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Madden M, Stewart D, Cambridge JM. 'Really putting a different slant on my use of a glass of wine': patient perspectives on integrating alcohol into Structured Medication Reviews in general practice. ADDICTION RESEARCH & THEORY 2023; 31:459-467. [PMID: 38465260 PMCID: PMC7615723 DOI: 10.1080/16066359.2023.2207017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/21/2023] [Indexed: 03/12/2024]
Abstract
Background Alcohol is often overlooked in primary care even though it has wide-ranging impacts. The Structured Medication Review (SMR) in England is a new 'holistic' service designed to tackle problematic polypharmacy, delivered by clinical pharmacists in a general practice setting. Implementation has been protracted owing to the COVID-19 pandemic. This study explores early patient experiences of the SMR and views on the acceptability of integrating clinical attention to alcohol as another drug linked to their conditions and medicines, rather than as a standalone 'healthy living' or 'lifestyle' question. Method Semi-structured interviews with a sample of 10 patients who drank alcohol twice or more each week, recruited to the study by five clinical pharmacists during routine SMR delivery. Results SMRs received were remote, brief, and paid scant attention to alcohol. Interviewees were interested in the possibility of receiving integrated attention to alcohol within a SMR that was similar to the service specification. They saw alcohol inclusion as congruent with the aims of a holistic medicines review linked to their medical history. For some, considering alcohol as a drug impacting on their medications and the conditions for which they were prescribed, introduced a new frame for thinking about their own drinking. Conclusions Including alcohol in SMRs and changing the framing of alcohol away from a brief check with little meaningful scope for discussion, toward being fully integrated within the consultation, was welcomed as a concept by participants in this study. This was not their current medication review experience.
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Affiliation(s)
- Mary Madden
- Department of Health Sciences, University of York, York, UK
| | - Duncan Stewart
- Centre for Primary Health and Social Care, School of Social Professions, London Metropolitan University Department, London, UK
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Madden M, Stewart D, Mills T, McCambridge J. Alcohol, the overlooked drug: clinical pharmacist perspectives on addressing alcohol in primary care. Addict Sci Clin Pract 2023; 18:22. [PMID: 36998099 PMCID: PMC10062268 DOI: 10.1186/s13722-023-00378-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 03/23/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Attempts to routinely embed brief interventions in health systems have long been challenging, with healthcare professionals concerned about role adequacy, legitimacy, and support. This is the first study to explore clinical pharmacists' experiences of discussing alcohol with patients in their new role in UK primary care, in developing a novel approach to brief intervention. It investigates their confidence with the subject of alcohol in routine practice and explores views on a new approach, integrating alcohol into the medication review as another drug directly linked to the patient's health conditions and medicines, rather than a separated 'healthy living' issue. The study forms part of wider efforts to repurpose and reimagine the potential application of brief interventions and to rework their contents. METHODS Longitudinal qualitative study of 10 recruits to the new clinical pharmacist role in English primary care, involving three semi-structured interviews over approximately 16 months, supplemented by 10 one-off interviews with pharmacists already established in general practice. RESULTS When raised at all, enquiring about alcohol in medication reviews was described in terms of calculating dose and level of consumption, leading to crude advice to reduce drinking. The idea was that those who appeared dependent should be referred to specialist services, though few such referrals were recalled. Pharmacists acknowledged that they were not currently considering alcohol as a drug in their practice and were interested in learning more about this concept and the approach it entailed, particularly in relation to polypharmacy. Some recognised a linked need to enhance consultation skills. CONCLUSIONS Alcohol complicates routine clinical care and adversely impacts patient outcomes, even for those drinking at seemingly unremarkable levels. Changing clinical practice on alcohol requires engaging with, and supportively challenging, routine practices and entrenched ideas of different kinds. Framing alcohol as a drug may help shift the focus from patients with alcohol problems to problems caused for patients by alcohol. This is less stigmatising and provides role legitimacy for pharmacists to address alcohol clinically in medication reviews, thus providing one element in the formation of a new prevention paradigm. This approach invites further innovations tailored to other healthcare professional roles.
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Affiliation(s)
- Mary Madden
- Department of Health Sciences, University of York, York, UK.
| | - Duncan Stewart
- Centre for Primary Health and Social Care, School of Social Professions, London Metropolitan University, London, UK
| | - Thomas Mills
- PHIRST South Bank, London South Bank University, London, UK
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Madden M, Morris S, Stewart D, Atkin K, Gough B, Mills T, McCambridge J. Using qualitative process evaluation in the development of a complex intervention to advance person-centred practice by pharmacists: The Medicines and Alcohol Consultation (MAC). SSM. QUALITATIVE RESEARCH IN HEALTH 2021; 1:None. [PMID: 34988545 PMCID: PMC8689404 DOI: 10.1016/j.ssmqr.2021.100012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 09/15/2021] [Accepted: 09/22/2021] [Indexed: 11/22/2022]
Abstract
In order to effectively evaluate complex interventions, there have been calls for the further integration of qualitative methods. Qualitative process studies of brief alcohol interventions and medicines reviews are notably lacking. This article provides a grounded example through the presentation of findings from an embedded qualitative process evaluation of a multi-site, pilot cluster RCT of a new intervention: the Medicines and Alcohol Consultation (MAC). MAC is designed to increase the capacity of community pharmacists (CPs) to conduct person-centred medicines reviews in which the subject of alcohol consumption is raised in connection with medications and associated health conditions. Participant-focused qualitative studies (interviews, observations, recorded consultations) sought to understand how CPs engaged with and implemented MAC in context. This article documents effects of the intervention on developing person-centred consultation practice and highlights how qualitative process studies can be used formatively to develop middle range programme theory and to optimise intervention design for testing in a definitive RCT.
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Affiliation(s)
- Mary Madden
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
| | - Stephanie Morris
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
| | - Duncan Stewart
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
| | - Karl Atkin
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
| | - Brendan Gough
- School of Social Sciences, Leeds Beckett University, Room 919, Calverly Building, City Campus, Leeds, LS1 9HE, UK
| | - Thomas Mills
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
| | - Jim McCambridge
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
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McCambridge J, Atkin K, Dhital R, Foster B, Gough B, Madden M, Morris S, O'Carroll R, Ogden M, Van Dongen A, White S, Whittlesea C, Stewart D. Addressing complex pharmacy consultations: methods used to develop a person-centred intervention to highlight alcohol within pharmacist reviews of medications. Addict Sci Clin Pract 2021; 16:63. [PMID: 34656171 PMCID: PMC8520232 DOI: 10.1186/s13722-021-00271-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 10/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background Alcohol is challenging to discuss, and patients may be reluctant to disclose drinking partly because of concern about being judged. This report presents an overview of the development of a medications review intervention co-produced with the pharmacy profession and with patients, which breaks new ground by seeking to give appropriate attention to alcohol within these consultations. Methods This intervention was developed in a series of stages and refined through conceptual discussion, literature review, observational and interview studies, and consultations with advisory groups. In this study we reflect on this process, paying particular attention to the methods used, where lessons may inform innovations in other complex clinical consultations. Results Early work with patients and pharmacists infused the entire process with a heightened sense of the complexity of consultations in everyday practice, prompting careful deliberation on the implications for intervention development. This required the research team to be highly responsive to both co-production inputs and data gathered in formally conducted studies, and to be committed to working through the implications for intervention design. The intervention thus evolved significantly over time, with the greatest transformations resulting from patient and pharmacist co-design workshops in the second stage of the process, where pharmacists elaborated on the nature of the need for training in particular. The original research plans provided a helpful structure, and unanticipated issues for investigation emerged throughout the process. This underscored the need to engage dynamically with changing contexts and contents and to avoid rigid adherence to any early prescribed plan. Conclusions Alcohol interventions are complex and require careful developmental research. This can be a messy enterprise, which can nonetheless shed new insights into the challenges involved in optimising interventions, and how to meet them, if embraced with an attitude of openness to learning. We found that exposing our own research plans to scrutiny resulted in changes to the intervention design that gained the confidence of different stakeholders. Our understanding of the methods used, and their consequences, may be bounded by the person-centred nature of this particular intervention.
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Affiliation(s)
- Jim McCambridge
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, YO10 5DD, York, UK.
| | - Karl Atkin
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, YO10 5DD, York, UK
| | - Ranjita Dhital
- Department of Pharmacy, University of Reading, Reading, UK
| | | | - Brendan Gough
- School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Mary Madden
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, YO10 5DD, York, UK
| | - Stephanie Morris
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, YO10 5DD, York, UK
| | | | - Margaret Ogden
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, YO10 5DD, York, UK
| | - Anne Van Dongen
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, YO10 5DD, York, UK
| | - Sue White
- North of England Commissioning Support (NECS), Newcastle, UK
| | | | - Duncan Stewart
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, YO10 5DD, York, UK
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