Highlighting alcohol use in medication appointments with clinical pharmacists: the CHAMP-1 mixed methods research programme

Background

Brief interventions have been the cornerstone of alcohol prevention in the National Health Service, but there are important limitations to the underpinning evidence base, and implementation has been problematic. We completed the first community pharmacy brief intervention trial and found no effect. A different approach was needed. This programme proposed to integrate attention to alcohol clinically within existing pharmacy service delivery, supporting pharmacists to discuss alcohol as a toxic psychoactive drug in the contexts of potential impacts on treatments, conditions and health.

Aims

The aims were to: (1) work with pharmacists and patients to design and evaluate an intervention that develops the health and well-being role of pharmacists in relation to alcohol consumption, specifically within the context of an existing medication review service; (2) engage with policy-makers throughout the duration of the programme about the intervention and wider systemic and workforce development needs for the pharmacy profession.

Design and methods

Methods incorporated reviews, qualitative observational and interview studies, coproduced intervention development and process studies, and a cluster pilot randomised controlled trial. During the programme, national policy decisions moved National Health Service-commissioned medication reviews from community pharmacy into newly created Primary Care Networks of general practices, in the form of a new service, the Structured Medication Review. With funder approval, we adapted the programme and the intervention to the general practice setting. This included early studies of Structured Medication Review implementation and feasibility study of using primary care data sets for evaluation purposes.

Setting

Community pharmacies initially, and subsequently general practice.

Participants Pharmacists and medication review patients.

Interventions

The Medicines and Alcohol Consultation was developed to support pharmacists to integrate attention to alcohol within routine medication reviews.

Results

The programme comprised three phases, reflecting major, unanticipated changes in the organisation of National Health Service medication review services, and thus to the research plan. Phase 1 developed the intervention with patients and community pharmacists, informed by the conceptual work, reviews, observational and interview studies. Feasibility studies established the planned trial methods, and the external cluster pilot trial met main trial progression criteria for rates of recruitment and follow-up. In phase 2, now in general practice, we studied how national policy was being translated into practice, in order to understand contextual factors influencing the early implementation of Primary Care Networks and the Structured Medication Review, including substantial COVID-19-related delays. Interviews with senior staff, clinical pharmacists and patients indicated that Structured Medication Review practice had fallen short of the original person-centred policy vision for the service, and clinical pharmacist role development in Primary Care Networks was limited. The quality of national Structured Medication Review data was uncertain. In such circumstances, it was decided that it was not possible to undertake a definitive trial. In phase 3, the Medicines and Alcohol Consultation programme was delivered to a cohort of 10 clinical pharmacists in general practice, with data from pharmacists, patients, practice development coaches and audio-recordings triangulated. Progress towards more skilful, person-centred practice was observed for the pharmacists who completed the programme, with acknowledged limitations. This was particularly the case for alcohol itself. The local policy and service contexts were examined in an integrated care system stakeholder interview study that laid bare major challenges to be faced in addressing alcohol.

Limitations

The programme has comprised predominantly qualitative studies within the North East and Yorkshire region, so transferability to other regions is not known.

Conclusions

Pharmacists can be supported to increase skilfulness in working clinically on alcohol with patients. Workforce development and systemic pressures make this more difficult than it needs to be. The idea that alcohol should be regarded as a drug, to be discussed alongside prescribed medications, is foundational for clinical pharmacists. The new thinking about how healthcare professionals more broadly talk about alcohol with patients has been articulated as a new paradigm, brief interventions 2.0, for advancing future research.

Future work

Implications for future work on alcohol are far-reaching. Advancing brief interventions 2.0 requires interventions to focus on personal health and social contextual factors, entailing much broader discussions of the place of alcohol in peoples’ lives. This means avoiding the pitfalls of focusing on stereotyped notions of problem drinking. It requires a systemic, strategic approach to prevention. The Medicines and Alcohol Consultation is a starting point for this agenda, which we will advance in debate and new research.

Study registration

This study is registered as Current Controlled Trials ISRCTN57447996 (pilot trial).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref.: RP-PG-0216-20002) and is published in full in Programme Grants for Applied Research; Vol. 13, No. 12. See the NIHR Funding and Awards website for further award information.