5 years ago

NAT 6/08 - THL

NAT 6/08 - THL

Screening and brief

Screening and brief intervention for alcohol problems in Norway The 1994 GP survey and WHO Phase III Norway also participated in Phase III of the WHO collaborative study (Saunders & Wutzke 1998). In preparation for this project a survey of 159 Norwegian general practitioners was performed in 1994, parallel to identical surveys in the nine other countries that participated in Phase III (Australia, Canada, Denmark, Hungary, Italy, New Zealand, Poland, Russia and the UK). The purpose of the survey was to assess and document the GP’s current practice and opinions on preventive medicine in general and early intervention for alcohol in particular, and how they perceived their role in providing these services. In addition to the questionnaire survey, 12 telephone interviews with general practitioners and 5 interviews with “key persons” (GPs, administrators and politicians) were conducted A total 307 of the nearly 2,000 general practitioners in the membership register of the Norwegian Medical Association were randomly selected to receive a postal questionnaire, and 159 GPs returned a usable questionnaire, giving a response rate of 51.8% (159/307). The responses reflected the typical working situation for Norwegian GPs with little time left for more than the necessary checks and messages. Smoking was the best managed preventive intervention, and only 7% of the general practitioners were themselves daily smokers. A more ambiguous attitude towards alcohol intervention was also clearly documented. However, once the concern for hazardous or harmful consumption was raised, the Norwegian GPs responded with advice and further investigations. One of 518 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 the most striking findings was the assumed low upper limits for potential patient advice in Norway by GPs: 11 g/day (78 g/ week) for men and 7 g/day (51 g/week) for women. At that time, no official limits on safe drinking existed in Norway. Nevertheless, our findings on upper limits came out considerably lower than for instance contemporary British advice of 3–4 units (24–32 g) per day for men and 2–3 units (16–24 g) per day for women (Department of Health 1995). This suggests that daily drinking in itself may be regarded as abnormal by Norwegian GPs. There is clearly a cultural difference here, also reflected in Norwegian GPs’ own alcohol habits: only 3% were daily drinkers in 1985 (Aasland 1987b). In a preparatory Australian study, Gomel et al. (1998) randomly assigned general practitioners to one of three marketing strategies designed to promote the “uptake” of a brief intervention package for hazardous and harmful alcohol consumption: direct mail, telemarketing, and academic detailing (doctors were given training and support by competent colleagues in their practices). Tele-marketing was found to be more cost-effective than academic detailing and direct mail in promoting the uptake of the package. This design was then tried out in all the participating countries. Following the survey and the interviews, Norway embarked on a controlled trial of three dissemination methods. We managed to recruit 75 GPs, of which 21 were willing to try out the package. This reduced our study to a pilot study that instead looked at attitudes to brief intervention. A full scale study in Norway would cost 2 mill NOK (24,000 €), and was not feasible (Jo-

hannesen & Rysst 1998). The pilot study showed that Norwegian general practitioners have a conservative view on what amounts to hazardous drinking, and that they feel more competent to give advice on smoking than on alcohol. In this study the most important obstacles for better alcohol counseling, as judged by the doctors themselves, were lack of time and lack of brief intervention competence. However, the doctors found brief intervention interesting, but preferred to use it selectively on patients presenting with symptoms indicative of suspected high-risk consumption. General screening of every patient could be regarded as an intrusion of patient autonomy. A special fee for case finding and intervention Despite efforts to implement AUDIT as a tool for case finding, the authors of this paper have at times felt themselves to be the only Norwegian advocates for placing more emphasis on the implementation of standardised procedures of secondary prevention of alcohol-related problems in primary health care. Governmental bodies and doctors’ associations have given plenty of lip service, but the final steps have been extremely slow. In 2001 a “reference group” appointed by the Directorate for the prevention of alcohol and drug problems and the Ministry of Health produced a report on “The role of the primary health care service in the prevention and treatment of alcohol and drug problems” (Borgestadklinikken 2001). One of the conclusions from this report was that if the doctors should participate more in the efforts against alcohol and drug problems it should be remunerated like other Screening and brief intervention for alcohol problems in Norway efforts and interventions from GPs. After several years of lobbying the Norwegian Medical Association finally decided to include screening for alcohol problems, for instance with AUDIT; the fee is presently NOK 60 (approx. 7 €). So far there is no special fee for active intervention or systematic follow-up, as there is for other lifestyle interventions (diet and exercise). Economic incentives are powerful tools for behaviour change. However, the experience with a specific fee for counselling on diet and exercise in Norway (“Green prescription”) has not been very effective (Bringedal & Aasland 2006). We have, on the other side, seen some effect of intervention on tobacco (Meland et al. 2000; Gallefoss & Drangsholt 2002). Whether a special fee for alcohol intervention (not only case finding) will increase the GPs motivation for such procedures therefore remains to be seen. A new research initiative In 2008 the Norwegian Institute for Alco- hol and Drug Research (SIRUS), in collaboration with The Research Institute of the Norwegian Medical Association started a new project on the use of screening and brief intervention in general practice. The project investigates the use of screening and brief intervention for alcohol and tobacco by GPs in Norway, and will gain insight into the types of problems experienced by GPs concerning screening and brief intervention. In June 2008 a questionnaire was mailed to 2000 general practitioners, with 901 usable responses (45%). The findings from the survey will be used as a basis for several focus group interviews throughout the country, and the ultimate aim of the study being to gauge the present potential NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 519

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