Brief Intervention (BI)
Trainer Notes
& Activities
Overview
Key Points:
Brief Interventions are easy and effective. They:
1. can be done in one consultation, in as little as five minutes
2. are ideal in the early stages of drug use
3. have been developed for alcohol, tobacco and cannabis
4. are being developed for illicit drugs.
Suggested Objectives:
To enable GPs to:
· identify what constitutes BI
· develop their basic skills in BI
· incorporate BI into their practice consultations.
Resource Kit for GP Trainers on Illicit Drug Issues
Part B3 Clinical Process: Brief Intervention
Topic Contents
Slides:
The slides with slide notes cover:
· effectiveness of BI, especially at early stages of drug use
· limited effectiveness of BI for heavily dependent drug users
· key clinical principles and processes for implementation of BI.
The slides are on the Resource Kit CDROM under this topic.Brief Intervention. Trainers are encouraged advised to select and/or adapt this slide set to meet the focus of the training and information needs of their participants.
Activities:
The activities enable GPs to:
· discuss reasons for using, or not using, BI
· skill rehearse
· use BI for other chronic relapsing disorders.
Handouts:
1. Five A’s of Assessment
CDHA 2003, ‘Tobacco’ in Alcohol and Other Drugs: A Handbook for Health Professionals (3rd Edition), Appendix D, ch. 4, Commonwealth Department of Health and Ageing, Canberra.
2. Brief Intervention for Alcohol in an Urban AMS
Brady, M., Sibthorpe, B., Bailie, R. et al. 2002, The Feasibility and Acceptability of Introducing Brief Intervention for Alcohol Misuse in an Urban Aboriginal Medical Service Drug and Alcohol Review, vol. 21, pp. 375–380.
3. AUDIT with FLAGS
Adapted from APF 2001, Babor et al. 2001, p. 14 and O’Connor & Simmons 2001.
Please refer to the Resource Kit CDROM for a copy of handouts (PDF and Word).
Resource Kit for GP Trainers on Illicit Drug Issues
Part B3 Clinical Process: Brief Intervention
Sources of Additional Information
Patient Resources
NDARC (National Drug & Alcohol Research Centre) no date., Quitting Cannabis? Client Booklet & Clinician Guidelines, University of NSW, Sydney.
DASC (Drug and Alcohol Services Council) 1995, Drinkers Guide to Cutting Down or Cutting Out, DASC, Adelaide, www.dasc.sa.gov.au/resources/documents/
Key Readings
APF (Alcohol Pharmacotherapy Forum) 2001, Diagnosis and Management of Alcohol Misuse: A Guide for General Practice in Australia, Intramed Pty Ltd, North Sydney.
ANSWD (Alliance of NSW Divisions) 2000, ‘Brief Intervention for Alcohol Use in the General Practice Setting’ [GP Tip Sheet], GP Liaison Project Alcohol and Other Drug Tip Sheet Series, Central Coast Health Service Drug and Alcohol General Practitioner Project, 1994–2000, www.answd.com.au.
Babor, T. & Higgins-Biddle, J. 2001, Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care, WHO, Department of Mental Health and Substance Dependence, Connecticut, USA.
Litt, J., Ali, R. & White, J. 1993, Dealing with Alcohol Problems in General Practice, Commonwealth Department of Health, Housing, Local Government and Community Services, Canberra.
NCETA 2003, ‘Tobacco’, in Handbook for Medical Practitioners and Other Health Care Workers on Alcohol and Other Drug Problems, ch. 4, National Centre for Education and Training on Addiction, Commonwealth Department of Health and Ageing, Canberra.
Additional Resources:
Aristeiguieta, C. 2000, ‘Screening Patients for Alcohol, Tobacco, and Other Drug Misuse: The Role of Brief Interventions’, Western Journal of Medicine, vol. 172, pp.53–57.
Baker, A., Boggs, T. & Lewin, T. 2001, ‘Randomized Controlled Trial of Brief Cognitive-behavioural Interventions Among Regular Users of Amphetamines’, Addiction, vol. 96, pp. 1279–1287.
Copeland, J., Swift, W., Roffman, R. & Stephense, R. 2001, ‘A Randomized Controlled Trial of Brief Cognitive-behavioural Interventions for Cannabis Use Disorder’ Journal of Substance Abuse Treatment, vol. 21, pp. 55–64.
Department of Health and Community Services 1999, The Public Health Bush Book, 1st edn,
http://www.nt.gov.au/health/healthdev/health_promotion/bushbook/volume1/ch3.htm [Accessed 22 July 2003].
Dunn, C. & Gentilello, L. 2000, ‘Brief Interventions for Substance-abusing Trauma Patients’, Trauma Quarterly, vol. 14, issue 4, pp. 419–428.
Fleming, M., Mundt, M., French, M., Manwell, L., Stauffacher, E., & Barry, K. 2002, ‘Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Cost-Benefit Analysis’, Alcoholism: Clinical and Experimental Research, vol. 26, issue 1, pp. 36–43.
Hansen, L., Olivarius, N., Beich, A. & Barford, S. 1999, ‘Encouraging GP’s to Undertake Screening and Brief Intervention in Order to Reduce Problem Drinking: A Randomized Controlled Trial’, Family Practice, vol. 16, issue 6.
Jarvis, T., Tebutt, J. & Mattick, R. 1995, ‘A Final Note: Early Intervention’, Treatment Approaches for Alcohol and Drug Dependence, An Introductory Guide, ch.19, John Wiley & Sons, Brisbane.
O’Brien, C.P. & McLellan, A.T. 1996, ‘Myths About the Treatment of Addiction’, Lancet, vol. 347, pp. 237–246.
Roche, A. & Freeman, T. 2003, Brief Interventions: Good in Theory but Weak in Practice, paper presented to the International Research Symposium, Preventing Substance Use, Risky Use and Harm: What is Evidence-Based Policy?
Saunders, B., Wilkinson, C. & Phillips, M. 1995, ‘The Impact of Brief Motivational Intervention with Opiate Users Attending a Methadone Programme’ Addiction, vol. 90, pp.415–424.
WHO Brief Intervention Study Group 1996, ‘A Cross-National Trial of Brief Interventions with Heavy Drinkers’, American Journal of Public Health, vol. 86, issue 7, pp. 948–955.
Wutzke, S., Shiell, A., Gomel, M. & Conigrave, K. 2001, ‘Cost Effectiveness of Brief Interventions for Reducing Alcohol Consumption’, Social Science & Medicine, vol. 52, pp. 863–870.
Resource Kit for GP Trainers on Illicit Drug Issues
Part B3 Clinical Process: Brief Intervention
Brief Intervention (BI)
Activities
Activity 1: Skill Rehearsal – Kevin
purpose:
To develop Brief Intervention skills through skill rehearsal (role play).
Process:
1.1 Organise participants into groups of three (so that each group has a ‘patient’, ‘doctor’ and ‘observor’) and brief them about the case vignette ‘Kevin’(see below)
1.2 Inform the ‘players’ (‘patient’ and ‘doctor’) that they have five to ten minutes to role play, and inform the ‘observor’ that he or she should make notes on signifigant information/interchange/BI strategies that he/she observes
1.3 ‘Players’ engage in skill rehearsal
1.4 Debrief the ‘players’ if needed and ask the groups to discuss and note:
· how the skill rehearsal went from the ‘doctor’s’ perspective
· how the skill rehearsal went from the ‘patient’s’ perspective
· what were some strengths
· what were some areas that could be improved
1.5 Each group presents their findings to the group
1.6 Facilitate whole group discussion on BI stratgies used in the skill rehearsal and how these relate to clinical practice.
Case Vignette: Kevin
Kevin’s Presentation
Kevin is a 52 year-old manager in the public sector. He describes his job as ‘pressured’ and says he is stressed at the moment because of conflict with his director. Kevin has two children in their late teens who have been in trouble with the police for graffiti and theft. He feels he is becoming distant from his wife, which he attributes to their careers.
Kevin generally drinks a couple of schooners with colleagues after work (Monday to Friday), has a couple of stubbies or glasses of wine at home and often has a couple of six packs over the weekend. He has a single drink driving charge from five years ago. He says he never misses work because of drinking.
Kevin has presented complaining of chest pain. He has become overweight over the past ten years, and is not involved in any physical activity. His father died of a myocardial infarction at the age of 53. Kevin is mildly hypertensive (BP 155/100) and investigations reveal mild heart disease that requires lifestyle change rather than surgery.
Action
You decide to talk with Kevin about his drinking and how it may relate to his chest pain.
Resource Kit for GP Trainers on Illicit Drug Issues
Part B3 Clinical Process: Brief Intervention
Activity 2: Skill Rehearsal - Mr and Mrs Jones
purpose:
To develop BI skills through skill rehearsal.
Process:
Inform participants that there are two parts to this skill rehearsal, and that they will be working in groups of three.
For Part 1: Screening and Assessment of an Alcohol Problem
2.1 Ask for two group members to role play – a ‘doctor’ and a ‘patient’ (Mr. or Mrs. Jones) – and the third group member to be an ‘observor’
2.2 Give the role descriptions and case presentations (see further on) to the relevant ‘actors’
2.3 Allow 10 to 15 minutes for the interview to take place
2.4 Ask for feedback from the ‘doctor’, Mr. and Mrs. Jones and the observers (in that order). The initial question to each of the participants should be quite general, e.g., ‘What was that like for you?’
2.5 Review the key points in taking the alcohol history such as:
· ask general questions
· do detailed quantity-frequency inquiry, including maximum consumption
· clarify quantity in standard drinks
· use a screening questionnaire such as CAGE, Problem Question or T-ACE (for Mrs. Jones)
· ask about withdrawal and consequences of drinking
2.6 Ask the observers what category of alcohol use Mr./Mrs. Jones belongs to (i.e., low-risk drinker, at-risk drinker, problem drinker or alcohol dependent)
For Part 2: Providing Brief Advice to a Person with an Alcohol Problem
2.7 Follow steps 2.1 to 2.4 above. As an alternative, you may wish to ask all participants to split into doctor/patient pairs
2.8 Debrief by
· asking the ‘doctors’ felt about the interview
· asking ‘patients’ how they felt about the interview, and
· finally, by eliciting questions and concerns about the interview.
If time allows, you may wish to demonstrate this intervention first (using the same role play) and then get participants to try it.
2.9 Review key strategies:
· provision of brief advice (e.g., relate drinking to hypertension, discuss low-risk drinking levels)
· encouraging patient commitment to the drinking goal
· assisting patients to develop skills and confidence to self-monitor
· provide tips for avoiding intoxication
· order relevant investigations (e.g., GGT)
· follow-up and referral.
Part 1: ROLE description for MR. JONES
Screening and Assessment of an Alcohol Problem
You are a 40-year-old, married accountant, with two children aged five and nine. You drink 4-6 ‘doubles’ of scotch on Fridays, Saturdays and Sundays, and 1 glass of wine with dinner on most weekday nights. The most you’ve had to drink in the past month was 8 doubles, at a party two weeks ago. You have been drinking in this manner for 15 years. You used to drink more heavily when you were at university. You drink with a group five or six high school friends at bars or each other’s homes. You drink because you enjoy it and to enjoy the company you’re with. Your friends drink as heavily as you do. You often drink moderately, for example on week nights and when visiting your wife’s parents.
You do not feel that your drinking is a major problem. You did get charged with impaired driving five years ago, but you were found not guilty in court, and have never again driven while intoxicated. You used to have the occasional blackout while in university, but have not had one for at least 10 years. You have not tried to cut down on your drinking. You have felt annoyed about your wife criticising you for being too noisy at parties when you drink. You do not feel guilty about your drinking. You have never consumed an ‘eye opener’ in the morning. You have had no symptoms of withdrawal and have no other major social or health-related problems due to your drinking. Your father was a very heavy drinker who spent little time with his family.
Due to your wife’s complaints that you embarrass her at social gatherings because you’re too loud and overly jovial, she doesn’t often go with you any more, preferring to stay at home. She wishes you had more of a social life together. You can see your wife’s point, but you also feel that you work hard and deserve to enjoy yourself on the weekends, and your friends are important to you. You feel that, on a whole, you have had a good relationship with your wife and your drinking is a minor issue.
Sometimes you’re tired in the morning after drinking heavily, and don’t feel like playing with the children. You also feel tired and ‘fuzzy’ on Monday morning, and it takes you a while to become productive. Otherwise, drinking has not affected your relationships at work or with your children.
Part 1: ROLE description for MRS. JONES
Screening and Assessment of an Alcohol Problem
You are a 40-year-old married accountant, with two children aged five and nine. You drink 2 ‘doubles’ of scotch on at least five to six nights of the week. The most you’ve had to drink in the past month was 5 doubles, after a very stressful day. You have been drinking in this manner for 15 years. You used to drink more heavily when you were in university. You drink after work, starting while you prepare supper and continuing into the evening. You drink because it relaxes you; you are very successful at your job but it is demanding. You have only 1-2 drinks when out with friends or when visiting your parents.
You do not feel that your drinking is a problem. You have not tried to cut down on your drinking and have not felt annoyed about others criticising your drinking. You do feel guilty that sometimes you are too tired to do activities with your children, especially the day after a night of heavy drinking. You have had no blackout or symptoms of withdrawal, and have no other social or heath-related problems due to your drinking. You father was a very heavy drinker who spent very little time with the family.