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Alcohol in primary care

With the Public Health (Alcohol) Bill expected to be debated during the current Dáil session, there will be a political focus again on the health consequences of alcohol misuse in Ireland. Those working in primary care have particular  first-hand experience of the real human cost of this problem.

On average, Irish adults binge-drink more than other Europeans, with 44 per cent of drinkers saying that they binge-drink on a regular basis.

According to the RCPI Policy Group on Alcohol, every month 88 deaths in Ireland are directly attributable to alcohol.

“Alcohol-related harm costs the country an estimated €3.7 billion a year in health, crime/public order and other ancillary costs, such as workplace absenteeism,” warned the RCPI group in its pre-Budget submission last year.

However, despite the challenges posed by alcohol misuse, it is not a cause for despair entirely. Medical intervention and advice can have a significant positive impact on both individual and societal levels. According to the HSE, more than half of people who receive treatment for alcohol misuse will either reduce their drinking to a safer level than what is was previously, or give up drinking altogether.

Primary care

GPs and others working in primary care are at the front line in dealing with alcohol misuse and how it affects individuals, families and communities in Ireland.

The GP is most often the first point of call for anyone who is experiencing problems as a result of alcohol misuse. But screening for alcohol problems can often be a delicate and difficult process for staff within primary care.

To help in this process, the ICGP Quality in Practice Committee has produced a detailed short guide called Helping Patients with Alcohol Problems: A Guide for Primary Care Staff. Written by Mr Rolande Anderson in 2007, the guide recently received an important update (in 2014), written by Dr Joseph Martin, Mr Adrian Aherin, Mr Pearse Finegan and Dr Conor Farren.

This practical document provides resources such as sample questionnaires and patient information leaflets to help GPs to assist patients in this challenging area.

In an honest introduction, the authors outline the vital role primary care can play in tackling alcohol abuse, but also the reasons why many GPs have found it hard to make an impact.

“Primary care has the responsibility to identify and intervene with patients whose drinking is hazardous and harmful to their health,” write the authors.

“Yet, only a small percentage of patients with alcohol problems are actually screened and treated in primary care, as there is a reluctance to get involved in this area. This has been due to many factors, including lack of training, poor outcome expectations and lack of support.

“These guidelines attempt to redress some of these difficulties.”

Intervention

The ICGP document signals the importance of even brief interventions in such situations, while also stating that any interventions should consider the patient’s individual needs.

“It is not a ‘one-size-fits-all’ approach, but that of trying to tailor the best fit to the patient. Many approaches are implementable in, and appropriate to, the primary care setting,” write the authors.

“In a Cochrane Review, Kaner et al (2007) concluded that brief intervention in primary care settings consistently led to reductions in alcohol consumption.

The screening approach advocated in the ICGP document involves what is called the ‘double-AA approach’. These steps are A for Ask, A for Assess, A for Assist and A for Arrange

“In a meta-analysis review of 22 studies, Vasilaki et al (2006) concluded that motivational interviewing is an effective intervention in relation to reducing alcohol consumption.

“Its value was particularly noticeable among young, heavily- or low-dependent drinkers, and among those who voluntarily seek help for alcohol problems.”

The introduction ends with a call to inspire those in primary care to make a difference in the challenges posed by alcohol misuse.

“If you are not already doing so, you are encouraged to incorporate alcohol screening and intervention into your practice.

“You are in a prime position to make a difference.”

Screening

To the question ‘why screen for alcohol problems?’, the ICGP document says that alcohol problems are very common in Ireland and “all heavy drinkers have increased health risks”. Added to that, it states: “It makes sense! Numbers needed to treat; eight patients need to be advised for one patient to benefit”.

To the question ‘what is an alcohol problem?’, the answer has become more complicated than was traditionally believed. The ICGP document provides clear definitions of varying levels, including hazardous, harmful and dependence (Table 2).

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Table 1: Alcohol measurements*

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Table 2: Alcohol definitions

“Traditionally, alcohol problems were equated with alcohol dependence. In fact, there are a range of alcohol problems — ‘low risk’, ‘hazardous’, ‘harmful’ and ‘dependent’.

“Patients are often unaware of risk limits, therefore primary care staff have an important role in giving accurate information on limits in general, as well as specific limits, such as age, gender, life events and biological factors,” notes the advice.

“What constitutes low risk for one patient may be hazardous for another, so clinical judgement is always important.”

But how can GPs help patients to find their risk category?

“As a rough guide, the consumption arrow chart [in document] can be used to assess risk. This can be copied and discussed with patients.”

In busy practices, the question may be posed by under-pressure GPs: How long should it take to screen for alcohol risk? “According to the World Health Organisation (WHO) guidelines on brief intervention in hazardous alcohol drinking, screening should only take two-to-four minutes, with less than one minute taken to score the test,” reads the guide.

“Alcohol consumption and pattern of drinking should be recorded. The results of the questionnaire(s) should be noted and dated. If possible, information given by family members regarding the patient’s drinking should be included in the notes.”

Different screening tools are found in the guide. Full AUDIT is probably best (Appendix 1) but AUDIT ‘C’ (Appendix 2) is recommended for initial screening. The CAGE (Grade B) questionnaire (Appendix 2) can be used in addition, usually only when dependence is suspected.

Tools

The screening approach advocated in the ICGP document involves what is called the ‘double AA approach’. These steps involve A for Ask, A for Assess, A for Assist and A for Arrange.

In terms of ‘ask’, GPs are urged to “ask patients about their alcohol consumption. Ask about amounts, frequency and patterns.”

GPs are then asked to ‘assess’ the “level of risk (hazardous, harmful or dependent), by using results of full AUDIT, consumption arrow chart and clinical observations/examination/biological tests. You can use CAGE in addition, if dependence is suspected”.

The GP is also directed to take into account mental state, with particular reference to depression, and treat accordingly, and any “collateral history from a relative or friend, if possible”.

Next, the GP is to ‘assist’ the patient and inform the patient of the results from the assessment. He or she should then “give advice on alcohol interaction with any medication prescribed”.

The GP should also encourage “patients to change, by using brief intervention and motivational techniques, gentle persuasion, mutual respect, sincere concern and patience”.

Depending on what category of drinker the patient falls into, the guide provides a series of different practical advice the GP can give.

The final step is to ‘arrange’ a follow-up appointment for patients in hazardous, harmful and dependent categories and continue to be actively involved.

“Formal assessment tools should be used to determine the nature and severity of the alcohol misuse to include a determination for assisted withdrawal, whether by primary care interventions or specialist services.

“Relapse should be addressed as a learning opportunity and the approach should be based on patience and long-term goals. Arrange appropriate repeat prescriptions, tests and appointments if necessary. Consider arranging a consultation with family members to support.”

Setting this specific intervention on an individual level within a wider societal context, the ICGP document concludes: “Given the significant public health consequences associated with heavy drinking and the benefits associated with its reduction, all healthcare professionals working in community health services must consider reduction of heavy drinking as a meaningful measure of treatment effectiveness.”

See www.icgp.ie for full details of alcohol resources for GPs.

Additional resources

There are a number of other resources GPs can avail of to help patients with alcohol issues. One of these is BRIEFcases, an alcohol management toolkit that covers all aspects of alcohol health information, including screening and intervention for addressing alcohol issues in the community setting. BRIEF stands for Begin, Reassure, Intervene, Engage, and Finish.

Developed by Mr Rolande Anderson, Addiction Counsellor and former Project Director of the ICGP Alcohol Awareness Project and sponsored by Lundbeck, BRIEFcases is a local adaptation of current international best practice recommendations and is a structured approach to brief interventions that can be adapted for each patient. The BRIEFcases kit contains patient information leaflets, targeted questionnaires, and a desktop quick resource booklet.

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