alcohol our favourite drug: the big picture: can nurses and midwives make a difference?
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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
• Hazardous/harmful drinkers 142
Population aged 14-19 years• Drinkers 641
• Hazardous/harmful drinkers 671
Aboriginal & Torres Strait Islander Peoples• Drinkers 621
• Hazardous/harmful drinkers 821
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
Factors in Acute Alcohol-related Damage
Acutealcohol
consumption
CNS depression:Impairment of• Motor function• Coordination• Judgment• Respiration• Consciousness
Factors in Acute Alcohol-related Damage
Drinking Circumstances and Environment
Acutealcohol
consumption
CNS depression:Impairment of• Motor function• Coordination• Judgment• Respiration• Consciousness
Motor vehiclesWorkplaceHotels & barsOther social venuesSporting activitiesAssociated drug use
Factors in Acute Alcohol-related Damage
General Environment
Drinking Circumstances and Environment
Acutealcohol
consumption
CNS depression:Impairment of• Motor function• Coordination• Judgment• Respiration• Consciousness
Motor vehiclesWorkplaceHotels & barsOther social venuesSporting activitiesAssociated drug use
Trauma
Trauma• Fall injuries
• Road injuries
• Occupational and machine injuries
• Fire injuries
• Drowning
• Assaults
• Suicide
Factors in Acute Alcohol-related Damage
General Environment
Drinking Circumstances and Environment
Acutealcohol
consumption
CNS depression:Impairment of• Motor function• Coordination• Judgment• Respiration• Consciousness
Motor vehiclesWorkplaceHotels & barsOther social venuesSporting activitiesAssociated drug use
Overdose/poisoning
Overdose/Poisoning
• Acute ethanol overdose and poisoning
• Aspiration
• Combined alcohol and drug overdose and poisoning
• Methanol poisoning
Factors in Acute Alcohol-related Damage
Drinking Circumstances and Environment
Acutealcohol
consumption
CNS depression:Impairment of• Motor function• Coordination• Judgment• Respiration• Consciousness
Motor vehiclesWorkplaceHotels & barsOther social venuesSporting activitiesAssociated drug use
Obstructivesleep apnoea
Factors in Acute Alcohol-related Damage
Drinking Circumstances and Environment
Acutealcohol
consumption
CNS depression:Impairment of• Motor function• Coordination• Judgment• Respiration• Consciousness
Motor vehiclesWorkplaceHotels & barsOther social venuesSporting activitiesAssociated drug use
PregnancySexual assaultChild Abuse
Factors in Acute Alcohol-related Damage
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
Factors in Acute Alcohol-related Damage
General Environment
Drinking Circumstances and Environment
Acutealcohol
consumption
CNS depression:Impairment of• Motor function• Coordination• Judgment• Respiration• Consciousness
Motor vehiclesWorkplaceHotels & barsOther social venuesSporting activitiesAssociated drug use
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
Effects of Long-term Alcohol Consumption
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
Effects of Long-term Alcohol Consumption
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
Effects of Long-term Alcohol Consumption
Long-termalcohol
consumption
Alcohol a contributory factor to disease outcome
Alcohol a Contributory Factor to Disease Outcome
• Hepatitis C
• Pulmonary infection
• Post-operative complications
Effects of Long-term Alcohol Consumption
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
Effects of Long-term Alcohol Consumption
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
Alcohol UseAlcohol Use
HazardousHazardous
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
Case finding &Case finding &early interventionearly intervention
Alcohol UseAlcohol Use
HarmfulHarmful
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
TreatmentTreatment
Alcohol UseAlcohol Use
Alcohol-Alcohol-relatedrelated
problemsproblems
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
Alcohol UseAlcohol Use
Alcohol-Alcohol-relatedrelated
problemsproblems
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
Case finding &Case finding &early interventionearly intervention
Alcohol UseAlcohol Use
Alcohol-Alcohol-relatedrelated
problemsproblems
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
TreatmentTreatment
Alcohol UseAlcohol Use
NilNil
SafeSafe
HazardousHazardous
HarmfulHarmfulAlcohol-Alcohol-relatedrelated
problemsproblems
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
Case finding &Case finding &early interventionearly intervention
TreatmentTreatment
General NursesGeneral Nurses
The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical Practice
Safe Drinking Safe Drinking PracticesPractices
General NursesGeneral Nurses
The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical Practice
Safe Drinking Safe Drinking PracticesPractices
Drinking HistoryDrinking History
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)
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
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)
Specialist referralSpecialist referral
Brief Brief interventionintervention
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)
Treatment of Treatment of withdrawalwithdrawal
Specialist referralSpecialist referral
Brief Brief interventionintervention
General NursesGeneral Nurses
The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical Practice
The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical Practice
Public healthPublic healthCommunity healthCommunity health
Mental healthMental healthEmergencyEmergencyCritical careCritical care
GastroenterologyGastroenterologyHepatologyHepatologyNeurologyNeurologyMidwiferyMidwiferyPaediatricsPaediatrics
SpecialtySpecialtyNursing andNursing and
Clinical NurseClinical NurseSpecialistsSpecialists
ConsultationConsultation & support & support
The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical Practice
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
Public healthPublic healthCommunity healthCommunity health
Mental healthMental healthEmergencyEmergencyCritical careCritical care
GastroenterologyGastroenterologyHepatologyHepatologyNeurologyNeurologyMidwiferyMidwiferyPaediatricsPaediatrics
Management ofManagement ofspecialty problemsspecialty problems
ConsultationConsultation & support & support
SpecialistSpecialistassessmentassessment
The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical PracticeSpecialtySpecialty
Nursing andNursing andClinical NurseClinical Nurse
SpecialistsSpecialists
Public healthPublic healthCommunity healthCommunity health
Mental healthMental healthEmergencyEmergencyCritical careCritical care
GastroenterologyGastroenterologyHepatologyHepatologyNeurologyNeurologyMidwiferyMidwiferyPaediatricsPaediatrics
Management ofManagement ofmedical problemsmedical problems
ConsultationConsultation & support & support
SpecialistSpecialistassessmentassessment
FollowFollow-up-up
The Role of Nursing: Clinical PracticeThe Role of Nursing: Clinical PracticeSpecialtySpecialty
Nursing andNursing andClinical NurseClinical Nurse
SpecialistsSpecialists
Public healthPublic healthCommunity healthCommunity health
Mental healthMental healthEmergencyEmergencyCritical careCritical care
GastroenterologyGastroenterologyHepatologyHepatologyNeurologyNeurologyMidwiferyMidwiferyPaediatricsPaediatrics
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 Practice
General hospitalsGeneral hospitalsPsychiatric hospitalsPsychiatric hospitalsCommunity healthCommunity health
Detoxification unitsDetoxification unitsOther D & A servicesOther D & A services
ConsultationConsultation & support & support
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 Practice
General hospitalsGeneral hospitalsPsychiatric hospitalsPsychiatric hospitalsCommunity healthCommunity health
Detoxification unitsDetoxification unitsOther D & A servicesOther D & A services
ConsultationConsultation & support & support
SpecialistSpecialistassessmentassessment
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
General hospitalsGeneral hospitalsPsychiatric hospitalsPsychiatric hospitalsCommunity healthCommunity health
Detoxification unitsDetoxification unitsOther D & A servicesOther D & A services
ConsultationConsultation & support & support
Management ofManagement ofalcohol problemsalcohol problems
SpecialistSpecialistassessmentassessment
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
General hospitalsGeneral hospitalsPsychiatric hospitalsPsychiatric hospitalsCommunity healthCommunity health
Detoxification unitsDetoxification unitsOther D & A servicesOther D & A services
ConsultationConsultation & support & support
Management ofManagement ofalcohol problemsalcohol problems
Follow-upFollow-up
SpecialistSpecialistassessmentassessment
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
General hospitalsGeneral hospitalsPsychiatric hospitalsPsychiatric hospitalsCommunity healthCommunity health
Detoxification unitsDetoxification unitsOther D & A servicesOther D & A services
Safe Drinking Safe Drinking PracticesPractices
Drinking HistoryDrinking History
Screening Screening (AUDIT)(AUDIT)
Treatment of Treatment of withdrawalwithdrawal
Specialist referralSpecialist referral
Brief Brief interventionintervention Management ofManagement of
medical problemsmedical problems
ConsultationConsultation & support & support
ConsultationConsultation & support & support
General NursesGeneral Nurses
Management ofManagement ofalcohol problemsalcohol problems
Follow-upFollow-up
SpecialistSpecialistassessmentassessment
SpecialistSpecialistassessmentassessment
FollowFollow-up-up
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
SpecialtySpecialtyNursing andNursing and
Clinical NurseClinical NurseSpecialistsSpecialists
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
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