Introduction to SIPS Professor Colin Drummond Institute of Psychiatry King’s College London

Topics What do we already know about screening and brief interventions? What research questions will SIPS address? What is SIPS and how did it come about? What will come out of SIPS over the next year?

What do we already know?

Source: Anderson & Baumberg, 2006

Alcohol: It’s a drug Jim, but not as we know it.

Alcohol is a toxic and dependence producing DRUG Acute effects –Highly variable –Pleasure, relaxation –Impaired judgement, coordination, balance –Mood effects –Argumentativeness and aggression –Drowsiness –Impaired consciousness –Coma, respiratory depression and death. Chronic effects –Toxic effects on organs –Over 60 diseases –Psychiatric disorders –Foetal alcohol effects –Psychoactive effects: alcohol dependence –3 rd leading cause of disability after tobacco and hypertension –No universally “safe” level

Alcohol use disorders: prevalence Drummond et al., % of the adult population have an alcohol use disorder (AUD) Includes 38% of men & 16% of women aged % of the adult population are hazardous or harmful alcohol users (7.1 million people in England) 21% of men and 9% of women engage in binge drinking Prevalence of alcohol dependence is 3.6% overall, 6% among men, and 2% among women (1.1 million people in England) Alcohol Needs Assessment Research Project, 2005 Alcohol dependence is considerably more prevalent than drug abuse

Chronic liver disease and cirrhosis mortality rates per 100,000 population,

National A&E study Drummond et al., 2003 Funded by Strategy Unit/Dept of Health Maximum burden of alcohol on A&E departments Regional variations 36 randomly selected A&Es in England (18%) stratified by region and urban/rural 116 researchers, 25 regional coordinators All A&E attenders > 18 years between 0900 and 0859hr Saturday/Sunday

National A&E study Predictors of ETOH+ –Young, white, males, single/divorced, unemployed, living with parents or NFA, frequent attenders (1.6x) –More often brought by police/ambulance Reasons for attendance –Violent assaults involving weapons, RTA, psychiatric emergency, DSH –Weapons: fists, knives, shoes, glasses –Locations: clubs, pubs, public transport Correlations with general population data Fridays and Saturdays: Estimated 1,000,000 alcohol related A&E attendances per annum

Screening and referral to an alcohol health worker in AED (Crawford et al., 2004, Barratt et al., 2005) Pragmatic RCT comparing leaflet with referral to Alcohol Health Worker Screening using Paddington Alcohol Test 599 randomised AHW group less drinking than leaflet Fewer AED attendances (mean 0.5) AHW more cost effective

SBI in primary care Prevalence ~20-30% Frequent attenders Screening & health promotion role Early detection & intervention Effect of alcohol intervention on health outcomes 5-30 min of targeted advice

Evidence-Base for SBI Freemantle trials in primary care –24% drop in consumption (95% CI 18 to 31%) Moyer 2002 – 56 trials, 34 relevant to PHC –Consistent positive effect, NNT 8-12 (smoking=20) –Cost savings found at 4 years in the USA Kaner 2007 – 29 trials in PHC & A&E –Consistent positive effects ~7 drinks less/week –Evidence strongest for men, less work on women –No significant benefit of longer versus shorter BI

What is known already about SBI? A&E: SBI is effective and cost effective in academic centres (e.g. St Mary’s Model) Primary Health Care: SBI is effective and some evidence of cost effectiveness across range of international settings General Hospital: SBI less effective General lack of research in UK In all cases SBI effective for opportunistic intervention in non-treatment seeking populations. Less effective for treatment seeking/alcohol dependent patients

What is not known about SBI? A&E: can it be effectively implemented outside academic centres in UK? PHC: is it cost effective and can it be implemented in “typical” PHC setting? CJS: is it feasible to implement SBI, and is it effective? All settings: –What are the best screening tools (short vs longer) and method (universal vs targeted)? –Is extended BI better than 5 min advice? –What are the barriers/facilitators for implementation in the “typical” setting? –Effectiveness in females, young, BME

Alcohol Screening and Brief Intervention Research Programme SIPS A&E St. Mary’s 'Scientia Vincit Timorem'

Programme design Funded by Department of Health for 3 years Jointly led by IOP & Newcastle University 3 cluster randomised clinical trials of alcohol screening and brief intervention (PHC, AED, CJS) to assess: –What are the barriers/facilitators to implementation in a “typical setting”? –What is the most effective screening method? –What is the most effective and cost effective intervention approach? Total target of 2,403 subjects, completed 2,600 July and 12 months follow up, currently 6 months (mainly phone)

21 SIPS Research Project Group King’s College London Prof C Drummond (CI) Dr J Myles PI Dr P Deluca PI Mr T Phillips PI Ms K Perryman PI Dr M Cochrane Ms D Jeffery Dr M Hobbs Ms R Cappello Mr S Keating Ms L James Ms L Rail Ms J Reid Ms R Lee Mr S Gordon Ms L Floodgate Mr D Kerr Mr H Mosaheb Ms C Elzerbi St George’s Dr A Oyefeso PI York Prof S Coulton PI (now Kent Univ) Prof C Godfrey PI Mr S Parrott PI Prof M Bland PI Newcastle Prof E Kaner (DCI) Prof C Day PI Dr E Gilvarry PI Dr P Cassidy PI Dr D Newbury-Birch PI Prof Nick Heather PI Ms K Jackson Ms N Brown Ms M Clifford Ms E Phinn Ms C Shaw Ms R McGovern Ms A Hindhaugh Ms G Hawdon Ms D Carpenter Mr G Scott Ms J Armstrong Ms D MacDonald Imperial College and St Mary’s Hospital Dr M Crawford PI Prof R Touquet PI Alcohol Concern Mr D Shenker PI Primary Care Research Network Mental Health Research Network

22 1 AED 2/3 PHC 2/3 CJS 1 AED 2/3 PHC 2/3 CJS 1 AED 2/3 PHC 2/3 CJS 1 AED 2/3 PHC 2/3 CJS 1 AED 2/3 PHC 2/3 CJS 1 AED 2/3 PHC 2/3 CJS 1 AED 2/3 PHC 2/3 CJS 1 AED 2/3 PHC 2/3 CJS 1 AED 2/3 PHC 2/3 CJS 9 Clusters Newcastle General Darlington Memorial Hexham South Tyneside Winchester King’s CollegeSt Thomas’sCentral MiddlesexNorth Middlesex

How will we assess effectiveness? Effectiveness of implementation –Extent of screening and intervention activity –Attitudes to SBI implementation Patient outcome measures –Alcohol consumption (extended AUDIT-C) –Alcohol related problems –Health related quality of life –Health related and wider societal costs

Website 24

Training and intervention tools 25

Presentations Accident and Emergency study: Dr Paolo Deluca Primary care study: Prof Eileen Kaner Criminal justice study: Dr Dorothy Newbury-Birch Early findings on screening: Prof Simon Coulton Discussant: Dr Peter Anderson