Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy: Ethical Practice 3031183800, 9783031183805

Table of contents :
Acknowledgement
Contents
Editor and Contributors
About the Editor
Contributors
1: Introduction
1.1 Introduction
1.2 Description
1.3 Terminology
1.3.1 Alcohol Use
1.3.2 Problem(S) and Disorders
1.3.3 Individual, Person, People
1.3.4 Professional
1.3.5 Never Presume
1.4 Conclusion
2: Alcohol Use
2.1 Alcohol
2.1.1 Current Levels of Alcohol Use
2.1.2 Deaths from Alcohol Dependence
2.1.3 Treatment for Alcohol Use Disorder
2.2 Including the Family in Treatment
2.2.1 Indications and Impacts for Families and Communities: Physical, Psychological, Social
2.2.2 Effects on Family Relationships
2.2.3 Effects on Family Finances
2.2.4 Domestic Violence
2.3 Diagnosis and Assessment for Alcohol Dependency
2.3.1 Assessment
2.3.2 Mental Health Status Examination (See Chap. 5)
2.3.3 Key Assessment Points
2.3.4 Screening Tools: Severity of Alcohol Dependence Questionnaire (SADQ-C)
2.3.5 Screening Tools: The AUDIT Questionnaire
2.4 Effects of Alcohol Consumption
2.5 The Disease Burden from Alcohol Use Disorders
2.6 Mental Health Disorders as a Risk Factor for Alcohol Dependency
2.7 Stigma, Burden, Support, and Best Practice
2.7.1 Guidelines: Safe Levels of Alcohol Consumption
2.8 Intervention and Treatment Options (What Is Out There to Support?)
2.8.1 Interventions: Rehabilitation Services
2.8.2 Detoxification
2.8.3 Relapse Prevention and Harm Minimization (See Chap. 22)
2.8.4 Talking Therapies (Psychological)
2.8.5 Motivational Interviewing (See Chap. 23)
2.8.6 Motivational Interviewing: The Distinct Phases of the Trans-Theoretical Model of Change
2.8.7 Solution-Focused Brief Therapy
2.8.8 Cognitive Behavioral Therapy (CBT)
2.9 Chapter Summary
2.10 Conclusion
References
To Learn More
Useful Resources/Websites
Alcohol Rehabilitation Guide
Hello Sunday Morning
Drinkaware
Alcohol Help Centre
Rethinking Drinking
3: Transcultural Considerations
3.1 Multicultural Treatment in Behavioural Healthcare
3.2 Access and Utilisation of Behavioural Healthcare
3.3 Approaching Multicultural Treatment
3.4 Multicultural Competencies
3.4.1 The MCC Approach Stipulates Three Broad Ideas
3.5 Multicultural Psychosocial Approaches
3.6 Pluralism
3.7 Multicultural Orientation (MCO)
3.8 Illness Myth
3.9 Identifying Professionals’ Multicultural Practices
3.9.1 Feedback-Informed Cultural Practice
3.10 Implications for Practitioners
3.11 Family Considerations
3.12 Ethical Considerations
3.13 Conclusion
References
To Learn More
4: Lesbian, Gay, Bisexual, Transgender and Questioning+ (LGBTQ+)
4.1 Introduction
4.2 Being LGBTQ+
4.2.1 Terminology
4.2.2 Gender Identity
4.2.3 What Do We Mean by ‘Coming Out’?
4.3 A Theoretical Framework: The Minority Stress Model
4.4 Impact of Discrimination on the Individual’s Psychological Health and Well-Being
4.5 LGBTQ+ and the Family
4.6 Conclusions
References
To Learn More
Useful Resources
5: Mental Health Problems Associated with Alcohol
5.1 Problems Associated with Co-occurring Diagnosable Psychological Distress and Alcohol Use
5.2 Language of Addiction and Mental Health
5.3 The Language of Alcohol Use
5.4 Alcohol and Mental Health in the UK: Context and Current Challenges
5.5 Falling Through the Cracks
5.6 Epidemiological Evidence
5.7 Aetiology: The Chicken or the Egg Paradox
5.8 Serial, Parallel and Integrated Treatments
5.8.1 The Serial Treatment Model: One Disorder at a Time Please!
5.8.2 The Parallel Treatment Model: Two Disorders—Two Doors
5.8.3 The Integrated Treatment Model: Two Disorders—One Door
5.8.3.1 Disorder-Centred Care
5.8.3.2 A Different Focus: No Disorders
5.9 Acceptance and Commitment Therapy
5.10 Role of Family
5.11 Ethical Considerations
5.12 Transcultural Considerations
References
To Learn More
6: Physical Problems Associated with Alcohol
6.1 Intoxication
6.1.1 Absorption
6.1.2 Metabolism
6.1.3 Clinical Effects
6.1.4 Effects on Driving
6.2 Acute Confusion and Agitation
6.2.1 Wernicke-Korsakoff Syndrome
6.2.2 Hepatic Encephalopathy (HE)
6.2.3 Hyponatremia and Other Electrolyte Disturbances
6.2.3.1 Hyponatremia Is Common and Can Contribute to Confusion
6.2.3.2 Hypophosphatemia Is Also Common
6.3 Chronic Confusion
6.4 Difficulty with Walking: Cerebellar Ataxia, Wernicke’s Encephalopathy, Peripheral Neuropathy
6.5 Abdominal Pain
6.6 Alcohol-Related Liver Disease
6.7 Alcohol-Related Malignancies
6.8 Conclusion
References
To Learn More
7: Alcohol Use in Forensic Mental Health and Criminal Justice Settings
7.1 Introduction
7.2 Alcohol Use in Forensic Mental Health Services and the Criminal Justice System
7.3 Theories on the Link between Alcohol and Crime
7.4 Framework for Assessment and Treatment
7.5 Assessment
7.6 Therapeutic Treatment Options
7.7 Challenges of Assessment and Treatment
7.8 Family
7.9 Conclusion
References
To Learn More
8: Supporting and Including Families in Professional Care for Alcohol Use
8.1 Family Involvement
8.2 Sometimes a Complex Ethical Dilemma
8.3 The Family and Identification of Alcohol-Related Problems
8.4 The Family and Interventions Related to Alcohol-Related Problems
8.4.1 Why Is It an Ethical Decision to Involve the Family?
8.4.2 The Family and the Treatment Journey
8.4.3 The Family and the Assessment of the Seriousness of an Alcohol Problem
8.4.4 The Family and Withdrawal Management (If Necessary)
8.4.5 The Family and Motivating Problem Alcohol Users to Accept Help
8.4.6 The Family and Involvement in Treatment or Interventions
8.4.7 The Family and Their Own Support Needs
8.5 Cross-Cultural Factors
8.6 Conclusions
References
To Learn More
9: Responses and Referral
9.1 Introduction
9.2 Important Therapeutic Principles
9.3 Trauma-Informed Care
9.4 Core Conditions
9.5 Mentalising Conversations
9.6 Initial Assessment/Screening (See Chap. 10)
9.7 Brief Interventions (See Chap. 17)
9.8 Brief Advice
9.9 Extended Brief Interventions
9.10 Referral to Specialist Alcohol Services
9.11 Service Design and Accessibility
9.12 Conclusion
References
To Learn More
10: Assessment
10.1 Introduction
10.2 Therapeutic Presence and the Assessment of Alcohol Use
10.3 Harmful Use of Alcohol Across the Lifespan
10.4 Ethical Considerations in the Assessment of Alcohol Use
10.5 Conclusion
References
To Learn More
11: Child, Adolescent and Young Adult
11.1 Introduction
11.2 The Prenatal Period and Alcohol
11.3 The Childhood Years
11.4 The Teenage and Young Adult Years
11.5 Conclusion
References
To Learn More
12: Alcohol Use During Pregnancy and Its Impacts on a Child’s Life
12.1 Introduction
12.2 What Is Fetal Alcohol Spectrum Disorder (FASD) and How Common Is It?
12.3 Historical Developments in Awareness of FASD and the Impact of Alcohol on the Developing Fetus
12.4 Diagnosis of FASD
12.5 Diagnostic Process
12.5.1 Overlapping Exposures and Other Adverse Childhood Experiences (ACEs)
12.6 Exposures to ACEs and Other Substances Complicate the Diagnosis of FASD
12.7 Role of the Parent/Carer in Obtaining Diagnosis
12.8 The Impacts of Having FASD on the Individual and the Family
12.9 Treatment and Therapies to Support those Experiencing FASD
12.10 Transition from Child to Adult
12.11 Conclusion
References
To Learn More
Resources
13: Female Adult
13.1 Introduction
13.2 Alcohol Use in Context
13.3 Alcohol-Related Harm
13.4 Context of Vulnerability
13.5 Context of Comorbidity
13.6 Assessment
13.6.1 Aims
13.7 Care Planning
13.7.1 Involvement of Partners
13.8 Treatment
13.9 Withdrawal
13.9.1 Withdrawal Management
13.10 Pharmacotherapy
13.11 Other Interventions
13.12 Pregnancy Care
13.12.1 Pregnancy Advice and Education
13.13 Engagement
13.13.1 Child Protection Notification
13.14 Pregnancy Care Setting
13.15 Care Planning
13.15.1 Content of Care Plans
13.16 Treatment
13.17 Withdrawal
13.17.1 Setting
13.18 Pharmacotherapy
13.19 Ethical Issues and Dilemmas Arising from Harm to a Baby
13.19.1 Pre-discharge Information
13.20 Follow-Up Care
13.21 Ethical Issues and Dilemmas
13.22 Stigmatisation
13.22.1 Impact of Stigma on Healthcare Consumers
13.23 Self-Determination to Cease Treatment
13.24 Partner and Family Members Dominance and Coercive Control
13.25 Domestic Violence
13.26 Conclusion
References
To Learn More
14: Male Adult
14.1 Introduction
14.2 Male Alcohol Use in Context
14.3 Low-Risk Drinking Guidelines
14.4 Alcohol-Related Harm
14.5 Assessment
14.6 Treatment
14.7 Other Interventions
14.7.1 Specific Men’s Health Issues and Need for Education
14.8 Relationship Issues, Relapse and Relationship Counselling
14.9 Loss of Children and Adult Offspring
14.10 Ethical Issues
14.11 Increased Risk for Self-Harm and Suicide
14.12 Stigmatisation
14.13 Domestic and/or Family Violence
14.14 Interventions for Violence
14.15 Family Court Processes
14.16 Conclusion
References
To Learn More
15: Older Adult
15.1 Introduction
15.2 Screening, Prevention, and Intervention Within Primary Care
15.2.1 The Spectrum of Risk
15.2.2 Screening for AUD in Older Adults
15.2.3 Talking with Older Adults About Alcohol Risks and Harms
15.2.4 Care Pathways and Case Studies
15.3 Care Pathway for Moderate-Risk Drinkers
15.3.1 Care Pathway for Moderate-Risk Drinkers with a Moderate Alcohol Use Disorder
15.4 Care Pathway for Severe Alcohol Use Disorder
15.5 Assessment and Withdrawal Management Older Adult Considerations
15.5.1 Cognition
15.5.2 Psychosocial Supports
15.6 Conclusion
References
To Learn More
16: Binge Drinking
16.1 What Is Binge Drinking?
16.2 Epidemiology Perspectives
16.3 Biological Harms
16.4 Societal Harms
16.5 Specific At-Risk Groups
16.5.1 Lesbian, Gay, Bisexual Transgender and Questioning+ (LGBTQ+) Community
16.5.2 18–30 (University Students)
16.5.3 Learning Disabilities
16.5.4 Deaf and Impaired Hearing
16.5.5 Neurodiversity
16.6 Implications of Binge Drinking on the Family System
16.6.1 Binge Drinking During Pregnancy and Its Consequences
16.6.2 The Postnatal Period
16.6.3 Childhood
16.7 Brief Interventions
16.7.1 Assessment
16.8 What Clinical Interventions Are Available to You?
16.9 Interventions
16.10 Plan
16.11 Looking for Triggers
16.11.1 Preparing for Change
16.11.2 Look for Alternatives
16.11.3 Motivation Card
16.11.3.1 Instructions
16.11.3.2 Consideration
16.11.4 Solution-Focused Question to Ask the Individual
16.11.4.1 Questions
16.11.5 Work with the Emotions and Consequences: Visualise a Compassionate Person
16.12 Conclusion
References
To Learn More
17: Brief Intervention
17.1 Brief Intervention
17.1.1 Simple Brief Intervention
17.1.2 Extended Brief Intervention
17.2 Brief Intervention Theory
17.3 Interventions for Alcohol in Hospital Settings
17.4 Interventions for Alcohol in Home and Other Nonmedical Settings
17.5 Conclusion
References
To Learn More
18: Preparation for Detoxification
18.1 Introduction
18.2 Side Effects Associated with Repeated Medically Assisted Withdrawals
18.3 Structured Preparation for Alcohol Detoxification (SPADe)
18.4 Components/Aspects of Structured Preparation for Detoxification
18.4.1 Family Preparation for Detoxification and Abstinence
18.5 Partial Control over Drinking
18.6 Introduction of Lifestyle Changes of the Individual
18.7 Planning Aftercare
18.8 The Role of Medications in Pre-habilitation (See Chap. 19)
18.8.1 Nutritional Supplementation
18.8.2 Medications for Detoxification (See Chap. 19)
18.8.3 Relapse Prevention Treatments (See Chap. 22)
18.8.3.1 Acamprosate
18.8.3.2 Opioid Receptor Antagonists
18.8.3.3 Baclofen
18.9 Conclusion
References
19: Drugs Used in Withdrawal Management and Post-Withdrawal Management
19.1 Medications for Alcohol Withdrawal Treatment
19.2 Medications for Post-Withdrawal Management
19.3 Ethical Issues
19.3.1 Beneficence and Nonmaleficence: Misuse of Benzodiazepines with Alcohol
19.3.2 Beneficence and Fidelity: Gabapentin for AWS and AUD
19.3.3 Justice: Fairness for Vulnerable Populations
19.3.4 Autonomy: Independent Decision-Making
19.3.5 Autonomy, Coercion, and Collaboration: Family Issues
19.4 Conclusion
References
To Learn More
20: Hospital Withdrawal Management
20.1 Introduction
20.2 Assessment
20.3 Withdrawal Management Complications
20.3.1 Alcohol Withdrawal Seizures
20.3.2 Delirium Tremens
20.3.2.1 Characteristic Symptoms
20.3.2.2 Associated Symptoms
20.3.2.3 Complications
20.4 Family and Significant Others
20.5 Safeguarding and Social Care
20.6 Withdrawal Management
20.7 Choice of Medication Used in Alcohol Withdrawal Management
20.7.1 Other Medications
20.8 Management During Admission and on Discharge
20.9 Post-Detoxification Intervention
20.10 Conclusion
References
To Learn More
21: Home Withdrawal Management
21.1 Home Withdrawal Management
21.2 Definitions
21.2.1 Detoxification
21.3 Introduction
21.4 Assessment
21.4.1 Assessment of Suitability
21.4.2 History Taking within the Home Environment
21.4.3 Home Environment
21.5 Signs and Symptoms of Alcohol Withdrawal
21.6 Frequency of Home Visits
21.7 The Procedure
21.7.1 Physical Tests
21.8 Vitamin Replacement
21.8.1 Commencing Home Alcohol Withdrawal
21.9 Conclusion
References
To Learn More
22: Relapse and Relapse Prevention
22.1 Relapse
22.2 The Stages of Relapse
22.2.1 Emotional Relapse
22.2.2 Mental Relapse
22.2.3 Physical Relapse
22.3 Cause of Relapse
22.3.1 Predisposing Factors
22.3.2 Precipitating Factors
22.3.3 Protective Factors
22.4 The Relapse Prevention Model
22.4.1 Cognitive Behavioral Therapy
22.4.2 Mindfulness
22.5 The Five Rules of Recovery
22.5.1 Rule 1: Change Your Life so That It Is Easier to Not Use
22.5.2 Rule 2: Ask for Help and Develop a Recovery Circle
22.5.3 Rule 3: Be Completely Honest with Yourself and Everyone in Your Recovery Circle
22.5.4 Rule 4: Practice Self-Care
22.5.5 Rule 5: Don’t Bend the Rules or Try to Negotiate Your Recovery
22.6 Relapse Prevention for the Family
22.6.1 Some Things Family Members Can Do for the Individual
22.6.2 Some Things Family Members Can Do for Themselves
22.7 Relapse Prevention and Self-Assessment Scales
22.7.1 AWARE
22.7.2 RAPID
22.7.3 TOPPS
22.7.4 OCDS
22.7.5 MBRP-AC
22.8 Conclusion
References
To Learn More
23: Motivational Interviewing
23.1 Introduction
23.2 MI as an Evidence Base for Shared Decision-Making
23.3 Research Evidence and MI
23.4 Supporting Treatment Concordance
23.5 Improving Readiness to Reduce or Stop Problematic Use of Alcohol
23.6 Effectiveness of MI Brief Alcohol Interventions in Primary Care
23.7 Alcohol Use Assessment
23.8 Further Research in MI
23.9 The Principle of Recovery and MI
23.10 Building MI Knowledge and Skills in Practice
23.10.1 Understanding the ‘Spirit of MI’
23.11 The Foundational Principles of MI
23.11.1 Expressing Empathy
23.11.1.1 MI Practice Application Example
23.11.2 Support Self-Efficacy
23.11.2.1 MI Practice Application Example
23.11.3 Righting Reflex
23.11.4 Rolling with Resistance
23.11.4.1 MI Practice Application Example
23.11.5 Develop Discrepancy
23.11.5.1 MI Practice Application Example
23.12 MI Skills and Strategies
23.13 Micro Skills of Open-Ended Questions, Affirmation of a Person’s Strength, Reflection, and Summaries (OARS)
23.13.1 Open-Ended Questions
23.13.1.1 A Practitioner May Ask an Open Question by Saying
23.13.2 Affirmations
23.13.2.1 A Practitioner May Affirm by Saying
23.13.3 Reflective Listening
23.13.3.1 A Practitioner May Demonstrate Reflective Listening by Saying
23.13.4 Summaries
23.13.4.1 A Practitioner May Summarise by Saying
23.14 Offering Advice and Information (Ask-Share-Ask)
23.15 MI as a Four-Process Method
23.15.1 Engaging
23.15.2 Focus
23.15.3 Evoke
23.15.4 Plan
23.16 Practice Application of MI in Various Parts of the Care Delivery Process in Alcohol Use
23.17 Conclusion
References
To Learn More
24: Problematic Alcohol Use Within End-of-Life Care
24.1 Introduction
24.2 End-of-Life Care Experiences for People with Problematic Alcohol Use
24.3 Family and Informal Carer Experiences
24.4 Professional Experiences and Responses
24.5 Conclusion
References
To Learn More

Citation preview

Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy Ethical Practice David B. Cooper Editor

123

Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy

David B. Cooper Editors

Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy Ethical Practice

Editor David B. Cooper Drug and Alcohol Research Centre Middlesex University Horsham, West Sussex, UK

ISBN 978-3-031-18380-5    ISBN 978-3-031-18381-2 (eBook) https://doi.org/10.1007/978-3-031-18381-2 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is dedicated to my wife, Jo Cooper. By the time this textbook is published, Jo and I will have been married for 50 years. Throughout that time, Jo has supported me in whatever I do, she has co-authored textbooks and articles alongside me and functioned as second editor for all 13 books that I have either written and/or edited since 1994. Even through my ill health problems, Jo has always cared for me and looked after me when I was unable to do so. And I will always be eternally grateful to my wife, my love, and my friend. Jo is a retired Macmillan Clinical Nurse Specialist in Palliative Care, and during that time she has been as dedicated to those she meets both professionally or privately offering the utmost ethical care and practice throughout. Thank you. In addition, I would like to dedicate this, my final textbook, to my children (Philip, Marc, and Caroline) and my grandchildren (Ella, Megan, Daisy, Daniel, Noah, Alfred, and Elijah). All have special place in my heart, and I thank them for supporting my work throughout the years, and for caring and loving me. Thank you.

Acknowledgement

I am grateful to all the contributors for having faith in me to produce a valued text and I thank them for their hard work, support, and encouragement. I hope that faith proves correct. Thank you to those who have commented along the way and whose patience has been outstanding. Many people have helped me along my career paths and life—too many to name individually. Most of them do not even know what impact they have had on me. Many were individuals who touched my professional life and who contributed most to my knowledge and understanding, leading me to appreciate the importance of compassion in care… and my effort to move towards this in practice and life. My sincere thanks to my friends and colleagues along my career paths: those who have touched my life in a positive way—and a minority, in a negative way (for I have always learned from the negative in life to ensure that I do better for others next time). A final heartfelt statement: any errors, omissions, inaccuracies, or deficiencies within these pages are my responsibility.

vii

Contents

1

Introduction������������������������������������������������������������������������������������������������   1 David B. Cooper

2

Alcohol Use ������������������������������������������������������������������������������������������������   7 Bernadette Solomon

3

Transcultural Considerations ������������������������������������������������������������������  33 Daryl Mahon

4

Lesbian, Gay, Bisexual, Transgender and Questioning+ (LGBTQ+) ������������������������������������������������������������������  57 Alfonso Pezzella

5

 Mental Health Problems Associated with Alcohol����������������������������������  71 Daren Lee

6

Physical Problems Associated with Alcohol��������������������������������������������  99 Chris Holmwood and Victoria Cock

7

Alcohol Use in Forensic Mental Health and Criminal Justice Settings ������������������������������������������������������������������������������������������ 113 Mary Munro and Lolita Alfred

8

Supporting and Including Families in Professional Care for Alcohol Use ������������������������������������������������������������������������������������������ 129 Richard Velleman, Miriam Sequeira, and Urvita Bhatia

9

Responses and Referral ���������������������������������������������������������������������������� 151 Scott Macpherson and Dan Warrender

10 Assessment�������������������������������������������������������������������������������������������������� 165 Michael Hazelton, Ellen Sinclair, and Hayley Wicks 11 C  hild, Adolescent and Young Adult���������������������������������������������������������� 179 Philip D. James 12 Alcohol  Use During Pregnancy and Its Impacts on a Child’s Life�������� 193 Penny A. Cook, Alan D. Price, and Raja A. S. Mukherjee

ix

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Contents

13 Female Adult���������������������������������������������������������������������������������������������� 209 Jacqueline (Jacky) Talmet 14 Male Adult�������������������������������������������������������������������������������������������������� 231 Jacqueline (Jacky) Talmet and Susan Gates 15 Older Adult ������������������������������������������������������������������������������������������������ 245 Marilyn White-Campbell, David Brown, Peter R. Butt, and W. J. Wayne Skinner 16 Binge Drinking ������������������������������������������������������������������������������������������ 267 Simon Hall and Natalie Finch 17 Brief Intervention�������������������������������������������������������������������������������������� 287 Catherine Haighton and Peter J. Kruithof 18 Preparation for Detoxification������������������������������������������������������������������ 301 Christos Kouimtsidis, Musa Sami, and Nicola Kalik 19 Drugs  Used in Withdrawal Management and Post-Withdrawal Management ���������������������������������������������������������������������������������������������� 317 Michael F. Weaver, Judy H. Hong, and Adrienne Gilmore-Thomas 20 Hospital Withdrawal Management���������������������������������������������������������� 329 Fiona Robinson 21 Home Withdrawal Management�������������������������������������������������������������� 341 David B. Cooper 22 Relapse  and Relapse Prevention�������������������������������������������������������������� 349 Steven M. Melemis 23 Motivational Interviewing������������������������������������������������������������������������ 363 Lyn Williams 24 Problematic Alcohol Use Within End-of-­Life Care�������������������������������� 381 Gary Witham

Editor and Contributors

About the Editor David B. Cooper  has specialised in mental health and substance use for over 45 years. He has worked as a practitioner, manager, researcher, author, lecturer, and consultant. He has served as editor, or editor-in-chief, of several journals, most recently as editor-in-chief of Mental Health and Substance Use. David is currently an Associate Editor: nursing and dual diagnosis for the Journal of Substance Use. He has published widely and is ‘credited with enhancing the understanding and development of community detoxification for people experiencing alcohol withdrawal’ (Nursing Council on Alcohol; Sigma Theta Tau International citations). Seminal work includes Alcohol Home Detoxification and Assessment and Alcohol Use, both published by Radcliffe Publishing, Oxford, UK. David edited a series of seven textbooks series titled Mental Health and Substance Use, all published by Routledge, New York: USA and he co-edited with Jo Cooper three book series titled Palliative Care within Mental Health. He has authored many chapters, including one for the World Health Organization on community detoxification, and articles throughout his career. David is currently looking for a new publisher to take forward as publisher of the International Journal of Mental Health and Substance Use.  Drug and Alcohol West Sussex, UK

Research

Centre,

Middlesex

University,

Horsham,

Contributors Lolita Alfred  is a lecturer and admissions lead for Mental Health at City University of London. She teaches across a variety of areas in mental health but is most passionate about substance use, and more specifically alcohol. She is a registered mental health nurse who has worked in forensic mental health where she specialised in supporting individuals who struggled with substance use, and/or substance-related offending. Upon the realisation that she wanted to support a wider range of people who may be struggling with substance use and a desire to contribute towards health promotion and prevention work; she earned a Master’s in Public Health (MPH), and then spent a number of years working in public health, coordinating community level xi

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alcohol harm reduction initiatives and contributing towards the development of alcohol harm reduction strategies. She has had the privilege of working collaboratively on alcohol harm reduction with a wide range of stakeholders, community members, professionals across primary care, secondary care, the third sector, and with professionals from the police service, criminal justice system, trading standards, and pub licensees. School of Health Sciences, University of London, London, UK Urvita Bhatia  is a psychologist and clinical researcher. She is a Research Fellow at the Addictions Research Group in Sangath and is part of the NIHR Global Health Research Group focused on developing a package of care for the mental health of survivors of violence in South Asia. She was previously awarded a Wellcome Trust DBT India Alliance Research Training Fellowship to work on the adaptation of an evidencebased intervention for family members affected by a relative’s alcohol use. Urvita is also currently pursuing her doctoral studies at Oxford Brookes University (Oxford, UK) through a Global Challenges Research Award. Her PhD is focused on the development of a sports-based adolescent substance use prevention programme in India. She trained in Clinical Psychology in India before completing her MSc in Global Mental Health at the London School of Hygiene and Tropical Medicine and King’s College London (London, UK). Urvita has been working for most of the last decade with the Indian mental health research NGO, Sangath (Goa, India) and has focused her efforts on interventional research. Her research and clinical interests span community-based prevention and treatment approaches for substance use-related problems, for both individuals and families, and the development and evaluation of such interventions. She is also interested in culturally appropriate treatments for addictions, gender-based violence, particularly intimate partner violence, and common mental disorders. Addictions Research Group, Sangath Community Health NGO, Goa, India Department of Psychology, Health and Professional Development, Oxford Brookes University, Oxford, UK David Brown  has over 30 years of experience in applied social and health research, with expertise in the use of multiple methods and community-based research. His career has included holding the positions of Research Director with the Addictions Foundation of Manitoba, Senior Scientist with the University of Wisconsin Faculty of Medicine, and Research Scientist and Policy Adviser with BC Mental Health and Addiction Services. David contributed the development and implementation of Canada’s National Treatment Strategy. David has collaborated on several major projects related to service-level and system-level initiatives to improve substance use prevention or intervention. His work has included authoring client-centred brief intervention workbooks to support those striving to reduce or stop their use of alcohol, use of cannabis, or gambling. Pathway Research, Winnipeg, MB, Canada Peter R. Butt  is a graduate of McMaster University Medical School in Hamilton, Ontario. He is a Certificant and Fellow with the College of Family Physicians of

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Canada with additional certification in Addiction Medicine. He is an Associate Professor in the Department of Family Medicine at the University of Saskatchewan in a position dedicated to Addiction Medicine and serves as a consultant in Mental Health and Addictions in the Saskatchewan Health Authority. Current national committee work includes co-chair of the update of the Canadian Low Risk Drinking Guidelines and previous co-chair of the Standard Drink Label Working Group for the Canadian Centre on Substance Use and Addiction. He was also physician lead on the Alcohol Screening, Brief Intervention and Referral project for the College of Family Physicians of Canada. Provincially, he is the physician lead on the Saskatchewan provincial opioid and methamphetamine task forces and ‘Take Home Naloxone’ project. University of Saskatchewan and Addiction Medicine, Saskatchewan Health Authority, SHA Mental Health and Addiction, Saskatoon, SK, Canada Victoria Cock  is an Addiction Medicine Physician in South Australia and is the current clinical lead at the Drug and Alcohol Services of South Australia’s Inpatient Withdrawal Unit. Victoria has a special interest in the management of medical comorbidities associated with substance use including complex withdrawal states in medically unwell individuals; the treatment of blood-borne viruses in those that use substances and the assessment and management of those with alcohol-related liver disease—including work up towards orthotopic liver transplant and alcohol relapse prevention in this group. Victoria is a keen educator supervising both undergraduate and postgraduate students as well as lecturing both groups. Victoria has been involved in numerous research trials related to the provision of hepatitis C care to the most marginalised and vulnerable. DASSA Inpatient Withdrawal Unit, Glenside, SA, Australia Penny A. Cook  is Professor of Public Health at the University of Salford, where she leads a research group, protecting the Public’s Health, and teaches on the MSc and BSc Public Health programmes. Professor Cook researches in alcohol harm and fetal alcohol spectrum disorders (FASD) and was the Principal Investigator of the ‘Assessing the Prevalence of Fetal Alcohol Spectrum Disorder in Greater Manchester School Children’ carried out on behalf of the Greater Manchester Health and Social Care Partnership. She is also funded by the Medical Research Council to develop a parenting intervention for families affected by FASD. She leads a National Institute of Health Research-funded ‘community alcohol health champions’ project, CICA, which is looking at how the communities can support each other with alcohol advice and whether communities can influence local alcohol licensing decisions. Previous research on alcohol harm has included ‘the Big Drink Debate’, an investigation of the public’s attitude to alcohol that attracted the opinions of nearly 30,000 people and screening for alcohol-related liver disease in workplaces using non-invasive blood tests. In her wider research, she is also interested in other health behaviours, and carries out research in sedentary behaviour, physical activity, and the health benefits of greenspace. Current and recent research includes investigating the overlap of health and environmental indicators, identifying health benefits of urban parks, quantifying access to country parks, and evaluating the socioeconomic,

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psychosocial, and environmental factors that promote sedentary behaviour. In her career to date, she has published over 50 scientific publications and attracted £4m in research funding. Follow her on Twitter @profpennycook. School of Health Sciences, University of Salford, Salford, Greater Manchester, UK David B. Cooper  has specialised in mental health and substance use for over 45 years. He has worked as a practitioner, manager, researcher, author, lecturer, and consultant. He has served as editor, or editor-in-chief, of several journals, most recently as editor-in-chief of Mental Health and Substance Use. David is currently an Associate Editor: nursing and dual diagnosis for the Journal of Substance Use. He has published widely and is ‘credited with enhancing the understanding and development of community detoxification for people experiencing alcohol withdrawal’ (Nursing Council on Alcohol; Sigma Theta Tau International citations). Seminal work includes Alcohol Home Detoxification and Assessment and Alcohol Use, both published by Radcliffe Publishing, Oxford, UK. David edited a series of seven textbooks series titled Mental Health and Substance Use, all published by Routledge, New  York: USA and he co-edited with Jo Cooper three book series titled Palliative Care within Mental Health. He has authored many chapters, including one for the World Health Organization on community detoxification, and articles throughout his career. David is currently looking for a new publisher to take forward as publisher of the International Journal of Mental Health and Substance Use. Drug and Alcohol Research Centre, Middlesex University, Horsham, West Sussex, UK Natalie  Finch  is a registered mental health nurse and currently works as an Assistant Professor of Nursing at the University of Bradford. She is also a fellow of the Advanced HEA. Prior to working in academia, Natalie was in full-time clinical practice as a senior specialist nurse practitioner in an alcohol and drug service where she collaborated with people who were experiencing co-occurring mental health, alcohol, and/or drug problems. She is also a Dialectical Behaviour Therapist. Natalie is passionate about working with student healthcare professionals in order to educate them about compassionate, evidence-based approaches to working with people who use drugs and alcohol in order to reduce stigma and improve outcomes for this group of service users. Outside of work, she is a mother of two, and a volunteer for a mental health and safer drug use service. Faculty of Health Studies, University of Bradford, Bradford, West Yorkshire, UK Susan Gates  Following completion of General Nursing training Susan specialised in Critical Care and worked in Intensive Care Units for a decade. Susan then worked as a Nurse Educator for the Diploma of Enrolled Nursing programme before

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seeking a career change and worked in prison health where she coordinated the Methadone program. During her time working in prisons, Susan developed an interest in AOD and after a move interstate, secured a position within a community-based alcohol and other drug service and supported the introduction of Methadone treatment in the prison sector in that state. Whilst undertaking this work, Susan completed graduate studies in MHN and worked in the mental health sector for 3 years prior to obtaining a drug and alcohol nurse consultant position in a country region. In 2020, Susan commenced a Master’s in Nurse Practitioner programme at the University of South Australia and is currently a nurse practitioner candidate within a metropolitan drug and alcohol service. Susan is enthusiastic about evidence-based clinical practice and the provision of an integrated AOD and MH comorbidity service to vulnerable people and in addressing stigmatisation. DASSA Northern Services, Adelaide, SA, Australia Adrienne Gilmore-Thomas  is the Program Manager for the HEARTS@UTHealth program in the Department of Psychiatry and Medical Director of the Center for Neurobehavioral Research on Addiction (CNRA) at the McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth). HEARTS@ UTHealth (HIV Education, Awareness, and Referral, and Treatment for Substance Use Disorders) provides individual counselling to adults with substance use disorders. As the programme manager, Adrienne provides individual counselling and oversees the daily operations of the program. She graduated with her Doctor of Philosophy in Clinical Psychology from Prairie View A&M University. Her area of research focuses on attitudes and perceptions of substance use, HIV prevention, and risky sexual behaviours. Adrienne has conducted research examining the relationship between self-perception and coping styles. She continues to explore the attitudes, perceptions, and decision-making of HIV prevention, risky behaviours, and whether these are impacted by substance use and mental illness. University of Texas Health Science Center of Houston, Houston, TX, USA Catherine Haighton  is a Professor of Public Health at Northumbria University. She is an experienced applied health researcher, specialising in public health with an educational background in psychology. She is committed to translational research and works closely with policy and practice partners in the NHS, local and regional government, and other public and voluntary organisations to facilitate evidence-­ informed practice and policy. Catherine’s research on alcohol screening and brief intervention is nationally and internationally recognised, and she has significant methodological expertise in the development (through systematic reviews) and evaluation of complex interventions, using natural experiments, feasibility studies, pilot, and full trials. Catherine is a member of Fuse, the centre for translational research in public health, the Applied Research Collaboration North East and North

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Cumbria and the Healthy Living Lab at Northumbria University which focuses on public health interventions. Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, Tyne and Wear, England Simon  Hall  is a registered mental health nurse and currently works as a Senior Teaching Fellow at the University of Southampton. He is also a fellow of the advanced HEA and working towards a senior fellowship and has an MSc THORN qualification. Prior to joining Southampton University, he was a senior lecturer at the University of West of England running an MSc module on addictions: Dual Diagnosis. His clinical background was leading a regional early intervention service for psychosis. A key aspect of this work was supporting young people with any comorbid alcohol and other substances issues. Simon values the support of the voluntary sector who often provide the bridge and sustainability required, with people experiencing substance misuse issues. They are integral in supporting his teaching and for Simon himself to keep up to date with the latest issues. Simon champions to get service user and families/carers experiences heard as they are the real experts. Outside of work he is the inclusivity officer at his local lawn bowls club, rugby selector, and supports sand tray interventions training for schools. Department of Nursing, Midwifery and Health, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, Hampshire, UK Michael Hazelton  is a Conjoint Professor in the School of Nursing and Midwifery at the University of Newcastle Australia. He was Professor of Mental Health Nursing at Newcastle until his retirement in early 2020. Mike has published widely in mental health nursing and mental health, is a past Editor of the International Journal of Mental Health Nursing, and a Fellow and Life Member of the Australian College of Mental Health Nurses. Mike has supervised 22 students to successfully complete their PhD and was a member of the National Health and Medical Research Council expert committee that guided the development of the Australian Clinical Practice Guideline for the management of Borderline Personality Disorder. Mike was appointed Ambassador for Borderline Personality Disorder Awareness Week 2019 by the Australian BPD Foundation and is the current president of the Australian College of Mental Health Nurses. School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, The University of Newcastle, NSW, Australia Chris Holmwood  is an Addiction Medicine Physician and is currently the Director of Clinical Partnerships within Drug and Alcohol Services, South Australia. He was previously the Clinical Director of the South Australian Prison Health Service and

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prior to that was a Medical Educator and State Director with the Royal Australian College of General Practitioners’ Training Program, with responsibilities for South Australia and the Northern Territory. Chris has a keen interest in improving non-specialist health services’ responses to the needs of people with alcohol and drug problems. He has three adult children and spends his leisure time with his wife Linda, cycling, bushwalking, birdwatching, and collecting minerals. Drug and Alcohol Services South Australia, Stepney, SA, Australia Judy H. Hong  is a Postdoctoral Research Fellow at the Center for Neurobehavioral Research on Addiction (CNRA) at the McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth). She received her Clinical Psychology PhD from the University of Houston as part of the Culture, Risk, and Resilience Lab focusing on mental health and suicide in people of colour. Her scholarly work is related to racial/ethnic mental health, particularly in Black and Latinx populations as well as justice-involved/incarcerated populations. Currently, Dr. Hong is involved in both patient care at the Innovations Addiction Treatment Clinic at UTHealth and research to extend knowledge on risk and protective factors for substance use in people of colour. University of Texas Health Science Centre, Houston, TX, USA Philip D. James  trained as a psychiatric nurse in Dublin 1999 and was appointed as the first Clinical Nurse Specialist in Adolescent Substance Misuse in 2006. He has worked fulltime clinically in the public health service with teenagers presenting with substance use problems. Initially, he worked in the HSE’s Youth Drug and Alcohol (YoDA) service and in 2016 established the first treatment service for teenage substance users in the North East of Ireland. He continues to work as Clinical Nurse Specialist and Coordinator of the Substance Use Service for Teens (SUST). Phil completed an MSc in Nursing in 2005 and an MSc in Addiction Recovery in 2019. In addition to his clinical work, he has been involved in a number of research projects and publications. He has published various research articles and is co-­ author of The Handbook of Adolescent Substance Use which was published by Radcliffe in 2013. He is a reviewer for numerous international academic journals and was previously on the International Advisory Committee of the Journal Mental Health and Substance Use. He provides lectures on a variety of addiction and mental health-related topics with several colleges. In 2021, he was awarded a scholarship to complete a PhD in Trinity College Dublin which will examine treatment services for teenagers with substance use problems. Substance Use Service Team (SUST), HSE Social Inclusion, Drogheda, County Louth, Ireland

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Nicola  Kalik  is a clinical academic, working as a Consultant in Addiction Psychiatry in the King’s College Hospital Alcohol Care Team. She is currently Honorary Clinical Lecturer in the Department of Addictions, King’s College London. She is a member of the Faculty Executive at the Royal College of Psychiatrists and a member of the expert group contributing to the Public Health England Alcohol Treatment Guidelines. She previously contributed to the Advisory Council for the Misuse of Drugs report on Synthetic Cannabinoid Receptor Agonists. She is also a trustee of the Gordon Moody Association, a charity which provides residential rehabilitation and online therapy for people with problem gambling. Nicola studied medicine at the University of Cape Town, graduating in 2002. She won a Rhodes Scholarship to Oxford University where she completed an MSc in Comparative Social Policy (2004) and an MSc in Neuroscience (2005). She continued her psychiatric training as an NIHR academic clinical fellow based at the University of Bristol, where she completed her Membership of the Royal College of Psychiatrists (2010). She was then awarded a Wellcome Trust GlaxoSmithKline Translational Training Fellowship based at Imperial College London, which supported her during her PhD in Addiction Psychiatry (2010–2013). Following her PhD, she worked as an NIHR Clinical Lecturer at King’s College London. She has worked for the South London and Maudsley NHS Foundation Trust as a consultant psychiatrist since 2019. Nicola’s research interests include clinical addictions, psychopharmacology, substance use in psychiatric crisis, and problematic smartphone use. She has co-authored over 40 peer-reviewed publications and contributed to several books. Alcohol Care Team, Addictions Department, IOPPN, Kings College Hospital, King’s College, London, UK Christos Kouimtsidis  has been the National Co-ordinator for Addressing Drugs of Greece since 2019. He is responsible for the development and implementation of the National Drugs Strategy. Dr. Christos Kouimtsidis is a clinical academic, working as a Consultant in Addiction Psychiatry in England. He is currently Honorary Senior Lecturer at Imperial College London and at St Andrew’s University of Scotland. He has also private practice with The London Psychiatry Centre. Christos studied medicine in Thessaloniki Greece and continued his psychiatric training in London since 1994. He has an MSc on psychological Medicine (1997) from the University of London and a PhD from King’s College London (2009). He has received several awards in the UK, including the best employee award from his two NHS employers (2011 and 2016) and the prestigious HSJ Award for Clinical Research Impact (2015). He has been the Chief Investigator for three Randomised Controlled Trials funded by NIHR UK and Principal Investigator for several other studies. He has published several peer-reviewed papers, chapters in books and he is the first author on three books. Surrey and Borders Partnership NHS Foundation Trust, Chertsey, Surrey, UK Department of Medicine, University of St Andrew’s, St Andrews, Scotland Department of Medicine, Brain Science Division, Imperial College, London, UK

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Peter  J.  Kruithof  is a Postgraduate Researcher at Northumbria University and Lecturer in Global Health at Sunderland University. He currently lectures on the MSc Public Health and MSc Nursing and is the module lead for ‘Social Determinants of Global Health and Health Systems’. Currently, he is writing his PhD thesis ‘Pathways to diagnosis, treatment and care of individuals with Alcohol Related Brain Damage (ARBD): A grounded theory approach from the perspective of health and social care professionals in the North East of England’. Peter has a bachelor’s degree in social work from the University of applied science Windesheim and an MSc in Global Health from Maastricht University. He has experience working in different countries, cultures, and social backgrounds in the health and social care sector. Peter works closely with key stakeholders in the North East and is committed to the improvement of diagnosis, treatment, and care of individuals with ARBD. Department of Social Work, Education & Community Wellbeing, Northumbria University, Newcastle upon Tyne, Tyne and Wear, England Daren Lee  C Psychol, MBACP (Accred) is a Counselling Psychologist working in NHS secondary care psychological therapies services. Currently, he combines clinical practice with his role as an Associate Lecturer at Birkbeck, University of London. Daren has previously worked for a national social care charity supporting people with alcohol reduction and co-existing mental health problems. Previously, he has authored articles for the British Psychological Society magazine The Psychologist, advocating a review of exclusion criteria for mental health services and greater integration between mental health and recovery services. Daren has recently concluded qualitative research on group members’ experiences of attending online mutual aid groups during the COVID-19 pandemic (expected publication early 2022). Twitter: @dleepsych Tunbridge Wells, East Sussex, UK Scott Macpherson  One-time recipient of a Boys’ Brigade ‘Sporting Endeavour’ award, Scott is a mental health nurse, university lecturer, and cognitive behavioural therapy practitioner. Scott has authored a number of book chapters and journal articles on topics such as human rights, palliative mental health care, personality disorders, and mental health in movies. Prior to lecturing, Scott has worked as the team leader for an integrated drug service, charge nurse in an addiction’s hospital, pizza maker, and door-to-door egg salesman. When not teaching or marking, Scott can be found experimenting with dairy-free recipes, exploring the Angus glens with his wonderful children, Jayden and Cally, or pandering to a needy but loving cat. You can listen to Dan and Scott on their podcast ‘Mental Health in Movies’, which is available wherever you get your podcasts, and you can contact Scott on twitter @ SMacphersonRGU School of Nursing, Midwifery and Paramedic Practice, Robert Gordon University, Aberdeen, Scotland

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Daryl Mahon  BA, MA (Doctorate candidate) is a therapist, lecturer, and trainer. He has worked in public and private services for over a decade with individuals engaged in substance use. Daryl lectures in the broader health and social care area. His research interests relate to improving therapy outcomes for the individual and practitioners alike. He has published across several areas including using client feedback to improve therapy outcomes, using deliberate practice to train therapists to develop ongoing expertise and Servant Leadership. In addition, Daryl offers training in multicultural practice to professionals. Outcomes Matter, Wicklow, Ireland Steven M. Melemis  MD PhD FRSM has an MD and PhD from the University of Toronto and a Postdoctoral Fellowship from the University of California at Berkeley. He has been Vice-Chair of Addiction Medicine for the Ontario Medical Association, Medical Inspector for the College of Physicians and Surgeons of Ontario, and Clinical Advisor to the Physician Health Program of the Ontario Medical Association. Edgewood Health Network, Toronto, ON, Canada College of Physicians and Surgeons of Ontario, Toronto, ON, Canada Physician Health Program of Ontario Medical Association, Toronto, ON, Canada Raja A. S. Mukherjee  is an Adult Learning Disability Consultant Psychiatrist for Surrey and Border’s Partnership NHS Foundation Trust, with interest in the management of developmental disorders across the lifespan. In September 2009, he started the first NHS-based specialist Fetal Alcohol Spectrum Disorder behavioural clinic and since then has seen over 250 cases for specialist second opinion as a national referral service. Raja completed his PhD about Fetal Alcohol Syndrome in 2014. Dr. Mukherjee has also functioned as an invited advisor to the BMA board of science, The Department of Health, and the World Health Organization about FASD. In 2015, Raja gave evidence to the first All Party Parliamentary Group on FASD at the House of Commons. He has continued to support national clinical developments related to FASD.  Dr. Mukherjee is a member of the NICE quality standards group for FASD. He is currently the only UK representative to a US, NIH sponsored initiative to consider the research criteria for FASD. In his own time, he volunteers as a medical advisor to various FASD charities both in the UK and internationally. In wider work, he is currently Clinical Lead for Adult neurodevelopmental services provided by Surrey and Borders including Adult ASD and ADHD services across Surrey, Hampshire, and Portsmouth. He is an executive committee member of the RCPsych SIG on neurodevelopmental disorders, taking over as Finance officer in July 2021. Foetal Alcohol Spectrum Disorder Service, Surrey and Borders Partnership NHS Foundation Trust, Redhill, Surrey, UK

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Mary Munro  is a Mental Health Nurse based in the North East Scotland with a specialist interest in individuals who use drugs and alcohol. She has worked within drug and alcohol treatment and support services over the past 13 years across Scotland, having had the privilege and opportunity to collaborate with many individuals and their families within the Criminal Justice and Mental Health System. Her passion to work in this area stems from consistent reporting that individuals who use substances within the criminal justice system can be some of the most stigmatised individuals in our societies. She has always had a passion for tackling health inequalities in people who use drugs and alcohol, and her work has involved a number of different settings including: Prison, Forensic Mental Health in-patient, Community Substance Use Nursing, Third Sector Drug and Alcohol Services, Academia as a Lecturer in Mental Health Nursing and tutor for the Royal College of General Practitioners, voluntary sector including homelessness charities, Quality Improvement, Research, and most recently with The Scottish Ambulance Service as a Drug Harm Reduction Lead. She has a keen interest in research and has been fortunate enough to complete her Master of Research (Mres) exploring the support needs of family members of those who use substances. A move from blue nursing tunic to green ambulance service shirt was a bold but brilliant move and has allowed her to identify gaps and attempt to bridge those for frontline services to make impactful change in how we approach individuals who use substances. Clinical Effectiveness Lead Drug Harm Reduction (North of Scotland), Fraserburgh, UK Alfonso Pezzella  is a Lecturer in Mental Health at Middlesex University. Alfonso is programme leader for the master’s degree in mental health studies and teaches on a variety of topics including research methods, mental health, LGBTQ+ issues, and transcultural health. Alfonso’s research focuses on LGBT+ issues, mental health, and inclusive education. Alfonso has published peer-reviewed articles and chapters on sexuality, LGBT+, and cultural competence. Alfonso is the chair of the Sexuality and Social Work international group and secretary of the European Transcultural Nursing Association (ETNA). Alfonso has a professional Twitter feed @AlfPezzella where he enjoys bringing the community together and discussing topics related to mental health, LGBTQ+, and psychology. Department of Mental Health & Social Work, Middlesex University London, London, Greater London, UK Alan D. Price  was awarded a PhD in Psychology and Public Health in 2019 for his work on the interaction between prenatal alcohol exposure and childhood trauma. His work has been published in peer-reviewed journals, books, and in magazine articles. He has presented his research at conferences in the UK, Sweden, Germany, and Canada and has organised and hosted a specialist FASD conference at the University of Salford. Alan has worked with local government

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in Greater Manchester on a project to prevent alcohol-exposed pregnancies, is a member of the Expert Advisory Panel for Irish FASD charity EndPAE, and is a founding member of the UK FASD Research Collaboration. He is involved with a number of ongoing research projects and bids which mainly focus on the field of FASD although he has also worked on research related to the psychology of alcohol consumption, infant skin care, fuel poverty interventions, and urban traffic calming measures. Alan regularly gives guest lectures on FASD to students and has presented his research in seminars for professionals and the general public. He has taught psychology at undergraduate level as a graduate teaching assistant at the University of Salford and started a new role as lecturer in psychology at Liverpool John Moores University in November 2021. School of Health Sciences, University of Salford, Salford, Greater Manchester, UK Fiona  Robinson  is a Consultant with Drug and Alcohol Services provided by Surrey and Borders NHS Foundation Trust. She has worked in the field of addiction for the past 20 years providing both community and inpatient services. She works tirelessly to provide the best service possible to help individuals reach their personal recovery goals. Until 2018, she was the clinical lead for a 13-bed inpatient unit providing detoxification and a primary rehabilitation programme. The unit offered safe and effective detoxification for individuals with complex health problems. She developed and is clinical lead for the community detoxification service in Surrey. Fiona has championed the identification and effective management of alcohol-­dependent individuals in both acute general and mental health hospitals in Surrey through collaboration on writing guidelines, teaching and the development of pathways to ensure individuals have access to ongoing support post detoxification. Drug & Alcohol Services, i-access East, Surrey & Borders NHS Foundation Trust, Redhill, UK Musa Sami  is a Clinical Associate Professor in Psychiatry at the University of Nottingham. He works as a Consultant Psychiatrist in Bracken House, an 18-­bedded high-dependency rehabilitation unit in Nottinghamshire Healthcare Foundation Trust. His main interests relate to schizophrenia, serious mental illness and the overlap with addictive disorders and dual diagnosis. Musa undertook a PhD through a Medical Research Council fellowship at King’s College London in the area of cannabis and psychosis. He has established a Clinical Network for Dual Diagnosis in Nottingham and Nottinghamshire and was centrally involved in helping to obtain a Doctoral Training Programme from the Wellcome Trust in mental health and neuroscience in the Midlands universities (awarded August 2021). He has put together symposia in the Society of Study for Addictions (2019) in ethical dilemmas in addiction treatment; for the RCPsych International Congress (2021) in the area of dual diagnosis; and for the Institute of Mental Health in the neurobiology of psychosis and schizophrenia (2021 upcoming). Musa has a longstanding

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interest in alcohol addiction having worked clinically in the NHS, third sector and private detoxification settings. He won the Michael Frowen, second prize from the Medical Council of Alcohol, the Royal College of Psychiatrists Addiction Faculty prizes and wrote the chapter on Alcohol in The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry. Institute of Mental Health, University of Nottingham, Nottingham, UK Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, England Miriam  Sequeira  is a psychologist by training and works at Sangath (a mental health research organisation) in Goa, India. Over the past 7 years at Sangath, she has worked with various teams to develop contextually relevant psychosocial interventions that can be delivered by community-based non-specialist health workers in India. She has led the development of a culturally adapted problem-solving therapy intervention, funded by the National Institute of Health, USA, aimed at preventing depression in the elderly in resource-constrained settings like India. Miriam currently works within the Addictions Research Group (ARG) at Sangath, assisting with the development of similar interventions to address alcohol misuse and tobacco use. She has experience using the Medical Research Council’s Framework for the development of complex interventions particularly in the context of digital interventions for substance use. During her work at the ARG, she has interviewed substance users and their families in India to understand the barriers and facilitators to overcome their substance misuse. Her areas of interest are common mental disorders and addictions among adults in low- and middle-income countries. Addictions Research Group, Sangath Community Health NGO, Goa, India Ellen Sinclair  has extensive experience as a Registered Nurse mainly specialising in mental health. A former Clinical Nurse Consultant in psychiatric rehabilitation, Ellen holds Bachelor of Nursing and Master of Mental Health Nursing degrees and is a Member of the Australian College of Mental Health Nurses. She has taught nursing students at the University of Newcastle and co-authored articles and book chapters on mental health nursing. Until recently, Ellen worked in a private hospital inpatient mental health unit and as a Mental Health Practice Nurse in a suburban General Practice; both positions she had held for 10 years. Ellen’s work in both inpatient and primary care settings has often involved the assessment and management of people with serious drug and alcohol problems. Ellen currently works as a Community Clinical Care Coordinator in a Veterans counselling service. Veteran’s Counselling Service, New Lambton Heights, NSW, Australia W. J. Wayne Skinner  MSW, RSW is a graduate of the Faculty of Social Work at the University of Toronto. He is active as a clinical consultant, trainer, and educator. At the Centre for Addiction and Mental Health (CAMH), he served as Clinical Director of the Concurrent Disorders Program and, until he retired in 2016, headed

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the Leadership Team of Program Gambling Institute of Ontario and was Deputy Clinical Director in the Ambulatory Care and Structured Treatment Program. He has held appointments as an assistant professor in the Department of Psychiatry and adjunct senior lecturer in the Factor-Inwentash Faculty of Social Work at the University of Toronto. He is a member of the international Motivational Interviewing Network of Trainers (MINT). Wayne edited the book Treating Concurrent Disorders: A Guide for Counsellors (CAMH, 2005), and co-edited Fundamentals of Addiction: A Practical Guide for Counsellors (CAMH, 2014). With Marilyn Herie, he authored Substance Abuse in Canada (Oxford University Press, 2010), and with Caroline O’Grady, A Family Guide to Concurrent Disorders (CAMH, 2007). Wayne and Carolynne Cooper authored Motivational Interviewing for Concurrent Disorders (Norton, 2013). He co-chaired the expert panel that produced RNAO’s best practices document, Engaging People Who Use Substances, in 2015. Between 2008 and 2014, he was associate editor for the journal Mental Health and Substance Use. He is a member of the editorial board of the Journal of Gambling Issues. He participates regularly in peer-reviewed journals as an author and a reviewer. Department of Psychiatry, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada Bernadette Solomon  Bernadette graduated as a registered and psychiatric nurse in the 1980s in the UK. Bernadette is currently a senior lecturer and research lead in mental health and addictions at Manukau Institute of Technology in Auckland, New Zealand. Bernadette has extensive experience as a mental health nurse academic and educator and her specialty practice is forensic mental health nursing. Bernadette’s doctoral (DHSc) research focused on mental health recovery. The research explored the experience and meaning of recovery-oriented practice for nurses working in an acute inpatient mental health service. She is particularly passionate about the empowering potential of embedding recovery-oriented practice into mental health services and nurse education. Her other research interests are in nursing education, mental health, and forensic mental health. Her current research project involves investigating non-fatal strangulation and the mental health consequences of intimate partner violence. Manukau Institute of Technology, Auckland, New Zealand Jacqueline (Jacky) Talmet  Jacqueline (Jacky) Talmet (nee Powell) is a registered nurse with over 40 years postgraduate experience in mental health and communitybased drug and alcohol nursing and has a special interest in ethical issues in practice and how this relates to people with A&OD and MH comorbidity. Jacky has worked with colleagues over many years to address discrimination and the stigmatisation of vulnerable people in healthcare settings. This work has focused on equitable access to supportive, compassionate, appropriate, and evidence-based healthcare in which a person’s rights are upheld within a framework of risk identification and management. DASSA Northern Services, Adelaide, SA, Australia

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Richard Velleman  (FBPsS, FRSS, PhD, MSc, C Psychol) is Co-Director, Addictions Research Group, Sangath NGO, Goa, India; Emeritus Professor of Mental Health Research, University of Bath, UK; and Treasurer and founder-­Trustee, Addiction and the Family International Network (AFINet). He is both a practicing clinical and an academic psychologist, has been awarded grants of more than £10,500,000 (UK) over his research career to date, and has more than 300 publications including 15 books, more than 180 published refereed academic papers and scholarly chapters, and more than 25 major reports. His work has been cited by other publications more than 8700 times. Richard is a leading authority on substance misuse and the impact of this misuse on other family members, including children. He has worked in the addictions and mental health fields in the UK for over 40 years, and internationally for the past 25 years, working on both research and policy development with many international bodies, including government or research organisations in Australia, Hong Kong, India, Italy, Mexico, New Zealand, etc., and international bodies such as the EMCDDA and the EU. He has developed theory and practice in relation to resilience in children who have lived within problem families; and in relation to adults who are Affected Family Members (AFMs), dealing with the addiction problems of a close relative. He is one of the developers of the Stress-Strain-Information-Coping-Support model, and of the 5-Step Method which was developed from that, both of which are used extensively with understanding and helping AFMs. His current projects include the ones in India, developing and researching new ways of delivering psychological interventions to people (and their families) experiencing mental health problems, including using both community lay health workers and/or new technologies to deliver these services and projects in a number of countries (New Zealand, Australia, India, Netherlands, Ireland, Italy, etc.) implementing interventions to help affected family members deal with the addiction problems of a close relative. Addictions Research Group, Sangath Community Health NGO, Goa, India Department of Psychology, University of Bath, Bath, UK Dan  Warrender  Although Dan’s proudest moments may have been during time spent as singer and guitarist for criminally overlooked rock band ‘Evil Demon Theory’, if you asked Dan what he does, he’d say he is a mental health nurse, lecturer, and mentalisation-based treatment practitioner. He is a keen writer and philosopher who enjoys thinking critically about the world in which we live, and in particular healthcare provision. Professional interests are around ‘personality disorder’, psychological trauma, risk, ethics, and the arts, and he is well published in these areas. Personal interests include music, comics, film, and exploring the stone circles of the UK with his wife and children. Always keen to play ‘top trumps’ with co-author Scott Macpherson, he’d like everyone to know he was the proud recipient of a green Blue Peter badge, awarded for caring about the environment. Alongside Scott, he is cofounder of ‘Mental Health in Movies’, a pop-up cinema and podcast which encourages conversations about mental health using film as a platform. ‘Mental health in Movies’ is on twitter @MH_in_Movies, and Dan himself @dan_warrender School of Nursing, Midwifery and Paramedic Practice, Robert Gordon University, Aberdeen, Scotland

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Michael F. Weaver, MD, DFASAM  is a Professor in the Department of Psychiatry and Medical Director of the Center for Neurobehavioral Research on Addiction (CNRA) at the McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth). He received his MD degree from Northeast Ohio Medical University and completed Residency in Internal Medicine and a Clinical Research Fellowship in Addiction Medicine at Virginia Commonwealth University (VCU) Health System, and he is Board-certified in Internal Medicine through the American Board of Internal Medicine and certified in Addiction Medicine through the American Board of Preventive Medicine. Dr. Weaver received a Mentored Clinical Scientist Development Award (K-Award) from the U.S. National Institute on Alcohol Abuse and Alcoholism for the study of alcohol withdrawal treatment in a general medical inpatient setting and has published extensively on the treatment of alcohol withdrawal syndrome, including articles on the ethics of alcohol withdrawal treatment. He is currently involved in patient care, medical education, and research. Michael sees patients in the Innovations Addiction Treatment Clinic at the Texas Medical Center in Houston. He has extensive experience teaching about addiction to medical students, residents, and community professionals at all levels for over 20 years. He has been involved in multiple research projects, and currently is collaborating with other researchers in the CNRA on studies involving cocaine, methamphetamine, marijuana, and electronic cigarettes. Michael has multiple publications in the field of addiction medicine. Centre for Neurobehavioral Research on Addiction, The University of Texas Health Science Center at Houston, Houston, TX, USA Marilyn White-Campbell  BA Dip Grt is a Clinical Geriatric Addictions Specialist with Baycrest Long-Term Care Behavioural Support Outreach teams. She is the provincial Lead for Behavioural Supports Ontario BrainXchange Older Adult Substance Use Collaborative and has recently launched ‘Cannabis and Older Adults, Know the Facts’. Marilyn is a co-investigator with Canadian Coalition for Seniors Mental Health project which established four national clinical best practice guidelines for SUDs in older adults including alcohol, benzodiazepines, cannabis and opiates and is co-chair for the Alcohol Working Group. She is the recipient of the Ontario Psychogeriatric Award of Excellence and recipient of the inaugural CAGP/CCSMH Seniors’ Mental Health Outstanding Care and Integrative Practice Award from the Canadian Academy of Geriatric Psychiatry/CCSMH.  With over 35 years clinical experience working with older adults with SUDs, she is recognised as a pioneer in the field of Geriatric Addictions. Baycrest Health Sciences, Toronto, ON, Canada Hayley Wicks  is Clinical Lead in a Drug and Alcohol Clinical Service in New South Wales Australia. Hayley was instrumental in founding a specialised service for people who experience life limiting biopsychosocial decline resulting from severe substance dependence. The service is intensive, mobile, and community based and aims to

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stabilise and reduce drug and alcohol use and preventable repeated hospital presentations. Hayley is a Credentialed Mental Health Nurse with the Australian College of Mental Health Nurses, holds Bachelor of Nursing and Master of Mental Health Nursing degrees and other postgraduate qualifications in addiction studies, and has undertaken training in DBT and other psychosocial interventions. Hayley is a conjoint lecturer in the School of Nursing and Midwifery at the University of Newcastle, Australia. Local Area Drug and Alcohol Service, Hunter New England Health, NSW, Australia Lyn  Williams  is a registered Mental Health Nurse and Associate Director for Quality Improvement. Lyn is also a Senior Honorary Research Fellow at De Montfort University in Leicester, UK. She has been qualified as a Mental Health Nurse since 1983 and trained at St George’s Hospital in Stafford working in the field of Mental Health and Substance Use for the last 27 years. Lyn has been a practitioner in Motivational Interviewing since 1994 and trained as a trainer in MI with the MI International Network in Crete in 2003. Lyn whose focus is into participatory methods, received her practice doctorate in 2015 from Birmingham City University after undertaking an improvement project utilising participatory action research and MI in ‘Co Creating Conversations for Management and Leadership Development’ in a drug and alcohol charity in the UK. She has through participatory design co-­ produced and implemented a clinical quality improvement system in large NHS Trust. She has also led on and implemented a programme of training with peer vaccinator staff in MI and brief interventions to improve Vaccine Confidence during the Covid Pandemic supporting the uptake of flu and covid-19 vaccines. Lyn has also co-designed and co-facilitated a course at De Montford University which has been running successfully for the last 3 years, incorporating MI practice conversations for change into collaborative care planning practice. Lyn has extensive experience teaching MI in Health Behaviour Change to medical students in training, student nurses, managers, and community professionals at all levels for over 18 years. Nottinghamshire Healthcare Nottinghamshire, UK

NHS

Foundation

Trust,

Nottingham,

Gary  Witham  is a Senior Lecturer in Nursing at Manchester Metropolitan University. His research interests are exploring marginalised populations experiences and access to palliative and end-of-life care services. Specifically, he has co-­ investigated the experiences of people using substances at the end-of-life, their carers/family as well as health and social care professionals. In addition, Gary has worked on projects exploring the implementation of good practice models of care related to supporting people using substances at the end of life. Department of Nursing, Manchester Metropolitan University, Manchester, UK

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Introduction David B. Cooper

1.1 Introduction This author wrote the book Alcohol Home Detoxification and Assessment that was published in 1993. At that time, and over the years, this author felt there was a need for a more comprehensive text covering alcohol use to continual post-detoxification care and treatment. Now seems the time to bring this together in one multi-specialist author textbook. Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy—Ethical Practice aims to explore the comprehensive concerns and dilemmas occurring from alcohol use and to inform, develop and educate by sharing and pooling knowledge, and enhancing expertise, in this developing region of ethical practice. This volume concentrates on ethical issues, dilemmas and concerns specifically interrelated, as a collation of problem(s) that directly or indirectly affect(s) the life of the individual and family. Whilst presenting a balanced view of what is ethically best practice today, this title challenges concepts and stimulates debate, exploring all aspects of the development in treatment, intervention and care responses, and the adoption of research-led best practice. The book is about alcohol use, assessment, withdrawal management, treatment and therapy, applying new-found skills to care and practice. The focus is on combining the principles and philosophy of alcohol prevention and intervention, in hospital and community. It reviews ethical intervention and treatment in care and practice including: • • • •

Person-centred practice Relationship-based connectedness A belief in compassionate care Respect for autonomy and choice

D. B. Cooper (*) Drugs and Alcohol Research Centre, Middlesex University, Horsham, West Sussex, UK © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_1

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• Quality of life issues • The family as the unit of care • The need for democratic and intra−/interdisciplinary teamwork Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy is an intervention, treatment, care and practice text. It delivers the practical skills needed to offer ethical intervention and treatment, therefore implementing ethical person-centred care. Each chapter develops a theoretical framework, broadening out to include application in care and practice. Throughout, the book adopts a person-­ centred approach. The reader is able to follow the reason for ethical practice and care from assessment to application and to question what is acceptable in practice. Each author addresses the ‘what, when, where and why’. However, paramount to each chapter, each author will specifically concentrate on the ‘how’. Consequently, each chapter will move from informing to implementation—the ‘how to’. The aim is to improve, above all else, ethical relationships, responses, care and practice necessary to be effective in interventions and treatment with those experiencing alcohol use and health problems. The emphasis will be on the individual, the family and stigma throughout.

1.2 Description For the individual and family experiencing alcohol use and health problems, life presents many problems. The needs are complex and all-encompassing and can cause many ethical concerns and dilemmas for the individual, family and professional alike. For the professional, educator, researcher, manager and service developer, this presents multifaceted challenges. To successfully, and innovatively, deliver ethical interventions, treatment, care responses, practice and comprehensive services, professionals need to continually explore, and update, the concept of ethical knowledge and skills. This book provides a practical base from the sound theoretical base, building a best ethical practical care foundation for discussion and dissemination around the subject of alcohol use health problems, bringing innovative, developing and proven ethical practice—by aspiring to collate existing knowledge, understanding, research, education, service development and managerial expertise—from alcohol use, assessment, withdrawal management, treatment and therapy. The book does not address ‘alcohol use’, ‘assessment’, ‘withdrawal management’, ‘treatment’ and ‘therapy’ as individual subjects. Such concerns relate not only to the individual and family but also to the future direction of practice before we introduce care, interventions and treatment. Whilst presenting a balanced view of what is best ethical practice today, the book challenges concepts and stimulates debate, exploring all aspects of the development of ethics and the adoption of research-led best ethical practice within this complex area of need and understanding. To achieve this, the book draws from a variety of perspectives facilitating consideration of how professionals meet the challenges, now and in the future, and how

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best to implement and practice these within the care environment. The book assembles international insight into current ethical thinking and developments from a variety of perspectives related to the needs of the individual and family experiencing alcohol use health problems. By using a humanistic approach, i.e. emphasising the personal worth of each individual, the text introduces the many and diverse facets of alcohol use, assessment, withdrawal management, treatment and therapy. This book is practice-based and includes all aspects of psychological, physical, social, spiritual, sexual and emotional health and cohesive intra-/interdisciplinary teamwork— each chapter emphasises stigma, the family and communication across boundaries, therefore meeting the changing needs of the person and family experiencing the associated alcohol use health problems. Case scenarios demonstrate the complex ethical concerns and dilemmas faced by the individual, family and professional within the concept of autonomous practice—and ‘how’ to implement ethics in practice. As a solution-focussed, person-centred text, self-assessment/reflection and key points are integral to extending and maintaining an ethical knowledge base within the context of alcohol use, assessment, detoxification and treatment.

1.3 Terminology Whenever possible, the following terminology has been applied. However, in certain instances, when referencing a study and/or specific work(s), when an author has made a specific request, or for the purpose of added clarity, it has been necessary to deviate from this applied ‘norm’.

1.3.1 Alcohol Use Here we were challenged on how to term ‘alcohol use’, and there are a number of ways: abuse, misuse, dependence, addiction. The decision is that within these texts we use the term alcohol use to encompass all (unless specific need for clarity at a given point). It is imperative the professional recognises that whilst we may see another person’s ‘alcohol use’ as misuse or abuse, the individual experiencing it may not consider it to be anything other than ‘use’. Throughout, we need to be aware that we are collaborating with unique individuals. Therefore, we should be able to meet the individual at the point where he/she is at that time.

1.3.2 Problem(S) and Disorders The terms ‘problem(s)’ and ‘disorders’ can be used interchangeably, as stated by the author’s preference. However, where possible the term ‘problem(s)’ has been adopted as the preferred choice.

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1.3.3 Individual, Person, People There seems to be a need to label the individual—as a form of recognition! Sometimes the label becomes more than the person! ‘Alan is an alcoholic’—thus it is Alan, rather than a health problem, that impacts on Alan that he lives alongside. We refer to patients, clients, service users, customers, consumers, etc. Yet, we feel affronted when we are addressed as anything other than what we are—individuals! We need to be mindful that every person we see during our professional day is an individual—unique. Symptoms are in many ways similar (e.g. delusions, hallucinations, physical and/or mental health problems), some interventions and treatments are similar (e.g. specific drugs, psychotherapy), but people are not. Alan may experience an alcohol use problem, and so may John, Beth and Mary and you or me. However, each will have his/her own unique experiences—and life. None will be the same. To keep this constantly in the mind of the reader, throughout the book we refer to the individual, person or people—just like us but different to us by their uniqueness.

1.3.4 Professional We are all professionals, whether students, nurses, doctors, social workers, researchers, clinicians, educationalists, managers, service developers or religious ministers and others. However, the level of ability may vary from one professional to another. We are also individuals. There is a need to distinguish between the person with an alcohol use problem and the person interacting professionally (at whatever level) with that individual. To acknowledge, and to differentiate, between those who experience—in this context—and those who intervene, we have adopted the term professional and/or clinician. It is indicative that we have had, or are receiving, education and training related specifically to help us (the professional and/or clinician) meet the needs of the individual. We may or may not have experienced mental health substance use problems, but we have some knowledge that may help the individual—an ability to be shared. We have a specific knowledge that, hopefully, we wish to use to offer effective intervention and treatment to another human being. It is the need to make a clear differential, for the reader, that forces the use of ‘professional and/or clinician’ over ‘individual’ to describe our role—our input into another person’s life.

1.3.5 Never Presume Never presume that what you say is understood. It is essential to check understanding, and what is expected of the individual and/or family, with each person. Each person needs to know what he/she can expect from you, and other professionals/ clinicians involved in his/her care, at each meeting. Jargon is a professional language that excludes the individual and family. Never use it in conversation with the

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individual, unless requested to do so; or explain what we mean by it; it is easily misunderstood. Remember, we all, as individuals, deal with life differently. It does not matter how many years we have spent studying human behaviour, listening and treating the individual and family. We may have spent many hours exploring with the individual his/her anxieties, fears, doubts, concerns and dilemmas and the health-related experience. Yet, we do not know what that person really feels and how they see life and health. We may have lived similar lives, or experienced the same health problems, but the individual will always be unique, each different from us, each independent of our thoughts, feelings, words, deeds and symptoms, each with an individual experience.

1.4 Conclusion It has been our intention to offer an overall picture in relation to alcohol use. However, it is not possible in one text to cover all that relates to alcohol use and the individual. Here we ‘introduce’ the topic in the hope the reader will move on to learn and understand more about each aspect of alcohol use and her/his role in offering an ethical effective intervention and treatment to that person whom we come into contact with on a daily basis in our work. Of primary focus, we have emphasised the autonomy of an individual and her/his family. At the end and during our therapeutic relationship, we are connecting with human beings holistically and eclectically and must encompass that person in all that we do. At the completion of our specific intervention, it is important that we prepare and arrange the future care and/or interventions available. It should not close with a bang, but as a gradual move to more independence in her/his own life.

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Alcohol Use Bernadette Solomon

Learning Outcomes The material in this chapter will support you to: • Discuss the impact and incidence of alcohol-related disorder for individuals, families, and society • Identify the significance of undertaking alcohol assessments for individuals who use alcohol • Describe a range of appropriate interventions that can be used for individuals with alcohol challenges • Apply knowledge to support individuals who are dependent on alcohol and their families who are subsequently impacted • Critically analyze the range of treatment services available for individuals with alcohol dependency diagnosis

2.1 Alcohol Alcohol is a central nervous system depressant that slows down the receptors (messages) that flow between the brain and the physical body and, in turn, affects responses such as concentration and mood. Despite these adverse effects on the physical body, for many individuals, historically and in present times, alcohol has played a role in their social engagements. Indeed, moderate alcohol consumption can be a pleasurable experience. However, alcohol consumption, especially in

B. Solomon (*) Manukau Institute of Technology, Auckland, New Zealand e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_2

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excess, is associated with a number of negative outcomes including being a risk factor for diseases and health impacts; being linked to increased crime and road incidents; and, for some, alcohol dependence. Globally, alcohol consumption causes 2.8 million premature deaths per year [1].

2.1.1 Current Levels of Alcohol Use Around 107 million people or 1.4% of the global population have an alcohol use disorder; of which it was estimated that 75 million were male, relative to 32 million females (see Fig. 2.1). When comparing across age groups, globally the prevalence is highest in those aged between 25 and 34 years (for which approximately 2.5% of the population has an alcohol use disorder). Significantly, prevalence among Russians aged 30–34 years is just under 10%, while overall prevalence in Russia is 4.7%, meaning that almost 1 in 20 experiences an alcohol dependency.

2.1.2 Deaths from Alcohol Dependence It is estimated that around 185,000 people across the world died directly from alcohol use disorders in 2017. The total estimated number of deaths by country from 1990 to 2017 can be seen in Fig. 2.2 which shows direct death rates (not including

Fig. 2.1  Prevalence of alcohol use disorders in males versus females, 2017

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Fig. 2.2  Death rates from alcohol use disorders, 2017

suicide deaths) from alcohol use disorders globally. Belarus had the highest death rate in 2017, with around 19 per 100,000 individuals dying from alcoholism. For most countries, the rate significantly ranges from 1 to 5 deaths per 100,000 individuals. In addition to direct deaths, indirect deaths from alcohol use disorders can occur through suicide. The link between mental health and substance use disorders and suicide is discussed under the entry “Mental Health.” Although clear attribution of indirect deaths by means of suicide is challenging, alcohol use disorders are a known and established risk factor. It is estimated that the relative risk of suicide in an individual with alcohol dependence is ten times higher than an individual without an alcohol use disorder [2].

2.1.3 Treatment for Alcohol Use Disorder Global data on the prevalence and effectiveness of alcohol use disorder treatment is incomplete. Figure 2.3 captures data across nine countries on the share of people with an alcohol use disorder who received treatment. These data are based on estimates of prevalence and treatment published by the World Health Organization [1].

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Share of people with alcohol use disorders receiving treatment, 2008 New Zealand

30% 10%

Germany United States

8%

Hungary

7.5%

Japan

7% 5.6%

United Kingdom Namibia Netherlands South Korea 0%

Our World in Data

5% 3% 1.6% 5%

10%

15%

20%

25%

Source: WHO, Global Health Observatory (GHO)

30% CC BY

Fig. 2.3  Share of people with alcohol use disorder receiving treatment, 2008

2.2 Including the Family in Treatment The family is key to providing good information about how their loved one’s dependency developed and is maintained. They can help support the individual, thereby influencing the treatment of the disorder (see Chap. 8). Indeed, treating only the individual experiencing the active disease of addiction is limited in effectiveness, and education and training emphasize the significant impact the environment, including the family, has on the individual. Research demonstrates that evidence-­ based family approaches provide better outcomes over individual- or group-based treatments [3]. Treating the individual without family involvement, therefore, may be detrimental as it ignores the devastating impact of alcohol on the family, and does not recognize the family’s own needs or the potential benefit of family as collaborators in supporting change.

2.2.1 Indications and Impacts for Families and Communities: Physical, Psychological, Social The family remains the primary source of attachment, nurturing, and socialization for humans in modern society. Therefore, the impact of substance use disorders on the family and individual family members merits attention. Alcohol misuse has been commonly termed as a “family disease” [4]. Alcohol dependence does have a

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genetic link; however, that is not why it is called a family disease. While each family and each family member are uniquely affected by the individual using alcohol, the term “family disease” is used because it is believed that one person’s dependence to alcohol can affect the whole family in a myriad of ways including, but not limited to, having unmet developmental needs, impaired attachment, legal problems, domestic violence, neglect, vulnerability/sexual risks, and economic hardship [5]. Significantly, for young children in the family, there is an increased risk of developing an alcohol dependency themselves [6] (see Chaps. 11 and 12).

2.2.2 Effects on Family Relationships Substance use causes significant instability which may lead to physical and emotional dysregulation for families. It is, of course, the individual who experiences the majority of the physical and emotional effects of their dependence. However, those family members who are close to the individual often experience emotional distress associated with caring for the person. This distress can manifest in a range of symptoms such as anxiety, depression, or even shame with regard to their loved one’s alcohol dependency. Additionally, family members may experience the brunt of emotional or physical disturbances or outbursts. Relationships are built on trust, but many individuals often find themselves blaming their family or friends for their challenges. They are often in denial about their disease and minimize how much alcohol they consume or the problems that their alcohol consumption causes, which can erode the trust among their close relationships and may result in family members becoming distressed, angry, or resentful toward their loved one. The individual who is experiencing alcohol issues may also attempt to isolate themselves in order to shield or protect their family members from the impact of their addiction. However, isolation or distancing can further erode trust and has ramifications for family in the form of financial problems associated with alcohol.

2.2.3 Effects on Family Finances Alcohol costs—both in the monetary sense and the emotional demand it places on family. There is a burden of financial stress, dependent on the amount and type of alcohol beverage, for a person and their family when individuals are dependent on alcohol [5]. Such expense can have a serious impact for family members with regard to budgets and outgoing expenses. Other monetary considerations may be indirect results of alcohol use and include the cost of fines or arrests due to impulsive driving while under the influence of alcohol and subsequent damage costs to car breakages, hospital charges, etc. Financial ramifications can also be felt when an individual loses their employment due to their alcohol issues, a situation that can have a devastating effect upon the entire family.

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2.2.4 Domestic Violence Studies on alcohol use have found a significant, complex link between alcohol and domestic abuse. Studies have indicated that alcohol can be a contributing cause or factor that may lead or trigger episodes of violent behaviors in domestic or home environments [7]. International evidence reveals that men tend to perpetrate more severe assaults when they have been drinking alcohol [8, 9]. When intoxicated, women are highlighted within the evidence to be more vulnerable to assault; but this is, at least partly, because those living with misusers are less aware or vigilant at responding to self-care and safety strategies when they have been drinking alcohol [10] (see Chap. 13).

2.3 Diagnosis and Assessment for Alcohol Dependency Alcohol use is common and needs to be considered with every individual in every setting. There are various assessment tools and criteria that can help inform a diagnosis and, importantly, lead to the appropriate management and treatment necessary to support each individual (see Chap. 10). The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) [11] is used for classifying mental health and drug and alcohol addictions. In comparison to the previous version (DSM-IV), the DSM-5 does not use the terms “dependence, addiction, or substance abuse” as these terms do not encompass a recovery focus and can be misunderstood or regarded as judgmental. Rather, the terminology of “substance use disorder” (when referring to drugs or alcohol) has been deemed more appropriate. The severity of the disorder can be determined by the number of symptoms present (see Box 2.1).

Box 2.1 DSM-5 Criteria for Substance Use Disorder

• Taking the substance in larger amounts or for longer than was intended • Wanting to cut down or stop using the substance but not managing to • Spending a lot of time getting, using, or recovering from use of the substance • Cravings and urges to use the substance • Not managing to do what you should at work • Continuing to use, even when it causes problems in relationships • Giving up important social, occupational, or recreational activities because of substance use • Using substances again and again, when it is physically hazardous • Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance

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• Needing more of the substance to get the effect you want (tolerance) • Development of withdrawal symptoms, which can be relieved by taking more of the substance Two or three symptoms indicate a mild substance disorder, whereas four to five symptoms indicate a moderate substance disorder; and six or more would indicate a severe substance disorder. The DSM-5 permits the professional to specify the severity of the substance use disorder, depending on how many symptoms are identified. Source: American Psychiatric Association. (APA, 2013) Diagnostic and Statistical Manual of Mental Disorders, fifth ed. (DSM-5). American Psychiatric Association, Washington

2.3.1 Assessment When assessing an individual’s physical and mental state, there may be a point when the professional is alerted to evidence of recent substance use. Signs may include a strong smell of alcohol or tremors which might indicate withdrawal (see Chap. 10). Other alert signs may include poor physical and mental health status and poor levels of hygiene. An assessment should ideally include: • Appearance: Is the individual malnourished or underweight? Are they gaunt? Look for signs of agitation (may indicate withdrawal symptoms from alcohol use). • Signs of intoxication: Observe for ataxia (unsteadiness and lack of coordination). Is the person argumentative or is there an odor of alcohol about their person? • Signs of withdrawal: May include tremors or sweating (in particular of the hands and face). • Bruising or scarring: May indicate falling or accidents while under the influence of alcohol. • Physical observations: Pulse, respirations, and blood pressure may indicate head injury, etc., and it may be pertinent to use the “Glasgow Coma Scale,” a neurological scale which gives reliable objectivity to evidence and record the consciousness state of an individual, particularly if they are intoxicated [12]. Self-Assessment Exercise 2.1 Critical Thinking Challenge When assessing an individual for possible substance use, which of the following would alert the professional to alcohol intoxication? (A) Pupillary constriction (B) Slurring of speech (C) Smell of alcohol on the person’s breath (D) Ataxia (unsteady gait)

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2.3.2 Mental Health Status Examination (See Chap. 5) When enquiring about substance use, it is important to use an open manner toward the topic and to speak about alcohol use as an accepted behavior. Doing so will help build the relationship and show the individual that, as a professional, you are accepting of and nonjudgmental toward them. Adopting an open manner will help facilitate the individual to feel more comfortable in sharing their journey. When taking a substance use (alcohol) history, it is essential to undertake a thorough assessment of the following: • • • • • •

Risk indicators Medical history (present and past) Psychosocial factors Physical health Mental health status Pathology indicators (blood results)

It is vital, however, to remember that no single sign or symptom alone is conclusive evidence of an alcohol-related issue [12].

2.3.3 Key Assessment Points As part of the assessment process, it is important to clarify with the individual the following points: • • • • •

Type of alcohol frequently used Frequency of alcohol consumption Duration of time spent drinking and drinking patterns Time and amount of the last alcohol period How alcohol is affecting them—physically, mentally, socially, occupationally

As a professional, it is important to recognize that it may be difficult to enquire about such personal issues; however, the following tips may help make the experience less problematic in practice: • Communication is key! Use a respectful and nonjudgmental style of communication. Remember how difficult it may be for the individual to open up about their life (often with someone they have not yet built a therapeutic relationship). Remember that many individuals may be guarded about revealing the full extent of their alcohol use until they feel that you are to be trusted. Therefore, when asking questions around alcohol use, be relaxed and introduce the subject as an everyday occurrence. • Make sure that you choose a private area in which to conduct the assessment.

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• Remember that when interviewing an individual, there may be inconsistencies in their story. Do not challenge these discrepancies; just make a note. It is possible to clarify details in a later interview. • If the individual becomes agitated or angry, leave the question or line of discussion, and, if possible, try to rephrase it at a later point in the assessment. • If the individual agrees, it may be possible to gain more information regarding alcohol use from family and friends. • Procedural guidelines are there to protect the professional. If necessary, check with senior staff regarding concerns around legality, confidentiality, or duty of care.

2.3.4 Screening Tools: Severity of Alcohol Dependence Questionnaire (SADQ-C) There are many types of screening tools that support the assessment of alcohol dependency. Widely used, internationally, is the self-assessment Severity of Alcohol Dependence Questionnaire (SADQ-C) [13]; see Box 2.2. The SADQ-C was developed by the Addiction Research Unit at the Maudsley Hospital, UK, and is a measure of the severity of dependence. The SADQ-C questions cover the following aspects of dependency syndrome: physical withdrawal symptoms, affective withdrawal symptoms, relief drinking, frequency of alcohol consumption, and speed of onset of withdrawal symptoms.

Box 2.2 Severity of Alcohol Dependence Questionnaire (SADQ-C)

SEVERITY OF ALCOHOL DEPENDENCE QUESTIONNAIRE (SADQ-C) NAME ___________________________AGE __________ NO._______ DATE: Please recall a typical period of heavy drinking in the last 6 months. When was this? Month: ………………………………… Year: …………………… Please answer all the following questions about your drinking by circling your most appropriate response. During the period of heavy drinking 1. The day after drinking alcohol, I woke up feeling sweaty ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 2.  The day after drinking alcohol, my hands shook first thing in the morning. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 3. The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn’t have a drink.

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ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 4. The day after drinking alcohol, I woke up absolutely drenched in sweat. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 5. The day after drinking alcohol, I dreaded waking up in the morning. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 6. The day after drinking alcohol, I was frightened of meeting people first thing in the morning. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 7. The day after drinking alcohol, I felt at the edge of despair when I awoke. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 8. The day after drinking alcohol, I felt very frightened when I awoke. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 9. The day after drinking alcohol, I liked to have an alcoholic drink in the morning. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 10. The day after drinking alcohol, I always gulped my first few alcoholic drinks down as quickly as possible. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 11. The day after drinking alcohol, I drank alcohol to get rid of the shakes. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 12. The day after drinking alcohol, I had a very strong craving for a drink when I awoke. ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 13. I drank more than a quarter of a bottle of spirits in a day (OR 1 bottle of wine OR 7 beers). ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 14. I drank more than half a bottle of spirits per day (OR 2 bottles of wine OR 15 beers). ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 15. I drank more than one bottle of spirits per day (OR 4 bottles of wine OR 30 beers). ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS 16. I drank more than two bottles of spirits per day (OR 8 bottles of wine OR 60 beers). ALMOST NEVER  SOMETIMES  OFTEN  NEARLY ALWAYS Imagine the following situation: 1. You have been completely off drink for a few weeks 2. You then drink very heavily for 2 days How would you feel the morning after those 2 days of drinking? 17. I would start to sweat. NOT AT ALL  SLIGHTLY  MODERATELY  QUITE A LOT

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18. My hands would shake. NOT AT ALL  SLIGHTLY  MODERATELY  QUITE A LOT 19. My body would shake. NOT AT ALL  SLIGHTLY  MODERATELY  QUITE A LOT 20. I would be craving for a drink. NOT AT ALL  SLIGHTLY  MODERATELY  QUITE A LOT Scoring: Answers to each question are rated on a 4-point scale: Almost never—0 Sometimes—1 Often—2 Nearly always—3 • A score of 31 or higher indicates “severe alcohol dependence.” • A score of 16–30 indicates “moderate dependence.” • A score of below 16 usually indicates only a “mild physical dependency.” • A chlordiazepoxide detoxification regime is usually indicated for someone who scores 16 or over. • It is essential to take account of the amount of alcohol that the individual reports drinking prior to admission as well as the result of the SADQ. • There is no correlation between the SADQ and such parameters as the MCV or GGT.

2.3.5 Screening Tools: The AUDIT Questionnaire The AUDIT questionnaire, or AUDIT-C (AUDIT alcohol consumption questions), is a validated screening tool used to assess whether or not there is a problem with dependence. It is a quick measure that can be used in a consultation (Table 2.1). Case Study 2.1: Jay Jay (19) has been attending community mental health services for the past year. His family has noticed over the past year that he seemed to be drinking more alcohol and getting into trouble with the police due to his aggressive behaviors when drunk. In addition, Jay has recently lost his job due to absenteeism and has found it difficult to find other employment. Consequently, he has had financial difficulties, which, in turn, has led to him consuming more alcohol. Currently his alcohol intake is at least two bottles of wine and six beers daily. Jay’s family has encouraged him to seek help over the past year, and he has attended detoxification and rehabilitation programs, but unfortunately has not sustained abstinence for any significant period of time. In regard to his health status, Jay has had an ulcer (see

Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly

Never

Questions 9. Have you or someone else been injured as a result of your drinking?

0 point No

Never

Never

Never

Never

Never

1 or2

1 point Monthly or less 3 or 4

0 point Never

Monthly

Monthly

Monthly

Monthly

Monthly

Monthly

2 points 2–4 times per month 5 or 6

Weekly

Weekly

Weekly

Weekly

Weekly

Weekly

3 points 2–3 times per week 7 or 9 Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily

4 points 4+ times per week 10+ Your score

2 point 4 point Your score Yes, but Yes, during not in the the past year past year 10. Has a relative or friend, doctor or other health worker been No Yes, but Yes, during concerned about your drinking or suggested you cut down? not in the the past year past year A score of 8 or more is associated with harmful or hazardous drinking, a score of 13 or more in women, and 15 or more in men, is likely to indicate alcohol dependence Saunders JB, Aasland OG, Babor TF et al. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II. Addiction 1993, 88: 791–803

4. During the past year, how often have you found that you were not able to stop drinking once you had started? 5. During the past year, how often have you failed to do what was normally expected of you because of drinking? 6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session? 7. During the past year, how often have you had a feeling of guilt or remorse after drinking? 8. During the past year, have you been unable to remember what happened the night before because you had been drinking?

2. How many standard drinks containing alcohol do you have on a typical day when drinking? 3. How often do you have six or more drinks on one occasion?

Table 2.1  The AUDIT questionnaire Questions 1. How often do you have a drink containing alcohol?

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Chap. 6) and recently attempted to stop drinking abruptly, which led to a seizure, leading to a hospital admission. Self-Assessment Exercise 2.2 1. How will you as a health professional approach Jay regarding his increased pattern of over drinking? 2. What strategies would you utilize to support Jay’s journey? 3. How best would you involve Jay’s family in the process? Or would you? (What ethical implications can you identify?) 4. Name some relevant styles of interviewing techniques you might use when meeting Jay. 5. What are the social deficits that Jay is experiencing now, and what collaborative could you use to work alongside Jay to support these short- and long-term deficits?

2.4 Effects of Alcohol Consumption The short-term effects are dependent on the amount that the individual consumes and how good the individual’s physical condition is at the time. However, short-­ term effects of alcohol can include: • • • • • • • • • • • • • • •

Heightened confidence and feelings of happiness Relaxation Lowering of inhibitions Blunted responses Slurring of speech and blurred vision Lack of concentration Mood changes (lability/exaggerated emotions) Aggression and outbursts Confusion Muscle control weakness and lack of coordination of movements Diarrhea and vomiting Headaches Unconsciousness Anemia (loss of red blood cells) Memory lapses or “blackouts”

Consuming alcohol over a long period of time and in large quantities is associated with many health problems and includes harms in the following areas: • Brain injury and damage resulting in poor memory, confusion and hallucinations, and permanent damage (Korsakoff’s syndrome) • Unintentional risks of harm (e.g. car accidents and crashes, burns, choking)

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• Intentional risk of injuries (e.g. sexual assault, firearm injuries, domestic violence) • Psychological risks, psychosis, hallucinations, depression • Liver (cirrhosis) disease • Neuropathy • Sexual problems • Gastritis • Vitamin B deficiency, which has a subsequent link to amnesia, apathy, and confused states • Malnutrition • Cancer (mouth and throat predominantly)

2.5 The Disease Burden from Alcohol Use Disorders Alcohol is one of the world’s largest risk factors for premature death and is responsible for 2.8 million premature deaths each year. However, these statistics, that indicate mortality alone, do not represent the true picture of the often devastating impact that alcohol plays in the individual’s overall well-being. The “disease burden”— measured in disability-adjusted life years (DALYs)—considers both mortality and years lived with disability or health burden. Figure 2.4 shows DALYs per 100,000 people which result from alcohol use disorders.

Fig. 2.4  Disease burden from alcohol use disorders, 2017

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Number of deaths by risk factor, World, 2017

Our World in Data

Total annual number of deaths by risk factor, measured across all age groups and both sexes. High blood pressure Smoking High blood sugar Air pollution (outdoor & indoor) Obesity Outdoor air pollution Diet high in sodium Diet low in whole grains Alcohol use Diet low in fruits Diet low in nuts and seeds Indoor air pollution Diet low in vegetables Diet low in seafood omega-3 fatty acids Low physical activity Unsafe water source Secondhand smoke Low birth weight Child wasting Unsafe sex Diet low in fiber Poor sanitation No access to handwashing facility Drug use Diet low in legumes Low bone mineral density Vitamin-A deficiency Child stunting Diet low in calcium Non-exclusive breastfeeding Iron deficiency Zinc deficiency Diet high in red meat Discontinued breastfeeding 0

4.9 million 4.72 million 3.41 million 3.2 million 3.07 million 2.84 million 2.42 million 2.06 million 1.64 million 1.46 million 1.44 million 1.26 million 1.23 million 1.22 million 1.1 million 1.08 million 1.03 million 873,408 774,241 707,248 585,348 534,767 327,314 232,777 220,678 184,760 160,983 59,882 28,595 24,833 10,012

2 million

4 million

7.1 million 6.53 million

6 million

Source: IHME, Global Burden of Disease (GBD)

8 million

10.44 million

10 million CC BY

Fig. 2.5  Number of deaths by risk factor, World, 2017

The Institute for Health Metrics and Evaluation’s (IHME) Global Burden of Disease Study estimated the number of deaths per year attributed to a range of risk factors [14] (see Fig. 2.5). This chart is shown for the global total but can be explored for any country or region using the “change country” toggle.

2.6 Mental Health Disorders as a Risk Factor for Alcohol Dependency Figure 2.6 summarizes the results from a study by Swendsen et al. [15] in which the authors followed a cohort of more than 5000 individuals, with and without a mental health disorder (but without a substance use disorder), over a 10-year period; following which, they reassessed the participants for whether they had a nicotine, alcohol, or illicit drug dependency. The results (Fig.  2.6) show the increased risk of developing alcohol dependency (results for illicit drug dependency are shown in the entry “Substance Use”) for someone with a given mental health disorder (relative to those without). For example, a value of 3.6 for bipolar disorder indicates that illicit drug dependency became in excess three times more likely in individuals with bipolar disorder than those without. The risk of an alcohol use disorder is highest in individuals with intermittent explosive disorder, dysthymia, oppositional defiant disorder, bipolar disorder, and social phobia.

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Mental health as a risk factor for alcohol dependency or abuse Increased risk of developing alcohol dependency or abuse in individuals with a given mental health disorder relative to those without. A value of 3.2 for PTSD, for example, would indicate that individuals with PTSD are 3.2 times as likely to develop alcohol dependency relative to those without.

Our World in Data

Intermittent explosive disorder

6

Dysthymia (persistent, mild depression)

4.1

Oppositional defiant disorder

3.9

Bipolar disorder

3.6

Social phobia

3.3

Any anxiety disorder

3.2

Post-traumatic stress disorder (PTSD)

3.2 3.2

Panic disorder Any disruptive behaviour disorder

2.8

Separation anxiety

2.7

Specific phobia

2.7

Antisocial personality disorder

2.4

Agoraphobia

2.3

Conduct disorder

2

Attention deficit hyperactivity (ADHD)

1.8

Any mood disorder

1.8

Generalized anxiety disorder (GAD)

1.6 1.6

Major depression 0

1

2

3

4

Source: Swendsen et al. (2010)

5

6 CC BY

Fig. 2.6  Mental health as a risk factor for alcohol dependence or abuse

2.7 Stigma, Burden, Support, and Best Practice 2.7.1 Guidelines: Safe Levels of Alcohol Consumption Guidelines from the Alcohol Advisory Council of New Zealand suggest an upper limit for men of 6 standard drinks on any 1 occasion and a limit of no more than 21 drinks (units) per week. For women, the suggestion is an upper limit of 4 standard alcoholic drinks on any 1 occasion, with no more than 14 drinks per week. A standard drink contains 10 g (12 mL) of pure alcohol [16]. Interestingly, the World Health Organization stated that one unit (standard drink) of alcohol is equal to 10 g of pure alcohol [17]. However, the metric used as a “standard measure” can vary across countries, with several European countries adopting 12 or 14 g per unit [1].

2.8 Intervention and Treatment Options (What Is Out There to Support?) 2.8.1 Interventions: Rehabilitation Services Community alcohol and drug services (CADS) are available, as well as medical detoxification services for people who experience a physical dependence on alcohol and other drugs (e.g. methamphetamines, benzos, opiates) (see Chaps. 20 and

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21). Physical dependence is when people need to increase how much they take to get the same effect, and they experience physical and psychological withdrawal symptoms if they stop drinking alcohol. CADS provide medical detoxification services to support people to withdraw or reduce their use or stabilize on medications. The Community and Home Detox Service (CHDS) team can also support individuals at home or in the community setting. However, an alternative option for alcohol treatment is to offer an inpatient detoxification within a specialized unit for people who need 24-h medical supervision.

2.8.2 Detoxification This is often one of the first stages for individuals who are finding alcohol a challenge in their lives. Individuals enter an agreed detoxification treatment arrangement. The method of detoxification can be medical or nonmedical. The overall aim is to offer a safe space that will support and reduce the severity of alcohol withdrawal syndrome while managing potential complications. Detoxification programs are either at the individual’s home or in an inpatient setting (see Chaps. 20 and 21). While engaging in detoxification, the individual (if they agree) will sometimes require medication; this is gauged carefully on the severity of the withdrawal symptoms. Withdrawal symptoms may range from mild (uncomfortable) to severe, which can be potentially life-threatening. The management of detoxification withdrawal encompasses the following: • Reducing the development of severe symptoms of withdrawal • Minimizing the risk of harms to self and others • Removing the potential risk of physical decline, dehydration, nutritional and electrolyte imbalances • Reducing the potential risk of seizures

2.8.3 Relapse Prevention and Harm Minimization (See Chap. 22) The harm minimization policy around alcohol use and the key goals of the New Zealand Ministry of Health’s national drug policy [18] consists of three main considerations: 1. Reduction of supply: Prevent or reduce the availability of alcohol and other drugs. Supply reduction is a focused approach that involves consistent work from policymakers, criminal justice, and legislators in both the local and wider international picture. 2. Reduction of demand: Education is mainly key via health and education services. Education will focus on the risks, physical (see Chap. 6) and psychological harms (see Chap. 5), with an emphasis on making healthy life choices.

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3. Reduction of harm: Requires services to be actively involved (and proactive/ assertive) in reaching individuals and supporting them to reduce or stop alcohol use altogether.

2.8.4 Talking Therapies (Psychological) Health professionals play a significant role in supporting individuals experiencing alcohol challenges. Communication, especially validation of what the person is going through, is one of the most vital skills that help support the individual to make sense of what is happening for them and provides an opening for them to move positively forward. Health professionals can provide and facilitate many talking interventions to help the individual regain some sense of peace and motivation to keep going forward in their recovery journey.

2.8.5 Motivational Interviewing (See Chap. 23) One such talking therapy is motivational interviewing, which uses the trans-­ theoretical model of change and offers a safe place to start a conversation with an individual struggling with alcohol issues [19]. Motivational interviewing was developed by Miller and Rollnick [19]. The model is designed for working collaboratively alongside the individual to assess and then help raise their motivation to modify their level of alcohol use. The aim of motivational interviewing is to engage individuals to recognize how to move toward a future in which they are less conflicted or ambivalent and more engaged and motivated to work toward the changes they will need to make in their lives to reduce the risk of alcohol-related harm.

2.8.6 Motivational Interviewing: The Distinct Phases of the Trans-Theoretical Model of Change • Pre-contemplation. There is no recognition that a change in behavior is needed. The individual is in a form of “denial” about their alcohol behaviors. It is of the utmost importance during this stage that the professional continues to connect and engage respectfully, and without judgment, with the individual. The professional will also offer education around the impact and risks associated with continued alcohol misuse at this stage. • Contemplation. The individual starts to recognize a need to change, albeit still having a level of ambivalence. Here, the professional continues to support the individual despite their indecision about their alcohol misuse. The professional tries to provide a space that creates awareness to “tip the balance” of indecision by highlighting the pros versus the cons of risks and the benefits or how positive life might look minus excessive alcohol use. Ultimately, it is the individual who takes self-responsibility for change [20].

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• Preparation. The individual is engaged, albeit they may be struggling or confused about how to instigate change. The professional becomes the inspiring catalyst, offering encouragement and hope, facilitating choices around what support and help they might be able to action. The professional and the individual collaboratively work together to create a plan for change. • Action. This is the phase where actual change behavior begins, and the individual formulates a realistic plan of action. Both parties—the individual and professional—work together, monitoring the ongoing progress and embracing even the smallest of successes, including cessation or reduction in drug or alcohol use. • Maintenance. At this point the desired behavioral change has become embedded in a new lifestyle. There is a need for both the professional and the individual to be vigilant to avoid relapse. It is important that realistic hopes and expectations are engaged within this stage. It is not unusual for the individual to slip back a stage (from preparation to pre-contemplation). This is often an anticipated part of the journey and requires the professional to understand the stages of when the individual presents “readiness to change” and provide education and information to enable the individual to positively move forward once more. The person is more likely to maintain positive change behaviors, if they understand what is happening to them. Ultimately, it is imperative that the professional rolls with any resistance presented by the individual along their recovery journey [21].

2.8.7 Solution-Focused Brief Therapy Another widely used therapy that helps to support individuals experiencing alcohol use disorders is solution-focused brief therapy (SFBT). This is a psychological intervention used to support and modify cognitive distortions and maladaptive behaviors. It is a person-centered approach that focuses on the individual’s strengths and coping skills and explores their propensity to see a positive future [22]. The professional aims to help the person to explore and elaborate what is currently going well and focuses on what the individual’s goals are both in the present and the future. While the importance of acknowledging past experience is not ignored, the emphasis in SFBT is how the individual is enabled to adapt to change [23]. Therefore, the current problem is an opportunity to change what may be considered maladaptive coping strategies in which the individual may have previously engaged. The health professional’s role, therefore, is to be able to facilitate and support the person toward recovery, help the person find a way to imagine a future without alcohol problems, and look at ways to create small achievable goals. As the individual begins to see that small things can be changed, and is able to reflect on their small success, they then keep moving forward in incrementally constructive steps to achieving more rewarding and positive changes in their lives [22]. This type of therapy aligns well with motivational interviewing while having some core elements also found within cognitive behavioral therapy.

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2.8.8 Cognitive Behavioral Therapy (CBT) Cognitive behavioral therapy is an effective evidence-based talking therapy commonly used to treat many types of psychological and dependence issues [24] (Fig. 2.7). Research has shown that alcohol use disorders are closely linked with social phobia and anxiety affecting one in four and one in seven people, respectively, in their lifetime [25]. Cognitive behavioral therapy is an effective talking therapy that supports individuals with comorbid presentations. The premise is that one’s thoughts and emotions influence behavioral responses. These thoughts can provoke either a positive or negative response in an individual’s life. A key concept in CBT is that these thoughts and behavior patterns can be changed. Often inaccurate perceptions or thoughts lead to psychological distress for individuals, and this is where health professionals can facilitate (in collaboration with the individual) and support the person to make sense and meaning of their experience. It is important, while working on establishing their current cognitive and belief systems, how the individual’s negative thought patterns directly link to their maladaptive patterns of behaviors. Black and white thinking or polarized thinking is one of the most common maladaptive thinking processes for those struggling with alcohol issues. Individuals with black and white thinking have an all-or-­ nothing perspective (e.g. they will “never get sober” or a relapse is always impending) [24]. It is important to recognize these are common thinking patterns and, more importantly, how to work toward changing these often-entrenched thinking patterns. Once the individual begins to recognize these patterns, they can learn how to reframe their thoughts in a more positive and helpful way. Therefore, learning how to address and change these patterns can help the individual to deal effectively with their problems as they arise—ultimately reducing future levels of distress.

Cognitive-behavioural Model BELIEFS selective attention

confirm

Activating event

Thoughts/ interpretations

influence

Symptoms e.g. emotions actions

biases in thinking Fig. 2.7  Cognitive behavioral model

reactions

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2.9 Chapter Summary This chapter has presented information and activities designed to deepen understanding in the following areas: • Alcohol dependency is a major depressant that can lower central nervous system activity leading to lower heart rate and respiration and has a major health impact on individuals, families, and society. It should be noted that every individual is unique and responds differently to alcohol and its effects. • Person-centered care approaches are important when working with individuals experiencing alcohol problems. Motivational interviewing, SFBT, and CBT are all useful tools which can enable the opening of good therapeutic relationships between professionals and the individual seeking support and instill hope in each individual. Professionals must, however, have the correct training and a full understanding of dynamics related to readiness to change and acknowledge that each individual may move between stages several times before moving forward in their recovery journey. • Solution-focused therapy also supports the individual’s personal strengths, coping strategies, inclusion in the process, and a vision for a healthy future. Many health services have been able to effectively integrate care and provide services that support those individuals presenting with alcohol problems. However, it must be acknowledged that many people have co-existing issues and will benefit from the support of mental health, drug, and alcohol services during this time. • Alcohol misuse affects the well-being and health of each individual. Psychological and alcohol problems often need a multi-model approach to produce good health outcomes; yet, this is often difficult to achieve for various reasons, not least of which is that some health services allocate certain issues (either alcohol- or mental health-related) to different streams of care or service providers. Therefore, the coordination and transition of meaningful, comprehensive healthcare is fraught with hurdles for individuals experiencing alcohol issues. • Harm minimization: Alcohol use is an inevitable part of society, which can include occasional to dependent use. Therefore, a harm minimization focus needs to be used in a multiagency approach to succeed. The reduction of supply will hopefully minimize the harms that alcohol brings to society and is a necessary focus that government agencies and legislators need to continuously monitor and act accordingly. • Education plays a significant part of the reduction in demand. Health and education that empowers the person to have correct and accurate knowledge may facilitate more healthy and informed choices around their alcohol use. The reduction of harm for individuals must include assertive efforts for health professionals to engage the individual in alcohol services. This is vital in supporting those who need professional support to reduce or cease using alcohol.

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2.10 Conclusion The harmful use of alcohol remains a global problem causing more than 5% of the total global burden of disease and resulting in approximately 3 million deaths [17]. In addition, there is a significant link with alcohol consumption to mortality much earlier in those individuals who drink excessively. Many people manage to socially use alcohol regularly and not experience any long-term or harmful effects. However, some individuals drink to excess and, subsequently, develop dependence to alcohol with detrimental effects on many areas of their lives including physical and mental health and social well-being. Evidence suggests that many individuals who have co-occurring substance use and mental health disorders are at significantly higher risk of experiencing alcohol issues than the general population [26]. As a health professional, it is vital that each individual is correctly assessed for their alcohol use and given timely and person-focused treatment options. Thorough assessment is key to being able to offer the most appropriate treatment package to individuals presenting with alcohol challenges. It is critical that individuals are engaged early in their treatment regarding withdrawal management and detoxification to reduce risk and provide the safest environment for them and their journey to recovery. Treatments include medical interventions as well as many forms of brief talking interventions that can be offered either in an inpatient setting or in the community. Recommendations from research literature suggest that integrated working models aligned with what works best for the individual are most effective. The individual’s readiness to change must be considered; and being hopeful, skillful, and nonjudgmental as a health professional must be a priority when working with those who are struggling with alcohol. Ultimately, being there for the individual (no matter what stage the individual is at) is vital. The individual is not a diagnosis; they are a person. Therefore, the therapeutic relationship between the health professional and the individual is one of the most valuable keys to success and recovery.

References 1. Ritchie H, Roser M.  Alcohol consumption. 2018. https://ourworldindata.org/alcohol-­ consumption. Accessed 18 Oct 2021. 2. Pompili M, Serafini G, Innamorati M, Dominici G, Ferracuti S, Kotzalidis GD, et al. Suicidal behavior and alcohol abuse. Int J Environ Res Public Health. 2010;7:1392–431. https://doi. org/10.3390/ijerph7041392. 3. Baldwin S, Christian S, Berkeljon A, Shadish W. The effects of family therapy for adolescent delinquency and substance abuse: a meta-analysis. J Marital Fam Ther. 2012;38:281–304. 4. Graham AV, Berolzheimer N, Burge S.  Alcohol abuse. A family disease. Prim Care. 1993;20:121–30. 5. Lander L, Howsare J, Byrne M. The impact of substance use disorders on families and children: from theory to practice. Soc Work Public Health. 2013;28:194–205. https://doi.org/1 0.1080/19371918.2013.759005. 6. Zimic JI, Jakic V. Familial risk factors favoring drug addiction onset. J Psychoactive Drugs. 2012;44:173–85. https://doi.org/10.1080/02791072.2012.685408.

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7. Leonard KE, Quigley BM. Thirty years of research show alcohol to be a cause of intimate partner violence: future research needs to identify who to treat and how to treat them. Drug Alcohol Rev. 2017;36:7–9. https://doi.org/10.1111/dar.12434. 8. Graham K, Bernards S, Wilsnack SC, Gmel G. Alcohol may not cause partner violence but it seems to make it worse: a cross national comparison of the relationship between alcohol and severity of partner violence. J Interpers Violence. 2011;26:1503–23. https://doi. org/10.1177/0886260510370596. 9. Reno J, Marcus D, Leary ML, Samuels JE. Full report of the prevalence, incidence, and consequences of violence against women. 2010. https://www.ncjrs.gov/pdffiles1/nij/183781.pdf. Accessed 18 Oct 2021. 10. Iverson KM, McLaughlin KA, Gerber MR, Dick A, Smith BN, Bell ME, et al. Exposure to interpersonal violence and its associations with psychiatric morbidity in a U.S. national sample: a gender comparison. Psychol Violence. 2013;3:273–87. https://doi.org/10.1037/a0030956. 11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. San Francisco: American Psychiatric Association; 2013. 12. New South Wales Health. Clinical guidelines for nursing and midwifery practice in NSW. In Identifying and responding to drug and alcohol issues. Sydney: NSW Health; 2013. https:// www1.health.nsw.gov.au/pd/ActivePDSDocuments/GL2008_001.pdf. Accessed 18 Oct 2021. 13. Stockwell T, Hodgson R, Edwards G, Taylor C, Rankin H. The development of a questionnaire to measure severity of alcohol dependence. Br J Addict Alcohol Other Drugs. 1979;74:78–87. 14. Institute for Health Metrics and Evaluation (IHME). Findings from the global burden of disease study 2017. Seattle, WA: IHME; 2018. 15. Swendsen J, Conway KP, Degenhardt L, Glantz M, Jin R, Merikangas KR, et  al. Mental disorders as risk factors for substance use, abuse and dependence: results from the 10-year follow-up of the National Comorbidity Survey. Addiction. 2010;105:1117–28. https://doi. org/10.1111/j.1360-­0443.2010.02902.x. 16. Alcohol Advisory Council of New Zealand 2008. http://www.alcohol.org.nz. Accessed 18 Oct 2021. 17. World Health Organization. Global status report on alcohol and health 2018. 2018. www.who. int/substance_abuse/publications/global_alcohol_report/en. Accessed 18 Oct 2021. 18. Ministry of Health. National drug policy 2015 to 2020: minimise alcohol and other drug-related harm and promote and protect health and wellbeing. Wellington: Ministry of Health; 2015. 19. Miller WR, Rollnick S.  Motivational interviewing. Preparing people for change. 2nd ed. New York: Guilford; 2002. 20. Department of Health. Working with young people on AOD issues the stages of change model. 2004. https://www.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-­pubs-­ front9-­wk-­to-­drugtreats-­pubs-­front9-­wk-­secb-­3-­3. Accessed 18 Oct 2021. 21. Prochaska JO, CC DC, Norcross JC. In search of how people change: applications to addictive behaviours. Am Psychol. 1992;47:1102–14. https://doi.org/10.1037//0003-­066x.47.9.1102. 22. Wand T. Mental health nursing from a solution focused perspective. Int J Ment Health Nurs. 2010;19:210–9. https://doi.org/10.1111/j.1447-­0349.2009.00659. 23. Smith S, Macduff C. A thematic analysis of the experience of UK mental health nurses who have trained in solution focused brief therapy. J Psychiatr Ment Health Nurs. 2017;24:105–13. https://doi.org/10.1111/jpm.12365. 24. Beck A.  Cognitive therapy: nature and relation to behavior therapy. Behav Ther. 1970;1:184–200. https://doi.org/10.1016/j.beth.2016.11.003. 25. Baillie AJ, Sannibale C, Stapinski LA, Teesson M, Rapee RM, Haber PS.  An investigator-­ blinded, randomized study to compare the efficacy of combined CBT for alcohol use disorders and social anxiety disorder versus CBT focused on alcohol alone in adults with comorbid disorders: the combined alcohol social phobia (CASP) trial protocol. BMC Psychiatry. 2013;13:199. https://doi.org/10.1186/1471-­244X-­13-­199. 26. Lai HM, Cleary M, Sitharthan T, Hunt GE. Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990–2014: a systematic review and meta-­analysis. Drug Alcohol Depend. 2015;154:1–13. https://doi.org/10.1016/j.drugalcdep.2015.05.031.

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To Learn More Useful Resources/Websites Ferrari AJ, Norman RE, Freedman G, Baxter AJ, Pirkis JE, Harris MG, et al. The burden attributable to mental and substance use disorders as risk factors for suicide: findings from the Global Burden of Disease Study 2010. PLoS One. 2015;9:e91936. https://doi.org/10.1371/journal. pone.0091936. GBD. 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. 2018. Mahato B, Ali A, Jahan M, Verma AN, Singh AR. Parent-child relationship in children of alcoholic and non-alcoholic parents. Ind Psychiatry J. 2009;18:32–5. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC3016696/. Accessed 18 Oct 2021. National Institute on Alcohol Abuse and Alcoholism. Children of alcoholics: are they different? Alcohol Alert. 2000;(9):PH288. https://pubs.niaaa.nih.gov/publications/aa09.htm. Accessed 18 Oct 2021. ONS. Adult drinking habits in Great Britain. UK Office of National Statistics 2018. https://www. ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/ datasets/adultdrinkinghabits. Accessed 18 Oct 2021. The Awareness Center Resources for Adult Children. The 13 characteristics of adult children of alcoholics. n.d. http://www.drjan.com/13-­characteristics-­children-­growing-­up-­in-­broken-­ homes.php. Accessed 18 Oct 2021. The National Domestic Violence Hotline. Home. n.d. http://www.thehotline.org/. Accessed 18 Oct 2021. University at Buffalo Research Institute on Addictions. RIA reaching others: Does drinking affect marriage? 2014. http://www.buffalo.edu/ria/news_events/es/es12.html. Accessed 18 Oct 2021. WomensHealth.gov. Emotional and verbal abuse. 2017. https://www.womenshealth.gov/ relationships-­and-­safety/other-­types/emotional-­and-­verbal-­abuse. Accessed 18 Oct 2021. World Health Organization. Intimate partner violence and alcohol. n.d. http://www.who.int/violence_injury_prevention/violence/world_report/factsheets/fs_intimate Accessed 18 Oct 2021.

Alcohol Rehabilitation Guide Geographical coverage: Universal guidance; support options for the United States. https://www. alcoholrehabguide.org/support/. Accessed 18 Oct 2021. Information: Guidance on the signs of alcoholism, unhealthy drinking behaviors, and support on where to go for help.

Hello Sunday Morning Information: A social movement with the aim to reduce stigma around alcohol and to encourage people to consider their relationship with alcohol. HelloSundayMorning.org Accessed 18 Oct 2021.

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Drinkaware Geographical coverage: United Kingdom. https://www.drinkaware.co.uk/alcohol-­support-­ services/. Accessed 18 Oct 2021. Information: List and contact details of a range of places for support on alcohol issues.

Alcohol Help Centre Geographical coverage: Global. http://www.alcoholhelpcenter.net/. Accessed 18 Oct 2021. Information: Free guidance, support, and discussion groups on concerns related to alcohol.

Rethinking Drinking Geographical coverage: Global; assesses relative to United States drinking patterns. Information: Test to assess your drinking patterns relative to the American population. What’s your drinking pattern? Accessed 18 Oct 2021.

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Learning Outcomes • Reflect on their professional and organisational practices as they relate to multicultural treatment. • Assess the current evidence within the multicultural competency literature. • Identify different multicultural psychosocial interventions and their application in the assessment and treatment of alcohol dependency.

3.1 Multicultural Treatment in Behavioural Healthcare Research within the psychosocial literature is generally conducted within the Western world which brings about various issues when it is then generalised to wider demographics. Consequently, Sue et  al. [1] suggest that interventions are therefore more suitable to this dominant culture and may not be congruent with other ethnic or racial groups, beliefs or values. At the same time, other researchers [2, 3] argue that therapeutic interventions are culturally encapsulated healing processes specific to certain cultural contexts. Consequently, and supported by an ever-­ growing body of evidence [4–8], cultural experiences, when addressed in treatment, can lead to more successful psychosocial outcomes. This chapter takes the following working definition of multicultural: a broad concept that refers to a shared set of beliefs, norms, and values among any group of people, whether based on ethnicity or on a shared affiliation and identity. [1, p. 7]

Thus, we can consider many aspects of identity to impact multicultural understanding, including, but not limited to: D. Mahon (*) Outcomes Matter, Wicklow, Ireland © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_3

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Gender Sexuality Socioeconomic status Age Disability Race/ethnicity Religion

However, these are not static aspects of identity; rather they are fluid and interact to provide a person with a unique overall sense of identity through what is termed intersectionality. These identities often provide a person with more privilege, or indeed more oppressed experiences in society, and thus impact treatment experiences. It is impossible to learn about the vast cultural identities of people from a book chapter, not least because in-group difference can be as large as between-groups differences. What may appear to be a cultural identity can often be a stereotype. Hence, learning from the individual, their important cultural identities, rather than learning about their cultural identities, becomes essential and is at the heart of person-­centred ethical care. Therefore, the focus of this chapter will be to explore methods to work with differential multicultural identities that they present to services and professionals, that is, a transcultural approach. Reflective Practice Exercise 3.1 Thinking About Your Own Identities Reflect on yourself and the different privileges/disadvantages that you may experience due to your: • • • • • • • • •

Socioeconomic status Race Ethnicity Gender Sexuality Religion Disability Age Others

While the broader field of psychology and the psychosocial field, specifically, have been attempting to address gaps within the multicultural treatment research space [9], there is a paucity of research examining multicultural approaches to alcohol treatment. However, there is much that we can learn from the general literature within behavioural healthcare settings in relation to access, utilisation and treatment within a multicultural context. It is clear from this literature that those with diverse identities are often underrepresented when it comes to accessing behavioural healthcare services, and when they do access these services, disparities are found across many treatments and quality of life measures [1, 4–9].

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3.2 Access and Utilisation of Behavioural Healthcare It is beyond the current chapter to examine the many different multicultural and diverse populations and their interactions within behavioural healthcare settings. However, to provide context to this chapter, the author provides a brief snapshot of some of the outcomes associated with minorities in an international context. Internationally, research from several countries has demonstrated that individuals from racial and ethnic minority communities have more problems getting access to, and issues interacting with, behavioural healthcare services and experience poorer outcomes [10]. For example, in America, minorities find it more difficult to access healthcare services and when they do so, they are of poor quality [11]. At the same time, African Americans are less likely to receive treatment, and when they do, they often have higher attrition rates. Interestingly, African Americans are more likely to seek out alternative therapies [11]. Whether this is due to the lack of care they receive within the behavioural healthcare arena or if this has more to do with cultural beliefs regarding treatment efficacy is under research. However, it is worth noting that in some African cultures, individuals often seek help and healing from their pastor, and others do not prescribe to terms such as mental health due to issues of stigma [12]. Research demonstrates [11] that only 1  in 11 Hispanic Americans uses specialist’s mental healthcare when needed. In an Australian context, the Victorian Transcultural Psychiatry Unit research suggests that minorities access healthcare less than those within the general population [13]. At the same time, non-natives were more likely to be admitted to hospitals under involuntary legislation and to stay longer when they were admitted. Within an English context, similar research demonstrates disparities in access and treatment [11]. Specifically, members of the Black Caribbean community were more likely to be involuntarily committed to hospital. Indeed, meta-analysis suggests that Black Caribbean individuals are as many as four times more likely to be involuntarily admitted than White individuals [14]. Reflective Practice Exercise 3.2 Thinking About Your Service • • • •

In your professional context or setting, who are the people accessing the service? What multicultural identities do they present with? Can you identify any treatment barriers in accessing the service? How about the outcomes they experience? Are there any disparities?

As noted already, there is a paucity of research within the substance use treatment of minorities, and even less specific to alcohol use, which is often included as a substance category in such studies. Two relatively recent studies highlight disparities in substance use treatment for minorities. Using the Treatment Episode Dataset Discharge (n = 416,221), Mennis and Stahler [15] demonstrated disparities in treatment completion rates with Whites at 50%, Hispanics 47% and African Americans 40%. The disparities in treatment completion between Whites and African Americans became even more pronounced when alcohol was the primary substance.

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This raises cause for concern when we consider the findings of [16]; using the Treatment Episode Dataset Discharge for the period 2000–2012, they illustrate that alcohol was the number one substance being treated (77–64%), although a downward trend is identified. In the most recent study, Zainab et  al. [17] illustrated that African Americans were 37% less likely to complete treatment compared to Whites. Hispanics were 26% more likely than Whites to complete treatment. Supports such as the family in Hispanic individuals are thought to mediate this, a topic to be explored later in this chapter. Internationally, both access to healthcare and treatment outcomes are greatly diminished for those from diverse racial and ethnic minority backgrounds. While structural issues such as socioeconomic and marginalisation can contribute to and exacerbate these disparities [17], other issues such as the multicultural approach, or lack thereof, taken by professionals can also impact upon the effectiveness of an intervention.

3.3 Approaching Multicultural Treatment While accessing and utilising behavioural healthcare systems presents many challenges for those from diverse minorities, treatment approaches equally present as problematic. Concerns have consistently been noted within the literature regarding the extent to which diversity has been included in research trials of evidence-based therapies and the extent to which these therapies are actually effective for those from diverse ethnic and racial populations [9, 18–20]. This, of course, led for calls to research and make treatment more applicable and effective to diverse people. Reflective Practice Exercise 3.3 Thinking About Your Treatment Approach • In your professional context, what are the evidence-based treatments that you or your service provide? • How was the research initially conducted in research trials? • Were there diverse samples used to establish efficacy/effectiveness? Although minority-focused treatment seems to work well across a broad spectrum of mental health difficulties [9], there is some ambiguity within the literature regarding multicultural psychosocial interventions as a general competency. So, while there is ambiguity regarding the when and how approach to take when working with multicultural presentations as a general competency, there is strong evidence that multicultural adaptations work, that older adults (40+) benefit most and that tailored ethnocultural interventions have bigger effect sizes than general competency-­based multicultural approaches [9]. While this may be helpful for those professionals working with these specific demographics, it falls short of meeting the diverse and intersectional identities that many individuals present to treatment with. Huey et al. [9] provide the following effect sizes for minority-focused treatments

1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

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Chart 3.1  Effect sizes of minority-focused treatments

across different diagnoses. Although substance use has the smallest of all effect sizes for culturally adapted treatments, it is still significant at (d = 0.36) (Chart 3.1). Thus, we may take heed from the recommendations of Huey et al. [9, p. 329] who assert: …individualizing treatment to match the specific needs of ethnic minority clients. Rather than adapting treatment on the basis of ethnic affiliation, clinicians would attend (implicitly or explicitly) to ethnocultural factors primarily when they seemed relevant to treatment goals or clinical concerns.

This is perhaps one of the best ways we can move forwards and is most consistent with the idea that this chapter promotes, learning from the individual, not learning about the individual, their important cultural values, beliefs and identities. It is essential to move beyond the individual treatment intervention and approach treatment provision with a wider evidence-based practice lens. Therefore, it is integral to operationalise evidence-based practice in routine care, as opposed to the narrower approach of applying a clinical intervention in isolation. The American Psychological Association defines evidence-based practice as the: …integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences. [21]

Using this model, professionals will have a guiding approach that takes account of the many factors that can impact psychosocial outcomes. Reflective Practice Exercise 3.4 Thinking About Your Evidence-Based Practices In your professional context or practice setting, how do you or your service operationalise evidence-based practice for diversity/minorities?

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3.4 Multicultural Competencies Disparities in mental healthcare treatment have been consistently identified within racial/ethnic minority groups, and those from other diversity backgrounds. Studies have documented that many professionals have better outcomes with White individuals [22–25], than those from underrepresented demographics. In addition, Hook et al. [26] suggest that there have been high rates of racial/ethnic microaggressions in therapy, with as many as 53% to 81% of individuals reporting experiencing at least one microaggression. These statistics present a worrying picture for professionals, many of whom may not realise that they engage in microaggressions, or how to broach such issues if they occur in their practice. The multicultural competency movement can be considered the fourth force in psychotherapy, following on from the psychodynamic, behavioural and humanistic traditions [27]. The competency movement has gained increasing attention since the 1980s across settings such as psychiatry, psychology, therapy and social work. Multicultural competency (MCC) proposes that it is possible to learn to work with diverse populations across cultures, identities and treatment paradigms by adopting treatment to specific cultural identities. Reflective Practice Exercise 3.5 Thinking About Multicultural Practices In your professional context and practice setting: • • • •

How would you rate your service’s multicultural competencies? Have you or your services received training? Are there anti-oppressive policies in place? Is there a diverse workforce?

3.4.1 The MCC Approach Stipulates Three Broad Ideas 1. That there are a set of competencies that can impact individual outcomes and can be acquired by professionals through a standardised training regime. 2. Competency in these skills can be assessed and identified in the professional. 3. The competencies are a standard characteristic of the professional working with differentiated multicultural people. However, as articulated previously, there is not much empirical support for the position that multicultural competencies are a stable characteristic of the professional, as studies have not illustrated adequate convergence across ratings of the same professional [28], or that competencies are strongly linked to outcomes across populations. This is not surprising when we contextualise it within the general outcome research in the professions. That is, the correlation between professional competency and individual outcomes is weak, with less than 1% of the variance in therapy outcomes accounted for by competency [7, 29, 30]. Thus, employing

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another competency framework for cultural interventions may not be the most effective method to improve outcomes for individuals. Instead, a ‘way of being’ [6] in practice settings is proposed, which would be more aligned to the factors set out in evidence-based relationships [31–33] and consistent with the idea of learning from the individual their vast cultural identities. The model of cultural competency most often cited and recognised is the person-­ based model [34]. The person-based model proposes three components, namely: • Self-awareness of one’s own cultural background and how this impacts practice • Knowledge about the worldview and culture of those from diverse cultural backgrounds • Learning skills in culturally appropriate treatment interventions [1, 35, 36] This is often referred to as the tripartite model [34], of multicultural knowledge, skills and attitude, or KSA [37]. Perhaps reflecting the wider intervention discourse, Watkins et al. [37] argue that the knowledge and skills components have received more attention, with the attitudinal aspect lagging. However, Ratts and Pederson [38] and Ratts et al. [39] would suggest that it is the attitude component that provides the KSA with its foundation and successful implementation. As Gonsalvez and Crowe [40, p. 22] argue: the “big” competencies with deep impact are attitude-value attributes.

3.5 Multicultural Psychosocial Approaches Smith et al. [41] in a meta-analysis of 65 quasi-experimental studies found that culturally adopted treatments had a medium effect size of (d = 0.46), with treatments adopting metaphors/symbols that match the individual’s cultural worldview; therapeutic goals that explicitly match the individuals goals; and older individuals and treatments to specific ethnocultural identities all being effective moderators. Similarly, Griner and Smith’s [42] meta-analysis found that treatment adapted to specific ethnocultural identities was as much as four times as effective (d = 0.45) as opposed to ethnic mix treatment; those individuals that are older and matching clients to therapists who speak their own (non-English) language were up to twice as effective. Huey et al. [9, p. 1] in their Annual Review of Clinical Psychology posit that: Support for cultural competence as a useful supplement to standard treatment remains equivocal at best.

However, they do note the findings from the Benish et al. [8] study (discussed later) and the adaptation of the illness myth and its link to relational common factors. Also, they note some of the findings from the [41] meta-analysis, specifically, matching interventions to the cultural worldview of individuals in treatment, metaphors and symbols. The illness myth adaptation would seem to be congruent with

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the general psychotherapy outcome variance literature that suggests building expectancy and hope and providing a rationale for treatment outcome/credibility produce superior outcomes [2, 7, 29, 43–45].

3.6 Pluralism The pluralistic approach is a collaborative philosophy and practice, rooted in humanistic and person-centred values. Its fundamental proposition is that each individual is unique and therefore may need different things from treatment [46]. This is brought into focus by Cooper et al. [47] in a general sense, with their study exploring the style of therapy lay persons want compared to mental health professionals as clients. Mental health professionals prefer a style of therapy more consistent with their training, deeper emotionality and less direction; it is thought that in many instances, professionals may generalise these experiences onto the individuals who they work with. While this is problematic in general practice, a cultural dimension may mean individuals in treatment could experience this as microaggressions and/ or unsensitive to their cultural treatment needs. Reflective Practice Exercise 3.6 Thinking About Shared Decision-Making In your professional context or practice setting: • How do you and your service incorporate preference accommodation/shared decision-making with individuals who use your service? • Do you have more than one treatment approach to offer? • If not, how can/do you promote involvement in treatment? One way the pluralistic approach can help with mitigating against some of the abovementioned issues is through preference accommodation. Swift et al. [48] and Lindhiem et  al.’s [3] meta-analyses demonstrate that preference accommodation/ shared decision-making is associated with superior individual psychosocial outcomes and reduced early attrition, both of which have been shown to disproportionately impact individuals of diversity. Cooper and Norcross [49] provide the Cooper-Norcross Inventory of Preference to help incorporate important issues into treatment. For example, individuals are asked about the style of therapy, format, focus and duration. There are also preference questions relating to the individual’s treatment preference across demographics regarding the type of professional that they would like to be treated by, such as gender, race/ethnicity and medication. While not a culturally specific inventory, it does provide a good starting point to begin incorporating important treatment preferences in general, with a cultural element component where identified. The implications of Western world research, treatment and understanding also need to be carefully considered within a cultural context; they are not congruent

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with the individual’s experience of their emotional problems. While this is important for all people, it comes into sharper focus when we consider diversity. For example, the Western world’s diagnostic system of pathologising is certainly not consistent with all cultures’ views of problem onset and maintenance of mental health difficulties. Western world research and training has taught us to recast other people’s experiences in terms of our own culturally situated symbolic system, be that medical or psychosocial. Thus, the preference accommodation inventory can be incorporated into alcohol treatment as a starting point for addressing cultural preferences during the assessment phase, orientating professionals to important cultural markers that are identified that can be adapted and accommodated, where appropriate, into alcohol treatment plans. While preference accommodation and assessment is a starting point, we also need a way to work in the here and now with individuals of diverse identities. The multicultural orientation framework is one way we can do this. Reflective Practice Exercise 3.7 Thinking About Your Professional Training Reflect on your professional training: • What part of the world where you trained in? • How does your professional discipline view the mind-body connection? • If you have trained in the Western world, how does/can this training bias your interactions with people of diverse multicultural identities?

3.7 Multicultural Orientation (MCO) The most recent secondary analysis within the multicultural literature is a narrative review [4]. This review examined the evidence for the multicultural orientation with individual studies within the narrative review providing evidence for correlations between one of the three aspects of MCO and outcomes. The MCO provides a lens in which the professional considers how their own cultural identity interacts with the individual they are treating and the healing potential and barriers that may come from these interactions, in addition to providing a general direction on how to go about broaching cultural markers as they present in practice settings [4, 5]. Thus, MCO is a process-orientated approach that can be used as a lens to view multicultural issues as they arise in the here and now of our work with individuals. The benefit of this practice is that professionals will have a general way of working with multicultural identities that does not involve having to learn specific ethnocultural treatment approaches with their limited applicability, or a general competency framework with its lack of empirical evidence across demographics. For Watkins et al. [37, p. 39], the multicultural orientation can be viewed: As a process-oriented, attitudes-additive perspective to the MCC KSA framework.

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MCO is used to operationalise the process-orientated perspective and as a complement to the attitudes component of the KSA framework and the multicultural competency approach in general [4]. The MCO approach is made up of three interconnected and interdependent ideas: 1. Cultural humility 2. Cultural opportunity 3. Cultural comfort And it is made up of how these: Cultural worldviews, values, and beliefs of the individual and the professional interact and influence one another to cocreate a relational experience that is in the spirit of healing. [4, p. 90]

Culturally humble professionals seek out markers for cultural opportunities to enquire into individuals’ identities that arise in practice settings. These culturally humble professionals seek to find cultural comfort in these interactions while engaging differential individual cultural identities. While cultural humility seems to be the foundation to this orientation, Watkins et al. [37] suggest that on its own, it may not be enough to improve outcomes in behavioural healthcare settings. Cultural humility can be considered a virtuous component of the MCO approach. Increasingly, those across disciplines within the mental health domains have come to understand humility as an alternative and/or complementary language to the competency approach [4, 50, 51]. Humility is conceptualised as consisting of both intrapersonal and interpersonal components, that is, a level of self-awareness regarding the view a professional holds of themselves and their limitations and the extent to which one is other orientated rather than being consumed with self and their superiority over others. We can therefore extrapolate that cultural humility as a subdomain of humility is the extent to which a professional can hold an interpersonal position with an individual that is curious about their cultural identity or as Hook et al. [26, p. 354] articulate: The ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the individual.

Importantly, cultural humility goes beyond the traditional position of ‘not knowing’ adapted by some professionals and actively seeks to learn from individuals, their cultural identities. If cultural humility is the motivational factor for professionals who want to find out about other’s important identities, then cultural opportunity and cultural comfort can be considered the behaviours of the professional when these markers are identified and need to be broached. Said another way, through cultural humility, professionals identify important cultural markers as they present and broach the subject using cultural opportunities and cultural comfort.

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Owen et al. [6] describe cultural opportunities as those points in a practice setting where important cultural beliefs, values and identities present and can be explored by both professional and the individual. At the same time, cultural opportunities are always present, and professionals should feel that they can broach these issues if they feel that there will be therapeutic value in situations where cultural opportunities may not be explicitly manifest. Davies et al. [4] suggest doing this gently and authentically and without big transitions or forcing the issue. Hence, professionals who practice cultural humility and opportunity will have a certain level of ease with engaging in these practices, that is, cultural comfort. Cultural comfort explains the level of ease that professionals experience before, during and after conversations with individuals about their cultural identities [52]. While cultural comfort would be needed to navigate the complex interpersonal dynamics that occur interpersonally, cultural discomfort may be a good indication that something has been triggered and needs attending to. As such, Davies et al. [4] use the language of cultural transference and countertransference. Viewed under this lens, feelings of cultural discomfort may precede cultural humility and would seem important for professionals to identify as they may impede therapeutic engagement and outcomes of alcohol treatment. The current evidence for MCO effectiveness in psychosocial settings is emerging as strong across a number of studies [4–6, 26, 50, 53]. Owen et al. [54] found that individuals who experienced microaggressions from the professional that they work with experience worse therapeutic alliances and worse psychosocial outcomes. At the same time, Owen et al. [54] found that professionals’ ability to identify one of three microaggressions in simulated practice settings was 38% to 52%. Hook et al. [26] demonstrated that for individuals who experienced microaggressions, cultural humility predicted the number and impact of these aggressions after controlling for general multicultural competencies, indicating the added value of humility and the MCO framework. A retrospective study [6] examined professionals’ cultural humility and cultural missed opportunities. Findings suggest that individuals who rated the professional that they worked with as culturally humble had better psychosocial outcomes, while those who rated the professional as having missed opportunities to discuss their cultural identity (cultural opportunity) reported worse psychosocial outcomes. Owen et al. [5] in a study focused on religious cultural identities reported that professionals who were more culturally humble with religious and spiritual individuals had better outcomes. This may be an important consideration for professionals working in alcohol treatment to consider, as: 1. Many cultures place huge importance on religion and spiritual experiences 2. Often alcohol treatment can have a religious/spiritual component to it It’s not surprising those multicultural orientations seem to be mediated by the therapeutic alliance. Hook et al. ([52], study 1) found that cultural humility was correlated with the alliance.

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In a second study, Hook et al. ([52], study 2) demonstrated that cultural humility correlated with the alliance and individuals’ psychosocial outcomes. In a third study, Hook et al. ([52], study 3) found that cultural humility mediates the alliance and individual outcomes. Taken together, these seven empirical studies demonstrated positive outcomes for individuals, and thus, MCO would seem to be an important process orientation for working with multicultural presentations in alcohol and behavioural healthcare settings.

3.8 Illness Myth In their meta-analysis, Benish et al. [8] found that culturally adapted psychotherapy for race/ethnic minorities is more effective than unadapted (d = 0.32) when compared against bona fide therapies. Adaptation of the illness myth was the sole moderator of superior outcomes via culturally adapted psychotherapy through the illness myth. The smaller effect size when analysed against the Smith study [41] cited previously may be accounted for by the direct comparison studies used and thus provides us with more reliable findings. Reflective Practice Exercise 3.8 Thinking About the Illness Myth In your professional context and practice setting, what is the view of the illness myth? How can you adapt your stance to incorporate other cultures’ ideas of the illness myth? In a 1962 paper, Wrenn [55] described interventions as culturally encapsulated, calling for more cultural diversity in the delivery of treatment. Frank and Frank [2] and Imel et al. [25] suggest that an important aspect of universal healing is the cultural explanation and a set of healing rituals provided to the individuals, which are embedded within a cultural context. What is important to the sufferer, is not the scientific validity or falsifiability of the illness explanation, but rather the congruence of the explanation with the individuals’ cultural beliefs about the illness. [8, p. 281]

The adaptation of illness myth works by providing a treatment rationale that is consistent with the client’s cultural understanding, beliefs about symptoms, aetiology, how the issues will evolve and opinions on acceptable treatment approaches. Incorporating the illness myth may be one method of incorporating individual’s treatment ideas and preferences into their care. For example, our Western worldview regarding the scientific method and how we consider the mind, body, environmental makeup and how these interact impacts upon our treatment assumptions [56]. However, these Western assumptions may not be fully acceptable to those from diverse ethnic backgrounds, making treatment more difficult to engage in and derive benefit from. At the very least, we must consider how our cultural understanding may differ from the individuals we treat and accommodate their important cultural understandings where appropriate.

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Considering the impact that incorporating the illness myth has when incorporated into treatment [8], and its attitudinal/process orientation, the author considers it to compliment both the MCO framework and the assessment and accommodation of preferences. Illness myth complements the MCO adaptation by having utility during the assessment process when individuals are first articulating their problems and attempting to make sense of their experience, although it can be used throughout care at different points when important cultural dynamics present. Thus, professionals should take time in their initial assessment to solicit the meaning that individuals attribute to their alcohol use, and the possible cultural meaning this holds for them. At the same time, professionals should enquire as to possible treatment methods that may be consistent with cultural identities.

3.9 Identifying Professionals’ Multicultural Practices One of the most cited rationales for clinicians incorporating multicultural competencies into therapy is how poorly clinicians attend to ethnic and other minorities [9], and the disparities within mental health outcomes for these populations. However, individual clinician experiences and opinions may not be congruent with the literature. For example, several studies during the last 30 years [57–61] of predominantly White therapists illustrate that between 72% and 91% of clinicians perceive themselves as practicing multicultural competencies to some extent. For the author, it is difficult to reconcile these statistics when we consider the wider disparities within behavioural healthcare for those from diverse backgrounds. While Benish [8] suggests that this may be reflective of a certain level of cultural competency as a norm, which certainly could be the case, another way to view these statistics could be through the lens of bias on the part of professionals. For example, the less expertise one has in a certain domain, the more likely one is to overestimate one’s degree of expertise [62]. So, having less expertise working with an area of diversity might make it harder for one to see one’s limitations in that area. This bias, combined with self-enhancement dispositions, may make it difficult for professionals to perceive and take responsibility for their limitations [4]. Indeed, Fuertes et al. [62] and Dillon et al. [63] found that professional’s self-assessment of their multicultural competencies was found to exceed the assessments of the individuals they worked with. At the same time, the general psychotherapy literature informs us that professionals tend to overestimate their rates of improvement in those individuals who they work with and underestimate their rates of client deterioration [64, 65]. Thus, in the studies cited above, clinicians may be overestimating their abilities and/or use of cultural competencies. One method to help practitioners improve these issues is by tracking their progress, outcome and process of care with standardised measures. Coupled with the previous research attesting to the impact of multicultural orientation on the alliance and outcomes, feedback approaches would seem to be indicated as helpful tools.

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Reflective Practice Exercise 3.9 Thinking About How We Can Learn from the Individuals We Work with • How do you/can you collect meaningful feedback on your multicultural practices in your professional organisational context? • How can you ensure this is not tokenism and left in a filing cabinet?

3.9.1 Feedback-Informed Cultural Practice Feedback-informed treatment (FIT) is an evidence-based trans-theoretical approach for improving the outcomes and process of interventions for individuals in behavioural healthcare settings. It involves using two ultra-brief measures at every visit to solicit feedback from individuals on the therapeutic alliance and outcome of care and using the information provided to adapt the professional/service approach in real time to meet these needs. FIT uses the Outcome Rating Scale (ORS) to solicit feedback on how the individual is responding to treatment, that is, the benefit they are getting from the interventions/service. For the author, one of the benefits of using the ORS is that the four items on the scale are not predetermined outcomes, which can often be politicalised by policymakers and commissioning bodies [66]. Rather, the ORS is a global measure of general wellbeing; thus, individuals can respond to it based on their subjective experience of their distress by naming the important aspects of their lives that they would like treatment to address, and within a cultural context. The Session Rating Scale (SRS) is used to assess the therapeutic alliance [67], that is, the extent of the agreement by the individual in treatment on the goals and tasks of treatment, the agreement of the methods and approach and the bond between the individual and professional. The therapeutic alliance has emerged as one of the strongest predictors of treatment outcome across behavioural healthcare in general, with multiple meta-analyses demonstrating this correlation [68, 69], and in alcohol treatment specifically [70, 71]. Both measures are reliable and valid tools, and meta-analysis has demonstrated their use to improve therapy outcomes by helping to identify those not benefiting from care, those at risk of early termination and those actively deteriorating while in care [72, 73] all of which make up a significant per cent of clients in routine practice. More specifically, those of diverse racial and ethnic backgrounds experience these same issues disproportionately. Thus, being able to capture these issues in real time and responding to them in a culturally informed manner may be one way to limit the extent of poor outcomes for those with diverse identities. Specifically, the SRS can be used to keep track of the therapeutic alliance in general, but also within a culturally informed manner, as the measure tracks the extent to which individuals are satisfied with the bond between themselves and the professional; the goals and topics discussed; and the methods and approach used. In doing so, professionals may also garner a clearer picture of their multicultural abilities and align their process orientation more towards the individual diversity and

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intersectionality that they are presented with, reducing possible self-effectiveness bias. While FIT has a specific meaning regarding feedback, all the concepts discussed previously seek feedback from individuals and their multicultural identities in some manner. It is this attitude of learning from the client that needs to be at the heart of any alcohol treatment approach with diverse multicultural populations.

3.10 Implications for Practitioners Learning about the individual’s culture can be quite difficult, not least because what we learn may not be representative of the wider population. Re-stereotyping may occur, and outliers are always present. While adapting to specific ethnocultural populations is one limited way of providing multicultural support, it is beyond the scope of any professional to learn about all cultures, and their intersectionality. It is just not feasible to learn about other’s important beliefs, values and cultural identities from a book chapter and bring it into a practice setting successfully. Therefore, an approach that can be utilised with differential cultures and their intersectionality would certainly be more feasible for the average professional. Huey et al. [9] in their Annual Review of Clinical Psychology note that approaches to multicultural interventions that have high training needs, complex protocols and substantial costs that further narrow their applicability to specific demographics are unlikely to be adapted and maintained by clinicians. In response to this, this author offers a brief, ethical and uncomplicated multicultural process model that can be used with diverse multicultural populations and can be assimilated into current practices with relative ease (Fig. 3.1). Fig. 3.1  A conceptual model

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3.11 Family Considerations The role of the family can be influential in the treatment of alcohol use. While different cultures may experience both the idea of and behaviour of family in different ways, it is important to capture these often-nuanced meanings. The sociocultural implications of alcohol use will need to be considered in some instances, due to the meaning and possible stigma attached to its use. Where one individual may want the support of their family and indeed extended family, others may fear family involvement due to experiencing discrimination and stigma associated with alcohol use. At the same time, families may fear approaching services due to perceived stigma. Thus, enquiring into the cultural meaning of substance use as it connects to the family and wider community should be assessed in general, rather than adapting a position of cultural applicability based on what we already think we know of different cultures’ attitudes and behaviours. With that in mind, we must remain conscious of the importance of the role of the family for certain cultural demographics and we must pay heed to this also. As articulated previously [17], it is suggested that Hispanics had better alcohol treatment outcomes due to the involvement of their family members. Both Hispanic and Native Americans place importance on the family and extended family, and thus, this should be considered within the treatment context. Again, while I mention Hispanics and Native Americans here, I use this as an example, because of course we cannot learn about all the differential family dynamics and their cultural implications. At the same time, many Hispanics and Native Americans may have poor family relations and not wish to have that family involvement, underscoring the importance of assessing such issues individually and ethically. For those who do have specific cultural attachments to the family, it is important that professionals can consider such issues as they relate to alcohol treatment. Factors such as access to the family while in residential facilities should be considered, including practical issues such as numbers of visitors admitted to such facilities, and more long-term considerations for integration and aftercare as set out in treatment plans. The involvement of the wider family unit can act as a protective factor in the recovering individual and was indicated as a cultural imperative; professionals and systems of care should be responsive. At the same time, the family has its own needs, and we must consider how the individual’s alcohol use has impacted the family and how to address healing within the family unit from a cultural perspective. The family unit may be at a crisis point, and reaching out to alcohol treatment providers could be the only hope that they have remaining. Ultimately, the general approach described in this chapter can be used to assess and inform any psychosocial interventions that may be warranted for the family as a whole unit or individuals who make up its composition.

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3.12 Ethical Considerations As far back as 1994, Clement [73] suggested that professionals have an ethical obligation to systematically evaluate their outcomes; indeed, he suggested that it is unethical to not monitor them. In a review of the ethical practice literature, Barnett [74] argues that changes in the practice of psychosocial interventions and in our knowledge base require an updating of the profession’s code of ethics on an ongoing basis. Thus, we can now say with certainty that those from diverse backgrounds experience large disparities in behavioural healthcare outcomes and this necessitates an ethical response in policy and practice. Muir et al. [75] consider feedback systems as potentially mitigating against such ethical issues, such as using evidence to identify those deteriorating in our care; those at risk of dropping out of treatment early; and matching individuals to systems of care that show effectiveness. Ridley [76, p. 107] recommends collaborating with minority clients who: ‘…often enter counselling feeling powerless’ [and] ‘gain a sense of empowerment and ownership of the counselling process when they participate.’

Moreover, Muir et al. [75] suggest that the use of feedback can be operationalised to refer individuals to specific professionals and systems of care who have shown their competency in certain domains, such as working with diversity. This may be one of the more important utilisations of feedback systems within an ethical and multicultural context and should be considered by professionals and systems of care. At the same time, we must be conscious that historically many minorities have had bad experiences of different assessment instruments, where the data have been used to discriminate and further oppress them. We must listen to feedback if this occurs and remember that our prime concern is to solicit feedback to make the treatment process a better experience. If this feedback is about the tools we are using, we must listen also. Assessment methods for diagnosing alcohol use problems should also be investigated to establish if they are reliable and valid for use in your specific cultural context. A further ethical implication is that a lack of cultural competency by professionals and systems of care contributes to ineffective services; thus the following considerations can be used to improve outcomes for those with diverse cultural identities: • Hiring employees with similar diverse backgrounds to the individuals the service works with • Using treatment methods and approaches that incorporate culturally specific values and beliefs • Assessing the extent to which professionals and services use culturally informed interventions

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One study demonstrated that individuals from an ethnic minority would not access an alcohol treatment service because there were no employees from that demographic working there [77]. Research has demonstrated that employee composition is essential to treatment initiation and retention when working with diversity [78, 79] and, as such, deserves consideration in organisational policy and practice.

3.13 Conclusion Ultimately, the multicultural approach taken by services and professionals must be multifaceted and take account of systems and individual professionals’ practice. While there is emerging research on multicultural psychosocial interventions’ effectiveness, this is often specific to ethnocultural populations or practices and conducted mainly in the United States [80–86] with African Americans, Native Americans and Latinos. Other Western world research in New Zealand, Australia and Europe has demonstrated some treatment effectiveness [87–90], and although important studies in their own right, these trials were also ethnocultural specific. Thus, if you are not practicing with one of these specific homogenous groups, the research may not be of much benefit to you in your practice. So, in the absence of any clear empirical evidence or evidence synthesis for a general multicultural skillset across populations, an orientation approach as outlined in this chapter may be most beneficial to professionals and services working with individuals and families in alcohol treatment settings. Reflective Practice Exercise 3.10 Thinking About Improving Your Multicultural Service Thinking about your professional context and service: • How can you improve your multicultural practice? • What systems, processes and policies can you or your service implement? • Are there any ethical considerations that need to be explored for your particular context?

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To Learn More This chapter has provided a substantial bibliography which will direct the reader to a multitude of sources and resources regarding the different factors that have been discussed in the multicultural space. For additional resources provided are the following: If you are interested in assessing statistics related to your specific context and country, contacting your local government and health services may be helpful to ask for some signposting of where you can find such statistics, or indeed, if such data are collated in your country. To learn more about pluralism, the following website has a plethora of information: https://pluralisticpractice.com/introduction-­to-­pluralistic-­counselling-­and-­psychotherapy/. To self-administer the Cooper-Norcross Inventory of Preference (C-NIP), you can find an electronic version here: https://www.c-­nip.net/. To learn more about using feedback approaches and the assessments used, you can find a host of research and access the assessments from https://centerforclinicalexcellence.com/# and https:// acorncollaboration.org/acorn-­leadership. To learn more about the multicultural orientation approach, I have cited much of the available research in this chapter. Other information and emerging studies can be found here: https:// www.multiculturalorientation.com/. To learn more about the general multicultural competency and diversity literature, the American Psychological Association (APA) has some good information ­ (https://www.apa.org/ monitor/2018/01/multicultural-­guidelines).

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Lesbian, Gay, Bisexual, Transgender and Questioning+ (LGBTQ+) Alfonso Pezzella

Learning Outcomes After reading this chapter, you will be able to: • Articulate the importance of being aware of the differences between sex, gender and sexual orientation • Discuss the importance of using a non-stigmatising, non-discriminatory approach towards individuals from diverse gender and sexual orientations • Develop and use inclusive language to improve the care provided for sexual minorities • Discuss the importance of understanding the specific needs of LGBTQ+ individuals • Articulate LGBTQ+ inclusive practice • Reflect on your own practice and challenge your perspective and beliefs towards LGBTQ+ individuals

4.1 Introduction Reflective Practice Exercise 4.1 • Examine your personal attitudes to LGBTQ+ individuals. • Write down your thoughts. • Be honest with yourself and examine any prejudices you may hold.

A. Pezzella (*) Department of Mental Health & Social Work, Middlesex University London, London, Greater London, UK e-mail: [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_4

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• After reading this chapter, write down how it has impacted on your personal viewpoint. • Do you recognise any change in your attitude? Research suggests there is a need for health and social care professionals to be capable of delivering inclusive care, particularly to those who identify as a minority in terms of sexual orientation and gender identity, including lesbian, gay, bisexual, transgender and questioning+ (LGBTQ+) [1–4]. Discrimination against LGBTQ+ people in health and social care continues to exist. Despite the many attempts to eradicate this, many official public health agencies continue to call for programmes addressing the specific needs of LGBTQ+ people [5–7]. A Stonewall report, Unhealthy Attitudes [8], showed that health and social care workers’ attitudes towards LGBTQ+ individuals could be discriminatory. The report indicates that 1 in 10 of the respondents directly involved in patient care had witnessed colleagues expressing a belief in ‘gay cure’. Although negative societal attitudes towards LGBTQ+ people cannot be eradicated overnight, health and social care professionals must set aside their personal beliefs and act in their service users’ best interests. One way to change negative attitudes is by raising awareness of LGBTQ+ issues and ensuring these issues are included in the curriculum to enable health and social care professionals to provide quality services free from sexual prejudice and discrimination. Research into the health of LGBTQ+ populations shows that LGBTQ+ people experience poorer health outcomes than the general population and have worse experiences of healthcare services, such as cancer care [9], palliative/end-of-life care [10], dementia care [11] and mental health provision [12, 13]. Their poorer health may be attributable to: 1. Social inequalities, including ‘minority stress’ [14], i.e. the cumulative effects of lifelong exposure to prejudice and discrimination. 2. Health-risk behaviours (e.g. comparatively greater smoking, excessive drug/ alcohol use and obesity than non-LGBTQ+ people) linked to stress adaptation, loneliness and isolation, affecting physical/mental health and mortality. Healthcare experiences are associated with anticipated/experienced discrimination and inadequate understandings of needs among healthcare providers [15]. Past research has consistently shown that individuals who are LGBTQ+ are at higher risk of misuse of alcohol, drugs and tobacco compared to their heterosexual counterparts [16]. However, much of this research has come from studies that only focus on men who have sex with men whilst often excluding other sexual or gender minorities from these studies [17]. There is also some evidence to suggest an earlier age of initiation of drug use among LGBTQ+ individuals [18], although this may just be a reflection of the existing body of research that has most recently concentrated on LGBTQ+ youth and substance use. A third trend within the literature has focused on the use of ‘party drugs’ or sexualised drug use (usually referred to as chemsex; chemsex is a novel phenomenon referring to the consumption of illicit

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drugs to facilitate, enhance and prolong the sexual experience in men who have sex with men [MSM]) which is linked to risks of sexually transmitted infections, with a particular emphasis on human immunodeficiency virus (HIV) transmission [19]. Necessarily, this research is narrow in focus on specific sub-groups within the LGBTQ+ community. Protective factors, usually indicating a reduced risk of substance use in heterosexual populations, appear to have less impact within LGB (lesbian, gay and bisexual) individuals where this has been measured. For example, being female or older (>35 years) tends to correlate with lower levels of substance use, and while this has been seen for LGB groups in previous research, it tends to be less pronounced [16]. Within this body of research, several reasons for reported increased levels of problematic substance use have been suggested, including as a response to sexual and gender minority-related stressors (discrimination, stigma) and perceived normalisation of substance use within LGBTQ+ communities [20]. This has led to some researchers advocating for a more culturally competent approach to substance use treatment for those who are LGBTQ+ [16]. However, there are constraints in only trying to understand problematic substance use among LGBTQ+ communities as one needing a cultural explanation, which implies a homogeneity that does not necessarily exist and one that is in danger of excluding many smaller groups such as older people, migrants, refugees and asylum seekers. Several gaps are evident within the research literature, including information about substance use, whether problematic or not, among those across the LGBTQ+ community: • Older LGBTQ+ individuals and substance use; access to, and uptake of, treatment services for these groups • Whether there is an established need for specialised treatment services for LGBTQ+ substance users • What is happening within the practice in terms of providing substance use services for the LGBTQ+ community

4.2 Being LGBTQ+ 4.2.1 Terminology The acronym LGBTQ+ is an umbrella term, an abbreviation which indicates lesbian, gay, bisexual, transgender and questioning and all of those who otherwise identify as a minority in terms of sexual orientation and gender identity/expression. • Lesbian is a term used for a woman whose enduring physical, romantic and/or emotional attraction is to other women. Some lesbian women may prefer to identify as gay or as gay women. • Gay is used to refer to a person whose enduring physical, romantic and/or emotional attraction is to the same sex, for example, a man who is romantically or sexually attracted to a man.

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• Bisexual is used to refer to a person who has the capacity to form enduring physical, romantic and/or emotional attractions to those of the same sex or gender or to those of another sex or gender. • Transgender is an umbrella term for a person whose gender identity and gender expression do not conform to that normatively associated with the gender they were assigned at birth and to persons who are gender transgressive. Gender identity refers to a person’s internal sense of being a man, a woman or something else. Gender expression refers to the way a person communicates their gender identity to others through behaviour and/or appearance. ‘Trans’ or ‘trans*’ with an asterisk can be used as shorthand to reflect the full spectrum but is not exclusive to transgender; transfeminine; transmasculine; transsexual; transvestite; genderqueer; gender-fluid; non-binary; genderfuck; genderless; agender; non-­ gendered; third gender; two-spirit; bigender; androgynous; and gender non-­ conforming. In summary, transgender activists acknowledge the complexity of the area and the difficulties in negotiating through a vast range of terms. • The Q at the end of the LGBT acronym can mean questioning. This term describes someone who is questioning their sexual orientation or gender identity. Homophobic discrimination occurs when general discriminatory behaviour, such as verbal and physical abuse or social exclusion, is accompanied by or consists of hostile or offensive action against lesbians, gay or bisexual (LGB) people. Similarly, transphobic discrimination takes place against transgender people. Sexual orientation is an enduring pattern of romantic or sexual attraction (or a combination of these) to the individual of the opposite sex, the same sex or to both sexes or gender. These attractions are generally subsumed under heterosexuality, homosexuality and bisexuality. However, people may use other labels to describe their sexual orientation.

4.2.2 Gender Identity Sexual identity is a complex biological and social characteristic, which influences the individual’s choice of emotional and/or physical attractiveness. Sexual identity influences the sexual orientation of the person, which can be heterosexual (a person who is attracted to the opposite sex), homosexual (a person who is attracted to the same sex), bisexual (a person who is attracted to the same and opposite sex) or questioning. The term ‘questioning sexual orientation’ is used for individuals who are not yet compelled to call themselves homo- or bisexual and are unsure about their sexual identity. Historically, gender identity referred to either male or female. However, gender identity is not as binary as one might think. There are at least 71 gender categories in which people identify themselves (this is often symbolised by the plus sign after the acronym LGBTQ+), for example, cisgender, queer, intersex, asexual, pansexual, trans and so on. ‘Trans’ or ‘trans*’ with an asterisk can be used as shorthand to reflect the full spectrum but is not exclusive to:

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• • • • • • • • • • • • • • • • •

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Transgender Transfeminine Transmasculine Transsexual Transvestite Genderqueer Gender-fluid Non-binary Genderfuck Genderless Agender Non-gendered Third gender Two-spirit Bigender Androgynous Gender non-conforming

In summary, transgender activists acknowledge the complexity of the area and the difficulties in negotiating through a vast range of terms [21]. Trans* people experience similar challenges to LGB people. However, their needs might be different and could require different approaches. For example, a person who wishes to transition from male to female will need practical support, such as they may still have anatomical parts associated with being male (i.e. a prostate), and therefore, they will need support in terms of physical health needs and cancer check-ups, similar to a person who wishes to transition from female to male. Furthermore, there is still an abundance of prejudice, ignorance and stigma towards trans* people, and often their needs are difficult to understand, leading to transphobia.

4.2.3 What Do We Mean by ‘Coming Out’? To describe the process of acceptance and disclosure of one’s sexual identity, the term ‘coming out’ is used. ‘Coming out’ has a complicated structure for LGBTQ+ individuals, which influences different areas of their social life [22], as well as psychological well-being and self-acceptance [23]. The disclosure of sexual identity and orientation, or ‘coming out’, has been identified as a key feature of the lives of LGBTQ+ individuals. When encountering new people, LGBTQ+ individuals need to make rational choices as to whether or not to disclose their sexual identity and/or sexual orientation, based on social roles and environment and gender, cultural and religious beliefs. One of the challenges within this is deciding whether or not to disclose one’s sexual identity and sexual orientation to health and social care professionals. Disclosure may, for example, increase the likelihood of LGBTQ+ individuals experiencing discrimination [24, 25], verbal attacks [26] or physical threats [27].

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The non-disclosure of one’s sexual identity or sexual orientation can at times lead to internalised sexual stigma or internalised homophobia. Internalised homophobia can be developed by individuals in a heterosexist environment that devalues and offends non-heterosexuals. It can be described as negative emotions and self-hate towards one’s own sexual identity, which indicates psychological distress and lower self-esteem [22]. Self-acceptance is one of the critical factors in an individual’s decision to disclose their sexual identity or not, along with rejection and reprimand [28]. The term sexual stigma, or internalised homophobia, is used to describe the shared belief system through which non-heterosexual sexualities, in particular homosexuality, are denigrated, discredited and invalidated. When society incorporates such a belief system into an ideology that reinforces stigma, the result is a phenomenon commonly labelled as heterosexism [27, 29]. For heterosexuals, sexual stigma tends to be significant only when sexual orientation becomes personally relevant; for sexual minorities, stigma is a lifelong experience [30]. When heterosexuals internalise sexual stigma about sexual minorities, the result is sexual prejudice. On the other hand, when homosexual people internalise the society’s negative perception of sexual minorities, the result is internalised homophobia or homonegativity [31–34]. The internalisation of negative attitudes, feelings and representations towards homosexuality that lesbian or gay men experience, even unconsciously, towards themselves is a significant correlate of mental health [35, 36] and may consistently interfere with the psychological and relational well-being of the person [30, 37–44]. Internalised homophobia can operate at both a conscious and unconscious level. Conscious internalised homophobia may be manifested as a belief of the self as being inferior or worthless on account of one’s sexual identity or orientation; people with conscious internalised homophobia may experience discomfort around other LGB individuals and may actively avoid social situations. In unconscious internalised homophobia, individuals may engage in subtle self-sabotaging symptoms [45]. Examples of these self-sabotaging behaviours may include tolerating mistreatment from others, abandoning their career or educational goals, having numerous or brief relationships and substance use leading to poor mental health outcomes.

4.3 A Theoretical Framework: The Minority Stress Model Meyer [41] proposed the minority stress model to explain how various factors may interact to explain the higher levels of psychological distress in the LGBTQ+ population. According to the model, the stigmatising social context in which LGBTQ+ people live increases the changes of psychological distress. This stigmatisation leads to frequent experiences of victimisation and prejudice, which become a chronic stressor, in addition to the general life stressors that everybody faces. This chronic stress from being part of a sexual minority has been referred to as minority stress [46], consisting of five factors:

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1. Experience of discrimination 2. The anticipation of rejection 3. Hiding and concealing sexual identity 4. Internalised homophobia 5. Coping strategies [41] In addition, societal and cultural values also contribute to this stigmatisation leading to internalised sexual stigma where LGBTQ+ people become vigilant, learn to expect rejection and attempt to conceal their sexual identity.

4.4 Impact of Discrimination on the Individual’s Psychological Health and Well-Being Discrimination and oppression throughout the life course have been shown to impact LGBTQ+ people’s health, mental health and well-being, and the evidence shows that they may experience a heightened risk of negative mental health outcomes compared to their heterosexual counterparts. A recent large-scale US survey indicated that transgender populations are similarly at risk of poorer health outcomes [47]. These disadvantages are being linked to cultural, political, institutional and interpersonal practices that privilege heterosexuality and binary gender norms [48]. Lesbian, gay and bisexual (LGB) young people report higher levels of depression [49] and substance abuse [50] which are both associated with suicidality [51]. A larger study of mental health issues and sexual orientation [52] noted that environmental responses were significant contributing factors. Risk factors for suicide in transgender individuals include: • • • • • •

Self-reported depression Having a history of substance use Being under 25 years old Being forced into sex Feeling victimised Discrimination based on gender identity [53] Risk factors shared with LGB students include:

• • • •

Parental rejection Substance use Peer victimisation Family violence [54]

The mental health and well-being of sexual minority members is an under-­ researched subject in the UK and other countries. Meta-analysis of studies on perceived discrimination and health [55] showed that discrimination has a negative influence on one’s mental and physical health; in particular, heterosexism has a

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positive correlation with depression and psychological distress [56]. The decision of some LGBTQ+ people not to come out and to pretend to be heterosexual is psychologically demanding and limits one’s gender performance [57]. The minority stress model by Meyer [41] describes the impact of stigmatisation on LGBTQ+ people’s experience of discrimination stress. According to this theory, psychological distress increases if individuals experience discrimination, hide or conceal their sexual identity and internalise negative social views on the LGBTQ+ community. Members of sexual minorities use different types of coping mechanisms to deal with the stress of discrimination, and one coping mechanism is positive reframing, where a person learns from a negative experience and turns it into something positive. Positive outcomes correlate with reduced depressive symptoms and amelioration of stresses. Self-reinforcement disrupts negative stereotypes and transforms institutionalised stigmatisation into increased compassion for oneself and others [41, 58]. However, some individuals avoid dealing with the psychological influence of experiences of rejection [58].

4.5 LGBTQ+ and the Family As we have seen in this chapter, LGBTQ+ individuals may not profess their sexual orientation or gender identity for fear of restrictions in different environments, including health settings. In addition, discrimination and stigmatisation or stereotyping of people on account of their sexual orientation or gender identity have resulted in countless people having to conceal or suppress their identity and to live in fear and invisibility, even within their family. Often, LGBTQ+ are subject to rejection by their family members, leading to isolation and, in some case, to homelessness. Furthermore, LGBTQ+ people often live alone and cannot count on family support. In a Portuguese study, the authors point to older LGBTQ+ individuals who are also more likely to be alone without family support and have greater difficulty in accessing the health system adapted to their needs [59]. Due to the aforementioned, it is common for LGBTQ+ people to choose their families and network, i.e. a ‘family of choice’ where they can freely express themselves and be their true, authentic self. In terms of health and social care services, there seems to be a lack of theoretical engagement with the dynamics and pressures of LGBTQ+ caring relationships and care practices which recognise ‘families of choice’ and different family structures, friendship networks and differences in caring in which reciprocity and giving care are not always kinship based. These relationships may not be recognised, particularly if not validated in legal terms such as through civil partnerships and same-sex marriage [60, 61]. It is, therefore, vital for health and social care professionals to understand these issues so that they can incorporate them in their practice to develop a more inclusive service and better quality of care for LGBTQ+ people.

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4.6 Conclusions LGB and T individuals continually make rational decisions as to whether or not they come out to family, friends or health and social care professionals. This decision-­ making process can be affected by many factors, including internalised homophobia, religion and culture. It is therefore vital for health and social care professionals, educators and policymakers to join hands and provide both educational material and policies to protect LGBTQ+ rights and to make services more inclusive. Challenging discriminative behaviour, such as homophobic remarks or indirect discrimination, is everyone’s business, not just in the interests of LGBTQ+ people. It is often a complex process to challenge one’s personal beliefs and stereotypes, but as health and social care professionals, these beliefs need to be set aside when the interest and the priority is the person we are caring for. Health and social workers must be unbiased and support the person for whom they are caring. Self-Assessment Exercise 4.1 Write down four definitions (or a simple discursive description) of the key LGBT+ terminology: • • • •

Questioning Non-binary Cisgender LGBT+

Reflective Practice Exercise 4.2 • Are there any words related to LGBTQ+ issues we have covered that you did not know or you knew with a different meaning or in a wrong way? • Have you ever used heteronormative assumptions about the life of your colleagues? If yes, describe them and analyse them in a critical way. Self-Assessment Exercise 4.2 • In your own words, could you explain what the difference is between gender identity and sexual orientation identity? • Can you explain why it is important to meet the cultural needs of LGBTQ+ individuals? • Are there any concepts we have covered so far which you are struggling with and need more discussion or information? Self-Assessment Exercise 4.3 Create a mind map, infographic, crib sheet or 5–10-min recorded talk summarising the key points you would include if you wanted to tell people about how to be a better ally and advocate for LGBTQ+ people. Use whichever format is most accessible to you. The aim is to condense the main points you have learned from this module which you would like to tell others about or remind yourself.

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42. Riggle EDB, Rostosky SS, Horne SG. Psychological distress, well-being, and legal recognition in same-sex couple relationships. J Fam Psychol. 2010;24:82–6. 43. Sue DW. Microaggressions in everyday life: race, gender, and sexual orientation. Hoboken, NJ: Wiley; 2010. 44. Williamson IR.  Internalized homophobia and health issues affecting lesbians and gay men. Health Educ Res. 2000;15:97–107. 45. Gonsiorek JC.  Gay male identities: concepts and issues. In: D’Augelli AR, Patterson CJ, editors. Lesbian, gay, and bisexual identities over the lifespan: psychological perspectives. New York: Oxford University Press; 1995. p. 24–47. 46. Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav. 1995;36:38–56. 47. Herman J. LGB within the T: sexual orientation in the National Transgender Discrimination Survey and Implications for Public Policy. In: Martinez-San MY, Tobias S, editors. Trans studies: the challenge to hetero/homo normativities. New Brunswick, NJ: Rutgers University Press; 2017. p. 17. 48. Kulick A, Wernick LJ, Woodford MR, Renn K. Heterosexism, depression, and campus engagement among LGBTQ college students: Intersectional differences and opportunities for healing. J Homosex. 2017;64:1125–41. 49. Westerfeld JS, Maples MR, Buford B, Taylor S. Gay, lesbian, and bisexual college students: the relationship between sexual orientation and depression, loneliness, and suicide. J Coll Stud Psychother. 2001;15:71–82. 50. Bontempo DE, D’Augelli AR.  Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths’ health risk behavior. J Adolesc Health. 2002;30:364–74. 51. Russell ST, Joyner K. Adolescent sexual orientation and suicide risk: evidence from a national study. Am J Public Health. 2001;91:1276–81. 52. Oswalt SB, Wyatt TJ. Sexual orientation and differences in mental health, stress, and academic performance in a national sample of U.S. college students. J Homosex. 2011;58:1255–80. 53. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex. 2006;51:53–69. 54. Grossman AH, D’Augelli AR. Transgender youth and life-threatening behaviors. Suicide Life Threat Behav. 2007;37:527–37. 55. Pascoe EA, Smart RL. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135:531. 56. King EB, Cortina JM. The social and economic imperative of lesbian, gay, bisexual, and transgendered supportive organizational policies. Ind Organ Psychol. 2010;3:69–78. 57. McDermott E. Surviving in dangerous places: lesbian identity performances in the workplace, social class and psychological health. Fem Psychol J. 2006;16:193–211. 58. Riggle ED, Whitman JS, Olson A, Rostosky SS, Strong S.  The positive aspects of being a lesbian or gay man. Prof Psychol Res Pract. 2008;39:210–7. 59. Pereira H, Serrano JP, de Vries B, Esgalhado G, Afonso RM, Monteiro S.  Aging perceptions in older gay and bisexual men in Portugal: a qualitative study. Int J Aging Hum Dev. 2018;87:5–32. https://doi.org/10.1177/0091415017720889. 60. Fish J. Heterosexism in health & social care. Basingstoke: Palgrave; 2006. 61. Fish J. Social work and lesbian, gay, bisexual and trans people: making a difference. Bristol: Policy Press; 2012.

To Learn More To learn about the topic and to consolidate your learning, we recommend that you do the self-­ assessment exercises. In addition to these exercises, we recommend that you look at the reference list and engage in additional reading.

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Useful Resources LGBT 101: https://www.youtube.com/watch?v=DE7bKmOXY3w&vl=en EU glossary: https://www.ilga-­europe.org/resources/glossary GIRES terminology UK: https://www.gires.org.uk/lgbtqi-­cataloguing-­terminology­survey-­msc-­information-­management-­preservation LGBT+ Flags: https://www.youtube.com/watch?v=MjEk6lyow4M The Genderbread Person: https://www.genderbread.org/

5

Mental Health Problems Associated with Alcohol Daren Lee

Learning Outcomes When you have studied this chapter, you should: • Be able to consider the role of language and psychiatric diagnosis in mental health and social care services that support people with alcohol use • Demonstrate a critical awareness of the relationship between psychological distress and alcohol use • Be able to identify different types of treatment models for people seeking support for their psychological distress and alcohol use Note To be cognisant with published research that is being cited, the following sections use terminology that directly corresponds with the authors’ work, the reproduction of which does not confirm endorsement by the current author.

5.1 Problems Associated with Co-occurring Diagnosable Psychological Distress and Alcohol Use Over the past 30 years in developed countries, there has been an increasing recognition of concurrent mental health and alcohol use, and this has been associated with increased burden of disease, as operationalised by the sum of early deaths and years lived with disability [1]. The National Institute for Health and Care Excellence (NICE) points to the:

D. Lee (*) Tunbridge Wells, East Sussex, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_5

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D. Lee …growing awareness that individuals with dual diagnosis experience some of the worst health, wellbeing and social outcomes, and are among the most vulnerable in society. [2, p. 8]

Research shows that mental health problems are experienced by up to 86% of alcohol users in community substance misuse treatment [3], leading some to argue that individuals that present with simultaneous mental health disorders and alcohol use disorders is the norm rather than the exception [4]. Individuals with a co-occurring psychiatric disorder and substance use problems (including alcohol use disorder) face a myriad of challenges and poor treatment outcomes [5, 6], suicide attempts [7], suicide deaths [8, 9], higher rates of emergency admissions, psychiatric hospitalisations and increased rates of risky behaviours, linked to higher unemployment and homelessness rates, or violent or criminal behaviour than individuals without such comorbidity [10]. In addition to being more complex to diagnose and treat, individuals are also at higher risk of additional multimorbidity, becoming socially marginalised, entangled with the legal system [11] and subject to stigma [12]. For individuals with co-occurring diagnosable psychological distress and alcohol use, the adverse effects can pervade and inhabit almost every aspect of their lives. Viewed from a humanistic lens, these map onto and correspond with the five basic needs identified in Maslow’s hierarchy of needs: 1. Physiological 2. Safety 3. Love and belonging 4. Self-esteem 5. Self-actualisation [13] It would be prudent to keep this in mind when we contemplate how to support relevant individuals in a manner that promotes autonomy, beneficence and a recognition of the whole person. The language we use, the planning we undertake, the collaboration we join and our treatments with individuals all have the potential to recognise the individual behind the disorders.

5.2 Language of Addiction and Mental Health Discourse can be a powerful thing. It is instrumental in how we communicate information about phenomena and how we relate to it on interpersonal and systemic levels. The language used to refer to people seeking support for their psychological distress and/or alcohol use is dominated by a biomedical model, in which diagnosis is championed. Diagnostic manuals are readily utilised to catalogue pathological presentations of experiences, which have their own discrete properties. By having an agreed set of clinical characteristics or psychiatric taxonomy, experiences can be classified according to agreed diagnostic micro categories (disorders) that are subsumed into broader macro categories (axes) [14, 15]. The existence of agreed

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clusters of symptoms lends itself to measurement, recommended treatments and the assessment of the efficacy of protocolised (or evidence-based) treatments. But this approach can present problems for individuals with multiple psychiatric (or mental health) diagnoses which include alcohol use disorder (AUD). Due to the absence of biological tests that are sensitive and specific enough to establish a diagnosis, psychiatry is vulnerable to the non-specificity and overlap of symptoms in different disorders [16]. Furthermore, most diagnoses in medicine are based on a combination of symptoms, their time course and a threshold judged to be clinically relevant [17], but it is commonplace for individuals to present with co-­ existing psychological symptoms that span across multiple disorders and with varying thresholds. What do we do when an individual’s experiences do not fit classification? The problem is not so much the proverbial ‘round peg and a square hole’, but more a peg with non-manufactured parts with a mixture of straight and round edges that do not fit any of the predetermined holes. But what if you are the peg? One would assume that the incompatibility must be perplexing to say the least. Phenomenologically speaking, an individual does not delineate their experiences to fit psychiatric classification, but rather they live according to their immediate psychosocial demands, adapting as best as they can using the psychological toolkit that they have managed to pick up along their way. For some people, their toolkit is less well stocked or consists of items that do not offer long-term solutions to their perceived demands and distress. Despite the reservations that I have alluded to, psychiatric classifications are ubiquitous within mental health services and healthcare settings. A review of the dilemmas that psychiatric classification poses is beyond the scope of the current chapter, but it would be prudent to highlight some of the most salient strengths and limitations, as positioned within the context of healthcare services. A common argument is that diagnosis of psychiatric disorders can be destigmatising; however, there is evidence to suggest that being in receipt of diagnostic label can increase stigma and discrimination [18, 19]. In Boyle and Johnstone’s [20] chapter on their perceived problems with diagnosis, they point out that some individuals welcome the interpretation of their distress as a ‘symptom of illness, as it has fewer negative connotations with personal weakness or failure, as their undesired patterns in experience can be attributed to their ‘illness’.’ Nevertheless, the label that absolves individuals from perceiving that they are ‘weak’ or ‘a failure’ is based on a biologically deterministic idea, that they have no control over. The assumption that an individual has a mental illness removes personal fault but could also be seen to remove personal agency and autonomy. This view is advocated by Johnstone [21] who argues that diagnostic labels can ‘create hopelessness and exclusion and limits possibilities for change’ [21, p. 26]. The counter-argument is that individuals still possess agency to seek help and work on recovery from their ‘illness’. Nevertheless, an individual’s free will to seek support in pursuit of their well-being can be obstructed by their diagnostic labels. The presence of service exclusion criteria (utilised by mental health and substance use services) and the potential lack of continuity of care is troubling; this author would argue that it could strip away any such personal agency.

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The co-existence of psychological distress and alcohol use when they are judged to reach a suitable threshold is commonly referred to as ‘dual diagnosis’ or ‘comorbidity’. A review of the definitions that are commonly used highlights that there is some variation in what constitutes each. In the UK, the National Institute for Health and Care Excellence (NICE) uses the following definition for the former: Dual diagnosis refers to people with a severe mental illness (including schizophrenia, schizotypal and delusional disorders, bipolar affective disorder and severe depressive episodes with or without psychotic episodes) combined with misuse of substances. [2, p. 8]

You will note that the definition makes specific reference to schizophrenia spectrum (and other psychotic disorders) and mood disorders but that anxiety disorders are a notable omission. In contrast the National Institute on Drug Abuse (NIDA) adopts a less discriminative definition of comorbidity, describing: …two or more disorders or illnesses occurring in the same person. They can occur at the same time or one after the other. Comorbidity also implies interactions between the illnesses that can worsen the course of both. [22, p. 1]

More recently a third term, ‘concurrent disorder’ [23, 24], has been used, which is equally inclusive. Concurrent disorder (also called dual diagnosis, co-occurring disorder, comorbidity) refers to a specific form of multimorbidity within the area of mental health, where at least one substance use disorder and at least one non-substance-bound mental disorder is simultaneously in need of treatment. [23, p. 1]

This leaves one to wonder are these terms synonyms or is there some nuanced difference between them? A range of organisations, including the World Health Organization, and research literature appear to use the terms synonymously to refer to people experiencing from the co-existence of substance use and other psychiatric (or mental health) disorders (for examples see [10, 23–28]). In keeping with this synonymisation, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) refers to ‘comorbidity/dual diagnosis’ as the: …temporal coexistence of two or more psychiatric disorders as defined by the International Classification of Diseases, one of which is problematic substance use. [10, p. 15]

However, in practice, it has been suggested that the term dual diagnosis is employed implicitly to refer to the co-existence of severe mental illness (psychosis, schizophrenia, bipolar affective illness) and substance misuse disorder [11]. Navigating through the lexicon for shared disorders somehow seems unsatisfactory. If the strength of psychiatric taxonomy is having a shared language to diagnose, research and treat individuals, it could be argued that it falls someway short for people with multiple disorders. One of the many challenges elucidating dual diagnosis (or comorbidity or co-occurring disorders) is the lack of a shared language to describe the heterogenous population that it refers to [11, 29] (Table 5.1).

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Table 5.1  A summary of terms used to refer to co-existing psychiatric disorders and AUD by country Popular terms Concurrent disorder [30] Co-occurring disorders [24] Dual diagnosis [31] Comorbidity [31] Co-existing mental health and substance use disorders [31] Coinciding mental illness and substance abuse [31] Co-existing problems [31] Dual diagnosis [23] Dual diagnosis [23, 31, 32] Co-occurring mental health and alcohol/drug use conditions [33] Comorbidity [33] Dual diagnosis [34]

Country Canada USA Australia

New Zealand Spain UK

Germany India

5.3 The Language of Alcohol Use The language used to describe someone’s alcohol use has arguably become more nuanced over time with various categories of alcohol use being recognised [2, 25, 35–37]. Nonetheless, there is often a dissonance between the language adopted by mental health and alcohol services when provision is offered separately. Furthermore, their respective choice of language for alcohol use implies varying degrees of pathologisation or judgement. This is significant as it could intersect with the process of pathologisation associated with individual’s co-occurring psychological distress. It is easy to imagine how counting up someone’s ‘disorders’ could lead to feelings of disempowerment, rather than promote autonomy and beneficence. Furthermore, this could be compounded in an organisational system which offers diagnoses that paradoxically render individuals ineligible for treatments [11, 38]. The terms ‘addict’ and ‘alcoholic’ are not recommended for use by professionals, but some individuals seeking support for their alcohol use choose to use the term ‘addict’ or ‘alcoholic’, and this remains widely accepted in the work of Alcoholics Anonymous [39] and other mutual aid providers. As previously highlighted the assignment of a label can imply that an individual has reduced personal agency. Additionally, it can act as a barrier to change for some people, and it has been suggesting trying to work out if you are ‘alcoholic’ or not encourages an absolutist view of alcohol use [39]. However, some individuals in group settings find it useful to galvanise a shared sense of identity with other mutual aid group members [40]. The discourses that separate mental health and alcohol services employed can be incompatible, impeding coordinated care for individuals that seek support for co-­ existing psychological distress and alcohol use. It is common for mental health services to adopt language that could be perceived as stigmatising and judgemental

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when referring to alcohol use. This is notable when consulting the exclusion criteria adopted by primary mental healthcare services and accompanying National Health Service (NHS) guidance for Improving Access to Psychological Therapies (IAPT) services in the UK [41], which employs the term ‘alcohol misuse’ widely [23, 41]. This author has argued that the term ‘alcohol misuse’ is misused [42], as it implies that individuals have engaged in action that is in some way wrong or that individuals have not understood how to carry out the action of consuming alcohol. This could be perceived as a hostile and uncompassionate interpretation of an individual’s alcohol use. To an individual experiencing sustained psychological distress, alcohol use might not subjectively be seen as ‘misuse’ but held as one of their few viable coping strategies. Given the documented sense of shame and internalised stigma that can accompany diagnosable psychological distress [43, 44], and alcohol use [45], it could be argued in the strongest sense that the term alcohol misuse should not be adopted, as it could activate and perpetuate a sense of shame that individuals are prone to. Fortunately, alcohol services would appear to employ a greater sensitivity to their choice of language and the messages that this perpetuates. Trauma-informed care (TIC) is widely adopted in such services and encourages the use of language that avoids deficit-based terms (such as misuse) in favour of that which reframes alcohol use as a strength-based adaptation [46]. It should be emphasised that this is not just another example of terminology rising and falling in popularity, nor can we advocate a mere change in vocabulary. As Johnson and Boyle [47] have highlighted, simply refining diagnostic terms fails to address how we view individuals’ experiences. They state that: …changing language is not simply about using alternative vocabulary, but opens up new ways of thinking, experiencing and acting. Until this happens, we will simply continue to reproduce existing practices in slightly different, but equally unsatisfactory forms. [47, p. 313]

The vocabulary in question, ‘alcohol misuse’, offers little in terms of facilitating person-centred care; rather, it promotes stigmatisation. It does not uphold and promote human dignity and well-being as recommended by the British Association of Social Workers (BASW) [48], and it could be argued to be ethically indefensible. In contrast, framing alcohol use as a strength-based adaptation invites a curiosity in the person behind their diagnosis and the context of their distress, a much needed ‘new way of thinking’ about alcohol use.

5.4 Alcohol and Mental Health in the UK: Context and Current Challenges In 2002 in the UK, the Department of Health [49] acknowledged the enormity of the challenge that services face in supporting individuals with co-occurring mental health problems and ‘alcohol misuse’, stating that:

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Supporting someone with a mental health illness and substance misuse problems—alcohol and/or drugs—is one of the biggest challenges facing frontline mental health services … with service users being at higher risk of relapse, readmission to hospital and suicide. [49, p. 5]

It advocated that mental health services should offer provision for both mental health and substance misuse problems, based on the assumption that co-occurrence is usual rather than exceptional [4]. In 2021, how far have we come in working toward a solution to this challenge and a panacea for the elevated relapse, readmission and suicide noted? In 2007, the Care Services Improvement Partnership [50] published a report which highlighted that 40% of Local Implementation Teams (LITs) did not have a dual diagnosis strategy agreed with Drug and Alcohol Action teams and mental health commissioners. Furthermore, the report indicated that less than 50% of LITs had assessed for service training needs. In 2012, the Centre for Mental Health, in collaboration with DrugScope and the UK Drug Policy Commission [51], identified that support for people with a dual diagnosis was largely inadequate. The summary revealed that progress was observable in relation to more severe mental health conditions. However, provision for less severe conditions appeared to be prone to fragmentation of services and commissioning between mental health and ‘substance misuse services’. Nonetheless, the report expressed optimism about an increasing focus on such individuals, citing the publication of a ‘positive practice guide for working with people who use drugs and alcohol’ [52] for UK primary mental healthcare services. In 2016, NICE commissioned a review into the epidemiology of co-existing severe mental illness and substance misuse and the configuration of health and social care services. The review indicated that there was a distinct lack of uniformity in dual diagnosis provision, concluding that there were ‘great inconsistencies in the configuration of dual diagnosis services within NHS trusts across the UK’ [2, p. 25], which related to funding, service structure, staffing, services offered and care coordination. It is of note that the systematic review focused on the epidemiology and provision exclusively for individuals experiencing severe mental illness. The review identified five broad categories of care underlining the lack of uniform provision for dual diagnosis in the UK; the lack of parity in definitions of ‘dual diagnosis’ is likely to maintain this opacity. In 2017, Public Health England (PHE) published a report which ominously highlighted the lack of progress that had been achieved following the preceding guidelines published between 2002 and 2009 and concluded that they: ‘… had not been widely implemented’ [32, p. 10]. [It unequivocally stated that] ‘services have a joint responsibility to work collaboratively to meet the needs of people with co-­ occurring conditions.’ [32, p. 9]

… and endorsed the internationally recommended ‘no wrong door’ policy for alcohol/drug and mental health services [53, p. 18].

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Despite these recommendations, the Centre for Mental Health [54] 2018 report highlighted that people with co-occurring alcohol problems and poor mental health were still frequently being turned away from support as a result of complexity, attributing this to discriminatory entry thresholds for services and/or a lack of confidence among practitioners [55]. This is disappointing as guidance for primary mental health services in the UK [52] has highlighted that: … only a small proportion of drug and alcohol users will require specialist treatment services’ [52, p. 2] and that people with a history of alcohol problems do not present special challenges for services but ‘there are often substantial clinical gains to be made in working with them. [52, p. 1]

NICE guidelines state that there is no evidence that substance misuse renders conventional psychological therapies ineffective [56]. More recently, Buckman et al. [57] demonstrated that primary mental healthcare services can successfully treat depression and anxiety disorders in people with comorbid alcohol problems, with higher-risk drinkers having comparable treatment outcomes to non-drinkers. The Centre for Mental Health Commission for Equality [55] published a briefing in July 2020, calling for the UK government to create: … a new alcohol strategy which would include clear expectations about the provision of integrated help and support.

Over the last 20 years in the UK, there have been calls for greater inclusivity and more integrated care but that there is still much work to do.

5.5 Falling Through the Cracks The context presented herein is troubling. As previously outlined, provision offered by alcohol and mental health services ‘can be fragmented and people can fall down the cracks’ [49, p. 5]. How many individuals might be falling through the cracks and missing valuable support and recovery opportunities? By its nature, the problem is not one that lends itself to being quantified. Many services will not record, audit and publish data on individuals that they opt not to treat, as this does not confer an advantage to performance management records presented to stakeholders and commissioners. This data is a notable omission from the otherwise rigorous Improving Access to Psychological Therapies (IAPT) Executive Summaries that are prepared by primary mental healthcare services in the UK [42]. In the absence of published data on the rates of individuals deemed ineligible for services, a review of epidemiological data of co-existing AUD and mental health problems can offer some insight into the sense of the scale of the problem. However, we should be cautious not to overlook the numerous individuals omitted from data with mental health problems who have not been the recipient of a formal AUD diagnosis and those individuals considered ineligible for mental health services due to their alcohol use exceeding prescribed low-risk levels [41].

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5.6 Epidemiological Evidence Reflective Practice Exercise 5.1 To accord with the discourse of healthcare services and positivistic epidemiological evidence, a summary of research highlighting co-existing diagnosable psychological distress and alcohol use follows. However, it should be pre-empted with an invitation to the reader to keep in mind the functional use and relationship that individuals have with alcohol use. When surrounded by a language of disorders, it is easy to be seduced by diagnostic labels and become desensitised and depersonalised with individuals. One way of sharing the space with diagnoses is to consider how these labels fit into each individual’s life story and how their alcohol use relates to this, in other words, to be curious and to try to think in terms of an evolving formulation rather than diagnosis. Epidemiological research has revealed that individuals having a diagnosis of AUD greatly increase the likelihood of having a further diagnosis from a broad range of psychiatric (or mental health) disorders, and vice versa. As previously mentioned, Weaver and colleagues found that mental health problems are experienced by up to 86% of alcohol users in community substance misuse treatment [3]. AUD is associated with psychiatric comorbidities, including personality disorders, generalised anxiety disorder (GAD), panic disorder, post-traumatic stress disorder (PTSD), schizophrenia [58] and mood disorders, including bipolar disorder [59, 60]. Epidemiological research [60] has demonstrated that the lifetime prevalence rate for any mood disorder and AUD is 21.8%. Major depressive disorders (MDD) and AUD have been found to frequently co-occur [61–64], with elevated rates in women compared to men with lifetime prevalence of 48% and 24%, respectively [61]. Rates of co-occurrence in clinical samples between MDD and alcohol dependence were greater still, ranging from 50% to 70%, and that co-occurrence significantly increased suicidality [63]. Correspondingly, anxiety disorders are particularly common in people experiencing AUD [61, 64–66]. Lifetime prevalence rates for co-occurring alcohol dependence and anxiety disorders in the USA were greater than those seen for depression with rates of 60.7% in women and 35.8% for men [61], and elevated rates of anxiety disorders have also been observed in Australian individuals experiencing alcohol dependence [65], which is associated with poorer prognosis and increased rates of relapse [61, 66]. As per Minkoff’s [4] forewarning that their co-occurrence is the norm rather than the exception, the brief review of epidemiological evidence above confirms that diagnosable psychological distress and alcohol use frequently co-exist.

5.7 Aetiology: The Chicken or the Egg Paradox Different aetiological models have been proposed, which offer plausible explanations of how co-existing diagnoses emerge and interact, including the tension reduction hypothesis (TRH) [67, 68] and the self-medication hypothesis (SMH) [69–71].

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The tension reduction hypothesis has its origins in drive-reduction theory and suggests that alcohol use is negatively reinforced due to its tension/anxiety-reducing quality. Khantzian’s SMH [69] suggests that individuals’ addictive behaviour represents their attempts to manage perceived intolerable affect. This view, though widely acknowledged now, was a departure from pre-existing ideas that addictive behaviour was the result of the peer pressure, self-destruction or the pursuit of euphoria [69]. Furthermore, Khantzian suggested that unique affective states were instrumental in individuals’ choice of drug use, claiming that: The specific psychotropic effects of these drugs interact with psychiatric disturbances and painful affect states to make them compelling in susceptible individuals. [69, p. 1259]

This idea was developed further and incorporated into SMH through its reference to ‘psychopharmacologic specificity’ [70, 71]. For instance, Khantzian [71] suggests that despite alcohol not having an anti-depressant property per se, it is frequently used to self-medicate depressive symptoms, as it assuages defences which predispose individuals to depression. Both the TRH and the SMH see psychological distress as being antecedent and causal in elevating alcohol consumption. Nonetheless, the relationship between diagnosable psychological distress and alcohol use is not unequivocally unidirectional. The complex interplay between psychological distress and alcohol use has not gone unnoticed, with a multiplicity of organisations and empirical literature recognising the apparent causality dilemma. As the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) [72] put it: Determining the aetiology of co-morbidity results in a chicken and egg discussion: what came first? (p. 96)

In the USA, the National Institute on Drug Addiction’s [22] guidance on comorbidity highlights some of the aetiological variations of co-existing mental illness and alcohol use, indicating that mental illnesses can contribute to alcohol use or vice versa. Additionally, the guidance suggests that AUD and mental illness could share common risk factors (such as genetics or epigenetics), a view supported by Milani and Perrino [73] in their comprehensive chapter on alcohol and mental health. Comparable advice has been previously presented in the UK, by the Department of Health. In their Dual Diagnosis Good Practice Guide from 2002 [49], the complex nature of the relationship between these two conditions is accepted, and different temporally sequenced hypotheses are offered including: A primary psychiatric illness precipitating or leading to substance misuse, substance misuse worsening or altering the course of a psychiatric illness, intoxication and/or substance dependence leading to psychological symptoms or substance misuse and/or withdrawal leading to psychiatric symptoms or illnesses. [47, p. 9]

Additionally, the EMCDDA’s [72] section on the aetiology of dual diagnosis cites Krausz [74] who suggests that it has a developmental course that follows one of the four possibilities, which includes:

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A primary diagnosis of a mental illness with a subsequent (dual) diagnosis of substance misuse that adversely affects mental health, a primary diagnosis of drug dependence with psychiatric complications leading to mental illness, concurrent diagnoses of substance misuse and psychiatric disorders or a dual diagnosis of substance misuse and mood disorder, both resulting from an underlying traumatic experience, for example post-traumatic stress disorder. [72, p. 96]

So, there are a range of developmental (and causal) pathways that diagnosable psychological distress and alcohol use can follow, with both being posited as the ‘chicken’ and the ‘egg’. This causality dilemma can be further evidenced with regard to specific presentations. The association between depressive symptoms and AUD has been the subject of considerable interest, with both being posited as the primary causal variable. It has been suggested that the pharmacologic effects of alcohol may produce symptoms of depression [75, 76] and can contribute to depression indirectly through stressful life circumstances, such as interpersonal disruption [77], or that AUD develops through individuals’ attempts to manage negative affect [75, 77], which has been supported by prospective research [78]. The aetiological relationship between post-traumatic stress disorder (PTSD) (or non-diagnosable experiences of trauma) and alcohol use is equally controversial. Research has highlighted those traumatic events including child sexual abuse are a risk factor for alcohol-related problems [79] and that prior exposure to trauma was associated with higher alcohol dependence scores [80]. Such evidence points to traumatic events preceding changes in alcohol use. However, a lack of a conclusive aetiological directionality has been documented by Suh and Ressler [81], who reported that the diagnosis of PTSD confers a major risk factor for the development of AUD, but that AUD increases PTSD symptoms, signalling a bidirectional relationship. The bidirectional relationship between psychological distress and alcohol use has also been documented in research which takes anxiety disorders as its point of focus. Research has demonstrated that anxiety disorders preceded AUD in as many as 75% of individuals [82] and that individuals with anxiety disorders who endorsed alcohol use as a coping strategy were at higher risk for developing alcohol dependence [83]. It has been proposed that observing anxiety symptoms in abstinent individuals can offer an insight into aetiology to identify the primary disorder [84]. However, the notion of a ‘primary disorder’ lacks sensitivity to the nuances of the interaction between alcohol use and experiences of anxiety. Furthermore, alternative research has concluded that AUD and anxiety disorders appear to be subject to mutual maintenance [27]. A brief review of the documented relationship between diagnosable psychological distress and alcohol use is indicative of a developing consensus that there is a complex and reciprocal interaction between the two, with each mutually influencing the other [22, 27, 41, 72, 73]. This has significant implications for how we attempt to conceptualise and treat such individuals, which operate on service-wide and inter-personal levels.

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5.8 Serial, Parallel and Integrated Treatments Understanding the co-existence of psychological distress and alcohol use is a pressing issue; if dual diagnosis is an ‘expectation, not an exception’ [4, p. 1], it would be remiss of authorities and services to overlook the scale of issues and dilemmas it presents. The question is which service model is in the best interest of the individual seeking help? Broadly speaking, there are three models that could be utilised, which can be referred to as serial, parallel and integrated services [85]. Each has its own implications for how services interact with individuals seeking support and theoretically how distressing experiences are understood. The implications of utilising disorder-­centred care are presented for each of the three models.

5.8.1 The Serial Treatment Model: One Disorder at a Time Please! The serial treatment model refers to a: …treatment model in which one treatment follows the other but are not offered simultaneously. [26, p. 205]

Despite the ‘no wrong door policy’ being widely advocated in international policy [53, 86, 87], most healthcare systems have yet to adapt and adhere to this recommendation [23]. Frequently individuals are offered treatments which aim to attend to the ‘primary need first’ [41, 83, 88]. However, as illustrated the notional ‘primary disorder’ is the subject of some debate, given the inherently ambiguous aetiological relationship between AUD and psychiatric disorders [89]. Consequently, the serial treatment model poses a significant dilemma. If one treatment follows the other, which one should services start with? Comorbidity can contribute to individuals being passed between specialist mental health services and specialist alcohol services [56, 90], indicating a reluctance for either service to offer the primary treatment. Furthermore, exclusion criteria adopted by mental health services would suggest that there is a systemic expectation that individuals should be denied access to mental health services until their alcohol problems are resolved [32, 41, 53, 88, 90–92]. This approach opposes the widely cited recommendations posited by Minkoff’s [4] guidelines for co-occurring psychiatric and substance disorders some 20 years ago, which called for: … arbitrary barriers to mental health assessment based on alcohol level or length of sobriety should be eliminated. (p. 4)

The proverbial ‘chicken or the egg’ paradox seems out of place and obstructs whole-­ person care and beneficence. The question is not which disorder came first but how do disorders interact with and compound each other (see [22, 27, 41])? As the EMCDDA [10] put it:

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Comorbid disorders are reciprocally interactive and cyclical, and poor prognoses for both psychiatric disorders and substance use disorders are likely unless treatment tackles each. (p. 9)

These arguments would suggest that it is not prudent to become embroiled with the chicken or egg paradox, in favour of a chicken and egg solution, by embracing an acceptance of their bidirectionality. By individuals attracting a diagnostic label, this can subsequently cause them to fall outside the remit of either service [11]. The expectation that individuals should resolve their alcohol ‘problem’ or ‘misuse’, in addition to seeming hostile and rejecting, is also inadequate on the level of psychological formulation. For individuals that consume alcohol as a form of a safety behaviour (one which relieves distress in the short-term but maintains it in the longterm), or coping strategy for psychological distress, resolving their alcohol problem is likely to expose individuals to potentially overwhelming levels of distress which could negatively reinforce alcohol use (akin to cognitive-behavioural principles) or result in enactment of aggressive drives in response to their perceived rejection from the service (if one were adopting a psychodynamic formulation). In the absence of specialist support on psychological conceptualisation and alternative coping strategies, exclusion from mental health services could be instrumental in the onset of further self-medicating alcohol use and relapse. Furthermore, the presence of diagnosable psychological distress could inhibit engagement with alcohol use recovery work, due to its reliance on peer-based recovery support (or mutual aid) groups [88, 92], due to the presence of acutely distressing experiences (for instance, anxiety or a sense of hopelessness). When conceptualising individuals’ psychological distress and alcohol use, it is difficult to understand one, without understanding the other, which calls for greater phenomenological reconciliation between the two. As Hayes and Levin [92, p. 4] argue: Arcane details of diagnosis or complicated sequences of intervention simply are not central.

To them, the key processes that underlie multiple problems should be the subject of clinical focus rather than diagnoses and the temporal order of their treatments. Treating one diagnosis at a time has some inherent problems and poses the risk of creating obstacles to service provision.

5.8.2 The Parallel Treatment Model: Two Disorders—Two Doors The parallel treatment model refers to a treatment model: … in which the treatments are given concurrently by the participating clinical teams. [26, p. 205]

In principle, concurrent treatments offer some solutions to the uncertainty and exclusion that some individuals experience through serial treatment, with two clinical teams being available to offer support. Nonetheless, it can be seen as another

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example of disorder-centred care, characterised by discordant organisational structures and philosophies. This concern has been articulated by the National Institute for Health and Care Excellence (NICE): In the UK, service configurations, treatment philosophies and funding streams mitigate against integrated provision. Mental health and substance misuse services are separate, often provided by different organisations, and even when both are provided by the same NHS trust they usually have different organisational and managerial structures, and staff within each service often lack the knowledge and skills for working with people from the ‘other’ group. [2, p. 28]

The difference in philosophies between mental health and alcohol services [2, 11] is no more transparent than in regard to the recovery focus that they adopt. Mental health services frequently utilise a remission-focused approach, which pursues ‘recovery’ as operationalised by psychometric scales. This is in direct contrast to alcohol services, which conceptualise recovery referring to an ongoing process of growth and personal change [93]. This involves the individual building the unconditional perception of a meaningful life [94]. The difference reflects the two service’s distinct organisational structure [2, 95], their respective developmental histories [11] and funding streams [2], with ‘recovery’ contingent funding driving decision-making in diverging ways. In addition, Todd et al. argue that services designed to support people with their mental health problems and alcohol use have evolved separately and utilise different language [11], which can be incompatible. Many alcohol services endorse language which refers to non-deficit-based language to accord with a TIC approach [45], for instance, framing alcohol use as a strength-based adaptation, contrary to mental health services which frequently use more biomedical language such as AUD or refer to alcohol misuse [52, 56]. The dissonance in language use is likely to lead to a disjointed approach to care, through the absence of a shared language, with the respective implications being that consuming alcohol represents something that is being ‘misused’ but simultaneously is ‘adaptive’ depending on particular appointment the individual happens to be attending. A separate challenge can be found in adopting two separate diagnoses. It has been demonstrated that increased levels of stigmatisation are associated with mental health problems [42, 43, 96] and substance abuse [97]. Consequently, the assignment of two co-occurring disorders could be seen to contribute to a form of dual stigma in relation to individuals’ identity, which can be instrumental in the development of a sense of worthlessness/disempowerment [12] and poorer outcomes than those with SUD alone [98]. The obstacles and complications that characterise the parallel model of treatment indicate that it offers little promise for a more holistic alternative to serial model treatments, which according to Edeh [26] do not offer individuals with dual diagnosis a: … realistic prospect of treatment effectiveness. (p. 213)

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5.8.3 The Integrated Treatment Model: Two Disorders— One Door The integrated treatment model: … offers a comprehensive range of interventions which include pharmacological, psych-­ educational, behavioural, case management and self-help approaches. [26, p. 205]

Carrà et al. [99] have argued in favour of the integrated treatment model as it offers a more holistic alternative to divided mental health and substance misuse services. This is achieved through one team offering mental health and addiction services in the same setting [23, 100]. Encouragingly, Hakobyan et al.’s [23] systematic review of 24 clinical management guidelines for adult concurrent disorders between 2000 and 2020 found that all guidelines promoted the benefits of integrated services. Emerging evidence suggests that integrated care has been found to be consistently superior compared to its non-integrated counterparts [87, 98, 101] and is associated with a greater reduction in the incidence of psychiatric hospitalisation and arrest [102]. A recent systematic review [90] concluded that integrated models of care were associated with greater reductions in substance use disorders and improvement of mental health in individuals with concurrent disorders and were demonstrably more cost-effective than alternative treatment models [90, 103–105]. Additionally, research has demonstrated that despite the treatment cost for comorbidities being higher than mental health treatments alone, the cost of the integrated model of care is less than the net cost of separate care for each comorbid disorder [106, 107]. An accumulating body of evidence supports the clinical efficacy and overall cost-effectiveness of the integrated treatment model. In 2013, Kelly and Daley [100] highlighted this, stating that: It is becoming increasingly clear that integrating the best elements of different evidence-­ based psychotherapies is necessary to produce more effective outcomes. [98, p. 13]

Despite the growing consensus that serial and parallel services are obsolete and that integrated treatment approaches are a superior alternative, many healthcare systems have yet to transition to this model [23]. As Hakobyan puts it: The traditional approach in healthcare systems has been, and still is to address each issue separately, with limited or no standards to simultaneously address both components of concurrent disorder within the same care team. [23, p. 2]

The proposed lack of progress in transitioning from non-integrated to fully integrated care represents resistance to the recommended paradigm shift in service provision. This is likely to be attributable to the complexities of any such transition, which requires an overhaul of the demarcation of service characteristics, including: • Service structures • Settings

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Funding structures Discourse Training requirements Philosophy Culture Language use

5.8.3.1 Disorder-Centred Care By focusing on an individual’s diagnostic label first, individuals can find themselves encountering obstacles to non-integrated service provision. This tendency can lead to an indefinite stand-off, with each separate service waiting for the individual to demonstrate that they are ‘ready’ for treatment, ultimately, failing to receive treatment for either disorder [87]. When disorders are centre stage, the individual can easily be overlooked. 5.8.3.2 A Different Focus: No Disorders The endemic disconnection between mental health services and alcohol services poses the question, are psychiatric diagnoses the foundations of disjointed care? One wonders whether individuals with comorbid psychiatric disorders and AUD (or dual diagnosis) are in the midst of a figurative ‘Tower of Babel’, with respective services unable to speak the same language, thereby preventing them from accessing treatment. It has been mooted by Karapareddy that the issues surrounding what does and does not count as comorbidity have obstructed research and the development of what constitutes a good model for delivery of provision [90]. One is left to contemplate, if individuals with psychiatric (or mental health) disorders and AUD are ineligible for alcohol services, and individuals with AUD and psychiatric (or mental health) disorders are ineligible for mental health services, where do we go from here? Hayes and Levin [108] express reservations about the use of psychiatric taxonomy when being confronted with comorbid addiction and psychiatric disorders: The long list of comorbidities documented earlier has limited any tendency of addiction treatment providers to push human beings into narrow diagnostic categories, as if a human life could be captured by a syndromal label. The problems clients face are too numerous and too broad for that to appear to be useful. [4, 108]

When diagnosis-centred care stops being useful, is it ethical to maintain a focus on them? It has been proposed that adopting transdiagnostic interventions might be the way forward [70], as they do not rely on ‘syndromal classification’ of multiple disorders, favouring a focus on core processes that are ‘functionally unitary’ [109, p. 43]. In other words, functionally what do they have in common? A coordinated approach to supporting people with psychological distress and alcohol use has not been forthcoming. In the interim, could decreasing the focus on disorders in favour of transdiagnostic therapies offer a solution? Through this author’s professional experiences, one such intervention, found to be particularly supportive for individuals, is acceptance and commitment therapy (ACT).

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5.9 Acceptance and Commitment Therapy Professionals who support individuals with psychological distress and alcohol use confront multidimensional ethical dilemmas. Often, they have to manage the tensions between seemingly contradictory ethical principles, such as respecting individuals’ autonomy, while encouraging beneficence through increased proactivity. With ACT’s transdiagnostic tradition, it offers the possibility of circumventing disorder-­specific exclusion criteria, permitting early intervention and encouraging proactivity and valued living. Acceptance and commitment therapy (ACT) is a transdiagnostic intervention [110] which can be classed as a third wave cognitive behavioural therapy (CBT) or contextual CBT [109]. Hayes [111] defines contextual CBT as a type of therapy that is: … sensitive to the context and functions of psychological phenomena, not just their form. [111, p. 27]

ACT follows the psychological flexibility model, which describes six functional processes which underpin human suffering and adaptability: 1. Acceptance 2. Diffusion 3. Present-moment awareness 4. Self-processes 5. Values-based living 6. Committed action [109, p. 27] There are a number of reasons why ACT is a good fit for individuals who are experiencing co-existing psychological distress and alcohol use. Contextual cognitive behavioural therapy (CBT) such as ACT aligns itself well with areas that are particularly difficult to treat [92], as they are not subject to the weight of dilemmatic judgements about nosology or the temporal order of symptom onset, thereby bypassing the ‘chicken or the egg’ dilemma. Therefore, it does not matter whether an individual’s mental health disorder or AUD originated first; in either case, the approach aims to support the individual to accept their experiences and defuse (separate) from each moment of distress. This allows individuals freedom to develop consonance with their values and behave according to these. ACT offers individuals support that is not obstructed by the heterogenous presentations [11, 29] or complexity that can accompany co-occurring mental health problems and alcohol use, as it focuses on their contextual function. As Hayes and Levin put it, ACT is applicable to a broad range of: …topographically distinct but functionally similar problems. [92, p. 30]

Another strength of ACT as a treatment for psychological distress and alcohol use is its compatibility with widely utilised mutual aid groups for alcohol use. DuFrene

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and Wilson [112] argue that Alcoholic Anonymous (AA) and ACT have sufficient overlap and interaction to complement one another. Furthermore, Stott and Priest [93] point out that alcohol services conceptualise recovery as an ongoing process of growth and personal change which is synchronous with ACT’s emphasis on individuals achieving a sense of valued living [109]. Furthermore, many individuals that have sought support for alcohol use experience feelings of shame and internalise pejorative attitudes [12] which can result in self-stigma [45, 113]. ACT promotes a sense of self-acceptance through the exploration of individuals’ alcohol use with reference to their unique contextual demands. As such, alcohol use is framed as an understandable example of experiential avoidance [106], as opposed to shame-­ inducing ‘alcohol misuse’. It has been documented that higher experiential avoidance is associated with a range of mental health problems and addiction [113]. Hayes et al. [114] define experiential avoidance as occurring: … when a person is unwilling to remain in contact with particular private experiences and takes steps to alter the form, frequency, or situational sensitivity of these experiences. (pp. 74, 75)

Experiential avoidance can be seen as analogous to self-medicating alcohol use but compounds suffering in the long-term. This is aptly highlighted by Harris [115] who suggests that ‘addiction’ begins as a series of attempts to avoid unwanted thoughts and feelings, which help temporarily but increase suffering in the long-term. Unlike cognitive behavioural therapy, ACT does not take symptom-reduction as its primary focus. ACT emphasises contextual and experiential change rather than ‘an eliminative approach’ [116, p. 5]. Put simply, ACT aims to support individuals to live alongside their distress, rather than to eliminate it. Individuals can become preoccupied by attempts to avoid distress, which paradoxically primes them to attend to their distressing experiences, resulting in rebound effects during attempts at thought suppression [117]. By trying to not think about our psychological distress, ironically, it is brought into focus. As an alternative to becoming invested in grappling with distress, ACT allows individuals to develop the space to reunite with their values and live according to them. ACT practitioners prefer to conceptualise human pain as a normal emotional reaction [118, p.  27], rather than reflecting pathology. By accepting that difficult emotions and thoughts are transient experiences that can be separated from, individuals are afforded the opportunity to rediscover their values and given the space to be able to invest in these. By using a contextual lens, as opposed to disorder-specific conceptualisations of individuals, ACT attempts to understand psychological distress and alcohol use holistically. This approach is congruent with the British Association of Social Workers’ Code of Ethics for Social Work [48], as it promotes individuals’ engagement with services, fosters a view of the whole person (p. 7), and advocates the view that individuals’ alcohol use and psychological distress are collective rather than separate entities.

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5.10 Role of Family Seeing a loved one experience cycles of psychological distress and alcohol use can present a combination of conflicting reactions in family members, and the importance of their opportunities to process what they are going through should not be understated. Seeing a loved one use alcohol in a way that involves taking risks or self-harm, naturally, evokes strong emotions. Unfortunately, there are occasions in which this pattern of heightened emotions can be perceived as threatening by those individuals that are using alcohol as an attempt to cope with psychological distress in the first instance, resulting in an escalation of tension and further self-medicating alcohol use. This presents an ethical dilemma, as a failure to confront a loved one about their alcohol use could be seen to collude with its use, while challenging the behaviour could result in escalation and further self-medicating alcohol use. Furthermore, individuals’ continued alcohol use could, at times, represent an outward demonstration of their autonomy to show their relatives that they are in charge [119, p.  30]. The principle of ACT can be helpful to navigate this challenge. Observing alcohol use in a loved one is likely to result in an acute emotional experience, whether it be worry, disappointment or exasperation. Remembering that our contact with these heightened emotions is transitory and practising exercises to defuse from emotions can offer relatives the space and time to reflect on the functional use of their loved one’s alcohol use. Once the initial emotional response has dissipated, relatives are better placed to have a dialogue with their loved one, guided by curiosity about the functional and contextual use of their alcohol consumption (i.e. what using alcohol use meant to them in that moment). The Substance Abuse and Mental Health Services Administration guidance on starting conversations [120] offers useful advice suggesting that relatives should try to identify an appropriate time and place, express concerns and be direct, acknowledge feelings and listen, offer to help and try to be patient. Having these conversations can seem daunting when there is a history of escalation, but being guided by curiosity and giving oneself space for emotional temperatures to lower can allow a new pattern of communication to emerge (see Chap. 8).

5.11 Ethical Considerations Forester-Miller and Davis [121] identify several foundational principles of ethical practice relevant to helping professions: • • • • •

Autonomy Justice Beneficence Non-maleficence Fidelity

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ACT offers a therapeutic approach which complements such principles. • Autonomy—It is actively encouraged through an invitation to individuals to identify and act on their own values. • Justice—Professionals have a duty to maintain equality, which raises the possibility of treating individuals differently, provided there is rationale and necessity to do so [121]. The implications for such adjustments to therapeutic protocols and policies should be borne in mind when working with individuals with co-­ existing psychological distress and alcohol use. • Beneficence—With ACT’s transdiagnostic tradition, it offers the possibility of circumventing disorder-specific exclusion criteria. Consequently, ACT can foster beneficence by permitting early intervention and encouraging proactivity in the pursuit of valued living. • Non-maleficence—It is the concept of not causing harm to others. Weighing potential harm against potential benefits is important in a professional’s efforts toward ensuring ‘no harm’. Professionals can offer empowering experiences to individuals, but it is also pertinent to highlight their role in mitigating harm. The goal of alcohol reduction or abstinence requires suitable guidance from alcohol services to avoid potentially dangerous sudden reductions in alcohol use [122], which has implications for how individuals approach learning to live alongside psychological distress in the absence of alcohol use (which underpins attempts to reduce experiential avoidance). Consequently, access to this expertise is an imperative in the short-term and should be incorporated into training programmes for professionals in the field on mental health in the long-term. • Fidelity—A sense of fidelity can be developed by professionals honouring commitments. Greater sense of continuity of care and service inclusivity is likely to nurture a greater sense of trust, as the experience of being sent between services due to exclusion criteria is likely to obstruct the development of healthy alliance between individuals and services. Reflective Practice Exercise 5.2 Taking each individual’s ethical principle, review your own work ethic and practice. • How much or how little do these principles apply to the care you provide?

5.12 Transcultural Considerations During conceptualisation and treatment planning, it is important to consider how transcultural issues can intersect with individuals’ experiences of psychological distress and alcohol use. As previously mentioned, many individuals with related diagnosable disorders experience stigma [12, 113], feelings of shame and isolation [123], but this can be more severe for people from ethnic minority communities. Exposure to racism and exclusion within the wider community can exacerbate these

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experiences, while there may also be stigma within their own community [123]. Refugees and immigrants might hold reservations about working with UK services [123], particularly if they have felt disempowered by their historical relationship with these. Furthermore, for some individuals seeking help outside of the family or community might feel pressuring, as it deviates from their own implicit cultural norms (see Chap. 3).

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78. Conner KR, Pinquart M, Gamble SA. Meta-analysis of depression and substance use among individuals with alcohol use disorders. J Subst Abus Treat. 2009;37:127–37. 79. Sartor CE, Lynskey MT, Bucholz KK, McCutcheon VV, Nelson EC, Waldron M, et  al. Childhood sexual abuse and the course of alcohol dependence development: findings from a female twin sample. Drug Alcohol Depend. 2007;89:139–44. 80. Stewart SH, Pihl RO, Conrod PJ, Dongier M. Functional associations among trauma, PTSD, and substance-related disorders. Addict Behav. 1998;23:797–812. 81. Suh J, Ressler KJ.  Common biological mechanisms of alcohol use disorder and post-­ traumatic stress disorder. Alcohol Res. 2018;39:131. 82. Kushner MG, Maurer E, Menary K, Thuras P. Vulnerability to the rapid (“telescoped”) development of alcohol dependence in individuals with anxiety disorder. J Stud Alcohol Drugs. 2011;72:1019–27. 83. Menary KR, Kushner MG, Maurer E, Thuras P. The prevalence and clinical implications of self-medication among individuals with anxiety disorders. J Anxiety Disord. 2011;25:335–9. 84. Torrens M, Gilchrist G, Domingo-Salvany A. Psychiatric comorbidity in illicit drug users: substance-induced versus independent disorders. Drug Alcohol Depend. 2011;113:147–56. 85. Canaway R, Merkes M. Barriers to comorbidity service delivery: the complexities of dual diagnosis and the need to agree on terminology and conceptual frameworks. Aust Health Rev. 2010;34:262–8. https://doi.org/10.1071/AH08723. 86. Roberts BM, Maybery D. Dual diagnosis discourse in Victoria Australia: the responsiveness of mental health services. J Dual Diagn. 2014;10:139–44. 87. Clark HW, Power AK, Le Fauve CE, Lopez EI. Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders. J Subst Abus Treat. 2008;34:3–13. 88. Milani RM, Nahar K, Ware D, Butler A, Roush S, Smith D, et al. A qualitative longitudinal study of the first UK dual diagnosis anonymous (DDA), an integrated peer-support programme for concurrent disorders. Adv Dual Diagn. 2020;13(4):151–67. 89. Brown SA, Vik PW, Patterson TL, Grant I, Schuckit MA.  Stress, vulnerability and adult alcohol relapse. J Stud Alcohol. 1995;56:538–45. 90. Karapareddy V. A review of integrated care for concurrent disorders: cost effectiveness and clinical outcomes. J Dual Diagn. 2019;15:56–66. 91. Gil-Rivas V, Grella CE. Addictions services treatment services and service delivery models for dually diagnosed clients: variations across mental health and substance abuse providers. Community Mental Health J. 2005;41:251–66. https://doi.org/10.1007/s10597-­005-­5000-­3. 92. Hayes SC, Levin ME, editors. Mindfulness and acceptance for addictive behaviors: applying contextual CBT to substance abuse and behavioral addictions. Oakland: New Harbinger Publications; 2012. 93. Stott A, Priest H. Narratives of recovery in people with coexisting mental health and alcohol misuse difficulties. Adv Dual Diagn. 2018;11(1):16–29. 94. Shepherd G, Boardman J, Slade M. Making recovery a reality. London: Sainsbury Centre for Mental Health; 2008. 95. Schulte SJ, Meier PS, Stirling J, Berry M. Treatment approaches for dual diagnosis clients in England. Drug Alcohol Rev. 2008;27:650–8. 96. Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harv Rev Psychiatry. 2006;14:249–56. 97. Luoma JB, Twohig MP, Waltz T, Hayes SC, Roget N, Padilla M, Fisher G.  An investigation of stigma in individuals receiving treatment for substance abuse. Addict Behav. 2007;32(7):1331–46. 98. Laudet AB, Magura S, Vogel HS, Knight E. Recovery challenges among dually diagnosed individuals. J Subst Abus Treat. 2000;18:321–9. 99. Carrà G, Bartoli F, Brambilla G, Crocamo C, Clerici M. Comorbid addiction and major mental illness in Europe: a narrative review. Subst Abus. 2015;36:75–81. 100. Kelly TM, Daley DC. Integrated treatment of substance use and psychiatric disorders. Soc Work Public Health. 2013;28:388–406. https://doi.org/10.1080/19371918.2013.774673.

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101. Burnam MA, Watkins KE. Substance abuse with mental disorders: specialized public systems and integrated care. Health Aff. 2006;25:648–58. 102. Mangrum LF, Spence RT, Lopez M. Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders. J Subst Abus Treat. 2006;30:79–84. 103. Domino ME, Morrissey JP, Chung S, Huntington N, Larson MJ, Russell LA.  Service use and costs for women with co-occurring mental and substance use disorders and a history of violence. Psychiatr Serv. 2005;56:1223–32. https://doi.org/10.1176/appi.ps.56.10.1223. 104. Rosenthal RN, Hellerstein DJ, Miner CR.  A model of integrated service for outpatient treatment of patients with comorbid schizophrenia and addictive disorders. Am J Addict. 1992;1:339–48. https://doi.org/10.3109/10550499208993154. 105. Torchalla I, Nosen L, Rostam H, Allen P. Integrated treatment programs for individuals with concurrent substance use disorders and trauma experiences: a systematic review and meta-­ analysis. J Subst Abuse Treat. 2012;42:65–77. https://doi.org/10.1016/j.jsat.2011.09.001. 106. King RD, Gaines LS, Lambert EW, Summerfelt WT, Bickman L. The co-occurrence of psychiatric and substance use diagnoses in adolescents in different service systems: frequency, recognition, cost, and outcomes. J Behav Health Serv Res. 2000;27:417–30. https://doi. org/10.1007/BF02287823. 107. Morse GA, Calsyn RJ, Klinkenberg WD, Helminiak TW, Wolff N, Drake RE, et al. Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes. Community Mental Health J. 2006;42:377–404. https://doi.org/10.1007/s10597-­006-­9050-­y. 108. Yalom ID, Leszcz M.  The theory and practice of group psychotherapy. London: Hachette Book; 2020. 109. Wilson KG, Schnetzer LW, Flynn MK, Kurz AS. Acceptance and commitment therapy for addiction. In: Hayes SC, Levin ME, editors. Mindfulness and acceptance for addictive behaviors: applying contextual CBT to substance abuse and behavioral addictions. Oakland: New Harbinger Publications; 2012. p. 27–68. 110. Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: the process and practice of mindful change. New York: Guildford; 2011. 111. Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Ther. 2004;35:639–65. 112. DuFrene T, Wilson K.  The wisdom to know the difference: an acceptance and commitment therapy workbook for overcoming substance abuse. Oakland: New Harbinger Publications; 2012. 113. Corrigan PW, Watson AC, Barr L. The self-stigma of mental illness: implications for self-­ esteem and self-efficacy. J Soc Clin Psychol. 2006;25:875–84. 114. Hayes SC, Masuda A, Bissett R, Luoma J, Guerrero LF. DBT, FAP, and ACT: how empirically oriented are the new behavior therapy technologies? Behav Ther. 2004;35:35–54. 115. Harris R. ACT made simple: an easy-to-read primer on acceptance and commitment therapy. Oakland: New Harbinger Publications; 2019. 116. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44:1–25. 117. Wenzlaff RM, Wegner DM. Thought suppression. Annu Rev Psychol. 2000;51:59–91. 118. Harris R. The happiness trap: based on ACT—a revolutionary mindfulness-based programme for overcoming stress, anxiety and depression. London: Robinson; 2008. 119. McCollum EE, Trepper TS. Family solutions for substance abuse: clinical and counselling approaches. Oxon: Routledge; 2014. 120. The Substance Abuse and Mental Health Services Administration. Supporting a loved one dealing with mental and/or substance use disorders: Starting the conversation. https://www. samhsa.gov/sites/default/files/samhsa_families_conversation_guide_final508.pdf. Accessed 31 Sept 2021. 121. Forester-Miller H, Davis TE.  Practitioner’s guide to ethical decision making. Rev. ed. Alexandria, VA: American Counseling Association; 2016. https://www.counseling.org/docs/ default-­source/ethics/practioner-­39-­s-­guide-­to-­ethical-­decision-­making.pdf. Accessed 31 Sept 2021

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122. National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and management of physical complications. 2017. https://www.nice.org.uk/guidance/cg100/chapter/ Recommendations#acute-­alcohol-­withdrawal. Accessed 31 Sept 2021. 123. Turning Point. Dual diagnosis toolkit mental health and substance misuse: a practical guide for professionals and practitioners. 2004. https://amhp.org.uk/app/uploads/2017/08/dualdiagnosistoolkit.pdf. Accessed 31 Sept 2021.

To Learn More Hayes SC, Levin ME, editors. Mindfulness and acceptance for addictive behaviors: applying contextual CBT to substance abuse and behavioral addictions. Oakland: New Harbinger Publications; 2012. ACT Mindfully. Worksheets, book chapters & ACT made simple: extra bits. https://www.actmindfully.com.au/free-­stuff/worksheets-­handouts-­book-­chapters/. Accessed 31 Sept 2021. Milani RM, Perrino L.  Alcohol and mental health: co-occurring alcohol use and mental health disorders. In: Frings D, Albery IP, editors. The handbook of alcohol use: understandings from synapse to society. London: Academic; 2021. p. 79–106.

6

Physical Problems Associated with Alcohol Chris Holmwood and Victoria Cock

Leaning Outcomes At the completion of this chapter, readers should understand approaches to the assessment and management of alcohol-related intoxication, acute and chronic alcohol-related confusion, difficulties with gait and coordination, abdominal pain, and alcohol-related liver disease. They will also have an understanding of alcohol attributable malignancies.

6.1 Intoxication Case Study 6.1 Tom (19) was brought to the emergency department by ambulance. He was found by passersby lying on the footpath in a busy night-life precinct, smelling of alcohol, just able to speak non-sensibly in response to verbal commands, unable to sit or stand without assistance, and incontinent of urine. There was a mildly oozing laceration on his scalp. His identity was established from his wallet, which contained his ID, some cash, and a debit card. His Glasgow Coma Score is 11, opening eyes to verbal command, still speaking inappropriate words, and able to localize pain. His BP is 118/70, pulse 80, and temp 36.8 °C. Respiratory rate is 12/min. Pupils react to light and accommodation and are 3 mm diameter. He is able to maintain an airway and his oxygen saturation is 97% on room air. Blood glucose is 4.5 mmol/L. ECG and chest X-ray are normal.

C. Holmwood (*) Drug and Alcohol Services South Australia, Stepney, SA, Australia V. Cock Glenside, SA, Australia e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_6

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He has a 3 cm laceration over his frontotemporal scalp. Contacts in his wallet cannot be contacted. His mobile phone is password protected and Tom can’t tell the access code due to his confusion. There are no witnesses to events leading up to this presentation. Alcohol intoxication is a distinct syndrome but often occurs in complex contexts, and management is driven by parallel consideration of various problems which might be contributing to the presentation. Individuals such as Tom need to be investigated and treated as being confused for unknown reasons. Key Point 6.1 The smell of alcohol is one clinical sign but is unreliable. An assessment of the concentration of alcohol in the person’s blood (blood alcohol level (BAL)) is more accurate. There is a very strong correlation between breath alcohol level and blood alcohol levels. The term BAL is often used interchangeably for breath and blood concentrations. In the conscious cooperative person, a breath alcohol level using a regularly calibrated breath analyzer should be obtained. If unconscious, then a blood alcohol level may be required. Nevertheless, interpretation of the BAL is difficult because Tom may have high levels of tolerance. Tolerance to alcohol occurs because of repeated/continuous exposure to alcohol. A BAL of 0.35 g dL−1 may be near lethal to a novice drinker or to a person who has been abstinent for some time, but another person with a long history of drinking leading up to the present time might tolerate a BAL of 0.35 g dL−1 and be alert, able to conduct a conversation, and be only slightly unsteady on their feet. In this known tolerant group, a presentation such as Tom’s points toward another cause for the confusion. Self-Assessment Exercise 6.1 What other causes for Tom’s presentation could you include? Other causes for Tom’s presentation would include a closed head injury, post-­ ictal syndrome, hyponatremia, low glucose (if diabetic treated with insulin or oral hypoglycemics), intoxication with other sedative substances (benzodiazepines, opioids, gamma-hydroxybutyrate (GHB), sedative antipsychotic or antidepressant medications), and more rarely other central nervous system (CNS) problems such as encephalitis or stroke. There could be several causes operating in parallel. Management relies on diagnosing and managing all factors contributing to the presentation, frequent monitoring, and symptomatic treatment including resuscitation (airway, breathing, circulation (ABC), etc.).

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6.1.1 Absorption Alcohol is a small water- and fat-soluble molecule, absorbed from the stomach and small and large intestines. Absorption is delayed by slowed gastric motility and by eating food. BALs reached for any particular ingested dose are dependent on absorption rate and the person’s weight. Women achieve a higher BAL for a given amount of alcohol consumed, due to less first-pass metabolism of the alcohol in the gastric mucosa. Generally, BAL will increase by approximately 0.02 g dL−1 for every 10 g of alcohol consumed although this will vary considerably in accordance with the factors above. All mathematical models have considerable errors and cannot accurately predict what a person’s BAL will reach.

6.1.2 Metabolism There are two routes of elimination of alcohol: Alcohol is metabolized by alcohol dehydrogenase to acetaldehyde, and this is quickly broken down to acetic acid by acetaldehyde dehydrogenase. Acetaldehyde is carcinogenic, and it is this brief conversion of ethanol to toxic acetaldehyde before it is detoxified to acetic acid which is thought to underlie the link between alcohol and various types of cancer. Alcohol is also metabolized by the cytochrome P450 system of enzymes, in particular CYP2E1. The rate of metabolism is fixed (zero-order kinetics) at approximately 10 grams per hour but can vary significantly. Men metabolize it faster than women. Heavy drinkers metabolize alcohol a little faster as well. Small amounts are excreted by breath, urine, and sweat.

6.1.3 Clinical Effects There is a raft of physical health problems linked to the consumption of alcohol. It has been noted that alcohol was the seventh contributing factor to the Global Burden of Disease [1]. The overwhelming disease burden is due to the physical impact of alcohol consumption. These consequences manifest in the clinical effects from use of alcohol at many levels. Below we describe the clinical effects associated to such use. Alcohol acts via activity with various receptor systems modulating ion channels and neuronal activity; in particular: 1. GABA-A: Alcohol increases GABA-A receptor activity. GABA-A receptors mediate sedation, so alcohol augments this. 2. The NMDA glutamate: Alcohol reduces the activity of the excitatory NMDA glutamate system, resulting in some of the sedation seen with alcohol.

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3. In addition, 5HT3 (serotonin), nicotinic acetylcholine, small conductance/large conductance (SK/BK) potassium channels, adenosine, dopamine, and endorphin systems: These are implicated in some of the effects of alcohol and form the basis for some pharmacological treatments for alcohol dependence. Features of alcohol intoxication are dependent on blood alcohol levels. The following describe the features seen in a non-tolerant person, at various blood alcohol concentrations: 0.01 to 0.05 g−1: 0.06 g−1 to 0.08–0.10 g dL−1: 0.11 g dL−1 to 0.15–0.2 g dL−1: 0.21 g dL−1 to 0.3 g dL−1:

Mild euphoria, reduced anxiety, increased sociability Some disinhibition, impaired judgment and motor function/coordination Marked ataxia, impaired reaction time, amnesia, slurred speech Severe motor impairment, difficulty maintaining airway, vomiting, and susceptibility to aspiration

6.1.4 Effects on Driving Driving is a highly complex psychomotor task and is subject to the effects of alcohol as predicted from the above. Effects are mediated through impaired function in the prefrontal cortex and frontal cortex, cerebellum, motor cortex, basal ganglia, parietal and temporal cortices [2], as well as hippocampus [3]. Effects on driving can be derived from two types of studies, clinical tests looking at actual performance in simulators and epidemiological studies looking at crash, injury, and death rates according to BALs of people involved in road crashes. Epidemiological studies have shown that a BAC of 0.05 g dL−1 doubles the risk of involvement in a fatal collision, 0.10 g dL−1 increases the risk by 5 times, and 0.20 g dL−1 increases the risk by 25 times [4]. This risk escalates with younger drivers. For example, the risk in a young male driver with less than 5 years’ experience with a BAL between 0.05 and 0.079 g dL−1 of being involved in a single-vehicle accident is 17 times background risk (not twice the risk observed more generally) [5]. Key Point 6.2 As a result of these factors, the downstream physical effects of alcohol intoxication via motor vehicle accidents can be appreciated. Alcohol causes 30–50% of fatal road traffic accidents and 15–30% of injuries from accidents [6].

6.2 Acute Confusion and Agitation Case Study 6.2 Ailsa (55) is a heavy drinker in a small country town of 5000 people. She lives on her own in public housing; her self-care is poor, and diet is very restricted. She

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attends the local hospital or general practice four or five times per year over the past few years as local police take her there when she is excessively intoxicated. She usually sobers up, is then reasonably coherent and is competent, and self-discharges, to return to drinking. Tests previously found abnormal liver function tests consistent with her alcohol use, and an ultrasound 5 years ago found changes consistent with fatty liver. Next of kin live several hours away and do not engage much. This time she is brought in by the police as neighbors were concerned about her behaving strangely. Ailsa says her last drink was about 24 h ago. She drinks between 1 and 2 L of fortified wine per day. There is no recorded history of withdrawal seizures. She is alert and a little restless but can be easily directed. She does not know the day, date, month, or year, but she does know the town she lives in and her address and that she is at the hospital. She is unable to count by 3 s up beyond 12. She is a little distracted and seems to be hallucinating but can be diverted back to the conversation with the clinician. She cannot describe what she is seeing. She is mildly jaundiced and has a non-tender but moderately distended abdomen and some ankle edema. Her BP is 156/98 lying, pulse is 100 BPM, temperature is normal, and respiratory rate is 14 breaths per minute. She has a mild tremor. Heart sounds are normal; her chest is clear. Ailsa is unsteady on her feet and has some sustained bilateral nystagmus on lateral gaze in both directions. There are no photophobia and no neck stiffness. A general survey does not find any signs of trauma including head injury. Her breath alcohol is 0.06 g dL−1. Her finger prick glucose is 4.8 mmol/L. Recent-onset confusion in a person such as Ailsa can be due to multiple causes, but her heavy drinking adds another level of complexity. Often the causes of the confusion are multiple. Self-Assessment Exercise 6.2 What possible causes could be attributed to Ailsa’s presentation?

6.2.1 Wernicke-Korsakoff Syndrome Wernicke-Korsakoff syndrome (or WKS) is a distinct neurological syndrome caused by thiamine deficiency. It is used for a spectrum of clinical features from acute to chronic. The acute condition (Wernicke’s encephalopathy or WE) is characterized by the full clinical “triad” described by Karl Wernicke. This triad consists of confusion (the most common feature affecting 80% of people found to have postmortem brain changes of WK syndrome [7]) but also eye signs (such as nystagmus and paralysis of lateral gaze) and cerebellar dysfunction. Magnetic resonance imaging (MRI) can assist with diagnosis, but sensitivity, timing, and availability are problematic. Tests for blood thiamine or red cell transketolase are not readily available and take time.

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More recently Caine’s criteria have been validated [8]. Wernicke-Korsakoff Syndrome (WES) can be diagnosed with high sensitivity and specificity in the presence of at least two of the four following criteria: dietary deficiencies, oculomotor abnormalities, cerebellar dysfunction, and altered mental state or mild memory impairment. Self-Assessment Exercise 6.3 • What treatment would you prescribe for Ailsa? • What are the potential risk factors? Key Point 6.3 Treatment with thiamine IV should not be delayed. WE is at least partially reversible and should be treated with intravenous (IV) thiamine, but dose recommendations vary. The European Federation of Neurological Societies [9] recommends 200 mg IV three times per day until no further improvement in clinical features for treatment of Wernicke’s encephalopathy. Key Point 6.4 Thiamine is also recommended for prevention of Wernicke’s encephalopathy. The UK National Institute for Health and Care Excellence (NICE) guidelines recommend IV thiamine for people who have decompensated liver disease and whose nutrition is poor [10]. Key Point 6.5 Magnesium is an important cofactor for thiamine’s actions. Low plasma magnesium levels will impair the action of thiamine, so check levels and rectify as needed either orally or IV [11, 12]. The more longer-term chronic irreversible condition termed Korsakoff’s psychosis occurs as a result of untreated or late-treated WE which can lead to permanent cognitive impairment which particularly effects short-term memory. This can be severely disabling resulting in the need for long-term care. The transition from acute (potentially reversible) to chronic (irreversible) is often unclear. The two conditions Wernicke’s encephalopathy and Korsakoff’s psychosis are often grouped together and termed “Wernicke-Korsakoff [or WK] syndrome.” Ailsa is at risk of alcohol withdrawal given her past history for heavy drinking leading up to the very recent past. Alcohol withdrawal is a syndrome which develops in the neuro-adapted person, when alcohol intake is suddenly ceased. It is due to hyperactivity of the glutamate-aspartate-NMDA neurotransmitter systems, no longer kept in check by alcohol and its agonist effects of GABA, which is a depressant neurotransmitter. It is potentially life-threatening. Alcohol withdrawal itself

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can cause confusion and delirium (in the absence of Wernicke’s encephalopathy), so in Ailsa’s case it could well be a contributing factor (see Chaps. 18–21). Ailsa should be commenced on two to four hourly observations looking at vital signs and using the Clinical Institute Withdrawal Assessment Scale (CIWA-Ar) tool developed for assessing severity of alcohol withdrawal [13]. Treatment is with benzodiazepines linked with the severity of the withdrawal based on CIWA-Ar scores and vital signs. If someone has decompensated liver disease where hepatic synthetic function is impaired (raised bilirubin, INR (international normalized ratio) above 1.5, low albumin levels), then use lorazepam or oxazepam instead to avoid excessive sedation. These drugs have shorter durations of action and do not have active metabolites. It is highly likely Ailsa is withdrawing from alcohol given her tachycardia, hypertension, and tremor. Given Ailsa’s jaundice due to acute liver dysfunction, lorazepam should be used to treat her withdrawal.

6.2.2 Hepatic Encephalopathy (HE) Ailsa’s confusion could also be exacerbated by hepatic encephalopathy. She is jaundiced, has a distended abdomen, and recent-onset edema which may be due to ascites and liver failure. HE is not well understood but is thought to be caused by accumulation of gut-derived neurotoxins which are not detoxified by the failing liver and find their way into the brain. Hepatic encephalopathy can be gradual or rapid in onset. Self-Assessment Exercise 6.4 What are the possible causes that have triggered Ailsa’s deterioration? The question with Ailsa is what has triggered this clinical deterioration? Possible triggers could be an infection (pneumonia, urosepsis, spontaneous bacterial peritonitis), a sudden high protein load on the gut (as might occur with a bleed from esophageal varices or peptic ulcer), or an electrolyte disturbance. Ailsa should be transferred to a tertiary facility with full diagnostic and intensive care capacity.

6.2.3 Hyponatremia and Other Electrolyte Disturbances Electrolyte and acid-base problems are common in people admitted to hospital with alcohol-related problems. If the person is protein-kilojoule- or vitamin-deficient and in poor general health, then electrolyte disturbances are more common. Often these are exacerbated by other conditions such as gastritis and pancreatitis, with severe and prolonged vomiting, diarrhea, and volume depletion.

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6.2.3.1 Hyponatremia Is Common and Can Contribute to Confusion Hypomagnesemia also commonly occurs and reduces the action of thiamine in the carboxylic acid cycle, contributing to Wernicke’s encephalopathy and inhibiting any response to IV thiamine. It should generally be rectified by oral replacement therapy. 6.2.3.2 Hypophosphatemia Is Also Common In malnourished people, alcoholic ketoacidosis is common, but there may be a mixed picture if the person has been vomiting which may result in an alkalosis. Electrolyte disturbances often rectify themselves with volume replacement and oral electrolyte replacement. If using IV saline or hypertonic saline to rectify life-­ threatening hyponatremia, this should be done so slowly. Ensure that the person has had IV thiamine before any IV dextrose to avoid precipitation of acute Wernicke’s encephalopathy [12].

6.3 Chronic Confusion Epidemiological evidence establishing that alcohol at low or moderate levels results in decreased cognitive function is vexed, and a causal relationship cannot be established based on current evidence [14]. However, there is little doubt that heavy alcohol consumption results in severely disabling cognitive impairment which is termed alcohol-related brain injury (ARBI). The mechanisms whereby alcohol causes brain injury are not clear but include direct neurotoxicity, nutritional deficiencies causing Wernicke-Korsakoff (WK) syndrome, traumatic brain injury from falls and head strikes, and periods of hypoxia from severe intoxication. Wernicke-Korsakoff (WK) syndrome if not treated early will result in short-term memory loss and sometimes persistent gait ataxia and nystagmus. People with WKS will remember events from the distant past, but not recent experiences. People with such memory loss often confabulate to compensate for their short-term memory loss, the so-called Korsakoff’s psychosis. Their presentation can sometimes seem normal on cursory examination, but more targeted delving into recent events, especially if third-party information can be obtained, will usually reveal the deficits. It is extremely disabling, and people often need full-time supports for the remainder of their lives. Dementia directly due to alcohol is different from WK syndrome. Individuals have functional impairment across a range of domains in addition to memory. They often have an inability to plan and problem solve and demonstrate personality and behavior changes more akin to frontal dementia. In a computerized tomography (CT) scan, the brain will often show enlarged sulci and ventricles, although this is not universal. In reality with most alcohol-dependent people exhibiting cognitive decline, the clinical picture is mixed.

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Key Point 6.6 They should be investigated to exclude other causes of cognitive decline. Oral thiamine supplementation should be instituted. Abstinence from alcohol has been shown to result in some improvement [15, 16]. It is also important to assess their legal capacity, and if this is lacking, then legal measures can be put in place to ensure their physical, emotional, and financial safety. The arrangements for this vary from country to country.

6.4 Difficulty with Walking: Cerebellar Ataxia, Wernicke’s Encephalopathy, Peripheral Neuropathy Ataxia or difficulty with controlling movements has multiple causes. In the context of alcohol, there are several key mechanisms for the loss of control of movement. Acute intoxication with alcohol has acute dose-related effects on cerebellar function. The timeline and presence of an increased blood alcohol level will assist with the diagnosis. Intoxication-related ataxia resolves as BAL reverts to normal. Pay attention to recent-onset ataxia not previously experienced in individuals who drink heavily which does not resolve as BAL normalizes. Third-party reports may be helpful in these circumstances. This may indicate other causes such as alcohol-­related cerebellar degeneration, a stroke, or peripheral neuropathy. Sudden-onset ataxia in the alcohol-dependent person, especially in the context of alcohol withdrawal, may be due to Wernicke’s encephalopathy (WE) as mentioned previously in this chapter. Confusion or delirium is usually present with WE, but on occasions cerebellar presentations are predominant. This requires high-dose IV thiamine. Chronic thiamine deficiency can also contribute to the development of a peripheral neuropathy, which itself can cause gait disturbance. Alcohol seems to be directly neurotoxic and cause neuropathy, but frequently other B vitamin deficiencies (B2 and B6 especially) contribute. Alcohol- and vitamin deficiency-related peripheral neuropathies are slow in onset, have a glove and stocking distribution, and may be painful. They resolve slowly with abstinence from alcohol and vitamin supplementation over months. Key Point 6.7 Persistent ataxia regardless of the cause is important to identify as it presents a falls risk and reduces people’s independence. Walking aids and community assistance with transport and activities of daily living may be required to help the person to continue to live independently. There is evidence that longer-term abstinence results in improvement of chronic ataxia related to alcohol [17].

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6.5 Abdominal Pain Case Study 6.3 Boris (40) an advertising executive, married with children, presents to the local metropolitan emergency department with a 3-day history of increasing abdominal pain and intermittent vomiting. The pain is central upper abdominal/epigastric, radiating into the back, fairly constant, and is worsened by coughing and sneezing. He last opened his bowels 48 h ago. He has taken some antacids, but these did not make any difference. In the last 24 h, he has not been able to keep anything down due to the vomiting. The vomitus is just water he has been trying to drink – no blood. He has just been able to provide a urine sample, but he last passed urine 8 h before presentation. He has been drinking one bottle of wine per night for the past 5 years, but in the week prior to the onset of the abdominal pain, he increased this to two or more bottles per day due to some intense socializing which arose as a result of sorting out a business deal. Prior to 5 years ago, he drank about ½ bottle of wine per night for the preceding 10 or 15 years. He takes perindopril and metoprolol for high blood pressure. On examination his mouth is dry, his pulse is 100 BPM at rest, and his BP is 120/86 lying dropping to 98/60 on standing. Respiratory rate is 12. He is not jaundiced. Temp is 37.2 °C. His abdomen is slightly distended and tender to moderate palpation centrally and in the epigastrium. There is some cough peritonism. Chest is clear to auscultation. Heart sounds are normal. There are no bowel sounds to be heard. Urinalysis shows 3+ ketones, no glucose, and no protein and urine is visibly clear but has a quite deep yellow color. pH is 7–8 on visual test strips. Plain abdominal X-ray shows two small bowel air-fluid levels but no free gas under the diaphragm. Blood count shows an elevated neutrophil count. Biochemistry shows a hypochloremic alkalosis, again due to vomiting. Bilirubin is not elevated. Alanine aminotransferase (ALT), aspartate transferase (AST), and gamma-glutamyl transferase (GGT) are in the low 100 s. Alkaline phosphatase (ALP) is not elevated. Lipase is 550 (upper limit of normal is 150 IU/L). Self-Assessment Exercise 6.5 Consider the most likely causes of Boris’s presentation. The most likely causes of Boris’ abdominal pain and presentation include alcoholic gastritis and pancreatitis. Alcoholic hepatitis is less likely in the absence of jaundice. Other causes of pain such as a perforated viscus, appendicitis, and upper urinary tract infection need to be excluded. He is dehydrated and ketotic from vomiting. Of the possibilities above, the mostly likely is alcoholic pancreatitis. Alcohol induces oxidative stress in the pancreatic acini, which then triggers cell death, with variable degrees of inflammation or frank necrosis. In most countries 30% of pancreatitis presentations are due to alcohol. Other causes such as gallstones need to be excluded. The imaging of choice in assessing acute pancreatitis is a CT

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abdomen. Severity varies. While most people recover, overall mortality is 5%, and 22% have recurrent acute episodes, and 10% develop chronic pancreatitis. Gastritis is common in people who drink alcohol. While there are characteristic endoscopic appearances, it is often a diagnosis made once other diagnoses are excluded.

6.6 Alcohol-Related Liver Disease Alcohol is hepatotoxic. On a population level, there is a strong correlation between per capita daily alcohol consumption and cirrhosis. There does not seem to be a lower threshold below which there is no risk [18]. There are three overlapping clinical syndromes comprising the term “alcoholic liver disease,” alcoholic fatty liver (or hepatosteatosis), alcoholic hepatitis, and cirrhosis. 1. Fatty liver: Alcohol is metabolized in the liver into acetaldehyde and then acetic acid. Acetaldehyde stimulates the development of free oxygen and nitrogen ­radicals which result in cell damage which in turn causes triglyceride accumulation in the hepatocyte causing them to balloon (steatosis). See Diagram 6.1. Increasing oxidative stress due to ongoing alcohol consumption results in inflammation (steatohepatitis). The other main cause of hepatic steatohepatitis is the metabolic syndrome with obesity, impaired glucose tolerance, hyperinsulinemia, and actual diabetes. Treatment consists of abstinence from alcohol if this is the cause and weight reduction and exercise if the metabolic syndrome is the cause (or all three). Diagram 6.1 Mechanism for development of alcoholic steatosis

Ethanol Alcohol dehydrogenase

Acetaldehyde Acetaldehyde dehydrogenase

Acetate

Free reactive oxygen and nitrogen – enzyme deactivation, DNA disruption, cell death ↑FFA production, ↓ β-oxidation, ↓ VLDL production

TG accumulation FFA = free fatty acids, VLDL very low density lipoprotein

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2. Alcoholic hepatitis: It is an acute clinical syndrome with right upper quadrant pain, fever, recent-onset jaundice, abdominal distention due to ascites, and characteristic laboratory abnormalities  – elevated AST and ALT (usually under 300 IU/L, rarely over 500 IU/L, and usually AST/ALT ratio greater than 2:1) and raised bilirubin, neutrophils, and international normalized ratio (INR). Other causes for the fever need to be excluded (e.g. spontaneous bacterial peritonitis, pneumonia, urinary tract infection). If ALT and AST levels are higher than 300–500, then alternative causes for the liver toxicity need to be considered. Viral hepatitis, drug toxicity (in particular paracetamol), or biliary obstruction needs to be considered. Self-Assessment Exercise 6.6 What treatment would you prescribe for Boris? Treatment consists of abstinence from alcohol, volume replacement, nutritional support with parenteral thiamine and vitamin K, and correction of coagulopathy and hypoalbuminemia. Determine the degree of severity using the Mayo End-stage Liver Disease (MELD) score [19]. The benefits of oral glucocorticoids in acute alcoholic hepatitis remain uncertain [20]. 3. Cirrhosis: Eventually fibrosis develops in reaction to the chronic inflammation causing progressive deterioration in hepatic function. Cirrhosis results in three main sets of manifestations: • Hepatic failure: jaundice, encephalopathy, impaired coagulation, hypoalbuminemia • Portal hypertension: ascites, splenomegaly, thrombocytopenia, varices (+/− hemorrhage), encephalopathy • An increased risk of hepatocellular carcinoma (HCC) Key Point 6.8 Seek other causes in addition to alcohol. Hepatitis B and C can be treated; hemochromatosis, autoimmune hepatitis, and Wilson’s disease require targeted treatments which will alter prognosis. Individuals should be assisted in achieving and maintaining abstinence (see Chap. 23). Treatments should be initiated depending on the associated problems. These may include medications for the portal hypertension, the use of lactulose and oral antibiotics and protein restriction with nutritional support for encephalopathy, endoscopic surveillance for varices, and ultrasound and αFetoprotein (αFP) surveillance for hepatocellular carcinoma (HCC).

6.7 Alcohol-Related Malignancies Globally, malignancies account for over 20% of deaths attributable to alcohol. Alcohol is responsible for 5.8% of all cancer deaths [21]. This burden is particularly important in developing countries.

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The link between alcohol and oropharyngeal, upper gastrointestinal (GI) malignancies and hepatocellular carcinoma has been recognized for many years. Acetaldehyde, while only present transiently before being oxidized into acetic acid, is carcinogenic. This is the reason why the strongest links are between alcohol and oropharyngeal and upper GI malignancies, due to direct exposure to these tissues. Less obvious but nevertheless strong correlations with breast and colon malignancies have more recently been noted, and alcohol consumption is also linked to pancreatic and prostate cancers [22]. There is a strong public health case for a range of measures known to reduce per capita alcohol consumption to reduce this often-unrecognized burden.

6.8 Conclusion Alcohol is a total-body toxin affecting all organ systems to some degree or other. It can be a very major contributor to some conditions such as hepato-steatosis, hepatitis, or cirrhosis. Its more subtle role as a cause of malignancies is less obvious but nevertheless contributes to the total burden of disease. In all areas of health care, alcohol has a significant impact on service delivery.

References 1. Global Burden of Disease. Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental, and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390:1345–422. 2. Rzepecki-Smith CI, Meda SA, Calhoun VD, Stevens MC, Jafri MJ, Astur RS, et al. GD 2010, disruptions in functional network connectivity during alcohol intoxicated driving. Alcohol Clin Exp Res. 2010;34:479–87. https://doi.org/10.1111/j.1530-­0277.2009.01112.x. 3. Zheng H, Kong L, Chen L, Zhang H, Zheng W.  Acute effects of alcohol on the human brain: a resting-state FMRI study. Biomed Res Int. 2015;2015:947529. https://doi. org/10.1155/2015/947529. 4. Borkenstein RF, Crowther RF, Shumate RP. The role of the drinking driver in traffic accidents. Blutalkohol. 1974;11:1–131. 5. Zador PL. Alcohol-related relative risk of fatal driver injuries in relation to driver age and sex. J Stud Alcohol. 1991;52:302–10. 6. AUSTROADS Assessing Fitness to drive. Last amended 2022. https://austroads.com.au/publications/assessing-fitness-todrive/ap-g56/about-this-publication(austroads.com.au). Accessed 5 Jan 2023. 7. Harper CG, Giles M, Finlay-Jones R. Clinical signs in the Wernicke- Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy. J Neurol Neurosurg Psychiatry. 1986;49:341–5. 8. Caine D, Halliday G, Harper C. Operational criteria for the classification of chronic alcoholics: identification of Wernicke’s encephalopathy. J Neurol Neurosurg Psychiatry. 1997;62:51–60. 9. Galvin R, Bråthen G, Ivashynka A, Hillbom M, Tanasescu R, Leone MA, European Federation of Neurological Societies. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol. 2010;17:1408–18. https://doi.org/10.1111/j.1468-­1331.2010. 03153.x.

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10. National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and management of physical complications. 2010. www.nice.org.uk/guidance/cg100. Accessed 4 Sept 2021. 11. Traviesa DC. Magnesium deficiency: a possible cause of thiamine refractoriness in Wernicke-­ Korsakoff encephalopathy. J Neurol Neurosurg Psychiatry. 1974;37:959–62. 12. Sechi G, Serra A.  Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007;6:442–55. 13. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989;84:1353–7. 14. Brennan SE, McDonald S, Page MJ. Long-term effects of alcohol consumption on cognitive function: a systematic review and dose-response analysis of evidence published between 2007 and 2018. Syst Rev. 2020;9:33. https://doi.org/10.1186/s13643-­019-­1220-­4. 15. Harper C.  The neuropathology of alcohol-related brain damage. Alcohol Alcohol. 2009;4:136–40. 16. Sullivan EV.  Neuropsychological vulnerability to alcoholism: evidence from neuroimaging studies. In: Noronha A, Eckardt MJ, Warren K, editors. Review of NIAAA’s neuroscience and behavioral research portfolio, National Institute on Alcohol Abuse and Alcoholism (NIAAA) Research Monograph No. 34. Bethesda, MD: NIAAA; 2000. p. 473–508. 17. Smith S, Fein G. Persistent but less severe ataxia in long-term versus short-term abstinent alcoholic men and women: a cross-sectional analysis. Alcohol Clin Exp Res. 2011;35:2184–92. 18. Rehm J, Taylor B, Mohapatra S, Irving H, Baliunas D, Patra J, et al. Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis. Drug Alcohol Rev. 2010;29:437–45. https://doi.org/10.1111/j.1465-­3362.2009.00153.x. 19. Sheth M, Riggs M, Patel T.  Utility of the Mayo end-stage liver disease (MELD) score in assessing prognosis of patients with alcoholic hepatitis. BMC Gastroenterol. 2002;2:2. 20. Pavlov CS, Varganova DL, Casazza G, Tsochatzis E, Nikolova D, Gluud C. Glucocorticosteroids for people with alcoholic hepatitis. Cochrane Database Syst Rev. 2017;11(11):CD001511. Update in: Cochrane Database Syst Rev. 2019;4:CD001511 21. Praud D, Rota M, Rehm J, Shield K, Zatoński W, Hashibe M, et al. Cancer incidence and mortality attributable to alcohol consumption. Int J Cancer. 2016;138:1380–7. 22. University of Sheffield. Mortality and morbidity risks from alcohol consumption in Australia: analyses using an Australian adaptation of the Sheffield Alcohol Policy Model (v2.7) to inform the development of new alcohol guidelines. Sheffield: University of Sheffield Press; 2019.

To Learn More The following readings are recommended: National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and management of physical complications. 2010. www.nice.org.uk/guidance/cg100. Accessed 4 Sept 2021. Ries R. Principles of addiction medicine. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2009. Saunders J, Conigrave K, Latt N, Nutt D, Marshall E, Ling W, et al., editors. Addiction medicine (Oxford specialist handbooks). Oxford: Oxford University Press; 2016.

7

Alcohol Use in Forensic Mental Health and Criminal Justice Settings Mary Munro and Lolita Alfred

Learning Outcomes • Evidence suggests that alcohol use and crime are closely linked. • Assessing and identifying the different levels of problematic alcohol use for individuals who enter the criminal justice system and forensic mental health settings is key to providing an opportunity for timely provision of appropriate treatment and support. • Therapeutic and pharmacological interventions are the most common treatment options within the CJS and forensic mental health services. • Approaches to care and treatment should also include or consider family members where possible.

7.1 Introduction Alcohol is regarded as a social lubricant, and it forms an important part of social, family and work life for many that choose to drink [1]. The alcohol industry contributes a significant amount to economies all over the world. In the United Kingdom (UK), for example, the alcohol industry creates approximately 1.8 million jobs and annual revenue of over £29 billion [2]. Despite these positive aspects, however, excessive alcohol use continues to be a major contributor to preventable mortality, morbidity and a broad array of psychosocial problems such as suicide, homelessness, violence, poor parenting, crime and disorder [3]. This chapter will explore M. Munro (*) Clinical Effectiveness Lead Drug Harm Reduction (North of Scotland), Fraserburgh, UK e-mail: [email protected] L. Alfred School of Health Sciences, University of London, London, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_7

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alcohol problems related to individuals within the criminal justice system and forensic mental health services with an emphasis on how these services are working towards reducing alcohol-related harm and supporting individuals from assessment through to treatment. For services in the criminal justice system, we will refer mainly to prisons and custody settings; and for forensic mental health care, this will encompass low, medium and high secure mental health service provision.

7.2 Alcohol Use in Forensic Mental Health Services and the Criminal Justice System Forensic services date as far back as the eighteenth century after it became recognised that a safe custody setting was required for offenders who had mental health problems [4]. One of the earliest examples of a safe custodial setting is Broadmoor—a high secure hospital in Berkshire, England, built in 1863 to provide conditions of security (a locked environment), as well as appropriate therapeutic health care and support (for the individual’s mental health treatment needs). High secure forensic hospitals provide the highest level of security for detained individuals with mental health problems and behaviour that is regarded as extremely dangerous or high risk. Medium secure services are designed for individuals with a medium risk of harm to self and others, and as such they do not need the physical security arrangements of a high secure hospital [5]. Low secure services provide care for individuals who present with a low risk but still require care within a locked setting. When compared to the general population, problematic alcohol use in those who have severe or enduring mental health problems is considerably higher. For individuals receiving care in forensic mental health services, the statistics are often even higher, with rates ranging from 50% to 90% [6]. Forensic mental health services are best suited to providing a secure setting where an individual can also receive appropriate mental health (and alcohol/substance use) assessment and treatment. Individuals within the criminal justice system also have a higher prevalence of alcohol problems than individuals in the general population. Studies on alcohol use and offending behaviour show that alcohol is implicated in almost half of violent crimes carried out [7]; those who binge drink are more likely to commit an offence [8]; and more than 50% of individuals who are imprisoned admit to drinking heavily on the lead up to or on the day of their offence taking place [8, 9]. Among young offenders aged between 18 and 20 years old, nearly half (49%) express that they are determined to engage in binge drinking [10]. These statistics show the scale of the problem with alcohol-related offending. However, it is noted that problematic alcohol use often goes undetected, and this represents a real missed opportunity to identify and support those that require help for their alcohol use problems. The literature highlights that some of the missed opportunities may be due to the focus on illicit

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drug use, and less of an understanding or focus on the assessment of problematic alcohol use [11]. With over 90% of the world’s population having exposure to alcohol [12], the legality of alcohol makes it more available and accessible than illicit drugs. Considering this, and the fact that alcohol use disorders are the most prevalent substance use disorder in the criminal justice system, it is important to give alcohol-related offending equal emphasis in research, policy and approaches to treatment and support [13].

7.3 Theories on the Link between Alcohol and Crime There is a long-established body of evidence across the disciplines of economics, public health and criminology that demonstrates the link between alcohol and crime [14, 15]. However, not all individuals who drink alcohol will go on to commit crimes, and it is important to acknowledge that there may be a wide range of other factors (apart from the alcohol consumption) that might influence or contribute towards offending. Some attempts have been made to explain the link between alcohol and criminal behaviour. The causal link is debated in the literature. However, some theories that seek to explain this link include: • Differential sensitivity and response profile to alcohol ingestion [16] • The pharmacological influence of alcohol on executive functions and cognitive processes, reducing inhibition and heightening emotional responses [14, 17] • Alcohol consumption as a factor that increases the likelihood of aggression by interacting with the personal, situational and cultural factors in which drinking occurs [15]

7.4 Framework for Assessment and Treatment An example of a guiding framework for the commissioning and provision of planned and integrated local systems of alcohol treatment in the UK is the Models of Care for Alcohol Misusers (MoCAM) [18]. The MoCAM outlines a four-tier framework of provision which incorporates effective assessment and screening, care planning and treatment as well as integrated alcohol treatment pathways. The MoCAM presents a broad conceptual framework for visualising the levels of need and provision required. However, it is worth noting that there is no precise way of mapping the category of drinker to the tier or level of intervention as this requires consideration of a range of factors that may differ between individuals [18]. Table 7.1 adapted from Rassool [19] provides a summary of the key points from the MoCAM and where criminal justice and forensic services would sit within this framework.

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Table 7.1  Models of care for alcohol misusers four-tier system Tier Settings 1 Primary healthcare services

2

Specialist settings Specialist liver disease units

Acute hospitals, e.g. A&E departments

Specialist psychiatric wards

Psychiatric services Social services department

Forensic units Residential provision for the homeless Domestic abuse services

Homelessness services Antenatal clinics General hospital wards Police settings, e.g. custody cells Probation services Prison services Education and vocational services Occupational health services Education and vocational services Primary healthcare services Acute hospitals, e.g. A&E departments Psychiatric services

Social services department

Homelessness services

Antenatal clinics General hospital wards Police settings, e.g. custody cells Probation services Prison services Education and vocational services Occupational health services

Alcohol services Forensic units

Intervention strategies Interventions include provision of identification of hazardous, harmful and dependent drinkers Information on sensible drinking; simple brief interventions to reduce alcohol-related harm Referral of those with alcohol dependence or harm for more intensive interventions

Alcohol-specific information, advice and support Extended brief interventions and brief treatment to reduce alcohol-related harm Alcohol specific assessment and referral of those requiring more structured alcohol treatment Partnership or shared care with staff from tier 3 and tier 4 Provision or joint care of individuals attending other services providing tier 1 interventions Mutual aid groups, e.g. alcoholics anonymous Triage assessment, which may be provided as part of locally agreed arrangements

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Table 7.1 (continued) Tier Settings 3 Primary care settings (shared care schemes)

GP-led prescribing services The work in community settings can be delivered by statutory, voluntary or independent services providing care-planned, structured alcohol treatment Prisons Police settings, e.g. custody cells

Specialist settings Community-based structured care-­ planned alcohol treatment Forensic units

Probation services

4

Inpatient provision-general psychiatric wards

Hospital services for pregnancy, liver problems, etc. with specialised alcohol liaison support Prisons

Alcohol specialist inpatient treatment and residential rehabilitation Forensic units

Intervention strategies Comprehensive substance misuse assessment

Care planning Case management

Community detoxification Prescribing interventions to reduce risk of relapse Psychosocial therapies and support Interventions to address co-existing conditions Day programmes Liaison services, e.g. for acute medical and psychiatric health services (such as pregnancy, mental health or hepatitis services) Social care services (such as childcare) and housing services and other generic services Comprehensive substance misuse assessment

Care planning and review

Prescribing interventions Alcohol detoxification Prescribing interventions to reduce risk of relapse Psychosocial therapies and support Provision of information, advice, training and ‘shared care’ to others

Adapted from Rassool H. Alcohol and drug misuse: a handbook for students and health professionals, professionals, 1st Edition. 2009. Printed with the kind permission of Professor G. Hussein Rassool and Routledge

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7.5 Assessment Validated assessment tools or questionnaires such as the Alcohol Use Disorders Identification Test (AUDIT) are helpful for assessing the different risk levels associated with an individual’s consumption. By identifying what level the person is drinking, this can enable better signposting to, and provision of, the most appropriate interventions. The AUDIT provides detailed information in distinct categories which include: • • • •

Low-level drinking Increased-risk drinking High-risk drinking Potential dependence

These categories sit well alongside the four tiers of provision identified in Table 7.1. For example, if an individual completed the AUDIT and it indicated they were in the ‘increased-risk’ category, one of the interventions that might be used is an alcohol brief intervention (ABI) (which will be discussed in the treatment options section below). If an individual’s AUDIT score suggests ‘potential dependence’, then a referral can be made to enable further in-depth assessment on the nature and severity of alcohol misuse, and risk assessment can also be undertaken [20]. The AUDIT questionnaire can be incorporated into the individuals’ holistic assessment upon admission to forensic mental health settings or upon detention in prison or contact with probation settings.

7.6 Therapeutic Treatment Options In the criminal justice system and forensic services, there are various treatment options available to support individuals who have alcohol use disorders. The options may vary from country to country; however a few of the common ones used in the UK include: • Pharmacological Treatments—Examples such as acamprosate and disulfiram which act on neurotransmitters in the brain that underlie alcohol seeking and reduce the brain’s dependence on the alcohol [21]. • Therapeutic Communities—The use of therapeutic communities in prison settings in the United States of America (USA) and the UK has shown positive results in reducing reconviction rates in attendees [22]. Therapeutic communities are designed to: …change dysfunctional behaviour through living in a democracy where residents confront and correct each other’s maladaptive behaviours, while offering each other support through the difficult change process. [23, p. 226]

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• Alcohol Brief Interventions (ABI)—ABI form part of the National Institute for Health and Care Excellence (NICE) Quality Standards in the UK [24]. An alcohol brief intervention is a short, evidence-based conversation that is facilitated in a nonjudgemental way to help an individual think about their alcohol use. An ABI can support the individual to consider changing their drinking by setting short-term goals, exploring harm reduction advice and lifestyle counselling to provide suggestions on ways to reduce drinking levels. Furthermore, ABI are designed to be used in many different settings and are ideal for using when time is limited. For those who may require more support with their drinking, extended brief interventions (EBI) would incorporate more detailed discussions of an ­individual’s drinking [25]. Due to the nature of the ABI and EBI, these can be delivered in any setting (whether specialist or non-specialist) and in an ‘opportunistic’ way [26]. • Motivational Interviewing (MI)—Supporting individuals to change behaviours such as alcohol consumption which may have led to the offending behaviour can be a complex process [27]. MI presents an approach to treatment that can help an individual work towards changing their drinking behaviour. MI uses a guiding style to engage individuals, clarify their strengths and aspirations, promote autonomy in decision-making and evoke their own motivations for change [28]. The negative consequence of committing an offence while under the influence presents a teachable moment that can motivate an individual to change their consumption of alcohol; and criminal justice and secure settings provide an opportune time to support individuals with that change. An important consideration when working with individuals, however, is the issue of stigma, particularly for individuals who have been through the criminal justice system and are receiving care within forensic mental health services because they may experience ‘triple stigma’—firstly, stigma because of the offence, secondly, stigma because of their alcohol consumption or dependence and, thirdly, stigma associated with having a mental health condition. It is important for professionals in these settings to remain nonjudgemental and empathetic and to build a therapeutic relationship that creates a safe environment in which individuals can explore and work towards change and recovery. This aligns well with the main principles of MI which include: –– Adopting a nonjudgemental and empathetic approach –– Reflective listening skills –– Rolling with resistance and avoiding arguments –– Supporting efficacy to change For those in the criminal justice or forensic mental health settings, readiness to engage with changes that may reduce the risk of reoffending is a focal point for the delivery of interventions and services. • Cognitive Behavioural Therapy—This helps individuals see how their thoughts and feelings may affect their substance use behaviour. Forensic and criminal justice settings have additional accredited psychological treatments that are tar-

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geted specifically at addressing substance use which is connected to the individual’s offending behaviour. An example is the Addressing Substance-Related Offending (ASRO) programme [29], which was introduced in the UK in the early 2000s, and the courts could order an individual to undertake this treatment programme to reduce reoffending. Addressing Substance-Related Offending (ASRO) programme is underpinned by cognitive behavioural therapy principles and is designed to support individuals to strengthen their self-control, enhance motivation for change, learn and enhance skills and thinking patterns required to reduce or stop alcohol or drug use and offending and develop relapse prevention and management strategies. It has been used predominantly by individuals who are on probation serving community sentences outside of the prison setting [29]. Addressing Substance-Related Offending (ASRO) programme was adapted and provided for individuals with substance-related offending in prisons (P-ASRO) [30] and for individuals in forensic secure settings (ASRO-S). Evaluations of the P-ASRO showed increased problem-solving, self-control (associated with likelihood to affect prosocial behaviour) and motivation to change substance use behaviour [30]. Evaluations of the ASRO in probation showed that those who did not complete the programme had a higher likelihood of reconviction than those who completed the programme and those in the control group; however there was no significant difference in reconviction between those who completed the programme and those in the control group. As the evidence suggests the high prevalence rate of those affected by problematic alcohol use in the CJS and forensic mental healthcare settings, it is imperative that treatment options include post-discharge plans or provision of support. Alcohol treatment offered while in prison or while in forensic secure care may benefit an individual while they are within the safety of those environments; however the period immediately following discharge from these settings is classed as a high-risk time for increased alcohol consumption and relapse.

7.7 Challenges of Assessment and Treatment Forensic mental health and prison settings offer an opportune time to provide assessment, support and treatment for individuals who struggle with their alcohol use. Forensic mental health service users, for example, are detained and treated for longer periods of time, and this gives the opportunity to positively affect their lifestyle choices (such as alcohol consumption) for a substantial time [31]. However, because such settings do not offer the real-world context which individuals can test out their ability to maintain abstinence (or low-risk drinking), there is a risk of individuals facing challenges upon discharge. It is, therefore, important that part of treatment and discharge planning considers individuals’ access to community support and relapse prevention. The principles of assessment for alcohol problems in forensic or prison settings are similar to assessment in other settings, the emphasis being on establishing the

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current levels and pattern of alcohol consumption, past consumption and a holistic assessment which considers interaction between the individual and their environment, bio-psychosocial factors or circumstances that might be influencing or maintaining their consumption. Assessment in these settings does however offer different challenges, for example, due to the practicalities of the secure environment, the motivation issues that may be associated with the involuntary status of individuals in those settings and the notion of coerced treatment. This is not to say that all those who are legally mandated into treatment are unwilling or unmotivated to engage; however the notion that the treatment is coerced brings about some polarised debates. Coercion generally means an individual has been forced into something against their will [32]. In cases where an individual has committed an offence and alcohol was a contributing factor, legally coerced alcohol treatment can be stipulated by the criminal justice system [33]—the justification for coerced intervention being that structured alcohol treatment will result in a reduction of any future alcohol-related crime by that individual. Seddon [34] notes a rising trend in the use of coerced treatment across western countries such as the USA, Australia and the UK. In England and Wales, for example, the Annual Offender Caseload Management statistics [35] shows a continual year on year rise in probation commencements that include a legally coerced alcohol treatment order, from 1356  in 2005 to 6485  in 2009. Although these figures have fluctuated up and down in subsequent years and encouraging results from research suggest that alcohol treatment may reduce the likelihood of reoffending [36], authors warn against using coerced alcohol (or substance use) treatments as a lone solution for reducing reoffending. This is because individuals have much more complex and interrelated aspects of their lives that they might support with the following, but are not limited to: • • • • • • • •

Safety Basic human needs Shelter Food Clothing Education Employment Connections

Some of these areas may also have direct or indirect connections with the offence they committed [32, 36]. Legally coerced alcohol interventions also present a challenge for effective treatment [37], a challenge which spotlights the ethics of coerced treatments. It is acknowledged that the criminal justice system justifiably views alcohol treatment as a necessary condition for an individual to comply with as part of their sentence or conditions for probation. However, given that the treatment approach often used for alcohol problems is underpinned by motivational interviewing, which views persuasion, confrontation and punishment as yielding little or no benefit to substance use treatment [38], this places coerced treatment somewhat at odds with the ethos of motivational interviewing. Furthermore, Seddon [34]

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articulates that the ethical questions relate to the ways in which the use of coercion and the criminal justice agenda can distort the principles and practice of treatment. One other ethical concern relates to whether giving priority access to individuals who are court ordered into treatment can inadvertently negatively impact those individuals who are already voluntarily on the treatment waiting list and may need to be pushed back further to the court order to take priority [3]. A public health approach would emphasise primary and secondary prevention of both health and criminal harms. It would not be based on coercion, but on expanding opportunities and assistance for all to lead healthy and productive lives [32]. One aspect to take into consideration and that may lead to the under-detection of problematic alcohol use is during the initial assessment process within forensic or prison settings. When using evidence-based tools, a number of individuals may not be provided with treatment options or support due to the fact that they do not fall into the category of ‘dependent drinkers’. While an individual may not be dependent, as presented in this chapter, binge drinking cultures and crime are closely linked. For these individuals they may not be offered or provided with subsequent support or engaged in formal treatment and may be resistant to public health promotion guidance. Evidence provided in this chapter suggests that there are unmet needs in assessment and treatment options for those who experience problematic alcohol use, compared to those with an illicit drug problem. Assessment and treatment of an individual’s alcohol use is essential in planning and delivering effective services. When treatment options and interventions are tailored and person centred, this has the potential for better outcomes not only for the individual, but for friends, family and the wider community.

7.8 Family Alcohol use can often be described as hidden in nature, which may mean that there are a large number of individuals affected by problematic alcohol use unknown to care services or treatment [39, 40]. Furthermore, the hidden nature of problematic alcohol use means that the evidence available about individuals supporting this population group is limited [41]. It is estimated that there are currently 1.4 million affected family members for individuals experiencing illicit drug and alcohol use issues in the UK and that 1 in 20 households has experienced addiction in their family at some point [41]. This figure is believed to be an underestimate because individuals may not access support due to barriers to access services and other factors such as stigma or embarrassment [42]. Providing appropriate support for family members could improve health and wellbeing outcomes for not only the family member themselves but also the individual(s) that they are caring for or living with (see Chap. 8) [42]. People with problematic alcohol issues, however isolated, will have networks of families and friends who will feel the impact of drug and alcohol issues, whether they have become estranged or continue to provide vital support [43]. Family members are frequently an unrecognised, unappreciated and unpaid resource providing economic and other forms of support to the individuals whom

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they support, particularly for those individuals who have been incarcerated or within forensic mental health services. Supporting an individual with alcohol issues can often be upsetting if the person is physically or mentally unwell or if there is unpredictability and challenging behaviours. A change in behaviour can affect the family members’ emotions, and in some cases, they can experience feelings of loss, particularly when a family member has been incarcerated [44]. Being a family member and supporting someone with alcohol issues can affect the family member’s ability to work which may affect their finances. If the individual they are caring for or living with was the main household earner and their condition has meant that they have had to give up paid employment, this may add to significant stress for the household and family [40]. Often family members put the needs of the cared-for person first and do not have the time to fully consider their own needs, leading to these being neglected [39, 40]. In some situations, it can be difficult for the family member to make any future plan. Planning for the future can be stressful in any area of their life from their career, their education and development, or even their social life. They may be forced to delay starting work or training, give up work or a course, take early retirement or reduce their working hours as a result of their supporting role [45]. One method which has been trialled to help support the individual within the forensic or prison setting and family members is by utilising the behavioural family therapy (BFT), a therapeutic approach that uses the Meriden model of family therapy. This model is an NHS programme hosted in Birmingham and Solihull Mental Health Foundation NHS Trust and operates at national and international levels. It is based on a psychoeducational approach developed by Professor Ian Falloon and colleagues [46]. However, families in secure services are often the victims of service users’ crimes or have been subjected to a significant degree of stress and burden [47]. This may have an effect on families’ willingness and motivation to get involved in family and recovery work.

7.9 Conclusion The high prevalence of problematic alcohol use identified within forensic and criminal justice settings and the varied patterns of heavy drinking behaviours, together with links between drinking, crime and recidivism, support the argument for more extensive provision of alcohol-focused interventions in prison and related criminal justice settings. There is need for a tiered approach to provision with a ladder of intervention options that vary in intensity according to the associated risk level and appropriate signposting based on effective initial screening and assessment. Moreover, it is important to recognise that alcohol treatment for individuals may go some way towards supporting them to change their drinking and reduce alcohol-­ related offending; however, if we are to see a bigger impact on reducing offending, the approach needs to be more holistic and cognisant of the wider determinants of offending.

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Reflective Practice Exercise 7.1 1. Firstly, find out about the initial assessment process for identifying problematic alcohol use in your own profession. Secondly think about how you would approach an ABI with a person. For example, what environment would you conduct it in? What might the challenges be? How confident would you be in carrying this out? 2. Firstly, think about some of the practical challenges of managing problematic alcohol use in the criminal justice system (CJS) and forensic mental health settings. Secondly what might be some of the challenges for the individual both in these settings and when they return to their home environments? Finally think of your current practice. Do you currently engage family members within the care and treatment of an individual with problematic alcohol use? What might be some of the challenges in doing this? 3. As criminal justice system (CJS) treatment programmes may differ from country to country, try and find out what treatment programmes are available for alcohol in your local area or country. For example, search the internet to see if there is any information available on your local probation services webpages. You may also wish to explore what types of treatments or programmes are offered in other countries to compare with what is available in your area or country.

References 1. Baggott R. Public health policy and practice. 2nd ed. Hampshire: Palgrave Macmillan; 2011. 2. Her Majesty’s Government. The governments alcohol strategy. London: Home Office; 2012. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/224075/alcohol-­strategy.pdf. Accessed 10 Oct 2021. 3. Drug Policy Commission (UKDPC). Reducing drug use, reducing reoffending are programmes for problem drug-using offenders in the UK supported by the evidence? 2008. https://www. ukdpc.org.uk/publications/. Accessed 10 Oct 2021. 4. United Kingdom Central Council for Nursing. Nursing in secure environments. London: UKCC/UCLAN; 1999. 5. Department of Health. Environmental Design Guide Adult Medium Secure Services. Environmental Design Guide Adult Medium Secure Services (publishing.service.gov. uk). 2011. 6. Birch D, Coulton S, Bland M, Cassidy P, Dale V, Deluca P, et al. Alcohol screening and brief interventions for offenders in the probation setting (SIPS trial): a pragmatic multicentre cluster randomised controlled trial. Alcohol Alcohol. 2014;49:540–8. 7. Kelly JF, Wakeman SE, Saitz R. Language, substance-use disorders, and policy: the need to reach consensus on an “addiction-ary”. Alcohol Treat Q. 2016;34:116–23. 8. Doyle MF, Shakeshaft A, Guthrie J, Snijder M, Butler T. A systematic review of evaluations of prison-based alcohol and other drug use behavioural treatment for men. Aust N Z J Public Health. 2019;43:120–30. https://doi.org/10.1111/1753-­6405.12884. 9. McKeganey N, Russell C, Barclay T, Barnard M, Page G, Lloyd C. Meeting the needs of prisoners with a drug or alcohol problem: no mean feat. Drugs Educ Prev Policy. 2016;23:120–6. https://doi.org/10.3109/09687637.2016.1150965. 10. Newbury-Birch D, McGovern R, Birch J, Oneil G, Kaner H, Sondhi A, et al. A rapid systematic review of what we know about alcohol use disorders and brief interventions in the criminal justice system. Int J Prison Health. 2017;12:57–70.

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11. Holloway A, Landale S, Ferguson J, Oneil G, Kaner H, Sondhi A. Brief interventions for male remand prisoners: protocol for a complex intervention framework development and feasibility study (PRISM-A). BMJ. 2017;7(4):e014561. 12. Stein LAR, Clair M, Lebeau R, Colby S, Barnett N, Golembeske C, et al. Motivational interviewing to reduce substance-related consequences: effects for incarcerated adolescents with depressed mood. Drug Alcohol Depend. 2011;118:475–8. 13. Welsh WN.  A multisite evaluation of prison-based therapeutic community drug treatment. Crim Justice Behav. 2007;34:1481–98. 14. Carpenter C, Dobkin C. Alcohol regulation and crime. In: Cook P, Ludwig J, McCrary J, editors. Controlling crime: strategies and tradeoffs. Chicago, IL: University of Chicago Press; 2011. p. 291–330. 15. Martin SE. The links between alcohol, crime and the criminal justice system: explanations, evidence and interventions. Am J Addict. 2001;10:136–58. 16. Pihl RO, Assaad JM, Hoaken PNS. The alcohol-aggression relationship and differential sensitivity to alcohol. Aggress Behav. 2003;29:302–15. 17. Giancola PR. Executive functioning: a conceptual framework for alcohol-related aggression. Exp Clin Psychopharmacol. 2000;8:576–97. 18. Department of Health. Models of care for alcohol misusers (MOCAM). London: National Treatment Agency for Substance Misuse; 2006. 19. Rassool GH.  Alcohol and drug misuse. A handbook for students and health professionals. London: Routledge; 2009. 20. National Institute for Health and Care Excellence. Alcohol care pathways. 2021. Pathways. nice.org.uk. Accessed 10 Oct 2021. 21. Toates F. Alcohol—the links to brain, behaviour and mind. In: Smart L, editor. Alcohol and human health. Oxford: Oxford University Press/The Open University; 2007. 22. Martin C, Player E. Drug treatment in prison: an evaluation of the RAPt treatment programme. Winchester: Waterside Press; 2000. 23. McMurran M. What works in substance misuse treatments for offenders. Crim Behav Ment Health. 2007;17:225–33. 24. National Institute for Health and Care Excellence. 2014. https://www.nice.org.uk/guidance/ ph24/documents/review-­2-­screening-­and-­brief-­interventions-­effectiveness-­review2. Accessed 1 Oct 2021. 25. Bowes N, McMurran M, Williams B, David S, Zammit I. Treating alcohol-related violence: intermediate outcomes in a feasibility study for a randomized controlled trial in prisons. Crim Justice Behav. 2012;39:333–44. 26. Welsh WN, Grain PN. Predictors of therapeutic engagement in prison-based drug treatment. Drug Alcohol Depend. 2008;96:271–80. 27. Newbury-Birch D, Ferguson J, Landale S, Giles E, McGeechan G, Gill C, et al. A systematic review of the efficacy of alcohol interventions for incarcerated people. Alcohol Alcohol. 2018;53:412–25. https://doi.org/10.1093/alcalc/agy032. 28. Rollnick S, Miller WR, Butler CC. Applications of motivational interviewing. Motivational interviewing in healthcare: helping patients change behaviour. Washington, DC: Guildford; 2008. 29. Palmer E, Hatcher R, McGuire J, Bilby C, Ayres HC. Evaluation of the addressing substance-­ related offending (ASRO) program for substance-using offenders in the community: a reconviction analysis. Subst Use Misuse. 2011;46:1072–80. 30. Crane MAJ, Blud L.  The effectiveness of prisoners addressing substance related offending (P-ASRO) programme: evaluating the pre and post treatment psychometric outcomes in an adult male category C prison. Br J Forensic Pract. 2012;14:49–59. 31. Pedersen ALW, Lindekilde CR, Andersen K, Hjorth P, Gildberg FA.  Health behaviours of forensic mental health service users, in relation to smoking, alcohol consumption, dietary behaviours and physical activity-a mixed methods systematic review. J Psychiatr Ment Health Nurs. 2021;28(3):444–61. https://doi.org/10.1111/jpm.12688.

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32. Stevens A, McSweeney T, Van Ooyen M, Uchtenhagen A.  On coercion. Int J Drug Policy. 2005;16:207–9. 33. Hall W. The role of legal coercion in the treatment of offenders with alcohol and heroin problems. Aust N Z J Criminol. 1997;30:103–20. https://doi.org/10.1177/000486589703000201. 34. Seddon T. Coerced drug treatment in the criminal justice system: conceptual, ethical and criminological issues. Criminol Crim Just. 2007;7:269–86. 35. Ministry of Justice. Offender Management Caseload Statistics. 2009. https://webarchive. nationalarchives.gov.uk/20161022113748/https://www.gov.uk/government/statistics/ offender-­management-­caseload-­statistics-­annual-­ns. Accessed 10 Oct 2021. 36. O’Conner R. How alcohol and drug treatment helps to reduce crime. Public Health Matters, Public Health England. 2017. https://publichealthmatters.blog.gov.uk/2017/11/02/how-­ alcohol-­and-­drug-­treatment-­helps-­to-­reduce-­crime/. Accessed 10 Oct 2021. 37. Pycroft N. Understanding and working with substance misusers. Los Angeles: Sage; 2010. 38. Miller W.  Motivational factors in addictive behaviours. In: Miller W, Carroll K, editors. Rethinking substance use: what science shows and what we should do about it. New York: Guilford; 2006. p. 134–50. 39. Velleman R, Orford J, Templeton L, Copello A, Patel A, Moore L, et  al. A 5-step intervention to help family members in Italy who live with substance misusers. J Ment Health. 2008;17:643–55. 40. Biegel D, Ishler K, Katz S, Johnson P. Predictors of burden of family caregivers of women with substance use disorders or co-occurring substance and mental disorders. J Soc Work Pract Addict. 2007;7:25–49. 41. Scottish Families Affected by drugs and alcohol. Carers. 2017. http://www.sfad.org.uk/. Accessed 10 Oct 2021. 42. United Kingdom Drug Policy Commission. Families report. 2012. https://www.ukdpc.org.uk/ publications/#Families_report. Accessed 10 Oct 2021. 43. ADFAM. Family Carers 2017. https://adfam.org.uk/. Accessed 10 Oct 2021. 44. Manthorpe J, Moriarty J, Cornes M. Supportive practice with carers of people with substance misuse problems. Soc Work Pract. 2015;27:51–65. 45. Copello A, Templeton L, Orford J, Velleman R, Patel A, Moore L, et al. The relative efficacy of two levels of a primary care intervention for family members affected by the addiction problem of a close relative: a randomized trial. Addiction. 2009;104:49–58. 46. Barrowclough C, Tarrier N, Lewis S, Sellwood W, Mainwaring J, Quinn J, Hamlin C. Randomised controlled effectiveness trial of a needs-based psychosocial intervention service for carers of people with schizophrenia. Br J Psychiatry. 1999;174:505. 47. Copello A, Templeton L, Velleman R. Family interventions for drug and alcohol misuse: is there a best practice? Curr Opin Psychiatry. 2006;19:271–6.

To Learn More Cognitive Behavior Therapy: Beck JS, Beck AT. Cognitive behavior therapy: basics and beyond. 3rd ed. New York: Guilford; 2021 Alcohol Brief Interventions: Babor TF, Higgins-Biddle JC.  Brief intervention for hazardous and harmful drinking. World Health Organization; 2001. https://apps.who.int/iris/bitstream/ handle/10665/67210/WHO_MSD_MSB_01.6b.pdf;jsessionid=E905555B1505D90CDA6EF6 7C3BC6F603?sequence=1 Alcohol Screening: Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The alcohol use disorders identification test. World Health Organization; 2001 Stages of Change and the Transtheoretical Model of Change: Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones Irwin; 1984

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Motivational Interviewing: Miller WR, Rollnick S. Motivational interviewing: helping people change. 3rd ed. London: Guilford; 2013 DSM-5: American Psychiatric Association, & American Psychiatric Association. DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. American Psychiatric Association. 2003 ICD-11 International Classification of Diseases, Section 6: Mental Behavioural and Neurodevelopmental Disorders & Disorders due to Substance Use or Addiction. 2019. https:// icd.who.int/browse11/l-­m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f76398729 Mental Health (Care and Treatment) (Scotland) Act 2003: https://www.legislation.gov.uk/ asp/2003/13/contents

8

Supporting and Including Families in Professional Care for Alcohol Use Richard Velleman, Miriam Sequeira, and Urvita Bhatia

Learning Outcomes • To understand the centrality of the family to ethical practice in the assessment, management and treatment of people experiencing problems related to their alcohol use • To develop practice that both supports family members who are affected by a relative’s alcohol use and includes family in the person’s treatment journey • To understand that such involvement sometimes creates complex ethical, cultural and practical dilemmas • To encourage professionals to explore cultural differences around family involvement and effectively address the resultant ethical dilemmas

R. Velleman (*) Addictions Research Group, Sangath Community Health NGO, Goa, India Department of Psychology, University of Bath, Bath, UK e-mail: [email protected] M. Sequeira Addictions Research Group, Sangath Community Health NGO, Goa, India e-mail: [email protected] U. Bhatia Addictions Research Group, Sangath Community Health NGO, Goa, India Department of Psychology, Health and Professional Development, Oxford Brookes University, Oxford, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_8

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This book focuses on ethical practice in the assessment, management and treatment of people with problems related to their alcohol use. The position of this chapter is that the family is central to all aspects of this.1

Box 8.1 What We Mean by ‘Family’

The ‘family’ can be thought of in many ways: in this chapter we are referring to a person or group of people who have a close relationship with the person experiencing the alcohol problem. This could be the ‘family of origin’ (parents, siblings); or a later, adult family (spouse, children); or even a very close friend or group of friends. Some people use the term ‘concerned significant others’ to capture this idea. The point here is that it is not who the family comprises that is important; it is that helping people experiencing alcohol problems needs to take account of their social context, and that context will almost always involve one or more people who have a close relationship with the person and whose involvement will be important.

8.1 Family Involvement Some people, members of the public and professionals alike, frequently conceptualise alcohol-related problems as being individual problems: after all, it is an individual who decides to drink alcohol, and many of the problems that can be associated with drinking alcohol affect people at the individual level—especially health problems but also many social problems too. However, we consider that viewing alcohol-related problems in this way is unhelpful, and unethical, at many levels. The family is centrally involved in alcoholrelated problems in at least two ways. First, people’s alcohol-related behaviours will have many effects on others in the family [2]. They may drink at home, or return intoxicated after drinking elsewhere, and behave in ways that may be troublesome to others in the family. There may be economic or social consequences of their drinking (they might lose a job, or have a fight, or get into trouble with the law), and each of these is likely to have knock-on effects on others in the family. Second, the family is not only involved by virtue of the consequences of a relative’s drinking, on themselves and the relative. They are also involved in all aspects of the help that an individual may seek or receive, related to their drinking. This is looked at in more detail later in this chapter, but briefly, there are a range of issues here.  The family is also central in the prevention of alcohol-related problems (e.g. there exist many universal prevention parenting programmes for alcohol use), but we shall not be considering prevention in this chapter. For a discussion about prevention and the involvement of the family in that, see [1]. 1

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• The willingness to be involved if one or more members of the close family needs to be assessed. Some family members may not wish to be involved, and the drinker may not wish this either. Often, time needs to be spent exploring what is likely to be successful about treatment and the options for achieving this, with either family members or the drinker. But if it is agreed that a family member will be involved, then there are many reasons why that involvement is important. • Others in the family (a spouse, a parent, an adult child) will know ‘the drinker’ far better than any professional can hope to, and hence their involvement in the range of assessments and in the range of intervention decisions will be of great benefit. • If an individual requires help to withdraw from alcohol, it is generally the case that home-detoxification and withdrawal management will only be allowed at home (where it is generally conducted) if there are family members available and willing to help (see Chap. 21). • If an individual receives individual or group support, either ‘stand-alone’ or after a stay within a residential facility, they are likely only to see any professional who is delivering such help irregularly and infrequently—at best once a week, more likely less frequently—yet at least some family members are likely to be with their relative on a vastly more frequent basis and are likely to have opinions about the type of help that their relative ‘ought’ to be receiving. Key Point 8.1 If they are involved in treatment decisions, they are much more likely to support an intervention as opposed to inadvertently working against it. • Further, the ways that family members themselves behave can potentially exacerbate a relative’s use of alcohol: there may be an absence of family understanding, a lack of family support, poor parenting skills and supervision, poor conflict management, etc. Working with some of these ways that family members might inadvertently disrupt therapeutic help can be a vital part of an intervention. • Family members therefore will become involved in treatment, and if they do not understand what the treatment is and its rationale, they might easily and inadvertently say or do things which run counter to that intervention. Moreover, if they are actively involved in planning out the treatment, they are much more likely to support it and be helpful to the process (e.g. in helping the drinker implement strategies to reduce drinking or remain abstinent). Given all of this, it is unhelpful to take an individualistic perspective which treats the drinker in isolation from the context in which she/he lives. But this chapter also holds that it is unethical: • To not support, or to withhold support from, family members who are affected by a relative’s use of alcohol • To not involve and include members of the family in any assessments and any treatment decisions

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This is for two reasons. First, because it is unethical not to use all of the resources and help at one’s disposal; and there is considerable evidence that family involvement greatly increases the chances of therapeutic success [3]. Second, because these treatment decisions being taken in relation to their relative are likely to impact upon them, as members of the family, and hence it is unethical not to consult and involve them in decisions that will impact on them.

8.2 Sometimes a Complex Ethical Dilemma Generally, then, it is important to include at least some family members in the person’s treatment journey. Nevertheless, the ethics of inclusion are complex and dilemmas over family involvement do arise. If an individual has ‘capacity’,2 it is important that the ‘identified patient’ makes decisions over who is consulted and involved and the extent to which they are involved. This sometimes leads to competing ethical dilemmas—on the one hand, it is ethically correct to include and involve family members. On the other hand, it is also ethically correct for the ‘identified patient’ to make decisions over who is involved, and the situation may arise (and often does) that the ‘identified patient’ does not wish their family (or some members of that family) to be involved. At the very least, therefore, there needs to be a discussion over how to ethically resolve this issue. Practitioners should balance the needs of the individual and of the family, which requires careful understanding of each stakeholder’s perspective, appreciation of these differing perspectives, with a focus on how a mutual understanding can help benefit treatment goals. In addition, we would expect that a practitioner would make use of motivational interviewing techniques [4] (see Chap. 23) to examine the advantages and disadvantages of family involvement with the ‘identified patient’ and/or with the family member. Key Point 8.2 Another issue is that, ethically, one also must consider and take account of cultural differences around family involvement (see Chap. 3). Some cultures expect far more family involvement than do others and resolving these competing ethical dilemmas may be difficult. The question of how to resolve some of these issues, and these competing ethical demands, in an ethical manner, goes to the heart of the development of multi-cultural acceptance and practice. What is important is that practitioners are aware of these potentially competing interests; that these issues are discussed with the individual and the family; that they are placed at the centre of decision-making; and that those practitioners seek continued professional support from peers and supervisors who have experienced similar dilemmas.  Capacity is the ability to use and understand information to make a decision and communicate any decision made. A person lacks capacity if their mind is impaired or disturbed in some way, which means they’re unable to make a decision at that time. 2

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8.3 The Family and Identification of Alcohol-Related Problems The issue of identification of alcohol-related problems is also a complex one [4, 5]. Alcohol-related problems are extremely common, meaning that a wide range of professionals are going to encounter people experiencing these problems, even though the fact that they have such problems may not be an overt part of the reason for the consultation. For some professionals, there may be an obvious link between the consultation and the drinking, even if not made explicit: the emergency department doctor and nurse who treat someone with accident damage, the police officer at the scene of a fight or a road traffic accident; the lawyer dealing with a criminal case, or with a divorce; the youth worker dealing with a teenager with behavioural problems. With others, there may be no obvious link, but the sheer prevalence of alcohol-related problems means that many of the people with whom a professional comes into contact will have alcohol-related problems. However, in most countries and cultures, talking about someone else’s behaviour choices is not seen as a legitimate or polite subject for discussion. This reluctance to discuss another’s behaviour spills over into professional consultations, where the professional in any of the examples given above will usually be extremely reluctant to raise the issue of the relationship between their drinking behaviour and the physical or mental health or social problem that they are seeing the person about. There are three situations (outlined in Box 8.2 and then discussed in the subsequent paragraphs) where the family must be considered in relation to identifying alcohol-related problems: Box 8.2 Situations where the Family must be considered in relation to Identification of Alcohol-Related Problems

• Where a family member might provide further information, which would be useful for assessment and treatment • Where identifying that there are alcohol-related problems raises concern about how these are affecting others in the family • Where, in dealing with someone, a professional comes to realise that they are a family member of a relative with alcohol-related problems When a professional is dealing or consulting with someone, knowing that the person’s use of alcohol might be a factor in the issue is helpful, in enabling the professional to offer better care. And the family can be extremely helpful to a wide range of professionals by providing information which will assist the professional in identifying and better understanding whether alcohol has had a role in their relative’s problems. This is the case in a wide range of contexts. It is most clear in the heath or social care sectors, where it can be very helpful to know from a family member that the issue for which the person has come to see the primary care physician, or the secondary care specialist, or the social worker, may be related to the amount or frequency of alcohol consumption. But it can be very helpful in many other contexts too—for an employer or a university teacher, for example, to know that an observed decline in performance may be related to a person’s alcohol use, because knowing

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this might mean that ‘normal’ disciplinary actions might not be taken, with the person instead being given an opportunity to make changes in their behaviour.3 For that reason, we consider it good practice to involve close members of someone’s family in consultation sessions, either as part of a joint session/sessions with the person with whom the professional is working or as a separate session with one or more family members. The information that they provide can be of great help in better understanding the problem and in attempting to find solutions to that problem. To assist this, we recommend that services and professionals within them use a standard ‘Information Sharing Protocol’, introduced as part of routine working, where people are asked for their agreement that family members can be consulted to help with treatment. Key Point 8.3 However, the question arises as to whether gaining information from a family member is ethical and whether using such information is ethical. It is the position of this chapter that it is ethical to both gain such information (as opposed to deliberately remaining ignorant of a potentially important set of facts) and to use such information, because the task of the professional who is attempting to help someone is to understand the situation as best as they can, so that they can then take the best and most helpful decisions. However, care must be taken not to use information in a way that might place the family-member ‘informant’ in any danger; and all information needs to be used in a way that is respectful of both the drinker and of the family member who has provided the information. So it may be that, because of the information gained through the family member, the professional might gently raise the issue, in a non-­ confrontational way, using a range of motivational interviewing [4] skills and techniques, and attempt to start a discussion with the person over their drinking and to raise the issue of whether the person might consider that their drinking might have had any impact on the reason that they are consulting with the professional. This would have the effect of introducing a discussion about alcohol consumption into the consultation without breaching any confidentiality over the fact that a family member had provided this information and hence ensuring that the family member was not ‘blamed’. The second situation where the family must be considered is when a professional identifies that there are alcohol-related problems, and this raises concern about how these are affecting others in the family. One all-too-common approach is not to consider this at all. Many professionals argue that their ‘duty of care’ is to their patient or client, and that is where their  It does need to be acknowledged however that, although this may be the result, in other contexts with less enlightened institutions, if someone discloses problematic alcohol use, she/he is more likely to be penalised, and even in some contexts publicly shamed, in the belief that this would have a deterrent effect on other people who might engage in similar behaviours. 3

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responsibilities end [6]. In the UK and in many other countries, this has been challenged as far as children are concerned, with National Guidance being issued, which clearly states that child welfare is paramount, even in organisations where the service’s client or patient is not the child, but that child’s parent. One example of such guidance comes from Scotland, where Getting our Priorities Right [7] argued that any service (health, social care and others) was simply …one prong of a multi-agency approach, focused not on the parent-patient, but on the family. According to the guidance, it starts with incorporating family-focused questions in the assessment of new patients and continues with an alertness to how changes in their substance use and treatment (such as being detoxified) might affect associated children [8].

Even here with children, there has been very slow progress and uptake in encouraging services to take a more ‘child-in-need/child-in-danger’ approach. Encouraging services to take a more ‘family-focused’ approach, and to consider the needs of other adult family members, is even more difficult. It is the position of this chapter (and this book) that this is an unethical stance. Instead, the position is that there is an ethical responsibility incumbent on all professionals and all services to take this wider, family-focused view, and to consider what help and support, members of a family might need, if the professional or service identifies that the person with whom they are working has alcohol-related problems. The range of ethical responses to this are to: • Raise the issue with the ‘identified’ person with whom one is working and ask them directly about the support needs of other family members • Provide informative materials (websites, apps, leaflets informing about services or about how best to cope) for the family members • Ask permission to contact other family members to offer them support or help (e.g. counselling), or to refer them to appropriate services if they wish for that The third situation where the family must be considered is when a professional is consulting with someone, and they come to realise that this person is a family member of someone with an alcohol-related problem, and where that issue is exacerbating whatever problem the family member has come to see the professional about. Many professionals in this situation choose to ignore such information, arguing that this does not concern them, or that it is not central to the issue with which the person in front of them has come, or that there is nothing that they can do unless the relative who is drinking presents for any help. The position of this chapter is that it is ethical to offer support to, and/or referral to specialist help for, affected family members, when one identifies that this is the case, and to provide information for the family member about how the person experiencing problem can access help.

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8.4 The Family and Interventions Related to Alcohol-Related Problems 8.4.1 Why Is It an Ethical Decision to Involve the Family? The discussion above has outlined why ethically it is important to involve the family, or some family members, in the identification of alcohol-related problems. Similar considerations apply to the inclusion and involvement of family members in assessing the seriousness and extent of alcohol-related problems, and in their treatment. However, professionals working with problem drinkers are constantly faced with ethical dilemmas related to the care of the individual, in the context of the family. This chapter has so far argued that generally it is helpful to engage family members. However, the decision to engage family members needs to be taken with much consideration, particularly in consultation with the ‘identified patient/client’ (in this context, usually the drinker but sometimes an affected family member who has directly sought help from the practitioner). It is important to acknowledge that not all families are the same. Some may enjoy and benefit from positive family relationships; but for some individuals, engaging with the family (in their own personal life and in treatment) can be a very distressing experience. Hence, in some situations, it may be counterproductive to engage with the family, for the person undergoing treatment. Consequently, it is important that one considers the ‘family’ from the individual drinker’s perspective (see Box 8.1) and to accept who they would prefer to describe as a family member/significant other and accept if they decide not to engage with ‘the family’. One common dilemma that occurs in many cases where an individual is experiencing an alcohol problem is where family members hold strong views related to the drinker’s responsibility for drinking, with consequent issues of blame. Often, where there is family involvement, one task for the professional is to enable the drinker and the family to hold open, honest and nonjudgemental conversations and empower them to start to work collaboratively on resolving problems. A common and related dilemma occurs when there is a dissonance between the drinker’s treatment goals and the family’s goals for the drinker, and for his/her treatment. This often shows itself over whether the aim of the help offered should be for the drinker to stop drinking entirely (an abstinence goal) or to work towards reducing or controlling their drinking (a harm-reduction goal). Key Point 8.4 Balancing the needs of the individual and the family requires careful understanding of each stakeholder’s perspective, appreciation of these differing perspectives, and a focus on how a mutual understanding can help benefit treatment goals. Although family involvement can be very helpful, it can also sometimes be detrimental, where a family member is judgemental, or controlling. In these circumstances it requires a skilled professional to ensure that family involvement remains positive.

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A final issue is of confidentiality, which relates to the information sharing agreements mentioned above, within which confidentiality should be clarified. It is the ethical responsibility of the practitioner to disclose to and be honest with the individual seeking treatment about situations in which certain aspects of assessment and treatment (e.g. in situations where the individual is actively suicidal) will be disclosed to family members. All these dilemmas should not detract from a focus on trying to involve selected family members. These attempts to involve them can be seen against a very long-­ standing historical neglect of the importance of the family in the treatment of alcohol-­related problems. Despite the evidence of burden on family members, their own support needs and the critical role family members can play in treatment services, addiction services still remain primarily focused on the individual drinker. The drinker’s family are typically neglected, or at best peripherally involved, and in terms of receiving help themselves are typically offered only ‘psychoeducation’. The result for many families is that they experience increased impacts on their physical and mental health, incur more costs in terms of time and money and are less likely to receive further support [9].

8.4.2 The Family and the Treatment Journey Families can play a key role at various points in the treatment journey for the drinker. In the initial stages of assessment or history taking, the family can play a role in asserting the seriousness and extent of the problem and providing information about the patterns of alcohol use, its impact on the drinker and the family as a whole and what has worked in the past for/against positive change for the drinker. All of this will enable a practitioner to triangulate the information received from the drinker with this information from another ‘key informant’. Throughout the following stages in the ‘treatment journey’, family members will often play a powerful role, such as in the management of withdrawal symptoms and assisting in accessing in-­ patient or community care, by encouraging the individual, ‘nudging’ him/her towards change, sharing lessons, alerting the treating team during emergencies, participating in relapse prevention planning and helping to plan out a post-problem-­ drinking life. For families to provide such positive support, it is important that services are open to their engagement, focus on them and provide both family educational programmes and family support and interventions [10].

8.4.3 The Family and the Assessment of the Seriousness of an Alcohol Problem Once a professional has identified that a person has or may have an alcohol-related problem, or that their alcohol use may be exacerbating the other problem(s) they are being consulted about, there needs to be a relatively comprehensive assessment of the nature of the person’s drinking. This will commonly involve gaining a much

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clearer understanding of the frequency and quantity of their drinking; their drinking practices, where, with whom, when; and the effects of that use of alcohol [4, 5] (see Chap. 10). Family members can often be extremely helpful in providing both corroborating and sometimes contradictory information, both of which are extremely helpful in enabling an investigating professional to obtain a clear view of the person’s drinking and its effects. For many reasons, many people with alcohol-related problems will minimise both the amount and frequency of their drinking and also the effects that their drinking has on both themselves and on others. It is also (although more rarely) the case that some people will exaggerate their drinking when they are asked about it. Both of these may occur because the individual may not be comfortable with the professional, or may distrust the professional, or because social desirability bias may be at play, etc. The purpose of the assessment is not to ‘catch someone out’; it is to obtain as good an impression as possible about the nature of the person’s drinking, so as to be able to best match any interventions with the actual situation. The family therefore can be very helpful to this process. • If they corroborate what the person is stating about drinking patterns and consequences, then the professional can proceed with greater confidence that what they are going to suggest matches the actual situation. • On the other hand, if members of the family present a different picture, then that is worthy of further investigation. It is not the case that the family must always be believed over the testimony of the drinker—the family may not know of the extent of the drinking and may not know of consequences of the drinking that the drinker has reported. But in some circumstances, the family may present a more extreme version of events, and this is often vital information which can be extremely helpful in deciding on the most appropriate intervention plan.

8.4.4 The Family and Withdrawal Management (If Necessary) Most people with alcohol-related problems will not require withdrawal management. That is only needed when someone is dependent on alcohol, and the majority of people who may need help with their drinking are harmful or risky drinkers, not dependent drinkers [11]. For the minority who are dependent drinkers, however, detoxification and withdrawal management will be important; and worldwide, this is primarily undertaken in the community (see Chaps. 16 and 22). In high-income countries, this is usually undertaken through primary care [12]; in most low- or middle-income countries, primary care does not get involved, and although in-­ patient care is occasionally provided, the usual case is for dependent drinkers to

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attempt to detoxify on their own, solely with family support [12]. In almost all of these cases, therefore, the family will be involved, and in primary care-led community detoxification, a primary requirement is that there is at least one family member who will oversee the detoxification and subsequent withdrawal management programme [12]. In such situations, the family member will be involved in a variety of ways, including taking responsibility for any prescribed medications; ensuring that their relative takes any medications prescribed for withdrawal relief; ensuring that they drink plenty of fluids and have regular healthy meals; overseeing their general health and informing their family doctor or a hospital if their relative starts experiencing hallucinations, fits or serious confusion; ensuring that they do not drive a vehicle or operate dangerous machinery until after the detoxification is completed; and dealing with seizures, if that occurs.

8.4.5 The Family and Motivating Problem Alcohol Users to Accept Help Although family members are usually ignored or excluded from alcohol interventions, one area where professionals have realised that the family is important is in motivating the drinker to accept help. This can occur both by family members helping to facilitate entry into treatment, by, for instance, helping the drinker make decisions regarding help-seeking, and by family members helping throughout a treatment episode by encouraging treatment adherence. One of the most widely evaluated approaches using this focus is the Community Reinforcement and Family Training (CRAFT) approach [13]. CRAFT has been investigated across a range of addiction-type problem behaviours including alcohol, illicit drugs and gambling, and a range of vulnerable groups [14], although we will only look at alcohol here. CRAFT aims to involve family members to positively reinforce abstinence and to provide support for the drinker in changing behaviours. The idea is to assist the drinker to enter treatment by helping the family understand and communicate about dependencies, learn how to reward positive behaviour and encourage their drinking relative to seek help. Several studies have shown that, through engaging with family members in this way, the majority of drinkers enter treatment [14]. There are other approaches: for example, ‘Pressures to Change’ also aims at engaging the family member to bring about change in the user [15], by focusing on psychoeducation (i.e. educating the family about the nature and impact of alcohol use), discussion about the family member’s coping and response to the drinking, helping the family member set up activities that discourage drinking and helping the family member confront the drinker and get help. A drawback is the limited amount and quality of research evidence for this approach.

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8.4.6 The Family and Involvement in Treatment or Interventions Other approaches seek to fully involve members of the family as central parts of an intervention. Two important examples are where a couples therapy (or family therapy) approach is adopted, where the focus is very much on the couple (or family) and their interactions, and where a social network approach is used, where the focus is on increasing the support that someone has to change their behaviour and decreasing the support to continue with their drinking. Couples/family approaches have emerged from both a ‘family systems’ and a ‘behavioural family theory’ background. The former acknowledges the role of each family member as a ‘part’ in the ‘system’, where all parts are interrelated. Because of this, change in any part of ‘the system’ will necessarily lead to change in other parts of that system; so, any change in the way the family functions, or in the behaviour of individuals in that system, will lead to change in the behaviour of the drinker. Behavioural family theory focuses on the role of behavioural interactions between a drinker and their partner, typically looking at how a couple or a family communicates. The most common intervention approaches based on these theories are the ‘Behavioural Couples Therapies’ (BCTs) developed independently by Barbara McCrady [16] and Tim O’Farrell [17]; and two recent reviews have identified that BCT performs better than individual therapies in improving both drinking and relationship outcomes in married or cohabitating individuals [18, 19]. An important example of the social network approach which uses the family or other elements within a person’s social network to effect change is Social Behaviour and Network Therapy (SBNT), which uses a drinker’s social network (usually including family but also involving peers, especially helpful when working with adolescent drinkers or adults who have lost contact with their families) to help drinkers achieve positive change by focusing on improving the support for change that they get from their network and reducing the support for continuing drinking [20]. A number of studies (e.g. [21, 22]) have shown that this approach is often very effective in helping people with alcohol-related problems to change their drinking and other behaviour.

8.4.7 The Family and Their Own Support Needs The discussion so far has been about how the involvement of family members can have positive effects on the drinker’s treatment journey. But as well as this, family members will usually have their own needs: it is often extremely challenging for family members to live, or be closely involved, with someone with a drinking problem, and the experience of a family member affected by their relative’s alcohol use is typically characteristed by considerable stress related to family disharmony and sometimes violence, uncertainties around and threat to family life, emotional consequences such as worry and ill health and social consequences including housing, income and food insecurities [23]. Therefore, when assessing and helping drinkers, professionals should also consider the range of psychological, physical and social

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problems that family members may be experiencing. It is important that both the person who is drinking and the family are empowered to voice such needs, negotiate their difficulties in the relationship and assert boundaries that may help bring about change in their lives. Historically however, there have been few interventions which have catered for family members’ needs. Although many of the interventions outlined above have taught family members useful skills (communication, behavioural management, etc.), these have been oriented towards assisting the drinker through her/his journey. They have kept the drinker at the heart of the intervention while ignoring the needs of those affected by the drinker’s behaviours. But it has been argued that family members need help in their own right. A programme of international research undertaken by a group based in the UK (partly led by the first author of this chapter) has examined the experiences and needs of family members, developing the Stress-­ Strain-Information-Coping-Support model [9], to better understand these experiences, and leading to the 5-Step Method, an approach that works with family members to explore positive ways of coping and support [24]. Studies have shown the positive impact of this intervention on family members’ symptom levels and coping methods [24] and have shown that they can be used in a wide range of settings and countries, including with indigenous communities [9]. Other interventions also focus on family members in their own right, including group therapy or mutual help groups for family members (such as Al-Anon and SMART Recovery Family and Friends), a small number designed specifically for parents of drug-using adolescents and another small number which focuses on counselling or providing coping skills training for family members (all outlined in [9]).

8.5 Cross-Cultural Factors There are a range of cultural issues which might require a professional to alter the general principles mentioned in this chapter, in order to improve the quality of care provided to both those experiencing drinking problems and their families. It is increasingly understood that professionals in all areas (not solely related to alcohol use) need to culturally tailor their services. There is good evidence [25] to show that culture strongly influences the effectiveness of almost all treatments, for example, by way of increasing or decreasing treatment-seeking behaviours, or adherence to and satisfaction with the care received, etc. Culture influences when, where and what treatment an individual seeks (or can seek) for their problem. A testimony to the importance of cultural influence on treatments for mental health is the recent Lancet commissions (e.g. [26]) that have argued that engaging with the unique features of social contexts is necessary, both to adequately prevent, diagnose or treat health conditions and to achieve high-quality health systems, by improving user experience and trust, fostering collaboration across sectors, facilitating access and increased use of care to reduce preventable illnesses and overcoming barriers encountered in programme scale-up [27]. Even in cases when the health

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professional shares several aspects of a culture in common with the individual, there are other aspects of identity such as language, race, ethnicity, age, gender, class, sexual orientation, nationality, religion and immigration status, among others which may differ. Box 8.3 gives examples of cultural issues that might arise when involving family in the management of a person experiencing alcohol problems (see Chap. 3). Box 8.3 Cultural Factors to Explore When Involving the Family

• Language-related: Are the healthcare professional and family members able to fluently and comfortably express their ideas in a common language? Is the professional using expressions, terms and references that the family members can both relate to and comprehend? For example, immigrant families may be more likely to be comfortable expressing their thoughts and feelings in their native language • Health and illness beliefs: Do the family members have a health and illness belief system to explain their loved one’s drinking problem that differs from the professional’s belief system? Have they been given an opportunity to share those beliefs? For example, Eastern medicine takes into account the ‘spirit’ in addition to the mind and body in influencing people’s behaviours • Access to services: Racial and ethnic minorities are more likely to live further away from healthcare services and can find it difficult to attend their appointments because of transport difficulties or having to lose a day’s wage. The professional might misinterpret this as disinterest of the family in helping the person with a drinking problem • Preconceived notions about the services: Families belonging to a socially or economically vulnerable community are more likely to perceive public health services and providers as ‘outsiders’ and mistrust them and hence consider those to be inappropriate for them. Their past experiences with professionals from the same system may reinforce these beliefs, which can render the services inaccessible or the treatment ineffective, if unaddressed • Family and social norms: Some ethnic groups have gender- and age-­ based norms where, for example, older men have a dominant role in decision-making when compared to the women and younger members of their communities. This particularly influences treatment-related decisions for the person experiencing alcohol problems • Family and social structures: It is common for certain communities to live with their extended family members in the same home and be influenced by the values, attitudes and beliefs of others in the home. This has implications on help-seeking behaviour and management plans for the person experiencing alcohol problems

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• Sexual orientation: Non-heterosexual individuals from racial and ethnic minority communities are more likely to keep their sexual orientation a secret, fearing ostracism or violence from their families and communities. Such conflicts are often associated with problematic alcohol use and can interfere with effective help • Religious beliefs: Families who are deeply religious might prefer and encourage their drinker to use faith or religious healers instead of evidence-­ based care for alcohol problems

Therefore, while assessing the clinical aspects of a person’s drinking problem, professionals also need to gather information that will help them to develop a cultural formulation (review of a person’s cultural background and its role in the manifestation of symptoms and experiences) of the person. One needs to do this from a position of ‘cultural humility’, i.e. accepting that there may be gaps in knowledge and understanding of the person’s cultural influences, and genuinely exploring the person’s cultural identity, while being aware of the power dynamic in the helper-­ helpee relationship. Professionals need to avoid stereotyping of those they are helping based on the information they gather in this process. Health professionals need to rely on their own subjective judgement of how culture and identity play out in an individual’s life. A good start is to explore the areas listed in Box 8.3, after establishing rapport with the person and his/her family, although there are more objective measures which can be used to assist this process: for example, the Cultural Formulation Inventory (CFI: [28]) or the Brief Cultural Interview (BCI: [29]). In addition, it is important to remember that cultural identities are complex and fluid in the extent of their influence on the person’s life. For example, an Indian-origin student might identify more prominently as a university student while at university and be influenced by attitudes and behaviours that are popular among university students. However, the same student’s ethnic identity may rise to prominence after being bullied on account of their ethnicity; or their identity might revert back if they return to live with their parents, post-university. Box 8.4 lists the skills required by a professional while exploring the cultural factors above.

Box 8.4 Skills Required by the Professional While Exploring Cultural Factors

• Building rapport and trust (Rapport is a connection or relationship with someone else and forms the basis of meaningful, close and harmonious relationships between people. It’s the sense of connection that you get when you meet someone you like and trust, and whose point of view you understand. You build rapport by your use of eye contact, showing of empathy, using open communication, keeping your word and the use of active listening.)

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• Active listening (i.e. a technique of careful listening and observation of both verbal and non-verbal cues, with feedback in the form of accurate paraphrasing; using non-verbal cues which show understanding such as nodding, eye contact and leaning forwards; and using brief verbal affirmations like ‘I see’, ‘that’s clear’, ‘yes’ or ‘I understand’) • Unconditional positive regard (i.e. the professional accepts and supports the person, no matter what they say or do, placing no conditions on this acceptance) • Ability to reduce discomfort of the other person • Ability to reflect on personal biases, attitudes and beliefs • Questioning skills • Ability to find common ground with the person’s and family’s beliefs • Ability to effectively use interpreter services when needed

The general guidelines about involving family members discussed earlier in this chapter may need to be altered, based on this cultural formulation, in order to optimise the quality of care provided to both the individual and their family members. In order to do this, there need to be certain system-/organisational-level measures in place and certain others that are implemented at the professional level. Examples of system-level measures are shown in Box 8.5: Box 8.5 System-Level Ways to Address Cultural Factors

• • • • •

Create a diverse workforce reflecting service user populations Make healthcare services convenient and easy to access Provide interpreter services Provide regular training of staff in cultural sensitivity and responsiveness Develop community outreach services to supplement facility-based services • Offer childcare services for the duration that the family is talking to the professional

Measures that can be implemented at the healthcare professional level are explained in Table 8.1, based on the type of cultural factor identified in the initial assessments. There are other circumstances too which are likely to create ethical dilemmas around family involvement. One such situation can occur when there are clearly defined laws which state that a competent person should be making their own treatment decisions, even if their family and healthcare professional disagree with them.

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Another is when such a law exists, but the hierarchical norms defined by a person’s cultural environment deprive the person of this right to make independent treatment decisions, and instead decisions are made by an elder in the family. For example, even if an individual seeks help for their drinking problem, engaging a family member in the assessment might mean that the problem is discussed at home and a decision is taken to seek help from a faith healer instead of a healthcare professional. Table 8.1  Ways to Address Cultural Factors at the Healthcare Professional Level Cultural factor Language

Health and illness beliefs

Access to services

Preconceived notions about the services

Family and social norms

Ways to address them • Use language that is free from technical jargon • Develop resource materials that are in the person’s language • Use interpreter services • Explore and integrate the person’s and their family’s beliefs about the causes and reasons for the alcohol use • Find a common ground between their explanations and yours • Use a more psychosocial model to explain the alcohol problem rather than a purely biological one. Develop management and treatment plans that are sensitive to the person and their family’s health beliefs • Allow them to feel free to seek alternative forms of help while still adhering to the agreed intervention plan and to discuss if the alternative is in conflict • Collaboratively schedule appointments with family members • Use outreach workers to communicate with the family through home visits • Offer to have sessions over the phone, or online if preferred • Open up as many aspects of the services as possible. This includes setting up service centres in the community, culturally adapting treatment programmes and translating resource materials • Listen to and acknowledge past negative experiences that they might have had in seeking care • Clarify misconceptions in a non-confrontational and non-­ condescending manner • Collaborate with local, community-based groups or individuals from those groups to engage with distrusting family members • Check with the person about existent family and social norms before interacting with the family • Discuss and agree with the person about what information can be shared with the family and what cannot • Learn about the norms relevant to a particular family prior to your interaction with them • Respect and adhere to the family and social norms as long as the person’s needs and goals are not compromised • Seek permission to interact with certain members of the family (e.g. women in certain cultures may need the consent of their family members to participate in treatment), and invite a colleague of the same sex to be present in the session to reduce discomfort (continued)

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Table 8.1 (continued) Cultural factor Family and social structures

Sexual orientation

Religious beliefs

Ways to address them • Factor in the family and social environment when making home-­based care plans • When there are indicators that the family is overriding the person’s autonomy, have a private discussion with the person to understand how the decision was reached in light of their goals and preferences • Be cautious about forming too strong an alliance with either family members or the drinker, so that the drinker’s autonomy is not compromised in an attempt to reduce discomfort caused by family pressure • Accept a decision that was made collectively by the person and their family after ensuring that the person had sufficient autonomy and information to make the decision • Find out as much as possible about attitudes held towards sexual minorities by their respective communities prior to the session with the person’s family • Avoid giving the family any indication of the person’s sexual orientation if that was their preference (and is in their best interest) • Limit discussions about the intersection of sexual orientation and alcohol use to be only with the person • Be aware of local community resources specific to sexual minorities such as peer support groups • Allow families to seek help from traditional and religious healers (provided they do not cause harm to the person) while they comply with jointly developed management and treatment plans • Leverage the resources created by their religious affiliation in the treatment plan, e.g. working with their priest to motivate them to adhere to drinking goals

Although there are not clearly defined algorithms to help healthcare professionals navigate these situations, some of the guidelines in Table 8.1 will assist them in the decision-making process. There is also a growing literature about ethical practice in family involvement (e.g. [30–32]).

8.6 Conclusions Some major challenges in the field include the lack of rigorous research exploring how family-based approaches can be implemented in routine care or practice, i.e. in existing substance use interventions. Further, more work is needed to understand how family-based interventions can be optimised in specific contexts by uncovering what works, for whom and in which settings. More efforts are needed at a multisectoral level, with service providers, programme planners and policymakers coming together to shift the focus from individual-oriented to inclusive and holistic family-based approaches to care.

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Self-Assessment Exercise 8.1: See Answers below 1. What are three situations where the family must be considered in relation to identifying alcohol-related problems? 2. A professional consulting a person with an alcohol problem gets information that the person’s family is negatively impacted due to the alcohol use. What are some ethical ways in which the professional could respond? 3. What is the most widely evaluated approach which involves family members to help motivate and encourage someone with an alcohol problem to seek help or adhere to an intervention? 4. Give two examples of effective evidence-based interventions/approaches that fully include the family as central parts of the care of a person with alcohol-use problems. Reflective Practice Exercise 8.1 1. Think back to a moment when you encountered a person with alcohol problems in your practice. • Did you involve their family in any of the stages of care, e.g. in assessment, management or treatment? • If yes, what was helpful about that for the person and/or their family? • What would you do differently after reading this chapter? • If no, what would you have done after reading this chapter? 2. A person with alcohol problems has been actively participating in the treatment plan and had achieved their goal of controlled drinking. However, their family does not accept this goal since alcohol is associated with immoral and unacceptable behaviour in their culture. They want the person to abstain from alcohol consumption. • What will you do to help the person and their family in this case? Answers to Self-Assessment Exercise 8.1 1. There are three situations where the family must be considered in relation to identifying alcohol-related problems: (a) Where a family member might provide further information which would be useful for assessment and intervention purposes (b) Where identifying that there are alcohol-related problems raises concern about how these are affecting others in the family (c) Where in dealing with someone, a professional comes to realise that they are a family member of a relative with alcohol-related problems 2. The range of ethical responses are to: (a) Raise the issue with the ‘identified’ person with whom one is working and ask them directly about the support needs of other family members (b) Provide informative materials to the person for them to take home to their family members (c) Ask permission to contact other family members to offer them support or help, or to refer them to appropriate services if they wish for that 3. CRAFT—Community Reinforcement and Family Training. 4. Behavioural Couples Therapy and Social Behaviour and Network Therapy.

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References 1. Gilligan C, Wolfenden L, Foxcroft D, Williams A, Kingsland M, Hodder R, et  al. Family-­ based prevention programmes for alcohol use in young people. Cochrane Database Syst Rev. 2019;(3):CD012287. https://doi.org/10.1002/14651858.CD012287.pub2. 2. Commission on Alcohol Harm [UK]. ‘It’s everywhere’—Alcohol’s Public Face and Private Harm—final report. London: Commission on Alcohol Harm; 2020. https://ahauk.org/wp-­ content/uploads/2020/09/Its-­Everywhere-­Commission-­on-­Alcohol-­Harm-­final-­report.pdf. Accessed 24 Sept 2021. 3. Kourgiantakis T, Ashcroft R, Mohamud F, Fearing G, Sanders J. Family-focused practices in addictions: a scoping review. J Soc Work Pract Addict. 2021;21:18–53. https://doi.org/10.108 0/1533256X.2020.1870287. 4. Miller W, Rollnick S. Motivational interviewing—helping people change. 3rd ed. New York: Guilford; 2013. 5. Velleman R. Counselling for alcohol problems. 3rd ed. London: Sage (Counselling in Practice Series); 2011. 6. Itäpuisto M.  Helping the children of substance-abusing parents in the context of outpatient substance abuse treatment. Addict Res Theory. 2014;22:498–504. https://doi.org/10.310 9/16066359.2014.892930. 7. Scottish Government. Getting our priorities right: good practice guidance. 2013. https://www. gov.scot/publications/getting-­priorities-­right/. Accessed 24 Sept 2021. 8. Drug & Alcohol Findings. How can you prioritise the child when your patient is the parent? 2021. https://findings.org.uk/PHP/dl.php?f=Matrix/Alcohol/C5.htm&format=open&s=eb&sf =mx#issue3. Accessed 24 Sept 2021. 9. Orford J, Velleman R, Natera G, Templeton L, Copello A. Addiction in the family is a major but neglected contributor to the global burden of adult ill-health. Soc Sci Med. 2013;78:70–7. https://doi.org/10.1016/j.socscimed.2012.11.036. 10. Templeton L, Velleman R, Russell C.  Psychological interventions with families of alcohol misusers: a systematic review. Addict Res Theory. 2010;18:616–48. 11. Alcohol Change. The alcohol change report. London: Alcohol Change; 2018. 12. Nadkarni A, Endsley P, Bhatia U, Fuhr D, Noorani A, Naik A, et al. Community detoxification for alcohol dependence: a systematic review. Drug Alcohol Rev. 2017;36:389–99. https://doi. org/10.1111/dar.12440. 13. Meyers R, Roozen H, Smith J.  The community reinforcement approach—an update of the evidence. Alcohol Res Health. 2011;33:380–8. 14. Archer M, Harwood H, Stevelink S, Rafferty L, Greenberg N. Community reinforcement and family training and rates of treatment entry: a systematic review. Addiction. 2020;115:1024–37. https://doi.org/10.1111/add.14901. 15. Barber JG, Gilbertson R. An experimental study of brief unilateral intervention for the partners of heavy drinkers. Res Soc Work Pract. 1996;6:325–36. 16. McCrady BS.  Family and other close relationships. In: Miller WR, Carroll KM, editors. Rethinking substance abuse: what the science shows, and what we should do about it. New York: Guilford; 2006. p. 166–81. 17. Klostermann K, O’Farrell TJ. Couple and family therapy in treatment of alcoholism and drug abuse. In: el-Guebaly N, Carrà G, Galanter M, Baldacchino AM, editors. Textbook of addiction treatment. Cham: Springer; 2021. https://doi.org/10.1007/978-­3-­030-­36391-­8_31. 18. Meis L, Griffin J, Greer N, Jensen A, MacDonald R, Carlyle M, et  al. Couple and family involvement in adult mental health treatment: a systematic review. Clin Psychol Rev. 2013;33:275–86. 19. Powers M, Vedel E, Emmelkamp P. Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis. Clin Psychol Rev. 2008;28:952–62. 20. Copello A, Orford J, Hodgson R, Tober G, Barrett C. On behalf of the UKATT research team. Social behaviour and network therapy: basic principles and early experiences. Addict Behav. 2002;27:345–66.

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21. UKATT Research Team. Effectiveness of treatment for alcohol problems: findings of the randomised UK alcohol treatment trial (UKATT). BMJ. 2005;331:541. 22. Watson J, Back D, Toner P, Lloyd C, Day E, Brady L-M, et al. A randomised controlled feasibility trial of family and social network intervention for young people who misuse alcohol and drugs: study protocol (Y-SBNT). Pilot Feasibil Stud. 2015;1:1–11. 23. Orford J, Velleman R, Copello A, Templeton L, Ibanga A. The experiences of affected family members: a summary of two decades of qualitative research. Drugs Educ Prev Policy. 2010;17(Suppl. 1):44–62. 24. Velleman R, Orford J, Templeton L, Copello A, Patel A, Moore L, et al. 12-month follow-up after brief interventions in primary care for family members affected by the substance misuse problem of a close relative. Addict Res Theory. 2011;19:362–74. 25. Gainsbury S.  Cultural competence in the treatment of addictions: theory, practice and evidence. Clin Psychol Psychother. 2017;24:987–1001. https://doi.org/10.1002/cpp.2062. 26. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018;392:1553–98. https://doi. org/10.1016/S0140-­6736(18)31612-­X. 27. Gómez-Carrillo A, Lencucha R, Faregh N, Veissière S, Kirmayer LJ. Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice. BMJ Glob Health. 2020;5:e002689. https://doi.org/10.1136/bmjgh-­2020-­002689. 28. American Psychiatric Association. The cultural formulation interview (CFI). American Psychiatric Association; 2013. https://www.psychiatry.org/File%20Library/Psychiatrists/ Practice/DSM/APA_DSM5_Cultural-­Formulation-­Interview.pdf. Accessed 24 Sept 2021. 29. Groen S, Richters A, Laban C, Deville W. Implementation of the cultural formulation through a newly developed brief cultural interview (BCI): pilot data from the Netherlands. Transcult Psychiatry. 2017;54:3–22. https://doi.org/10.1177/1363461516678342. 30. Gilbar R. Asset or burden? Informed consent and the role of the family: law and practice. Leg Stud. 2012;32:525–50. https://doi.org/10.1111/j.1748-­121X.2011.00223.x. 31. Ho A.  Relational autonomy or undue pressure? Family’s role in medical decision-making. Scand J Caring Sci. 2008;22:128–35. 32. Menon S, Entwistle VA, Campbell AV, van Delden JJM. Some unresolved ethical challenges in healthcare decision-making: navigating family involvement. Asian Bioeth Rev. 2020;12:27–36. https://doi.org/10.1007/s41649-­020-­00111-­9.

To Learn More Copello A, Velleman R, Templeton L. Family interventions in the treatment of alcohol and drug problems. Drug Alcohol Rev. 2005;24:369–85. https://doi.org/10.1080/09595230500302356. Orford J, Velleman R, Natera G, Templeton L, Copello A. Addiction in the family is a major but neglected contributor to the global burden of adult ill-health. Soc Sci Med. 2013;78:70–7. https://doi.org/10.1016/j.socscimed.2012.11.036. Velleman R. Counselling for alcohol problems, Counselling in Practice Series. 3rd ed. London: Sage; 2011.

9

Responses and Referral Scott Macpherson and Dan Warrender

Learning Outcomes • To understand the impact of individual and societal attitudes towards alcohol and how these may influence both people’s relationship with alcohol and the care they receive • To appreciate the importance of key therapeutic principles in providing useful responses for people experiencing problems with alcohol • To understand the assessment process and options for appropriate referral • To understand brief interventions and how they may help

9.1 Introduction This chapter explores the proper responses and referral process for people experiencing problems with alcohol. People may present to a variety of different services and professionals, many of whom may not be alcohol specialists. However, each presentation should be seen as an opportunity to engage, empathise and, if required, appropriately refer or signpost. We feel it important to firstly appreciate the oft confusing context which people may find themselves in, which may make it difficult to identify when alcohol use has become a problem. We begin with an honest monologue from stand-up comedy: That’s what I hate about the war on drugs, I’ll be honest with you, it’s what I can’t stand is all day long when we see those commercials: “Here’s your brain, here’s your brain on drugs”. “Just say no.” “Why do you think they call it dope?” And then the next commercial is: ‘This Buds for you.’ Come on everybody let’s be hypocritical … It’s OK to drink your S. Macpherson (*) · D. Warrender School of Nursing, Midwifery and Paramedic Practice, Robert Gordon University, Aberdeen, Scotland e-mail: [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_9

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drug. (laughs) We meant those other drugs. Those untaxed drugs. Those are the ones that are bad for ya. Nicotine, alcohol … good drugs. Coincidentally, taxed drugs. Oh, how does this … work?

[1, p. 37] It’s hard to argue with the late Bill Hicks, as the comedian/philosopher emphasises the systematic hypocrisy which has seen some drugs demonised and criminalised yet others normalised and incorporated into everyday life. Any person with alcohol problems living in many (particularly) Western societies may need to navigate their way through a cultural acceptance of alcohol use, as a drug fitting any occasion, through celebrating the highs to commiserating the lows, and a mainstay of socialisation. As alcohol is so socially acceptable, the pressure to drink has been felt by people across their lifespan, with pressure experienced as either overt and aggressive or more subtle and friendly [2]. However, despite a pressure to drink, there is also a stigma around drinking too much. People dependent on alcohol have been regarded as responsible for their own predicament, inviting negative emotions, social rejection and discrimination [3]. Although socialisation relying on alcohol may be changing, with innovations such as the world’s first alcohol-free bar [4], change is slow. For the moment, the experience of many is contending with two messages: that abstinence is not socially acceptable and that drinking too much is also not socially acceptable. As both ends of the spectrum can be stigmatised, it may be difficult for many to navigate through this swamp and find the line, the goldilocks zone, of ‘just right’ drinking. Thinking about alcohol use and problems as a spectrum rather than in binary terms such as ‘alcoholic’ and ‘social drinker’ may be useful. Key Point 9.1 This may help professionals to see people rather than labels and avoid simplification, appreciating the complexity of human beings and their relationship with alcohol. As authors, we ourselves are aware of the extent to which alcohol has been normalised, even glamorised in our culture. We write this acutely aware of the dangers of alcohol dependence yet still in awe of the art of brewing, and the exquisite taste, of a good Belgian beer. Many health and social care practitioners will enjoy using alcohol; it is essential that we are aware of how our own attitudes may influence our practice. Just as people may find it difficult to balance their own use of alcohol, our own perceptions and interactions with alcohol may influence what we define or understand as problem drinking. This may lead to missed opportunities for conversations about the use of alcohol, as we may overtly accept its use, or be worried about looking in the mirror at our own problems. Useful interactions always start with an acute self-awareness.

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Attitudes play a significant role in how care is delivered and received. People experiencing problem alcohol use (as well as people experiencing problem drug use) are the most stigmatised group, within an already highly stigmatised group (people with mental disorders) [5–8]. An awareness of this stigma and a checking in about our own attitudes and beliefs may challenge any negative attitudes we bring into the room with us. Reflective Practice Exercise 9.1 Thinking/reflection point: • Consider your own relationship with and beliefs about alcohol. • How might your own experiences impact on the care you deliver to others?

9.2 Important Therapeutic Principles Practitioners may be fearful and feel out of their depth in collaborating with people experiencing alcohol problems. At times they may feel that they lack the necessary skills and competence to be useful. However, whilst an appropriate referral can be incredibly important, knowing that there is specialist care on the other side of the referral should never allow any practitioner to overlook their own role in providing a therapeutic response. One could furthermore argue that without the following key therapeutic skills, any engagement, whether it be screening, assessment or brief intervention, may not be as comprehensive or effective as it otherwise could be. We would strongly argue that one of the most important tasks of any practitioner, which could be considered an intervention, is creating a true connection, rapport and relationship. One is more likely to be useful to another through listening and hearing to understand a person’s perspective, than ritualistically following any tick-box approach to assessing a person’s human experience. The key skills and considerations briefly discussed below should be part of any therapeutic response (see Box 9.1). Reflective Practice Exercise 9.1 Thinking/Reflection Point: • If you were seeking help from someone, what kinds of things would be important to you? Box 9.1 Key considerations and skills for therapeutic responses [9–12]: • Trauma-informed care • Empathy • Positive regard • Congruence • Mentalising conversations

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9.3 Trauma-Informed Care Trauma-informed care encourages all practitioners to consider the life experiences and context which may link to the current difficulties of the people they are working with. Felitti et  al.’s [13] now seminal study on adverse childhood experiences (ACEs) in the USA argued that many public health problems may be personal solutions to the trauma people have experienced. Alcohol thus may be considered as something a person may use to self-medicate and manage their distress. Whilst people consume alcohol for many reasons and trauma is not an inevitability, it is important that any practitioner looks through the trauma lens and has the curiosity to consider it as a possibility. It may be worth considering that if alcohol is a person’s solution, what alternative solutions are available to them? Simply telling someone not to do something without offering an alternative, when it is being done for a purpose, is at best useless, and at worst patronising and punitive. Whilst we would not place an expectation that the problems will be resolved and alternative coping mechanisms will be discovered by the end of an interaction, it is at least an area worthy of exploration, provided it is explored with empathy. Key Point 9.2 Key principles of trauma-informed practice are listed below [12]: • Being mindful that people who you work with may have experienced trauma and adversity • Ensuring that the person feels safe • Being mindful not to inadvertently retraumatise people, particularly through power dynamics which replicate earlier ‘power over’ relationships • Being trustworthy and transparent • Adopting a truly collaborative approach • Empowering people and offering them as much choice and control as possible

9.4 Core Conditions Additionally, and crucially, Carl Rogers’ [10, 11] core conditions of the therapeutic relationship (empathy, congruence and unconditional positive regard; Box 9.2) are a necessary platform for any therapeutic interaction and are as relevant now as when they were first discussed many years ago.

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Box 9.2 Rogers’ core conditions of the therapeutic relationship • Empathy – An attempt to understand the perspectives and experiences of another through their frame of reference • Congruence  – The practitioner engaging as their genuine self and being open about their own experiences of the engagement, where this may be beneficial to the person • Unconditional Positive Regard – Accepting and valuing a person’s worth. Setting aside our own judgement regarding their thoughts, feelings and behaviours that may otherwise get in the way of providing care and support for the person The core conditions encourage us to imagine the experiences of the people we are working with, connect with their emotional experiences, stay out of judgement and be genuine, walking the line between our professional and personal selves. If we remove any one of these conditions, we quickly lose our usefulness to other humans, being blind to their experiences and mental states, judging them and being experienced as robotic or false. Whilst a reminder of these may feel patronising, they can be too easily forgotten.

9.5 Mentalising Conversations Mentalisation is defined as: … the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. [9, p. 11]

It is a useful concept and frame for conversations. Mentalising focuses on the mind rather than behaviour and understands what people do based on what they think and feel. This will allow conversations to move beyond drinking and alcohol use, to what the person is thinking and feeling. Importantly, mentalising encourages thoughts not only about ourselves but also others around us. One person reflects on their relationship: ‘my ex-wife who I always thought, through my drunken years, hated my guts’, later realised, ‘didn’t – she just wanted me to get back to living again’ [14]. It could be argued that encouraging mentalising others, even in a brief interaction, could hugely benefit people’s relationships. The more significant, caring and trusted others around anyone experiencing problems with alcohol, the better.

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9.6 Initial Assessment/Screening (See Chap. 10) Opportunistic alcohol screening should be an integral part of the care we provide. It may not be possible to screen everyone. However NICE [15] recommends that screening is particularly focused on people who have alcohol-related conditions, such as hypertension or liver disorders, and those who may be at an increased risk of harm from alcohol, such as: • • • •

People who often experience accidents or minor traumas People at risk of domestic abuse People who self-harm People with relevant mental health problems, e.g. anxiety, depression or other mood disorders

‘Screening’ is the process of using a validated alcohol questionnaire such as the Alcohol Use Disorders Identification Test (AUDIT) [16] to identify people whose current contact with services is not about seeking help with an alcohol problem but who may require support around their alcohol use (see Fig. 9.1). Screening tools such as the AUDIT can be used to inform decisions about whether to offer a person a brief intervention (and, if so, what type) or whether to make a referral to specialist alcohol services. If time is limited, an abbreviated screening tool can be used (such as AUDIT-C, AUDIT-PC, SADQ (Severity of Alcohol Dependence Questionnaire) or FAST (fast alcohol screening test) [17]). Screening tools should be appropriate to the setting, for instance, in an emergency department, FAST or PAT may be most appropriate due to their brevity [17]. Alcohol problems do not discriminate between demographics; thus professionals should be aware when screening not to overlook potential issues based on societal expectations around gender, age, ethnicity or social class. Any conversations between different social groups offer potential for misunderstanding; therefore whilst these conversations around alcohol use should be navigated with cultural sensitivity, they must not be avoided for fear of offending (see Chap. 3). The therapeutic principle of transparency allows an honesty in telling people your concerns and also telling the person about your worries around ‘getting it wrong’. Key Point 9.3 Whilst communication between humans is always complex, people usually respond well to honesty.

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AUDIT The Alcohol Use Disorders Identification Test: Interview Version (16) Read questions as written and record answers carefully. Begin the AUDIT by saying ”Now I am going to ask you some questions about your use of alcoholic beverages during this past year." Explain what is meant by"alcoholic beverages" by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks”. Place the correct answer number in the box at the right. 1. How often do you have a drink containing alcohol? (0) (1) (2) (3) (4)

Never (skip to Questions 9 and10) Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) (1) (2) (3) (4)

1 or 2 3 or 4 5 or 6 7,8, or 9 10 or more

3. How often do you have six or more drinks on one occasion? (0) (1) (2) (3) (4)

Never Less than monthly Monthly Weekly Daily or almost daily

Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0

4. How often during the last year have you found that you were not able to stop drinking once you had started? (0) (1) (2) (3) (4)

Never Less than monthly Monthly Weekly Daily or almost daily

5. How often during the last year have you failed to do what was normally expected from you because of drinking? (0) (1) (2) (3) (4)

Never Less than monthly Monthly Weekly Daily or almost daily

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (0) (1) (2) (3) (4)

Never Less than monthly Monthly Weekly Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking? (0) (1) (2) (3) (4)

Never Less than monthly Monthly Weekly Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? (0) (1) (2) (3) (4)

Never Less than monthly Monthly Weekly Daily or almost daily

9. Have you or someone else been injured as a result of your drinking? (0) (2) (4)

No Yes but not in the last year Yes during the last year

10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? (0) (2) (4)

No Yes but not in the last year Yes during the last year

Record total of specific items here

Fig. 9.1  The Alcohol Use Disorders Identification Test (AUDIT): interview version

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9.7 Brief Interventions (See Chap. 17) The term ‘brief intervention’ refers to a session that aims to help a person to reduce or abstain from alcohol consumption. This can take the form of either a short session between a practitioner and a person experiencing an identified alcohol problem that consists of structured brief advice from the practitioner around the person’s alcohol use or a longer session (called an extended brief intervention) that is based more on the principles of motivational interviewing (see Chap. 23). Both types of brief intervention can safely be carried out by non-alcohol specialists. For people aged 18+ years, NICE [15] recommends screening and structured brief advice as a first step. People who do not respond to this structured brief advice should then have an extended brief intervention. A person who may be dependent on alcohol should not be offered simple brief advice. Instead, they should be referred to specialist alcohol services. If a person who may be dependent on alcohol is reluctant to accept a referral to specialist alcohol services, then they should be offered an extended brief intervention. Offering an intervention is less likely to cause harm than failing to act when we have concerns; however if in doubt, we should seek to contact relevant specialists to discuss.

9.8 Brief Advice Training in brief advice on alcohol should be available and accessible to people working in a range of settings and services, including healthcare services, social services, criminal justice services, further and higher education and other public services. Having identified, through screening, that a person is drinking a hazardous or harmful amount of alcohol, a professional should immediately offer the person a session of structured brief advice. In exceptional circumstances where it is not possible to offer this session at once, then an appointment for this should be offered as soon as possible after identification. A brief advice session should last 5–15 min in total and should use an evidence-based resource that is based on the FRAMES [18] (Box 9.3) principles.

Box 9.3 Frames

• Feedback – The professional should provide the person with verbal feedback that is personally relevant to them and their situation. This should include information about the person’s alcohol use and problems derived from the assessment or screening that has been carried out, e.g. their score from the AUDIT screening tool. The feedback can also include information about personal risks due to the person’s current pattern of alcohol use and more general information about alcohol-related risks and harms. If the person’s current presentation is potentially linked to alcohol use, then it is also important to highlight this link

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Key Point 9.4 Many people are unaware that their drinking is at a hazardous or harmful level, and highlighting the risks related to this can be a powerful motivator for behaviour change. • Responsibility – Empowering the person to acknowledge that they retain personal responsibility and control over their behaviours, decisions and consequences has been shown to play an important part in motivation for behaviour change and in reducing resistance to change in people with alcohol problems • Advice – People should be provided with advice about the risks and harms related to the continuation of their current pattern of alcohol use. It is often the case that people are unaware of the potential risks (health or otherwise) that their current pattern of drinking may pose. Providing advice that reducing or ceasing alcohol use will reduce the person’s risk of future problems enhances the person’s understanding of their personal risk and helps to provide them with reasons to consider changing their pattern of alcohol use. It is important to ensure that any advice that is provided is unambiguous and easy to understand • Menu – Professionals delivering brief interventions (see Chap. 17) should provide the person with a range of alternative strategies that they can use to help change their alcohol behaviours. Providing a range of options allows the person to exercise choice over which strategies may be most useful and suitable for them and reinforces the sense of personal responsibility and control that can be useful in strengthening their motivation for change • Examples of alternative strategies include: –– Putting aside money that would usually be spent on alcohol to be spent on something else –– Providing information on peer support or self-help resources that the person can access –– Keeping an alcohol use diary –– Alternating alcoholic drinks with soft drinks –– Having regular alcohol-free days –– Identifying other hobbies/interests to engage in that do not involve alcohol –– Identifying personal high-risk situations and developing strategies for avoiding them • Empathy – A good therapeutic alliance is a strong predictor of reduced alcohol use at follow-up [19], and this cannot be achieved through the use of an authoritarian, directive, confrontational or coercive approach. Professionals must use an empathic, warm, understanding, reflective style to work collaboratively with the person to consider the risks, harms and reasons for change

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• Self-efficacy – It is important that professionals express hope and encourage people’s confidence in their ability to make change happen in relation to their alcohol use. Working to elicit self-efficacious statements about changes in alcohol use is a key component of brief interventions as people are likely to trust the things they hear themselves say. People who believe that they are likely to make changes are far more likely to succeed in doing so than people who feel powerless or helpless to make changes [19]

The word ‘advice’ in the name of the approach and in these principles could lead to an unhelpful interpretation of what is required by professionals. This could lead to professionals taking an authoritarian or paternalistic approach; however if there is a most important principle here, it is empathy. Key Point 9.5 A person who does not feel listened to or understood by a professional is unlikely to place importance on the advice given by that professional. During the session the professional should collaborate with the person to look at the potential harm caused by their drinking and explore reasons for changing this, including the potential health and well-being benefits. It is important to carefully and empathically explore potential barriers to change with the person and empower the person to generate strategies for overcoming these (addressing the self-efficacy principle). The professional can outline practical strategies for reducing alcohol consumption, or better still, the person may be able to offer some strategies for this. The discussion should lead the person to set goals for the reduction of their alcohol consumption. It can be easy for the professional to forget the importance of collaboration and set goals for the person. However, self-efficacy is of prime importance in health behaviour change, so the professional must resist this ‘righting reflex’ and instead collaborate with the person, allowing the individual to set their own goals that are both meaningful and achievable for them. Where the professional has an ongoing relationship with the person, there should be regular discussion about the person’s progress towards achieving their goals. Where necessary, the person can be offered an additional session of structured brief advice, or where the person does not seem to have benefited from brief advice, an extended brief intervention should be offered.

9.9 Extended Brief Interventions As with brief advice, training for extended brief interventions should be available and accessible to all professionals who may meet people who are at risk of harm from alcohol use. This type of session should be offered to people for whom

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structured brief advice has not proved useful. An extended brief intervention should last 20–30  min and should use motivational interviewing [19] or motivational-­ enhancement therapy [20], to help a person reduce their alcohol use to low-risk levels, reduce any risk-taking behaviour or consider abstaining from alcohol use. Key Point 9.6 It is very important to collaborate with the person rather than telling them what they should do. People who have received an extended brief intervention should be followed up in order to monitor any progress and any need for further sessions or referral to specialist alcohol services.

9.10 Referral to Specialist Alcohol Services Professionals should not offer brief interventions to people who show signs of moderate or severe alcohol dependence (as indicated by a screening tool such as the AUDIT), people who show signs of severe alcohol-related impairment or people who have a related co-morbid condition (e.g. liver disease or alcohol-related mental health problems). Instead, these people should be referred to specialist alcohol services at the earliest opportunity. Additionally, people who have not benefited from structured brief advice and an extended brief intervention should be referred to specialist alcohol services if they wish to receive further help.

9.11 Service Design and Accessibility Ideally, services should provide a facility for people to self-refer in order that opportunities for seeking help are not missed through the, sometimes lengthy, process of referral to first appointment at the specialist service. Unfortunately, there can be problems with service design that make it difficult for a person to access specialist help after a referral. Some services still operate on a 9 am–5 pm, Monday–Friday basis, which will exclude those who tend to be awake through the night and asleep through the day. Other areas have separate alcohol and drug services and exclude people referred to alcohol services if they use any other drugs. This can miss an opportunity to find out from the person who should be at the centre of care, which service they might be most likely to engage with and why. Some find themselves in the ridiculous position of being excluded from specialist alcohol services due to issues with mental disorders (see Chap. 5) whilst at the same time being excluded from other mental health services due to their alcohol dependence. Whilst we accept that ‘dual diagnosis’ is a term recognised by health and social care services, we would argue that no diagnosis can ever comprehensively describe the difficulties and distress of any human being, and furthermore ‘dual diagnosis’ may encourage us to look at separate issues, rather than the person as a whole.

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9.12 Conclusion This chapter has explored ideas around the context of alcohol in our society, important principles when engaging with people experiencing alcohol problems, some key interventions and considerations for service design. However, if we would like you to take one thing away from this chapter, it would be this: many people experience alcohol problems and overcome these. Whilst we always need to respond to people with empathy, moreover we need to do this with hope in our hearts.

References 1. Hicks B. Love all the people. London: Constable; 2005. 2. Morris H, Larsen J, Catterall E, Moss AC, Dombrowski SU. Peer pressure and alcohol consumption in adults living in the UK: a systematic qualitative review. BMC Public Health. 2020;20:1014. https://doi.org/10.1186/s12889-­020-­09060-­2. 3. Schomerus G, Lucht M, Holzinger A, Matschinger H, Carta MG, Angermeyer MC. The stigma of alcohol dependence compared with other mental disorders: a review of population studies. Alcohol Alcohol. 2011;46:105–12. 4. Brewdog. Brewdog launches world’s first alcohol-free beer bar. 2020. https://presshub. brewdog.com/presshub/brewdog-­launches-­worlds-­first-­alcohol-­free-­beer-­bar. Accessed 20 Dec 2021. 5. Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. Am J Public Health. 1999;89:1328–33. 6. Corrigan PW, Kuwabara SA, O’Shaughnessy J. The public stigma of mental illness and drug addiction: findings from a stratified random sample. J Soc Work. 2009;9:139–47. 7. Corrigan PW, Tsang HW, Shi K, Lam CS, Larson J.  Chinese and American employers’ perspectives regarding hiring people with behaviorally driven health conditions: the role of stigma. Soc Sci Med. 2010;71:2162–9. 8. Phillips LA, Shaw A. Substance use more stigmatized than smoking and obesity. J Subst Abus. 2013;18:247–53. 9. Bateman A, Fonagy P.  Mentalization based treatment for borderline personality disorder. World Psychiatry. 2010;9:11–5. https://doi.org/10.1002/j.2051-­5545.2010.tb00255.x. 10. Rogers CR.  The necessary and sufficient conditions of therapeutic personality change. J Consult Psychol. 1957;21:95–103. 11. Rogers CR.  The interpersonal relationship: the core of guidance. Harv Educ Rev. 1962;32:416–29. 12. Sweeney A, Filson B, Kennedy A, Collinson L, Gillard S. A paradigm shift: relationships in trauma-informed mental health services. BJPsych Adv. 2018;24:319–33. 13. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14:245–58. 14. National Institute of Health and Care Excellence. Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence. Appendix 14. Experience of care: personal accounts and thematic analysis. 2011. https://www.ncbi.nlm.nih. gov/books/NBK65504/. Accessed 2 Dec 2021. 15. National Institute of Health and Care Excellence. Screening and brief interventions for harmful drinking and alcohol dependence. 2021. https://pathways.nice.org.uk/pathways/alcohol-­use-­ disorders/screening-­and-­brief-­interventions-­for-­harmful-­drinking-­and-­alcohol-­dependence. pdf. Accessed 20 Dec 2021.

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16. World Health Organisation. AUDIT: The Alcohol Use Disorders Identification Test guidelines for use in primary care. 2nd ed. Geneva: WHO; 2001. 17. National Institute of Health and Care Excellence. Alcohol-use disorders: prevention. 2010. https://www.nice.org.uk/guidance/ph24. Accessed 2 Dec 2021. 18. Bien T, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction. 1993;88:315–36. 19. Miller WR, Rollnick S. Motivational interviewing. 2nd ed. London: Guilford; 2002. 20. Miller WR, Zweben A, DiClemente CC, Rychtarik RG.  Motivational enhancement therapy manual. A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: U.S. Department of Health and Human Services; 1994.

To Learn More Bandura A.  Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191–215. Mosher CJ, Akins S. Drugs and drug policy: the control of consciousness alteration. 2nd ed. Sage: Thousand Oaks, CA; 2014. Curra J. Drugs and drug taking. In: The relativity of deviance. Thousand Oaks, CA: Pine Forge; 2011. p. 261–286. Kelly JF, Saitz R, Wakeman S. Language, substance use disorders, and policy: the need to reach consensus on an “addictionary”. Alcohol Treat Q. 2016;34:116–23. European Monitoring Centre for Drugs and Drug Addiction. Health and social responses to drug problems: a European guide. Luxembourg: Publications Office of the European Union; 2017.

Assessment

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Michael Hazelton, Ellen Sinclair, and Hayley Wicks

Learning Outcomes Readers will be able to: • Identify and discuss key technical and ethical aspects of conducting an assessment of alcohol use in individuals in various age groups across the lifespan • Identify and discuss negative impacts associated with alcohol use in children and adolescents • Outline questions to be asked when conducting an alcohol use assessment • Discuss ethical considerations when conducting an alcohol use assessment

10.1 Introduction This chapter considers issues in the assessment of alcohol use across the lifespan. However, given the high risks associated with underage alcohol consumption, particular attention will be given to assessment in young people. While the chapter addresses aspects of the assessment of alcohol use in the authors’ own country,

M. Hazelton (*) School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, The University of Newcastle, NSW, Australia e-mail: [email protected] E. Sinclair Open Arms Veteran’s Counselling Service, NSW, Australia e-mail: [email protected] H. Wicks Local Area Drug and Alcohol Service, Hunter New England Health, NSW, Australia e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_10

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Australia, the material covered will be relevant to the service conditions of readers from many other countries. The National Health and Medical Research Council (NHMRC) [1] of Australia publishes guidelines to reduce health risks from drinking alcohol, to provide evidence to inform Australians about low-risk drinking. Alcohol is a common form of substance used to alter mental states in most cultures and has the potential to damage health and wellbeing across the lifespan. While not all individuals who consume alcohol will develop health problems, alcohol use is a common aspect of many social activities, with many health and social harms being linked to the intoxicating, toxic and dependence effects of alcohol [2]. It has been estimated that 5.1 per cent of the global burden of disease is attributable to alcohol use. Approximately 2 billion people worldwide consume alcohol, and the number with diagnosable alcohol use disorders is more than 76 million. Taken together, alcohol, tobacco and illicit drugs account for 12.4 per cent of all deaths worldwide [3]. Hence alcohol use is considered a serious public health issue worldwide [2]. Alcohol has long been an important but complex aspect of Australian culture. Most people in Australia drink alcohol for enjoyment, relaxation and sociability. The legal drinking age was lowered from 21 to 18 in 1974, and this led to a rise in alcohol consumption by young people and an increase in alcohol-related accidents, mortality and morbidity. An increasing number of Australians live with alcohol use disorders. In Australia, alcohol consumption causes over 5000 deaths per year, and for each death about 19 years of life are prematurely lost. About one-third (35%) of the Australian population drink at levels that put them at risk of short-term harm, while about 10 per cent of the population drink at levels that put them at risk of long-term harm [1]. Regardless of the type of risk, people who drink excessively experience numerous physical and psychological symptoms [4, pp.  3–21, 5, pp. 259–260]. For many individuals who go on to develop alcohol use-related problems, consumption of alcohol begins at an early age, often prior to the minimum legal age for alcohol consumption. It is not unusual for a person to receive a diagnosis of alcohol use disorder early in adulthood indicating that problematic consumption of alcohol had likely commenced during childhood or adolescence. Accordingly, assessment of alcohol use can often be an important component of health assessment during the adolescent and early adulthood years. Alcohol use may also contribute to mental health issues, which often originate at an early age. All countries face challenges with substance use, with alcohol typically being the most pressing, and substance use disorders often co-occur with mental health problems. About half of all mental illness begins by the age of 14 and many cases go undetected and untreated [6]. In many countries substance use and mental health services are often separated from other healthcare services, and individuals presenting with substance use problems, including alcohol use disorders, are subject to stigma and discrimination, often being exposed to rejecting attitudes and injustices in health system encounters and in the wider society. Exposure to such negative professionals’ attitudes and behaviours makes the assessment and treatment of alcohol use problems both clinical and ethical issues [7, 8]. While this can have serious

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consequences for treatment adherence in all age groups, it is of particular concern in adolescents and young adults.

10.2 Therapeutic Presence and the Assessment of Alcohol Use Effective history taking and assessment is fundamental to being able to determine a person’s treatment needs in any area of health care [4] and is certainly the case when working with a person presenting with alcohol use problems. If alcohol use problems are to be comprehensively assessed and understood, the quality of the working relationship or alliance a practitioner forms with the person with whom they are working is of the utmost importance. This is where therapeutic presence is important. Therapeutic presence has been defined as ‘the state of having one’s whole self in the encounter with the individual by being completely in the moment on a multiplicity of levels—physically, emotionally, cognitively, and spiritually’ [9, p. 7]. In outlining a model of therapeutic presence, Geller and Greenberg [9] point to what the practitioner brings to their work with an individual, among other things: • • • •

An attitude of openness Acceptance Interest Nonjudgement They also point to key activities such as:

• Building trust • Being accessible • Avoiding preconceptions Treatment outcome depends on how assessment has been performed and the strength of the therapeutic relationship that underpins that assessment will be important. Hence, therapeutic presence has been acknowledged as a core quality that enhances the therapeutic relationship [9]. The practitioner qualities associated with therapeutic presence, as part of building and maintaining a working alliance with an individual seeking treatment, can contribute to combating the well-recognised problems of stigma and discrimination faced by people presenting with substance use problems, including alcohol use disorders [8]. The therapeutic attitude a practitioner takes into the process of assessing alcohol use in a person seeking help will likely influence how that person responds to the professional subsequently involved in providing care and treatment. Thus, while assessment raises technical and clinical questions, it also poses ethical and moral concerns. Health equity is also an important consideration when working with people adversely affected by harmful alcohol use. In Australia, the disease and injury

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burden from alcohol use has been shown to be skewed towards people in the lower socioeconomic groups. In 2011, the greatest amount of burden was experienced by those in the lowest socioeconomic group, while the lowest burden was experienced by those in the highest socioeconomic group [1, p. 61]. Therefore, it is of critical importance that healthcare practitioners are aware of such issues and are able to reflect on them and to understand the problems faced by people presenting with substance use problems such as alcohol use disorder. As assessment is typically an aspect of the early stages in which a person presents for help to a healthcare service, the nature of that encounter can have an important influence on the conduct and direction of care and how an individual responds to it.

10.3 Harmful Use of Alcohol Across the Lifespan The effects of alcohol are both immediate and cumulative and can affect various neural pathways and parts of the brain. Alcohol use-related harm in individuals is influenced not only by the amount of alcohol consumed but by complex interaction between: • • • •

The age and experience of the person drinking Their social situation Genetics Overall health status [2]

Alcohol consumption can adversely affect the health of an individual in various ways (see Chaps. 5 and 6) including direct and indirect toxic impacts on various organs and body systems [4, pp.  3–21]; increased risk of a range of harms, for example, accidents and acute intoxication; and harms related to alcohol dependence. Such negative impacts on health depend on a range of factors, including the frequency and level of consumption, and can be observed in both the short and long term [1, p. 18]. The World Health Organization [6] has identified the harmful use of alcohol as one of five major risk factors contributing to the rise of non-­communicable diseases such as diabetes, cancer and heart disease worldwide (see Chap. 6). Taking into account individual variability, there is no level of alcohol use that can be considered ‘safe’ for everyone. Factors that affect individual responses to alcohol use include: • • • • • • •

The amount of alcohol used The rate and pattern of consumption Sex Age The person’s physical and mental health The persons’ medication and drug use Family history of alcohol dependence [1, p. 17] (see Chap. 8)

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The guideline developed by Australia’s NHMRC refers to the maximum amount of alcohol an average adult, in good health, could drink without exceeding a 1 in a 100 chance of dying from alcohol-related disease and injury over their lifetime [1, p. 24]. While all international guidelines recommend limiting alcohol consumption to reduce harm and over time there has been a general lowering of recommended limits, there is no consensus on the exact level of alcohol consumption recommended to maintain a low risk of alcohol use-related harm. In addition, there is also no international consensus regarding whether women should drink as much as men or less, or how best to define what should constitute a standard drink [1, p. 20, 4, pp. 3–21]. The harmful use of alcohol is widespread in all age groups. In Australia in 2016, 17.1% of people aged 14 years and older exceeded the NHMRC [1] lifetime risk guideline by consuming more than four standard drinks per day, and 25.5% exceeded the single occasion of drinking guideline by consuming more than four standard drinks on a single occasion at least once a month. Individuals exceeding the lifetime risk guideline were most likely to be aged between 40 and 49 years (20.6%) or 50 and 59 years (20.4%). Those most likely to exceed the single occasion risk guideline at least once a month were aged between 18 and 24 years (42%) [1, p. 14]. Alarming as such figures are, it is important to note that alcohol consumption is often under-reported in clinical examinations [4, pp. 3–21] and in alcohol use surveys [1, p.  14], and thus caution should be exercised when such estimates are considered. Underage alcohol use is a particular area of concern for parents, healthcare practitioners and policymakers. In Australia in 2016, 7.9% of young people aged 12–15 years and 43.8% of adolescents aged 16–17 reported consuming at least one full serve of alcohol in the previous 12 months. Almost two out of every five (38%) young people aged 12–17 that consumed alcohol on at least 1 day in the previous week intended to get drunk most of the times or every time they drank. The most common source supplying a first glass of alcohol to these children and young people (12–17 years of age) was a friend or an acquaintance (48.1%) or a parent (35.2%). A small proportion (5.4%) of children and young people reported consuming more than four standard drinks on a single occasion at least once a month [1, p. 15]. On a more positive note, there has been a significant increase in the proportion of young people aged 12 to 17 in Australia abstaining from alcohol use, from 54.3% in 2004 to 81.5% in 2016. At the same time, the average age at which young people first use alcohol has risen from 14.8 years in 2004 to 16.1 years in 2016 [1, p. 15]. Between 1984 and 2017, the proportion of young Australians aged 16–17 years drinking five or more drinks on a single occasion decreased from 20% to 11% [1, p. 42]. In children and young people, physical immaturity, the developing brain and lack of experience of drinking and its effects and the propensity to risk-taking behaviours combine to expose them to greater risk of injury and other forms of harm [1, p. 17, 10, p. 473]. Suicide/self-inflicted injuries, alcohol use disorder, road traffic injuries/motor vehicle occupant injuries and depressive disorders have been identified as the top four causes of burden of disease for males aged 15–24  years in Australia. In females in the same age group, the top four causes were suicide/

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self-­inflicted injuries, back pain, alcohol use disorders and poisoning [1, p.  43]. There is also an increased likelihood of adolescents engaging in risky sexual behaviour when alcohol is involved [1, p.  44]. There is thus no clear level of alcohol consumption considered ‘safe’ or ‘no risk’ for children and young people under 18 years of age. The age of first consumption of alcohol is considered to be a risk factor for a range of longer-term health problems and harm in adulthood, including greater risk of heavy drinking, development of alcohol use disorders (including dependence), involvement in alcohol use-related road accidents, anxiety, depression and drug-­ related problems. Heavy alcohol consumption in late adolescence appears to persist into adulthood and is associated with alcohol problems, including dependence, premature death and diminished work capacity [1, p. 45]. It is important to note that for many people both alcohol use and mental health problems begin in the teenage years or younger, or in late adolescence or early adulthood [11, 12]. Moreover, people who live with mental health conditions (see Chap. 5) or who are vulnerable to developing such conditions—for example, anxiety, depression and schizophrenia—may experience a deterioration in their mental health after drinking alcohol [1, p. 18]. Alcohol use disorders, in conjunction with major depression, represent an especially high-risk profile for adolescent suicidal behaviour and completed suicide. In addition, adolescents with alcohol use disorders tend to complete suicide at a greater rate than those without alcohol problems. Adolescents who use drinking as a method of coping may be more likely to suffer Box 10.1 Considerations for Reducing Health Risks from Drinking Alcohol in Children and Adolescents

Given the increased risks of harm from alcohol use (e.g. injury, effects on brain development) by young people, there is no clear ‘safe’ level of alcohol consumption for children and people under 18 years of age Accordingly, the NHMRC guideline recommends that children and people under 18 years of age should not drink alcohol Early commencement of alcohol use may put young people at greater risk of longer-term alcohol-related harms, including alcohol use disorders that often appear in early adulthood Alcohol use is a leading cause of premature death and morbidity in young people due to increased risk of injury, including alcohol poisoning Alcohol-related emergency department injury presentations are higher among Australian teenagers 15–19 years of age than in other age cohorts [1, p. 41, 10, p. 461] Possible characteristics exhibited by a young person who misuses alcohol: • Deterioration of performance at school, university or work • Frequent episodes of intoxication • Tendency to use alcohol in times of stress or boredom

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• Deficient interpersonal relationships; can relate only when under the influence of alcohol • Declining interest in interpersonal relationships; preferring to use alcohol when alone [10, p. 473] Useful questions when exploring a young person’s alcohol use behaviours: • What meaning does the behaviour or problem hold for the young person? • What message might the young person be trying to convey through the behaviour? • What impact does this problem have on the young person in this developmental stage? • Is this behaviour usual or unusual for this young person’s peer group? • How have resulting changes, if any, affected the young person and their relationships with others? • What goals does the young person have for the immediate and distant future? • What strengths does the young person have to help deal with this problem? • What considerations have been given to other developmental, familial, biological or sociocultural factors involved? [10, p. 459]

from depression, precipitating heavy drinking, which is itself predictive of suicidal behaviour [1, p. 45]. Box 10.1 outlines considerations for reducing the health risks from drinking alcohol in children and adolescents. The risks associated with alcohol use by young adults are similar to those found in adolescents. Box 10.2 outlines considerations for reducing the risk of alcohol use-related harms in young adults.

Box 10.2 Considerations for Reducing Health Risks from Drinking Alcohol in Young Adults

• Young adults aged 18–25 years are likely to be at increased risk of alcohol-­ related harm, particularly injury • The issues for young adults are similar to those for adolescents: Alcohol affects a young person’s developing brain; thus drinking, particularly heavy drinking, at any time brain development is incomplete (up to 25 years of age) may adversely affect later brain function • As with adolescents, young adults tend to be greater risk takers than older adults, a factor that is reflected in the high levels of injury sustained by this age group • Young adults are less experienced at certain tasks that require attention and psychomotor coordination [1, p. 38]

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10.4 Ethical Considerations in the Assessment of Alcohol Use Any history taking and assessment of a person’s alcohol use has the potential to be a sensitive and difficult conversation. While it is important that questions regarding past and current alcohol use are addressed directly, this should be done in a manner that takes account of the individual’s past and present life circumstances. Put another way, it is crucial that clinical concerns are addressed alongside ethical concerns. The person being assessed should be: • Asked directly whether they drink alcohol, and if so, what type, how much and how often? An effort should be made to ascertain the type of alcohol the person drinks—beer (full/mid/light strength), red or white wine (150/200 mL glass) or spirits (‘nip’ or ‘shot’). People who are heavy users of alcohol can be unreliable when describing their alcohol intake. Sometimes the healthcare practitioner may need to suspend belief and, providing the person being assessed gives permission, talk to family members (4, pp. 3–21) (see Chap. 8). Follow-up questions can then be asked to gain an accurate idea of the person’s alcohol intake and to explore the possibility of a developing alcohol dependence problem: • How often do you have a drink containing alcohol? • How many drinks containing alcohol do you have on a typical day when you are using alcohol? • How often do you have six or more alcoholic drinks on any one occasion? • Have you ever felt you ought to cut down on your drinking? • Have people annoyed you by criticising your drinking? • Have you ever felt bad or guilty about your drinking? • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (4, pp. 3–23) Framing questions used in assessing an individual’s alcohol using behaviours within a framework of ethical practice can assist the health professional to stay attuned to the vulnerability, treatment and safety needs of the person being assessed. Chiovitti [13] has developed an approach to balancing safety concerns with a person’s choices; she refers to this as ‘protective empowerment’. Based on a set of key ethical principles (autonomy, beneficence, non-maleficence), protective empowerment can be applied to situate the process of alcohol use assessment within a framework of ethical practice. Depending on the life circumstances and healthcare needs of the person being assessed, protective and empowering aspects of care are considered in varying degrees through:

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Showing respect for the person Not taking their behaviour personally Maintaining safety Encouraging and supporting health-promoting behaviours Authentic relating Interactive teaching [13]

In the application of protective empowerment, respecting the individual and not taking their behaviours personally are key actions in the caring encounter [13]; this would certainly include assessment. Not taking an individual’s behaviour personally assists in gaining therapeutic perspective in situations in which a health professional’s safety concerns and a person’s life choices may not align. Opportunities to encourage health-promoting behaviours, authentic relating and interactive teaching may present during the process of assessment and align with the safety concerns of the health professional and the choices of the person living with alcohol use-related problems. Case Study 10.1: ‘Janet’ ‘Janet’ (49) is an assistant in nursing who is the eldest child in her family with a younger brother. She attended school up to year 11 and enjoyed the social side of school but did not see herself as ‘academic’. Janet’s parents were married during most of her youth but separated and divorced after she had left home at 17 years of age. She describes her mother as an anxious woman, preoccupied with her own health, who was overly critical of Janet and seemed to favour her brother. Janet had a closer relationship with her father, but he was often away due to work commitments or spending time drinking with his friends at the local pub. When he was home, there was a lot of hostility in the house between Janet’s parents, which she and her brother would avoid, going to their rooms or leaving the house. After leaving home, Janet had a range of lower-paid jobs, mostly in hospitality and as a cleaner. She also had a series of relationships with emotionally distant young men, until she met and married her husband at age 25, with whom she had a daughter. This marriage was difficult for Janet, as her husband became more distant until her daughter was around 15, when she became a single mother, with little support from her estranged husband. Janet managed to gain a qualification to work as an assistant in nursing, and this improved her employment prospects. Janet started drinking regularly in her late teens, after leaving home, although she admits to having a ‘drink or two’ while at high school, sometimes sneaking a couple of her dad’s beers from the fridge. Having a drink ‘relaxed’ her; she felt less anxious and could be more sociable and fun. Janet also noticed that despite often feeling overwhelmed and ‘sad’, drinking made her feel better. It also helped her sleep, although this did not lead to her feeling refreshed the next day. Over time ‘Janet’ began to drink more wine as her social life increasingly revolved around work colleagues and her daughter left home to live with her

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boyfriend, after finishing school. As her drinking increased, Janet was drinking more at home to ‘wind down’; her mood also worsened. She often felt ‘down’ when on her own and increasingly felt irritable and angry with the increasingly stressful workplace. Janet’s relationships with work colleagues became more fractured, and her social circle shrunk to a couple of friends with whom she had previously worked, with only one or two from her current workplace. Janet’s daughter’s demands for money to help pay bills and prop up her own relationship caused resentment and fearfulness, as her daughter wanted money, but would not accept advice on how to manage better; Janet didn’t push it as she was concerned about losing her daughter. Janet was now in a new relationship with a man who had been introduced to her by a friend, and this had a positive effect on her mood; she felt good about life. When she had to leave her rented flat at the end of a lease, Janet had no hesitation in moving in with her new partner, after he asked her. He owned his own home and Janet felt they were ‘in it for the long haul’. Unfortunately, ‘Janet’s’ new partner drank much more heavily than she realised. She enjoyed sharing a drink together in the early days of the relationship and, when she had stayed over, assumed the ‘big nights’ were because they were drinking together. However, Janet realised he was drinking large amounts whether she was there or not, and his level of intoxication affected how he spoke to her; he was often irritable and aggressive. More recently Janet has been having much time off work and has clashed with management regarding this. Her mood has become progressively lower; she is more anxious and is now drinking one to two bottles of wine most nights. Janet has tried to ‘detox’ at home with the assistance of her GP but on each occasion has quickly relapsed. She has recently found another GP and spoken to him about her mental health, especially her depression and anxiety. As this practice has a team approach, the GP referred her to the mental health nurse at the practice for assessment and support. Mental Health Diagnosis • Major depression with anxious distress • Alcohol use disorder Medical Diagnoses • Obesity • Prediabetic • Perimenopause Reflective Practice Exercise 10.1 1. Imagine you are seeing Janet for the first time. What strategy would you adopt to build an authentic and trusting connection with Janet so as to conduct an assessment of her alcohol use?

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2. List six [6] questions you would ask Janet as part of conducting an assessment of her alcohol use. 3. What safety concerns ought to be considered when assessing Janet’s alcohol using behaviours? 4. Identify opportunities for instilling hope for the future in your interactions with Janet. In recommending an approach to working alongside vulnerable individuals experiencing severe mental health problems, Hazelton and Rossiter [14] have pointed to the importance of health professionals: • Challenging stigma-laden narratives and practices when these are encountered in clinical work • Regularly engaging in conversations addressing the moral and ethical implications of practice • Using reflective practices, self-awareness and mindfulness to combat the misuse of power inherent within clinical work • Adopting person-centred therapeutic assumptions such as the ‘the person is doing the best that they can’ • Seeking to treat those with whom they are working as they would wish to be treated Such an approach would be equally applicable to working with people undergoing assessment for alcohol use problems, especially in circumstances in which such individuals are highly vulnerable and live with very complex and serious alcohol use-related health and social problems. Case Study 10.2: ‘Anthony’ ‘Anthony’ (26) is an Aboriginal man who was born the middle of three boys (see Chap. 3). At 12 months of age, his mother’s health deteriorated and she became bed bound. Anthony’s volatile alcohol-dependent father became the primary care giver to all members of the family. Consequently, Anthony’s environment became fractured and unpredictable. He had poor attendance at school, struggled with literacy and following intervention by a school counsellor was diagnosed with attention deficit hyperactivity disorder (ADHD) and dyslexia. Anthony refers to himself as ‘slow’ when describing leaving school at 15 years of age to take up a labouring job. Anthony is currently estranged from siblings and describes feeling ‘grief-­ stricken’ over the death of his parents 2 years ago, within 4 months of each other. He has intermittent support from an elderly maternal uncle, who arranges lawn mowing and essential maintenance for the family and community services-operated residence where Anthony lives. His Uncle also provides Anthony assistance with grocery shopping and food preparation. Anthony occasionally uses public transport for essential appointments, does not have a current driver’s licence and has no significant previous intimate relationships or long-term employment.

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Anthony lives alone in squalid living conditions and has poor personal hygiene; his self-neglect and malnutrition are evident. Anthony’s sole source of income is a jobseeker allowance for which he must be able to prove attendance at job interviews to maintain. Anthony is isolated and rarely leaves his house due to social anxiety and panic attacks; he has accumulated multiple mental health diagnoses throughout his short life. Mental Health Diagnoses • • • • • • •

Adjustment disorder Generalised anxiety disorder Major depressive disorder Complicated grief Alcohol use disorder Nicotine use disorder Borderline personality disorder with recent self-harm and multiple suicide attempts

Medical Diagnoses • • • • •

Alcoholic liver disease—Child-Pugh C cirrhosis History of decompensated liver disease Past episodes of acute renal failure/chronic pancreatitis Gastrointestinal bleeding Significant electrolyte imbalance due to self-neglect and poor diet

Anthony’s current alcohol consumption pattern is binge type (see Chap. 16), up to 4–8 L of white wine per day for the previous 5 years. His daily nicotine intake is 30 ‘roll-your-own’ cigarettes per day. He denies any other problematic substance use. Recent History Anthony has a long history of intermittent engagement with mental health services and has been unwilling to engage with addiction services. His recent and historical emergency department presentations are comorbid in nature with heavy alcohol consumption and withdrawal. He accesses wine via a home delivery service. Anthony’s treatment involves symptom management rather than maintenance of chronic health conditions. Desire to cease alcohol consumption coupled with an aversion to social contact has resulted in several unsafe attempts at self-­detoxification, consequent seizures and delirium tremens. Ongoing debilitating avolition (severe lack of motivation) has compounded Anthony’s physical and mental health complexities. He is aware of his diagnosis of cirrhosis and poor prognosis but lacks motivation for specialist support in management. He regularly misses medical appointments, rarely obtains prescribed medications, struggles to initiate behaviour change and continues to consume 4–8  L of

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wine per day. Anthony describes himself as suffering an ‘awful depression’ and is often tearful; his engagement with treatment is superficial. Anthony describes an episode of self-harm in the last 24 hours as a means of distress tolerance. He freely admits to feeling helpless regarding his ability to control alcohol consumption. Given the context of Anthony’s young age, resigned pre-­ contemplation and life-limiting health conditions, his suitability for an Involuntary Treatment Order under the Drug and Alcohol Treatment Act 2007 (NSW) is currently being considered. Reflective Practice Exercise 10.2 Read the case study on Anthony and answer the following questions: 1. What safety concerns ought to be considered when conducting an assessment of Anthony’s alcohol using behaviours? 2. In what ways might you be able to show respect for Anthony while working with him? 3. What opportunities exist for encouraging health-promoting behaviours in Anthony? 4. What strategy would you use to contemplate the moral and ethical implications of your work with Anthony?

10.5 Conclusion This chapter has outlined clinical and ethical considerations in the assessment of alcohol use across the lifespan. Noting concerns surrounding underage and heavy alcohol use during adolescence and young adulthood, particular attention was paid to clinical and ethical considerations in the assessment of alcohol use in these age groups. The chapter considered therapeutic presence as an important aspect of developing the therapeutic alliance that is essential to conducting a safe and effective assessment of an individual’s alcohol use. Consideration was also given to protective empowerment as an ethical approach that could be used when a health professional must balance safety concerns with an individual’s alcohol use-related lifestyle choices. The chapter included two case studies and associated reflective activities.

References 1. National Health and Medical Research Council. Australian Guidelines to reduce health risks from drinking alcohol. Canberra: National Health and Medical Research Council; 2020. 2. World Health Organization. Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018. 3. Naegle M.  Health promotion strategies for substance use. In: Yearwood EL, Hinds-Martin VP, editors. Routledge handbook for global mental health nursing. London: Routledge; 2017. p. 238–57.

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4. Talley NJ, O’Connor S. Clinical examination. 8th ed. Sydney: Elsevier; 2017. p. 3–21. 5. Brighton R, Smith K. Substance use disorders. In: Moxham L, Hazelton M, Muir-Cochrane E, Kneisl CR, Trigaboff E, editors. Contemporary psychiatric-mental health nursing. Melbourne: Pearson Australia; 2018. p. 251–89. 6. World Health Organization. Ten threats to global health in 2019. Geneva: World Health Organization; 2019. https://www.who.int/emergencies/ten-­threats-­to-­global-­health-­in-­2019. Accessed 7 Nov 2021. 7. Johansson L, Wiklund-Gustin L.  The multifaceted vigilance: nurses experiences of caring encounters with patients suffering from substance use disorder. Scand J Caring Sci. 2016;30:303–11. https://doi.org/10.1111/scs.12244. 8. Lancaster K, Seear K, Ritter A.  Reducing stigma and discrimination for people experiencing problematic alcohol and other drug use. Drug Policy Modelling Program Monograph Series; No. 26. National Drug and Alcohol Research Centre. 2017. https://doi. org/10.26190/5b8746fe72507. Accessed 7 Nov 2021. 9. Geller SM, Greenberg LS. Therapeutic presence. Washington, DC: American Psychological Association; 2012. 10. Sinclair E, Swinson I, Hazelton M.  The mental health of younger people. In: Moxham L, Hazelton M, Muir-Cochrane E, Kneisl CR, Trigaboff E, editors. Contemporary psychiatric-­ mental health nursing. Melbourne: Pearson Australia; 2018. p. 455–82. 11. Hazelton M. Understanding severe persistent mental health problems and disorders. In: Cooper DB, Cooper J, editors. Palliative care within mental health: ethics. New  York: Routledge; 2019. p. 49–64. 12. Boden J, Blair S, Newton-Howes G. Alcohol use in adolescents and adult psychopathology and social outcomes: findings form a 35-year cohort study. Aust N Z J Psychiatry. 2020;9:909–18. 13. Chiovitti RF. Theory of protective empowering for balancing patient safety and choices. Nurs Ethics. 2011;1:88–101. 14. Hazelton M, Rossiter R. ‘Talk about trouble’: practitioner on service users who are judged to be resisting, contesting or evading treatment. In: O’Reilly M, Lester JN, editors. The Palgrave handbook of adult mental health. Houndmills: Palgrave Macmillan; 2016. p. 419–40.

To Learn More Chiovitti RF.  Theory of protective empowering for balancing patient safety and choices. Nurs Ethics. 2011;1:88–101. Geller SM, Greenberg LS.  Therapeutic presence. Washington, DC: American Psychological Association; 2012.

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Learning Outcomes • The reader will be able to articulate the range of effects alcohol can have on the unborn child. • The reader can articulate the range of obstacles faced by a person living with FAS or ARND and understands the challenges in getting appropriate diagnosis and support. • The reader can outline common risk and protective factors which may inhibit a child’s healthy development. • The reader can articulate strategies that parents and society can do which will reduce teenage alcohol use.

11.1 Introduction Due to alcohol’s prevalence in many societies, its impact is wide ranging and significant. In fact, not only can alcohol affect one’s life before one has drunk it, it can affect your life before you are born. For this reason, we will examine alcohol and childhood in three broad stages. First, we will examine the effect of alcohol use during pregnancy on the unborn child. Once children are born, they may be affected by their parents’ use of alcohol, and so the second section will broadly cover childhood from birth to age 12 or 13. During the childhood years, children are primarily P. D. James (*) Substance Use Service Team (SUST), HSE Social Inclusion, Drogheda, County Louth, Ireland e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_11

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affected by the alcohol use of those around them, such as parents and care givers. Finally, we will examine the adolescent or teenage years, typically the time when most people commence alcohol use.

11.2 The Prenatal Period and Alcohol Prior to birth, babies spend approximately 9 months in their mothers’ womb. During these 9 months, they are reliant on their mother to provide them with the necessary circumstances until their birth. The baby receives oxygen and nutrients via the placenta, which also removes waste products, for instance, carbon dioxide, from the baby. Anything that inhibits the mother’s ability to function correctly can have a knock-on effect on the baby. Various illness, malnutrition or being born before full term can have a negative impact on the child. Research has consistently shown that a variety of licit and illicit substances can cross the placenta, reaching the baby resulting in a plethora of negative effects [1, 2]. Teratogenic is the term used to describe substances which may affect the normal development of the baby during the preterm period. In the mid-1970s it was observed that babies being born to women who drank alcohol sometimes exhibited a particular pattern of defects. Three features were identified: abnormal facial features, impaired growth and central nervous system (CNS) abnormalities which were termed fetal alcohol syndrome (FAS; see Chap. 12 for a detailed text related to FAS) [3]. Since then, further research has broadened our understanding of the effects of alcohol in utero and further categories have emerged. Fetal alcohol spectrum disorders (FASDs) are used to refer to a spectrum of disorders consisting of FAS, partial fetal alcohol spectrum (PFAS) disorder, alcohol-­ related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD) [4]. Exposure to alcohol prenatally is now recognised as the primary cause of intellectual disabilities in the western world [4, 5]. While a full description of each of the disorders within the spectrum is beyond the scope of this chapter, a brief overview will be provided. FAS is the most severe form of FASD, and recent estimates suggest that approximately 15 of every 10,000 children born worldwide have FAS, resulting in almost 120,000 FAS births per year worldwide [6]. Popova et al. [6] note that these rates make FAS more common than spina bifida and about as common as Down’s syndrome. The three classic features of FAS are facial anomalies, growth deficiencies and central nervous system (CNS) dysfunction [7]. Typical facial features include less smooth philtrum (the creases running from the top lip to the nose), flat nasal bridge and thin upper lip [4]. Growth deficiencies refer to either height or weight below the tenth percentile for their age and can be assessed pre- or postnatal [4]. CNS dysfunctions can refer to small head circumference, seizures or structural abnormalities in the brain [4]. A fourth symptom cluster, neurobehavioural impairment, exists for children above the age of 3. In addition to the symptoms above, they must also display evidence of global or specific cognitive impairments such as low

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IQ or a specific learning impairment or behavioural impairment such as impulsivity, attentional difficulties or behavioural dysregulation [7]. All four symptom clusters should be present to make a diagnosis, which can be made without documented prenatal alcohol exposure. Partial FAS (PFAS) can be diagnosed in cases where at least three of the symptom clusters are evident but the facial dysmorphology and neurobehavioural impairment must be present [4]. By contrast, ARND is believed to be more common than FAS.  While FAS is thought to affect 15 births per 10,000 (0.15%), ARND is estimated to affect about 100 per 10,000 (1%) [3]. A diagnosis of ARND is made when there is a documented history of alcohol exposure during pregnancy and there is significant neurobehavioural impairment which can include cognitive or behavioural difficulties [7]. It is worth noting that the neurobehavioural symptoms are usually not diagnosed until the child is at least 3  years old and so ARND cannot be conclusively diagnosed before this. The facial features of FAS are not present in ARND, and if they are, having three criteria met (documented alcohol exposure, facial features and neurobehavioural symptoms) would be enough for a partial FAS diagnosis to be made instead (see To Learn More at the end of this chapter). The relationship between alcohol use during pregnancy and these disorders is somewhat complicated and even controversial. While about 9.8% of women are thought to consume alcohol during pregnancy [6], this is complicated by different patterns around the globe. The five countries with the highest rate of alcohol use during pregnancy are all in Europe with this author’s own country of Ireland having the highest rate, with over 60% of women consuming alcohol during pregnancy [6]. Women in Middle Eastern countries, which typically have low level of alcohol use compared to western countries, have exceptionally low levels of alcohol use during pregnancy [6]. However, the proportion of women drinking during pregnancy is not a basis for measuring rates of FAS.  While Ireland has the highest proportion of alcohol use during pregnancy, the rate of FAS is estimated to be 89.7 per 10,000 births, significantly below the 585.3 per 10,000 in South Africa, for instance [6]. It has been argued that binge drinking, leading to higher blood alcohol levels, is the drinking pattern most likely to lead to FAS and is more common in South Africa leading to its disproportionate level of FAS [8]. This leads us to the somewhat fraught question of ‘safe levels’ of alcohol use during pregnancy. Recent estimates indicate 10% of women globally consume alcohol during pregnancy and 1  in every 67 births by women who consume alcohol during pregnancy will have FAS [6]. Not only does the rate of alcohol use during pregnancy vary considerably in different cultures and regions; so does the pattern and timing of drinking. A British study found that alcohol consumption during the first trimester of pregnancy had the highest association with adverse outcomes [9]. This is in keeping with the general literature that first trimester is probably the time of greatest risk [8, 10], but not all studies indicate consumption in the first trimester conveys more risk [11]. In addition, relatively low levels of alcohol intake are also associated with negative consequences [10, 12]. Nykjaer et al. highlighted that at the time of their research, the Department of Health in the UK had guidelines that

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suggested pregnant women never drink more than 20 mL of pure alcohol per week, which they found was not a safe limit [9]. Current guidelines in the UK recommend abstinence from alcohol for pregnant women and those seeking to become pregnant [13]. This brings it in line with US health advice dating back decades [14]. As we can see, there is considerable evidence that alcohol use during pregnancy causes harm and while the harm increases with the amount of alcohol taken, the scientific evidence suggests there is no safe level of alcohol intake during pregnancy. However, many children will continue to experience negative consequences due to alcohol exposure prenatally given the high rate of alcohol use in many populations. Many women who have an unplanned pregnancy may not realise they are pregnant and continue to drink. To prevent or reduce FASD, a clear message of the risks must be conveyed. Thus, our attention needs to turn to children and alcohol. Key Point 11.1 • About 10% of women consume alcohol during pregnancy. • This ranges from as low as 1% in some countries, particularly in the Middle East, up to over 50% in some European countries. • There is no safe level of alcohol use during pregnancy. • The more alcohol consumed, the greater the risk, and 1 in 67 births to women who consume alcohol will meet criteria for FAS—the most severe disorder. • Prenatal alcohol consumption is linked with facial abnormalities, growth deficiencies, CNS dysfunction and neurobehavioural difficulties.

11.3 The Childhood Years Children are primarily affected by alcohol in two ways: alcohol exposure prenatally and secondly alcohol use by those around them. In this section we will examine the longer-term effects of FASDs on children and what can be done to support them. We will then examine the effect of alcohol use by parents and carers of children. In addition to examining the evidence regarding these effects, this section will also examine what can be done to mitigate these risks. The effects of prenatal alcohol, such as the facial features, are observable from birth. A Danish study of 561 children exposed to low to moderate level of alcohol prenatally found that 10 had the facial features at birth but by age 5 none met criteria for FAS but partial FAS could not be ruled out as all the necessary psychological testing for neurobehavioural symptoms had not been completed due to the young age [10]. So, most children exposed to prenatal alcohol use may not present at birth with noticeable features of FAS but may develop problems. As discussed in the previous section, ARND requires the prenatal alcohol exposure and neurobehavioural symptoms. However, even if the alcohol exposure is noted, the relevant symptoms are unlikely to present until the child is around schoolgoing age, and so diagnosis may not be made without dedicated follow-up. The neurobehavioural challenges faced by those with ARND include poor cognitive and intellectual functioning, as well as problems with self-regulation,

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concentration, impulsivity and daily activities of living [10, 12]. A large systematic review identified numerous medical and psychological conditions that occur at remarkably high rates in those with FAS, but two that are particularly relevant are conduct disorder and attention deficit hyperactivity disorder (ADHD) at 90.7% and 51.2%, respectively [15]. Many writers caution against the assumption of a causal relationship within these findings [3, 15]. For example, ADHD is estimated to affect about 5% of children [16] although some studies have suggested figures as high as 15.5% [17]. If 5% of children have ADHD and about 10% worldwide (and more than 30% in many European countries) are exposed to alcohol prenatally, it is natural that many children will experience both conditions. However, this does not explain the fact that ADHD is ten times more common among those with FAS [15]. The relationship between alcohol exposure prenatally and ADHD diagnosis is clinically important with those exposed to alcohol prenatally being more impaired and responding differently to ADHD medications [18]. If children experiencing alcohol exposure prenatally are to be afforded the necessary support, they must be first identified and then followed into childhood as many of the symptoms and comorbidities may be not become apparent for several years. Key Point 11.2 • FASD may not be easily identifiable at birth. • Expectant mothers should be assessed in relation to their alcohol use during pregnancy, and it should be documented if they are consuming alcohol as this may be relevant for future diagnosis. • Follow-up of children who are exposed to alcohol prenatally is needed as many features may not present until they are approaching schoolgoing age. • These include behavioural and emotional symptoms such as impulsivity, ADHD, learning and conduct problems. In 1998 Vincent Felitti and colleagues published a paper that was to have a significant impact on health providers’ understanding of the effect of childhood experiences on adults. Termed ‘The Adverse Childhood Experiences (ACE) Study’ [19], it identified 17 potential experiences and measured how frequently they occurred in the population. It found that living with someone with an alcohol problem (23.5%) was the most common item, closely followed by being touched or fondled sexually (19.3%) and living with someone with a mental illness (17.5%). Further studies have streamlined this into ten categories with alcohol and substance use combined into a single item but still the most common ACE experienced by the population [20]. In the original study, living with someone with an alcohol problem was nearly five times more common than living with someone with a drug problem [19]. As the number of ACEs increases, so does the rate of various medical, mental health and substance use disorders [19]. For example, comparing those with 4 or more ACEs with those with no ACEs shows an increased odds ratio of 12.2 for ever attempted suicide, 7.4 for considering oneself an alcoholic, 10.3 for ever injecting drugs and 4.9 for chronic bronchitis or emphysema [19].

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Alcohol abuse in the home, primarily by parents or guardians, is the most common ACE experienced, and the authors highlight the reality that the ACEs are interrelated and having one ACE dramatically increases the chance of having another [19, 20]. This is perhaps unsurprising when one examines the ACEs; neglect, physical and emotional abuse, domestic violence and mental illness are all associated with alcohol misuse, and so children living with a parent who misuses alcohol are more likely to experience one of these ACEs. What the ACE demonstrates to us is some of the risk factors that may exist for young people; various experiences increase an individual’s risk of suffering several negative outcomes. The flipside of risk factors is protective factors. While the ACEs research examined the potential increased risk associated with various experiences, other research has examined the reduction in risk or potential protection afforded by a variety of experiences in one’s life. The 40 Developmental Assets is a framework initially published over 30 years ago [21]. To date over 5 million young people have been assessed [22], and it has proven to be a robust framework that is valid regardless of gender, socioeconomic situation, race or cultural background [23]. The assets are categorised as internal and external; internal assets are behaviours, attitudes and skills the young person possesses, and the external assets are those helpful and protective factors in the young person’s environment or provided to them by others [24]. Internal assets include the child’s engagement in learning, ability to self-­ regulate and interpersonal skills, while external assets include level of family support, involvement in structured activities, boundaries set by parents and the support received from various adults in their life. The more assets a child has, the less likely they are to suffer a variety of negative consequences, and the more likely they are to achieve positive outcomes. For example, 53% of those with ten or fewer assets will misuse alcohol and 61% will experience violence. The corresponding rates for those with 31 or more assets are 3% and 6%, respectively [25]. Positive outcomes such as maintaining good health and succeeding in school are also strongly related to number of assets [25]. Unlike the ACEs which focus on identifying risk and harmful factors, the 40 Developmental Assets takes a more positive approach and seeks to identify and increase the number of protective factors. One of the most concerning aspects of the research in this area is that children only have an average of 18 of the 40 potential assets with 20% having 10 or less and only 8% having 31 or more [25]. Thus, nearly three-quarters of children have between 11 and 30 assets; things could be worse but could also be a lot better. Self-Assessment Exercise 11.1 • The 40 Developmental Assets is a list of 40 items that, if present, promote good health and wellbeing and protect against negative outcomes like developing an alcohol problem. • There are 20 external assets, things outside the child, in their environment that are assets. An example is having a consistently loving and supportive family. • Think of a typical 8-year-old child. Brainstorm a list of what you think might be some of the other 19 external assets.

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• Internal assets are attitudes, characteristics or behaviours within a child that also act as protective factors. An example is the child reading daily for pleasure outside of school. • Return to your typical 8-year-old child and brainstorm a list of what might be some of the other 19 internal assets. • Go the www.search-­institute.org and read the 40 Developmental Assets—you can register for printable handouts of them—and see how your list compares. Considerable research has gone into examining the outcome of children whose parents, particularly mothers, have a substance use or alcohol problem. For example, young people who perceive their parents as having alcohol problems are more likely to report poorer relationships with their parents and have more emotional or internalising problems compared to those who do not perceive their parents as having an alcohol problem [26]. Another study compared outcomes for children whose mothers have either depression or alcohol problems and found that internalising problems are more associated with maternal depression symptoms while externalising behaviours are more associated with maternal alcohol use problems [27]. While comparing the outcomes of children raised by parents with different disorders is relatively straightforward, it is much trickier to examine what causes these differences; is it different parenting practices, or genetics, or some form of abuse? Tentative research has identified observable differences in the parenting practices of moderate alcohol-consuming mothers and abstaining mothers; abstaining mothers tend to pay more attention to their child’s hygiene and education, but there is no difference in physical activities such as play [28]. Further research has confirmed a negative effect of parental alcohol use on their children’s outcomes [29]. They further found that maternal parenting practices have a bigger effect than paternal practices, but fathers’ alcohol use appears to be the significant mediator of developmental delays in their children [29]. Frequent alcohol use is also associated with an increased risk of child physical abuse by parents [30]. It is not hard to visualise the negative effect significant parental alcohol use can have in a child’s world. Research from the UK articulates the various challenges faced by children because of their parents’ alcohol use. These include a lack of time and support from parents, frayed emotions, worry about family breakup, inconsistent or non-existent rules and boundaries and children having to take on parental roles for young siblings [31, 32]. The ACEs study gives us an insight into the things that inhibit child development, and the 40 Developmental Assets lets us see the things that help children thrive. Not drinking does not make someone good at parenting. But drinking is likely to reduce someone’s ability to engage in positive parenting practices and expose their children to more risks. To protect children from the effect of their parent’s alcohol use, we must first be aware of it. In 2003 the UK Advisory Council on the Misuse of Drugs (ACMD) published a report entitled ‘Hidden Harms’. This report highlighted the negative impact parental substance use, including alcohol, can have on their children and recommended a comprehensive suite of measures to address the problem [33]. All agencies and professionals need to recognise the potential risks for children and

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work together to reduce them. For example, substance use services need to proactively assess services users’ family situation and assist in getting appropriate support. Services not specifically related to substance use, including maternity, child and adolescent mental health and schools, need to be aware of the risks associated with parental substance use and work to identify cases. Tusla, the Irish Child and Family Agency, has recently launched a similar approach in Ireland [34] (see To Learn More at the end of this chapter for directions to UK Hidden Harm Report and Irish Hidden Harm Report). Once parental substance use is identified, various treatment options for the substance use may reduce the negative impacts for the family, and so parents need to be prioritised for substance use treatment for the children’s sake. Substance use treatment is not the only option. A two-pronged approach focuses on reducing risks and simultaneously increasing protective factors [35]. Reducing risks can involve providing supports and interventions that improve the quality of parenting the children receive and can involve parental educational programmes, while increasing protective factors can involve any activity that increases a child’s number of developmental assets. Key Point 11.3 • Children may be affected by their parent or guardian’s alcohol use both pre- and post-birth. • Children with FASD may require additional resources and supports. • Alcohol use may inhibit parents’ ability to parent effectively, and so children living with a parent with significant alcohol use are at greater risk of a variety of negative outcomes. • Professionals should be aware and monitor for the risk factors (ACEs) and promote protective factors (40 Developmental Assets).

11.4 The Teenage and Young Adult Years Alcohol is legal in most countries and despite age restrictions alcohol still tends to be the most used substance among teenagers. The Health Behaviour of School Children (HBSC) found that internationally 1% of 11-year-olds report being drunk in the past month, and this figure rises to 4% and 15% at age 13 and 15, respectively [36]. The rate of drunkenness varies considerably from country to country; among 15-year-olds, for instance, Iceland has one of the lowest rates of last month drunkenness at 5%, while Denmark has one of the highest at 34%. The European School Project on Alcohol and other Drugs (ESPAD) commenced in 1995 and is carried out every 4 years on schoolgoing 16-year-olds in Europe. The most recent iteration of the study gathered data in 2019. They report alcohol was consumed on an average of 5.6 days in the preceding month by EU 16-year-olds and typically 46 mL of pure alcohol was consumed [37]. Interestingly, the trend across 24 years suggests that lifetime alcohol use is the same for both genders and there is little change over the years; about four out of five 16-year-olds have drunk alcohol [37]. Alcohol use in

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the last 30 days has remained consistent at about 50% over the decades with little gender difference. Initially in 1995 we saw a gender difference for heavier alcohol use (defined as five drinks or more) with 40% of boys reporting having done so in the past month compared to 30% of girls. In the intervening years, the rates have trended towards each other with about 35% of boys and girls now engaging in heavy episodic drinking in the last month [37]. It is worth comparing these rates to cannabis use as cannabis is the most used illicit drug in western countries. While rates of cannabis use increased among teens in the mid-1990s into the early 2000s, since 2003 rates of cannabis and other illicit drugs across Europe have remained stable [37]. Naturally, there is some variance within specific countries. So, while about 79% of 16-year-olds have ever consumed alcohol, only 16% have ever smoked cannabis, and less than 5% have ever used an illicit drug other than cannabis [37]. Thus, alcohol is by far the most used and misused substance in most countries. The highest rate of lifetime cannabis use in Europe is in the Czech Republic and Italy (28% and 27%, respectively), while numerous countries have alcohol rates of over 90% [37]. Should we be concerned about such high levels of alcohol use? Whether or not we should be, it appears we are not. In the UK, the number of under 18 being treated for alcohol use is a fraction of those being treated for cannabis use [38]. Similar trends exist in Ireland where 107 minors were treated for alcohol problems in 2019 [39] compared to 822 for drug use [40]. It appears society has a greater tolerance for alcohol use by teenagers than for illicit drug use. Perhaps the wide use of alcohol in society and by many parents when they were teenagers has led to normative beliefs. Scientific literature has raised concern about the potential of various mediums to normalise alcohol use to teenagers including various magazines [41], alcohol advertising during sports [42] and even the Harry Potter books [43]. Parents’ role in adolescent alcohol use has been examined but provides some mixed results. For example, in Australia it was found that about 25% admitted to supplying alcohol to their teenagers but there was no significant difference between those who provided alcohol and those that did not in terms of their own alcohol use or socioeconomic characteristics [44]. Meanwhile an Irish study found that 27% of parents thought it was a good idea to introduce alcohol to their teens at home but only 11% admitted to having done so [45]. This study also found that being more affluent and drinking more frequently were associated with a more permissive attitude towards alcohol supply to teenagers and such liberal attitudes and parental drinking have been linked with more problematic alcohol use by teens [46, 47]. Unsurprisingly a parenting programme which encourages parents to take a zero-tolerance approach to underage drinking has proven to reduce adolescent drunkenness [48]. However, the key message is that parental expectances are important—if parents maintain strict rules in relation to their adolescents’ drinking, they are less likely to drink [49]. In this author’s clinical work with parents, they frequently argue what is the point of telling their children not to drink as they are going to do it anyway. This author has therefore come to use the analogy of speed limits—the reason we need speed limits is because people often drive fast. Enforcing a speed limit of say 60 km/h does not guarantee people will not speed, but it may reduce the frequency with which they

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drive faster than this and reduce the amount by which they exceed the limit. It is a harm reduction strategy. We should emphasise to parents that the holding of strict attitudes towards alcohol use and communicating them to our children is an evidence-­based approach to dealing with adolescent alcohol use. We should be concerned about adolescent substance use. Firstly, the adolescent brain is still in development and does not mature until the mid-20s. As a result of this development, adolescents compared to adults react differently both to emotions and rewards [50]. Alcohol use during this sensitive developmental period is associated with a variety of structural and functional deficits in the adolescent brain including reductions in cognitive functioning, reading and verbal skills and decreased brain activation during rewards [51]. These translate into increased risks for adolescents who consume alcohol including risk of accidents, being the victim or perpetrator of violence, adult substance use problems, teen pregnancy and sexually transmitted infections [52] (see To Learn More at the end of this chapter for direction to more information related to teenage brain and alcohol). There are actions society and parents can take to decrease teenage alcohol use. A review of the literature identified numerous parenting variables which either delayed onset of adolescent alcohol use or reduced later levels of adolescent drinking, including parental role modelling around alcohol, reducing availability to alcohol, quality of parent–child relationship and overall discipline and rules [53]. These authors also completed a Delphi study and identify a plethora of strategies for parents to reduce their child’s alcohol use [54]. These strategies are the type of things recommended to increase the number of developmental assets a teenager has (see To Learn More at the end of this chapter about parenting strategies for alcohol use). Finally, it would be remiss to not mention Iceland in a discussion about preventing harms associated with adolescent substance use. In the 1990s various reports highlighted high levels of alcohol and substance use among Icelandic teens, and the country decided to implement changes to address the concerns. Since 1998 the ‘Drug-Free Iceland’ programme has aimed to encourage emotional support and engagement from parents, prompting engagement by teens in various extracurricular activities, particularly sport, and supporting youth organisations across the country [55]. Results have been dramatic with Iceland’s rates of adolescent substance use plummeting. Since 1995 the rates of Icelandic teens who have never drunk alcohol has increased from 20.8% to 65.5% in 2015, and the proportion who report consuming alcohol more than 40 times dropped from 13.7% to 2.3% in the same period [56]. Iceland shows what can be achieved when parents and society take adolescent alcohol seriously and decide to do something about it—based on science. Key Point 11.4 • Alcohol is the most common substance used by teenagers in almost every country. • By age 16 about 80% of teenagers have tried alcohol—much higher than the rates of any other substance use. • Younger onset of alcohol use and adolescent drinking is associated with more negative outcomes including later substance use and mental health problems.

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• Clear rules prohibiting alcohol use by parents reduce alcohol use and risk. • Rates of young people receiving help for alcohol-related problems suggest that many teenagers are not receiving the help they need.

11.5 Conclusion Alcohol has a significant presence in western countries and the effect it has should not be underestimated. From conception to death, alcohol can have significant impacts. Elimination of exposure to alcohol prenatally is essential, and once a child is born, society needs to be aware of the potential harm alcohol can have. Some effects, such as abuse, are obvious, but many are ‘hidden harms’. Moreover, we should not accept teenage alcohol use as the norm and just accept it. Teenage alcohol use is harmful in a variety of ways and can be the start of problems that can persist for life. Importantly, it is treatable—just ask the Icelanders.

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14. Seiler NK.  Alcohol and pregnancy: CDC’s health advice and the legal rights of pregnant women. Public Health Rep. 2016;131:623–7. 15. Popova S, Lange S, Shield K, Mihic A, Chudley AE, Mukherjee RAS, et al. Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis. Lancet. 2016;387:978–87. 16. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164:942–8. 17. Rowland AS, Skipper BJ, Umbach DM, Rabiner DL, Campbell RA, Naftel AJ, et  al. The prevalence of ADHD in a population-based sample. J Atten Disord. 2015;19:741–54. 18. Glass L, Ware AL, Crocker N, Deweese BN, Coles CD, Kable JA, et al. Neuropsychological deficits associated with heavy prenatal alcohol exposure are not exacerbated by ADHD. Neuropsychology. 2013;27:713–24. 19. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med. 1998;14:245–58. 20. Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003;111:564–72. 21. Search Institute. Our story. Search Institute. 2021. https://www.search-­institute.org/about-­us/ our-­story/. Accessed 6 Sept 2021. 22. Syvertsen AK, Scales PC, Toomey RB.  Developmental assets framework revisited: confirmatory analysis and invariance testing to create a new generation of assets measures for applied research. Appl Dev Sci. 2021;25(4):291–306. https://doi.org/10.1080/10888691.201 9.1613155. 23. Scales PC, Roehlkepartain EC, Shramko M.  Aligning youth development theory, measurement, and practice across cultures and contexts: lessons from use of the developmental assets profile. Child Ind Res. 2017;10:1145–78. 24. Leffert N, Benson PL, Scales PC, Sharma AR, Drake DR, Blyth DA.  Developmental assets: measurement and prediction of risk behaviors among adolescents. Appl Dev Sci. 1998;2:209–30. 25. Scales PC. Reducing risks and building developmental assets: essential actions for promoting adolescent health. J Sch Health. 1999;69:113–9. 26. Pisinger VSC, Bloomfield K, Tolstrup JS. Perceived parental alcohol problems, internalizing problems and impaired parent—child relationships among 71,988 young people in Denmark: perceived parental alcohol problems. Addiction. 2016;111:1966–74. 27. Mesman GR, Edge NA, McKelvey LM, Pemberton JL, Holmes KJ. Effects of maternal depression symptoms and alcohol use problems on child internalizing and externalizing behavior problems. J Child Fam Stud. 2017;26:2485–94. 28. Tyrlík M, Konečný Š. Moderate alcohol consumption as a mediator of mother’s behaviour towards her child. Cent Eur J Public Health. 2011;19:143–6. 29. Guttmannova K, Hill KG, Bailey JA, Hartigan LA, Small CM, Hawkins JD. Parental alcohol use, parenting, and child on-time development: parental alcohol use. Infant Child Dev. 2017;26:e2013. 30. Freisthler B. Alcohol use, drinking venue utilization, and child physical abuse: results from a pilot study. J Fam Violence. 2011;26:185–93. 31. Turning Point. Bottling it up—alcohol misuse and the effect on children and families. London: Turning Point; 2006. 32. Templeton L, Velleman R, Hardy E, Boon S. Young people living with parental alcohol misuse and parental violence: ‘no-one has ever asked me how I feel in any of this’. J Subst Abus. 2009;14:139–50. 33. Advisory Council on the Misuse of Drugs. Hidden harm: responding to the needs of children of problem drug users: the report of an inquiry by the Advisory Council on the Misuse of Drugs. London: Home Office; 2003. 34. Tusla Child & Family Agency. Hidden harm practice guide: seeing through hidden harm to brighter futures. Dublin: Health Service Executive; 2019. https://www.tusla.ie/uploads/content/PracticeGuide.pdf. Accessed 6 Sept 2021.

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35. Velleman R, Templeton L.  Understanding and modifying the impact of parents’ substance misuse on children. Adv Psychiatr Treat. 2007;13:79–89. 36. Inchley J, Currie D, Budisavljevic S, Torsheim T, Jastad A, Cosma A, et al., editors. Spotlight on adolescent health and well-being: findings from the 2017/2018 Health Behaviour in School-­ Aged Children (HBSC) Survey in Europe and Canada International Report: volume 2. Key data. Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2020. 276 p. (Health policy for children and adolescents). 37. The ESPAD Group. ESPAD Report 2019. Results from the European school survey project on alcohol and other drugs. Luxembourg: Publications Office of the European Union; 2020. 38. Public Health England. Young people’s substance misuse treatment statistics 2018 to 2019: report - GOV.UK. gov.uk. 2019. https://www.gov.uk/government/statistics/substance-­misuse-­ treatment-­f or-­y oung-­p eople-­s tatistics-­2 018-­t o-­2 019/young-­p eoples-­s ubstance-­m isuse-­ treatment-­statistics-­2018-­to-­2019-­report#contents. Accessed 6 Sept 2021. 39. Condron I, Carew AM, Lyons S.  National Drug Treatment Reporting System 2013–2019 alcohol data. Dublin: Health Research Board; 2020. p.  10. https://www.hrb.ie/fileadmin/2._Plugin_related_files/Publications/2020_publication-­related_files/2020_HIE/NDTRS/ Alcohol_bulletin/Alcohol_treatment_in_Ireland_2013_to_2019.pdf. Accessed 6 Sept 2021. 40. O’Neill D, Carew AM, Lyons S. National Drug Treatment Reporting System 2013–2019 drug data. Dublin: Health Research Board; 2020. p.  12. https://www.hrb.ie/fileadmin/2._Plugin_ related_files/Publications/2020_publication-­related_files/2020_HIE/NDTRS/Drugs_2013_ to_2019/Drug_treatment_in_Ireland_2013_to_2019.pdf. Accessed 6 Sept 2021. 41. Thomsen SR, Rekve D. The differential effects of exposure to “youth-oriented” magazines on adolescent alcohol use. Contemp Drug Probl. 2004;31:31–58. 42. Carr S, O’Brien KS, Ferris J, Room R, Livingston M, Vandenberg B, et al. Child and adolescent exposure to alcohol advertising in Australia’s major televised sports: alcohol advertising in sport. Drug Alcohol Rev. 2016;35:406–11. 43. Welsh C. Harry potter and the underage drinkers: can we use this to talk to teens about alcohol? J Child Adolesc Subst Abuse. 2007;16:119–26. 44. Ward BM, Snow PC.  Factors affecting parental supply of alcohol to underage adolescents. Drug Alcohol Rev. 2011;30:338–43. 45. Smyth BP, Darker CD, Donnelly-Swift E, Barry JM, Allwright SP. A telephone survey of parental attitudes and behaviours regarding teenage drinking. BMC Public Health. 2010;10:297. 46. Gilligan C, Kypri K, Johnson N, Lynagh M, Love S. Parental supply of alcohol and adolescent risky drinking: parental supply of alcohol and adolescent drinking. Drug Alcohol Rev. 2012;31:754–62. 47. Murphy E, O’Sullivan I, O’Donovan D, Hope A, Davoren MP. The association between parental attitudes and alcohol consumption and adolescent alcohol consumption in southern Ireland: a cross-sectional study. BMC Public Health. 2016;16:821. 48. Özdemir M, Koutakis N.  Does promoting parents’ negative attitudes to underage drinking reduce adolescents’ drinking? The mediating process and moderators of the effects of the Örebro prevention Programme: parents’ negative attitudes to drinking. Addiction. 2016;111:263–71. 49. Mares SHW, Lichtwarck-Aschoff A, Burk WJ, van der Vorst H, Engels RCME. Parental alcohol-­ specific rules and alcohol use from early adolescence to young adulthood: parental alcohol-­ specific rules and adolescent alcohol use. J Child Psychol Psychiatry. 2012;53:798–805. 50. Dumontheil I. Adolescent brain development. Curr Opin Behav Sci. 2016;10:39–44. 51. Lees B, Meredith LR, Kirkland AE, Bryant BE, Squeglia LM. Effect of alcohol use on the adolescent brain and behavior. Pharmacol Biochem Behav. 2020;192:172906. 52. Boden JM, Fergusson DM. The short and long term consequences of adolescent alcohol use. In: Saunders J, Rey J, editors. Young people and alcohol: impact, policy, prevention, treatment. Chichester: Wiley-Blackwell; 2011. p. 32–46. 53. Ryan SM, Jorm AF, Lubman DI. Parenting factors associated with reduced adolescent alcohol use: a systematic review of longitudinal studies. Aust N Z J Psychiatry. 2010;44:774–83.

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54. Ryan SM, Jorm AF, Kelly CM, Hart LM, Morgan AJ, Lubman DI. Parenting strategies for reducing adolescent alcohol use: a Delphi consensus study. BMC Public Health. 2011;11:13. 55. Sigfusdottir ID, Kristjansson AL, Thorlindsson T, Allegrante JP. Trends in prevalence of substance use among Icelandic adolescents, 1995–2006. Subst Abuse Treat Prev Policy. 2008;3:12. 56. Arnarsson A, Kristofersson GK, Bjarnason T. Adolescent alcohol and cannabis use in Iceland 1995–2015: adolescent alcohol and cannabis use in Iceland 1995–2015. Drug Alcohol Rev. 2018;37:S49–57.

To Learn More For a full description of diagnostic criteria of all the FASD, readers are encouraged to consult Hoyme et al. [6] and Denny, Coles, and Blitz [4]. Read the UK Hidden Harm Report (https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/120620/hidden-­harm-­full.pdf) and the Irish Hidden Harm Report (https://www.tusla.ie/uploads/content/PracticeGuide.pdf). To read about the effect of alcohol on the adolescent brain, read Lees et  al. (2020) recent article which is published open access (https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7183385/#:~:text=Findings%20from%20human%20adolescent%20studies,%2C%20 executive%20functioning%2C%20and%20impulsivity). To learn more about strategies parents can employ to specifically delay and reduce adolescent substance use, see the user-friendly guide for parents produced by Ryan et al. 2011 as part of their Delphi study which is also open access ­(https://bmcpublichealth.biomedcentral.com/artic les/10.1186/1471-­2458-­11-­13#Sec12)

Alcohol Use During Pregnancy and Its Impacts on a Child’s Life

12

Penny A. Cook, Alan D. Price, and Raja A. S. Mukherjee

Learning Outcomes Readers will gain: • An awareness of fetal alcohol spectrum disorder (FASD) as a consequence of exposure to alcohol during pregnancy and the understanding that alcohol is a potent teratogen that damages the brain and other body systems • An understanding of some of the features of FASD and the complexities of diagnosis of FASD • An understanding that interrelated exposures and adverse childhood experiences can complicate the presentation and diagnosis of FASD • An appreciation of the lifelong impact of FASD on the individual and the family

12.1 Introduction The impacts of prenatal alcohol consumption are significant and have lifelong negative consequences for the individual. Despite there being much evidence of these impacts from studies across the world with birth parents, adoptive families and affected individuals themselves, fetal alcohol spectrum disorders (FASD) continue to be poorly recognised [1, 2]. Even where there is direct evidence from birth mothers who have a clear history of exposure and are seeking help to address the clear P. A. Cook (*) · A. D. Price School of Health and Society, University of Salford, Salford, Greater Manchester, UK e-mail: [email protected]; [email protected] R. A. S. Mukherjee Fetal Alcohol Spectrum Disorder Service, Surrey and Borders Partnership NHS Foundation Trust, Redhill, Surrey, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_12

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and evident needs of their children, there remain challenges with regard to garnering support and help for these children, adolescents and eventually adults [1, 2]. Whilst the recognition of the condition has moved a long way over the last 20 years [3], there is demonstrated cynicism in some parts of the medical and associated healthcare profession [4] which continues to have impact on those families and individuals, a decade after the concerns were first highlighted [2, 5]. This chapter will seek not only to identify some of the complexities associated with prenatal alcohol on the individual but also highlight how the understanding of this complex presentation has moved on and how the factors influencing some of these complexities have been teased apart to better understand the overall impact on the individual. It is therefore hoped that long-term consequences, for example, involvement with the criminal justice system in adult life, can be reduced leading to an overall better quality of life.

12.2 What Is Fetal Alcohol Spectrum Disorder (FASD) and How Common Is It? Alcohol is a potent teratogen that can lead to physical and neurodevelopmental birth defects known as fetal alcohol spectrum disorders (FASD) [6]. FASD is an umbrella term that includes the diagnoses of FAS (fetal alcohol syndrome), pFAS (partial fetal alcohol syndrome), ARBD (alcohol-related birth defects) and ARND (alcohol-­ related neurodevelopmental disorder)/ND-PAE (neurobehavioural disorder associated with prenatal alcohol exposure). FAS is the most distinctive condition on the continuum, and therefore the most likely to be identified. An estimated 10% of pregnancies globally are exposed to alcohol. The four countries with the highest known rates of prenatal alcohol exposure are Ireland, Belarus, Denmark and the UK. In each of these countries, over 40% of pregnancies are exposed to alcohol [7]. For every 13 pregnancies exposed to alcohol, it is estimated that there is one case of a child born with FASD [8]. FASD is more prevalent than is commonly recognised, with 0.8% of children being affected globally and around 2% of children in Europe being affected [8]. This makes it the most common preventable neurodevelopmental disorder [9]. In those countries with higher rates of drinking in pregnancy, such as the UK, the prevalence is likely to be yet higher. For the UK, there is a modelled estimate that suggests that 3.2% of children and young people may have FASD [8]. An indirect estimate comes from the Avon Longitudinal Study of Parents and Children (ALSPAC), a cohort study of babies born in the 1990s with high levels of exposure. Here, 79% of mothers drank during the pregnancy (with 25% at binge levels), and 6–17% of children screened positive for features of FASD [10]. Recently, in the first direct evidence for the UK, a small-scale study of 220 children found 1.8% (95% CI: 1.0%, 3.4%) of children had FASD, and when including possible cases, the figure was 3.6% (2.1%, 6.3%) [11]. Despite the fact that we have good reason to suspect that FASD is common in countries like the UK, the number of persons diagnosed with the condition is small

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in comparison [12]. In general, the lack of direct evidence of prevalence contributes to lack of recognition of FASD as an issue and underinvestment in diagnostic, treatment and prevention services [13].

12.3 Historical Developments in Awareness of FASD and the Impact of Alcohol on the Developing Fetus Awareness of the impacts of alcohol on the developing fetus, whilst not formally recognised in the English-speaking scientific literature until 1973 [14, 15], can be seen in reports throughout history. For example, a report in the 1800s from a UK women’s prison identified the impacts of alcohol on children whose mothers had consumed alcohol during their pregnancy [16]. Despite this, the UK has remained behind many other nations in terms of its relationship with, and acceptance of, FASD as both a concept and condition that requires clear guidance for women. An example of this can be seen in governmental guidelines. When the Avon Longitudinal Study of Parents and Children (ALSPAC) database was first created in the early 1990s, 79% of the women in that sample of pregnant women were noted to have drunk alcohol [10]. At that time, government guidelines identified only ‘heavy’ drinking as being dangerous and harmful. Other interventions, such as drinking the Irish dry stout Guinness, for iron deficiency, were also common practice around those times [17]. In the mid-2000s, the UK government changed its messaging from alcohol being ‘safe’ to one where it was ‘safer to avoid alcohol’. It was not until 2016 that the guidance moved to an unambiguous message of abstinence, a message in line with the majority of countries around the world [18]. A consistent message of abstinence being the safest course of action during pregnancy has arisen because it is not possible to define the exact risk for any individual. Despite this, even now there remains resistance in some quarters to the abstinence messaging because it can be framed as being against the rights of the mother [19]. This is especially the case where the harm of consumption of low levels of alcohol is debated [19, 20]. This uncertainty has led to confusion and cynicism in many parties. Research over a decade has consistently shown poor understanding in both public and professionals [4, 5, 21], and a lack of ability to access support and system-wide problems in diagnostic and support pathways for children and their families [2, 5, 13]. Without appropriate support, individuals with FASD are more likely to experience the secondary disabilities that were identified in early cohort studies. This continues to be reported anecdotally in the UK in adults and adolescents who are born with this condition.

12.4 Diagnosis of FASD FASD is an overarching term that covers a number of diagnoses, including fetal alcohol syndrome (FAS). FAS is the most obvious end of a spectrum, with distinctive facial features alongside neurocognitive deficits. Several diagnostic approaches

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have been developed, including the 4-Digit approach [22], the Canadian 2005 guidance [23] (updated in 2016 [6]) and the Australian Guidance [24]. More recently the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has proposed a new category of FASD diagnosis: neurobehavioural disorder associated with prenatal alcohol exposure (ND-PAE) [25]. In Scotland, following a review by the Scottish Intercollegiate Guidance Network (SIGN), the 2016 Canadian guidance was adapted and incorporated into guidelines for Scotland (SIGN 156) [26], and this has been adopted by the National Institute for Health and Care Excellence (NICE) for England and Wales [27]. Early descriptions of FASD had a focus on physical characteristics such as the tendency to have short palpebral fissures, flattened philtrum and thin upper lip as well as growth restrictions. The presence of these specific stigmata along with neurological effects makes an FASD diagnosis more straightforward as these characteristics are distinctive. However, only around 5% to 10% of those showing cognitive effects may show the classic facial stigmata. The neurological deficits are more common but harder to recognise on their own. Therefore the Canadian guidance (later adopted in the UK) recognises two categories: FASD with and FASD without sentinel features [26]. When considering the neurodevelopmental profiles in those with FASD, classic presentations can be seen. These include impairments exhibited across multiple domains such as with higher-level planning, memory, processing speed, receptive language skills and sensory integration. However, many of these impairments are not obvious, unless looked for, and unfortunately the neurocognitive presentation of a person with FASD in terms of IQ, executive function or language skills can overlap with other neurodevelopmental disorders [28]. Many of those with FASD have only FASD-related cognitive impairments. However, in the most severe cases, other neurodevelopmental conditions such as autism spectrum disorders (ASD) and attention deficit hyperactivity disorder (ADHD) can be diagnosed as comorbid outcomes. This means that, if present, ASD or ADHD are outcomes of the underlying neurological impairment caused by FASD [28, 29]. The majority of cases with FASD, however, do not meet the clinical threshold for a diagnosis of ASD or ADHD, although they may be diagnosed as such, and instead have the neurodevelopmental and neurocognitive profile typically expected with FASD alone. However, this subtlety makes the diagnosis of FASD without sentinel features challenging and is one reason why FASD is underdiagnosed. The diagnostic assessment is complicated further because in testing situations, if it is possible to reduce arousal and/or other environmental stressors, individuals tend to perform better than they function in real-world scenarios. There is evidence to suggest that if individuals experience multiple demands at the same time, this can lead to deterioration of function. For example, in testing scenarios people experiencing FASD can sequence (i.e. do actions in a predictable set order), or they can shift sets (i.e. shift attention between one task and another), but cannot do both together [30]. Real-world tasks, such as capacity and decision-making, rely on

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multiple-­level processing and are also, in the real world, influenced by emotion. Real-world function therefore tends to be worse than performance assessed in a clinic environment [30].

12.5 Diagnostic Process The process of diagnosis is challenging, partly because individuals often present to services because of other conditions rather than for an assessment of FASD alone. A study completed in 2016 highlighted that there were 427 comorbid presentations linked to FASD diagnosis [31]. However, requests for FASD assessment are increasing. The diagnostic process for FASD is one of the exclusions, and much of the diagnostic time is spent ruling out, as far as possible, other common causes of a neurodevelopmental presentation (Box 12.1). The most common of the alternative causes of neurodevelopmental conditions is genetic. As a minimum, it is recommended that, in those people who do not display the characteristic facial features (i.e. who are non-dysmorphic), a microarray is arranged [32]. Where there is dysmorphia, it is always wise to include a clinical geneticist or dysmorphologist in the assessment, who can potentially direct the individual to more specific testing, including, potentially, a microarray or genome-wide assessment.

Box 12.1 Core Areas to Rule Out When Considering Other Aetiological Causes of the Neurodevelopmental Presentation

• • • • •

Genetic factors Other substances in pregnancy Prematurity (generally before 34 weeks) Perinatal hypoxia and significant physical trauma Extreme post-natal neglect

A multidisciplinary team is usually used when assessing individuals with FASD [26]. Whilst this implies that a single person cannot undertake an FASD assessment, this is not the case. Information can be collated by a single individual, where different assessments are brought together, allowing a diagnosis to be made. Reports by a psychologist, occupational therapist or a speech and language therapist are important to help identify the level of deficits and the identified needs. This is very much in keeping with the widely used medical model of assessment. Given the difficulty and the lack of expertise on how to recognise and formulate conditions that may be caused by prenatal exposure to alcohol, cases of FASD are often missed or misdiagnosed. Therefore, those with undiagnosed FASD are likely to present later with secondary psychiatric mental health conditions. Table  12.1, taken from a long-term cohort study over 30 years [33], identifies that mental health problems are common, as are problems with substance misuse.

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Table 12.1  Risk of secondary outcomes in persons with fetal alcohol spectrum disorder: results from a long-term follow-up study (Streissguth et al. [33])

Adverse life outcome Disrupted school experience Trouble with the law Confinement (detention/jail/prison/ psychiatric or alcohol/drug inpatient setting) Inappropriate sexual behaviour Alcohol/drug problems

Odds ratio (95% confidence intervals) if risk factor present Late diagnosis Low per cent of life Per cent with (aged over in stable/nurturing outcome 12 years) home 61 3.27 (1.85, 5.78) 3.10 (1.79, 5.37) 60 2.92 (1.66, 5.15) 2.16 (1.27, 3.69) 50 3.03 (1.69, 5.41) 2.97 (1.75, 5.04)

49 35

2.25 (1.27, 4.00) 4.16 (2.07, 8.36)

3.13 (1.83, 5.36) 2.44 (1.40, 4.26)

Based on long-term follow-up of 415 patients (254 of whom were adolescents/adults)

12.5.1 Overlapping Exposures and Other Adverse Childhood Experiences (ACEs) A feature of children who have been exposed to alcohol in the womb is that there are often multiple other life circumstances that could have an impact on development, including exposure to other substances in the womb and traumatic events during childhood. Examples of adverse childhood experiences (ACEs) include physical, sexual or emotional abuse, problematic alcohol or substance use in the family and witnessing violence. There is a well-established literature on ACEs, which has challenged the conventional thinking about the impacts of childhood conditions on long-term health [34, 35]. Children with toxic stress are described as living lives in fight, flight or fright mode, states that are mediated by stress hormones such as adrenaline and cortisol, which affect brain development [34]. Such children are unable to function appropriately, cannot focus on learning and may experience behaviour problems [36]. They may fall behind in school or fail to develop healthy relationships with peers or create problems with teachers. Despair, guilt and frustration lead to a plethora of adverse outcomes, again overlapping with the list used to describe those of FASD. The presence of certain ACEs can both confound the presentation of FASD, adding to the difficulty in obtaining a diagnosis, and separately may impact on the individual’s longer-term trajectory of life chances. It is useful to consider the different possible broad circumstances surrounding children who have been exposed to alcohol prenatally. Some broad categories could be: 1. Overlapping exposures of alcohol and ACEs at lower than threshold for child removal 2. Overlapping exposures of alcohol and potential ACEs detected early, child removed

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3. Overlapping exposures of alcohol and ACEs detected later, child removal after period of post-natal abuse/neglect to add to the prenatal damage 4. Solely alcohol exposure, no other exposures to substances or ACEs These are illustrated in Fig. 12.1, which shows the overlapping exposures. Secondly, the stability of the current environment may have an influence on how a person could present. Children could currently be experiencing: 1. Stable and nurturing adoptive/foster home 2. Other looked-after child environments (and possible exposure to further ACEs) 3. Remaining with birth parents: stable and nurturing 4. Remaining with birth parents: troubled and continued exposure to ACEs The questions are as follows: to what extent do these other exposures cause extra difficulties, over and above the damage caused by prenatal alcohol, and to what extent is their presence confounding a diagnosis and making treatment difficult because FASD is not considered? To what extent does the current living arrangement impact on likelihood of achieving a diagnosis/obtaining further support? The general ACE literature does not include consideration of the role of prenatal exposure to alcohol and other substances. Whilst FASD researchers have begun to examine this, there are relatively few studies that have investigated the combined impact of prenatal alcohol exposure and ACEs. Those that have have shown that the two exposures tend to co-occur to a high degree, at least within clinical populations. In individuals with FASD, studies have shown that higher numbers of ACEs are associated with increased risk of comorbid disorders, especially attachment disorder and PTSD [5, 37], and involvement in the criminal justice system [37]. However, Exposed to abuse/neglect (postnatal)

Exposed to alcohol (prenatal)

Threshold for child removal not reached or neglect/abuse not recognised

Child removed in infancy

2

Child removed later in childhood (prolonged exposure abuse/neglect)

1

Exposure to alcohol and abuse/neglect

Alcohol is the only exposure

4

3

Fig. 12.1  Diagram to illustrate some of the complexity in overlapping exposures to abuse/neglect in childhood and prenatal alcohol

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there is no evidence that ACEs have an additional impact on neurocognitive functioning, over and above that which would be expected from the FASD alone [5, 38–41]. More research is needed to further delineate the effects of prenatal alcohol and ACEs, and especially alongside other pre- and post-natal exposures. However, the emerging picture is that individuals exposed to both prenatal alcohol and ACEs are likely to experience more difficulties with mental health, but no more difficulties with cognitive development, than individuals with prenatal alcohol without ACEs.

12.6 Exposures to ACEs and Other Substances Complicate the Diagnosis of FASD Other adverse exposures, such as post-natal neglect and exposure to other substances, complicate the diagnosis of FASD because they can in themselves cause developmental difficulties. This does not preclude alcohol also having a comorbid teratogenic effect, but it does complicate the picture and obscure the presentation of the unique phenotype. Due to the complexity and difficulty in delineating the different factors, in these cases, the diagnosis of FASD cannot be confidently made. However prenatal alcohol should be listed as an aetiological factor alongside the other factors. Increasingly, through careful evaluation, it is becoming possible to delineate and rule out the influence of some of these other exposures based on the neurological deficits. Other drugs, rather than being considered as social constructs, must be looked at from the perspective of their differing biological mechanisms. For example, cocaine acts on dopaminergic reuptake and therefore can have some frontal lobe activation and effect; however longer-term studies indicate that, where used alone, this has low potency for ongoing damage [42]. Heroin, whilst having significant social impacts on the person and society, has a limited biological impact. Studies that have monitored those using methadone, for example, show no long-­ term consequences on the prenatally exposed child [42]. However, the exact mix of substances used is often difficult to determine, and where there is chaotic multi-­ substance use, alcohol is often also consumed. Box 12.1 also highlights post-natal neglect as also a potential factor that can lead to behavioural presentations. However, as for drug use above, if alcohol exposure has also occurred in cases of post-natal neglect, alcohol is increasingly being seen as having a greater neurodevelopmental impact. Post-natal neglect does however impact on the wider vulnerabilities and the subsequent psychological experience of life. This is increasingly understood as complex trauma but must always be seen in the light of the underlying neurology. There are multiple pathways by which alcohol directs its effects on the developing fetus. This to some extent explains the different vulnerability of individuals. Accurate information on exposure is vital. Not everybody who was exposed to prenatal alcohol will develop FASD. However, it is the absence of information of exposure to the risk factors that remains the most common reason to preclude diagnosis, rather than the lack of exposure itself.

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12.7 Role of the Parent/Carer in Obtaining Diagnosis Some of the circumstances outlined in Fig. 12.1 also mean that children will differ in the extent to which they have supportive adults around them. The diagnosed group are overrepresented by those who are adopted; the least likely to be identified may be those who have not come to the attention of authorities, possibly living in environments that are not ideal and with parents who are less able to support the child, hampered by lack of awareness that alcohol in pregnancy could have caused harm. There is evidence that in many cases, a diagnosis of FASD has only been achieved after a persistent campaign by a knowledgeable parent/carer. In many cases these would be adoptive parents [2, 5].

12.8 The Impacts of Having FASD on the Individual and the Family FASD has a complex presentation, with individuals having difficulties over a number of domains, and this can lead to complex and varied outcomes. Salmon and Buetow give some of the impacts from the perspectives of those experiencing FASD [43]: There is an immediate impact of the child’s struggle to learn effectively and process the world around them. They struggle with impulse control; hence they are more likely to get into trouble at school, in their care environment or with the law. They struggle with memory and therefore may not learn from their mistakes. They struggle to form social relationships. These difficulties lead to frustration for the child and the family [2, 44]. Alongside this is the stress caused by the fact that the condition is rarely recognised or supported, and the ongoing battle to get authorities to recognise the problem [1, 2]. Caregivers of children with FASD in the UK have been shown to have very high, even clinically significant, levels of stress related to caring for their children [44]. Even if a diagnosis is obtained, there are few evidence-­ based interventions to support individuals and families [13]. Individuals with FASD are likely to need lifelong support from services since the difficulties caused by FASD do not lessen with time. In longer term, these challenges can lead to loss of engagement with school and poor mental health [45], in turn leading to increased risk of alcohol and drug abuse [46]. Evidence shows that in the longer term, if unsupported, those with FASD have a much higher risk of various adverse outcomes, such as criminal justice involvement [33]. This is illustrated in Table 12.1, where the odds of various adverse outcomes are increased two- to fourfold in those who are diagnosed later. This can be due to being naive/impulsive, or due to being wrongly accused and unable to defend themselves in a criminal justice system that does not recognise FASD as a cause [47]. Due to the increased risk of alcohol misuse, there is also a risk of women experiencing FASD themselves having an alcohol-exposed pregnancy, and thus, the cycle perpetuates [48, 49]. These early studies, based on cohorts who were very

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significantly affected, have been criticised for being overly negative, and indeed, there is evidence that with appropriate support, children with FASD can have good outcomes.

12.9 Treatment and Therapies to Support those Experiencing FASD Since the difficulties caused by FASD are lifelong, it is important to consider what interventions might improve functioning and quality of life and reduce the risk of negative outcomes later in life. Research into effective treatment and therapy for FASD is relatively limited, with a recent systematic review finding only 25 randomised controlled intervention studies [50]. However, 12 of the studies have been carried out relatively recently (since 2015), suggesting that the field is expanding. The interventions tended to focus on single domains of impairment, for example, motor skills, mathematics, attention, executive functioning, adaptive functioning, impulsivity and social skills. Such cognitive and behavioural interventions have led to statistically significant improvements compared to control groups with no intervention [50]. Interventions for families typically show better treatment effects than interventions directed only at children. A small number of studies have evaluated caregiver-focussed interventions, and these have shown that long-term support and advocacy along with training in FASD and a child component can be effective [51, 52]. It was notable that in the systematic review, only one study was found that aimed to improve outcomes for adolescents, in this case, an intervention to reduce alcohol harm: the intervention was shown to be promising [53]. Whilst there is no specific medication to treat FASD in itself, other presentations linked to FASD such as ADHD or anxiety will warrant treatment. The presence of FASD will modify the approach to treatment. For example, Young et al. [54] highlighted modifications to pathways for ADHD treatment in people where this was caused by FASD.

12.10 Transition from Child to Adult FASD is a lifelong disorder. Whilst aspects of the presentation can improve, other challenges and difficulties remain, which can lead to an individual’s trajectory being poor. Early work by Streissguth et al. [33] identified secondary disabilities in a long-­ term cohort. This was followed up over 30  years showing significant difficulties with criminality, mental health, sexuality and their own addictions. Where ongoing support could be offered, and scaffolding of the individuals in the appropriate situations maintained, better long-term outcomes were seen. For example, the odds of having better outcomes were two to four times higher if an FASD diagnosis had occurred at an earlier age (see Table 12.1) and if the child had been nurtured in a stable environment.

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Anecdotal reports from families where caregivers better understand the child’s needs, leading to better self-esteem and ongoing support for remaining difficulties, have been shown to have positive lifelong sustainable benefits. Where this is not the case, the secondary disabilities are far more commonly seen. Therefore early identification alongside regular reassessments of need with a view to suitable supportive interventions is an appropriate way forward. Changing the trajectory of an individual’s life should be the first and primary purpose of diagnosis. Understanding their neurocognitive profile and an individual’s needs is essential in helping the people around that individual to make reasonable adjustments and accommodations. Whilst individuals will develop and progress, many require ongoing help in order to achieve their full potential.

12.11 Conclusion Alcohol is a potent teratogen that can lead to physical and neurodevelopmental birth defects. Although FASD is common, prenatal alcohol exposure tends not to be recognised as a cause of a young person’s problems. In part, this is because exposure to alcohol commonly occurs in environments that are also characterised by multiple other stresses and adverse childhood experiences. Even when alcohol exposure is known or suspected, obtaining a diagnosis of FASD can be difficult, due to lack of awareness in professionals and lack of diagnostic services. Whilst many of those with FASD experience challenges and have poor long-term outcomes, early recognition and support can be life-changing. However, there are many gaps in knowledge and services, including what interventions can best support those with FASD and their families. In particular, research on the needs of adolescents and adults with FASD is underdeveloped.

References 1. Thomas R, Mukherjee R.  Exploring the experiences of birth mothers whose children have been diagnosed with fetal alcohol spectrum disorders: a qualitative study. Adv Dual Diagn. 2019;12:27–35. 2. Mukherjee R, Wray E, Commers M, Hollins S, Curfs L. The impact of raising a child with FASD upon carers: findings from a mixed methodology study in the UK.  Adopt Foster. 2013;37:43–56. 3. Mukherjee R. FASD: the current situation in the UK. Adv Dual Diagn. 2019;12:1–5. 4. Mukherjee R, Wray E, Curfs L, Hollins S. Knowledge and opinions of professional groups concerning FASD in the UK. Adopt Foster. 2015;39:212–24. 5. Price AD. The impact of traumatic childhood experiences on cognitive and behavioural functioning in children with foetal alcohol spectrum disorders [Doctoral thesis]. University of Salford; 2019. http://usir.salford.ac.uk/id/eprint/51974/. 6. Cook JL, Green CR, Lilley CM, Anderson SM, Baldwin ME, Chudley AE, et al. Fetal alcohol spectrum disorder: a guideline for diagnosis across the lifespan. CMAJ. 2016;188:191–7. 7. Popova S, Lange S, Probst C, Gmel G, Rehm J. Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Global Health. 2017;5:E290–E9.

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8. Lange S, Probst C, Gmel G, Rehm J, Burd L, Popova S. Global prevalence of fetal alcohol spectrum disorder among children and youth a systematic review and meta-analysis. JAMA Pediatr. 2017;171:948–56. 9. Sokol RJ, Delaney-Black V, Nordstrom B.  Fetal alcohol spectrum disorder. JAMA. 2003;290:2996–9. 10. McQuire C, Mukherjee R, Hurt L, Higgins A, Greene G, Farewell D, et al. Screening prevalence of fetal alcohol spectrum disorders in a region of the United Kingdom: a population-­ based birth-cohort study. Prev Med. 2019;118:344–51. 11. McCarthy R, Mukherjee RAS, Fleming KM, Green J, Clayton-Smith J, Price AD, et  al. Prevalence of Fetal Alcohol Spectrum Disorder (FASD) in Greater Manchester, UK: an active case ascertainment study. Alcohol Clin Exp Res. 2021;45(11):2271–81. 12. Morleo M, Woolfall K, Dedman D, Mukherjee R, Bellis MA, Cook PA. Under-reporting of foetal alcohol spectrum disorders: an analysis of hospital episode statistics. BMC Pediatr. 2011;11:14. 13. Scholin L, Mukherjee RAS, Aiton N, Blackburn C, Brown S, Flemming KM, et al. Fetal alcohol spectrum disorders: an overview of current evidence and activities in the UK. Arch Dis Child. 2021;106(7):636–40. 14. Jones KL, Smith DW.  Recognition of fetal alcohol syndrome in early infancy. Lancet. 1973;2:999–1001. 15. Jones KL, Smith DW, Ulleland CN, Streissguth AP. Pattern of malformation in offspring of chronic alcoholic mothers. Lancet. 1973;301:1267–71. 16. Sullivan WC.  A note on the influence of maternal inebriety on the offspring. J Ment Sci. 1899;45:489–503. 17. Bhuvaneswar CG, Chang G, Epstein LA, Stern TA. Alcohol use during pregnancy: prevalence and impact. Prim Care Companion J Clin Psychiatry. 2007;9:455. 18. UK Chief Medical Officers. UK Chief Medical Officers’ low risk drinking guidelines. London; 2016. 19. McCallum K, Holland K. ‘To drink or not to drink’: media framing of evidence and debate about alcohol consumption in pregnancy. Crit Public Health. 2018;28:412–23. 20. Gavaghan C. “You can’t handle the truth”; medical paternalism and prenatal alcohol use. J Med Ethics. 2009;35:300. 21. Mukherjee R, Wray E, Hollins S, Curfs L. What does the general public in the UK know about the risk to a developing foetus if exposed to alcohol in pregnancy? Findings from a UK mixed methodology study. Child Care Health Dev. 2015;41:467–74. 22. Astley SJP, Stachowiak JR, Clarren SKM, Clausen CR. Application of the fetal alcohol syndrome facial photographic screening tool in a foster care population. J Pediatr. 2002;141:712–7. 23. Chudley AE, Conry J, Cook JL, Loock C, Rosales T, LeBlanc N. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ. 2005;172(5 Suppl):S1–S21. 24. Bower C, Elliott EJ, Zimmet M, Doorey J, Wilkins A, Russell V, et  al. Australian guide to the diagnosis of foetal alcohol spectrum disorder: a summary. J Paediatr Child Health. 2017;53:1021–3. 25. APA.  Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013. 26. Scottish Intercollegiate Guidance Network (SIGN). Children and young people exposed to prenatal alcohol. Health Improvement Scotland: Edinburgh; 2019. 27. National Institute for Health and Care Excellence. Fetal alcohol spectrum disorder, in development [GID-QS10139]. 2021. https://www.nice.org.uk/guidance/indevelopment/gid-­qs10139. 28. Mukherjee RAS. The relationship between ADHD and FASD. Thrombus. 2016;8:4–7. 29. Mukherjee RAS, Layton M, Yacoub E, Turk JT. Autism and autistic traits in people exposed to heavy prenatal alcohol: data from a clinical series of 21 individuals and a nested case control study. Adv Mental Health Intellect Disabil. 2011;5:43–9. 30. Mohamed Z, Carlisle ACS, Livesey AC, Mukherjee RAS. Comparisons of the BRIEF parental report and neuropsychological clinical tests of executive function in fetal alcohol Spectrum disorders: data from the UK national specialist clinic. Child Neuropsychol. 2019;25:648–63.

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31. Popova S, Lange S, Shield K, Mihic A, Chudley AE, Mukherjee RAS, Bekmuradov D, Rehm J.  Comorbidity of fetal alcohol spectrum disorders: a systematic review and meta-analysis. Lancet. 2016;387:978–87. 32. Douzgou S, Breen C, Crow YJ, Chandler K, Metcalfe K, Jones E, et  al. Diagnosing fetal alcohol syndrome: new insights from newer genetic technologies. Arch Dis Child. 2012;97(9):812–7. 33. Streissguth AP, Bookstein FL, Barr HM, Sampson PD, O’Malley K, Young JK. Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. J Dev Behav Pediatr. 2004;25:228–38. 34. Oral R, Ramirez M, Coohey C, Nakada S, Walz A, Kuntz A, et al. Adverse childhood experiences and trauma informed care: the future of health care. Pediatr Res. 2016;79:227–33. 35. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14:245–58. 36. Burke NJ, Hellman JL, Scott BG, Weems CF, Carrion VG. The impact of adverse childhood experiences on an urban pediatric population. Child Abuse Negl. 2011;35:408–13. 37. Tan GKY, Symons M, Fitzpatrick J, Connor SG, Cross D, Pestell C. Adverse childhood experiences, associated stressors and comorbidities in children and youth with fetal alcohol spectrum disorder across the child protection and justice settings in Western Australia. BMC Pediatr. 2022;22(1):587. 38. Hemingway SJA, Davies JK, Jirikowic T, Olson EM. What proportion of the brain structural and functional abnormalities observed among children with fetal alcohol spectrum disorder is explained by their prenatal alcohol exposure and their other prenatal and postnatal risks? Adv Pediatr Res. 2020;7:41. 39. Flannigan K, Kapasi A, Pei J, Murdoch I, Andrew G, Rasmussen C. Characterizing adverse childhood experiences among children and adolescents with prenatal alcohol exposure and fetal alcohol spectrum disorder. Child Abuse Negl. 2021;112:104888. 40. Mukherjee RAS, Cook PA, Norgate SH, Price AD. Neurodevelopmental outcomes in individuals with fetal alcohol spectrum disorder (FASD) with and without exposure to neglect: clinical cohort data from a national FASD diagnostic clinic. Alcohol. 2019;76:23–8. 41. Price A, Cook PA, Norgate SH, Mukherjee RAS.  Prenatal alcohol exposure and traumatic childhood experiences: a systematic review. Neurosci Biobehav Rev. 2017;80:89–98. 42. Preece PM, Riley EP. Alcohol, drugs and medication in pregnancy. London: MacKeith; 2011. 43. Salmon JV, Buetow SA. An exploration of the experiences and perspectives of New Zealanders with fetal alcohol spectrum disorder. J Popul Ther Clin Pharmacol. 2012;19:e41–50. 44. Mohamed Z, Carlisle AC, Livesey AC, Mukherjee RA. Carer stress in fetal alcohol Spectrum disorders: the implications of data from the UK national specialist FASD clinic for training carers. Adopt Foster. 2020;44:242–54. 45. Streissguth AP, O’Malley K.  Neuropsychiatric implications and long-term consequences of fetal alcohol spectrum disorders. Semin Clin Neuropsychiatry. 2000;5:177–90. 46. Baer JS, Sampson PD, Barr HM, Connor PD, Streissguth AP. A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking. Arch Gen Psychiatry. 2003;60:377–85. 47. Allely CS, Mukherjee R.  Suggestibility, false confessions and competency to stand trial in individuals with fetal alcohol spectrum disorders: current concerns and recommendations. J Crim Psychol. 2019;9:166–72. 48. Kvigne VL, Leonardson GR, Borzelleca J, Welty TK. Characteristics of grandmothers who have grandchildren with fetal alcohol syndrome or incomplete fetal alcohol syndrome. Matern Child Health J. 2008;12:760–5. 49. Rouleau M, Levichek Z, Koren G. Are mothers who drink heavily in pregnancy victims of FAS. J FAS Int. 2003;1:1–5. 50. Ordenewitz LK, Weinmann T, Schlüter JA, Moder JE, Jung J, Kerber K, et al. Evidence-based interventions for children and adolescents with fetal alcohol spectrum disorders – a systematic review. Eur J Paediatr Neurol. 2021;33:50–60.

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51. Petrenko CLM, Demeusy EM, Alto ME. Six-month follow-up of the families on track intervention pilot trial for children with fetal alcohol Spectrum disorders and their families. Alcohol Clin Exp Res. 2019;43:2242–54. 52. Bertrand J. Interventions for children with fetal alcohol spectrum disorders (FASDs): overview of findings for five innovative research projects. Res Dev Disabil. 2009;30:986–1006. 53. O’Connor MJ, Quattlebaum J, Castañeda M, Dipple KM. Alcohol intervention for adolescents with fetal alcohol Spectrum disorders: project step up, a treatment development study. Alcohol Clin Exp Res. 2016;40:1744–51. 54. Young S, Absoud M, Blackburn C, Branney P, Colley B, Farrag E, et al. Guidelines for identification and treatment of individuals with attention deficit/hyperactivity disorder and associated fetal alcohol spectrum disorders based upon expert consensus. BMC Psychiatry. 2016;16:324.

To Learn More All Party Parliamentary Group on FASD.  Initial report of the inquiry into the current picture of FASD in the UK today. London; 2015. https://nationalfasd.org.uk/learn-­more/policy/ appg-­on-­fasd/ Astley SJ. Comparison of the 4—digit code and the Hoyme diagnostic guidelines for fetal alcohol spectrum disorders. Paediatrics. 2006;118:1532–45. British Medical Association. Fetal alcohol spectrum disorders, a guide for healthcare practitioners; update. London: British Medical Association; 2016. Chudley AE, Conry J, Cook JL, Loock C, Rosales T, LeBlanc N. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ. 2005;172(5 Suppl):S1–S21. Clarren SK, Jones KL. The fetal alcohol syndrome. N Engl J Med. 1978;298:1063–7. Douzgou S, Breen C, Crow YJ, Chandler K, Metcalfe K, Jones E, et al. Diagnosing fetal alcohol syndrome: new insights from newer genetic technologies. Arch Dis Child. 2012;97(9):812–7. Hoyme HE, May PA, Kalberg WO, Kodituwakku PW, Gossage JP, Trujillo PM, et al. A practical clinical approach to diagnosis of fetal alcohol spectrum disorders; clarification of the 1996 Institute of Medicine Criteria. Pediatrics. 2005;115:39–47. Jones KL, Smith DW. Recognition of the fetal alcohol syndrome. Lancet. 1973;302:999–1001. McQuire C, Mukherjee R, Hurt L, Higgins A, Greene G, Farewell D, et al. Screening prevalence of fetal alcohol spectrum disorders in a region of the United Kingdom: a population-based birth-­ cohort study. Prev Med. 2019;118:344–51. Morleo M, Woolfall K, Dedman D, Mukherjee R, Bellis MA, Cook PA. Under-reporting of foetal alcohol spectrum disorders: an analysis of hospital episode statistics. BMC Pediatr. 2011;11:14. Mukherjee RA, Hollins S, Curfs L. Fetal alcohol spectrum disorders: is it something we should be more aware of? J R Coll Physicians Edinb. 2012;42:143–50. Mukherjee RAS, Aiton N, editors. Recognition and management of fetal alcohol spectrum disorders. Cham: Springer; 2021. Price A, Cook PA, Norgate S, Mukherjee R. Prenatal alcohol exposure and traumatic childhood experiences: a systematic review. Neurosci Biobehav Rev. 2017;80:89–98. Price AD. The impact of traumatic childhood experiences on cognitive and behavioural functioning in children with foetal alcohol spectrum disorders [Doctoral thesis]. University of Salford; 2019. http://usir.salford.ac.uk/id/eprint/51974/. Scholin L, Mukherjee RAS, Aiton N, Blackburn C, Brown S, Flemming KM, et al. Fetal alcohol spectrum disorders: an overview of current evidence and activities in the UK. Arch Dis Child. 2021;106(7):636–40. Scottish Intercollegiate Guidance Network (SIGN). Children and young people exposed to prenatal alcohol. Health Improvement Scotland: Edinburgh; 2019.

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UK Chief Medical Officers. Low risk drinking guidelines. London; 2016. Warren KR, Foudin LL. Alcohol-related birth defects—the past, present, and future. Alcohol Res Health. 2001;25:153–8.

Resources Seashell Trust and National Organisation for FASD. ‘Me and My FASD’ toolkit: resources for young people and adults experiencing FASD. https://fasd.me/ The National Organisation for FASD (formerly NOFAS-UK) is dedicated to supporting people affected by fetal alcohol spectrum disorders (FASD), their families and communities ­(https:// nationalfasd.org.uk/)

Female Adult

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Learning Outcome On reading this chapter, the reader will have considered and gained an understanding of the: • Lifelong risk to health when women consume alcohol above low risk, drinking guidelines and how this differs to men • Psychosocial vulnerabilities which can arise when women consume alcohol to the point of intoxication, or are living with alcohol dependence • Specific issues which arise and need to be discussed and incorporated into care plans when planning care to facilitate women’s engagement and retention in treatment • Components of care of women living with alcohol use problems during pregnancy • Ethical issues which arise when providing care to women and strategies to resolve them • Competent and ethical assessment and care

13.1 Introduction Women living with alcohol use problems, including dependence, are more likely to experience physical, social and emotional harm than their male counterparts [1, p. 99, 2, p. 16]. They are also more likely to be highly censured and stigmatised by society and health professionals, whose role is to provide nonjudgmental care [1, pp. 99, 100].

J. (J). Talmet (*) DASSA Northern Services, Adelaide, SA, Australia e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_13

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Through the healthcare process, health professionals navigate complex ethical issues and dilemmas arising from vulnerability, healthcare consumer rights, protective legislation, the actions of family members and/or partners, health professionals, other human service providers and health systems. Due to the significance of these issues on the willingness to engage or remain in treatment, adhere to its requirements and on the outcomes of care, attention is given to exploring common ethical issues and dilemmas and identifying strategies which may assist in their remediation.

13.2 Alcohol Use in Context Women’s alcohol consumption in the middle of the last century was more likely to be in small amounts, on rare occasions and at special events. In that era, women were more likely to work at home with a specific role of home management, care of children and their partners, whereas male partners were seen as head of the family and holders of authority who made decisions including those related to finances. In recent decades, there are more women in paid work away from home at least on a part- or full-time basis as well as having primary responsibility for home management and child care, although men may be more involved in parenting and in house work. There may also be shared decision-making and financial management. In this new era, while women who consume alcohol, on average, drink less than men, they are now likely to drink in the same venues, at the same times and in similar patterns to men. For women, alcohol consumption above low-risk guidelines increases the risk of dying from an alcohol-related health condition at all levels of use than their male counterparts [2, p. 32].

13.3 Alcohol-Related Harm Women on consuming alcohol are likely to have a higher blood concentration, reached more quickly, which lasts longer than in men as women are smaller in size, have more body fat and less lean muscle and metabolise less alcohol in the stomach [2, p. 16]. Women are more likely to experience greater immediate effects (intoxication) and increased reaction times and impact on coordination, speech and cognition [2, p. 20]. Women drinking above low-risk guidelines have an increased risk of irregular menses, spontaneous miscarriage and infertility [2, p. 35] and breast, cervical and endometrial cancer (4–16). However, despite well-established evidence of alcohol related harm, high-risk use, and dependence can occur without harm and the severity of dependence does not necessarily equate to the need for intensive, long-term treatment and/or intervention, although it might. For some, dependence can be a lifelong relapsing condition with significant harm to health and wellbeing.

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Case Scenario 13.1: Barbara Barbara (42) recently finished working as a beautician on a cruise line. In-between contracts, Barbara had a difficult relationship with Peter because of his controlling behaviour. While on the final contract, Barbara realised that despite the difficulties, she loved Peter and began writing to him. While away, Barbara worked long hours, drank on average eight standard drinks (SD’s) a day and was sexually promiscuous. Barbara had been the victim of stepfather sexual abuse, has a strained relationship with her mother and sees her biological father as ineffectual. Barbara has a wide circle of friends. Some are living with alcohol use problems including dependence. On return home, Barbara quickly became pregnant and had a son. During the late stages of pregnancy and after the birth, Peter’s mother provided some support with meals and house cleaning, for which Barbara was grateful. Three months postnatal was a stressful time. Peter did not help with baby care or housework or provide emotional support. Barbara was tired, teary and exhausted but saw this as normal. When Peters’ lack of support continued, Barbara became increasingly emotional when requesting help. Peter’s past controlling and verbally abusive behaviour returned. Peter started belittling Barbara calling her mad and a bad mother and commented that his mother said she was lazy and should be cleaning the house and looking after him and the baby. When Barbara raised his mother’s kindness, she was told his mother had complained about helping and only did this because she was so lazy. Barbara became increasingly emotional when she fought back or stood up for herself. Peter’s negative comments escalated, and Barbara was pushed a few times. Prior to going out with female friends for the first time in over 15  months, Barbara ensured her sons safety by ensuring baby had appropriate care and had expressed breast milk to avoid exposing baby to alcohol on return home. On that night Barbara consumed three glasses of wine. On returning, Peter grabbed Barbara angrily, bruised her wrists, called her an alcoholic, threatened to obtain custody and advised he had documented concerns about her mad behaviour since the birth. Shortly after, a health professional noted that Barbara was subdued and asked how things were. Barbara told her story. The health professional was immediately concerned that Peter might be grooming Barbara for physical violence and noted the risk factors of having a young baby, escalating isolation and psychological and early-stage physical violence. The health professional provided support and raised concern. Barbara became defensive, saying she was the problem. Her parents had divorced, and she wanted her child to have both parents at home. Barbara said she could address relationship issues without assistance when encouraged to speak with a relationship counsellor. Barbara was provided with information about domestic violence, the indicators for violence escalation as well as relationship counselling services. Advice was given to:

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Document Peter’s behaviour Keep all abusive messages as evidence Consider setting limits and actions to be taken if these were breached To develop a safety plan for herself and baby

Shortly after, Peter assaulted Barbara who sustained injuries. Barbara contacted domestic violence services, ended the relationship and pursued formal child access arrangements. Peter continued control attempts by refusing access visits when Barbara was working or going out. Barbara responded by arranging alternative childcare arrangements and continued recording Peters behaviours. Barbara later disclosed to the health professional that she was getting drunk during access weekends and had started drinking on weeknights when caring for her son. Barbara also reported unsafe sex with multiple unknown partners and a recent weekend incident of drinking more than usual, resulting in concussion, hospitalisation and no memory of events. She was shocked when friends later advised of her behaviour. Barbara was advised to reduce her alcohol use, and an offer to drop off some information resources designed specifically for women was accepted. Barbara was asked about last Pap smear and STD risks and was advised to consider testing. Barbara immediately took action to change her drinking pattern. A few months later, Barbara voiced dissatisfaction with the men she saw and was advised to consider the negative impact that multiple sexual partners might be having on her emotional wellbeing, whether her needs were being met and what she wanted in a relationship. A few months later, Barbara advised that her needs were not being fulfilled and that she wanted more and ceased one-night sexual encounters. Reflective Practice Exercise 13.1 Consider the following: 1. What part did Barbara’s workplace and vulnerability play in her and risk taking? What were the consequences? 2. When Barbara resisted concerns about violence risk, what was done to encourage and prepare her to think about change? 3. What ethical dilemmas do you think arose for the health professional in this situation?

13.4 Context of Vulnerability Women with alcohol use problems may have a higher risk of harm to social and emotional wellbeing arising from adult physical or sexual assault or childhood neglect or trauma [1, pp. 99, 100].

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Trauma can create other vulnerability such as attracting partners who are exploitative or perpetrators of physical and/or sexual violence and/or those who abuse children. Where the sequela of trauma is enmeshed with alcohol use problems, there may be a need to address these issues for treatment and other interventions to be effective.

13.5 Context of Comorbidity Women living with alcohol use problems have the same healthcare needs as any other woman in society and for the same range of co-occurring physical and mental health (MH) comorbidities, disabilities and/or chronic pain conditions. The same applies to the same range of social and emotional wellbeing issues, family and marital problems, insecure housing and financial difficulties, which occur in the absence of alcohol use problems.

13.6 Assessment While assessment components are the same, irrespective of gender, there are some differences related to women’s healthcare needs, family roles, vulnerability and stigma, which need consideration during assessment, care and intervention planning and treatment (see Chap. 10). Assessment offers an opportunity for planning to improve overall health as women experiencing alcohol use problems often neglect their general health needs and/or avoid regular women’s health or dental checks. This can occur over the long-­ term when healthcare is unaffordable and the needs of partners and/or children are given priority. Ethical issues frequently arise during the assessment process, such as identification of disease or harm to health when there are no available or affordable treatments or other intervention options. The presence of harm raises dilemmas. These might include consideration of the costs of treatment and or care, the likelihood of quality of life or positive outcomes, the level of pain or suffering treatment involves and the length and likely success of recovery.

13.6.1 Aims Engagement is a priority aim of assessment and particularly when this is the first contact. Engagement is enhanced through taking a kind, open, honest and nonjudgmental approach that builds rapport and trust. The engagement process acknowledges past negative healthcare experiences or concerns and seeks to allay fear, provide reassurance and support for engagement in treatment.

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The assessment process provides opportunities to begin the process of: • • • • • • •

Building self-efficacy beliefs Healing trauma Removing self-blame Improving self-esteem Building hope for successful change Improved life situation Positive health outcomes

Assessment also allows time to answer questions, to provide information on options and harm reduction strategies and to enable immediate action to commence preparation for change. Information provision and advice, where it is safe for action to be taken, includes: • • • • •

Use of a thiamine supplement and magnesium for its absorption Avoidance of drink driving To not abruptly cease use To slowly reduce amounts prior to planned withdrawal Ensuring children are cared for by a trusted non-using adult when intending to drink • Provision of relevant printed self-help information in accordance with literacy skills See Table 13.1 for the content of assessment relevant to women.

Table 13.1  Assessment content Presenting problem—Precipitating events: Alcohol use, trauma, loss, distressing incident, recent stressors, losses, grief, work, illness, relationships, family, parenting, housing, finances, legal issues Health issues and/or healthcare needs—General health, dental health for woman or her children, any concerns regarding affordability Women’s health issues—date of last health assessment, pap smear, mammogram, BSE practice, menses and its associated difficulties, e.g. endometriosis, likelihood of pregnancy and screening, if indicated to identify withdrawal risk and setting based on gestational age. Previous pregnancies and their outcome Current medications—Prescribed, illicit and over-the-counter medicines and herbals (to identify potential interactions with withdrawal medications and alcohol pharmacotherapies), purpose for use, dose and method of administration Perceived alcohol-related harm and consequences of use—Health sequelae Risky behaviour—Unsafe sex; risk for sexually transmitted disease (STD), including chlamydia or past or current blood-borne virus infection (BBV); contraception and risk for unwanted pregnancy

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Table 13.1 (continued) Risk of harm from others—Family violence history in family of origin (physical or sexual assault) or domestic violence, e.g. ever hit or hurt by or fearful of current or ex-partner(s), or of going home from appointment, if yes what assistance is required. Any partner-inflicted head injury, risks related to trauma Risk of harm to others including partner or children, e.g. drink driving, neglect Risk of harm to self—Including risk taking, exploitation, self-harm or suicide risk Intoxication and its consequences or risks—Symptoms usually experienced and duration; physical injury; risk taking when intoxicated, e.g. unsafe sex, drink driving with young children or baby in the car; use of machinery; victim of physical or sexual violence; unconsciousness, blackouts (no memory) or greyouts (vague recollection); head injury history; symptoms of alcohol-related brain injury (ARBI) Psycho social history—Losses MH problems, e.g. anxiety, depression, any diagnosed condition and risk of self-harm Children’s health issues or healthcare needs—Current children in the woman’s care, name, age, child physical, mental or dental health issues or concerns Children and parenting concerns, planned, parenting and childcare supports, concerns about child behaviours, needs for childcare or parenting assistance, concerns about alcohol use and parenting. Who cares for child when consume alcohol? Are children in care of others—Who provides child care, relationship to the child, how long in care, access arrangements, how often, is access supervised, by whom, when were children last seen, any previous or current involvement with child protection agencies (when, where, caseworker, outcomes) or any current child protection concerns including those related to partner child abuse. Goals related to care of children Personal relationships—Spouse/partner, gender identity, long-standing friendships, support persons, current relationship issues and their impact, loss of relationships due to alcohol use, family issues, relationships with family members—Any concerns Significant others/carer, friends, family support network—Who, relationship with, any conflict, how the person might be involved in the woman’s care, type of support carers will provide, information sharing consent Employment—Satisfaction with employment; full, part time or casual (hour per week); income adequacy; security; any concerns or problems Transport—Current drivers’ licence, mode of transport to attend appointments and travel time of day or evening when can attend appointments Housing: Accommodation/housing/home environment—Where, with whom, adequacy and safety including risk of violence, AOD use at home, any concerns or urgent housing needs, stability of tenure, impact of alcohol use on housing stability or risk of homelessness

By its nature, assessment of alcohol use problems can lead to disclosure or result in the identification of a history of trauma. This means all health professionals need to be prepared for disclosure and aware of the significant importance of the immediate response and particularly when trauma has never been previously disclosed. This is significant as while some women raise trauma, others are fearful of disclosure, which may be due to past negative experiences, including fear of overwhelming health professionals with their story, unfortunate responses such as disbelief or being blamed for what occurred or not receiving the assistance sought.

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When disclosure occurs, it is important to allow the woman to share the information she wishes to share rather than direct questioning, as this can be re-­traumatising. A sensitive and supportive approach includes listening; provision of supportive messages which reinforces perpetrator responsibility, that the woman was not responsible for and did not deserve what occurred; and an authentic expression of sorriness for what happened. This can lead to asking general questions about whether or what problems the incident(s) caused in the past, what is impacting now and its significance for the present rather than about the incident. This approach enables the provision of advice about effective help being available, referral options and provision of support. It also enables asking about any immediate risk or assistance needs. An open offer to revisit at any time and of coming back to this when planning care removes any immediately felt fear or pressure and gives the woman time to consider options and acceptance of available interventions. This approach validates and provides reassurance of understanding the woman’s experience and frees her of responsibility for what occurred, instils hope of effective help being available and ameliorates concern about disclosure overwhelming the health professional. It respects boundaries around the willingness to raise or discuss issues and empowers the woman to control decisions related to what to discuss, whether assistance is required and what is addressed.

13.7 Care Planning Assessment informs needs and options for alcohol use problems treatment, co-­ occurring comorbidities and other interventions including those related to vulnerability, parenting, social, family or relationship issues, including domestic violence, or risk to self or others. When planning care, consideration is given to the identified issues that are likely to impact on decisions, including treatment type, the required setting, level of engagement required and capacity to adhere to treatment and other intervention requirements. Planning also includes consideration of factors, which might confound care and their mitigation. The care planning meeting supports the establishment of treatment goals that leads to a discussion where treatment and other interventions are selected from a menu of acceptable options and preferences (see Table 13.2).

13.7.1 Involvement of Partners Male partners often refuse to be involved in their female partners care and particularly where there is coercive control or domestic violence, whereas women are often supportive and seek to be engaged in their male partners’ care [1, p. 99].

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Table 13.2  Considerations for care planning Stigma—Issues impacting on woman arising from previous healthcare access and their likely impact on decisions to engage and retain in treatment or other interventions Preferences—For same gender counsellor, single gender residential programs or withdrawal services, to receive care in services which ensure privacy, protection from sexual harassment or standover tactics or, coercion for withdrawal medication diversion and risk for sexual or physical violence Available supports and needs related to their significance—Related to capacity for inpatient withdrawal, residential rehabilitation, availability and capacity to attend appointments, how support persons will be involved in the woman’s care Needs of first nation women—Any greater health, social and life disadvantage than other women, particularly when living with dependence and multiple other health conditions, homelessness or living in a violent household Women’s roles and responsibilities—As a partner, mother, employee, housekeeper, childcare and carer responsibilities (needs related to referral for childcare and respite care for elderly parents), requirements for times and days for appointments and potential impact on engagement in treatment and mitigation strategies Parenting—Skills development and/or to manage children’s behaviour, strategies to reduce potential harm to children when intending to consume alcohol, e.g. plan for children to be with responsible adults when intending to drink and to avoid drinking prior to driving and particularly with children in the car Risk management strategies—Domestic or family violence—Safety planning for personal and children’s safety, the safety of others, risk taking, nutrition, self-harm and harm from others, STD and BBV testing, previous treatment and willingness to consider treatment where this is indicated Treatment—What setting and treatment type Women’s health needs—Dentition, breast self-examination (BSE) education, mammogram, pap smear, date of last menses, possible pregnancy, pregnancy test results, contraception, pregnancy care needs Education—Needs related to empowerment, enhancement of self-esteem and self-efficacy beliefs for successful change and skill development, relapse prevention Other interventions and its setting(s)—Family and relationship issues and or trauma

Partners can be of benefit to positive outcomes through enacting strategies to provide support for recovery, including addressing stressors, enjoyable lifestyle activities, support appointment attendance, early identification and intervention for lapse or relapse (see Chap. 8). It is, therefore, important in, accordance with the woman’s wishes, to encourage partner involvement in the development and implementation of care plans. However, when involving partners, boundaries and the focus of discussions with the partner are clarified. Partners may also benefit from receiving answers to questions about alcohol treatment, supportive counselling to address issues related to the woman’s or their own alcohol use problems and/or to identify other issues and referral to another service(s) for assistance. Where the partner is a perpetrator of domestic violence or coercive control their support and involvement in supporting the recovery process and can provide an opportunity to secure engagement in relationship and or family counselling. This

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includes referral for domestic violence interventions (where the woman has raised this as an issue and has given consent) when this would not create risk of further violence. Domestic violence may also be raised and addressed when the health service is allocated a responsibility from a multi-agency meeting, which coordinate responses to address high-risk domestic or family violence which is likely to result in mortality or significant morbidity.

13.8 Treatment Women often present late in their alcohol use history for several reasons, including shame and fear of stigma, but once engaged, women remaining in treatment achieve better outcomes than men at 6 months, although in general treatment outcomes are similar [1, pp. 96, 97]. At moderate levels (seven standard drinks per day or less), women achieve better outcomes, through the use of self-help strategies, whereas men have better outcomes when engaged in talking therapies [1, p. 98]. The aim of treatment is to achieve recovery to the best possible health and life situation and maintaining achieved change, health improvement, harm reduction, withdrawal or respite residential admission. For women living with severe dependence, recovery can be a long process, involving multiple relapses in the first year(s) of treatment and for some over many years. It is important to view each incident as an opportunity for learning and further relapse prevention planning and not as a failure or lack of willingness for change. Palliative strategies may be implemented where the severity of dependence is making change difficult and is resulting in frequent lapses and relapse. Palliative strategies seek to reduce harm, improve health, maintain contact with a primary healthcare provider and build self -capacity for change over time. This may include ongoing withdrawal or respite admissions, relapse prevention (see Chap. 22) planning and other interventions, such as support for daily activities of life and maintenance of nutrition. For some, palliative strategies might be aimed at providing support and ensuring basic human needs for shelter and food are met until the end of life.

13.9 Withdrawal Withdrawal is not a stand-alone treatment and is usually the first step in the recovery process or is a respite response used to improve current health and wellbeing or to enable thinking and decision-making about goals related to alcohol use and/or treatment (see Chaps. 18–21).

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The severity of withdrawal can be unpredictable as symptom severity may not always be related to the level of alcohol use or dependence. Withdrawal symptoms can change over time with increased or decreased consumption levels since the previous withdrawal episode. Alcohol withdrawal can be life-threatening, and its management seeks to control the symptom severity to maintain comfort and prevent complications. This includes prevention of thiamine deficiency related to Wernicke’s encephalopathy (WE), which can be an ongoing risk when there is permanent interruption to thiamine absorption in the gut, withdrawal seizures and delirium tremens (DTs). Each withdrawal setting has well-established criteria, which is based on the severity of dependence and predicted withdrawal, recent increased or decreased consumption, previous withdrawal symptoms, experience or complications, current health and available supports. Settings might include social (non-medicated), outpatient, home-based, specialist residential withdrawal, hospital ward or intensive care unit (ICU).

13.9.1 Withdrawal Management While the supportive strategies for management of withdrawal depend on individual needs, medication management of withdrawal symptoms and their monitoring are similar for each level of symptom severity for anyone undergoing alcohol withdrawal. The differences for women related to gender specific matters in relation to withdrawal, such as no woman of childbearing age who is likely to be pregnant, should undergo withdrawal without a pregnancy test and addressing risks from others such as domestic violence. Women who are the victims of violence or coercive control from current partners should have the opportunity to develop safety plans prior to discharge and be linked with domestic violence and/or relationship counselling services. No one, irrespective of gender, should ever be discharged to homelessness following withdrawal. Housing needs are always a primary consideration throughout the assessment and withdrawal process. Plan for transfer to safe accommodation on discharge is an important component of care where housing has not been secured prior to the admission.

13.10 Pharmacotherapy Alcohol pharmacotherapy might be commenced towards the end of the withdrawal period or shortly after its completion. See Chap. 19 for drugs used in withdrawal management and post-withdrawal management.

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13.11 Other Interventions Interventions specifically for women, which commonly impact on recovery and require assistance to address: • • • • • •

Parenting, childcare or the involvement of child protection services Care of elderly parents or other family members Family or relationship issues including child custody Past or recent trauma Domestic violence, coercive control and/or to develop safety plans Vulnerabilities to exploitation

13.12 Pregnancy Care Most women want what is best for their baby and for their baby to be healthy, which makes pregnancy an opportunistic time to engage women in treatment and/or other interventions. During pregnancy, assertive engagement is aimed at risk assessment, encouraging acceptance of obstetric care, seamless referral for treatment and other interventions [3, p. 12] and as early as possible in the pregnancy is critical for the safest outcome for the woman and her baby. The woman’s partner also receives priority access to alcohol and other drug treatment. Strategies where health services have been unable to engage parents in treatment and/or other interventions include assertive follow-up, seamless referral and priority access to treatment, including on the same day an appointment offer is accepted. In securing engagement, any opportunity to commence assessment, treatment and/or other interventions is taken, including a hospital admission for another purpose.

13.12.1 Pregnancy Advice and Education Advice and education in pregnancy aim at encouraging informed and healthy decision-­making, which is based on information. This includes information about known and unknown risks related to alcohol use and pregnancy and the best available current evidence.

13.13 Engagement Engagement strategies in pregnancy are like those for all women and include being welcoming and involving partner and/or significant others during the pregnancy and postnatal period in accordance with the woman’s wishes [3, p. 14].

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Women living with alcohol use problems may avoid antenatal care, present late in pregnancy or in labour, because of concern about the loss of her baby and particularly where a previous child or baby has been removed by child protection services. This may also result in non-disclosure of alcohol use so as to avoid monitoring [3, p. 39]. The woman and her partner may also seek to avoid detection of the pregnancy by changing services, delivering at another hospital unexpectedly or moving to other states or regions. Engagement in antenatal care can be enhanced by providing reassurance of child protection notifications only occurring when it is reasonably considered a mother or others are placing her unborn baby at risk of harm [3, pp. 9, 10]. This may include harm arising from alcohol use, intoxication, domestic and/or family violence, refusal of obstetric care, is lost to follow-up or delivers unexpectedly at another hospital or other state for no demonstrated reason [3, pp. 41–44].

13.13.1 Child Protection Notification When making notifications, dilemmas arise from competing concerns for alcohol-­ related harm to the unborn baby and the potential negative impact on the mother should a baby be removed at birth. Notification early in pregnancy can initiate decision-making by child protection agencies to remove a baby at birth and can be very likely when a previous child has been removed. This removal may occur despite active treatment engagement and/or positive reports regarding progress and abstinence. Engagement in pregnancy care and providing support for a baby to remain with the mother can be enhanced where child protection and health services work together, and there is continued engagement in treatment, parenting and baby care programs and maintenance of abstinence or lower risk consumption. When collaborative care is possible, where a woman is living with severe dependence and struggling with abstinence and a baby is removed at birth, the woman is aware of the reason, any potential for reunification and treatment outcome requirements. This approach maintains the woman in treatment and enables hope for reunification at the right time where this is possible.

13.14 Pregnancy Care Setting Intervention for infrequent, low(er)-risk alcohol use in the absence of problems might occur within the context of routine pregnancy care and risk management. Interventions in this circumstance might include information about the risks of alcohol-related harm to the unborn baby, encouragement and strategies to cease use and/or harm reduction information to both reduce use and its risks. Verbal information may be supplemented with printed information about alcohol use in pregnancy and self-help materials.

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Where alcohol use problems including dependence is identified, referral is usually made to a specialist high-risk pregnancy service. These services include allocation of a primary case worker(s), a specialist multidisciplinary team consisting of AOD, mental health and/or other specialist services, depending on needs for care [3, p. 12]. Each of these services provide assessment, treatment and other interventions, which have significance for pregnancy outcomes as a part of each antenatal review, to reduce the number of appointments, coordinate and ensure continuity of care [3, p. 12] and health professionals and respond to any changing needs. This approach enhances continuity by reducing the risk of losing the woman to treatment or other interventions for alcohol use problems, which can occur when there are multiple appointments and particularly during late pregnancy.

13.15 Care Planning Care plans seek to ameliorate risks to the woman and the unborn baby and to address AOD and/or other health issues, which arise during pregnancy and includes postnatal period and longer-term follow-up care [3, p. 14]. For First Nation women, care plans may include the involvement of women from the same community or a culturally specific health service to ensure support, culturally sensitive care and postnatal continuity [3, p. 13]. In high-risk pregnancy obstetric services, care planning usually occurs following midwives’ completion of the general obstetric intake assessment. Plans are developed in collaboration with and in accordance with the woman’s wishes.

13.15.1 Content of Care Plans Withdrawal is encouraged as early in the pregnancy as possible and includes consideration of risk to the woman and her baby, the required withdrawal setting based on maternal health, pregnancy complications and gestational age. All concurrent health comorbidities including dental issues are stabilised, treated, monitored and reviewed from as early in the pregnancy as possible, with priority given to those which are likely to have a negative impact on pregnancy outcomes (Table 13.3).

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Table 13.3  Content of care plans Presence and/or involvement of partners, family members and/or friends during antenatal appointments, labour, the delivery room and/or in care of baby during NAS care and support following discharge Labour management and delivery—Mother and baby care and strategies related to the potential impact of concurrent comorbidities for childbirth Postnatal care—Mother and baby care and strategies and needs for postnatal specialist care (e.g. diabetes and baby monitoring for hypoglycaemia), management of expected maternal withdrawal and NAS where alcohol consumption continues until delivery and for assessment and follow-up of a baby who has an identified risk for or confirmed FASD Risk management and safety planning—To prevent risk of physical harm to the woman and/ or her baby from domestic violence, high-risk housing or alcohol use including falls when intoxicated, health problems, disease or nutrition deficiency Needs support following discharge or on an ongoing basis—Appointments or home visiting for routine baby care checks or referral to home visiting baby care services Needs for voluntary admission to an obstetrics unit—To improve the woman’s and/or baby’s health or physical condition and/or manage risk or complications

13.16 Treatment In rare circumstances, a woman might continue to drink at levels, which pose a significant risk to her baby and/or avoid pregnancy care. In this instance, some jurisdictions have legislative provisions for child protection agencies to obtain a court-­ ordered admission for the welfare of the baby after 28 weeks gestation. In this, the right of the unborn baby to safety overrides the woman’s rights to self-determination.

13.17 Withdrawal Withdrawal during pregnancy carries a risk for miscarriage, premature labour, foetal hypoxia, distress and/or death [3, p. 47]. These risks create significance for the consideration and selection of the safest withdrawal setting. The management of alcohol withdrawal symptoms is the same as for any other alcohol withdrawal. During withdrawal, the mother and unborn baby are monitored very closely for signs of withdrawal, distress and complications, which are assertively managed as they arise.

13.17.1 Setting The required withdrawal setting depends on gestational age, previous withdrawal severity and/or current pregnancy complications [3, p. 57]. Where there are current pregnancy complications or risks, and/or there has been no antenatal care to date and/or psychosocial risks, admission to a specialist hospital-­based obstetrics service may be indicated at any gestational age [3, p. 59]. This is to monitor foetal distress and prevent or manage complications [3, p. 57].

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Women are usually admitted to a residential specialist alcohol and other drug (AOD) withdrawal service up to 20  weeks gestation [3, p.  40]. After 28  weeks, withdrawal is usually managed in a specialist obstetric service with the advice of addiction obstetrics specialist consultant [3, p. 40]. While most women accept treatment and other interventions, on rare occasions some avoid engagement and continue drinking throughout the pregnancy and arrive in labour while under the influence, having received no antenatal care.

13.18 Pharmacotherapy Alcohol pharmacotherapy medications are not used during pregnancy due to the lack of safety evidence for their use [3, p. 103].

13.19 Ethical Issues and Dilemmas Arising from Harm to a Baby It can be difficult to feel compassion where a woman avoids engagement in antenatal care and continues alcohol use throughout pregnancy in full knowledge of the likely harm. This difficulty can be enhanced in the very rare circumstance, where a previous FASD baby or babies have been removed and when no concern is shown by the mother for the baby’s health or withdrawal distress. Caring for a distressed baby in withdrawal is distressing for those who witness it and more so when symptoms are severe. Once heard, a neonates withdrawal cry is never forgotten. For health professionals, this can give rise to feelings of anger that this was done to an unborn baby, which can make it difficult to avoid remonstration with the woman, as well as impacting on those unable to have children. Debriefing and employee assistance programs, clinical support and supervision can assist in maintaining a harm reduction and therapeutic perspective with focus on providing care, which encourages and supports treatment and other intervention acceptance and care of baby.

13.19.1 Pre-discharge Information All discharge information is given verbally, questions are answered and printed information and resources are given for further reference. Information provision includes standard infant care, alcohol or tobacco use and sudden unexpected infant death (SUID), care for any special needs, breast-feeding and contraception. Breast-feeding is encouraged due to its postnatal benefits (nutritional and skin contact) for the mother and the baby [3, p. 32], but breast-feeding by women who consume alcohol is not encouraged due to the risk of harm to the baby [3, p. 32].

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Where a woman chooses to consume alcohol and breast feed, this can be done safely by minimising the infant’s exposure to alcohol [3, p. 32]. When choosing to consume alcohol, women are advised to maintain abstinence in the first month until breast-feeding is well-established [4, p.  174] and to consume no more than two standard drinks (SD’s or units) on any occasion [3, p. 34]. Women are also advised to express milk before consuming alcohol for later use or wait until level drops to zero (can be some hours) before breast-feeding or to use a supplemental feed. There is no need to express and discard breast milk as levels in breast milk will reduce as the mothers’ blood alcohol levels reduce [3, p. 34]. Contraception advice is provided to reduce the likelihood of unplanned pregnancies and harm to a baby and increase the likelihood of future planned pregnancies [3, p. 9].

13.20 Follow-Up Care Prior to discharge, the women’s community-based AOD treating team is notified prior to discharge to enable assertive follow-up and/or ensure seamless care transition. Appointments are made to continue treatment and/or other interventions. Plans are also made for home midwifery visits and/or routine contact with mothers and babies support services and monitoring for any issues arising for baby or from parenting and to maintain engagement. Where a baby is at risk for (e.g. neonatal abstinence syndrome—NAS) or diagnosed with FASD at birth, appointments are made for assessment and follow-up as this is important for early identification and intervention. (see Chap. 12) [4, p. 105]. Monitoring for developmental delay when FASD is identified occurs over several years or longer and specialist health and education interventions may be required [3, p. 63]. Following discharge, admission to a specialist residential service, which supports a mother to care for a baby with special needs, may be required. These services usually provide parenting support or skill development and the management of challenges in baby care. This may include problems related to settling baby, managing excessive crying or distress, establishment of feeding, sleep management and/or medication administration.

13.21 Ethical Issues and Dilemmas Ethical issues and dilemmas are continually present and are managed on a daily basis by health professionals throughout the process of providing care. The issues, which impact equally on any person living with alcohol use problems or dependence, arise from health systems issues, consumer rights, professional ethics and practice standards, protective legislation, the actions of other human services providers and the misuse of family court processes by partners to obtain child custody.

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Women are more likely than men to be stigmatised, vulnerable to exploitation and impacted on by the actions of family members, partners and others, including coercive control, sexual, financial, social and/or physical violence including isolation and intrusive monitoring. In exploring these ethical issues and dilemmas, several themes emerge, which mirror or have similar impact, negative consequences and/or outcomes for healthcare consumers, their families and health professionals.

13.22 Stigmatisation Intoxication among men may be accepted or tolerated in the absence of violence but is abhorred in women who are commonly seen as losing control, weak, irresponsible and/or unworthy of respect, which translates to ridicule, derogatory labelling and disrespect. Health professionals might hold the same attitudes as the community and act in the same way towards women living with alcohol use problems in healthcare settings. This can manifest as negligent care and/or a lack of empathy at a time of increased vulnerability and where there is need for support. This creates an environment in which women are censured, shunned, shamed and blamed, including in the media for adverse events perpetrated by others, including sexual and/or physical assault. Within this environment, women from First Nation cultures can have the added burden of racism and amplified vilification. Stigma perpetrated by health professionals might also arise from beliefs that alcohol use problems are self-inflicted, negative judgmental attitudes and/or from lived experience related to a family member or partners’ alcohol use and its personal impact on them.

13.22.1 Impact of Stigma on Healthcare Consumers There is no place for stigmatisation within caring and supportive healthcare settings. It is abusive and traumatising to its victims and instils a fear of ridicule and loss of trust in the actions of health professionals and can result in significant harm to health. Healthcare consumers feeling upset and angry at repeated negative experiences who seek to assert their right to receive care often receive further censure and allegations of aggressive behaviour, which creates conflict with health professionals. Stigma undermines self-esteem by reinforcing personal negative self-views related to AOD use, including shame, guilt, self-blame and loathing, injustice, frustration, anger and negative self-beliefs of worthlessness, deservedness of disrespect and abuse and of knowing no better. It can also reinforce the harm to social and emotional wellbeing arising from childhood or partner abuse and for some might create a risk for self-harm, which is also stigmatised.

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Stigma fosters feelings of sadness, despair, hopelessness, powerlessness and helplessness which results in loss of self-efficacy beliefs in the capacity to achieve and maintain change, which leads to thoughts of giving up (‘no one cares why should I’), particularly when maintaining abstinence is difficult due to the severity of dependence. The loss to treatment and other interventions results in the loss of any gains through fostering a loss of hope for an improved life situation and loss of positivity. Stigmatisation often creates an unwillingness to access healthcare, which results in increased health morbidity and early loss of life. This may manifest as avoidance of routine health checks, chronic disease follow-up and/or pregnancy care as well as ignoring concerning signs of disease and/or refusal of lifesaving treatment. Poor health outcomes, including injury, disability or disfigurement, might arise from inadequate or negligent care, as it frequently leads to early self-discharge against advice and subsequent non-adherence to post-discharge requirements and/ or loss to follow-up care. Past negative experiences can result in future avoidance of disclosing alcohol use problems, which can confound the clinical presentation and create clinical risk from changes to medication tolerance, metabolism and potential for toxicity or ineffectiveness and/or the unexpected emergence of withdrawal symptoms.

13.23 Self-Determination to Cease Treatment Health professionals may also need to uphold the right to cease treatment for healthcare consumers living with life-long severe dependence with irretractable cravings when changes to alcohol consumption is viewed as being unachievable. In this instance, both the healthcare consumer and the health professional have full knowledge that the decision includes alcohol consumption and is likely to result in death from alcohol-related harm, e.g. oesophageal varices bleed. It can be difficult for health professionals to support decisions, which will lead to loss of life, and this can result in consideration of all options to intervene to preserve life. However, as decision-making occurred in full understanding of the consequences in the presence of capacity for informed consent, there is the right to cease treatment even if this will result in early death and the right to be supported in their decision. Responses in addition to advising the general practitioner of the decision to cease treatment and contact with the service, a welcome is given to change the decision and/or return for any reason at any time. Wherever possible, consent to contact at agreed times is sought, and where this is refused, palliative strategies to ensure basic human needs are met are negotiated. These might include meal delivery, housing, emergency assistance, welfare checks and respite care. Support may also be provided to family members, which may continue after the death of their loved one.

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13.24 Partner and Family Members Dominance and Coercive Control Partners and/or other family members may genuinely try to help and inadvertently use unhelpful strategies, such as increasing everyday control, limiting access to alcohol and supporting abstinence by controlling the woman’s freedoms and access to money. Partners and family members may then become frustrated and angry when their well-meaning efforts are unsuccessful, and they may leave the relationship or withdraw support. While many partners and family members genuinely try to help and use positive strategies, such as listening to and providing support throughout the treatment journey, and are an important factor in securing positive treatment outcomes, this is not always the case. Partner dominance and coercive control have been reported by women with alcohol use problems over several decades and only recently have been identified as a form of subtle abuse, with a range of psychological impact and symptom manifestation on its victims. Dominance and control are often reported by women as manifesting as anger, withdrawal of affection, rejection and emotional unavailability should concerns be raised; denial of money for housekeeping and/or no access to money (taken out of the bank by partner); not having a voice; control of social contacts or complete isolation from family and friends; and the partner owning everything as means of control. Coercive control can escalate to physical violence when it is challenged by a victim. See section “Case Scenario 13.1: Barbara”. Women living with severe dependence often report a dominant controlling partner as the reason for relapse, which indicates an alcohol use problem is enmeshed with relationship issue. AOD health professionals in practice-based evidence have noted dominance and control as being associated with adverse outcomes, including death from alcohol-related physical harm. This results in health professionals facing dilemmas when a woman refuses a referral for relationship counselling. Refusal of relationship counselling in this circumstance may be erroneously labelled by health professionals as the woman reporting issues as an excuse or rationalisation for relapse. This constitutes victim blaming, as there is fear of consequences from taking action to address control issues. On many occasions, there is also collateral information which supports the woman’s reported lived experience. Responses to coercive control include acceptance of concerns, including those related to the consequences of taking action, expressing compassion and accurate empathy for the woman’s situation and concerns for her welfare, if issues are not addressed. This response can be followed by providing ongoing supportive counselling and information to raise awareness of the impact of coercive control on social and emotional wellbeing, alcohol use and relapse. Over time, provision of information about relapse related harm, identification of fears about the relationship and motivational enhancement and encouragement can build the case for change. This can lead to referring the woman for relationship

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counselling to assist in developing strategies to manage relationship issues. See Case Scenario 13.1: Barbara. Assessment for and management of depression and/or anxiety may also assist where this may have hindered the woman’s capacity for action.

13.25 Domestic Violence Most violence is committed by men, although it can be perpetrated by women; a higher proportion of women are the victims of physical and sexual violence [5, p. 2]. Women often remain in violent and/or abusive relationships, do not act to protect themselves and may be living with violence-related injuries, a risk of suicide arising from depression or feelings of powerlessness, hopelessness and anger. Dilemmas arise when women remain in the home and do not wish to address violence. This creates risk for continued harm, which is in direct conflict with healthcare obligations to ensure safety or provide timely referral to programs aimed at protecting life. In responding to these dilemmas, the health professional seeks to ensure the woman’s protection by making reports to family safety meetings, police reports and providing assistance with decision-making about remaining in the home or obtaining intervention orders where the woman remains in the home and the perpetrator leaves. Assistance with housing and finances, safety planning and referral to supportive lawyers for advice on preemptive court proceedings or to document violence and abuse for evidence as well as practical support based on the woman’s needs and pressing issues such as a new untraceable mobile phone (perpetrators often track their victims) can enhance engagement and facillitate AOD treatment continuing as planned usual.

13.26 Conclusion Women are particularly vulnerable to the impact of harm to health and social and emotional wellbeing arising from alcohol use problems and are highly stigmatised. This stigma often results in multiple losses and an unwillingness to seek or engage in treatment for any health condition and non-adherence to follow-up or post-­ treatment requirements and further harm or disability. In the process of providing care, several complex ethical issues and dilemmas arise, which require reflection on the ethic to be upheld, and initiation of appropriate interventions, which ensure vulnerabilities are managed and rights are upheld. When health professionals demonstratively uphold the rights of healthcare consumers and provide safe, humane and ethical care in a supportive environment, women are enabled to develop trust and are empowered to engage in healthcare. This seeks to address harm to health and social and emotional wellbeing and to achieve treatment goals, recovery and an improved life situation.

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References 1. National Drug Strategy. An outline for the management of alcohol problems. Quality Assurance in the Treatment of Drug Dependence Project: Monograph Series No. 20. Canberra: Australian Government Publishing Service; 1993. 2. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol. Canberra: Commonwealth of Australia; December 2020. https:// www.nhmrc.gov.au/about-­us/publications/australian-­guidelines-­reduce-­health-­risks-­drinking-­ alcohol. Accessed 2 Nov 2022. 3. New South Wales Health. Management of substance use during pregnancy birth and the postnatal period. 17 December 2014. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/ GL2014_022.pdf. Accessed 14 Dec 2021. 4. de Crespigny C, Talmet J, editors. Alcohol, tobacco and other drugs: clinical guidelines for nurses and midwives. Version 3. Adelaide: The University of Adelaide School of Nursing and Drug and Alcohol Services of South Australia; 2012. https://digital.library.adelaide.edu.au/ dspace/bitstream/2440/73718/1/hdl_73718.pdf. Accessed 3 Jan 2022. 5. AIHW.  Monitoring Perpetrator Interventions in Australia, Summary Canberra 2021. https:// www.aihw.gov.au/reports/domestic-­v iolence/monitoring-­p erpetrator-­i nterventions-­i n-­ australia/contents/summary. Accessed 19 Apr 2022.

To Learn More For further information access links above and: Office for Women, Family Safety Framework Manual: https://officeforwomen.sa.gov.au/__data/ assets/pdf_file/0005/86801/FINAL-­Family-­Safety-­Framework-­Practice-­Manual-­Version-­6-­ May-­2015-­FOR-­WEBSITE-­2020.pdf. Accessed 16 Jan 2021 World Health Organization, Lexicon of alcohol and other drug terms date: https://www.who.int/ substance_abuse/terminology/who_lexicon/en/ World Health Organization, Classification of disorders due to the use of alcohol date: https://icd. who.int/browse11/l-­en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1676588433 World Health Organisation, Management of Alcohol Withdrawal. 2012: https://www.who.int/ mental_health/mhgap/evidence/alcohol/q2/en/ World Health Organisation: https://www.who.int/publications-­detail-­redirect/the-­who-­assist-­ package-­for-­hazardous-­and-­harmful-­substance-­use

Male Adult

14

Jacqueline (Jacky) Talmet and Susan Gates

Learning Outcomes On completion of this chapter, readers will: • Have gained an understanding of low- and high-risk alcohol consumption and the development of alcohol use problems • Be able to explain alcohol-related health sequelae, risks to self and/or others, social and family consequences arising from behaviour when intoxicated and dependence • Have information related to assessment, withdrawal and other interventions when providing care for men which can be incorporated into everyday practice • Explain the rationale for providing ethical and humane care

14.1 Introduction Whilst women are at greater risk for alcohol-related harm at any level of consumption, men in some jurisdictions are more likely to consume alcohol at higher levels than women and are therefore more likely to experience greater physical harm. This harm often results in early loss of life when men neglect their health, ignore symptoms indicating health problems and/or avoid accessing healthcare. Men also take more risks than women and are more likely to experience immediate harm [1].

J. (J). Talmet (*) · S. Gates DASSA Northern Services, Adelaide, SA, Australia e-mail: [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_14

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This chapter, whilst considering specific issues and healthcare needs of men in relation to assessment, care planning, treatment for dependence and other interventions, acknowledges many components of assessment, intervention planning and care, which are similar for any person living with alcohol use problems (see Chap. 2). When providing care to men, health professionals identify and navigate the same ethical issues and dilemmas, and their impact, as those which arise when providing care to women and any other person experiencing alcohol use problems. These commonly arise from the actions of partners, health professionals and other human service providers, alcohol-related harm to health, healthcare consumer rights and legislation. Despite commonalities, there are some differences in issues, including the risk to men arising from intoxication, e.g.: • • • • • •

Violence Drink driving Suicide arising from factors related to depression Male gender stereotyping which triggers feelings of guilt and failure Stigmatisation arising from erroneous perceptions of verbal aggression When men are identified as perpetrators of family and/or domestic violence

14.2 Male Alcohol Use in Context Alcohol use and intoxication in men is often tolerated in the absence of violence or harm to others. Use is normalised as a ‘male thing to do’ and an integral part of socialisation, having fun, playing or watching sport, in occupations where entertaining is a workplace expectation and/or to relax after a day’s work. Within this environment, intoxication is often seen as the norm on special celebratory occasions, such as birthdays, signalling adulthood and ‘the rights of passage’, winning sport events or grand finals, engagement, bucks’ (stag) nights, weddings and the births of children. Men might use alcohol for the same potentially unhelpful reasons as women. These include to: • • • •

Overcome social shyness Sleep after a stressful day Enhance positive or manage negative mood states and/or traumatic memories Manage feelings of guilt, shame, self-loathing and regret for behaviour, actions and/or the harm caused to loved ones, arising from alcohol use problem and/or dependence

When considering the underlying cause of alcohol use problems, whilst familial and/or personal vulnerabilities and experience of trauma create risk, these are not always present and alone are not the cause.

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Men often report the use of alcohol to relax and/or to deal with stress related to family responsibilities, relationship problems, partner pregnancy or a baby in the home and managing family financial change, such as through loss of employment. Men who work away from home are also at an increased risk of developing alcohol use problems, regardless of relationship status. Irrespective of being single, in a relationship where a partner works at home or away from home, men can be vulnerable to developing alcohol use problems following the loss of employment and its associated change to finances and when regaining employment becomes a long-term issue. Some men report a male first-degree relative as having an alcohol use problem or as a perpetrator of childhood physical abuse and/or sexual abuse and/or rape as an adult, which often remains undisclosed due to shame. Case Scenario 14.1: James James (40) consumes approximately 30 standard drinks daily (see Chap. 2). James takes high doses of prescribed and illicitly obtained benzodiazepines for an anxiety disorder and has a chronic pain condition, for which pregabalin and combination paracetamol and codeine medication is prescribed. James has a very sad family history, which includes his father living with lifelong alcohol use problems, dying of liver cirrhosis when James was 35 years old. James was sexually assaulted by his father prior to puberty, and the abuse continued until he was 15  years of age as was his older sister Diane, which was unknown to their mother. James had also been physically abused by his father using a belt buckle, which had resulted in painful haemorrhages and hospitalisation, where James, fearful of retribution, gave plausible reasons for his injuries. James is a haemophiliac. After a few beatings, James’ mother would interrupt James’s father and insisted he hit her. The father then beat his mother whilst James was forced to watch. When James was 14 years old, he interrupted his intoxicated father hitting his mother by thrashing him repeatedly about the head and shoulders in the same way his father had abused him and walked away from home. James kept in contact with his mother when he could but did not see her until she left his father several years later. James was homeless, living on the streets and did whatever he could get to earn enough money to eat including having sex with men for money or favours, which included somewhere to sleep and a meal. James began drinking to manage the traumatic effects of ongoing abuse. On reaching the legal age to work at 16, James obtained low-paid work, where he was exploited with heavy manual tasks and sustained a back injury, which was not treated and led to chronic pain and an inability to work. James’s drinking increased and over time, other medications were prescribed and used in increasing amounts. James had been taken by ambulance with a drug overdose on several occasions in the last year. In the emergency department, James’s overdose would be treated and he would be released without follow-up.

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When aged 38 years, after taking a full prescription of all of his medications with a litre of vodka, James picked up a Stanley knife, cut his lower leg and wrist several times and lost consciousness. The wounds were not life-threatening. James was found by a flat mate and taken to hospital. On arousal James, advised hospital staff he was a haemophiliac, which was well documented in his medical records. James attempted to gain attention for his haemophilia, need for ‘factor VIII’ (deficient or ineffective blood clotting protein factor VIII that seals off damaged blood vessels to prevent further blood loss) [2, p. 156], pain, and that he was bleeding under the sutures. Health professionals ignored James’s advice. James sutures opened from the internal bleeding, resulting in large open areas across his leg and arm, which extended to the depth of his muscles and tendons. At seeing this, health professionals accused James of cutting his sutures. James insisted in his record being checked, and he was finally given factor VIII. James’ wounds required significant skin grafting, resulting in permanent disfigurement to his arm and leg. During the lengthy hospitalisation, James disclosed his history to the alcohol and other drug (AOD) professionals, who he had seen as being kind when supporting him during his alcohol and benzodiazepine withdrawal period and after and had referred him to a chronic pain specialist after reporting his pain and was commenced on an evidence-based care plan. On discharge from hospital, James was seamlessly referred to and supported by AOD professionals, and in addition to the standard AOD interventions, trauma counselling and mental health assessment and treatment for depression were provided with his consent. James also encouraged his mother, who was living with depression, to seek support. James had a lengthy recovery period, undertook work training and obtained permanent paid work. He and his mother supported each other throughout their treatment journeys. James received significant financial compensation from the hospital for his disfigurement and pain and suffering, which was used to purchase a home for him and his mother. Reliving past traumatic experiences (including following armed service in theatres of war or rape, or childhood trauma) can impact negatively on care outcomes until such time disclosure occurs, and the required care and support is provided. Reflective Practice Exercise 14.1 Consider the following: 1. What risk factors and trauma may have led to James developing AOD use problems? 2. What led to James disclosing his history that led to appropriate care being provided for the first time?

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3. What was unhelpful in the response to James’s report regarding his haemophilia? Why might his report have been ignored? 4. What might be helpful in gaining trust when providing care to people who self-­ harm which can lead to disclosure and appropriate care, treatment and support? Men do not deliberately set out to develop alcohol use problems, which arise irrespective of gender from the amount used (dose), the frequency of use, acute effects (e.g. accidental injury) and physiological adaption to effects and harm to health over time. This means alcohol use problems are a physical health issue which is an insidious, unwanted and accidental consequence of use and not from personal deficit or weakness.

14.3 Low-Risk Drinking Guidelines In many world jurisdictions, low-risk consumption guidelines vary from 10 standard drinks per week in Australia to 20 per week in the United States [1, p. 21]. A standard drink contains 10 g of pure acetyl alcohol. The low-risk drinking guideline for adult men to avoid the long-term health risks related to alcohol use is no more than 10 standard drinks (SD) per week and to reduce short term risks by not consuming more than 4 standard drinks on a single day [1, p. 2]. Every drink above this level increases the risk of death from an alcohol-­ related disease or accident [1, p. 26]. This level of consumption carries a lifetime risk of less than 1 in 100 dying from an alcohol-related condition. Risks related to alcohol use reduce with lower frequency of use and levels of consumption than recommended levels and increase with higher consumption [1, p. 26].

14.4 Alcohol-Related Harm The only way to avoid alcohol-related harm is to avoid the use of alcohol [1, p. 4]. Men are more likely to experience immediate alcohol-related harm arising from a higher level of risk-taking behaviour including road accidents and injury, falls and self-harm, including active suicide [1, p. 17], e.g. driving off the road at high speed in an isolated area late at night. Suicide might be indicated when there is no evidence of braking before impact but not provable, as intoxication can also result in falling asleep whilst driving. Intoxicated men are more likely to commit assault and/or to be assaulted when behaving inappropriately or aggressively towards others, resulting in injury and/or death from traumatic head injury, for example. There is growing evidence of some cancers when consuming alcohol at less than one standard drink per day, including liver, pancreatic, colorectal, oesophageal, oral, mouth and throat with the risk for cancer increasing with increased consumption [1, p. 29] (see Chaps. 6 and 24).

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Higher levels of consumption can lead to a higher severity of dependence, withdrawal syndrome, increased risk of withdrawal complications (see Case Scenario 14.2: Bruce), and need for intensive care unit withdrawal under sedation (see Chap. 20). Case Scenario 14.2: Bruce Bruce had been taken to a sobering up unit by police after being called to a fight in the centre of a large town at 4 pm. On arrival, Bruce’s blood alcohol level (BAL or BAC—blood alcohol concentration) was 0.45 p/dL. Bruce was known to consume methylated spirits when money was short. Thirty-six hours later, when the BAL reached 0.09 p/dL, Bruce accepted a referral to a community AOD health professional. Bruce agreed to undergo withdrawal and was immediately transferred to a specialist withdrawal unit within the local hospital. An hour later, whilst a full assessment was underway, Bruce rapidly changed colour from red to blue, and it appeared he was going to have a seizure. Withdrawal observations were immediately commenced, and a pulse of 100 and BP of 160/90 was noted, and Bruce very quickly became increasingly agitated and sweaty and advised the staff that he had ‘electric fleas’ (formication) on his skin. A medical alert was called, and Bruce given 40 mg of diazepam and was transferred to the intensive care unit (ICU) for management. Symptoms settled with higher than usual diazepam loading doses. Bruce had a particularly lengthy and severe withdrawal syndrome, and he scored 13 on the Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) Scale on day 9. The withdrawal syndrome lasted 12 rather than the usual 5 days. Bruce’s withdrawal was continually monitored and required high levels of diazepam to manage symptoms and to prevent complications. Bruce was also administered intravenous thiamine for 3  days, followed by intramuscular for 3  days and then orally to prevent Wernicke’s encephalopathy. Bloods were monitored for thiamine absorption. Bruce was transferred to a residential rehabilitation facility and engaged in a year-long program. He remained abstinent. Reflective Practice Exercise 14.2 Consider the following: 1. What were the indications Bruce was likely to have a severe withdrawal episode and onset may occur prior to reaching a BAL of zero, which prompted urgent transfer to hospital? 2. Why were Bruce’s blood thiamine levels monitored? Could Bruce be at risk of thiamine deficiency? If so, why might this occur?

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High-risk alcohol consumption above the recommended levels increases the likelihood of alcohol-related harm to health including: • • • • •

Oesophageal varices and fatal varices bleeding Cardiovascular disease, risk of haemorrhage from low platelet levels Alcohol-related liver cirrhosis and death whilst awaiting transplant Alcohol-related brain injury Wernicke’s encephalopathy and Korsakoff’s psychosis (see Chaps. 5 and 6)

14.5 Assessment Although men often neglect their health, they are more likely than women to seek assessment and treatment for alcohol use problems due to societal attitudes towards alcohol use problems in men. Within this, seeking treatment is seen as identifying a problem and doing something about it, which is seen as an acceptable and a manly thing to do and is thus less stigmatised than for women. Specific considerations in assessment arise from the stereotypical roles of men to be the strong, the problem solver and being responsible for the family’s housing and financial support. When undertaking assessment, consideration is given to men often being more reluctant to disclose sexual assault due to feelings of shame and, where indicated, may need to be raised later once trust has been secured. Often disclosure may not be acknowledged until after multiple relapses and a health professional revisited this issue. Assessment with men covers the same components as any alcohol assessment (see Chaps. 10 and 13). Key Point 14.1 First nation men are more likely to have significant and continued loss of country, cultural practices, community status and traditional roles and unemployment, which are significant factors in the light of issues related to alcohol and other drug (AOD) use and relapse risk when planning care (see Chap. 3)

14.6 Treatment Whilst there are some differences, the provision of treatment to men living with alcohol use problems, including withdrawal and pharmacotherapies, is the same for anyone living with the same complexity of issues. For example, due to higher alcohol consumptions levels than most women, men may experience more severe withdrawal symptoms (see Case Scenario 14.2: Bruce) and higher risk of complications (seizures, delirium tremens) and may require intensive care unit withdrawal under sedation for the management of symptoms.

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For further information related to withdrawal onset and duration, symptom assessment, medication regimes, withdrawal setting determination, management of complications, supportive care and discharge planning, see Chaps. 17–22.

14.7 Other Interventions Differences in interventions with men include those relating to specific men’s health needs, relationship issues and their impact on relapse, the impact of loss, risk taking and perpetration of violence (see Chap. 23).

14.7.1 Specific Men’s Health Issues and Need for Education Specific care planning considerations relate to men being more likely than women to neglect their health and ignore concerning symptoms often requiring dental and health assessment as well as a focus on specific men’s health needs. Men’s health advice needs include education to practice breast self-examination (BSE—men also develop breast cancer). Testicular self-examination (TSE—higher risk of testicular cancer in men living with an alcohol use problem) and regular prostate checks when over 50 years of age are essential. Multiple sexual partners when intoxicated may indicate the need for blood-borne viruses (BBV) and sexual transmitted diseases (STD) testing and information provision about prevention of infection (see Chap. 4). Men experiencing alcohol use problems are more likely to have an increased risk of prostate cancer, which impacts on fertility arising from a low sperm count and motility, lower testosterone levels and erectile dysfunction. It is recommended to cease or reduce drinking levels at least 3 months before planning for a pregnancy [3].

14.8 Relationship Issues, Relapse and Relationship Counselling Whilst male partners are less likely to be involved in the care of their female partners, it is very common for women to seek involvement and to support their male partner (see Chaps. 8 and 13). This is important as men, following withdrawal or a residential rehabilitation program and/or intensive support, often feel positive and ready to resume their roles within the family. The female partner may also be living with resentment and/or unresolved relationship issues related to past experiences of coerced intimacy, unacceptable behaviour or violence, when the male partner was intoxicated, and financial issues, due to money being spent on alcohol, leading to the partner taking control of managing the home and finances.

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Women, unlike their male partner in treatment, may have received little support for these issues and may remain concerned at what would happen if these responsibilities are relinquished and relapse occurs. Left unaddressed, these issues can manifest in a relationship dynamic and an ongoing scenario, which is commonly reported by the male partner as being the main trigger for relapse. Working alongside female partners can assist in developing an understanding of the impact of their male partners’ problem, the adaptations they have made and to explore how they can address and support their partners recovery (see Chap. 8). Strategies may include: • Referral for relationship counselling • Strategies to address unhelpful actions, such as focussing on one at a time and positive feedback when done • Joint planning and financial management, joint decision-making • Working on a project together • Taking time for mutually enjoyed activities • Plans for gradual return to sharing of household management

14.9 Loss of Children and Adult Offspring Men acutely feel the loss of relationships with their children, irrespective of whether the reason is through child protection orders, family separation and loss of custody or access, a child or baby’s death, or when an adult offspring severs contact due to their father’s behaviour when intoxicated (see Chaps. 11 and 12). These losses can lead to continued psychogenic pain, feelings of guilt, grief, powerlessness and/or shame, which can lead to high-risk alcohol consumption, involving alcohol-related harm and, sadly, further loss. On obtaining and maintaining abstinence, men often have goals of re-­establishing contact and the relationship with their child or adult offspring and/or partner, to apologise or make reparation and/or show they have addressed their alcohol use problem and have changed, or to obtain or provide closure. Dilemmas arise from the impact of refusal by the children, or other parent or adult offspring, to see them and the potential for relapse or suicide in the presence of depression. In such a scenario, interventions include: • • • • •

Discussing the goal Aims and achievements How contact may be made Support and skills rehearsal or assistance with initial letter writing or phone calls Consideration of ‘what if’ there is refusal and its likely impact

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Strategies to manage acceptance, and refusal of contact, are important in managing outcomes including: • • • •

How to contact the service Accepting this Writing any apologies Expressing a willingness to have contact in the future, if they wish to maintain hope for the future and to assist in closure and accepting that, at times, reparation can take time or may not be possible. Helping the person to understand that this is okay and to feel good about being alcohol-free and ready for whatever the future brings is key to good quality healthcare.

14.10 Ethical Issues There are some issues that arise and impact on men living with alcohol use, which occur in slightly different ways to those for women and are discussed below (see Chap. 3). Men are likely to be living with long-term sadness, anger, shame, guilt and remorse, which might arise from a number of factors, including loss of employment, feelings of failure and/or behaviour when intoxicated, including driving and violence-related harm to others.

14.11 Increased Risk for Self-Harm and Suicide Men living with alcohol use problems often experience multiple losses due to their behaviour when intoxicated, family and partner violence, loss of their children and relationships with adult offspring, and feelings of letting their partner and family down are areas that need thoroughly addressing. This can give rise to a risk for suicide, which might not be related to depression but related to shame, self-loathing and/or guilt for causing harm to their loved ones, including adult offspring or a reactive response to rejection (see section “Case Scenario 14.1: James”). Men, if they are the sole parent, without relevant supports, can be highly vulnerable. They may be at risk of self-harm and/or suicide following child protection services or court processes, denying them access to their children.

14.12 Stigmatisation Men are more likely to be stigmatised by health professionals due to erroneous perceptions of verbal aggression, which is an attempt to communicate health problems and needs for care or treatment (see section “Case Scenario 14.1: James”), and perpetration of family and/or domestic violence or harm to and from others [1, p. 2]. Requests for care or information provided regarding their medical conditions from both men and women can be ignored by health professionals viewing any

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information or request considering their ‘alcohol problem,’ which results in critical information being ignored. James (Case Scenario 14.1) was stigmatised for self-­ harm that led to his hospitalisation. Death can also arise when care is denied for this same reason.

14.13 Domestic and/or Family Violence Domestic violence is rarely perpetrated by women and is mostly perpetrated by men [4, p. 6]. Although not a cause, male domestic violence perpetrators are more likely to be violent towards women after consuming alcohol or when intoxicated. Alcohol is not the cause of violence and is often used as an excuse. Male domestic violence perpetrators are more likely than women to perpetrate violence that results in death or morbidity and to threaten the use of weapons and use alcohol at the time of the homicide, e.g. firearm [4, pp.  8, 45, 46, 5, pp. 9–16, 28–29]. This is more likely in the presence of high-risk signals, which include: • • • • •

A history of domestic violence and/or murder/manslaughter and/or rape An AOD problem and/or being intoxicated at the time of perpetrating violence Has had access to or used a weapon in previous partner violence Level of abuse escalation, threats to life Serious victim injuries resulting in morbidity, e.g. brain injury from concussion or haemorrhage from choking [4, pp. 5, 8, 45, 46]

On occasion, both the perpetrator and victim are injured during an episode of violence and in need of care at the same time. It is rarer for a woman to kill her male partner, and those who do have often endured years of abuse and are likely to have a domestic violence protection order at the time of her death [5, p.  23]. The difference in women who kill their male partners is that women often use a fast and fatal method, e.g. stabbing with a sharp weapon [5, pp. 19–24, 28]. In this, it appears women do not torture their male violence perpetrators and in killing the perpetrator does so with the motive of stopping the violence, not necessarily to kill.

14.14 Interventions for Violence Men are more likely to perpetrate physical and sexual violence towards women and require referral for interventions, protection of women and children, justice system [6] and behavioural and attitudinal change programs, in combination with AOD and MH interventions [6, p. 31].

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14.15 Family Court Processes Female partners of men living with alcohol use problems are more likely than men to misuse child protection legislation and make erroneous allegations of child physical and sexual abuse in family court processes to obtain custody of children. This can create significant issues for men to address, as there may be no evidence related to the allegations of physical or sexual abuse. These falsehoods leave men in an invidious position of creating suspicion of guilt, irrespective of whether they deny or do not deny the allegations, and women are often successful when using this as a strategy to deny their male partners access to children.

14.16 Conclusion Men are particularly vulnerable to the impact of harm to health and social and emotional wellbeing arising from loss and alcohol use problems. Men are stigmatised in healthcare settings and can experience significant harm as a result of not being listened to and their needs for care ignored. In the process of providing care, ethical issues related to intoxication and violence arise. This requires reflection regarding the ethics of appropriate care, ensuring vulnerabilities are managed, and the right to humane care is upheld irrespective of the situation. When health professionals demonstratively uphold the rights of healthcare consumers and provide safe, humane and ethical care in a supportive environment, men are enabled to develop trust and are empowered to engage in change. This change seeks to address harm to self, and the social and emotional wellbeing of other individuals, and to achieve treatment goals, and recovery, if possible.

References 1. National Health and Medical Research Council (NH&MRC), Australian guidelines to reduce health risks from drinking alcohol. Canberra: Commonwealth of Australia; December 2020. https://www.nhmrc.gov.au/about-­us/publications/australian-­guidelinesreduce-­health-­risks-­ drinking-­alcohol. Accessed 17 Feb 2022. 2. Cape BF. Nurses’ dictionary. 17th ed. London: Bailliere Tindall; 1972. 3. Ghoshal M. Does alcohol kill sperm and other fertility facts. Health Line. 2019. https://www. healthline.com/health/does-­alcohol-­kill-­sperm-­2. Accessed 17 Feb 2022. 4. Office for Women. Family Safety Framework Practice Manual, Version 6. 2015. Updated 2020. Office for Women. Currently under review. https://officeforwomen.sa.gov.au/__data/ assets/pdf_file/0005/86801/FINAL-­Family-­Safety-­Framework-­Practice-­Manual-­Version-­6-­ May-­2015-­FOR-­WEBSITE-­2020.pdf. Accessed 16 Jan 2022. 5. Australian Domestic and Family Violence Death Review Network. https://officeforwomen. sa.gov.au/__data/assets/pdf_file/0004/70708/ADFVDRN_Data_Report_2018_.pdf. Accessed 16 Jan 2022. 6. AIHW. Monitoring Perpetrator Interventions in Australia, Summary Canberra. 2021. https:// www.aihw.gov.au/reports/domestic-­v iolence/monitoring-­p erpetrator-­i nterventions-­i n-­ australia/contents/summary Accessed 14 Mar 2022.

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To Learn More de Crespigny C, Talmet J, editors. Alcohol, tobacco and other drugs: clinical guidelines for nurses and midwives. Version 3. Adelaide: The University of Adelaide School of Nursing and Drug and Alcohol Services of South Australia; 2012. https://digital.library.adelaide.edu.au/dspace/ bitstream/2440/73718/1/hdl _73718.pdf. Accessed 17 Feb 2022. Australian guidelines to reduce health risks from drinking alcohol. Canberra: Commonwealth of Australia; December 2020. https://www.nhmrc.gov.au/about-­us/publications/australian-­ guidelinesreduce-­health-­risks-­drinking-­alcohol Accessed 17 Feb 2022. Specialty of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health at the University of Sydney, 2021. Australian Guidelines for Treatment of Alcohol Problems. https://www.drugsandalcohol.ie/34245/1/Australia_guidelines-­for-­the-­treatment-­of-­alcohol-­ problems.pdf. Accessed 22 Mar 2022.

Older Adult

15

Marilyn White-Campbell, David Brown, Peter R. Butt, and W. J. Wayne Skinner

Learning Outcomes 1. Learners will be able to identify level of risk when supporting an older adult with substance use disorders (SUD). 2. To understand and apply approaches to care for older adults with alcohol use disorders (AUD). 3. Through case-based reflective practice, readers will be able identify a stepped approach to treatment options for older adults with alcohol use disorders (AUD).

15.1 Introduction Societies around the world are, for the most part, ageing better than ever: more people are surviving into old age. In Western democracies, it is expected that those over the age of 65 will soon represent one quarter of the population [1]. One of the

M. White-Campbell (*) Baycrest Health Sciences, Toronto, ON, Canada e-mail: [email protected] D. Brown Pathways Research, Winnipeg, MB, Canada e-mail: [email protected] P. R. Butt College of Medicine, University of Saskatchewan and Addiction Medicine Consultant, Saskatchewan Health Authority, SHA Mental Health and Addiction, Saskatoon, SK, Canada e-mail: [email protected] W. J. W. Skinner Department of Psychiatry, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_15

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prerogatives of becoming elderly, in good circumstances, is the ability to enjoy this time of life. That includes social connections and frequently social drinking. Yet, what do we know about alcohol and ageing? We know that alcohol is a social lubricant, not only because of its mood-altering effects but also because of the way it is inscribed with positive meanings at the personal level and with valued and rewarding social experiences. Because of that, drinking alcohol is deeply embedded in the lives of many people who are entering old age. It is also a commodity that is marketed and sold as an integral element in good times: relaxing, eating good food, and socializing with others. The evidence shows that in the general adult population, there are alcohol use risks and harms that impact the biological, psychological, and social wellbeing of those who drink, even in moderate amounts. Experts around the world have proffered advice, based on epidemiological evidence and medical science, about low-­ risk drinking guidelines (LRDG) for adult men and women and with growing confidence for older adults, both male and female [2–4]. While there is no pinpoint precision in the guidelines from nation to nation, there is consensus on two bits of advice: one, if you don’t drink, don’t start now, and, two, if you do drink, it is always wisest to drink less. LRDGs provide more precise parameters on safer limits for those who do drink. While the details differ from country to country, the basic principles are endorsed by all of them. All this encourages the hopeful expectation that the burden of illness due to alcohol consumption will diminish as the population ages. Unfortunately, that is not the case. For one, many adults who have had years and decades of drinking, even moderately, are more likely to show symptoms of health problems for which alcohol use is a cause or cofactor, later rather than sooner. For another, the habit of using alcohol to self-regulate and to manage social occasions is well-established in many adults. In Canada, for example, almost 80% of adults admit to being drinkers [4]. More than 13% of Canadians aged 55 and older report a pattern of problematic binge drinking [4]. In the USA, 65% of adults report at risk drinking, and a further 10% report binge drinking [5]. According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA) [6], about 40% of US adults ages 65 and older drink alcohol. As people age and experience decline in tolerance to alcohol, continuing to drink at the same levels can change what once was bearable physiologically to more overtly problematic and harmful. The experience of many people in ageing, even as there are many exemplars of how to live well and thrive in the later years of life, involves an increased loss of physical and cognitive capacities; of social isolation, loneliness, and loss; of economic disadvantage; and of increasing dependency on others for care and support for even basic activities of daily living, as well as demoralization and hopelessness as their future horizons close. Predictably, as the older adult population grows in numbers, the problems related to alcohol use disorders will, in the coming several decades, increase and become more complex and challenging. The problematics of alcohol use in older adults needs to be acknowledged. There is a strong social and medical science base to

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approach these problems confidently, respectfully, and ethically. This chapter presents an evidence-informed, person-centred, and family-focused approach to working with older adults along the full spectrum of risks and harms related to alcohol use, including the complexities of withdrawal for the older adults. We provide a background perspective that creates a context for looking at the range of clinical challenges, along with case illustrations that include observations and clinical reflections (reflective practice exercises—RPE) that encourage the reader to apply what is offered here to the situation in which they live and work. Counterintuitively, most of the burden of alcohol use is associated with non-­ dependent risky drinking [7]. The impact on the individual is reflected in increased risk for onset or worsening of preventable chronic illnesses, including some forms of cancer, heart disease, hypertension, and diabetes [8]. In turn, the costs to health systems and communities are very large [8, 9]. The World Health Organization (WHO) has identified approximately 48 alcohol-related harms [10]. Sometimes these harms become evident only in later life. In many societies, alcohol-related harms are not well tracked and therefore hide in plain sight. Reflective Practice Exercise 15.1 • In your practice with older adults who drink, is the primary focus on identifying people who drink excessively and are therefore at risk of a severe alcohol use disorder? • To what degree do you explore the ways even moderate alcohol use could be a factor in the older person’s physical symptoms, psychological complaints, their social functioning, or all the above? Key Point 15.1 Excessive alcohol intake may be related to treatment-resistant high blood pressure, atrial fibrillation, reflux esophagitis, gastritis, peptic ulcer disease, liver disease, pancreatitis, various GI and breast cancers, thrombocytopenia, malnutrition, falls, depressed mood, social isolation, inability to cope, and cognitive decline. One should inquire into alcohol use when addressing these conditions.

15.2 Screening, Prevention, and Intervention Within Primary Care 15.2.1 The Spectrum of Risk Risks from chronic alcohol use present along a continuum of severity. A spectrum of risk implies variability in risk levels across the population. Risk levels for alcohol use are complex and reflect the probability for: (a) Onset or worsening of preventable disease and injuries (b) The development or worsening of an alcohol use disorder

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Alcohol screening tools and treatment have focused almost exclusively on the latter, even though the burden of disease and health system costs lies most heavily with the former. Acute harms: People who drink within LRDG may still experience harms. Acute harms related to alcohol use include accidents, injuries, and interpersonal conflict, including violence. Evidence-guided LRDGs, based on risk related to preventable disease and serious injuries, allow clinicians to screen for both acute and chronic forms of risk from alcohol use. In practice, this means assigning an initial risk level based on whether the criteria for (a) or (b) are met. Treatment programs for severe alcohol issues have traditionally focused their efforts on helping individuals recover from an alcohol use disorder, with little or no emphasis on other harms from alcohol use (such as increased risk for cancer, stroke, heart disease, and diabetes as well as serious injury). Our systems for addressing alcohol issues in the population have concentrated almost solely on addiction to alcohol as the ultimate harm. It may be useful to think of problematic use of alcohol as a compounding risk factor for the onset or worsening of the physiological harms mentioned above, rather than the primary problem in and of itself. The amount and circumstances of alcohol use are clearly risk factors for the onset of serious disease and injury. For the minority of risky drinkers who develop a severe alcohol use disorder, their dependence further increases the likelihood of a disease or injury by compromising the ability of individuals to control the amount and circumstances of their alcohol use, as well as interfering in obtaining care. For the older adult, the consequences of alcohol use even at low levels can have severe consequences. In our work with people at risk or experiencing harm due to their alcohol use, we observe that alcohol problems, all too often, are not just about dependence but also about something else. Understanding these drivers can be crucial to engaging and helping the person to a plan of action [11]. Thus, in a spectrum of risk for harms resulting from alcohol use, those with alcohol use disorder would be considered high risk as they are, by definition, already experiencing negative consequences. The person who drinks beyond low-risk guidelines in terms of quantity and frequency but without indication of having an alcohol use disorder would be at moderate risk. To address the full spectrum of alcohol use, we need to have screening tools that can identify older adults as being at low, moderate, or high levels of risk or harm. Moreover, we need prevention and intervention care pathways matched to each level of risk. This has implications for the selection of screening tools and for the roles that primary care practitioners might play in terms of prevention and intervention.

15.2.2 Screening for AUD in Older Adults Alcohol screening in primary care for risky use among older adults is a recommended opportunity to improve health outcomes through prevention and early intervention (US Preventive Services Task Force) [12]. The evidence supports

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primary care-delivered brief interventions for those who drink at levels above the low-risk drinking guidelines but not with the harms consistent with a moderate or severe alcohol use disorder (AUD) [13]. However, despite the evidence for the efficacy and cost-effectiveness of these clinical practices, research tells us that it is still challenging for family physicians and other primary care practitioners to implement these practices. Reflective Practice Exercise 15.2 • In what ways might you, as a matter of clinical routine, be inclined to ask (or not ask) an older adult about their drinking, the context, and the good and not-so-­ good aspects of their use? • What other assumptions underlie your clinical routines with older adults?

15.2.3 Talking with Older Adults About Alcohol Risks and Harms Since alcohol use issues can arise with older adults at any time, it is wise to screen most adults at least annually as part of routine healthcare. This is justified, given that the burden of morbidity and mortality associated with risky drinking is at least as great as other factors that are screened for on an annual basis in primary care, especially for women and individuals with existing chronic disease [3, 14]. At the same time, primary care practitioners require the means to respond in evidence-based ways to potential screening results. Only then we can expect them to engage in systematic alcohol screening. Also, the severe time and resource constraints common in primary care challenge the effective integration of screening and intervention processes into already existing clinical protocols. Key Point 15.2 Linking screening to a routine lifestyle inquiry as well as potential alcohol-related harms [2] would be a natural and effective way for the clinician to associate alcohol screening with the individual’s wellbeing. Since co-occurring mental health disorders are so common, it is important to interpret screening results and risk levels in the context of such issues as depression and anxiety disorders. A much greater level of complexity is present if individuals screen as being at moderate risk from alcohol use and at low-moderate severity for depression or anxiety disorders. Such co-occurring disorder situations may call for a high-risk classification on both counts. This would lead to a referral for specialized assessment and treatment of both issues together. Losses in late life, such as those associated with changes in social connections, change in income due to retirement, changes or decline in health, loss of independence, or bereavement, are factors for increased drinking in older adults [3]. The selected care pathway is ultimately negotiated based on the primary care provider’s clinical judgement about the persons actual risk level. This decision would be informed by formal screening results as well as knowledge of the

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individuals’ medical history, circumstances, and motivation. Taking such factors into account may lead the clinician to assume a higher risk level than the screening tool suggests. The care pathway recommended is then matched to the risk level that the clinician judges to apply most clearly. To screen based on the low-risk drinking guideline (LRDG) criteria requires that both clinicians and the individual understands what a standard drink is. Standard drinks, or units in some countries, vary in the amount of ethanol and are seldom labelled on beverage alcohol. In the Canadian context, one standard drink is 13.6 g or 17.5 mL of ethanol. One must be specific in asking quantity and frequency questions, such as those comprising the Alcohol Use Disorders Identification Test (AUDIT) or AUDIT-C [15], to determine if the person is drinking within the LRDG (tentatively at low risk) or have a pattern that suggests that they are at a more elevated level of risk (i.e. moderate or high). This is in keeping with the logic used in the College of Family Physicians of Canada (CFPC) web-based resource for addressing alcohol issues with the individual. The low-risk drinking guidelines are modified for older adults, however. Reduced body water, lean body mass, and volume of distribution lead to a 30% increase in blood alcohol concentration, with the same amount of ingestion, compared to younger adults [16]. This is compounded by varying decreases of increased vulnerability and frailty, depending upon their age, health status, comorbidities, and use of prescription medication. The Canadian guidelines therefore recommend a decrease in the LRDGs by 50% at age 65 (or sooner) with further tapering over time [3]. Box 15.1 Canadian Low-Risk Drinking Guidelines for Older Adults, 65 and Older, with Substance Use Disorders (SUDs) Recommendation 1 The Canadian low-risk drinking guidelines for older adults suggest a reduction of 50% of alcohol intake for older adults, compared to adults under the age of 65. For men, that means no more than one standard drink per day for a maximum of seven standard drinks per week. For women, the weekly maximum is five standard drinks, with two nondrinking days and up to one standard drink on the other 5 days. Nondrinking days are recommended every week. Ideally, older adults would gradually taper their alcohol consumption over the years, as frailty and vulnerability progress. As general health declines and frailty increases, alcohol should be further reduced to one drink or less per day, on fewer occasions, with consideration given to drinking no alcohol [17]. Once we know whether individuals are drinking beyond the guidelines, further screening criteria are needed to differentiate between levels of elevated risk and the potential for the harms consistent with an alcohol use disorder. Under Diagnostic and Statistical Manual of Mental Disorders (DSM 5), 2–3 negative consequences equate to a mild alcohol use disorder, 4–5 moderate, and 6 or more severe. The AUDIT-C is sometimes used for this purpose. However, it only asks quantity and frequency questions without asking about

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indicators of alcohol use disorder. Thus, a more robust approach is to use the full audit tool or the ASSIST [18]. There are reliable screening tools specifically for older adults, such the SMAST-G, SAMI, and AUDIT [3], to assist in differentiating between those who drink at risk and those experiencing harms. An appropriate screening tool will: (a) Have been validated to measure what it purports to in each client population (b) Be comprised of questions that are well within the client’s level of reading comprehension (c) Be of a size and format that are feasible for implementation in the clinical settings in which it is being used In a busy primary care clinic, annual adult self-screening during routine care visits may be one of the most viable options. To apply alcohol use disorder criteria, we need to ask about the occurrence of adverse consequences from drinking over some period. The language for expressing these kinds of consequences varies considerably across different screening tools, but in general, they tend to ask about the following: • Did the individual have a strong need to drink? • Did the individual find that their drinking made things worse for themselves or others? • Did the individual find that their drinking made it harder to do important things? • Was the individual told by someone that they should drink less? • Did the individual find it hard to drink less? Key Point 15.3 Be sure to use screening tools that are specific to older adults, as these tools are more sensitive to that population. Identifying alcohol use disorder (AUD) may be obscured by retirement from work and decreased work or family responsibilities. The potential for social harms is thereby reduced, and the individual may deny the presence of any personal problems. The astute clinician needs to understand the social context to appreciate how the impact may change with age.

15.2.4 Care Pathways and Case Studies Since the components of the different care approaches are matched to the individual’s risk level, they vary in intensity and complexity. Low- and moderate-risk levels (within or just above the LRDG) put the focus on prevention (reinforcing in the case of low risk and cautionary in the case of moderate risk). Older adults can have risk even at low levels of alcohol consumption. These two categories together may account for as much as 60–70% of a given primary care clinic’s population. Although their numbers are relatively high, research shows simple and short evidence-based prevention conversations are effective and help conserve clinician time and other resources for use with higher risk clients [19].

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Moderate and high risk call for an emphasis on active intervention (brief behavioural change counselling in the case of moderate risk and more intensive assessment and treatment in the case of high risk). Notwithstanding these differences, a common thread of engaging the individual in a supportive, listening, and non-­ judgemental manner runs through all the approaches, regardless of risk level. Key Point 15.4 Dialogue actively about alcohol and other substance use as a routine part of helping older adults to manage their own health, the same with any medical concern in an effective person-centred/or therapeutic relationship. Reflective Practice Exercise 15.3 What one or two things can you enhance or add to your practice to keep the dialogue about alcohol and other drug use as open as possible?

15.3 Care Pathway for Moderate-Risk Drinkers An older adult drinking within low-risk drinking guidelines and without any indicators of an alcohol use disorder is at low risk. The care pathway in this case would be to provide a reinforcing prevention message individualized in the context of the older adult’s comorbidities, age, vulnerabilities, and frailty. An older adult who drinks within the guidelines that reports 2–3 adverse consequences indicative of a mild alcohol use disorder can be considered as being at moderate risk. Similarly, if someone drinks beyond the guidelines without any disorder indicators, they may also be at moderate risk. The care pathway for those at moderate risk would be to explore the older person’s perceptions of the good and not-so-good things about their alcohol use and, after that, to offer some feedback and advice. This would include an explanation of alcohol risks for physical and mental health as well as the low-risk drinking guidelines for older adults. It would also include encouragement to shift to a low-risk level of drinking, possibly a period of sustained abstinence, or regular abstention on 2 or more days per week. It’s helpful to ask the person what they think of the advice and to ask them what they are likely to do, offering support for any change they want to make. Case Study 15.1: Mrs. B Moderate risk. Elevated consumption with emerging harm. The most common pattern: Mrs. B (82) was married for 60 years. Her spouse died 5 months ago. She continues to live independently and manages tasks of everyday living but has some unresolved grief from the loss of her life partner. On presentation, she is alert and there appears to be no issues with her cognition. She was a professional administrator for a high-profile company. The doctor notices she is not her usual cheerful self.

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She admits to feeling sad and lost. She reports feeling a lack of purpose since her husband died. She requested to see her primary care provider because of stomach issues. On closer examination, the doctor smells alcohol on Mrs. B’s breath. The 5 A’s of brief intervention help the clinician to explore the drinking behaviour: 1. 2. 3. 4. 5.

Ask Assess Advise Assist Arrange

1. Ask: The doctor asks permission to explore her drinking. He asks about her daily and weekly drinking pattern and when she last had a drink. He asks about her stomach complaints. She indicates she is not eating well, has an upset stomach most of the time, avoids food, and has lost weight, and her appetite is poor. 2. Assess: The doctor mentions her previous drinking history of a two to three social drinks with her husband a couple of times a week. Today he asks, ‘How has your drinking changed since your husband passed away?’ She responds, ‘I seem to be drinking almost every day now and with the wine bottle in front of me it’s easy to have a drink before dinner and one after dinner. I drink because I miss him and I know it’s not helping, in fact, I feel worse the next day’. The doctor asks if there is any wine left in the bottle at the end of the day. She responds that ‘A bottle of wine lasts me 2 days’. The doctor offers her a screening tool and gives her a copy of the WHO-ASSIST questionnaire to self-complete and bring back on the next visit. Even with presumably low-level drinkers, we should ask the questions pertaining to quantity, frequency, and consequences. We need to be comfortable asking questions in standardized screening tools. If the risk level is deemed higher, further assessment tools for an alcohol use disorder, such as Michigan Alcohol Screening Test (GMAST) or Senior Alcohol Misuse Indicator (SAMI), should be utilized. 3. Advise: The doctor indicates that he wants to investigate her gastrointestinal (GI) problems and possibly refer to a gastroenterologist. He asks if he could comment further about her drinking. She agrees and the doctor explains that there are low-risk drinking guidelines for older adults [3]. He explains that for older women, a maximum of one drink per day with two nondrinking days per week is advisable, with further tapering as she ages or encounters problems. She reports ‘That’s how much I used to drink before I lost Harry’. 4. Assist: The doctor advises that the extra drinking could be a factor in her stomach complaints. He asks if she would be willing to change her drinking pattern even while they investigate her health issues. She admits that the dinner drink with Harry was always a special part of the day for her. The doctor replies that the options could include cutting back on the amount she drinks per day, reducing the number of days she drinks per week, or stopping altogether for a while. She asks, ‘What do you think I should do?’ The doctor indicates that the quickest

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way to rule out alcohol as the cause is to stop drinking for a while and monitor her symptoms. He asks, ‘How realistic is that for you?’ She says the stomach problem is really starting to worry her and elects to stop for the next 2–4 weeks, monitor her symptoms, and follow up. The doctor says, ‘Cutting back or ­abstaining is never a bad idea when it comes to your health. It may improve both your appetite and your mood’. 5. Arrange: The doctor arranges for physical investigations, including blood work (complete blood count (CBC), electrolytes and renal function, liver enzymes, albumin, bilirubin, international normalized ratio (INR), lipase), ultrasound, and a referral for endoscopy. He asks if she thinks she will have strong urges to drink or if she has any concerns around stopping. She says, ‘I didn’t realize it until now, but my drinking has become a habit’. He suggests that they have weekly contact and to feel free to call if there are any concerns. Reflective Practice Exercise 15.4 • How do you feel about exploring these issues as a normal part of clinical practice? • Healthcare professionals are often reluctant to ask older adults about alcohol use. What might make you hesitate? • How do the five A’s fit with the ways you currently discuss alcohol with the individual? • How do you feel about respecting Mrs. B’s right to make choices (no change, reduction, or temporary cessation) rather than just prescribing what she should do? • What are one or two things that you could do to implement this approach in your practice? People who are given choices tend to do better in treatment than those who are prescribed a course of action by a healthcare professional [19]. Respecting self-­ determination and autonomy helps shape the commitment to change when individuals own and are authors of the change. Even when the doctor gives advice, he asks ‘What would you like to do?’ or ‘What do you think of that?’ Motivational interviewing (MI—see Chap. 23) is one way to start where the client is at and work to evoke their reasons for making a change [20].

15.3.1 Care Pathway for Moderate-Risk Drinkers with a Moderate Alcohol Use Disorder The individual who reports an emerging pattern of adverse consequences indicative of a mild to moderate alcohol use disorder can be considered at moderate risk. It is for this group that the research literature has found brief interventions focusing on behavioural self-change to be relatively effective [21] (see Chap. 17). These individuals are experiencing some problems with their drinking, though not enough to justify referring them to specialized treatment and

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thereby adding to already crowded waiting lists. At the same time, there is an emerging pattern of problems that suggests we should do more than provide a cautionary prevention message. The care pathway in this case is to explain the health risks associated with alcohol and the low-risk drink guidelines for older adults, engage the person in conversation to assess and bolster their readiness for change, as well as help them to strengthen their motivation and plans for change. These conversations, sometimes referred to as brief interventions or behavioural action planning, borrow principles from MI and cognitive behavioural therapy (CBT). While not particularly demanding in terms of time, as it might be sequenced over several visits, the process does require a minimal degree of training and the empathic disposition of the clinician [22]. This guided behavioural change process is sometimes supported by use of a workbook that individuals can use with their clinicians, on their own, or through a combination of both modalities. Such workbooks are built around the same kinds of questions that a clinician would ask a person to consider for themselves as part of self-directed or therapist-guided change process. These questions in both cases borrow principles from MI and cognitive behavioural therapy (CBT) to help the person reframe their own readiness for change and pursue their own action plans for changing drinking patterns [20]. If the individual declines an offer to engage in brief intervention, the clinician can at least restate their encouragement to shift to low-risk or abstinent drinking of alcohol and provide the person with printed information on alcohol health risks and LRDG. If the individual engages in a brief intervention process but is unable to realize a substantial reduction in his or her drinking, this might suggest a higher level of severity and the likelihood of concurrent factors, be they biological, psychological, or social. This would involve further assessment as well as more intensive forms of treatment, possibly pharmacotherapy (see Chap. 19) or a referral to a specialized provider. It is an opportunity to engage key family members or concerned others whose involvement may provide further insight. It is often the case that concerned others are also deeply affected by persistent unresolved heavy drinking or binging [11, 20] (see Chap. 16). Case Study 15.2: Moderate to Severe Alcohol Use Disorder Mr. B (74) was a ‘social drinker’ up until retirement. His wife was diagnosed with Alzheimer’s disease, and he has been caring for her at home for 8 years. In the past year, she declined dramatically, and in response, his drinking escalated to problematic levels. The family do not think it’s safe for their mother to be at home with him as he is intoxicated most of the day. He drinks 40 ounces of vodka over the course of 2 days or approximately 13 standard drinks per day. He does not eat when he is drinking and recently fell after a binge episode and cut his head on broken glass. He was taken to the emergency department and after 24 h began to experience withdrawal-­related delirium. He was combative and wandered. The nursing team was unable to manage his aggression, so they sedated

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and restrained him. His withdrawal was protracted, and he decompensated while in hospital, requiring physiotherapy to regain his strength. After 2  weeks, his delirium cleared, but he began craving alcohol and elected to discharge against medical advice (AMA). He returned home and resumed drinking. He had three subsequent emergency visits to the hospital with 2-week stays ending in him discharging AMA, repeatedly. An application for long-term care is initiated, as it is clear he can no longer manage at home. An outreach older adult addiction counsellor suggests he return to hospital, where there is an addiction medicine team to support him during the withdrawal process (see Chap. 20). He consents, is readmitted, and is supported by addiction medicine. Due to his confusion, continuous attendance is required. On day 11, his confusion clears, and he can recognize family and the care team. He agrees with the initiation of anti-craving medication and feels that he is much stronger and would be able to return home without relapsing. Mr. B continues his anti-craving medications, organizes the sale of his home, and moves into a retirement residence to be near his wife where he has more social engagement. He maintains his abstinence, gets his driver’s licence back, and volunteers in the community. He has purpose and meaning in his life. Reflective Practice Exercise 15.5 Reflections: • How have problematic behaviours negatively affected your perceptions of older adults and their worthiness of help? Have you become demoralized and nihilistic and believed these situations are utterly hopeless? • When factors such as excessive drinking and the compromised older adult with an oppositional attitude are present, how likely is it they will receive optimal care? • Is it worth the effort, especially given the age of the person? • What reflective awareness needs to be present at the personal and team level to ensure that Mr. B, as challenging as he is, receives the standard of care that we would expect if he were a family member? • What approaches to care may have contributed to him successfully completing his stay in the first admission? How important are these interactive processes in effecting the persons outcomes? • What factors in the way he was treated may have contributed to his desire to leave AMA? • Is it fair to explain his premature discharges as entirely due to his uncontrolled desire to drink alcohol? • What factors, including the interpersonal communication skills of the worker, might have inclined Mr. B to accept help the last time? If the outreach worker had not engaged Mr. B, so that he received the specialized care he needed, what would the outcome have been? Would he have been prematurely institutionalized?

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• What are some of the distinctive things that a dedicated addiction medicine team would bring to working with an elderly man with heavy alcohol intake that might be different from the way he was treated in a general medicine environment? • If you were Mr. B, what aspects of your interactions with the healthcare providers, who are responding to your situation, are going to motivate you to stay in their care and seek change? What factors would demotivate you so that you feel frustrated, unheard, and demoralized about the point of seeking help? • Going forward, what do you think is important to ensure that Mr. B feels supported in recovery? Key Point 15.5 The onset of withdrawal for older adults (OA) may occur several days after cessation of alcohol. Alcohol withdrawal in OA can take longer than younger counterparts.

15.4 Care Pathway for Severe Alcohol Use Disorder The individual who reports a strong pattern of adverse consequences indicative of alcohol use disorder (6 or more per DSM 5) can be at high risk for further or worsening harms from their drinking and is usually chemically dependent. When there is alcohol dependence in older adults, the threshold for further harm is lower, due to changes in blood alcohol concentration associated with age, the presence of comorbidities, psychosocial vulnerabilities, and increasing frailty. These individuals are experiencing problems to such an extent that they would be unlikely to benefit from a brief intervention alone. In addition to explaining the alcohol health risks as well as assessing and enhancing their readiness for change, the clinician will strive to engage the person in more in-depth assessment and intensive treatment. This may include pharmacological treatments to supplement psychosocial therapies. The latter may be carried out by the primary care clinician or through a referral to a specialized provider. Medically supported withdrawal may be required. The time required will be dependent on degree of severity, complexity (including potential co-occurring mental health issues), and availability of local resources. Older adults may require geriatric specific resources. Case Study 15.3: Severe Alcohol Use Disorder Home Supported Withdrawal Mr. A (67) has a diagnosis of Alzheimer’s disease. Prior to his diagnosis, he never drank more than two drinks per day. In the second year of his diagnosis, his drinking escalated to 11 standard drinks per day. He drank beer in the daytime and ended the evening with a bottle of wine. The combination of dementia and drinking undermined any insight into his problematic drinking. He was injured in a fall, required treatment in an emergency department (ED), but left to purchase beer. He often vomits after drinking and his nutritional intake is poor. He chews his food and spits it out, rather than swallowing. He wanders and gets lost. He is seen in an older adult clinic and is given an additional diagnosis of frontal-temporal variant.

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The spouse is now the designated decision maker. She would like him to go into care as she is no longer able to manage his needs at home because of his drinking, wandering, vomiting, failing nutrition, and incontinence. He is assessed by a care coordinator and deemed incapable of making decisions. Withdrawal management is also required for eventual placement in long-term care. Reflective Practice Exercise 15.6 • What are the ethical considerations for admission to long-term care? • If abstinence is required, what are the supports to achieve that state? • Are there, or should there be, low-barrier options? • Is the drinking a reflection of his progressive dementia rather than a conscious process? How does that impact the assessment of his alcohol use disorder per DSM 5? • How does one be compassionate and person-centred in the context of dementia and reduced insight? • How involved is the spouse as proxy decision maker in care decisions that balance her knowledge of his values and the options for care? • Is a therapeutic resolution based on what is objectively right or wrong, or what is best for the person? Mr. A has declined admission for medical withdrawal, and although his spouse is the substitute decision maker (SDM), she cannot force him to go without a court order. Addiction medicine and the SDM elect to taper him gradually from alcohol with the increasing substitution of dealcoholized beverages (beer and wine). He is prescribed anti-craving naltrexone as well, which his wife tells him is a vitamin. He responds to the naltrexone, and she can taper him by one standard drink every 1–2 weeks over the course of 4 months. He is no longer drinking, but believes he is having beer and wine daily. He moved into a supportive dementia care unit. Reflective Practice Exercise 15.7 • What are the ethical concerns of deceptive substitution therapy? • Is this a reasonable approach to person-centred care, to achieve optimal outcomes?

15.5 Assessment and Withdrawal Management Older Adult Considerations The Predictor of Alcohol Withdrawal Severity Scale (PAWSS) [23] is an important aid in determining withdrawal risk and the necessity of medically supported withdrawal. It is primarily based on the severity of the alcohol use disorder and a history of complicated withdrawal but requires additional attention to be paid to comorbidities, particularly in older adults. Withdrawal symptom-based monitoring, scoring,

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and protocols are recommended, such as Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, (CIWA-Ar), with short-acting benzodiazepines, such as lorazepam, preferred to long-acting ones, unless otherwise indicated. In some circumstances, it may be preferable to conduct a very gradual home taper in a manner that is physiologically less traumatic [3]. Assessing for withdrawal risk in older adults can be different from the general population. There is need for a comprehensive assessment which includes alcohol quantity, frequency, last drink, and potential harms, including medication or other substances. Evaluation of physical and mental comorbidities, cognitive status, nutrition, chronic pain, social conditions, family/social supports, overall functioning, and collateral history are important to consider, as are considerations for age and frailty, when triaging to the appropriate withdrawal process, from support in the community to hospital admission. Delirium Tremens: With age, multiple comorbid conditions and frailty can be the cause of complications during withdrawal. Things taken for granted in a younger population can be cause for concern in the older age group. Dehydration, constipation, and urinary tract infections (UTI) can be a cause of delirium in older adults, as can relocation to a foreign environment. Five percent of alcohol withdrawal deaths occur because of delirium [24]. Delirium in withdrawal is considered an even higher risk in older adults. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. Withdrawal in older adults can be protracted and, in this instance, medically supported withdrawal in a hospital setting is justified. The PAWSS Prediction of Alcohol Withdrawal Severity Scale [25] is a useful tool to predict complicated withdrawal and is recommended in the Canadian Coalition Seniors Mental Health (CCSMH) alcohol use disorder (AUD) guidelines [3]. A review of comorbid medical conditions is important in older adults who drink and require an elective surgery. They may require pre- and peri-operative care for medically supported withdrawal due to either a planned or emergency hospitalization. The older adult or their caregivers may not disclose heavy drinking, which can complicate an otherwise routine surgery. Screening for alcohol at all points of care should include a medication review, alcohol and other substance use, as well as a thorough older adult assessment. There are physiological changes in older adults, which may be an added risk even at low levels of alcohol consumption. Older adults become intoxicated at lower levels of alcohol consumption than younger cohorts due to age-related changes in the volume of distribution [16, 26], leading to a risk of heightened effects from alcohol even at relatively low levels of consumption. All these complexities add additional risk when there is problematic alcohol use in the older adult. Similarly, other risks such as falls may be catastrophic compared to a younger person.

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Key Point 15.6 Access tools to support withdrawal management for older adults including the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), CIWA-Ar, benzodiazepine protocols, benzodiazepine Tapers, managed alcohol programs, alcohol tapers, and pre- and peri-operative care [3].

15.5.1 Cognition It is important to assess older adults for cognitive impairment. Use of validated tools, such as the Montreal Cognitive Assessment (MoCA) [27], can be useful in determining the level of impairment and to weigh risks for a home supported, medically supported, or hospital-based withdrawal. The Montreal Cognitive Assessment (MoCA) is a brief, 30-question test that helps healthcare professionals detect cognitive impairments early on, allowing for faster diagnosis and individuals’ care. MoCA is a sensitive test, measuring executive functions and multiple cognitive domains, which are important components not measured by the Mini-Mental Status Exam (MMSE) [28]. When an alcohol use disorder is detected, it is important to have a baseline assessment of cognition [3], repeating at 6 and 12 months to assess response to treatment. Supporting an older adult through withdrawal and their continued abstinence is key to the prevention of further unnatural cognitive decline [28]. Research suggests that there is at least no deterioration and possible improvement over time with abstinence in persons with a diagnosis of alcohol-related dementia (ARD).

15.5.2 Psychosocial Supports Consider a practical, comprehensive approach to the necessary supports: • Does the individual live alone and independent with meal preparation and personal care? • Are there supports in the home to ensure support during withdrawal? • Is the person able to self-administer medications if they are required? • Is there cognitive impairment which would place the person at risk if there were complications, such as falls, hallucinations, seizures, or delirium? • How can managed alcohol be supported by the individual? • Is the withdrawal a planned taper from alcohol as part of a pre-operative surgery? • Is the withdrawal part of a transition plan for admission to retirement or long-­ term care? • If the older adult has cognitive issues, can you safely taper alcohol and substitute non-alcohol-based beverages, such as dealcoholized wine or beer? • Having social capital can be a factor in resiliency for an older adult. Are there any supports in place at home and in the community? • Are there family caregivers or friends and community services to support relapse prevention as part of the withdrawal plan?

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Case Study 15.4: Severe Alcohol Use Disorder: Hospital Withdrawal (see Chap. 20) Ms. D (59) is intermittently homeless due to problems managing her rent. She has a diagnosis of Wernicke’s-Korsakoff syndrome and is falling, because of her alcohol use and poor nutrition. She has been admitted to the hospital multiple times and was discharged home on anti-craving medications only to relapse into heavy drinking, repeatedly. She was inconsistent with her medication, and her friends could not confirm compliance. She decompensates with each discharge to the community with increased risks, including fires, assaults, and arrests, due to petty theft. Her Mini-Mental State Exam (MMSE) is 24/30 and her Montreal Cognitive Assessment (MoCA) score is 17/30, which is suggestive of dementia. After a lengthy hospitalization, she is deemed incapable of healthcare decisions, and an application is sent for admission to long-term care. She is on the waiting list to be transferred to long-­ term care, but Covid-19 has affected the hospital’s flow capacity, and she is discharged to wait for a long-term care bed back in the community. Discharge plans include daily visits from the Personal Support Worker (PSW) to assist with home keeping and medication reminders. She has a friend who lives in the building who brings her alcohol daily. Last week, she was intoxicated and left a pot on the stove. The fire has prompted the housing provider to pursue eviction. Ms. D is not paying her rent as she is spending all her money on alcohol. She has another fall and is taken to the emergency room. The discharge planner is asked to ensure that a capacity assessment for finances is completed before discharge. She is discharged to a supportive residence where there is a managed alcohol program. She is eventually stabilized on 5 oz of wine three times per day, supplemented with dealcoholized wine, naltrexone to address her cravings and oral thiamine, 50 mg per day. Reflective Practice Exercise 15.8 While most street involved individuals are male, the implications of social marginalization for women are likely to be particularly severe. The risks of physical violence, sexual abuse, and exploitation are pronounced. Indigenous and racialized women have higher rates of victimization (see Chap. 3). When mental health addiction and cognitive decline are present, the index of concern is multiplied. • • • • • • • • •

When you know a person is this vulnerable, is there a duty to assess for capacity? How early in this scenario would you have undertaken a capacity assessment? What is the threshold that you would set to assess for capacity? What are the risks and harms in not identifying loss of capacity earlier? Different cultures have differing views on the right to autonomy in decision-­ making. What are the norms, values, and beliefs we hold around those who are marginalized and vulnerable? Are they different than those who are not so marginalized? What are the cultural norms around the person’s right to make poor decisions? Alternatively, is it embedded prejudice that people and systems hold that allows stereotypes to shape how we respond? We have a social responsibility to be compassionate. What would social responsibility based on compassion look like at the level of personal and system responses?

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• In Canada, the threshold for determination of capacity to manage finances is high. In other countries, the bar for state intervention may be lower. What are the challenges and opportunities you have in your work to help and protect vulnerable older adults? • There are many factors that have compromised Ms. D’s health, including a recurring set of injuries. In addition, there are bio-psycho-social complexities related to her age, gender, social class, and health status (see Chaps. 3 and 4). It could be suggested that Ms. D is subject to systemic abuse with inadequate assessment and discharge planning. What aides and evidence-based tools would be helpful in guiding action around capacity issues? • In this case, there is a radical absence of a relative or caregiver to provide support or act as a proxy when there is lack of capacity to make personal care and financial decisions. What challenges do you face in your practice when you face these circumstances? • What are the supports and resources that can be drawn upon to ensure the right things are done in the right way?

15.6 Conclusion Alcohol-related problems are already significant but under-identified factors that negatively affect the health of older adults. As the percentage of the population that is over 65 increases in the coming decades, the challenges that come with this will increase. And yet, there are opportunities to mitigate the risks and harms that come with alcohol consumption, particularly with older adults. A general shift in public health messaging could contribute to changes in the general adult population. Even more important for older adults at risk is the role played by the healthcare system. As people age, their healthcare needs tend to grow; as a result, they will have more contact with healthcare professionals. An informed, prepared, and committed multidisciplinary set of healthcare workers, particularly in primary and community healthcare settings, are strategically well-placed to make a difference in the lives of older adults at risk to or experiencing harms from alcohol use. For most older adults the focus on alcohol needs to be on health promotion and risk mitigation. Next, the second largest group (mild to moderate drinkers) meet criteria for psychoeducation and early intervention, be it self guided or therapist directed. Finally, in a way that seems true to Pareto’s law, 20% of this population will require 80% of the therapeutic effort. The significant minortiy of clients who use alcohol the most will require more intensive and therapeutic effort. An informed, prepared and committed multidisciplinary set of health care workers, working across the heathcare settings, from primary and community to tertiary and specialized settings are strategically well placed to making a difference in the lives of older adults at risk or experiencing harms from alcohol use. Key Point 15.7 The key point here is not just to recognize that this continuum exists but to mobilize the health and social services that older adults rely on so much.

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This needs to take a ‘Bio-Psycho-Social Plus’ (BPS+) approach here ‘plus’ includes cultural and spiritual dimensions. BPS+ also means that these five dimensions are important to wellbeing, each in its own right, and all intertwined and interdependent [11]. The approach to care then becomes one that sees the whole person. If an approach like BPS+ identifies key dimensions for a truly person-centred care, treating problems involves the practical ability to identify the issues affecting the person’s functioning and—just as importantly—working skillfully with the older person on the person-to-person basis that giving care requires. This then becomes the perfect opportunity for using compassionate curiosity and empathic respect to build a strong therapeutic relationship. This is no less important when the person is someone the health professional sees for just a few minutes than when the client and helper have a longstanding relationship [3, 11, 18]. As our examples show, to work effectively with older adults with problems related to alcohol use requires some specific knowledge, particularly when dealing with more severe and complex presentations. However, in order to optimize the benefits of health promotion, psychoeducation, and early intervention, we need to normalize the expectation that healthcare and social service professionals across the widest range of settings should be able to engage with older adults who use alcohol. It is important to recognize the broad trajectory of a life course, to see ageing as a process that varies in the paths it takes in the lives of those fortunate enough to have made it to the stage of being older adults. And it is empowering for both the individual and the professional to see the ways that respect, choice, and caring can both evoke new potentials and ease the hard experiences that ageing inevitably brings. In the case examples, and in your real-life work, what matters is not just what you do technically but how you work with the older adult who is in need of the care that in that moment is your opportunity to provide.

References 1. Crome IB, Crome P. Alcohol and age. Age Ageing. 2018;47:64–167. 2. World Health Organisation (WHO). Screening and brief advice programmes. In: Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol related-harm, 2009. www.euro.who.int/__data/assets/pdf_file/0020/43319/E92823.pdf. Assessed 31 Oct 2021. 3. Canadian Coalition on Seniors Mental Health (CCSMH). Recommendation Guidelines, 2019. https://ccsmh.ca/wp-­content/uploads/2019/12/Final_Alcohol_Use_DisorderV6.pdf. Assessed 31 Oct 2021. 4. Canadian Centre on Substance Use and Addiction (CCSA). Improving quality of life substance use and aging. 2018. https://www.ccsa.ca/sites/default/files/2019-­04/CCSA-­Substance-­ Use-­and-­Aging-­Report-­2018-­en.pdf. Accessed 31 Oct 2021. 5. SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2018 and 2019. https://www.samhsa.gov/data/data-­we-­collect/nsduh-­national-­ survey-­drug-­use-­and-­health. Accessed 31 Oct 2021. 6. National Institutes on Alcohol Abuse and Alcoholism. Alcohol’s effects on health: older adults. https://www.niaaa.nih.gov/alcohols-­effects-­health/special-­populations-­co-­occurring-­ disorders/older-­adults. Accessed 31 Oct 2021.

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7. Babor TF, Higgins-Biddle JC, Dauser D, Burleson JA, Zarkin GA, Bray J. Brief interventions for at-risk drinking: client outcomes and cost-effectiveness in managed care organizations. Alcohol Alcohol. 2006;41:624–31. 8. Rehm J, Shield KD. Global alcohol-attributable deaths from cancer, liver cirrhosis, and injury in 2010. Alcohol Res. 2013;35:174–83. 9. Mohapatra S, Patra J, Popova S, Duhig A, Rehm J. Social cost of heavy drinking and alcohol dependence in high-income countries. Int J Public Health. 2010;55:149–57. 10. Iranpour A, Nakhaee N. A review of alcohol-related harms: a recent update. Addict Health. 2019;11:129–37. 11. Skinner W, White-Campbell M, Meier R, Kahan M. Chapter 5: The older adult’s perspective. In: Cooper DB, editor. Responding in mental health-substance use. London, UK: Routledge; 2011. p. 34–47. 12. Unhealthy alcohol use in adolescents and adults: screening and behavioral counseling interventions. US Preventive Services Task Force; 2018. https://pubmed.ncbi.nlm.nih.gov/30422199/. Accessed 10 Oct 2021. 13. Kaner E, Fiona RB, Muirhead C, Campbell F, Pienaar ED, Bertholet N, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;24:2. 14. Trillo A, Merchant R, Baird J, Liu T, Nirenberg T. Gender differences in alcohol misuse and estimated blood alcohol levels among emergency department patients: implications for brief interventions. Addict Sci Clin Pract. 2012;7:A47. 15. Johnson J, Lee A, Vinson D, Seale P.  Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: a validation study. Alcohol Clin Exp Res. 2013;37(S1):E253–E2597. 16. Vestal RE, McGuire EA, Tobin JD, Andres R, Norris AH, Mezey E. Aging and ethanol metabolism. Clin Pharmacol Therap. 1977;21:343–54. 17. Butt PR, White-Campbell M, Canham S, Dowsett Johnston A, Indome EO, Purcell B, Tung J, Van Bussel L.  Canadian guidelines on alcohol use disorder among older adults. Can Geri J. 2020;23(1):143–8. https://cgjonline.ca/index.php/cgj/article/view/425. Accessed 31 Oct 2021. 18. World Health Organization (WHO). ASSIST V 3.0. https://www.who.int/substance_abuse/ activities/assist_v3_english.pdf?ua=1. Accessed 31 Oct 2021. 19. Sanchez-Craig M, Annis HM, Bronet AR, MacDonald KR. Random assignment to abstinence and controlled drinking: evaluation of a cognitive-behavioral program for problem drinkers. J Consult Clin Psychol. 1984;52:390–403. 20. Miller WR, Rollnick S. Motivational interviewing: helping people change. 3rd ed. New York, NY: Guilford; 2013. 21. Miller WR, Forcehimes A, Zweben A. Treating addiction: a guide for professionals. 2nd ed. New York, NY: Guilford Press; 2019. 22. Naar S, Safran SA.  Motivational interviewing and CBT: combining strategies to enhance effectiveness. New York, NY: Guilford Press; 2017. 23. Kahan M, Meier R, White-Campbell M. Management of alcohol use disorders in older adults: what doctors need to know. NICE Tools. 2014. p. 10. https://static.wixstatic.com/ugd/d1d295_ f7ad7fb10bfb418482a641bbae20fcd1.pdf. Accessed 31 Oct 2021. 24. Trevisan LA, Boutros N, Petrakis IL, Krystal JH. Complications of alcohol withdrawal pathophysiological insights. Alcohol Health Res World. 1998;22:1. 25. Maldonado JR. Acute brain failure: pathophysiology, diagnosis, management, and sequelae of delirium. J Crit Care. 2017;33:461–519. 26. Tupler LA, Hege S, Ellinwood EH. Alcohol pharmacodynamics in young elderly adults contrasted with young and middle-aged subjects. Psychopharmacology. 1995;118:460–70. 27. Nasreddine Z, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et  al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695–9.

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28. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of clients for the clinician. J Psychiatr Res. 1975;12:189–98.

To Learn More Canadian Centre on Seniors Mental Health. Alcohol use disorder among older adults. Tools for seniors and families. Tools for clinicians. https://ccsmh.ca/substance-­use-­addiction/alcohol-­ guidelines/. Accessed 31 Oct 2021. Canadian Centre on Seniors Mental Health. Online resources for alcohol use disorder. https:// ccsmh.ca/substance-­use-­addiction/alcohol-­guidelines/resources/. Accessed 31 Oct 2021. Kahan M, Meier R, White-Campbell M.  Management of alcohol use disorders in older adults: what doctors need to know. NICE Tools. 2014. p. 10. https://static.wixstatic.com/ugd/d1d295_ f7ad7fb10bfb418482a641bbae20fcd1.pdf.

Binge Drinking

16

Simon Hall and Natalie Finch

Learning Outcomes • The reader will be able to explore the complexity of defining ‘binge drinking’ and investigate what constitutes binge drinking within a global context. • The reader will be able to identify some of the key harms and consequences from ‘binge drinking’ from an interconnective perspective. • The reader will be able to examine that there are a number of specific ‘at-risk groups’ that binge drinking has a significant impact with and they may need further investigation and support. • The reader will be able utilise some key interventions, techniques and recommendations to support those who binge drink.

16.1 What Is Binge Drinking? The concept of binge drinking has evolved over recent times. Whilst in its lexicon of terms, the World Health Organisation characterises binge drinking as an extended episode of alcohol use, generally over a period of some days [1]. It is now internationally accepted within the field of addiction care that the term is broadly used to describe excessive alcohol consumption in a single episode of drinking [2]. For the practitioner, this definition of binge drinking does not only pose various issues partly due to the vague definition around the number of units of consumption within S. Hall (*) Department of Nursing, Midwifery and Health, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, Hampshire, UK e-mail: [email protected] N. Finch Faculty of Health Studies, University of Bradford, Bradford, West Yorkshire, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_16

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a short time frame but also because of the underlying complexity that surfaces due to its interface of cultural sensitivity, portrayals in the media and the associations between ‘lack of control’ rather than a specific dependency disorder or disease. In the UK, the National Health Service (NHS) states binge drinking refers to drinking lots of alcohol in a short space of time or drinking to get drunk. The focus is centred on the intensity of the use, rather than a specific duration, but it is the later concept of deliberate drinking to get drunk that underpins the contemporary understanding of the behaviour in question. Currently in the UK, binge drinking is described as drinking more than 8  units for a man and more than 6  units for a woman, in a single episode [3] (see Chap. 2). To put this into context, that is 2 pints of 5% beer, which is 6 units or a bottle of 13.5% wine, which averages is 10 units.

16.2 Epidemiology Perspectives International variations in how binge drinking is defined and measured create distinct challenges in understanding the worldwide prevalence. In its 2014 global report on alcohol and health, the World Health Organisation (WHO) has made an attempt to synthesise the data which is available, proposing that 7.5% of the worldwide population engages in binge drinking at least once per week. This figure is mediated by significant parts of the world, where binge drinking rates are statistically negligible as a result of religious or cultural beliefs. An example of the variances in definition can be found in the USA, and it has some significance as there are now several big studies on binge drinking in the research. In the USA, binge drinking is considered to be the consumption of about five drinks for men and four drinks for women in a 2-h period, where blood alcohol concentration has typically risen to 0.08% or above [4]. Similar variations exist across the world, but whilst there is no universal definition of exactly how much alcohol must be drunk to be considered a binge episode, there is an acceptance that binge drinking is undertaken with the aim of becoming significantly intoxicated. Where data is available in relation to young people and binge drinking, there is a general pattern of onset of binge drinking in adolescence, peaking in early adulthood and then declining as maturation occurs (see Chap. 11), although this trend is not seen in some parts of South Asia and Africa, where binge drinking is more prevalent at a later stage in life [5]. There is also the complexity that many Western societies see alcohol consumption as a transition and as part of adult life and engage alcohol consumption with food, for example [6]. There is little evidence around cultural differences around binge drinking except associated factors linked to spirituality and societal norms [7]. There is research between cultural groups from North America, but these results are difficult to generalise to the population in UK and Europe. Data from across the world suggests that in all contexts, men engage in binge drinking more than women, even where gender-specific criteria to define bingeing is applied. There are, however, significant variations in this gender gap, thought to be attributable to a complex combination of biopsychosocial factors [8]. However, the gap between women’s and men’s excessive and harmful consumption of alcohol

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in the UK has narrowed in recent years [9], and men still drink more than women, experience more drink-related health and social problems, and face twice women’s alcohol-related mortality of 15.9–7.8 deaths per 100,000 population, respectively, in 2012 [10] (see Chaps. 13 and 14). It is important to note that in the media, women are portrayed more as problem drinkers linked to putting themselves at risk supported by descriptions linked to appearance and mortality (see Chap. 14). This contrasts with men being perceived as violent and aggressive [10] (see Chap. 14). National guidelines have typically issued different alcohol consumption guidance for men and women, with women being advised to drink less than men, but the UK have recently joined Australia and Portugal in issuing the same low-risk consumption guidance for men and women [11], drawing on evidence that the health risks posed to each gender are similar at low-risk levels of consumption. Thus, a clinical emphasis around the assessment of ‘risk’ is required by practitioners to make sense of acts of deliberate toxification, which is needed to help prioritise interventions and the resources on an individual basis [12]. However, it must be noted that this is somewhat distancing itself from those individuals who consume over the recommended daily units on a regular basis and do not identify with getting drunk and as a result may not seek or receive help for this. This also offers a convenient alternative that suits Western societies and overstretched health services to focus its resources for those presenting with risky behaviours rather than those with static risk factors. Self-Assessment Exercise 16.1 Consider the challenges that the lack of a consistent definition of ‘binge drinking’ poses to clinicians when trying to understand drinking behaviours. Consider • What constitutes a ‘drink?’ • How well do you understand what constitutes a ‘unit (standard drink)’ of alcohol? • How well do you think an individual is able to accurately assess and report how many units of alcohol they have consumed in a single drinking episode? • What might the barriers to this be? • How likely are you to have access to a blood alcohol concentration (BAC) measure in your daily practice?

16.3 Biological Harms A significant proportion of drinking behaviours may meet the broad definition of binge drinking. Consequently, the acute health consequences that may occur from binge drinking encompass a wide spectrum of eventualities. Where there is mild to moderate intoxication, the person may experience: • Variability in mood • Have poor psychomotor control • Have slurred speech and blurred vision

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Exhibit signs of confusion Experience loss of inhibitions Reduced reaction times Minor memory loss Nausea and vomiting In more extreme cases of intoxication, the person may also experience:

• • • •

Seizures Hypothermia Hypotension Respiratory depression

In the most serious cases, this may lead to death. Alcohol is as potent as heroin or cocaine in terms of the ratio between a normal and lethal dose [13], a fact which many who engage in binge drinking are dangerously unaware of. Acute conditions, as a result of binge drinking, are estimated to account for up to 50% of all alcohol related deaths [14]. However, it should be borne in mind that a significant portion of that number may be heavy drinkers who meet the definition of bingeing at the most extreme end of the spectrum. It is often wrongly assumed that alcohol must be used in a dependent manner for it to contribute to chronic health conditions (see Chaps. 5 and 6). This is not the case. Sustained heavy drinking, albeit in a binge pattern, can contribute to immune system impairment, respiratory infections, cancers, and depression [13]. There is an emerging evidence base, which highlights significant harm to the developing brain in young people who engage in binge drinking, particularly those whose drinking follows the pattern of social binges (most likely at the weekend) followed by days of abstinence [15].

16.4 Societal Harms This is complex due to the ever-changing complexity of societal norms: the changing ways we live and furthermore how these impact on different demographics within society. There are issues throughout media coverage around ‘binge drinking’ as mentioned previously, and this can often create stigma causing a reluctance to seek support or the opposite by creating a sense of idolisation and heroism. A variety of social harms may arise out of binge drinking. There is a correlation between level of intoxication and risky sexual behaviours, which may result in unplanned pregnancy (see Chap. 12), and/or sexually transmitted infections, along with an increase in risk to personal safety [16]. In terms of gender equality (see Chap. 4), an important additional consideration around risk is that practitioners do need to be mindful when looking at risk and that

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women are traditionally being expected to carry the responsibility for the risk posed by perpetrators if under the influence of alcohol. This risk is dynamic, because we might be making ourselves more vulnerable, as opposed to the risk that women might be more likely to be targeted for violence/unwanted sexual advances from others. It is important as practitioners not to assert blame or misjudge the risk due to gender bias. There is a risk of injury to self or to others as a result of poor decision-making and impaired judgement (such as driving a car). Not surprisingly, heavy binge drinking has been found to contribute to domestic violence, relationship breakdown and neglect of responsibility around work and education (see Chap. 8). Repeated episodes of drinking that fit the definition of bingeing, even when quantity of alcohol consumed remains relatively low, increase the likelihood of engaging in other behaviours with the potential to cause harm such as the use of tobacco or illicit drugs [17]. Binge pattern alcohol use is a risk factor in suicides. In a 2017 meta-analysis by Borges et al. [18], it was found that people who are heavily intoxicated have up to 37 times increased risk of suicidal behaviour, and whilst little is known about the mechanisms that underpin this, it is theorised that dysphoria and increased impulsivity in the presence of alcohol are significant in this risk. Another key factor to explore for practitioners is around risk is ‘Joiners Theory’ on suicide [19], which states that the key factors to predict suicide is: • Isolation (‘I am a lone’) • Feelings of burdensome (‘I am a burden’) • Capability to commit suicide (‘I am not afraid to die’) These factors can become very real for those who binge drink, especially for those individuals trying to get drunk as quickly as possible to cope with emotional and social stresses in their lives. Binge drinking carries with it a complex range of biological, psychological and social concerns. It is highly likely that many of those who engage in binge pattern drinking behaviours have a limited understanding of the associated risks. A consideration linked back to risk and the effects that binge drinking has on cognition is the reduced capacity to assessing our own safety factors or reduced capacity for assessing impact of behaviours on others.

16.5 Specific At-Risk Groups In working within a risk framework for interventions and support around binge drinking, there are a number of specific groups that practitioners need to be aware of to help shape support packages.

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16.5.1 Lesbian, Gay, Bisexual Transgender and Questioning+ (LGBTQ+) Community The impact on binge drinking for the LGBTQ+ community became more widely known after the Part of the Picture 2009–2011 report [20] exploring substance use amongst lesbian, gay and bisexual people in England (see Chap. 4). They found: • 34% of gay and bisexual males, and 29% of lesbian and bisexual females, reported binge drinking at least once or twice a week • Binge drinking is more than twice as common amongst lesbian, gay and bisexual people when compared with the wider population. • Lesbian, gay and bisexual people demonstrate a higher likelihood of being substance dependent. • Significant barriers exist to seeking information, advice or help about substance use issues amongst lesbian, gay or bisexual people. There is an interesting study looking of the role that alcohol in identity construction within the LGBT community (in England). Respondents perceived heavy drinking as central to the commercial gay scene, and for some, the choice of drink and drinking vessel was an important part of identity construction. Key Point 16.1 A key point for clinicians to consider in the engagement of this group was not to get drawn into stereotypes, as the respondents discussed the perception that gay men would drink alcopops and cocktails, whilst lesbians would drink pints of beer. They found this unhelpful. Interestingly, those respondents who did not identify as male or female, and those who used drag, were particularly aware of their choice of drink to express identity or to challenge people’s preconceptions about gender. In terms of interventions, several respondents found specialist services were not geared up for the LGBTQ+ community and that they found Alcoholics Anonymous (AA) groups as not being safe places and were unaware of any specific LGBTQ+ AA groups or support networks. Practitioners will need to think about this to ensure positive engagement if this is a recommendation.

16.5.2 18–30 (University Students) The biggest evidence base on binge drinking is around individuals who are at college or university due to the nature of it being a significant transition period, and it is easier to access students as a sample group. There are several studies around the world which have identified that students are prone to binge drinking [21]. There is also evidence of a reduction of cognitive ability for those students who binge drink

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[22]. Interestingly some studies are suggesting that males in this population are more prone to impulsivity than females, and this may inform specific areas of interventions and expectations of them working [23].

16.5.3 Learning Disabilities Individuals experiencing learning disabilities who actually binge drink or consume significant amounts of alcohol is not significant when compared to the general population [24], but those who do are often complex and require multiagency work. There are no specific National Institute of Health and Care Excellence UK (NICE) guidelines to support those with a learning disability and dependency, and there are too few specialist practitioners or teams that are dedicated to this. However, you do need to make reasonable adjustments [25]. There is some research that indicates that some people with mild learning disabilities who enter mainstream services are never assessed or interventions modified to meets those with an IQ lower than 70 [24].

16.5.4 Deaf and Impaired Hearing There is not a great deal of research around the relationship alcohol and binge drinking with those individuals who are deaf or hard of hearing in the UK; however, in the USA, there have been a number of studies that suggest that those who are deaf or have a hearing impairment are not any more likely to binge drinking more than those who can hear, but they are more likely to consume more when they do and take multiple substances [26, 27]. Furthermore, they are more likely to start using alcohol and start binge drinking earlier, as this may be due to not having the same health education as their hearing peers [28]. There is a need for more research in this area, but all the research refers to the need for more adaptable health resources and assessment for this client group and that primary care has a key role for this [29].

16.5.5 Neurodiversity There is little evidence that explores individuals experiencing neurodiversity and binge drinking. Neurodiversity covers a range of differences in behaviour and cognitive functions that all have their unique presentations, and this is further highlighted when linked to substance use. There is emerging evidence that those experiencing Asperger’s report binge drinking to help with verbal communication in social situations and enhance positive feelings rather than for conformity or coping [30]. Those experiencing attention deficit hyperactivity disorder (ADHD) are prone to impulsive actions, and they are at risk of binge drinking in childhood and into adulthood [31].

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Key Point 16.2 A key aspect for clinicians is that those experiencing ADHD find it hard to stop any inhibitory control over their behaviour even with external cues [32]. There are several conditions under neurodiversity, but it is worth exploring if any is present, as it may impact delivery of interventions and success of others [33]. Reflective Practice Exercise 16.1 • How would you amend your engagement strategy for individuals experiencing learning disabilities, hearing impairment or neurodiversity? • How would you amend your interventions and education materials to meet the needs of individuals with specialised needs?

16.6 Implications of Binge Drinking on the Family System Whilst the impact of dependent parental alcohol use on children is well understood, the impact of non-dependent drinking, including binge drinking, is less well-­ documented in the literature. This is of concern, given the prevalence discussed in this chapter. Earlier sections of this chapter have touched upon the impact of binge drinking in relationship breakdown. This section considers the children of people who binge drink (see Chaps. 10−12). In the UK, it is estimated that around 29% of children (around 3.4 million) live with at least one binge drinking adult [34].

16.6.1 Binge Drinking During Pregnancy and Its Consequences Binge drinking during pregnancy is linked to miscarriage (see Chap. 12). Research does not elude to what a safe dose of alcohol in pregnancy might be (if such thing exists); however, there is a strong body of evidence to show that the risk of miscarriage increases in a dose-dependent way, meaning that drinking in a binge pattern is a particularly risky practice [35]. Binge drinking during pregnancy is acknowledged to be a direct cause of foetal alcohol spectrum disorders (FASD). FASD is an umbrella term to describe a group of diagnoses, all of which are directly attributable to alcohol consumption in pregnancy. FASD causes global developmental delay, impacting on the physical, emotional, behavioural and neurological domains of function, and is irreversible. FASDs represent one of the most preventable causes of nongenetic learning disabilities in the world [36]. A large-scale meta-analysis considering 162 countries discovered that in 40% of those countries, over 25% of all women, who drunk any alcohol in pregnancy, did so in a binge drinking pattern [37]. Though there was significant international variance, these figures should alert all healthcare professionals to the significant risk attached to binge drinking behaviours in pregnancy.

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16.6.2 The Postnatal Period Sudden infant death syndrome (SIDS) is the term used to describe the unexplained death of a baby between birth and its first birthday (see Chap. 12). Numerous factors are known to contribute to this, including alcohol during pregnancy [38]. It is worth noting, when considering risk to infants of people who binge drink is the evidence which demonstrates a rise in SIDS rates after public holidays, and on weekends, both times when binge drinking is statistically more likely to take place [39]. Whilst more needs to be understood about the underlying mechanisms of this phenomenon, it is important to be alert to this risk and to share harm minimisation advice around safe sleeping and the risks to the child from smoking, which increase with binge drinking.

16.6.3 Childhood Despite the relative poverty of literature in the area, there is growing international evidence to suggest that non-dependent parental drinking impacts globally on the child (see Chaps. 10 and 11), particularly where parents are drinking quantities at the extreme end of the binge drinking spectrum. There are higher rates of childhood injury in this group, particularly where there is maternal alcohol use. Children from this group are more likely to experience externalising psychological problems: aggression, rule breaking, and antisocial and offending behaviours, along with poorer levels of educational engagement and attainment. Unsurprisingly, children in this group are more likely to have lower levels of resilience than their peers [40]. Key Point 16.3: Will the Child of a Person Who Binge Drinks Go on to Binge Drink Themselves? The evidence base is unclear about the correlation between parental and teenage child’s alcohol use, and there is little that focuses particularly on the impact of binge drinking on teen drinking behaviours. A 2015 systematic review, by Rossow et al. [41], did identify a handful of studies, which looked at this area but found that the evidence was not robust enough to be generalisable. Not surprisingly, there is little consideration in the literature about this link at a later stage in life. That which is available demonstrates that parental binge drinking during childhood positively correlates with offspring binge drinking at the age of 28 [42]. This suggests that the impact of parental binge drinking in childhood persists well into the adult life of affected children, perpetuating between generations the risks described earlier in this chapter. It also poses some questions about the hereditary nature of the propensity to engage in binge drinking behaviours reference on gender.

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16.7 Brief Interventions The aim of a brief intervention (see Chap. 17) is using a short systematic approach over a short period of time using evidence-based interventions to reduce the levels of an individual’s consumption of alcohol. There are several stages that start with screening and assessment, followed by various interventions primarily aimed at reducing harmful levels of alcohol. The evidence suggests these do reduce alcohol consumption compared to no treatment and can be as effective as extensive treatment programmes [43]. A recent literature review demonstrated that barriers to such interventions were attitudes towards alcohol use, lack of structural and organisational support, unclear role definition as to responsibility in addressing alcohol use, fears of damaging professional/patient relationships and competition with other pressing healthcare needs [44]. Moreover, there is a growing use of digital-­based screening tools and self-directed-based interventions that can be used and developed. Some studies suggest that there is little difference in the outcomes when compared to delivering the same programme face to face [45].

16.7.1 Assessment There are several traditional tools and assessments that are helpful and can be found in this book (see Chap. 10). The Audit tool or the Alcohol Use Disorders Identification Test-C (AUDIT-C) is good to way to measure the amounts of alcohol consumed and bearing in mind that the criteria for binge drinking is low, so practitioners need to be mindful that this is a just a blunt tool when used on its own. It is worthwhile checking the dependence levels of alcohol, and this can establish any thresholds from binge drinking to identifying those with a significant drinking problem, as this can escalate quickly. Other assessments that can be used in primary care is the DAPA-PC (Drug Abuse Problem Assessment for Primary Care). A key aspect of the assessment is to establish any root causes of binge drinking to link these to the various known causations previously identified. The real value in pursuing this area of enquiry is this will help with formulation and offer a clean transition into the education and harm reduction interventions that are often required. Most people binge drink as a way of coping or managing their stresses and then drink to get drunk which acts as a reward to themselves.

16.8 What Clinical Interventions Are Available to You? There are not any pharmacological treatments for binge drinking (see Chap. 19). Nalmefene is the only real possibility, but that is really licensed for adult-dependent drinkers (psychologically not physically dependent) and is considered a second-tier form of treatment. There currently is no evidence for pharmaceutical interventions for binge drinking, although there have been some studies using mice that suggest

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there might be potential for pharmaceutical intervention. The main emphasis needs to be a combination of education and harm reduction activities with the aim of overlaying new learned behaviours on top of old ones. When looking at the pharmacology aspect of supporting binge drinkers, the priority needs to be around considering the ‘risk’ of binge drinking with other medications, but this would come under education and harm reduction. Advice to prescribers would be to be cautious in binge drinkers, especially with the use of sedating medications, for example, benzodiazepines and opiates, because of risk of accidental overdose if taking a combination of these. Moreover, prescribers need be cautious about not introducing more medications, like opiates and benzodiazepines, as they might simply replace the old ones (alcohol) with binging and/or dependency with the new ones. People can swap substances and medications but do not change the behaviours or the process underlying events that have helped develop the ‘coping mechanism’ in the first place. In the USA, a significant study [46] where opioid prescribing was high, there was a significantly high level of deaths associated with binge drinking and opioid use. And there are suggestions that over half of those who prescribed opiates, which is estimated to 4.3 million also binge drink. It is worth taking a detailed medication history to avoid any potential accidental overdoses and to explore any potential risks of intentional overdoses of prescribed medication, if there is significant risky behaviours and mood swings related to the binge drinking. Those with coexisting mental health problems or individuals with previous self-­ harm history, extra caution needs to be applied (see Chap. 5).

16.9 Interventions It is important to use a conversational approach. A key aspect from the assessment is to establish any root causes of binge drinking to see and to link these to the various known causations previously identified. The idea is that brief interventions try to bring back ‘control’ and ‘choice’ to drinking habits (see Chap. 17). This is not just an exercise about reducing units (standard drinks), as a study by Furtwangler and Visser [47] found that university students were not motivated to adhere to unit-­ based guidelines and that they lacked the skills required to apply them to reduce their own drinking. Key Point 16.4 Individualised plans will be essential for any success, and they need to be linked to personal goal setting approaches that are covered in the following sections. The idea is for the practitioner to work through several steps with the individual. Some individuals will move through the stages quickly, whilst others, depending on their situation and root causes, may take longer. In the extra resources, there is a good guide on how to work within a recovery focused way.

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16.10 Plan It is important to establish the nature of binge drinking, and to do this, we use several open-ended questions that can be helpful to explore the second part of the definition, which refers to drinking habits that solely aim to result in getting drunk. Key Point 16.5 It is really important to understand the circumstances and issues rather than focusing on the consequences. Here are some opening questions that you might want to start with: Practitioner ‘Can you share with me what your best night looks like?’ ‘Would that be the 10/10?’ ‘How many nights look like that over the last month?’ Trying to explore the reality of the drinking with the pursuit of the good times. This is significant to dependency and the craving of highs and the pursuit of fun. ‘Say a good night is 10 and a bad night is 0, over the last month how would you rate your average scores.’ Just asking why ‘do you binge drink?’ is actually a blunted alternative, and it is often replied with ‘I don’t know.’ The alternative way shown also fits closer to demonstrating compassion and empathy. Ask the individual to picture a recent drinking occasion. The practitioner can relate it to a recent night from the previous series of questions. You can pick a high one and/or a low one. Practitioner ‘Can you share with me the events of why this was an 8. How did it all start?’ Key Point 16.6 It is important when using these Socratic questions to establish the types of alcoholic drinks being consumed, the number of units and the time frame between drinks, where and with whom. Also, it is useful to establish any other drinks and substances that are consumed during this time. Be cautious if exploring a low number on the scaling system, as there would be a reason for this. The clinician may uncover a significant trauma. A good follow up question is ‘can you tell me a little bit more on….’ It is important to summarise the responses back to the individual and offer them the opportunity to add more informational that might be useful. One way of recording the responses is using a Timeline, which is often used to help formulate the events around a mental health condition [48]. This simple technique can be used to identify any possible rituals, consumption rates and help get the persons narrative of events. More importantly, it can provide a visual to the practitioner and the individual involved on the current presentation. When using the Timeline, and it might be worth expanding it to prior to the drinking episode or using specific timelines that may examine the buildup to the

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event. It is useful to know significant influencers. The use of genograms is also a helpful way to look at social circles and their key roles. They can help provide potential risk factors previously identified in the chapter around family systems. Crucially, it will identify those who drink on their own, which may mean more psychology input might be required; the individual is more at risk of developing a chronic drinking problem.

16.11 Looking for Triggers This next section may be viewed as a seamless activity from the previous one. The practitioner and the individual can see that certain events, people and emotions might be key triggers. However, practitioners do need to be aware that although this can appear to be a seamless transition from the planning phase, it can also be an emotive one in itself. The realisation of the true impact on relationships, a person’s identity and the realisation of potential change can occur. Moreover, it is in this phase that a significant area of resistance can occur. Self-Assessment Exercise 16.2 • What motivational interviewing skills can you deploy (see Chap. 23)? • Consider asking the individual to list all the benefits of drinking, followed by a list of negative. You may need to ask more about the relationships that the individual may have around an individual(s), event(s) or identity, as this might be important information to add to your formulation and chosen interventions. Another key point is, if the individual is stuck in the precontemplation phase, to explore with that individual their thoughts just before going out and just prior to that first drink. It is important to explore this at a micro level. It is important when completing this section to focus on the triggers and not get drawn into some of the negative consequences of their binge drinking.

16.11.1 Preparing for Change This is an interesting transition period and links well with a harm reduction philosophy. This is an important area, where the practitioner works alongside the individual on key triggers and rituals during a potential binge drinking situation. The idea of this piece of work is to explore power, influence and alternative consequences to various triggers that might occur. These are best delivered within a coaching style rather than an opportunity to offer education and advice on alternatives. It is important to establish the sphere of influence that the individual has when drinking. This is based on Covey’s work [49], but it is important to get across that they do have options. It is important to work through various scenarios that have been identified

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as key events or triggers and what influence they have. It is helpful to work around saying ‘no,’ looking at alternative drinks, which may have less alcohol content, meeting later with friends or spacing the drinking out over several days instead of drinking all on 1 day. It is important to be explicit around the notion of responsibility that the individual has personal choice and is responsible for their actions. Other factors may also arise that are linked to risk, so it is important to ensure that individuals protect their drinks from getting spiked or have robust strategies for getting home safety.

16.11.2 Look for Alternatives The basis for this brief intervention is around understanding motivational factors that build on links with other motivational theories that originated from Harlow [50] and Deci [51]. These theories recognise that we all have ‘intrinsic rewards in life’ that motivate us beyond our basic needs of living. McClelland motivation theory [52] is a good base for this intervention, especially for those who binge drink as part of a group, such as university students. Although it has been used in organisational leadership, it can help identify individuals key motivating incentives that are intrinsic to the individuals’ ambitions and life’s goals. McClelland states that three motivating factors are achievement, power and affiliation. We all have all the components, but there is one dominant one. It will explore the individual’s role in group drinking and help to explore any possible alternatives.

16.11.3 Motivation Card A useful resource may be the Motivation Card Sort. This is based on basic desire theory by Reiss [53, 54].

16.11.3.1 Instructions Place all the cards on the table and ask the person to share what each notion means to them. and then ask them to prioritise them in order into which are the most meaningful to them. Get the individual to have three remaining cards left from the sort. This exercise really tells you a lot about what a person’s goals might be… Sometimes, the individual will pick conflicting cards like, curiosity, social justice and tranquillity. You probably could not have tranquillity if you wanted the other two. It is good to unpick this with the individual and ask the individual if they would consider another alternative card. An example might be switching tranquillity for power to influence change. Explore with the person how they might go about achieving their goals and it’s good to start small. It’s good to explore how binge drinking impacts on their goals and motivations.

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16.11.3.2 Consideration Is binge drinking used because they are not achieving their goals or is it an activity of trying to achieve them? Reflective Practice Exercise 16.2 How could the practitioner use motivational interviewing (see also Chap. 23) to explore these concepts at a deeper level? If discussing money and the impact of binge drinking on finances if might be worth thinking how this works with smoking cessation. This could work well especially with younger people who do not have a regular income. Although the evidence is not robust, there appears to be an association with debt and a reduced quality of life and poorer mental health. Exploring finances might prove to be a good motivational factor for some and in some circumstances may allow the practitioner to explore alternative ways to connect to people and not feel embarrassed around connecting with wealthier peers. When looking at alternative activities to reduce or replace binge drinking opportunities on the surface, it is easy just to offer alternative activities. However, they do need to be associated with fulfilling the emotional needs of the individual. This section has its roots in behavioural activation. A significant barrier to this is the power of the group dynamics and other mental health factors like anxiety. There is significance in exploring hobbies and activities that people enjoy and then trying to reconnect individuals to these activities. It is worth asking ‘do you know other people with an interest in…?’ Be mindful that when coming up with alternative activities like swimming or heading to the coast that drinking is not part of the activity.

16.11.4 Solution-Focused Question to Ask the Individual • Let us imagine that life felt a little bit unusual, and alcohol did not exist, how would life be different? • What would you miss most? • What would you think would be in its place? The practitioner may discover other issues or coping mechanisms. These can be followed up with simple reflections alongside the individual to explore how to use this new alternative time. This new time can be fearful to the individual as it can provoke anxiety. As a practitioner, it is vital to look at the new time as positive for some people find being alone a new and confused concept.

16.11.4.1 Questions • What could you do with the time? • What untapped dreams could you realise? • What do you notice that would be different?

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• Who would be the first person to notice any changes as to how you spend your new time? • What would you hope they would notice? • What would you notice in yourself? Encourage the individual to make a list of these. The practitioner can refer to the cycle of change and see if there is a change to the perception to change (see Chap. 23).

16.11.5 Work with the Emotions and Consequences: Visualise a Compassionate Person This section is based on Gilberts work and compassionate-focused therapy [55]. For some individuals, there will be elements of guilt and shame [56] that can be linked to the binge drinking; hence, we need to break the association. It is important to build on the previous question around waking up and life being different and what would the individual notice. A potential area of work links to confidence and self-­ esteem building. However, for some individuals it might be worth using an element of the Cognitive-Behavioural Integrated Treatment (C-Bit) model and create a simple cognitive model that offers a positive perspective. This links in well with the first area of assessment when we question the individual’s intentions of drinking.

16.12 Conclusion Binge drinking is an evolving term that varies in meaning across the world. However, binge drinking is a potential hazard for society if left ignored and not resourced sufficiently. The consequences of binge drinking are varied and for some extremely traumatic. More significantly, for some individuals binge drinking can quickly become a serious dependency with potential consequences for themselves and their family. However, personalised brief interventions can make a real difference whether in a digital or personalised context.

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51. Deci EL. Effects of externally mediated rewards on intrinsic motivation. J Pers Soc Psychol. 1971;18:105. 52. McClelland DC.  Human motivation: CUP archive. Cambridge: Cambridge University Press; 1987. 53. Reiss S. Multifaceted nature of intrinsic motivation: the theory of 16 basic desires. Rev Gen Psychol. 2004;8:179–93. 54. Reiss S. Intrinsic and extrinsic motivation. Teach Psychol. 2012;39:152–6. 55. Gilbert P. Introducing compassion-focused therapy. Adv Psychiatr Treat. 2009;15:199–208. 56. Gilbert P.  The origins and nature of compassion focused therapy. Br J Clin Psychol. 2014;53:6–41.

To Learn More You can find a great resource here to support those with learning disabilities and substance misuse. https://www.sabp.nhs.uk/application/files/7615/1669/9810/Research_manual4Alc.pdf There are a number of key resources from an Australian research-driven organisation called Orygen. Although it is Australian, there are some transferable tips and advice we can use. Orygen is an organisation that specialises supporting young people and the challenges that they face. There is a great deal of useful resources on their website, but we would like to share you these. Practical Tips for Clinicians: Part-­three-­tips-­for-­clinical-­care (orygen.org.au) Practical tips for young people and their families during a COVID (and potentially future pandemics) Substance use behaviours and COVID -­Orygen, Revolution in Mind Here is an interesting literature review looking at drinking in later life. There is little research of binge drinking in later life, but there are some themes that come up which are similar to the research we found with young people and that drinking is routinised across the life course and it’s more difficult to change drinking habits in later life Bareham KB, Kaner E, Spencer LP, Hanratty B.  Drinking in later life: a systemic review and thematic synthesis of qualitative studies exploring older people’s perceptions and experiences. Age Ageing. 2019;48(1):134–46.

Brief Intervention

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Catherine Haighton and Peter J. Kruithof

Learning Outcomes • To understand the difference between simple and extended brief alcohol interventions and recognise the principles underlying alcohol brief intervention • To gain knowledge of the theory underpinning brief alcohol interventions and the most common settings in which brief alcohol interventions have been successfully provided • To be aware of some of the issues surrounding delivery of brief alcohol intervention • To have reflected on the challenges and opportunities presented by brief alcohol interventions

17.1 Brief Intervention ‘Brief interventions are those practices that aim to identify a real or potential alcohol problem and motivate an individual to do something about it’ [1].

Two basic forms of brief intervention have been developed, simple brief intervention (structured feedback and advice) and extended brief intervention (brief behavioural counselling) [2].

C. Haighton (*) · P. J. Kruithof Department of Social Work, Education & Community Wellbeing, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK e-mail: [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_17

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17.1.1 Simple Brief Intervention Simple brief intervention refers to a range of activities focused on the use of a talk-­ based therapeutic approach aimed at changing certain health-limiting behaviours (including smoking, diet/exercise, and alcohol use) and their associated problems. Simple brief interventions have been applied opportunistically to nontreatmentseeking populations, with the core aim of secondary prevention, as well as to those undergoing treatment (sometimes referred to as brief treatments). See Box 17.1 for levels of prevention. Box 17.1 Levels of Prevention Primary prevention Secondary prevention Tertiary prevention

Primary prevention aims to prevent disease or injury before it ever occurs Secondary prevention aims to reduce the impact of a disease or injury that has already occurred Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects

Key components of simple brief interventions include simple structured advice, written information, behaviour change counselling, and motivational interviewing, and each of these elements can either occur alone or in combination with each other. Simple brief interventions can be delivered either in a single appointment or a series of related sessions. Sessions can last between 5 and 60 min, and while simple brief intervention for nontreatment-seeking populations do not tend to exceed five sessions in total, those in treatment can have many more than five sessions, including cognitive behavioural therapy and motivational interviewing. Although there is a wide variation in simple brief intervention activities, there are a number of essential principles to delivery; simple brief interventions should obviously be short and should be deliverable by professionals without specialist training and who are working in busy settings. Simple brief interventions are often based on a fundamental set of ingredients summarised by the acronym FRAMES (see Box 17.2) [2]. Box 17.2 Frames Feedback Responsibility Advice Menu Empathy Self-efficacy

Provides feedback on the individual’s risk for behaviour The individual is responsible for change Advises reduction or gives explicit direction to change Provides a variety of options for change Emphasises a warm, reflective, understanding approach Empowers and encourages optimism about changing behaviour

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Given the variability in activity, it is important to note that simple brief interventions are not merely traditional treatments (psychiatric or psychological) carried out in a short timescale; they have more specific properties than that. Brief interventions are techniques that a variety of professionals (doctors, nurses, pharmacists, health workers, drug workers, social workers, psychiatrists, etc.) can easily incorporate into their practice in a variety of cultural settings, populations, and systems [2]. The National Institute for Health and Care Excellence (NICE) guidelines for behaviour change recommend that all health and social care professionals should, as a minimum, be able to deliver a very brief intervention. More than a hundred clinical trials have been conducted to evaluate the efficacy and cost-effectiveness of alcohol screening and brief interventions in both nontreatment- and treatment-seeking populations. There is now a very strong evidence base supporting the effectiveness of brief alcohol interventions in reducing alcohol-­ related problems. Many systematic reviews and meta-analyses have reported beneficial outcomes of brief interventions, compared to control conditions, in terms of reductions in hazardous and harmful drinking [3–5]. Opportunistic brief intervention is made up of interventions typically designed for, and evaluated among, individuals not seeking help for alcohol use problems who are identified by opportunistic screening in primary healthcare settings. Such individuals often have less severe problems and lower motivation for change. These interventions are typically shorter, less structured, less theoretically based, and delivered by a non-specialist [3]. Brief treatment has typically been evaluated among individuals seeking or being persuaded to seek treatment for alcohol use problems. These interventions are usually longer, more structured, theoretically based, and delivered by a specialist [6]. Although the evidence for brief interventions in nontreatment seekers is stronger than those in treatment settings, the distinction between generalist and specialist delivery is becoming increasingly blurred [6]. Brief interventions are also highly cost-efficient due to the minimal cost of the intervention and the breadth of scope for prevention of more serious and costly problems [7].

17.1.2 Extended Brief Intervention An extended brief intervention typically takes 20–30 min to deliver and can involve a small number of repeat sessions. It is essentially a condensed form of motivational interviewing in which an attempt is made to elicit, rather than impose, an increase in motivation to change behaviour. More specifically, extended brief intervention is based on generic principles of health behaviour change (express empathy, develop discrepancy, roll with resistance, and support self-efficacy), described by Rollnick and colleagues [8]. The level of training required to carry out this form of brief intervention effectively is substantially greater than that for simple advice and should involve an emphasis on experiential learning [2].

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17.2 Brief Intervention Theory Brief interventions are firmly grounded in theory from within the field of psychology, which is concerned with understanding, predicting, and changing human behaviour. Different theories are relevant to the context of brief intervention and its content or delivery mode. In general terms, the principles of brief intervention are broadly based on social cognitive theory, which is drawn from the concept of social learning by Albert Bandura [9]. Bandura reported that awareness can facilitate behaviour change and proposed the need for self-reinforcement in modelling behaviour [9]. Consequently, brief interventions address, in a structured format, an individual’s knowledge, attitude, and skills in relation to behaviour, so as to encourage behaviour change for subsequent health benefit. In terms of therapeutic application, brief interventions in pioneering research were based on principles of cognitive behavioural therapy, which was itself closely linked to the social learning perspective [10]. Cognitive behavioural therapy is a talk-based treatment designed to make individuals change how they think (cognitive) and what they do (behaviour). Unlike some other therapies, it focuses on ‘here and now’ problems and difficulties instead of focusing on causes or symptoms in the past. Recently in brief intervention research and practice, there has been a move away from condensed cognitive behavioural therapy toward adaptations of motivational interviewing (see Chap. 24) [11]. Motivational interviewing is a person-centred interviewing style with the goal of resolving conflicts regarding the pros and cons of change, enhancing motivation, and encouraging positive changes in behaviour. The interviewer style is characterised by empathy and acceptance, with an avoidance of direct confrontation. Any statement associated with positive behaviour change that the individual brings up in the discussion is encouraged to support self-efficacy and a commitment to take action. Although within the time constraints for brief interventions, particularly in general health and social care settings, it is not possible to carry out motivational interviewing, the general ethos and some of the techniques of motivational interviewing can be adapted for this purpose. Adapted or condensed versions of motivational interviewing are often referred to as behaviour change counselling or adapted motivational interventions [12]. The transtheoretical (stages of change) model has been widely used to inform the context for brief intervention activities [13]. Initially developed by Prochaska and DiClemente to describe the stages through which people progress in smoking cessation, this model has since then proved influential in guiding treatment across a range of addictive behaviours, including alcohol [13]. Individuals are characterised as belonging to one of six internal ‘stages’, depending on the individual’s awareness of a problem and their readiness to change behaviour to address this problem. The stages consist of: 1. Precontemplation (not thinking about change for at least 6 months) 2. Contemplation (planning to change in the next 6 months) 3. Preparation (planning to change in the next month) 4. Action (changing behaviour within the last 6 months)

17  Brief Intervention Precontemplation Contemplation • Not thinking about change for at least 6 months.

• Planning to change in the next 6 months.

291 Preparation • Planning to change in the next month.

Action • Changing behaviour within the last 6 months.

Maintenance

Termination

• Having changed for more than 6 months.

• Permanetly changed behaviour.

Fig. 17.1  The transtheoretical (stages of change) model

5. Maintenance (having changed for more than 6 months) 6. Termination (permanently changed behaviour) (see Fig. 17.1). Individuals progress through these stages sequentially, and it may take several cycles around the stages of change (i.e. relapses) before a sustained recovery is achieved. The model also proposed that different self-change strategies or ‘processes of change’ are involved in moving between different stages and that different stages are associated with different beliefs about a problem. It argued that brief interventions to promote change should be designed, so that they are appropriate to an individual’s current stage. Although the theory has provided a heuristic model, evaluations to date have not supported its use in improving treatment outcomes [14]. In a review of 57 digital brief alcohol intervention studies, which randomised a total of 34,390 participants, the most frequently mentioned theories or models in the included studies were motivational interviewing theory, transtheoretical model, and social norms theory. However, over half of the interventions made no mention of theory, and only two studies used theory to select participants or tailor the intervention. There was no evidence of an association between reporting theory use and intervention effectiveness. This systematic review highlights the need for clearer selection, application, and reporting of theory use for the development of interventions in order to assess how useful theory is in this field as well as using study findings to refine the relevant theory to advance this field [15].

17.3 Interventions for Alcohol in Hospital Settings Hospital wards are an ideal location for brief alcohol intervention, as both individuals and professionals generally have the time available for this type of interaction. In 2011, a review of 14 studies involving 4041, mainly male, participants reported benefits of delivering brief interventions to heavy alcohol users admitted to general hospital wards in terms of reduction in alcohol consumption and death rates [5]. This review was superseded however by a review of 22 studies, enrolling 5307 people of the effectiveness of interventions in reducing alcohol consumption in general hospital wards, which also concluded that brief interventions, of more than one session, could be beneficial in reducing alcohol consumption [16]. While a more recent randomised controlled trial of the effectiveness of an alcohol brief intervention within a general hospital setting only served to corroborate these findings reporting brief intervention as beneficial in reducing alcohol consumption compared with screening for alcohol problems alone [17].

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There is also abundant international evidence that brief interventions delivered in other medical settings are effective in leading to reduced alcohol consumption. A comprehensive systematic review of this evidence considered 34 randomised controlled trials carried out in generalist settings among individuals not seeking treatment for alcohol problems. Small to medium aggregate effects were seen consistently across different follow-up points. At follow-ups of between 3 and 6 months inclusive, the effect for brief interventions compared to control conditions was significantly larger when individuals showing more severe alcohol problems were excluded from the analysis [6]. In terms of strength of the evidence and relevance to individuals and professionals, the most obvious setting for brief intervention to reduce excessive drinking is primary healthcare. This setting represents most people’s first point of contact with health services in the majority of countries worldwide. Primary healthcare is also where people tend to present with less acute conditions, return regularly for follow­up appointments [18], and build long-term relationships with their doctor [19]. Primary healthcare generally refers to general practice-based healthcare with a relatively large distribution of health centres or doctor’s surgeries across a wide geographical area. However, primary healthcare can be defined as all immediately accessible, general healthcare facilities that treat a broad range of possible presenting problems and which can be accessed by a wide range of people on demand, and not as the result of a referral for specialist care. Thus, emergency care (accident and emergency departments) can also be considered to be part of primary healthcare. The most recent review of brief interventions in primary care settings reported that brief interventions delivered in primary care reduce alcohol consumption in hazardous and harmful drinkers by approximately two to three UK standard drinks per week compared to controls receiving usual care, screening or assessment only, or minimal alcohol advice [3]. Longer or more intensive intervention appeared to have little effect in significantly improving outcomes within this setting. Although brief interventions seem to be effective at reducing hazardous and harmful consumption in adult men and women primarily based in high income countries, there is a clear need for more evaluative research on brief interventions with younger people, from cultural minority groups and in low- and lower-middle income countries. Moreover, there is some suggestion that screening alone may result in alcohol consumption reduction, and this should be investigated further [3]. While a screening effect has also been suggested in other studies [20], the reason for a reduction in alcohol consumption in some study control groups is not yet fully understood [21]. In a review aiming to assess the impact of brief alcohol interventions in primary healthcare, 24 systematic reviews were identified published between 2002 and 2012. Across the reviews, it was consistently reported that brief intervention was effective for addressing hazardous and harmful drinking in primary healthcare, particularly in middle-aged, male drinkers. Evidence gaps included brief intervention effectiveness in key groups, including older and younger drinkers, minority ethnic groups, and those living in transitional and developing countries [4]. Given the frequency with which individuals seek treatment for alcohol-related consequences in emergency departments, they may be the optimal setting to deliver

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brief interventions for harmful alcohol use. Early studies (n = 14) examining the effectiveness of brief alcohol interventions conducted in emergency departments yielded mixed results [22]. However, in an updated systematic review on the effectiveness of brief alcohol interventions delivered to adults in emergency departments, which identified 34 studies, all studies reported a significant reduction in alcohol consumption at 3 months post-brief intervention. While some studies found significant differences between the brief intervention and control groups, other studies found significant decreases in both conditions but no between-groups differences [23]. At the same time, another systematic review and meta-analysis of 28 studies, testing the impact of brief intervention on alcohol consumption, found evidence for very small effects of brief interventions on alcohol consumption reductions, although more intensive interventions showed no benefit over shorter approaches [24]. Hospital inpatient and emergency care settings provide frequent opportunities for professionals to provide brief interventions to individuals who engage in the harmful use of alcohol. However, these services are not always provided, with several reasons given in different studies. In a systematic review of 25 studies, professionals cited a multitude of factors that impeded their delivery of alcohol brief interventions in hospital and emergency department settings. The most cited barriers were related to capability (lack of knowledge), opportunity (lack of time and lack of resources), and motivation (personal discomfort). Twenty-two other barriers were reported but with lower frequency [25]. However, while professionals may be reluctant to intervene for alcohol problems in hospital and emergency department settings, people report finding brief alcohol intervention acceptable in this setting. Individuals also report expecting to be asked about their alcohol consumption and to receive brief intervention during hospital visits [26]. Similarly, despite considerable efforts over the years to persuade primary care professionals to adopt brief interventions in practice, most have yet to do so. Indeed, there is international literature on barriers to brief alcohol intervention in primary healthcare. These barriers include lack of time, training, and resources; a belief that people will not take advice to change drinking behaviour; and a fear among professionals of offending people by discussing alcohol [27]. It has therefore been argued that today’s challenge is more about how to encourage the uptake and use of brief alcohol intervention in routine practice and less about financing additional research on its effectiveness [28]. It has been reported however that people respond positively to brief intervention when delivered in an appropriate context and by a health professional with whom they had developed a relationship and rapport. Overall, the doctor has been deemed the preferred health professional to discuss alcohol issues. Therefore, brief alcohol intervention is a legitimate role of the doctor when carried out in an appropriate context [29]. Reflective Practice Exercise Using the information provided in this chapter, complete the cells in Table 17.1 to reflect on the challenges and opportunities primary care professionals perceive about delivering alcohol brief interventions in a medical setting (to compare your answers, see Table 17.2).

294 Table 17.1 Reflective practice exercise 17.1

C. Haighton and P. J. Kruithof Challenges Can I do this? How can I do this? Opportunities Benefits to individuals

Should I do this? What is the point? Benefits to professionals/organisations

Table 17.2  Suggested answers to reflective practice exercise Challenges Can I do this? (Role adequacy) You do not need to be an expert on alcohol to deliver a brief intervention. In fact, successful delivery of a brief intervention depends upon a cooperative approach and is, therefore, at odds with the idea of the professional as an expert How can I do this? (role support) You may feel that you do not have sufficient support to deliver brief interventions. Most concerns relate to time, but brief intervention can take as little as 2 to 3 min. Keeping people healthy may reduce your workload in the longer term Opportunities Benefits to individuals Psychological/social/financial Improved mood, improved relationships, reduced risks of drink driving, save money Physical Sleep better, more energy, lose weight, no hangovers, reduced risk of injury, improved memory, better physical shape, reduced risk of high blood pressure, reduced risk of cancer, reduced risks of liver disease, reduced risks of brain damage

Should I do this? (Role legitimacy) You may be worried that people will be offended but the evidence suggests that people are not offended by professionals asking them about their drinking habits. When asking you are checking to see whether a reduction in consumption would lower their risk of future problems What is the point? (motivation) You might feel that problem drinkers are never going to change, and you will not make a difference. However, the evidence indicates that brief alcohol interventions work for enough people to make their delivery both cost-effective and time effective Benefits to professionals/organisations Improved relationships, reduced healthcare utilisation, reduced healthcare and other economic costs, reduced absenteeism, reduced presenteeism, reduced antisocial behaviour, reduced crime

17.4 Interventions for Alcohol in Home and Other Nonmedical Settings Recent innovations in technology have allowed people to interact directly with brief interventions designed to address problem alcohol consumption via computer, mobile device, or smartphone from the comfort of their own home. A Cochrane review assessed the effectiveness and cost-effectiveness of digital interventions for reducing alcohol consumption in people living in the community. The review found moderate-quality evidence that digital interventions lowered alcohol consumption, with an average reduction of up to three (UK) standard drinks per week compared

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to control participants. Low-quality evidence from fewer studies suggested there was little or no difference in impact on alcohol consumption between digital and face-to-face interventions [15]. In 2020, over 97% of the population were covered by a mobile network [30]. The global growth in mobile phone subscriptions has led to new opportunities for brief interventions through the use of text messaging. A recent systematic review with meta-analysis of the effects of text messaging brief interventions on alcohol consumption among risky drinkers found that text messaging brief alcohol interventions reduced alcohol consumption compared with no or basic health information [31]. Interestingly, digital brief interventions may be more acceptable than professional delivered brief interventions, particularly to young people. Eighty one percent of a random sample of 1910 university students, who indicated their preferences for various brief intervention approaches in an internet survey, favoured a web-based brief alcohol intervention [32]. As in many areas of life, the necessity for remote working, as a result of lockdown restrictions imposed during the COVID pandemic, may lead to more web-based brief alcohol intervention in the future [33]. Excessive alcohol consumption is associated with social as well as health problems, which means that interventions sometime occur within this context. Prevalence of excessive alcohol consumption is higher among those in contact with the criminal justice system. One review found that 64–88% of adults in a police custody setting; 95% in a magistrate court setting; 53–69% in a probation setting, and 13–86% in the prison system, and 64% of young people in the criminal justice system in the UK scored positive for an alcohol use disorder [34]. However, there is very little evidence of effectiveness of brief interventions in the various stages of the criminal justice system, mainly due to the lack of follow-up data [34]. While brief intervention shows promise with some effects being shown on alcohol-related harm as well as with young people in the USA, more robust research is needed to ascertain effectiveness of alcohol brief interventions in this setting [35]. Meta-analyses have consistently reported that students who received brief interventions in educational settings subsequently reduced their drinking behaviour compared to control conditions who typically received assessment only. The key elements of the brief interventions are motivational interview approaches and/or personalised feedback on alcohol consumption typically with a normative component. Brief Alcohol Screening and Intervention of College Students (BASICS) is a specific protocol for a preventive alcohol brief intervention programme for college students aged 18–24 years old. It is aimed at students who drink alcohol heavily and have either experienced or are at risk for alcohol-related problems, such as poor class attendance, missed assignments, accidents, sexual assault, and violence. BASICS is designed to help students make better alcohol-use decisions. The programme: • • • •

Reduces the adverse effects of alcohol consumption Promotes reduced drinking Promotes healthier choices among young adults Provides important information and coping skills for risk reduction

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BASICS is conducted over the course of only two 50-min interviews, and these brief, limited interventions prompt students to change their drinking patterns. It can be implemented in a variety of settings, including university health and mental health centres, residential units, and administrative offices. Students can be identified through routine screening or through referral from medical, housing, or disciplinary services. BASICS has been evaluated and found to be effective with nontreatment-seeking students in large, traditional university settings but may be tailored for use with young adults in other settings, such as the military [36]. Other settings where research studies have shown some positive effects of brief intervention include the workplace [37, 38] and social services [38]. The stigma associated with receiving an alcohol-related intervention impacts significantly on the implementation of brief intervention in the workplace. Indeed, the reviewed studies suggest that this may be a reason for the low-participation rates of hazardous and harmful drinkers in this particular setting. Employees may be anxious about participating in brief intervention delivered at their workplace because of the potentially negative consequences of self-disclosure [38]. One systematic review measured how the effect of brief interventions on alcohol consumption differed by the setting, professional group, and content of the intervention. The review included 52 trials contributing data on 29,891 individuals and found that brief interventions reduced the quantity of alcohol consumed. While neither the setting nor content appeared to significantly moderate intervention effectiveness, the provider did in some analyses. Interventions delivered by nurses had the most effect in reducing quantity but not frequency of alcohol consumption. It was concluded therefore that brief interventions play a small but significant role in reducing alcohol consumption and that nurses play a positive role in their delivery. The lack of evidence on the impact of content of intervention reinforces advice that services should select the brief intervention tool that best suits their needs [39].

17.5 Conclusion Brief interventions for alcohol are an effective and cost-effective approach to addressing the needs of the many people, who may benefit from reducing their alcohol consumption in both hospital, home, and other settings. As in many areas of life, the necessity for remote working, as a result of lockdown restrictions imposed during the COVID pandemic, may lead to more web-based brief alcohol intervention in the future.

References 1. Babor TF, Higgins-Biddle JC. Brief intervention for hazardous and harmful drinking. A manual for use in primary care. Geneva: World Health Organization; 2001. https://apps.who.int/ iris/handle/10665/67210. Accessed 25 Sept 2021. 2. Heather N. The case for extended brief interventions. Slovenian J Public Health. 2011;50:1–6.

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24. Schmidt CS, Schulte B, Seo HN, Kuhn S, O’Donnell A, Kriston L, et al. Meta-analysis on the effectiveness of alcohol screening with brief interventions for patients in emergency care settings. Addiction. 2016;111:783–94. 25. Gargaritano KL, Murphy C, Auyeung AB, Doyle F. Systematic review of clinician-reported barriers to provision of brief advice for alcohol intake in hospital inpatient and emergency settings. Alcohol Clin Exp Res. 2020;44:2386–400. 26. Snowden C, Lynch E, Avery L, Haighton C, Howel D, Mamasoula V, et al. Preoperative behavioural intervention to reduce drinking before elective orthopaedic surgery: the PRE-OP BIRDS feasibility RCT. Health Technol Assess. 2020;24:1–176. 27. Johnson M, Jackson R, Guillaume L, Meier P, Goyder E. Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health. 2010;33:412–21. 28. Gual A, Do Amaral Sabadini MB. Implementing alcohol disorders treatment throughout the community. Curr Opin Psychiatry. 2011;24:203–7. 29. Lock CA. Alcohol and brief intervention in primary health care: what do patients think? Prim Health Care Res Dev. 2004;5:162–78. 30. International Telecommunication Union. Measuring digital development: facts and figures 2020. Geneva: ITU Publications; 2020. 31. Bendtsen M, McCambridge J, Åsberg K, Bendtsen P.  Text messaging interventions for reducing alcohol consumption among risky drinkers: systematic review and meta-analysis. Addiction. 2020;116:1021–33. 32. Kypri K, Saunders JB, Gallagher SJ. Acceptability of various brief intervention approaches for hazardous drinking among university students. Alcohol Alcohol. 2003;38:626–8. 33. Chick J. Alcohol and COVID-19. Alcohol Alcohol. 2020;55(4):341–2. https://doi.org/10.1093/ alcalc/agaa039. 34. Newbury-Birch D, McGovern R, Birch J, O’Neill G, Kaner H, Sondhi A, et al. A rapid systematic review of what we know about alcohol use disorders and brief interventions in the criminal justice system. Int J Prison Health. 2016;12:57–70. 35. Gamblin D, Tobutt C, Patton R. Alcohol identification and brief advice in England’s criminal justice system: a review of the evidence. J Subst Abus. 2020;25:591–7. 36. Fachini A, Aliane PP, Martinez EZ, Furtado EF. Efficacy of brief alcohol screening intervention for college students (BASICS): a meta-analysis of randomized controlled trials. Subst Abuse Treat Prev Policy. 2012;7:40. 37. Yuvaraj K, Eliyas SK, Gokul S, Manikandanesan S. Effectiveness of workplace intervention for reducing alcohol consumption: a systematic review and meta-analysis. Alcohol Alcohol. 2019;54:264–27. 38. Schulte B, O’Donnell AJ, Kastner S, Schmidt CS, Schäfer I, Reimer J. Alcohol screening and brief intervention in workplace settings and social services: a comparison of literature. Front Psychiatry. 2014;5:131. 39. Platt L, Melendez-Torres GJ, O’Donnell A, Bradley J, Newbury-Birch D, Kaner E, et al. How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and meta regression analysis. BMJ Open. 2016;6:1–20.

To Learn More BISTAIRS: Brief interventions in the treatment of alcohol use disorders in relevant settings (http:// www.bistairs.eu/) Hutchings D, Cassidy P, Dallolio E, Pearson P, Heather N, Kaner E. Implementing screening and brief alcohol interventions in primary care: views from both sides of the consultation. Prim Health Care Res Develop. 2006;7:221–9.

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National Institute on Alcohol and Alcohol Abuse. Helping patients who drink too much (http:// pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm) Primary Health Care European Project on Alcohol. Training programme (http://inebria.net/phepa/) Public Health England. The Alcohol Identification and Brief Advice e-learning project (https:// www.e-­lfh.org.uk/programmes/alcohol/) Screening and intervention programme for sensible drinking (SIPS) (http://www.sips.iop.kcl. ac.uk/index.php#) Tanner-Smith EE, Lipsey MW.  Brief alcohol interventions for adolescents and young adults: a systematic review and meta-analysis. J Subst Abuse Treat. 2015;51:1–18. World Health Organisation. Screening and brief intervention for alcohol problems in primary health care (http://www.who.int/substance_abuse/activities/sbi/en/) CDC. Planning and implementing screening and brief intervention for risky alcohol use (https:// www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf) Substance Abuse and Mental Health Services Administration. Resources for screening, brief intervention, and referral to treatment (http://www.samhsa.gov/sbirt/resources) SAMHSA-HRSA Center for Integrated Health Solutions. SBIRT: screening, brief intervention, and referral to treatment (­ https://www.thenationalcouncil.org/topics/ screening-­brief-­intervention-­referral-­treatment-­sbirt/)

Preparation for Detoxification

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Christos Kouimtsidis, Musa Sami, and Nicola Kalik

Learning Outcomes • Structured preparation prior detoxification is possible, acceptable by individuals and could improve completion of detoxification and maintenance of abstinence. • It could be easily added as a group intervention and as part of a three-stage treatment programme, to be followed by community or inpatient detoxification and aftercare. • Structured preparation includes the preparation of the individual’s family for change, planning for aftercare, partial controlled drinking, and early lifestyle changes made by the individual.

C. Kouimtsidis (*) Surrey and Borders Partnership NHS Foundation Trust, Chertsey, Surrey, UK Department of Medicine, University of St Andrew’s, St Andrew, Scotland Department of Medicine, Brain Science Division, Imperial College, London, UK M. Sami Institute of Mental Health, Nottingham, UK University of Nottingham, Nottingham, UK Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK e-mail: [email protected] N. Kalik Alcohol Care Team, Addictions Department, IOPPN, King’s College, Kings College Hospital, London, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_18

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18.1 Introduction In this chapter, we will discuss the importance and the role of structured preparation before medically assisted withdrawal (also referred to as detoxification), an approach which is consistent with the pre-habilitation paradigm in medicine. Such an approach is necessary given the limited effectiveness of urgent detoxifications [1] and the limited effectiveness of existing treatment models [2]. The concept of prehabilitation is not new. It was recently reintroduced in the field of orthopaedics and surgery [3]. It represents a proactive way of preventing and managing several risk factors associated with an intervention. It is described as a shift away from an impairment-driven reactive model and as an opportunity for long-term changes in lifestyle for improved and sustainable quality of life [3]. Central to the successful implementation of pre-habilitation are the concepts of expected harm and proactive planning to manage those harms [3]. Planning is crucial in all aspects of everyday life. The ability to predict or anticipate certain harm or certain risks is associated with the human ability of learning from experiences and achieving sustainable outcomes. Planning is not restrictive of improvisation and innovation; on the contrary, it provides a stable environment for progress and positive change to take place. Evidence suggests that individuals’ who undergo unplanned detoxification relapse sooner and more frequently than those who undergo planned detoxification [4].

18.2 Side Effects Associated with Repeated Medically Assisted Withdrawals There is evidence from animal models, pharmacological studies, and psychological experimental studies to suggest that abrupt withdrawal from alcohol, as well as medically assisted withdrawal, may contribute to cognitive impairment, stress sensitivity, and exaggeration of cravings [5]. Furthermore, it seems that currently used medication during withdrawal cannot protect from these adverse effects [6]. Animal models, despite their limitations, demonstrate a variety of withdrawal-­ induced cognitive impairments, such as in learning, cognitive flexibility, memory, sociability, as well as increasing anxiety and sleep disruption. In addition, they indicate the worsening of withdrawal symptoms given multiple withdrawal episodes, such as increased frequency of seizures, and worsening the effect on some of the associated cognitive impairments [6]. During recent years, accumulating evidence suggests that individuals who have experienced repeated episodes of withdrawal have increased risk of withdrawal seizures [7], show changes to their affect [8], increased craving, significant deterioration of cognitive abilities, when they are compared to persons with fewer withdrawals [8], as well as impaired control and reduced resistance to relapse [9]. It is evident that alcohol withdrawal and its complications develop as alcohol levels decrease [10]. Currently available treatment of alcohol withdrawal generally attenuates the risk of such consequences, through the manipulation of the Gamma-­aminobutyric acid (GABA—neurotransmitter that sends chemical messages through the brain and the nervous system) system [10]. Current treatment with benzodiazepines may not be

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optimal in attenuating the hyperglutamatergic state of alcohol withdrawal, and consequently, recurrent withdrawals result in an increase in severity of symptoms due to kindling effect [11]. We discuss in detail the risks associated with repeated alcohol withdrawals with or without medication in our review paper [6].

18.3 Structured Preparation for Alcohol Detoxification (SPADe) Pre-habilitation has been applied in the treatment of alcohol dependence, and it is described as Structured Preparation for Alcohol Detoxification (SPADe) [12]. SPADe has been applied as an open rolling group programme, described in the early days as Preparation for Alcohol Detoxification (PAD) and more recently as Abstinence Preparation Group (APG). The first ever implementation of SPADe took place in 2005 as a three-stage treatment programme: 1. Preparation 2. Detoxification 3. Relapse prevention Evaluation of this attempt showed that it could increase treatment capacity by 123%, improve detoxification outcome from 57% to 85%, and reduce dropouts by 55%. The programme was proven to be cost-effective as the average number of clients per PAD group session was higher than the minimum required [12]. The introduction of structured preparation has increased the percentage of community detoxifications [13]. Further evaluation showed that 70% of individuals entering services entered PAD groups. Ninety percent have completed their detoxification. Most importantly, 73% of those who have completed the PAD group programme were abstinent at 1 month post-detoxification and 49% at 3 months, which was significantly higher compared with those who did not wish to or could take part to PAD [14]. An evaluation by participants of the PAD groups sessions showed that they felt able to actively participate despite the structured nature of the sessions. The positive experience reported to be related to the engagement in active exploration of their difficulties and practice of potential solutions, achieving a balance between didactic and experiential style [15]. Key Point 18.1 Key benefits of PAD group attendance from the participant perspective included both generic group factors such as not feeling ‘alone’, being supported by, and supporting, peers, and theory specific factors such as increased self-efficacy and coping strategies for reducing drinking and managing high-risk situations [16]. A second implementation of the SPADe pathway showed that 77% of individuals were able to finish the APG. Consequently, 44% of those entering the service were

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completely abstinent (without even a single occasion of drinking) at 1 month, 38% at 3  months, and 39% at 6  months. Around 50% of individuals attending APG achieved guided self-detox (see below) and had better outcomes than the rest of the cohort [17]. Process evaluation showed that APG has reduced symptoms of dependence during the period of intervention and at follow-up. Key concepts according to the underlying cognitive behaviour theory, such as urges, positive expectancies, and self-efficacy, have changed significantly both during the intervention and at followup, except for negative expectancies. All these changes were consistent with theory prediction [18]. A recent feasibility randomised controlled trial indicated that the intervention is acceptable by both individual and professional and that the intervention could be delivered safely within the NHS [19].

18.4 Components/Aspects of Structured Preparation for Detoxification 18.4.1 Family Preparation for Detoxification and Abstinence Although much of the focus in alcohol detoxification has traditionally been on the individual engagement with the family, this provides the clinician with the opportunity to engage active partners in treatment and recovery. The family has been advocated as the unit of treatment and family involvement, and support networks can be a key component of engagement with successful treatment and recovery (see Chap. 8) [20]. There is at present limited evidence base for how to best achieve this in the detoxification setting. There are no Cochrane reviews that have synthesised the evidence for family interventions at this stage, while a systematic review of successful detoxification of program factors involved in successful detoxification programmes identified family involvement in programs as a favourable factor [21]. The identified studies included an early large single centre report of outpatient detoxification services aided by peer support and family involvement [22] and a small to moderate size (n = 45) randomised control trial (RCT) after inpatient detoxification of behavioural family therapy versus treatment as usual evidencing large effect sizes for reduced alcohol use outcomes after 3 months [23]. Other studies have evidenced other positive outcomes with family therapy intervention at other stages, for example, behavioural marital therapy with a relapse prevention component performed better than without relapse prevention (n = 59, follow-up 30 months) (see Chap. 22) [24]. There is, however, less information about the detoxification stage. It is often observed that at the time the person is seeking help, families might have suffered and tolerated for years the person’s dysfunctional or problematic drinking. Consequently, at the time the person is asking for help and starts the process of change, the family might have been already exhausted and might have unrealistic and often magical expectations from treatment. To that effect, the management of family’s expectations from treatment with the provision of information as early

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as possible is recommended. This could be done with carer’s information material which could include a step-by-step guide of the treatment pathway, facts about the treatment, and advice about the role of families at every step of the treatment process. The clinician should be alert to family dynamics within the family system. Different family interactions related to alcohol use have been described, including the ‘functional family system’, the ‘neurotic family system’, ‘the divided family’, and ‘the deprived family’ [25, 26]. It is perhaps less important to categorise individual families for the clinician in this context, although it would be useful for the clinician to bear in mind that the family and the individual may have had extended or intense reactions to the individual’s alcohol use. These may have exerted an emotional, financial, or social toll and may frequently lead to a certain sense of alienation that may be variably experienced by the individual or the family. Occasionally remedying this can be incorporated into a broader aim of treatment or may be the presenting reason for why an individual wishes to undertake detoxification. Key Point 18.2 It is important not only to involve family members as early as possible in the preparation process but also to generate support during the community detox (discussed below). It is important to communicate and plan for changes of drinking for all members of the family or at least the partner or most significant other. This is important for two reasons: 1. To manage and eliminate any environmental triggers, such having alcohol in the house 2. Reduce any high-risk situations associated with alcohol consumption within the family and associated social occasions Furthermore, it is important that the challenge of changing lifestyle is to be shared within all family members as this way of living would be easier to achieve. Such a change, without displacing the responsibility of the individual for his/her recovery, would provide an opportunity to revisit and modify any family dynamics, communication difficulties, and long-standing dysfunctional adaptations of the family system that made the individual vulnerable to drinking and would most likely (if they remain unchanged) compromise the individual’s chances to achieve a sustainable outcome. The development of an all-purpose coping plan as well as the development of new activities, hobbies, and pleasure activities would be easier done and implemented within a supportive and flexible family system. Principles of family involvement at the pre-detoxification stage should broadly follow principles of good medical practice. The clinician’s first responsibility is to the individual, and a direct conversation should be had whether the individual wishes to involve a supportive family member or close friend.

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For outpatient detoxification, as a rule of thumb, this should never be completed alone due to the risks of undertreatment (seizures, delirium tremens), overtreatment (sedation, somnolence, respiratory depression), or misuse of the benzodiazepine prescription. In these instances, should the individual not wish to engage with the family member who lives with them, some other suitable friend or supportive person may be identified (who preferably resides with them during the detoxification period), or the individual referred for inpatient or residential detoxification. It is often preferable to see the individual with the family member. It is not unusual for family members to differ with the individual regarding extent of alcohol consumption or effects or the effect on social functioning. The aim at this stage should not be to clarify exact details (which should already have been established) but the provision of shared information for the detoxification. For the purpose of outpatient detoxification, a clear benzodiazepine reducing regimen should be drawn up, the risks and benefits of treatments be clearly outlined, consent taken, and clear advice given on: 1. Undertreatment. 2. Overtreatment. 3. Who is responsible for ensuring medication is administered? 4. Who to contact in the case of emergencies? In inpatient and residential detoxifications, these pragmatic concerns are usually managed by the unit, but an outline of the process, being a safe medical procedure with concomitant risks, should still be outlined. It is particularly important to outline to both the individual and the family member that detoxification is one component of a multicomponent strategy, including aftercare and strategies for relapse prevention (see Chap. 22). Although getting to this stage, evidence acknowledgement of the problem and an initial commitment to recovery will by itself almost certainly not be enough. Both individual and family member should be prepared to take a long-term view. The clinician can broadly refer to evidence that high-quality support networks decrease risk of relapse [26, 27]. As mentioned, there may be cogent reasons for individuals not wishing to involve family members in the recovery process, and these should be respected with a focus on respecting the choices and enhancing self-­ efficacy in the individual. In summary, it could be argued that family is equally both part of the problem and part of the solution. From a pre-habilitation point of view, it is crucial to prepare the immediate social and family environment for the risks and the changes required at least during the early stages of abstinence. These changes would include: 1. Changes of drinking for all members of the family 2. Identification and management of stress factors 3. Adoption of a team approach to combat drinking as a shared family issue

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18.5 Partial Control over Drinking The concept of controlled drinking has generated intense conflict within the field of addiction medicine. It was presented as an alternative to lifelong abstinence, as the sole treatment outcome. In clinical guidelines such as NICE, controlled drinking within healthy limits is considered as an appropriate treatment target for harmful drinkers. For dependent drinkers (i.e. those with the most severe drinking behaviour), abstinence remains the preferred treatment aim [1]. Within the SPADe treatment approach for alcohol dependence, controlled drinking is referred to as ‘partial’ for two main reasons: 1. It is an intermediate treatment stage rather than the final treatment aim, which remains to be abstinent. 2. The amount and pattern of drinking during this process is not always within healthy limits. To that effect, SPADe has been described as a variant of harm reduction. Within SPADe, the main aim of the partial controlled drinking is the stabilisation of both the amount and pattern of drinking. Alcohol is considered as ‘if it were medication’ with frequent and regular dosing to prevent rather than treat withdrawal symptoms. This proactive elimination of symptoms is considered fundamental from a biological perspective as it protects against brain acute dysregulation, which in turn might sensitise the brain, leading to an exaggeration of the negative impact associated with the disturbance of the brain’s homeostatic system. From a psychological perspective, it empowers the individual into regaining some control over the decision-making and reduces the impulsivity associated with the experience or avoidance of experiencing cravings and withdrawal symptoms. Furthermore, it provides a relatively stable environment for the individual and the family or close social environment to start implementing lifestyle changes, leading to an increase of self-­ efficacy, which is considered the final mediating factor in social learning theory and cognitive behavioural treatment models [28]. The amount of drinking following stabilisation, as described above, could be reduced gradually, following the principle of small sustainable changes. The aim is to avoid any heroic and dramatic change to the amount of drinking, which not only would be unsustainable but also might lead to precipitation of withdrawal symptoms, which could be life-threatening. Once stability is achieved, then gradual reduction can be safely achieved. Our experience suggests that roughly half of the individuals will be able to come off alcohol without the use of detoxification medication [17]. This model of detoxification is called ‘guided self-detox.’ It refers to the process of using alcohol as if it were medication and as a safe detoxification tool. Depending on the duration of dependent drinking, some individuals might have lost any anchor points or activities during the day. Their drinking might be around the clock. In such difficult cases, it is important to agree ‘when’ the day starts. It is important then to agree the amount that the individual would feel comfortable with. This is usually somewhere between the maximum amount consumed and the

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minimum amount tolerated. Usually when the individual tries to reduce too much, the following day the amount increases to compensate. The question asked should be ‘how much do you think you need to drink to feel comfortable?’ Some individuals might need to be asked to drink more than what they would report. What is important is to feel comfortable without experiencing any withdrawal symptoms. Dependent individuals will report needing alcohol to alleviate withdrawal symptoms in the morning. It is important to acknowledge this and allow them to consume the amount they need to ‘stabilise the nerves’. At a later stage, any reduction starts with omission of drinks in the middle of the day, keeping stable the amount at the beginning and end of the day. Some individuals, but not all, might be able to delay initiation, and others might be able to stop drinking earlier in the evening. To that effect, it is crucial to ask individuals for their own experience and their belief of what they might be able to achieve and involve them fully into the stabilisation and gradual reduction plan.

18.6 Introduction of Lifestyle Changes of the Individual Stabilisation of drinking provides, for a short period, a relatively stable and safe environment for the individual and the immediate family and social network to develop and test lifestyle changes. Those early and gradual implementation of changes within the individual’s lifestyle are necessary to provide: 1. A routine in everyday life that would protect from early relapse 2. Fill in the void that alcohol detoxification would leave behind 3. Could be used as distraction strategies against cravings 4. Would enhance personal responsibility 5. Would demystify alcohol and challenge the omnipotence of cravings or withdrawal symptoms 6. Would protect from the acute stress experienced in the early days of abstinence As discussed above, it is expected that during the detoxification as well as during the first few week’s post-detoxification, major changes are taking place in the brain. To that effect, it could be anticipated that the ability of the individual to learn new information and adjust and adapt to a new reality might be compromised. This new learning and adaptation are expected to be easier within a protective clinical environment, where real-life stimulation is controlled. It could represent an additional advantage of inpatient detoxification of the safe management of severe withdrawal symptoms. However, this inpatient environment carries a major disadvantage. It is artificial and prevents testing new skills in real settings. It postpones the challenge of real-life adaptation to a later time when the expected changes in the brain are settled. It is, however, well reported that the change from a protective to real social environment is linked with high relapse rate, even if the stay in the protective environment is 6 months long. This indicates that the adaptation to a new reality could have been compromised either because new skills and behaviours were not tested in

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the real new social environment (which raises questions on the effectiveness of skills-based interventions in an inpatient setting) or that the social environment itself has not been modified (i.e. expectations and behaviours of family members and levels of stress). Hence, the SPADe model proposes that these lifestyle changes should be initiated and tested while alcohol is stabilised and to be augmented, as well as evaluated after the detoxification. These new activities should start small and short and build up gradually in a constant interactive process with the steps of alcohol reduction. They should fill in any gap left by the omission of a particular drink. Similarly, to the efforts to stabilise the amount and pattern of consumption, some individuals might find it extremely challenging to initiate any activities. It is a common response, ‘I can’t do anything’. Suggestions such as incorporation of three meals per day, as symbolic anchor points of structured daily routine, or consolidating the time of an existing activity, such as dog walking, might be an easy start.

18.7 Planning Aftercare Key Point 18.3 Aftercare for alcohol detoxification is intrinsic to the process, and planning should ideally be commenced alongside planning for the detoxification. Clearly a planned detoxification is ideal. However, in emergency detoxifications, the basic principles of such conversations remain the same and should still be had as early as practically possible. Both individual and clinician should be clear about the goal after detoxification—sobriety or controlled drinking. The clinician should never assume that the individual wishes to abstain from alcohol. In practice, sobriety is often the realistic and achievable goal, particularly features in the alcohol dependence history, such as compulsive use, reinstatement after use, and failure of controlled drinking, or considerable medical risk may point away from controlled drinking as a realistic goal. A recent meta-analysis has shown that neither approach is unequivocally superior, although caution must be applied when interpreting the results due to the heterogeneity of the studies, which were not solely conducted in the post-detoxification population [29]. Unrealistic outcomes by the individual may point to a lack of understanding of the condition and limited motivation and may lead to a reconsideration of whether detoxification is indicated at this stage or further preparation work needs to be undertaken. The aftercare package should focus on a bio-psycho-social approach. Perhaps the most important of these, but also the most difficult to offer intervention for, is the social aspect—the environment to which the individual is returning to. Returning to a high-risk environment, for example, where there are other individuals in the immediate environment who drink heavily; cues or triggers, which are likely to precipitate heavy drinking episodes; and ready availability to alcohol may jeopardise chances of remaining abstinent and shorten the length of time to relapse. One

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possible component to aid with this, particularly in refractory or complex cases, is the use of longer-term rehabilitation placements. Psychological therapies for relapse prevention may also offer benefits to the individual (see Chap. 22). These may include cognitive behavioural therapy, motivational enhancement, or motivational interviewing informed approaches. As discussed above, there is some evidence for family therapy-based approaches (see Chap. 23). Key Point 18.4 The important aspect to remember here is that no one size fits all. The evidence base is heterogenous and does not identify a single ‘gold standard’. Previous large-scale studies had attempted to identify characteristics to stratify ‘patients’ to specific treatments without success  – therapies were largely equally effective [30, 31]. An important predictor of effective therapies is the therapeutic alliance with the individual. A particular intervention that has been shown to have high rates of effectiveness for some individuals is the 12-step facilitation approach popularised by Alcoholics Anonymous (AA). A recent Cochrane review comparing AA/12-step facilitation manualised approaches to other established therapies has found this superior to other established therapies in promotion and maintenance of longer-term abstinence [32]. However, this is not appealing to all, requiring a belief in a higher power or purpose in life, is not likely to work in those who have difficulty in subscribing to these tenets. The practitioner should be aware of parallel resources for family members and teenagers: Al-Anon (https://www.al-­anonuk.org. uk) and Alateen (https://www.al-­anonuk.org.uk/alateen/) for 12–17 years old, which can provide valuable support to carers at any stage of the alcohol journey. Finally, biological treatments should also be discussed (see below for a discussion on relapse prevention medications). Although not the focus of this chapter, concomitant psychiatric comorbidities should be attended to as part of the relapse plan, as these have been noted to be associated with a worse prognosis and higher likelihood of relapse [30]. Taken together, the salient points in planning for after care are to: 1. Involve the individual early in these discussions 2. Emphasise the point that detoxification by itself is not an effective treatment in the absence of a clear plan for relapse prevention 3. Undertake a holistic plan targeting the domains across the bio-psycho-social approach There is reason for optimism – one large study showed 12% of alcohol dependent individuals in the untreated group to be abstinent at 1 year, rising to 57% with treatment [33]. In another nationally representative US sample, around a third of individuals with alcohol use disorder were classified as low-risk drinkers or abstinent by 1 year follow-up [34].

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18.8 The Role of Medications in Pre-habilitation (See Chap. 19) Medication has not been explored explicitly as a part of pre-habilitation, although interest in the role of medication in reducing total alcohol consumption rather than maintaining abstinence is increasing, making this a potentially fertile ground for future research. The role of medication in individuals who are actively drinking may be thought about in terms of: • Harm reduction • Neuroprotection Harm reduction during continued consumption of a substance is accepted as a goal of treatment in other addictions but research has only recently demonstrated health benefits for patients experiencing alcohol use disorder [35]. The relationship between alcohol consumption and mortality risk is exponential, so a meaningful reduction in alcohol consumption might be expected to yield health benefits [36]. Medications which could aid the individual in reducing alcohol use prior to detoxification may also provide benefit in reducing the risk of complications and reducing benzodiazepine requirement, provided reduction is managed gradually. Neuroprotection – protection from the neurotoxicity of withdrawal from medications started before withdrawal occurs – has a preclinical evidence base but has not been explored to the same extent clinically.

18.8.1 Nutritional Supplementation Individuals with alcohol dependence have impaired absorption, storage, and utilisation of thiamine. In addition, many miss meals because of lack of funds or nausea. Alcohol withdrawal places a further physiological demand, and at this time, individuals often begin eating again, increasing the body’s demands for thiamine, so Wernicke’s encephalopathy, a confusional state caused by thiamine deficiency, often emerges during detoxification. Therefore, it is recommended practice for parenteral B vitamins to be given prior or exceedingly early during detoxification in the UK, to prevent the development of Wernicke’s Encephalopathy, but this has not been prospectively evaluated [1, 37].

18.8.2 Medications for Detoxification (See Chap. 19) Benzodiazepines are the gold standard medication for alcohol withdrawal and its complications [1]. The goal of treatment is to prevent or treat alcohol withdrawal seizures or delirium. However, the increased risks of seizures following repeated episodes of withdrawal as well as progressive cognitive impairment are not

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mitigated by treatment with benzodiazepines [6, 38]. Preclinical evidence indicates that the neurotoxicity of alcohol withdrawal is related to increased glutamate release and NMDA-mediated transmission [5, 39]. As benzodiazepines impact glutamate transmission indirectly – by potentiating GABA transmission which exerts an inhibitory effect on glutamatergic neurons – this may be a reason for progression despite benzodiazepine treatment.

18.8.3 Relapse Prevention Treatments (See Chap. 22) Many randomised controlled trials for alcohol dependence either involve people with mild alcohol dependence who do not require detoxification or start medication after detoxification. This is set to change as a reduction in drinking levels, rather than abstinence, become more widely accepted goals of treatment. A recent network meta-analysis studied the efficacy of relapse prevention medications in reducing total alcohol consumption before detoxification by including studies where randomisation occurred prior to 5 days of abstinence being attained and where prior detoxification was not an inclusion criterion [40]. We have taken this approach to consider the role of medications in pre-habilitation.

18.8.3.1 Acamprosate Acamprosate is a functional glutamate antagonist, which is a first-line relapse prevention treatment for alcohol dependence in the UK, particularly for those whose goal is abstinence [1]. Most acamprosate trials occur in individuals who have already undergone detoxification. There is an intriguing potential role for acamprosate in neuroprotection, as preclinical studies demonstrate a reduction in the progressive escalation of glutamate transmission with repeated cycles of withdrawal [41], and in such studies, acamprosate was initiated prior to the onset of withdrawal. For this reason, early initiation of acamprosate during detoxification is recommended in the UK [10], despite evidence from a single trial that early initiation was related to increased risk of relapse [42]. The single trial of acamprosate reporting reduction in total alcohol consumption  – that is, applicable to an active drinking state – showed no effect [42]. 18.8.3.2 Opioid Receptor Antagonists Nalmefene and naltrexone are both opioid receptor antagonists, which differ slightly in pharmacology: while both are mu opioid antagonists, nalmefene is a partial kappa opioid agonist [10]. Nalmefene was the first medication licensed in Europe for reduction of drinking rather than relapse prevention in individuals with mild alcohol dependence (i.e. those who do not require detoxification). Both naltrexone and nalmefene reduce self-reported craving in experimental medicine studies and

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randomised controlled trials and reduce number of heavy drinking days rather than abstinence per se. Naltrexone is pragmatically prescribed to people who continue to drink as a harm reduction measure, but a recent systematic review examining harm reduction as an outcome in alcohol RCTs found no evidence of superiority over placebo with respect to total alcohol consumed or heavy drinking days [40]. An additional concern in actively drinking individuals is the potential hepatotoxicity of naltrexone [43], although the absence of a significant rise in transaminases in many individuals in subsequent RCTs suggests that this concern is potentially overstated (e.g. [44]). Nalmefene has evidence of efficacy in reducing total alcohol consumption and heavy drinking days [40], but the evidence base pertains to individuals who do not require medicated detoxification.

18.8.3.3 Baclofen Baclofen’s development as a medication for alcohol dependence famously involved initiation and titration during active drinking [45], and such initiation continues to be standard practice in France. However, systematic review and meta-analysis of studies with initiation during drinking found no benefit and in fact a risk of increased drinks per drinking day [46]. Subsequently, the Bacloville study, which studied individualised titration of baclofen during heavy drinking, did not show a clear benefit relative to placebo [47], and there have been criticisms of the conduct and reporting of the trial [48]. Within the Bacloville study, safety concerns emerged: both adverse events and mortality were higher in the baclofen arm [48]. Electronic health record data from France also demonstrated a dose-related increased risk of hospitalisation and death in patients taking baclofen relative to other relapse prevention medication for alcohol dependence, at least at doses exceeding 30  mg per day [49].

18.9 Conclusion The concept of pre-habilitation is not new. It is derived from the evolutionary theory and aims to predict risks and side effects associated with a given intervention and prepare the individual to mitigate them. In the field of alcohol dependence, a pre-­ habilitation-­based approach is important to manage risks associated with the process of detoxification itself and the immediate personal and social changes that follow cessation of alcohol. Pre-habilitation includes actions initiated prior to the cessation of alcohol such as i) preparation of family for detoxification and abstinence; ii) partial control over drinking with stabilisation of the amount and guided gradual reduction, iii) early lifestyle changes, and iv) aftercare planning. Medication that reduces cravings could be used alongside the above actions.

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References 1. NICE.  CG115 alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. London: National Institute for Health and Clinical Excellence; 2010. 2. Public Health England. Alcohol and drug treatment for adults: statistics summary 2017 to 2018. https://www.gov.uk/government/statistics/substance-misusetreatment-for-adults-­­statistics-2017-to-2018/alcohol-and-drug-treatment-for-adults-statisticssummary-­2017-to-2018. Accessed 3 Nov 2021. 3. Wynter-Blyth V, Moorthy K.  Prehabilitation: preparing patients for surgery. BMJ. 2017;358:j3702. https://doi.org/10.1136/bmj.j3702. 4. Quelch D, Pucci M, Coleman J, Bradberry S. Hospital management of alcohol withdrawal: elective versus unplanned admission and detoxification. Alcohol Treat Q. 2019;37:278–84. https://doi.org/10.1080/07347324.2018.1527664. 5. Duka T, Townshend JM, Collier K, Stephens DN. Kindling of withdrawal: a study of craving and anxiety after multiple detoxifications in alcoholic inpatients. Alcohol Clin Exp Res. 2002;26:785–95. https://doi.org/10.1111/j.1530-­0277.2002.tb02606. 6. Kouimtsidis C, Duka T, Palmer E, Lingford-Hughes A. Prehabilitation in alcohol dependence as a treatment model for sustainable outcomes. A narrative review of literature on the risks associated with detoxification, from animal models to human translational research. Front Psychiatry. 2019;10:339. https://doi.org/10.3389/fpsyt.2019.00339. 7. Brown ME, Anton RF, Malcolm R, Ballenger JC. Alcohol detoxification and withdrawal seizures: clinical support for a kindling hypothesis. Biol Psychiatry. 1988;23:507–14. https://doi. org/10.1016/0006-­3223(88)90023-­6. 8. Duka T, Townshend JM, Collier K, Stephens DN. Impairment in cognitive functions after multiple detoxifications in alcoholic inpatients. Alcohol Clin Exp Res. 2003;27:1563–72. https:// doi.org/10.1097/01.ALC.0000090142.11260.D7. 9. Duka T, Stephens DN.  Repeated detoxification of alcohol-dependent patients impairs brain mechanisms of behavioural control important in resisting relapse. Curr Addict Rep. 2014;1:1–9. https://doi.org/10.1007/s40429-­013-­0009-­0. 10. Lingford-Hughes A, Welch S, Peters L, Nutt DJ.  BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP.  J Psychopharmacol. 2012;26(7):899–952. https://doi.org/10.1177/0269881112444324. 11. Lechtenberg R, Worner TM. Relative kindling effect of detoxification and non-detoxification admissions in alcoholics. Alcohol Alcohol. 1991;26:221–5. https://doi.org/10.1093/oxfordjournals.alcalc.a045104. 12. Kouimtsidis C, Ford L.  A staged programme approach for alcohol dependence: cognitive behaviour therapy groups for detoxification preparation and aftercare; preliminary findings. Short report. Drugs Educ Prev Policy. 2011;18:237–9. https://doi.org/10.3109/0968763 7.2010.498392. 13. Kouimtsidis C. Community alcohol detoxification; the challenge of changing service provision. Short report. J Subst Use. 2013;18(2):166–9. 14. Kouimtsidis C, Drabble K, Ford L. Implementation and evaluation of a three stages community treatment programme for alcohol dependence. A short report. Drugs Educ Prev Policy. 2012;19:81–3. https://doi.org/10.3109/09687637.2011.562938. 15. Kouimtsidis C, Kolli S.  Preparation for alcohol detoxification group programme. Service users’ evaluation of individual sessions. J Subst Use. 2014;19:184–7. https://doi.org/10.310 9/14659891.2013.770568. 16. Croxford A, Notley C, Maskrey V, Holland R, Kouimtsidis C. An exploratory qualitative study seeking participant views evaluating group cognitive Behavioural therapy preparation for alcohol detoxification. J Subst Abus. 2015;20:61–8.

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Drugs Used in Withdrawal Management and Post-Withdrawal Management

19

Michael F. Weaver, Judy H. Hong, and Adrienne Gilmore-Thomas

Learning Outcomes • Understand that differing medications are recommended depending on severity levels of alcohol withdrawal. Although benzodiazepines are the “gold standard” medication for AWS, there are several alternative medications. • Consider issues when selecting a medication, such as dosing schedule, treatment setting, substance abuse history, cross-tolerance, and post-withdrawal management. • Provide information for professionals on ethical principles of beneficence, nonmaleficence, fidelity, justice, and autonomy, for example, in adhering to autonomy, to involve the individual as much as possible in treatment planning to increase adherence. • Present case studies to illustrate possible issues when managing AWS by treating professionals.

19.1 Medications for Alcohol Withdrawal Treatment Pharmacotherapy is indicated for management of moderate to severe alcohol withdrawal syndrome (AWS), and any cross-tolerant medication may be used. However, there is little consistency in treatment of withdrawal, and there are no standard protocols for withdrawal management in widespread use [1, 2]. It is inappropriate to give beverage alcohol to prevent or treat AWS. The use of intravenous alcohol infusion is reserved for poisoning with methanol, isopropanol, or ethylene glycol and should not be given for treatment of acute AWS because of complications such as intoxication M. F. Weaver (*) · J. H. Hong · A. Gilmore-Thomas Centre for Neurobehavioral Research on Addiction, The University of Texas Health Science Center at Houston, Houston, TX, USA e-mail: [email protected]; [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_19

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with delirium or development of gastritis [3]. Both benzodiazepines and barbiturates effectively treat AWS [4]. Benzodiazepines are first-line treatment due to well-documented effectiveness in reducing signs and symptoms of AWS, including the incidence of seizures and delirium [5]. The choice of benzodiazepine depends on characteristics, such as duration of action, need for metabolism, and speed of onset of effects. No specific benzodiazepine is superior to any other for AWS treatment, although longer-acting benzodiazepines may allow for a smoother withdrawal course. Clonazepam is a long-acting benzodiazepine with generally less euphoria than other benzodiazepines, such as diazepam or chlordiazepoxide, so it is more suitable for withdrawal management. Lorazepam and diazepam have a rapid onset of action when given intravenously, although the duration of action is shorter than when given orally. Benzodiazepines are most often used to manage AWS, but barbiturates also have been used successfully to treat AWS, and phenobarbital has been used most as an appropriate alternative to benzodiazepines [5]. For individuals who have been misusing benzodiazepines, a different type of sedative may be appropriate to use for treatment of alcohol withdrawal symptoms, such as phenobarbital. With its longer half-life, people rarely achieve a ‘high’ as they do from other sedatives, and it is available in multiple dosage forms [6]. Several alternative non-sedative-hypnotic medications are available for the treatment of acute AWS.  Beta-adrenergic blockers (atenolol, propranolol), clonidine, and anticonvulsant agents (gabapentin, carbamazepine, valproate) decrease withdrawal symptoms and have been used successfully in treatment of mild to moderate withdrawal. However, they are not cross-tolerant with alcohol and may result in progression of AWS.  These alternative medications are not appropriate as single agents to treat moderate or severe withdrawal. Gabapentin is a favourable choice to treat AWS when a professional also plans to use it for ongoing treatment of alcohol use disorder (AUD) [5]. A fixed-dosing schedule is commonly used for treatment of acute withdrawal, but either fixed-schedule or symptom-triggered dosing (given as needed for withdrawal signs) is efficacious, even in individuals with medical comorbidity [7]. The medication is repeated at 1- to 2-h intervals as indicated by the signs of withdrawal the individual is exhibiting. Observe closely for signs of worsening withdrawal, especially acute elevations in vital signs and worsening delirium. It is better to err on the side of slightly over-rather than under-medicating. Tapering is started from the total daily dose requirement calculated. Reducing the dose by 10 percent of the initial dose each day over 10 days provides a comfortable taper. It is usually better to reduce the dose rather than the dosing interval in order to avoid development of sedative withdrawal symptoms between doses. In addition to pharmacotherapy for AWS, some individuals need intravenous glucose because many people experiencing AUD are hypoglycaemic as a result of poor diet and hepatic dysfunction [8]. It is essential to administer thiamine and folate, as well as magnesium and phosphate, before or concurrently with glucose. Therefore, it is important to complete certain labs or assessments to determine the presence of coexisting conditions, such as hypoglycaemia, cirrhosis, depression, hepatitis, and/or liver disease, when services are provided in an inpatient setting [8, 9].

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Acute withdrawal is most safely managed in an inpatient setting if the individual has been using large amounts of alcohol, has a history of seizures or delirium tremens, has unstable comorbid medical or psychiatric problems, or has current/history of benzodiazepine abuse [10]. This allows for close medical monitoring during treatment of withdrawal to prevent complications from progression to severe withdrawal, which can be life-threatening. Severe withdrawal (delirium tremens), manifested by abnormal and fluctuating vital signs with delirium, should be treated aggressively in a medically monitored environment with sufficiently large doses of medication to suppress the withdrawal [6]. Medications with a rapid onset of action should be used intravenously for immediate effect. For example, lorazepam, 1–4 mg every 10–30 min, should be given until the individual is calm but awake and the heart rate is less than 120 beats/min [6]. A continuous intravenous infusion may be warranted to control withdrawal symptoms, and the infusion rate can be titrated to the desired level of consciousness. After stabilization, the professional can substitute an equivalent dose of a long-acting sedative that will be tapered. Severe AWS that is refractory to high-dose benzodiazepines has been treated successfully with the addition of phenobarbital [11], propofol [12], dexmedetomidine [13], baclofen [14], and even ketamine [15]. However, these agents require close monitoring in an intensive care unit setting [5]. Failure to respond to benzodiazepines may be due to benzodiazepine resistance from multiple previous episodes of AWS. Individuals who misuse alcohol often have some degree of liver dysfunction, either from acute alcohol-induced hepatitis or from cirrhosis due to long-term consumption. Hepatically metabolized sedatives, such as benzodiazepines and barbiturates, may worsen hepatic encephalopathy in individuals with cirrhosis. They should be used with caution to avoid adverse outcomes from accumulation of metabolites requiring liver metabolism. Lorazepam, temazepam, and oxazepam are intermediate-­ acting benzodiazepines that have no active metabolites (hepatic metabolism of these involves only glucuronidation for excretion), unlike other benzodiazepines, which makes them safer in severe liver disease. Despite the long half-life and metabolism by the liver, phenobarbital is still safe to use for individuals with liver disease who are not at risk for hepatic encephalopathy, because approximately 30% is excreted unchanged in the urine [16]. This is an advantage over most long-acting benzodiazepines (e.g. chlordiazepoxide and diazepam), which undergo extensive liver metabolism to additional active metabolites [17].

19.2 Medications for Post-Withdrawal Management Benzodiazepines prescribed for AWS should be discontinued after withdrawal is complete, because individuals are at risk for developing physiological dependence on benzodiazepines, developing a sedative use disorder, or experiencing benzodiazepine withdrawal [5]. Treating AWS is only a first step in the treatment of the disease of AUD.  Long-term treatment is necessary to prevent continuing problems. When proceeding with treatment, it is recommended that the professional confirm

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the diagnosis of AWS, choose an appropriate medication regimen, determine the setting (i.e. inpatient vs. outpatient), and monitor for adverse reactions and side effects [18]. Three medications have been approved by the US Food and Drug Administration (FDA) for treatment of AUD. Disulfiram acts as an aversive agent by inhibition of aldehyde dehydrogenase, which prevents metabolism of alcohol to acetaldehyde. When alcohol is ingested, this results in accumulation of acetaldehyde in the blood leading to: • • • • • • •

Nausea and vomiting Flushing Palpitations Dyspnea Hypotension Headache Sympathetic overactivity

This reaction to alcohol consumption discourages further drinking. Disulfiram is not generally chosen as initial therapy and is contraindicated for individuals who are actively using alcohol [19]. It is also contraindicated with psychotic disorders. Naltrexone affects alcohol consumption through blockade of opioid receptors, because some reinforcing effects of alcohol are mediated through the endogenous opioid system. Naltrexone reduces the pleasurable effects of alcohol, which reduces the risk of relapse, especially among those with a family history of AUD and those with strong cravings [20]. Naltrexone is available as a daily pill or as a monthly intramuscular depot injection given in a physician’s office [21]. Because naltrexone is an opioid blocker, treatment of acute or postoperative pain can be challenging in an individual who is using naltrexone for treatment of AUD. For unexpected severe pain, such as trauma, nonopioid analgesics should be considered, including nonsteroidal anti-inflammatory agents, or local anaesthesia with a nerve block or epidural catheter [22]. It also may be feasible to titrate typical opioid analgesics upward to individual comfort under medical observation without causing oversedation or respiratory depression. Acamprosate antagonizes N-methyl-d-aspartate glutamate receptors, restoring balance between excitatory and inhibitory neurotransmission that was deregulated by chronic alcohol consumption, which reduces negative affect and craving during abstinence [23]. Acamprosate has no known drug interactions. Compared with disulfiram and naltrexone, which have multiple drug interactions and potential complications (hepatotoxicity), acamprosate may be a good choice for individuals with medical and/or psychiatric comorbidities, especially those taking other medications. Several other medications may be effective for treatment of AUD. Gabapentin is an anticonvulsant that may provide bridge therapy from AWS treatment to long-­ term AUD treatment [24]. It improves abstinence rates and reduces heavy drinking days as well as cravings for alcohol. The recommended dosage of gabapentin for AUD is 1800 mg per day [23]. The individual must be started on a small dosage and

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then gradually increased to the optimal dosage to reduce mild symptoms of AWS, such as insomnia, dysphoria, and cravings. Topiramate is another anticonvulsant that reduced heavy drinking days in most, but not all, studies [25]. It has multiple side effects, including cognitive dysfunction, dizziness, and paresthesia. These may be reduced with gradual dose titration, similar to gabapentin.

19.3 Ethical Issues 19.3.1 Beneficence and Nonmaleficence: Misuse of Benzodiazepines with Alcohol Within the AWS context, adhering to the ethical principle of beneficence, professionals relieve symptoms of AWS and prevent death by treating with appropriate medications. In considering nonmaleficence, treatment of current AWS symptoms should not have negative long-term side effects, such as relapse back into benzodiazepine misuse, or use of non-benzodiazepine medications if they are not effective for the severity of AWS. The gold standard of treating AWS is with benzodiazepines, but it can seemingly present an ethical dilemma when the individual has a current or history of benzodiazepine abuse. In this case, would the professional prescribe benzodiazepines when the individual is having/had dependence issues? Would this cause relapse even after the AWS is treated? Would it be effective on an individual with tolerance to the medication? These are all common questions. It is standard and ethical to use benzodiazepines to treat an individual experiencing AWS and concomitant benzodiazepine misuse. Preferably, the individual should be treated in a residential or ambulatory setting where medication use can be tightly controlled and the individual can be monitored to minimize the chance of benzodiazepine misuse [5]. Additionally, after evaluating AWS severity, the minimum dose should be administered to stabilize the individual and the effects continuously monitored [5]. Considering the benzodiazepine misuse history of the individual can act as a guide—for those that misuse short-acting benzodiazepines (e.g. alprazolam), long-acting benzodiazepines, such as clonazepam or chlordiazepoxide, can be used as a substitute. For individuals with benzodiazepine tolerance, increasing the dose would be one solution; another would be to use phenobarbital [26]. Alternatively, phenobarbital can be used as monotherapy to treat moderate or severe alcohol withdrawal [6]. This is an appropriate alternative for those who experience adverse effects of benzodiazepine use [5]. Phenobarbital will provide less of a euphoric effect while still adequately treating symptoms of AWS [6]. Additionally, side effects such as over-sedation and respiratory depression necessitate close monitoring with an experienced professional [5]. Nonmaleficence dictates that the professional should not use phenobarbital if not familiar with how to use it successfully.

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Case Study 20.1 A 29-year-old male, brought by his family, arrives at the emergency room. This individual is experiencing a severe level of alcohol withdrawal from reported symptoms of sweating, severe anxiety, and moderate tremors, but no signs of confusion, hallucinations, or seizures. You are told by the family that he has a decade-long history of abusing benzodiazepines. How do you proceed to treat this individual? Suggestions Although the professional should take into consideration the benzodiazepine use disorder, the more pressing issue is the AWS, which can be life-threatening. Phenobarbital can be used as an alternative treatment option in place of benzodiazepine, but if for some reason phenobarbital cannot be used, then benzodiazepine treatment should be utilized with close monitoring so that the medication is not misused, ideally at a treatment facility or an inpatient setting.

19.3.2 Beneficence and Fidelity: Gabapentin for AWS and AUD Gabapentin is an appropriate medication for treatment of acute AWS and long-term treatment for AUD [27]. Gabapentin can be used long-term to reduce cravings and increase abstinence, which is consistent with beneficence. The ethical principle of fidelity dictates that the individual be informed that gabapentin can be stopped after the AWS is treated. Individuals being considered for long-term AUD treatment with gabapentin should be assessed for willingness to participate in treatment. This respects the individual’s autonomy and enhances active participation in treatment.

19.3.3 Justice: Fairness for Vulnerable Populations It is well-documented that certain marginalized groups receive poorer care and less attention compared to the general population. These include groups distinguished by race/ethnicity, economic and insurance status, immigration status, and incarcerated individuals [28, 29]. In the context of AWS treatment, adhering to the ethical principle of justice includes not only non-discriminatory access to medication but also fairness in time spent determining the best course of action, providing education, advocacy for post-withdrawal needs, supportive care, and recording of medical information. For those that do not receive the same quality of care, the results can be an exacerbation of withdrawal symptoms, improper long-term AUD treatment, or even death from AWS itself.

19.3.4 Autonomy: Independent Decision-Making Autonomy is another ethical principle to consider with groups that are more susceptible to unequal treatment. This information includes risks and benefits, is balanced, and is free from coercion, ultimately with the individual having choices in the

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treatment of AWS.  Autonomous decision-making is critical in the treatment of AWS, because it increases the individual’s participation in treatment and maximizes an individual’s benefits from treatment [3]. There are exceptions to this rule where another party makes medical decisions regarding treating the individual’s AWS. Individuals experiencing AWS may not be capable of making decisions independently due to presenting symptoms. In cases where the individual is a minor or intellectually disabled or lacks capacity for decision-­making (such as exhibiting AWS symptoms that impair judgment), a surrogate or medical professional must decide the best course of action. When there is a designated surrogate, the same level of support and respect should be given to the surrogate as would be given to the individual [5]. When appropriate, speak with supportive persons who are close to the individual or have witnessed the individual’s symptoms for information and/or guidance [4]. Gather information regarding cessation of alcohol use, symptoms exhibited, and alcohol use prior to cessation. These decision-makers may not have knowledge of the individual’s medical or substance use history, and in these cases, the minimum effective dose of medication should be administered until the individual is stable and regains autonomy [30]. It is the professional’s ethical and professional responsibility to protect the individual and make treatment decisions. However, once they are stabilized and competent to consent, decision-making capacity should be returned to the individual [30]. Some researchers go as far to argue that autonomy should take priority among the four principles [31], suggesting that: ‘far more harm than good would result from a social or moral system that permits, let alone requires, compulsory medical treatment—even lifesaving treatment—of competent adults …’

An individual’s decisions can be based on: • • • • • •

Personal circumstances History Culture (see Chap. 3) Religious beliefs Financial situation Preference

… and as such is a personal decision. Here, the antithesis of choice is involuntary, forced medication to treat AWS. The best course of action is to involve the individual in the decision-making process to the greatest extent possible, give medication to stabilize withdrawal symptoms with the minimum dose, and then return autonomy to the individual when possible [30].

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19.3.5 Autonomy, Coercion, and Collaboration: Family Issues Case Study 20.2 A 17-year-old male arrives at the emergency department exhibiting an elevated heart rate, sweating, shortness of breath, tremors, and an upset stomach. The parents disclose their son has been consuming a large amount of alcohol and had a significant change in his behaviour. The day prior, he was detained for driving while intoxicated. When the parents visited him in the detention centre, he was anxious and not feeling well, so he was taken to the emergency department. The parents state emphatically that they do not want their son to be given medications that ‘he can get hooked on’. The professional may prescribe benzodiazepines or an alternative medication. Which should the professional prescribe? What are the ethical implications? Suggestions The adolescent’s parents, as the primary guardians, are legally obligated to make medical decisions for their son. This moment can either empower the adolescent by allowing him to play a role in his treatment or impede treatment by forcing the adolescent into treatment when he is unwilling to participate. Therefore, the approach to treatment for AWS should start with the first contact with the individual. The professional has a responsibility to educate the adolescent and the parents/caregivers regarding treatment options along with possible side effects, contraindications, and adverse reactions. This includes the risks of misuse and dependence on benzodiazepines as well as worsening of AWS if not treated adequately. The professional can start with an anticonvulsant medication for AWS but must explain to the individual and parents that benzodiazepines may be necessary if AWS worsens. Caution Caution must be used when considering use of coercion to the adolescent’s benefit. A court may decide to use coercion by giving the adolescent the option of abstinence and treatment or detention. This form of legal coercion is ethical because the offender retains the autonomy to make a choice about whether to go to addiction treatment, although the alternative is incarceration and is less desirable. The coercive powers of the court system can contribute to recovery from AUD [32, 33]. In these cases, the adolescent’s autonomy is reduced, which may decrease willingness to participate in a program to address alcohol use. The adolescent’s autonomy need not be thwarted in circumstances where participation in treatment for AUD is required. In most states in the USA, a child can consent to treatment in substance use programs. Regardless of whether an individual is being coerced or is a willing participant, a therapeutic relationship should be established as early as possible. The adolescent should be allowed to voice concerns regarding participation in treatment, especially medication for addiction treatment to address AWS and AUD.

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Reflective Practice Exercise 20.1 From what you have learned from the above, reflect on the following. Make note if this helps. • Would treatment vary based on the individual’s ability to pay? • Racial descriptions were omitted from the cases intentionally. If you inserted a race different from your own, what assumptions would you make regarding the individual’s ability to make decisions, pay, and actively participate in treatment (see Chap. 3)? Case Study 20.3 A 17-year-old female presented to the emergency room experiencing high blood pressure, seizures, fever, and extreme confusion (see Chap. 11). A significant history of treatment for severe AWS was reported, and she failed to respond to benzodiazepines. Which medication would be best if the professional were to consider beneficence and autonomy? Suggestions Due to current severe AWS with a history of failure to respond to benzodiazepines, phenobarbital is an appropriate medication to treat her AWS.  Beneficence requires treating this individual for life-threatening AWS. After being stabilized, her autonomy can be considered and she can be asked whether she is interested in treatment for AUD. Case Study 20.4 A 24-year-old woman presents to her primary care physician with a request for help to quit drinking. She has been drinking 2–3 12-ounce bottles of beer every day, usually with her partner, for the past 2 years. She broke up with her partner 2 months ago and tried to stop drinking on her own but developed hot flashes, sweating, and a fine tremor in her hands after a day without drinking. She then went back to drinking daily. Her longest abstinence was for 1  week last year when she visited her parents for the holidays, but she had cravings to drink during that time. The individual asks if there is anything she can take to ‘get her through’ these symptoms if she tries to stop drinking. What would a professional prescribe in this situation? What about long-term treatment of AUD? Suggestions For long-term treatment of AUD, FDA-approved medication can be used. Gabapentin is an appropriate choice for both acute mild AWS symptoms and AUD for this individual. In addition to long-term maintenance with medication, an individual should be encouraged to participate in treatments such as 12-step groups or cognitive-behavioral therapies.

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19.4 Conclusion Benzodiazepines are the medication of choice for treatment of AWS, although alternative cross-dependent sedatives such as phenobarbital are also appropriate. For mild to moderate withdrawal, anticonvulsants, beta blockers, or alpha-2-adrenergic agonists are appropriate. Medications for long-term treatment of AUD include naltrexone, acamprosate, disulfiram, and anticonvulsants such as gabapentin. Beneficence, autonomy, justice, and fidelity are the primary ethical issues when prescribing pharmacological interventions for treatment of AWS. Regardless of the medication prescribed, for safety reasons, individuals experiencing AWS should be monitored closely.

References 1. Weaver MF, Jarvis MAE, Schnoll SH.  Role of the primary care physician in problems of substance abuse. Arch Intern Med (1960). 1999;159:913–24. https://doi.org/10.1001/ archinte.159.9.913. 2. Weaver MF, Schnoll SH.  Drug overdose and withdrawal syndromes. Curr Opin Crit Care. 1996;2:242–7. https://doi.org/10.1097/00075198-­199606000-­00016. 3. Weaver MF. Dealing with the DTs: managing alcohol withdrawal in hospitalized individuals. Hospitalist. 2007;11:22–5. 4. Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. JAMA. 1997;278:144–51. 5. Wong J, Saver B, Scanlan JM, Gianutsos LP, Bhakta Y, Walsh J, et al. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S):1–72. 6. Weaver M, Jewell C, Tomlinson J. Phenobarbital for treatment of alcohol withdrawal. J Addict Nurs. 2009;20:1–5. https://doi.org/10.1080/10884600802693066. 7. Weaver MF, Hoffman HJ, Johnson RE, Mauck K. Alcohol withdrawal pharmacotherapy for in individuals with medical comorbidity. J Addict Dis. 2006;25:17–24. https://doi.org/10.1300/ j069v25n02_03. 8. Weaver MF. Substance-related disorders. In: Levenson JL, editor. Textbook of psychosomatic medicine and consultation-liaison psychiatry. 3rd ed. Washington, DC: American Psychiatric Association Publishing; 2018. p. 435–62. 9. Slomski A.  Gabapentin treats alcohol use disorder with withdrawal symptoms. JAMA. 2020;323:1999. https://doi.org/10.1001/jama.2020.7969. 10. Saitz R. Introduction to alcohol withdrawal. Alcohol Health Res World. 1998;22:5–12. 11. Gold JA, Rimal B, Nolan A, Nelson LS. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007;35:724–30. 12. Brotherton AL, Hamilton EP, Kloss HG, Hammond DA. Propofol for treatment of refractory alcohol withdrawal syndrome: a review of the literature. Pharmacotherapy. 2016;36:433–42. 13. Linn DD, Loeser KC. Dexmedetomidine for alcohol withdrawal syndrome. Ann Pharmacother. 2015;49:1336–4. 14. Liu J, Wang LN.  Baclofen for alcohol withdrawal. Cochrane Database Syst Rev. 2015;4:CD008502. 15. Wong A, Benedict NJ, Armahizer MJ, Kane-Gill SL.  Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015;49:14–9.

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16. Hadama A, Ieiri I, Otsubo K, Morita T, Kimura M, Urae A, et al. P-hydroxylation of phenobarbital: relationship to (S) mephenytoin hydroxylation (CYP2C19) polymorphism. Ther Drug Monit. 2001;23:115–8. 17. Olkkola KT, Ahonen J.  Midazolam and other benzodiazepines. Handb Exp Pharmacol. 2008;182:335–60. 18. McKeon A, Frye MA, Delanty N.  The alcohol withdrawal syndrome. J Neurol Neurosurg Psychiatry. 2008;79:854–62. https://doi.org/10.1136/jnnp.2007.128322. 19. Reus VI, Fochtmann LJ, Bukstein O, Eyler AE, Hilty DM, Horvitz-Lennon M, et  al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatr. 2018;175:1. 20. Jarosz J, Miernik K, Wąchal M, Walczak J, Krumpl G. Naltrexone (50 mg) plus psychotherapy in alcohol-dependent individuals: a meta-analysis of randomized controlled trials. Am J Drug Alcohol Abuse. 2013;39:144–60. 21. Weaver MF: Alcohol. In: Addiction treatment. Newburyport, MA: Carlat Publishing; 2017,p.93–116. 22. Vickers AP, Jolly A. Naltrexone and problems in pain management. BMJ. 2006;332:132–3. 23. Plosker GL. Acamprosate: a review of its use in alcohol dependence. Drugs. 2015;75:1255–68. 24. Leung JG, Hall-Flavin D, Nelson S, Schmidt KA, Schak KM. The role of gabapentin in the management of alcohol withdrawal and dependence. Ann Pharmacother. 2015;49:897–906. https://doi.org/10.1177/1060028015585849. 25. Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A.  Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med. 2014;174:70–7. https:// doi.org/10.1001/jamainternmed.2013.11950. 26. Weaver MF. Prescription sedative misuse and abuse. Yale J Biol Med. 2015;88:247–56. 27. McHugh KR, Hearon BA, Otto MA. Cognitive behavioral therapy for substance use disorders. Psychiatr Clin North Am. 2010;33:511–25. https://doi.org/10.1016/j.psc.2010.04.012. 28. Betancourt JR, Green AR, Carrillo JE, Owusu Ananeh-Firempong II. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2016;118:293–302. 29. Baciu A, Negussie Y, Geller A, Weinstein JN.  Communities in action: pathways to health equity. Washington, DC: National Academies Press; 2017. 30. Clark CD, Weaver MF. Balancing beneficence and autonomy. Am J Bioeth. 2015;15:62–3. 31. Gillon R. Ethics needs principles—four can encompass the rest—and respect for autonomy should be “first among equals”. J Med Ethics. 2003;29:307–12. 32. Klag S, O’Callaghan F, Creed P.  The use of legal coercion in the treatment of substance abusers: a an overview and critical analysis of thirty years of research. Subst Use Misuse. 2005;40:1777–95. 33. Weaver MF. Choices for patients and clinicians: ethics and legal issues. In: Saitz R, editor. Addressing unhealthy alcohol use in primary care. New York: Springer; 2013. p. 195–205.

To Learn More Wong J, Saver B, Scanlan JM, Gianutsos LP, Bhakta Y, Walsh J, et al. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S):1–72. Saitz R, editor. Addressing unhealthy alcohol use in primary care. New York: Springer; 2013. Reus VI, Fochtmann LJ, Bukstein O, Eyler AE, Hilty DM, Horvitz-Lennon M, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018;175:1. Weaver MF. Addiction treatment. Newburyport, MA: Carlat Publishing; 2017.

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Learning Outcomes The reader will be able to: • Understand how hospital detoxification used to work in comparison to how it works today • Understand the assessment process • Understand the inpatient detoxification process and drugs used • Understand hospital-based therapy • Understand the process of discharge and how future care is organised • Understand the importance of follow-up care and intervention

20.1 Introduction Since 2005, the overall amount of alcohol consumed in the UK, the proportion of people reporting drinking, and the amount drinkers report consuming have all fallen [1]. That is not to say that alcohol use is not still a major problem in the UK and many other countries. Alcohol use is thought of as a ‘normal’ part of life for many, a rite of passage for teenagers, and an essential part of celebrations and funerals. In 2017, 20% of the population reported that they did not drink at all; however, 24% of adults drink over the Chief Medical Officers recommended safe levels of 14 or less units/week, and 27% drink more than 6 units for females and 8 units for males in one session [2, 3].

F. Robinson (*) Drug and Alcohol Service, i-access East, Surrey, and Borders Partnership NHS Foundation Trust, Redhill, UK Horsham, West Sussex, UK © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_20

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The majority of the population therefore expect to be able to drink ‘normally’. That is to ‘take it or leave it’, to know when they have had enough. The audit score brings out the fundamental areas where people with alcohol problems struggle [4] (for a more in-depth view of alcohol use, see Chap. 2). Alcohol-related hospital admissions are divided into those directly attributable to alcohol and those where alcohol may be a secondary contributor. Moreover, there are a proportion where the reason for admission is unrelated to alcohol but where alcohol withdrawal is an ‘incidental’ finding. It is, therefore, essential that all admitted individuals, in all hospital-based services, are asked about their alcohol consumption. Accurate identification of people drinking over safe levels allows appropriate advice, monitoring and management. We all have pre-conceptions of which people might have alcohol problems, and of those unlikely to drink to excess, which can influence how and what we ask individuals admitted to hospital. It is, therefore, essential to make questions on alcohol use a routine part of history taking and ensure we are not using language or inflections that might be heard as judgemental by the individual (see Chaps. 3–6). Reflective Practice Exercise 20.1 Who do you feel might develop alcohol problems? In the following examples, what is your first thought? Reflect on why? • A 72-year-old retired GP is admitted following a fall at home. • A 19-year-old unemployed man, admitted on a Friday evening with abdominal pain. • A 48-year-old homeless man with jaundice. • A 36-year-old Asian businessman with chest pain. It is suggested that health professionals are more likely to develop a dependency on alcohol and substances in comparison to the general population [5]. Retirement often causes a loss of status. The person may have been forced to retire even though he or she does not feel ready to do so, as can early retirement through health-related problems. This causes grief for the loss of their position, responsibilities and respect associated with working relationships. People who promise to keep in touch fail to follow that through as time goes by leading to increased loneliness. Falls are common in the elderly as instability may increase, especially in those experiencing health problems (see Chap. 15). Moreover, the death of people we know and love and the loss of a spouse causes bereavement and grief and may lead to excessive alcohol use to ease the pain of losing the loved one. Young people are the one group whose alcohol use has reduced over recent years [6] However, some young adults have experiences of alcohol use at an early age or associated to parental alcohol use and attitudes towards teenage drinking (see Chap. 11). Jaundice could be due to alcoholic liver disease, blood-borne viruses (BBV’s), or malignancy (see Chaps. 6 and 24). Homeless people often fail to access health services timely; consequently, the impact on the health problem is increased. Such problems will require careful hospital detoxification and careful planning of care.

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Only 43% of Asians in the UK are Muslims [7]. Not all individuals conform to all beliefs of a religion (see Chap. 3). It is imperative that the individual is understood and heard, with an interpreter or language speaking care professional in attendance. It is important to be aware of all cultural needs and especially of stigma associated with cultures. Identifying those who may be at risk of developing withdrawal symptoms requires thorough assessment. For a more detailed view of assessment of alcohol problems, see Chap. 10. In the past, individuals who might develop alcohol withdrawals when admitted to hospital were prescribed a detoxification regime based on the amount they were drinking and the history. However, in the past 5 years, there has been a move to monitoring those who may withdraw and only prescribing a regime if they exhibit withdrawals symptoms, as described by NICE guidelines [8]. The general impression is that this has reduced the numbers of individuals who require medicated alcohol withdrawal [9].

20.2 Assessment A knowledge of a hospital-based assessment is essential before proceeding with any treatment and interventions. Moreover, the professional must be non-judgement in his or her approach. It is imperative to discuss these problems and progress the assessment at a pace that is acceptable to the individual. In addition, it may be helpful to include the family in discussions if that is the individuals wish, for a broader picture of alcohol use. Corroboration from family or carers can be very helpful if the individual is unable to give a clear account of their alcohol use or if there is a high suspicion that the person is being unclear about his/her alcohol use, for fear of stigma or judgement by the professional (see Chap. 8). Key areas to cover in assessment must include: • What about alcohol, how often would you have a drink? • Gather details of amount and frequency and calculate the units/week. • It is important to be patient and ensure the individual is comfortable with you to enable the individual to openly disclose the actual amount of alcohol consumed on any one drinking occasion. This will enable to professional to gather sufficient information to accurately determine the units of alcohol consumed. • What strength of lager is that? What size of wine glass? Is that pub or home measures of spirits? This is important so the correct intervention is provided to meet the individual’s needs. Drinking above 14 units but under 35 units for women and 50 units for men in a week is termed hazardous. Increasing level over a period can be harmful and needs to be investigated thoroughly. If the professional identifies that the individual is drinking over recommended levels but not harmful amounts, it is an opportunity to deliver a brief intervention (see Chaps. 16 and 17).

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It is important to ascertain if the individual is prescribed any regular medication and also if they are taking it as directed. A number of medications, e.g. benzodiazepines or gabapentinoids, may be misused to ameliorate withdrawal symptoms. Ask the individual or family what medication they are taking and if they are prescribed by a healthcare professional, over-the-counter drug, bought online, or illicit drugs. The proliferation of Internet ‘pharmacies’ has led to people obtaining medications without prescriptions. This is not just a ‘younger generation’ occurrence and requires careful, non-judgemental assessment by the professional. The professional’s role always is never to judge and to demonstrate they are caring and willing to listen to the individual. It is important to know about benzodiazepine use as this can mask alcohol withdrawal and affect the amount needed to be prescribed during detoxification, if appropriate. Further, the professional should look at daily consumption of alcohol and to what extent the individual may experience alcohol and/or other substance use withdrawal symptoms. Alcohol withdrawal symptoms typically start to develop 6–24  h after the last drink. It is a self-limiting condition characterised by symptoms of autonomic overactivity. Symptoms are like those experienced in anxiety or panic attacks, and they will of course be relieved by drinking alcohol. • • • • • • •

Tachycardia Hypertension Insomnia Nausea Anxiety Tremor Seizures

20.3 Withdrawal Management Complications 20.3.1 Alcohol Withdrawal Seizures Many alcohol-dependent people will never experience an alcohol withdrawal seizure. However, it is not possible to determine who will and who will not. It is, however, known that individuals who have undergone frequent alcohol withdrawals or detoxifications can experiencing kindling, meaning the chance of having a seizure increases each time an attempt is made to withdraw alcohol. The seizures are of generalised tonic-clonic type, and they can progress to status epilepticus and death.

20.3.2 Delirium Tremens Delirium tremens (DT’s) can develop over a 24–72-h period following cessation of last alcohol-based drink. Delirium tremens has a mortality rate of 15–30% if

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untreated. It should be treated as a medical emergency and the individual carefully managed in a general hospital service [10].

20.3.2.1 Characteristic Symptoms • Confusion and clouded consciousness • Vivid illusions and hallucinations • Marked Tremor 20.3.2.2 Associated Symptoms • Delusions • Agitation • Insomnia • Marked anxiety • Autonomic over activity 20.3.2.3 Complications Complications may include: • • • •

Cardiac arrhythmias Acute hallucinations in clear consciousness often causing self-harm Withdrawal seizures Fluid and metabolic disturbances

Reflective Practice Exercise 20.2 Reflect on what could happen if we fail to identify drinking behaviour that is detrimental to the individual’s health and could lead to alcohol withdrawal symptoms. Failure to identify people who may develop alcohol withdrawal and possible complications can arise if the person decides to leave the healthcare setting to obtain alcohol. Consequently, the individual is in danger of suffering a seizure. This may lead to the development of confusion and agitation … this often occurs when the individual is trying to leave the hospital. The individual can become aggressive and a danger to themselves and others, if the withdrawal is not managed appropriately. Furthermore, they may die! [11].

20.4 Family and Significant Others Alcohol dependence is poorly understood by healthcare workers and the public alike. Individuals may face stigma and judgemental views. Family members may exhort professionals to ‘lock up’ their relatives, or ‘dry them out’, believing that a period of hospitalisation will effect a cure. They can feel angry with the individual, and this can spill out to professionals who do not facilitate the ‘cure’. Moreover, they may feel angry with themselves for not being able to help the family member in their time of need.

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Patience and an explanation of the nature of alcohol dependence may not be heard. However, it is important not to get embroiled in trying to help the situation by facilitating emergency ‘detoxification’, which is unlikely to bring about any long-lasting change. Facilitating the family or significant other to contact a local support agency can be helpful. Moreover, the professional must listen and ‘hear’ what is being said and, by listening, will understand how best to support the family and significant others. The organisation Al-Anon can be helpful for some individuals. However, it is important to remember that this may not be appropriate for all family members (see Chap. 8).

20.5 Safeguarding and Social Care Through the course of their alcohol use, many individuals lose family, friends, jobs and the ability to care for themselves. It is an important aspect of caring for people experiencing alcohol-related problems to assess what their home environment and situation is like. Most people like to leave their house clean and tidy before they go away on holiday. Have you thought about why this is? So that rested feeling is not disrupted by arriving home to find ‘the mess you left behind’. Imagine then if, following a period of hospitalisation for an illness and alcohol withdrawal management the individual goes back to her/his home, which is dirty, full of empty cans or bottles and generally in disarray … having a drink to blot it all out might be the likely outcome! Full preparation prior to discharge from the hospital setting must be undertaken to ensure there is adequate support to meet the individuals needs and chosen goals. The individual should never be discharged on a Friday or over the weekend if support is not available at the time. Organising proper support does take time but in the long-term may prevent readmission.

20.6 Withdrawal Management Having identified those who may be alcohol dependant it is essential to closely monitor for withdrawal symptoms. The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, (CIWA-Ar) is a validated tool that gives an objective measure of alcohol withdrawals and whether medication is required [12]. This assessment for monitoring withdrawal symptoms requires approximately 5  min to administer. Scoring should be performed 8-hourly for the first 24–48 h. The individual, family or significant others should be encouraged to alert a professional if they perceive the individual is experiencing symptoms in between these times. Moreover, the individual must feel adequately supported to approach the professional if she/he suspect they are experiencing alcohol withdrawal symptoms, no matter how minor they feel they are. The scoring also incorporates routine observations of Pulse, BP, respiratory rate, and PO2.

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Total Score = 0 − 9 : absent or minimal withdrawal



= 10 − 19 : mild to moderate withdrawal



= more than 20 : severe withdrawal

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A person scoring less than 10 does not usually need medication for withdrawal. However, medication should be given if the scoring is greater than 15. It is important to remember that such tools are a means of collecting information. However, they should never be used solely to identify withdrawal symptoms and should never exclude appropriate observation by the professional. Fixed-dose or symptom-triggered medication regimens can be used in assisted withdrawal programmes in hospital settings. If a symptom-triggered regimen is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely. Most settings use a mixture of both, with symptom triggered medication dosing then forming a fixed dose regime from day 2 or 3. After 24–36 h the total daily amount of medication required to control symptoms should be converted into a fixed decreasing dose regime, the duration of which can be decided daily. All fixed dose regimes should reduce to zero. Additional medication for breakthrough symptoms should be available for the first 72 h.

20.7 Choice of Medication Used in Alcohol Withdrawal Management The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam) in the UK (see Chap. 19). However, there is no evidence that either is more effective [13]. In settings where medication may be diverted then chlordiazepoxide is preferable as it does not have a street value.

20.7.1 Other Medications All individuals who are suspected of being alcohol dependent should be prescribed either intra-venous (IV) or per rectum (PR) Diazepam to be used in the event of a seizure. The B group of vitamins have an integral role in the Krebs cycle (also known as the citric acid cycle or the tricarboxylic acid cycle) is one of the most important reaction sequences in biochemistry. Hans A Krebs described this as the cycle of chemical reactions that are the major source of energy in living organisms [14]. They ensure the metabolism of pyruvic acid, the product of glycolysis; the active form of thiamine, is involved in the maintenance of myelin sheaths. Thiamine absorption normally occurs in the small intestine, but uptake is inhibited by alcohol.

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Thiamine (100 mg three times daily) can be considered for prescription if the individual is at risk and/or a dependent drinker admitted to hospital. This should be continued on discharge for 4–6 weeks if abstinence continues, or indefinitely if they return to alcohol use. Parenteral thiamine should be given to all alcohol dependent people admitted to a general hospital with an acute physical illness or injury. If alcohol dependence is identified during a planned hospital admission, e.g. an operation, or to a mental health ward (see Chap. 5), then it should be given to any person judged to be malnourished, with decompensated liver disease, or any concerns regarding cognitive functioning. Chronic alcohol dependence with malnutrition in susceptible individuals can lead to Wernicke-Korsakoff Syndrome [15] (see Chap. 6). Untreated, this carries a mortality rate of up to 75%. Survivors have a very high chance of developing permanent brain damage [16]. When an individual experiencing alcohol-related problems presents to the healthcare professional, there can be lengthy delays before they arrive at their bed on the ward, where they will be cared for. Given the development of withdrawal symptoms over time, it is therefore important that: • Those at risk of withdrawing are identified at initial presentation. • Monitoring must be instigated and continued during transit processes; this may be waiting in the emergency department, a short-term assessment unit before a bed is found, or in a mental health sect. 136 suite. Police can use this section if the individual is believed to be experiencing mental ill-health and in need of care and control. The individual can be taken to a place of safety. One of the options is to stay in a police station until appropriate assessment and help can be given. • While going for an investigation before arrival at a ward. • For transfer between organisations, it is essential that documentation (or copies thereof) accompany the individual so all information about monitoring and prescribing can be reviewed. Reflective Practice Exercise 20.3 Think about the health system you work within. None of us would like to think that there were periods when an individual might be at increased risk of their condition worsening or developing serious complications. However, the fact is that not all systems have them! Consider one or two things that you could do to improve the situation for this group of individuals in your own work environment?

20.8 Management During Admission and on Discharge Reflective Practice Exercise 20.4 Having identified that an individual is alcohol dependent or drinking hazardous amounts of alcohol, it is essential that they are given further information, support, and onward referral. Reflect on what happens in your current setting?

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Unfortunately, this part of care management frequently gets neglected. Many people who have a medical detoxification believe they will be able to carry on their lives without further problems; they feel physically and mentally better and often have absolutely no understanding of the nature of dependence [17]. Surprisingly, many healthcare professionals have the same beliefs [18]. Dependence is more than a ‘bad habit’, it is a complex psychological condition combined with the use of alcohol and a strong physical dependence. All individuals identified should be advised (not told) to continue abstinence from alcohol and access additional support. Many general hospitals now have alcohol care professionals although the size and scope of these teams varies enormously, often only being one nurse. It is really useful to have these more specialised professionals to offer advice to the individual, family, significant others, and the professional. It does not, however, negate the obligation for all professionals to understand alcohol problems and how to manage them.

20.9 Post-Detoxification Intervention It is imperative that the professional is aware that detoxification is not the end of the intervention. On hospital discharge, the individual (and the family) will still need ongoing care and support. Indeed, it is merely the beginning of intervention, and aftercare should be prepared at the outset. Whatever the individual decides is best, follow-up intervention needs to be planned. The individual must be introduced to the ongoing care and treatment service before discharge from hospital, preferably to a named individual. Effectively, follow-up intervention preparation should begin at the commencement of the detoxification and not as an add on post-detoxification, so there is a reliable continuation of care. However, it is important to be guided by the individual as to what aftercare she/he feels is appropriate to their needs. What is available in one area or country may not be available in another area or country. Alcoholics anonymous (AA) is a unique, worldwide organisation, which provides support for millions of people to live in recovery from alcohol addiction. SMART (Self-Management and Recovery Training) is another self-help organisation that has grown in popularity in recent years. There are in the UK voluntary sector services, mainly charities when ongoing support and intervention is available. Local services can provide information on their referral processes and what they are able to provide. Some individuals prefer to refer themselves as this indicates motivation to address their alcohol problem. While this is appropriate in many cases, there are situations where it is preferrable for professionals to make a referral.

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Self-Assessment Exercise Which of these situations would merit a professional referral? All individuals were alcohol dependent and required medically assisted detoxification. • • • • •

Denise (52) admitted for a hysterectomy. Henry (58) admitted after a fall where there was evidence of self-neglect. Lucy (23) admitted to a mental health ward following a suicide attempt. John (40) admitted with chest pain. Chris (27) admitted with alcoholic hepatitis.

In some areas or hospitals, either the alcohol care team or the community alcohol service may be able to continue the detoxification to its conclusion in the community (see Chap. 21). The individual can leave hospital if appropriate and continue treatment as an outpatient. These services will also offer psychosocial support and recovery support.

20.10 Conclusion Dependence on alcohol or other substances is exceptionally difficult to treat successfully and is generally thought of as a relapsing, chronic condition. The attitudes of the individual, their friends, and family; professionals; and society all confound the correct identification, education, and management, supporting individuals to access appropriate support. Hospital admission for any reason can be an opportunity for empathetic and non-judgemental discussion around alcohol, with safe and effective management of withdrawals being the starting point for the individual’s journey to recovery from their addiction.

References 1. Statistics on Alcohol, England 2020. Office for National Statistics. 2020. https://digital.nhs.uk/ data-and-information/publications/statistical/statistics-on-alcohol. 2. Adult Drinking Habits in Great Britain, 2017. Office for National Statistics. 2018. https://www. ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/ bulletins/opinionsandlifestylesurveyadultdrinkinghabitsingreatbritain/2017. 3. Burton R, et al. The public health burden of alcohol and the effectiveness and cost-­effectiveness of alcohol control policies: an evidence review. PHE Publications. 2016. https://www.gov.uk/ government/publications/the-public-health-burden-of-alcohol-evidence-review. 4. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M.  Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II. Addiction. 1993;88:791–804. https://doi. org/10.1111/j.1360-­0443.1993.tb02093.x. 5. Baldisseri M. Impaired healthcare professional. Crit Care Med. 2007;35(Suppl 2):S106–16. https://doi.org/10.1097/01.CCM.0000252918.87746.96.

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6. Smoking, drinking and drug use among young people in England 2018. Office for National Statistics. 2019. https://digital.nhs.uk/data-and-information/publications/statistical/ smoking-drinking-and-drug-use-among-young-people-in-england/2018. 7. 2011 census—office for national statistics. https://www.ons.gov.uk/census/2011census. 8. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence Clinical guideline (CG115). NICE Guidance. 2011. https:// www.nice.org.uk/guidance/cg115/evidence/full-guideline-136423405. 9. Melkonian A, Patel R, Magh A, Ferm S, Hwang C. Assessment of a hospital-wide CIWA-Ar protocol for management of alcohol withdrawal syndrome. Mayo Clin Proc Innov Qual Outcomes. 2019;3(3):344–9. https://doi.org/10.1016/j.mayocpiqo.2019.06.005. 10. Schuckit MA.  Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med. 2014;371(22):2109–13. https://doi.org/10.1056/NEJMra1407298. 11. Ignjatovic-Ristic D, Rancic N, Novokmet S, Jankovic S, Stefanovic S. Risk factors for lethal outcome in patients with delirium tremens—psychiatrist’s perspective: a nested case-control study. Ann General Psychiatry. 2013;12(1):39. https://doi.org/10.1186/1744-­859X-­12-­39. 12. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353–7. https://doi.org/10.1111/j.1360-­0443.1989.tb00737.x. 13. Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010;3:CD005063. https://doi.org/10.1002/14651858.CD005063.pub3. 14. Krebs HA, Johnson WA.  Metabolism of ketonic acids in animal tissues. Biochem J. 1937;31(4):645–60. https://doi.org/10.1042/bj0310645. 15. Torvik A.  Wernicke’s encephalopathy—prevalence and clinical spectrum. Alcohol Alcohol Suppl. 1991;1:381–4. 16. Sanvisens A, Zuluaga P, Fuster D, Rivas I, Tor J, Marcos M, Chamorro AJ, Muga R. Long-term mortality of patients with an alcohol-related Wernicke-Korsakoff syndrome. Alcohol Alcohol. 2017;52(4):466–71. https://doi.org/10.1093/alcalc/agx013. 17. McGovern MP, Caputo GC.  Outcome prediction of inpatient alcohol detoxification. Addict Behav. 1983;8(2):167–71. https://doi.org/10.1016/0306-­4603(83)90010-­2. 18. Clay SW, Allen J, Parran T.  A review of addiction. Postgrad Med. 2008;120(2):E01–E7. https://doi.org/10.3810/pgm.2008.07.1802.

To Learn More Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. Clinical guideline [CG115] Published: 23 February 2011. NICE Guidance. https://www.nice.org.uk/guidance/cg115 Alcohol-use disorders: diagnosis and management of physical complications. Clinical guideline [CG100] Published: 02 June 2010. https://www.nice.org.uk/guidance/cg100 Alcohol dependence and withdrawal in the acute hospital. Royal college of physicians 2012. https:// www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-andwithdrawal-acute-hospital Alcohol withdrawal - Symptoms, diagnosis and treatment. BMJ Best Practice 2020

Home Withdrawal Management

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David B. Cooper

Leaning Outcome • To appreciate the importance of a safe home • To appreciate the importance of an ethically safe detoxification procedure • To appreciate the function of medication used for the home detoxification • To understand the need for vitamin replacement when alcohol is removed from the system of the individual

21.1 Home Withdrawal Management Prereading Exercise 21.1 For 1 week, stop using your favourite substance, e.g. tea, coffee, alcohol, chocolate or tobacco. Each day, and at the end of the week, make a few notes of the following: • • • • • •

How easy did you find it to live without your favourite substance? Was your mood affected? If so, in what way? Did you experience craving or any other symptoms? What strategies did you use to avoid using your favourite substance? What worked and what did not work?

D. B. Cooper (*) Drug and Alcohol Research Centre, Middlesex University, Horsham, West Sussex, UK © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_21

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21.2 Definitions 21.2.1 Detoxification • The process of removing harmful or toxic chemicals [1] • The process of giving medical treatment to remove the effects of poisoning from alcohol [1]

21.3 Introduction Alcohol detoxification is the beginning of a treatment intervention to remove alcohol from the individual’s physical system. Once this is completed… and preparation must start at the beginning… there is still much to be done by the professional and individual to maintain that persons chosen goals, whatever they may be. It is not a one off, once and for all treatment. It is singularly a process to remove alcohol from the body (see Chaps. 18, 19, 22, and 23). Key Point 21.1 Home alcohol detoxification involves a specific clinical procedure and should be undertaken by a qualified professional, who has undergone a period of training and supervision and whose level of competence has been affirmed. Ideally, an open referral system should be considered for community withdrawal management, i.e. medical doctor (MD—general practitioner GP), other professionals, voluntary sector services, the individual his or her self, family and significant others. The withdrawal procedure itself and the correct assessment procedure should be followed. It is important to bear in mind that the individual experiencing the alcohol use problem agrees to an assessment, exactly what this entails and what is required of that person and professional. At the beginning, there is a need to ensure that there is always appropriate support throughout the detoxification procedure. It is not enough, or ethical practice, to give the individual a bottle of tablets to assist reducing the effects of withdrawal and be allowed to proceed unsupported.

21.4 Assessment Flowchart 21.1 offers a withdrawal management flowchart that can be used when planning and throughout the withdrawal procedure.

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21  Home Withdrawal Management Request for withdrawal management assessment received Stage 3

Stage 2

Stage 1

HD initial steps

HD preparation

Check with GP—physical exam, medical problems, agree suitability, GP agrees to prescribe drugs/act as Responsible Medical Officer Take BP, T & P. Devise and agree care plan with individual and primary supporting person. Explain/discuss/agree alcohol withdrawal with the individual/family— give monitoring leaflet. Agree level of supervision. Discuss medication & monitoring. Request permission to take blood tests if required. Request permission to breathalyze. Discuss relapse & management. Sign contract/consent forms. Advise, support, reassure etc. Record in individual clinical record.

Agree start day/time. Arrange collection of medication. Give/explain medication monitoring form. Explain drug sideeffects/observations/ actions. Give crisis contact name & number. Check all alcohol/drugs removed from Premises together with the person. Discuss relapse & management. Agree individual has stopped drinking. Advise, support, reassure etc. Record in individual clinical record.

Initial assessment Assess suitability/risk & establish need .Check: previous withdrawal; home environment; physical & psychological state; family situation. Use chosen assessment tools and personal observation during assessment. Ascertain level of support required. Record in individual clinical record

NOT SUITABLE Hospital alcohol withdrawal. Health education Controlled drinking Social drinking Ascertain level of support required. Record in individual clinical record Person exits Other intervention

Stage 6 Home Withdrawal Management Ends Revise/review care plan Remind regarding follow-up care Assess and evaluate Ascertain level of support required. Confirm continuing care intervention Record in individual clinical records

Exit Home Withdrawal Management

S U I T A B L E

S U I T A B L E

NOT SUITABLE Hospital withdrawal management Other intervention Person exits Stage 5

Stage 4 Daily Supervision

Monitor withdrawal/review medication Complete symptom severity check, Blood Pressure & temperature, and pulse Take blood test if required Evaluate/review/revise care plan Advise/counsel, reassure & support etc Introduce follow-up member of staff/counsellor asap, if Home Withdrawal Management clinician is not to remain key worker Discuss relapse & management Review crisis contact procedure Agree daily visit or agreed level of visits If within agreed limits, proceed with Home Withdrawal Management Ascertain level of support required. Record in individual clinical record

WITHDRAWAL UNCONTROLLED Hospital Withdrawal Management

RELAPSE Assess/develop strategy/identify relapse factors/discuss Hospital Withdrawal Management Continue Home Withdrawal Management Individual elects to exit

Flowchart 21.1  Home withdrawal management [2]

Commencing Home Withdrawal Management Check alcohol consumption as agreed Complete symptom check Take blood test if needed Commence medication/re-advise regarding monitoring Take Blood Pressure, temperature, and pulse Discuss relapse management Review crisis contact procedure Commence Home Withdrawal Management if assessed within agreed limits Agree daily visits Inform Medical Practitioner Home Withdrawal Management has commenced Revise/review care plan Ascertain level of support required. Record in individual clinical record

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21.4.1 Assessment of Suitability Assessment for home withdrawal management should be carried out by a suitably qualified community clinician (e.g. alcohol clinical nurse specialist), with a recognised level of competence to supervise the alcohol withdrawal in the home environment. Ideally, assessment of the individual at home should be undertaken within 24–48  h of the referral being received. The decision to clinically commence and support the home withdrawal from alcohol should be that of the supervising clinician and is not something that should be delegated. The initial assessment procedure addresses two questions: 1. Is there a need for medication to manage alcohol withdrawal symptoms? 2. Are there strong reasons for not keeping the individual withdrawing from alcohol at home whilst the withdrawal is being monitored and that medication is taken in the home environment for the withdrawal? When establishing the need for the home withdrawal management, it is essential that the individual experiencing the alcohol-related problem expresses a clear wish to work alongside the clinician during the withdrawal period. In addition, the supporting person or persons are clear about the procedure and that alcohol should not be consumed during the withdrawal period. It is not the clinician’s role to ‘hard sell’ the home withdrawal procedure.

21.4.2 History Taking within the Home Environment A complete assessment of the individual experiencing the problem (see Chap. 10) is important to establish the individual’s use of alcohol and the impact this has had on the individual’s life. There are various tools to aid assessment. However, it should be stressed that such a tool merely assists in the process of identification and cannot replace the observations of the person, more importantly, what the person says and does not say. The key five areas requiring assessment are: 1. Physical withdrawal signs and symptoms 2. Affective withdrawal signs 3. Withdrawal relief drinking 4. Quantity and frequency of alcohol consumption 5. Rapidity of onset of withdrawal symptom following a period of abstinence Depending on the country, different assessment tools can be used. These tools include: • Severity of Alcohol Dependence Questionnaire (SADQ) • The revised Clinical Institute Withdrawal Assessment for Alcohol Scale Assessment (CIWA-Ar) • Alcohol use Disorders Identification Test (AUDIT)

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Each explores the impact of alcohol use on the individual and the level of alcohol consumption. The Alcohol Use Symptom Severity Test can be used during daily assessment by the individual to aid the monitoring of withdrawal symptoms.

21.4.3 Home Environment It is as important to assess the home environment as it is to look at the physical and psychological impact of alcohol use on the individual and family. An environment with intense noise, unruly children or drinking supporters who live in the home, who will continue to consume alcohol whilst withdrawal is in progress, would be unhelpful in inducing a calm atmosphere and environment for the person who is undertaking the alcohol withdrawal. Key Point 21.2 Moreover, it is essential to check who will be supporting the person experiencing the withdrawal. The family, usually a spouse or partner, may have had years of promises about reducing alcohol intake from the person, and the relationship may be strained for many reasons (see Chap. 8). Drinking friends who visit often and alcohol use within the home are not conducive to home alcohol withdrawal.

21.5 Signs and Symptoms of Alcohol Withdrawal Signs and symptoms of the action of alcohol leaving the body in a person, who is mildly dependent or chronically dependent, can be physical and psychological and may include: • • • • • • • • • • • • • • • • • •

Headaches Depression Irritability Increased blood pressure Breathing problems, e.g. rapid abnormal breathing Anxiety Sweating Tremors, ‘shakes’ Uncontrolled restlessness Pulse rate above 100 beats per min, indicating increased heart rate Insomnia Nausea Vomiting Fatigue Mood changes Gastrointestinal disturbances Loss of appetite Heart palpitations

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• Hyperthermia • Hallucinations • Seizures [3–6] It is important that the individual and the supporting person are competent to recognise the above signs and to feel able to report them to the specialist community alcohol nurse, medical doctor/general practitioner (MD, GP) or other clinician when concern relates to these signs and symptoms.

21.6 Frequency of Home Visits A home visit is essential by the specialist community alcohol nurse (or supervising clinician) once or twice daily for the first 4 days. A face-to-face visit is essential as, at this stage, a telephone conversation will not provide the actual eye view of potential withdrawal symptoms and could delay essential immediate action required when symptoms are severe. This could indicate an increase or decrease in oral medication or in case of severe withdrawal and continuation of the detoxification procedure within the hospital environment.

21.7 The Procedure Once the home withdrawal management has been agreed, the procedure is explained to the individual and the supporting person, who will remain with the individual throughout the detoxification process. A care plan can then be organized and agreed, and the home withdrawal procedure can commence.

21.7.1 Physical Tests 1. Blood pressure 2. Temperature 3. Pulse The procedure for home withdrawal management requires a responsible medical professional who is prepared to prescribe the appropriate medication. Once agreed and the duration for alcohol withdrawal medication agreed—usually 7 to 9 days— the medication of choice depends on the country. In the United Kingdom, the tendency is to prescribe a reducing dose of chlordiazepoxide. The clinical nurse specialist supervising the detoxification will have the authority to titrate the dose, as needed, through the detoxification procedure. Dose initially prescribed may be: • Day 1—25–30 mg four times daily (QDS) • Day 2—20 mg four times daily (QDS)

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Day 3—15 mg four times daily (QDS) Day 4—10 mg four times daily (QDS) Day 5—5 mg twice daily (BD) Day 6—5 mg twice daily (BD) Day 7—5 mg daily (OD)

This can be increased or decreased as the assessment and procedure progresses.

21.8 Vitamin Replacement People experiencing alcohol dependence are at risk of developing Wernicke’s encephalopathy. The individual undergoing the detoxification process may have a very poor diet or and liver disease whilst drinking, and as such, the essential vitamins required to prevent Wernicke Encephalopathy due to depleted thiamine deficiency are needed. Prophylactic drug therapy to replace the vitamin deficiency is essential for all individuals undergoing alcohol home detoxification. Vitamins B1 (thiamine), B6 (pyridoxine) and C (ascorbic acid) are important nutrients normally deficient in people who consume excessive amounts of alcohol. Therefore, replacement of these vitamins is essential as a preventative measure. Parenteral thiamine 250–300  mg should be given for 3–5  days; the dose for higher risk of thiamine deficiency is 250–500 mg. This should then be given orally for as long as is required [7].

21.8.1 Commencing Home Alcohol Withdrawal Once it is agreed with the individual, supporter and the responsible medical officer that the individual is ethically safe to undergo the withdrawal period at home, then a start date should be agreed. The individual and supporter should be visited once or twice on days 1 to 3 or 4. It is essential that these visits are in person by the specialist alcohol community nurse or appropriately qualified clinician, as not all areas of concern may be discovered by telephone conversation, especially uncontrolled visibly recognised withdrawal symptoms. If all progresses are agreed, then telephone calls daily will be beneficial for the individual and supporting persons(s). It should have been agreed at the outset of the assessment what the individual’s chosen goals are and the ongoing support that will be needed post-detoxification. Early during the first few days of withdrawal, the individual should meet who it is that will be supplying follow-on support, whatever that may be. It is unethical to leave this until the last day. Moreover, to end contact with the individual and supporter on a Friday with no follow-on support available until the Monday is poor practice and unethical.

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21.9 Conclusion This chapter describes the procedure to assist an individual withdraw from alcohol safely within the home environment. Appropriate support by the clinically responsible person should happen daily until the alcohol withdrawal is completed. Above describes the procedure for home withdrawal management. There is essential pre-detoxification preparation that is explained in Chap. 18. Medication use during alcohol detoxification and post-withdrawal management has been described in Chap. 19. It is essential that relapse and relapse prevention has been discussed pre-­ detoxification, during detoxification and post-detoxification, and this is covered in detail in Chap. 22. The detoxification is an important part of alcohol intervention withdrawal for just a few days. The prolonged intervention begins pre-detoxification and post-­ detoxification. Alcohol detoxification is not the full intervention and treatment needed but merely a small part of the whole intervention required by the individual and family.

References 1. Cambridge Academic Content Dictionary. Cambridge University Press. https://dictionary.cambridge.org/dictionary/english/detoxification. Accessed 16 Apr 2022. 2. Cooper DB.  Alcohol home detoxification and assessment. Oxford: Radcliffe Medical Press; 1993. 3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 4. Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, et al. Identification and management of alcohol withdrawal syndrome. Drugs. 2015;75:353–65. 5. Jesse S, Brathen G, Ferrara M, Keindl M, Ben-Menachem E, Tanasescu R, et  al. Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurol Scand. 2017;135:4–16. 6. Stephane M, Arnaout B, Yoon G. Alcohol withdrawal hallucinations in the general population, an epidemiological study. Psychiatry Res. 2018;262:129–34. 7. Dervaux A, Laqueille X. Thiamine (vitamin B1) treatment in patients with alcohol dependence. Presse Med. 2017;46:165–71.

To Learn More Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, et al. Identification and management of alcohol withdrawal syndrome. Drugs. 2015;75:353–65. Jesse S, Brathen G, Ferrara M, Keindl M, Ben-Menachem E, Tanasescu R, et al. Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurologica Scandinavica. 2017;135:4–16. Stephane M, Arnaout B, Yoon G. Alcohol withdrawal hallucinations in the general population, an epidemiological study. Psychiatry Res. 2018;262:129–34. Dervaux A, Laqueille X. Thiamine (Vitamin B1) treatment in patients with alcohol dependence. Presse Med. 2017;46:165–71. Cooper DB. Alcohol home detoxification and assessment. Oxford: Radcliffe Medical Press; 1993.

Relapse and Relapse Prevention

22

Steven M. Melemis

Learning Outcome • In this chapter, you will learn about the causes and stages of relapse. You will learn the role that cognitive therapy and mind-body relaxation play in the relapse prevention model. You will see how the five rules of recovery can offer another way of understanding relapse prevention. You will understand what family members can do to assist recovery and what they should do to help themselves. Finally, you will discover some relapse prevention self-assessment scales.

22.1 Relapse Relapse is one of the defining features of dependence [1]. There are many ways to relapse and many qualities to relapse [2]. A relapse can be a one-day event or multiday. It can involve one drink or many drinks. It can be a relapse on the original drug of choice or on a substitute drug, such as cannabis or prescription drugs. It can be on ‘lite beer’ or hard liquor. Key Point 23.1 A widely used definition of relapse is—an interruption in the process toward a desired behavior by a reversion to the previous behavior [3]. Full relapse is sometimes distinguished from a short-term “lapse,” because it is theorized that the term

S. M. Melemis (*) Edgewood Health Network, Toronto, ON, Canada College of Physicians and Surgeons of Ontario, Toronto, ON, Canada Physician Health Program of Ontario Medical Association, Toronto, ON, Canada e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_22

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“relapse” can sound like a failure to some individuals and reduce their motivation to continue recovery [4]. It is worth noting that the distinction between lapse and relapse becomes less important the further along individuals are in recovery. Most individuals with long-­ term recovery see any lapse as a relapse. In this sense, the definition of relapse varies with the level of recovery.

22.2 The Stages of Relapse Relapse happens gradually. It begins weeks and sometime months before an individual picks up a drink or drug. Gorski [5] has broken the relapse process into 11 phases. These phases can be grouped into three larger stages: emotional, mental, and physical [6]. One of the goals of relapse prevention is to help individuals identify the early warning signs of relapse, when the chance of relapse prevention is greatest. This has been shown to significantly reduce the risk of physical relapse [7].

22.2.1 Emotional Relapse In emotional relapse, individuals are not consciously thinking about using drugs or alcohol. They do not want to relapse. But their emotional state can lead to relapse down the road. These are some of the signs of emotional relapse [8]. • • • • • •

Bottling up emotions Isolating Not going to meetings Going to meetings but not sharing Poor eating and sleeping habits Focusing on other people’s problems

Because individuals are not consciously thinking about using during this stage, denial is a big part of emotional relapse. There are many possible triggers of emotional relapse. Emotional discomfort, such as low self-worth, guilt and shame, and unresolved trauma, can be a trigger, [9, 10]. Physical discomfort such as chronic pain can be a trigger [11]. Poor self-care can be a trigger, where self-care is defined to include emotional, psychological, and physical care [6]. A common example of poor self-care is when individuals don’t address feeling hungry, angry, lonely, or tired (HALT) [12]. The transition from emotional relapse to mental relapse occurs if individuals don’t effectively address their discomfort. If they remain in emotional relapse for too long, they can begin to feel restless, irritable, and discontent. As their discomfort and tension build, they begin to think about using to escape [6].

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22.2.2 Mental Relapse In mental relapse, individuals begin to think about using. In early mental relapse, those thoughts are fleeting and easily dismissed. But if individuals continue to live with emotional or physical discomfort, those thoughts can grow stronger. As individuals go deeper into mental relapse, their cognitive resistance to relapse declines, and their need to escape increases. These are some of the signs of mental relapse [8]. • Negative thinking: all-or-nothing thinking, disqualifying the positives, catastrophizing, and negative self-labelling • Thinking about people, places, and things associated with past use • Minimizing consequences of past use, or glamorizing past use • Craving drugs or alcohol • Bargaining • Lying • Thinking of schemes to better control using • Looking for relapse opportunities • Planning a relapse All these thoughts or actions are fruitful areas for cognitive therapy [13]. A common example of bargaining is when individuals think of scenarios when it would be acceptable to use such as holidays or on a trip. Airports and all-inclusive resorts are high-risk environments in early recovery. Another form of bargaining is when people start to think that they can relapse periodically, perhaps in a controlled way, a few times a year. Bargaining can also take the form of switching from a drug of choice to another addictive substance. Key Point 23.2 Whether mental relapse culminates in physical relapse depends on an individual’s coping skills [3].

22.2.3 Physical Relapse In physical relapse individuals begin actually using. Most physical relapses are relapses of opportunity. They occur when the individual has a window in which they feel they will not get caught. When individuals do not understand the process of relapse, they think that relapse happens quickly, over a matter of hours, instead of over days or weeks [6]. They will often say that one minute they were fine and the next minute they had a drink in their hand. When individuals can’t recognize the many warning signs before physical relapse, it is harder for them to interrupt the relapse process and to ask for help.

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Even physical relapse can be a gradual process, in which individuals move from a first drink to full relapse behavior. One study found that the median time from the first drink to full dependence behavior is about 7 days [14].

22.3 Cause of Relapse 22.3.1 Predisposing Factors Basic predisposing factors of relapse include genetic factors, health issues, coexisting mental health issues such as anxiety or depression, and use of other addictive substances [15]. Poor life skills are also predisposing factors [16]. Lack of understanding of the relapse process is a predisposing factor. When people do not understand the process of relapse, they tend to focus their relapse prevention on the final stage of relapse, which is the most difficult stage at which to stop. Negative beliefs about self, addiction, recovery, and the world at-large can be predisposing factors. The following are some examples of negative beliefs about relapse and recovery. • I don’t think I can handle life without using. • I don’t think I can handle my cravings. I can’t resist them. • If I stop, I’ll only start up again. I have never finished anything; Maybe I’m not capable of recovery. • Maybe I have been so damaged by my addiction that I can’t recover. • Recovery requires too much work. • Life will not be fun, or I will not be fun without using. • Maybe I can just use occasionally. • No one has to know if I relapse. Some of these negative beliefs can be interpreted in terms of expectancy theory, which states that if individuals expect that the benefits of addictive behavior outweigh the benefits of healthy behavior, they are more likely to relapse [17]. Similarly, if they expect that the costs of healthy behavior outweigh the costs of addictive behavior, they are also more likely to relapse. Key Point 23.3 One way of framing expectancy theory is that individuals need to learn to feel comfortable with being uncomfortable [6].

22.3.2 Precipitating Factors Common precipitating triggers of relapse include people, places, things, withdrawal symptoms, and HALT (hungry, angry, lonely or tired). Two important precipitating

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factors are negative emotional states and positive emotional states in a social context [18]. People either use drugs or alcohol to drown their sorrows or because they are feeling good with a group of friends, and they want to feel even better. There is some disagreement as to whether cravings are a risk factor for relapse [15, 19]. If an individual’s drug of choice is something other than alcohol, then alcohol consumption can be a precipitating factor that can lead back to their primary drug. Alcohol consumption can also lead to alcohol becoming the primary drug of choice [20]. This is seen with cocaine, where after using for a number of years, individuals often switch from cocaine use to alcohol use. If an individual meets the criteria of alcohol misuse, an attempt at controlled drinking is a strong precipitating factor. It has been shown that once a recovering individual attempts controlled drinking, full relapse is likely to follow [21].

22.3.3 Protective Factors Basic protective factors include older age, younger age of onset of alcoholism, having been married, and participation in Alcoholics Anonymous (AA) [22]. A sense of self-efficacy and motivation for change are also protective factors [15, 16]. Coping skills for dealing with stress have also been shown to reduce the risk of relapse [23]. Prolonged abstinence is also a protective factor. After abstinence had been maintained for 5 years, relapse is rare [21]. Involvement in ongoing counselling or treatment program aftercare also significantly reduce the risk of relapse [24].

22.4 The Relapse Prevention Model The relapse prevention model [RP] of Marlatt and George is the most commonly used framework for understanding relapse. It emphasizes cognitive-behavioral skills and coping responses as the primary tools for preventing relapse [3].

22.4.1 Cognitive Behavioral Therapy The benefit of using a cognitive-behavioral approach in relapse prevention is that it offers a way to both understand and address the problem. The underlying idea is that negative beliefs and thoughts can be predisposing and precipitating factors of relapse. If the individual can learn to change their thinking, they can reduce their risk of relapse. Helping individuals avoid high-risk situations is an important goal of the relapse prevention model. Clinical experience has shown that individuals have a hard time identifying their high-risk situations in the beginning and a hard time believing that they are high-risk. Even after they have identified high-risk situations, they sometimes think that trying to avoid them is a sign of weakness.

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Using high-risk situations as a starting point for therapy, professionals can work backward, to identify predisposing and precipitating factors, and forward, to develop coping skills [3]. Acceptance and commitment therapy (ACT), a subset of cognitive behavioral therapy, can help individuals deal with the shame of dependence and recovery [25]. For example, individuals often struggle with occasional, brief thoughts of using. These thoughts are normal in early recovery and are different from mental relapse [6]. When people begin recovery, they often say, “I want to never have to think about using again.” They are sometimes reluctant to even mention that they continue to have these thoughts because they are embarrassed by them.

22.4.2 Mindfulness Self-Assessment Exercise 23.1 • Write down how you think mindfulness and relaxation therapy may help the individual. Numerous studies have shown that mind-body relaxation and mindfulness-based relapse prevention therapy reduce the use of drugs and alcohol and increase the chance of long-term recovery [26]. Mind-body relaxation plays several roles in recovery [12]: • It reduces stress and tension which are common triggers of relapse. • It helps individuals let go of negative thinking such as dwelling on the past or worrying about the future, which can be triggers for relapse. • It emphasizes self-care, which is a critical part of relapse prevention. • It strengthens an individual’s ability to monitor and cope with discomfort [26].

22.5 The Five Rules of Recovery A complementary way of looking at some of the concepts of the relapse prevention [RP] model is in terms of the five rules of recovery [6]. They provide a simple and comprehensive framework for understanding relapse and motivating change. The five rules are as follows. 1. Change your life so that it’s easier to not use. 2. Ask for help and develop a recovery circle. 3. Be completely honest with yourself and everyone in your recovery circle. 4. Practice self-care. 5. Don’t bend the rules or try to negotiate your recovery.

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22.5.1 Rule 1: Change Your Life so That It Is Easier to Not Use The most important rule of recovery is that recovery is not achieved by just stopping using—recovery involves changing one’s life so that it is easier to not use. When individuals do not change their life, all the factors that contributed to their substance use can eventually catch up with them. This is contrary to the initial goal most people have in recovery. They often enter treatment saying, “I want my old life back—without the using.” Part of therapy is helping individuals understand that wishing for their old life back is like wishing for relapse. Key Point 23.4 Rather than seeing change as a negative, individuals are encouraged to see recovery as an opportunity for change. They can go forward and be happier than they were before. Recovering individuals are often overwhelmed by the idea of change. As part of their all-or-nothing thinking, they assume that change means they must change everything in their lives. It helps to know that there is usually only a small percent of their lives that needs to be changed. It can also be reassuring to know that most people need to make similar changes. Two broad categories that people need to change are predisposing and precipitating factors of the RP model: (1) negative beliefs and thinking patterns and (2) people, places, and things associated with using.

22.5.2 Rule 2: Ask for Help and Develop a Recovery Circle Most people start the recovery process by trying to do it on their own. The negative thinking involved is that asking for help is a sign of weakness or will make the problem seem bigger than it is. For a successful recovery, individuals are encouraged to develop a recovery circle of people that includes their close family, friends, doctors, counsellors, self-help groups, and recovery mentors. Joining a self-help group has been shown to significantly increase the chances of long-term recovery. The combination of a substance abuse program and self-help group is the most effective recovery strategy [27]. The way to get the most out of 12-step groups is to attend meetings regularly, have a sponsor, and read 12-step materials [28]. These are some of the generally recognized benefits of active participation in self-help groups. • Individuals feel that they are not alone. • They learn what the voice of dependence sounds like by hearing it in others. • They learn how other people have done recovery and what coping skills have been successful. • They have a safe place to go where they will not be judged.

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There is one benefit of self-help groups that deserves special attention. Guilt and shame are common emotions in dependence and obstacles to recovery [29]. Self-­ help groups can help individuals overcome their guilt and shame of dependence by seeing that they are not alone. These are some of the reasons individuals give for not joining self-help groups. • • • • • • •

If I join a group, I will be admitting that I am an addict or an alcoholic. I want to do it on my own. I don’t like groups. I am not a joiner. I don’t like speaking in front of other people. I don’t want to switch from one dependence to becoming dependent on AA. I am afraid I will be recognized. I don’t like the religious aspects of 12-step groups. The negative thinking in all these objections can be material for cognitive therapy.

22.5.3 Rule 3: Be Completely Honest with Yourself and Everyone in Your Recovery Circle Dependence requires lying. When individuals feel they cannot be completely honest, it is a sign of emotional relapse. Individuals are encouraged to be completely honest within their recovery circle. A simple test of complete honesty is if individuals feel ‘uncomfortably honest’ when sharing in their recovery circle. This is especially important in self-help groups where, after a while, individuals sometimes start to go through the motions of participating. Probably the most common misinterpretation of complete honesty is when individuals feel they must be honest about what is wrong with other people. Honesty, of course, is self-honesty. A common question about honesty is how honest a person should be when dealing with past lies. The general answer is that honesty is always preferable, except where it may harm others [30, 31].

22.5.4 Rule 4: Practice Self-Care Most people use drugs or alcohol to escape, relax, or reward themselves [6]. They use drugs or alcohol as a form of temporary self-care. Self-care is difficult for recovering individuals, because they tend to be hard on themselves [13]. Self-care is especially difficult for adult-children of dependent individuals [32] (see Chaps. 11, 13, 14, and 15). Self-care can be difficult because recovering individuals tend to think that selfcare is being selfish. Changing that belief involves understanding that selfishness is taking more than one needs, whereas self-care is taking as much as one needs. Poor self-care can play a role when positive emotions are a trigger for relapse. For example, suppose an individual works hard to achieve a certain goal, and after

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they achieve it, they want to celebrate. The problem is that when they were working toward their goal, they felt they didn’t deserve a reward until the job was done. Afterward, they feel their celebration must be big enough to make up for their previous deprivation. Poor self-care while working can be a trigger for relapse when celebrating. Mind-body relaxation is an important form of self-care. As mentioned earlier, mind-body relaxation and mindfulness help reduce the use of drugs and alcohol and increase the chance of long-term recovery [26]. Part of changing ones’ life in recovery is finding time to relax [6].

22.5.5 Rule 5: Don’t Bend the Rules or Try to Negotiate Your Recovery The idea behind this rule is to remind individuals not to resist or sabotage their recovery. A simple test of whether a person is bending the rules is if they look for loopholes in recovery, for example, when an individual asks for professional help and consistently ignores the advice [6]. In the words of AA, “If you’re looking for the easiest way to achieve recovery—you’re not going to make it.” Some individuals have long-term recovery but still feel like denied users [6]. They seem to be doing all the right things, including going to self-help groups, but secretly they feel that life was better when they were using, and they often make a secret deal with themselves that at some point they will try using again. Key Point 23.5 Denied users can use important milestones such as recovery anniversaries as excuses to relapse.

22.6 Relapse Prevention for the Family Family support is an important component of relapse prevention. The completion rate of individuals in a residential dependency program increases when family members or significant others participate in the therapeutic process [33] (see Chap. 8). But family involvement can have both a positive and negative influence. Key Point 23.6 One study showed that perceived family support reduced the risk of relapse, whereas expressed emotions from the family increased the risk of relapse [34].

22.6.1 Some Things Family Members Can Do for the Individual • Educate yourself on substance use. • Do not enable, provide excuses, or cover up for the individual.

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• Do not shield the individual from the consequences of their dependence. People are more likely to change if they have suffered enough negative consequences. • Provide a sober environment that reduces triggers for using. • Set boundaries that the whole family can agree on. The purpose of boundaries is to improve the health and functioning of the family. Do not use boundaries to punish or shame. • Even if the individual does not want to talk, simply state that you are ready to listen when they are ready to talk.

22.6.2 Some Things Family Members Can Do for Themselves • Let the individual set the pace. Do not work harder than the person you are trying to help. Using this as a guideline can help you gage how much or how little help you can offer at any time. • Working harder than the other person will only exhaust you and could make them resent your efforts. • Loving someone with substance use problems is not always easy. You also need time to recover and take care of yourself. • If the individual does not want to do anything right now, you can still be helpful by being an example of balance and self-care. • Avoid self-blame. You cannot control another person’s decisions, and you cannot force them to change when they are not ready. Understand that there is only so much you can do. • Ask for help. Talk to a professional. Go to a support group. You need as much support as they do.

22.7 Relapse Prevention and Self-Assessment Scales There are several scales that are used to predict the likelihood of relapse and that can be used as self-assessment tools. They can also be used to monitor changes in thinking toward recovery.

22.7.1 AWARE The Advance WArning of RelapsE (AWARE) scale [35] is a 28-item questionnaire based on the Gorski and Miller early warning signs of relapse [8]. The score ranges from 28 to 196. It has been shown to be predictive of 6-month relapse prevention [36].

22.7.2 RAPID The RelApse Prevention Identification Diagnostic (RAPID) is based on the five rules of recovery. It consists of 25 questions with a total score of 0 to 100 [37].

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22.7.3 TOPPS The Therapy Orientation by Process Prediction Score (TOPPS) is based on the following variables: • • • • • • • •

Experience of resources Abstinence self-efficacy Implicit craving Relapse alertness Relapse risk Disease concept Dysfunctional therapeutic engagement Dysfunctional problem solving of current problems It has been shown to be predictive of 4-year relapse prevention [38].

22.7.4 OCDS The Obsessive-Compulsive Drinking Scale (OCDS) is a 14-item scale. Although not predictive of relapse, it is sensitive to dependence severity and to changes in thinking during abstinence [38].

22.7.5 MBRP-AC The Mindfulness-Based Relapse Prevention Adherence and Competence Scale (MBRP-AC) measures an individual’s competence and adherence to mindfulness-­ based relapse prevention [39].

22.8 Conclusion Relapse is a gradual process. Part of relapse prevention is teaching individuals how to recognize the early warning signs of relapse, so that they can intervene early, when the chance of recovery is greatest. Cognitive therapy and mind-body relaxation reduce the predisposing and precipitating factors and increase the protective factors of relapse. The five rules of recovery offer a simple and comprehensive way of understanding relapse and teaching relapse prevention. Relapse prevention scales are a useful way to monitor an individual’s progress during recovery.

References 1. American Psychiatric Association. DSM-5: the diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 1993. 2. Miller WR. What is a relapse? Fifty ways to leave the wagon. Addiction. 1996;91(Suppl):S15–27.

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3. Hendershot CS, Witkiewitz K, George WH, Marlatt GA.  Relapse prevention for addictive behaviors. Subst Abuse Treat Prev Policy. 2011;6:17. 4. Larimer ME, Palmer RS, Marlatt GA. Relapse prevention: an overview of Marlatt’s cognitive-­ behavioral model. Alcohol Res Health. 1999;23(2):151–60. 5. Gorski TT, Miller M. Counseling for relapse prevention. Independence, MO: Herald House/ Independence Press; 1982. 6. Melemis SM.  Relapse prevention and the five rules of recovery. Yale J Biol Med. 2015;88(3):325–32. 7. Bennett GA, Withers J, Thomas PW, Higgins DS, Bailey J, Parry L, et al. A randomised trial of early warning signs relapse prevention training in the treatment of alcohol dependence. Addict Behav. 2005;30(6):1111–24. 8. Gorski T, Miller M.  Staying sober: a guide for relapse prevention. Independence, MO: Independence Press; 1986. 9. Easton CJ, Swan S, Sinha R. Prevalence of family violence in clients entering substance abuse treatment. J Subst Abus Treat. 2000;18(1):23–8. 10. Khoury L, Tang YL, Bradley B, Cubells JF, Ressler KJ. Substance use, childhood traumatic experience, and posttraumatic stress disorder in an urban civilian population. Depress Anxiety. 2010;27(12):1077–86. 11. Vadivelu N, Kai AM, Kodumudi G, Haddad D, Kodumudi V, Kuruvilla N, et  al. Recommendations for substance abuse and pain control in patients with chronic pain. Curr Pain Headache Rep. 2018;22(4):25. 12. Melemis SM. I want to change my life: how to overcome anxiety, depression and addiction. Toronto: Modern Therapies; 2010. 13. Beck AT, Wright FD, Newman CF, Liese BS. Cognitive therapy of substance abuse. New York: Guilford; 1993. 14. Kvamme BO, Asplund K, Bjerke TN. Drinking resumption: problematic alcohol use relapse after rehabilitation. A phenomenological hermeneutical perspective. Scand J Caring Sci. 2015;29(4):716–23. 15. Sliedrecht W, de Waart R, Witkiewitz K, Roozen HG. Alcohol use disorder relapse factors: a systematic review. Psychiatry Res. 2019;278:97–115. 16. Miller WR, Westerberg VS, Harris RJ, Tonigan JS. What predicts relapse? Prospective testing of antecedent models. Addiction. 1996;91(Suppl):S155–72. 17. Hasking PA, Oei TP. Incorporating coping into an expectancy framework for explaining drinking behaviour. Curr Drug Abuse Rev. 2008;1(1):20–35. 18. Connors GJ, Longabaugh R, Miller WR. Looking forward and back to relapse: implications for research and practice. Addiction. 1996;91(Suppl):S191–6. 19. Drummond DC, Litten RZ, Lowman C, Hunt WA.  Craving research: future directions. Addiction. 2000;95(Suppl 2):S247–55. 20. Staiger PK, Richardson B, Long CM, Carr V, Marlatt GA.  Overlooked and underestimated? Problematic alcohol use in clients recovering from drug dependence. Addiction. 2013;108(7):1188–93. 21. Vaillant GE.  A long-term follow-up of male alcohol abuse. Arch Gen Psychiatry. 1996;53(3):243–9. 22. Schuckit MA, Tipp JE, Smith TL, Bucholz KK. Periods of abstinence following the onset of alcohol dependence in 1,853 men and women. J Stud Alcohol. 1997;58(6):581–9. 23. Anderson KG, Ramo DE, Brown SA.  Life stress, coping and comorbid youth: an examination of the stress-vulnerability model for substance relapse. J Psychoactive Drugs. 2006;38(3):255–62. 24. Blodgett JC, Maisel NC, Fuh IL, Wilbourne PL, Finney JW. How effective is continuing care for substance use disorders? A meta-analytic review. J Subst Abus Treat. 2014;46(2):87–97. 25. Luoma JB, Kohlenberg BS, Hayes SC, Fletcher L. Slow and steady wins the race: a randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders. J Consult Clin Psychol. 2012;80(1):43–53.

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26. Bowen S, Witkiewitz K, Clifasefi SL, Grow J, Chawla N, Hsu SH, et al. Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial. JAMA Psychiatry. 2014;71(5):547–56. 27. Pagano ME, White WL, Kelly JF, Stout RL, Tonigan JS.  The 10-year course of alcoholics anonymous participation and long-term outcomes: a follow-up study of outpatient subjects in project MATCH. Subst Abus. 2013;34(1):51–9. 28. Zemore SE, Subbaraman M, Tonigan JS. Involvement in 12-step activities and treatment outcomes. Subst Abus. 2013;34(1):60–9. 29. Bradshaw J.  Healing the shame that binds you. Deerfield Beach, FL: Health Communications; 1988. 30. Corley MD, Schneider JP.  Disclosing secrets: when, to whom, & how much to reveal. Wickenburg, AZ: Gentle Path Press; 2002. 31. Alcoholics Anonymous World Services. Alcoholics anonymous big book. 4th ed. New York: Alcoholics Anonymous World Services; 2002. 32. Woititz JG. The complete ACOA sourcebook: adult children of alcoholics at home, at work, and in love. Deerfield Beach, FL: Health Communications; 2002. 33. McPherson C, Boyne H, Willis R. The role of family in residential treatment patient retention. Int J Mental Health Addict. 2017;15(4):933–41. 34. Atadokht A, Hajloo N, Karimi M, Narimani M.  The role of family expressed emotion and perceived social support in predicting addiction relapse. Int J High Risk Behav Addict. 2015;4(1):e21250. 35. Miller WR, Harris RJ.  The AWARE questionnaire (Advance WArning of RElapse). 2020. https://casaa.unm.edu/inst/Aware.pdf. 36. Kelly JF, Hoeppner BB, Urbanoski KA, Slaymaker V. Predicting relapse among young adults: psychometric validation of the advanced WArning of RElapse (AWARE) scale. Addict Behav. 2011;36(10):987–93. 37. Melemis S. Relapse prevention inventory diagnostic—RAPID. 2020. https://www.addictionsandrecovery.org/tools/relapse-prevention-inventory-diagnostic-rapid.pdf. 38. Anton RF, Moak DH, Latham PK. The obsessive compulsive drinking scale: a new method of assessing outcome in alcoholism treatment studies. Arch Gen Psychiatry. 1996;53(3):225–31. 39. Chawla N, Collin S, Bowen S, Hsu S, Grow J, Douglass A, et  al. The mindfulness-based relapse prevention adherence and competence scale: development, interrater reliability, and validity. Psychother Res. 2010;20(4):388–97.

To Learn More Addictions And Recovery (www.addictionsandrecovery.org) Find Treatment (https://findtreatment.samhsa.gov) HealthDirect - Alcohol (www.healthdirect.gov.au/alcohol) NIAAA - National Institute on Alcohol Abuse and Alcoholism (www.niaaa.nih.gov) NHS - Alcohol Misuse (www.nhs.uk/conditions/alcohol-­misuse) WHO - Alcohol Use (www.who.int/health-­topics/alcohol)

Motivational Interviewing

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Lyn Williams

Learning Outcomes • To appraise and understand the evidence base, behind motivational interviewing to effectively support people with problematic alcohol use. • Describe the underlying spirit, guiding principles and strategies of brief MI. • Describe the roles of ambivalence and patient engagement in health behaviour change related to alcohol use. • Learn about the basic skills of motivational interviewing that support brief interventions.

23.1 Introduction Motivational interviewing (MI) is an evidence-based conversation for change, is a collaborative therapeutic approach, and is relationally focused in practice. The practitioner pays attention to natural language as indicators as to where the person is in relation to their health situation. MI has its origins in the treatment of substance use disorders and has over time been developed into being used in practice in other areas of health behaviour and lifestyle changes, including long-term conditions, weight management, mental health, and sports science. MI has been evidenced as effective for treating problematic and dependent alcohol use [1] and can be used at different points of interventions to support decisions determined by the person on their desire to change their pattern of use. MI and brief intervention (BI) techniques (see Chap. 17) are also a practical way to train practitioners in helping to change behaviour.

L. Williams (*) Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, Nottinghamshire, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_23

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An important feature of MI is that it strengthens and improves treatment engagement focusing on a person’s own motivation and commitment to change. MI uses a person-centred style of engagement designed to help the individual explore and resolve their ambivalence about making changes, to support their health and wellbeing. Developed in the 1980s by psychologists Williams Miller and later joined by Stephen Rollnick, MI has grown from its practice roots [2]. MI is person centred, is grounded in a collaborative partnership focusing on the person’s own internal resources, lived experience, motivations, and strengths for change. The emphasis is on resolving ambivalence through reflective listening, expressing empathy, acceptance, and adopting a supportive person-centred position rather than argumentative and confrontational. MI avoids argumentation and is not authoritative, leaving the person in a passive role, nor is it prescriptive, which is often reverted to when collaborating with people experiencing problematic use of substances. Neither does the practitioner lead most of the conversation nor just give information. MI is described as a way of gently guiding the conversation [2] as opposed to directing or following and that ambivalence to change is accepted as a normal way of being by the practitioner. A person presenting for help and engaging in an MI conversation will feel understood and accepted as being ‘in two minds’ about whether or not they want to make a change in their health situation. This is viewed a normal part of preparing or considering life changes [3, 4]. The guiding style is important, as any other approach to interacting with a person who is feeling ambivalent will often argue for staying where they are if confronted with being told that they need to make changes. Therefore, MI works well when collaborating in the context of the respectful therapeutic relationship, as the approach supports the person building their confidence and self-efficacy. A person’s own arguments for change are more likely to be acted upon than being told what they need to do, so the emphasis is on guiding. Internal motivation is asking the question ‘What matters to you?’ Feeling motivated to stop or reduce using alcohol can be really challenging faced with difficulties in life, even when the risks could be greater in terms of the negative longer-term outcomes; MI provides a way of navigating through the person’s lived experience with a sense of hope. MI helps a person in building confidence towards making their own informed decision based on their values and interests that matter to them. It is grounded in relational connectedness. Alcohol prevention, harm reduction, and treatments are goals and decisions that need to be made through an informed person-centred decision-making framework. There may be many reasons as to why this is happening, and exploring the lived experience of the ‘why’ is central to working towards a positive outcome together. These reasons can be complex even though the harm physically and mentally may far outweigh the reasons to continue to use alcohol. It is in the work of working within an MI way that this exploration can be respectfully conducted to help support the person towards taking their next steps. This chapter sets out in more detail the evidence behind MI and the principles and skills used in MI conversations that can help a practitioner collaborating with

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people using alcohol in way that may cause them harm or have become dependent on it. Consideration is given as to how this can be applied in practice across a range of interventions and treatment from alcohol assessment through to relapse prevention towards a positive outcome defined by the person experiencing this.

23.2 MI as an Evidence Base for Shared Decision-Making MI is described as a key element of the principles of care by the National Institute Centre of Excellence guidelines CG 115 [5] on alcohol use disorders. It is made clear that people have a fundamental right to be involved in discussions and make informed choices about their care and treatment in relation to alcohol use. This is strengthened further by the recently launched NICE ‘shared decision-making guidelines’ (NG197) [6]. NICE state that: • Shared decision-making is a joint process in which a healthcare professional works together with a person to reach a decision about care. • It involves choosing tests and treatments based both on evidence and on the person’s individual preferences, beliefs, and values. • It makes sure the person understands the risks, benefits, and possible consequences of different options through discussion and information sharing. The person should also be asked if they want to involve family members, carer, or advocates to support any decisions in relation to treatment. MI aligns with the NICE [6] shared decision-making guidelines CG197 and underpins these through the helpful conversational style, which creates space to elicit and recognise problems or potential problems related to drinking problematically and the range of treatment options that may be available. MI helps to enable resolution to ambivalence and encourages positive change by strengthening self-­ belief in a person’s ability to change. Reflective Practice Exercise 23.1 Note: There are also NICE guidelines to cover decision-making for those individuals who may lack capacity now or in the future and that aims to help practitioners to support people to make their own decisions where they have the capacity to do so. These guidelines are available at https://www.nice.org.uk/guidance/ng108. Ethical practice concerns can sometimes appear when the practitioner has an aspiration for change that the person does not share, and this is not in the spirit of shared decision-making. Moreover, it is not proper to use MI to influence choice when the practitioner has a personal investment in a certain outcome. The use of MI must be adapted based on what the person needs, so not eliciting these and acting from an expert position not wholly person-centred. • How would you counter these possible ethical concerns? • What role does good practice supervision play in this for you?

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Key Point 23.1 Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change [2] aligns and accords well with NICE guidelines for shared decision-making [6] and alcohol use disorders [5].

23.3 Research Evidence and MI From literature searches, there is evidence of a large body of research now available examining the effectiveness of MI, which has grown significantly over the last 30 years from the application of brief to more intensive psychological interventions. The National Clinical Excellence Guidelines [6] contain evidence-based references and recommendations in using MI and psychosocial interventions in alcohol use across a range of care settings, such as primary care, mental health services, hospitals, and pharmacy. Clinical trials have evidenced that people exposed to MI (versus treatment as usual) are more likely to enter and engage with treatment and that use of substances decrease, including smoking cessation. Lundahl et al. [1] in a meta-analysis examining the evidence base and research for MI and the therapeutic effects identified that MI possesses a sound theoretical base for the conversational approach and process, which follows into practice.

23.4 Supporting Treatment Concordance MI has been shown to work with supporting treatment concordance and adherence. Zomahoun and colleagues [7] undertook a systematic review and meta-analysis of the effectiveness of MI interventions on medication adherence in adults with chronic disease. They concluded that there was evidence through analysis of random control trials that suggested that ‘MI interventions might be effective at enhancing medication adherence in adults treated for chronic diseases’ [7]. Alcohol use disorders can often persist over a long period, and this research has relevance to the use of MI in this context as an intervention to support treatment concordance, through shared decisionmaking and subsequent adherence. It follows that MI could be beneficial in supporting concordance and adherence with a person engaged with and undergoing a pharmacological alcohol detoxification and treatments for relapse prevention (see Chaps. 18–22).

23.5 Improving Readiness to Reduce or Stop Problematic Use of Alcohol Improving readiness to reduce and stop problematic use was studied through another key piece of research examining the impact of brief interventions, such as motivational enhancement therapy (MET). MET was developed as one of a range of

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matched treatments as part of the largest clinical trial of psychotherapies known as Project MATCH [8]. Several interventions were examined and delivered positive impact and outcomes from this trial. Brief MI interventions such as information advice giving framed in an MI approach have grown from this research evidence base into practice.

23.6 Effectiveness of MI Brief Alcohol Interventions in Primary Care A Cochrane review on the effectiveness of brief alcohol interventions in primary care populations (see Chap. 17) [9] also concluded that there was moderate-quality evidence that brief interventions of which MI was included seemed to reduce hazardous and harmful consumption of alcohol in men and women. Brief interventions can last between 5 and 10 min or up to half an hour and follow the principles of an MI conversation about lifestyle changes and is followed up with the person’s permission to be given a range of agreed information that will help with decisions on using harm reduction approaches and improve self-care.

23.7 Alcohol Use Assessment Evidence-based NICE guidelines have set out the importance of conducting a motivational intervention as part of the initial alcohol use assessment. This can provide opportunities for brief interventions and advice giving, which includes measuring levels of alcohol use (see Chap. 10). This is also fundamental to informing shared decision-making about a person’s choices in treatment and care formulation.

23.8 Further Research in MI There are further opportunities and gaps in research to be explored in terms of the impact of MI through prevention and harm reduction. The Cochrane review [9] concluded that although brief interventions seem to be effective at reducing hazardous and harmful consumption, it was identified that many of these were based in high-income countries. The recommendation was that there is a… …clear need for more evaluative research on brief interventions with younger people, from cultural minority groups and also in low and lower- middle income countries [9].

Key Point 23.2 There is an evidence base that suggests that MI when matched well with a person using alcohol, problematically that positive engagement through assessment, brief advice, and information interventions and medication concordance can lead to improved outcomes.

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23.9 The Principle of Recovery and MI The concept of recovery aligns with MI in that it goes beyond the medicalisation of substance use. The term recovery can mean different things to different people and can be self-defined. For many people, recovery is more about working towards realisation of their goals in life, relationships and connectedness, and developing skills that support wellbeing and a positive life. Recovery can be destigmatising as there is a strong link between recovery and social inclusion, as it is about having the right to participate fully in life. So, the idea that it starts and ends with symptoms and a cure that leads to a person being ‘recovered’ is not how it is seen in this context now. There is no universally accepted single definition of recovery, and it is often referred to as a process that is made up of a set of evidence-based concepts CHIME [10]: • • • • •

Connectedness Hope and optimism Identity Meaning and purpose Empowerment

This set of concepts aligns, supports, and blends with MI in practice and within the practice settings for mental health and substance use. It has wider applicability in physical care practice settings moving towards a more integrated approach.

23.10 Building MI Knowledge and Skills in Practice This next section draws on the application of MI skills into practice and builds practice knowledge by layering understanding around MI spirit, principles, MI skills, and strategies and the four processes of an MI conversation.

23.10.1 Understanding the ‘Spirit of MI’ To understand the benefits of using MI in conversations about change, there is a need to gain a deeper understanding of the underlying spirit of MI defining this approach. This is seen to be exemplified by conveying genuineness by the practitioner in acting to understand a person’s lived experience, accepting that the person is an expert in themselves and their world. There are four important conceptual areas to consider which are described as ‘MI spirit’ and these are: 1. 2. 3. 4.

Collaboration Compassion Evocation Acceptance

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Explaining these concepts in more depth helps with thinking through how to bring these to life in MI practice. Firstly, collaboration is viewed as the partnership that is developed between the practitioner and the person, based on the idea that the conversation that develops between them is one of ‘dancing’ rather than ‘wrestling’ [2, 11]. MI is therefore enacted by the practitioner as a conversation that is collaborative, rather than being done to them from the expert perspective. Key Point 23.3 The practitioner and the person are experts in their own respective worlds, and this is respected. Secondly, activating compassion is conveyed in practice as a genuine concern by the practitioner for others without judgement and is very well described by the 14th Dalai Lama [12] as being ‘by nature gentle, peaceful and soft, but it is very powerful’. Thirdly, evocation is activated within an MI conversation where the practitioner pays attention to understanding and eliciting the person’s strengths. This concept in conversational practice is where the practitioner creates the respectful therapeutic space to evoke and elicit the ideas from the other person. The underlying belief here from the practitioner is that these resources and strengths already reside in the person. Often health behaviour conversations are based in problematised deficit-based thinking and conversations rather than focusing the person’s own internal resources and strengths for change. In MI, the practitioner’s role is to learn to evoke and elicit these through the art of skilful conversation. Finally, there is an unconditional acceptance or positive regard for the person by seeing them in a non-judgemental way with their lived situation, believing that they have the potential to grow and flourish. Reflective Practice Exercise 23.2 In your next conversation with an individual, actively use the key areas in your practice that you have learned about that make up the MI spirit. • What did you notice when you did this? • What happened and what did you notice in how you were relating to each other? • Write a short reflective piece on this experience.

23.11 The Foundational Principles of MI There are five foundational principles of MI, which are described here as part of the building blocks in practice that bring together and support working with the underlying spirit.

23.11.1 Expressing Empathy Empathy can be described as seeing the world through the other person’s eyes and that their view of the world is valid, affirmed, and valued. This principle underpins

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the relational basis for a person feeling heard and understood. A person is more likely to share their feelings openly and honestly if they feel that a practitioner is showing empathic regard for them and it feels safe to do so as a result.

23.11.1.1 MI Practice Application Example Practitioner: ‘I can see that this is hard for you right now and you do not know where to start with reducing or stopping your drinking.’

23.11.2 Support Self-Efficacy MI is a strengths-based approach and one where it is inherently built into the principles that the skills and resources lie with the person, to be able to make the changes that are important to them. The person’s own self-belief that they can change is important as with building a sense of hope that change is possible during the difficulties that they are experiencing. Building on and focusing into previous successes no matter how small they are, highlighting skills and strengths supports growth in the person’s belief that the outcome can be positive.

23.11.2.1 MI Practice Application Example You have said that there have been a number of times where you have been able to reduce your drinking and have alcohol free periods, which shows you, you can do this. Tell me a little more about what helped you, when you have been able to do this.

23.11.3 Righting Reflex In MI the righting reflex is where a practitioner feels the urge to tell the other person why they must make a change. Being aware of the ‘righting reflex’ is an important part of the practitioner’s self-awareness not to jump in and advise on the persons behalf. This can be experienced as being disempowering. The practitioner reverting to righting or advocating for change rather than the person whose change dilemma it is can cause the individual to defend their reason for staying where they are, sustaining their position. This will put the practitioner in an adversarial role and create a tension in the conversation. This often happens because of the practitioner’s eagerness to provide solutions or is anxious about making sure that progress is made. Simply being aware as a practitioner not to resort to positioning into the righting reflex is enough to remember not to progress down this route.

23.11.4 Rolling with Resistance Within MI, resistance that can occur in a conversation often arises when a person feels that their view of what is happening to them is not felt to be understood. This is often associated with the feeling of being ambivalent about change, which is

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viewed as a normal state of mind as part of MI. So, rolling with it is the practice response to this, not arguing for change from the practitioner’s perspective, or this will result in positioning in the relationship. This acts to reduce and counter any arguing for staying where the person is, allowing the person to be open about their thinking and motivation at that point in time. There is a metaphor that is often described as a conversation where both the practitioner and the individual are ‘dancing’ rather than ‘wrestling’. Moreover, at this point from a practitioner’s perspective is that in giving thier view without being invited is described in MI as the ‘righting reflex.’ This can happen if the practitioner gives their view on why the person needs to change. This is a mismatch to where the person is in their thinking and can lead to the conversation closing. So, the aim of rolling with resistance and holding back on the righting reflex can open up the exploration of new possibilities, by inviting the other person’s perspectives.

23.11.4.1 MI Practice Application Example Practitioner: I think you need to do something about this more quickly as you are doing yourself more harm by continuing to drink in this way (righting reflex). Individual: I don’t feel ready to do anything right now (defends position). Practitioner: So, it all seems too difficult for you to consider right now and to think about making changes is just a step too far for you now. So, let’s talk a little more about how you have been since I last saw you (motivational interviewing rolling with it).

23.11.5 Develop Discrepancy Developing discrepancy is based on the premise that change occurs when a person can perceive a mismatch between where they are now and where they want to be. It will, if given in the right spirit without judgement, present a reason to progress to potentially do something different rather than the person staying where they are. MI works well in eliciting these mismatches in a person-centred way, as it supports the exploration of what is happening currently in comparison with their values and future goals. The direction and the supportive style of the MI conversation enable the person to become more aware of their current behaviours that are not supporting the change they want to experience, and through this, the practitioner helps steer them away, rather than towards, what they want to achieve for themselves.

23.11.5.1 MI Practice Application Example Practitioner: You have talked about wanting to address your drinking, to reduce this, though you also say that this is too hard for you right now, even though you have described how much it is getting in the way of you feeling happier and living your life. Individual: That’s right, on the one hand, I want to do something about how much I am drinking that will make me feel better, and, on the other hand, I know that it contributes to feeling low every day. It doesn’t work, I feel rubbish, and I do want to make that change to feel relief from the stress and burden of repeating the same pattern with drinking every day.

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23.12 MI Skills and Strategies With an understanding as to the importance of bringing together the spirit of MI and the underlying principles of MI skills and strategies is where the approach is strengthened in practice by developing and opening into change talk and commitment. Change talk is where the person is using words to describe their desire to progress towards change and eventually committing to changes. The skill is in recognising it and being able to reflect it back in the conversation. This will be described further in the four processes of MI later.

23.13 Micro Skills of Open-Ended Questions, Affirmation of a Person’s Strength, Reflection, and Summaries (OARS) OARS is an acronym for a set of four micro skills that are used by the practitioner to develop the MI conversation with the person considering making changes. Using these skills will help establish and strengthen engagement, maintain genuine rapport, and support an accurate assessment of their needs whilst developing their motivation to work towards making changes in their use of alcohol.

23.13.1 Open-Ended Questions The first of these micro skills are open questions that are used by the practitioner to enable the person to answer in their words and elaborate further on what they are experiencing. These types of questions contrast with asking a closed question which can shut the conversation down. Open-ended questions keep the conversation going and give a person the opportunity to talk and elaborate further. These types of questions help the practitioner to understand more deeply the person’s experience, thoughts, feelings, and hopes. Open questions are a key skill in engaging a person and can take a practitioner a long way. However, they do need to be joined up with the other three sets of MI skills and need to be balanced out with ‘reflections’, which are described later.

23.13.1.1 A Practitioner May Ask an Open Question by Saying • What brings you here today? • What has been happening for you since we last met? • What is important to you right now that you need to consider in making this decision? • When would be the right time for you to consider starting this? • You seem to have concerns about your alcohol use, tell me a little more about this?

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23.13.2 Affirmations Affirming as a skill is used in MI to acknowledge and take notice as to what a person has said by commenting on the positive aspects of what has been heard by the practitioner. Affirmations are focused into putting into words what has been noticed about the person’s strength’s and can also come from themselves in talking about what has worked for them and how they have coped. In MI, affirmations can have an impact on increasing ‘change talk’ [13, 14] which are descriptive words towards change and reduce ‘sustain talk’ arguing to stay where a person is. Any affirmation offered needs to be conveyed in a genuine and respectful way that strengthens the person’s confidence in their capability and motivation to create the change they are contemplating.

23.13.2.1 A Practitioner May Affirm by Saying • Thank you for coming today as I know it’s not been easy for you to get here, and you have still persevered. • You are obviously a resourceful person to have got through so much. • You have been really trying hard to make these changes and the progress is becoming clearer to you now. • I can see that this is hard for you to talk about…I really appreciate you keeping on with this.

23.13.3 Reflective Listening Reflective listening is viewed as an active process in MI in the conversation and is used to check out whether the practitioner has understood the person. A reflection in a conversation practice is unlike a question when said aloud and is noticeable in that the inflection in the voice rises at the end of the sentence. However, with a reflection, there is difference in the tone that it remains flatter and neutral [15] so is therefore communicating understanding. The practitioner as a reflective listener forms a reasonable guess as to what the original meaning was, from what they have heard the person say, and then gives this back in a set of words in the form of a statement. A well-formed reflective statement is less likely to elicit resistance. Reflections work well when engaging with a person early into conversations. In relation to encouraging behaviour change, good reflective listening helps to explore reasons for change and can take a conversation a lot further than just with open questions. Although the primary focus is on what the person says, the practitioner can also reflect in words what they notice in the person’s tone of voice, body language, and sometimes by what is not said or gaps in their account of what has been said.

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23.13.3.1 A Practitioner May Demonstrate Reflective Listening by Saying Individual: I can’t see a way through with reducing drinking and something has to change as I am not coping well with my job and with looking after myself`. Practitioner: It is becoming harder for you each day to continue drinking and yet you want to be able to find a solution that works for you. Individual: Yes, it is, and I want to do something about it though I seem to be caught in the middle of this and I don’t know where to start. Practitioner: You are not sure how you could find the space to do this, given your responsibilities, though looking at options might be a possibility if you knew where to start.

23.13.4 Summaries Summaries are a helpful way help to move through a conversation and pull together what has been said so far in a short statement back to the person. A summary of what has been said also helps the practitioner check their understanding about what has been heard and understood with the person, it can help clarify what has been said so far.

23.13.4.1 A Practitioner May Summarise by Saying • So, let’s go over what we have talked about so far… • You said that you wanted to talk to your partner, that this has been difficult up to this point as there has never been quite the right time to do this. It is important that he is on board so that he can support you in reducing your drinking… Would you like to talk more about how you might want to make that happen? • So, you’ve just described your hopes and your plan to help you get through this and what the first steps would be for you in the next few days whilst you are not using alcohol. What other questions do you have that you may want to explore before you leave today, which may help you to strengthen your resolve and to make progress?

23.14 Offering Advice and Information (Ask-Share-Ask) Where there is an option to give advice and information, either planned or emerging from the conversation, this can be given framed within MI practice as a brief intervention (BI). The MI framework of Ask-Share-Ask is helpful here: 1. Ask permission to give advice and information that may help with the person’s thinking or for factoring into what is being understood. If agreed. 2. Share the information you have factually. 3. Ask if there is anything else that they need to know, and talk through what this may mean for them in considering their next steps.

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A practitioner asking for the persons permission to share information with them before doing so sets the collaborative spirit of MI right from the outset and provides the person with the autonomy to say yes or no to the offer. A person may want to go away and think about what they have heard and be given time to process facts that have been shared.

23.15 MI as a Four-Process Method There are four processes in MI, which frames the approach and offers a pathway into developing the conversation about change. It needs to be noted that in the application of these four processes into conversation, skills of engaging and the need for re-engaging will often need to occur frequently. The four processes are not linear; they are building blocks to help with the direction of the conversation towards progress. The practitioner can always strengthen the foundations by reverting to OARS at any time to explore and elicit the persons perspective further and deepen understanding.

23.15.1 Engaging Engaging is about building the relationship, developing a safe space to talk, and this is an early and important task in MI. Engaging is promoted as previously discussed by using skills of: • • • •

Open questions Affirmations of a person’s strengths Reflections Summaries (OARS)…

…and through this, engagement could happen very quickly. Using OARS skills stands apart from a usual style of questioning for facts and supports more of a natural style in conversation that is understanding, creating a conversational space for eliciting and understanding the person’s perspective. Key Point 23.4 Using OARS helps with engagement in the first of the four processes in an MI conversation and creates a more natural style of actively listening to the other person’s perspective whilst still gaining an understanding of the situation. Reflective Practice Exercise 23.3 • How well do I understand how this person is experiencing their situation and their alcohol use? • Have I given them their voice and space to express how they are experiencing this situation from their view?

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23.15.2 Focus The practitioner may need to set the focus in a respectful guiding style on what the person is describing is emerging about the situation, through the MI conversation. Setting the focus is not a one-time event; refocusing may be needed, and during an interaction, the focus may change on behalf of the person sharing their situation. It is important how the practitioner attends to focusing into what they understand is an area for further discussion and exploration and pays attention to the way this is said so as not to cause the person to respond in an adversarial way. This is where the underlying spirit of MI is important in continuing to hold collaboration and compassion at the heart of the conversation. Key Point 23.5 Focusing in on a key area helps shape the conversation around what is emerging for the person in relation to their change focus. However, the spirit and pace in how this is undertaken is important. What is important here is that engagement must come first before moving to focus, so as not to move prematurely into this, causing the conversation to close down. Practitioner Reflective Practice Questions 23.4 • Am I conveying a spirit of collaboration and partnership in what I am saying? • Am I creating a safe space to explore the area of concern that the person feels comfortable to open more about what matters to them? • Have I focused too quickly and caused discord in the conversation? • Do we have a shared understanding as to what outcome is wanted here from the person’s perspective? • Does the person talk about what they have for their change? • Have I opened up conversation to explore the possibilities that may be emerging here?

23.15.3 Evoke Evoking as a process is aligned to preparing for change in the conversation and is about eliciting the person’s own ideas and internal motivation for change. In other words, what matters most to them. At this point, in the conversation the practitioner is listening out for a change in the type of words known as ‘change talk.’ Change talk is anything that is being said that identifies that there is movement toward change. This can happen through using open questions and reflections to support the person to explore and elicit what changes are possible from their perspective. Here, the practitioner during the conversation needs to listen for and notice if there are any words that are signalling change talk as an anchor to explore further? The person at this point may be verbalising words that express a desire, ability, reasons, need, commitment, and/or action to be taken in relation to the change they want to work towards (DARNC-CAT). A straightforward way to remember this ‘change talk’ is

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through the acronym DARNC-CAT, and here are some examples of what a person might say to listen out for, which identifies possibilities for change words that are either for supporting further exploration for change or are indicating that a person is ready to act towards change. Desire: I can’t go on like this and I would like/I want/I wish things to be different … Ability: I could/might be able to/I can do this for my own health… Reasons: I would probably feel better if I cut down on wine every night… Need: I ought to/I have to/I really should do this as drinking every day is something that I feel I cannot do anymore… Commitment: I am going to/I intend to do something about this now… Activation: I am ready to/I will start reducing down my alcohol use on … Taking steps/action: I have actually started to have an alcohol-free night; I did this last week… Practitioner Reflective Practice Questions 23.5 • Am I strengthening and affirming what the person has shared with me about their situation? • What is emerging from the conversation? • Do I hear reasons, needs, desires, and wants that may be a basis for exploring and encouraging more of a conversation about change? • Am I noticing and reinforcing change talk and is this increasing?

23.15.4 Plan Planning is the bridge to change and is based on what the person is saying, which indicates readiness to change. Planning brings together both a person’s developing a commitment to change and the co-creation collaboratively of a specific plan of agreed steps towards what the person wants to achieve. Planning needs to be taken at the pace of the individual. This can work well in a conversation when there is a summary of what has been explored. This is used to identify the possibilities that may have emerged, leading to the potential of commitment to act on this. If this is done too quickly, then the person may revert to ambivalence, because the individual may have concerns not yet worked through. Moving into reflective listening will reopen the conversational space to explore what may be important right now and what would strengthen confidence further to help the person to move forward. The key is to gain deeper insight as to what their next step is. Co-producing a plan with a person can form the basis for shared decision-making with treatment options, and with agreeing collaborative care or support planning, about the desired outcome of a treatment goal. Discussions can range across the treatment options from psychosocial interventions, harm reduction approaches (moderating drinking) to abstinence from alcohol for a period where there are health risks that indicate dependency. Other areas of the persons’ life will likely factor into this plan, such as support from family and friends and other outside support. Moreover, it is important to collaborate fully on the plan and summarise the agreements and steps in writing.

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It is time to start to develop a plan when a person is: • • • •

Fully engaged and feeling more confident. There is shared agreement on a change goal. The person has, in their own words, identified their own reasons for change. The person is hopeful and internally motivated for change.

Reflective Practice Exercise 23.6 Practitioner Reflective Practice Bridging Summaries You have talked a lot about some good reasons to stop using alcohol right now and you see that your relationships may improve because of this, which may positively impact on your career opportunities which are important to you. You also talked about having more energy engage in social activities that you’re interested in. So, in thinking about all these possibilities and if you were able to take a step towards your aspirations, what would that first step be? Question If the person starts to find this hard to contemplate during a conversation about planning, then the practitioner can always go back to OARS skills to re-engage with the person at the point where they are.

23.16 Practice Application of MI in Various Parts of the Care Delivery Process in Alcohol Use MI can be used in a variety of care process settings and can be included in conversations related to the care process itself. NICE guidance [16, 17] sets out evidence-­ based guidelines as to how this can be incorporated into practice. NICE guidelines for alcohol use disorders also set out the key elements of the care pathway and where motivational interviewing would support a conversational intervention from: • Assessment of need—assessment of risk to self, in using alcohol harmfully, is part of the assessment. This informs the overall part of the care plan, such as agreeing alcohol treatment goals, which can consist of moderating drinking, harm reduction, abstinence, or structured treatment, depending on whether alcohol dependence has been identified. • Psychological and pharmacological evidence-based interventions for screening and brief interventions for harmful drinking and alcohol dependence. • Acute alcohol withdrawal. • Relapse prevention (see Chap. 22), psychological and pharmacological interventions

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23.17 Conclusion MI is a particular kind of conversation regarding change and is fundamentally about compassionate care and positive regard for a person presenting to services. MI conveys a respect for the individuals autonomy and choice and allows for exploration as to ‘what matters to you’, beyond the presenting alcohol use and that it creates a conversational space to consider the person’s quality of life issues and how this can impact on coping mechanisms. MI is about relational connectedness and inclusion, understanding the persons lived experience, to build the foundations towards a selfdefined set of recovery choices and goals to improve health and wellbeing. The experience of shared and respectful collaborative decision-making framed conversation, between the practitioner the individual, is the recommended standard set in all services.

References 1. Lundahl B, Burke BL.  The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. J Clin Psychol In Session. 2009;65:1232–45. https://doi.org/10.1002/jclp.20638. 2. Miller WR, Rollnick S.  Motivational interviewing: helping people change. New  York: Guilford; 2013. 3. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to the addictive behaviors. Am Psychol. 1992;47:1102–14. 4. DiClemente CC. Addiction and change: how addictions develop and addicted people recover. New York: Guilford; 2018. p. 21–2. 5. National Institute for Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. Leicester: British Psychological Society; 2011. 6. National Institute for Clinical Excellence. Screening and brief interventions for harmful drinking and alcohol dependence. 2021. https://pathways.nice.org.uk/pathways/alcohol-­use-­ disorders. Accessed 14 Jan 2022. 7. Zomahoun HTV, Guénette L, Grégoire JP, Lauzier S, Lawani AM, Ferdynus C, et  al. Effectiveness of motivational interviewing interventions on medication adherence in adults with chronic diseases: a systematic review and meta-analysis. Int J Epidemiol. 2017;46:589–602. https://doi.org/10.1093/ije/dyw273. 8. National Institute on Alcohol and Alcoholism. Matching alcoholism treatments to client heterogeneity: project MATCH posttreatment drinking outcomes. J Stud Alcohol. 1997;58:7–29. 9. Kaner EF, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;2:CD004148. https://doi.org/10.1002/14651858.CD004148.pub4. 10. Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry J Ment Sci. 2011;199:445–52. https://doi.org/10.1192/bjp.bp.110.083733. 11. Miller R, Rollnick S. Motivational interviewing in health care: helping patients change behavior. New York: Guildford; 2008. 12. Dalailama.com. India. 2022. https://www.dalailama.com/. Accessed 9 Feb 2022.

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13. Apodaca TR, Longabaugh R. Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence. Addiction. 2009;104:705–15. https://doi. org/10.1111/j.1360-­0443.2009.02527.x. 14. Critcher CR, Dunning D, Armor DA. When self-affirmations reduce defensiveness: timing is the key. Personal Soc Psychol Bull. 2010;36:947–59. 15. Passmore J. MI techniques: reflective listening. Coach Psychol. 2011;7:49–52. 16. National Institute for Clinical Excellence Guidelines: Behaviour change: the principles for effective interventions. 2007. https://www.nice.org.uk/Guidance/ph6. Accessed 14 Jan 2022. 17. National Institute for Clinical Excellence Guidelines. Behaviour change: individual approaches. 2014. https://www.nice.org.uk/guidance/ph49. Accessed 14 Jan 2022.

To Learn More Recovery: Online free resources on developing a recovery approach to practice. Mental Health Foundation. Recovery. 2021. https://www.mentalhealth.org.uk/a-­to-­z/r/recovery Accessed 2 Feb 2022. The Alcohol Identification and Brief Advice e-learning project: Online resources to learn how to identify individuals whose drinking may be impacting on their health. Health Education England. Alcohol identification and brief advice. 2021. https://www.e-­lfh.org. uk/programmes/alcohol. Accessed 2 Feb 2022. Shared Decision-Making: Undertake the free shared decision-making learning package and training resource developed at Keele University, which is signposted from the NICE guidance website. It contains six modules and takes 4 h. A brief advice e-learning course is available through Health Education England to support developing these brief intervention skills for alcohol and tobacco and a further course on alcohol identification and brief advice for care settings, such as primary care, community pharmacy, hospitals, and dental teams [18].

Problematic Alcohol Use Within End-of-­Life Care

24

Gary Witham

Learning Outcomes • To critically explore the context of problematic alcohol use at the end-of-life • To examine and analyse the experiences of informal carers, family and experts by experience • To appraise and synthesise the evidence to effectively support people with problematic alcohol use at the end-of-life

24.1 Introduction There are increasing rates of alcohol-related morbidity and mortality connected to chronic and acute alcohol difficulties [1, 2] with over 7600 alcohol-specific deaths in the UK in 2017 [3]. This presents a complex picture of alcohol-related harm with higher consumption amongst affluent groups of the population [4], but the majority of alcohol-related problems are situated with the least affluent [5]. Most evidence related to end-of-life care and alcohol use relates to advanced cancer and liver disease [6] with alcohol problems having been associated with increased cancer risk in oropharynx, oesophagus and colon cancers [7]. Lin et al. [8], for example, found 70% of their sample of patients with head and neck cancer had a history of problematic substance use. Current estimates suggest that alcohol-attributable cancers make up between 3.6% and 5.8% of all cancer deaths worldwide [9]. There is also increasing evidence of the links between alcohol use and certain cancers [10]. There appears to be a clear relationship between alcohol consumption and reporting chronic pain [11] with problematic alcohol use associated with younger cancer

G. Witham (*) Department of Nursing, Manchester Metropolitan University, Manchester, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. B. Cooper (ed.), Alcohol Use: Assessment, Withdrawal Management, Treatment and Therapy, https://doi.org/10.1007/978-3-031-18381-2_24

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palliative populations [12], often referred earlier as specialist palliative care, with more symptom experiences and more frequently on prescribed opioids [12, 13]. Alcohol-­related liver cirrhosis is responsible for 0.9% of global deaths and 47.9% of cirrhosis-­related deaths [14]. The main interventions for end-of-life care alcohol liver disease are psychosocial, focused on abstinence [15]. The barriers to effectively implementing this are complex, due to both the symptom burden of end stage liver disease and the challenges of health professionals effectively communicating to individuals who may be intoxicated [16].

24.2 End-of-Life Care Experiences for People with Problematic Alcohol Use Within end-of-life literature, people with problematic alcohol use often describe an anticipation of discrimination related to health and social care staff, precipitated by prior negative experiences within formalised care [17, 18]. This can create a reticence and mistrust for people with problematic alcohol use with avoidance behaviour, often leading to late presentation to end-of-life care services. People may find ‘opening up’ difficult due to isolation, loneliness and mental health problems, causing fear in talking to health professionals, particularly if they are drinking heavily and have an assumption that they will be required to abstain to receive professional support. People using alcohol at the end-of-life may have limited psychological capacity to engage in therapeutic discussions or interventions. Some people who do access health and social care services may hide alcohol use to reduce discrimination. This can cause a reluctance to engage in open communication with formalised care providers [19] and subsequently lead to only accessing emergency services at crisis point whilst caring for themselves at home with little or no support [17, 20]. In terms of hospitals, there may be a perception that they are unsafe, inflexible and paternalistic that again can lead to late presentation, particularly when associated with structural vulnerability like homelessness [21, 22]. There may also be psychological challenges for people using alcohol at the end-of-life. Many participants in a study by Ashby et al. [17] referred to feelings of regret, guilt and shame associated with their past behaviour with self-stigmatisation leading to a perception that they had brought ill health upon themselves and therefore do not deserve healthcare. McCormack [23] indicated that there may also be an increase in alcohol consumption at the end-of-life as a maladaptive coping mechanism in dealing with psychological distress. The acceptance of the need for end-of-life services may also be psychologically challenging with palliative care units perceived as places of ‘no return’ and for people who ‘deserve’ a good end to their life [21]. There is a general lack of information about end-of-life conditions, for example, people with advanced head and neck cancer often lack information about prognosis, treatment and symptoms [24]. People using alcohol and/or other substances are often not in regular contact with healthcare services and therefore may have unmet information needs, made more challenging in having to try to communicate prognosis to friends and family [17], especially if relations are strained between them and their family/friends due to frustration about their ongoing alcohol use (see Chap. 8).

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Open communication with care professionals about prognosis is also commonly lacking. When in contact with formalised health systems, the often-fragmented nature of hospital encounters, without contextualising knowledge of a social background, can make end-of-life support for people with problematic alcohol use challenging. It can overlook the impact that structural vulnerability such as poverty, homelessness or mental health stigma has upon the individual [25]. For people with problematic alcohol use, receiving an end-of-life diagnosis, can be challenging to cope with because of a number of factors, including a lack of honest communication with health professionals underpinned by stigmatising attitudes towards alcohol use [17]. The uncertainty and unpredictability of end-of-life trajectories for people using substances can also be a challenge, since recognising dying in the presence of multiple comorbidities can be difficult [21, 26]. People using substances can struggle to understand end-of-life care, partly due to anticipated discrimination by formal health and social care providers, leading to emotional and psychological withdrawal to protect themselves from judgement [19]. The person may also be concerned with stigma and perceive that there would be a withdrawal of care and medication if they were open and honest about their alcohol use. This could lead to a delay in approaching end-of-life services [17]. Moreover, there may be problems related to memory or cognitive capacity and few families and friends to help interpret the information given by health professionals. The often-late presentation to healthcare services of people experiencing problematic alcohol use can mean that decisions and advance care planning may need to be facilitated through the imminent dying phase of someone’s life. Potential rapid decision-making can be challenging within this context [17]. There is a focus on the ‘here and now’ for many people using substances, and this can mean a broader discussion of end-of-life preferences is often avoided [19]. Day-to-day survival becomes the priority, and this makes proactively managing common end-of-life symptoms difficult for this population. Figure  24.1 highlights the challenges for people using substances at the end-of-life. Reflective Practice Exercise 24.1 Case Study 24.1 Jane (67) lives alone in a flat. She worked as a teacher but found the stress of this job made it difficult to cope. This led to her retiring. For the past 10 years, her drinking has steadily increased and has slowly worsened following a fall 3 years ago that left her with chronic back pain. Jane has a history of depression and anxiety. Jane has a few close friends, and these are heavy drinkers. She has no children and has had several ex-partners that remained within her social network. Jane used a walker to get about. She went on holiday, and binge drinking (see Chap. 16) led to a hospital admission after her return. She was presenting with symptoms of advanced liver cirrhosis and spent 3 weeks as an inpatient. Jane remained unsure of why she needed to be in hospital for this length of time and was confused about why she had symptoms such as a swollen abdomen and fluid buildup in her legs. At times, Jane became confused, and some of her friends remained unaware of what was going on, receiving limited information from the health professionals that were supporting Jane.

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Experience stigma and discrimination including self-stigma leading to the person using substances to minimise their own care needs

Poor access to end-of-life care services, often presenting late with greater symptom burden

Experiences of people using substances at the end-of-life

Often open to structural vulnerability, for example, homelessness or poverty

Lack of information about prognosis with poor communication with health professionals

Fig. 24.1  Thematic cluster highlighting the experiences of people using substances at the end-of-life

Discussion Points 24.1 • Make some notes on your reflection. • Compare your notes with colleagues. 1. What would be your initial question to Jane about her alcohol use? How would you assess this? 2. How would you raise issues about advance care planning and end-of-life care with Jane and when? 3. How would you address the information needs of Jane’s friends? 4. How could you support Jane with underlying problems, such as anxiety and depression and chronic back pain?

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Key Points 24.1 • Exploring structural vulnerability and identity is a significant task to the provision of effective end-of-life care. People using alcohol and/or other substances are often reticent to both seek or sustain relationships with health and social care services or may not acknowledge that their alcohol use is problematic. • Psychological support may assist people to manage feelings of guilt or self-­ blame related to a belief that they are responsible for the ‘choices’ that have led to end-of-life context. This may be particularly important due to isolation and a limited social network. • Examining appropriate healthcare environments may assist people with problematic alcohol use to combat loneliness and enhance social networks in relation to end-of-life care. • Refocusing to end-of-life priorities can be challenging for people with problematic alcohol use, since there is often a move away from treatment to risk reduction predicated on symptom management. • Establishing effective ways to open communication for people experiencing problematic alcohol use in order to explore talk related to death and dying is important, particularly within a context of discrimination, stigma and self-blame. There is a need to explicitly demonstrate compassion towards the individual and their family/carers. Articulate that you do not judge the individual for her/his drinking and that she/he deserve good-quality care. Learning about motivational interviewing (see Chap. 24) techniques would be helpful with this [27].

24.3 Family and Informal Carer Experiences At least 1.5 million adults in the UK are estimated to be affected by a relative’s drug use [28]. Of those affected adults it is highly likely that some will be caring for a relative at the end of their life. Families of people who use alcohol problematically experience psychological struggles as they try to deal with the impact of this and their own need for support [29–31] (see Chap. 8). This burden is at an equivalent level to other conditions, such as chronic illness, disability and mental illness [32, 33]. Problematic alcohol use can negatively affect intimate relationships and cause chronic stress and poor physical and mental wellbeing for family members [34]. Given this context, having the emotional/psychological capacity to support a dying relative is often a heavy burden for families to deal with [35]. This issue has received little policy focus with only the UK National End-of-Life Care programme mentioning how care pathways that could be relevant for people using alcohol for people with advanced liver disease [36]. For relatives of someone dying from alcohol use, communicating effectively with health and social care professionals can be challenging. Support is often sought through their relative’s general practitioner (GP)/medical doctor (MD), although even after warnings of the consequences of alcohol use in causing premature death, the individual may still continue to drink. This can cause frustration and anger for many families directed at their relative who has not stopped drinking or sought help.

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There is often an attachment of blame for not stopping, feeling a life is wasted, with the individual’s denial of problematic alcohol use, shutting down potential discussions about the consequences and the introduction of end-of-life care discussions or advance care planning. Families and informal carers can also be liable to structural vulnerabilities themselves, for example, Stajduhar et al. [37] found that almost half of their sample of the informal carers, supporting someone homeless using substances at the end-of-­ life, were street family or friends. This highlights the nontraditional family networks that can develop, particularly given the fractured family relationship that can exist because of years of problematic alcohol use. These are an untapped resource that are not often identified by care professionals, even though they can provide trusted support to the person using alcohol. Key workers for socially isolated individuals (i.e. people whose families have disintegrated or who are homeless) may take on a much more central (and emotionally demanding) role in the person’s life. Consequently, they may experience loss and bereavement on a par with family members but with the added burden of having to fill out ‘Death in Service Review’ paperwork and provide evidence that they followed all the right procedures/protocols. Where there were more traditional family networks the end-of-life experience of their relative was often traumatic, since there was an erroneous belief that there would be recovery (as there often had been on previous occasions) and recognising dying was often missed [35]. There can be attempts by families to get help for acute crisis requiring medical care either through GPs or Accident and Emergency (A&E)/ Emergency Department (ED), with the hope that the cause of the admission, their relative’s alcohol use, would be recognised and support given to change. This often did not happen with families potentially interpreting this as alcohol being too shameful, an issue for health professionals to discuss with them. This offered limited opportunities to discuss the risk of a relative dying with care professionals and no initiation of anticipatory end-of-life care planning that could involve appropriate support for the family [20, 38]. This meant that when the relative died, it often occurred quickly, was associated with mental incapacity for the relative and was unexpected and psychologically traumatic for the family. This is particularly challenging, since there may be some regrets about conflictual family relationships, disrupted by alcohol problems, and the unexpected nature of their relative’s death with no opportunity to say ‘sorry’ and ‘goodbyes’ or to potentially reach some conflict resolution at the end-of-life. The sense of loss was exacerbated by feelings of shame in relation to the relative’s substance use and reinforced by negative experiences with care professionals, who did not appear to address any family concerns or care needs when asking for assistance [20]. Family members may well also have substance use problems and so are at risk of increasing their use as an attempt to overcome grief, particularly in response to a distressing/undignified death. Even if they do not have substance use problems themselves, they may be worried about other family members’ overreliance on substances and/or have concerns about any children developing problems in the future. Families described feeling embarrassed about their relative’s alcohol use and the subsequent deteriorating wellbeing [35]. Families anticipated

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discrimination and stigma with no expectation of empathy or sympathy, even though small acts of kindness from care professionals appeared to mitigate against those negative feelings, particularly through the bereavement process [39]. Cold professionalism reinforced stigma and reinforces the social isolation often experienced by families over the years. Families may avoid disclosing the relative’s alcohol use to wider family members, friends and neighbours and therefore reduce the opportunities for informal support and again increase their social isolation [35]. Reflective Practice Exercise 24.2 Case Study 24.2 Margaret described her brother John history of hospital admissions associated with his alcohol use. John had been declined a liver transplant 3  months before death, because he was too unwell. According to the family, despite the severity of the John’s alcohol use problem, there were no discussions about the potential need for the family to consider end-of-life care, despite repeated interactions with hospital staff (including liver transplant teams). Margaret said that the family thought the brother would recover. Margaret felt the hospital staff were not interested in addressing her questions and were dismissive of her concerns. Discussion Points 24.2 Make some reflective notes as before in discussion points 24.1 1. How could you support Margaret in opening a conversation about goals of care in relation to end-of-life? 2. If it is not your ‘job’, who should initiate these discussions and when? 3. Why are health and social care professionals so reluctant to have conversations about end-of-life with families? 4. How could you better prepare Margaret for the imminent death of John? 5. What is your own experience and attitude towards family members of a relative with problematic alcohol use? Key Points 24.2 • Families may be unprepared for their relative to die, since people with alcohol problems are often reticent to engage with health and social care services and may not acknowledge their alcohol use as problematic. This can lead to late presentation to end-of-life services. This is often compounded by poor communication from care professionals and the unpredictable nature of many chronic conditions, which mean advance care planning for end-of-life care may not be initiated or initiated too late. • Families that are caring for a relative with alcohol problems are prone to chronic stress but have limited insight into their own support needs, including through the bereavement process as well as prior to their relative’s death. • Underlying issues related to stigma, discrimination and emotionally ambivalent feelings, such as frustration, anger and shame, may be prevalent within families of people with alcohol problems. This, in combination with limited medical

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information or support about end-of-life care, may prevent them from adequately providing informal care. • The definition of family may require a broad interpretation, since there may be fractured familial relationship related to a relative’s problematic alcohol use. For example, if someone is homeless and lost touch with familial contacts, it may be friends and peers in a shelter or the streets that are the main support at the end-of-life.

24.4 Professional Experiences and Responses To meet the needs of people using alcohol at the end-of-life, it is important to understand the contextual issues that mean adaptation of care is of central importance. There is a significant body of literature examining homelessness, end-of-life and other problems, such as substance use [21, 22, 26, 40, 41]. Within the context of homelessness and problematic alcohol use, terms such as ‘home’ may need to be reimagined, since for those who are precariously housed a shelter could be home. Furthermore, palliative care units may be interpreted as hopeless places, too middle class and to be avoided with potentially more meaningful support, given by shelter workers and peers rather than familial relationships and palliative care teams [21, 42]. It is, therefore, important that intra-disciplinary and interdisciplinary working is developed with drug and alcohol services engaging with palliative and end-of-life services to seek support/training. This may change the traditional delivery of end-­ of-­life services requiring flexibility and low-barrier interventions with a focus on harm reduction [43, 44]. Many homelessness services focus on recovery, assisting people to access and engage with substance use services and move towards independent living [26]. Narratives of harm reduction and recovery can make the focus of care challenging [45] with terms such as ‘dying’ or ‘recovery’ seen as contradictory. Narratives of recovery, the overriding paradigm within substance treatment services, may have limited application to people using alcohol nearing the end-oflife and affect the delivery of alcohol treatment interventions. At this stage, a person may not want to ‘recover’ (reduce or be abstinent) from their alcohol use but rather be supported in their alcohol use at the end-of-life. They may not want to be ‘fixed’ [26]. Some people, however, may want detoxification (see Chaps. 19–22) with a view to repairing family relationships and having meaningful conversations with loved ones. The complexity of recognising dying in people with problematic alcohol use is compounded by an unclear disease progression with a population that may have multiple chronic conditions. Galvani et al. [46] quote a senior health and social care professional referring to liver disease. So, the steady decline that you see in malignancy [cancer], which is where palliative and end-of-life care developed as a specialty … is not there in liver disease, so that unpredictability of the trajectory, which can sometimes even result in survival from the disease, makes it very difficult.

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Distinguishing between the impact of fluctuating symptoms related to ongoing alcohol use or that related to general health condition can be challenging, as alcohol use can mimic or mask declining health. Recognising dying is not straightforward, and a simple question to ask is ‘Would I be surprised if this person were to die in the next 12 months?’ [47]. The Gold Standard Framework [48] has developed a Prognostic Indicator Guide to identify, assess and plan end-of-life care. However, it requires care professionals to begin conversations about end-of-life and decision-­ making. Galvani et al. [42] found that professionals working in drug and alcohol services found talking about dying was often a ‘taboo’ topic and that they felt ill-­ equipped to address, and for end-of-life care services, broaching the topic of alcohol use was challenging and an area they had limited expertise. There is evidence that people using alcohol may increase drinking in light of deteriorating health in order to cope psychologically with a potentially life limiting condition like cancer and to manage increasing symptoms [45]. It is, therefore, important to reassure the person that symptoms like pain will be taken seriously and managed in the same way as people without substance use problems. This is particularly important, given the stigma and discrimination people experiencing problematic alcohol use have often encountered with care professionals. This may lead to a fuller disclosure of alcohol use and allay fears that symptom management will be dependent on a model of recovery with a focus on alcohol absence or reduction [49]. Some people may welcome the offer of detoxification, with a view to rebuilding personal relationships and having the opportunity to have meaningful conversations before they die. Clear and honest communication can also support informed decision-making in relation to any potential interaction with prescribed medication. Moreover, this needs to account for physical deterioration to a point where someone may not be able to drink independently. Key Point 24.3 Professionals need to be aware of the potential requirement to prescribe additional medications to maximise comfort at the end-of-life. Care professionals need to acknowledge the challenges of people using substances in accessing different services and ‘fitting’ in with current healthcare delivery [40]. Reflective Practice Exercise 24.3 Joint working is an important element in supporting end-of-life care for people experiencing problematic alcohol use. In Box 24.1, there are some good practice recommendations (Galvani et al. [49, p. 8]. Read Box 24.1 and think about: • Make some notes on your reflections. • A discussion amongst your team may be helpful. 1. How these recommendations can be applied to your own practice? 2. What barriers are there that can prevent you from applying these recommendations in your practice? 3. How could you effectively overcome the barriers you have identified?

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Box 24.1 (Galvani et al. [49])

• Building closer working relationships with GP’s/MD’s who are a main contact for prescription management • Building good relationships with other specialist services – even just one lead from each service can keep communication channels open • Bringing experts in to team meetings to discuss particular issues around end-of-life care and problematic alcohol use, especially experts in asking about ‘sensitive’ issues • Offering training or guidance to other agencies. This is particularly important in order to provide specialist advice, emotional and practical support, and clinical supervision to practitioners to counter the emotional demands of working with people who are dying • Working with homelessness professionals, hostels and drug and alcohol services to maximise the support they can offer and to try to keep people safer than on the street • Get consent to share information to avoid the person having to repeat the same information frequently • Share information on a person’s care needs with GP’s/MD’s, and be prepared to advocate for them, particularly around palliative care registration • Acute or social care professionals could consider whether referrals are needed to both addictions team and end-of-life services • Work together on what advance care planning might look like for someone at end-of-life experiencing problematic alcohol use • Discuss with practice partners who is taking responsibility for the oversight of the person’s care otherwise the person might fall between the gaps in services

Key Points 24.4 • The focus on a narrative of recovery for drug and alcohol services can be seen to be problematic when applied to people at the end-of-life but still have need of alcohol use expertise. • There is often unpredictability or uncertainty about diagnosing end-of-life for people, whose health problems are related to alcohol use, and this can restrict the potential for appropriate referral into end-of-life care services. Moreover, there is frequent failures on the part of GPs/MDs and hospitals services to recognise serious illness and to refer early to either substance use or end-of-life services. • Professionals need to present a non-judgmental attitude in working with the individual founded on providing a person-centred and needs led approach to care, including working with the individual’s choice to continue using alcohol (in a safe way) at the end-of-life.

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There is a need to increase training for intra-disciplinary and interdisciplinary services, involved in supporting someone experiencing problematic alcohol use and their family; training on communication, recognition of dying and principles of good end-oflife care for those in Drug and Alcohol Services; and training on communication and dependence within end-of-life care services. This could also facilitate joint working and support integration of care working with a complex population.

24.5 Conclusion This chapter has explored end-of-life experiences for individuals experiencing alcohol use problems. It has examined the context of care and how this can impact on end-of-life experiences, for example, those that may be precariously housed or those with primarily nonfamilial social networks. It has explored the stigma and discrimination that can prevent access to good end-of-life services and the challenges for those experiencing problematic alcohol use in navigating both drug and alcohol services and end-of-life care providers. The concerns of family and informal carers were often marginalised with poor information about the health decline of their relative and limited recognition of dying from both family and care professionals. This was often compounded by a denial of the consequences of alcohol use by the families’ relative, poor communication between formalised services and family and limited recognition or support of carer burden of family involved in their relative’s care. Health and social care professionals often found it challenging to manage the change of focus, at the end-of-life, from a model of recovery to one of harm reduction in the face of imminent dying. The complexity of managing end-of-­life symptoms in the presence of alcohol use requires effective communication and honest discussions about the goals of care and advance care planning that take account of the individuals alcohol use. This situation necessitates effective intra-­disciplinary and interdisciplinary working in order to provide optimum care.

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To Learn More Good practice guidance: Supporting people with substance problems at the end of life. 2019. https://endoflifecaresubstanceuse.files.wordpress.com/2019/05/good-­practice-­guidance-­ supporting-­people-­with-­substance-­problems-­at-­the-­end-­of-­life.pdf. https://endoflifecaresubstanceuse.com/. Accessed 11 Aug 2021. National Council for Palliative Care (NCPC). Who cares? Support for carers of people approaching the end of life. 2012. http://www.ncpc.org.uk/sites/default/files/Who_Cares_Conference_ Report.pdf Accessed 11 Aug 2021. Inequalities in Palliative care. https://www.youtube.com/watch?v=0U3Kn3aKS7M&feature=yo utu.be. Accessed 11 Aug 2021.