IMPLEMENTING SCREENING AND BRIEF ALCOHOL INTERVENTION IN PILOT GP PRACTICES IN THE TYNE AND WEAR HEALTH ACTION ZONE Level 1 Training Screening and simple, structured advice 1 ST SESSION (Background)

What is a standard unit of alcohol? 1 Unit equals: 1 half pint of beer, lager or cider (3.5% abv) 1 pub measure (125ml) of wine (8% abv) 1 pub measure (50ml) of fortified wine (20% abv) 1 pub measure (25ml) of spirits (40% abv)

Varieties of alcohol-related harm: acute Homicide Suicide Other intentional injuries (i.e., interpersonal violence) Domestic violence Sexual assault Unprotected sex Motor vehicle accidents Other accidents Drowning Burns Public disorder

Varieties of alcohol-related harm: chronic Liver cirrhosis and other forms of alcohol- related liver disease Hypertension and haemorrhagic stroke Cancers of the mouth, larynx, pharynx and oesophagus Other cancers, including breast cancer Foetal Alcohol Syndrome (FAS) and foetal alcohol effects Mental illness Alcohol Dependence Syndrome

Other alcohol-related harms Lower workplace productivity Unemployment To family & social networks Truancy & school exclusion Homelessness Economic costs

Recommended limits Adult Women: regular consumption of no more than 2-3 units per day and no more than 14 units per week Adult Men: regular consumption of no more than 3-4 units per day and no more than 21 units per week Lower limits in younger people (< 18 years) 2 alcohol-free days after an episode of heavy drinking Consistent consumption at the upper limit is not recommended “Very heavy” drinking is defined as over 35 (women) or 50 (men) units/week

Terminology Low-risk drinking - below medically recommended limits Hazardous drinking - a pattern of consumption which increases the risk of harm (physical, psychological or social), i.e., drinking above recommended limits Harmful drinking - a pattern which is likely to have already led to harm (physical, psychological or social) or, for some purposes, drinking at “very heavy” levels Binge drinking – originally episodic heavy drinking but now heavy drinking in a single session, i.e., twice the daily limit, above 6 units for women 8 units for men Alcohol dependence – a cluster of physiological, behavioural and cognitive phenomena conforming to the “alcohol dependence syndrome”.

How the English adult population drinks

Prevalence In the English general population, 27% of adult (16+) males and 15% of adult females are hazardous drinkers or above 6% of adult males and 3% of adult females are “very heavy drinkers” In 2001, 21% of men and 9% of women reported “binge drinking” at least once in preceding week Usual figure for prevalence of hazardous and harmful drinkers in general practice population is 20% Average GP sees 364 hazardous/harmful drinkers per year; however most GP’s have only 7 patients registered for alcohol problems GPs may be missing as many as 98% of hazardous and harmful drinkers on their lists In terms of years lost to poor health and premature death, excessive alcohol consumption is the 3 rd most important risk factor after smoking and raised blood pressure It has recently been estimated that alcohol-related harm costs England £20 billion each year

Screening for hazardous and harmful drinking Screening is necessary to detect risky drinkers whose level of consumption may not be apparent Short questionnaires offer the most efficient means of screening Biochemical markers (GGT, MCV, CDT) can be used too but are relatively expensive, intrusive and not more accurate than questionnaires Screening can be either universal, in which all or nearly all patients attending the practice are screened, or targeted, in which only specific groups of patients on the list are screened If screening is targeted, it might be directed at patients who are unlikely to object to questions about their drinking (e.g. new patient registrations) or those thought to be at higher risk for excessive drinking (e.g. diabetes clinics, CHD clinics, Emergency contraception, Smear clinics; IHD clinics Patients who under-estimate their alcohol consumption can be assumed not to wish to receive advice about it and have a prefect right to hold this view.

Screening tools suitable for primary care Full AUDIT (10 items) AUDIT-C (3 items) FAST (1 item plus 3 further items depending on response to 1 st item) SASQ (1 item)

Harmful Hazardous 8-15 Low risk 1-7 Abstainers 0 Possible Dependence Diagnose & refer to specialist service Brief counselling/follow-up Simple structured advice Positive reinforcement ? No action indicated Drinker typology based on AUDIT scores

Shortened versions of AUDIT The full AUDIT tool has the best sensitivity and specificity (overall accuracy) but takes longer to complete In routine consultations a shortened version of AUDIT may be more feasible However, there is a trade-off between shortness of the screening tool and its accuracy Several practices in the Tyne & Wear HAZ Project used AUDIT-C and FAST and were satisfied with them.

AUDIT-C Stands for AUDIT-consumption questions Consists of first 3 items from the full AUDIT, q.v. Takes 1 minute to administer A score of 5+ is indicative of hazardous or harmful drinking Men: 78% sensitivity & 75% specificity Women: 50% sensitivity & 93% specificity AUDIT-C cannot by itself be used to determine which level of brief intervention is appropriate or if a referral for treatment is called for. In the event of a positive result on AUDIT-C, these decisions should be based on clinical judgement or administration of the full AUDIT

The Fast Alcohol Screening Test (FAST)

SASQ Stands for Single Alcohol Screening Question “When was the last time you had more than X drinks in 1 day”, where X=4 for women and X=5 for men Never/ More than 12 months ago/ 3-12 months ago/ Within the past 3 months “Within the past 3 months” = +ve response Sensitivity and specificity = 86% for detecting hazardous drinking in past 3 months or alcohol use disorder in past year Equally efficient among men and women Will be used in SBI Implementation Pilot Project funded by Department of Health but details of UK adaptation (i.e., values of X) have yet to be finalised

What is brief alcohol intervention? “… the giving of information, advice and encouragement to the patient to consider the positives and negatives of their drinking behaviour, plus support and help to the patient if they do decide they want to cut down on their drinking.” “Brief interventions are usually ‘opportunistic’ – that is, they are administered to patients who have not attended a consultation to discuss their drinking” (from the Alcohol Harm Reduction Strategy for England, p.37)

Features of brief interventions A family of interventions ranging from a few minutes simple but structured advice to 20 minutes counselling with repeat consultations We recommend 2 levels of brief intervention: (i) simple structured advice (simple brief intervention) taking 1-2 minutes to deliver (ii) brief counselling (or extended brief intervention) taking minutes to deliver and involving repeat consultations where necessary Brief interventions are delivered by generalists in community settings, e.g. GPs, practice nurses, health visitors, dieticians and other primary health care professionals in the normal course of their work But they can also be delivered by more specialist workers (CPNs, lifestyle counsellors, alcohol health workers) or NHS health trainers if one is employed by the practice Normally aimed at a goal of low-risk drinking (i.e., under medically-recommended levels) But patients who prefer to become abstinent should not be discouraged

What is the rationale for screening and brief intervention? Early intervention and secondary prevention, i.e., of medical and social harm but also more severe dependence Contribution to public health – broadening the base of interventions against alcohol-related harm Reduced use of health-care resources and cost-effectiveness

ADVANTAGES OF LOCATING SBI IN PRIMARY HEALTH CARE 78% of population visit GP at least once a year Stigma can be avoided Intervention possible at “teachable moments” Intervention in context of ongoing relationship with patient and family Advice from GPs, practice nurses and other PHC staff likely to be respected

Who are the targets for SBI ? Hazardous drinkers, including regular excessive drinkers and “binge drinkers” Harmful drinkers, including regular excessive drinkers and “binge drinkers” NOT “alcoholics”

Evidence on the effectiveness of brief interventions At least 56 controlled trials of effectiveness, the majority in primary health care At least 13 meta-analyses and/or systematic reviews, including 5 specifically focused on primary health care and reaching favourable conclusions on the effectiveness of brief interventions In the best meta-analysis so far (Moyer et al., 2002), small to medium aggregate effect sizes in favour of brief interventions emerged across different follow-up points At follow-up of 3-6 months or more, the effect for brief interventions compared to control conditions was significantly larger when individuals showing more severe alcohol problems were excluded from the analysis

Evidence on the effectiveness of brief interventions cont… Estimates of NNT range from 8 to 12 This compared favourably smoking cessation advice (NNT = 20) Some recent evidence of a reduction in mortality following SBI Also evidence of reductions in number of alcohol- related problems Effects of intervention still present after 4 years in one US study and after years in a Swedish study, though an Australian study did not find an effect after 10 years

Summary of main points Screening and brief intervention (SBI) for hazardous and harmful drinkers in PHC is effective in reducing alcohol-related harm SBI is highly cost-effective in terms of reducing future burden on NHS Screening should be targeted rather than universal It is suggested that practices should offer simple structured advice to all patients screening positive … and, if resources permit, brief counselling to patients who would benefit from it and are willing to accept it Patients with significant alcohol dependence should be offered or referred to more intensive intervention