Screening for alcohol use disorders in a genitourinary medicine setting

Introduction

Twenty-six percent of people in England have an ‘alcohol-use disorder.’ ¹ The World Health Organization (WHO) has subcategorized this definition into ‘hazardous drinking’ (alcohol consumption that will probably eventually cause harm), ‘harmful drinking’ (alcohol consumption that is already causing damage to physical or mental health) and ‘dependent drinking’ (the diagnosis of which requires three of the following: a compulsion to drink, difficulty in controlling drinking, physiological withdrawal, tolerance, neglect of other pursuits, or persistent drinking despite evidence of harm). ²

Genitourinary (GU) medicine clinics specialize in the prevention and treatment of sexually transmitted infections (STIs) and problem drinking has previously been shown to be clearly associated with an increased risk of STI, across a wide variety of populations. ³ The recent publication of the National Institute for Health and Clinical Excellence (NICE) public health guidance, Alcohol-use Disorders: Preventing Harmful Drinking, therefore specifically cites GU medicine clinics as one location where screening for, and giving advice on, harmful drinking should take place. ⁴

There are validated questionnaires available as screening tools. FAST (Fast Alcohol Screening Tool) is a shortened form of the 10-item AUDIT questionnaire, which was developed by WHO. It contains four questions and takes 20 seconds to complete. ² It is scored between 0 and 16 and a score of 3 or more indicates hazardous, harmful or dependent drinking. In a recent systematic review of the use of alcohol screening tools in the emergency department, FAST was shown to be the best tool for identifying alcohol misuse with a sensitivity of 93-94% and a specificity of 86-88% ⁵

The north east of England is recognized as being an area of the UK with a higher than average problem with alcohol ⁶ and this audit looks at the use of the FAST questionnaire within the GU medicine service in Northumberland.

Methods

Since June 2009, all first attendees to the GU medicine service in Northumberland have been given a FAST questionnaire upon arrival at the clinic. It is completed in the reception. Their FAST score is then available in the clinic notes when they are seen. Those patients with a score of three or more are given verbal advice and written information and are then offered brief intervention or referral into alcohol services (See Table 1). An audit was carried out looking at all first GU medicine attendees in April 2010. Local standards set for this audit were (target 100%):

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Table 1

Interventions provided to those scoring three or more on the FAST screening questionnaire

Written	• Credit card-sized leaflet detailing the alcohol content (in units) of alcoholic drinks information
Verbal advice	• Given by the healthcare professional at the time of sexual history taking
	• Lasted approximately two minutes
	• Covered FAST score results, potential health consequences of current levels of alcohol consumption as well as patterns of drinking in relation to sexual risk-taking
Brief intervention	• A more in depth discussion of individual alcohol use, offered to all patients
	• Administered by health advisers who had been trained by local alcohol misuse service staff
	• Individual intervention lasting 15-20 minutes
	• Covered reasons for alcohol use, barriers to change and resulted in practical strategies aimed at reducing alcohol consumption
Specialist referral	• Offered to those showing signs of alcohol dependence

FAST = Fast Alcohol Screening Tool

Data were also collected on rates of STI diagnoses, levels of condom use and average number of sexual partners.

Results

Two hundred and fifty-six sets of notes were audited. One hundred and fifty-four (60.2%) had a FAST score of three or more and 91 patients (35.5%) scored less than three. Only 11 (4.3%) patients declined completing the questionnaire. The average age of the sample was 25 years and 53.5% were men.

The main findings from this audit are presented in Table 2.

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Table 2

Summary of audit findings

	FAST score 3 or more	FAST score less than 3
Total number	154(60.2%)	91 (35.5%)
Men	84	32
Women	70	59
Age range (years)	14-58	15-61
Average age (years)	23.6	27.6
Sex without a condom in past 6 months	143(92.9%)	72(79.1%)
Average number of sexual partners in past 6 months	2.73 (SD 4.83)	1.56 (SD 1.67)
Number of patients diagnosed with at least one STI	60 (39.0%)	27 (29.7%)
Number of patients presenting as a contact of an STI	20(13.0%)	6 (6.6%)
Total number diagnosed either with an STI or presenting as an STI contact	80 (52.0%)	33 (36.3%)

STI = sexually transmitted infection; FAST = Fast-Alcohol Screening Tool

STI diagnoses included; chlamydia, gonorrhoea, genital herpes (laboratory confirmed), genital warts, molluscum contagiosum, pelvic inflammatory disease (PID) and non-specific urethritis (NSU)

People, during the audit period, presented as contacts of: chlamydia, gonorrhoea, NSU, PID or primary syphilis

A statistically significant association was found between a FAST score of three or more and a higher number of sexual partners (Mann-Whitney U test P < 0.01), higher rates of diagnosis either with an STI or as an STI contact (Fisher's exact test, P < 0.05) and higher rates of unprotected sex (Fisher's exact test, P < 0.01).

Of those patients identified with an alcohol use disorder, 94/154 (61.0%) received verbal or written advice, 12/154 (7.8%) received an additional brief intervention but 31.2% did not have their alcohol use addressed.

Discussion

The link between alcohol and poor sexual health is well documented.^7,8 As has been demonstrated in our audit and elsewhere, increasing levels of alcohol use leads to increased STI exposure.^3,9 Alcohol intake may lead to a loss of willpower or inhibitions, unprotected sex, not knowing whether sex has taken place or sexual assault. ¹⁰ It also has an adverse effect on the immune system.^3,11

This audit has shown that screening for alcohol-use within a GU medicine setting is achievable. However, probably the main challenge in the GU medicine setting will not be screening for but dealing with issues of excessive alcohol consumption once identified. This is demonstrated in this audit by 31.2% of patients receiving no intervention. The main reason for this was patient choice, but time constraints and availability of appropriately trained staff also played a part.

The management of alcohol-use disorders is dependent on the level of alcohol consumed. Advice and brief interventions are appropriate for hazardous or harmful drinkers; however, alcohol dependence always requires specialist input. ²

With payment in the GU medicine setting being largely driven by number of patients seen, whether it is possible to dedicate this extra time will be a real challenge. However, it is clear both from this audit and prior research that excessive alcohol use and risky sexual behaviour, leading to an excess of STI diagnoses, are inextricably linked.