Skip to main content
Log in

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice

  • Original Article
  • Published:
Irish Journal of Medical Science Aims and scope Submit manuscript

Abstract

Background

Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment.

Aims

This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among this population.

Methods

The guidelines were developed in three stages: (1) identification of key stakeholders, (2) development of evidence-based draft guidelines, and (3) determination of a modified ‘Delphi-facilitated’ consensus among the group members.

Results

The guidelines incorporate advice for physicians on all aspects of care, including (1) definition of problem alcohol use among problem drug users, (2) alcohol screening, (3) brief intervention, and (4) subsequent management of patients with alcohol dependence.

Conclusions

Primary care has an important role to play in the care of problem alcohol use among problem drug users, especially opiate substitution patients. Further research on strategies to inform the implementation of these guidelines is a priority.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

Notes

  1. ‘Project Steering Committee’ members (www.drugsandalcohol.ie/15260)

References

  1. Keenan E, Barry J (1999) Managing drug misuse in general practice. Republic of Ireland has set up scheme to regulate methadone prescribing by GPs. BMJ 319(7223):1497

    Article  CAS  PubMed  Google Scholar 

  2. Kenny K, O’Carroll A (2012) The use of psychotherapeutic interventions by primary care GPs in Ireland in the treatment of their methadone patients: a grounded theory study. Ir J Med Sci 181(1):43–48

    Article  CAS  PubMed  Google Scholar 

  3. Farrell M, Barry J (2010) The introduction of the opioid treatment protocol. Health Service Executive, Dublin

    Google Scholar 

  4. Ryder N, Cullen W, Barry J, Bury G, Keenan E, Smyth BP (2009) Prevalence of problem alcohol use among patients attending primary care for methadone treatment. BMC Fam Pract 10:42

    Article  PubMed Central  PubMed  Google Scholar 

  5. Srivastava A, Kahan M, Ross S (2008) The effect of methadone maintenance treatment on alcohol consumption: a systematic review. J Subst Abuse Treat 34(2):215–223

    Article  PubMed  Google Scholar 

  6. Hartzler B, Donovan DM, Huang Z (2010) Comparison of opiate-primary treatment seekers with and without alcohol use disorder. J Subst Abuse Treat 39(2):114–123

    Article  PubMed Central  PubMed  Google Scholar 

  7. Ostapowicz G, Watson KJ, Locarnini SA, Desmond PV (1998) Role of alcohol in the progression of liver disease caused by hepatitis C virus infection. Hepatology 27(6):1730–1735

    Article  CAS  PubMed  Google Scholar 

  8. White JM, Irvine RJ (1999) Mechanisms of fatal opioid overdose. Addiction 94(7):961–972

    Article  CAS  PubMed  Google Scholar 

  9. Darke S, Zador D (1996) Fatal heroin ‘overdose’: a review. Addiction 91(12):1765–1772

    Article  CAS  PubMed  Google Scholar 

  10. Teplin D, Raz B, Daiter J, Varenbut M, Plater-Zyberk C (2007) Screening for alcohol use patterns among methadone maintenance patients. Am J Drug Alcohol Abuse 33(1):179–183

    Article  PubMed  Google Scholar 

  11. Nyamathi A, Cohen A, Marfisee M, Shoptaw S, Greengold B, de Castro V et al (2009) Correlates of alcohol use among methadone-maintained adults. Drug Alcohol Depend 101(1–2):124–127

    Article  PubMed Central  PubMed  Google Scholar 

  12. Joseph H, Appel P (1985) Alcoholism and methadone treatment: consequences for the patient and program. Am J Drug Alcohol Abuse 11(1–2):37–53

    Article  CAS  PubMed  Google Scholar 

  13. Gossop M, Marsden J, Stewart D (2002) Dual dependence: assessment of dependence upon alcohol and illicit drugs, and the relationship of alcohol dependence among drug misusers to patterns of drinking, illicit drug use and health problems. Addiction 97(2):169–178

    Article  PubMed  Google Scholar 

  14. Hunt DE, Strug DL, Goldsmith DS, Lipton DS, Robertson K, Truitt L (1986) Alcohol use and abuse: heavy drinking among methadone clients. Am J Drug Alcohol Abuse 12(1–2):147–164

    Article  CAS  PubMed  Google Scholar 

  15. Field C, Klimas J, Barry J, Bury G, Keenan E, Lyons S et al (2012) Alcohol screening and brief intervention among drug users in primary care: a discussion paper. Ir J Med Sci 181(2):165–170

    Article  CAS  PubMed  Google Scholar 

  16. Bellerose D, Carew AM, Lyons S, Long J (2009) Trends in treated problem cocaine use in Ireland, 2002 to 2007, vol 6. HRB Trends series. HRB, Dublin

    Google Scholar 

  17. Bellerose D, Lyons S, Carew AM, Walsh S, Long J (2010) Problem benzodiazepine use in Ireland: treatment (2003 to 2008) and deaths (1998 to 2007), vol 9. HRB Trends series. HRB, Dublin

    Google Scholar 

  18. ICGP (2008) Working with opiate users in community based primary care. ICGP, Dublin

    Google Scholar 

  19. Anderson RJ (2007) Helping patients with alcohol problems. A guide for primary care staff. ICGP, Dublin

    Google Scholar 

  20. Cullen W, Kelly Y, Stanley J, Langton D, Bury G (2005) Experience of hepatitis C among current or former heroin users attending general practice. Ir Med J 98(3):73–74

    CAS  PubMed  Google Scholar 

  21. Field CA, Klimas J, Cullen W, Barry J, Bury G, Keenan E et al (2011) Exploring healthcare professionals experience and attitudes towards screening for and treatment of problem alcohol use among drug users attending primary care. Paper presented at the ADEGS/AUDGPI Scientific Meeting, 20–21 Jan 2011, Dublin

  22. Raistrick D, Heather N, Godfrey C (2006) Review of the effectiveness of treatment for alcohol problems. National Treatment Agency for Substance Misuse, London

    Google Scholar 

  23. Bennett GA, Edwards S, Bailey J (2002) Helping methadone patients who drink excessively to drink less: short-term outcomes of a pilot motivational intervention. J Subst Use 7(4):191–197

    Article  Google Scholar 

  24. Nyamathi A, Shoptaw S, Cohen A, Greengold B, Nyamathi K, Marfisee M et al (2010) Effect of motivational interviewing on reduction of alcohol use. Drug Alc Depend 107(1):23–30

    Article  Google Scholar 

  25. Darker CD, Sweeney BP, El Hassan HO, Smyth BP, Ivers J-HH, Barry JM (2011) Brief interventions are effective in reducing alcohol consumption in opiate-dependent methadone-maintained patients: results from an implementation study. Drug Alcohol Rev 31(3):348–356

    Article  PubMed  Google Scholar 

  26. Klimas J, Field CA, Cullen W, O’Gorman CSM, Glynn LG, Keenan E et al (2012) Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database Syst Rev 11:CD009269

    PubMed  Google Scholar 

  27. Kaner EF, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C et al (2007) Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2:CD004148

    PubMed  Google Scholar 

  28. Williams EC, Johnson ML, Lapham GT, Caldeiro RM, Chew L, Fletcher GS et al (2011) Strategies to implement alcohol screening and brief intervention in primary care settings: a structured literature review. Psychol Addict Behav 25(2):206–214

    Article  PubMed  Google Scholar 

  29. Anderson P, Laurant M, Kaner E, Wensing M, Grol R (2004) Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis. J Stud Alcohol 65(2):191–199

    PubMed  Google Scholar 

  30. Harris GH, Strauss SM, Katigbak C, Brar BS, Brown LS Jr, Kipnis SS et al (2010) Variation among state-level approaches to addressing alcohol abuse in opioid treatment programs. J Subst Abuse Treat 39(1):58–64

    Article  PubMed  Google Scholar 

  31. Klimas J, Field CA, Barry J, Bury G, Keenan E, Lyons S et al (2011) Commentary on ‘the research translation problem: alcohol screening and brief intervention in primary care—real world evidence supports theory’. Drugs Edu Prevent Policy 0 (0):1–3

    Google Scholar 

  32. EMCDDA (2010) Annual report 2010: the state of the drugs problem in Europe. European Monitoring Centre for Drugs and Drug Addiction, Lisbon

    Google Scholar 

  33. Carew AM, Bellerose D, Lyons S (2011) Treated problem alcohol use in Ireland 2005 to 2010, vol 11. HRB Trend Series. HRB, Dublin

    Google Scholar 

  34. WHO (1993) The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. WHO, Geneva

    Google Scholar 

  35. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR, 4th edn. Text Revision edn. American Psychiatric Publishing, Inc., Washington

    Google Scholar 

  36. Gerlach FM, Beyer M, Berndt M, Szecsenyi J, Abholz HH, Fischer GC (1999) The DEGAM-concept–development, dissemination, implementation and evaluation of guidelines for general practice. Z Arztl Fortbild Qualitatssich 93(2):111–120

    CAS  PubMed  Google Scholar 

  37. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC (2009) Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 4:50

    Article  PubMed Central  PubMed  Google Scholar 

  38. Humphreys K, Trafton JA, Oliva EM (2008) Does following research-derived practice guidelines improve opiate-dependent patients’ outcomes under everyday practice conditions? Results of the multisite opiate substitution treatment study. J Subst Abuse Treat 34(2):173–179

    Article  PubMed  Google Scholar 

  39. Field MJ, Lohr KN (1992) Guidelines for clinical practice: from development to use. National Academies Press, Washington

    Google Scholar 

  40. Conroy M, Shannon W (1995) Clinical guidelines: their implementation in general practice. Br J Gen Pract 45(396):371–375

    CAS  PubMed Central  PubMed  Google Scholar 

  41. Onion CW, Dutton CE, Walley T, Turnbull CJ, Dunne WT, Buchan IE (1996) Local clinical guidelines: description and evaluation of a participative method for their development and implementation. Fam Pract 13(1):28–34

    Article  CAS  PubMed  Google Scholar 

  42. de Wit NJ, Mendive J, Seifert B, Cardin F, Rubin G (2000) Guidelines on the management of H. pylori in primary care: development of an implementation strategy. Fam Pract 17(Suppl 2):S27–S32

    Article  PubMed  Google Scholar 

  43. Shekelle PG, Woolf SH, Eccles M, Grimshaw J (1999) Clinical guidelines: developing guidelines. BMJ 318(7183):593–596

    Article  CAS  PubMed  Google Scholar 

  44. Barry J, Bourke M, Buckley M, Coughlan B, Crowley D, Cullen W et al (2004) Hepatitis C among drug users: consensus guidelines on management in general practice. Ir J Med Sci 173(3):145–150

    Article  CAS  PubMed  Google Scholar 

  45. Jones J, Hunter D (1995) Qualitative research: consensus methods for medical and health services research. Br Med J 311:376–380

    Article  CAS  Google Scholar 

  46. Broomfield D, Humphris G (2001) Using the Delphi technique to identify cancer education requirements of general practitioners. Med Educ 35(10):928–937

    CAS  PubMed  Google Scholar 

  47. Field CA, Klimas J, Barry J, Bury G, Keenan E, Lyons S et al (2011) Alcohol screening and brief intervention among drug users in primary care: a discussion paper. Irish J Med Sci. Early online:1–6

  48. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J (2004) Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive services task force. Ann Intern Med 140(7):557–568

    Article  PubMed  Google Scholar 

  49. Sullivan E, Fleming M (1997) A guide to substance abuse services for primary care clinicians: treatment improvement protocol (TIP) series 24. Center for substance abuse treatment. DHHS Publication, Rockville

    Google Scholar 

  50. Babor TF, Higgins-Biddle J (2001) Brief Intervention for hazardous and harmful drinking. A manual for use in primary care. WHO, Geneva

    Google Scholar 

  51. Haber P, Lintzeris N, Proude EM, Lopatko O (2009) Guidelines for the treatment of alcohol problems. Dept. of Health and Ageing, Sydney

    Google Scholar 

  52. Pilling S, Yesufu-Udechuku A, Taylor C, Drummond C (2011) Diagnosis, assessment, and management of harmful drinking and alcohol dependence: summary of NICE guidance. BMJ 342:490–492

    Article  Google Scholar 

  53. Scottish Intercollegiate Guidelines Network (2003) The management of harmful drinking and alcohol dependence in primary care. A national clinical guideline. Scottish Intercollegiate Guidelines Network, Edinburgh

    Google Scholar 

  54. Miller WR, Sanchez VC (1994) Motivating young adults for treatment and lifestyle change. In: Howard GS, Nathan PE (eds) Alcohol use and misuse by young adults. University of Notre Dame Press, Notre Dame, pp 55–81

    Google Scholar 

  55. Conigrave KM, Hall WD, Saunders JB (1995) The AUDIT questionnaire: choosing a cut-off score. Alcohol use disorder identification test. Addiction 90(10):1349–1356

    Article  CAS  PubMed  Google Scholar 

  56. Skipsey K, Burleson JA, Kranzler HR (1997) Utility of the AUDIT for identification of hazardous or harmful drinking in drug-dependent patients. Drug Alcohol Depend 45(3):157–163

    Article  CAS  PubMed  Google Scholar 

  57. Daiter J, Teplin D, Varenbut M, Worster A, Raz B (2007) Diagnostic value of self-report of alcohol use in patients enrolled in a methadone maintenance treatment program (MMTP). J Addict Dis 26(3):87–92

    Article  PubMed  Google Scholar 

  58. Towers A, Stephens C, Dulin P, Kostick M, Noone J, Alpass F (2011) Estimating older hazardous and binge drinking prevalence using AUDIT-C and AUDIT-3 thresholds specific to older adults. Drug Alcohol Depend 117(2–3):211–218

    Article  PubMed  Google Scholar 

  59. Roux P, Cohen J, Lascoux-Combe C, Sogni P, Winnock M, Salmon-Ceron D et al (2011) Determinants of the underreporting of alcohol consumption by HIV/HCV co-infected patients during face-to-face medical interviews: the role of the physician. Drug Alcohol Depend 116(1–3):228–232

    Article  CAS  PubMed  Google Scholar 

  60. American Public Health Association and Education Development Center (2008) Alcohol screening and brief intervention. A guide for public health practitioners. National Highway Traffic Safety Administration, U.S. Department of Transportation, Washington

  61. Rollnick S, Miller WR, Butler C (2007) Motivational interviewing in health care: helping patients change behavior. The Guilford Press, Guilford

    Google Scholar 

  62. Stein MD, Charuvastra A, Makstad J, Anderson BJ (2002) A randomized trial of a brief alcohol intervention for needle exchanges (BRAINE). Addiction 97(6):691

    Article  PubMed  Google Scholar 

  63. Gilchrist G, Moskalewicz J, Slezakova S, Okruhlica L, Torrens M, Vajd R et al (2011) Staff regard towards working with substance users: a European multi-centre study. Addiction 106(6):1114–1125

    Article  PubMed  Google Scholar 

  64. National institute on alcohol abuse and alcoholism (NIAAA) (1999) Brief Intervention for Alcohol Problems. Alcohol Alert 43, Rockville, MD

  65. O’Shea J, Goff P (2009) SAOR model. Screening and brief interventions for problem alcohol use in the emergency department and acute care settings. HSE, Waterford

    Google Scholar 

  66. Lingford-hughes A, Nutt D (2003) Neurobiology of addiction and implications for treatment. Br J Psychiatry 182(2):97–100

    Article  PubMed  Google Scholar 

  67. Doyle J, Ivanovic J (2010) National drugs rehabilitation framework document. National Drugs Rehabilitation Implementation Committee. HSE, Dublin

    Google Scholar 

  68. Lawson PJ, Flocke SA (2009) Teachable moments for health behavior change: a concept analysis. Patient Educ Couns 76(1):25–30

    Article  PubMed Central  PubMed  Google Scholar 

  69. Cullen W, O’Brien S, O’Carroll A, O’Kelly FD, Bury G (2009) Chronic illness and multimorbidity among problem drug users: a comparative cross sectional pilot study in primary care. BMC Fam Pract 10:25

    Article  PubMed Central  PubMed  Google Scholar 

  70. Arias AJ, Kranzler HR (2008) Treatment of co-occurring alcohol and other drug use disorders. Alcohol Res Health 31(2):155–167

    Google Scholar 

  71. EMCDDA (2011) Guidelines for the treatment of drug dependence: a European perspective. Publications Office of the European Union, Luxembourg

    Google Scholar 

  72. O’Brien S, Cullen W (2011) Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper. Ir J Med Sci 180(4):787–792

    Article  PubMed  Google Scholar 

  73. Betterton J, Haywood J, Heaversedge J, Gerada C (2004) Developing new roles for general practitioners: senior house officer posts caring for patients who are homeless or have substance misuse problems. Educ Prim Care 15(1):58–63

    Google Scholar 

  74. Klimas J, Dunne C, Cullen W (2013) Study on psychosocial intervention for poly-drug use. Forum 30(2):8

    Google Scholar 

  75. Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C et al (2010) Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med 8:63

    Article  PubMed Central  PubMed  Google Scholar 

  76. Sorensen JL, Kosten T (2011) Developing the tools of implementation science in substance use disorders treatment: applications of the consolidated framework for implementation research. Psychol Addict Behav 25(2):262–268

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgements

All authors reviewed and approved the final draft of this manuscript. A core group of authors prepared this manuscript (JK, WC, CAF). A complete list of the members of the ‘Problem Alcohol/Drug Use Guideline Development Group (PADU-GDG)’ is at the end of this manuscript. The authors would like to thank the Health Research Board in Ireland who provided a research project grant for this work (www.drugsandalcohol.ie/15260). A limited portion of this manuscript was presented at the Annual Scientific Meeting Association of University Departments of General Practice in Ireland, hosted by the Royal College of Surgeons in Ireland on 9 March 2012 in Dublin.

Conflict of interest

The authors acknowledge that they have no conflict of interests regarding this study.

Author information

Authors and Affiliations

Authors

Consortia

Corresponding author

Correspondence to W. Cullen.

Additional information

The Problem Alcohol/Drug Use Guideline Development Group (PADU-GDG) in 2011-12 included 21 members, for complete listing of experts, see Appendix.

Complete listing of authors (PADU-GDG)

Complete listing of authors (PADU-GDG)

Rolande Anderson

Counselling Consultant, the Charlemont Clinic, Dublin 2, e-mail: rolandea@eircom.net

Joseph BarryFootnote 1

Department of Public Health and Primary Care, TCD and Health Service Executive, e-mail: joebarry@tcd.ie

Declan Bedford

Department of Public Health, Health Service Executive North East Area, Navan, e-mail: declan.bedford@maile.hse.ie

Margaret Bourke

Addiction Treatment Services, South Western Area Health Board, e-mail: margaret.bourke@hse.ie

Gerard Corrigan

Medical Centre, Ballingarry, Co. Limerick, e-mail: rylanesmedicalcentre@yahoo.com

Walter Cullen*

General Practitioner and Professor, Graduate Entry Medical School, University of Limerick (UL), e-mail: walter.cullen@ul.ie

Joseph Doyle

National Rehabilitation Coordinator, Integrated Services Directorate, HSE, Dublin, e-mail: joseph.doyle@hse.ie

Catherine Anne Field*

Project Researcher / PhD student, School of Medicine and Medical Science, UCD, e-mail: catherine-anne.field@ucd.ie

Jean Flanagan

Hepatitis C Liaison Nurse Specialist, Addiction Services, HSE Northern Area, e-mail: jean.flanagan@hse.ie

Hugh Gallagher

Addiction Treatment Services, HSE Northern Area & Solas Clinic, e-mail: hugh.gallagher@hse.ie

Noreen Geoghegan

Nurse Manager, Addiction Services HSE Dublin, e-mail: noreen.geoghegan@hse.ie

Kieran Harkin

General Practitioner, Inchicore Medical Centre, Dublin 8, e-mail: kieran@inchicoredoctors.ie

Eamon Keenan*

Addiction Services, Health Service Executive, e-mail: eamon.keenan@hse.ie

Jan Klimas*

Project Researcher, UCD and UL, e-mail: jan.klimas@ucd.ie

John Lambert

Consultant physician, Mater Misericordiae University and Rotunda Hospitals, e-mail: john.lambert@ucd.ie

Ruaidhri McAuliffe

Union for Improved Services Communication and Education, Dublin (UISCE), e-mail: uiscepost@hotmail.com

Mary Ellen McCann

School of Applied Social Science, University College Dublin (UCD), e-mail: mary.mccann@ucd.ie

Aiden McCormick

Department of Hepatology, St Vincent’s University Hospital, Dublin, e-mail: a.mccormick@ucd.ie

Denis O’Driscoll

Chief Liaison Pharmacist, HSE Dublin Mid-Leinster, e-mail: denis.odriscoll@hse.ie

Colin O’Gara

Department of Psychiatry, Saint John of God Hospital, Stillorgan, County Dublin, e-mail: colin.ogara@sjog.ie

Nicola Perry

Community Response, Meath St, Dublin 8, e-mail: nicolaper@gmail.com

Bobby Smyth*

Addiction Services, Health Service Executive, e-mail: bobby.smyth@hse.ie

Fiona Weldon

Rutland Centre, Templeogue, Dublin, e-mail: fionaweldon@rutlandcentre.ie

Rights and permissions

Reprints and permissions

About this article

Cite this article

Klimas, J., Cullen, W., Field, CA. et al. Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice. Ir J Med Sci 183, 89–101 (2014). https://doi.org/10.1007/s11845-013-0982-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11845-013-0982-2

Keywords