Paired intervention model for identified alcohol misuse in secondary care

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Pract. Dev. Health Care 6(4) 221–231, 2007Copyright © 2007 John Wiley & Sons, Ltd DOI: 10.1002/pdh

Research and review

Paired intervention model for identifi ed alcohol misuse in secondary care

John Sims—Clinical Nurse Specialist and Manager of Alcohol Services, Sub-stance Misuse Service, North West Wales NHS Trust, Anglesey

Marc R Kristian—IT Development Offi cer/Relapse Prevention Worker, Substance Misuse Service, North West Wales NHS Trust, Anglesey

Karen Pritchard—Service Consultant/Educator, Substance Misuse Service, North West Wales NHS Trust, Anglesey

Linda Jones—Service Consultant/Educator, Substance Misuse Service, North West Wales NHS Trust, Anglesey

ABSTRACT

High numbers of individuals with identifi ed alcohol misuse are being admitted to the second-ary care setting. Once individuals are stabilized, from a physical treatment point of view, there is a ‘window of opportunity’ that presents itself from a psychological perspective. Once individuals are stabilized, they often do not require any acute care input but they stay in hospital in order to complete a cross-tolerance prescribing regimen. Listening to the voice of the service user and considering their experience of care, this article discusses the merits of a ‘paired intervention’ response during this period. This refers to the concept of initiating psychological interventions to run in ‘tandem’ with chemically based treatments. Giving equal importance to psychological interventions delivered in conjunction with physical treatments

Practice Development in Health CarePract. Dev. Health Care 6(4) 221–231, 2007Published online 31 October 2007 in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/pdh.234

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is a way of optimizing this window of opportunity. Initiating a group-based psychological re-sponse utilizing a motivational model of intervention can be an extremely facilitative experi-ence within the in-patient environment. The importance of a collaborative delivery of the message regarding the benefi ts to a paired intervention is discussed. Recognition from medical colleagues of the benefi ts to a paired intervention is acknowledged. A coordinated response is important if individuals are to be facilitated towards maintenance of positive behavioural change following hospital discharge. Copyright © 2007 John Wiley & Sons, Ltd.

Key words: paired intervention, motivational model, window of opportunity

The scale of the problem of alcohol misuse nationally

It is known from a variety of sources that the misuse of alcohol in the UK is extensive. Data from the General Household Surveys (1998, 2002) confi rmed what front-line clini-cians already suspected: one in three men and one in fi ve women in the UK regularly consume above the suggested safe limits. Farrell et al. (2001) expressed this estimate as 8 million Britons drinking above recommended levels. These safe limits are defi ned as being no more than 14 units a week for women and no more than 21 units a week for men. The Royal College of Physicians (2001), in its report ‘Alcohol – can the NHS af-ford it?’, attempted to quantify the problem and then went on to make a number of recommendations. The in-patient costs resulting from alcohol misuse are huge. It is estimated that 20% of all hospital admissions have an alcohol component in their presentations, and the in-patient costs alone have been estimated to be in the region of £3 billion a year. This fi gure accounts for 12% of total NHS expenditure and is obviously a huge drain upon NHS resources.

Recently, the Royal College of Physicians, together with the Royal College of Gastroenterologists, in their conference entitled ‘Alcohol-related harm – a growing crisis: time for action’ (2005), identifi ed a signifi cant increase in individuals requiring medical intervention. They estimated that one in 20 individuals in the UK is alcohol dependent. A similar number is also considered to be at risk from developing alcoholic liver disease. The same Royal Colleges also reported a seven-fold increase in alcohol-related liver deaths.

Recommendations made by the Royal College of Physicians (2001) included the appointment within each district general hospital of an individual with a recognized expertise in the fi eld of alcohol misuse. This individual is advised to establish a steering group to facilitate the development of a coherent alcohol strategy within the secondary care setting to respond to this extensive problem. Of course, the misuse of alcohol does not take place in isolation. It is often accompanied by other forms of anti-social behav-iours. These can include the following:

• Domestic abuse/violence (Abbott et al., 1995; Barron, 2004; Galvani, 2004; Sims and Iphofen, 2003a; Stella Project, 2004)

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• Child protection concerns (Sims and Iphofen, 2003b; Tunnard, 2002; The Advisory Council on the Misuse of Drugs, 2004)

• Dual diagnosis (mental ill health associated with alcohol misuse) (Sims et al., 2003c; Welsh Assembly Government, 2004)

• Offending behaviour (Criminal Justice Act, 2004)

While in a hospital setting, individuals with alcohol-related problems are given the necessary life-saving physical interventions required to facilitate their survival. Once physically stabilized, these individuals often become self-caring and fully ambulant. Most hospital pharmacy departments do not consider patient discharge, while the pa-tient is still in receipt of benzodiazepines, as safe/good practice. Consequently, these individuals are required to stay in hospital to complete their cross-tolerance prescribing regimen. These patients are often viewed in a negative way by some medical and nurs-ing staff as being less deserving of treatment, as they are perceived as having infl icted their plight upon themselves.

Local statistics in north-west Wales

The North West Wales NHS Trust has a responsibility for providing health and social care to the populations of the two unitary authorities of Gwynedd and Mon (Anglesey), both situated on the western seaboard of North Wales. This is a predominantly Welsh-speaking area, with the majority of residents having Welsh as their fi rst language. As a requirement of the Welsh Language Act (1995), all materials must be produced through the medium of Welsh and English. The North West Wales NHS Trust is com-mitted to the provision of services through the language of fi rst choice wherever possi-ble. The total population covered by the Trust is 181,400 in 1500 square miles. The Alcohol Service is part of the Substance Misuse Service (SMS), provided by the Mental Health Directorate part of the North West Wales NHS Trust. The SMS is a practice development unit (PDU), accredited via the Centre for the Development of Healthcare Policy and Practice (University of Leeds).

In the 12 months between the beginning of April 2005 and the end of March 2006 there were 143 assessments undertaken by the lead author. The assessment of these individuals utilized well-established screening tools for alcohol and mental health assessment of need. These screening tools comprised the Alcohol Use Disorders Iden-tifi cation Test (AUDIT) and The Health of the Nation Outcome Scales (HoNOS). AUDIT consists of a ten-item self-complete questionnaire with a scaled response score ranging from 0–4. The total AUDIT score is the sum of the scores rated by the response to each individual question. Individuals are assigned to one of three categories in response to their total AUDIT score: hazardous drinking (8–15), harmful drinking (16–19) and chemically dependent drinkers (20+). The ‘cut-off’ point for AUDIT is 8. Similarly, the Health of the Nation Outcome Scales (HoNOS) (Wing et al., 1998) is a set of 12 scales designed for use in routine clinical practice. The scales measure the health and social functioning of individuals accessing mental health services. The

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HoNOS provides four sub-scale scores (behavioural problems, impairment, psychiatric problems and social problems) and a total score (0–48). Of the 143 initial assessments undertaken within the in-patient population, the minimum HoNOS score was 14 and the maximum HoNOS score was 35, with a mean HoNOS score of 18.

From a cognitive perspective, how can this ‘window of opportunity’ best be exploited so as to maximize the potential for maintained sobriety following hospital discharge?

A recent review of the literature pertaining to the most effective psychological clinical interventions has been offered by Luty (2006), who discussed the outcome of randomized controlled trials such as Project MATCH in the USA and, more recently, the UK Alcohol Treatment Trial (UKATT). Favourable clinical outcomes are achieved through cost-effective intervention, adopting the brief interventions model (Miller and Rollnick, 1991).

If an in-patient is perceived as having an alcohol problem, one suggestion would be to alert the patient of the long-term dangers of continued problem drinking, via an empathetic approach, and to initiate use of a brief interventions model (Miller and Rollnick, 1991) while the patient is still in the hospital. A way of delivering this mes-sage can be by inviting the patient to attend a group activity away from the acute ward environment. This forum can also be used as a way of addressing the negative staff culture towards this client group, by inviting staff to attend the sessions together with patients, and can provide an excellent and safe forum in which to challenge these negative perceptions.

Within Wales, each unitary authority has a substance misuse action team (SMAT). The membership of each SMAT is made up of all agencies involved in re-sponding to substance misuse problems.

Valuing the patient voice

Services for individuals with substance misuse problems in north-west Wales are pro-vided by the SMS, which is a Practice Development Unit (PDU) fully accredited at stage II via the Centre for the Development of Healthcare Policy and Practice (Uni-versity of Leeds). It is vital that services listen to the experience of patients in order that services can develop appropriately. Their experience of what it is really like to be an in-patient is invaluable. We are responding to the challenge of learning from this experience.

Accusations of tokenism are often levelled at organizations for using past or current users of services in a way that does not necessarily result in signifi cant appropri-ate changes in service delivery. Individuals who have used or who are currently using the SMS are involved in a variety of ways to advise us regarding the development of our service. These levels of involvement can be witnessed by representation on the practice development steering group and user-/ex-user-led support groups. This develop-ment of paired intervention is further confi rmation of the level of importance that we as a service place on listening to the patient’s/user’s voice.



Centres of learning, such as the Faculty of Health at the University of Leeds, have long been advocates of valuing the patient experience and harnessing this experi-ence in order to enhance the learning of health care trainees and providers of health and social care (O’Neill et al., 2006). Signifi cant learning can be achieved by profes-sionals being willing to think ‘outside the box’. The experience of sharing their valued experience can be very liberating for individuals who have been in receipt of care; they are best placed to give advice on how the quality of care can be improved upon. Service users should not be made to feel that they are passengers in their own treatment and should be welcomed as partners in the development of services (Freire, 1996).

The following dialogue is an example of the patient experience of negative staff attitudes that can impact upon clinical outcomes:

‘My time in hospital was good in the sense of getting you fi t physically. There was

no one really to talk to, just hours alone to dwell on things. The fi rst doctor I saw

talked only to my daughters about my health, even asking them how much I drank.

They fi red a question at me suddenly asking if I was in pain, then dismissing me,

as if I was of no consequence. When I woke up on the fi rst day I was there I felt I

wanted to use the toilet. The nurses ignored me completely; in the end when they

saw me struggling to get out of bed they told me in a very unfriendly fashion that

I didn’t need to go as I had a catheter and left me there without any explanation. I

could hear them talking about my alcohol problem at the desk. They would give me

tablets and take my blood pressure and weigh me without uttering a word.

They came to take some fl uid from my abdomen. I was not told what they were

doing or why they were doing it. When I saw this tube thing it scared me; they

then told me rather fl eetingly what they were doing. One doctor, on being asked

by my daughter if I was going to die, said ‘yes she could’, ignoring me!

One nurse was talking about a lady that came in and said ‘she’s in because of

alcohol abuse too’ and looked at me and said ‘Like her there’.

The whole stay was unpleasant. Lack of communication, no privacy (doctors dis-

cussing my case openly). I was described as a chronic alcoholic in front of every-

one else in the ward. No understanding and no patience. On the whole you were

treated as someone that was a waste of space and a waste of their time’.

This example of a real patient experience can obviously have a devastating impact upon individual motivation and is likely to infl uence patient outcomes.

What do we mean by paired intervention?

When individuals with alcohol-related health problems are admitted to hospital, they often require intensive medical treatment responses. Once chemical dependence upon alcohol is established, these physical treatments take the form of cross-tolerance pre-scribing with chlordiazepoxide (Librium). This is a benzodiazepine prescribed for con-trolled alcohol withdrawal. High doses of chlordiazepoxide are prescribed and, once the patient is stabilized, the dose is then titrated downwards and by this means is gradually

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withdrawn over the course of seven to ten days. Often, as a co-pharmacotherapy adjunct, thiamine (Pabrinex) is added to the patient’s drug regimen as a prophylactic measure to prevent the development of symptoms conducive to a diagnosis of Wer-nicke’s encephalopathy. This can be a common complication of alcohol withdrawal syndrome due to nutritional defi ciency in chronic alcohol misusers, who have a history of poor dietary intake, often accompanied by daily vomiting, resulting in loss of essen-tial nutrients and urea and electrolyte imbalance. An alcohol withdrawal complication such as Wernicke’s encephalopathy can often prove fatal if undiagnosed or untreated (Nursing Council on Alcohol, 2004). With the afore-mentioned emergency drug therapy, therefore, the patient can be treated successfully. However, this should only be viewed as part of the initial treatment. Also important to the long-term maintenance of the patient’s newly acquired sobriety, psychological interventions must play a part in order to achieve any cognitive change resulting in long-term positive clinical outcomes. Without this important component of treatment, the positive physiological outcome is unlikely to be maintained.

Once the patient has been stabilized medically, messages regarding the negative effects of alcohol misuse can be imparted. Patients undergoing alcohol withdrawal medical treatment are often at their most motivated while in hospital. The principles behind combining physical treatments and psychological interventions are to exploit optimally this window of opportunity that presents itself while the individual is hospi-talized. The style of psychological interventions is often in the form of brief psychologi-cal interventions and working with partners and families of individuals, adopting the principles of psycho-social interventions and the brief interventions model.

This early initiation of hospital-based interventions is also an attempt to initi-ate cognitive changes and to smooth the transition for the patient from secondary care back into the primary care setting. Hospital-based staff then work in a coordinated and collaborative fashion with colleagues in the community in order to give individuals the best chance of maintaining positive behavioural change once discharged back into the community. The recruiting of service consultants to assist in this process is vital if we are able to understand better the patient experience while in hospital. Other valuable initiatives include the recruitment of family members and partners in an attempt to reinforce the messages initiated in the clinical environment and transfer these messages into patients’ homes following hospital discharge.

The intervention itself and the method of delivery

An important aspect of offering any clinical intervention is to be consistent – in other words, to be where you say you will be at the time you said you would be there – and also to have a fi rm evidence base for what you are delivering. The intervention itself consists of a series of PowerPoint slides that discuss the effects of alcohol misuse. Prior to commencement of the alcohol education group, individuals are asked to re-appraise their relationship with alcohol. The intervention takes the style of a brief interventions



model. This approach is educational and motivational, and has two modes of delivery, both group and individual. The intervention is delivered in four components:

I. Group educationII. Group shared experienceIII. Individual appraisal of relationship with alcoholIV. Patient information

The evidence base supporting the benefi ts of brief psychological interventions with alcohol-misusing individuals is vast (Beich et al., 2003; Bien et al., 1993; Copello et al., 2002; Drummond, 1997; Hungerford et al., 2000, 2003; John et al., 2002; UKATT Research Team, 2001; Wright et al., 1998).

Inviting patients to get away from often hectic and high stress clinical environ-ments can be therapeutic in itself. The intervention is laptop based and, as discussed above, is designed to be delivered both on a group and individual basis. Advantages to the group delivery are that it provides patients with a safe forum in which to explore their use of alcohol and an opportunity to meet others in a similar situation.

Exclusion criteria

All patients with a terminal diagnosis/prognosis are excluded from the programme. Separate to this, a written protocol is in place, whereby any individual who presents with vulnerability during the group session will be referred on to the appropriate agency. A good example of this is disclosure regarding childhood trauma such as sexual abuse.

Protocol/policy for self-disclosure of childhood abuse

Childhood experiences that can be a driver for drinking behaviours may be disclosed during interaction with clients. A protocol to guide the responses of the group facilitator has been written. This will invite the client to discuss the issue on an individual basis with the group facilitator, who will then refer the patient on to specialist services.

Patient information

Each person attending the group, once they have given their consent, is then given a typed leafl et containing more detailed information regarding the group. Separate to this, all those attending the group will also be given written feedback regarding their self-assessment. A further leafl et will be given explaining all of the types of medications used in the hospital setting for the withdrawal from alcohol.

Consent

All patients are given an explanation of the intervention itself and are asked to give written consent.

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Educational component of the paired intervention

Health information is given regarding the negative effects of alcohol (both physical and psychological), as discussed above. These health messages are delivered visually via a PowerPoint animation. This then generates discussion within the group regarding all health issues relating to alcohol misuse, identifying positive and negative aspects of continued alcohol use and misuse.

Individual discussions around personal use of alcohol

A structured assessment of the amounts of alcohol being consumed is undertaken on an individual basis. This is self-administered with pen and paper. This process contrib-utes to the demystifi cation of medicalized jargon. Patients may not have had their di-agnosis and associated health issues adequately explained. Medical colleagues, due to limitations of time, are not always able to explain these issues adequately. Often, the language used is not appropriate for patients to develop a deeper understanding of the impact of their diagnosis. This forum provides a confi dential and safe environment for patients with alcohol-related problems to explore their anxieties and develop a better understanding of their alcohol use while they are in hospital.

Motivational component of the paired intervention

A motivational profi le is established by undertaking the intervention. The imparting of information contributes to the devolving of ownership of the problem to the patient. A further part of this discussion will involve individual goal setting and information giving with regard to support networks available following hospital discharge. Each in-dividual is given a printed version of their individual assessment.

Transitional care planning

By participating in the paired intervention programme, the patient is entering into a partnership dialogue with helping agencies. This patient/service provider dialogue be-comes a fundamental component of the process designed to negotiate the aftercare planning in preparation for the patient’s discharge from hospital. This negotiation dia-logue is a vital contribution to ensure a seamless transition for the patient between the secondary and primary care setting and as a way of enhancing the potential for sus-tained sobriety. Those attending the group are given a date for their initial supportive follow-up appointment with their community alcohol worker and the contact details of the latter.

Conclusion

This method of intervention is cost effective and is a good use of existing resources. A range of intervention styles, drawing mainly on the brief intervention and motivational interviewing styles, are integrated into its delivery. Without the need for any extra



resources, an increased number of patients can be targeted at any one time, in addition to individuals seen in the ward situation. The target audience can be anyone, at any stage of the cycle of change (Prochaska and DiClemente, 1990), irrespective of whether they are pre-contemplative, contemplative or in the action stage of the revolving model of change. Individuals attending the group are invited to become partners, together with alcohol workers, in the planning of their follow-up and support package for their continued sobriety and recovery in the community.

Separate to this, the group can also be an ideal forum in which to deliver training to those undergoing professional training in this fi eld. By providing this style of training, trainees will be facilitated towards close personal contact with individuals who have alcohol-related health problems. By having this experience, trainees can de-velop a better understanding of the needs of these individuals and have a more positive and less judgmental attitude to this client group.

Service consultant programme

The SMS greatly values the patient experience of services. This is evidenced by the level of involvement that patients have in the development of their service, the SMS. Most recently, this was further evidenced by the SMS undergoing an external accredita-tion process via the University of Leeds. The Centre for the Development of Healthcare Policy and Practice offers a systematic accreditation programme that focuses upon a number of developmental issues. These are, specifi cally, positive sustainable change, innovation and creativity, with the central focus on service users. The experience of service users is a valuable resource that can be utilized and exploited as a way of deter-mining what works. As a way of harnessing this invaluable experience, the SMS is undertaking a number of projects that involve the process of listening to the voice of the service user and empowering them to contribute to service development. The paired intervention model is a good example of this, as we encourage input into the group activity component of the intervention from ex-service users.

There are great benefi ts to introducing measurements to be administered prior to the intervention and follow-up periods after hospital discharge. The authors now wish to develop these ideas further by formally applying for ethics approval to follow up patients who have chosen to undergo the paired intervention.

ReferencesAbbott J, Johnson R, Kozlot-McLain J, Lowenstein SR (1995). Domestic violence against women. Inci-

dence and prevalence in an emergency department population. Journal of the American Medical Association 273(22): 1763–7.

Barron J (2004). Struggling to survive. Safe-Domestic Abuse Quarterly. Autumn: issue 11, 10–12.Beich A, Thorsen T, Rollnick S (2003). Screening in brief intervention trials targeting excessive drinkers

in general practice: systematic review and meta-analysis. British Medical Journal 327(7414): 536–42.

Bien TH, Miller WR, Tonigan JS (1993). Brief interventions for alcohol problems: a review. Addiction 88: 315–35.

Sims et al.230


Copello A, Orford J, Hodgson R, Tobin G, Barrett C, on behalf of the UKATT Research Team (2002). Social behaviour and network therapy: basic principles and early experiences. Addictive Behaviours 7: 345–66.

Drummond DC (1997). Alcohol interventions: do the best things come in small packages? Addiction 92: 1699–704.

Farrell M, Howes S, Bebbington P (2001). Nicotine, alcohol and drug dependence and psychiatric comor-bidity. Results of a national household survey. British Journal of Psychiatry 179: 432–7.

Freire P (1996). The Pedagogy of the Oppressed. Hamondsworth: Penguin Books.Galvani S (2004). Responsible disinhibition: alcohol, men and violence to women. Addiction Research

and Theory 12(4): 357–71.General Household Survey (1998). London: Offi ce of National Statistics.General Household Survey (2002). London: Offi ce of National Statistics.Government responses to hidden harm: the report of an inqury by the Advisory Council on the Misuse

of Drugs. The Advisory Council on the Misuse of Drugs, London (2004).Hungerford DW, Pollock DA, Todd KH (2000). Acceptability of emergency department-based screening

and brief intervention for alcohol problems. Academic Emergency Medicine 7(12): 1383–92.Hungerford DW, Pollock DA (2003). Emergency department services for patients with alcohol problems:

research directions. Academic Emergency Medicine 10(1): 79–84.John B, Alwyn T, Hodgson RJ, Smith AJ, Waller S (2002). The feasibility of alcohol interventions in ac-

cident and emergency departments. The Drug and Alcohol Professional 2(2): 8–16.Luty J (2006). What works in alcohol use disorder? Advances in Psychiatric Treatment 12: 13–22.Miller W, Rollnick S (1991). Motivational Interviewing: Preparing People to Change Addictive Behaviour.

New York: The Guildford Press.Nursing Council on Alcohol (2004). The detection of alcohol misusers attending hospital and the man-

agement of alcohol withdrawal syndrome and Wernicke’s encephalopathy: an evidence-based protocol. Link Pharmaceuticals.

O’Neill F, Morris P, Symons J (2006). Bridging the gap: learning with patient teachers in health professional education. Practice Development in Healthcare 5(1): 26–9.

Prochaska DO, DiClemente C (1990). Revolving door model of change in Relapse Prevention for Addictive Behaviours: A Manual for Therapists. Page 8. (eds Wanigaratne S et al.) Blackwell Science.

Royal College of Physicians (2001). Alcohol – can the NHS afford it? Recommendations for a coherent alcohol strategy for hospitals. London: Royal College of Physicians.

Royal College of Physicians (2005). Alcohol-related harm – a growing crisis: time for action. London: Royal College of Physicians.

Sims J, Iphofen R (2003a). Substance misuse and the abuse of women. Wetherby: British Library Special Acquisitions Unit (Catalogue Number m03/3/37596).

Sims J, Iphofen R (2003b). Parental substance misuse and Its effects on children. The Drug and Alcohol Professional 3(3): 33–40.

Sims J, Iphofen R, Payne K (2003c). The triangular treatment paradigm in dual-diagnosis clients with a mental illness. Journal of Substance Use 8(2): 112–118.

Stella Project (2004). Domestic violence, drugs and alcohol: good practice guidelines. London: The Stella Project.

Substance misuse treatment framework – co-occuring substance misuse and mental health problem. Welsh Assembly Government, Cardiff (2004).

Tunnard J (2002). Parental Problem Drinking and Its Impact on Children. Research in Practice. Devon: Blacklers.

UKATT Research Team (2001). United Kingdom Alcohol Treatment Trial: hypotheses, design and methods. Alcohol and Alcoholism 36: 11–21.

Wing JK, Beevor AS, Curtis RH, Park SBG, Hadden S, Burns A. (1998). Health of the nation outcome scales (HoNOS): Research and development. British Journal of Psychiatry 172: 11–18.

Wright S, Moran L, Meyrick R, O’Connor R, Touquet, R. (1998). Intervention by an alcohol health worker in an accident and emergency department. Alcohol and Alcoholism 33(6): 651–6.



Address correspondence to: John Sims, Clinical Nurse Specialist & Manager Alcohol Service, Substance Misuse Service, North West Wales NHS Trust, Castellfryn, The Old Surgery, Star, Gaerwen, Anglesey, LL60 6AS. E-mail: [email protected]

Paired intervention model for identified alcohol misuse in secondary care

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