43

How to deliver a brief intervention

  • Upload
    kavroom

  • View
    28

  • Download
    0

Embed Size (px)

Citation preview

Page 1: How to deliver a brief intervention
Page 2: How to deliver a brief intervention

How to do a brief interventionAdvanced Clinical management of Addiction

Dr Bob PattonAddictions Department

Page 3: How to deliver a brief intervention

In this 1 hour introductory lecture you will learn about brief intervention

At the end of this session you should be able to:

Understand what is meant by “brief intervention”

Recognise the Stages of Change and how they relate to brief interventions

Describe the FRAMES approach to Motivational Interviewing

Translate examples of BI in the alcohol field to the wider substance misuse arena

Page 4: How to deliver a brief intervention

Introduction

In todays lecture we will cover the basics of how to deliver a brief intervention, covering identification & brief advice (IBA), the Stages of Change, and FRAMES based approaches.

As my background is in alcohol research, I will be utilising examples from work that I have been involved with, however the principles remain valid across all areas of substance misuse.

Page 5: How to deliver a brief intervention

Features of Brief InterventionsA family of interventions ranging from a few minutes of simple, but structured, advice to 20 minutes counselling with repeat consultations.

Two basic levels of brief intervention:• simple structured advice ~ 1-2 minutes to deliver.

• brief counselling (extended brief intervention) ~ 10-20 minutes.

Page 6: How to deliver a brief intervention

Features of Brief InterventionsBrief interventions can be delivered by different practitioners in community settings, e.g. GPs, practice nurses, health visitors, dieticians and other primary health care professionals in the normal course of their work.

They can also be delivered by more specialist workers (CPNs, lifestyle counsellors, alcohol health workers).

Normally aimed at a goal of harm reduction(i.e., under medically recommended levels).

But patients who prefer to become abstinent should not be discouraged.

Page 7: How to deliver a brief intervention

Brief Interventions

• Time-limited, structured.• Self-help.• Prevention strategy.• Orientated to reduction in use rather than

abstinence.• Not teaching specific skills.• Not changing social environment.

Page 8: How to deliver a brief intervention

Brief Intervention for alcohol• Describes short information and

advice sessions where patients are given motivational interviewing / counselling and may be referred on to specialist agencies

• Assessment of alcohol consumption

• Provision of guidance / advice

• One or more sessions

• Aims to convince recipient that they are drinking at a level that could be harmful to their health

Page 9: How to deliver a brief intervention

Identification & Brief Advice

Detection with an appropriate screening tool is followed by the delivery of an intervention.

This could be an information booklet, a few minutes of focused dialogue or a longer in-depth assessment and either a motivational intervention or onward referral to specialist services.

Page 10: How to deliver a brief intervention

Screening (Alcohol)

Although the recording of an alcohol history should form part of routine clinical practice, ambiguity regarding the level of consumption regarded as problematic may lead physicians to overlook potential alcohol problems.

We know that using a specialist screening tool detects almost twice as many hazardous drinkers as staff relying upon their clinical intuition alone.

AUDIT FAST

CAGE SASQ

PAT AUDIT - C

Page 11: How to deliver a brief intervention

CAGE• C Have you ever thought you should CUT DOWN on

your drinking?• A Have you ever felt ANNOYED by others' criticism of

your drinking?• G Have you ever felt GUILTY about your drinking?• E Have you ever had a drink first thing in the morning

to steady your nerves or to get rid of a hangover (EYE- OPENER)?

The CAGE screening test is short and easy to administer. Two or more positive answers are correlated with alcohol misuse in 90% of cases.

Page 12: How to deliver a brief intervention

The AUDIT was developed by the World Health Organization to identify persons whose alcohol consumption has become hazardous or harmful to their health.

AUDIT is a 10-item screening questionnaire with 3 questions on the amount and frequency of drinking, 3 questions on alcohol dependence, and 4 on problems caused by alcohol.

A score of 8+ is indicative of alcohol misuse.

The AUDIT

Page 13: How to deliver a brief intervention

AUDIT-C

Page 14: How to deliver a brief intervention

© SIPS

The FAST alcohol screening test

Page 15: How to deliver a brief intervention

The Paddington Alcohol Test

A brief instrument that measures quantity / frequency of consumption.

Designed for use in busy ED settings.

Page 16: How to deliver a brief intervention

M-SASQ

M-SASQ comprises only question 3 from the full AUDIT and will identify very quickly whether or not a patient's drinking is beyond lower risk (Fig 1). It is simple enough that, with a little practice, practitioners can usually deliver the question orally and mentally calculate a score.

Page 17: How to deliver a brief intervention

Which screen?• As the variety of settings in which SBI can be delivered in is so wide,

practitioners will need a variety of tools from which to choose:

• In most situations there will be time to spend 2 or 3 minutes completing a full AUDIT, which will give an accurate indication of the patient's level of risk and possible dependence

• Where there is less time, AUDIT-C might be used or the three questions asked orally

• For occasions where there is really very little time, or the patient appears unlikely to submit to any screening, there is the modified single alcohol screening question (M-SASQ), which uses one question to establish simply whether the patient is drinking above lower risk levels or not. The question can be asked orally, even conversationally, to establish whether it would be appropriate to deliver brief advice.

Page 18: How to deliver a brief intervention

The Teachable Moment

Interventions are best delivered at a time of accident, illness or crisis. This is called the teachable moment.

To maximise attendance the delay between identification and intervention should be minimal, preferably on the same day.

Patient selection of an appointment could offer a compromise

Williams S, Touquet R & Patton R, 2005, The Half-Life of the ‘Teachable Moment’ for Alcohol Misusing Patients in the Emergency Department, Drug & Alcohol Dependence, 77(2):205-208

Page 19: How to deliver a brief intervention

Stages of change (i)

Not everyone is ready for an intervention. Prochaska & DiClemente (1992) devised their Stages of Change model to illustrate the processes an individual must go through in order to effect a change in behaviour:

Page 20: How to deliver a brief intervention
Page 21: How to deliver a brief intervention

Stages of change (ii)Pre-contemplation ~ Not considering any changeContemplation ~ Thinking about changePreparation ~ Gathering info, making a planAction ~ Changes are being madeMaintenance ~ New behaviours are preserved

Brief interventions can be tailored to suit whatever stage of change the patient is at, with a goal to move them to the next level.

Page 22: How to deliver a brief intervention

A middle-aged business woman attends her doctor’s surgery with concerns about her weight and insomnia. During her consultation she mentions her alcohol consumption twice.

In relation to her alcohol use, in which stage of the change cycle is she most likely to be?

Contemplation

Page 23: How to deliver a brief intervention

A graduate in his first job with an active social life complains of feelings of anxiety. Further discussion discovers that he is having problems in his relationship and, when asked, he claims not to drink much - about four pints a night and eight on a Saturday.

In relation to his alcohol use, which stage of the change cycle is he most likely to be in?

Pre-contemplation

Page 24: How to deliver a brief intervention

A man in his 60s who has a history of high blood pressure, high blood sugar levels and who has recently experienced chest pains, consults a specialist. He decides to start using a drinks diary to record the number of units he consumes each week. Which stage of the change cycle is he most likely to be in?

Preparation

Page 25: How to deliver a brief intervention

Brief Interventions - Steps

1. Screening2. Assessment3. Advice giving4. Assessing motivation for change5. Establishing drinking goals6. Conducting follow-up

Page 26: How to deliver a brief intervention

Enhancing Motivation for Change: FRAMES

• Feedback (personalized, non-judgmental)

• Responsibility (respect for autonomy)

• Advice (clear and timely)

• Menu of options (what works for you?)

• Empathy (reflective listening)

• Self-efficacy (offer optimism and hope

Page 27: How to deliver a brief intervention

Evidence of EffectivenessA recent review of reviews (O’Donnell et al, 2014) found that BI was consistently effective at reduction both consumption and harm in both hazardous and harmful drinkers.

Most effective among Male, Middle Aged patients. The evidence on its effectiveness on an adolescent population is less clear cut (Pilowsky & Wu, 2013)

However the design of the trials themselves can influence outcomes. Reactivity to screening refers to the potential intervention that screening and baseline measurement of behaviour might represent (McCambridge & Kypri, 2011)

Page 28: How to deliver a brief intervention

Evidence of effectiveness cont…

Estimates of number needed to treat (NNT) range from 2 to 12.

Compares favourably with smoking cessation advice (NNT = 20).

Some recent evidence of a reduction in mortality following screening and brief intervention.

Also evidence of reductions in number of alcohol-related problems.

Effects of intervention still present after 4 years in one US study and after 10-16 years in a Swedish study, though an Australian study did not find an effect after 10 years.

Page 29: How to deliver a brief intervention

An example of brief advice

This is taken from the SIPS training programme and is an illustration of how a health worker can help a client work out how much they are drinking, how risky that is, and what can be done.

Page 30: How to deliver a brief intervention

Using the Brief Advice Tool

Page 31: How to deliver a brief intervention

Using the Brief Advice Tool

Page 32: How to deliver a brief intervention

Brief Advice Delivery Structure

1. Start with general information regarding drinking that increases risk of harm.

2. Give the patient an opportunity to consider what this means to them.

3. Show the patient how their drinking compares with the general population.

4. Go through the benefits of reducing drinking.5. Look at strategies for reducing drinking.6. Discuss the sensible drinking targets they should aim for.

“Your drinking places you at an increased level of risk, you can work out where you would fit in this table by counting the units you drink… some of the effects of drinking at this level could be..”

“ How do you feel about this?”

Page 33: How to deliver a brief intervention

Training video – Brief Advice

• Add links to the Alcohol Learning Centre training videos here

Page 34: How to deliver a brief intervention

Talking to people about their alcohol consumption can be quite emotive and helping them to recognise ways in which they could reduce their alcohol intake requires skill.

Which of the characteristics listed below do you think would be useful? Select one or more options ...

• A. A blaming or confrontational attitude • B. Empathy • C. A practitioner-centred approach • D. Using active listening • E. A patient-centred approach • F. An approach which instils self-efficacy

Page 35: How to deliver a brief intervention

Talking to people about their alcohol consumption can be quite emotive and helping them to recognise ways in which they could reduce their alcohol intake requires skill.

Which of the characteristics listed below do you think would be useful? Select one or more options ...

• A. A blaming or confrontational attitude • B. Empathy • C. A practitioner-centred approach • D. Using active listening • E. A patient-centred approach • F. An approach which instils self-efficacy

Page 36: How to deliver a brief intervention

Which of the following statements best describes the clinical approach that a practitioner should take during Brief Advice?

Select one option from the list below:

1. The practitioner should be firm, authoritative and determined in his or her efforts to get the patient to cease drinking

2. The practitioner needs to be authoritative but concerned as he or she facilitates the patient’s decision making

3. The practitioner needs to debate with the patient, the risks associated with drinking while highlighting the patient’s weaknesses with regards to alcohol

Page 37: How to deliver a brief intervention

Which of the following statements best describes the clinical approach that a practitioner should take during Brief Advice?

Select one option from the list below:

1. The practitioner should be firm, authoritative and determined in his or her efforts to get the patient to cease drinking

2. The practitioner needs to be authoritative but concerned as he or she facilitates the patient’s decision making

3. The practitioner needs to debate with the patient, the risks associated with drinking while highlighting the patient’s weaknesses with regards to alcohol

The practitioner providing Brief Advice should aim to be empathetic and non judgemental while facilitating the patient’s decision making process. Deflecting denial and being authoritative about the facts relating to alcohol consumption can help the patient focus on the risks associated with alcohol. Patients will respond best to genuine concern for their health and wellbeing.

Page 38: How to deliver a brief intervention

Approaches to Brief Advice• Each patient will be at a different stage of awareness about how their

alcohol consumption is negatively impacting on their life.

• Reducing their alcohol consumption may be one of many aspects of their health that they should ideally address

• One of the simplest ways to assess a patient’s readiness to change their drinking is to ask them to rate, on a scale of 1 to 10, ‘How important is it for you to change your drinking?’

• The patient’s level of motivation to change (stage of change) indicates to the practitioner how best to approach the Brief Advice

Page 39: How to deliver a brief intervention

Note on your own behaviour:

If you indulge, it may be tempting to demonstrate your empathy by taking the "We've all done it" approach. Resist this temptation if it arises. Your role is to give the patient information, so that they can make decisions about their own behaviour. Your own use should not be discussed, even if the patient asks directly.

The practitioner, whilst friendly and empathic, is acting in a professional capacity. For some patients this may play an important part in the effectiveness of the intervention.

Page 40: How to deliver a brief intervention

• Ensure adequate confidentiality for the intended discussion

• Be non judgmental

• Recommended clinical approach is to be encouraging, empathetic, authoritative and aim to facilitate the patient's decision making

• If dealing with an angry question or response from a patient be assertive but calm, drawing the patient's attention back to the relationship between the screening test and their health

• Single item screening to establish whether the patient is using above lower risk levels or not, can be used for occasions where there is really very little time

• Addressing potential dependency is beyond the scope of the Brief Advice session, offer referral to a specialist service

In summary

Page 41: How to deliver a brief intervention

Split into small groups of three: Patient, Practitioner & Observer

Take turns to engage in delivering FRAMES based BI for a patient who is :

1. Pre-contemplative2. Contemplative3. In Preparation

ROLE PLAY (in your own time… )

Page 42: How to deliver a brief intervention

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol  problems: A review. Addiction, 88, 315-336. doi: 10.1111/j.1360-0443.1993.tb00820.x  Dunn C, Deroo L & Rivara FP (2001) The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 96(12):1770-2

Background reading

Page 43: How to deliver a brief intervention

THANK YOU!