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  • We do not need to use the drug to have a conversation about it
  • Point of heroin = 0.1g. Halfweight
  • Tobacco and alcohol biggest drug-related problems
  • People understate use - start high, and they'll bring it down
    • Overestimating benzos: 20-30 tabs/day
  • Cutting down is not useful - but it's an achievable goal to ask people for. But they actually have to work out for themselves that they can't just cut down, they need to quit.
  • Ask about drinking younger than 18
    • CAGE question: cut down, annoyed about drinking, ever feel guilty, ever need an eye opener?
      • Withdrawal symptoms?
  • 4 Ls: liver (physical consequences), love (relationship), lifestyle (hobbies, work, exercise), law (consequences)
  • Readiness to change
  • Quantity and frequency - need standard drinks; a standard drink is 10g
  • Alcohol withdrawal: seizures/fitting, sympathetic overload, nausea, vomiting, sweating, anxiety, flushed, agitation, delirium
    • Withdrawal: >6 standard drinks a day for a long period
    • Withdrawal is the opposite effect of the drug
  • Ask them about every day of the week and specifically what they drank and how much they drank
  • "What do you think about how much you drank?". The acceptable amount is x. "Do you want to have a think about this and come back".
    • Most people are precontemplative.
  • Study the handout for the common presentations of heavy drinking
  • Assess - physical health, mental health, domestic, employment, legal impact, social conditions, financial state
    • How are things going at home? Ask wife? Drink driving?
  • Learn to use the alcohol audit; memorise the questions to include in your interview
  • Assess readiness to change
  1. Precontemplation (not ready)
  2. Contemplation (unsure)
  3. Action (ready to cut down my drinking)
  4. Maintenance (have cut down my drinking)
  5. Relapse (have resumed drinking at the previous level)
  • Alcohol embedded in social stuff - people do it to hook up etc
  • People get grumpypants when you tell them to quit: grief and loss due to leaving the relationship with alcohol (like relationships with people)
    • People don't realise that alcohol is a problem for them
    • Just like friends don't get that it's an unhealthy relationship they're in
  • Action - reconnect with your friends, get back to sport
    • Alcohol - cutting down or stopping
  • Maintenance - keep up abstinence
  • Relapse - normal part of getting through addiction; learning experience
    • People realise they can't stop at 2 drinks
  • Ambivalence = 2 extreme opposing views about an issue
    • This ambivalence is normal - don't be scared by it
  • Motivational interviewing - nonconfrontational, reduce resistance, increase probability for change
    • What are the good things about drinking?
      • Set up the idea that you're not judging them
    • What are the less good things about drinking?
    • Summarise back to the patient the + and -
    • Look to the future - is the good/not so good balance going to change?
  • Roll with resistance - it's normal. Open up and externalise their ambivalence
  • Alcohol positives
    • Socialising - less inhibition
    • Bonding with mates
    • Relaxing/escape
    • Get to sleep (but not as good sleep)
    • Taste
    • Help you forget
    • Fixes withdrawal
  • Alcohol negatives
    • Hangover
    • Poor decision making
    • Risky sexual behaviour
    • Memory loss
    • Social anxiety
    • Injury
    • Spend all your money
    • Fight
    • Suicide attempts
    • Relationship breakdown/crying
  • Try to have a genuine interest in the person
  • Say "less good" rather than "bad"
  • Paraphrasing makes them happy
  • Where do we go from here?
  • If they agree, say "how many days a week do you want to drink?", "how much would you like to drink on any one occasion?"
    • Make them to commit to specific goals
  • Whole point of counselling = try to get someone to say something themselves
  • Strategies
    • Alternate a glass of water between drinks
    • Alcohol diary
    • Social support from family and friends
    • Provide written enforcement
    • Dont take credit card to pub
    • Take defined amount of money
    • Don't partake in shouts
    • Have a full meal at the pub
  • Most of this stuff doesn't really work in the short term, but in the long term it gets them thinking about their problem
  • How do you describe yourself when you drink
  • Have a think about it - we'll make another appointment and talk about it then
  • Don't sell to hard
  • Approaching motivational interviewing
    • Express empathy
    • Develop discrepancy (good/bad)
    • Roll with resistance and avoid argumentation
    • Support self-efficacy: so that people feel like they're able to do it
  • Don't assume that they ought to change, wants to change, are motivated by health, or that if they don't change, then you've failed.
  • Not motivated:
    • Disagrees with doctor
    • Refuses to accept the diagnosis
    • Expresses no desire or need
    • Does not appear distressed by their condition
      • Then you start the motivational interviewing
  • What might make it easier for you to keep this contract?
  • What might help you slow down?
  • Who is it you want to tell about your drinking?
  • Avoid shout sysem
  • Low alcohol beer
  • Count drinks
  • Alternate alcool and soft drinks
  • Maintain nearly full glass
  • Sipping drinks
  • Put glass down between sips
  • Measure spirit serves
  • Smaller servings
  • Add more mixer


  • Set dates and stuff so they stick to the contract