Alcohol misuse - a GP approach

Alcohol misuse - a GP approach

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ObjectivesObjectives

• Improve confidence in• Detection • Assessment• Managementof problem drinking

• Improve confidence in• Detection • Assessment• Managementof problem drinking

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Detection 1Detection 1

• When to ask?• Opportunistically

• New patient check• Health check• Lifestyle questionnaire

• When suspicion raised• Physical problems• Mental health problems• Social problems

• When to ask?• Opportunistically

• New patient check• Health check• Lifestyle questionnaire

• When suspicion raised• Physical problems• Mental health problems• Social problems

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Detection 2Detection 2

• Who should ask?• Doctors• Nurses• Health care assistants• Receptionists• Implications for training • Whole team alcohol aware

• Who should ask?• Doctors• Nurses• Health care assistants• Receptionists• Implications for training • Whole team alcohol aware

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Detection 3Detection 3

• What to ask?• Simple questions about drinking

• How many days a week do you drink alcohol? • How many drinks do you have on a typical

day when you are drinking?• Screening questionnaire e.g. Audit-PC

• Quick • Validated• Combination of questions will detect

hazardous, harmful and binge drinking and dependence

• What to ask?• Simple questions about drinking

• How many days a week do you drink alcohol? • How many drinks do you have on a typical

day when you are drinking?• Screening questionnaire e.g. Audit-PC

• Quick • Validated• Combination of questions will detect

hazardous, harmful and binge drinking and dependence

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Assessment 1 - the foundations

Assessment 1 - the foundations

• Be clear about units• Be clear about sensible

drinking• Man: 3-4 units a day• Woman: 2-3 units a day• Pregnancy: max 1 unit day• No binge drinking (>1/2 recommended

weekly units in 1 session) • 48hrs alcohol free after any binge

• Be clear about units• Be clear about sensible

drinking• Man: 3-4 units a day• Woman: 2-3 units a day• Pregnancy: max 1 unit day• No binge drinking (>1/2 recommended

weekly units in 1 session) • 48hrs alcohol free after any binge

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Assessment 2 - definitionsAssessment 2 - definitions

• Hazardous drinking• Regularly drinking >5 units / day

(man) or >3 units / day (woman)• Risk of damage to physical or

mental health• Doubles man’s risk of liver disease,

hypertension, some cancers, violent death

• Hazardous drinking• Regularly drinking >5 units / day

(man) or >3 units / day (woman)• Risk of damage to physical or

mental health• Doubles man’s risk of liver disease,

hypertension, some cancers, violent death

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Assessment 3 - definitionsAssessment 3 - definitions

• Harmful drinking• Damage caused to physical or

mental health of drinker• Diagnosis from history,

examination and investigation

• Harmful drinking• Damage caused to physical or

mental health of drinker• Diagnosis from history,

examination and investigation

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Assessment 4 - definitionsAssessment 4 - definitions

• Alcohol dependence• Suspect in men drinking >50 units a

week, women drinking >35 units a week• 3 or more of these features• Strong desire or compulsion to drink• Difficulty controlling drinking (starting, stopping,

quantities)• Withdrawal symptoms / relief drinking• Tolerance• Alcohol use “taking over”

• Persisting use despite awareness of harmful consequences

• Alcohol dependence• Suspect in men drinking >50 units a

week, women drinking >35 units a week• 3 or more of these features• Strong desire or compulsion to drink• Difficulty controlling drinking (starting, stopping,

quantities)• Withdrawal symptoms / relief drinking• Tolerance• Alcohol use “taking over”

• Persisting use despite awareness of harmful consequences

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What to do next?What to do next?

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The alcohol pyramidThe alcohol pyramid

• 79.1% low risk• 16.3% hazardous drinkers• 4.1% harmful drinkers• 0.5% dependent drinkers• Main primary care focus - the 20%

hazardous and harmful drinkers• Change more likely• Bigger overall impact

• 79.1% low risk• 16.3% hazardous drinkers• 4.1% harmful drinkers• 0.5% dependent drinkers• Main primary care focus - the 20%

hazardous and harmful drinkers• Change more likely• Bigger overall impact

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Management 1 Minimal Intervention

Management 1 Minimal Intervention

• Focus - hazardous drinkers• Give clear information about• Sensible drinking• Hazardous / harmful drinking

• Emphasize by giving written information

• Quick - 2mins• Can be done by all PHCT with training

• Focus - hazardous drinkers• Give clear information about• Sensible drinking• Hazardous / harmful drinking

• Emphasize by giving written information

• Quick - 2mins• Can be done by all PHCT with training

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Management 2

Brief interventionManagement 2

Brief intervention• Focus - hazardous or harmful drinkers• Give clear information about sensible

drinking• Explore motivation for change• Set goals and discuss how they will

be achieved• ? Arrange follow up• Can be done by doctors and nurses

• Focus - hazardous or harmful drinkers• Give clear information about sensible

drinking• Explore motivation for change• Set goals and discuss how they will

be achieved• ? Arrange follow up• Can be done by doctors and nurses

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Management 3 - counselling and other more intensive input

Management 3 - counselling and other more intensive input

• Focus - harmful or dependent drinkers

• Motivational interviewing• Drug treatment• Harm minimisation• Detoxification

• More time consuming, regular follow-up needed

• ? role for developing Enhanced Service

• Focus - harmful or dependent drinkers

• Motivational interviewing• Drug treatment• Harm minimisation• Detoxification

• More time consuming, regular follow-up needed

• ? role for developing Enhanced Service

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Drug treatmentDrug treatment

• Detox regime• Chlordiazepoxide 20mg qds, reduce by

10mg daily• Vitamin supplements

• Thiamine 100mg x1-3 daily• Vit B Co Strong 3 daily• Folic acid / Ascorbic Acid

• Acamprosate• Disulfiram

• Detox regime• Chlordiazepoxide 20mg qds, reduce by

10mg daily• Vitamin supplements

• Thiamine 100mg x1-3 daily• Vit B Co Strong 3 daily• Folic acid / Ascorbic Acid

• Acamprosate• Disulfiram

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Referral to Alcohol Services 1

Referral to Alcohol Services 1

• Refer Piccadilly Project• When the patient asks for additional

help• When the patient is having problems

cutting down• When the patient is alcohol dependent• To enhance motivation for change• For counselling to explore drinking and

related issues

• Refer Piccadilly Project• When the patient asks for additional

help• When the patient is having problems

cutting down• When the patient is alcohol dependent• To enhance motivation for change• For counselling to explore drinking and

related issues

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Referral to Alcohol Services 2

Referral to Alcohol Services 2

• Refer Bradford Community Drug & Alcohol Team

• When the patient is alcohol dependent and is not suitable for primary care treatment

• Pregnancy• Significant mental health problems• Drug misuse• History of withdrawal fits or DTs - inpatient detox needed• Previous failed attempts• Difficult social circumstances e.g. poor support, homeless• Too complex for resources of Primary Health Care Team

• The team has psychiatrist and community psychiatric nurse support with beds available in hospital

• Refer Bradford Community Drug & Alcohol Team

• When the patient is alcohol dependent and is not suitable for primary care treatment

• Pregnancy• Significant mental health problems• Drug misuse• History of withdrawal fits or DTs - inpatient detox needed• Previous failed attempts• Difficult social circumstances e.g. poor support, homeless• Too complex for resources of Primary Health Care Team

• The team has psychiatrist and community psychiatric nurse support with beds available in hospital

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Referral to Alcohol Services 3

Referral to Alcohol Services 3

• Refer to Caleb Project or Ripple Project

• Alcohol dependent patients who would benefit from Day-Care Rehabilitation with group-work

• Motivated• Chaotic lifestyle, poor social support • Attend daily 10 – 4, expected to attend AA

meetings

• Refer to Caleb Project or Ripple Project

• Alcohol dependent patients who would benefit from Day-Care Rehabilitation with group-work

• Motivated• Chaotic lifestyle, poor social support • Attend daily 10 – 4, expected to attend AA

meetings

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Referral to Alcohol Services 4

Referral to Alcohol Services 4

• Alcoholics Anonymous• Regular self-help group support

• Community Alcohol Support Team

• Practical social support for individuals or families

• Alcoholics Anonymous• Regular self-help group support

• Community Alcohol Support Team

• Practical social support for individuals or families