1. Alcohol Our Favourite Drug: The big picture: can nurses and midwives make a difference? Prof. Jim Rankin Ist International Alcohol, Tobacco and Other Drugs Nursing & Midwifery Conference Adelaide, April 16, 2003

2. Advances in Knowledge and Understanding: Alcohol - Before 1960 Alcoholism a moral problem or a manifestation of mental illness Alcoholism a disease - Alcoholics Anonymous

3. The Scene 1964: Treatment Services Completely inadequate Psychiatric hospitals Residential Custodial care Inmates: –Inebriates’ Act –Psychiatric complications –Temporary accommodation & support

4. Sister Mary Christina Wellsford, RSC

5. Advances in knowledge and understanding of alcohol problems A spectrum of drinking behaviours that may cause problems A spectrum of alcohol-related problems A spectrum of responses involving health promotion, prevention and intervention/treatment

6. Broadening the base of treatment: Establishment of services in general hospitals Shift of resources from psychiatric hospitals to community-based services Shift of resources to provide a balance of residential and non-residential services Initiatives to increase the involvement of general practitioners

7. Responding to alcohol problems in Australia: potential resources Medical practitioners 70,000 (est) Addiction medicine specialists –Certified 140 –Certification pending 60 Registered nurses 250,000 (est) –Registered midwives 67,000 (est) Members of DANA200+ Number of D & A services 2000 (est)

8. VISION

9. The role of nursing and midwifery

10. A whole of profession responsibility Practitioners Clinical nurses Nurse educators/academics Nurse managers Nurse researchers Organisations Registration bodies General professional organisations Academic organisations Alcohol and drug

11. A Vision of Nursing and Midwifery Professions that play active roles in the development and implementation of comprehensive alcohol policies and programs for prevention and treatment

12. A Vision of Nursing and Midwifery: Prevention and Health Promotion Professions whose members incorporate into their professional activities strategies and practices that have as their objectives maintenance of abstinence and safe patterns of alcohol use, and reductions in hazardous and harmful use.

13. A Vision of Nursing and Midwifery: Clinical Care Professions whose members play a complementary role to these preventive strategies by identifying and intervening with their patients whose are at risk because of their alcohol use; and Identifying and responding to the health needs of their patients who already have alcohol-related damage

14. Topics Drinking patterns in Australia and their consequences Effects of alcohol on health Prevention, intervention and treatment Potential roles of nursing and midwifery Systems’ impediments to progress

15. Drinking Patterns in Australia Population aged 14+ years% Drinkers81 1 Hazardous/harmful drinkers 35 1 Hazardous/harmful drinkers14 2 Population aged 14-19 years Drinkers64 1 Hazardous/harmful drinkers67 1 Aboriginal & Torres Strait Islander Peoples Drinkers62 1 Hazardous/harmful drinkers82 1 1 = Last 12 months 2 = Last week

16. Alcohol-attributable deaths and hospital bed days, 1998-9 Deaths Caused4,286 Prevented(7029) 1 Total(2,744) Note 1. 94% aged 60+ years Hospital beddays Caused394,417 Prevented 2 (255,433) Total138,974 Note 2. 79.7% aged 60+ years

17. Potential benefits of policies designed to prevent alcohol misuse Preventable deaths4,286 Preventable hospital beddays 394,417

18. Social costs of drug abuse, 1998-9 $m % Alcohol7,560.3 1 22.0 Tobacco21,063.061.2 Illicit drugs6,075.817.6 Total34,439.8100.0 Avoidable costs of alcohol misuse $3,928.6m (62.1%) Note 1. Costs of alcohol misuse 1.98% of GDP

19. Effects of alcohol on health

20. Factors in Acute Alcohol-related Damage Acute alcohol consumption

21. Factors in Acute Alcohol-related Damage Acute alcohol consumption CNS depression: Impairment of Motor function Coordination Judgment Respiration Consciousness

22. Factors in Acute Alcohol-related Damage Drinking Circumstances and Environment Acute alcohol consumption CNS depression: Impairment of Motor function Coordination Judgment Respiration Consciousness Motor vehicles Workplace Hotels & bars Other social venues Sporting activities Associated drug use

23. Factors in Acute Alcohol-related Damage General Environment Drinking Circumstances and Environment Acute alcohol consumption CNS depression: Impairment of Motor function Coordination Judgment Respiration Consciousness Motor vehicles Workplace Hotels & bars Other social venues Sporting activities Associated drug use Trauma

24. Fall injuries Road injuries Occupational and machine injuries Fire injuries Drowning Assaults Suicide

25. Factors in Acute Alcohol-related Damage General Environment Drinking Circumstances and Environment Acute alcohol consumption CNS depression: Impairment of Motor function Coordination Judgment Respiration Consciousness Motor vehicles Workplace Hotels & bars Other social venues Sporting activities Associated drug use Overdose/poisoning

26. Overdose/Poisoning Acute ethanol overdose and poisoning Aspiration Combined alcohol and drug overdose and poisoning Methanol poisoning

27. Factors in Acute Alcohol-related Damage Drinking Circumstances and Environment Acute alcohol consumption CNS depression: Impairment of Motor function Coordination Judgment Respiration Consciousness Motor vehicles Workplace Hotels & bars Other social venues Sporting activities Associated drug use Obstructive sleep apnoea

28. Factors in Acute Alcohol-related Damage Drinking Circumstances and Environment Acute alcohol consumption CNS depression: Impairment of Motor function Coordination Judgment Respiration Consciousness Motor vehicles Workplace Hotels & bars Other social venues Sporting activities Associated drug use Pregnancy Sexual assault Child Abuse

29. Factors in Acute Alcohol-related Damage General Environment Supportive HOME ENVIRONMENT Non-supportive Affluence INCOME Poverty Very good COMMUNITY SERVICES Absent Very good HEALTH SERVICES Absent Privileged SOCIAL CLASS Under-privileged

30. Factors in Acute Alcohol-related Damage General Environment Drinking Circumstances and Environment Acute alcohol consumption CNS depression: Impairment of Motor function Coordination Judgment Respiration Consciousness Motor vehicles Workplace Hotels & bars Other social venues Sporting activities Associated drug use Obstructive sleep apnoea Overdose/poisoning Trauma Pregnancy Sexual assault Child Abuse

31. Effects of Long-term Alcohol Consumption Long-term alcohol consumption

32. Relationship between alcohol consumption and cirrhosis mortality, Ontario 1928-1972

33. Effects of Long-term Alcohol Consumption Long-term alcohol consumption Alcohol a necessary cause of diseases

34. Alcohol a Necessary Cause of Disease Behavioural and Neurological Alcohol dependence Acute alcohol withdrawal Delirium tremens Acute alcoholic hallucinosis Alcoholic polyneuropathy Alcoholic cerebellar atrophy Neuro-psychological impairment Wernicke-Korsakoff syndrome

35. Alcohol a Necessary Cause of Disease Other diseases: Alcoholic gastritis Alcoholic hepatitis Alcoholic cirrhosis Alcoholic cardiomyopathy Foetal alcohol effects Foetal alcohol syndrome

36. Effects of Long-term Alcohol Consumption Long-term alcohol consumption Alcohol a contributing cause of disease

37. Alcohol a Contributing Cause of Disease Cancer Oropharyngeal Oesophageal Laryngeal Liver Female breast

38. Alcohol a Contributing Cause of Disease Gastro-intestinal and hepatic Oesophageal varices Gastro-oesophageal haemorrhage Unspecified cirrhosis Haemochromatosis Acute pancreatitis chronic pancreatitis

39. Alcohol a Contributing Cause of Disease Other diseases: Epilepsy Hypertension (males) Ischaemic stroke (males) Haemorrhagic stroke (males) Psoriasis Depression, attempted suicide and suicide Spontaneous abortion

40. Effects of Long-term Alcohol Consumption Long-term alcohol consumption Alcohol a contributory factor to disease outcome

41. Alcohol a Contributory Factor to Disease Outcome Hepatitis C Pulmonary infection Post-operative complications

42. Effects of Long-term Alcohol Consumption Long-term alcohol consumption Alcohol a protector from diseases

43. Alcohol a Protector from Disease Ischaemic heart disease Hypertension (females) Supra-ventricular cardiac dysrhythmias Hear failure Ischaemic stroke (females) Haemorrhagic stroke (females) Cholelithiasis

44. Effects of Long-term Alcohol Consumption General Environment Long-term alcohol consumption Alcohol a necessary cause of diseases Alcohol a contributory cause of diseases Alcohol a protector from diseases Alcohol a contributory factor to disease outcome

45. Prevention & Treatment of Alcohol-related Problems: A Spectrum of Problems and Responses The goal: Harm minimization

46. Advances in disease prevention & health promotion Drinking Guidelines Low alcohol content beers Labelling of alcoholic beverage containers with the number of drinks Drink-driving counter measures ▬ Random breath testing ▬ Zero blood alcohol levels for probationary drivers

47. Advances in disease prevention & health promotion Thiamine supplementation of flour Indexation of alcohol taxes Initiatives to reduce alcohol-related harm in and near licensed premises

48. Advances in clinical management Screening instruments (AUDIT) Assessment instruments Effective behavioural interventions  Motivational interviewing  Cognitive behavioural restructuring  Brief interventions Pharmacotherapies:  Naltrexone  Acamprosate Management of alcohol-related physical diseases

49. Changes in alcohol problems Between 1988 and 1998 per capita consumption as fallen from 9.4 to 7.5 litres Australia has fallen from 12th to 19th place internationally in per capita consumption These declines associated with falls in: –Incidence of alcohol-related road injury and deaths –Total alcohol-caused mortality –Deaths where alcohol is the sole cause –Deaths where alcohol is a contributing cause

50. Alcohol Use Nil Safe Prevention and Treatment of Alcohol-related Problems: A Spectrum of Problems and Responses Primary prevention

51. Alcohol Use Hazardous Prevention and Treatment of Alcohol-related Problems: A Spectrum of Problems and Responses Case finding & early intervention

52. Alcohol Use Harmful Prevention and Treatment of Alcohol-related Problems: A Spectrum of Problems and Responses Treatment

53. Alcohol Use Alcohol- related problems Prevention and Treatment of Alcohol-related Problems: A Spectrum of Problems and Responses Primary prevention

54. Alcohol Use Alcohol- related problems Prevention and Treatment of Alcohol-related Problems: A Spectrum of Problems and Responses Case finding & early intervention

55. Alcohol Use Alcohol- related problems Prevention and Treatment of Alcohol-related Problems: A Spectrum of Problems and Responses Treatment

56. Alcohol Use Nil Safe Hazardous Harmful Alcohol- related problems Prevention and Treatment of Alcohol-related Problems: A Spectrum of Problems and Responses Primary prevention Case finding & early intervention Treatment

57. General Nurses The Role of Nursing: Clinical Practice

58. Safe Drinking Practices General Nurses The Role of Nursing: Clinical Practice

59. Safe Drinking Practices Drinking History General Nurses The Role of Nursing: Clinical Practice

60. Safe Drinking Practices Drinking History Screening (AUDIT) General Nurses The Role of Nursing: Clinical Practice

61. Safe Drinking Practices Drinking History Screening (AUDIT) Brief intervention General Nurses The Role of Nursing: Clinical Practice

62. Safe Drinking Practices Drinking History Screening (AUDIT) Specialist referral Brief intervention General Nurses The Role of Nursing: Clinical Practice

63. Safe Drinking Practices Drinking History Screening (AUDIT) Treatment of withdrawal Specialist referral Brief intervention General Nurses The Role of Nursing: Clinical Practice

64. Public health Community health Mental health Emergency Critical care GastroenterologyHepatologyNeurologyMidwiferyPaediatrics Specialty Nursing and Clinical Nurse Specialists

65. Consultation & support The Role of Nursing: Clinical Practice Public health Community health Mental health Emergency Critical care GastroenterologyHepatologyNeurologyMidwiferyPaediatrics Specialty Nursing and Clinical Nurse Specialists

66. Consultation & support Specialist assessment The Role of Nursing: Clinical Practice Specialty Nursing and Clinical Nurse Specialists Public health Community health Mental health Emergency Critical care GastroenterologyHepatologyNeurologyMidwiferyPaediatrics

67. Management of specialty problems Consultation & support Specialist assessment The Role of Nursing: Clinical Practice Specialty Nursing and Clinical Nurse Specialists Public health Community health Mental health Emergency Critical care GastroenterologyHepatologyNeurologyMidwiferyPaediatrics

68. Management of medical problems Consultation & support Specialist assessment Follow -up The Role of Nursing: Clinical Practice Specialty Nursing and Clinical Nurse Specialists Public health Community health Mental health Emergency Critical care GastroenterologyHepatologyNeurologyMidwiferyPaediatrics

69. D and A Nursing and Clinical Nurse Specialists The Role of Nursing: Clinical Practice General hospitals Psychiatric hospitals Community health Detoxification units Other D & A services

70. Consultation & support D and A Nursing and Clinical Nurse Specialists The Role of Nursing: Clinical Practice General hospitals Psychiatric hospitals Community health Detoxification units Other D & A services

71. Consultation & support Specialist assessment The Role of Nursing: Clinical Practice D and A Nursing and Clinical Nurse Specialists General hospitals Psychiatric hospitals Community health Detoxification units Other D & A services

72. Consultation & support Management of alcohol problems Specialist assessment The Role of Nursing: Clinical Practice D and A Nursing and Clinical Nurse Specialists General hospitals Psychiatric hospitals Community health Detoxification units Other D & A services

73. Consultation & support Management of alcohol problems Follow-up Specialist assessment The Role of Nursing: Clinical Practice D and A Nursing and Clinical Nurse Specialists General hospitals Psychiatric hospitals Community health Detoxification units Other D & A services

74. Safe Drinking Practices Drinking History Screening (AUDIT) Treatment of withdrawal Specialist referral Brief intervention Management of medical problems Consultation & support General Nurses Management of alcohol problems Follow-up Specialist assessment Follow -up The Role of Nursing: Clinical Practice D and A Nursing and Clinical Nurse Specialists Specialty Nursing and Clinical Nurse Specialists

75. A special need: services for impaired nurses

76. Progress in Australia Services in general hospitals1964 Appointment of assistant directors of nursing (D and A) in NSW1982 Establishment of clinical nurse specialists and consultants in some states Establishment of DANA1986 NSW Nursing Project Academic appointments Establishment of academic programs Availability of educational resources

77. Systems impediments to progress Increasing and competing demands on nurses and nursing services Deceasing availability of nurses Silo organizational structures Fragmentation of patient care Shift of Federal government support away the concept of universal health care Inadequate funding of public hospitals Increasing numbers of for-profit private hospitals