1. Early interventions in alcohol problems – a European Perspective in Primary Health Care Antoni Gual Addictions Unit. Psychiatry Dept. Neurosciences Institute. Hospital Clínic de Barcelona. IDIBAPS. tgual@clinic.cat

2. Conflicts of interest 2 InterestName of organisation Current roles and affiliations Addictions Unit, Psychiatry Department, Neurosciences Institute, Hospital Clinic, University of Barcelona; IDIBAPS; Vice President of INEBRIA Grants Lundbeck, D&A Pharma, FP7, SANCO Honoraria Lundbeck, D&A Pharma, Servier, Lilly, Abbvie Advisory board/consultant Lundbeck, D&A Pharma, Socidrogalcohol (Alcohol Clinical Guidelines) 2013

3. Index Prevalence of AUD in PHC Attitudes of patients and PHC professionals towards alcohol Diagnosis of AUD in PHC The double gap

4. Alcohol Dependence In Primary Health Settings. The Size Of The Problem: APC STUDY Alcohol use disorders and treatment utilization in 6 European countries – a large-scale representative epidemiological study in primary care The research was financially supported by an investigors’ initiated grant by Lundbeck.

5. APC group  Co – PIs:  Antoni Gual, Jürgen Rehm, Marcin Wojnar  Country Investigators:  Germany: Hans-Ulrich Wittchen, Lars Pieper  Hungary: Zsuzsanna Elekes  Italy 1: Piero Luigi Struzzo  Italy 2: Allaman Allamani, Fabio Voller  Latvia: Marcis Trapencieris  Poland: Marcin Wojnar, Andrzej Jakubczyk  Spain: Antoni Gual, Jose Moreno  Analysis team:  Jakob Manthey, Charlotte Probst, Jürgen Rehm APC Study

6. Background Low AUD recognition among GPs. Estimated treatment rate of AD in Europe: 10% Potential barriers: – high stigma, denial of problems – perceived low effectiveness of treatment, – financial reasons – low perceived treatment need, – lack of knowledge, – lack of treatment options attractive to patients Key role of GPs in – Identification – Interventions – Referral APC Study

7. Key objectives 1.What is the prevalence of AD and AUD in primary health care? 2.How many clients with AD and AUD are being recognized by GPs, and what is the proportion receiving professional treatment? 3.What characteristics of the client are linked to recognition and treatment provision? APC Study

8. Methods – Regions and drinking patterns 1.Germany a : East Germany 2.Hungary b: entire country 3.Latvia b: entire country 4.Italy 1 c :Friuli-Venezia Giulia 5.Italy 2 c : Tuscany 6.Poland b :Łódź & Podkarpackie provinces 7.Spain c :Catalonia a Central-western drinking style: frequent drinking partly with, partly without food, beer is favourite beverage b Eastern European drinking style: drinking often irregular (almost no daily drinking) with heavy drinking occasions; mostly outside of meals c Southern European Mediterranian drinking style: drinking often daily, usually wine alongside with meals, few heavy drinking occasions APC Study

9. Methods APC Study  Sampling by country

10. Methods - Data collection GP assessment of 13,003 clients  Sociodemographics  Main health characteristics  Questions on AU, AUD (and treatment) of patient Interview of 7,901 clients  Sociodemographics  WHO-DAS 2.0  K10+  CIDI and questions on AUD treatment  Smoking  Service Utilization Questionnaire APC Study

11. Index Prevalence of AUD in PHC Attitudes of patients and PHC professionals towards alcohol Diagnosis of AUD in PHC The double gap

12. Attitudes of PHC professionals towards alcohol

15. Nalmefene blocks the μ-opioid receptor 3 Nalmefene modulates the  -opioid receptor 3 Percentage of patients Reasons given for not receiving alcohol treatment in the past year by persons who needed treatment and who perceived a need for it: 2009 to 2012 Survey of approx. 67500 interviewed persons in the US SAMHSA. Results from the 2012 National Survey on Drug Use and Health, 2013 Attitudes of patients towards alcohol

16. How to identify and decrease barriers Meyers, R. J., Miller, W. R., Smith, J. E., & Tonigan, J. S. (2002). Miller, Sovereign and Krege (1988)

17. How to identify and decrease barriers Respondents Indicating “Important” or “Very Important” %Reason not to ask for treatment 78.5I liked getting drunk. 64.7I thought I could handle it on my own. 60.0I didn’t want to be told to stop using alcohol. 58.8Using alcohol was a way of life for me. 56.9I didn’t think of myself as an alcoholic. 54.9I liked alcohol and didn't want to give it up. Most relevant reasons for not asking for treatment

18. Index Prevalence of AUD in PHC Attitudes of patients and PHC professionals towards alcohol Diagnosis of AUD in PHC The double gap

19. Comparing AD diagnoses by GP & CIDI APC Study

20. 12-months prevalence of AD in % Comparing AD diagnoses by GP & CIDI

21. Index Prevalence of AUD in PHC Attitudes of patients and PHC professionals towards alcohol Diagnosis of AUD in PHC The double gap

22. The double treatment gap Patients with AUD in PHC settings Risky drinkers offered brief advice to reduce Alcohol dependent offered abstinence oriented treatment 1 st GAP 2 nd GAP

23. THE PROBLEM: Effect size of BIs decreases if dependent patients are included BIs not effective for dependent drinkers BIs do not show an effect on alcohol related problems

24. The solutions Brief motivational interventions show equal effectiveness than other interventions in alcohol dependent patients. They focus on problems perceived by the individual. New pharmacological approaches aiming at a reduction goal, rather than abstinence, may increase the acceptance by patients and the uptake by GPs.

25. Reduction using Brenda & TLFB (Sense study) Change from baseline in HDDs per month Change from baseline in TAC (g/day) Monthly period HDDsTAC Placebo arm

26. HDD/TAC: change from baseline in the 1-year study – patients with at least high DRL at baseline and randomisation 100 g/day 33 g/day 19 HDDs 7 HDDs Difference: -3.6 HDDs, p=0.0164 Difference: -17.3 g/day, p=0.0129 SENSE – change in TACSENSE – change in HDDs MMRM (OC) FAS estimates and SE; *p<0.05; MMRM=mixed-effect model repeated measure; OC=observed cases; FAS=full analysis set; SE=standard error van den Brink et al. SENSE. Poster at EPA 2013; Data on file

27. Summary Alcohol use disorders are very prevalent accross PHC settings in Europe Underdiagnosis is frequent, specially in younger populations There is a double gap: low levels of identification and lower levels of treatment SBIRT programs may help to reduce the identification gap New psychological and pharmacological techniques may help to fill the treatment gap

28. Early interventions in alcohol problems – a European Perspective in Primary Health Care Antoni Gual Addictions Unit. Psychiatry Dept. Neurosciences Institute. Hospital Clínic de Barcelona. IDIBAPS. tgual@clinic.cat VIELEN DANK !!!