Transcript harmful drinking - Society for the Study of Addiction

Problem alcohol use among
drug users:
Clinical guidelines development for
primary care
Jan Klimas, Catherine Anne Field, Walter Cullen
& Guideline Development Group
Overview
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HCV
Background
Methodology
Content
Implementation issues
Overdose
Addiction
treatment
• 68/196(35%) had ‘AUDIT’ score >7
• Risk behaviours and health service utilisation
common: e.g. ED, benzodiazepines
• … and comparable to findings from more
specialist settings
What now?
What now?
To develop clinical guidelines to
improve screening and
treatment for problem alcohol
use among patients on
methadone treatment in primary
care
Methods
Approach:
Identification of
Key Stakeholders
(n=21)
Evidence-based
draft guidelines
Modified ‘Delphifacilitated’
consensus
Informed by:
1. Qualitative survey of
healthcare professionals
and patients
2. Systematic literature
review
Key areas
1. Definition of problem alcohol use among
problem drug users
2. Screening / identification
3. Interventions / treatment
4. Referral to secondary care
5. Ongoing management
1. Definition of problem alcohol
• Alcohol Use Disorders Identification Test
Low-risk
0-6
Hazardous
7-15
Harmful
16+
Dependent
16+
2. Screening / Identification
• Perform a yearly AUDIT-C, i.e. first 3 questions
• If positive, administer full AUDIT
Example first question:
3. Treatment and management
Brief intervention: FRAMES approach
• F- Feedback regarding personal risk following assessment of
alcohol use and associated problems
• R- Responsibility for change is on the patient
• A- Advice about changing alcohol use is clearly given to the
patient by the practitioner when requested
• M- Menu of options for change and treatment alternatives
• E- Empathic counselling style
• S- Self-efficacy or optimism to encourage behaviour change
(Miller & Sanchez, 1994)
4. Referral to secondary care
Who might benefit?
• High ‘AUDIT score’ (16+): harmful drinking
• Protracted, severe alcohol problems, resistant
to brief intervention
• Requiring: psychological counselling, alcohol
detoxification, pharmacotherapy, intensive case
monitoring, etc.
• Concurrent, significant psychiatric illness
5. GPs role in ongoing care
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Harm reduction / low-risk drinking tips
Relapse prevention – learning opportunity
Ongoing care / After care:
General medical problems in/directly
associated with drinking:
e.g. GI, psychological, respiratory disease, etc.
In summary
Broad principles same as general population, BUT:
1. screening and treatment should be more
systematically delivered in all problem drug users,
especially if concurrent chronic illnesses
2. lower thresholds should be applied for identification
and intervention for problem alcohol use / referral
3. special skills / specialist supervision required to
manage persistent dependent alcohol use
What now?
What now?
• Systematic review?
• Qualitative study?
• Complex intervention?
• Feasibility…international
collaborations?
Thank you….
R Anderson, J Barry, D Bedford, M Bourke, G Bury, G
Corrigan, J Doyle, J Flanagan, H Gallagher, N
Geoghegan, K Harkin, E Keenan, J Lambert, S Lyons,
R McAuliffe, ME McCann, McCormick, D O’Driscoll, C
O’Gara, N Perry, BP Smyth, F Weldon
[email protected]
Whom are these guidelines for?
• Methadone patients – but implications for all
‘Problem Drug Users’
• EMCDDA definition accepted in Ireland:
‘injecting drug use or long-duration/regular use of
opioids, cocaine and/or amphetamines’
• i.e. specifically includes regular or long-term use of
prescribed opioids such as methadone. (regular = at
least 1x weekly)
I Low
risk/Abstain
AUDIT: 0–7
Raise the
IV
II Harmful III Hazardous
Dependent
subject
Provide
feedback
Enhance
motivation
Negotiate
plan
© www.sbirtoregon.org
AUDIT:
8–15
AUDIT:
16-19
AUDIT:
20+
• “If it’s okay with you, let’s take a minute to talk about the annual screening
form you’ve filled out today.”
• “As your doctor, I can tell you that drinking at this level can be harmful to your
health and possibly responsible for the health problem you came in for
today.”
“On a scale of 0-10, how ready are you to cut back your drinking?”
• If >0: “Why that number and not a ____ (lower one)?”
• If 0: “Have you ever done anything while drinking that you later regretted?”
• “What steps can you take to cut back your use?”
• “How would your drinking have to impact your life in order for you to start
thinking about cutting back?”