Intervening with harmful and hazardous drinkers

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Intervening with harmful and hazardous drinkers

• Screening and brief interventions in primary care
  a pragmatic approach
• Dr Linda Harris

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Whose drinking is the problem?
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The importance of applying consistent definitions

• Hazardous use e.g. above recommended limits but
  no problems yet
• Harmful use already experiencing physical or
  psychological harm from drinking
• Dependence

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Definitions can be helpful

• Dependent drinkers usually need to completely
  stop drinking, and may experience a withdrawal
  syndrome
• Non-dependent drinkers can usually cut down

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• The primary goals of alcohol screening and brief
  interventions are to
• Reduce alcohol use to low-risk levels
• Encourage abstinence in persons who are alcohol
  dependent.

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OPTIONS

• Hazardous drinking - simple brief
  interventions/minimal advice
• Harmful drinking - structured brief
  interventions
• Dependent drinking - detoxification in community
  or as inpatient
• Plus relapse prevention
• GPs can deliver all interventions except
  inpatient detoxification for severely dependent
  patients
• Goals of treatment harm reduction and improved
  quality of life
• Abstinence vs moderate drinking?
• severity of dependence
• preference of patient

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When is an intervention a brief intervention?

• There is no standard definition of a brief
  intervention
• The optimum brief intervention is yet to be
  defined -interventions can range from a short
  conversation with a doctor or nurse to a number
  of sessions of motivational interviewing.
• There are some elements which are common to all
  brief interventions

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WHAT WORKS? THE EVIDENCE BASE

• Mesa Grande (2) Study 2002
• Meta-analysis of 361 eligible studies comparing
  46 treatment modalities with 3 or more studies
  each
• Evaluated efficiency of interventions and placed
  in a ranked order for 2 populations all studies
  regardless of severity, and clinical populations
  only
• Brief interventions were ranked first in both
  rankings
• Motivational enhancement was in top 5 for both
  rankings
• Acamprosate and Naltrexone were 3rd and 4th
  respectively in both rankings
• Bottom of both groups psychotherapy, counselling
  and educational lectures/films/groups

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SHOULD GPs GET INVOLVED?

• All the most successful interventions in the Mesa
  Grande can be delivered in general practice (2)
• All categories of drinkers except the most
  severely dependent category (requiring inpatient
  detox) can be treated in general practice (1)
• The vast majority of problem drinkers (hazardous
  and harmful drinkers) will only ever be seen in a
  primary care environment
• Practitioners already have many of the required
  skills and carry out many elements of SBI work in
  current routine practice
• Many studies show prolonged improvements in
  peoples drinking following a brief intervention
  by a GP (3,4,5,6)

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• Research has found that when given brief advice
  1 8 individuals drinking at hazardous and
  harmful levels act on their doctors advice and
  moderate their drinking to within low risk
  levels.
• ( COMPATED TO 1 20 INDIVIDUALS OFFERRED SMOKING
  ADVICE REDUCING TO 1 10 WHEN NICOTINE
  REPLECAMENT IS OFFERRED AS WELL)

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• In general, when patients enter treatment,
  exposure to any treatment is associated with
  significant reduction in alcohol use and related
  problems, regardless of the type of intervention
  use
• Reference Alcohol No Ordinary Commodity -
  Research and Public Policy (Babor et al 2003)
• WIDESPREAD IMPLEMENTATION OF ALCOHOL MISUSE CASE
  FINDING THROUGH THE USE OF BRIEF QUESTIONNAIRES
  FOLLOWED BY BRIEF ADVICE WOULD HELP OVER 300,000
  PEOPLE ANNUALLY TO REDUCE THEIR ALCOHOL TO WITHIN
  LOW RISK LEVELS

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Brief Interventions a pragmatic approach
Potential for two levels of involvement
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BIs in primary care key principles -

• Aimed at those drinking at hazardous or harmful
  levels (but who may not be aware of the harms to
  their health)
• Includes the giving of information and advice
• Encourages the patient to consider the positives
  and negatives of their drinking behaviour
• Offers support to the patient if they do decide
  that they want to cut down
• Is timely and opportunistic

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Level 1 for the hazardous drinker

• Brief advice
• Alternatively referred to as
• Minimal intervention
• Or .
• Teachable moment

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Brief Advice THREE key components in ONE single
patient contact

• Some assessment of alcohol use
• Provision of information on hazardous and harmful
  levels of drinking
• Some clear advice on how to cut down or stop
  drinking
• Seven and a half minutes for the patient?
• Asking the difficult question
• Confirming what is safe drinking (units etc)
• Offer information on the health benefits of
  reducing intake
• Advise on how to cut down

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Asking the difficult question
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Calculating Units

• Volume in mls x strength in abv (alcohol by
  volume) / 1000
• units of alcohol
• e.g. John drinks 2 litres of 4 / day and 3 at
  weekends
• How many units per week?
• 1 pint 568mls

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Advising people to cut down

• Goal setting
• Start date/quit date
• Establish drink diaries
• Set daily limit
• Cut out most potent alcoholic beverage
• Alternate alcohol with water
• Reduce daily drinks,
• 1 - 2 alcohol free days per week

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DRINK DIARIES

• A useful tool
• An easy way of obtaining a picture of someone's
  drinking
• By inviting them to record what they drank, where
  they drank it, when they drank it and how many
  units they consumed

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as the patient is leaving

• Homework
• Patient is given a self help booklet to take
  home, and advised to consider what the doctor has
  said
• Follow Up
• Appointment is made for follow-up

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Summary of the level 1 intervention

• - Give feedback
• - Explain units binge etc
• - Provide information
• - Establish a goal
• - Confirm start date
• - Give advice on limits

• Empathy
• Non-judgmental
• Authoritative
• Deflect denial
• Facilitate
• Follow-up
• Patient education brochure
• (Babor Higgins-Biddle, 2001)

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• Captured in the acronym F.R.A.M.E.S.
• F Feedback on personal risk and harm
• R Responsibility to change lies with user
• A Advice on how to cut down or route to
  abstinence
• M Menu of alternative options for tackling
  triggers and goal setting
• E Empathic interviewing style
• S Self efficacy, enhancing peoples belief in
  their ability to change

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Level Two Brief Intervention ( for the harmful
and dependent drinker)

• A detailed assessment followed by structured
  (planned) intervention as opposed to just
  screening and advice
• Careful history
• Clinical examination looking to identify drink
  related complications harm
• Laboratory testing
• Over minimum of two sessions

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Level 2 Interventions Brief treatment/Extended
Brief

• Higher level of assessment
• Provide patients with tools to change behaviours
• Case managed approach
• Deals with underlying problems
• Specialist talk therapies

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• Brief treatments take longer and are more
  intensive
• Typically involve a total of 3-4 hours of
  detailed assessment and counselling
• Brief treatments are usually delivered by
  specialist workers
• but may be offered in primary care by those with
  an interest, sometimes on a shared-care basis
• Motivational interviewing
• most popular form
• Brief treatments are most appropriate for
  individuals with definite alcohol-related
  problems but only a moderate degree of
  dependence.
• Can be used as basis of stepped approach
  preparing patients for more intensive treatment

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Components of level 2 intervention

• 20-30 minutes structured advice, repeated e.g.
• Identification of drinking pattern above
  recommended limits
• Comprehensive holistic assessment
• Detailed drinking diary
• Identification of high risk situations
• Plans to deal with high risk situations
• Simple rules to limit consumption
• Alternatives to drinking
• Feedback of blood test results
• But no evidence that this is more effective than
  a simple brief intervention (1)

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Comprehensive Assessment

• When looking at alcohol use, it is important to
  clarify the
• following -
• What they are drinking
• How much
• How long
• When
• Where
• Periods of abstinence
• Previous treatments
• Withdrawal symptoms
• Reasons for them seeking help
• Their perception of why they drink / what help
  they need /
• what they want to do
• Function of alcohol in their lives
• Where they are on the cycle of change.

• Also, it is important to collect some personal
  information about the
• individual user -
• Family background
• Medical / psychiatric history / self-harm / mood
• Personal relationships / support
• Employment
• Financial / debt
• Accommodation
• Forensic History - current / past
• Drink related - do you ever drive under the
  influence?
• Prescribed / illicit drug use
• Other services involved
• Investigation of bloods (see Section 2, page 5).

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Holistic
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In the examination look out for..

• Injuries
• Smell of alcohol on breath
• Tremor of hands and tongue
• Excessive capillarisation of the skin and
  conjunctivae
• Ascites
• Symptoms of acute alcohol withdrawal, sweating,
  nausea, severe agitation confusion, paranoia,
  visual and auditory hallucinations

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Feedback on blood results

• Full blood count (FBC) and liver function tests
  (LFTs). FBC with a raised mean corpuscular volume
  (MCV), and LFTs with raised transaminases,
  alkaline phosphatase, or bilirubin, can be useful
  for
• Diagnosis of liver disease in individuals
  drinking at harmful levels. Raised alkaline
  phosphatase and bilirubin are indicative of
  serious liver damage.
• Monitoring progress - following cessation of
  drinking, gamma-glutamyl transferase (GGT) levels
  return to normal after several weeks, unless
  there is significant liver damage. MCV will
  remain elevated for months, reflecting the
  120-day lifespan of red blood cells.
• Therapeutic tool repeating the test say a month
  later so the effectiveness of advice and
  subsequent action can be demonstrated clearly to
  the patient

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AUDIT/FAST/CAGE/ opportunistic vs. targeted
Screen
L E V E L 1
Assessment, Typical days drinking, maximum
drinking, Physical, Psychological. Domestic,
Occupational problems
Elicit and Record
Leaflet, organise blood tests, Homework
Brief Advice
Appointed sessions care planned Approach/multidisc
iplinary
Move on to Brief Treatment
L E V E L 2
Stepped Care to achieve goal to cut down
Response
No response
Action intensive treatment care plan
Annual Health Check
Secondary care
Community detox
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To reduce or to abstain that is the question

• Reduce
• Responding well to brief interventions
• Motivated to change
• Evidence of controls in place
• Biological tests provide evidence of reduction

• Abstain
• Alcohol related severe organ damage
• Severe dependence
• ( e.g. DTs, continuous drinking)
• Epilepsy
• Deteriorating social factors

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Clinical Knowledge Summaries

• http//www.cks.library.nhs.uk/alcohol_problem_drin
  king/in_summary/scenario_dependence

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Learning Trios

• In groups of 3 you will take turns to be the GP,
  patient and observer each person will have a go
  at being all three
• The patient and the GP will each play the
  character identified in the case given to them on
  the card
• The GPs role is to respond and deliver a brief
  intervention to the patient in the standard
  consultation time (10 minutes)
• The Observers role is to note what helps and
  hinders the interactions between GP and Patient
  and then feedback to the GP and Patient in the
  five remaining minutes before swapping roles
• The exercise is completed when all members have
  had an opportunity to play GP, patient and
  observer