Implementing an effective intervention for problem drinkers on medical wards
Mcmanus S, Hipkins J, Haddad P, Guthrie E and Creed F;
Commented by , 25 Sep 2003
Background
Despite the high prevalence of alcohol use disorders in medical inpatients, detection and treatment referral rates remain low.
Purpose
Evaluate the impact of a brief (1 session) intervention delivered to medical inpatients by a nurse alcohol counselor.
Methods
Consecutive admissions to 5 general medical wards at a Manchester teaching hospital were screened, and considered if they consumed more than 33 (men) or 23 (women) drinks/week.
Exclusion criteria included: chronic physical complications of alcoholism; recent contact with addictions services; major psychiatric illness; self-harm related admission; no fixed address.
3-phase study design
Phase 1 – Using a drinking diary, the nurse counselor obtained baseline alcohol consumption data on all eligible patients. There was no intervention for this comparison group. An alcohol training program for ward nursing staff was also initiated by the counselor.
Phase 2 – Patients were screened as in Phase 1 by ward nurses or counselor. The counselor provided a 1-hour in-hospital counseling session to eligible patients; based on the stages of change model (1) and supplemented by written information.
Phase 3 – Screening was performed by the ward nurses only. Eligible patients received one in-hospital counseling session with a follow-up session 1-month later at home.
Patients in all 3 phases were assessed for alcohol consumption at 6-month follow-up by an independent blinded rater. Pre-post evaluations were compared using the Wilcoxon test.
Results
Of the 1360 patients screened in Phases 1 and 2, 177 (13%) were drinking above the cut-off levels; 19.6% and 4.8% of men and women, respectively. 52 were non-eligible; the remaining 125 entered Phases 1 and 2. In Phase 3, 45 patients were detected and referred by ward nurses.
There were no group differences on demographics or baseline alcohol consumption.
78% of patients were re-assessed at follow-up. Patients unavailable (N=37) were accounted for, and there were no differences (demographics, baseline consumption) between this group and those available at follow-up.
Counseling yielded a reduction from a median of 49 drinks/week at baseline to 17 drinks/week at 6-months; or a 63-68% reduction compared to a 7% reduction in the control group. There was no advantage of a second counseling session. Based on similar detection rates in Phase 3, it was inferred that ward nurses were screening effectively.
Discussion
The modest and sustained reductions in consumption following a brief intervention for medical inpatients is an encouraging finding, challenging the nihilism of healthcare professionals underlying the low detection and treatment referral rates.
Successfully delivering the intervention on a medical inpatient unit also challenges the antiquated divide between the “medical” and “addictions” model.
The alcohol counselor being a nurse likely served as a bridge, helping ward nursing staff “buy into” the importance of the program.
Patients confronting a medical crisis are more likely to be considering the impact of their drinking than the general population, thereby be more open to the timely intervention and moving through the stages of change (2). This may be reflected in the absence of further benefit from a second counseling session outside of hospital.
Chick et al (3) demonstrated similar findings almost 20 years ago, yet little progress has been made since their important study, as evidenced by the notable absence of such interventions.
This leads to one of the study’s limitations, whereby more objective measures such as reduction in healthcare costs would have strengthened the findings, and perhaps motivated contemplation and change among hospital administrators.
Finally, the skewed population (less severe spectrum) in this study limits generalizing these findings to all medical inpatients with excessive drinking.
References
1. Prochaska JO, Diclemente CC and Norcross JC. In search of how people change: applications to addictive behaviours. The American Psychologist 1992; 1102-1114
2. Shinitzky HE and Kub J. The art of motivating behavior change: The use of motivational interviewing to promote health. Public Health Nursing 2001; 18 (3); 178-185
3. Chick J, Llyod G and Crombie E. Counseling problem drinkers in meical wards: a controlled study. BMJ 1985; 290; 965-967