1. Alcohol Screening & Interventions Steve Brinksman SMMGP Clinical Lead

2. The scale of the problem

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

4. 9 Million Adults drink at levels that increase the risk of harm to their health. 1.6 Million adults have some level of alcohol dependency Alcohol is 3 rd biggest risk factor for illness and death Alcohol accounts for 7% of all hospital admissions What is the result?

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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 The relentless rise of liver deaths in the UK! British Liver Trust analysis of Office for National Statistics mortality statistics covering all deaths related to liver dysfunction, January 2009

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8. Alcohol consumption is the third highest risk factor for ill- health, after high blood pressure and tobacco 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)

9. Chronic health conditions and alcohol 9Alcohol interventions in Primary Care

10. 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 10 Alcohol interventions in Primary Care 13 Alcohol interventions in Primary Care

11. Working with alcohol users in primary care http://en.wikipedia.org/wiki/Reg_Smythe. Accessed November 2014.

12. 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, etc 12Alcohol interventions in Primary Care

13. I.B.A. Working with non- dependent alcohol misusers Alcohol interventions in Primary Care 13

14. Requirements of screening tools Ease of use Brevity Accuracy for the clinician Comfort for the patient Effective at case finding Easy to interpret

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

16. AUDIT – gold standard 16Alcohol interventions in Primary Care Developed by the WHO 10 questions Identifies drinkers as lower, increasing or higher risk or potentially dependent has 92% sensitivity and 94%specificity using the ≥8/40 threshold

17. 17 AUDIT Score ScoreCategory 0-7Lower Risk 8-15Increasing Risk 16-19Higher Risk 20+Possible Dependence Alcohol interventions in Primary Care

18. AUDIT - C 18 Alcohol interventions in Primary CareAlcohol interventions in Primary Care The AUDIT-C is a shortened version of the 10 question full AUDIT, using the first 3 questions only. Using a cut-off ≥4, Audit-C has a sensitivity of 86% to patients drinking above lower risk with a specificity of 72%.

19. SASQ - Single Alcohol Screening Question “When was the last time you had more than X drinks in 1 day?” (X = 6 units for women and 8 units for men, in the past month is a positive result)

20. When to screen - targeting 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 contracep tion

21. What is a brief intervention? There is no standard definition of a brief intervention Brief interventions can range from a short conversation with a doctor, nurse or other health professional to a number of sessions of motivational interviewing Levels of intervention relate to alcohol related harm Level 1 – for the hazardous drinker – identification and brief advice Level 2 – for the harmful/dependent drinker – care-planned prescribing/referral on For the Harmful drinkers a more in depth motivational intervention can be added.

22. When is a brief intervention a brief intervention? Primary goal of brief interventions are to help the patient understand What consequences likely to be What they can do about it What help is available

23. 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 23Alcohol interventions in Primary Care

24. One unit is equivalent to 10ml or 8g of pure alcohol Can use “standard” drinks but wide variation in concentration and amount of standard drinks A formula that can be used: Volume (L) X concentration (% alcohol by volume or ABV) = number of units Understanding units

25. Brief Interventions – FRAMES 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.

26. Who is Brief Intervention for? AUDIT scoreDefinitionIntervention 0 - 7Lower risk drinkingPositive reinforcement 8 - 15Hazardous drinkingBrief Intervention Level 1 16 - 19Harmful drinkingBrief Intervention Level 2 20+Probable dependenceFurther Assessment for Detoxification

27. Level 1 – The hazardous drinker Brief Structured advice Feedback Consequences of drinking Action plan Leaflet and/or short conversation 10 minutes or less

28. How to advise patients to “cut down” Realistic goal setting Set a date to cut down Set daily limit Establish drink diaries Cut out most potent alcoholic beverage Alternate alcohol with non-alcoholic drinks Reduce daily drinks Aim for two alcohol free days per week Leaflets to support verbal advice

29. Thinking about Drinking Drink Diary or Drinks Meter A useful tool An easy way of obtaining a picture of someone's drinking Offers self-reflection and assessment of drinking behaviour

30. Level 1 intervention – Summary Give feedback Provide information Establish a goal Confirm start date Empathy Non-judgmental Authoritative Deflect denial Facilitate Follow-up Patient education brochure Alcohol screening and brief intervention: dissemination strategies for medical practice and public health. Babor TF, Higgins- Biddle JC. Addiction. 2000 May;95(5):677-86. Review.

31. Level 2 – the harmful drinker Extended brief intervention consisting of structured motivation enhancing intervention as opposed to just screening and brief advice:  Careful history  Clinical examination – looking to identify drink related complications or harm  Laboratory testing  Over minimum of two sessions

32. Level 2 interventions – how are these different? Longer than Level 1 (30 – 45 min) Multi-disciplinary Detailed alcohol history taking Physical examination Laboratory testing Regular comparative drink diaries Identify and dealing with triggers

33. Level 1 vs. Level 2 Level 1Level 2 Hazardous drinkingHarmful drinking Brief structured advise, often in a single consultation up to 10 minutes Up to 45 minutes structured intervention in multiple consultations Goal settingGoal setting over time Further examinationPhysical examination and investigations Likely single practitioner contactMulti-disciplinary Limited follow-upStructured follow up; drink diary and detailed assessment

34. 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) 34Alcohol interventions in Primary Care

35. 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)  35Alcohol interventions in Primary Care

36. Is 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 36Alcohol interventions in Primary Care

37. 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 37Alcohol interventions in Primary Care

38. SMMGP / RCGP – SIPS Response 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, encourage areas to consider universal screening in primary care 38Alcohol interventions in Primary Care

39. e – Learning courses Alcohol interventions in Primary Care 39 SMMGP Freelearn: Community Management of Alcohol Use Disorders