478
Journal of the Royal Society of Medicine Volume 85 August 1992
lifestyle'. It does not take long: Wiseman et aL " showed that an adequate alcohol history can be obtained in two minutes in general practice. People who drink to excess may be reluctant to disclose their habits (there are simple techniques for making them talk), but they may also genuinely not know how much they drink. Attempts to discover the exact amount may be less important than exploring the circumstances of drinking and the role that alcohol plays in their lives.
Alcohol misuse is a hopeless case Low expectations about treatment for alcohol misuse are universal. It would help if the experts were to admit that they can do little to alleviate alcohol dependence and that curative treatment of serious physical damage is rarely possible - hardly surprising given that they are the end result of years of damaging drinking. As a physician I find it helpful to regard the chronic alcohol misuser in the same way as a patient with chronic bronchitis or rheumatoid arthritis: I do not complain that they cannot be 'cured'. The way to improve the therapeutic image must surely be to shift the emphasis towards promotion of healthy drinking and earlier detection of problems. The value ofbrief interventions at this stage has been shown both in general practice6'7 and in hospital12. Pessimists say that uncovering problems will overwhelm services which are already stretched, yet doctors can do much themselves without having to seek specialist advice. They need, too, to shed their suspicion of cooperating with other health workers, since management of alcohol problems is a good example of the value of teamwork. They should also be prepared to learn from local alcohol agencies, whose members often know a great deal more about alcohol misuse than doctors and are only too willing to share their experience. Specialists will, of course, still be necessary to deal with difficult problems; all hospitals should have a consultant with an interest in alcohol misuse, who can also be involved in postgraduate training.
Conclusion One ofthe difficulties about alcohol is that conferences such as this usually consist of the (worldly) wise leading the wise. Nothing I have said will surprise anyone in the audience; many of us have been saying similar things for a long time. But if we believe that knowledge among doctors is inadequate isn't it time for action rather than words? Do we have a consensus
Primary care physicians and alcohol P Anderson MRCGPMFPHM Formerly, Director, HEA Primary Health Care Unit, Block 10, Churchill Hospital, Headington, Oxford OX3 7LJ Keywords: alcohol; general practice; screening; treatment
Introduction Over the last 5-10 years there has been an increasing recognition of the importance of primary care
on what should be done? If so, could we produce a series of guidelines which would be acceptable to educational authorities? I would like to propose the following as some of the core topics that could be tested: alcohol history taking, communicating about alcohol, how to undertake early detection and health promotion, techniques of brief intervention, familiarity with types of socio-economic as well as physical harm, how to work in a team, and knowledge of community networks and specialist support. Finally, doctors might examine their own attitudes; they could influence public opinion, as they did over smoking, by keeping their own drinking within sensible limits. References 1 Paton A. New survey of medical education. Alcohol Concern J 1986;2:14-16 2 Department of Health and Social Services. Alcohol related problems in undergraduate medical educatiom A survey of English medical schools. London: DHSS, 1987 3 Glass IB. Substance abuse and professional education: a tops-down or bottom-up approach? Br J Addict 1988;83:999-1001 4 Geller G, Levine DM, Mamon JA, Moore RD, Bone LR, Stokes EJ. Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism. JAMA 1989; 261:3115-20 5 Department of Health and Social Services. Alcohol related problems in higher professional and postgraduate medical education. London: DHSS, 1987 6 Wallace P, Cutler S, Haines A. Randomised controlled trial ofgeneral practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297:663-8 7 Anderson P, Scott E. The effect of general practitioners' advice to heavy drinking men. Br J Addict 1992; 87:891-900 8 Farrell MP, David AS. Do psychiatric registrars take a proper drinking history? BMJ 1988;296:395-6 9 Paton A. Alcohol misuse and the hospital doctor. Br J Hosp Med 1989;42:394-400 10 Bell G, Cremona A. Alcohol and death certification: a survey of current practice and attitudes. BMJ 1987; 295:95 11 Wiseman SM, McCarthy SN, Mitcheson MC. Assessment of drinking problems in general practice. J R Coll Gen Pract 1986;36:407-8 12 Chick J, Lloyd G, Crombie E. Counselling problem drinkers in medical wards: a controlled study. BMJ 1985;290:965-7
(Accepted 30 August 1991)
physicians in the prevention and management of problems related to alcohol use1'2. A number of centres have developed initiatives in the field of primary care and alcohol and this has been supported by reports from governmental and non-governmental organizations3-6. The European office of the World Health Organization commissioned a series of three meetings on alcohol and primary care which culminated in a technical report publication7. The World Health Organization in Geneva has recognized the importance of primary health care and has initiated a number of collaborative projects developing screening instruments for use in primary
Paper read to joint meeting of Sections of Epidemiology & Public Health and Psychiatry, 13 February 1991
0141-0768/92 080478-05/$02.00/0 © 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 August 1992 479 health care8 and evaluating minimal intervention strategies9. Despite these initiatives, negative attitudes are held' by primary care physicians about managing alcohol problems'0-12 and evidence sugges'ts that limited action is taking place in primary care for both preventing and managing alcohol problems13. This paper reviews why primary care physicians should be involved with alcohol problems, why primary care physicians are not currently involved, and what can be done to increase the involvement o,£primary care Dhvsicians in the Drevepntion "and manaraement of alcohol problems.
Why should we do it? Alcohol is a major cause of health care woorkload Alcohol is recognized as a major public healt;h problem in many countries second only to cigarette E.nWoklng4. In the United Kingdom, it has been estixriated that alcohol is the cause of 6% of all deaths in the age range 15-74's. Up to one fifth of male medical a dmissions to hospitals are alcohol related6. In the primary care setting one fifth of adult patients iregistered with a UK general practitioner are drinkiing alcohol at levels that put their health at risk6. A]Icohol is a risk factor for many social, psychological and physical
conditions'6. Many excessive drinkers do not seek help for their alcohol problems A number of studies have shown that only about one in five of adults with a drinking probAem seek specialist help for their problem'7. Althoiagh many people accept that they have a drinking problem because of recognition that their alcohol cornsumption is excessive, often help is only sought when the negative consequences of excessive alcoh4 ol use are experienced. This means that it is as imjportant to identify and offer advice to those who are drinking excessively rather than solely providing opp ortunities for management for those who have sulffered the negative consequences of alcohol. .
Socially stable individuals at early stages Of excessive drinking have better prognosis A review of 19 studies comparing outcome aIt one year follow-up for individuals who were excessiv e drinkers' and individuals who had serious problems related to alcohol use demonstrated that excessive drinkers had a success rate of 72% compared with 53% for those with serious problems'8. Whereas one half of those with a serious problem had resolved this by abstinence, the majority of- ecessive driners had improved by reducing their alcohol consumption. Health professionals in primary care settings are in an excellent position to identify problem drinkers The UK is fortunate in having a Health Service in which patients must register with- a GP to receive care. It is estimated that 98% of the population are registered with a GP. This means that GPs have defined populations for whose health 'care they are responsible. Primary care services are also accessible. It has been estimated that in the UK (population 50 million) there are 0.75 million consultation with a GP every week day. In addition two-thirds of registered patients consult their doctor in any one year. This patient contact allows -opportunistic screening programmes.
A number of studies have shown that primary health care professionals are seen to be credible by their patients as health educators. When asked for a raiking of sources ofhealth educational information, family doctors are put as number one on the list. Fourfifths 6f patients believe that their GP should be interested in their alcohol consumption19. Primary care services also lack the stigma of specialist treatment services. Primary care services are therefore more approachable to excessive drinkers without the fear of labelling.
Brief interventions by health professionals in primary care settings are effective Three studies have been undertaken in the UK investigating the effectiveness of priwmary health care professionals in giving advice to heavy drinkers to reduce their alcohol consumption20-23. These studies have demonstrated that 10-15 min of GP advice result in reduction of alcohol consumption of around 15% and reductions in the proportions of excessive drinkers of around 20%. The World Health Organization has coordinated a collaborative study in eight different centres of the world investigating the effectiveness of minimal intervention strategies- in -primary health care settings9. Interim results from a number of the participating centres are encouraging.
Why are we not doing it? Pessimism about effective intervention Studies have demonstrated that primary health care physicians hold negative attitudes about their ability and effectiveness to help heavy drinkers cut down on their drinking'0-12 A quote from a study by Thom and Tellez"l called 'A Difficult Business' succinctly summarizes attitudes held by primary care physicians: i'One of the things I don't do is ask too many questions because I don't want to uncover a whole lot of things I can't deal with. So my technique sounds awful but it is to wait until something comes to my attention generally. I'm not going hunting out problems I don't know how to treat. I could spend hours and hours every dayytring to deal with it. Now if it were obvious how I couild deal with it effectively then I might go out looking for a few patients'.
Confusion regarding who is responsible for confronting alcohol problems Is alcohol a medical problem, contributing to 6% of all adult deaths in the United Kingdom, or a social probkem, costing the United Kingdom in excess of £2 billion per year, or a- political problem for which fiscal policy and action on licensing laws are required? Although the most effective way of reducing'alcohol problema is by reducing overall consumption, which is best achieved by flscal- policy through taxation", the importance of aleohol to health care workload needs to be stressed. The 20% of adult patients registered with a GP who are drinking at levels of alcohol consumption that put their health at risk require a personalized health education message that has been demonstrated to be effective. Uncertainty about the appropriate target population It is estimated that 81% of adult drinkers in a UK -general practice poptlation are driniking levels of -alcohol consumption that constitute a low risk to
480
Journal of the Royal Society of Medicine Volume 85 August 1992
their health.6 Fifteen per cent are drinking levels of alcohol consumption that constitute a hazardous risk to their health and 4% are drinking levels of alcohol consumption that constitute a high risk to their health. Traditionally in general practice attention has been focused on the high risk group. The target population should be all drinkers. Low risk drinkers should be encouraged to maintain healthy drinking. Brief advice should be given to the at-risk drinker to reduce their alcohol consumption. The process of change model is an appropriate intervention strategy for the high risk group25. Inappropriate management programmes and philosophies The Royal College of General Practitioners in their report 'Alcohol-A Balanced View', published in 1986, concluded that: 'We do not subscribe to the view that alcoholism is in itself a disease'6. The disease approach is inappropriate to dealing with the high risk drinker in the general practice setting. It has led to poor success rates with frustration, poor work satisfaction and low self esteem on the part of the practitioner. The Royal College of General Practitioners report went on to say: 'We see everyone's drinking as spread along a continuum from harm free drinking at one end to harmful drinking at the other. An individual's behaviour is learned and modified by experience; at any stage it is determined by a balance of the advantages and disadvantages of drinking. Everyone, whatever their current level of drinking, has the choice to move forward or backward along this continuum'. The Royal College of General Practitioners concluded that this understanding of the reasons for alcohol consumption, a concept developed by the British Psychological Society26, forms a more helpful basis for developing management programmes in general practice. Practical skills and techniques are not being taught to health professionals There is considerable evidence of a lack of teaching of appropriate practical skills and techniques at both the undergraduate and postgraduate level of medical training27. In addition there needs to be sufficient input to continuing education programmes. Once qualified, many practitioners will spend up to 40 years of a professional life. During this time continuing education programes need to be offered so that new developments and techniques are learned. A study of GPs demonstrated that whereas over 90% felt that they had a legitimate role to work with drinkers, only 40% felt capable to work with drinkers and 40% felt motivated to work with drinkers'0. Less than one in three were satisfied with the way in which they worked with drinkers and less than 10% obtained work satisfaction from working with drinkers. This study demonstrated that although practitioners felt they have a legitimate role to work with drinkers they lacked the necessary skills and techniques to do so. A lack of skills leads to frustration and dissatisfaction which in turn lead to low feelings of self esteem.
How can we do it effectively? Adopt a basic strategy for intervention There are four components to a basic strategy for management of alcohol problems in general practice'3. These are:
(1) to recognize that alcohol is a risk factor for ill health; (2) to set a systematic programme for screening for alcohol consumption; (3) to conduct a systematic assessment where appropriate; (4) to base the response on the level of risk of harm from alcohol consumption. Recognition that alcohol is a risk factor for ill health A review of 154 published studies on the relationship between alcohol consumption and harm suggests that for most conditions there is a direct linear relationship between alcohol consumption and harm16. Alcohol is a risk factor for ill health in much the same way as blood pressure, cigarette smoking, serum cholesterol or body weight are. The more alcohol is consumed the greater the risk to individual health. Nevertheless it is appropriate to have a pragmatic response based on levels of risk. In the United Kingdom risk has been divided into three groups as follows: Units per week
Lower risk Raised risk Higher risk
Women 14 and under 15-21 22 and over
Men 21 and under 22-35 36 and over
1 unit=% pint of beer, single glass of wine or pub measure of spirits and contains approximately 10 g of alcohol
Set up a systematic programme for screening for alcohol consumption General practice populations need to be screened for alcohol consumption. Screening programmes can be done using lifestyle approaches in which alcohol consumption is measured by self-administered questionnaires28 or computerized assessment procedures29. Screening can also be undertaken using a clinical approach determining both consumption and harm. Questionnaires such as the World Health Organization audit screening instrument30-3' and the Alcohol Clinical Index developed by the Addiction Research Foundation, Ontario32-33 can be used.
Adopt a systematic assessment where appropriate Individuals in the high risk category should undergo a structured assessment including history, examination and investigations6. Base response on level of risk of harm from alcohol consumption The response to individuals can be structured according to their level of alcohol consumption. Individuals consuming levels of alcohol that are lower risk to their health should be provided with a health maintenance strategy supporting consumption of alcohol within the amounts that are lower risk to their health. Individuals consuming levels of alcohol that are a moderate risk should be included in a minimal intervention strategy. This strategy includes giving brief advice to reduce alcohol consumption34. The strategy can be undertaken within a 10 minute
Journal of the Royal Society of Medicine Volume 85 August 1992
consultation by a primary care practitioner, doctor or nurse. The strategy can be easily transferable so that it can be used by primary care nurses and physicians in different circumstances and health care settings. The process of change strategy should be initiated for high risk drinkers35. This strategy which is based on the work of Prochaska and DiClemente recognizes that in changing any type of behaviour individuals go through four stages of change25. The stages include a pre-contemplation stage in which individuals are not aware that their behaviour is risky to their health; a contemplation stage in which individuals are aware that their behaviour is of risk to their health but in which no definite action had been taken to change the behaviour; an action phase in which individuals are actively trying to change their behaviour; and a maintenance stage in which individuals are attempting to maintain a changed behaviour. Make practical techniques available Professional support literature: There is an extensive range of professional support literature available for
practitioners34'35. Screening instruments: Screening instruments have been produced, tested and validated in primary care settings36. Screening instruments include health questionnaires measuring alcohol consumption28 and combined questionnaires which measure both consumption and harm such as the World Health Organization Audit Screening Instrument30'31. Assessment instruments: There are a number of assessment instruments, many of which, however, have not been- validated in general practice
settings36. Patient support literature: Patient support literature has been developed for the health maintenance strategy37 and the minimal iivtervention strategy and for the process of change strategy38. Provide ongoing support and training to health care professionals Traditional techniques of continuing medical education include publications and clinical guidelines, both written and audio visual and workshops and courses. New developments in continuing education have emphasized the importance of taking education to the practices where programmes can both be incorporated into every day work tailored to individual needs40'41.
Convince key people to implement the-programme Having adopted a strategy to manage alcohol problems in the primary care setting it is important to convince
key people of the importance of these programmes so that they can be initiated and maintained. In its new contract for GPs the Department of Health has emphasized the importance of preventibn and health promotion activitiesO2. It is now a required part of the terms and conditions of service that general practitioners should undertake prevention and health promotion activities. These include screening for alcohol consumption and offering simnple advice to those groups who are found to be at risk because of their drinking. It Is important to ensure that specialist agencies support the strategy for general practice. This means a strengthening of the role of specialist agencies to both offering management facilities themselves and an increased role in supporting primary health care4..
Conclusion This paper has reviewed why primary care physicians should be involved in the prevention and management of alcohol problems. The paper has indicated the diffilculties involved for primary health care physicians and suggested ways in which physicians can prevent and manage alcohol problems more effectively. Implementing the-strategies outlined in the paper would broaden the base of treatment for alcohol
problems43. References 1 Babor TF, Ritson B, Hodgson R. Alcohol related problems in primary health care setting: a review of early intervention strategies. Br J Addict 1986;81:2346 2 Anderson P. Early intervention in general practice. In: Stockwell T, Clement S, eds. Helping the problem drinker. London: Croom Helm, 1984 3 Treatment and rehabilitation programmes in alcohol abuse. Copenhagen: WHO Regional Office for Europe, 1986 (unpublished document ICP/ADA 993/sOl) 4 The respective roles of primary health-care and alized services in the development and implementation of programmes for problem drinkers. Copenhagen: WHO Regional Office for Europe, 1987 (unpublished document ICP/ADA 010) 5 Working group on implementation and evaluation of programmes for problem drinking: summary report. Copenhagen: WHO Regional Officer for Europe, 1987 (unpublished document EUMRICP/ADA 031(S)) 6 Alcohol - a balanced view. Report from General Practice No. 24. London: Royal College of General Practitioners, 1986 7 Anderson P. The management of drinking problems. WHO Regional Publications, European series, No. 32. Copenhagen: WHQ Regional Officer for Europe, 1991 8 Babor TF, DeLa Fuente JR, Saunders J, Grant M. The alcohol use disorders identification test: guidelines for use for primary health care. World Health Organization, Division of Mental Health, Geneva, 1989 9 Saunders JB. The WHO project on early detection and treatment of harmful alcohol consumption. Aust Drug Alcohol Rev 1987;6:303-8 10 Anderson P. Managing alcohol problems in general practice. BMJ 1985;290:1873-5 11 Thomr B, T-ellez C. A difficult business: detecting and managing alcohol problems in general practice. Br J Addict 1986;81:4Q0-18 12 Clement S. The identification of alcohol-related problems by general practitioners. Br J Addict 1986;81:257-64 13 Skinner HA. Early detection of alcohol and drug problems - why? Aust Drug Alc Rev 1987;6:293-301 14 Walsh D. Alcohol related medicosocial problems and their prevention. Copenhagen: WHO Regional Office for - Europe, 1982 (Public Health in Europe No.-,17) 15 Anderson P. The excess mortality associated with alcohol consumption. BMJ 1988;297:824-6 16 Turner C. A quantitative assessment of harm related to alcohol use. Oxford: Alcohol Research Centre, 1991 17 Hingson R, Mangione T, Meyers A, Scotch N. Seeking help for drinking problems; a study in the Boston metropolitan area. J Stud Alcohol 1982;43:273-88 18 Miller WR, Hester RK. Treating the problem drinker: Modern approaches. -In: lMiller WR, ed. The addictive behaviours. New York: Pergamon, 1980 19 Wallace PG, Brennan PJ, Haines AP. Are general practitioners doing enough to promote healthy lifestyle? Findings of the Medical Research Council's General Practice Research Framework Study on Liifestyle and Health. BMJ 1987;,24:940-2 20 Heather N, Campion PD, Neville RG, Maccabe D. Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS schemxe). J- R Coll Gen Pract 1987; 37:358-63 --
481
482
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21 Wallace P, Cutler S, Haines A. Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297: 663-8 22 Anderson P, Scott E. The effect of general practitioner advice to heavy drinking men. Br J Addict (in press) 23 Scott E, Anderson P. Randomized controlled trial of general practice intervenvtion in women with excessive alcohol consumption. Drug Alcohol Rev 1990;10:313-21 24 Maynard A, Tether P, eds. Preventing alcohol and tobacco problems, vol I. Aldershot: Avebury, 1990 25 Prochaska JO, DiClemente CC. The transtheoretical approach. Illinois: Dow Jones-Irwin, 1984 26 Robertson I, Hodgson R, Orford J, McKechnie R. Psychology and problem drinking. Leicester: British Psychological Society, 1984 27 Preventing alcohol problems: the challenge for medical education. Proceedings of a National Conference, Niagara-on-the-Lake, Ontario. Toronto: University of Toronto, 1989 28 Wallace PG. Drinking patterns in general practice patients. J R Coll Gen Pract 1987;37:354-7 29 Skinner HA. Lifestyle assessment: applying microcomputers in family pactic. BMJ 1985;290:212-14 30 Babor TF. AUDIT. The alcohol use disorders identification test. guidelines for use in primary health care. Geneva: World Health Organization, 1989 (unpublished document WHO/MNH/DAT/89.4) 31 Saunders JB, Aasland OG. AUDIT The World Health Organization screening instrument for harmful and hazardous alcohol consumption. Geneva: The World Health Organization, 1990
32 Skinner HA, Holt S, Israel Y. Early identification of alcohol abuse. 1. Critical issues and psychosocial indicators for a composite index. J Can Med Assoc 1981;124:1141-52 33 Holt S, Skinner HA, Israel Y. Early identification of alcohol abuse. 2. Clinical and laboratory indicators. J Can Med Assoc 1981;124:1279-99 34 Anderson P. Reducing alcohol consumption. Practitioner 1991,285:612-14 35 Alcohol and Drugs. London: Royal College of General Practitioners (in press) 36 Anderson P. Self administered questionnaires for diagnosis of alcohol abuse. In Watson RR, ed. Diagnosis of alohol abuse. CRC Press, 1989 37 Health Education Authority. That's the limit. London: Health Education Authority, 1991 38 Health Education Authority. Cut down on your drinking pack. London: Health Education Authority, 1991 39 Scottish Health Education Group. DRAMS Pack. Edinburgh: Scottish Health Education- Group, 1990 40 Fullard E, Fowler G, Gray M. Facilitating prevention in primary care. BMJ 1984;289:1585-7 41 Fullard E, Fowler G, Gray M. Promoting prevention in primary care: controlled trial of low technology, low cost approach. BMJ 1987;294:1080-2 42 Department of Health. Terms of service for doctors in general practice. London: Department of Health, 1989 43 Institute of Medicine. Broadening the base of treatment for alchol problems. Washington: National Academy Press, 1990
(Accepted 22 October 1991)
A major Anglo-American event to celebrate the 25th Anniversary of the-RSM Foundation Inc
5-9 October 1992 Monday and Tuesday Specialist satellite meetings organised by RSM Sections in various medical centres in and around Lonon Wednesday to Friday An Anglo-American conference at tie Royal Society of Medicine on:
The impact of molecular medicine on clinical practice Speakers wiU include: Sir Walter Bodmer Prof Leroy Hood
Dr Sydney Brenner Sir John Vane
Dr Kay Davies Dr Joseph Goldstein Sir David Weatherall Prof Robeit Williams
Registration fees: RSM members: £120/$210, non-members: £150/S260 For further information, please contact: Pimna MaTis, The Royal Society of Medicine, 1 Wimpole Sueet, L Tel: 071 408 2119 Fax: 071 355 3197
WIM 8AE, UK
William O'Reilly, The RSM Foundation Inc, 150 E 58th Steed, New York, NY 10155, USA Tel: 212 371 1150 Fax: 212 371 1151
Journal of the Royal Society of Medicine Volume 85 August 1992
lifestyle'. It does not take long: Wiseman et aL " showed that an adequate alcohol history can be obtained in two minutes in general practice. People who drink to excess may be reluctant to disclose their habits (there are simple techniques for making them talk), but they may also genuinely not know how much they drink. Attempts to discover the exact amount may be less important than exploring the circumstances of drinking and the role that alcohol plays in their lives.
Alcohol misuse is a hopeless case Low expectations about treatment for alcohol misuse are universal. It would help if the experts were to admit that they can do little to alleviate alcohol dependence and that curative treatment of serious physical damage is rarely possible - hardly surprising given that they are the end result of years of damaging drinking. As a physician I find it helpful to regard the chronic alcohol misuser in the same way as a patient with chronic bronchitis or rheumatoid arthritis: I do not complain that they cannot be 'cured'. The way to improve the therapeutic image must surely be to shift the emphasis towards promotion of healthy drinking and earlier detection of problems. The value ofbrief interventions at this stage has been shown both in general practice6'7 and in hospital12. Pessimists say that uncovering problems will overwhelm services which are already stretched, yet doctors can do much themselves without having to seek specialist advice. They need, too, to shed their suspicion of cooperating with other health workers, since management of alcohol problems is a good example of the value of teamwork. They should also be prepared to learn from local alcohol agencies, whose members often know a great deal more about alcohol misuse than doctors and are only too willing to share their experience. Specialists will, of course, still be necessary to deal with difficult problems; all hospitals should have a consultant with an interest in alcohol misuse, who can also be involved in postgraduate training.
Conclusion One ofthe difficulties about alcohol is that conferences such as this usually consist of the (worldly) wise leading the wise. Nothing I have said will surprise anyone in the audience; many of us have been saying similar things for a long time. But if we believe that knowledge among doctors is inadequate isn't it time for action rather than words? Do we have a consensus
Primary care physicians and alcohol P Anderson MRCGPMFPHM Formerly, Director, HEA Primary Health Care Unit, Block 10, Churchill Hospital, Headington, Oxford OX3 7LJ Keywords: alcohol; general practice; screening; treatment
Introduction Over the last 5-10 years there has been an increasing recognition of the importance of primary care
on what should be done? If so, could we produce a series of guidelines which would be acceptable to educational authorities? I would like to propose the following as some of the core topics that could be tested: alcohol history taking, communicating about alcohol, how to undertake early detection and health promotion, techniques of brief intervention, familiarity with types of socio-economic as well as physical harm, how to work in a team, and knowledge of community networks and specialist support. Finally, doctors might examine their own attitudes; they could influence public opinion, as they did over smoking, by keeping their own drinking within sensible limits. References 1 Paton A. New survey of medical education. Alcohol Concern J 1986;2:14-16 2 Department of Health and Social Services. Alcohol related problems in undergraduate medical educatiom A survey of English medical schools. London: DHSS, 1987 3 Glass IB. Substance abuse and professional education: a tops-down or bottom-up approach? Br J Addict 1988;83:999-1001 4 Geller G, Levine DM, Mamon JA, Moore RD, Bone LR, Stokes EJ. Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism. JAMA 1989; 261:3115-20 5 Department of Health and Social Services. Alcohol related problems in higher professional and postgraduate medical education. London: DHSS, 1987 6 Wallace P, Cutler S, Haines A. Randomised controlled trial ofgeneral practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297:663-8 7 Anderson P, Scott E. The effect of general practitioners' advice to heavy drinking men. Br J Addict 1992; 87:891-900 8 Farrell MP, David AS. Do psychiatric registrars take a proper drinking history? BMJ 1988;296:395-6 9 Paton A. Alcohol misuse and the hospital doctor. Br J Hosp Med 1989;42:394-400 10 Bell G, Cremona A. Alcohol and death certification: a survey of current practice and attitudes. BMJ 1987; 295:95 11 Wiseman SM, McCarthy SN, Mitcheson MC. Assessment of drinking problems in general practice. J R Coll Gen Pract 1986;36:407-8 12 Chick J, Lloyd G, Crombie E. Counselling problem drinkers in medical wards: a controlled study. BMJ 1985;290:965-7
(Accepted 30 August 1991)
physicians in the prevention and management of problems related to alcohol use1'2. A number of centres have developed initiatives in the field of primary care and alcohol and this has been supported by reports from governmental and non-governmental organizations3-6. The European office of the World Health Organization commissioned a series of three meetings on alcohol and primary care which culminated in a technical report publication7. The World Health Organization in Geneva has recognized the importance of primary health care and has initiated a number of collaborative projects developing screening instruments for use in primary
Paper read to joint meeting of Sections of Epidemiology & Public Health and Psychiatry, 13 February 1991
0141-0768/92 080478-05/$02.00/0 © 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 August 1992 479 health care8 and evaluating minimal intervention strategies9. Despite these initiatives, negative attitudes are held' by primary care physicians about managing alcohol problems'0-12 and evidence sugges'ts that limited action is taking place in primary care for both preventing and managing alcohol problems13. This paper reviews why primary care physicians should be involved with alcohol problems, why primary care physicians are not currently involved, and what can be done to increase the involvement o,£primary care Dhvsicians in the Drevepntion "and manaraement of alcohol problems.
Why should we do it? Alcohol is a major cause of health care woorkload Alcohol is recognized as a major public healt;h problem in many countries second only to cigarette E.nWoklng4. In the United Kingdom, it has been estixriated that alcohol is the cause of 6% of all deaths in the age range 15-74's. Up to one fifth of male medical a dmissions to hospitals are alcohol related6. In the primary care setting one fifth of adult patients iregistered with a UK general practitioner are drinkiing alcohol at levels that put their health at risk6. A]Icohol is a risk factor for many social, psychological and physical
conditions'6. Many excessive drinkers do not seek help for their alcohol problems A number of studies have shown that only about one in five of adults with a drinking probAem seek specialist help for their problem'7. Althoiagh many people accept that they have a drinking problem because of recognition that their alcohol cornsumption is excessive, often help is only sought when the negative consequences of excessive alcoh4 ol use are experienced. This means that it is as imjportant to identify and offer advice to those who are drinking excessively rather than solely providing opp ortunities for management for those who have sulffered the negative consequences of alcohol. .
Socially stable individuals at early stages Of excessive drinking have better prognosis A review of 19 studies comparing outcome aIt one year follow-up for individuals who were excessiv e drinkers' and individuals who had serious problems related to alcohol use demonstrated that excessive drinkers had a success rate of 72% compared with 53% for those with serious problems'8. Whereas one half of those with a serious problem had resolved this by abstinence, the majority of- ecessive driners had improved by reducing their alcohol consumption. Health professionals in primary care settings are in an excellent position to identify problem drinkers The UK is fortunate in having a Health Service in which patients must register with- a GP to receive care. It is estimated that 98% of the population are registered with a GP. This means that GPs have defined populations for whose health 'care they are responsible. Primary care services are also accessible. It has been estimated that in the UK (population 50 million) there are 0.75 million consultation with a GP every week day. In addition two-thirds of registered patients consult their doctor in any one year. This patient contact allows -opportunistic screening programmes.
A number of studies have shown that primary health care professionals are seen to be credible by their patients as health educators. When asked for a raiking of sources ofhealth educational information, family doctors are put as number one on the list. Fourfifths 6f patients believe that their GP should be interested in their alcohol consumption19. Primary care services also lack the stigma of specialist treatment services. Primary care services are therefore more approachable to excessive drinkers without the fear of labelling.
Brief interventions by health professionals in primary care settings are effective Three studies have been undertaken in the UK investigating the effectiveness of priwmary health care professionals in giving advice to heavy drinkers to reduce their alcohol consumption20-23. These studies have demonstrated that 10-15 min of GP advice result in reduction of alcohol consumption of around 15% and reductions in the proportions of excessive drinkers of around 20%. The World Health Organization has coordinated a collaborative study in eight different centres of the world investigating the effectiveness of minimal intervention strategies- in -primary health care settings9. Interim results from a number of the participating centres are encouraging.
Why are we not doing it? Pessimism about effective intervention Studies have demonstrated that primary health care physicians hold negative attitudes about their ability and effectiveness to help heavy drinkers cut down on their drinking'0-12 A quote from a study by Thom and Tellez"l called 'A Difficult Business' succinctly summarizes attitudes held by primary care physicians: i'One of the things I don't do is ask too many questions because I don't want to uncover a whole lot of things I can't deal with. So my technique sounds awful but it is to wait until something comes to my attention generally. I'm not going hunting out problems I don't know how to treat. I could spend hours and hours every dayytring to deal with it. Now if it were obvious how I couild deal with it effectively then I might go out looking for a few patients'.
Confusion regarding who is responsible for confronting alcohol problems Is alcohol a medical problem, contributing to 6% of all adult deaths in the United Kingdom, or a social probkem, costing the United Kingdom in excess of £2 billion per year, or a- political problem for which fiscal policy and action on licensing laws are required? Although the most effective way of reducing'alcohol problema is by reducing overall consumption, which is best achieved by flscal- policy through taxation", the importance of aleohol to health care workload needs to be stressed. The 20% of adult patients registered with a GP who are drinking at levels of alcohol consumption that put their health at risk require a personalized health education message that has been demonstrated to be effective. Uncertainty about the appropriate target population It is estimated that 81% of adult drinkers in a UK -general practice poptlation are driniking levels of -alcohol consumption that constitute a low risk to
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their health.6 Fifteen per cent are drinking levels of alcohol consumption that constitute a hazardous risk to their health and 4% are drinking levels of alcohol consumption that constitute a high risk to their health. Traditionally in general practice attention has been focused on the high risk group. The target population should be all drinkers. Low risk drinkers should be encouraged to maintain healthy drinking. Brief advice should be given to the at-risk drinker to reduce their alcohol consumption. The process of change model is an appropriate intervention strategy for the high risk group25. Inappropriate management programmes and philosophies The Royal College of General Practitioners in their report 'Alcohol-A Balanced View', published in 1986, concluded that: 'We do not subscribe to the view that alcoholism is in itself a disease'6. The disease approach is inappropriate to dealing with the high risk drinker in the general practice setting. It has led to poor success rates with frustration, poor work satisfaction and low self esteem on the part of the practitioner. The Royal College of General Practitioners report went on to say: 'We see everyone's drinking as spread along a continuum from harm free drinking at one end to harmful drinking at the other. An individual's behaviour is learned and modified by experience; at any stage it is determined by a balance of the advantages and disadvantages of drinking. Everyone, whatever their current level of drinking, has the choice to move forward or backward along this continuum'. The Royal College of General Practitioners concluded that this understanding of the reasons for alcohol consumption, a concept developed by the British Psychological Society26, forms a more helpful basis for developing management programmes in general practice. Practical skills and techniques are not being taught to health professionals There is considerable evidence of a lack of teaching of appropriate practical skills and techniques at both the undergraduate and postgraduate level of medical training27. In addition there needs to be sufficient input to continuing education programmes. Once qualified, many practitioners will spend up to 40 years of a professional life. During this time continuing education programes need to be offered so that new developments and techniques are learned. A study of GPs demonstrated that whereas over 90% felt that they had a legitimate role to work with drinkers, only 40% felt capable to work with drinkers and 40% felt motivated to work with drinkers'0. Less than one in three were satisfied with the way in which they worked with drinkers and less than 10% obtained work satisfaction from working with drinkers. This study demonstrated that although practitioners felt they have a legitimate role to work with drinkers they lacked the necessary skills and techniques to do so. A lack of skills leads to frustration and dissatisfaction which in turn lead to low feelings of self esteem.
How can we do it effectively? Adopt a basic strategy for intervention There are four components to a basic strategy for management of alcohol problems in general practice'3. These are:
(1) to recognize that alcohol is a risk factor for ill health; (2) to set a systematic programme for screening for alcohol consumption; (3) to conduct a systematic assessment where appropriate; (4) to base the response on the level of risk of harm from alcohol consumption. Recognition that alcohol is a risk factor for ill health A review of 154 published studies on the relationship between alcohol consumption and harm suggests that for most conditions there is a direct linear relationship between alcohol consumption and harm16. Alcohol is a risk factor for ill health in much the same way as blood pressure, cigarette smoking, serum cholesterol or body weight are. The more alcohol is consumed the greater the risk to individual health. Nevertheless it is appropriate to have a pragmatic response based on levels of risk. In the United Kingdom risk has been divided into three groups as follows: Units per week
Lower risk Raised risk Higher risk
Women 14 and under 15-21 22 and over
Men 21 and under 22-35 36 and over
1 unit=% pint of beer, single glass of wine or pub measure of spirits and contains approximately 10 g of alcohol
Set up a systematic programme for screening for alcohol consumption General practice populations need to be screened for alcohol consumption. Screening programmes can be done using lifestyle approaches in which alcohol consumption is measured by self-administered questionnaires28 or computerized assessment procedures29. Screening can also be undertaken using a clinical approach determining both consumption and harm. Questionnaires such as the World Health Organization audit screening instrument30-3' and the Alcohol Clinical Index developed by the Addiction Research Foundation, Ontario32-33 can be used.
Adopt a systematic assessment where appropriate Individuals in the high risk category should undergo a structured assessment including history, examination and investigations6. Base response on level of risk of harm from alcohol consumption The response to individuals can be structured according to their level of alcohol consumption. Individuals consuming levels of alcohol that are lower risk to their health should be provided with a health maintenance strategy supporting consumption of alcohol within the amounts that are lower risk to their health. Individuals consuming levels of alcohol that are a moderate risk should be included in a minimal intervention strategy. This strategy includes giving brief advice to reduce alcohol consumption34. The strategy can be undertaken within a 10 minute
Journal of the Royal Society of Medicine Volume 85 August 1992
consultation by a primary care practitioner, doctor or nurse. The strategy can be easily transferable so that it can be used by primary care nurses and physicians in different circumstances and health care settings. The process of change strategy should be initiated for high risk drinkers35. This strategy which is based on the work of Prochaska and DiClemente recognizes that in changing any type of behaviour individuals go through four stages of change25. The stages include a pre-contemplation stage in which individuals are not aware that their behaviour is risky to their health; a contemplation stage in which individuals are aware that their behaviour is of risk to their health but in which no definite action had been taken to change the behaviour; an action phase in which individuals are actively trying to change their behaviour; and a maintenance stage in which individuals are attempting to maintain a changed behaviour. Make practical techniques available Professional support literature: There is an extensive range of professional support literature available for
practitioners34'35. Screening instruments: Screening instruments have been produced, tested and validated in primary care settings36. Screening instruments include health questionnaires measuring alcohol consumption28 and combined questionnaires which measure both consumption and harm such as the World Health Organization Audit Screening Instrument30'31. Assessment instruments: There are a number of assessment instruments, many of which, however, have not been- validated in general practice
settings36. Patient support literature: Patient support literature has been developed for the health maintenance strategy37 and the minimal iivtervention strategy and for the process of change strategy38. Provide ongoing support and training to health care professionals Traditional techniques of continuing medical education include publications and clinical guidelines, both written and audio visual and workshops and courses. New developments in continuing education have emphasized the importance of taking education to the practices where programmes can both be incorporated into every day work tailored to individual needs40'41.
Convince key people to implement the-programme Having adopted a strategy to manage alcohol problems in the primary care setting it is important to convince
key people of the importance of these programmes so that they can be initiated and maintained. In its new contract for GPs the Department of Health has emphasized the importance of preventibn and health promotion activitiesO2. It is now a required part of the terms and conditions of service that general practitioners should undertake prevention and health promotion activities. These include screening for alcohol consumption and offering simnple advice to those groups who are found to be at risk because of their drinking. It Is important to ensure that specialist agencies support the strategy for general practice. This means a strengthening of the role of specialist agencies to both offering management facilities themselves and an increased role in supporting primary health care4..
Conclusion This paper has reviewed why primary care physicians should be involved in the prevention and management of alcohol problems. The paper has indicated the diffilculties involved for primary health care physicians and suggested ways in which physicians can prevent and manage alcohol problems more effectively. Implementing the-strategies outlined in the paper would broaden the base of treatment for alcohol
problems43. References 1 Babor TF, Ritson B, Hodgson R. Alcohol related problems in primary health care setting: a review of early intervention strategies. Br J Addict 1986;81:2346 2 Anderson P. Early intervention in general practice. In: Stockwell T, Clement S, eds. Helping the problem drinker. London: Croom Helm, 1984 3 Treatment and rehabilitation programmes in alcohol abuse. Copenhagen: WHO Regional Office for Europe, 1986 (unpublished document ICP/ADA 993/sOl) 4 The respective roles of primary health-care and alized services in the development and implementation of programmes for problem drinkers. Copenhagen: WHO Regional Office for Europe, 1987 (unpublished document ICP/ADA 010) 5 Working group on implementation and evaluation of programmes for problem drinking: summary report. Copenhagen: WHO Regional Officer for Europe, 1987 (unpublished document EUMRICP/ADA 031(S)) 6 Alcohol - a balanced view. Report from General Practice No. 24. London: Royal College of General Practitioners, 1986 7 Anderson P. The management of drinking problems. WHO Regional Publications, European series, No. 32. Copenhagen: WHQ Regional Officer for Europe, 1991 8 Babor TF, DeLa Fuente JR, Saunders J, Grant M. The alcohol use disorders identification test: guidelines for use for primary health care. World Health Organization, Division of Mental Health, Geneva, 1989 9 Saunders JB. The WHO project on early detection and treatment of harmful alcohol consumption. Aust Drug Alcohol Rev 1987;6:303-8 10 Anderson P. Managing alcohol problems in general practice. BMJ 1985;290:1873-5 11 Thomr B, T-ellez C. A difficult business: detecting and managing alcohol problems in general practice. Br J Addict 1986;81:4Q0-18 12 Clement S. The identification of alcohol-related problems by general practitioners. Br J Addict 1986;81:257-64 13 Skinner HA. Early detection of alcohol and drug problems - why? Aust Drug Alc Rev 1987;6:293-301 14 Walsh D. Alcohol related medicosocial problems and their prevention. Copenhagen: WHO Regional Office for - Europe, 1982 (Public Health in Europe No.-,17) 15 Anderson P. The excess mortality associated with alcohol consumption. BMJ 1988;297:824-6 16 Turner C. A quantitative assessment of harm related to alcohol use. Oxford: Alcohol Research Centre, 1991 17 Hingson R, Mangione T, Meyers A, Scotch N. Seeking help for drinking problems; a study in the Boston metropolitan area. J Stud Alcohol 1982;43:273-88 18 Miller WR, Hester RK. Treating the problem drinker: Modern approaches. -In: lMiller WR, ed. The addictive behaviours. New York: Pergamon, 1980 19 Wallace PG, Brennan PJ, Haines AP. Are general practitioners doing enough to promote healthy lifestyle? Findings of the Medical Research Council's General Practice Research Framework Study on Liifestyle and Health. BMJ 1987;,24:940-2 20 Heather N, Campion PD, Neville RG, Maccabe D. Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS schemxe). J- R Coll Gen Pract 1987; 37:358-63 --
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21 Wallace P, Cutler S, Haines A. Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297: 663-8 22 Anderson P, Scott E. The effect of general practitioner advice to heavy drinking men. Br J Addict (in press) 23 Scott E, Anderson P. Randomized controlled trial of general practice intervenvtion in women with excessive alcohol consumption. Drug Alcohol Rev 1990;10:313-21 24 Maynard A, Tether P, eds. Preventing alcohol and tobacco problems, vol I. Aldershot: Avebury, 1990 25 Prochaska JO, DiClemente CC. The transtheoretical approach. Illinois: Dow Jones-Irwin, 1984 26 Robertson I, Hodgson R, Orford J, McKechnie R. Psychology and problem drinking. Leicester: British Psychological Society, 1984 27 Preventing alcohol problems: the challenge for medical education. Proceedings of a National Conference, Niagara-on-the-Lake, Ontario. Toronto: University of Toronto, 1989 28 Wallace PG. Drinking patterns in general practice patients. J R Coll Gen Pract 1987;37:354-7 29 Skinner HA. Lifestyle assessment: applying microcomputers in family pactic. BMJ 1985;290:212-14 30 Babor TF. AUDIT. The alcohol use disorders identification test. guidelines for use in primary health care. Geneva: World Health Organization, 1989 (unpublished document WHO/MNH/DAT/89.4) 31 Saunders JB, Aasland OG. AUDIT The World Health Organization screening instrument for harmful and hazardous alcohol consumption. Geneva: The World Health Organization, 1990
32 Skinner HA, Holt S, Israel Y. Early identification of alcohol abuse. 1. Critical issues and psychosocial indicators for a composite index. J Can Med Assoc 1981;124:1141-52 33 Holt S, Skinner HA, Israel Y. Early identification of alcohol abuse. 2. Clinical and laboratory indicators. J Can Med Assoc 1981;124:1279-99 34 Anderson P. Reducing alcohol consumption. Practitioner 1991,285:612-14 35 Alcohol and Drugs. London: Royal College of General Practitioners (in press) 36 Anderson P. Self administered questionnaires for diagnosis of alcohol abuse. In Watson RR, ed. Diagnosis of alohol abuse. CRC Press, 1989 37 Health Education Authority. That's the limit. London: Health Education Authority, 1991 38 Health Education Authority. Cut down on your drinking pack. London: Health Education Authority, 1991 39 Scottish Health Education Group. DRAMS Pack. Edinburgh: Scottish Health Education- Group, 1990 40 Fullard E, Fowler G, Gray M. Facilitating prevention in primary care. BMJ 1984;289:1585-7 41 Fullard E, Fowler G, Gray M. Promoting prevention in primary care: controlled trial of low technology, low cost approach. BMJ 1987;294:1080-2 42 Department of Health. Terms of service for doctors in general practice. London: Department of Health, 1989 43 Institute of Medicine. Broadening the base of treatment for alchol problems. Washington: National Academy Press, 1990
(Accepted 22 October 1991)
A major Anglo-American event to celebrate the 25th Anniversary of the-RSM Foundation Inc
5-9 October 1992 Monday and Tuesday Specialist satellite meetings organised by RSM Sections in various medical centres in and around Lonon Wednesday to Friday An Anglo-American conference at tie Royal Society of Medicine on:
The impact of molecular medicine on clinical practice Speakers wiU include: Sir Walter Bodmer Prof Leroy Hood
Dr Sydney Brenner Sir John Vane
Dr Kay Davies Dr Joseph Goldstein Sir David Weatherall Prof Robeit Williams
Registration fees: RSM members: £120/$210, non-members: £150/S260 For further information, please contact: Pimna MaTis, The Royal Society of Medicine, 1 Wimpole Sueet, L Tel: 071 408 2119 Fax: 071 355 3197
WIM 8AE, UK
William O'Reilly, The RSM Foundation Inc, 150 E 58th Steed, New York, NY 10155, USA Tel: 212 371 1150 Fax: 212 371 1151
