Family Practice Vol. 21, No. 2, 222-223
Family Practice Vol. 21, No. 2 © Oxford University Press 2004, all rights reserved.
Correspondence |
Screening for alcohol misuse
New Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SU a St Mary's Hospital, Praed Street, London W2 1NY, UK
E-mail: robin.touquet{at}St-marys.nhs.uk
Aira et al.'s constructive paper1 identifies seven categories influencing the physician:patient dialogue for alcohol consumption. We recently have completed a study of Senior House Officer (SHO) attitudes to screening for alcohol misuse in Accident and Emergency (A&E) (127 SHOs over 5 years)2. Briefly, we compare the experiences of GPs and A&E staff under the headings identified.
Sensitive nature of alcohol drinking
It is likely to be more problematic for GPs to broach the subject of alcohol as they are community rather than hospital based. A&E practitioners are less likely to meet their patients socially. Both types of doctor are equally likely to collude with the patient in terms of their own culturally engrained attitude to alcohol use/misuse—insight is the key.
Reason for consultation
Aira et al. comment "None of the physicians was ready to ask about alcohol consumption routinely in every consultation, but only when the reason is connected to alcohol." We have identified a list of presenting complaints (‘the top 10’) which mandate the recording of an alcohol history using the Paddington Alcohol Test (PAT),3 which takes <1 min to administer. Over 60% of all A&E attendees have a presenting complaint from the ‘top 10’.3 We educate our practitioners to respond to the patient's agenda first before introducing our own agenda of possible alcohol misuse. Further, in order to make it appear the natural course of the consultation, we teach our practitioners to introduce the subject non-judgementally by saying, ‘we routinely ask all patients who have had a fall (or whichever presenting complaint is relevant) do you drink alcohol?’ We emphasize the importance of detecting alcohol misuse at an early stage in a patient's drinking history, when they may be more amenable to opportunist intervention.
Awareness of patient's alcohol problem
Prior knowledge concerning a patient's alcohol problem is an advantage that primary care physicians have over A&E staff. We use the PAT routinely with repeat attenders, ‘repeat attendance’ being the 10th condition of the ‘top 10’.
Patient factor
GPs are inhibited from asking about alcohol consumption by value judgements concerning appearance, age, sex and profession. Alcohol is no respecter of such arbitrary divisions; doctors need education to gain insight.
Availability of intervention tools
Aira et al. describe the feelings of inadequacy that many GPs have with regard to managing early alcohol problems, and counselling in particular. At St Mary's A&E, the doctor's role is limited to detection and referral to designated alcohol health workers. The appropriately trained professional undertakes the brief intervention, which is time and stress relieving for the referrer.
Expectations of effectiveness of interventions
Aira et al. describe the expectations of the effectiveness of counselling as being ‘very low’. However, brief interventions have been demonstrated to be effective, especially for the hazardous as opposed to the dependent drinker. In A&E, patients may present at a moment of heightened crisis, making the ‘teachable moment’ more vivid.
Lack of time
Time is frequently identified as a limiting factor by A&E and primary care staff alike. In A&E, we limit the doctor's role to detection and referral. This also passes the decision to attend, or not, back to the patient—though the first step of the brief intervention has been taken by enquiring about alcohol consumption.
The major contrast between the two screening systems is that one is formalized with adequate support—a screening (PAT) and referral system with A&E designated alcohol health workers. We suggest that primary care should embrace a similar system, rather than the GP attempting to deal with a common and potentially time/effort-exhausting problem on an ad hoc basis, especially as new alcohol strategies place increased emphasis on brief interventions, largely through primary care.4
References
1 Aira M, Kauhanen J, Larivaara P, Rautio P. Factors influencing inquiry about patients' alcohol consumption by primary care physicians: qualitative semi-structured interview study. Fam Pract 2003; 20: 270–275.
2 Huntley JS, Touquet R. Attitudes of accident & emergency senior house officers to the detection of alcohol misuse. 2003. Submitted.
3 Huntley JS, Blain C, Hood S, Touquet R. Improving detection of alcohol misuse in patients presenting to an accident and emergency department. Emerg Med J 2001; 18: 99–104.
14 Gerada C. Alcohol and substance misuse in the new NHS. Alcoholis 2003; 22: 1–3.
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