A Feasibility Study: The role of Community Pharmacists in the Identification and Treatment of Hazardous Drinking
Tony Goodall – Alcohol Strategy Lead – Leeds Primary care Trust.
Peter Dawson – Development Officer – LeedsPharmaceutical Committee.
Introduction
Excessive alcohol consumption is a major risk factor for physical social and mental well-being, and there is good evidence that early intervention can be effective in modifying this.(1)
The pharmacy contract in EnglandWales includes the promotion of healthy lifestyles and prescription-linked public health interventions as an Essential Service.(2) As the Pharmacist’s Public Health role develops, supportive evidence for feasibility and effectiveness is required.
Hazardous drinking refers to a pattern of drinking that is associated with a high risk of psychological or physical problems in the future. The drinking appears to cause no current harm, and is probably thought of as both normal and socially acceptable. The drinker is unaware of the health damage being incurred.
Harmful drinkers are already experiencing these problems. The dependent drinker is experiencing symptoms of dependence including impaired control or a subjective experience of compulsion to drink. The term alcohol misuse is used to cover all these categories.
Brief Interventions (3,4) in primary care settings have been shown to reduce Hazardous Drinking, and the aim of this study was to investigate the feasibility of screening for Hazardous Drinking, with subsequent Brief Interventions if indicated, as a routine part of the community pharmacist’s public health role.
It was hypothesised that a brief intervention could be given at the same time as other activities in the pharmacy, such as prescription counselling or Medicine Use Reviews, hopefully adding little to the time involved. The aim of the intervention was to raise awareness and motivation to change, while facilitating decision-making. Health professionals have status and credibility, and it was envisioned that a Community Pharmacist might be the right person to carry out this activity, and that immediately after a health concern, as indicated by filling a prescription for example, might be the right time.
The intention was to capitalise on the trusted relationship that exists between pharmacist and patient, and the opportunity for encounters in a professional setting without an appointment.
Although the primary outcome measure was feasibility, where data was available, alcohol use was analysed.
Implicit in the study design is the efficacy of Brief Interventions. There is a very large body of research evidence on alcohol brief interventions, including at least 56 controlled trials of effectiveness (5). There have been at least 14 meta-analyses (6-19) or systematic reviews. All these have reached conclusions, in one form or another, favouring the effectiveness of brief interventions in reducing alcohol consumption to low-risk levels among hazardous and harmful drinkers.
Method
The study was designed to answer the research questions:
1. Can a Pharmacist, as part of their usual working day, opportunistically identify Hazardous Drinkers by using a FAST(20) Questionnaire?
2. Similarly, in that setting, can a Pharmacist conduct BRIEFInterventions?
The study was conducted by Pharmacists from six differing Community Pharmacies, each with consulting room facilities, and each serving populations with differing social and ethnic background, over a three month period in late 2006. The Pharmacists attended specifically designed tutorials on the health impact of excessive alcohol, and were trained in the use of the FAST Questionnaire and in the nuances of Brief Interventions by one of the Investigators, TG. Regular meetings to discuss progress and impediments, and to share experiences, took place through the study.
Patient Recruitment
No patient was actively excluded. Although it was envisaged that the study would capitalise on those patients making regular visits to collect repeat prescriptions, Pharmacists were encouraged to recruit women. Being a Feasibility Study, Pharmacists were encouraged to improvise and adapt to local conditions to maximise recruitment.
FAST (Fast Alcohol Screening Test)Questionnaire
The FAST questionnaire offers a validated, rapid and efficient way of screening for hazardous alcohol consumption that can be used in a variety of settings. It is designed to lead directly into a brief intervention.
The prescription, or purchased medicine, was the pretext for the screening – alcohol intake being frequently relevant to disease and treatment
It consists of just five items, and average administration time is less than 30 seconds.
The patient encounter developed as it would usually in that pharmacy for medicines counselling. If the patient were identified as a hazardous drinker, agreement was sought to discuss drinking and the brief intervention enacted. Follow up counselling, where possible, was pursued as the Patient returned for monthly repeat prescription.
Refer to Appendix 1 for a description of the application and scoring system for the FAST Questionnaire
This study included an additional question: - ‘Is the drinking of a family member, friend or work colleague causing you concern?’ This was not recorded within the validated scoring system, but those identifying the issue were made aware of Al-Anon as a potential source of support.
The Brief Intervention
Emphasis was placed upon the evidence that ‘a few words given at the right time by the right person can have a significant influence.’ Lengthy discussions with patients were discouraged.
The whole basis to the study was to capitalise upon and exploit the trusted relationship that exists between the Pharmacist and customers. There was no explicit content to a brief intervention i.e. there was no script to follow – it was the professional decision of the Pharmacist as how to proceed with each individual patient, the common goal being to raise awareness and motivation to change, while facilitating decision-making. A non-judgemental empathetic approach was encouraged.
The implementation of the intervention is described by its acronym -
Benefits – the client should be aware of the benefits of sensible drinking
Risk factor – exploration of the substance (i.e. alcohol) as a risk factor in the client’s current situation can raise awareness
Intentions – clarify the client’s future intentions
Empathise – the practitioner should empathise and retain a non-judgemental attitude
Feedback – the practitioner should give the client feedback on their levels of consumption.
The manuals for the FAST screen (21) and Brief Interventions (22) , along with the document ‘Process of Change’,(23) were supplied as reference material to each Pharmacist.
Record Keeping
Alcohol intake was determined both through use of the FAST questionnaire.
Signposting
For those patients who revealed harmful or dependent drinking, referral to one the following agencies was recommended.
Local GP
Local Alcohol Service
Alcoholics Anonymous
Al-Anon
RESULTS
One Pharmacist withdraw before data collection due to a change of pharmacy ownership
Pharmacist Verdicts on Feasibility:
Each Pharmacist submitted a report with their verdict on feasibility.
Pharmacy A.
It was not feasible to incorporate the intervention due to Workload considerations – competing demands for Pharmacist time, and Patient Embarrassment – resistance was encountered when the FAST questionnaire was introduced.
The Pharmacist report included the observation that the highlighting of the health issues around alcohol was well received and he will continue to emphasise this in his practice, but there was not sufficient time to overcome the resistance to ‘digging a little deeper’. Follow up was not possible.
The training package was highly rated
Pharmacy B
Opportunistic screening proved to be almost impossible due to time constraints and workload. The training was highly rated and the FAST questionnaire simple to use o those few occasions when it was possible.
Pharmacy C
Workload and competing demands prevented significant participation. The support material was considered very useful and the Pharmacist will continue to offer advice around alcohol. However a service of any more than provision of advice could not be accommodated in the work routines.
Pharmacy D
The intervention was highly rated and well accepted by patients, but the existing workload prevented greater participation.
Pharmacists B, C and D all felt that patient acceptability was high and that given more resource they could conduct the screen and the interventions. In particular, they felt that knowing the patient well greatly helped the conduct of the screen and brief intervention. There recommendation was that given the appropriate resources, the screen and the intervention should be incorporated into the Medicine Use Review, and become a contractual obligation.
They also reported the training had increased their awareness of their own drinking habits and they had reduced their intake accordingly!
Pharmacy E
Of the 352 patients this Pharmacy contributed 292, thereby dominating the overall results. Clearly in this case the feasibility of the service was proven.
A review of his approach revealed the following differences
His study population was not restricted to being prescription linked. Initially customers purchasing medicines with alcohol related issues were entered into the study and subsequently no restrictions were made on who was entered.
Staff involvement. The Pharmacy support staff were trained by the Pharmacist to conduct the FAST questionnaire. This was really well received by the staff and resolved the initial problem encountered elsewhere of Pharmacist availability.
Specific days and specific times of day were identified for specific staff to conduct the FAST questionnaires. These were geared to levels of activity and surgery opening hours
On different occasions specific patient groups – e.g. young mothers - would be targeted.
Targets were established and rewarded for numbers of FAST questionnaires completed.
The major difficulties described in Pharmacy E were following up patients and the resistance among young people, and in particular young females, to modify a hedonistic lifestyle. The Pharmacy continues to offer the service, which has been well received in the local community, as a part of a comprehensive public health service.
Table 1. Identification of Hazardous Drinking leading to Brief Interventions
Pharmacy / Hazardous Drinking / No Hazardous DrinkingA n = 13 / 3 (22%) / 10 (78%)
B n = 17 / 2 (12%) / 15 (88%)
C n = 12 / 6 (50%) / 6 (50%)
D n = 18 / 9 (50%) / 9 (50%)
E n = 292 / 85 (30%) / 207 (70%)
Total n = 352 / 105 (30%) / 247 (70%)
Pharmacy E dominated the study results. Numbers from the other Pharmacies are too low to warrant separate analysis.
Of 352 people entered into the study, approximately 1 in 3 were found to Hazardous Drinkers. This is a dramatic and disturbingly high proportion, particularly as, by definition, study participants showed no signs of alcohol misuse.
Table 2. Concern over a friend or colleagues drinking.
Study PatientsN = 352 / No of Study Patients who expressed concern over a friend / colleagues drinking
N = 281 (80 %)
8 out of 10 people interviewed express concern over the drinking of a friend or colleague. This is remarkably high figure, but is supported by the incidence of Hazardous Drinking described above.
CONCLUSION
All Pharmacists were highly motivated and wanted to implement the service, but only one Pharmacy was able, through an innovative approach and staff involvement, to demonstrate the feasibility of conducting FAST questionnaires and delivering Brief Interventions.
All Pharmacists found the service to have potential value.
The feasibility of introducing such a service into Pharmacies is therefore dependent on the following key factors
•involvement of all staff
•private consulting area
•patient enrollment method should reflect the in house situation as employed by Pharmacy E
•availability of pharmacist for brief interventions in face of competing demands.
The Medicine Use Review (Advanced Services, Pharmacy Contract), with revised funding, could provide the vehicle for such a service.
The prevalence of hazardous drinking detected in this study is consistent with other reports and describes a major health issue. The high numbers of family members with drink problems might be a significant and largely hidden influence on the mental and physical health of those around them.
References
1 Raistrick D. Tackling Alcohol Together; London: Free Association Books; 1999
2. The Community Pharmacy Contract, Department Health, March 2006
3 Poikolainen K. Effectiveness of brief interventions – a meta analysis. Preventive Medicine 1999; 28:503-9
4 Review of the effectiveness of treatment for alcohol problems; Duncan Raistrick, Nick Heather, Christine Godfrey (National Treatment Agency 2006).
5 Moyer et al 2002
6 Bien, Miller and Tonigan, 1993;
7 Freemantle et al., 1993;
8 Kahan, Wilson and Becker, 1995;
9 Wilk, Jensen and Havighurst, 1997;
10 Poikolainen, 1999;
11 Irvin, Wyer and Gerson, 2000;
12 Moyer et al., 2002;
13 D’Onofrio and Degutis, 2002;
14 Berglund, Thelander and Jonsson, 2003;
15 Emmen et al., 2004;
16 Ballesteros et al., 2004a;
17 Whitlock et al. 2004;
18 Cuijpers, Riper and Lemmens, 2004;
19 Bertholet et al., 2002
20 Hodgson R. The FAST Alcohol Screening Test. Alcohol and Alcoholism 2002; 37:61-66.
21. Manual for the Fast Alcohol Screening Test (FAST). Fast screening for alcohol problems
22 Babor et al Brief Interventions. For Hazardous and Harmful Drinking. A manual for use in primary care. 2001
23 - Helping People Change HEA 1994 - Prochaska & DiClemente, 1986
Appendix 1.
FAST questionnaire –guide for community pharmacists
FAST ALCOHOL SCREENING TEST (FAST)
Male ------Female ------
Patient ID (name and / or pmr no.) ------
For the following questions please circle the answer which best applies.
1 drink = ½ pint of beer or 1 glass ( regular size) of wine or 1 single spirit
- MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
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
- How often during the last year have you failed to do what was normally expected of
because of drinking?
NEVER / LESS THAN MONTHLY / MONTHLY / WEEKLY / DAILY OR ALMOST DAILY- In the last year has a friend or relative, or a doctor or other health worker, been
concerned about your drinking or suggested you cut down?
NO / YES, ON ONE OCCASION / YES, MORE THAN ONCEScore questions 1,2 & 3 : 0,1,2,3,4
Score question 4 : 0,2,4
Do not score question 5
5Is the drinking of a family member, friend or work colleague causing you concern?
NO / YESAdministration
The FAST questionnaire consists of just five items. Average administration time is less than 20 seconds.
Scoring the FAST questionnaire
Scoring is quick and can be completed with just a glance at the pattern of responses as follows:
Stage 1
The first stage only involves question 1.
If the response to question 1 is Never then the patient is not misusing alcohol.
Around 50% of people will be classified using just this one question.
Only consider questions 2, 3 and 4 if the response to question 1 is other than ‘Never’.
Stage 2
Continue with Q 2,3,4.
Each of the four questions is scored 0 to 4. These are then added together, resulting in a total
score between 0 and 16. The person is misusing alcohol if the total score for all four questions is 3 or more.
In summary:
Score questions 1 to 3: 0, 1, 2, 3, 4
Score question 4: 0, 2, 4
The minimum score is 0
The maximum score is 16
The score for hazardous drinking is 3 or more.
Q5 is an addition by us and is not scored. It may lead to a referral to Al-Anon.
If the answer to Q1 is Weekly or Daily, the patient is probably beyond the stage of hazardous drinking and is in the realm of harmful ,or dependent drinking. However, we wish you to continue with the questionnaire. Please refer to the sign posting section for referral advice.
The authors thank the AERC for their generous sponsorship of this research
The authors thank the following Leeds Pharmacists for their participation
Fiona Fox Lloyds Chemist
Mike Manning Mannings Pharmacy
Ivan Ng Medichem Pharmacy
Sarah Armitage Medichem Pharmacy
Jim Liptrot Liptrot’s Pharmacy
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