Training of Practitioners March 2017 1 Introduction Attendance register Housekeeping Toilets Breaks Cellphones 2 Training overview and outcomes To be introduced to the AUDIT tool To review the AUDIT tool and how to use it as a screening tool ID: 570659
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Slide1
Alcohol Use Disorder Identification Tool
Training of PractitionersMarch 2017
1Slide2
Introduction
Attendance registerHousekeeping ToiletsBreaks
Cellphones
2Slide3
Training overview and outcomes
To be introduced to the AUDIT toolTo review the AUDIT tool and how to use it as a screening toolTo review the brief interventions for the different risk profiles of clients
3Slide4
Expectations
4Slide5
The training manual
Two partsBoth published by the World Health OrganisationFirst part is the brief interventionsThe second part is the screening tool guide
5Slide6
The Audit Tool: What is it?
6Slide7
The Audit
EffectiveEfficientInexpensiveReplicated in many contexts
7Slide8
The Audit Tool
Can be used by:
Health care workers
Social workers
Social auxiliary workers
Development workers
Child and youth care workers
Lay counsellors
8Slide9
The Audit Tool
Respond to four levels of risk:Low risk or abstainersHazardous drinkingHarmful drinking
Alcohol dependence
9Slide10
Definitions
Hazardous drinkingHarmful drinkingAlcohol dependence
10Slide11
Definitions
Hazardous drinkingHarmful drinkingAlcohol dependence
11
Page 13 (part 1)Slide12
Hazardous drinking
Way of drinking alcohol which increases risk of harmful consequences to the user or others
12Slide13
Harmful drinking
Way of drinking alcohol which results in negative social, physical and mental health consequences
13Slide14
Alcohol dependence
Cluster of behavioural, cognitive and physiological issues that develop after repeated alcohol use
14Slide15
South African Context
The prevalence of alcohol use disorders amongst South African males is 10%, and for women it is
1.5%
The prevalence of alcohol dependence amongst South African males is
4.2%,
and amongst women it is
0.7
%
15Slide16
South African Context
52.2% of road traffic accidents involving males are caused by alcohol-related factors. The same statistics for females is
11.6
%
47.7 %
of deaths of males resulting from road traffic accidents are caused by alcohol consumption. For female deaths, it is
16.2%.
16Slide17
South African Context
Average alcohol consumption (litres per person per annum) in South Africa for both genders is 11 litres. For males it is
18.4 litres
and for females it is
4.2 litres
. The average for the rest of Africa is
6 litres
per person per annum.
17Slide18
Foetal Alcohol Spectrum Disorder (FASD
)According to the White Paper on Safety and Security, alcohol consumption is correlated with intimate partner violence. South Africa has one of the highest FAS rates in the world. Alcohol consumption during pregnancy increases the risk of Foetal alcohol syndrome (FAS). Children affected by FAS have higher rates of adverse
childhood
and adulthood outcomes.
18Slide19
Foetal Alcohol Spectrum Disorder (
FASD)These include:
Deficits
in cognition and executive functioning strongly associated with early onset and lifelong persistent offending trajectories
Hyperactivity
Mental
health
problems
Difficulties with educational engagement
Poor employment prospects
Inappropriate sexual behaviour
19Slide20
Increased
conflict with the lawAddiction to substances. Higher rates of people affected by FAS are found in the criminal justice system. The risks of FAS are much higher in communities characterised by low socio-economic status, low educational attainment, high number of pregnancies and heavy alcohol consumption.
20
Foetal Alcohol Spectrum Disorder (
FASD
)
contin
…Slide21
Alcohol and Child Abuse
Parental substance use is associated with the increased risk of the sexual victimisation of children:Parental substance misuse is a significant risk factor for young people’s victimisation, increasing the risk of a young person reporting sexual abuse by between 2.2 and 3.4 times. As with parental absences, this may be because quite possibly parents who are intoxicated are not able to supervise their children adequately, or because their substance misuse weakens their relationship with their child.
21Slide22
Costs of Alcohol Abuse
The total tangible and intangible costs related to harmful alcohol use represent 10 - 12% of South Africa’s 2009 Gross Domestic Product (GDP).
(
Matzopoulos, Truen, Bowman, & Corrigall, 2014)
22Slide23
Effects of Alcohol Consumption
23Slide24
Effects of Alcohol Consumption:
Individual Level24
Neuropsychiatric
conditions
Gastrointestinal
diseases
Cancers
Intentional
injuries
Unintentional
injuries
Cardiovascular
diseases
Foetal alcohol syndrome (FAS) and preterm birth complications
Diabetes mellitus
Infectious
diseasesSlide25
Effects of Alcohol Consumption:
Family Level25
Injury to other individuals can be
intentional
Neglect
or
abuse.
Default on social
role
Property damage
Toxic
effects on other individuals include most notably foetal alcohol syndrome (FAS) and preterm birth complications Slide26
Effects of Alcohol Consumption:
Community Level26
High costs of:
Hospitalizations
Ambulatory care
Nursing home care
Prescription medicines
Home health care
Damage to property from vehicle crashes
Arrests for being “drunk and disorderly” Slide27
Effects of Alcohol Consumption:
Community Level27
Increased
crime
Lost productivity due to absenteeism
Unemployment
Decreased output
Reduced earnings potential
Lost working years due to premature pension or death Slide28
The AUDIT Test
28Slide29
The Drinker’s Pyramid
29Slide30
The Audit Tool
Respond to four levels of risk:Low risk or abstainersHazardous drinkingHarmful drinking
Alcohol dependence
30Slide31
The Audit Tool: What is it?
Screening and brief intervention tool
31
AUDIT
Alcohol Use Disorder Identification TestSlide32
The screening tool
Why screen for alcohol use?
32Slide33
The screening tool
Page 5: why screen for alcohol use?To differentiate between different risk levels of consuming alcohol
To match client risk levels with appropriate interventions
To implement appropriate interventions
33
Why is this important?Slide34
Options for Usage
34
Advantages of Different Approaches to AUDIT Administration
Self-Report Questionnaire
Interview
Takes less time
Easy to administer
Suitable for computer administration and scoring
May produce more accurate results
Allows clarification of ambiguous answers
Can be administered to people with low literacy levels
Allows seamless feedback to people and initiation of brief adviceSlide35
Structure & Components
35
Domains
Question Number
Item Content
Hazardous alcohol use
1
2
3
Frequency of drinking
Typical quantity
Frequency of heavy drinking
Dependence symptoms
4
5
6
Impaired control over drinking
Increased salience (conspicuousness) of drinking
Morning drinking
Harmful alcohol use
7
8
9
10
Guilt after drinking
Blackouts
Alcohol-related injuries
Others concerns about drinkingSlide36
Scoring
36
AUDIT SCORE
AUDIT Zones
Intervention Type
0 – 7
Zone 1
Alcohol education
8 -15
Zone 2
Advice
16 – 19
Zone 3
Advice
Brief counselling
Continued monitoring
20 - 40
Zone 4
Referral to specialist for diagnostic evaluation and treatmentSlide37
The Brief Intervention
37Slide38
Changing Behaviour
38Slide39
How do you change behaviour?
39Slide40
Model of Behaviour Change
40Slide41
Model of Behaviour Change
41Slide42
Model of Behaviour Change:
Pre-Contemplation
Not necessarily thinking about changing their substance use;
Focused on the positive aspects of their substance use;
Unlikely to have any concerns about their use of psychoactive substances;
May show resistance to talking about their substance use;
Unlikely to know or accept that their substance use is
problematic;
Unlikely
to respond to direct advice to change their behaviour but may be receptive to information about the risks associated with their level and pattern of substance use (if approached appropriately).
42Slide43
Model of Behaviour Change:
Contemplation
Thinking about cutting down or stopping substance use;
Ambivalent about their substance use when they may be able to see both the good things and the ‘less good things’ about their substance use;
Likely to have some awareness of the problems associated with substance use and may be weighing up the advantages and disadvantages of their current substance use pattern;
Likely to respond to information about their substance related risks, advice to cut down or engage in discussion about their substance use (if approached appropriately).
43Slide44
Model of Behaviour Change:
Preparation
Intending to take action;
May vocalise their intentions to others;
Making small changes in their substance use behaviour;
Re-evaluating their current behaviour and considering what different behaviour could offer them;
Becoming more confident and ready to change their behaviour;
Considering the options available to them;
Setting dates and determining strategies to assist change.
44Slide45
Model of Behaviour Change:
Action
Have made the decision that their use of substances needs to change;
Have commenced cutting down or stopping;
Are actively doing something about changing their behaviour;
Have cut down or stopped completely;
Are likely to continue to feel somewhat ambivalent about their substance use and to need encouragement and support to maintain their decision.
45Slide46
Model of Behaviour Change:
Maintenance
Attempting to maintain the behaviour changes that have been made;
Working to prevent relapse (the risk of relapse decreases with time);
Focusing attention on high risk situations and the strategies for managing these;
Best equipped when they develop strategies for avoiding situations where they are at risk of relapse;
Are more likely to remain abstinent if they receive reward, support and affirmation.
46Slide47
The Stages of Change and Associated Brief Intervention Elements
47
Stage
Brief Intervention Elements to be Emphasised
Pre-contemplation
Feedback about the results of the screening, and Information about the hazards of drinking
Slide48
The Stages of Change and Associated Brief Intervention Elements
48
Stage
Brief Intervention Elements to be Emphasised
Contemplation
Emphasize the benefits of changing, give information about alcohol problems, the risks of delaying, and discuss how to choose a goalSlide49
The Stages of Change and Associated Brief Intervention Elements
49
Stage
Brief Intervention Elements to be Emphasised
Preparation
Discuss how to choose a goal, and give advice and encouragementSlide50
The Stages of Change and Associated Brief Intervention Elements
50
Stage
Brief Intervention Elements to be Emphasised
Action
Review advice, give encouragement
Slide51
The Stages of Change and Associated Brief Intervention Elements
51
Stage
Brief Intervention Elements to be Emphasised
Maintenance
Give encouragement
Slide52
Brief Interventions
Intervention for low risk or abstainersIntervention for hazardous drinkingIntervention for harmful drinkingIntervention for probable alcohol dependence
52Slide53
Interventions by Risk Level
Risk Level
AUDIT Score
Intervention
Part 1
1
0-7
Alcohol education
14-16 plus appendix A
2
8-15
Simple advice
17-22 plus appendix A
3
16-19
Simple advice, brief counselling and continued monitoring
23-26 plus appendix A
4
20-40
Referral for diagnostic
evaluation and treatment
53Slide54
Interventions for Zone 1 Drinkers
54Part 1 pages 14 - 16Slide55
Interventions for Zone 2 Drinkers
55Slide56
Interventions for Zone 3 Drinkers
56Slide57
Giving Brief Counselling
57Slide58
Miller’s Readiness Ruler
One of the simplest ways to assess a person’s readiness to change their drinking is to use the “Readiness Ruler” recommended by Miller.
Ask the person to rate on a scale of 1 to 10, “How important is it for you to change your drinking?” (With 1 being not important and 10 being very important).
People who score in the lower end of the scale are pre-contemplators
.
58Slide59
Miller’s Readiness Ruler
4.
Those
who score in the middle range (4-6) are contemplators, and those scoring in the higher range should be considered ready to take action.
5.
It
is helpful to begin counselling in a way that meets the person’s current motivation level. For example, if the person is at the pre-contemplation stage, then the advice session should focus more on feedback in order to motivate the person to take action.
59Slide60
10 Steps for Zone 3 Interventions
Ask clients if they are interested in seeing their questionnaire scores.
Provide personalised feedback to clients about their scores
Give advice about how to reduce risk associated with their drinking habits
Allow clients to take ultimate responsibility for their choices.
Ask clients how concerned they are about their scores
.
60Slide61
10 Steps for Zone 3 Interventions
6.
Weigh
up the good things about using the substance against
the bad
7.
Emphasise
the less good things / more undesirable consequences about their drinking habits
8.
Summarize
and reflect on clients’ statements about their substance use with emphasis on the ‘less good things’.
9.
Ask
clients how concerned they are by the ‘less good things’ discussed
above.
10
. Give
clients take-home materials to bolster the brief intervention
61Slide62
Interventions for Zone 4 Drinkers
62
Where?Slide63
Summary & Reflection
63Slide64
Evaluation & Closure
64