“The management of problem alcohol use

among problem drug users in primary care:

Patients’ experience of screening and treatment”

Catherine Anne Field

School of Medicine and Medical Science – University College Dublin

J.Klimas, W.Cullen, J.Barry, G.Bury, E.Keenan,

S.Lyons, B.Smyth

BackgroundMMT Patients

Problem Alcohol Use -

35%

Brief interventions effective for

problem alcohol use

Motivational interviewing may be

feasible to reduce problem alcohol use among problem drug

users

Alcohol &

Methadone

“..the interaction between alcohol

and methadone is harmful and dangerous in

toxicity” (GP 4.1)

“it generally reduces compliance with the treatment programme” (GP 4.1)

“80% and 90% of all our ex heroine users

have Hepatitis C” (GP 6.1)

“it tends to destabilise their mental state” (GP 10.1)

Patients’ views?

• Aims• Methods– Purposeful sampling of patients with known

alcohol use– Semi structured interviews using piloted topic

guide– AUDIT to assess alcohol use– Thematic analysis (Nvivo) – Validity testing of analysis

Subject Recruitment

John*35, injected heroin for 14 years

HCV+, never treatedAlcohol use – drinking 6-10 cans (12-20 units) per day

“… I was in a coma there a couple of weeks ago – I was found in a river. I went up the mountains drinking, I fell

in the river and the next day it was two Polish people took me out of the river – I was in a coma… I drank

myself stupid that day, just kept drinkin”

Patients – sociodemographics

85% Unemployed

55% HCV+

Mean age 39 years

80% Past injectors

75% living in council / rented

accommodation

Study findings1. Patients’ current and previous alcohol use and

drinking patterns

2. Patients’ attitudes to problem alcohol use

3. Experience and knowledge of alcohol related harm and safe drinking

4. Patients’ experience of and attitudes towards therapeutic interventions

Patients’ alcohol use

• AUDIT - 25% hazardous, 20% dependent

• Began in adolescence

• Inverse relationship with drugs / heroin

• Used as substitute – safe alternative, sedative

• Attitudes – mixed levels of concern,

ambivalence

“we were only kids, 13,14m and we would keep our few quid until the weekend and put our money together, get a couple of litres every

Saturday” (patient 7.3)

“…when people get seriously into heroin it just takes over everything”

(17.3)

“That is the way I am… it is just part of me and it’s not changing at the moment. I don’t want to

change” (Patient 2.2)

Knowledge of alcohol related harm

• Good knowledge of harm, poor level of safe drinking levels

• Experience led knowledge

– HCV– Fatal effects

– Psychological damage– Relapse

– Damage to family

“I have hepatitis C and if I was to drink spirits for a year... I wouldn’t even get a year out of it I don’t

think…” (Patient 11.5)

“My neighbour drank every morning, 6 packs of cider, one day, a Tuesday or Wednesday, I said get the

doctor, he was bright yellow, by the Saturday he was dead. [Clicks fingers] Out like that, because he drink

cider, 6 cans of cider beside his bed every morning, when he woke up...” (Patient 17.2)

1 unit

3 units4 units per

week

50 units per week

Experience of screening and treatment

• Screening inconsistent• Reliance on clinical detection and self reports • Non-detection and concealment

• Brief intervention • Referral to specialist services • Service restrictions• Pharmacological interventions

Positive reactions to interventions

• Accepting

• Receptive

• Open

• Understanding

“I’d no problem telling him things, there’s no point in lying to a doctor. He’s there to help

you so…I was up front with him and whatever he asked me about I just told him the

truth because it’s for my own benefit” (7.3)

Negative reactions to interventions

• Fear

• Embarrassment /

shame

• Guilt

• Resentment

• Controlled

“I find it a bit hard… I kind of think that they don’t know what

I’m going through… I don’t think you have a mind to tell

you the truth, especially when you’re drinking you feel like an idiot talking about it because

you’re only telling a load of lies” (5.3)

Barriers and enablers

• Healthcare professionals– Patients prefer primary care– Importance of therapeutic relationships – Need for support and encouragement

• Patient– Attitude, motivation and readiness to change– Personal / social complications– Need to access help

Therapeutic relationship

“because you used drugs once you will never be trusted by a doctor. Like, I’m not able to give a urine sample with somebody else in a cubicle. I just can’t…

I am nearly 47, I’m an old man” (5.4)

“I did have arguments with him saying “You don’t realise how much power you have over people. And you are not judge, jury and executioner.” Because they have that much power over you the doctors when you’re on the methadone, you have to comply with them” (Patient 11.3)

Patient attitudes / experience

Positive relationship Negative relationship

> Honest about alcohol use

> To initiate discussion

> Understanding and receptive to advice and intervention

“nothing to hide”

< Honest about alcohol use

> To conceal alcohol use

Fear of clinical implications

Distrust of professionals

Motivation / readiness to change

“No, I wasn’t ready for it. I know in my heart and soul… 99% of me wanted to be away from it, and 1% didn’t, that 1% would overcome the 99%.” (Patient

20.2)

“Like all the excuses are there… there’s a million and one excuses an addict can come up with. Either you want it or you don’t. And if you don’t you make your excuses… I don’t think there is any help for them until the person is

individually ready within themselves” (Patient 11.5)

Barriers and enablers

• Social factors– Support systems– Childcare responsibilities– Social acceptance of alcohol

• Structural factors– Stricter service delivery– Opportunistic screening– Service availability

Conclusions

• Problem alcohol use common and harmful

• Awareness and concern – ambivalence

• Inconsistent management

• Importance of therapeutic relationship

• Importance of motivation

What next?

• Implications for further research, practice policy– Development of clinical guidelines– Quantitative national cross sectional survey – Cochrane systematic review– Feasibility study• Education / training for GPs / students / practice nurses

Acknowledgements

• Patients and staff at participating practices

• Health Research Board

• Colleagues at Coombe Health Care Centre, UCD and the University of Limerick

catherine-anne.field@ucd.ie