Brief Interventions

Brief interventions can be very successful in primary care (SIGN, 2003) (Box 49-6). The father of the concept of stages of change, Prochaska (2009) reviews motivation to change in alcohol addiction. Family physicians can apply motivational interviewing in helping patients to move to the next level in stages of change. Part of any substance abuse intervention is the physician's assessment of the patient's readiness to change. First described by Prochaska and DiClimente (1983) while studying smokers, assessing the state of change assists the family physician in targeting the interventional approach to the patient. Change consists of the following six states: 1. Precontemplation. The physician can plant the seed of how alcohol is harming the patient (think of creative ways to list reasons) physically or emotionally. Written information is helpful, and support to the family and others involved must be offered. Further biologic or historical data should be collected, with follow-up at reasonable intervals and availability to help the patient when ready. A nonjudgmental approach is best.

2. Contemplation. The patient is aware that harm is occurring but is not yet ready for action. The physician tries to motivate patent to the action phase by listing more reasons for urgency, such as bleeding, ulcers, pancreatitis, and family violence. The physician offers referral advice if the patient is interested, collects more data, performs follow-up at a short interval, and is ready to help the patient when ready to start.

3. Preparation. The physician assists the patient in preparing for reduction or cessation of use.

4. Action. The patient is ready for referral, has "hit bottom," or is otherwise ready for change. The physician arranges inpatient or outpatient detoxification and involvement in a treatment program and completes a history and physical examination, with laboratory studies as appropriate.

5. Maintenance. The physician performs follow-up on the patient; reviews participation in the self-help program and use of the 12 steps as well as the frequency of Alcoholics Anonymous (AA) attendance; monitors target organ issues; performs mental status and depression screening; counsels regarding relapse prevention; monitors laboratory values (e.g., GGT, CDT); prescribes vitamins, naltrexone, acamprosate, antidepressants, or disulfiram (Antabuse) as needed; monitors urine ethyl-glucuronide (ETG) to determine alcohol use in the previous 72 hours; monitors and schedules; and performs follow-up regularly, as with any chronic disease.

6. Relapse. The physician anticipates relapse with any addictive disorder, is ready to help the patient again with entry into a recovery program, and offers nonjudgmen-tal support.

Brief interventions can be carried out in the context of a routine office visit (Edwards and Rollnick, 1997; Fleming et al., 1999). Interventions can follow assessment of the patient. When the physician sees sufficient evidence to conclude or strongly suspect that an alcohol use disorder is present, the brief intervention can be targeted to the patient's stage of change. An encounter with a precontemplative patient would include presentation of the physician's analysis of the problem in a supportive and nonconfrontational manner, with the goal of moving the patient to another state of change. For example:

Mr. Smith, your recent accident, alcohol use pattern, liver enlargement on physical examination, and abnormal laboratory test results lead me to conclude that your use of alcohol is a problem. As your family physician, I am concerned about your ongoing health risks. What can we do to deal with this problem?

Alternatively, a patient who is in the contemplation phase of change would be asked a different set of questions, such

Mr. Smith, I am glad that you are able to realize the impact that your alcohol drinking is having on your health, but we need to move forward and discuss treatment options.

An effective brief intervention should include feedback summarizing the physician's assessment; patient responsibility should also be emphasized, followed by clear, direct advice to change given in a nonconfrontational manner. The patient is given a menu of options from which to choose (Bien et al., 1993). Authoritative approaches are generally less effective than an empathetic approach. This type of approach will take practice and refinement for busy family physicians but can be integrated into the office practice without substantial time or expense. These techniques are more generally known as motivational interviewing. Motivational interviewing is effective in helping family physicians to engage patients in a variety of behavioral changes, including alcohol or tobacco abuse. Motivational interviewing has been a successful technique when used with alcohol brief interventions (Vasilaki et al., 2006).

The Smoker's Sanctuary

The Smoker's Sanctuary

Save Your Lungs And Never Have To Spend A Single Cent Of Ciggies Ever Again. According to a recent report from the U.S. government. Centers for Disease Control and Prevention, more than twenty percent of male and female adults in the U.S. smoke cigarettes, while more than eighty percent of them light up a cigarette daily.

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