Post-its from Practice:
Brief interventions for alcohol can work (Sep 2008)
Peter came to have his blood pressure measured yesterday, and for the first time in four years of being on treatment, his blood pressure was within the normal range. He and I were both very excited! Peter is 48 years old, married with 3 children and works full-time in his own human resources business. His only risk factor for blood pressure was alcohol. He is an ex-smoker, not overweight and has no family history of blood pressure, but he has 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 had told him or what he had read. So what was the catalyst for change? He had scored positive on the SIPS (Screening and Intervention Programme for Sensible Drinking).
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 had signed up to be a pilot site in the Primary Health Care (PHC) section of the study. The study is testing three models of implementation: a control group receiving a patient information leaflet (PIL); brief advice provided by PHC staff plus PIL; and brief lifestyle counselling provided by PHC staff plus PIL. Two screening approaches (targeted versus universal) and two screening tools of different complexity are being compared. 744 patients who drink to a hazardous or harmful level are being recruited for the study (31 per PHC). The PHC 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 PIL arm of the study. Peter was the first patient of our 31 on the first morning of the study and he agreed to take part. I'd thought that I had given him several varied brief intervention sessions, but perhaps post my recent training or due to 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, weekly or daily then you go on to the rest of the questionnaire. You then receive your brief intervention from your friendly PHC staff member. Even Peter was shocked when he realised he drank over eight units most days.
Until answering that simple question he had not really seen himself to have 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! Or perhaps it is as Malla said "...unlike other disorders (alcohol misuse), is a disease many primary care physicians do not want to detect. In addition most alcoholics do not want their disease detected".
People drinking hazardously make up over a quarter of the UK population. They do not present directly for treatment yet are at higher risk of accident, crime, health problems and social problems. The physical health problems such as gastritis, obesity, heart problems, stroke and cancer are numerous, as are the psychological problems such as depression (65% suicide attempts), anxiety and brain damage. Social and family problems should not be forgotten, such as the involvement of alcohol in child abuse and in 40% of domestic violence.
After 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 (his justification for drinking), he was taking more exercise and his concentration was improved. He hasn't stopped drinking alcohol but allows himself to share a bottle of wine twice a week which keep 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 on all patients you see, especially if they use other drugs. Remember to undertake brief interventions on all heavy drinkers, offer support for behavioural change and refer on when necessary. Why not start with yourself - I did, scored positive and gave myself a brief intervention which seems to be working!