Pulse May 2019 issue - Page 32

32 1.5 CPD hours Key questions on addiction Dr Yasir Abbasi on very brief advice for smoking cessation, safely supporting an alcoholic to reduce their drinking and managing opiate addiction in pregnancy Q Can you outline the principles of ‘very brief advice’ (VBA) for smoking addiction and how this can be used in a normal GP consultation where time is limited? Primary care services are working A under tremendous pressure. There are limited resources and increasingly demanding work. In this type of setting it is still possible to provide a quick smoking cessation consultation. VBA is known as the 30-second consultation that can save lives. 1 It’s covered by the three As: • Ask and record smoking status. • Advise on the best way of quitting (medication and specialist support). • Act on patient response (build confidence, refer, prescribe). The National Centre for Smoking Cessation and Training (NCSCT) offers an online course on VBA that can be accessed at any time. 2 Remember that change does not occur immediately, and do not rush or impose change. Try to build up a good rapport with the patient and give them time to understand why they should consider quitting. Give them a lot of information about the hazards of smoking in a non-judgmental and empathic manner. Q How would you manage a patient who had a known opiate addiction but also a genuinely painful or malignant diagnosis requiring opiates? Patients who have a known opiate A addiction might develop comorbid health problems that result in them experiencing pain. Pain is a subjective experience and should be taken seriously. The first step is to complete a holistic assessment, which includes assessing pain score and function. If the pain is of an acute nature, this would need to be addressed with a short course of either non-opiate painkillers, if appropriate, or even opiate painkillers. However if the pain is more chronic, there would need to be a more candid discussion about realistic expectations and goals from any pain relief Pulse May 2019 interventions during the initial assessment. Malignant diagnosis would need closer monitoring and liaising with a specialist to agree the best duration of treatment for the malignancy the patient has. In any case, whatever the reason for the pain, once an opiate painkiller has been prescribed, it is crucial to regularly review pain score, function and the need to continue the painkiller. It is useful to regularly assess the patients, according to the ‘4 As’ principle (analgesia, activity, adverse effects, aberrant behaviors). 3 There needs to be an open and clear discussion with the patient about long-term benefits versus the risk of opioid use so that an informed and collaborative decision can be made. Q If a patient is newly registered with you and is taking a dose of benzodiazepines that you are not happy to continue prescribing, how do you wean them off ? There is no easy answer. This A depends on the dose and length of the time the patient has been taking the benzodiazepine. The first step is to invite the patient for a consultation and find out why they are prescribed it and why they are on the dose that makes you uncomfortable. Sometimes they have an undertreated or untreated underlying comorbid mental health problem, like generalised anxiety disorder, social anxiety disorder or mild depressive disorder. It is important to establish this and start discussing the appropriate biopsychosocial treatment for these problems before considering the reduction of the dose of benzodiazepines. You would then need to have a discussion about the harm of long-term and high-dose benzodiazepine use, which includes and is not limited to cognitive impairment, dizziness, falls and dependence. Once you have come to a joint agreement on reducing the dose, discuss and agree the pace of reduction. If you are considering tapering, it is best done with diazepam and converting the existing benzodiazepine dose to diazepam. The suggested approach is to generally reduce the original dose by 5% every two to three weeks. 8 It would be best to supply the patient with a weekly prescription if there are risks of overdose or misuse. There is flexibility to withhold further reduction for a short period of time if the condition of the patient becomes destabilised. The aim is to achieve your collaborative goal slowly but steadily. Q How would you manage a heavy drinker who wishes to stop but can’t or won’t engage with local alcohol services and is worried about the ill-eff ects of stopping suddenly? Is it reasonable to suggest they drop down gradually and what sort of rate would you suggest for someone who drinks, for instance, 10 pints of strong lager per day? It is important to not address A addiction in isolation. There are many social triggers and underlying psychological issues that lead to alcohol dependence. Learning motivational interviewing techniques will help prevent conflicts during consultations and also leads to better engagement with the clinician. It is also useful to involve someone from the patient’s social life who does not have alcohol on a regular basis and can support them through their journey in a non-judgmental manner. It is important to highlight the harms that alcohol can do to them and see if they realise why they should reduce their intake. Check they understand that suddenly stopping can lead to intense withdrawal, with possible complications such as seizures or delirium tremens. When recommending a reduction, it is good to first understand how much they are drinking and reduce by 5% every two to three days. So 10 pints of strong lager a day would equate to about 28.4 units, and a safe rate of reduction would be about half a pint every three days (1.4 units every two to three days). However, if the patient struggles or experiences any