Problem alcohol use among drug users: Clinical guidelines development for primary care Jan Klimas, Catherine Anne Field, Walter Cullen & Guideline Development Group

Overview Background Methodology Content Implementation issues HCV Overdose Addiction treatment

68/196(35%) had ‘AUDIT’ score >7 Risk behaviours and health service utilisation common: e.g. ED, benzodiazepines … and comparable to findings from more specialist settings

What now?

To develop clinical guidelines to improve screening and treatment for problem alcohol use among patients on methadone treatment in primary care

Methods Approach: Identification of Key Stakeholders (n=21) Evidence-based draft guidelines Modified ‘Delphi- facilitated’ consensus Informed by: 1.Qualitative survey of healthcare professionals and patients 2. Systematic literature review

Key areas 1.Definition of problem alcohol use among problem drug users 2.Screening / identification 3.Interventions / treatment 4.Referral to secondary care 5.Ongoing management

1. Definition of problem alcohol Alcohol Use Disorders Identification Test Low-risk Hazardous Harmful Dependent

2. Screening / Identification Perform a yearly AUDIT-C, i.e. first 3 questions If positive, administer full AUDIT Example first question:

3. Treatment and management Brief intervention: FRAMES approach F- Feedback regarding personal risk following assessment of alcohol use and associated problems R- Responsibility for change is on the patient A- Advice about changing alcohol use is clearly given to the patient by the practitioner when requested M- Menu of options for change and treatment alternatives E- Empathic counselling style S- Self-efficacy or optimism to encourage behaviour change (Miller & Sanchez, 1994)

4. Referral to secondary care Who might benefit? High ‘AUDIT score’ (16+): harmful drinking Protracted, severe alcohol problems, resistant to brief intervention Requiring: psychological counselling, alcohol detoxification, pharmacotherapy, intensive case monitoring, etc. Concurrent, significant psychiatric illness

5. GPs role in ongoing care Harm reduction / low-risk drinking tips Relapse prevention – learning opportunity Ongoing care / After care: General medical problems in/directly associated with drinking: e.g. GI, psychological, respiratory disease, etc.

In summary Broad principles same as general population, BUT: 1.screening and treatment should be more systematically delivered in all problem drug users, especially if concurrent chronic illnesses 2.lower thresholds should be applied for identification and intervention for problem alcohol use / referral 3.special skills / specialist supervision required to manage persistent dependent alcohol use

What now?

Systematic review? Qualitative study? Complex intervention? Feasibility…international collaborations?

Thank you…. R Anderson, J Barry, D Bedford, M Bourke, G Bury, G Corrigan, J Doyle, J Flanagan, H Gallagher, N Geoghegan, K Harkin, E Keenan, J Lambert, S Lyons, R McAuliffe, ME McCann, McCormick, D O’Driscoll, C O’Gara, N Perry, BP Smyth, F Weldon

Whom are these guidelines for? Methadone patients – but implications for all ‘Problem Drug Users’ EMCDDA definition accepted in Ireland: ‘injecting drug use or long-duration/regular use of opioids, cocaine and/or amphetamines’ i.e. specifically includes regular or long-term use of prescribed opioids such as methadone. (regular = at least 1x weekly)

“If it’s okay with you, let’s take a minute to talk about the annual screening form you’ve filled out today.” Raise the subject “As your doctor, I can tell you that drinking at this level can be harmful to your health and possibly responsible for the health problem you came in for today.” Provide feedback “On a scale of 0-10, how ready are you to cut back your drinking?” If >0: “Why that number and not a ____ (lower one)?” If 0: “Have you ever done anything while drinking that you later regretted?” Enhance motivation “What steps can you take to cut back your use?” “How would your drinking have to impact your life in order for you to start thinking about cutting back?” Negotiate plan I Low risk/Abstain AUDIT: 0–7 II Harmful AUDIT : 8–15 III Hazardous AUDIT : IV Dependent AUDIT : 20+ ©