Screening & brief alcohol interventions in primary care

Dr Eileen KanerDr Paul Cassidy

Professor Nick Heather

Session 2 – Brief Alcohol Intervention

Linking screening to brief intervention

• Avoid labelling

• Start with reference to the patient’s screening score or consumption level

• Ask the patient how they feel about their screening score/consumption level

– eg. You appear to be drinking at a rate that increases your risk of harm. What do you think?

– eg. The way in which you are drinking may be affecting your health. What do you think?

Assessing interest/motivation

Not all patients are the sameAlcohol may not be at the top of their agenda

Stage of change & brief intervention

• Precontemplation (unaware/unready)• intervention unlikely to succeed, give information about risks

• Contemplation (aware/ambivalent)• offer advice &/or motivational work to move patient along

• Preparation (planning)• set date, make plans, be specific, anticipate difficulties

• Action (ready to go)• encourage, support, offer to follow-up

• Maintenance (keeping it up)• reinforce success, advise on managing slips/relapse prevention

Risk status & brief intervention

• Low Risk - Brief congratulation, positive reinforcement. Possibly ‘unit awareness’ work.

• Hazardous drinkers – Simple structured advice (level 1 BI), offer further support

• Harmful drinkers – Simple structured advice (level 1 BI) and offer motivational intervention (level 2 BI)

• Dependent drinking – Referral to specialist services

Clinical flow

Case finding

Negative screenCongratulate

Positive ScreenPossible dependence

Assess further, refer on

Assess interest/motivation

No interest – offer PILKeep door open for future

Interest/hazardous drinkerSimple structured advice

Interest/ harmful drinkerExtended brief intervention

What generally happens now?

Example 1 - avoidance

Example 2 - evasion

Example 3 – dictating

Level 1 brief intervention

• Simple structured advice

• Delivered in 1-2 minutes

• Following ‘How Much is Too Much’ protocol (level 1)

• Practical - ‘common sense’ content

• Offer of future follow-up/further discussion

• Clinicians already do many elements of BI– just needs some more structure

BI structure – FRAMES

•Feedback (personalised)

•Responsibility (with patient)

•Advice (clear, practical)

•Menu (variety of options)

•Empathy (warm, reflective)

•Self-efficacy (boosts confidence)

Discussion

• Issues to think about– What are the essential elements if time is short?– When, where and by whom?– What resources are required– What if patients want more than simple advice?

Level 2 brief intervention

• Motivationally enhanced intervention not MI

• Behaviour change counselling based on Rollnick S., et al. (1999) Health Behaviour Change: A Guide for Practitioners

• Following ‘How much is Too Much’ – level 2

• Takes 15-20 minutes

• 2-3 hour skill-based training available - Dr Malcolm Thomas, Effective Professional Interactions (http://www.effectivepi.co.uk)

Motivational approach fits with patient centred practice

• Both clinicians and patients are experts

• Distinction between disease and illness

• Understanding patients in a context

• Finding common ground

• Mutual decision making

Patient presents problem

Gathering information

Parallel search of two frameworks

Disease framework

Doctor’s agenda:Doctor’s agenda:• Symptoms• Signs• Investigations• Pathophysiology

Differential diagnosisDifferential diagnosis

Illness framework

Patient’s agenda:Patient’s agenda:• Ideas• Concerns• Expectations• Feelings

Understanding theUnderstanding thepatient’s uniquepatient’s uniqueexperience of experience of illnessillness

Integration of the two frameworks

Shared understanding & decision makingShared understanding & decision making

Patient centred practice - active listening

What I say What I hear

What I mean or feel

What I understand

patient practitioner

Clinician assumptions

• This person ought to change

• this person wants to change

• patient’s health is motivation

• no change=failure• either do or don’t

• Now is the right time• being tough is best• I know - my advice is

good• negotiation is always

best

Motivational Interviewing

• ‘client-centred , directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence’

1. Express empathy2. Develop discrepancy3. Avoid argumentation4. Roll with resistance5. Support self-efficacy

Miller & Rollnick 2002

Behaviour change counselling

• ‘ways of structuring a conversation which maximises the individual’s freedom to talk and think about change in an atmosphere free of coercion and the provision of premature solutions’ Rollnick et al. 1999– Assessing readiness

– Weighing up pros and cons

– Determining action - moving patients on

Rollnick et al. 1999

Discussion

• Issues to think about– How could this fit in PHC?– Who might be best place to deliver this?– In what context could it be offered?– How should it be incentivised– What about patients who need more?

Referral (1)

• Patients should be referred to specialist services who:

• show a relatively high level of alcohol dependence or alcohol-related harm

• are harmful drinkers who have not benefited from brief counselling and wish to receive further help for their alcohol problems

Referral (2)

• can be defined as score of 20+ on the full AUDIT

• obvious signs of physical dependence (e.g. withdrawal symptoms, withdrawal relief or avoidance drinking, very high tolerance, blackouts)

• severe alcohol-related problems or risk of such problems (e.g. possible loss of job, family, etc.)

• score on recognised measure of dependence (e.g. 10-item Leeds Dependence Questionnaire)