Transcript Relationship between Alcohol Consumption & National

Alcohol Our Favourite Drug:
The big picture: can nurses and
midwives make a difference?
Prof. Jim Rankin
Ist International Alcohol, Tobacco and
Other Drugs Nursing & Midwifery
Conference
Adelaide, April 16, 2003
Advances in Knowledge and
Understanding: Alcohol - Before 1960
• Alcoholism a moral problem or a
manifestation of mental illness
• Alcoholism a disease - Alcoholics
Anonymous
The Scene 1964: Treatment Services
•
•
•
•
•
Completely inadequate
Psychiatric hospitals
Residential
Custodial care
Inmates:
– Inebriates’ Act
– Psychiatric complications
– Temporary accommodation & support
Sister Mary Christina Wellsford, RSC
Advances in knowledge and
understanding of alcohol problems
• A spectrum of drinking behaviours that
may cause problems
• A spectrum of alcohol-related problems
• A spectrum of responses involving health
promotion, prevention and
intervention/treatment
Broadening the base of treatment:
• Establishment of services in general
hospitals
• Shift of resources from psychiatric hospitals
to community-based services
• Shift of resources to provide a balance of
residential and non-residential services
• Initiatives to increase the involvement of
general practitioners
Responding to alcohol problems in
Australia: potential resources
• Medical practitioners
• Addiction medicine specialists
– Certified
– Certification pending
• Registered nurses
– Registered midwives
• Members of DANA
• Number of D & A services
70,000 (est)
140
60
250,000 (est)
67,000 (est)
200+
2000 (est)
VISION
The role of nursing and midwifery
A whole of profession responsibility
Practitioners
• Clinical nurses
• Nurse educators/academics
• Nurse managers
• Nurse researchers
Organisations
• Registration bodies
• General professional organisations
• Academic organisations
• Alcohol and drug
A Vision of Nursing and Midwifery
Professions that play active roles in the
development and implementation of
comprehensive alcohol policies and
programs for prevention and treatment
A Vision of Nursing and Midwifery:
Prevention and Health Promotion
Professions whose members incorporate into
their professional activities strategies and
practices that have as their objectives
maintenance of abstinence and safe patterns
of alcohol use, and reductions in hazardous
and harmful use.
A Vision of Nursing and Midwifery:
Clinical Care
Professions whose members play a
complementary role to these preventive
strategies by
• identifying and intervening with their
patients whose are at risk because of their
alcohol use; and
• Identifying and responding to the health
needs of their patients who already have
alcohol-related damage
Topics
• Drinking patterns in Australia and their
consequences
• Effects of alcohol on health
• Prevention, intervention and treatment
• Potential roles of nursing and midwifery
• Systems’ impediments to progress
Drinking Patterns in Australia
Population aged 14+ years
• Drinkers
• Hazardous/harmful drinkers
• Hazardous/harmful drinkers
Population aged 14-19 years
• Drinkers
• Hazardous/harmful drinkers
Aboriginal & Torres Strait Islander Peoples
• Drinkers
• Hazardous/harmful drinkers
1 = Last 12 months
2 = Last week
%
811
351
142
641
671
621
821
Alcohol-attributable deaths and
hospital bed days, 1998-9
Deaths
• Caused
• Prevented
• Total
Hospital beddays
4,286
• Caused
394,417
(7029)1 • Prevented2
(255,433)
(2,744) • Total
138,974
Note 1. 94% aged 60+
years
Note 2. 79.7% aged 60+ years
Potential benefits of policies
designed to prevent alcohol misuse
Preventable deaths
Preventable hospital beddays
4,286
394,417
Social costs of drug abuse, 1998-9
Alcohol
Tobacco
Illicit drugs
Total
$m
7,560.31
21,063.0
6,075.8
34,439.8
%
22.0
61.2
17.6
100.0
Avoidable costs of alcohol misuse $3,928.6m (62.1%)
Note 1. Costs of alcohol misuse 1.98% of GDP
Effects of alcohol on health
Factors in Acute Alcohol-related Damage
Acute
alcohol
consumption
Factors in Acute Alcohol-related Damage
Acute
alcohol
consumption
CNS depression:
Impairment of
• Motor function
• Coordination
• Judgment
• Respiration
• Consciousness
Factors in Acute Alcohol-related Damage
Acute
alcohol
consumption
CNS depression:
Impairment of
• Motor function
• Coordination
• Judgment
• Respiration
• Consciousness
Motor vehicles
Workplace
Hotels & bars
Other social venues
Sporting activities
Associated drug use
Drinking Circumstances and Environment
Factors in Acute Alcohol-related Damage
Acute
alcohol
consumption
CNS depression:
Impairment of
• Motor function
• Coordination
• Judgment
• Respiration
• Consciousness
Trauma
Motor vehicles
Workplace
Hotels & bars
Other social venues
Sporting activities
Associated drug use
Drinking Circumstances and Environment
General Environment
Trauma
•
•
•
•
•
•
•
Fall injuries
Road injuries
Occupational and machine injuries
Fire injuries
Drowning
Assaults
Suicide
Factors in Acute Alcohol-related Damage
Acute
alcohol
consumption
CNS depression:
Impairment of
• Motor function
• Coordination
• Judgment
• Respiration
• Consciousness
Overdose/poisoning
Motor vehicles
Workplace
Hotels & bars
Other social venues
Sporting activities
Associated drug use
Drinking Circumstances and Environment
General Environment
Overdose/Poisoning
• Acute ethanol overdose and poisoning
• Aspiration
• Combined alcohol and drug overdose and
poisoning
• Methanol poisoning
Factors in Acute Alcohol-related Damage
Acute
alcohol
consumption
CNS depression:
Impairment of
• Motor function
• Coordination
• Judgment
• Respiration
• Consciousness
Obstructive
sleep apnoea
Motor vehicles
Workplace
Hotels & bars
Other social venues
Sporting activities
Associated drug use
Drinking Circumstances and Environment
Factors in Acute Alcohol-related Damage
Acute
alcohol
consumption
CNS depression:
Impairment of
• Motor function
• Coordination
• Judgment
• Respiration
• Consciousness
Motor vehicles
Workplace
Hotels & bars
Other social venues
Sporting activities
Associated drug use
Pregnancy
Sexual assault
Child Abuse
Drinking Circumstances and Environment
Factors in Acute Alcohol-related Damage
Supportive
HOME ENVIRONMENT
Non-supportive
Privileged
SOCIAL CLASS
Under-privileged
Affluence
INCOME
Poverty
Very good
COMMUNITY SERVICES
Absent
Very good
HEALTH SERVICES
Absent
General Environment
Factors in Acute Alcohol-related Damage
Acute
alcohol
consumption
CNS depression:
Impairment of
• Motor function
• Coordination
• Judgment
• Respiration
• Consciousness
Motor vehicles
Workplace
Hotels & bars
Other social venues
Sporting activities
Associated drug use
Trauma
Overdose/poisoning
Obstructive
sleep apnoea
Pregnancy
Sexual assault
Child Abuse
Drinking Circumstances and Environment
General Environment
Effects of Long-term Alcohol Consumption
Long-term
alcohol
consumption
Relationship between alcohol consumption
and cirrhosis mortality, Ontario 1928-1972
20
Cirrhosis mortality / 100,000 aged 20+ years
18
16
14
12
10
8
6
4
2
0
0
0.5
1
1.5
2
Alcohol consumption in gallons per capita aged 15+ yearsS
2.5
Effects of Long-term Alcohol Consumption
Alcohol a necessary
cause of diseases
Long-term
alcohol
consumption
Alcohol a Necessary Cause of Disease
Behavioural and Neurological
• Alcohol dependence
• Acute alcohol withdrawal
• Delirium tremens
• Acute alcoholic hallucinosis
• Alcoholic polyneuropathy
• Alcoholic cerebellar atrophy
• Neuro-psychological impairment
• Wernicke-Korsakoff syndrome
Alcohol a Necessary Cause of Disease
Other diseases:
• Alcoholic gastritis
• Alcoholic hepatitis
• Alcoholic cirrhosis
• Alcoholic cardiomyopathy
• Foetal alcohol effects
• Foetal alcohol syndrome
Effects of Long-term Alcohol Consumption
Long-term
alcohol
consumption
Alcohol a
contributing cause
of disease
Alcohol a Contributing Cause of Disease
Cancer
• Oropharyngeal
• Oesophageal
• Laryngeal
• Liver
• Female breast
Alcohol a Contributing Cause of Disease
Gastro-intestinal and hepatic
• Oesophageal varices
• Gastro-oesophageal haemorrhage
• Unspecified cirrhosis
• Haemochromatosis
• Acute pancreatitis
• chronic pancreatitis
Alcohol a Contributing Cause of Disease
Other diseases:
• Epilepsy
• Hypertension (males)
• Ischaemic stroke (males)
• Haemorrhagic stroke (males)
• Psoriasis
• Depression, attempted suicide and suicide
• Spontaneous abortion
Effects of Long-term Alcohol Consumption
Long-term
alcohol
consumption
Alcohol a
contributory factor
to disease outcome
Alcohol a Contributory Factor to
Disease Outcome
• Hepatitis C
• Pulmonary infection
• Post-operative complications
Effects of Long-term Alcohol Consumption
Long-term
alcohol
consumption
Alcohol a protector
from diseases
Alcohol a Protector from Disease
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•
•
•
•
•
•
Ischaemic heart disease
Hypertension (females)
Supra-ventricular cardiac dysrhythmias
Hear failure
Ischaemic stroke (females)
Haemorrhagic stroke (females)
Cholelithiasis
Effects of Long-term Alcohol Consumption
Alcohol a necessary
cause of diseases
Long-term
alcohol
consumption
Alcohol a protector
from diseases
Alcohol a
contributory cause
of diseases
Alcohol a
contributory factor
to disease outcome
General Environment
Prevention & Treatment of
Alcohol-related Problems:
A Spectrum of Problems and Responses
The goal: Harm minimization
Advances in disease prevention
& health promotion
• Drinking Guidelines
• Low alcohol content beers
• Labelling of alcoholic beverage containers
with the number of drinks
• Drink-driving counter measures
▬ Random breath testing
▬ Zero blood alcohol levels for probationary
drivers
Advances in disease prevention
& health promotion
• Thiamine supplementation of flour
• Indexation of alcohol taxes
• Initiatives to reduce alcohol-related harm in
and near licensed premises
Advances in clinical management
• Screening instruments (AUDIT)
• Assessment instruments
• Effective behavioural interventions
Motivational interviewing
Cognitive behavioural restructuring
Brief interventions
• Pharmacotherapies:
Naltrexone
Acamprosate
• Management of alcohol-related physical
diseases
Changes in alcohol problems
• Between 1988 and 1998 per capita
consumption as fallen from 9.4 to 7.5 litres
• Australia has fallen from 12th to 19th place
internationally in per capita consumption
• These declines associated with falls in:
– Incidence of alcohol-related road injury and
deaths
– Total alcohol-caused mortality
– Deaths where alcohol is the sole cause
– Deaths where alcohol is a contributing cause
Prevention and Treatment of Alcohol-related Problems:
A Spectrum of Problems and Responses
Safe
Nil
Alcohol Use
Primary
prevention
Prevention and Treatment of Alcohol-related Problems:
A Spectrum of Problems and Responses
Case finding &
early intervention
Hazardous
Alcohol Use
Prevention and Treatment of Alcohol-related Problems:
A Spectrum of Problems and Responses
Harmful
Alcohol Use
Treatment
Prevention and Treatment of Alcohol-related Problems:
A Spectrum of Problems and Responses
Alcoholrelated
problems
Alcohol Use
Primary
prevention
Prevention and Treatment of Alcohol-related Problems:
A Spectrum of Problems and Responses
Alcoholrelated
problems
Case finding &
early intervention
Alcohol Use
Prevention and Treatment of Alcohol-related Problems:
A Spectrum of Problems and Responses
Treatment
Alcohol Use
Alcoholrelated
problems
Prevention and Treatment of Alcohol-related Problems:
A Spectrum of Problems and Responses
Harmful
Case finding &
early intervention
Hazardous
Safe
Nil
Treatment
Alcohol Use
Primary
prevention
Alcoholrelated
problems
The Role of Nursing: Clinical Practice
General Nurses
The Role of Nursing: Clinical Practice
General Nurses
Safe Drinking
Practices
The Role of Nursing: Clinical Practice
General Nurses
Safe Drinking
Practices
Drinking History
The Role of Nursing: Clinical Practice
General Nurses
Safe Drinking
Practices
Drinking History
Screening
(AUDIT)
The Role of Nursing: Clinical Practice
General Nurses
Safe Drinking
Practices
Drinking History
Screening
(AUDIT)
Brief intervention
The Role of Nursing: Clinical Practice
General Nurses
Safe Drinking
Practices
Drinking History
Screening
(AUDIT)
Brief intervention
Specialist referral
The Role of Nursing: Clinical Practice
General Nurses
Safe Drinking
Practices
Drinking History
Screening
(AUDIT)
Brief intervention
Specialist referral
Treatment of
withdrawal
The Role of Nursing: Clinical Practice
Public health
Community health
Mental health
Emergency
Critical care
Gastroenterology
Hepatology
Neurology
Midwifery
Paediatrics
Specialty
Nursing and
Clinical Nurse
Specialists
The Role of Nursing: Clinical Practice
Public health
Community health
Mental health
Emergency
Critical care
Gastroenterology
Hepatology
Neurology
Midwifery
Paediatrics
Specialty
Nursing and
Clinical Nurse
Specialists
Consultation
& support
The Role of Nursing: Clinical Practice
Public health
Community health
Mental health
Emergency
Critical care
Gastroenterology
Hepatology
Neurology
Midwifery
Paediatrics
Specialty
Nursing and
Clinical Nurse
Specialists
Consultation
& support
Specialist
assessment
The Role of Nursing: Clinical Practice
Public health
Community health
Mental health
Emergency
Critical care
Gastroenterology
Hepatology
Neurology
Midwifery
Paediatrics
Specialty
Nursing and
Clinical Nurse
Specialists
Consultation
& support
Specialist
assessment
Management of
specialty problems
The Role of Nursing: Clinical Practice
Public health
Community health
Mental health
Emergency
Critical care
Gastroenterology
Hepatology
Neurology
Midwifery
Paediatrics
Specialty
Nursing and
Clinical Nurse
Specialists
Consultation
& support
Specialist
assessment
Management of
medical problems
Follow-up
The Role of Nursing: Clinical Practice
General hospitals
Psychiatric hospitals
Community health
Detoxification units
Other D & A services
D and A
Nursing and
Clinical Nurse
Specialists
The Role of Nursing: Clinical Practice
General hospitals
Psychiatric hospitals
Community health
Detoxification units
Other D & A services
D and A
Nursing and
Clinical Nurse
Specialists
Consultation
& support
The Role of Nursing: Clinical Practice
General hospitals
Psychiatric hospitals
Community health
Detoxification units
Other D & A services
D and A
Nursing and
Clinical Nurse
Specialists
Consultation
& support
Specialist
assessment
The Role of Nursing: Clinical Practice
General hospitals
Psychiatric hospitals
Community health
Detoxification units
Other D & A services
D and A
Nursing and
Clinical Nurse
Specialists
Consultation
& support
Specialist
assessment
Management of
alcohol problems
The Role of Nursing: Clinical Practice
General hospitals
Psychiatric hospitals
Community health
Detoxification units
Other D & A services
D and A
Nursing and
Clinical Nurse
Specialists
Consultation
& support
Specialist
assessment
Management of
alcohol problems
Follow-up
The Role of Nursing: Clinical Practice
General Nurses
Safe Drinking
Practices
Drinking History
Screening
(AUDIT)
Specialty
Nursing and
Clinical Nurse
Specialists
D and A
Nursing and
Clinical Nurse
Specialists
Consultation
& support
Consultation
& support
Specialist
assessment
Specialist
assessment
Management of
medical problems
Management of
alcohol problems
Follow-up
Follow-up
Brief intervention
Specialist referral
Treatment of
withdrawal
A special need:
services for impaired nurses
Progress in Australia
• Services in general hospitals
1964
• Appointment of assistant directors of
nursing (D and A) in NSW
1982
• Establishment of clinical nurse specialists
and consultants in some states
• Establishment of DANA
1986
• NSW Nursing Project
• Academic appointments
• Establishment of academic programs
• Availability of educational resources
Systems impediments to progress
• Increasing and competing demands on nurses and
nursing services
• Deceasing availability of nurses
• Silo organizational structures
• Fragmentation of patient care
• Shift of Federal government support away the
concept of universal health care
• Inadequate funding of public hospitals
• Increasing numbers of for-profit private hospitals