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Treatment for alcohol misuse in primary care

Jeff Fernandez
RGN MSc MPhil
Alcohol Lead Nurse for Primary Care Islington Primary Care Trust

Many patients needing treatment for alcohol abuse can be managed in primary care with the support of an experienced specialist nurse. This article presents a case study illustrating the importance of the nurse's role in improving patient care and supporting the GP in providing a detox service

Much of the literature looking at trends in drinking has shown that the consumption of alcohol is increasing, particularly in women and young men.1 This is a cause for concern in terms of law and order. The government has taken this seriously, with a report on the extent of binge drinking in society, which focused on the problematic nature of alcohol consumption and the increased levels of violence associated with binge drinking.2

However, there are also associated health complications, which, in many cases, need medical treatment, such as cardiovascular problems, hypertension and liver damage through hepatitis, which needs to be recognised.

So what can health professionals do in primary care? Presented here is a case study that illustrates that the specialist nurse is a valuable resource for improving patient care and providing support for GPs in the treatment of alcohol abuse. Alcohol detoxification carried out in primary care is sometimes referred to as community detox.

This article also shows the importance of developing "shared care" in the field of alcohol treatment. Detoxification from alcohol in a shared care setting is beneficial for the patient and can ensure a break from dependent drinking for up to six months to one year. Importantly, this article highlights the crucial and beneficial role a nurse specialist can play in treating patients in the field of alcohol misuse.

Role of the alcohol specialist nurse
In the author's practice in North London, there are generally two types of referral from general practice for alcohol misuse. The first can be categorised as patients with complex physical needs where alcohol is a major contributing factor, such as ascites or jaundice. The other can be categorised as dependent drinkers (drinking every day).

Initially, part of the alcohol specialist nurse's remit at our practice looked at increasing the level of assessment for GPs, including providing expertise and advice. However, this has changed, and patients who are dependent on alcohol, and who drink every day, are the most typical clients seen by the nurse.

They often request a desire to give up alcohol altogether.
Since 2005, the process of detoxification and encouraging patients to remain alcohol-free has played an increasing part in our practice; this is particularly due to the changes that have been made to accommodate a prescribing nurse who has been able take on the supplementary prescribing regimens for patients.

Our approach is based on the guidelines developed to provide a comprehensive treatment method, as outlined in the NHS Clinical Knowledge Summary, Alcohol – problem drinking.3 This document is based on two national guidelines: the Review of the effectiveness of treatment for alcohol problems by the National Treatment Agency for Substance Misuse (NTA), and The management of harmful drinking and alcohol dependence in primary care guideline by the Scottish Intercollegiate Guidelines Network (SIGN).4,5

The important point to remember is that unlike specialist alcohol services, the detoxification regimen in primary care will be less intensive. Therefore, to be considered for a detoxification from alcohol in primary care, the patient needs to be able to demonstrate that they have a good degree of "insight" into their alcohol pattern.

Background
There has been much debate on the subject of treatment regimens to enable a patient to be alcohol free. This is usually termed as "detoxing". Inpatient detoxification packages in a hospital setting for alcohol are common, but have a long waiting list and the demand for this treatment mode outstrips supply.

In their review of the effectiveness of treatment for alcohol problems,4 the NTA showed that detoxing is more effectively achieved when psychological services are used together with clinical input, such as medication to provide holistic care.

The NTA also analysed different settings for alcohol detoxification regimens: one was an inpatient setting, where the patient is detoxed in a hospital setting; the other was a primary care setting, where the nurse provides psychosocial interventions and the GP prescribes suitable medications (this is termed in primary care "community detoxification"). This model combines the psychosocial and pharmacological perspectives, maximising outcomes. The NTA concluded that there was no real evidence that inpatient detoxes were more successful than community detoxes. This is a debatable subject, and in this article the success of detoxification in primary care is promoted as a valuable and effective setting.

Detoxing for a patient in our practice involves the nurse providing the psychosocial interventions with the GP prescribing the detox. The medication used chlordiazepoxide and the dose starts from 25 mg QDS and is decreased by 5 mg a day. Box 1 shows a standard detoxification regimen for a patient.

[[Box 1 alc]]

Importantly, the patient has to be in a position where drinking on top of the medication is unlikely to ensure safety. Some GPs do not feel sufficiently skilled in treating this cohort of patients and some would not have the time to manage detoxing the patient.6 In this case, the role of the specialist nurse is advocated to address this gap, ensuring that detoxification from alcohol for patients dependent on alcohol is achieved with some success.

Methodology
The article examines patients who underwent a detoxification with the specialist nurse in Islington in 2006–07. In total, there were 45 completed detoxification regimens. At least two sessions with the specialist nurse were an important part of the preparation of the patient to detox long term. In some cases, more than two sessions were provided, as increased preparation time was needed to extend a patient's insight and work on their coping skills. The nurse is a registered independent prescriber but, as yet, under PCT guidelines, they can only carry out supplementary prescribing under a clinical management plan. Therefore, the detoxes are a shared care arrangement with the prescribing completed by the GP and nurse under a supplementary prescribing plan and all the management by the nurse specialist.

The research took the form of two stages. The first stage was an evaluation and audit of the patient undertaking the detoxification package. At the audit stage, all 45 patients' details were entered onto a database and analysed for gender and age. Ethnicity was not completed as the majority were White British and no Asian or Caribbean clients who attended the service were seen as suitable to detox from alcohol via primary care with the specialist nurse. Data were examined on the number of sessions attended for preparation, and the length of "dry" time (time without alcohol) achieved.

The second stage used structured qualitative questionnaires and all 45 patients were interviewed through a series of semistructured interviews conducted in primary care. The interviews were then coded and analysed into themes. The audit and subsequent research received ethical approved from the Camden and Islington ethical board.

Results
Shown in this section are the demographics of the people who completed a community detoxification regimen in 2007. Figures 1 and 2 show the age and gender breakdown. In terms of ethnicity, all patients were White British; no ethnic minorities were suitable for a community detoxification from primary care.

Figure 2 shows that a higher proportion of females detoxed from alcohol through the specialist nurse in primary care. This is a figure that is larger than the average seen in substance misuse in general, which is more of a male-dominated population in the ratio of 3:1.7

[[Fig 1 alc]]
[[Fig 2 alc]]

The demographics show a White-dominated clinical field for community detoxification, and more females than males. Below is a typical case study illustrating some of the typical findings of the research.

Case study
Gareth had been registered at his general practice since he was a young boy and the surgery knew him well. Alcohol was a prominent part of his life in his 20s and he had begun to drink heavily. But, as he stated, so did everybody else in his peer group. He did not go to his GP surgery for help until his wife asked him to. In the short term, the options for treatment of alcohol misuse when he was in his 30s were to start a detox regimen in hospital, or be referred to a specialist mental health unit that had experience in alcohol. Usually, a gastroenterology ward was the main route through which patients with dependent/problematic drinking patterns were accommodated and treated.

"My first detox was easy … but as soon as the tablets ended it was then that I found it difficult. I did not understand that at first, and starting the tablets and coping with the medication being easy gave you a false sense of security. I mean, if I was given more tablets it could have helped."

This medical model approach to some patients still exists today. It is often the case when treating addiction that the psychological aspects of surviving without alcohol are underestimated in the first detox or intervention. However, there was very little expertise in this field at the time of Gareth's first detox, and medication and an applicable medical model was the method used by the NHS in the 1980s. This is a very typical finding from the interviews conducted. But was anything learnt from this clinical experience?

"Every detox taught me more and more. Particularly, the 'habit' of it all. At times you … or I wondered what was habitual and what was psychological. But you learnt more about your pattern."

This was a common feeling among many of the patients interviewed, and it seems obvious; but it is this basic concept that enabled the small cohort of 7% to go dry for a substantial period of time. Despite the number of detoxes – and Gareth had five in all over 20 years – he learnt from each detoxification regimen. This made each detox stand a greater chance of success and each time he managed to stay drier for longer.

"I suppose, each time, you learn whether you want to do this or not. The first time it was my wife, and I was doing it for others. I knew I had to do something … it was embarrassing to interact with teachers and other friends at school (my daughter when she was young). I knew I did not want to be like this. But the other thing was, it was enjoyable drinking and everyone seemed to do it. Also, when I was young I was fairly shy and alcohol helped me to get over this. It was only later after detox three that I seemed to understand how it started."

This is also an important concept that emerged from the interviews; unless you are sure you really want to do a detox regimen, any compromised position will weaken the potential to make it a successful one. Also, remembering the reasons why you do not want alcohol when you are next tempted to drink are important in sustaining a dry period.

"I am sure now that I do not want to drink again. This was never that strong in the periods as it is now, from the detox regimes I have had in the past. That is a main difference. Also, I am aware of the health benefits for myself … particularly after 11 months off alcohol."

The main question to ask all the 7% was: could one detox alone work for a person, or are others truly necessary in order to finally benefit from some substantial "dry" time?

"Well … not sure – for most, one is never enough … as I said, you learn something from every detox regime and I certainly was learning about my pattern on each one. After the first I felt so guilty and embarrassed that I did not think I would be given another chance to detox. I know that I can now. Plus, the support you can have to stay dry is so much better now. This, with my better grip on my alcohol pattern, has enabled me for sure to stay dry for 11 months."

Conclusion
The number of detoxes, and assessing how they have changed the patient, are important factors to consider from the data that emerged from the qualitative interviews conducted in this research. Each detoxification regimen completed improved an individual's insight into their dependent pattern on drinking. This improved each outcome of any subsequent detoxes.

The patient in the typical interview has now been "dry" for nearly one year. From the primary care perspective this is a great achievement. It also verifies the prescribing plan designed by the nurse and the clinical management plan, as 45 patients safely detoxed with no adverse reactions to chlordiazepoxide.
The case study illustrates that a person with a dependent pattern would need more than one detoxification regimen over time. The national treatment outcomes for drugs and alcohol conducted in 1996 and 2006 showed that a similar number of detoxes were needed for patients to learn to stay off either drugs or alcohol. Therefore, a more patient-centred approach and a willingness to prescribe a detoxification regimen more than once should be promoted in primary care settings.

Overall, this article shows that the role of the alcohol specialist nurse can be a valuable resource for detoxing patients safely and successfully in primary care. It also shows that an experienced nurse in the field is able to assess and plan care effectively for a range of patients with different drinking patterns. Finally, it has demonstrated the importance of implementing a process for detoxing patients for alcohol in primary care and a safe and effective clinical management plan.

References
1. Waller S, Naidoo B, Thom B. Prevention and reduction of alcohol misuse: review of reviews. London: Health Development Agency; 2002.
2. Health Promotion Division (2003) Alcohol and drug services within community care. Local Authority Circular: Department of Health; 2003.
3. NHS Clinical Knowledge Summaries. Alcohol – problem drinking. Available from: http://cks.library.nhs.uk/alcohol_problem_drinking
4. Raistrick D, Heather D, Godfrey C. Review of the effectiveness of treatment for alcohol problems. London: National Treatment Agency for Substance Misuse; 2006.
5. Scottish Intercollegiate Guidelines Network (SIGN). The management of harmful drinking and alcohol dependence in primary care: a national clinical guideline. Edinburgh: SIGN; 2003.
6. Smith M. The Needs for Health Services for Alcohol Misuse in Camden and Islington. London: Islington PCT; 1996.
7. Fernandez J. The Evaluation of the Alcohol Nurse in Primary Care, 2007.