Do not look at wine when it is red, when it sparkles in the cup and goes down smoothly… at the last it bites like a serpent and stings like an adder (Proverbs 23:31)

The abuse of the ‘demon drink’ has long been a major problem affecting Irish society. The resultant financial, physical and emotional distress for communities, families and individuals is a cultural reality. From a general practice perspective, the ICGP position paper on prevention of alcohol related problems in Ireland¹ outlines the unique position of GPs in highlighting the dangers of excessive alcohol consumption and the College has provided training for both GPs and practice nurses in screening and brief interventions.² While recognising that GPs are seen as ‘the first port of call for any health-related problem’ it is important to remember that it is also practice nurses who have historically been identified internationally as central to the delivery of primary care services.³

In Ireland, practice nurses provide assessment, screening, treatment, care and education to patients from all sections of the community, ranging from infants to older adults. Therefore, general practice provides an important point of contact where problems relating to alcohol can be detected and managed.⁴

The nurse, whether located in practice, hospital or the community can incorporate assessment and screening for alcohol abuse into everyday practice thus flagging the problems early. The guidelines used in primary care for helping patients with alcohol problems pose the question ‘What is an alcohol problem’? There is a range, which spans low risk, hazardous, harmful and dependant, and patients can move from low risk to dependant and vice versa at any stage of their lives.⁵

Effective screening starts with asking the correct questions. Primary care professionals should be alerted by certain presentations and physical signs to the possibility that alcohol may be a contributing factor to the patient complaint and should ask about alcohol consumption.⁶ When managing patients with alcohol problems, the ICGP guidelines favour the four ‘A’s: Ask, Assess, Assist and Arrange.⁵

Effective screening – ask and assess

Time is often limited and patients can consult with a problem which may not be immediately recognisable as an alcohol issue. The presenting complaint may be anything from an immediate health risk such as an unintentional injury, miscarriage, violent behaviour, a child protection issue to a sexually transmitted disease or respiratory tract infection. Other chronic problems which frequently take up consulting time may be psychiatric such as depression and anxiety, or gastrointestinal problems such as pancreatitis, gastritis and cirrhosis.⁷

A host of social issues related to alcohol misuse can cause ‘compassion overload’ for the primary care practitioner when faced with a list of patient needs and requests. In these circumstances a short questionnaire can be used such as the AUDIT C questionnaire. Three questions are asked:

• How often do you have a drink containing alcohol?
• How many drinks containing alcohol do you have on a typical day when you are drinking?
• How often do you have six or more drinks on one occasion?

If the problem is flagged in this way it can be used as a means to encourage abstinence or cutting down, however a high score requires a more in-depth assessment.  

The Alcohol Use Disorders Identification Test or AUDIT is the gold standard and is a questionnaire which uses a scoring system. There are 10 questions which need to be explained while interviewing the patient. It is a simple and effective tool, which when carried out, can correctly identify which category the patient is in at the time of interview. Elevated scores can determine the presence or emergence of alcohol dependence.

Another useful assessment tool if dependence is suspected is the CAGE questionnaire. It has been recommended that the CAGE questions should not be preceded by any questions about alcohol intake – ie. its sensitivity is dramatically enhanced by an open-ended introduction.⁸ Four relevant questions can be used in the consultation. These focus on Cutting down/being Annoyed by criticism regarding drinking habits, feeling Guilty and needing an Eye opener to get rid of a hangover. 

The overall level of risk is determined by careful history taking using these assessment tools and combining them with physical examination, clinical observation and biomarkers (FBC, liver function tests, U&E and blood pressure as baseline). Depending on the outcome effective intervention is required whether it is hazardous, harmful or dependent drinking. 

Effective intervention – assist and arrange 

Once the assessment has been made the nurse should inform the patient of the results and discuss the situation while responding to the presenting complaint. The goal is to develop a positive, non-judgemental rapport with the patient. The results can be met with denial, disbelief or very often shame. At this stage the discussion should be compassionate, discussing evidence for concern if the drinking was to continue at the present state. 

Reassurance that support is available to treat the addiction is very important. Give the patient an opportunity to ask how he or she feels about your concerns as a professional. It may be necessary to address the stigma associated with having an addiction and initiate a discussion regarding a plan for the future. 

The goal of achieving normal blood pressure and liver function can be a useful strategy. The introduction of a treatment plan may include exercise, finding new friends who are not excessive drinkers, dealing directly with stress-producing problems, as well as a specific strategy for reducing or eliminating alcohol.⁹ Knowing the patient and the family environment is a distinct advantage when these goals are being discussed.

Strategies, which are often the simplest, can work, such as identifying the dominant hand for drinking, placing a glass of water in that hand and placing the alcoholic drink in the least dominant hand. Every time the patient takes a drink the movement is awkward and reminds them that they should be cutting down. In a practice setting a date for stopping is often possible and asking the patient to attend for a follow-up appointment on a Monday morning can be challenging. If they are serious the weekend is a time when all resources of friends and family are required to abstain from the usual entertainment. Several other strategies can be used including brief intervention and motivational techniques all documented well in the college guidelines.⁵

When entering treatment, people bring with them a ‘vast array of other concerns’, some of which are often of higher subjective priority than stopping substance use.¹⁰ Nurses recognise that they can deliver psychosocial interventions³ but may require additional support services than what is currently available in the majority of general practices. 

Social issues may cause great concern to the individual such as financial and housing needs. Primary care teams may have access to either clinical or counselling psychologists, addiction counsellors and social workers who can help navigate patients through the steps to recovery and relapse prevention. 

The ICGP guidelines⁵ suggest a ‘directive, client-centred style of counselling that helps patients to explore and resolve their ambivalence about changing behaviours’. These techniques improve trust, build confidence and reduce resistance to change. These skills can be learned and nurses are very familiar with the use of the Wheel of Change¹¹ which can help clients assess where they are in relation to effecting change in their lifestyle. 

The success of these brief interventions is on an individual basis with some responding well and others fatigued by hearing it all again. In these scenarios effective treatment may also depend on pharmacological intervention. These are frequently used in relation to dependence. 

Pharmacological management

Dependence syndrome¹² is defined as ‘a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state’. 

Dependence is very challenging to treat in general practice and can cause, as eluded to earlier, ‘compassion overload’. 

In a very busy inner city practice many patients arrive unscheduled and seek detoxification while under the influence of alcohol. To them it is an immediate health need and the resultant discomfort for other patients waiting to see the doctor or nurse can be very difficult to deal with. Receptionist staff are the first port of call and can be insulted and verbally abused. A practice policy of zero tolerance in relation to abuse or violence is mandatory. 

Drug seeking behaviour, often in the form of ‘I want my Librium!’ is a perplexing issue particularly when the patient is well-known and several detoxification plans have resulted in relapse. The patient is very familiar with the role that benzodiazepines play in the early days of abstinence however the issue is complex. 

Benzodiazepines, often in conjunction with an illicit substance have been implicated in more deaths than any other drug in Ireland. The impact of this type of drug needs to be addressed within treatment and prevention services.¹³ The GP is often faced with inappropriate requests which are first appealed for at the consultation with the practice nurse. It is important that a firm but fair approach is taken.

Other pharmacological treatments that can be used are disulfiram and acamprosate:

• Disulfiram (Antabuse) is used for dependence. Patients need to be advised that the ingestion of even a small amount of alcohol can cause reactions. These include throbbing headache palpitations, tachycardia, nausea and with large amounts of alcohol arrhythmias, hypotension and collapse  
• Acamprosate (Campral) reduces the desire to drink alcohol and can be used as soon as possible after abstinence is achieved.

If pharmacological interventions are to be used they are always as an adjunct to management. 

Treatment effectiveness, whether pharmaceutical or psychological, is related to the motivation of the patient. Key factors are the severity of the problem, how therapeutic the engagement is with the professional as well as the intensity of services and linkages to community-based social supports.¹⁴

Notwithstanding these issues the services provided by practice nurses in the Republic of Ireland in relation to patients with addiction have been highlighted and identified as a hidden role and one which has potential for further development.^15-17 Although the key to prevention and management of alcohol-related problems is multifaceted and involves a comprehensive approach both nationally and locally, practice nurses are ideally placed to identify the signs of harmful consumption of alcohol which impacts all areas of health. 

Practice nurses can ask, assess, assist and arrange services understanding the needs and expectations of patients who are addicted to alcohol. The attitudes of these professionals, the dynamics of treatment encounters, and the treatment programme design and structure all require further consideration in the Irish context of primary care.

References

1. ICGP Position paper on prevention of alcohol related problems in Ireland. ICGP, Lincoln Place, Dublin 2, 2012.
2. Anderson R, Collins C, Dalton Y, Doran,G, Boland M. Alcohol Aware Practice Service Initiative. Dublin: Irish College of General Practitioners and Health Service Executive, 2006.
3. Copello A,Templeton L, Orford J et al. The relative efficacy of two levels of a primary care intervention for family members affected by the addiction problem of a close relative: a randomized trial. Addiction 2009; 104(1): 49-58
4. King R, Roche E. The management of alcohol abuse by GPs. Forum 2011; 28: 27-28
5. Anderson R. (2009). Helping Patients with Alcohol Problems: A Guide for Primary Care Staff. Quality in Practice Committee. 2009. Available at: www.icgp.ie/library_catalogue/index.cfm/id/39053/event/catalogue.item.view.html. Revised from 2007
6. Scottish Intercollegiate Guidelines Network. The management of harmful drinking and alcohol dependence in primary care; A national clinical guideline. 2003. 
7. Centers for Disease Control and Prevention (CDC) Alcohol Related Disease Impact (ARDI) Fact Sheet Atlanta, GA: CDC Available at: www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm
8. Steinweg DL, Worth H. Alcoholism: the keys to the CAGE. Am J Med 1993; 94(5): 520-3. Available at: www.ncbi.nlm.nih.gov/pubmed/8498397?dopt=Abstract
9. University of Utah. The Alcoholic Patient in Denial: University of Utah, School of Medicine. 2007. Available at: http://healthsciences.utah.edu/utahaddictioncenter/index.htm
10. Miller PG, Miller WR. (2009) What should we be aiming for in the treatment of addiction? (Editorial). Addiction 2009; 104(5): 685-686
11. Prochaska JO, Di Clemente CC. Transtheoretical Therapy towards a more integrative model of change. US: 1982. 
12. nternational Statistical Classification of Diseases and Related Health Problems,10th Revision (ICD-10). Version for 2010 Available at: http://apps.who.int/classifications/icd10/browse/2010/en#/F10.2
13. MacNeela P, Scott A, Treacy P, Hyde A. Lost in Translation, or the True Text Mental Health Qualitative Health Research. 2007; 17(4) 501-509. Nursing Representations of Psychology. DOI: 10.1177/1049732307299215
14. Simpson DD. Introduction to 5-year follow up treatment outcome studies. J Substance Abuse Treatment 2003; 25(3): 123-124.
15. Wilkinson S, Mistral W. GP experiences and perceptions of methadone maintenance in the eastern region of Ireland. Research conducted by the Mental Health Research and Development Unit, University Of Bath, on behalf of the Eastern Region Health Board, 2003.
16. Latham L. An explorative Study of the perceptions and Experiences of Practice Nurses in Relation to Patients on a Methadone Treatment Protocol. MSc Thesis, University College Dublin, 2003.
17. Latham L. Methadone in Irish General Practice: Voices of service users.  Doctoral Thesis. University of Bath, UK, 2010.