‘Many roads to change’: The therapeutic alliance for AOD use

The RACGP’s Alcohol and Other Drugs (AOD) GP Education Program, delivered between 2020–22 and funded by the Department of Health and Aged Care, will continue to publish legacy resources, including a comprehensive education resource library.
 
In the March edition of the Australian Journal of General Practice (AJGP), the AOD GP medical education team Dr Shani Macaulay, Dr Paul Grinzi and Dr Simon Slota-Kan, published a clinical peer-reviewed article, ‘Engaging patients who use alcohol and other drugs: A practical approach’.
 
According to lead author Dr Macaulay, the article serves as a guide for foundational, whole-person care for patients experiencing AOD-related issues.
 
‘The main objective [of our paper] is to provide a universally applicable approach for GPs to assist all patients using any AOD substance, which as far as we know hasn’t been done before,’ she
told newsGP.
 
‘We aimed to do this in a manner that allows GPs to implement this information in practical terms. We aim to provide a “primary care lens” to provide healthcare to patients who use AOD.’
 
The approach to managing patients experiencing AOD use has shifted in more recent years from a punitive approach with attached stigma and shame – factors shown to adversely impact outcomes including a delay and low engagement with treatment.
 
An approach focusing on a trusted therapeutic relationship is best practice, incorporating a ‘strengths-based approach’ of whole-person, trauma-informed care and motivational interviewing to support behaviour change, according to the AJGP authors.
 
‘A person’s identity is much more than their AOD use and this forms the cornerstone of motivational interviewing,’ they write.
 
‘A respectful, non-judgemental approach that is trauma informed fosters rapport, directly counteracts stigma and improves treatment retention … By building the therapeutic alliance and taking a strengths-based approach, GPs can create safe spaces that act as an “open door” for AOD treatment across a person’s lifecycle.’
 
Referenced in the AJGP paper, the 5As framework to facilitate behavioural change is a familiar and practical tool for GPs, with each step of  ‘ask’, ‘assess’, ‘advise’, ‘assist’ and ‘arrange’ important to consider with patients on their AOD journey.
 
Dr Macaulay said her team’s paper aligns with participants’ feedback from the RACGP’s AOD GP Education Program.
 
‘Our research provides a generalist approach to AOD withdrawal management, along with a strengths-based, patient-centred approach, which is consistent with many of the RACGP AOD Educational resources which provide a deeper dive into related topics and addresses specific vulnerable patient groups,’ she said.
 
GPs can apply foundational, whole-person care for patients experiencing AOD-related issues through eliciting the patient’s agenda and seeking opportunities to work on a shared agenda, according to Dr Macaulay.
 
‘Reviewing performance and measuring outcomes in a holistic way, could involve GPs looking at a case of their own and be quite powerful,’ she said.
 
‘Ask the patient to describe their story rather than just answering questions. Take a person-centred approach, that is, treat the patient as a person who uses AOD, rather than an “AOD patient”.  
 
‘Take the long view on treatment and the therapeutic alliance. This involves treating the whole person – biomedical, mind-body, connection and relationships, obligations and activities, lifestyle –not just focusing on AOD, and realise there are many roads to change.’ 
 
The AOD GP medical education team cite both the AJGP article and the RACGP’s AOD resource library as offering ‘ample opportunities’ such as whole-of-practice education, case studies for teaching and suggestions to review clinical practice for GPs to address their 2022/23 CPD requirements.  
 
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