Alcohol misuse - a GP approach 1

2 Objectives Improve confidence in Detection Assessment Management of problem drinking Improve confidence in Detection Assessment Management of problem drinking

3 Detection 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

4 Detection 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

5 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 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

6 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

7 Assessment 2 - definitions Hazardous drinking Regularly drinking >5 units / day (man) or >3 units / day (woman) Risk of damage to physical or mental health Doubles mans 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 mans risk of liver disease, hypertension, some cancers, violent death

8 Assessment 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

9 Assessment 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

10 What to do next?

11 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 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

12 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

13 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 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

14 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

15 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 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

16 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

17 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

18 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

19 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