1. Alcohol Brief Interventions Training
(Training 4 Trainers)
Alcohol Brief Interventions Training
(Trainer to insert )
Name & contact details
Welcome, housekeeping rules etc.

2. Alcohol Brief Intervention Session
Alcohol Education & Unit Guidance – a Recap!
Brief Intervention – What and Why?
Screening (FAST Screening Tool)
Brief Intervention Skills
Overview
September 2018

3. Alcohol Brief Intervention Session
Alcohol Education
Unit Guidance Recap
Pre-reading review
Try exercise “Sarah” – (or create another exercise ) to test knowledge of alcohol units

4. Sarah starts drinking at 4pm on Saturday;
She has 2 large Vodka & Cokes (50ml, 40% abv each) and half a bottle of wine (375ml, 13.5%abv) with dinner. She then goes out with friends. Over the course of the evening she drinks 1 large glass of wine (250ml, 13% abv) and 6 bottles of Bacardi Breezer (275ml, 5%abv).
No of units?
Q. Approximately at what time will Sarah become alcohol free?
Total number of units is 20.6
2 large vodka & coke – 4 units
Half bottle of wine – 5 units
1 large glass of wine – 3.2 units
6 bottles bacardi breezer – 6 x 1.4 = 8.4
Sarah is potentially alcohol free at 12:30 on Sunday lunchtime.
Very general calculation of 1 hour to process 1 unit of alcohol. This takes no consideration of individual ability to process alcohol and is a very rough guide.

5. Basic Education, Information & Advice Resources & Tools Screening
Brief (Motivational) Intervention
Signposting
Referral
Assessment
Treatment
All the red text identified areas where you could be contributing. If you are not screening – you are missing an opportunity.
All staff can be involved in the first 6 steps above.
Professionals / have a lot of crediblity and there is an expectation that you will ask these questions.
Assessment and Treatment will be the remit of a professional service.
Introduce the ABI pack

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

8. WHO ABI Primary Care Definition (2017)

9. Although evidence of efficacy for ABIs tend to come from Primary Care no evidence to indicate this is not transferable to wider settings.

10. Efficacy of ABI is around 1 in 8 interventions leads to a reduction (approximately 20%) in consumption lasting for at least a year

12. Important to raise clearly and be non judgemental
Compare to guidelines
Listening Skills
Interchangeable, fluid strategies, not set

14. Alcohol Brief Intervention Session
Raising the Issue – Identifying presentations where the role of alcohol should be considered?
Everyone should be comfortable about their opportunity to raise the issue. Highlight the opportunities that present themselves during routine processes/ initial contact with services. What paperwork processes are in place? How are enquiries processed?
Potential exercise- Give everyone a yellow sticky and ask them to jot down brief details. Retain this for later in the training.
Q. Identify scenario example for each participant – jot down brief details – patient/client profile. Identify as Hazardous / Harmful / Dependent?
Opportunistic, Planned or Patient-Led.
Examples of raising the issue:
Timing, Appropriateness, Privacy, Linking the health conditions/ or other presentations to alcohol?

15. Raising the Issue Opportunistic (Practitioner Skilled) Planned
Identifying presentations where role of alcohol should be considered
Opportunistic
(Practitioner Skilled)
Planned
(Systematic)
Patient/Client Led
(Practitioner Aware)
Presentation led ... linking condition/situation/event to consumption
Diagnosed cases e.g. Cancers
Follow up e.g. Liver Function Test
Medication issues, interactions ...
Housing/Tenancy issues
Other contacts – fire/police
LONG TERM CONDITION MANAGEMENT (e.g. Diabetes, Hypertension, Depression/Anxiety)
Embedded within Assessment processes registration/admission paperwork
New Patient / Client registrations
Alcohol consumption acknowledged and readily related to condition / situation/ event e.g. Stressed, bereavement, breakdown of relationships, work, financial difficulties.
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

16. Handout Infographic/Leaflet as example of alcohol and condition self-management advice
Generic style infographics of alcohol impact can be produced to consider other impacts – perhaps stress

17. Alcohol Brief Intervention Session
Screening Tools
Depends on audience – could also include GMAST, Audit C, Cage etc. Trainers will identify most appropriate screening tool for their audience and use as required.

18. Some discussion regarding screening opportunities –
When can this be introduced?
Are there questions within existing paperwork that could relate to alcohol?

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

24. Screening tools Short MAST-Geriatric (SMAST-G)
10 Questions with a focus on older people.
Plus 1 additional question:
Do you drink alcohol and take mood or mind altering drugs,
including prescription tranquilizers, prescription sleeping pills, prescription pain pills, or any illicit drugs?”
This is a modified version of the evidence-based Short Michigan Alcoholism Screening Test – Geriatric Version or the S-MAST- G.  
Because older adults may show signs of drinking problems that are different, we ask 10 specific questions related to this population.
SCORING:
Score 1 point for each ‘yes’ answer and total the responses
2+ points = are indicative of an alcohol problem and an ABI should be conducted. The extra question below should not be calculated in the final score but should be asked.
Extra Q: Do you drink alcohol and take mood or mind altering drugs, including prescription tranquilizers, prescription sleeping pills, prescription pain pills, or any illicit drugs?”

25. www.nhsghpcat.org Short MAST-Geriatric (SMAST-G)
Opportunity to highlight older age groups in context of awareness and brief interventions – effects, risks, medication, nutrition etc and pass on the publication.
Short MAST-Geriatric (SMAST-G)
10 Questions with a focus on older people.
Plus 1 additional question:
Do you drink alcohol and take mood or mind altering drugs,
including prescription tranquilizers, prescription sleeping pills, prescription pain pills, or any illicit drugs?”
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.
This is a modified version of the evidence-based Short Michigan Alcoholism Screening Test – Geriatric Version or the S-MAST- G.  
Because older adults may show signs of drinking problems that are different, we ask 10 specific questions related to this population.
SCORING:
Score 1 point for each ‘yes’ answer and total the responses
2+ points = are indicative of an alcohol problem and an ABI should be conducted. The extra question below should not be calculated in the final score but should be asked.

27. Alcohol Brief Intervention Session
Screening Exercise
If possible into pairs
Use the most appropriate screening tool (blank) for the audience and use a scenario that fits the remit of the group being trained. This can be agreed and prepared in advance of the training.
Pairs should be able to complete one exercise each.
Do not deliver the ABI at this stage – stop at the screening process

28. 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
Embedded case studies which can be changed to suit context and audience. Patient ‘presenting’ information and context can be added by trainer as required

29. 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
e.g. James could be the victim of a crime and is to be followed up by police in an effort to gain more information about the assault. He was too intoxicated on the night of the crime to assist the police.
Maureen could have been locked out of her student accommodation, needed the welfare team to let her in – was too drunk at the time of the event for any follow.
The earlier exercise from slide 15 will help you set the context for the case studies.
For this exercise you are going to obtain a FAST score for Maureen and James. Do not go any further.

31. Alcohol Brief Intervention Session
Brief Intervention Skills

32. MI Techniques cautionary
MI works best when not prescribed simply by a manual or in a purely ‘technique-led’ approach
The ability of the practitioner to relate to the client is far more important – not just empathy – but being ‘genuine’ with real care and compassion
Some clients do not respond well to MI, they need or look for more explicit direction or already have commitment, therefore MI can be counterproductive
“Listening rather than telling, evoking rather than instilling” (Bill Miller) Annual Review of Clinical Psychology Vol. 1: (April 2005). See also “Manners Matter” (part 3) Drug & Alcohol Findings (2005)

33. Intervention levels Minimum Intermediate Longer
Screening result / Feedback
Simple Brief Advice
+ Motivational Techniques
Identification, feedback and information on drinking related to guidance provided as minimum
Identification, Structured simple brief advice (approx 5 minutes) using information, advice / menu options
Identification, with a discussion (utilising MI approach (approx 10 minutes +), follow-up if requested / agreed
Used where resistance to further discussion and if implementation challenges
To reduce risk
10 minutes > not proven to confer added benefits but useful for ambivalent individuals
Re-affirm what will count as an ABI.
Screening result and feedback – not an ABI
Simple brief advice that has involved screening, feedback, discussion around a harm reduction approach and agreement from client/patient will count as an ABI.
Simple brief advice and Motivational techniques – most certainly an ABI

34. 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 low risk 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

35. 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

36. 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

37. ‘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

38. 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

39. 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

40. 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?

41. 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
Refer to the handout – Harm Reduction tips from the Healthy Living section of the NHS Grampian website

42. 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

43. 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

44. Delivering an ABI Revisit “case studies” Maureen & James.
Use Case Studies
Patient
Practitioner
Deliver ABI as role-play and change around roles and repeat.
Summary & Discussion
Ideally looking at two case studies. - Bring back slide
This can also be delivered as a group discussion.
Trainer can pose a series of questions:
Identify behaviours; raise the issue, screen, score, feedback
What needs to change?
How do we maintain empathy throughout this process?

45. 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/client view / suggestions?
Hazardous (binge)
(Alcohol-free days (5))
What’s important to James about drinking?
Patient /client view / suggestions?

46. Do you have the facility to record ABIs?
Recording an ABI
Do you have the facility to record ABIs?
Can you instigate a simple system?
Can you report back to Aberdeen City ADP on numbers of ABIs delivered on a quarterly basis.
Ideally we want anyone trained to be able to record the number of ABIs delivered.
Trainers should be able to cascade arrangements in their own area to those attending the trainers as examples of how this can be done.

47. 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

48. 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 – again for Primary Care only

49. LOCAL SERVICES Aberdeen: Alcohol & Drugs Action (ADA)
Helpline Tel: / Text: (7 Days)
Aberdeenshire: Aberdeenshire Substance use, Support, Engagement and Treatment (ASSET)
Helpline:
Moray: Arrows Service
Helpline Tel:
Tel:
Re-cap of service information

50. Additional supports
NHS Alcohol & Units, Local Support:
NHS Health Information Resources: Tel: (01224)
HI-NET ABI page:
Sobering Thought:
Meet the Hendersons:
Alcoholics Anonymous:
Al-Anon Family Groups:
Scottish Familes affected by Alcohol or Drugs (SFAD):

51. Learning Pyramid
However, looking at the time pressures of ABI delivery this pyramid could be ‘inverted’ in terms of investment. So although only 10|% of what is read is remembered, it is often the easiest way of imparting information – i.e. in pre-reading literature. The practice element is most time intensive as with some of the other exercises which will also involve a degree of Q&A.

52. Making every Opportunity Count: inclusive three tier approach
3. Structured wellbeing conversation for complex needs
Complex
needs
2. Specific conversation
e.g. Money concerns, benefits, smoking, alcohol
Specific needs
1. Light touch conversation
Brief