Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Alcohol Problems

Alcohol Problems

Alcohol Screening and Brief interventions

 

It is recognised that ‘Interventions aimed at individuals can help make people aware of the potential risks they are taking, or harm they may be doing, at an early stage.

This is important, as they are most likely to change their behaviour if it is tackled early.

In addition, an early intervention could prevent extensive damage’

(NICE Guideline 24, 2011).

The 4-As Approach for a structured Screening or Brief Intervention comprises the following – Ask, Assess, Assist, and Arrange.

 

Step 1 - ASK

If you suspect that drugs may be abused as well as alcohol, then start with the CAGE and CAGE-AID tools.

The four CAGE questions assess alcohol consumption and dependency over a lifetime

The four CAGE-AID questions include the use of drugs

CAGE and CAGE-AID

or, alternatively use the 4 derivatives of the AUDIT (Alcohol Use Disorders Identification Test) tool

i.e. the M-SASQ, AUDIT-C, FAST and AUDIT-PC

as follows :

Start with the single screening question in M-SASQ

M-SASQ

then, either assess consumption (amounts, frequency and patterns) using the 3 questions in the AUDIT C tool.

Inform the patient of the results.

Encourage those who are at "low risk" to remain in that category, but if the total score is 4 or more for a woman or 5 or more for a man, then move to step two

AUDIT-C

or assess hazardous drinking over the past 12 months using the 4 questions in the FAST tool

Inform the patient of the results.

Encourage those who are at "low risk" to remain in that category, but if the total score is 3 or more on the first or all 4 questions, then move to step two

FAST

or proceed directly to the 5 questions in the AUDIT-PC tool, developed specifically for primary care nurses and doctors to use in their surgeries

Inform the patient of the results.

Encourage those who are at "low risk" to remain in that category, but if the total score is total of 5 or more, then move to step two

AUDIT-PC

Where withdrawal is suspected, screen for withdrawal with the CIWA-ar rool

CIWA-ar

Step 2 – ASSESS

 

Information about weekly alcohol consumption may be gathered using the Consumption Diary, including time and place of consumption, type and strength of alcoholic drink consumed, quantity consumed, cost, associated feelings and consequences .

Alcohol Consumption Diary

Use the 10 questions in the full AUDIT tool to assess the level of risk, be it hazardous, harmful or dependent

AUDIT

Use the 10 questions in the LDQ tool to assess for alcohol dependance

LDQ

or use the 20 questions in the SADQ tool to assess for alcohol dependance, predict the likelyhood of achieving drinking goals, and predict alcohol withdrawal

SADQ

Steps 3&4 – ASSIST & ARRANGE

 

At a minimum, advice on safe drinking levels and alcohol reduction should be provided,

When clients are unable to cut down their alcohol consumption or abstain, offer referral to an addictions treatment program, or referral to a support group or mental health professional as required

The Stages of Change tool helps Individuals to visualise and understand where they are along their journey of recovery,

The tool includes handy notes for carers pertaining to mindset, intervention and processes for each stage.

Stages of Change

The tool Using Your Senses to Cope is a conversation guide for substance abusers outlining the use of senses to cope when under stress

Using your senses to cope

The Stay on Course tool is a visual chart detailing various aspects of the journey to recovery that can be revisited to help stay on course.

Stay on course

Brief Interventions

There are several components that are common to most brief interventions:

  • Focus on substance use and related problems, specifically patients with problematic or at-risk use.

  • Can be done in a minimal amount of time (ranging from 5–15 minutes in length).

  • Are NOT intended to treat those who may have a substance use disorder diagnosis

  • Do not take the place of specialized addiction treatment but can be used to encourage those with more serious substance use problems to accept specialized assessment or treatment..

 

Specifically brief interventions focus on motivating patients to adopt healthier behaviors by

  • Helping the patient to perceive his/her use as putting him/her at risk for negative health and social consequences by presenting factual information in a non-judgmental manner.

  • Exploring variables in the patient’s life which reinforce the unhealthy behavior and identify variables which may promote positive change.

  • Eliciting specific beneficial behavior changes acceptable to the patient. By asking the patient for suggestions for what they would be willing to try and what steps they might take to reduce their use or to otherwise address the identified problem, they will be more likely to adopt those changes.

  • Agreeing upon a follow-up plan. Getting a patient to “say yes” and agree to next steps is a key component of getting them to actually take those steps.

Asking questions, understanding the patients’ perspective (in large part so they come to understand it better themselves as well!), and acting as a guide is more conducive to a Brief Iintervention approach than directive and authoritarian approaches (“Do this and  you will be much better off” simply is not effective with behavioral change).

FREE online training courses in Brief Intervention

for Healthcare Professionals

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SBIRT (Indiana University)

The primary goal of SBIRT efforts is to identify and respond to patients who use substances, including alcohol, in a hazardous, risky, or harmful manner.  A secondary benefit of SBIRT is that patients with substance use disorders (i.e. abuse, dependency) are recognized too and may be referred for additional assessment and/or specialty addiction treatment.

Understanding SBRIT : All about SBRIT and how to use it

Beyond SBRIT : All about Detox, Relapse, Specialized care, Abusable medications

Duration : 2 hours each

Requires registration. Does not include certificate of completion.

Go to : Understanding SBRIT course

Go to : Beyond SBRIT course

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HSC Public Agency (Queen's University Belfast)

Aim : To equip Health and Wellbeing advisers with the knowledge and skills necessary to deliver effective brief interventions in practice.

Following completion of this course you should be able to:

  • apply the model of behaviour change to your practice

  • outline the principles of effective communication

  • raise the subjects of smoking, alcohol consumption or physical inactivity with patients in routine practice

  • advise on the risks to health posed by smoking, alcohol and physical inactivity

  • assist patients/clients by signposting and providing additional information sources.

Duration : 2 hours

Requires registration. Includes certificate of completion.

Go to  HSC Public Agency course

Look in e-learning page, under Public Health

There are seven criteria for alcohol dependence used by Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), Revised.

   -  Tolerance: need to drink more to get same effect

   -  Withdrawal or morning drinking

   -  Impaired control: drink more or longer than intended

   -  Unable to cut down

   -  Large amount of time spent drinking or recovering from drinking

   -  Neglect other responsibilities or activities

   -  Continued use despite acknowledgement of problems caused by drinking

Treatment for alcohol problems has traditionally focused on individuals with moderate to severe alcohol dependence.

It is now recognised that this exclusive focus needs to be broadened to include the large group of drinkers whose problems are less severe.

Brief Interventions are effective for many. They should be carried out in general community settings and delivered by non-specialist, trained personnel and are associated with good outcomes and cost effectiveness’ (DoH ROI, 2012).

 

The terms Screening and Brief Intervention are likely to provoke anguish in some GPs as they imply a time commitment, which simply cannot be met.

This may be reinforced by the fact that the term Brief Intervention is used in the literature to describe both a series of short 15min-type of sessions, and also a once-off 2-4 minute structured discussion.

It is the latter that is suggested here, though it is acknowledged that in certain cases this short discussion will throw up issues that result in a significantly longer time commitment.

It is worth remembering in these instances that scheduling return appointments or referral to the practice nurse for support or follow-up might be a useful and appropriate option.

It is the structured element of the short session of structured brief advice that can allow a GP to gather and impart information in a short period of time.

Recommended target groups include those who may be at an increased risk of alcohol-related conditions which could include patients who :

-  have had an accident or a minor injury

-  regularly attend the genito-urinary clinics or repeatedly seek emergency contraception

-  are involved in crime or other antisocial behaviour

-  are truant or miss work on a regular basis  

-  self-harm

The most common components of brief interventions/counselling that have been shown to decrease drinking are :

 

  1. Expressed concern from the provider, regarding unhealthy alcohol use

  2. Feedback linking the client's drinking to his/her health issues

  3. Education about recommended drinking limits

  4. Offer of explicit advice to cut down drinking or abstain

  5. Follow-up 2 - 4 weeks later to assess the client's response

  6. Referral to specialty addictions treatment if indicate

 

The most effective interventions are explicitly client centered and non-confrontational.

Asking the clients' permission to discuss, eliciting their thoughts and using reflection are effective methods recommended for engaging clients in behaviour change.

 

Longer counselling sessions are not necessarily better. Five minutes of advice has been shown to be as effective as 20 minutes.

 

There is a growing body of evidence to show that Brief Interventions are effective for hazardous and harmful drinking while more specialist interventions are effective in people with co dependence.

There is good evidence to suggest that brief interventions for excessive alcohol use, aimed at reducing consumption, subsequent alcohol related harm and dependence are both clinically and cost effective and the primary care setting is seen as the most promising location to offer brief interventions (ICGP, 2013).

Thorny Issues

This is one of several topics presented in the Thorny Issues sector of this toolkit

Back To : Thorny Issues