goals that the therapist wishes the client would express, or dangers that the client isn’t acknowledging

  • Support system: including quality of ambient environment and culture, presence or absence of friends and family

3. Establishing a Hierarchy of Needs


The therapist helps the client choose the most manageable issues on which to focus, but not necessarily the most urgent. Clients should work towards self-directed goals whether they are abstinence, moderation, reduced use or safer use. Construct a matrix of the problems and risks, combined with the client’s level of concern and motivation to change (as indicated by how soon the client feels the issue should be addressed). Recognise that what is harmful for one person may not be for the next.


An example of a hierarchy of needs:

If not already mentioned in the BPSS, the stages of change model could be introduced here. Place each issue on the stages of change continuum to determine motivation to and progress towards change. This can help with determining the readiness of the client to pursue different change goals. Commencing by tackling areas that are in the most advanced stage of change can bring about success and increase motivation in other areas.


Child Aware Practice

Parents with mental health, addiction, homelessness and family violence issues can cause major difficulties for children. These can have life-long consequences, e.g. suicide, eating disorders, drug and alcohol abuse, high-risk sexual behaviour, violence and criminal offending, homelessness and abuse and neglect of one’s own children.


Therefore, it is important that those supporting adults also assess the impact of adults’ issues on children and take steps to support adults in their parenting role.


This is what Child Aware Practice is about. You will find this topic covered in more detail on the website at https://www.thesocialworkgraduate.com/post/child-aware-practice


Supporting Material

(available on request)


Alcohol Withdrawal – my summary of material found on the web


AUDIT (Alcohol Use Disorders Identification Test). Retrieved from https://www.dacas.org.au/sites/default/files/inline-files/AUDIT-interview-version.pdf


AUDIT-C (for brief screening). Retrieved from https://www.dacas.org.au/sites/default/files/inline-files/AUDIT-C.pdf


Australian Government. Department of Health. (2004). Topic 2: Introduction to AOD interventions. Retrieved September 17, 2020 from https://www1.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-front9-wk-toc~drugtreat-pubs-front9-wk-secb~drugtreat-pubs-front9-wk-secb-2


Australian guidelines to reduce alcohol health risks from drinking alcohol. Retrieved from https://www.nhmrc.gov.au/health-advice/alcohol


Drug Education in Schools. Retrieved from https://cdn.adf.org.au/media/documents/ADF_PositionPaper_DrugEducationSchools.pdf


Farrugia, C., & Hinkley, T. (2021). Alcohol-related harm in families and alcohol consumption during COVID-19. CFCA Paper 60. Retrieved from https://aifs.gov.au/cfca/publications/alcohol-related-harm-families-and-alcohol-consumption-during-covid-19


Hinkley, T., Tidyman, A., & Yeoman, M. (2021). Working with families to minimise alcohol-related harm. Retrieved from https://aifs.gov.au/cfca/webinars/working-families-minimise-alcohol-related-harm


Jani, A. (2013). Motivational interviewing skills & techniques: Examples, tips and tools.


Management of Withdrawal from alcohol and other drugs. Sax Institute, 2019. https://www.saxinstitute.org.au/publications/evidence-check-library/management-of-withdrawal-from-alcohol-and-other-drugs/


Mental Health First Aid Guidelines: Alcohol Use (2020)


Mental Health First Aid Guidelines: Problem Drug Use (2020)


National Alcohol Strategy 2019-2028. Retrieved from https://www.health.gov.au/sites/default/files/documents/2020/01/national-alcohol-strategy-2019-2028.pdf


Parenting strategies: Preventing adolescent alcohol misuse. Retrieved from https://positivechoices.org.au/parents/parenting-strategies-alcohol


Quinn, B. (2021). Alcohol use among teens allowed to drink at home (Growing Up in Australia Snapshot Series – Issue 2). Melbourne: Australian Institute of Family Studies. Retrieved from https://growingupinaustralia.gov.au/research-findings/snapshots/alcohol


Quinn, B., Swami, N., Terhaag, S., & Daraganova, G. (2020). Alcohol use among Australian males. Ten to Men: The Australian Longitudinal Study on Male Health. Retrieved from https://tentomen.org.au/sites/default/files/publication-documents/2020_ttm_insights_report_chapter_2.pdf


Role modelling alcohol consumption. Retrieved from https://adf.org.au/insights/role-modelling-alcohol-consumption/


Sarich, P., Canfell, K., Egger, S., Banks, E., Joshy, G., Grogan, P., & Weber, M. F. (2020). Alcohol consumption, drinking patterns and cancer incidence in an Australian cohort of 226,162 participants aged 45 years and over. British Journal of Cancer. https://doi.org/10.1038/s41416-020-01101-2


Talking to a young person about alcohol and other drugs. Retrieved from https://positivechoices.org.au/parents/talking-to-a-young-person-about-alcohol-and-drugs


Talking to young people. Retrieved from https://adf.org.au/talking-about-drugs/parenting/talking-young-people/


UTas Alcohol and drug abuse (2015)


Vakharia, S. P., & Little, J. (2016). Starting where the client is: Harm reduction guidelines for clinical social work practice. Clinical Social Work Journal, 45(1), 65-76. https://doi.org/10.1007/s10615-016-0584-3


Working on AOD Issues (2004)