Quality in Primary Care Open Access

Keywords

Addictive disorders; Therapeutic attitude; Emergency department

Introduction

Alcohol and drug users are more likely to attend Emergency Department (ED) compared to non-users [1]. One patient on five being treated in the ED tests positive for blood alcohol regardless of the reason for admission [2-4]. Literature on the effectiveness of screening and brief intervention in primary care and hospitals is growing [5-9]. Several authors recommend a systematic screening of addictive disorders in ED [10-12], but such interventions face barriers to screening as lack of time, lack of privacy or difficulty in motivating nurses to perform the screening and they only screen a small part of the eligible population in ED [4]. Therapeutic attitudes of ED caregivers are important points to consider. In Europe, few studies focused on caregivers’ attitudes towards addictive disorders, and the French studies were more specifically concerned with the elderly [13,14]. We did not find studies in ED in our country about caregivers’ attitudes where addictive disorders were concerned.

Materials and Method

Population

Inclusion criteria:

-Caregivers in the ED

-French comprehension (oral and written)

-Consent to the study

Exclusion criteria:

-Student

-Non comprehension of French language (oral or written)

-No consent

This study was approved by the ethics committee of the University of Brest. Our main objective was to conduct a selfreport on the therapeutic attitudes of caregivers in ED towards addictive disorders.

Questionnaire

No validated tools existed to assess in the health care population but we identified a tool, which had been used in previous studies on the same topic [11,12]. We generalized the questionnaire to include all age groups and addictive disorders.

Statistical analysis

Descriptive statistical analysis uses averages, standard deviations and percentages.

Results

We collected 25 questionnaires (N=41), a return rate of 61%. The responding population consisted of: 48% nurses, 32% doctors and 20% caregivers, with 40% men and 60% women. The seniority since graduation was 14 years ± 8.2 years. Respondents had been working in ED for a median of 8 years ± 20.9 years. 56% acknowledged that they themselves, or others, had experienced addictive disorders.

Identification and referral

64% of caregivers (100% of doctors and 58% of nurses) answered that they systematically proposed a specialized consultation.

ED caregivers said they confirmed their diagnosis by: « talking about it with the patient » (100%); talking about the problem with the family (80%); 56% said that they used a diagnosis tool and 28% said that they asked for help from the addiction team.

Information about addictive disorders were transmitted orally by the nurses (83%). 75% of medical doctors said that they wrote information in the patient’s file. 64% of ED caregivers estimated the proportion of patients with addictive disorders attending the ED at under 20%.

Attitudes and feelings assessed for all caregivers are summarized in Table 1 below. No patients were referred to the addictive disorders service through the ED during the study.

How they felt	Total (%)	Doctors(%)	Nurses (%)	Nursing assistant (%)
Available	40	50	41	20
Helpful	28	38	25	20
able to listen	62	61	73	40
Competent	4	0	8	0
Moralizing	12	30	8	2
Repressive	4	12	0	0
Powerless	68	88	58	60
Mal à l’aise Uncomfortable	8	0	0	40
Agressif Aggressive	0	0	0	0
Evasive	0	0	0	0

Table 1: Self-reported caregiver attitudes/feelings about people with addictive behaviours.

Discussion

This study is an exploratory study about the therapeutic attitudes of caregivers towards addictive disorders in ED, a quite a rare topic in literature.

An underestimation of the prevalence of addictive disorders in ED

The majority of caregivers questioned considered that less than 20% ED patients had addictive disorders. Alcohol use disorders in ED ranges from 13 to 37% [15-18] and 7 years after an admission in ED, 15.1% of patients reported alcohol dependence, 22.6% cocaine use; 13.5% sedatives use and 7.1% opioid use [19]. So this is a clear underestimation of addictive disorders in ED patients.

Limits to the identification of addictive disorders in ED

As identified by Patston et al. [4], lack of time seems to be a perceived limitation quite specific to the ED, as well as the experience of lack of vocational training, indicated by Kelleher and Cotter [13]. In our study, very few caregivers received training in addictive disorders. The lack of caregivers’ training risks degrading their perception of self-confidence and legitimacy in asking patients about their substance use [3,20]. Initial training, in-service training/experience and support are factors that can clearly improve team attitudes in the management of alcohol-related behaviour [21].

Another hypothesis is practice seniority in ED, which was quite high in our study (8 years-20.9 years). Authors reported that experienced caregivers’ feelings diminish as their years of experience increase [3,14].

An overestimation of specialised guidance

In this study, 64% of caregivers stated that in ED, they systematically directed patients with addictive disorders towards specialized care. They felt the need to refer patients with addictive disorders in 100% of cases. But, at the same time, no patients were sent from ED for an addictive disorders evaluation.

Therapeutic attitudes among caregivers towards addictive disorders: An underestimation of the influence of the personal experience

This work showed that more than half of caregivers report that they were personally concerned with addictive disorders (their own or close friends and family). A study conducted at the St Etienne University Hospital showed that 85% of those questioned used alcohol during the year, and one third of the users used alcohol on a weekly basis and 4.8% said they had used cannabis in the last 12 months [22].

It feels essential that this variable should be taken into account, bearing in mind that non-consumer caregivers would tend to increase the problems whereas those who are themselves in difficulty would minimize them [23]. Nevertheless, the results are sometimes contradictory in the literature on this subject and some studies, such as those by Iqbal et al. [21] have not shown differences in attitudes according to personal alcohol consumption.

Strengths and Limitations

This study is concerned with a topic considerable in terms of secondary prevention and harm reduction. But, our response rate was 60%. Our main limitation was the lack of statistical power. Our results could not be generalized.

Conclusion

ED is strategic place for identification of addictive disorders and for strategic therapeutic planning. However, there are significant limitations to screening which are not only linked to biomedical skills but, also to personal feelings and perceptions. If we keep trying to implement alcohol use screening in ED, without training on personal feelings and on perceptions about alcohol, it will continue to fail.

Conflicts of Interests

No conflict to declare.

Funding

No funding for this study.

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