Coaching, Motivational Interviewing and Brief Interventions (2) Flashcards
How do brief interventions differ from coaching and motivational interviewing?
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
What are the 3 common steos of brief interventions?
Identifies behaviour risk factor
Explains how to best change their high risk behaviour
And
What is MECC?
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
What are the targets of MECC?
§ Stopping smoking § Being physically active § Drinking alcohol only within the recommended limits § Keeping to a healthy weight § Healthy eating § Improving mental health and wellbeing
What is the size of the smoking problem?
Largest preventable cause of premature death
>50% of long-term smokers die prematurely to smoking-related diseases
Why are cigarettes bad for you?
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
What diseases does smoking making you more likely to get / exacerbate?
Cataracts Cancer Stroke CVD Peptic ulcers Psoriasis Infertility Erectile dysfunction - suggests small blood vessels are being affected = early signs of CVD
What are the effects of passive smoking? What conditions do they exacerbate?
Exacerbate:
Asthma
Premature births
Malnourished babies
Why do people smoke?
Stress relief Social Cognitive dissonance Confirmation bias Boredom Weightloss Taste Habit
BUT the real reason = nicotine addiction
How addictive is nicotine?
As much or more so than cocaine and heroine?
What questions can you ask to assess addiction level?
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
Why might asking ‘how many cigarettes do you smoke a day?’ not be appropriate?
Recall bias
Why is ‘cutting down’ smoking not appropriate?
- 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
How should addictive behaviours be treated?
All or nothing
No cutting down
What is the neurophysiology of nicotine addiction?
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
What is nicotine addiction / smoking addiction?
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
What percentage of smokers:
Want to stop?
Succeed?
70% want to stop
30% try each year
Only 3-5% manage through willpower akibe
How cost-effective are smoking cessation interventions?
Very
Estimates cost-effectiveness - costs below £2000 per Life Year Gained
£11,800 spent on statins compared to £2000 for smoking cessation
Smoking cessations signpost to what?
Behavioural support
Pharmacological therapies (NRT, Bupropion, Varenicline)
Very Brief advice
E-cigarettes
What do the NHS Stop Smoking Services offer?
§ 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
What is the standard supported quit regime?
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
What are the advantages of a doctor offering the smoking cessation service instead of other medical professionals?
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
What are the 3 key things required for long term cessation rates?
- Wanting to stop smoking
- But for 95-97% of smokers wanting to stop is not enough - Good Quality Support
- Evidence Based Medication
‘‘Support and Treatment’’
Number Needed to Treat (NNT) to obtain 1 long term quitter after behavioural support?
Brief Advice alone?
NRT?
Bupropion?
Varenicline?
Brief Advice alone = 51
NRT = 23
Bupropion = 22
Varenicline = 11
What behaviours do behavioural support groups target?
Reduce motivation to smoke Commitment to abstain Enhance ability to cope with cravings Ensure effective use of pharmacotherapy
What are the behavioural support options in order of efficacy for smoking cessation?
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)
What is NRT?
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
What are the pros and cons of E-cigarettes?
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
What to consider for patients using NRTs?
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.
What is Bupropion (Zyban)?
What are it’s side effects?
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
What is Varenicline (Champix)?
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
Key points
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.
What do cigarettes contain
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
NHS stop smoking guidance on treatment options
“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
E-cigarette recommendations
§ 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)
Why is VBA in smoking cessation important
- Advice on quitting smoking from a doctor can be one of the most important triggers
for a quit attempt
What is VBA for smokers
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
VBA for smokers
- Establish and record smoking status:
“Do you smoke? / Are you still smoking?” - Advise how to stop:
“The best way to stop is with support and treatment” - Offer support and treatment:
“When you are ready just make an appointment with
[XXX] who is great!”
What does VBA avoid
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
What is the BweL trial
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
