1. Alcohol Identification and Brief Advice (IBA) - Messages for Primary Care Don Lavoie Alcohol Programme Manager

2. What I hope to cover What is the problem? Why is this a problem? What can you do about it? How do you do it? 2IBA - Messages for Primary Care

3. What is the problem? 3IBA - Messages for Primary Care

4. Alcohol consumption over the years 4IBA - Messages for Primary Care

5. Alcohol consumption vs. price 5IBA - Messages for Primary Care

6. Alcohol consumption - Europe 6IBA - Messages for Primary Care

7. Why is this a problem? 7IBA - Messages for Primary Care

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9. 9IBA - MESSAGES FOR PRIMARY CARE

10. 10IBA - Messages for Primary Care

11. 11IBA - Messages for Primary Care

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13. 13IBA - Messages for Primary Care

14. Alcohol - adds to health risks 14IBA - Messages for Primary Care

15. QOF registers and risky drinking 15IBA - Messages for Primary Care

16. What can you do about it? 16IBA - Messages for Primary Care

17. Don’t ignore it Any health-care professional can play their part  Identify risk  Provide simple advice  Support and encourage change  Refer those who may need specialist assessment and help This process is Identification and Brief Advice - IBA 17IBA - Messages for Primary Care

18. Typical alcohol identification questions Common questionnaires –MAST – Michigan Alcohol Screening Test –CAGE Have you ever tried to Cut down on your drinking? Have you ever felt Angered by someone talking about your drinking? Have you ever felt G uilty about your drinking? Have you ever had to have an “Eye opener” drink in the morning? How many Units do you drink a week? 18IBA - Messages for Primary Care

19. Alcohol risk levels 19IBA - Messages for Primary Care

20. AUDIT – gold standard 20IBA - Messages for Primary Care

21. 21IBA - Messages for Primary Care 3 UNITS 2.3 UNITS 1 UNIT 1.7 UNITS 10 UNITS 2 UNITS 2.3 UNITS

22. Typical night in 22IBA - Messages for Primary Care 8.4 UNITS Half

23. Typical night out 23IBA - Messages for Primary Care 14 UNITS Half

24. Special night out 24IBA - Messages for Primary Care 10 UNITS Half

25. 40% of alcohol drunk by 10% 25IBA - Messages for Primary Care

26. Public perception of alcohol risk  Most people are unaware that they are drinking above the lower-risk guidelines  Many do not see drinking above the lower-risk guidelines as a problem  Many aware that alcohol caused liver problems, but few aware of its contribution to cancers 26IBA - Messages for Primary Care

27. AUDIT - C 27IBA - Messages for Primary Care

28. Drinking “At Risk” groups 28IBA - Messages for Primary Care Source: General Household Survey 2009 & mid-2009 population estimates (ONS) & Adult Psychiatric Morbidity Survey 2007

29. The numbers FACTSFIGURES LAs152 Inc + High %22 Dep %3.8 Practices 8,261 GPs 33,364 ENGLANDLAsPRACTICEGP Total Population 53,588,218 352,554 6,487 1,606 Adult Population 43,580,873 286,716 5,275 1,306 Dependent drinkers 1,568,911 10,322 190 47 Increasing and Higher Risk 9,849,277 64,798 1,192 295 29 IBA - Messages for Primary Care

30. Adult visiting GP Requesting help with alcohol problem New RegistrationOther health complaint Full Screen AUDIT AUDIT Score 8-15 Increasing-risk Full Assessment Consider Referral to Specialist Services Lifestyle Counselling AUDIT Score 16-19 Higher-risk AUDIT Score 20+ Possible Dependence AUDIT Score 0-7 Lower-risk Primary Care - Alcohol Care Pathway No action Positive Result Negative Result SASQFASTAUDIT - CAUDIT - PC Initial Screening Tools Brief Advice IBA - Messages for Primary Care30

31. 31 AUDIT Score ScoreCategory 0-7Lower Risk 8-15Increasing Risk 16-19Higher Risk 20+Possible Dependence IBA - Messages for Primary Care

32. Brief advice - FRAMES  Feedback - provide feedback on the client’s risk for harm  Responsibility - the individual is responsible for change  Advice - advise reduction or give explicit direction to change  Menu - provide a variety of options for change  Empathy – take a warm, reflective and understanding approach  Self-efficacy - encourage optimism about changing behaviour 32IBA - Messages for Primary Care

33. Alcohol brief advice Content  Understanding units  Understanding risk levels  Knowing where they sit on the risk scale  Benefits of cutting down  Tips for cutting down 33IBA - Messages for Primary Care

34. Where do you sit? 34IBA - Messages for Primary Care

35. Benefits of cutting down Physical Reduced risk of injury Reduced risk of high blood pressure Reduced risk of cancer Reduced risks of liver disease Reduced risks of brain damage Sleep better More energy Lose weight No hangovers Improved memory Better physical shape Psychological/Social/Financial Improved mood Improved relationships Reduced risks of drink driving Save money 35IBA - Messages for Primary Care

36. Tips for cutting down Have an alcohol-free day once or twice a week Plan activities and tasks at those times you usually drink When bored or stressed have a workout instead of drinking Explore other interests such as cinema, exercise, etc. Avoid going to the pub after work Have your first drink after starting to eat Quench your thirst with non-alcohol drinks before alcohol Avoid drinking in rounds or in large groups Switch to low alcohol beer/lager Avoid or limit the time spent with “heavy” drinking friends 36IBA - Messages for Primary Care

37. There are times when you will be at risk even after one or two units. For example, with strenuous exercise, operating heavy machinery, driving or if you are on certain medication. If you are pregnant or trying to conceive, it is recommended that you avoid drinking alcohol. But if you do drink, it should be no more than 1-2 units once or twice a week and avoid getting drunk. Your screening score suggests you are drinking at a rate that increases your risk of harm and you might be at risk of problems in the future. What do you think? This is one unit... Half pint of regular beer, lager or cider 1 very small glass of wine 1 single measure of spirits 1 small glass of sherry 1 single measure of aperitifs How many units did you drink today? A pint of regular beer, lager or cider A pint of “strong”/ ”premium” beer, lager or cider Alcopop or a 275ml bottle of regular lager 440ml can of “regular” lager or cider 440ml can of “super strength” lager 250ml glass of wine (12%) Bottle of wine...and each of these is more than one unit RiskMenWomenCommon Effects Lower RiskNo more than 3-4 units per day on a regular basis No more than 2-3 units per day on a regular basis Increased relaxation Sociability Reduced risk of heart disease (for men over 40 and post menopausal women) Increasing Risk More than 3- 4 units per day on a regular basis More than 2-3 units per day on a regular basis Progressively increasing risk of: Low energy Memory loss Relationship problems Depression Insomnia Impotence Injury Alcohol dependence High blood pressure Liver disease Cancer Higher RiskMore than 8 units per day on a regular basis or more than 50 units per week More than 6 units per day on a regular basis or more than 35 units per week (9%) “regular” 3 (12%) For more detailed information on calculating units see - www.units.nhs.uk/ IBA - Messages for Primary Care37

38. Making your plan When bored or stressed have a workout instead of drinking Avoid going to the pub after work Plan activities and tasks at those times you would usually drink When you do drink, set yourself a limit and stick to it Have your first drink after starting to eat Quench your thirst with non-alcohol drinks before and in-between alcoholic drinks Avoid drinking in rounds or in large groups Switch to low alcohol beer/lager Avoid or limit the time spent with “heavy” drinking friends The benefits of cutting down Psychological/Social/Financial Improved mood Improved relationships Reduced risks of drink driving Save money Physical Sleep better More energy Lose weight No hangovers Reduced risk of injury Improved memory Better physical shape Reduced risk of high blood pressure Reduced risk of cancer Reduced risks of liver disease Reduced risks of brain damage What targets should you aim for? Men Should not regularly drink more than 3–4 units of alcohol a day. Women Should not regularly drink more than 2–3 units a day ‘Regularly’ means drinking every day or most days of the week. You should also take a break for 48 hours after a heavy session to let your body recover. This brief advice is based on the “How Much Is Too Much?” Simple Structured Advice Intervention Tool, developed by Newcastle University and the Drink Less materials originally developed at the University of Sydney as part of a W.H.O. collaborative study. What’s everyone else like? % of Adult Population What is your personal target? IBA - Messages for Primary Care38

39. Alcohol Learning Resources 39IBA - Messages for Primary Care

40. IBA resources 40IBA - Messages for Primary Care

41. e – Learning courses 41IBA - Messages for Primary Care

42. Change 4 Life 42IBA - Messages for Primary Care

43. IBA support for primary care  Incentives (payments)  DES – New registrations  NHS Health Check  Primary Care Service Framework  Identification tools  Brief advice scripts  Leaflets and written information  Care pathway  e-Learning modules  Read codes  Templates for GP computer systems 43IBA - Messages for Primary Care

44. The message for primary care  There are 9+million adults drinking above lower risk and putting their future health at jeopardy  Identifying these individuals and delivering brief advice can make a big difference in cutting this risk  Primary care is well placed to provide this intervention  Research has shown this is effective  The intervention does not have to be intensive  Vast amounts of training are not needed  You do not have to be an “alcohologist” to do this  It is well worth a few minutes of your time 44IBA - Messages for Primary Care

45. Useful links IBA resources and e-Learning module http://www.alcohollearningcentre.org.uk/ NICE guidance http://guidance.nice.org.uk/PH24 http://guidance.nice.org.uk/CG115 Primary Care Framework http://www.pcc-cic.org.uk/article/alcohol SIPS Research Programme http://www.sips.iop.kcl.ac.uk/index.php Materials, Units Calculator and Drink Check http://www.nhs.uk/LiveWell/Alcohol/Pages/ Alcoholhome.aspx 45IBA - Messages for Primary Care

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47. Does IBA work?  Very large body of international research over 30 years supporting IBA  56 controlled trials (Moyer et al., 2002) all have shown the value of IBA  Cochrane Collaboration Review (Kaner et al., 2007) shows substantial evidence for IBA effectiveness  NICE Public Health Guidance – PH 24: Alcohol-use disorders: preventing the development of hazardous and harmful drinking (2010) recommends all healthcare workers should deliver IBA  SIPS research programme confirmed effectiveness of IBA in England (Kaner et al., 2013) 47IBA - Messages for Primary Care

48. Impact of IBA  For every eight people who receive simple alcohol advice, one will reduce their drinking to within lower-risk levels (Moyer et al., 2002)  Higher risk and increasing risk drinkers who receive brief advice are twice as likely to moderate their drinking 6 to 12 months after an intervention when compared to drinkers receiving no intervention (Wilk et al, 1997)  Brief advice can reduce weekly drinking by between 13% and 34%, resulting in 2.9 to 8.7 fewer mean drinks per week with a significant effect on risky alcohol use (Whitlock et al, 2004)  A reduction from 50 units/week to 42 units/week will reduce the relative risk of alcohol-related conditions by some 14%, the attributable fractions by some 12%, and the absolute risk of lifetime alcohol-related death by some 20% (Anderson 2008) 48IBA - Messages for Primary Care

49. IBA is cost effective  Project TrEAT showed a return of 5 to 1 {US$56,263 in societal savings for every US$10,000 in intervention costs} (Fleming et.al., 2000)  Findings from Kaner et al. (2007) and the analysis from the University of Sheffield (2009) it would appear safe to assume that screening and brief advice will result in long-term savings to the NHS and personal social services 49IBA - Messages for Primary Care

50. SIPS findings PC findings published (Kaner, BMJ 2013)  A&E and Criminal Justice studies currently ‘in publication’ Brief findings  Delivering alcohol brief advice does work in England  It is possible to implement in ‘real life’ settings  It can be delivered by front line staff  Staff can have confidence that it is effective and worthwhile  Targeted screening more efficient, but you miss a lot of people picked up by universal screening A BIG GENERALISATION – BUT “Less is More”  In most of the studies, the briefer intervention (feedback + leaflet) worked as well as the longer interventions 50IBA - Messages for Primary Care

51. SMMGP / RCGP – SIPS Statement  Alcohol screening, followed by simple feedback, supported by written alcohol information is an accessible and easy way to make a difference  BUT – this is “more than just a leaflet” – appropriate feedback about the screening results and appropriate tailored information pertaining to the patients situation need to be delivered – supported by a leaflet or written alcohol information  Longer forms of advice and brief lifestyle counselling did not appear to confer extra benefit and should be reserved for patients who do not respond to simple advice  All primary care teams are encouraged to implement this strategy  Although targeted screening approaches are more efficient, SMMGP & RCGP, in line with NICE guidance, universal screening in primary care should be considered 51IBA - Messages for Primary Care

52. Why don’t you do it? 52IBA - Messages for Primary Care

53. Barriers to GP implementation  Doctors are just too busy dealing with the problems people present with  Doctors are not trained in counselling for reducing alcohol consumption  Doctors have a disease model training and they don’t think about prevention  Doctors are not sufficiently encouraged to work with alcohol issues in the current GMS contract  Doctors do not believe that patients would take their advice and change their behaviour  Doctors do not know how to identify problem drinkers who have no obvious symptoms of excess consumption  Doctors themselves have a liberal attitude to alcohol  Doctors themselves may drink more than what is healthy for them  Doctors think that preventive health should be the patients’ responsibility, not theirs  Doctors believe that patients would resent being asked about their alcohol consumption  Doctors feel awkward about asking questions about alcohol consumption because saying someone has an alcohol problem could be seen as accusing them of being an alcoholic 53IBA - Messages for Primary Care

54. GPs suggestions  General support services (self-help/counselling) were readily available to refer to  Early intervention for alcohol was proven to be successful  Patients requested health advice about alcohol consumption  Quick and easy counselling materials were available  Quick and easy screening questionnaires were available  Training programmes for early intervention for alcohol were available  Public health education campaigns in general made society more concerned about alcohol  Providing early intervention for alcohol was included in the Quality and Outcomes Framework (QOF) 54IBA - Messages for Primary Care

55. GP suggested policies Policy Effective % agreement  Improve alcohol education in schools 71%  Further regulation of alcohol off-sales (e.g. supermarkets)57%  Institute minimum pricing for units of alcohol 55%  Increase restrictions on TV & cinema alcohol advertising54%  Lower blood alcohol concentration limit for drivers 53%  Make public health a criterion for licensing decisions49%  Raise minimum legal age for purchasing alcohol 48%  General changes in alcohol price through taxation 48%  Statutory regulation of alcohol industry 43%  Raise minimum legal age for drinking alcohol 39%  Government monopoly of retail sales of alcohol27% 55IBA - Messages for Primary Care

56. Government ambivalence 56IBA - Messages for Primary Care

57. References  Anderson, P. (2008) Reducing heavy drinking and alcohol admissions (Unpublished) Department of Health.  Fleming, M.F., Marlon, M.P., French, M.T., Manwell, L.B., Stauffacher, E.A. and Barry, K.L. (2000) Benefit cost analysis of brief physician advice with problem drinkers in primary care settings, Medical Care, 31(1): 7-18.  Kaner E, Beyer F, Dickinson H, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Bernand B. Brief interventions for excessive drinkers in primary health care settings. Cochrane Database of Systematic Reviews 2007, Issue 2. Art No.: CD004148 DOI: 10.1002/14651858.CD004148.pub3.  Kaner E, et.al.Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. BMJ 2013;346:e8501  Moyer, A., Finney, J., Swearingen, C. and Vergun, P. (2002) Brief Interventions for alcohol problems: a meta- analytic review of controlled investigations in treatment -seeking and non-treatment seeking populations, Addiction, 97, 279-292.  University of Sheffield (2009) Modelling to assess the effectiveness and cost effectiveness of public health related strategies and interventions to reduce alcohol attributable harm in England using the Sheffield alcohol policy model version 2.0 [online]. Available from www.nice.org.uk/guidance/PH24  Whitlock, E.P., Polen, M.R., Green, C.A., Orleans, T. and Klein, J. (2004) Behavioral counselling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the US Preventive Services Task Force. Annals of Internal Medicine, 140, 557-568.  Wilk, A.I., Jensen, N.M. and Havighurst, T.C. (1997) Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers, Journal of General Internal Medicine, 12, 274-283. NICE GUIDANCE: http://guidance.nice.org.uk/PH24 57IBA - Messages for Primary Care