1.  Alcohol - a Primary Care Perspective  Steve Brinksman  Clinical Director (SMMGP) - Substance Misuse Management in General Practice  www.SMMGP.org.uk

2. The scale of the problem Why primary care needs to be involved

3. Alcohol consumption in the UK: 1900 - 2000 Per capita consumption (100% alcohol) Source: British Beer and Pub Association 2000

4. Alcohol related admissions in 2008 Hospital admissions can be seen as indicator of severity of local alcohol problem Drinking patterns vary across England North-South divide © CHKS 2008

5. Costs (per annum) Health £1.7bn: 95 million specialist alcohol services 40% of all A&E admissions (70% on Saturday nights), 150,000 hospital admissions, 30,000 hospital admissions for alcohol dependency 22,000 premature deaths; 1000 suicides Crime £7.3bn: 1.2m alcohol-related violent crimes, 360,000 alcohol-related incidents of DV, 80, 000 arrests for drunk and disorderly behaviour Two-thirds of prisoners have alcohol problems Workplace £6.4bn, 17m working days lost Family and social 20,000 street drinkers Up to 1.3m children affected by alcohol misuse

6. Liver disease 600 500 400 300 200 100 0 Value 1970 197219741976197819801982198419861988199019921994199619982000200220042006 Year Circulatory Ischaemic heart Brain Cancer Respiratory Liver Endocrine Diabetes Blood Death rates for people under age 65 from major diseases compared with 1970 – UK Sheron et al. 2x increase in consumption  5x increase in death rates British Liver Trust analysis of Office for National Statistics mortality statistics covering all deaths related to liver dysfunction, January 2009

7. EMA treatment guidelines (WHO International guide for monitoring alcohol consumption and related harm. © WHO, 2000 1 UK unit = 8g alcohol According to this definition, ‘high-risk’ drinking equates to just 7.5 units per day (e.g. ¾ of an average 750ml bottle of 13% wine or just 3 pints of 4.4% beer) for men and 5 units per day for women.

8. Typology (general population) 1) McManus S et al. NHS Information Centre 2009 Severely dependent drinkers (0.1%) Moderately dependent drinkers (0.4%) Harmful drinkers (3.8%) Hazardous drinkers (20.4%) Low-risk drinkers (55.9%) Non-drinkers (14.0%) Mildly dependent drinkers (5.4%) Total Alcohol Dependence = 5.9%

9. Hazardous use of alcohol: 1 24% population 33% males 16% females Alcohol Dependent 5.9% 2 (1.6 milllion 3 ) 3.3% F; 8.7% M Alcohol Dependent 5.9% 2 (1.6 milllion 3 ) 3.3% F; 8.7% M Severe AD 0.1% 2 Severe AD 0.1% 2  The latest 2012 estimate is that alcohol misuse costs the NHS in England £3.5bn each year 3 1) Clinical Guideline 115 Alcohol Use Disorders. National Institute of Health and Clinical Excellence 2011 2) McManus S et al. NHS Information Centre 2009 3) National Treatment Agency for Substance Misuse, 2012

10. 1) Lim S et al. Lancet. 2013; 380(9859): 2224-60. 2) World Health Organization (WHO). Global Status Report on Alcohol & Health, 2011 Disability-adjusted life-years (%) High blood pressure –0.52468 Tobacco smoking, including second-hand smoking Alcohol use Household air pollution from solid fuels Diet low in fruits High body-mass index High fasting plasma glucose Childhood underweight Ambient particulate matter pollution Physical inactivity and low physical activity 0 Burden of disease in 2010 by risk factor (male and female)

11. % of all deaths by age group Number of deaths 2,500 2,000 1,500 1,000 500 0 30 25 20% 15 10 5 0 16–2425–3435–4445–5455–6465–7475+ Age group Male deaths from alcohol in the UK by age band (2005) 1  In England in 2010, 15,500 deaths were estimated to be attributable to alcohol consumption 2 Wholly attributable conditions Partially attributable acute conditions Partially attributable chronic conditions % of all deaths by age group Alcohol – a common reason for death in men under 50 1. Jones et al 2012: http://www.nwph.net/nwpho/publications/alcoholattributablefractions.pdf 2. National Treatment Agency for Substance Misuse, 2012

12. White et al. BMJ 2002;325(7357):191 01020304050607080 Alcohol (units/week) 01020304050607080 Alcohol (units/week) 01020304050607080 Alcohol (units/week) 01020304050607080 Alcohol (units/week) 01020304050607080 Alcohol (units/week) 5.0 4.0 3.0 2.0 1.0 0.0 Relative risk 5.0 4.0 3.0 2.0 1.0 0.0 Relative risk 5.0 4.0 3.0 2.0 1.0 0.0 Relative risk Lip, pharynx, and oral cancerOesophageal cancer Colon cancer Rectal cancer Ischaemic heart disease Liver cancerLaryngeal cancer Breast cancer Essential hypertensionInjuries Ischaemic strokeHaemorrhagic strokeCirrhosisNon-cirrhotic chronic liver diseaseChronic pancreatitis WomenMen Men and women

13. Screening is a method of identifying alcohol consumption at a level sufficiently high to cause concern. Brief Interventions are to help the patient understand What consequences likely to be What they can do about it What help is available Screening and Brief Interventions

14. AUDITalcohol use disorder identification test FASTfast alcohol screening test AUDIT-CAUDIT alcohol consumption questions AUDIT-PCAUDIT primary care M-SASQmodified single alcohol screening question

15. Developed by the WHO specifically for use in primary care Validated in more than 22 countries Sensitivity and specificity are high for criteria that define current hazardous use Seen as gold standard in screening tools Takes five minutes to complete, one minute to score Sensitivity 92% and specificity 94% to identify increased, higher risk and possible dependent drinking Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Addiction. 1993 Jun;88(6):791-804.

16. AUDIT score of 8 - 15 = Hazardous drinking or increasing risk AUDIT score of 16 - 19 = Harmful drinking or higher risk 10% of the population often binge drinkers At risk of suffering problems with the four Ls: Liver, Lover, Livelihood, Law AUDIT 20 + = severe problems Approximately 6% of the population Includes alcohol dependency syndrome AUDIT scores

17. Patients unlikely to object to alcohol questions… as part of a routine examination such as ◦ New patient check ◦ Chronic disease management e.g. diabetes/CHD/hypertension/depression ◦ Medication reviews opportunistically, e.g. ◦ Before prescribing a medication that interacts with alcohol ◦ In response to a direct request for help ◦ Recent attendance at A&E ◦ Request for emergency contraception

18. A structure of Brief Interventions Feedback (personalised) Responsibility (with patient) Advice (clear, practical) Menu (variety of options) Empathy (warm, reflective) Self-efficacy (boosts confidence) Bien, T. H., Miller, W. R. and Tonigan, J. (1993) Brief interventions for alcohol problems: a review. Addiction 88, 315–336.

19. 1 in 8 individuals drinking at hazardous and harmful levels act on their doctors advice and moderate their drinking to low risk levels. This compares to 1 in 20 individuals offered smoking advice, increasing to 1 in 10 when nicotine replacements are offered as well. Alcohol: No Ordinary Commodity - Research and Public Policy (Babor et al 2003)

20. Trial for Early Alcohol Treatment large-scale clinical trial conducted in primary care practices involved two brief face-to-face sessions scheduled 1 month apart, with a follow-up telephone call 2 weeks after each session. reduced alcohol use fewer days of hospitalization and fewer emergency department visits compared with control-group patients. found to be effective up to 4 years later

21. Lifetime risk of death due to alcohol-related injury Rehm et al. Addiction 2011;106(Suppl 1):11–19 Men Women 020406080100 Alcohol consumption (g/day) 18 12 4 0 Risk of death (%) 16 8 10 2 14 6 Reductions in high consumers  big health benefits

22. Improvements in: –Blood pressure 1 –Depression 2 Lowers lifetime risk of developing: 3,4 –Cancer –Cardiovascular disease –Diabetes –Epilepsy –Stroke –Liver Disease Rapid remission of depression in patients with alcohol dependence 2 N=191 1) Xin X et al. Hypertension 2001; 38 (5): 1112–1117 2) Brown SA & Schuckit MA. J Stud Alcohol 1988; 49 (5): 412–417 3) Gastfriend DR et al.. J Subst Abuse Treat 2007; 33 (1): 71–80 4) Rehm J et al. Addiction 2011; 106 (suppl 1): 11-19 Brown & Schuckit 1988

23. Patients should be referred to specialist services who: Have a high level of alcohol dependence ( see later) Have a high level of alcohol-related harm, with poor physical and mental health and social situation Are harmful drinkers who have not benefited from brief counselling and wish to receive further help for their alcohol problems.

24. ICD-10 classification of alcohol dependence 1 A diagnosis of alcohol dependence should be made when any three or more of the following criteria have been present simultaneously during the past year WHO. ICD-10, F10–F19 Cognitive/Behavioural 1 A strong desire or compulsion to take alcohol 2 Difficulties in controlling the use of alcohol Consequences 3 Neglect of alternative interests due to alcohol use 4 Persisting alcohol use despite evidence of harm Physiological 5 Tolerance to the effects of alcohol 6 Withdrawal symptoms

25.  Only 6% of people with alcohol dependence receive treatment each year 1  In 2009, under 10% of drinkers had discussed their alcohol consumption with a healthcare professional 2  Treating additional dependent drinkers will save significant amounts of NHS expenditure Alcohol dependence is significantly under-diagnosed and under-treated in the UK 1)Alcohol Concern 2010, NHS 2)The Health and Social Care Information Centre 2011

26. Assessment (AUDIT> 35) Need for medically assisted withdrawal and assessment of co-morbidity Motivation to change Preparatory investigations Case management approach/shared care

27.  Healthcare professionals can use quick and simple, validated tools that are recommended by NICE to help identify patients that may benefit from reduction 1  Psychosocial support is the backbone of an effective management strategy for alcohol dependence. Brief interventions and counselling are effective tools for primary healthcare professionals to help people to achieve their goals 2  Overwhelming evidence suggests that through appropriate treatment, people with alcohol misuse problems can change their behaviour 2,3 Management of alcohol dependence can be implemented in primary and secondary care 1) Clinical Guideline 115. Alcohol-use disorders. National Institute for Health and Clinical Excellence February 2011 2) British Liver Trust. 2011 3) Dawson DA et al. Addiction 2005; 100 (3): 281–292

28. Whinge Drinkers