Working with Problematic Drinking – Jun 2016 v.2 Page 1

Working with problematic drinking

1

A good practice guide

1Adapted from the Alcohol Concern ‘Bluelight Project’ document, “Working with change resistant

drinkers, a good practice guide for Custody staff” and ‘The Bluelight Project Manual’ (2014) http://www.alcoholconcern.org.uk/wp-content/uploads/2015/01/Alcohol-Concern-Blue-Light-Project-Manual.pdf

Working with Problematic Drinking – Jun 2016 v.2 Page 2

1. Introduction Alcohol problems are a major public health problem in Scotland and the relationship between alcohol and crime, in particular violent crime, is increasingly being recognised.

Around half of Scottish prisoners report being drunk at the time of their offence, more so for young offenders (75%). Nearly 70% of assaults in A&E setting are alcohol related.

There has been a rise in the proportion of young offenders who consider that alcohol has contributed to their offending, from 48% in 1979, to 58% in 1996 and 80% in 2007.

Offenders are three times more likely to have an alcohol problem (45%) when compared to the general Scottish male population (15%) with higher rates for women offenders.

Men most likely to drink to excess are those from deprived areas, with binge drinkers the most likely to offend. While prisoners in Scotland are predominantly young men from disadvantaged backgrounds, many of whom have substance misuse problems, there is a growing number of women being imprisoned.

The overall costs of alcohol misuse in Scotland are estimated to be around £3.5bn annually.

The population in prison represents an otherwise hard to reach group so prison-based services can enable alcohol-related services to be made more accessible and address the substantial health inequalities that exist for this population. The consequences of alcohol problems in offenders affect individuals, their families, as well as health and emergency services and wider society. Prison staff, Police custody staff including custody officers, detention officers (police, staff and private), custody nurses, and arrest-referral staff will regularly encounter people who appear likely to benefit from reducing or stopping drinking but who often resist change and, therefore, often continue to offend. For offenders who are not dependent on alcohol, but it is nevertheless a factor in their offending behaviour, a Community Payback Order (CPO) allows this to be addressed through 1-2-1 work with the CJSW under an offender Supervision Requirement, through a Programme Requirement, or through the "other activity" element of an Unpaid Work Requirement. In such cases interventions could generally be considered to include2:

alcohol counselling;

the giving of relevant information;

self help materials with alcohol specific information, advice and

support;

engagement with local projects and community based initiatives to

2 Scottish Government; “Alcohol and Offenders Guidance Statement” (2012)

http://www.gov.scot/Topics/Health/Services/Alcohol/treatment/offenders-guidance

Working with Problematic Drinking – Jun 2016 v.2 Page 3

raise awareness; or

referral to (peer-led) self help groups. This guidance sets out a model framework and options for responding to this client group3.

3 Further information; NHS Health Scotland, Alcohol & Offenders Criminal Justice Research

Programme http://www.healthscotland.com/topics/health/alcohol/offenders.aspx

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2. Problematic Drinking – a Model The term ‘problem drinking’ is often used to describe any or all forms of alcohol misuse, however below a model is outlined which proves useful in highlighting drinking patterns that are not necessarily associated with dependence or ‘alcoholism’. This is a useful concept to keep in mind when considering the variance in scores recorded when screening high risk populations:

Thorley’s Model (Problem Drinking & Harm)

Harm is not

always linked

to dependence

Intoxication is

a specific issue

Diagram adapted from; Thorley, A. (1985). ‘The Limitations of the alcohol-dependence syndrome in multi-disciplinary service development’ in The misuse of alcohol: crucial issues in dependence,

treatment and prevention (ed. N. Heather, I. Robertson, and P. Davies). Croom Helm, London. Therefore; “a problem drinker is thus defined as anyone falling within the perimeter of the three circles; a person can be designated a problem drinker by showing one, two, or all three elements of the scheme. Clearly, a drinker located at the intersection of the three circles has a severe problem, and it is within this group that the stereotypical ‘alcoholic’ would be located”4. 4 Heather, N. & Robertson, I. (1997) 3

rd ed ‘Problem Drinking’. Oxford University Press, Oxford. p127.

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3. Principles of Good Practice This guide is based around several key principles:

Recovery through abstinence is the best solution – but change is not the only option – we will work with clients to bring them to the point at which they decide to change and can choose abstinence. However it is recognised that at some point the focus will need to be on managing and containing harm.

Take every opportunity – we need to take every opportunity to engage treatment resistant drinkers and reduce the harms they pose.

Not everyone will change – this guide sets out best practice but it does not guarantee success. Some people will die as a result of drinking and some people will only change after causing immense suffering to other people. The aim of this guide is to minimise this harm through driving best practice into the system: it will not solve every problem.

Change is not the only option – ideally we will work with clients to bring them to the point at which they decide to change; however, we recognise that at some point the focus will need to be on managing and containing harm.

Whole system approach – the response to this client group will usually need to be the responsibility of a range of specialist and non-specialist services, not just a single agency or single worker.

Holistic approach – the focus cannot be solely on the alcohol, the response will need to address the whole range of needs presented by the client.

Recording unmet need – no system of treatment and care can provide for every client need. If gaps are being identified, especially consistent or serious gaps, staff should have mechanisms for recording and reporting these to those who commission services.

Learning lessons – when things go wrong staff and services should have the courage to review the case and learn lessons for future practice. Responses will only improve through being open when things go wrong.

The most important message: The most important thing is to demonstrate that you believe the person can change. Promoting self-belief is crucial. You will help them believe they can change if you demonstrate that belief yourself. At times this will be tough – some clients seem set on a course that will destroy their lives or the lives of others. However, people do change. Even people who seem to have abandoned all hope of a different life can turn themselves around. If we do not demonstrate a belief in the possibility of change we will reinforce the clients’ belief that they cannot change.

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4. Alcohol Screening The first step is to:

► Screen clients identifying those who are at risk of alcohol related harm using a validated screening tool i.e. Fast Alcohol Screening Test (FAST) or preferably the Alcohol Use Disorders Identification Test (AUDIT). A copy of the screening questions is included within this section.

The AUDIT was developed as a simple method of screening for excessive drinking and to assist in brief assessment. FAST on the other hand is simply an abbreviated version of the full AUDIT tool. Utilising the full AUDIT can help identify excessive drinking as the cause of the presenting illness/behaviour. It provides a framework for intervention to help risky drinkers reduce or cease alcohol consumption and thereby avoid the harmful consequences of their drinking. The AUDIT also helps to identify alcohol dependence and some specific consequences of harmful and problematic drinking. Of utmost importance for screening is the fact that people who are not dependent on alcohol may stop or reduce their alcohol consumption with appropriate assistance and effort. The manual is particularly designed for health care practitioners and a range of health settings, but with suitable instructions it can be self-administered or used by non-health professionals. The AUDIT manual guidance is available from: http://apps.who.int/iris/bitstream/10665/67205/1/WHO_MSD_MSB_01.6a.pdf Furthermore, structured use of AUDIT is of key importance in identifying individual needs and appropriate routes linked to care pathways, as well as gaining a clearer understanding of service requirements. Limited ‘aye or no’ questioning such as ‘Do you have an alcohol problem’? is very likely to meet with the answer ‘no’.5 Use of AUDIT allows a greater depth of exploration of alcohol issues in a structured and non-threatening way and experience suggests this helps opportunities for further discussions with individuals.

► People scoring less than 7 on AUDIT are considered ‘low risk’ drinkers and should be given praise for their lifestyle choices and encouragement to continue:

“Your answers suggest that your drinking is within recommended guidelines – keep up the good work”.

You may still choose to offer these clients information about units, safe limits and the risks associated with excessive drinking. This could be achieved by giving the client an alcohol leaflet and briefly going through the main points with them.

► Individuals scoring between 8 and 19 on AUDIT are a group who being eligible, would clearly benefit from participating in the alcohol brief intervention (ABI) process. In some cases however, access to low threshold services or additional support to address alcohol consumption patterns and behaviours would also be useful. (A diagram outlining the process and ‘stages’ of the alcohol brief intervention process is included below at page 10). As with the use of screening tools, alcohol brief interventions can be carried out by a range of non-specialist staff in a variety of settings. Specific training is available to support the delivery process and details can

5 MacAskill et al. (2011) Assessment of alcohol problems using AUDIT in a prison setting: more than an ‘aye or no’ question. BMC Public Health 11:865 http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-865

Working with Problematic Drinking – Jun 2016 v.2 Page 7

be obtained internally within various agencies or via local Alcohol and Drug Partnership or NHS Grampian contacts. ► Individuals scoring 20 > on AUDIT indicate a higher severity of problems which could also indicate ‘possible dependence’6. Seeking more specialist assessment and intervention is important for these individuals. For example, recent figures would suggest that less than a third of prisoners showing possible dependence report having been ‘in treatment’. A pathway diagram from the Scottish Prisons Guidance (2016) is included at the end of this document. ► The AUDIT screening tool has also highlighted variance in needs amongst those with higher scores and in particular identifies those who might not readily acknowledge that they have an alcohol problem. Referral and subsequent engagement with higher threshold services would be an ideal scenario, but this can often prove very challenging with some client/patient groups. For any practitioner enhancing service take up with their client/patient groups is an important outcome in its own right. Motivating and supporting change is a key aspect of preparation.

Printable copies of the FAST/AUDIT tool are included below:

6 WHO Dependence Syndrome definition:

http://www.who.int/substance_abuse/terminology/definition1/en/

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This is one unit of alcohol…

and each of these is more than one unit

FAST Qs Scoring system Your

score 0 1 2 3 4

How often have you had 6 or

more units if female, or 8 or

more if male, on a single

occasion in the last year?

Never Less than

monthly Monthly Weekly

Daily or

almost daily

How often during the last year

have you failed to do what was

normally expected from you

because of your drinking?

Never

Less

than monthly

Monthly Weekly

Daily or

almost daily

How often during the last year

have you been unable to

remember what happened the

night before because you had

been drinking?

Never

Less

than monthly

Monthly Weekly

Daily or

almost daily

Has a relative or friend, doctor or

other health worker been

concerned about your drinking or

suggested that you cut down?

No

Yes, but not in the last year

Yes, during

the last year

Scoring:

An overall total score of 3 or more is FAST positive.

What to do next?

If FAST positive, you also have the option to complete the remaining AUDIT

questions (this may include the three remaining questions above as well as the

six questions on the second page) to obtain a full AUDIT score.

SCORE

Get a clear

picture of what

the person

normally

drinks.

Find out the

average

number of Units

consumed per

week:

Working with Problematic Drinking – Jun 2016 v.2 Page 9

Score from FAST (previous sheet)

Remaining AUDIT questions

AUDIT Qs Scoring system Your

score 0 1 2 3 4

How often do you have a drink

containing alcohol? Never

Monthly or less

2 - 4 times per

month

2 - 3 times per

week

4+ times per

week

How many units of alcohol do you

drink on a typical day when you are

drinking?

1 -2 3 - 4 5 - 6 7 - 8 10+

How often during the last year have

you found that you were not able to

stop drinking once you had started?

Never Less than

monthly Monthly Weekly

Daily or

almost daily

How often during the last year have

you needed an alcoholic drink in the

morning to get yourself going after a

heavy drinking session?

Never Less than

monthly Monthly Weekly

Daily or

almost

daily

How often during the last year have

you had a feeling of guilt or remorse

after drinking?

Never Less than

monthly Monthly Weekly

Daily

or

almost daily

Have you or somebody else been

injured as a result of your drinking? No

Yes, but not

in the last year

Yes, during

the last year

TOTAL AUDIT Score (all 10 questions completed):

0 – 7 Lower risk

8 – 15 Increasing risk

16 – 19 Higher risk

20+ Possible dependence

TOTAL

SCORE

Working with Problematic Drinking – Jun 2016 v.2 Page 10

Health Scotland “Alcohol Brief Interventions – Training Manual” (2009):

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5. Enhancing service take up

► Some clients may believe that changing drinking requires total abstinence. This

is not the case. With the exception of 12-step organisations like A.A. most specialist

services offer the option of controlled drinking. It is true that clients with high levels

of physical damage will need to stop completely in order to prevent potentially fatal

problems. However, informing clients that treatment may not require total

abstinence may encourage some to visit a service.

► There can be a belief that alcohol treatment always involves group-work – this is

not usually the case but you can check with local services.

► Individuals may have had prior negative experiences or negative perceptions of

services (sometimes engendered by third party experiences) and this may need to be

addressed.

► Service referral pathways differ. In such cases it may be useful to investigate first

to ensure a smooth pathway.

► Clients where concern/particular problems exist, it would be worth asking if

services can offer a speedier appointment or perhaps even an appointment in the

community. Services may also need to be more flexible and not immediately turn

someone away if they arrive late or mildly intoxicated. These requests may require

input at a managerial level.

► With such clients it will be important to ensure that treatment services speedily

follow clients up if they disengage and report this back to the referrer.

► It is worth considering whether volunteers or mentors could be used to accompany people to their first appointments.

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6. Beginning to work with the change resistant drinker If staff have screened a client with the FAST/AUDIT tool, given brief advice and, if appropriate, referred to services, they have done a good job. However, we know that the majority of people will continue to drink. In general, these patients are beyond the reach of many services. However, if a person is repeatedly re-arrested, further action can and should be taken both to help the patient and reduce future workload. Some people have argued that if the person does not want to change there is nothing we can do. This is untrue. At the very least, it would be helpful to:

► Remind clients of the risk they run with their drinking in a non-judgemental manner ► Offer leaflets7 or new insights about the impact of drinking and services available ► Encourage a belief that change is possible

However, if the person is repeatedly coming to the attention of a range of services due to their drinking it is clear that further action/intervention is required. The definition of “repeatedly” in this context needs to be determined by local agreement. It is likely however this would be looking a multiple presentations over the course of a year. It is also recognised that time can be limited in many situations. The ideal approach will be to refer the person to the local arrest referral scheme or to local specialist alcohol services. If this is not possible or is not accepted a focus with the individual should remain on working toward three things:

► Encouraging a belief that change is possible ► Encouraging change itself ► Reducing harm

These options are explored in more detail in the next few pages. There are also a number of different resources which can be utilised as self-help tools and/or working with a client over a period of time.

Alcohol Unit/Calorie calculators

Online or paper Drink Diaries

Online self-screening (www.alcoholaberdeen.org.uk) (AUDIT self-administer)

Self-Help websites: www.downyourdrink.org or https://attentiontraining.co.uk/index.html

Health related and behaviour change leaflet/written information

Literature on mutual aid such as; SMART Recovery, 12 Steps (Alcoholics Anonymous) and other recovery orientated groups or communities. Check with local services and/or Alcohol & Drug Partnership for up to date information.

7 Visit www.nhsghpcat.org for details on a number of locally held alcohol resources

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In many cases clients will need ongoing support with access to and application of some resources. 7. Working with the ‘change resistant’ drinker – building motivation It is commonly said that change resistant drinkers are in denial and no amount of intervention will help until they become motivated to change. This is untrue. People with long term patterns of heavy drinking may appear to be ‘in denial’ but this is usually a façade. Behind that front the person will likely be far more ambivalent and the greater likelihood is that they do not believe they are either able to change or are worth changing.

► Building self-belief is a critical part of moving people towards change. People with long term patterns of heavy drinking may have low self-confidence in their ability to change their risky/problem behaviours; the objective is to increase their self-confidence and self belief that they can change. Staff should consider using statements which build self belief. Some basic examples would be:

• Thank you for coming to this appointment.

• I appreciate how hard it must have been for you to discuss this. You took a big step.

• I think it’s great that you want to do something about this problem.

• That must have been very difficult for you.

• It must be difficult for you to accept a daily life so full of stress.

• You’re certainly a resourceful person to have been able to live with the problem this long and not fall apart.

• That’s a good suggestion.

• I’m sure you can do this once you put your mind to it

• You managed to give up smoking, so this will be a breeze

• I bet you’ve made bigger changes than this before

• I know how determined you can be – this will be really good for you

• You’re doing nice work on your community service requirement.

• Thanks for telling me about that.

• It’s clear that you have thought a lot about this.

• It seems like that will really work for you.

• You care a lot about your kids and want to make sure they’re safe.

• Your willingness to respond to the hard questions shows that you’re really thinking about this.

• You’re the kind of person who speaks up when something bothers you, and that’s a real strength.

• You have a lot of leadership qualities. It’s clear that people listen to you.

Motivational Interviewing: At least some staff should consider training in ‘motivational interviewing’ (MI)8 techniques and should develop these skills to encourage belief in the possibility of engagement or change or to encourage the person to reduce harm. Two simple motivational interviewing approaches to consider are:

8 Miller W. & Rollnick S. (2012) ‘Motivational Interviewing: Preparing People to Change Addictive

Behaviour’, 3rd

Ed, Guilford Press.

Working with Problematic Drinking – Jun 2016 v.2 Page 14

► Asking permission to talk about the drinking and offering permission to disagree with

your view.

► Should a client deny a problem: roll with that resistance. Accept the client’s decision

and move on to exploring other issues e.g. wider health concerns, financial problems,

rather than focusing completely on drinking.

It is easy to dismiss the person as simply ‘unmotivated’ or ‘in denial’. Yet if a person is placing a significant burden on public services, their family or community the least that can be done is to try and understand why they do not change or engage with services. It is important to understand that the things which pushed someone to drink are not necessarily the same as those that prevent change. For example:

Evidence from clinicians is beginning to suggest that alcohol related brain injury is present in a far greater proportion of drinkers (35% of dependent drinkers post mortem) than previously considered and that other patterns of head injury may contribute to this. Both will make it difficult for clients to motivate themselves.

Poor nutrition not only contributes to brain injury but also reduces energy levels.

Conditions like liver disease can reduce energy and encourage a pattern of sleep problems.

A large proportion of drinkers will be in depressed states as a result of alcohol’s effects on the central nervous system.

Putting these factors together we can see that the problems of engagement are not simply ‘denial’ but the fact that the person is at the centre of a ‘perfect storm’ of conditions which make it harder and harder for them to organise and motivate themselves. Requiring motivation of such clients is as sensible as requiring the drowning person to swim to shore for help. Explaining this to clients will also help them to understand why they are finding it hard to change. It is not simply that they are ‘weak people’ rather they have real barriers that impede change. Therefore, assessments should try and identify barriers to change and engagement. This checklist is not designed as an assessment form. It is simply a useful prompt for workers to encourage them to think widely about potential barriers.

Is there evidence of:

Depression?

Anxiety disorders, phobias (especially agoraphobia, panic attacks)?

Other mental disorders?

Alcohol related brain injury?

Learning disabilities (Foetal Alcohol Syndrome/Foetal Alcohol Spectrum Disorder)?

Does the client:

Working with Problematic Drinking – Jun 2016 v.2 Page 15

Lack self belief due to prior lapse/relapses?

Believe that they will always be an ‘alcoholic’ (because parents were)?

Have peers or family members who are subverting efforts to change?

Have physical health problems impeding change?

Have literacy or numeracy problems reducing confidence to change?

Have poor nutrition?

Have mobility problems?

Have sleep disorders (or sleep reversal i.e. sleeping during the day – often a symptom of liver disease)?

Have accommodation/housing problems?

Is the client:

Isolated?

Fearful of change?

Ignorant about services?

Unable to access services?

Does the client have:

Previous negative experiences with services?

Anxieties about how they appear to others?

Money worries?

Concerns that may affect their benefits?

Are there:

People who have abused them, or who they owe money in or near to services?

Problems with the timings of access to services/support?

If someone has been identified, received a brief intervention or other advice and been offered services but is still not making changes, the next step to consider should be the use of more intensive motivational interviewing

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This is a technique that can be used by both specialist and non-specialist services. The aim of MI is to move the client from one of ambivalence to one where change is a possibility to be enacted. The approach emphasises the importance of not entrenching people in negative positions by trying to persuade them to change. Instead it emphasises encouraging the client to believe that change is possible and to non-judgementally develop reasons why change should be tried. Training in this approach should be available to non-specialist services (check with local Alcohol and Drug Partnerships for further information). Should time or the client themselves not allow or participate freely, staff should consider:

► Offering enhanced personalised education about the impact of alcohol on that person. This should be non-judgemental and factual feedback about risks that that person runs: not generalised statements about e.g. the risk of liver disease.

The ‘Stages of Change’9 model:

Other useful resources supporting this approach are available from:

National Treatment Agency (NTA) Toolkit [now Public Health England]: www.nta.nhs.uk/toolkits.aspx

Motivational Interviewing Assessment (MIA) Supervisory Tools for Enhancing Proficiency: http://www.motivationalinterviewing.org/ and http://www.motivationalinterviewing.org/sites/default/files/mia-step.pdf

9 For more detailed information see for example: Connors, G, Donovan, D. DiClemente, C. (2001)

Substance Abuse Treatment and the Stages of Change: selecting and planning interventions, Guildford Press.

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US guidance document on using MI with problem drinkers; Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 35: http://www.ncbi.nlm.nih.gov/books/NBK64967/

Self Efficacy, Strengths Based Assessment and Recovery Planning It is important to identify strengths and assets1011 within any assessment process. These will likely help support the recovery planning process for those individuals who are working through change. Recovery is a process through which a person addresses their problem alcohol use to become an active and contributing member of society. This concept of recovery and a belief that people can and do recover from problem alcohol use and dependency are at the heart of the Scottish Government's strategies on drugs and alcohol. There is no single path to recovery, it can begin anywhere; in a doctor's surgery, a hospital, treatment and support service, church, prison, peer support group or in someone's own home. Recovery happens every day across Scotland and there are effective solutions for people still struggling. Whatever the pathway to recovery, the journey will be far easier to travel when people are treated with dignity and respect.

In practice, people can best be empowered to recover through the establishment of a recovery-oriented system of care (ROSC).12 The underlying philosophy of a ROSC is that treatment, review and aftercare are integrated and priority is given to empowering people to sustain their recovery. Distinguishing features of a ROSC include:

• being person-centred

• being inclusive of family and significant others

• keeping people safe and free from harm

• the provision of individualised and comprehensive services - such as housing, employability and education

• services that are connected to the community

• services that are trauma-informed

At its centre it has strength-based assessments, which take account of individuals' recovery capital, and integrated interventions and services that are responsive to a person's needs and beliefs. There is a commitment to peer recovery support services, and most importantly, it is inclusive of the voices and experiences of people, and their families, in recovery. It also provides for system-wide education and training, ongoing monitoring and outreach, is outcomes driven and evidence informed. A ROSC is an effective drug and alcohol system empowering service users to progress at their own pace through a care pathway from first

10

Glasgow Centre for Population Health (2011) Asset based approaches for health improvement: redressing the balance http://www.gcph.co.uk/assets/0000/2627/GCPH_Briefing_Paper_CS9web.pdf 11

Glasgow Centre for Population Health (2014) Towards asset based health and care services http://www.gcph.co.uk/assets/0000/4200/BPCS13_Towards_asset-based_health_and_care_services_FINAL.pdf 12

SSKS ROSC Driver Diagram: http://www.ssks.org.uk/topics/drugs-and-alcohol/developing-recovery-orientated-systems-of-care-driver-diagram.aspx

Working with Problematic Drinking – Jun 2016 v.2 Page 18

entering drug, alcohol and other services to returning to the wider community and universal public services and activities. A number of tools and references are available and can be utilised to support this process: Routes to Recovery (PHE (NTA)): http://www.nta.nhs.uk/uploads/phemappingmanual.pdf Whole Person Recovery: a user centred systems approach (RSA): https://www.thersa.org/globalassets/pdfs/reports/rsa-whole-person-recovery-report.pdf Quality Alcohol Treatment & Support (Scottish Govt): http://www.gov.scot/Resource/Doc/346631/0115327.pdf Outcomes Star – evidence based tool for supporting and measuring change: http://www.outcomesstar.org.uk/outcomes-star-home/the-drug-and-alcohol-star.html SMART Recovery – Tool Chest: http://www.smartrecovery.org/resources/toolchest.htm Straight Ahead: Transition Skills for Recovery (TCU): http://ibr.tcu.edu/wp-content/uploads/2013/09/samanual.pdf Five Ways to Wellbeing (NEF): http://www.fivewaystowellbeing.org/ Relapse Prevention – Model Overview (NIAAA): http://pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf Wanigaratne, S. Et al (1990), Relapse Prevention for Addictive Behaviours: a manual for therapists, Wiley-Blackwell

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8. Enhanced personalised education After brief advice it may be useful to provide drinkers with what may be called enhanced personalised education. This is specific information about the impact of alcohol on that person. This should be non-judgemental and factual feedback about risks they are running. This may cover physical, psychological or social risks for both short-term and longer term13. The following are some examples of this:

Vulnerability due to intoxication effects (accidents, injuries, hospital admission, assault, financial abuse, exploitation etc)

Poorer sleep patterns. Alcohol in any quantity disrupts the natural sleep processes.

Memory loss / ‘blackouts’ which can occur after frequent heavy drinking episodes

Employment, educational and financial prospects harmed or exacerbated through problematic drinking consequences

Mental wellbeing. Alcohol misuse makes people far more vulnerable to suicide. Alcohol is a depressant drug and long term drinkers may become very low in mood. The suicide risk is worsened because not only are people depressed, but the alcohol is also likely to make them act impulsively

Long term heavy alcohol use prevents your body absorbing sufficient vitamins and minerals. This can lead to vitamin deficiency including anaemia. In particular, it causes brain damage. B vitamins are essential for brain repair and as a result of low intake of these vitamins the brain deteriorates until people begin to experience alcohol-related dementia.

Long term health issues. Alcohol can damage the pancreas. As a result it becomes enlarged and very painful. This damage can also lead to diabetes. The combination of alcohol plus diabetes is very risky and can lead to blindness and death. In some heavy drinkers it will lead to nerve damage which can cause loss of sensation and damage to the nerves in the hand and feet. There is emerging evidence of higher risk of cancer diagnosis for people who drink heavily and who are therefore at specific risk from a range of cancers including; oesophageal, liver, bowel and mouth/oral cancer.

A suggested example detailing enhanced personalised education in action would be to give clients a chart about urine colour. Hydration will help a drinker’s health and current status is readily seen when someone urinates. Knowing about the need to keep hydrated will be a personalised education message every time someone goes to the toilet! Urine colour charts are available on the internet: https://health.clevelandclinic.org/2013/10/what-the-color-of-your-urine-says-about-you-infographic/

13

A range of Alcohol Concern factsheets are available from: http://www.alcoholconcern.org.uk/training/publications/factsheets/

Working with Problematic Drinking – Jun 2016 v.2 Page 20

The Four ‘L’s: The Four ‘Ls’ is a useful concept to keep in mind when framing personalised education. It has a simple yet comprehensive approach to remind practitioners of the various domains they may wish to explore with clients:

LIVER: Health: physical, psychological, emotional issues

LOVER: Relationships: family, friends etc

LIVELIHOOD: Lifestyle: work, finance, housing, education

LAW: Criminality issues: charges, court cases, civil proceedings

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9. Identifying opportunities to reduce risk/harm It is not always possible for some staff to take on long-term client work. However, if a person is repeatedly presenting it could be useful for someone to:

► Undertake an assessment of risks specifically associated with problem drinkers e.g. fire risks, medication problems, trip hazards in the home, noise nuisance.

The checklist presented below is designed as a support to existing risk assessment and not as a replacement. A checklist of risks specifically associated with problem drinking:

Health

Do they require vitamin therapy?

Are there dangerous drug combinations?

Are they stockpiling medications?

Is alcohol interacting negatively with/counteracting any medications?

Have they had a recent physical and dental health check?

Have they attempted suicide or have histories of self-harm?

Is there a smell which may indicate health problems?

Is their diet adequate?

Are they smoking?

Is there adequate heating in the home?

Is there a risk of hypothermia?

Is there a risk of sunburn/dehydration from street drinking?

Practical risks

Are they drinking and driving (including mobility equipment/scooters?)

Are they using any other machinery?

Are they drinking in isolation? Will anyone know if they come to harm?

Are they drinking in risky locations? With whom are they drinking?

Do they have a smoke alarm fitted?

Are there other indicators of a fire risk?

Are they cooking in dangerous ways e.g. deep frying when intoxicated?

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Do their heating methods suggest a fire risk?

Are there trip hazards in the house?

Do they allow baths to overflow or fall asleep in the bath?

Are there any other environmental hazards such as an unstable television or simply the risks of general clutter?

Is there noise nuisance to neighbours?

Are there cigarette burns on clothes or carpet indicating a fire risk?

Is there glass littered in the home (to protect others as well as the client)?

Are there bodily fluids in the house?

Is the way they are buying alcohol putting them at risk?

Are they a nuisance on public transport?

Do they use gas in their house?

Is their disposal of refuse causing neighbour nuisance or putting their tenancy under threat?

Abuse and exploitation

Is alcohol safely stored if young people have access to the property e.g. grandchildren?

Are they at risk of exploitation e.g. for their benefits? Sexual exploitation?

Do they have safe storage facilities for drugs or cash?

Is their property by used by others for drug dealing etc?

Does someone else hold keys to the property, so that they can access their home if they lose keys when drunk?

Are they responsible for children or grandchildren?

Do they have any animals under their care?

There is also a list of twelve questions (page 23) that will be useful to ask when speaking to someone about their physical health. These are not specialist questions designed for medical diagnosis but rather some simple questions which may prompt and encourage someone to see a GP or health specialist. This approach supports the early identification of health problems which can be potentially serious. Some of these issues could of course be disclosed by someone which also suggests that a degree of alertness is required by practitioners in terms of recognising issues requiring urgent attention.

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It is suggested that open-ended questions are used at the beginning of the conversation such as:

Alcohol increases the risk of over 60 different conditions/diseases. Have you had any recent health problems? Can I run through some other health related questions?

12 Questions for the Generic Worker to ask about alcohol related physical ill health: ► Do you ever experience a painful feeling of heaviness or tightness, usually in the centre of the chest, which may spread to the arms, neck, jaw, back or stomach? ► Have you ever coughed or noticed blood in your vomit? ► Have you ever noticed or has someone else commented that the whites of your eyes have turned yellow? ► Have you passed any blood from your back passage?

In all of the above, urgent medical attention should be sought

► Do you have a sensation of numbness or pins and needles in your feet or hands? ► Have you a history of head injuries (including non-alcohol related and as a child)? ► Have you lost or gained weight unexpectedly recently? ► Have you noticed that you bruise more easily than normal? ► Do you experience, or have you experienced a severe, dull pain around the top of your stomach that develops suddenly? ► Has a relative, friend or carer expressed concerns about your memory?

► Are you practising safe sex? Are you using contraception? Are you thinking about or considering becoming pregnant? (females only) ► When was the last time you had your blood pressure checked or had a blood test?

In the remaining questions above, specific actions are required to be taken forward

For further details see pp 30-32 within the Alcohol Concern Bluelight Project Manual at: http://www.alcoholconcern.org.uk/wp-content/uploads/2015/01/Alcohol-Concern-Blue-Light-Project-Manual.pdf

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10. Diet and problematic drinking People with alcohol problems may be poorly nourished:

The calories absorbed in alcohol can reduce the stimulus to eat

Alcohol may be purchased instead of food

Lifestyle may interfere with cooking and eating

As alcohol related damage progresses the body will find it harder to absorb nutrition

Smoking is an appetite suppressant and leads to a loss of taste – reducing the desire to eat.

This will:

increase the likelihood of a variety of health problems; but will also:

make it harder for people to engage with treatment. Furthermore, a number of nutritional issues will impact on engagement. Various deficiencies will potentially:

reduce energy levels and, therefore, motivation to engage; and

worsen low mood and depression which again will impact on engagement14. Poor nutrition generally is associated with depression and poor motivation. Drinking instead of eating will lead to the use of the calories in alcohol for energy. These are of almost no nutritional value and are harder to break down. This takes a lot of energy which leads to fatigue. Magnesium is also needed in energy production. It is poorly absorbed even in a normal diet and the lack of magnesium will again reduce energy levels. The risk of dehydration exists with some drinks, e.g. spirits, wine and fortified wines. The body needs fluids to help combat confusion and lethargy. Dehydration also increases the likelihood of urinary tract infections. UTIs will lead to the prescription of antibiotics which can lead to diarrhoea which will lead to more dehydration. Regular vomiting will also reduce hydration. In the long term, vitamin B1 (thiamine) deficiency can result in alcohol related brain damage leading to confused states which can appear similar to dementia. This will make it hard for clients to structure themselves to engage with interventions. This has been seen as a state which is associated with a small group of very heavy and lifelong drinkers. However, it is possible that alcohol related brain damage may affect heavy drinkers earlier than was previously understood.

14

NDARC ‘Mood & Substance Use’ Guide available at: https://ndarc.med.unsw.edu.au/resource/mood-substance-use

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Vitamins B2 and B6 can lead to stomatitis (cracks in the sides of the mouth) and glossitis (an inflamed tongue). Cracked mouths and enlarged tongues make it harder to eat again leading to the problems above. Vitamin D deficiency is important for calcium absorption. This deficiency can be due to a lack of sunshine. Therefore the body may be unable to absorb calcium and bones don’t renew themselves. This increases the risk of fractures and, therefore, hospital visits. Magnesium is also important for cardiac health. Its lack can lead to cardiac arrhythmias and shakes. So some apparent alcohol related shakiness can be due to magnesium deficiency. It may also cause tingling in the hands. Peripheral neuropathy is also the result of thiamine deficiency. Addressing poor nutrition and dehydration Many approaches will help address these problems:

► Providing vitamin pills. These can be purchased over the counter. GPs can provide vitamin therapy. ► Bread has vitamin B and B1 can be found in spreads like marmite, cheese spread and peanut butter. ► Vitamins B2 and B6 are the most important and are found in meat, fish and eggs. ► Magnesium can be secured in over the counter medications. ► Liquids may be easier to consume for some people; even ice lollies can help with hydration. ► Even ‘pot noodles’ could be a starting point, as they contain carbohydrate albeit in small quantities.

Other safety issues It would be ideal if drinkers were regularly cooking themselves a nutritious meal. However, even if they were able to do this, cooking may pose risks. Before recommending cooking, workers should consider risks such as chip pan and other fire hazards. Drinkers should be encouraged to use timers whenever they are cooking in case they fall asleep. Shakiness or conditions such as peripheral neuropathy (with consequent loss of sensation in the hands) can increase the risks.

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11. Harm Reduction Techniques As a result of the risk assessment the worker should consider harm reduction advice. Harm reduction is an approach which, while still preferring that a patient seeks full recovery, recognises that some people will not change immediately. Therefore, it is best, either to protect them, their family or the wider community by reducing the harms associated with their drinking. Harm reduction techniques can include a wide range of approaches and do not forget that:

• Information sharing is harm reduction

• Engagement is harm reduction

• Consistency of worker and response is harm reduction Each client is different and the advice they need will be different. Therefore, this guide cannot offer a structured hierarchy of advice which should be followed with all clients. Instead it offers a few key issues which should be considered with all clients and then offers a range of other ideas and examples. Professionals will find it useful to review these options when working with a treatment resistant client in order to remind themselves of possible approaches. The following five ideas are techniques which should be used as a bare minimum with all treatment resistant drinkers

Have you encouraged these core techniques:

Vitamin therapy to prevent malnutrition that leads to dementia and other conditions

Drinking water alongside the alcohol

Eating (preferably nutritiously) while drinking.

Having a fire safety check

Having a physical health check

Other approaches you may wish to consider:

Medication:

Are there dangerous drug combinations?

Is alcohol reducing the effectiveness of any drugs?

Are medications being taken as prescribed?

Do they need dosette boxes for medication regimes?

Do they need locked boxes for specific medications?

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Are they hoarding medication?

Are other drugs over the counter, legal highs or illicit substances being used?

Have they had a flu jab?

Have they had a TB vaccination, Hep A & B vaccination?

With people who have stopped, has there been a conversation with a doctor about the use of relapse prevention drugs such as acamprosate, antabuse, nalmafene and naltrexone?

Has the family been educated about:

The risks they may face?

The impact of diet and vitamins?

Is the person having a nutritious diet?

Can the drinker change the type of alcohol consumed?

Can they be encouraged to cook before drinking not the other way round?

Do they need a nutritionist referral?

Can their cooking skills be improved?

Physical health:

Have they had an oral health check: a visit to the dentist which may be a way of detecting other oral problems such as cancers?

Do they carry identity, ICE details and details of any medical conditions in case of collapse?

Are they drinking in isolation? Will anyone know if they come to harm?

Has exercise been considered as a way of reducing depression?

Have they had an exercise referral?

Have you talked about any smell of urine or rotting flesh which could indicate ill health?

Have you given enhanced personalised education - how does alcohol really effect you?

Do they need help with sleeping?

Could they change to electronic cigarettes to potentially reduce the risk of oral cancers and other tobacco related health problems?

Have you considered whether there may be alternative reasons for apparently intoxicated behaviour e.g. head injury?

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Have you considered their sexual health and contraception needs?

Use blood pressure monitoring for health

Monitor weight for health

Has an end of life pathway been considered for seriously ill drinkers?

Fire safety:

Do they have a smoke alarm fitted?

Do they require a free Fire Scotland Home Fire Safety Visit?

Do they use gas?

If smoking and drinking presents a fire risk, have they considered using a sand bucket as an ashtray? A bucket is harder to miss than a small ashtray balanced on the arm of a sofa.

Are they cooking in dangerous ways e.g. deep frying chips when intoxicated?

Do their heating methods suggest a fire risk?

Do they put a timer on when they cook?

Other practical hazards:

Is drinking and driving an issue

Are they using any other machinery?

Are there trip hazards in the house, e.g. at the top of stairs?

Are there any other environmental hazards such as an unstable television or simply the risks of general clutter?

Does someone else hold keys to the property, so that they can access their home if they lose keys when drunk.

Are there animals in the house?

Do they run baths and then fall asleep?

Do they fall asleep in the bath?

Do they need safety catches on high windows to prevent falls?

Abuse and exploitation:

Are both alcohol and drugs safely stored if young people have access to the property. This is not simply about the drinker’s own children. Grandchildren and other relatives may visit the house. In some areas

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vulnerable drinkers have been exploited by local young people who have stolen drink or drugs.

Some vulnerable clients have also been exploited for their benefits, so does cash require safe storage?

Are taxi drivers being used to obtain alcohol and can this be prevented?

Are neighbours exploiting them?

Have they been referred as a vulnerable adult?

Nuisance:

Are they playing televisions or stereos loudly and annoying neighbours? This can be alleviated by putting noise limiting devices on equipment or timers which shut the equipment off if they fall asleep.

Are any animals making a noise, making a mess etc?

If a client is making inappropriate 999 callouts, arrange for emergency service staff to come along and talk about it with them.

Money:

Have they considered taking less money with them when going out?

Have they considered not taking a bank card when going out?

Drinking style: (Could they be advised to):

Always put their drink on the table between sips?

Leave the bottle in the kitchen so that they have to get up for another drink?

Not get involved in rounds?

Support:

Can we send daily text messages and other telehealth contact?

Can we involve the family?

Can we identify peer support?

Have we provided useful telephone numbers such as Samaritans or AA?

Incentives to engagement:

Offer food vouchers/travel reimbursement

Offer alternative therapies

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Is a behaviour contract possible?

Monitor alcohol:

Drink diaries

Put empty bottles into a plastic bag, or a bag for each day, so that the number can be monitored.

Use breathalysers to monitor change

Workers:

The importance of a positive attitude: promote self belief. Change is possible!

Consider the timing of sessions so that the person is more sober

Use home visits instead of requiring an office visit

Don't set unrealistic goals

Be consistent and persistent

Contingency:

Encourage the client to write a postcard/letter for him or herself to be posted at a time of lapse or crisis

Develop a contingency or relapse prevention plan for when things go wrong

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12. A multi-agency approach In the vast majority of cases, the approaches above will represent an appropriate response. Not everyone will change but reasonable efforts have been made to engage the drinker and reduce the harm posed. However some change resistant drinkers are so complex and risky or are being arrested so frequently that further action will be required. A decision on whether a client reaches this threshold will require a case by case approach. These clients are likely to be in contact with a number of agencies, therefore, a multi-agency care planning or care coordination role will be essential. A care coordinator will need to be nominated to ensure that the work of all agencies is integrated into a single multi-agency plan. Information sharing agreements will need to be in place to support this approach. Multi-agency planning will ensure a consistent approach to the client (i.e. know who is involved and who is meant to do what, when and why), help to identify risks and facilitate sharing information. It could also involve the drinker and their family/carers.

Aberdeen City Integrated Alcohol Service (IAS) provide a multi-agency approach to service delivery locally with a range of support from low threshold advice through to in-patient detoxification and community support.

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13. A note on Co-morbidity (dual diagnosis) A common factor in many change resistant drinkers is mental health problems (dual diagnosis). This combination is a real barrier to change and help should be sought from mental health services. The following documents provide the framework within which that care should be provided:

• Scottish Government (2007); Care and Support for People with Co-occurring substance misuse and mental health problems http://www.gov.scot/Resource/Doc/206410/0054849.pdf http://www.gov.scot/resource/doc/127647/0030582.pdf

• Department of Health (England) (2009) A guide for the management of dual diagnosis in prisons http://www.nta.nhs.uk/uploads/prisons_dual_diagnosis_final_2009.pdf

• National Drug & Alcohol Research Centre (Australia) (2011), Trauma and Substance

Use https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/NDARC_TRAUMA_FINAL.pdf

Staff should seek to access help from community mental health services.

Staff should seek help and be persistent if they feel they are not receiving a response that meets the client’s needs. This is of greater importance if the client’s needs pose greater risks (to themselves and others).

If problems persist in securing help, staff should be talking to their managers and they should be talking to managers and commissioners in mental health services.

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14. Supporting the process In order to make this process work several elements are required: Staff support Staff support is vital. Many treatment resistant clients will be challenging to work with, perhaps because they are directly confrontational, because of their risks or vulnerability or because of their impacts on others. Staff will need good managerial and peer support to deal with this client group. Recording of unmet need It is important that any shortfall in the resources required to meet the needs of these clients are recorded so that they can be reported to managers, commissioners and strategic leads.at contract monitoring meetings.

If workers do not record and report unmet need, they are protecting commissioners and those involved in service planning from the need to change.

Staff training Staff will need training in the skills outlined above such as motivational interviewing or harm reduction techniques. Specific training and development needs should also be identified and recorded through supervision processes. Celebrating and publicising success It is important to share examples of success with other agencies. This will need to be within the boundaries of confidentiality and client consent but, where possible, publicising success helps to build belief in the possibility of change among both workers and clients. A ‘local champion’ is a good way to oversee this agenda. Monitor the Impact The impact can be monitored by:

• Adopting appropriate data collection/recording systems • Gathering data on unmet need • Learning lessons from issues or incidents to help inform future action

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Problematic Alcohol Use Care Pathway (from NHS Scotland, “Drugs, Alcohol & Tobacco Health Services in Scottish Prisons: Guidance for Quality Service Delivery” (February 2016)) http://www.knowledge.scot.nhs.uk/media/11318713/20160226%20nphn%20substance%20misuse%20report%20final%20v1.0.pdf (p26)