Starting the journey: Screening
and brief interventions
Prof Alex Copello
Consultant Clinical Psychologist
Addiction Services
Birmingham and Solihull Mental Health Foundation NHS Trust &
Professor of Addiction Research
The University of Birmingham
[email protected]
Taking a closer look at alcohol and drug treatment
Birmingham, 27th April 2011
The journeys
Many people will recover from alcohol use disorders without
specialist treatment
Hazardous and harmful drinkers may respond to a brief
intervention provided in primary care without requiring
access to specialist treatment (NICE, 2010)
For others, their alcohol problems are overcome with the help of
a mutual aid organisation, such as Alcoholics Anonymous (AA)
Nevertheless, many will require access to specialist treatment by
virtue of having more severe or chronic alcohol problems, or a
higher level of complications of their drinking (e.g. social
isolation, co-existing psychiatric problems or severe alcohol
withdrawal)
Addiction problems are frequently
overlooked in a range of settings
e.g. a quarter of excessive drinkers
identified in primary care
Identification
A recent study found that UK GPs routinely
identify only a small proportion of people with
alcohol use disorders who present to primary care
• less than 2% of hazardous or harmful drinkers;
• less than 5% of alcohol dependent drinkers
(source: Cheeta et al., 2008).
Possible Reasons
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Not knowing what we are looking for
Lack of vigilance
Embarrassment at asking certain questions
Not knowing what to do if case uncovered
Client’s reluctance to discuss the issue
Identification
Important implications for the prevention and
treatment of addiction problems. Failure to
identify problems means:
• that many people do not get access to
interventions until the problems are more chronic
and difficult to treat and
• failure to address an underlying addiction
problem may undermine the effectiveness of
treatment for the presenting health problem (for
example, depression or high blood pressure).
Enhancing recognition rates
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Use of sensitive/appropriate questions
Remembering who is at risk
Common social presentations
Common psychological problems
Common physical problems
Not overlooking the obvious
Talking to others that may be affected
How are Families Affected
by Substance Misuse?
“Family members face a form of chronic stress that
affects them at a number of different
levels…..daily hassles…..relationships that
deteriorate……a number of threats….much
uncertainty….hence, family members find
themselves in a very disempowered
position….”
(Orford et al., 2005 p205-206)
Problems for the whole Family
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RITUALS
ROLES
ROUTINES
COMMUNICATION
SOCIAL LIFE
FINANCES
Symptoms of Ill Health
Control
Psych
P.Care
2
P.Care
1
Wives
Mexico
35
30
25
20
15
10
5
0
UK
Family Family members; psychiatric out-pts. and
community controls
members
Laboratory Tests
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MCV Mean Corpuscular Volume
GGT Gamma Glutamyl Transpeptidase
CDT Carbohydrate Deficient Transferin
BAC Blood Alcohol Level
Urine Tests
Screening Questionnaires
• CAGE (King, 1986)
• MAST (Selzer, 1971)
• AUDIT (Babor et al., 1989)
CAGE
Have you ever:
• Cut down on your drinking
• Angry at others criticising your drinking
• Guilty about your drinking
• Eye opener - drink first thing in the
morning
AUDIT items:
1. How often do you have a drink containing alcohol?
2. How many drinks containing alcohol do you have on a typical day
when you are drinking?
3. How often do you have five or more drinks on one occasion?
4. How often during the last year have you found that you were not
able to stop drinking once you had started?
5. How often during the last year have you failed to do what was
normally expected of you because of drinking?
6. How often during the last year have you needed a first drink in the
morning to get yourself going after a heavy drinking session?
7. How often during the last year have you had a feeling of guilt or
remorse after drinking?
8. How often during the last year have you been unable to remember
what happened the night before because of your drinking?
9. Have you or someone else been injured because of your drinking?
10. Has a relative, friend, doctor, or other health care worker been
concerned about your drinking or suggested you cut down?
Interviewing
• Raising the issue
• Feeling confident to respond
• Basic knowledge of substances and effects
Raising the Issue
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Legitimacy
Client’s fear of being judged
Need for time to contemplate
Therapist’s confidence
Substances
• Knowledge of the basic facts about substances
can increase confidence when discussing
substance use with clients.
What can be done to help
people with addiction
problems in a range of nonspecialist settings?
BRIEF
vs.
INTENSIVE
Brief interventions (BIs)
“Brief interventions involve opportunistic advice,
discussion, negotiation or encouragement
They are commonly used in many areas of
health promotion by a range of primary and
community care professionals”
NICE 2006
Types of Brief Interventions
• Opportunistic brief interventions (OBIs)
• Brief treatment (extended BIs)
“A single or a number of interventions aimed at
enabling change behaviour”
Types of Brief Interventions (2)
Delivered by:
– non-specialists in generic settings
– Specialists in alcohol treatment settings
The origins of brief interventions
• Alcoholism: a controlled study of
“treatment” and “advice”
Edwards, Orford, et al 1977
The study
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100 participants
Male
Married
Problem drinkers
• 3 hour comprehensive assessment
Randomised treatment
• Conventional (standard)
– Inpatient
– Outpatient
– Lasting several months
• Treatment (trial)
– Single session
– With psychiatrist
– With wife
– “constructive and
sympathetic terms”
Results
• No statistical difference in outcome between
intensive and brief therapy
– At 1 year
– At 2 years
Therapeutic principles of BIs
• Enshrined in the principles of motivational
interviewing
• Enabling change rather than forcing or
engendering change directly
5 Core principles…
1.
2.
3.
4.
5.
Avoiding arguments
Empathy
Self-efficacy
Rolling with resistance
Developing discrepancy
Tools
• Drink/drug use diaries to record weekly use
and establish baseline
Feedback: avoid labelling; responsibility with the
client; provide a menu of strategies; enhance
self efficacy
Addictions
• Two simple tools:
Substance Use Diaries
Decisional Balance
Brief Interventions Framework
Feedback
Responsibility
Advice
Menu
Empathy
Self-efficacy
(FRAMES; Bien et al., 1993)
Families
• The 5 Step-Method
A relatively brief intervention focused on family
members affected by addiction problems. Can
be delivered in a range of settings by a range
of professionals. Based on psychological
principles of stress and coping.
Screening and Brief Interventions
Screening and brief intervention delivered by a
non-specialist practitioner is a cost-effective
approach for hazardous and harmful drinkers
(NICE, 2010a)
However, for people who are alcohol
dependent, brief interventions are less
effective and referral to a specialist service is
likely to be necessary (Moyer et al., 2001)
Referral to specialist services
Around one third of people presenting to
specialist alcohol services in England are selfreferred
Around one third are referred by non-specialist
health or social care professionals (Drummond
et al., 2005).
The majority of the remainder are referred by
other specialist addiction services or criminal
justice services.
Assessment Framework
• Recent use
WHEN
HOW MUCH
WHAT
WHERE
WHO WITH
Assessment Framework
• Recent use
Recent abstinence
Recent withdrawal
Assessment Framework
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What influences use?
Usual pattern
Any changes
Dependence
Substance related problems
Periods of abstention or control
Current alcohol services
Alcohol needs-assessment in England identified
nearly 700 agencies providing specialist
alcohol treatment, with an estimated
workforce of 4,250 (Drumond et al., 2005;
National Audit Office, 2008). The majority of
agencies (70%) were community based and
the remainder were residential.
Current alcohol services
• Approximately half of all alcohol services are
provided by the non-statutory sector but
typically funded by the NHS or local
authorities. Approximately one third of
specialist alcohol services exclusively provide
treatment for people with alcohol problems,
but the majority (58%) provide services for
both drug and alcohol misuse.
Current alcohol services
• In terms of services provided by community
specialist agencies, the majority (63%) provide
structured psychological interventions either
on an individual basis or as part of a
structured community programme
(Drummond et al., 2005).
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screening and brief interventions by Prof Alex Copello