Microsoft word - how to manage risky drinkers in primary health care.doc

Title: How to manage risky drinkers in Primary Health Care Authors: Acknowledgements: This guide has been writen in accordance with the criteria of the PHEPA Training Programme on identification and brief interventions and the PHEPA Clinical Guidelines on identification and brief interventions. It is also inspired in ‘Helping patients who drink too much. A clinician’s guide. 2005 Edition’ from the NIAAA.
Introduction Alcohol increases the risk of a wide range of medical and social problems in a dose dependent manner, with no evidence for a threshold effect. Generally the more serious the crime or injury, the more likely alcohol is to be involved. Harm to others is a powerful to reason to intervene for hazardous and harmful alcohol consumption. Apart from being a drug of dependence, alcohol is a cause of 60 or so different types of disease, including injuries, mental and behavioural disorders, gastrointestinal conditions, cancers, cardiovascular diseases, immunological disorders, skeletal diseases, reproductive disorders and pre-natal harm. For the individual drinker, alcohol increases the risk of these diseases and injuries in a dose dependent manner, with no evidence for a threshold effect. The higher the alcohol consumption, the greater is the risk. The risk of death from alcohol is a balance between the risk of diseases and injuries that alcohol increases and the risk of heart disease that in small amounts alcohol decreases. This balance shows that, except for older people, the consumption of alcohol is not risk free. The level of alcohol consumption with the lowest risk of death is zero or near zero for women under the age of 65, and less than 5g of alcohol a day for women aged 65 years or older. For men, the level of alcohol consumption with the lowest risk of death is zero under 35 years of age, about 5g a day in middle age, and less than 10g a day when aged 65 years or older. Throughout the European Union as a whole, alcohol is one of the most important causes of ill-health and premature death. It is less important than smoking and raised blood pressure, but more important than high cholesterol levels and overweight. There are health benefits from reducing or stopping alcohol consumption. All acute risks can be completely reversed if alcohol is removed. Even amongst chronic diseases, such as liver cirrhosis and depression, reducing or stopping alcohol consumption are associated with rapid improvements in health. Primary Health Care (PHC) providers play a crucial role in this field since they are in a pivotal position inside Health Systems. Key questions and recommendations KEY QUESTIONS Should hazardous and harmful alcohol use be identified? Since alcohol is implicated in a wide variety of physical and mental health problems in a dose dependent manner, there is hazardous and harmful an opportunity for PHC providers to identify adult patients with hazardous and harmful alcohol consumption. Numerous episodic heavy drinking studies have shown that most patients with hazardous and harmful alcohol consumption are not known to their health In which groups of patients should hazardous and harmful alcohol use be identified? A truly preventive approach can only be reached if all adult patients are screened for hazardous and harmful alcohol consumption, including patterns of episodic heavy drinking. If such an approach is not feasible, limiting screening to high alcohol consumption at risk groups or to some specific situations may be a feasible option. Such groups could include young to middle aged males and special health clinics (e.g. for hypertension). What are the best questions or screening instruments to identify hazardous and harmful alcohol use? The simplest questions to use are those that ask about alcohol The use of the first three consumption. The first three questions of the World Health Organization’s Alcohol Use Disorders Identification Test, which was designed to identify hazardous and harmful alcohol consumption in primary care settings, have been well to identify hazardous and tested and validated. The first question asks about frequency harmful alcohol of drinking; the second the amount of alcohol consumed on an average drinking day; and the third the frequency of episodic heavy drinking. How should questions or screening instruments be administered? The identification of hazardous and harmful alcohol consumption works best when it is incorporated into routine clinical practices and systems, such as systematically asking all new patients when they register; all patients when they attend for a health check; or all men aged 18-44 years, when incorporated into routine they attend for a consultation. There is no evidence available clinical practices and to suggest that systematic identification of hazardous and harmful alcohol consumption lead to adverse effects, such as discomfort or dissatisfaction amongst patients. Are biochemical tests useful for screening? Biochemical tests for alcohol use disorders such as liver enzymes (e.g. serum γ-glutamyl transferase (GGT) and the aminotransferases), carbohydrate deficient transferrin (CDT) routine screening for and mean corpuscular volume (MCV) are not useful for screening because elevated results have poor sensitivity, identifying only a small proportion of patients with hazardous or harmful alcohol consumption. Are brief interventions effective in reducing hazardous and harmful alcohol consumption and alcohol related problems? Brief interventions are effective in PHC settings in reducing hazardous and harmful alcohol consumption and alcohol related problems in patients without alcohol dependence. Eight patients need to be advised for one patient to benefit. There is little evidence for a dose response effect and it does intervention to all not seem that extended interventions are any more effective than brief interventions. The effectiveness is certainly maintained for up to one year. Brief interventions are also effective in reducing mortality. 282 patients need to receive advice to prevent one death within one year. What are the components of effectiveness? Based on the contents of evaluated interventions, three essential elements of advice have been proposed, including feedback, the giving of advice and goal setting. There is mixed evidence to suggest interventions with more than one session are any more effective than one session alone. Motivational interviewing appears to be an effective alcohol consumption; agree on individual goals; assist patients for behaviour change; and arrange follow-up. What is the cost effectiveness of brief interventions? At a cost of €1960 per year of ill-health and premature death Within PHC activity and prevented, PHC brief interventions for hazardous and harmful alcohol consumption are amongst the cheapest of all treatment field, there medical interventions that lead to health gain. In other words, should be an urgent if a primary health care provider is going to undertake a new reorientation of activity, giving brief advice to patients with hazardous and harmful alcohol consumption will give one of the best health identification and brief benefits for the practice population than spending ten for hazardous and harmful alcohol consumption. KEY CONCEPTS Hazardous Alcohol Consumption. Hazardous drinking is a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others. Hazardous drinking patterns are of public health significance despite the absence of any current disorder in the individual user. Harmful Alcohol Consumption. Harmful use refers to alcohol consumption that results in consequences to physical and mental health. Some would also consider social consequences among the harms caused by alcohol. Risky drinking. This term is used as a synonimous of Hazardous Alcohol Consumption and is gaining increasing popularity even though it is not an accepted term by the WHO. Alcohol Dependence. Alcohol dependence is a cluster of behavioural, cognitive, and physiological phenomena that may develop after repeated alcohol use4. Typically, these phenomena include a strong desire to consume alcohol, impaired control over its use, persistent drinking despite harmful consequences, a higher priority given to drinking than to other activities and obligations, increased alcohol tolerance, and a physical withdrawal reaction when alcohol use is discontinued. Standard Drink Unit. A volume of beverage alcohol ( e.g. a glass of wine, a can of beer, or a mixed drink containing distilled spirits) that contains approximately the same amounts (in grams) of ethanol regardless of the type of beverage. The term is often used to educate alcohol users about the similar effects associated with consuming different alcoholic beverages served in standard-sized glasses or containers (e.g. the effects of one glass of beer are equal to those of one glass of wine). In Europe, the term ' unit" is employed, where one unit of an alcoholic beverage contains approximately 10 grams of ethanol; in North American literature, ' a drink" contains about 12 grams of ethanol. AUDIT. The Alcohol Use Disorders Identification Test is a questionnaire which consists of 10 questions about recent alcohol use, alcohol dependence symptoms, and alcohol-related problems. As the first screening test designed specifically for use in primary care it was developed and evaluated over a period of two decades, and it has been found to provide an accurate measure of risk across gender, age, and cultures settings. AUDIT-C. It contains the first 3 questions of the Audit. Reliable to screen hazardous drinking in primary health care settings. Brief Intervention. A treatment strategy in which structured therapy of short duration (typically 5-30 minutes) is offered with the aim of assisting an individual to cease or reduce the use of alcohol. It is designed in particular for general practitioners and other PHC workers. Also known as minimal intervention. Brief intervention is often linked to systematic screening testing for hazardous and harmful alcohol use. ** ICD-10 DEPENDENCE CRITERIAA definite diagnosis should be made only if 3 or 1: How often did you have a drink containing more of the following have been present together at (0) Never; (1) Monthly or less; (2) 2-4 times a month; (3) 2-3 times per week; (4) 4 or more times a week.
A strong desire or sense of compulsion to drink.
Difficulty in controlling drinking in terms of its 2: How many drinks did you have on a typical day when you were drinking in the past year? A physiological withdrawal state or drinking to relieve or avoid withdrawal symptoms.
3: How often did you have six or more drinks Progressive neglect of alternative pleasures or (0) Never; (1) Less than monthly; (2) Monthly; (3) Persisting with alcohol use despite awareness of Step 2-A. BRIEF ADVICE FOR AT-RISK DRINKING Ask for permission to state your recommendations: I’m a bit concerned on your drinking habits. May I share with you Respect the patients’ decision and restate discuss his drinking habits whenever he is • Don’t be discouraged. Ambivalence is • Specidfic steps the patient will take • Try to restate your concern about his health, encourage reflection on the pros and • Provide self-help & educational materials • Support and affirm the decision taken • Renegotiate drinking goals if necessary • Discuss openly barriers to reach the goal • Encourage to return if unable to maintain COUNSELING STYLE: Brief interventions are most likely to be succesful if delivered withempathy, showing the patient that we care, and that we respect that he holds the final responsibilityfor trying to change his drinking habits Step 2-B. ASSESSMENT, TREATMENT AND REFERRAL FOR ALCOHOL DEPENDENCE State your conclusions & recommendations with empathy, clearly and respectfully: I believe your drinking is impairing your health, and we should definitely do something Is the patient willing to talk about alcohol? • Assess alcohol related disorders.
health and offer to discuss his drinking habits whenever he is ready to do it • Encourage to return if unable to maintain the goals• Arrange followup every 3 months during 2 years Appendix I. Is there a need for detoxification? Detoxification Criteria - Previous DT or seizures - Morning withdrawal signs - Drinking first thing in the morning - Patient willing to take medication - Actual withdrawal signs - Severe physical condition Appendix II. Is home detoxification suitable? Conditions needed for outpatient detoxification - Daily alcohol consumption below 25 standard drinks/day. - No severe medical or psychiatric complications - Patients commitment to: - Alcohol abstinence during the detoxification. - Staying at home - Avoidance of risky activities. - One relative without addictive problems must be responsible to control the - No availability of alcoholic beverages at home during the detoxification. - Daily contact with GP or nurse (in person or by phone) Contraindications for outpatient detoxification - Confusion or hallucinations. - History of previously complicated withdrawal. - Epilepsy or history of fits. - Poor nutritional state. - Severe vomiting or diarrhoea. - Risk of suicide. - Severe dependence coupled with unwillingness to be seen daily. - Failure of home-assisted withdrawal. - Uncontrollable withdrawal symptoms. - Acute physical or psychiatric illness. - Polysubstance use. - Home environment unsupportive of abstinence Source: Scottish Intercollegiate Guidelines Network. The management of harmful drinking and alcohol dependence in primary care. A national clinical guideline. Draft 2.11, 2003. Appendix III. Outpatient Detoxification tapering doses Appendix IV. Medication for alcohol dependence* Whether or not a medication should be prescribed and in what amount is a matter between individuals and their health care providers. The prescribing information provided here is not a substitute for a provider’s judgment in an individual circumstance. pain; infection; flu syndrome; chills; somnolence; decreased libido; amnesia; confusion * Modified from Helping patients who drink too much. A clinician’s guide. 2005 Edition.National Institute on Alcohol abuse and alcoholism. US. Appendix V. Referral to an addiction specialist When to refer to specialized treatment - Previous unsuccessful treatment attempts - Severe complications: o Risk of withdrawal symptoms from moderate to severe. o Serious medical illness. o Family unable to provide support. o Psychiatric co morbidity. o Regular use of other addictive substances. - Treatment cannot be managed by the PHC team.


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