SAMMYY: Good evening everybody. It is 7:30 so we will make a start. Welcome to this evening’s Reducing Alcohol in your Patients webinar. Before we get started I would like to make a quick acknowledgement of country, so we recognise the traditional custodians of the land and sea on which we live and work.
So I will introduce to our presenters and our facilitator for this evening.
We are joined tonight by Dr Hester Wilson and Dr Tim Senior. Hester is an addiction specialist and she is also the Chair of the RACGP Addiction Medicine Network, with a Masters Degree in Mental Health and 25 years experience working in the health care setting. Hester is also a staff specialist in addiction at Sydney’s Langton Centre Drug and Alcohol Clinic and has facilitated training for doctors and other health care workers since 2001.
Dr Tim Senior is our facilitator for this evening. Tim is a GP at the Tharawal Aboriginal Corporation in South Western Sydney. He was originally trained in the UK and he is also an RACGP medical advisor for the National Faculty of Aboriginal and Torres Strait Islander Health and a senior lecturer in general practice and indigenous health at UWS.
With that being said, I will now hand over to Tim to go through the learning outcomes of this evening and we will then hand over to Hester who will take us through the rest of the presentation.
TIM: Thank you very much and I hope you can all hear me well. If you can’t hear properly just let us know in the question box.
So, the learning outcomes which is the educationist’s way of saying what you would have learnt by the end of this session, so that by the end of this session you should be able to discuss patient’s alcohol consumption using sensitive and non- stigmatising language, undertake a comprehensive assessment, use and interpret available patient screening tools and understand how they can enhance your assessment. I am also going to talk about integrating referrals, so the Get Healthy Information and Coaching Service, particularly the Alcohol Module and the Alcohol and Drug Information Service into our routine consultations and utilise feedback from them for better patient health.
SAMMY: Fantastic. Over to Hester now to begin the presentation.
HESTER: Thanks very much Sammy and thanks Tim. I just wanted to add something to those learning objectives, just to let the participants know that the focus of this webinar is to not on the dependent drinker, more on the risky, hazardous and harmful drinker. Actually that is a much bigger group, it is a bigger group that we see in general practice; not underestimating the issues that dependent drinkers have and the important role we have as GPs in that but the focus of this is what we might call binge, risky, hazardous or harmful drinker.
So, coming back to 2016 NSW Adult Health Survey, so this is NSW data and my apologies for any ACT participants or people from other states, but when we looked at what was happening in 2016 we have almost 30% of people drinking more than two standard alcoholic drinks in a day and nearly 28% drinking more than four standards drinks on a single occasion. We are also looking at high levels of emergency department presentations, so more than 13,000 and what is clear is that in this group of people who are not dependent, there is still very very high burden of illness and death as a result of their drinking and it is just under that of tobacco smokers and people who have a raised BMI.
Also back in 2014 at the NSW school students survey, looking at students between the age of 14 and 17, 14% of students had consumed alcohol in the last 7 days. It is pleasing however when we look at the overall data for young people around Australia, that the levels of drinking; of first starting drinking is getting older and it is a smaller percentage of young people that are drinking, so that is really terrific.
I always say to my kids Tim, I have just young tweens, I say to them that you have to wait until you have finished growing before you can drink, so you have your first drink when you are 25. At the moment they are still at that age where they think, yeah that’s cool mum, 25 is fine. I am not sure that I am going to be able to hold them to that as they get older
TIM: No, I don’t think so.
HESTER: But it is certainly a good way to be thinking about it.
TIM: I think from my experience with slightly older ones, no you are not going to be able to hold them to that.
HESTER: Ha ha. Tim would you like to make a comment about this and the following graph?
TIM: Yeah, so these two charts are from NSW Health and they show us the two factors of risky drinking; so one is the immediate risk to health which is essentially binge drinking and these are cut down by sex, males and females, and by age. Now, most important thing to get from this graph and you will see very similar from the next one is actually that it cuts across all ages, it isn’t just teenagers which is often spoken about in those bits, it cuts down slightly from 65-74 and then 75+ particularly in females, but essentially this shows that we should be asking all our patients of whatever age about their drinking.
If we move onto the next slide, it is even more the case for those drinking alcohol at long-term risk to health, you can see the bottom box is the average, it is fairly uniform across all age groups. So really, the take home lesson from these two graphs is, it is all our patients who could be drinking at risky levels and we need to ask everyone, if you feel like missing anyone out the only ones who you could miss out are probably women over the age of 75 but even then it is not really zero. So, that’s my take home message on those two charts there.
HESTER: So, yeah. Tim the other thing that I would say about the older Australians, people over the age of 75, is that what we might think are lower risk drinking levels in younger people, it is actually that they have come to more harm when they drink less because of the changes as we get older, the 75/85 year old who is having a hot toddy of scotch before bed may in fact be at high risk of harm as well.
TIM: So we need to be asking everybody.
HESTER: But one of the things and this is a general thing around drug and alcohol use and I think one of the backgrounds to this is to think about why do people drink, why do people use drugs, there are a multitude of reasons. If we think about alcohol in our society and it is not the same in all cultural groups but it is a bit part of Australian society and it does not always mean that if you are using some alcohol, if you are drinking some alcohol, that that actually is problematic and regular use may not mean that you are dependent, but however we know that as you use more and as you use it more regularly there are more risks and as Tim suggested with those previous slides, the acute risks from intoxication of assaults and injury and driving under the influence, that single occasion drinking as compared to the chronic ongoing level of drinking are both harmful and the other take home message from me is that it is becoming quite clear that even those in brackets safe for lower levels, there is still risk.
Moving on Sammy.
Now this is one of my things that I really think is worth having a look at, if you haven’t had a look, the Smoking, nutrition, alcohol and physical activity guide. So it has a really nice guide about talking to our patients about lifestyle issues and the longer I work in general practice the more I am aware of how important those issues are. Alcohol is really well covered in here and it actually gives a really nice approach around how you can actually talk to your patients to ask them about their use, do an assessment of their use, look at brief interventions and things that you can do to assist them, treatments and how you can follow up and arrange a referral if they need. So it is really worth having a look. My registrars will say to me now, Hester I snapped that patient and so many younger doctors are aware of this and it is a really useful guide available ‘ just google racgpsnap and it will come up as a pdf but also you can read it online as well.
TIM: We have just had a question come through about whether the harmful drinking has been changing at different ages over time and whether that would matter for us.
HESTER: Harmful drinking over time?
TIM: Yeah, so that have different ages changed their pattern of drinking.
HESTER: Oh, we certainly know. The group of us in our 40s and 50s that are drinking a bit more, that we are seeing that change in terms of the latest household survey that middle aged people are actually drinking a bit more. Young men are drinking and drinking at high levels but young women are catching up with them but our adolescents, our teenagers, are actually cutting down on their drinking and starting later, which is brilliant.
So, as it says in the snap guide in terms of asking about alcohol, what they suggest you ask everybody every three years, probably over the age of 14, unless there are other factors that you think you need to ask a younger person. The big flashing light for me is that if you have a person under the age of 14 who is smoking, I would always ask about alcohol use and other risks as well.
TIM: Yes, and other drugs use as well.
HESTER: Exactly. So, just in terms of this slide, we are just looking at how you ask about alcohol and look, there may well be many of us who are very comfortable and alcohol is just part of our patter when we are looking about lifestyle issues but if you are a little anxious about it, one of the things you can do is actually explain why you are doing it. I am your GP, I care about you, I understand lifestyle is very important, things life diet, exercise, smoking, alcohol and other drugs and I would really like to ask you about these, is it okay? So you are setting the scene and asking permission. So, if you don’t feel 100% comfortable in yourself, developing a little bit of patter that is just really quick, to actually assist you to actually ask that question.
One of the things that we do know is that GPs are quite often not asking people about alcohol use and I know there are very good reasons for that and part of what we are wanting to assist you with in this webinar tonight is to help you to feel more comfortable, help you to understand that this is not rocket science, it is not tricky, it does not all have to be sorted in one consultation but actually really brief advice is all you want to do. And the other thing I guess is why are you asking, what are you hoping to find out and putting that in the context of the lifestyle risks but also there are other individual risks and we spoke about this with young people and older people, but also women who are trying to get pregnant, pregnant or breast feeding, people who are on other medications, people who have liver disease, thinking of what those other risk groups are. Tim, how do you ask in your setting?
TIM: I find myself normalising it, so asking something like, I know I see all sorts of people coming through the surgery here, I was just wondering how much do you drink. We will talk about this, one of the slides that we will come to, one of the tools that we will be talking about, the Audit C which is embedded in our clinical software and often the nurses have already asked by the time I get to see them which actually allows me to take a bit more detail about when they are drinking and what makes them drink. So asking not just the routine questions but asking what they like about drinking, if they realise that it is risky, some of the more in depth questions but I think we will come to that sort of thing later on but the normalising, I know a lot of people in this situation and they find that they are drinking a bit more than they used to, that sort of thing.
HESTER: Yeah, I think the other thing for us as practitioners is perhaps feeling a bit uncomfortable about this. I have to say that I have never had a patient say ‘no I don’t want to tell you’ and the research does tell us that our patients want us to ask, they expect us to ask and they trust us to ask and they trust the information that we are giving and us asking can make a difference to the decisions that they make about their drinking.
TIM: I was just going to say, the next slide demonstrates this even though the headline isn’t about alcohol, it actually demonstrates us making a difference in asking about lifestyle things.
HESTER: Absolutely, I really like this infographic, yes it is about obesity but I see these all as lifestyle issues and this is in an NHS program which of course is a little bit different to ours but if GPs spent 30 seconds, if they just talked about it for 30 seconds and 40% of the people then went onto the program that they were offered. There was weight loss and 4 out of 5 patients agreed that it was helpful. So, it doesn’t have to be a long, long, long consultation and the other thing is understanding that it can happen over time and that is the fantastic place that we are as GPs, when we see people over time and so we can continue that conversation as well.
Moving on Sammy.
SAMMY: So, we are just going to have a look at the Your Room website now Hester, if I bring that up, if you want to have a chat about it as we go through.
HESTER: Yes. So, here we are at the Your Room website and what we are going to do here I think is just do a little standard drink game for everybody. So, Sammy are you thinking that people would do this themselves or are Tim and I going to actually have a little look at this.
SAMMY: So, we are going to have a look at it now and then on the next slide it will actually provide you with the link so that you can go and have a look at it yourself, you can look at the different glasses and see what the different standard drinks are for different glasses.
HESTER: So, large wine glass. I have got some wine glasses at home that take 600 mL, it’s just a glass.
TIM: Of course you never fill it up to the top?
HESTER: Just look, it’s a tiny amount.
TIM: I am curious as to how and I am not going to ask as to how many of our participants could judge their own wine glass while joining the webinars and the initiatives. What a beautiful thing about webinars.
HESTER: Yes and those people, as they are sitting here having a glass of wine while they listen to us. And also when you go out to a wine bar you may well find often the glasses have a little line, which is the standard drink line and it is when you look at it and you go “hey you could put a bit more wine in my glass” , they are actually doing the right thing and pouring you a standard glass so that you know how much you have had to drink. That is great Sammy, it is such a great little device.
TIM: We will send round the link to that everyone as well, so you can actually use that with patients, about saying this is actually a standard drink.
HESTER: Yes, so there is the link there at the bottom, Your Room. It is quite a nice one to have a play with yourself and maybe get your patients have a play. There is heaps of other really great information on Your Room about alcohol and other drugs.
But, just very briefly here, just so that we know what we are talking about when we are talking about a standard drink. It is 10 g of alcohol but none of my patients know what 10 g of alcohol is. You can kind of work it out, there is this nice formula that if you are a maths geek you can work it out, but very simply and I know it is not entirely correct, but the easiest way for me to remember it is that it is a nip of spirits which is 30 mL, it is a glass of wine which is 100 mL and it is a middy of beer which is 285 mL. You could also put in there if you have fortified wine drinkers, usually it is a 60 mL glass is one standard drink. I do find in my younger patients that they know what standard drinks are and they will be drinking quite often pre-packed and pre-bottled drinks and on the side you have the standard drinks and they are usually 1.2 to 1.4, but just helping our patients understand the area that maybe some of your patients might be talking about a schooner of beer and there is different strengths of beer. So if it is a full strength beer, a schooner is generally about 1.5 or maybe a little bit more of a standard drink. It is just really good that in my mind I go 30 mL, 60 mL, 100 mL, 285 mL and that is a nice way to talk to my patients about it. How about you Tim, do you have a different way of speaking about it.
TIM: There are actually some very good resources used in Aboriginal Health that give pictures in the same sort of way with talking to patients about that sort of thing. One of the things I enjoy is my craft beers actually and they are often stronger than the sort of standard strengths of beer, so often the strength seem to be a bit stronger than they used to be I think, that many are drinking. One of our eagle eyed viewers has spotted that this slide says 100 mL and the website said 110 mL, there is a slight difference.
HESTER: Absolute, there is a slight difference there. I find 100 mL easier to remember, so it is me being a bearer of a small brain. Okay moving on.
TIM: Or a pragmatic GP I would think.
HESTER: Yes okay. So, risky drinking and this is from the NHSMRC. So 2009 they bought out new guidelines and they are a little different to international guidelines but once again, really very, very simple. For any adult more than two standard drinks on a daily occasion or more than four standard drinks on a single occasion increases your risk and there is no safe drinking level for pregnant or breast feeding women and people under the age of 18.
So we have talked about the higher risk groups, but this is a really simple way of talking about it and quite often patients when you ask them about what are the safe levels, they will start talking about it is different for men and women. What the NHSMRC just did was make it really simple, two standard drinks on a daily basis or more than four standard drinks on a single occasion.
So, moving on.
So, let’s come to a patient. So, here is Susan, age 53. She has come in because she is just not sleeping, she is really stressed at work because her workplace is restructuring and she is concerned she is going to lose her job. So, here is a stage for you guys to put in some thoughts for us. What do you want to know about? What do you want to ask your Susan?
TIM: So, if you want to type into the comments box and you can answer that by text. Comments coming through, is she depressed? What is her sleep routine like?
HESTER: Previous mental health issues?
TIM: What time she has dinner? Coping/sleep/workforce/alcohol/family support/other drugs/medications that she is on/caffeine is an interesting one/self-medicating which may not be a term that people use but certainly people do self-medicate with various things including over-the-counter and natural remedies as well.
HESTER: Smoking. Smoking is a really important one. Periods and menopause, she is 53, yes what is going on there, absolutely. Any thoughts of self-harm? Once again coming back to mental health. Obstructive sleep apnoea? Beautiful. So, we have a wide range for us as GPs, we are thinking of really looking at what is going with her physical health, what is going on with her mental health, what is age-specific, what is gender specific and really looking how can I quantify and this is a really important part of looking at risk from alcohol use, how can I quantify how much she is drinking and what are the circumstances of that drinking.
So, moving onto the next slide there Sammy.
So, you ask permission. As a GP I am concerned about lifestyle factors that might be affecting my patients including diet, weight, exercise, smoking, alcohol and other drugs. Is it okay if I ask you about these issues? How often do people say no? In my experience they don’t. You might get someone that goes, oh look I have heard it all before, I am not going to change what I am doing or look, I really have to get away today I have got to pick up the kids or I am a little concerned who you are going to tell this information about. So, there might be some other things that you do need to talk about before you proceed but my general sense is that people are happy to tell me about their lifestyle issues. Have you found that Tim?
TIM: I do. I think there are probably some other people who are concerned because it may affect their job and things like if they are a driver, or if alcohol might have an impact on that, so that they can be wary about answering these questions too. I am aware Centrelink is into having a crackdown on using alcohol use and drug use for certificates and things as well and people are always wary about questions relating to that sort of thing. I think people, you can never reassure people about confidentiality too frequently.
HESTER: No, you do need to be clear about the bounds of confidentiality and that needs to be up front before you start having that conversation as well.
So, Susan says yes of course, I have never smoked, I have never used any drugs, I have put on a bit of weight lately, I usually keep a bit of a close eye on this but recently I have found it hard to get myself exercising. I am drinking wine at night, it helps me to sleep. Work has been stressful, they are restructuring and nobody is sure if we are going to keep our jobs. I felt very let down by this and since the death of my husband, with my son moving to Perth for work, I have felt pretty lonely.
So, we have a bit of a picture there of this woman who has had a bereavement, her son has moved away, she is feeling a bit lonely, work is stressful, she usually does exercise but she is finding it a bit harder, perhaps there is little bit of withdrawing from activities there. No history in the past but is drinking wine at night to help her sleep. So, this is really important. She is drinking wine at night, so we have a little bit more of a picture there.
Moving onto the next slide.
One of the things that we wanted to run through and Tim did mention this, is the role of screening tools or patient-reported outcome measures. You may know the DAS or the K10. The Cage is an older screening tool, I don’t think that it is a great one because it is very much focused around dependency, whereas the Audit addresses both of those and Tim mentioned the Audit C and we will talk a little about that as well.
The thing about the Audit is that it is validated, it is sensitive, it is specific, it is validated, it is cheap, it is free and you may, as is done in Tim’s surgery, decide to screen your patients before they come into you. I think you really need to be thinking about, I know I tried using the Audit in my general practice setting but because the levels of alcohol use is quite low in the group that I was seeing, but I had lots of people filling it in and getting zero score. But looking at the Audit C, the Audit C is the first three questions of the Audit and these are really great. I was having a conversation with a GP the other day, he was saying “what’s the one question you can ask”. I can get it down to three. So, first thing is “do you drink alcohol, how often, how much on a day when you are drinking and how often”. The Audit talks about six or more standard drinks because that is the World Health Organisation level, whereas the NHSMRC have set it at 4, so I would usually ask how often more than 4 drinks because I am following the NHSMRC. So those are the important screening questions which you can get form the Audit C as well. So, the Audit C is the first three questions of the Audit which is generally 10 questions. It is a similar setup to the K10.
And one of those important things when we look at what is happening with our 53-year-old Susan, is that we have a sense of all the stresses that are happening but we also need to quantify. When she says, I am having a bit of wine at night to help me sleep; this is really useful just to help us to run through it. I have to say, having a questionnaire can actually take some of the anxiety about talking about it away because people say that this is a questionnaire, it is like something out of a magazine, lots of us do questionnaires, it means that this is important and that this is normal and it can be an easier way for people to fill it out without having to actually run through the questions.
Moving onto the next one.
So, this is the Audit and as you can see I have put in red; quantity, dependence and concern. So the first three are about quantity, the second lot are about dependence – so how many times have you not been able to stop, have you failed to do what was normally expected, have you needed a drink in the morning, are you guilty, blackouts; and then concern is down the bottom – have you or someone else been injured or has someone been concerned about you.
Then if you move onto the next page, then you can do an Audit score. Now this is taken from a particular website, so right mix is some of the things that are available on that website which is particularly focused on returned service people. But once again, what it does is give you a 0 to 7 score, this is low risk, 8 to 15 is risky or hazardous, 16 to 19 is high risk or harmful and then 20 or more is high risk and almost likely to be dependent. Then it does point to the possible interventions that you can do, so I really encourage you to take a look at the Audit score and see if it is something that is going to be useful for you. Not all of us like scores or patient reported outcome measures and sometimes GPs will say to me, look I ask all these questions anyway. Fantastic, if that suits you, if you are asking the questions already that is brilliant. If you need some support or think this is going to be easier for you, then go ahead. And Tim you have it in your software but you are not using Best Practice or Medical Director are you?
TIM: No, so the particular reason for that is actually Audit C is used as a key performance indicator in the Aboriginal Medical Service which is why it is widely used. That is a bit controversial but we will not go into that here. The other thing that is worth noting is, I think if you are asking the difference between are you having six or more drinks; or are you having four or more drinks, that could potentially affect the score and so the actual discussion that you have is the important thing there as opposed to what the score will be, I think.
HESTER: Exactly. And I think the other place of these scores is that you can see how people are going over time. So you can, if you do this one year and then the following year or six weeks’ later you are doing it again and you see change, it can be really nice for people to see that change.
TIM: Absolutely. And the other really useful thing about standardised questionnaires like that, it can be a great way in for registrars starting out on their path to have a really simple way of starting to ask these questions and then as they develop their skills they sort of become a bit more nuanced in the way they ask but it is a great point for teaching as well.
HESTER: Yeah. Absolutely. Sammy, just moving onto the next page which was Susan’s score. So we did do an Audit with Susan. So she is having drink containing alcohol four or more times a week. She is drinking three or four a week. She is having occasions where she is drinking more than six. She feels guilty and remorseful and friends or family have expressed concern. So, she has a total score of 14 which tells us that her drinking is risky. Once again, this is a really nice way to have that conversation and to start discussing how she might do things differently.
There is not an awful lot on this to suggest that she is dependent apart from the fact that she feels bad about her drinking.
Moving on from that.
So, I am drinking half a bottle of wine at night, I really enjoy it, it helps me relax, I love the taste, I know that you are going to tell me to cut down and I know I should, I feel guilty about drinking, my son has told me I should, I do need to think about this but in the end I guess I just want to continue drinking.
So, Tim, what would you say to Susan saying this to you?
TIM: So, at that point I would be quite gentle and acknowledge that I would not be pushing too hard because I think as long as I can keep having conversations with her about it, then there is a prospect for improving but if I alienate her about talking about this, then it is much harder to open up conversations in the future. So, I think just making sure that she knows that it is always something she can talk about with us, it is likely that people are worried about her drinking because they really care for her and she has just started to think about this, so as she gets more ready or notices more harm to self coming on, then I would certainly be ready to take further action on this as soon as she wants to.
HESTER: Yeah and I think certainly one of the important things for this Susan, is that she feels quite guilty and quite shameful about her drinking, so you do need to be careful about buying into that shame, because I don’t know about you, but I just don’t find with any of my patients that shaming then actually helps to make good change.
Sammy we will move on.
So, once again this reiterates a lot of what I have said but the harms that happen from any substance use, whether it be alcohol or others, the acute harms from intoxication, the ongoing harms from regular use and then the harms again from dependence, they do overlap and for us and you guys have said this, it is really thinking about the bio-psychosocial health issues and the reasons of why this is happening, that you need to address with people.
I think that in terms of where Susan is at, she is saying oh I should change it but I don’t want to, so she is in that kind of ambivalent phase where she is maybe contemplating, maybe not contemplating and we do note at this point that it depends, as Tim said, how you have the conversation can help her to move to a place where she is maybe more ready to make change and it may not happen in one session, it may not happen over a number of months, but quite often people will make that change with support.
So, thinking about the other part of the assessment is not just what her overall picture is and quantifying her drinking, but does she want to change the drinking and when she has tried to change it, how has this been? Are there other issues going on? Is there other substance use? Is she using other sedatives? Is she on opioids? is she on benzodiazepines? Is she sedating antipsychotics or antidepressants, all of which increase her risk of harm. What else is going on in her life? Is she stably housed? She has issues with her employment. She is bereaved and missing her husband and missing her son. So all those are a really important part of that assessment, that help you to understand the role that alcohol has, the current skills and strengths that she has around doing that differently and where she is at in terms of wanting to change.
So moving on Sammy.
We have talked about this a little bit and in terms of where we are really interested in this webinar, with hazardous or harmful use. So, really hazardous is greater than the safer drinking levels but they don’t have problems yet, whereas harmful use is people that are drinking greater than those safer levels are actually having harm, whether that be acute or ongoing. So, ideally if you have people that you are talking to about their drinking at higher than safe levels, you want to catch them at the hazardous part before they actually come to harm and be able to talk to them about the harms that could happen and how they can actually improve their health and wellbeing and decrease their risk of harm by changing their drinking.
Sammy, moving on.
So, screening and brief interventions. There is oodles of evidence out there that brief interventions work and by brief interventions I mean things like brief advice around how can you set up a situation where you can cut your drinking. Part of the conversation about what are the safer levels, what is the standard drink, those simple conversations and then just delving in a little bit more deeply as Tim was suggesting, around what are the drivers and the strengths and the perpetuating factors that lead to this person drinking.
We do this all the time in general practice but when we look at the literature it would appear that, in the literature anyway, we are not actually doing this as much as we possibly could and we are missing it but it is a skill that we actually have. We know that it works well.
TIM: There is a question about that as well, about the importance of looking at the underlying causes that lead her to drink and maintain her pattern of drinking, as well as just discussing alcohol.
HESTER: Absolutely. So, you can talk about, you can quantify how much people are drinking but you also need to understand the meaning that the drinking has in their lives. So, if there whole social life is down at the pub it is going to be tricky for them to perhaps go to that pub and not drink, because it is such a big part of what they do.
We talked about brief advice and we will talk a little bit more about the sort of things that you can say but thinking about those smart goals and when people are at a point, after talking to Susan she says, look you know what I do need to do this differently; you say well what would that look like, how different would that be, how are you going to do it, when are you going to do it, how many drinks is it going to be, what are the circumstances around that, is that realistic and let’s follow up and see how you are going. So it is really making specific goals that are achievably realistic and is setting the scene for her to be able to do that.
We suggested before motivational interviewing, which is a fantastic technique. Unfortunately I am not in a position today to talk about that in any depth, but it is a collaborative approach which encourages change and it is really very, very useful.
We are going to be talking more about lifestyle as well, in terms of Ruth who is going to be talking about that in a minute.
So, as I said before, advising them about the lower risk drinking levels. Looking at how those risks impact on them. So, for Susan, in fact she might think that her drinking is helping her sleep but it might actually be making her sleep worse. It might be actually be helping her put on weight, it might be actually decreasing her mood because it is a central nervous system depressant. Think about where you drink and how you drink and if you have dinner before you drink, the type of alcohol that you use. Sometimes it is shifting away from one that you really, really love to one that you don’t like so much. Having at least one or two alcohol-free days a week. Drinking other fluids, do not drink alcohol to quench your thirst. The safety of the drinking environment and the consequences of intoxication. So, you know, once again, where are you when you are drinking, is that a safe place to be doing it and are you aware of the risks of intoxication and really thinking about what are the risks rather than drinking and drinking is bad, is the risks that happen from this behaviours, in this own individuals experience and their setting and what is true for them.
Moving onto the next one Sammy.
So while drinking, very basic things, don’t mix it with other drugs and medications that are sedating, careful with your babies and young children, don’t go fishing or hunting, don’t drive, leave your car keys at home, sort out your plan B for getting home, don’t get in the car or boat where others that are intoxicated and this is a big one for young people and we know this is an issue that car loads of young people dying because the driver, who is an inexperienced driver is also intoxicated. So really working with our young people around, it doesn’t matter even if it is your best mate, take the car keys off him and keep them safe and don’t get in that car with them. Thinking about how you are eating, how you are looking after your nutrition and your health generally.
So this may be, there may be people who don’t want to change what they are doing at all but you can help them to actually decrease harm in terms of the settings and how they are doing their drinking and also from the previous slide, things that they can do differently, very simple things that can help them cut their drinking down.
So, motivational interviewing, as I have said before, it is a fantastic supportive and phatic mode, it is not just supportive, it also has a focus which is around helping people to move towards change. I would really encourage anybody who hasn’t done any training or thought about motivational interviewing to seek that out, it really is a terrific way of having conversations that actually change the way we practice throughout medicine. I don’t know about you Tim, what has been your experience with motivational interviewing?
TIM: I find I use a lot , I think just having a way of having a conversation with people, that invites thoughts of a different way of doing things. I think asking people to consider what it is that keeps them doing the current activity and things that they like and don’t like about that and just sort of prompting them to imagine a different way of doing things. I think it is really very helpful actually as a model of doing that.
HESTER: Yes, absolutely. It speaks towards people’s strengths and actually helps/enables then to make the changes that are right for them.
Sammy, I am aware of the time. We do need to move on don’t we.
And this fits in with the stages of change. So really, with our Susan, she is contemplating, perhaps pre-contemplating and using motivational interviewing particularly in the contemplation of preparation stages is really, really useful. Once somebody is thinking about, I’m going to take action, then move into smart goals and be aware that relapse is common and it is something to prepare for. Maintenance is important, you do need to put some ongoing energy into maintaining the change that you have made.
TIM: And relapse is so common it could almost be viewed as normal and each time people do relapse they learn something about the process of giving up to make them more successful next time.
HESTER: Exactly. So they have been successful in giving up for a period of time and then they have learnt skills around how to do that next time. We know, just thinking about the smokers that I work with, that it takes them an average of five/six/seven times but they do get there in the end. Quite often people will say, oh I had a go and I failed. NO, you didn’t fail, you actually managed to give up even if it was only for a week, you had that week’s experience and working with people around looking at that in a positive way and using those strengths and skills for next time.
Sammy, moving on.
So, Alan, aged 76 attends with his wife who is concerned about him. He had a myocardial infarct about 20 years ago, he is overweight, he is a smoker and his wife says he is not sleeping well, he is withdrawn, his brother died two months ago. He says, don’t fuss I am okay, I am just getting old that’s all. So, once again, for you guys what do you reckon might be going on here? Put some answers in for us.
Depression, obstructive sleep apnoea, depression, grief, low mood, grief, depression, alcohol excess, yep. This is an alcohol conversation so alcohol is going to be in there somewhere. Bereavement.
TIM: And someone says confronting mortality which is a good point as well, that people might be having those processes without actually having a normal grief process, without it becoming pathological into depression.
HESTER: Yes absolutely.
Okay moving onto the next slide Sammy if we can.
So he is drinking two scotches at night. When you question him on that, it is actually probably maybe a little bit more than two standard drinks but they are not huge scotches. This is his little toddy at night and really the story with this one is that this man is 76, it is likely that there are bereavement issues, that there may be low mood, anxiety, I am also interested in his overall cognitive function as well but he has the cardiovascular risks, he is overweight and he is a smoker.
So, even though it not a huge amount for this particular man it may well be adding to the picture and causing him health issues as well as low mood.
Would you add anything to that Tim?
TIM: Only I think it is worth being aware that alcohol connects as a mood depressant as well, so that it may actually be making him a bit more depressed and certainly people can be more impulsive as well, so even on a low level of alcohol, even if it is within the guidelines, particularly in an older person you would want to be a little cautious about the effect that that may be having I think.
HESTER: Yeah. I think sometimes patients like Alan will say, look Hester I have had a hard life, I am 76, my brother has just died, I am getting older, I am not that well, this is my one pleasure, why would you take this away from me? And I think that is something that you do need to acknowledge that this perhaps for Alan has a really important place and how can he do this more safely or how can you help him to understand how he might do this differently and how that might actually make his life better.
TIM: There is an interesting comment as well, about ruling out Alzheimer’s, which could be important in terms of memory and the combination effect of alcohol on that and whether people actually remember how much they are drinking and the role of conditions like that.
HESTER: Yes, absolutely.
Moving on Sammy.
Once again, we are looking at his score, at Alan’s score. He is drinking more than four times a week, he is having three to four standard drinks. No other scores except his wife who is worried about him. So he gets a total score of 10 and once again, because this is the Audit, it does look at the five or six standard drinks being more of a risk and given his age, I think this is probably an underestimate of the possible risk for Alan, so do be aware of that. It is a very good score. I can’t count can I, it is actually 11. Sorry about that, maths is not my strong point. Great.
So this is just a question from Wendy, what is his drinking history? Is this a guy who has drunk a heap in the past, is the liver damaged, is this something new? It is important to work out where this sits in terms of his history and his family history as well.
Moving on from there.
SAMMY: Lucky enough tonight, we have got Ruth Chester-Hawkins here from NSW Health. She actually works for the Get Healthy Service and she is just going to have a quick chat to us about the alcohol reduction module that they run there.
RUTH: Thanks Sammy and thanks everyone for having me here on the webinar tonight. I am just going to provide a brief overview of the alcohol programs which are part of the Get Healthy Information and Coaching Service, which could be seen as a possible referral pathway for you after you see patients such as Susan or Alan in your surgery.
So in terms of what this service is, it is a free phone-based information coaching service that aims to support participants to achieve healthy lifestyle changes such as support for healthy eating, increasing physical activity, support to reach a healthy weight or a healthy gestational weight gain but in relation to this webinar tonight we will be focussing on support around alcohol abstinence and reduction.
TIM: We have just go a question coming in. Is this available to ACT residents as well or is it just NSW?
RUTH: Yeah, good question Melissa and you are just ahead of the game here. I was just about to say that the service is available in NSW, Queensland and South Australia. However, at the moment as we move forward to talk about our alcohol coaching programs, they are only available in NSW at this moment. So sorry about that Melissa, it is not available in the ACT.
So, our coaches are all university qualified health coaches, so they are dietitians and exercise physiologists and as I mentioned this service is available for all NSW residents 16 years and over. The service has been up and running since 2009 and we have had over 45,000 people engage with the service to date.
Participants have two main ways of entering the service. They may self-refer which is fine, it is brilliant, it could show a high level of motivation which is always positive or they can be referred by a health professional or a general practitioner like yourselves. We have had a research study conducted by the University of Sydney that found that referral from a trusted health care professional like yourself, show that it increases the rates of graduation from this coaching service. Following a referral, your patient will receive a call within three working days and the purpose of this call is to gather information and consent as well as sharing with the patient the options available as part of our service.
In terms of what is offered by our coaches, we have two levels to our service. We have one branch which is information only, so this is providing them with an information booklet which is in line with national guidelines as well as containing tracking tools and tips; where the participant can work towards their own goal. They can also receive one-off advice by a health coach and at any point they can enrol into our full coaching service at any point.
In terms of the actual coaching option, this provides ongoing motivational support over six months where participants receive 10 calls all organised at a time that is convenient to the participant and where they will have the same health coach throughout those 10 calls. They will have support to set their own goals and after they reach that goal then they are welcome to re-enrol as many times as they like afterwards, all for free.
So, within the coaching arm of the service, we offer several coaching programs which are all tailored to meet the needs of the participant and these needs are ascertained on the registration call.
So, in relation to the theme of this webinar, I will just now briefly provide an overview of our alcohol focus coaching programs. We have two alcohol-related programs which are for people identified by using the Audit C and the Audit tool as drinking at unsafe levels, so it is very much the people that we have been referring to in the webinar so far.
So, for anyone who is over the age of 18 years the Audit C questionnaire is asked as part of our screening process on their first call which is their registration call. If they score 4 or more for women or 5 in men, then they are then asked the full Audit questionnaire. Based on their score within this they are offered several choices. One that can be offered is to enrol in the Alcohol Reduction Program where they would receive support and motivation to set their own personal goal to reduce their alcohol intake. So here it is focused on your Susan’s or your Alan’s support to reduce their alcohol intake rather than potentially abstinence all along. Again, depending on their scores they could be offered to enrol into the alcohol program and offered further information on additional alcohol support services, whereas in NSW we have the Alcohol, Drugs and Information Service which is run at St Vincent’s Hospital. Again, if they do score 20 or more in the full Audit questionnaire, then as our service is just focused on those who are having unsafe levels of drinking, anyone who does score these this would perhaps indicated dependency, and therefore we would offer a direct referral to further alcohol support services.
If we are then to look at pregnant women, we do also offer an alcohol abstinence coaching program where this is for pregnant women. Again we ask the Audit C questionnaire and if they score 3 or more, then they are encouraged to enrol in our Alcohol Abstinence in Pregnancy Program and again with this, they would also then be offered a referral to Alcohol Services.
In terms of the benefits of the service, the Get Healthy Service is not a prescriptive program, it is not a case of one size fits all at all. It does not give specific advice around diet, physical activity or alcohol plans. Instead it uses motivational interviewing to guide and support participants to reach their own personal healthy lifestyle goals, which Tim and Hester have already explained further on, of how this can really be a useful way of developing people’s own skills and ability and to boost their own confidence to reach their own goal. The guidance that is provided though it based on national guidelines around alcohol intake in this instance. So what the health coach is there for is to help the client to identify areas that they feel they are ready to work on, to set realistic goals so all smart goals, not looking to set people up for failure and to really build on their strengths and to problem solve and address barriers to help them in this instance reach an alcohol reduction-related goal.
In terms of why you might be interested in referring participants, yourselves as GPs play such an important role in offering and referring your patients to this state wide service. It is there to aim to complement the care and advice that you are already providing and the service aims to keep you up to date with your patient’s progress through the service so that you can make sure that is does align with the care that you are providing. We also have independent evaluations show that the service does work and this has shown that participants do lose weight and that they do change their lifestyle behaviours.
Also as GPs, you see the people who are the most at risk of developing chronic disease including those who tend to not really engage with services or those who might not respond to our general advertising of this service. So you therefore really can be the link to this free service. If you do refer a patient to the Get Healthy Service, as I mentioned there, your involvement in this service does not just stop at the referral. So, as mentioned, we will provide you with updates on your patient’s progress through this service at certain points. So this is when they enrol, when they are half way through the coaching and when they graduate. So the progress reports that you receive contain information on your patient’s chosen goal and certain measurements as self-reported by the participant. It is hoped that this can be used as a way to not only keep you updated on their progress but so you can discuss this with your patient at their next consultation. You will also be notified as well if your patient does drop out of the service, so hopefully the next time you see your Susan or your Alan, you could encourage them to keep going with the service.
So, if after hearing all of this, you are keen to refer your patients that you think might need the support or the motivation to reduce their alcohol intake or other healthy lifestyle choices, then you will be pleased to know that the referral process is quick and easy and it does just take one form. It is important to say, because if a person does then re-enrol you don’t have to do anything further, that one referral form can allow the participant to stay in the service for as long as they would like. Our referral forms are available on Medical Director, Best Practice and also on the Get Healthy NSW website. Several of the sections can be prepopulated as well and we are also looking at introducing referral forms where you can just stick your patient’s sticker on and away it goes.
In terms of what support is available for yourselves as general practitioners to refer to this service, we really do acknowledge how time poor you are during your consultations and therefore the promotion of this service can be something that we can look to support not only yourself with but also your practice staff and nurses can be involved. So NSW Health staff can be available to support, get your practice Get Healthy ready, we have free resources available to use in promotion in your waiting rooms as well as support in training your staff to do the referral process. We are also working with Health Pathways and Medical Director and Best Practice to make our referral process easier as well.
SAMMY: That’s great Ruth, thanks for letting us know about that. I will hand back over to Hester now just to finish us off for the evening.
TIM: There is just a couple of quick questions, just if people are doing the alcohol they can still do the weight loss coaching as well?
RUTH: Yes, they can and that is where, whilst we do look to do that smart goals, so the coach would be there to encourage the participant to set a realistic goal, so perhaps not alcohol and weight loss at once but that the coach would gradually encourage the participant to introduce additional goals as they go through their coaching journey.
TIM: Excellent, thank you. I didn’t mean to delay us from Medicare Hester.
HESTER: Well, before we go onto Medicare, that is just fantastic because it fits back into that lovely little infographic that we had from the UK, so for us as GPs it is simply the screening, it is 30 seconds, it is let’s fill this in and let’s get you off to this group who can do fabulous things with you. You get kept in the loop as a GP but you know I suspect that what you will find is that patients will really like that it is a really great thing and so it is a fantastic thing that NSW Health is supporting it and I am keen to start using it with my patients, I think it is brilliant.
So just very simply with the Medicare benefit numbers. Look, you know, one of the issues for us in general practice is that we are time poor and we have fee for service and if we spend more time with patients the way the system is set up we actually lose money. But once again, remember that there are some Medicare benefit numbers that you can use, we are aware of all of these. Substance use disorders, who is somebody has the issues in terms of dependence or abnormal behaviours around their drinking, they actually do fit into a Mental Health Plan, GP Management Plan, team care arrangement, don’t forget case conferencing and so be using those to make sure that you do get paid for the good work that you are doing. Tim, would you add anything about that at all?
TIM: No, that’s right. Medicare is vague about the eligibility but leaves it up to us to determine, so they don’t say it is not eligible but if it would be justified by a group of peers who would think similarly, then you could certainly view substance use disorder, risky alcohol consumption as a chronic disease if you think there are larger implications than just purely a bit of extra excess alcohol. So it definitely can be used.
HESTER: Yep, beautiful.
Moving on Sammy.
I love this cartoon. For me, what this says is you know it is a stop, stop, stop telling you what to do, that actually we stop listening. So really working in with the person around, what are their goals, what is it that is important for them and what do they want to see different and the referral options there are just brilliant because they are based on the whole enablement of people that we see.
So in summary, it is really important to think about asking patients and as Tim said ask everybody and ask them repeatedly not just when you first see them or when you think they have a problem because quite often they will not present with alcohol and you may not pick it up if you don’t ask. Normalise it, explain why you are asking and ask for permission. Assess quantity, quantify the use, consider using the Audit, think about the other individual risk factors and once again put it in the context of their overall life and their other health issues and the other issues going on in their lives. Don’t under estimate the value of brief interventions, brief advice, referral options that we have talked about tonight and the fact that our patients really value the advice and the information that we give.
So I think that is it from us. Did you want to add anything else Tim, I know it is just after 8:30.
TIM: No, that’s right. This is another slide that summarises the learning outcome so if you have a quick look through those, we hope that is what we have covered tonight and you have a much better understanding of the learning outcomes and you will be able to do these things in your practice when you go back to work tomorrow. It is 8:30, you have been asking questions as we go which has been fantastic and demonstrating that you are really digesting all this. So I would like to thank Sammy, Hester and Ruth for taking us through this tonight. If people do have burning questions then send them through to Sammy at the College and we will do our best to answer those after hours.
SAMMY: Thanks again to everybody, Hester, Tim and Ruth for joining us tonight and thank you for everyone online. As Tim said, if you have any pressing questions that you feel were not answered, certainly send an email through to us, the same email contact that you have been receiving from correspondence for the webinar from. Enjoy the rest of your evening everybody.
I just also would like to add this is a QA and CPD activity, to make sure you receive your points please do fill out evaluation. It will pop up on your screen directly following the session. If it doesn’t pop up, don’t stress, there is an email that will go out in an hour that will contain a link to that as well.
In saying that, that wraps us up for tonight. Thank you all again for joining and enjoy the rest of your evening.
TIM: Thank you very much everyone, have a good evening.