Coaching, Motivational Interviewing and Brief Interventions (1)

Question 1

What are brief interventions

Answer 1

Brief Interventions = collective term for giving advice to help change harmful behaviours

Typically given whenever the opportunity arises

Referred to as ‘a teachable moment’/’making every contact count’

• VBA is gold standard
• preventative measure

Question 2

Structure of brief interventions

Answer 2

1. Identify behavioural risk factor
2. Explain how best to change high risk behaviour
3. Signpost how to obtain help

Question 3

What is very brief advice

Answer 3

VBA = a form of advice designed for busy clinicians to be used opportunistically in less than 30s in almost any consultation

Question 4

Discuss the benefits of making every contact count and very brief advice

Answer 4

Improves patient health in long term Reduces financial strain on NHS Can make patient feel like they are being seen as a whole person Helps doctor-patient relationship Cheap + simple to implement Can exist in both hospital and non-hospital settings Don’t need a background in public health to receive training Can be easily tailored to fit different needs

Question 5

Discuss the risks of making every contact count and very brief advice

Answer 5

• Patient may get offended
• Risk of worsening behaviours
• Practitioners may be resistant causing inconsistencies in MECC
• Can be seen as a burden on practitioners
• Requires more training
• Needs continuous follow-up/support services
• May have differing cultural assumptions about the role of health professionals (treat vs prevent)

Question 6

How can we apply the audit-c to assess alcohol use

Answer 6

Score meanings

1-4 = low risk (sensible drinking)

5-7 = increasing risk (hazardous drinking)

8-10 = higher risk (harmful drinking)

11-12 = potentially addicted/dependent

Question 7

Explain the psychobiology of nicotine addiction

Answer 7

• Inhaled nicotine from tobacco smoke is as/more addictive than heroin or cocaine
• Also habit/boredom/stress/social/taste/weight control

Psychobiology

• Has the highest binding affinity to 𝛼4𝛽2 nicotinic receptors
• Main mediators for nicotine addiction in the Ventral Tegmental Area (VTA) of the midbrain
• Inhaled nicotine reaches receptors in 7-10 seconds
• Triggers release of dopamine
• Regular smoking also increases no. of these receptors by 3 or 4 times
• Receptor changes are long term – more likely to relapse

Question 8

Explain the psychobiology of nicotine addiction treatments

Answer 8

Treatment

•Most effective when good quality support + evidence based treatments

Behavioural support

• Reduce smoking motivation, increase cessation motivation, help cope with cravings, ensure effective medication use
• Trained advisors: nurses, HCAs, pharmacists, specialist advisors
• 4-6 appointments over 6-12 weeks

Medications

•NRTs

•skin patches/gum/lozenges/inhaler/oral spray/nasal spray/oral film

•Bupropion – non-nicotine tablet

•modifies dopamine levels and noradrenergic activity (decreases cravings and withdrawal symptoms)

•Varenicline – partial nicotine agonist

•part stimulating – decreased craving + withdrawal, part blocking – reduced reward from smoking

•Consider all three for any patient

• What works for someone may not work for someone else
• Allows patient to choose
• If quit attempts fail – know there are other options

Question 9

How do we apply VBA to smoking cessation

Answer 9

Smoking Cessation - patients addicted to nicotine

Cons of advise to stop without VBA (similar effect to not saying anything at all)

• -ve message
• Nagging
• Conflict + denial
• Takes longer
• Frustrating

Should advise HOW to stop

_Ask –_establish and record/recheck status

Advise – on how to stop

Act – offer support + treatment

•Don’t push them to stop if they are not ready (let them know support is always available)

• best way to stop smoking is with combination of support and treatments

Question 10

How to apply VBA to physical activity

Answer 10

Physical inactivity harmful and increasing

woman more likely inactive and those in socio-economic deprived areas

leads to obesity

make patients aware of their own activity levels

•Ask + screen for activity (eg. risk factor reduces)

•Scot-PASQ

•Advise

• Signposting (sports England, couch to 5k, BBC sport, NHS, Park run)
• Need reinforcing yearly

•Act

•Remember that barriers are multifactorial! - may need to target at society level

Question 11

How to apply VBA to alcohol misuse

Answer 11

Alcohol Misuse

IBA = Identification and BA

1)Identification – who is at risk?

•AUDIT-C screening tool (if short on time)

2)Brief advice – cutting down

• MI skills (practical steps)
• Implementation intentions (what, where, when, how)

3)Support – self help/referral

• Mostly self help with a follow-up
• Refer to specialist if addicted

complete in matter of minutes

Question 12

alcohol unit reference

Answer 12

Question 13

What is making evey contact count

Answer 13

MECC is an approach to behaviour change than aims to give everyone in an organisation the tools and confidence to promote positive health messages to everyone they encounter.

Question 14

3 key elements to stop smoking

Answer 14

wanting to stop

good quality support

evidence based treatments

Question 15

Benefits of smoking VBA

Answer 15

■ Brief! (<30 seconds or it won’t be used)

■ Records smoking status (as 70% relapse rate)

■ Positive (or you put them off trying)

■ Not confrontational or nagging (not telling them to stop)

■ Opportunistic (suitable for almost any consultation)

■ Informative (saying how to stop)

■ Engaging (new information)

■ Evidence based

■ Not a smoking cessation consult (that’s for next time)

Question 16

Smokers pathway and how VBA can intervene

Answer 16

Smoker consults doctor for any problem

—> Very brief advice on smoking

—> Quit attempt involving support and medication

—> Non-smoker (70% relapse)

GIVING VBA 51 TIMES —-> LONG TERM QUITTER

Question 17

Does VBA advise smoker to stop

Answer 17

No

Question 18

If a patient smokes, what should you always do

Answer 18

Deliver VBA at every reasonable opportunity, including to patients with a cancer diagnosis

Question 19

What is the best advice in VBA

Answer 19

Advising the patient that the best way to stop is with a combination of support and medication

Question 20

If a patient is not ready to stop smoking, what should you advise

Answer 20

Say that is fine, that help will always be available and to let you know if they change their mind

Question 21

Where do doctors direct for support to stop smoking

Answer 21

It is reasonable for you as a doctor to support the smoker yourself even if there is a local stop smoking advisor available.

Question 23

Types of Screening tools uses for alchohol, activity and malnutrition

Answer 23

screening tools which can be used to identify people who might be misusing alcohol.

• AUDIT and AUDIT-C questionnaires.

determining the severity of someone’s alcohol dependence. - Severity of Alcohol Dependence Questionnaire (SADQ) is recommended by NICE

• guide whether someone requires assisted alcohol withdrawal and, if so, which setting is likely to be most appropriate (in the community or an inpatient setting).

assess the severity of acute, unplanned alcohol withdrawal,

• The Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA–Ar)
• a very serious condition which can result in seizures and death.
• often used in Accident and Emergency and on inpatient wards to assess whether a patient with known alcohol dependence is experiencing acute withdrawal and, if so, how severe it is.

Gaining objective view of how active someone is

General practice physical activity questionnaire (GPPAQ) was developed by the London School of Hygiene and Tropical Medicine

screen hospital inpatients for risk of malnutrition (can also be used in community settings)

Malnutrition Universal Screening Tool (MUST)

• Identifying and addressing malnutrition is important for a range of reasons, not least because malnutrition leads to impaired immune function and delayed healing.

Question 24

How to choose screening tool

Answer 24

screening tools are NOT created equal

• varying sensitivity (how many people with a particular condition they detect)
• Varying specificity (how well the tool identifies people without the condition).
• choose your screening tools carefully, ideally following local or national guidance.

Question 25

Principles of good IBA

Answer 25

Being empathetic

non-judgemental,

positive language to promote self-efficacy and facilitates the patient to make changes for themselves, as opposed to the clinician telling them what to do.

Question 26

Moving Medicine

Answer 26

• an organisation run by clinicians provides resources to evidence based, offers condition-specific information
• give advice on physical activity to patients of all ages at any stage of their treatment pathways.
• consultations can be tailored depending on the various clinical condition affecting the patient.

“Ask, explain, invite” - 1 minute conusltation

The 1 minute conversation compromises these three steps designed to sow the seed of change in someone’s mind in a way that you make it clear you recognise that what is important to them matters most to you.

Ask – “Would it be OK to spend a minute talking about something many patients with your condition find helpful?”

Explain – “Many people with your condition find that moving more helps them manage their condition and symptoms, as well as improving their general wellbeing. I wonder what you make of that?”

Invite – “Would you be interested in talking a little more about how physical activity might help with your health and wellbeing on another visit?”

Question 27

Physical Activity contributes to morbidity and mortality of a similar magnitude to that of smoking or obesity.

True or False?

Answer 27

True

As found in the Global Burden of Disease study from the Lancet:

Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219-229. doi:10.1016/S0140-6736(12)61031-9

Question 28

Brief Interventions allow for a personalised exercise prescription.

True or False

Answer 28

False

Question 29

Brief interventions should be done once and not repeated.

True or False

Answer 29

False

Evidence suggests that they do have a short term effect, but will likely need to be repeated yearly. However, given the opportunistic nature of these interventions, it is best that they are developed over time with the patient.

Question 30

Brief interventions work along a model where permission is asked to introduce the topic, brief advice is given, and the patient signposted or assisted to tools to overcome barriers.

True or False

Answer 30

True

This is the principle of brief interventions, although there is no single best model and the approach should be tailored to the context of the individual interaction.

Question 31

Brief interventions are part of an approach encompassing individual and societal interventions.

True or False

Answer 31

True

Brief interventions work well on an individual level, but as clinicians we need to take account of the wider societal context of barriers to physical activity, and make contributions to ameliorating these.

Question 32

Why should we focus on smoking prevention

Answer 32

■ Smoking is the largest preventable cause of disease

and premature death in the world 1

■ More than 50% of long-term smokers die prematurely

due to smoking-related diseases 2

Cigarette smoke contains more than 4,000 chemicals,

including over 60 known carcinogens and metabolic poisons

Question 33

List some health consequences of smoking

Answer 33

Cancers

Oropharynx

Larynx

Oesophagus

Trachea, bronchus.and lung

Acute myeloid leukemia

Stomach

Liver

Pancreas

Kidney and ureter

Cervix

Bladder

Colorectal

1. US Dept of Health and Human Services, 2010

Chronic diseases

Stroke

Blindness, cataracts

Congenital defects

Periodonitis

Aortic aneurysm

Coronary heart disease

Pneumonia

Atherosclerotic PVD

COPD, tuberculosis, asthma

Diabetes

Hip fractures

Ectopic pregnancy

Erectile dysfunction

Rheumatoid arthritis

Immune function

Overall diminished health

Question 34

Why do people smoke

Answer 34

• NICOTINE ADDICTION
• HABIT
• BOREDOM
• STRESS
• TASTE
• SOCIAL
• WEIGHT CONTROL

Inhaled nicotine from tobacco smoke is as or more addictive than heroin or cocaine

Nicotine relatively harmless but its what keeps you addicted and the smoke inhaling chemicals kills you

Question 35

Neurophysiology of nicotine effect on brain

Answer 35

Inhaled nicotine from tobacco smoke is as or more addictive than heroin or cocaine

Nicotine highest biding of alpha4ß2 Nicotinic Receptor; main mediator of nicotine in the Ventral Tegmental Area (VTA) of midbrain. Inhaled nicotine reaches receptors in 7-10s rapidly releasing dopamine (phelogroup neurotransmitter)

Dopamine increases number of alpha4beta2 receptors by 3-4x –> enhances addictive effect of inhaled nicotine — > long term receptor changes —> chronic relapsing organic brain disease

nucleus accumbens in brain

Question 36

Effective way to stop smoking

Answer 36

■ Good quality support

+

■ Evidence based treatments

= quit rate 4 times greater

Question 37

4 goals of behavioural support in smoking cessation

Answer 37

1. Reduce motivation to smoke
2. Enhance ability to cope with cravings
3. Bolster commitment to abstain
4. Ensure effective use of pharmacotherapy

Question 38

Who can be a trained stop smoking advisor

Answer 38

Trained stop smoking advisers can be:

■ Hospital nurses

■Practice nurses

■ Healthcare assistants

■ Pharmacists or pharmacy assistants

■ Specialist stop smoking advisers

Question 39

standard regime of support for smoking cessation

Answer 39

4-6 face to face appointments

over 6-12 weeks

Question 40

What are the Advantages of doctor delivered smoking cessation

Answer 40

■ Tobacco dependence - a medical condition responding to

medical treatment

■ Doctors are independent prescribers, used to tailoring treatment

■ Cessation advice can be more effective from doctors than counsellors

and nurses

■ Smokers know, trust and want help to stop from their doctor

Question 41

3 licesened pharmacotherapy for smoking cessation

Answer 41

■ Nicotine Replacement Therapy (NRT)

■ Bupropion

■ Varenicline

Varenicline shown most effective, 2 or more NRT then Bupropion

Question 42

Why is it important to introduce all options of smoking cessation pharmacotherapy to patients

Answer 42

• What works well for one person may not be so good for another
• It allows the patient to choose the treatment they want - You guide, but they decide
• ( If the quit attempt fails, they know there are other options)

Question 43

Types of NRT

Answer 43

Gum

Lozenges

Mini lozenges

Nasal spray

Skin patches

lnhalator

Oral spray

Oral film

aim is to replace nicotine with therapeutic nicotine without harmful chemicals contained in cigarettes to manatain addiction then to stop altogether

Question 44

Bupropion

Answer 44

Non-nicotine prescription tabletoriginally developed to treat depression

■ Modifies dopamine levels and noradrenergic activity

increases dopamine levels, reduces craving and withdrawal symptoms

Question 45

Mechanism of varenicline in smoking cessation

Answer 45

Varenicline - partial nicotine agonist of alpha4beta2 receptor

■ Part stimulating

• Relieves craving and withdrawal symptoms 1-3

■ Part blocking

• Reduces the pleasurable effects of smoking and potentially the risk of full relapse after a temporary lapse

Question 46

Use of E-cigarretes as alternative to pharmacotherapy

Answer 46

■ Over 3 million users in the UK

■ 95°/o safer than smoking 1

■ At least as effective as NRT for smoking cessation

■ Great potential for smoking cessation

■ BUT:

• Long term safety not known
• Half of users also smoke
• Controversial and many misconceptions

Question 47

Smoking cessation stats

Answer 47

■ 20-30% long term quit rate with support and treatment

■ 3-5% long term quit rate with willpower alone

■ Two or three quit attempts with support and treatment for >50% smokers to stop long term death

■ Smoking cessation with support and treatment is one of the most cost-effective interventions in healthcare

Question 48

Key points

Answer 48

Key points

a. Brief interventions are evidenced based approaches to facilitating positive behaviour change. They are low cost and often requires little training or expertise. Examples include Making Every Contact Count and Very Brief Advice
b. Very Brief Advice isn’t about engaging a person in a conversation but rather signposting them to resources where they can get more information and support to help change their behaviour
c. Brief interventions can be used to target any aspect of lifestyle, but have been tried most commonly in smoking cessation and reducing alcohol
d. A key aspect of brief advice is identifying the problem. This will sometimes come up in conversation, but specific and quick screening tools can be used to gauge the severity of the problem. The AUDIT-C is a short set of questions that lets you consider the risk level of an individual’s consumption, so you can then give brief advice and refer on to appropriate support
e. All of these interventions are designed to be quick enough to be used in GP practice and on the ward and will be more effective if you remember your health coaching: communicate with empathy, no judgment, positive language and encouraging the patient to make changes themselves (promoting self-efficacy).