Welcome to Alcohol misuse: reducing the risks

1
Welcome to Alcohol misuse reducing the risks
an interactive workshop designed to assist
general practitioners and their practice staff to
effectively identify patients drinking alcohol at
risky levels, and to help them reduce their
alcohol intake and risk to health.
2
How much alcohol does a standard drink contain,
as set out in the Australian alcohol guidelines?
QUIZQuestion 1
A. 0.01 gB. 0.1 gC. 1.0 gD. 10 g.
3
What constitutes a standard drink as set out in
the Australian alcohol guidelines?
Question 2
A. One average glass (130150 mL) of wineB. One
425 mL glass of regular beerC. One shot/nip (30
mL) of spiritsD. One can of full strength beer.
4
What is the low risk recommended limit for women?
Question 3
A. 2 standard drinks or less in any one day B. 2
standard drinks in an average weekC. 4 standard
drinks on an average dayD. 4 standard drinks in
an average week.
5
What is the low risk recommended limit for men?
Question 4
A. 2 standard drinks or less in any one day B. 2
standard drinks in an average weekC. 4 standard
drinks on an average dayD. 4 standard drinks in
an average week.
6
Not all Australians drink within the recommended
limits. What percentage of total alcohol
consumption in Australia is consumed at levels
that put the drinker at risk of acute or chronic
harm?
Question 5
A. 22B. 48C. 67D. 83.
7
Alcohol is absorbed into the bloodstream through
the stomach and small intestine, and then
metabolised by the liver.What percentage of
alcohol in the body is metabolised by the liver?
Question 6a
A. About 60B. About 80C. About 70D. About
90.
8
How long does it take the liver to metabolise one
standard drink?
Question 6b
A. About half an hourB. About 20 minutesC.
About 3 hoursD. About 1 hour.
9
Drinking alcohol can affect which of the
following body systems?
Question 7
A. Cardiovascular system, nervous system,
gastrointestinal systemB. Endocrine system and
the liverC. Cardiovascular system,
gastrointestinal system and the liverD. All of
the above.
10
What are the short term harms that can occur from
one heavy binge drinking occasion?
Question 8a
A. Alcohol dependenceB. Risk of traumaC. Risk
of trauma, stress, sleep disordersD. A and B.
11
There are many other short term harms that can
occur from alcohol. Name three other possible
short term harms from alcohol.
Question 8b
12
What are the long term harms that can occur from
regular and repeated drinking of alcohol over
months or years?
Question 9
A. Alcohol dependence, mental health problems,
brain damageB. Heart disease, strokeC. A, B and
DD. Diabetes, liver disease, cancer.
13
Alcohol is a risk factor for some types of
cancer. These include
Question 10
A. Mouth, pharynx, larynxB. Mouth, larynx,
pharynx, oesophagus, liver, breastC. Mouth,
oesophagus, liverD. Mouth, pharynx, larynx,
oesophagus, liver.
14
Excessive drinking of alcohol can increase the
risk of which of the following
Question 11
A. High blood pressureB. High blood pressure,
raised cholesterol and triglyceridesC. High
blood pressure, raised triglycerides and body
weightD. All of the above.
15
Heavy alcohol use and binge drinking is one of
the main risk factors for stroke. What are the
other main risk factors for stroke?
Question 12
A. Previous stroke or transient ischaemic attack
(TIA)B. High blood pressure, increasing ageC.
Coronary heart disease, peripheral vascular
diseaseD. All of the above.
16
Cardiovascular disease (stroke, heart disease and
blood vessel disease) causes the highest number
of premature deaths and disability among
Australians (45 670 deaths in 2006), but many
risk factors are preventable.List seven
preventable risk factors for cardiovascular
disease.
Question 13
17
Recognising early warning signs or red flags
indicating alcohol problems is key to
implementing interventions and reducing the risk
to health.List as many early warning signs or
red flags for detecting alcohol problems in
general practice.
Question 14
18
GP intervention can make a difference in risky
drinking behaviour 35 minutes of behavioural
counselling (using the 5As approach) has which
of the following outcomes?
Question 15
A. 2530 reduction in alcohol consumption for
every 1 in 10 patientsB. 10 reduction in
alcohol consumption for every 1 in 10 patientsC.
10 reduction in alcohol consumption for every 1
in 20 patientsD. 2530 reduction in alcohol
consumption for every 1 in 20 patients.
19
SLIDE PRESENTATION
A general practice approach to alcohol misuse
20

Alcohol in the community Individuals who have
hazardous or harmful drinking patterns are not
only at risk of damage to their health, but face
considerable social harms Regular use of
alcohol can lead to family and financial
problems, crime and violence.
21
Red flag conditions
Red flag conditions (health and social
indicators) alert GPs to the possibility of
alcohol related harm.
22
Common red flag conditions
Accidents/trauma, including injuries from falls
and drink driving Psychological/psychiatric
problems, eg. depression and stress Family/relat
ionship problems, including marital
difficulties Employment problems, eg. periods
off work and difficulties at work Involvement
in crime (risky behaviour) Sleep problems such
as insomnia Alcohol related health problems
such as sexual dysfunction and gastrointestinal
complaints.
23
Alcohol misuse reducing the risks to your
patients health
Identify a patients life stage.
24
Alcohol misuse reducing the risks to your
patients health
Determine a patients readiness for change
Apply motivational interviewing techniques.
25
Stages of change model
Precontemplation Contemplation Preparation Action Maintenance
No thoughts about changing behaviour Thoughts about the need to change, but no action taken yet Ready to take action to change Attempts made to change behaviour and avoid environmental triggers Behaviour has been changed and the person is adjusting to these changes and working to preventing relapse
National Prescribing Service 2002
26
Case studies
Case study Peter Aged 14 years lives in a
small country town and is a keen football
player Changed schools 6 months ago and trying
to make new friends Has been skipping classes,
staying out after footy training, and racing
cars Finds it difficult to get out of bed, is
pale and experiencing loss of
appetite Evidence of drinking (empty rum and
coke cans in his room).
27
Case study Peter
What are the key influences at this point in time
on Peters drinking?
28
Case study Peter
Key influences on Peters drinking are he may
be under peer pressure from new friends to try
drinking underage drinking is an increasing
problem small country towns are socially
isolated, with fewer recreational activities
available sport clubs have a strong drinking
culture.
29
Case study Peter
What stage of change is Peter in?A.
PrecontemplationB. ContemplationC.
PreparationD. ActionE. Maintenance.
30
Case study Peter
What intervention strategies would you consider
with Peter at this stage, and how would you
involve Peters mother?
31
Case study Peter
Intervention strategies will depend on Peters
willingness to engage motivational
interviewing techniques and gaining Peters
confidence suggest ways to deal with peer
pressure from his new friends include Peters
mother in the discussions.
32
Case study Kylie
19 year old university student Works part
time in a supermarket delicatessen Requests a
repeat script of the pill On examination,
Kylie is shaky and has cuts and bruises on her
legs Kylie regularly goes clubbing, drinks well
over the recommended limit, and feels sick the
following day.
33
Case study Kylie
How would you describe the pattern of Kylies
drinking?
34
Case study Kylie
Kylies drinking pattern includes she appears
to be a teenage binge drinker there is evidence
of trauma from intoxication possibility of
other high risk behaviours (eg. drug use and
unsafe sex) likely to experience
blackouts potentially at risk of serious
injury to herself.
35
Case study Kylie
What stage of change is Kylie in?A.
PrecontemplationB. ContemplationC.
PreparationD. ActionE. Maintenance.
36
Case study Kylie
What intervention strategies would you consider
with Kylie at this stage?
37
Case study Kylie
As Kylie is a regular patient requiring the oral
contraceptive pill, her GP has a potentially
important role to play here. Brief motivational
interviewing techniques, exploring advantages
and disadvantages of drinking Simple advice
and education about alcohol consumption Warnings
about drinking and driving, and operating
machinery Harm reduction approach.
38
Case study Amanda
24 year old busy executive Recently started a
new job in a competitive male environment Compla
ins of stomach ache is stressed and
agitated Feels the need to go out after work
for drinks with colleagues Usually drinks 23
glasses of red wine most nights to relax.
39
Case study Amanda
What are factors influencing Amandas drinking?
40
Case study Amanda
Factors influencing Amandas drinking Young
adult hoping to do well in her career Under
peer pressure from work colleagues to fit
in Amandas drinking level has started to
become a concern Short term harm from drinking
needs to be considered.
41
Case study Amanda
What stage of change is Amanda in?A.
PrecontemplationB. ContemplationC.
PreparationD. ActionE. Maintenance.
42
Case study Amanda
Investigations fail to demonstrate an obvious
cause for the stomach ache A
gastroenterologist feels that the pain may be of
psychological origin.Amanda has now returned
to see you. What intervention strategies,
regarding alcohol use, would you consider with
Amanda at this stage?
43
Case study Amanda
Intervention strategies for Amanda Detailed
alcohol use history Brief motivational
interviewing techniques for safe levels of
alcohol consumption and lifestyle
change Simple harm reduction strategies Furthe
r psychological assistance.
44
Case study Graham
Aged 32 years regular heavy drinker Family
history of alcohol related problems. Grahams
father has hypertension and ischaemic heart
disease grandmother has diabetes His partner
is expecting their first baby and he needs to
stop drinking He is finding it hard to stay
off the booze.
45
Case study Graham
How would you describe Grahams drinking?
46
Case study Graham
Graham is a regular heavy drinker at risk of
alcohol dependence now has a reason to change
his lifestyle, with a baby on the way is aware
of his family history of alcohol related
problems is ready to ask for help.
47
Case study Graham
What stage of change is Graham in?A.
PrecontemplationB. ContemplationC.
PreparationD. ActionE. Maintenance.
48
Case study Graham
What intervention strategies would you consider
with Graham at this stage?
49
Case study Graham
Intervention strategies will depend on Grahams
assessment for alcohol dependence. Medical
detoxification may be required Drug
intervention with acamprosate or naltrexone could
be considered Referral to local alcohol and
drug services.
50
Case study Dave
Aged 33 years recently lost driving licence
and job as a van driver Drinking and driving is
a familiar pattern Had trouble sleeping is
anxious and depressed Sometimes needs an early
morning drink to get out of bed.
51
Case study Dave
Why has Dave presented for help with his
drinking?
52
Case study Dave
Daves drinking Legal and employment problems,
and sleep disorders are indicators of alcohol
related harm He is dependent on alcohol to
function He has not tried to change his
behaviour.
53
Case study Dave
What stage of change is Dave in?A.
PrecontemplationB. ContemplationC.
PreparationD. ActionE. Maintenance.
54
Case study Dave
What intervention strategies would you consider
with Dave at this stage?
55
Case study Dave
Intervention strategies will require
detoxification and referral to a drug and alcohol
physician. Medical tests to assess the extent
of alcohol damage Needs to become motivated
before considering treatment for alcohol
dependence Education about alcohol related
harm May benefit from self help groups such as
Alcoholics Anonymous Alcohol withdrawal under
medical supervision Relapse prevention.
56
Using the 5As in risky drinking behaviour
57
A 1-minute intervention using the 5A framework
for hazardous drinkers
Ask Do you drink? How much on a typical day? How many days per week? Assess Concern about drinking Interest in cutting down Barriers to cutting down Advise Provide brief, personalised, nonjudgmental and clear advice to cut down Highlight other benefits of cutting down Assist Enlist support Arrange Offer relevant pamphlets on safe drinking levels and ideas to help reduce intake Follow up soon after
Look for red flag conditions (RACGP 2006)
58
Jans case study puts the 5As into practice
59
Using the 5As in risky drinking behaviour
What are the benefits of reduced
drinking? What are the strategies available to
GPs to help their patients overcome alcohol
misuse?
60
Case study Monica
Aged 29 years and presents to you for the first
time She finds it difficult to lose weight and
asks for your help.
61
Case study Monica
At this point, discuss how you would continue the
consultation ASK.
62
Case study Monica
ASK Monica if she has tried diet and
exercise she is experiencing any difficulties
with diet and exercising there is anything else
that may be contributing to her difficulty in
losing weight, eg. how much alcohol does she
drink per day or week?
63
Case study Monica
Discuss how you would continue the consultation
ASSESS.
64
Case study Monica
ASSESS Monicas readiness to change. Monica has
not been aware that her drinking may be
contributing to her difficulty in losing
weight Monica is on the low risk limit for
female drinkers (14 standard drinks per
week) Consider if Monica has other health
problems that may be helped by reducing her
alcohol intake A routine health assessment
could be performed diet, exercise, smoking
status, alcohol intake, blood pressure, weight,
BMI, waist circumference.
65
Case study Monica
Discuss how you would continue the consultation
ADVISE.
66
Case study Monica
ADVISE Monica alcohol is contributing to her
difficulty in losing weight reduce the amount
of alcohol she is drinking as part of a
lifestyle change.
67
Case study Monica
Monica wants to reduce her drinking which is
positive Monica is determined to stick to her
diet, despite not losing weight By changing her
lifestyle, Monica could also reduce her risk for
diabetes and heart disease.
68
Case study Monica
Discuss how you would continue the consultation
ASSIST.
69
Case study Monica
ASSIST Monica by suggesting she reduces the
number of times she goes out during the
week makes her second drink a nonalcoholic
drink tries drinks with less sugar content,
such as red wine or dry white wine limits
alcoholic drinks to two in an evening.
70
Case study Monica
Discuss how you would continue the consultation
ARRANGE.
71
Case study Monica
ARRANGE for Monica lifestyle risk factor
counselling an appointment with the practice
nurse to join the healthy lifestyle
clinic useful patient information, including
websites and guidelines follow up visit in 4
weeks.
72
Case study Michael
Aged 71 years, and has been a patient at the
practice for the past 10 years Presents due to
heartburn and lack of sleep Clinical history
includes precious depression, and medication for
hypertension and reflux oesphagitis.
73
Case study Michael
Discuss special considerations you would take
into account for an elderly patient.
74
Case study Michael
Special considerations The elderly population
has an increased prevalence of comorbid
conditions In patients over 65 years an
awareness is needed for symptoms of dementia and
depression Polypharmacy is more likely in this
population.
75
Case study Michael
Appears to be well controlled on proton pump
inhibitor medication Eats regular meals and
follows the diet sheet from the nurse Is sad
and anxious about his daughter and grandchildren
moving away Not taking any medication to help
him sleep, but has a drink of whisky.
76
Case study Michael
Discuss special considerations you would take
into account for alcohol use in the elderly
population.
77
Case study Michael
Special considerations for the elderly
population Alcohol use in the elderly
population can be easily missed GPs are in an
ideal position to intervene because of their high
level of contact with the elderly With a
higher level of comorbidity and polpharmacy,
intervention can have a positive impact on
outcome.
78
Case study Michael
Discuss the effects of alcohol with aging.
79
Case study Michael
Effects of alcohol with aging There is a
reduction in the level of gastric alcohol
dehydrogenase, so there are higher blood alcohol
levels for the same amount of alcohol
consumed Higher plasma concentration due to
smaller volume of distribution Renal impairment
can slow removal of alcohol from the
body Physical inactivity, bone density loss and
nutritional deficiencies worsen effects of
alcohol Complications due to other illnesses
and polypharmacy.
80
Case study Michael
Whisky may be interfering with blood pressure
medications and reflux, aggravating the
heartburn and causing discomfort.
81
Case study Michael
Discuss the support strategies you would suggest
for Michael.
82
Case study Michael
Try and cut out the night time drinks before
bed Counselling support from local aged care
team With Michaels past history of depression,
support from a psychologist and alcohol
counsellor Opportunities to build social
networks
83
Conclusion
GPs and practice nurses have an opportunity to
significantly lessen the burden of alcohol
misuse, and support their patients in adopting a
healthy lifestyle, by regular physical exercise,
healthy eating, and the avoidance of smoking and
excess alcohol.