© Bob Patton 2009 Alcohol Identification & Brief Advice in the Emergency Department Bob Patton Research Facilitator / Visiting Lecturer South London & Maudsley NHS Trust / Institute of Psychiatry

© Bob Patton 2009 The Nation’s favourite drug

© Bob Patton 2009 How big is the problem? 10 million people in the UK consume up to DOUBLE the recommended weekly units. 2 Million of those do it in a SINGLE session. Impacts on NHS, Criminal Justice System and UK industry.

© Bob Patton 2009 Take a closer look… Alcohol is involved in: 4 25% of hospital admissions 65% of suicide attempts 32,000 deaths 14 million work days lost 1.2 million crimes alcohol related 7% of all RTAs and 50% of fatalities

© Bob Patton 2009 And the cost? Impacts on NHS: costs £3 billion Criminal Justice System: costs £10.0 billion UK industry: costs £7.0 billion Total cost: £20 billion

© Bob Patton 2009 Alcohol & the ED In 2005, Drummond and colleagues undertook a 24hour assessment of alcohol related attendances to EDs finding that alcohol places a very significant burden on emergency departments at peak times: » 41 per cent of all attendees were positive for alcohol consumption » 14 per cent were intoxicated » 43 per cent were identified as problematic users after screening. » Between midnight and 5am 70% of attendances were alcohol related

© Bob Patton 2009 Definitions of Hazardous Drinking: General A pattern of consumption that may have a negative impact on either physical or mental well-being. & Contextual Men consuming 8 or more units, and women who consume 6 or more units, on at least one occasion per week. Additionally, any person who states that their accident or injury is related to their alcohol consumption.

© Bob Patton 2009 So….what can we do? In general the early detection and treatment of alcohol misuse is desirable, as the treatment of established (i.e.. Dependant) misuse is difficult. n Controlled withdrawal n 12 step approach n Psychological therapy n Pharmacology n Societal change n Brief advice

© Bob Patton 2009 Identification 9 Although the recording of an alcohol history should form part of routine clinical practice, ambiguity regarding the level of consumption regarded as problematic may lead physicians to overlook potential alcohol problems. We know that using a specialist screening tool detects almost twice as many hazardous drinkers as staff relying upon their clinical intuition alone. AUDITFAST CAGESASQ PATAUDIT - C

© Bob Patton 2009 The AUDIT 10 The AUDIT was developed by the World Health Organization to identify persons whose alcohol consumption has become hazardous or harmful to their health. AUDIT is a 10-item screening questionnaire with 3 questions on the amount and frequency of drinking, 3 questions on alcohol dependence, and 4 on problems caused by alcohol. A score of 8+ is indicative of alcohol misuse.

© Bob Patton 2009 CAGE 11 C Have you ever thought you should CUT DOWN on your drinking? A Have you ever felt ANNOYED by others' criticism of your drinking? G Have you ever felt GUILTY about your drinking? E Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (EYE-OPENER)? The CAGE screening test is short and easy to administer. Two or more positive answers are usually interpreted as indicative of hazardous drinking.

© Bob Patton 2009 The FAST alcohol screening test

© Bob Patton 2009 AUDIT-C

© Bob Patton 2009 SASQ

© Bob Patton 2009 The Paddington Alcohol Test A brief instrument that measures quantity / frequency of consumption.

© Bob Patton 2009

Alcohol and the ED It’s busy. Up to 40% presentations related to alcohol consumption, rising to 70% on Saturday nights. It’s a teachable moment – highlighting the relationship between alcohol and attendance. It’s an ideal location to access a wide cross-section of the population. ED attendances account for 27% of the NHS alcohol bill

© Bob Patton 2009 Global or Targeted identification Should we ask everyone about their drinking? In primary care environments this may be possible during registration, but in the ED it is considered impractical. Certain presenting conditions are associated with hazardous alcohol consumption.

© Bob Patton 2009 The AED ‘Top 10’ 1. Fall 2. Collapse 3. Head Injury 4. Assault 5. Accident 6. Non-Specific G.I. 7. “Unwell” 8. Psychiatric 9. Cardiac 10. Repeat Attendee These account for up to 77% of all hazardous drinkers attending the ED

© Bob Patton 2009

So…. What next? Screening instruments can reliably identify hazardous drinkers – patients who may well benefit from further help or advice. Emergency departments are a useful place to identify people who may be hazardous drinkers. What can be done to reduce levels of alcohol consumption?

© Bob Patton Delivers short information and advice session where patient is given motivational interviewing / counselling and may be referred on to specialist agencies Assessment of alcohol consumption Provision of guidance / advice Single session Brief Advice & Alcohol Health Worker

© Bob Patton 2009 Brief Advice and PIL

© Bob Patton 2009 Alcohol IBA and the ED – what’s the evidence…

© Bob Patton 2009 Previous studies Wright et al (1998). 202 / 335 patients attended an AHW appointment, 35% contacted six-months later, 65% reported reduced alcohol consumption Hungerford et al (2000). 63% of hazardous drinkers exposed to a brief intervention reduced their alcohol consumption Both these studies were uncontrolled.

© Bob Patton 2009 Evidence from RCTs Gentilello et al (1999). BI reduced alcohol consumption. Most effective in those with mild to moderate alcohol problems. Longabaugh (2001). BI with a booster session significantly reduced alcohol related consequences. Smith et al (2003). Reduced alcohol consumption among 50% of young men attending a facial injuries clinic.

© Bob Patton 2009 Meta Analysis Recent paper by Havard et al (2008) examined 10 RCTs of SBI in the ED. The authors concluded that SBI was associated with a significant reduction in alcohol related injuries, but that findings on alcohol consumption were less conclusive…

© Bob Patton 2009

REDUCE project – 2001/2003 n AIM: Examine the effect of referral to an AHW on levels of alcohol consumption. n DESIGN: Single blind pragmatic RCT n METHOD: Patients screened in the ED. Hazardous drinkers allocated to experimental or control conditions. Follow-up at six and twelve months.

© Bob Patton 2009 DETECTION by Dr/Nr PATIENT Accepts Problem REFERRAL by Dr/Nr & Information PATIENT Desires Help Communication&Alcohol A.H.W. Gives Feedback COUNSELLING by A.H.W. PATIENT ChangesLifestyle THE PATIENT Attends A&E

© Bob Patton 2009 Experimental & Control treatments All participants were given a copy of the HEA booklet ‘Think about drink’. Participants in the Experimental Treatment (ET) were made an appointment with the AHW. Control Treatment (CT) participants did not receive this appointment.

© Bob Patton 2009 Study Measures Alcohol consumption Screening using the PAT occurred at baseline for all participants. At follow-up we employed the Form 90 AQ, Steady Pattern Grid and the PAT. Psychiatric Morbidity & Quality of Life An indication of psychiatric caseness was assessed at six months using the GHQ-12. At twelve months we used the EQ-5D to gauge quality of life. ED attendance Data extracted form routine hospital records

© Bob Patton 2009 Encouraging participation During the study we noticed that the way in which results of the screening test were presented to patients influenced the proportion that were willing to accept advice By emphasising a link between the results and potential problems later in life, we increased the uptake of advice by about 15%

© Bob Patton 2009 Our Sample 5240patients screened 1167were hazardous drinkers 763accepted advice 599 gave consent & were randomised: 287 Experimental condition 312 Control condition There was a 26% loss to follow-up at 12 months

© Bob Patton 2009 Results – Alcohol Consumption Six months after randomisation participants referred to the AHW had significantly lower levels of weekly alcohol consumption (59 vs. 83 units / week) than the control group.

© Bob Patton 2009 Other measures of alcohol consumption There were significant differences between groups at 6 and 12 months on daily alcohol consumption No significant differences were observed on the percentage of days abstinent

© Bob Patton 2009 Results – Other Measures ET participants were also less likely to re- attend the ED in the one year following their initial presentation than CT (1.2 visits vs. 1.7, p<0.05, NNT=2) However we detected no significant differences between the groups on GHQ- 12 or EQ-5D.

© Bob Patton 2009 Cost / Benefit Screening and referral to the AHW has a cost, but this should be offset against the savings gained by reducing attendance: For every 1000 patients screened, costs are approximately £2500 (including the cost of the AHW for those referred), and savings of £4000. Net: £1500 savings

© Bob Patton 2009 Limitations of the study This was a pragmatic trial – we were unable to collect comprehensive data at baseline, and so were unable to measure the change in our primary and secondary outcome measures All study participants received as self-help booklet; a “no treatment” control group was considered unethical Low numbers of our ET group actually attended the AHW session

© Bob Patton 2009 Who accepts advice? n Based on REDUCE data n Heavy drinkers (20+ units / session) n GI patients most likely to accept. n Fall, Head Injury & other accident patients less likely to accept advice Patton et al, EMJ, 2004

© Bob Patton 2009 Who attends appointments? n Based on REDUCE data n Older patients (50+) – 50% attend n Believed attendance to ED was alcohol related – 64% attend Patton et al, EMJ, 2005

© Bob Patton 2009 Teachable Moment To maximise attendance the delay between identification and intervention should be minimal, preferably on the same day. Patient selection of an appointment could offer a compromise Williams et al, DAD, 2005

© Bob Patton 2009 Availability of the AHW n When the AHW was in post 3 sessions / week approximately 1/3 of patients referred attended their appointment. n After increasing AHW availability to 5 sessions / week, ½ of all patients referred now attend their appointment.

© Bob Patton 2009 DH funded £3.2 million multi-centre RCT of SBI set in ED, GP and CJ settings Will examine leaflet, short (physician) and extended (AHW) interventions, and compare SASQ and PAT / FAST

© Bob Patton 2009 SIPS update n 2600 participants in 3 settings. n 24 GP practices, 9 EDs and 18 probation offices. n 6 Month follow-up. n Compares FAST, PAT & SASQ with leaflet, brief advice and lifestyle counselling.

© Bob Patton 2009 Beyond the ED… n Patients staff and visitors to one south London hospital completed an Audit-C. n 360 completed questionnaires. n 37% were hazardous drinkers. n 44% of staff identified as hazardous….

© Bob Patton 2009 State of the Nation n Recent survey of all English AEDs (99% RR) n 4 using formal screening tools (24 ask alcohol questions) n 32 departments have access to AHW / CNS n 131 departments formally record alcohol related attendances. Conclusion – departments show willing, BUT drinkers remain undetected. Patton et al, EMJ, 2007

© Bob Patton 2009 Screening n Is just asking questions the briefest of brief interventions? n Jim McCambridge and colleagues randomised 421 students into two groups. n Group A were screened at Baseline, and A & B at 6 month follow-up

© Bob Patton 2009 Screening – It works! n Findings indicated a significant reduction in AUDIT score for those in Group A. n Estimated reduction of 1 point on AUDIT score attributed to screening alone. n Implies that SBI more effective than previous thought.

© Bob Patton 2009 Screening – where? n Recent self completion questionnaire in ED waiting area n 1100 completed in 7 days n 54% Male, 29% Female Hazardous Drinkers Patton et al, EMJ, 2009

© Bob Patton 2009 Conclusions IBA in an ED is feasible and results in lower levels of alcohol consumption over the following 12 months. Reduced alcohol consumption is associated with lower levels of reattendance in the department. Reduced reattendance in the ED offsets the costs of screening and providing brief intervention.

© Bob Patton 2009 A final thought… Screening works! If you want to start to address hazardous drinking, asking patients questions about consumption is effective. Providing information, further assessment and onward referral increases effectiveness.

© Bob Patton 2009