alcohol our favourite drug: the big picture: can nurses and midwives make a difference?

Alcohol Our Favourite Drug:The big picture: can nurses and midwives make a difference?

Prof. Jim RankinIst International Alcohol, Tobacco and

Other Drugs Nursing & Midwifery Conference

Adelaide, April 16, 2003

Advances in Knowledge and Understanding: Alcohol - Before 1960

• Alcoholism a moral problem or a manifestation of mental illness

• Alcoholism a disease - Alcoholics Anonymous

The Scene 1964: Treatment Services

• Completely inadequate

• Psychiatric hospitals

• Residential

• Custodial care

• Inmates:– Inebriates’ Act– Psychiatric complications– Temporary accommodation & support

Sister Mary Christina Wellsford, RSC

Advances in knowledge and understanding of alcohol problems

• A spectrum of drinking behaviours that may cause problems

• A spectrum of alcohol-related problems

• A spectrum of responses involving health promotion, prevention and intervention/treatment

Broadening the base of treatment:

• Establishment of services in general hospitals

• Shift of resources from psychiatric hospitals to community-based services

• Shift of resources to provide a balance of residential and non-residential services

• Initiatives to increase the involvement of general practitioners

Responding to alcohol problems in Australia: potential resources

• Medical practitioners 70,000 (est)• Addiction medicine specialists

– Certified 140– Certification pending 60

• Registered nurses 250,000 (est)– Registered midwives 67,000 (est)

• Members of DANA 200+• Number of D & A services 2000 (est)

VISION

The role of nursing and midwifery

A whole of profession responsibilityPractitioners• Clinical nurses• Nurse educators/academics• Nurse managers• Nurse researchersOrganisations• Registration bodies• General professional organisations• Academic organisations• Alcohol and drug

A Vision of Nursing and Midwifery

Professions that play active roles in the development and implementation of comprehensive alcohol policies and programs for prevention and treatment

A Vision of Nursing and Midwifery: Prevention and Health Promotion

Professions whose members incorporate into their professional activities strategies and practices that have as their objectives maintenance of abstinence and safe patterns of alcohol use, and reductions in hazardous and harmful use.

A Vision of Nursing and Midwifery:Clinical Care

Professions whose members play a complementary role to these preventive strategies by

• identifying and intervening with their patients whose are at risk because of their alcohol use; and

• Identifying and responding to the health needs of their patients who already have alcohol-related damage

Topics

• Drinking patterns in Australia and their consequences

• Effects of alcohol on health

• Prevention, intervention and treatment

• Potential roles of nursing and midwifery

• Systems’ impediments to progress

Drinking Patterns in AustraliaPopulation aged 14+ years %• Drinkers 811

• Hazardous/harmful drinkers 351


Population aged 14-19 years• Drinkers 641


Aboriginal & Torres Strait Islander Peoples• Drinkers 621


1 = Last 12 months2 = Last week

Alcohol-attributable deaths and hospital bed days, 1998-9

Deaths• Caused 4,286• Prevented

(7029)1

• Total (2,744)

Note 1. 94% aged 60+ years

Hospital beddays• Caused 394,417• Prevented2 (255,433)• Total 138,974

Note 2. 79.7% aged 60+ years

Potential benefits of policies designed to prevent alcohol misuse

Preventable deaths 4,286

Preventable hospital beddays 394,417

Social costs of drug abuse, 1998-9 $m %

Alcohol 7,560.31 22.0

Tobacco 21,063.0 61.2

Illicit drugs 6,075.8 17.6

Total 34,439.8 100.0

Avoidable costs of alcohol misuse $3,928.6m (62.1%)

Note 1. Costs of alcohol misuse 1.98% of GDP

Effects of alcohol on health

Factors in Acute Alcohol-related Damage

Acutealcohol

consumption


Acutealcohol

consumption

CNS depression:Impairment of• Motor function• Coordination• Judgment• Respiration• Consciousness


Drinking Circumstances and Environment

Acutealcohol

consumption


Motor vehiclesWorkplaceHotels & barsOther social venuesSporting activitiesAssociated drug use


General Environment


Acutealcohol

consumption



Trauma

Trauma• Fall injuries

• Road injuries

• Occupational and machine injuries

• Fire injuries

• Drowning

• Assaults

• Suicide


General Environment


Acutealcohol

consumption



Overdose/poisoning

Overdose/Poisoning

• Acute ethanol overdose and poisoning

• Aspiration

• Combined alcohol and drug overdose and poisoning

• Methanol poisoning



Acutealcohol

consumption



Obstructivesleep apnoea



Acutealcohol

consumption



PregnancySexual assaultChild Abuse


General Environment

Supportive HOME ENVIRONMENT Non-supportive

Affluence INCOME Poverty

Very good COMMUNITY SERVICES Absent

Very good HEALTH SERVICES Absent

Privileged SOCIAL CLASS Under-privileged


General Environment


Acutealcohol

consumption



Obstructivesleep apnoea

Overdose/poisoning

Trauma

PregnancySexual assaultChild Abuse

Effects of Long-term Alcohol Consumption

Long-termalcohol

consumption

0

2

4

6

8

10

12

14

16

18

20

0 0.5 1 1.5 2 2.5

Alcohol consumption in gallons per capita aged 15+ yearsS

Cirrhosis mortality / 100,000 aged 20+ years

Relationship between alcohol consumption and cirrhosis mortality, Ontario 1928-1972


Long-termalcohol

consumption

Alcohol a necessary cause of diseases

Alcohol a Necessary Cause of DiseaseBehavioural and Neurological• Alcohol dependence• Acute alcohol withdrawal• Delirium tremens• Acute alcoholic hallucinosis• Alcoholic polyneuropathy• Alcoholic cerebellar atrophy• Neuro-psychological impairment• Wernicke-Korsakoff syndrome

Alcohol a Necessary Cause of DiseaseOther diseases:

• Alcoholic gastritis

• Alcoholic hepatitis

• Alcoholic cirrhosis

• Alcoholic cardiomyopathy

• Foetal alcohol effects

• Foetal alcohol syndrome


Long-termalcohol

consumption

Alcohol a contributing cause

of disease

Alcohol a Contributing Cause of Disease

Cancer

• Oropharyngeal

• Oesophageal

• Laryngeal

• Liver

• Female breast

Alcohol a Contributing Cause of Disease

Gastro-intestinal and hepatic

• Oesophageal varices

• Gastro-oesophageal haemorrhage

• Unspecified cirrhosis

• Haemochromatosis

• Acute pancreatitis

• chronic pancreatitis

Alcohol a Contributing Cause of DiseaseOther diseases:• Epilepsy • Hypertension (males) • Ischaemic stroke (males)• Haemorrhagic stroke (males) • Psoriasis• Depression, attempted suicide and suicide• Spontaneous abortion


Long-termalcohol

consumption

Alcohol a contributory factor to disease outcome

Alcohol a Contributory Factor to Disease Outcome

• Hepatitis C

• Pulmonary infection

• Post-operative complications


Long-termalcohol

consumption

Alcohol a protector

from diseases

Alcohol a Protector from Disease

• Ischaemic heart disease

• Hypertension (females)

• Supra-ventricular cardiac dysrhythmias

• Hear failure

• Ischaemic stroke (females)

• Haemorrhagic stroke (females)

• Cholelithiasis


General Environment

Long-termalcohol

consumption

Alcohol a necessary cause of diseases

Alcohol a contributory cause

of diseases

Alcohol a protector

from diseases

Alcohol a contributory factor to disease outcome

Prevention & Treatment of Prevention & Treatment of Alcohol-related Problems:Alcohol-related Problems:

A Spectrum of Problems and ResponsesA Spectrum of Problems and Responses

The goal: Harm minimization

Advances in disease prevention & health promotion

• Drinking Guidelines

• Low alcohol content beers

• Labelling of alcoholic beverage containers with the number of drinks

• Drink-driving counter measures

▬ Random breath testing

▬ Zero blood alcohol levels for probationary drivers

Advances in disease prevention & health promotion

• Thiamine supplementation of flour

• Indexation of alcohol taxes

• Initiatives to reduce alcohol-related harm in and near licensed premises

Advances in clinical management• Screening instruments (AUDIT)

• Assessment instruments

• Effective behavioural interventionsMotivational interviewingCognitive behavioural restructuringBrief interventions

• Pharmacotherapies:NaltrexoneAcamprosate

• Management of alcohol-related physical diseases

Changes in alcohol problems• Between 1988 and 1998 per capita

consumption as fallen from 9.4 to 7.5 litres• Australia has fallen from 12th to 19th place

internationally in per capita consumption• These declines associated with falls in:

– Incidence of alcohol-related road injury and deaths

– Total alcohol-caused mortality– Deaths where alcohol is the sole cause– Deaths where alcohol is a contributing cause

Alcohol UseAlcohol Use

NilNil

SafeSafe

Prevention and Treatment of Alcohol-related Problems:Prevention and Treatment of Alcohol-related Problems:A Spectrum of Problems and ResponsesA Spectrum of Problems and Responses

Primary Primary prevention prevention


HazardousHazardous


Case finding &Case finding &early interventionearly intervention


HarmfulHarmful


TreatmentTreatment


Alcohol-Alcohol-relatedrelated

problemsproblems





problemsproblems





problemsproblems


TreatmentTreatment


NilNil

SafeSafe

HazardousHazardous

HarmfulHarmfulAlcohol-Alcohol-relatedrelated

problemsproblems




TreatmentTreatment

General NursesGeneral Nurses

The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical Practice

Safe Drinking Safe Drinking PracticesPractices




Drinking HistoryDrinking History





Screening Screening (AUDIT)(AUDIT)






Brief Brief interventionintervention






Specialist referralSpecialist referral







Treatment of Treatment of withdrawalwithdrawal






Public healthPublic healthCommunity healthCommunity health

Mental healthMental healthEmergencyEmergencyCritical careCritical care

GastroenterologyGastroenterologyHepatologyHepatologyNeurologyNeurologyMidwiferyMidwiferyPaediatricsPaediatrics

SpecialtySpecialtyNursing andNursing and

Clinical NurseClinical NurseSpecialistsSpecialists

ConsultationConsultation & support & support








SpecialistSpecialistassessmentassessment

The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical PracticeSpecialtySpecialty

Nursing andNursing andClinical NurseClinical Nurse

SpecialistsSpecialists




Management ofManagement ofspecialty problemsspecialty problems









Management ofManagement ofmedical problemsmedical problems



FollowFollow-up-up







D and AD and A Nursing and Nursing and

Clinical Nurse Clinical Nurse Specialists Specialists


General hospitalsGeneral hospitalsPsychiatric hospitalsPsychiatric hospitalsCommunity healthCommunity health

Detoxification unitsDetoxification unitsOther D & A servicesOther D & A services


D and AD and A Nursing and Nursing and

Clinical Nurse Clinical Nurse Specialists Specialists






The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical PracticeD and AD and A

Nursing and Nursing and Clinical Nurse Clinical Nurse

Specialists Specialists




Management ofManagement ofalcohol problemsalcohol problems









Follow-upFollow-up










Treatment of Treatment of withdrawalwithdrawal


Brief Brief interventionintervention Management ofManagement of

medical problemsmedical problems





Follow-upFollow-up



FollowFollow-up-up






A special need: services for impaired nurses

Progress in Australia• Services in general hospitals 1964

• Appointment of assistant directors of nursing (D and A) in NSW 1982

• Establishment of clinical nurse specialists and consultants in some states

• Establishment of DANA 1986

• NSW Nursing Project

• Academic appointments

• Establishment of academic programs

• Availability of educational resources

Systems impediments to progress

• Increasing and competing demands on nurses and nursing services

• Deceasing availability of nurses• Silo organizational structures• Fragmentation of patient care• Shift of Federal government support away the

concept of universal health care• Inadequate funding of public hospitals• Increasing numbers of for-profit private hospitals

alcohol our favourite drug: the big picture: can nurses and midwives make a difference?

Documents

alcohol problems

consequenceseffects

problemsa spectrum of

alcohol use andidentifying

safe patterns of alcohol

druga vision of nursing

treatmenta vision of

estvisionthe role of