1. Alcohol Brief Intervention Session
March 2017
Alcohol Education & Unit Guidance – a Recap!
Brief Intervention – What and Why?
Screening (FAST/AUDIT Screening Tools)
Brief Intervention Skills
Referral
Recording (read codes Primary Care)
Overview
**Insert Presenter Names Here**

2. Alcohol Brief Intervention Session
Alcohol Education & Unit Guidance Recap!
Try exercise “Anna” from Unit 5 (5.1) Q3 to test knowledge

3. If the training session requires to be shorter, use this exercise as a ‘shout out’ re-cap of unit knowledge bringing in wider aspects of the guidelines

4. Anna starts drinking at 7pm on Friday;
She has 1 Gin & Tonic (50ml, 40%abv) Gin & Tonic after work and half a bottle of wine (375ml, 12.5%abv) with dinner. She then goes out with friends. Over the course of the evening she drinks 8 bottles of Smirnoff Ice (275ml, 5%abv). No of units?
Q. Approximately at what time will Anna become alcohol free?
If time allows, complete in pairs and feedback, otherwise use previous exercise

5. Alcohol Brief Intervention Session
Brief Intervention – What and Why?

8. 1. Important to raise clearly and be non judgemental
2. Compare to guidelines
3. Listening skills
4. Interchangeable, fluid strategies, not set

10. Raising the Issue Opportunistic (Practitioner Skilled) Planned
Identifying presentations where role of alcohol should be considered
Opportunistic
(Practitioner Skilled)
Planned
(Systematic)
Patient Led
(Practitioner Aware)
Presentation led ... Linking condition to consumption
Medication issues, interactions ...
Embedded within Assessment processes – Admission paperwork
New Patient / Client registrations
Alcohol consumption acknowledged and readily related to condition / situation
Opportunistic most challenging – but will yield best results across population if opportunities identified and followed up. However, if presentation-led there are huge opportunities to link presentation with alcohol consumption – think back to earlier exercise and body-map circulating.
Planned is systematic, so not quite so challenging – can achieve a reasonable coverage of population, but nowhere near as much as regular opportunistic but does require a higher degree of planning and co-ordination which in itself could be challenging in terms of time resource
Patient led possibly the easiest – likely to be less frequent however - but only if prepared for the possibility and ready to respond

11. Alcohol Brief Intervention Session
Screening
(AUDIT & FAST Screening Tools)

14. Use these tools for screening exercises etc and as handouts

17. Opportunity to highlight older age groups in context of awareness and brief interventions – effects, risks, medication, nutrition etc and pass on the publication.
The SMAST-G screening tool is only highlighted for information and as a sensitised alternative to FAST/AUDIT for those staff working predominantly with older age groups.

18. Alcohol Brief Intervention Session
FAST Screening Exercise
If possible into pairs
Blank screening tools x1 each person (FAST/AUDIT). STOP after completing FAST and obtaining a score.

19. FAST Case Studies Maureen (28 yrs) James (45 yrs)
Drinking Information (offered by patient):
A glass (white wine) every evening at home Mon-Fri
5-6 G&Ts at pub Sat. Nothing Sundays
Doesn’t drink Sun-Thu.
6-8 pints (lager) pub Fri glasses (red wine) Sat night at home
Background Information:
Unsure about wine glass sizes. Buys 2-3 bottles weekly. Unsure about units and guideline etc. Gins are single measures. Sometimes goes clubbing after pub – 2/3 Smirnoff Ice (every couple months). No mention of eating prior. Considering having family in future
Shares bottle and half with wife Sat. Lager at pub – always Stella Artois straight from work. Takeaway later.
Bit ‘fuzzy’ some mornings which can cause a bit of friction at home. Missed work one Sat morning ‘a bad pint’.
Got drunk at a wedding – wife unimpressed but doesn’t think its a ‘problem’
Embedded case studies which can be changed to suit context and audience. Patient ‘presenting’ information and context can be added by trainer as required

21. Alcohol Brief Intervention Session
Brief Intervention Skills

22. Key to success in any brief intervention approach is to first and foremost LISTEN to the individual’s responses to the feedback on their drinking – compared to the sensible drinking guidance
Tailor your approach based on your judgement of that response
One such way of tailoring a response is to utilise the ‘stages of change model’ which aligns brief interventions within a health behaviour change framework

23. Matching Response to Approach:
“No I am not interested”
“I don’t want to talk about it”
Exit Strategy. Consider advice as minimum or stop
“What do you mean?”
“I didn’t know about the risks”
Information & advice, explore benefits etc
“I enjoy drinking”
“I don’t think I drink too much”
Explore motivation around drinking
“I think I should cut down”
“What can I do”
Menu of options – setting goals
“I should cut down but I am not sure how” … “I wouldn’t last”
Discuss coping strategies
“I have tried but its not easy”
“I tried before and it didn’t work”
Build confidence

24. Matching Response to Approach Summary:
Pre-Contemplation
Personalised feedback information & advice
Contemplation
Enhancing motivation – exploring concerns
Preparation
Menu of options – negotiating goals
Action
Building confidence
Maintenance
Coping strategies – no relapse to old behaviours

25. ‘OARS’ Practitioner-led Skills
Open-ended questions – allow the patient / client to discuss issues from their own point of view
Affirming – statements of appreciation and understanding providing positive reinforcement
Reflective listening – allowing the practitioner to check on his/her understanding and to invite the patient / client to expand on any issues
Summaries – useful for combining key points – demonstrating active listening and leading toward clarification and future action

26. Advice & Information:
Offering information – how might the patient / client benefit from cutting down on alcohol consumption?
Physical and Mental Wellbeing: Improved sleep, improved memory function, reduction in anxiety and stress, more energy, fewer hangovers, lower risk of high blood pressure, losing weight, lower risk of liver disease
Social and Financial: Lower risk of accident/injury, less chance of being involved in anti-social behaviours, lower risk of drink-driving, better relationships, saving money, more time for other interests, improved work relationships/prospects

27. Enhancing Motivation:
Rolling with resistance: confrontation in this scenario is unlikely to meet with any change of behaviour
Eliciting change talk: if there is any positive reaction, capitalise on this by examining negative aspects of current behaviour, if there is a negative reaction look at examining first the positives or perceived advantages of current drinking
Weighing up the pros and cons of change: the ‘motivational matrix’ can assist the practitioner in guiding elements of the conversation

28. Motivational Matrix: Advantages of Current Drinking
Disadvantages of Current Drinking
What do you enjoy about your drinking right now?
What is important about that and how does it make you feel?
Is there anything not so good about your drinking – what are the disadvantages?
What impact does this have?
Disadvantages of Change
Advantages of Change
What would be the worst thing about changing how you drink?
What effect would this have?
Any other negative aspects?
What would be the benefits of changing drinking habits?
What difference would this make?
Any other advantages this brings?

29. Menu of Options:
At this stage, it is important to try and see if patient / client can suggest their own changes or steps to begin. Using good knowledge of units/calculation may be a good place to start. For example:
Drinking on fewer occasions
On each occasion, drinking fewer alcohol drinks
Reducing the amount of alcohol in each drink

30. Building Confidence:
Self efficacy is an essential part of behaviour change. Occasionally this requires examining with the patient / client
A useful conceptual tool is the ‘readiness ruler’. Useful as visual aid to the process of discussing confidence.
Q. “On a scale of 0 (not at all confident) to 10 (very confident indeed), how confident would you say you are now about your ability to change drinking behaviour”?
Q. “Why here, and not (lower) (higher)”?
Q. “Where would you like to be”?
Q. “What would need to happen for you to get to a higher point”?
Such questions can help the patient / client to decide how important it is for them to make changes which may in turn reinforce determination to change
Useful strategies require looking at the patient / client’s previous successes It can be helpful to break down steps to changes already made and clarify further small steps towards goals. Role modelling may be useful to examine. Support is an essential element – identifying appropriate support within the patient / client’s life may help and sustain any attempt at behaviour change

31. Coping Strategies:
Any return to prior drinking behaviours or pattern, however briefly (slip or lapse) is common, however it can provide a possible learning opportunity. The key to any relapse prevention is to carefully identify potential triggers and high-risk situations and to develop the appropriate coping strategies
Coping strategies may include:
Utilising assertiveness skills
Managing stress
Changing personal routines or circumstances where possible
Looking ahead and identify potential high-risk situations
Pinpointing where and when pressure is likely
Describing any factors likely to influence decision making (mood, people, environment)
Being alert – earlier detection – better outcomes
Acknowledging the role emotions play
Devising specific strategies to cope with situations or avoid them in first instance
Looking at strategies around distraction or prevention
If a strategy fails for any reason – re-assess and look at factors required to be accounted for in future
Being realistic at all times when developing plans

32. Delivering an ABI
Using the Case Studies (from the FAST screening exercise on slide 17) as:
Patient &
Practitioner
Deliver the ABI as a role-play taking turns with each scenario.
Summary & Discussion of Practice (and own examples)

33. Case Study Feedback Maureen James Screening:
2-3 bottles wine would be units per week
Single spirits – 5-6 units
Additional Smirnoff Ice – between 3 – 5 units
Total Sat: 6 – 11 units
Total: 26 to 36 units
6-8 pints would be
18 – 24 units Fri
2-3 glasses wine Sat
7 units
Total: 25 to 31 units
Drinking Profile / Risks:
Harmful drinking generally
(No alcohol-free days)
Guideline knowledge?
Identified risks / issues?
What’s important to Maureen about drinking?
Harm reduction?
Patient view / suggestions?
Hazardous (binge)
(Alcohol-free days (5))
What’s important to James about drinking?
Check with attendees – FAST scores? Discuss issues arising from screening and BI process. Ask questions under the drinking profile / risks – to look at how the conversation was framed and how discussion flowed between practitioner/patient.

34. Alcohol Brief Intervention Session
Referral: When, Where & How
What does referral mean?
Identifying situations in which referral should be considered?
Concerned about potential alcohol dependence?
Handout 8.1 and CAGE tool and distinction between FAST and AUDIT scoring
CAGE better to be part of a discussion with a client rather than administered directly as with other tools

35. Problem Drinking Excessive regular consumption Dependence Intoxication
Re-cap of information from morning session

36. WHO ICD-10 Diagnostic Guidelines
Alcohol Dependence* Syndrome:
Strong desire or compulsion
Difficulties in controlling consumption
Physiological withdrawal state
Evidence of tolerance (require increase dose)
Progressive neglect of alternative pleasures or interests
Persisting with use despite harmful consequences
*Dependence refers to both physical and psychological elements
Biosocial markers for problematic drinking: 17 % men and 8% women with 2 or more problems (potential indicator of dependence)

37. Community based supports Aberdeen CiTY / aberdeenSHIRE: 01224 594700
Drop-In: Mon-Fri 11am-7pm • Sat-Sun 2pm-5pm Online AUDIT:
Local (free and confidential) services working on stepped care model are also available. Furthermore, on the ADA (Alcohol Aberdeen website) opportunity for patients to self-screen (AUDIT tool) incorporated into site, with feedback directly to the patient on their level of drinking and if they require to potentially make a change.
NHS Alcohol & Units, Local Support:
NHS Health Information Resources: Tel: (01224)

38. READ CODES for recording the provision of a Brief Intervention (Primary Care only)
Screening
Total screening (FAST or otherwise)
388u.00
Intervention
Brief Intervention for excessive alcohol consumption
9k1A
Referral
Referral to Specialist Alcohol Treatment Service
8HkG
Referral to community alcohol team
8H7p

39. Open Consultation Manager
VISION
EMIS
MEDICAL RECORD
Open Consultation Manager
Search for the Patient
Within the Read Term Field
Type ’#9k1A’ this will find the read code term Brief Intervention for excessive alcohol consumption completed
Click OK
Consultation Mode
Select Patient
Double click within H- History Field, select ‘F4’ on your keyboard
The Add Code screen opens, at the 1-Find field enter ‘9k1A’and press return.
This will find the read code term ‘Brief Intervention for excessive alcohol consumption completed’,
Click Select
Select ‘F8’on your keyboard to save
Select ‘F4’ on your keyboard, this opens ‘Add Clinical Term (Read Code)’ dialog box
Within the Clinical Term Field, enter ‘9k1A’and press return
This will find the read code term Brief Intervention for excessive alcohol consumption completed
Then click OK
Keystroke information for different systems

40. NHS Health Scotland Raising the Issue of Alcohol Online Module*
ABI H-Net Grampian Site – Resources downloadable
Health Behaviour Change Levels 1&2 and Raising the Issue of Alcohol
*(under revision January 2017)