Challenges to alcohol and other drug discussions in the general practice consultation

BACKGROUND There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity. AIM To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered. DESIGN Analysis of video-recorded primary care consultations. SETTING New Zealand General Practice. METHODS Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings. RESULTS AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change. CONCLUSIONS Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.