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Effective brief interventions for alcohol misuse

A recent report criticised GPs for failing to routinely use brief interventions for alcohol misuse. GP Dr Chris Ford describes how they can work

A recent report criticised GPs for failing to routinely use brief interventions for alcohol misuse. GP Dr Chris Ford describes how they can work

The use and misuse of alcohol is increasing and we know it causes significant harm to the physical, psychological and social health of individuals, families and communities throughout the world.

UK data from 2000 suggests 39% of men and 23% of women aged 16 and over drink above safe levels and 5% of the population is dependent. Some 15-30% of men and 8-15% of women have alcohol-related admissions and one adult death in 10 in the UK is alcohol related.

Specialist versus primary care services

In general practice we are well placed to identify, offer basic advice, treat and refer for alcohol problems. One study said most doctors think they should be involved with alcohol misuse but only 40% said they were.

A 1999 study found that an average GP would have a caseload of about 360 problem drinkers but found most intervene with seven or fewer drinkers per year (0.38%)1. Hence GPs fail to diagnose and treat more than six million people for whom there is a cost-effective and clinically effective intervention.

The author of the first study said we were failing to use a systematic approach, were not very good at assessing levels of drinking and units, and tended to rely on unstructured questioning and blood tests. This seems to be because we remain unconvinced of the effectiveness of our interventions2.

And just last month, a report from the National Audit Office said there was too great a reliance on drug and alcohol teams and too little use of brief interventions3. These interventions can be as simple as completing a questionnaire, advising patients they are drinking too much and giving them a leaflet.

Most specialist services are directed to a relatively small number of seriously alcohol-dependent individuals, not to the extremely large number of people drinking at damaging but non-dependent levels.

According to the psychiatric morbidity survey, 4% of the adult population are ‘harmful drinkers', causing imminent risk to health. A further 23% are described as ‘hazardous' drinkers. These hazardous drinkers are unlikely to seek treatment for their drinking, and on the whole they do not need treatment as such. What they do need is early identification and early intervention, based on proven clinical techniques.

So what would make us think about alcohol problems and how do we assess the problem in the consultation? Let me tell you about Peter and a study our practice has been involved with that might help.

Peter came to have his blood pressure measured, and for the first time in four years of treatment, his blood pressure was within the normal range. He is 48, married with three children and works full time in his own human resources business. He is an ex-smoker, not overweight and has no family history of blood pressure. His only risk factor for blood pressure was alcohol. He had been drinking above safe alcohol levels for years. Until five months ago he had refused to see this as a problem, in spite of what I told him or what he read.

So what was the catalyst for change? He had scored positive on the SIPS (Screening and Intervention Programme for Sensible Drinking). Download a copy of the questionnaire via the link (right).

National strategy

SIPS was designed to support the National Alcohol Harm Reduction Strategy for England. This called for ‘more information… on the most effective methods of targeted screening and brief interventions' and aimed to find out ‘whether the successes shown in research studies can be replicated within the health system in England'.

We signed up to be a pilot site in the primary care section of the study. The study is testing three models of implementation:

• a control group receiving a patient information leaflet

• brief advice provided by primary care staff plus a leaflet

• brief lifestyle counselling provided by primary care staff plus a leaflet.

Two screening approaches (targeted versus universal) and two screening tools of different complexity are being compared. Some 744 patients who drink to a hazardous or harmful level are being recruited for the study. The study is designed to answer key policy questions concerning the implementation of screening and brief intervention.

We were randomly allocated to the brief advice plus leaflet arm of the study. Peter was the first patient of our 31 on the first day of the study and he agreed to take part.

I'd thought that I had given him several varied brief intervention sessions, but perhaps because of my recent training or where he was in his cycle of motivation, he was much more receptive on this occasion.

The single screening question asked how often you drink eight standard (one unit) drinks as a man or six as a woman. If the answer is more than monthly, you go on to the rest of the questionnaire. The patient then receives brief intervention from their friendly primary care staff member.

Even Peter was shocked when he realised he drank more than eight units most days.

Until he had answered that simple question he had not really seen that he had a problem. He didn't wake up in the morning and need a drink. He ‘could' have a day without if he really wanted to, and the only people who complained about his drinking were his wife and his doctor.

Five months later we measured Peter's blood pressure and found it to be within the normal range. He also stated that he felt better. He was much less tired and stressed (which was his justification for drinking), he was taking more exercise and his concentration had improved. He hasn't stopped drinking alcohol but allows himself to share a bottle of wine twice a week, which keeps him well within safe levels. His wife came to see me today purely to say thank you and to explain that she was no longer embarrassed when putting the bottles out for recycling.

Don't forget to ask and record alcohol intake on all patients you see. An easy way to calculate units is by: volume in ml x strength in % alcohol by volume/1000.

Undertake brief interventions for all patients who are drinking above safe levels. For menthis is three to four units daily (21 per week), with two alcohol-free days, and for women two to three units daily (14 per week) with two alcohol-free days. Offer support for behavioural change and refer when necessary.

Why not start with yourself? I did, scored positive and gave myself a brief intervention, which seems to be working!

Dr Chris Ford is a GP in north London and clinical lead for the Substance Misuse Management in General Practice network.

The case history described here first appeared in Drink and Drugs News – a fortnightly free magazine for substance misuse professionals

SIPS patient questionnaire SIPS patient questionnaire SIPS patient questionnaire SIPS patient questionnaire Many patients do not realise they are drinking excessively until they complete a questionnaire Many patients do not realise they are drinking excessively until they complete a questionnaire

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