1. Alcohol Screening and Brief Interventions for Patients with Non-communicable Diseases Thomas F. Babor Department of Community Medicine University of Connecticut School of Medicine

2. Alcohol use is a risk factor for many NCDs Cirrhosis of the liver Certain cancers Heart disease Diabetes Many others

3. Example: Alcohol and Diabetes Moderate drinking can protect against Type II diabetes, but heavy drinking is a risk factor for both diabetes and poor treatment adherence. Heavy drinking (3+ drinks/day) can deteriorate glucose metabolism Alcohol can stimulate appetite, increase BP and triglyceride levels Beer and sweet wine contain carbohydrates

4. The role of alcohol SBIRT in NCD management Screening to find: -- hazardous and harmful drinkers -- patients with alcohol dependence Brief Intervention Referral of more serious cases to further diagnostic assessment and specialized care for alcohol dependence

5. Goals of Screening Identify both hazardous/harmful drinking and those likely to be dependent Use as little patient/staff time as possible Create a professional, helping atmosphere Provide the patient information needed for an appropriate intervention

6. Key Terms and Definitions Alcohol Dependence Syndrome A cluster of cognitive, behavioural, and physiological symptoms Harmful UseA pattern of drinking that has already caused damage to health Hazardous UseA pattern of alcohol consumption carrying with it a risk of harmful consequences to the drinker

7. AUDIT - The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care (second edition), 2001 This manual introduces the AUDIT, the Alcohol Use Disorders Identification Test, and describes how to use it to identify persons with hazardous and harmful patterns of alcohol consumption.

8. AUDIT Instrument Developed by WHO for international use More than 100 scientific articles on reliability, validity, training, translations, cultural adaptations Distinguishes risk levels: hazardous, harmful, dependence Can be used as an interview or questionnaire More information at: http://www.who.int/substance_abuse/

9. Domains and Item Content of the AUDIT DomainsQuestion Number Item Content Hazardous Alcohol Use 123123 Frequency of drinking Typical quantity Frequency of heavy drinking Dependence Symptoms456456 Impaired control over drinking Increased salience of drinking Morning drinking Harmful Alcohol Use 7 8 9 10 Guilt after drinking Blackouts Alcohol-related injuries Others concerned about drinking

10. AUDIT Scoring Alcohol Dependence/ Probable alcohol dependence High-Risk Drinkers Low-Risk Drinkers Abstainers Type of DrinkersAUDIT Scores 20+ 17-20 8-16 1-7 0

11. Risk LevelInterventionAUDIT Score* Non-drinkerAlcohol Education0-7 HazardousSimple Advice8-15 HarmfulSimple Advice plus Brief Counseling and Continued Monitoring 16-19 DependenceReferral to Specialist for Diagnostic Evaluation and Treatment 20-40

12. Patient Comfort with Screening % % (n = 35,257)

13. Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care, 2001 This manual is written to help primary health care workers - physicians, nurses, community health workers, and others - to deal with persons whose alcohol consumption has become hazardous or harmful to their health.

14. Elements of Brief Interventions  Present screening results  Identify risks and discuss consequences  Provide medical advice  Solicit patient commitment  Identify goal-reduced drinking or abstinence  Give advice and encouragement

16. Percentage of Male/Female Patients who Decreased Intensity of Drinking

17. Effectiveness of brief interventions with at-risk drinkers More than 80 trials/15 systematic reviews Participants reduced average number of drinks/week by 13% to 34% compared to controls Proportion of participants in intervention condition drinking at moderate or safe levels was 10% to 19% greater than controls (from Whitlock, et al, 2004 and individual studies)

18. Individualizing advice for patients with diabetes Advice to nondrinkers: Don’t drink Advice to moderate drinkers: Stay within ADA guidelines (no more than 2 drink/day for men, 1 drink for women and those over 65) Hazardous/harmful drinkers: Try to achieve ADA guidelines or stop drinking Suspected alcohol dependence: Seek diagnostic evaluation for abstinence-oriented therapy

19. Providing Referral to Diagnostic Evaluation and Treatment  Feedback  Advice  Responsibility  Information  Encouragement  Follow-up

20. Conclusions Many patients with NCDs consume alcohol Alcohol is a risk factor for complications Alcohol screening with AUDIT and other tests is quick, easy and accurate with most patients Brief interventions produce significant reductions in at-risk drinking, especially with motivated patients Patients with NCDs should be screened for alcohol use regularly, and all medical staff should become proficient in SBIRT