Shared Care In
Shared Care in the Management of Alcohol & Other Drug-Related Disorders:
A Review of the Literature
Jan Copeland (PhD)
Prepared as part of the Mental Health Shared Care Network Commitment to Divisions of General Practice
February 1998
School of Community Medicine, University of New South Wales
Funded by the Commonwealth Department of Health and Family Services, GP Branch
Acknowledgement:
The earlier drafts of this document were reviewed by Jonine Penrose-Wall, Prof Mark Harris (Integration SERU) and Prof Ian Webster (Reference Group to the Mental Health Shared Care Network). Layout and typsetting by Jane Drury.
TABLE OF CONTENTS
I
INTRODUCTION...... 3
THE EPIDEMIOLOGY OF SUBSTANCE USE DISORDERS...... 4
THE GENERAL PRACTITIONER AND SUBSTANCE USE DISORDERS...... 5
MODELS OF SHARED CARE SUBSTANCE USE DISORDERS...... 6
ASSESSMENT OF ALCOHOL AND OTHER DRUG-RELATED DISORDERS...... 8
Motivation...... 8
Social and Lifestyle Factors...... 9
ALCOHOL ABUSE/DEPENDENCE...... 10
Assessment...... 10
Brief and Early Intervention...... 10
Detoxification...... 11
OPIOID ABUSE/DEPENDENCE...... 13
Assessment...... 13
Detoxification and Abstinence Orientated Interventions...... 13
Replacement Pharmacotherapies...... 14
CANNABIS ABUSE/DEPENDENCE...... 17
Brief Interventions...... 17
Adolescents...... 18
HYPNO-SEDATIVE ABUSE/DEPENDENCE...... 19
Interventions with General Practitioners...... 19
Benzodiazepine Dependence...... 19
Management of Benzodiazepine Withdrawal...... 20
Benzodiazapine use among IDU...... 21
CONCLUSION...... 22
REFERENCES...... 24
1
CHAPTER 2
INTRODUCTION
Given the prevalence of alcohol and other drug abuse/dependence disorders, and the high levels of hazardous substance use in the community, coupled with the low levels of specialist help-seeking by this group there is an urgent need for the general medical practitioners to detect and intervene with at-risk patients and to develop shared care relationships with a variety of specialist agencies. This review of the literature examines the current policy and practice environment of the management of substance use disorders in the context of the role of general medical practitioners in shared management relationships with specialist alcohol and other drug service providers.
The published literature was searched electronically using the terms: substance use disorder, alcohol, drugs, opiates, hypnosedatives, benzodiazepines, general practitioner, physician, shared care, treatment, and intervention. The electronic databases consulted included Excerpta Medica/EMBASE, MEDLINE, Current Contents/Clinical Medicine and psycLIT. Only English language articles were included in the review, which comprises 102 items. While the majority of papers were peer-reviewed articles, the "grey literature" of government reports, technical reports, and practice manuals have been included where the authors are of sufficient eminence in the field to warrant their consideration. As there is a paucity of literature addressing shared care of substance use disorders, guidelines from the literature on the primary management issues for general practitioners have been included, to assist in building GPs' confidence in the shared management of such patients.
The review is presented in a number of sections. These include:
an epidemiological overview of substance use disorders in Australia
the general practitioner and substance use disorders
models of shared care
general assessment issues
alcohol abuse/dependence
opioid abuse/dependence
cannabis abuse/dependence
hypno-sedative abuse/dependence, and
evaluation issues in shared care of substance use disorders.
The terms substance use disorders, substance abuse/dependence, and alcohol and other drug problems are used interchangeably throughout the review.
THE EPIDEMIOLOGY OF SUBSTANCE USE DISORDERS
It has long been established that drug abuse leads to significant direct and indirect costs for the Australian community. Collins and Lapsley (1996) estimated the total tangible and intangible social costs of drug abuse in Australia in 1992 was $AU18,845 million, of which tobacco accounted for 67%. This represented a 26.5% increase from the 1988 figures. A recent national review of the quantifiable drug-caused morbidity and mortality in Australia has revealed that in 1992 hazardous and harmful alcohol use caused the loss of 3,660 lives and 55,450 person-years of life before 70 years at an average of 15.2 years of life lost per death. Among active tobacco smokers the figures were 18, 920 deaths and 88, 266 person years of life lost at an average of 4.7 years of life lost per death. Among illicit drug users for the same year there were 488 deaths and 17,899 person-years lost at an average of 36.7 years of life lost per death (English, Holman, Milne et al., 1995).
A number of epidemiological surveys of psychiatric morbidity have demonstrated that alcohol abuse/dependence is the most common lifetime diagnosis, and most frequent co-morbid diagnosis in the community. The 1992 National Comorbidity Survey in the United States of America (US) gathered data on 8,098 15 to 54 year olds in the noninstitutionalised civilian population using the Composite Diagnostic Interview (Kessler, McGonagle, Zhao et al., 1994). They reported that 35.4 % of males and 17.9% of females had a lifetime diagnosis of any substance abuse/dependence. The figures for a current 12 month diagnosis were 16.1% and 6.6% respectively. The next most common lifetime disorder was any affective disorder with a prevalence of 14.7% for men and 23.9% for women. This study further examined treatment seeking and reported that only 8.4% of the sample with one substance related diagnosis had ever sought treatment at a substance abuse facility, with the figure rising to 14.8% for those with three or more mental disorders.
The earlier US Epidemiologic Catchment Area study of 20, 291 community and institutional population members further noted that among those with a mental disorder, the odds ratio of having some substance use disorder was 2.7. That is, people with any mental disorder are almost three times as likely to also have substance use disorder than those in the community with no mental disorder. Further, for those with either an alcohol or a drug disorder, the odds of having the other disorder were seven times greater than the rest of the population without either an alcohol or a drug disorder. It therefore appears that having one substance use disorder greatly increases the odds of having a co-morbid substance use disorder. Among those with an alcohol disorder, 37% had a co-morbid mental disorder. The highest mental-substance use disorder co-morbidity rate was found for those with drug (other than alcohol) disorders, among whom more than half (53%) were found to have another mental disorder (Regier, Farmer, Rae et al., 1990). Aspects of these finding have been replicated in a small South Australian study (Clayer, McFarlane, Czechowicz and Wright, 1991) and in the 1986 Christchurch Psychiatric Epidemiology Study (Wells, Bushnell, Hornblow et al., 1989).
The most frequent measure of the patterns of alcohol and other drug use in Australia is the National Drug Strategy Household Survey. The 1995 survey of 3,850 personal interviews revealed that 76% of the population aged 14 years or more are current drinkers, with just over half of those drinking at least weekly (Commonwealth of Australia, 1996). According to National Health and Medical Research Council guidelines 33% of women and 28% of men were drinking at hazardous levels and 12% of women compared to 13% of men were drinking at harmful levels in 1995. Overall males aged 14-24 years and females aged 20-24 years were more likely to be drinking to excess than any other age group. Nearly half of all current drinkers had deliberately attempted to reduce their alcohol consumption in the past year, with more than a third of these doing so for health reasons (Commonwealth of Australia, 1996).
A companion survey of 2,993 Aboriginal and Torres Strait Islander (ATSI) peoples living in urban areas nationally, revealed that a smaller proportion of ATSI peoples drank alcohol (62%) compared with the general population living in urban areas (72%). Among those ATSI peoples who do drink, however, 68% usually consume harmful quantities of alcohol (Commonwealth of Australia, 1994).
The 1995 National Drug Strategy Household Survey further reported that 39% of the population aged more than 14 years had tried at least one illicit drug, and 17% had used one in the past 12 months. Cannabis accounted for the bulk of this group. Only 4% of the population had used any illicit drug, apart from cannabis, in the previous twelve months (Commonwealth of Australia). Illicit drug experimentation and use is more widespread among the urban ATSI community than among the general urban community with 50% having tried at least one illicit drug. The bulk of this was accounted for by cannabis with 48% having tried cannabis and 22% being regular users, however six per cent were current users of at least one other illicit drug (Commonwealth of Australia, 1994).
THE GENERAL PRACTITIONER AND SUBSTANCE USE DISORDERS
General practitioners are the first point of contact for people with a variety of mental health problems, including substance abuse/dependence and disorders. Approximately 30% of hospital admissions and up to 20% of patients presenting in primary care settings have alcohol or other drug related problems (Williams, Burns and Morey, 1978; Burns, Hanratty, Reznik et al., 1987). Authors such as Rush, Ellis, Crowe and Powell (1994) have made good arguments for improved involvement of GPs in their patients’ alcohol and other drug use problems. These include:
most adults visit a GP at least once a year, thus providing scope for opportunistic interventions;
patients believe that GPs have legitimate reasons for asking about their lifestyle, such as alcohol and other drug use (Sanson-Fisher, Webb & Reid, 1986; Swift, Copeland & Hall, 1996) ;
GPs are viewed as credible sources of information on such matters (Moore, Makkai & McAllister 1989; Copeland, 1995);
the prevalence of substance use disorders in the population is high; and
low cost detection efforts and brief, effective interventions and other forms of assistance are available.
While there is a great deal of scope for the involvement of GPs in managing their patients’ problematic alcohol and other drug use, evidence suggests that opportunities for such intervention are not often taken up (Brown, Carter & Gordon, 1987; Clement, 1986; Deehan, Taylor and Strang, 1997; Flaherty & Flaherty, 1983; Reid, Webb, Hennrikus et al., 1986; Rowland, Maynard, Beveridge et al., 1987). Australian surveys of recent medical graduates report that they possess barely adequate knowledge and skills in relation to the detection and management of alcohol and other drug related problems (Roche, Parle, Saunders & Stubbs, 1993) and have little confidence in the efficacy of early and brief interventions (Roche, Parle, Stubbs, Hall & Saunders, 1995).
A survey of 211 GPs on the Central Coast of New South Wales supports this view. It found 93% of respondents saw themselves as having a role in alcohol and other drug issues but predominantly in detection and referral (Edwards, Roche, Gill et al., 1996). Only 28% of GPs surveyed were willing to provide home detoxification and 19% were willing to provide methadone maintenance with many citing the need for support and training in order to feel confident in providing such interventions. Regarding knowledge and attitudes, while most GPs felt confident in dealing with smoking issues, there were significant gaps in knowledge and confidence concerning the management of illicit drug using patients with more than half of the respondents reporting they were the most "difficult" group of patients to work with as they were unmotivated to change. The survey further reported that GPs beliefs in the effectiveness of interventions was not consistent with current best practice. Almost all believed that Alcoholics Anonymous and residential rehabilitation were effective but only around one half believed methadone was effective. Less than a quarter of GPs endorsed controlled drinking as an effective intervention (Edwards et al., 1996).
It appears, therefore, that GPs see themselves as having a role in the detection and management of their patient's substance use issues but demonstrate significant gaps in their knowledge and confidence in general. This is particularly so with moving beyond assessment and referral to the management of illicit drug use by their patients.
In addition to education and training issues, GPs such as MacQueen (1997) highlight more practical barriers to undertaking alcohol and other drug work. He points out that there is little or no accredited and remunerated training for GPs in substance use disorders. Further, the length of consultation required for assessment, induction to methadone maintenance, and the management of polydrug use or psychiatric co-morbidity makes it an extremely stressful and an uneconomic undertaking for GPs. A final issue raised by MacQueen was the paucity of clinically-orientated research and publication in the addiction field to assist the busy clinician to readily incorporate best practice interventions.
Despite these concerns, a model of shared care between drug specialists and GPs in Edinburgh has led to a great increase in the number of services available to this group with 70% of Edinburgh's GPs now prescribing for around 1200 drug users (Greenwood, 1996). This model has led to a marked shift away from injecting drug use and towards oral pharmaceutical drugs, with a drop in HIV rates among new referrals to shared care from 21% to 8% (Greenwood, 1996).
MODELS OF SHARED CARE SUBSTANCE USE DISORDERS
From the available literature it is not possible to recommend a model of shared care for alcohol-dependent patients that has a sound empirical basis as the issue is largely unresearched. Reports such as the Joint Consultative Committee in Psychiatry's 1997 Primary Care Psychiatry- The Last Frontier (RACGP) suggests a variety of models of shared care in mental health that are worthy of consideration in the alcohol and other drugs field. These include:
attachment of a self-employed or publicly funded AOD specialist to one or more general practices either sharing management responsibility for those patients or receiving referrals;
employment of an AOD specialist by a GP practice for one or more sessions providing a specific service requested upon referral;
a shared base model of service where practitioners are co-located but may not collaborate beyond referral;
liaison and consultative models where there is a regularised link between GPs and AOD specialists with the GP maintaining primary management responsibility with the specialist serving as a consultant, supporter and educator;
other liaison models, such as, case conferencing to ensure a multidisciplinary approach with group practice GPs, and models of improved liaison that focus on expediting referral and discharge information;
and other models such as GP training to improve skills and confidence; reducing barriers between specialist and generalist services and enhancing networking possibilities.
A general reference of relevance to communication issues highlighted in models of shared care is that of Stoeckle, Ronan, Emanuel and Ehrlich (1997). This review discusses manners and courtesies for the shared care of patients within and across health care agencies.
Regarding allied health professionals and GPs, Bray and Roger (1995) reported a pilot demonstration project that linked psychologists and family physicians to improve the care of patients with alcohol and other drug problems. Ten pairs of psychologists and family physicians in rural Texas and Wyoming received training in establishing appropriate linkages. Unfortunately, inadequate evaluation information was provided to adequately assess the efficacy of that model.
In the United Kingdom there are models of shared care that have been developed by clinical nurse specialists within community drug and alcohol services. These involve practice visits by the specialist nurses to assist GPs to update their skills in substance use disorders and also in dealing with occasionally chaotic, demanding and verbally agressive patients. The model involves the development of a contract between the client, the GP and the community team clearly specifying their roles and responsibilities (King, 1997). This model has not been formally evaluated although GPs are reported to be participating and outcomes for some clients to have improved.
The most promising model in the current climate would appear to be the liaison and consultative model with the GP assessing and managing the bulk of patients with alcohol related problems and then referring for joint management the alcohol dependent clients or those with complicating physical, psychological or social factors. As Farrell and Gerada (1997) point out, the frequently complex clinical and social needs of substance dependent patients and the growing number of adolescents and those with problems related to drugs other than alcohol and opiates means that specialist services have a critical training and management role. The issues to be addressed by the literature include deciding how new patients are best matched with service providers, the on-going management of long-term patients, and the integration of health and social welfare needs of this patient group. The formalising of such a model and a rigorous outcomes-based evaluation is urgently required to address the significant gaps in the literature.
One of the principal barriers to maximising shared care of patients is GP/health system communication. A European electronic data interchange has been developed to enable shared care participants to intergrate medical records information (Branger, van't Hooft and van der Wouden (1995)). The adaption and evaluation of such a system would be a valuable tool to enhance communication between Australian GPs who almost all now use computer-based record systems.
ASSESSMENT OF ALCOHOL AND OTHER DRUG-RELATED DISORDERS
It is clear that there are high levels of substance use-problems in the community and that patients expect their medical practitioner to be involved in all aspects of health promotion and disease prevention. This raises the vexed question of how best should GPs intervene. The following literature review is based on clinical literature relevant to GP management of patients with essentially uncomplicated substance use disorders. The literature highlights the assessment, detoxification, brief intervention strategies and other management approaches within major drug classes that GPs manage.