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Effective nurse-led and patient-centred alcohol interventions

Dr Lynn Owens
PhD BA(Hons) DipHE CertEd RN
Nurse Consultant
Liverpool PCT The University of Liverpool Department of Pharmacology & Therapeutics

Debbie Morton
BSc(Hons) DipHE RN
Alcohol Specialist Nurse
Alcohol Services Lifestyles Team
Liverpool PCT

The burden of alcohol on the NHS is simultaneously enormous and underestimated.  Alcohol-related problems range from physical dependence to end organ damage, accident and trauma. They are rarely exclusive and are often not recognised by nurses and doctors who concentrate on the physical or psychological presentation, but fail to establish the cause. Thus, alcohol-related problems are often suboptimally managed.
Alcohol-related harm is not restricted to the dependent drinker, as adverse effects have been found in moderate drinkers who make up some 20% of the adult population. Evidence would suggest that much of the associated healthcare provision and ultimate mortality is preventable, thus the role of and impact on primary and secondary care cannot be understated. But despite this evidence, systematic screening for alcohol-related problems in both primary and secondary care is still lacking. Unfortunately, detecting the hazardous or problem drinker can be difficult, as physical examination or even biochemical markers are often grossly normal.(1)
An accurate alcohol history cannot be obtained by merely asking how many units an individual drinks, but should be systematically approached. This may be particularly pertinent within primary care, given that patients and staff often develop close and trusting relationships with whole families. Failure to adopt a systematic screening approach is unfortunate, as specific alcohol screening tools are available. In particular, the questionnaire, Alcohol Use Disorders Identification Test (AUDIT), can reliably detect hazardous drinking in the primary care setting.(2) Perhaps more importantly, AUDIT has been shown to be patient-friendly and inoffensive when used to obtain a patient's medical history (see Figure 1).(3)

[[nip36_52_fig1]]

What can we drink?
What constitutes safe drinking has caused some confusion. By far the most important factor for alcohol consumption is the number of units, not the choice of drink. The "sensible drinking message", which determines the level of alcohol consumption unlikely to cause harm, is three to four units a day, five days a week for a man, and two to three units a day, five days a week for a woman.(4) Clearly, there are occasions when no level of alcohol is safe; pregnancy, alcohol-related organ damage, and when patients drive, work or take medications such as warfarin.  

  • Binge drinkers consume more than three times their daily limit in one drinking session.
  • Hazardous or at-risk drinkers cause a risk to themselves or others as a consequence of their drinking.
  • Harmful or problem drinkers can cause themselves physical, psychological or social problems.
  • Dependent drinkers may start to show symptoms of alcohol dependence syndrome (ADS).5 This is characterised by the presence of at least one of the following: placing increasing importance on drinking, craving for alcohol, being able to consume more alcohol before experiencing any effects (tolerance), experiencing alcohol withdrawal symptoms or drinking to avoid withdrawal. The clinical manifestations of ADS can be divided into four stages (see Table 1).(6)

[[nip36_54_table1]]
 
What can we do about it?
In accordance with the Models of Care for Alcohol Misusers, a partnership has developed between primary and secondary care.(7) It aims to formulate care processes that support all patients with alcohol-related problems, from those amenable to brief interventions to those dependent on alcohol.(8,9)
The model aims to:

  • Provide timely, effective responses to alcohol-related problems.
  • Provide patients with a choice of treatment setting, and a range of treatment options.
  • Prevent unnecessary hospital attendances and admissions.
  • Reduce the length of hospital stays.
  • Support contemporaneous careers.
  • Optimise medical management.

A GP or staff working at an accident and emergency department or hospital ward can refer a patient for the programme. Referral criteria are based on a simple question: "Is alcohol a contributing factor in the presentation, and is the patient amenable to an assessment?"

Development of the nursing team
A central factor of the model is to provide a dedicated individual with the time and expertise to respond to those whose drinking is affecting their health. The service is nurse-led and nurse-managed, with support from medical colleagues, Drug and Alcohol Action Team commissioners, and NHS senior managers.

Nursing responsibilities
Nurses should aim to:

  • Screen for, and identify, alcohol-related problems and develop measured and timely responses.
  • Deliver safe and effective interventions in a variety of primary and secondary healthcare settings.  
  • Provide seamless access to services across primary and secondary care boundaries.
  • Develop "models of care" for patients with complex alcohol-related problems.
  • Provide education to health and social care professionals.
  • Provide clinical support for primary care staff.
  • Act as a resource to manage both the problem and the drinker.
  • Work in partnership with our patients, voluntary agencies, specialist alcohol treatment units, ambulance services and criminal justice services.

Treatment aims
Treatment aims are determined by clinical need. Brief interventions aim to reduce alcohol-related harm and improve health and social functioning. This would normally include a reduction in alcohol consumption or changes in patterns of alcohol consumption that contribute to harm or significant risk of harm to patients.
This is achieved through the utilisation of the FRAMES approach (see Table 2).(10) Most importantly, this model explores patients' perceptions of the link between their alcohol consumption and current health problems, and places an appropriate emphasis on this potential association.
Detoxification aims to provide a seamless support service across primary and secondary care for patients with moderate-to-severe alcohol dependency. This can avoid a hospital admission for alcohol detoxification. Where patients require admission to hospital for medical treatment, we aim to facilitate timely admission, through-care and transfer of care to the community, thus reducing hospital length of stay.

[[nip36_54_table2]]

Conclusion
Given that the NHS aim to provide a clinically effective service that responds to the physical and emotional needs of the patients, failure to identify route causes at the point of presentation is, perhaps, unforgivable.
The alcohol services lifestyle team provide real choices for patients that enable them to receive the help they need, when they need it, in a nonthreatening, nonjudgmental environment. This model of care provides timely, effective and safe management minimising pressure on the acute trust, and moving the focus of care into the community. An added bonus is that it presents an opportunity to engage patients' families and significant others in the whole care process, a model that further supports primary care and prevents the need to attend hospital.

References

  1. Holt S, Skinner HA, Israel Y. Early identification of alcohol abuse: 2: clinical and laboratory indicators. Can Med Assoc J 1981;124: 1279-94.
  2. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption II. Addiction 1993;88:791-804.
  3. Babor TF, Grant M. From clinical research to secondary prevention: international collaboration in the development of Alcohol Use Disorders Identification Test. Alcohol Health Res World 1989:13.
  4. Department of Health. Sensible drinking. London: DH; 1995.
  5. Edwards G, MM Gross. Alcohol dependence: provisional description of a clinical syndrome. BMJ 1976;1:1058-61.
  6. Bayard M, McIntyre J, Hill K, Woodside J. Alcohol withdrawal syndrome. Am Fam Physician 2004;69:108-15.
  7. Department of Health. Models of Care Alcohol Misusers (MoCAM). London:DH; 2004.
  8. Freemantle NG, Godfrey P, Long C, Richards A, Sheldon, T. Brief interventions and alcohol use. Effective Healthcare 7. Leeds: University of Leeds; 1993.
  9. Heather N. Effectiveness of brief interventions proved beyond reasonable doubt. Addiction 2002;97:293-4.
  10. Bien T, Miller W, Tonigan J. Brief interventions for alcohol problems: a review. Addiction 1993;88:315-35.