10 Addictions psychiatry10.8 Prevention, harm reduction and health promotion
10.8 Prevention of drug and alcohol harm
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Written by Resident Doctor Committee · Published
Levels of prevention
Level | Who it reaches |
|---|---|
Universal | Everyone, so it must be safe, affordable and acceptable |
Selective | Groups at higher risk, such as children of dependent parents |
Indicated | People with early problems below the threshold for a disorder, such as hazardous drinking |
Judge each measure against its own aim. Needle programmes aim to prevent infection and injury, not necessarily to reduce injecting.
Population measures for alcohol
Rose's prevention paradox holds that a small risk shared by many people can cause more harm than a high risk confined to a few. A modest population-wide fall in drinking therefore prevents much disease.
The National Institute for Health and Care Excellence (NICE) ranks population measures against alcohol-related harm in this order:
Making alcohol less affordable, for example with a minimum price per unit, is the most effective.
Controls on availability and marketing come next.
Education is the weakest.
Minimum unit pricing sets a legal price floor by alcohol content. Unlike a duty rise, it is not a tax, so the extra money goes to retailers.
It mainly raises the price of cheap, strong off-trade drinks such as white cider, which heavier drinkers buy most.
Scotland introduced it in 2018 and raised it to 65p in 2024. Its 2023 evaluation estimated 13.4% fewer alcohol-specific deaths, with the largest falls in men and deprived areas.
Alcohol in pregnancy
The UK Chief Medical Officers' 2016 guidance advises complete abstinence from alcohol throughout pregnancy and when planning one.
No safe level of prenatal alcohol exposure is known, so there is no unit allowance and no trimester in which drinking is acceptable.
Maternity staff should give this advice and address fears that stop people disclosing their drinking.
Schools
An effective school programme engages pupils' own existing attitudes and beliefs about drinking. It neither treats dependence nor endorses drinking.
Information-only education improves knowledge more than behaviour.
Fear-based programmes can cause harm: Scared Straight prison visits increased recorded offending, with an odds ratio of 1.68.
Better approaches build refusal and decision-making skills and correct exaggerated beliefs about how much peers drink or use drugs.
Screening and brief intervention
A positive short screen, such as an AUDIT-C score of 5 or more, leads to the full Alcohol Use Disorders Identification Test (AUDIT).
AUDIT score | Meaning | Response |
|---|---|---|
8 to 15 | Increasing-risk drinking | Brief intervention |
16 to 19 | Higher-risk drinking | Brief intervention; consider referral |
20 or more | Possible dependence | Specialist assessment, especially at 30 or more |
Brief intervention suits non-dependent drinking. Possible dependence needs specialist assessment and active referral, not brief advice alone.
Harm reduction for drugs
Take-home naloxone prevents opioid overdose deaths but does not treat dependence. Since December 2024, services including police, prisons and probation can supply it without prescription.
Needle and syringe programmes should match supply to need without arbitrary limits, and add hepatitis B vaccination and hepatitis C testing.
Safer-use advice includes not using alone and not combining opioids with alcohol or benzodiazepines.