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Y2 LMAP > Coaching, Motivational Interviewing and Brief Interventions (2) COPY > Flashcards

Coaching, Motivational Interviewing and Brief Interventions (2) COPY Flashcards

1
Q

How do brief interventions differ from coaching and motivational interviewing?

A

Brief Interventions = takes a view that the medical professional know best and they tell you how to do something
Opportunistic
High impact
Talking at the patient, not a conversation
Not specialist, psychological skills

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2
Q

What are the 3 common steos of brief interventions?

A

Identifies behaviour risk factor
Explains how to best change their high risk behaviour
And

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3
Q

What is MECC?

A

Make Every Contact Count

Opportunistic approach to behaviour change
Uses the millions of daily interactions in healthcare
Consistent and concise info
Focusing on the most important lifestyle issues

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4
Q

What are the targets of MECC?

A 
§ Stopping smoking
§ Being physically active
§ Drinking alcohol only within the recommended limits
§ Keeping to a healthy weight
§ Healthy eating
§ Improving mental health and wellbeing
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5
Q

What is the size of the smoking problem?

A

Largest preventable cause of premature death

>50% of long-term smokers die prematurely to smoking-related diseases

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6
Q

Why are cigarettes bad for you?

A

Smoke inhaled is unfiltered as it diffuses straight into the arteriole system - allows every cell in the body to be affected
Cigarettes contain over 4000 chemicals and over 60 carcinogens / metabolic poisons

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7
Q

What diseases does smoking making you more likely to get / exacerbate?

A 
Cataracts
Cancer
Stroke
CVD
Peptic ulcers
Psoriasis 
Infertility 
Erectile dysfunction - suggests small blood vessels are being affected = early signs of CVD
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8
Q

What are the effects of passive smoking? What conditions do they exacerbate?

A

Exacerbate:

Asthma
Premature births
Malnourished babies

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9
Q

Why do people smoke?

A 
Stress relief
Social 
Cognitive dissonance
Confirmation bias 
Boredom
Weightloss
Taste
Habit

BUT the real reason = nicotine addiction

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10
Q

How addictive is nicotine?

A

As much or more so than cocaine and heroine?

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11
Q

What questions can you ask to assess addiction level?

A

How long do you wait until for you first cigarette after you wake up?

  • wakes at night to smoke = very high addiction
  • <30mins from waking = high addiction
  • 30mins-2 hours from waking = moderate addiction
  • > 2 hours from waking = lower addiction

Number of cigarettes smoked a day
> 20 = high addiction
10-20 = moderate addiction
< 20 lower addiction

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12
Q

Why might asking ‘how many cigarettes do you smoke a day?’ not be appropriate?

A

Recall bias

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13
Q

Why is ‘cutting down’ smoking not appropriate?

A
  • Doesn’t reduce risk proportionately
  • Only safe level of smoking is no smoking
  • May be exaggerated by patient
  • Usually reverts to previous intake
  • Low cigarette consumption = longer smokes
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14
Q

How should addictive behaviours be treated?

A

All or nothing

No cutting down

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15
Q

What is the neurophysiology of nicotine addiction?

A

Most start at 14-15 y/o
Neuroplasticity - the nicotine allows for alpha-4-beta-2 receptors to develop and be activated
These receptors send a signal to the nucleus accumbens (pleasure centre)
Leads to sudden flood of dopamine release = pleasure rush
Once receptors developed, they remain (do not go away)
When the dopamine hit goes away, leads to low mood and craving, leads to negative reinforcement to smoke

Regular smoking leads to a 300%+ increase in brain nicotine
receptors

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16
Q

What is nicotine addiction / smoking addiction?

A

Chronic relapsing organic disease in the brain, not a lifestyle choice

It takes 24-48 hours for nicotine to leave
the body1
It takes 8-12 weeks for the nicotine
receptors to down-regulate

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17
Q

What percentage of smokers:
Want to stop?
Succeed?

A

70% want to stop
30% try each year
Only 3-5% manage through willpower akibe

18
Q

How cost-effective are smoking cessation interventions?

A

Very
Estimates cost-effectiveness - costs below £2000 per Life Year Gained
£11,800 spent on statins compared to £2000 for smoking cessation

19
Q

Smoking cessations signpost to what?

A

Behavioural support
Pharmacological therapies (NRT, Bupropion, Varenicline)
Very Brief advice
E-cigarettes

20
Q

What do the NHS Stop Smoking Services offer?

A 
§ Offer support to quit smoking
§ Designed to give access in local community
§ Trained stop smoking advisers can be:
- Practice nurses
- Hospital nurses
- Healthcare assistants
- Pharmacists or pharmacy assistants
- Trained specialist stop smoking advisers
21
Q

What is the standard supported quit regime?

A 
Pre-quit appointment 
--> Quit appointment
--> Follow up appointment 
(Over 2–3 months
(weekly or two weekly,
then monthly, for a total of
about 3 appointments)
--> Final appointment
22
Q

What are the advantages of a doctor offering the smoking cessation service instead of other medical professionals?

A

Trust and rapport between patient and doctor already established
Smokers visit their GP more than non-smokers
Independent prescribing = tailored pharmacological interventions for smoking cessation

23
Q

What are the 3 key things required for long term cessation rates?

A
  1. Wanting to stop smoking
    - But for 95-97% of smokers wanting to stop is not enough
  2. Good Quality Support
  3. Evidence Based Medication
    ‘‘Support and Treatment’’
24
Q

Number Needed to Treat (NNT) to obtain 1 long term quitter after behavioural support?

Brief Advice alone?
NRT?
Bupropion?
Varenicline?

A

Brief Advice alone = 51
NRT = 23
Bupropion = 22
Varenicline = 11

25
Q

What behaviours do behavioural support groups target?

A 
Reduce motivation to smoke
Commitment to abstain 
Enhance ability to
cope with cravings
Ensure effective
use of
pharmacotherapy
26
Q

What are the behavioural support options in order of efficacy for smoking cessation?

A

Most effective (at top)

  • Group
  • 1-2-1
    • Telephone helpline
    • Text messaging programmes
    • Stop smoking websites
    • Stop smoking books
    • Smartphone apps

Least effective (at bottom)

27
Q

What is NRT?

A 
Nicotine Replacement Therapy
8-12 week treatment, 
- nicotine needs to weaned off slowly 
9 different forms 
- Significantly reduces
withdrawal symptoms
and cravings vs placebo
 - Significantly increases smoking
cessation
rate vs placebo (odds ratio = 1.58) = 58%
- Standard regime is to start NRT on quit date
- Combination use now routine
28
Q

What are the pros and cons of E-cigarettes?

A 
Pros: 
Does not contain the carcinogens found in tobacco
Mimics their behaviour more closely
95% safer than smoking
As effective as NRTs

Cons:
Long-term side effects unknown
Many people decide to smoke actual cigarettes alongside e-cigarettes

29
Q

What to consider for patients using NRTs?

A

Plasma nicotine levels are higher from cigarettes than in NRT so essential treatment plan is followed strictly
- Use enough - avoid under-dosing and irregular use
- Long enough - don’t stop early, continue 8-12 weeks to desensitise the receptors
- NOT A PUFF!
Slower and less efficient source of nicotine
than cigarettes so can not compete.

30
Q

What is Bupropion (Zyban)?

What are it’s side effects?

A

Originally developed to treat depression
Modifies dopamine levels and noradrenergic actvity
Significantly increased smoking cessation rate by 1.94x compared to placebo

Insomnia
Dry mouth
Headache?
Nausea

31
Q

What is Varenicline (Champix)?

A

Partial nicotine agonist and partial nicotine antagonist
Part blocking - reduces pleasurable effects of smoking
Part stimulating - relieves craving and withdrawal symptoms
Higher abstinence prevalence than bupropion

32
Q

Key points

A

Key Points
a. Smoking comes at a huge cost to the NHS and public health. It impacts every tissue
type in the body, leading to an array of cancers and other health issues.
b. The most effective interventions for stopping smoking are nicotine replacement,
pharmacotherapy (bupropion and varenicline) combined with group support: willpower
is usually not enough to overcome an addiction.
c. Very Brief Advice and MECC have been shown to have positive impacts on the uptake
of stopping smoking services.
d. VBA does not engage a person in a conversation but rather assumes they want to
change and points them in the direction of support. Because of this it can feel awkward
to do at first- practice is key.
Department of Primary Care & Public Health
School of Public Health
Page 19 of 21
e. Different trusts and local authorities will have different services available so it is
essential you familiarise yourself with what is available so you can effectively refer on
at the end of the VBA process.

33
Q

What do cigarettes contain

A

Cigarette smoke contains more than 4,000 chemicals,
including over 60 known carcinogens and metabolic poisons

Nicotine Tar Arsenic
Carbon
monoxide Cadmium Hydrogen
Cyanide
Ammonia Toluene
Phenol
Nitrosamine Butane Naphthalene
DDT
34
Q

NHS stop smoking guidance on treatment options

A 
“Since all motivated quitters should be given
the optimum chance of success in any
given quit attempt, nicotine replacement
therapy (NRT), Champix (varenicline) and
Zyban (bupropion) should all be made
widely available in combination with
intensive behavioural support as first-line
treatments (where clinically appropriate
35
Q

E-cigarette recommendations

A

§ First recommend varenicline, bupropion and combination NRT
for cessation – and if smokers won’t use these, then it is
reasonable to recommend use of e-cigarettes
§ Always recommend support- stop smoking services do
support quit attempts with e-cigs
§ Advise complete cessation of smoking with e-cigarettes not
smoking reduction (45%-60% e-cig users continue to smoke)

36
Q

Why is VBA in smoking cessation important

A
  • Advice on quitting smoking from a doctor can be one of the most important triggers
    for a quit attempt
37
Q

What is VBA for smokers

A

A simple form of advice designed for busy clinicians to be used opportunistically in less than 30 seconds in almost any consultation with a smoker by telling them how to stop and
directing them

38
Q

VBA for smokers

A
  1. Establish and record smoking status:
    “Do you smoke? / Are you still smoking?”
  2. Advise how to stop:
    “The best way to stop is with support and treatment”
  3. Offer support and treatment:
    “When you are ready just make an appointment with
    [XXX] who is great!”
39
Q

What does VBA avoid

A 
VBA DELIBERATELY AVOIDS
“CHALLENGING THE ADDICTION”
SO DOES NOT:
• Advise smokers to stop
• Ask how much or what they smoke
• Ask if they want to stop
40
Q

What is the BweL trial

A

The BWeL trial tested the effect of a very brief behaviourally-informed opportunistic intervention delivered by GPs to patients who were consulting who were obese and where weight loss was not the focus of the consultation.

The study showed that brief interventions are effective for weight loss, but we also know that GPs and other healthcare professionals rarely use them. We are pursuing a programme of research to support implementation

30 seconds
- advise - offer referral to weight loss programme on prescription and make the appointment while in surgery

  • 4 in 10 people attended
  • 8 in 10 felt it was appropriate and helpful
  • weight loss seen more in those referred

Y2 LMAP (26 decks)

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