Doctor–patient relationship ‘the best tool’ for AOD harm minimisation

The efficacy of brief interventions in the general practice setting has been demonstrated when it comes to helping patients quit smoking, with the brief three-step approach ­of ‘Ask, Advise, Help’ enabling GPs to offer streamlined advice more frequently.
 
Dr Paul Grinzi recognises that brief intervention approaches have the potential for similar success when GPs are working to support their patients who may have issues with alcohol and other drugs (AOD).
 
Despite there being many strategies available for GPs to support this group of patients, including the brief intervention approach, Dr Grinzi believes fostering a therapeutic patient relationship is the most effective tool a GP can arm themselves with. newsGP discusses these approaches with him.
 
How can GPs best utilise their time during a standard consultation to discuss AOD use?
Brief interventions, for alcohol in particular, have a strong international primary care evidence base.
 
GP consultations tend to be tight for time, so incorporating brief intervention models such as FLAGS (Feedback, Listen, Advice, Goals, Strategies) within a consultation is important.

Assessing and addressing AOD issues is an important role for GPs. AOD conditions are frequently comorbid with many other health concerns.
 
How is a trusted relationship established and maintained with patients, ensuring they will keep coming back?
There is good research showing patients expect us to assess their AOD use, within a GP setting.
 
Patients, in general, trust their GP. Avoiding stigmatising language, focusing on the patient’s concerns and asking questions in a non-judgemental manner all go towards the development of that therapeutic relationship.
 
I suggest we stop thinking of [asking patients about their AOD use] as ‘thorny questions’.
 
The trick is to incorporate this assessment into the patient agenda, and not as a ‘tacked on’ side-assessment. There are plenty of opportunities to do so in everyday practice. Common presentations such as hypertension, falls, anxiety, GORD, pregnancy, respiratory symptoms, pain, etc, all have potential links to AOD that permit an entry into this part of the assessment.
 


Can you offer any tips for motivational interviewing and how to encourage patients to open up about their AOD use?
I suggest using similar approaches to other clinical areas focused on behaviour change: get the patient to talk more than you do by asking open-ended questions, using reflective statements, developing rapport and affirming what the patient has been already able to achieve.
 
These components of motivational interviewing can be both effective and time-friendly.
 
I recommend GPs sit beside their patient – at least figuratively, if not literally – to permit ‘seeing’ the health issues from the patient’s viewpoint. Then, we are best placed to understand how our advice and strategies will meet the patient’s goals.
 
With the introduction of SafeScript, the 1 June changes to the downsizing of opioid packs, and take-home naloxone pilots – is Australia on track to a national, streamlined approach to tackle AOD issues?
There’s certainly a lot happening to reduce the risks of harm and deaths from prescription medications, particular opioids. I believe that a national version of SafeScript is inevitable, with a significant part of Australia already using, or about to roll out, such systems.

GPs do a wonderful job for our communities. SafeScript programs, take-home naloxone and smaller opioid packets are tools GPs can use to reduce risks around prescribing drugs of dependence – but they aren’t sufficient in themselves.
 
In the end, it’s about that very individualised doctor–patient relationship and how we utilise our clinical knowledge, experience and skills within those relationships.
 
RACGP resources

• Generally Speaking podcast series – Episode 7 features Dr Grinzi discussing AOD use
• SafeScript webinar
• Prescribing drugs of dependence in general practice
• Drugs of dependence: Responding to requests fact sheet
• Alcohol and other drugs GP education program – online components now available

alcohol and other drugs AOD brief interventions doctor–patient relationship