Objective 5

To describe methods for providing office based treatment including techniques for brief intervention, advice giving and counseling.

As described in The Physician's' Guide To Helping Patients With Alcohol Problems. Step III involves advising your patient to take appropriate action.

Before we get into the proper advice to give your patients I would like to discuss a very important concept with you. This concept is CHANGE! What you will be doing in most cases is asking your patient to consider changing some of their most dearly held habits. These habits have major physiological and psychological payoffs for them, albeit accompanied by some major problems or potential problems.

Robert Westermeyer, Ph.D., explains an excellent model of change in his WEB published article, A User-Friendly Model Of Change. Please read this article now and then return here.

Well, this is certainly not your garden variety model of political correctness, but there are some very valuable concepts here worth considering. Chief among them are the notions that change is a process that should be modified to each individual's needs and that relapse is a natural part of the evolution that should be neither feared nor rejected.

Well, with that as a backdrop let's look at what you can do to be helpful to your patients that need advice to deal effectively with their alcohol or other drug problems. You should provide your patient with a brief intervention followed by appropriate advice and counseling. Here is an outline of the technique:

Brief Intervention

Step 1:  Feedback
By now you have completed a fairly intense assessment of your patients situation. Now you must give him or her some feedback so that the patient understands their personal situation. State your medical concerns. Do not mince words or minimize your concerns. Be sincere. Be gentle and considerate, but be honest and clear. A statement like, "I am very concerned about how smoking and drinking are affecting your health" is non-judgmental and direct and invites further discussion.

Step 2:  Relate the message to potential or current health effects associated with the substance use
As an example you might say to your patient, "The chronic bronchitis you have developed is caused by cigarettes," or you might say to another patient, "Your hypertension is related to your drinking and may lead to a stroke." Be as specific as you can about what the risks are to your patient if they make no change in their habits.

DO NOT EXAGGERATE! If your assessment is correct, you will not have to exaggerate the facts, they will stand on their own. Exaggeration is a means of loosing your credibility. Stick with the facts as you know them, when challenged, look it up and share the results of your search with your patient.

Step 3:  Discuss Normative Use
Most smoking patients don't realize that less than a third of the American population currently smokes and that nearly three-quarters of those who do smoke say they want to quit. Most heavy drinkers have no idea that the vast majority of the population drinks considerably less than they do. The current National Household Survey on Drug Abuse is an excellent source for this type of information. The exact numbers are not important but the rough percentages can be quite useful. For instance a man who drinks about a six-pack a day will be surprised to learn that only about 6% of the population drinks that heavily. He will find that hard to believe because most of his friends drink like he does. He may not agree with you and he may argue that you can't believe those surveys because most people lie about their drinking but over time the notion of how he compares to the general population may have a significant effect on his decisions regarding his own use.

Step 4: Advice Giving and Brief Counseling
Clearly state your recommendation. This is a time to lean heavily on your training and establish your role as a medical advisor. You may say something like, "As your physician, I strongly recommend that you stop smoking and cut down on your drinking to no more than two standard drinks per day." This is a recommendation based on your knowledge and experience. It is important that you do not use words like must or should.

Advise your patient to abstain if:

• there is evidence of alcohol or other drug dependency
• there is a history of repeated failed attempts to cut down
• your patient is pregnant or trying to conceive
• your patient has a medical condition or is taking medication that might have a negative
• interaction with alcohol or other drugs
• your patient is underage for the legal use of alcohol or tobacco
• your patient is using illegal drugs

Advise your patient to cut down if:

• your patient is drinking above recommended low-risk drinking amounts but shows no signs of alcohol dependence
• your patient is smoking but does not want to quit completely just yet

Step 5: Determine the Patients Goals
After you have given your advice, you should ASK your patient one of these questions:

Are you ready to try to cut down?

or

Are you ready to try to abstain?

Listen to the response and really try to understand what stage of the change model the patient is in at the moment.

If the patient has thought about changing before, they are past the pre-contemplation stage and are ready to move onto the other stages and you can be a increasingly more firm with your advice as they move along the stages toward action. If they are new to the thought of changing and indicate that they are not yet ready to give up their habits, you may need to move a little more slowly and gently. Demanding change very rarely works. Scare tactics ("you are going to die if you don't quit") almost never work in the long run. So what does seem to work best?

Contrary to popular beliefs, an empathic, non-confrontational style of counseling works best with problem drinkers and smokers and while there is less research on this technique with users of other drugs, it is reasonable to assume the approach will work best with them also.

Some specific counseling techniques that seem to work well are the following:

• Offer your patient some choices about how to effect change. Abstain for a period of time or cutting down to a low-risk level (one drink/day for women and two/day for men, for example)
• Emphasize your patient's responsibility for changing their alcohol, tobacco or other drug use habits - this is something they are going to do for themselves, not something you are going to do to them.
• Convey confidence in your patient's ability to change their self-defeating behaviors.

Remember that your patient wants control over their situation and the more you make them feel in charge of the situation the more likely you are to get compliance and the less likely you are to encounter resistance and denial!

Provide your patients with high quality educational materials. These can be obtained from local alcohol and drug programs, taken directly off of the WEB or developed by your own staff. The point is to give the patient materials that will reinforce the desire to change and tips on staying changed.

NOTE: For a patient that shows evidence of alcohol or other drug dependence, you should consider referring him or her for additional diagnostic evaluation or treatment. See Objective 7 for tips on making referrals.

For patients who are not ready to change follow these guidelines very closely:

• Do not become discouraged
• Do not become angry
• Restate your concern for your patient's health
• Restate you willingness to help when the patient is ready
• Continue to monitor substance use at subsequent visits
• Remember change is a process and the pre-contemplation and contemplation stages may take awhile but change does happen and your consistent input may play a big role in a successful outcome.

Study Questions:

1. What are the six stages of the change model developed by James Prochaska and Carlo Diclemente?
2. What are the five steps in a "brief intervention?"
3. When providing a brief intervention for substance abuse problems, are the following statements true or false?
   1. You should relate your concerns to the potential or current health effects associated with your patients substance use or abuse.
   2. You should only talk about your patients behavior and not discuss general things like national statistics or the results of local surveys.
   3. You should always ask your patients to quit using alcohol if they are drinking above safe levels.
   4. If your patient shows signs of being alcohol dependent, you should recommend abstinence as a goal.
   5. If your 55 year old female patient smokes and drinks 3 or 4 drinks per day but does not show signs of dependence on alcohol, you should recommend that she quit smoking as soon as possible and consider cutting down her drinking to no more than one standard drink per day.
   6. If your patient is recently married, is trying to become pregnant and reports drinking 1 or 2 glasses of wine a few times per week, you should advise cutting down to no more than one drink per day until after the baby is born.
   7. If your patient is a 69 year old male who is using mebrobamate (a sedative) you should warn him to not drink more that two drinks per/day while on this medication.
   8. If your patient refuses to accept your advice you should tell him you are not willing to act as his physician if he will not cooperate with you and that he should look for another physician as soon as possible.
   9. When counseling your patients with substance abuse problems, confrontation is the preferred method of motivation for change.
   10. Abstinence is the only acceptable goal for a 28 year old male who reports drinking 6 to 10 beers several times per week.

ESSAY QUESTIONS:

In Prochaska and Velicer's article The Transtheoretical Model of Health Behavior Change they argue that health promotion efforts should be looked at from an "impact" point of view rather than just from an "efficacy" position. Describe the formula for population impact and explain how this concept might be applied to a primary care practice vis-a-vis brief intervention?