Thematic analysis
Eight main themes and 19 sub-themes were identified. In this paper, we present data for the three of these themes relevant to the purpose of this paper. They are: (1) patients’ experience of, and (2) attitude towards, screening and treatment for problem alcohol use in primary care, as well as their (3) views on service improvement. See the ‘Summary of Main Themes and Subthemes’ section.
1)
Patients’ experience of therapeutic interventions for problem alcohol use.
a)
Patients’ experience of being screened for problem alcohol use.
The majority of patients were able to recall being screened at some stage. Patients, who reported no screening, explained that their healthcare professionals were not concerned about problem alcohol use as there was an understanding that it was not an issue for that patient. For those, who were screened for alcohol use in the past, the most common time of screening was at initial assessment, with most reporting no screening thereafter, except if there was a suspicion of problem alcohol use. In terms of screening methods, patients simply described “being asked” about their alcohol use, they did not report being subject to structured screening such as the ‘AUDIT’, nor did they recall being breathalysed or having liver function tests (LFTs). In some cases, patients themselves told the healthcare professional about their alcohol use:
“I speak. I don’t mind talking and explaining myself to people and being helpful, giving helpful information if needed” (Patient 3.3).
b)
Patients’ experience of interventions for problem alcohol use.
Patients were asked had they ever received any advice or ‘intervention’ about their alcohol use, specifically any form of advice or counselling that the healthcare professional may have provided. A number of patients reported receiving some form of what could be best described as a ‘brief intervention’, i.e. to give advice and motivate the patients to either alter their drinking habits or seek treatment, if needed [
36]. Patients explained how healthcare professionals gave them advice about the negative effects of problem alcohol use and also gave them advice about cutting down, drinking in moderation and possibly seeking further help.
“Dr [name], he does say to me ‘How are you drinking, are you going to ease off, it is not good for you.’ I know he means good” (Patient 0.1)
The main advice that patients received from the healthcare professionals was about the negative effects of problem alcohol use. The most common form of advice was warning about the hepatic effects of problem alcohol use (e.g. how problem alcohol use exacerbates the risk of liver damage by the presence of Hepatitis C -HCV). Other advice included reducing their alcohol intake and aiming to drink in moderation.
“They were telling me before I gotta stay off the drink… ‘We’re not telling you to stay away from drink altogether, you could have the odd drink, try once a month, occasional drink.’” (Patient 5.3).
A number of patients reported receiving medication for problem alcohol use; however, this was not as common as the brief intervention or advice. Three patients had received an outpatient detoxification with chloradiazepoxide (‘Librium’ ®) and had found it useful at the time. However, all noted that the detoxification was ‘too short’. Although they did not drink when they were taking it, they subsequently drank when the week was complete.
“You only get a one week supply of them, and you can’t take anymore after that… as soon as I stopped taking them, I went back on it again. They help you to sleep and they stop you from shaking from the withdrawals over the drink” (Patient 0.1).
A number of patients reported being referred to specialist psycho-social services, including psychiatry and counselling services. Referral to counselling was often for multiple issues other than alcohol, such as addiction to benzodiazepines or personal and social problems. Most recalled a positive experience of counselling and reported that they were able to discuss problem alcohol use with counsellors.
“I’ve done a lot of counselling over the years… it’s made me see a lot of things that I probably wouldn’t have thought about that much… It kind of gives you a chance to step back a little bit and have a look at yourself” (Patient 17.3).
“people are talking and they can’t wait to go home to have a can of beer. The other people that was there in the group – they are only fooling themselves… it started 10.00 in the morning.. I went in one day and there was this chap sitting beside me – the smell of drink off him was unreal” (Patient 0.1).
Restrictions imposed by healthcare professionals, as a way of tackling problem alcohol use were also reported, although patients acknowledged that this was more common in addiction clinics. Negative consequences included increased supervision, breathalysing, delayed dispensing and supervised consumption of methadone. Patients acknowledged that, in some cases, it is a necessary procedure due to the risks attached to problem alcohol use among methadone users.
2)
Patients’ attitudes to therapeutic interventions Patients’ attitudes to therapeutic interventions varied greatly; while some did not have an issue being asked about problem alcohol use or receiving advice, others acknowledged that although they did not like it they understood that it was necessary.
“I’d no problem telling him things, there’s no point in lying to a doctor. He’s there to help you so…I was up front with him and whatever he asked me about I just told him the truth because it’s for my own benefit” (Patient 7.3).
At the other end of the spectrum, some patients described their annoyance at being questioned, and others were able to identify that they became defensive and, at times, concealed their alcohol use.
“
I find it a bit hard… I kind of think that they don’t know what I’m going through… I don’t think you have a mind to tell you the truth, especially when you’re drinking you feel like an idiot talking about it because you’re only telling a load of lies” (Patient 5.3).
a)
Acceptance of therapeutic interventions
A positive or accepting attitude to therapeutic interventions was reported by a number of patients. Some patients initiated the discussion on alcohol use with their healthcare professional because it was a concern to them, but also because they felt happy to discuss it. Similarly, there were patients who did not mind discussing it, as they felt they had “nothing to hide”. There were other patients, who reported being receptive to the advice they received, such as the patient below, who described being happy that the healthcare professional was concerned for him.
“Ah no, now I take it on board [advice]
, I’m glad he has that concern” (Patient 11.3).
b)
Negative reactions to therapeutic interventions Negative reactions included fear, embarrassment and resentment. Some patients did not feel comfortable discussing their problem alcohol use. Others were afraid to discuss it or admit to a problem due to fear of repercussions (e.g. withdrawal of services, increased supervision and re-referral to a methadone clinic). As a result, some patients were concerned that non-compliance will result in negative consequences, as described earlier, and that because of this, the healthcare professional (in particular those with prescribing responsibility) hold the ‘power’ and can ‘control’ the patient. One patient described how he challenged his GP about this ‘power’ role:
“I did have arguments with him saying “You don’t realise how much power you have over people. And you are not judge, jury and executioner.” Because they have that much power over you the doctors when you’re on the methadone, you have to comply with them” (Patient 11.3).
c)
Patients’ relationship with healthcare professional The majority of participants reported a broadly positive relationship with healthcare professionals, although some of these noted that at times, there had been friction. As some had experienced negative relationships with healthcare professionals in the past, they were happy to have found a ‘good’ one, and those who had such a good relationship considered themselves ‘lucky’.
“he [GP] is not only intuitively good, but he attends very well - there is no doubt in my mind, primary care matters very much in treatment of this sort” (Patient 6.4).
In contrast, distrust or dishonesty and concealment of problem alcohol use was a feature for those patients who reported negative relationships with healthcare professionals.
“…because you used drugs once you will never be trusted by a doctor. Like, I’m not able to give a urine sample with somebody else in a cubicle. I just can’t… I am nearly 47, I’m an old man” (Patient 5.4).
3)
Patients’ views on service improvement Patients described a number of factors which enabled or hindered the management of problem alcohol use in primary care:
Potential of primary care professionals
Importance of professional – patient relationship
Need for support and encouragement
Healthcare professional factors highlighted the central role of the practitioner-patient relationship, especially in primary care to facilitating and supporting patients through screening, treatment and ultimately, recovery. Patient or social factors highlighted the importance of motivation and associated intrinsic/extrinsic factors, especially the wider social context and how this can impact on the problem and its care. Finally, structural issues relating to how services are organised and delivered, and especially their flexibility, accessibility and capacity to address the issue, were highlighted.
“when I used to go to counsellors it used to be just, you know, they’d give you an address, you’d go there and it’s be just like a little office, you’d go in and sit down and do your stuff. But the community places, you know, the drop in centre side of it makes it easier for people to go in” (Patient 17.3).
“I do think there should be decent facilities for people that are on drink you know” (Patient 9.2).
A complete list of factors conducive to, or hindering, the management of problem alcohol use in primary care from patients’ perspective is listed in the ‘List of Patients’ Views on Service Improvement’ section.