Treating Alcohol Misuse: Brief Assessment and Intervention Skills

Treating Alcohol Misuse: Brief Assessment and Intervention Skills Simon Adamson, DipClinPsych, PhD National Addiction Centre University of Otago, Christchurch Homespun Wisdom: NZCCP Conference, Auckland, March 2011

DrinkingContinuum No “Safe” Hazardous Problem Mild Moderate/severe drinking drinking drinking drinking dependent dependent drinking

Upper Limits for Responsible Drinking (ALAC, 1995) Per day, no more than: 4 standard drinks* for women 6 standard drinks for men Per week, no more than: 14 standard drinks for women 21 standard drinks for men And: Two or more alcohol-free days per week But, these limits may be too high for: Certain populations (eg pregnant, very thin, elderly, medical conditions, strong family history of alcohol or other drug dependence) Certain situations (eg driving, swimming, taking certain medications) *One standard drink = 10grams/12.7ml pure alcohol

Alcohol - some statistics road fatalities 30% v road injuries - male 37% n - female 18% n falls injuries 34% n fire injuries 44% n drownings 34% n assaults 47% n homicides 40% u child abuse 16% n street offences 77% u crime 60% u industrial accidents 25% v fatal workplace accidents 15% v n National Drug Strategy v NSW Health Adult Alcohol Action Plan 1998-2000 u Ireland &Thommeny, 1993 Section 7: Drinkcheck Training Workshop

Alcohol - related hospital admissions MALE FEMALE Breast cancer 0% 3% Hypertension 11% 6% Oesophageal cancer 14% 6% Epileptic seizures 15% 15% Stroke 17% 19% Liver cancer 18% 12% Laryngeal cancer 21% 13% Gastro-oesphageal haemorrhage 47% 47% Unspecified liver cirrhosis 54% 34% Chronic pancreatitis 84% 84% Alcoholic liver cirrhosis 100% 100% Alcoholic cardiomyopathy 100% 100% REF: English DR, Holman CDJ et al. The quantification of drug caused morbidity in Australia, 1995 edition. Commonwealth Department of Human Services and Health, Canberra, 1995 Section 7: Drinkcheck Training Workshop - Nurse Education: o/h 5

Drinking Continuum No “Safe” Hazardous Problem Mild Moderate/severe drinking drinking drinking drinking dependent dependent drinking

DSM IV Substance Abuse • Never had dependence on this substance • Maladaptive pattern of use with at least one of the following recurrent associated problems over a 12 month period: 1. Failure to fulfil major role obligations 2. Hazardous use 3. Legal problems 4. Social or interpersonal problems

Drinking Continuum No “Safe” Hazardous Problem Mild Moderate/severe drinking drinking drinking drinking dependent dependent drinking

DSM IV Substance Dependence Maladaptive pattern of use with at least three of the following occurring within a 12 month period: 1. Tolerance 2. Withdrawal 3. Use is often more than intended (quantity or time) 4. Unsuccessful attempts to cut down or control use 5. Much time spent in use related activity 6. Important activities given up or reduced 7. Continued use despite knowledge of associated problems

The Prevention Paradox To prevent the most harm, don’t target the most harmful drinkers

From Gastfriend et al, JSAT33;71-90:2007, adapted from Institute of Medicine (1990)

From: Taking the Pulse. The 1996/97 New Zealand Health Survey (MoH, 1999)

Promoting behaviour change in alcohol and drug use

Brief Intervention

What is needed Interventions which are: • Able to be used by a wide range of health and other community professionals • Are brief • Opportunistic • Capable of addressing the ambivalence inherent in lifestyle behaviour change • Adaptable to facilitating contact with specialist agencies for more serious problems

Brief Intervention • Development • Treatment Referral • Evidence • Widely studies • Effective • Cost effective • Validated in a wide array of countries and settings

Brief Intervention How to change someone’s drinking behaviour in five minutes

Brief Intervention • Assess • Summarise • Educate • Advise • Negotiate

Brief Intervention • Assess • Pattern of use • Associated problems • Other areas of functioning • Summarise • Pattern of use • Associated problems • Complicating factors • Educate • National drinking guidelines • Advise • Reduce to within guidelines • Risks of not changing • Negotiate • Reduction target • Reduction method • Follow-up

BRIEF CLINICAL ASSESSMENT HISTORY • Demographics • Beginnings (age at first intoxication, regular use, first alcohol-related problem) • Pattern (overview of pattern including the main problems and the six month period of heaviest use of alcohol) • Dependence (applying the DSMIV criteria to the heaviest six month period of heaviest use to establish a lifetime diagnosis or not) • Current use (quantity/frequency in the past six months) • Other drug use (brief history of other drug use) • Treatment (brief A&D treatment history) • Psychiatric (brief psychiatric history) • Medical (current significant medical conditions) • Family (family history of A&D) • Miscellaneous (is there anything else you would like to tell me at this stage, not necessarily related to your drinking?)

SIX COMMON ELEMENTS OF BRIEF INTERVENTIONS Feedback of personal risk of impairment Emphasis on personal Responsibility for change Clear Advice to change A Menu of alternative change options Therapeutic Empathy as a counselling style Enhancement of client Self-efficacy or optimism

BRIEF CLINICAL INTERVENTION Step 1: Summarise assessment findings • drinking pattern (quantity and frequency) • drinking-related problems • symptoms of dependence • presence of contra-indications • positive family history Step 2: Brief Tutorial • outline ALAC drinking guidelines • educate about what is a standard drink • give the information that about 20-30% of New Zealanders misuse alcohol • relate these guidelines to their own drinking, by calculating number of standard drinks consumed per session/week, and presence of contra-indications (driving, liver damage etc) • invite their comment Step 3: Giving Advice • advise drinking within the ALAC drinking guidelines which may include abstinence • in an engaging interactive way, suggest several drinking behaviour changes Step 4: Negotiating Change • negotiate what a new drinking goal and/or change in drinking behaviour will be • negotiate how this reduction will be brought about • negotiate when a review of this goal (normally less than three months) can occur

Alcohol-free days Spacers Thirst quencher Food – before and during Avoid rounds Be the designated driver?! Sipping Putting glass down Low alcohol alternatives Set budget Arrive late Leave early Buy bottles not bladders Buy 12oz not handle etc Use a smaller glass at home Tell people Find alternatives for unwinding Socialise in no/low alcohol consumption environments Keep a drinking diary Strategies for moderation

Fifth Year OSCE You are a trainee intern working in a general practice. As part of the standard screening process a patient, Julie, has completed the AUDIT in the waiting room and scored 12. You have completed a brief clinical assessment with Julie which has revealed the following information: • Julie is a 39 year old woman who reports drinking a bottle of wine twice per week and two to three glasses on most other days. • Her husband has been concerned about her drinking and this has led to arguments. • Julie is an accountant and conceded that her performance is sometimes below par on the morning following a more heavy drinking session. • Julie does not meet any criteria for alcohol dependence. • Her mother was a problem drinker who died six years ago of throat cancer. • Nil other substance use. Over the next 5 minutes, please conduct an appropriate intervention with Julie.

Jane is a 50 year of woman living on her own who has come to see you regarding issues of life satisfaction She is a successful stockbroker Wine every night with dinner (2 large glasses – 1 bottle twice a week when at dinner with clients) Stressed because of competition from younger colleagues – working harder, taking people out more and drinking more Worried as recently went home with a married client after a business dinner. Currently on fluoxetine, but compromised by drinking No other drugs Parents drank every night, but doesn’t remember any problems A 25 year old female referred to you due to depression. Recently sustained minor injuries from a fight with her boyfriend while she was intoxicated. Boyfriend nags about drinking too much and getting obnoxious Average 8 dble bourbons 3 times a week, plus bottle of wine in weekends. Also one joint per weekend and nicotine (1packet/day) Legal secretary with same firm for 2 years – recently had final warning for being late 1 x DIC Father alcoholic, mother depressed

Mark is a 35-year old web designer who reports normally drinking a bottle of wine and six cans of beer Thursday, Friday and Saturday nights From time to time he has become verbally abusive to people when drunk, which lead to a physical fight on at least two occasions Mark concedes that his work performance is sometimes below par on Friday mornings and he has taken intermittent “sickies” (sick days off work) Steve is a 45 year old Maori male who drinks infrequently but typically heavily. Once every week or two he will drink 15 stubbies and three 750ml bottles of beer at his local football club. Also, on Thursday nights he will stop in at the pub and have three jugs of beer on the way home. His wife resents these drinking occasions, but accepts that he needs a break from the family (they have three children) Steve is a lathe operator in an engineering firm and doesn’t think his work is affected. He does not meet any criteria for alcohol dependence. Steve’s father had a serious drinking problem. Steve has a long history of low mood for which he is being treated by his GP with fluoxetine Nil other substance use.

Treating Alcohol Misuse: Brief Assessment and Intervention Skills