Screening for Problem Drinking and Counseling by the Primary Care Physician‐Nurse Team

Abstract

Present methods to screen for alcohol abuse are generally obtrusive and result in referral to services that deal mainly with alcoholics. These factors deter physicians from identifying alcohol abuse patients at an early stage. In the present study, 81% of all primary care physicians of a single city evaluated (i) the efficiency and the acceptability of a nonobtrusive screening method for the identification of problem drinkers and (ii) the effectiveness of brief cognitive behavioral counseling given by a nurse in a lifestyle context. Patients (n = 15,686) attending the private practices of 42 primary-care physicians were asked four alcohol-neutral trauma questions in the reception area. Physicians asked about alcohol use and alcohol-related problems only to patients with previous trauma. Problem drinkers by defined criteria were offered an appointment with a nurse who, by random assignment, gave either 3-hr of cognitive behavioral counseling over 1 year or simply advised patients to reduce their alcohol intake. The screening method identified 62-85% of expected number of problem drinkers in this population. Following the application of exclusion criteria, 105 problem drinkers were entered in the intervention part of the study. After 1 year, patients who received counseling showed significant reductions in reported alcohol consumption (-70%; p < 0.001), psychosocial problems (-85%; p < 0.001) and serum gamma glutamyl transferase (-32% to -58%; p < 0.02). Physician visits were reduced (-34%; p < 0.02) following counseling. Patients receiving only advice showed neither reductions in psychosocial problems nor in serum gamma glutamyl transferase or physician visits, but reported a 46% reduction (p < 0.01) in alcohol consumption. Data indicate that asking patients about recent trauma is efficient and is well accepted as the first screening instrument in the identification of the problem drinker. Cost of screening per patient is under one dollar. Counseling of 3 hr given by a nurse is markedly superior (p < 0.05) to simple advice in reducing alcohol consumption, objective indicators of alcohol-related morbidity, and the frequency of physician visits.

Alcohol Screening and Changes in Problem Drinking Behaviors in Medical Care Settings: A Longitudinal Perspective

“…In fact, of those problem drinkers who were asked about their drinking during a medical contact, 40% of those who were problem drinkers at some subsequent follow-up period and who had a medical contact during that period reported not being asked about their drinking (results not shown). Such a fi nding might be a product of a number of different factors, including the discomfort of the physician, the lack of preparedness of the physician to deal with alcohol-related problems, or the lack of knowledge of whether a given level of drinking or symptoms necessitates broaching the subject or providing or referring the patient to alcohol treatment (Israel et al, 1996).…”

Intervenções breves para o uso abusivo de álcool em atenção primária

“…Intervenções que considerem esses elementos, portanto, parecem repercutir de forma mais ampla na vida do indivíduo, trazendo-lhe mais benefícios. 21,28,30,32 No estudo brasileiro realizado com adolescentes, observou-se que as intervenções de 20 minutos, baseadas nas técnicas de entrevista motivacional, foram mais eficazes do que as orientações oferecidas em dois a três minutos, instrumentalizadas com folhetos sobre os efeitos e conseqüências das substâncias psicoativas -apesar de este tipo de intervenção ainda ter-se mostrado mais efetivo do que a ausência de intervenções. 39 Em relação ao profissional que conduziu a intervenção, parece não fazer diferença se se trata de médico, enfermeiro ou agente comunitário.…”

“…Israel e colaboradores 30 compararam um aconselhamento pautado em abordagem cognitivo-comportamental de três horas de duração com um aconselhamento simples. Verificaram que, entre os sujeitos que receberam o aconselhamento na abordagem cognitivocomportamental, houve maior redução do consumo de álcool, diminuição de problemas psicossociais e melhores resultados em testes sangüíneos.…”

Efectividad de las técnicas de consejo breve

“…A pesar de la diversidad de diseños y resultados, existe una opinión consensuada por lo que respecta a su eficacia 1-4 y rentabilidad para la mayoría de sujetos de riesgo. La IB logra reducciones significativas del consumo de alcohol (en torno al 25% 8,-10,19 e incluso superior 11,20 , con una diferencia media del 15% con respecto a controles 8,11,19,22 , que puede llegar hasta el 24% en IB atípicas por su extensión 20 ). El porcentaje de bebedores excesivos se reduce alrededor del 45% 21 frente al 25-30% de los controles 8,19,22 aunque puede haber reducciones superiores al 60% 8,11,23 .…”

“…Los episodios de 'atracones de consumo' (binge drinking) disminuyen en torno al 50% (45,67% 11 -74% 23 ). La intervención breve logra disminuir la incidencia de problemas relacionados con el alcohol: problemas psicosociales (hasta un 85%) 20 ; bajas por enfermedad (80% en 4 años), días de hospitalización médica (en torno al 60% en 5 años) y mortalidad (50% en 6 años) 12 ; lesividad (47%) y días de hospitalización por traumas (48%), a los 3 años 24 . Los valores de GGT descienden de forma significativamente mayor en los pacientes a quienes se ha realizado una intervención breve que en los del grupo control.…”