1. Starting the journey: Screening and brief interventions Prof Alex Copello Consultant Clinical Psychologist Addiction Services Birmingham and Solihull Mental Health Foundation NHS Trust & Professor of Addiction Research The University of Birmingham a.g.copello@bham.ac.uk Taking a closer look at alcohol and drug treatment Birmingham, 27 th April 2011

2. The journeys Many people will recover from alcohol use disorders without specialist treatment Hazardous and harmful drinkers may respond to a brief intervention provided in primary care without requiring access to specialist treatment (NICE, 2010) For others, their alcohol problems are overcome with the help of a mutual aid organisation, such as Alcoholics Anonymous (AA) Nevertheless, many will require access to specialist treatment by virtue of having more severe or chronic alcohol problems, or a higher level of complications of their drinking (e.g. social isolation, co-existing psychiatric problems or severe alcohol withdrawal)

3. Addiction problems are frequently overlooked in a range of settings e.g. a quarter of excessive drinkers identified in primary care

4. Identification A recent study found that UK GPs routinely identify only a small proportion of people with alcohol use disorders who present to primary care less than 2% of hazardous or harmful drinkers; less than 5% of alcohol dependent drinkers (source: Cheeta et al., 2008).

5. Possible Reasons Not knowing what we are looking for Lack of vigilance Embarrassment at asking certain questions Not knowing what to do if case uncovered Client’s reluctance to discuss the issue

6. Identification Important implications for the prevention and treatment of addiction problems. Failure to identify problems means: that many people do not get access to interventions until the problems are more chronic and difficult to treat and failure to address an underlying addiction problem may undermine the effectiveness of treatment for the presenting health problem (for example, depression or high blood pressure).

7. Enhancing recognition rates Use of sensitive/appropriate questions Remembering who is at risk Common social presentations Common psychological problems Common physical problems Not overlooking the obvious Talking to others that may be affected

8. How are Families Affected by Substance Misuse? “Family members face a form of chronic stress that affects them at a number of different levels…..daily hassles…..relationships that deteriorate……a number of threats….much uncertainty….hence, family members find themselves in a very disempowered position….” (Orford et al., 2005 p205-206)

9. Problems for the whole Family RITUALS ROLES ROUTINES COMMUNICATION SOCIAL LIFE FINANCES

10. Symptoms of Ill Health 21 0 5 10 15 20 25 30 35 UK Mexico Wives P.Care Psych Control Family members; psychiatric out-pts. and community controls Family members

11. Laboratory Tests MCV Mean Corpuscular Volume GGT Gamma Glutamyl Transpeptidase CDT Carbohydrate Deficient Transferin BAC Blood Alcohol Level Urine Tests

12. Screening Questionnaires CAGE (King, 1986) MAST (Selzer, 1971) AUDIT (Babor et al., 1989)

13. CAGE Have you ever: Cut down on your drinking Angry at others criticising your drinking Guilty about your drinking Eye opener - drink first thing in the morning

14. AUDIT items: 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have five or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected of you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? 9. Have you or someone else been injured because of your drinking? 10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

15. Interviewing Raising the issue Feeling confident to respond Basic knowledge of substances and effects

16. Raising the Issue Legitimacy Client’s fear of being judged Need for time to contemplate Therapist’s confidence

17. Substances Knowledge of the basic facts about substances can increase confidence when discussing substance use with clients.

18. What can be done to help people with addiction problems in a range of non- specialist settings?

19. BRIEF vs. INTENSIVE

20. Brief interventions (BIs) “Brief interventions involve opportunistic advice, discussion, negotiation or encouragement They are commonly used in many areas of health promotion by a range of primary and community care professionals” NICE 2006

21. Types of Brief Interventions Opportunistic brief interventions (OBIs) Brief treatment (extended BIs) “A single or a number of interventions aimed at enabling change behaviour”

22. Types of Brief Interventions (2) Delivered by: – non-specialists in generic settings – Specialists in alcohol treatment settings

23. The origins of brief interventions Alcoholism: a controlled study of “treatment” and “advice” Edwards, Orford, et al 1977

24. The study 100 participants Male Married Problem drinkers 3 hour comprehensive assessment

25. Randomised treatment Conventional (standard) – Inpatient – Outpatient – Lasting several months Treatment (trial) – Single session – With psychiatrist – With wife – “constructive and sympathetic terms”

26. Results No statistical difference in outcome between intensive and brief therapy – At 1 year – At 2 years

27. Therapeutic principles of BIs Enshrined in the principles of motivational interviewing Enabling change rather than forcing or engendering change directly

28. 5 Core principles… 1.Avoiding arguments 2.Empathy 3.Self-efficacy 4.Rolling with resistance 5.Developing discrepancy

29. Tools Drink/drug use diaries to record weekly use and establish baseline Feedback: avoid labelling; responsibility with the client; provide a menu of strategies; enhance self efficacy

30. Addictions Two simple tools: Substance Use Diaries Decisional Balance

31. Brief Interventions Framework F eedback R esponsibility Advice Menu Empathy Self-efficacy (FRAMES; Bien et al., 1993)

32. Families The 5 Step-Method A relatively brief intervention focused on family members affected by addiction problems. Can be delivered in a range of settings by a range of professionals. Based on psychological principles of stress and coping.

33. Screening and Brief Interventions Screening and brief intervention delivered by a non-specialist practitioner is a cost-effective approach for hazardous and harmful drinkers (NICE, 2010a) However, for people who are alcohol dependent, brief interventions are less effective and referral to a specialist service is likely to be necessary (Moyer et al., 2001)

34. Referral to specialist services Around one third of people presenting to specialist alcohol services in England are self- referred Around one third are referred by non-specialist health or social care professionals (Drummond et al., 2005). The majority of the remainder are referred by other specialist addiction services or criminal justice services.

35. Assessment Framework Recent use WHEN HOW MUCH WHAT WHERE WHO WITH

36. Assessment Framework Recent use Recent abstinence Recent withdrawal

37. Assessment Framework What influences use? Usual pattern Any changes Dependence Substance related problems Periods of abstention or control

38. Current alcohol services Alcohol needs-assessment in England identified nearly 700 agencies providing specialist alcohol treatment, with an estimated workforce of 4,250 (Drumond et al., 2005; National Audit Office, 2008). The majority of agencies (70%) were community based and the remainder were residential.

39. Current alcohol services Approximately half of all alcohol services are provided by the non-statutory sector but typically funded by the NHS or local authorities. Approximately one third of specialist alcohol services exclusively provide treatment for people with alcohol problems, but the majority (58%) provide services for both drug and alcohol misuse.

40. Current alcohol services In terms of services provided by community specialist agencies, the majority (63%) provide structured psychological interventions either on an individual basis or as part of a structured community programme (Drummond et al., 2005).

41. Thank you for listening...