Why Alcohol History and Brief Intervention Is Tested
Alcohol misuse affects approximately 1 in 4 adults in the UK at some level, contributing to over 7,000 deaths and 340,000 hospital admissions annually. Taking an accurate alcohol history and delivering a brief intervention are core competencies expected of all doctors, regardless of specialty. NICE guideline PH24 (2010) and NICE guideline CG115 (2011) provide the evidence base for screening and intervention in alcohol misuse.
💡 Tip
This station often combines history-taking skills with communication skills. You are expected to take a non-judgmental, empathetic approach while being systematic and accurate. Avoid language that implies blame — use terms such as "alcohol use" rather than "drinking problem."
Setting the Scene
Before taking the alcohol history:
- Introduce yourself and confirm consent
- Explain the purpose: *"As part of my assessment today, I'd like to ask you some questions about your alcohol use. This is something we ask all patients as it can affect many aspects of health. Everything we discuss is confidential unless there is a safety concern."*
- Adopt an open, non-judgmental stance — body language is important in this station
Calculating Alcohol Units
One unit = 10 mL or 8 g of pure alcohol.
| Drink | Volume | ABV | Units |
|---|---|---|---|
| Pint of standard beer/lager | 568 mL | 4% | ~2.3 |
| Pint of strong beer/lager | 568 mL | 5.2% | ~3 |
| 175 mL glass of wine | 175 mL | 13% | ~2.3 |
| 250 mL glass of wine | 250 mL | 13% | ~3.3 |
| Single shot of spirits | 25 mL | 40% | 1 |
| Bottle of wine (750 mL) | 750 mL | 13% | ~10 |
Formula: Volume (mL) x ABV (%) ÷ 1000 = units
UK low-risk drinking guidelines (CMO 2016):
- No more than 14 units per week for men and women
- Spread over at least 3 days if drinking 14 units/week
- At least 2 alcohol-free days per week
- Pregnant women: advised to avoid alcohol entirely
⚠️ Red Flag
Ask specifically about daily, weekly, and binge patterns. Many patients underestimate their intake by 50% or more. Use specific quantities: *"When you had a glass of wine, was it a small 125 mL glass, a standard 175 mL, or a large 250 mL glass?"*
Structured Alcohol History
Quantity and Frequency
- *"How often do you drink alcohol?"*
- *"On a typical drinking day, how many drinks do you have?"*
- *"What type of drinks do you usually have?"*
- Calculate approximate units per week with the patient
Pattern of Use
- Daily vs. binge vs. weekend
- Drinking alone vs. social
- Drinking first thing in the morning (indicates dependence)
- Drinking to control withdrawal symptoms
CAGE Questionnaire (Brief Screen for Dependence)
| Question | Scoring |
|---|---|
| C — Have you ever felt you should Cut down on your drinking? | 1 if yes |
| A — Have people Annoyed you by criticising your drinking? | 1 if yes |
| G — Have you ever felt Guilty about your drinking? | 1 if yes |
| E — Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? | 1 if yes |
Score ≥2 suggests clinically significant alcohol misuse; score ≥3 suggests likely dependence.
AUDIT (Alcohol Use Disorders Identification Test)
The AUDIT is the full 10-question validated screening tool recommended by WHO and NICE. In OSCEs, AUDIT-C (first 3 questions only) is commonly used as a brief screen:
| Question | Options | Score |
|---|---|---|
| 1. How often do you have a drink containing alcohol? | Never / Monthly / 2-4 per month / 2-3 per week / 4+ per week | 0-4 |
| 2. How many units of alcohol do you drink on a typical day? | 1-2 / 3-4 / 5-6 / 7-9 / 10+ | 0-4 |
| 3. How often do you have 6 or more units on a single occasion? | Never / Less than monthly / Monthly / Weekly / Daily | 0-4 |
AUDIT-C interpretation:
- ≥3 (women) or ≥4 (men) = positive screen; full AUDIT recommended
Full AUDIT score interpretation:
- 0-7: Low-risk or abstinent
- 8-15: Hazardous drinking — brief advice
- 16-19: Harmful drinking — brief advice + simple structured counselling
- ≥20: Likely dependence — referral for specialist assessment
Dependence Symptoms (ICD-11 Criteria)
Ask about:
- Compulsion to drink: *"Do you feel a strong urge or craving to drink?"*
- Loss of control: *"Once you start drinking, do you find it hard to stop?"*
- Tolerance: *"Have you noticed you need to drink more to get the same effect?"*
- Withdrawal symptoms: tremor, sweating, nausea, anxiety, seizures, hallucinations on stopping
- Salience: *"Has drinking become one of the most important things in your life?"*
- Continuing despite harm: *"Have you continued drinking even though it's caused you problems?"*
Impact on Life — HELPS
| Domain | Questions |
|---|---|
| Health | Liver disease (jaundice, ascites), pancreatitis, neuropathy, gastritis, hypertension, cardiomyopathy |
| Employment | Has it affected work, attendance, or relationships with colleagues? |
| Legal | Any drink-driving convictions, criminal behaviour? |
| Psychiatric | Depression, anxiety, self-harm — often co-morbid with alcohol misuse |
| Social/Family | Relationship breakdown, impact on children, housing |
Previous Attempts to Cut Down
- Previous episodes of alcohol withdrawal — were there seizures or delirium tremens? This predicts future withdrawal severity
- Previous treatment: Alcoholics Anonymous (AA), Turning Point, NHS Alcohol Service
- Medications tried: acamprosate, naltrexone, disulfiram, chlordiazepoxide (for detox)
Brief Intervention — FRAMES Model
The FRAMES model provides a structured approach for brief intervention, recommended by NICE for hazardous and harmful drinkers:
| Letter | Element | Example Phrase |
|---|---|---|
| F | Feedback | *"Your AUDIT score suggests you're drinking at a harmful level — around 28 units a week, which is above the recommended 14 units."* |
| R | Responsibility | *"It's entirely your decision what you do with this information — I'm here to help if you'd like."* |
| A | Advice | *"I'd recommend reducing your drinking below 14 units per week and having at least two alcohol-free days."* |
| M | Menu | *"There are several options — I can give you written information, refer you to our local alcohol service, or we could discuss cutting down together today."* |
| E | Empathy | *"I understand this isn't easy, and I appreciate you being open with me today."* |
| S | Self-efficacy | *"Many people successfully cut down with the right support — and you've recognised this yourself, which is the first step."* |
Alcohol Withdrawal — Recognising and Preventing
Withdrawal risk: patients drinking >15 units/day or AUDIT score ≥20 are at significant risk.
Withdrawal timeline:
- 6-24 hours: tremor, sweating, anxiety, nausea
- 24-48 hours: risk of seizures (rum fits)
- 48-72 hours: risk of delirium tremens (DT) — confusion, hallucinations, autonomic instability — mortality up to 5% untreated
Management of alcohol withdrawal in hospital:
- Chlordiazepoxide (preferred benzodiazepine) using a symptom-triggered or fixed-schedule regimen (e.g., CIWA-Ar scale)
- Thiamine (Pabrinex IV): always before IV glucose — Wernicke's encephalopathy is preventable and irreversible if missed
- Monitor for Korsakoff's psychosis (anterograde amnesia, confabulation) — often irreversible
⚠️ Red Flag
Always give IV Pabrinex (thiamine) before any glucose infusion in suspected alcohol misuse. Giving glucose first to a thiamine-deficient patient can precipitate Wernicke's encephalopathy — a preventable, serious complication.
Common Mistakes
- Not calculating actual units (asking "do you drink a lot?" is not enough)
- Using judgmental language
- Forgetting to ask about withdrawal symptoms and history of seizures
- Not asking about the morning drink (key dependence marker)
- Failing to discuss the impact on family, work, and mental health
- Not offering a brief intervention or referral
Examiner Tips and Mark Scheme Pointers
Mark schemes typically award points for:
- 1Non-judgmental introduction and approach
- 2Accurate unit calculation using specific drinks
- 3CAGE or AUDIT-C administered correctly
- 4Dependence symptoms assessed
- 5Impact on life explored (health, social, employment)
- 6Withdrawal risk and Wernicke's mentioned
- 7Brief intervention delivered using FRAMES or equivalent
- 8Appropriate onward referral offered
Frequently Asked Questions
"What are the UK Chief Medical Officer's low-risk drinking guidelines and how do they come up in the OSCE?"
The CMO guidelines (updated 2016) recommend no more than 14 units of alcohol per week for both men and women, spread over at least 3 days, with at least 2 alcohol-free days per week. Pregnant women are advised to avoid alcohol entirely. In the OSCE, you will typically be expected to calculate the patient's weekly units during the consultation and compare them to this benchmark. Citing the guidelines directly (rather than saying "you're drinking too much") demonstrates professionalism and is part of the FRAMES feedback step.
"What does the AUDIT-C score measure and what is the threshold for a positive screen?"
The AUDIT-C is the first three questions of the full Alcohol Use Disorders Identification Test — a validated WHO tool. It screens for frequency of drinking, typical quantity per drinking day, and frequency of heavy drinking (6+ units). A score of ≥3 in women or ≥4 in men is a positive screen, indicating that the full 10-item AUDIT questionnaire should be completed. In OSCEs, you may be asked to administer AUDIT-C and interpret the score — examiners will specifically check whether you know the gender-specific thresholds.
"What is the most important question to ask to screen for alcohol dependence and why?"
The most diagnostically important question for dependence is whether the patient drinks first thing in the morning — the "Eye-opener" in the CAGE questionnaire. Morning drinking to relieve withdrawal symptoms (tremor, anxiety, sweating) is a hallmark of physical dependence that distinguishes it from harmful or hazardous drinking. Withdrawal seizures (typically 24-48 hours after stopping) and delirium tremens (48-72 hours, mortality up to 5% untreated) occur in dependent drinkers — making this question also a patient safety priority.
"What is Wernicke's encephalopathy and why is it critical to mention it in the OSCE?"
Wernicke's encephalopathy is a neurological emergency caused by thiamine (vitamin B1) deficiency, occurring in the context of alcohol misuse and malnutrition. The classic triad is confusion, oculomotor abnormalities (nystagmus, ophthalmoplegia), and ataxia — though all three are present in fewer than 20% of cases. It is preventable with IV thiamine (Pabrinex). Critically, IV glucose must never be given before IV thiamine in a thiamine-deficient patient — glucose metabolism rapidly depletes thiamine stores and precipitates Wernicke's. Mentioning Pabrinex-before-glucose in the alcohol withdrawal management section consistently scores marks.
"What is the FRAMES model and how does it structure a brief intervention in the OSCE?"
FRAMES is a structured brief intervention model recommended by NICE for hazardous and harmful drinkers. Each letter represents a component: Feedback (share the patient's units/AUDIT score and its health implications), Responsibility (emphasise that change is the patient's choice), Advice (give clear evidence-based advice on safe limits), Menu (offer a range of options — self-help, referral, apps), Empathy (non-judgemental, warm tone throughout), Self-efficacy (reinforce belief that change is achievable). Using FRAMES gives structure to the communication component of the station and ensures you cover every component required by the mark scheme.
"What should you do if the patient's AUDIT score is ≥20 and they are in alcohol withdrawal in hospital?"
A full AUDIT score of ≥20 suggests likely alcohol dependence, which requires specialist assessment rather than brief advice alone. In hospital, if withdrawal symptoms are present, initiate a chlordiazepoxide withdrawal regimen (symptom-triggered using the CIWA-Ar scale or a fixed tapering schedule). Give IV Pabrinex (thiamine) before any glucose. Refer to the liaison psychiatry alcohol service or hospital alcohol specialist nurse. Monitor for withdrawal seizures and delirium tremens, and involve the multidisciplinary team including social work if there are safeguarding concerns.
Related guides: Explaining a Diagnosis OSCE · Psychiatric History OSCE · Breaking Bad News OSCE Guide · Consent and Capacity OSCE