Alcohol misuse a GP approach

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Alcohol misuse - a GP approach
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Objectives

• Improve confidence in
• Detection
• Assessment
• Management
• of problem drinking

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Detection 1

• 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 2

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

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Detection 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

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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 (gt1/2 recommended weekly units
  in 1 session)
• 48hrs alcohol free after any binge

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Assessment 2 - definitions

• Hazardous drinking
• Regularly drinking gt5 units / day (man) or gt3
  units / day (woman)
• Risk of damage to physical or mental health
• Doubles mans risk of liver disease,
  hypertension, some cancers, violent death

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Assessment 3 - definitions

• Harmful drinking
• Damage caused to physical or mental health of
  drinker
• Diagnosis from history, examination and
  investigation

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Assessment 4 - definitions

• Alcohol dependence
• Suspect in men drinking gt50 units a week, women
  drinking gt35 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?
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The 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

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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

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Management 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

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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

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Drug 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

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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

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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

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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

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Referral to Alcohol Services 4

• Alcoholics Anonymous
• Regular self-help group support
• Community Alcohol Support Team
• Practical social support for individuals or
  families