Alcohol Screening & Interventions

Steve BrinksmanSMMGP Clinical Lead

The scale of the problem

Alcohol consumption in the UK: 1900 - 2000Per capita consumption (100% alcohol)

Source: British Beer and Pub Association 2000

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 3rd biggest risk factor for illness and death

Alcohol accounts for 7% of all hospital admissions

What is the result?

Alcohol interventions in Primary Care 5

Liver disease

600

500

400

300

200

100

0

Valu

e

19

70

19

72

19

74

19

76

19

78

19

80

19

82

19

84

19

86

19

88

19

90

19

92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

Year

CirculatoryIschaemic heartBrainCancerRespiratoryLiverEndocrineDiabetesBlood

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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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

–0.5 2 4 6 8

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)

Chronic health conditions and alcohol

9Alcohol interventions in Primary Care

The numbers

FACTS FIGURES

LAs 152

Inc + High % 22

Dep % 3.8

Practices 8,261

GPs 33,364

  ENGLAND LAs PRACTICE GP

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

10Alcohol interventions in Primary Care

13 Alcohol interventions

in Primary Care

Working with alcohol users in primary care

http://en.wikipedia.org/wiki/Reg_Smythe. Accessed November 2014.

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

I.B.A.

Working with non-dependent alcohol misusers

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

Screening tools in primary care

AUDIT alcohol use disorder identification test

FAST fast alcohol screening test

AUDIT-C AUDIT alcohol consumption questions

AUDIT-PC AUDIT primary care

M-SASQ modified single alcohol screening question

AUDIT – gold standard

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Developed by the WHO10 questionsIdentifies drinkers as lower, increasing or higher risk or potentially dependenthas 92% sensitivity and 94%specificity using the ≥8/40 threshold

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AUDIT Score

Score Category0-7 Lower Risk8-15 Increasing Risk16-19 Higher Risk20+ Possible Dependence

Alcohol interventions in Primary Care

AUDIT - C

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Alcohol 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%.

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)

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 contraception

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.

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

Alcohol brief advice

Content:-Understanding unitsUnderstanding risk levelsKnowing where they sit on the risk scaleBenefits of cutting downTips for cutting down

23Alcohol interventions in Primary Care

• 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 byvolume or ABV) = number of units

Understanding units

Brief Interventions – FRAMES

A structure of Brief InterventionsFeedback (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.

Who is Brief Intervention for?

AUDIT score Definition Intervention

0 - 7 Lower risk drinking Positive reinforcement

8 - 15 Hazardous drinking Brief Intervention Level 1

16 - 19 Harmful drinking Brief Intervention Level 2

20+ Probable dependence

Further Assessment for Detoxification

Level 1 – The hazardous drinker

Brief Structured advice• Feedback• Consequences of drinking• Action plan• Leaflet and/or short conversation• 10 minutes or less

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

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

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.

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

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

Level 1 vs. Level 2

Level 1 Level 2

Hazardous drinking Harmful drinking

Brief structured advise, often in a single consultation up to 10 minutes

Up to 45 minutes structured intervention in multiple consultations

Goal setting Goal setting over time

Further examination Physical examination and investigations

Likely single practitioner contact

Multi-disciplinary

Limited follow-up Structured follow up; drink diary and detailed assessment

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)

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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)

 

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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

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SIPS findings

PC findings published (Kaner, BMJ 2013)A&E and Criminal Justice studies currently ‘in publication’

Brief findingsDelivering alcohol brief advice does work in EnglandIt is possible to implement in ‘real life’ settings It can be delivered by front line staffStaff can have confidence that it is effective and worthwhileTargeted 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

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SMMGP / RCGP – SIPS Response

Alcohol screening, followed by simple feedback, supported by written alcohol information is an accessible and easy way to make a differenceBUT – 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 informationLonger 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

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e – Learning courses

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SMMGP Freelearn: Community Management of Alcohol Use Disorders