1. Warwickshire’s BIG Conversation about Alcohol  Alcohol A Primary Care Perspective  Steve Brinksman  Clinical Director Substance Misuse Management in General Practice  www.SMMGP.org.uk

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. 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. 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%

7. Alcohol Use Disorders in England 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  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

8. Alcohol consumption is the third highest risk factor for ill-health 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. Liver disease 600 500 400 300 200 100 0 Value 1970 197219741976197819801982198419861988199019921994199619982000200220042006 Year Circulatory Ischaemic heart Brain Cancer Respiratory Liver Endocrine Diabetes Blood 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

10. Dependency Stroke, Brain damage, dementia Depression Bleeding Varices High Blood Pressure Gastritis, Stomach Cancer Malabsorption Peripheral Neuropathy Mouth and oesophageal cancer Heart Arrhythmias, cardiomyopathy Liver Cirrhosis and Cancer Impotence & Infertility Breast Cancer Osteoporosis Physical Health Problems

11. Mixed Messages Alcohol is good for your health: Leading science writer claims tipple can prevent cancer and may help improve your sex life While medical advice says to avoid alcohol, medical science says it could actually be good for you

12. Relative risk of comorbid disease by alcohol consumption 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. But isn’t it good for the heart? Ischaemic heart disease Alcohol (units/week) 10 0 10 20 30 40 50 60 70 80 0.0 1.0 2.0 5.0 4.0 3.0 Relative Risk

14. Alcohol and accidents Alcohol is implicated in many accidents due to impairment of psychomotor and cognitive function Proportion of admissions to A&E by type of admission where BAC is over 80mg/100ml: Assaults50% Road traffic accidents8% Accidents in the home6% Accidents at work4% Road traffic accidents in England and Wales estimated as attributed to alcohol in 2007: Fatal460 Serious injury1760 Total attributable to alcohol14,480 Proportion of home accidents estimated to be attributable to alcohol = 10% Death from drownings estimated as attributable to alcohol = 13% References: Institute of Alcohol Studies (2009). Alcohol and accidents; IAS factsheet and Babor T et al (2003). Alcohol: no ordinary commodity; research and public policy. Oxford:Oxford University Press.

15. Alcohol is a depressant drug Much higher incidence of depression and anxiety in regular drinkers High rates of alcohol dependency amongst those with severe mental health problems 50% rough sleepers are alcohol dependent As many as 65% of suicides have been linked to excessive drinking Association with self harm in young men in up to 50% of cases Alcohol and Mental Health

16. Get the rounds in: Study officially proves that going out for a pint with pals is good for men's mental health

18. Isn’t it only tramps and young people?

19. Drinking and social class

21. Reducing unhealthy alcohol consumption can bring significant public health and social benefits Patients receiving intervention to achieve moderate drinking experienced: 1 –80% less sick leave –60% fewer hospital days –50% less mortality Number of hospital days in men during 5 years after screening 1 Total 2200 1800 1400 1000 600 200 Mental disorders Gastro- intestinal diseases Accidents Alcohol- related diseases Days hospitalised Controls (n=219; 91 hospitalised) Intervened (n=195; 68 hospitalised) 1) Kristenson H et al. Alcohol Clin Exp Res 1983; 7 (2): 203–209 Kristenson H et al. 1983 reproduced with permission

22. Reduced alcohol consumption correlates with: Fewer work problems 1 Fewer legal and financial issues 1 Improved quality of life 2 Less social harm* 3 Risk of at least one social harm* by yearly alcohol consumption 3 70 60 50 40 30 20 10 2468 121416 Experienced at least one harm (%) Yearly consumption of pure alcohol (litres) 0 0 UK Men *Social harm = fighting, harming home life, marriage, work, studies, friendships or social life 1)Gual A et al. Alcohol & Alcoholism 1999; 34 (2): 183-192 2) Pettinati HM et al. Alcohol Clin Exp Res 2009; 33 (2): 350–356 3) Anderson P & Baumberg B. Institute of Alcohol Studies, London 2006 Anderson P & Baumberg B. 2006 Reducing unhealthy alcohol consumption can bring significant public health and social benefits

23. Reducing unhealthy alcohol consumption reduces health harms 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

24. Lifetime risk of death due to alcohol-related injury Potential benefits of reduction on mortality 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

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 Use Disorder 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. The Role of Primary Care Not a core part of GP contract CCGS and Public Health should work together to ensure: Increase uptake of validated alcohol screening in Primary Care Delivery of Brief Interventions Access to Psychosocial Support Develop cohort more experienced GPs to support community detoxification Improve links to after care and Mutual Aid

27. 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

28. 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

29. AUDIT 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.

30. AUDIT score of 8 - 15 = Hazardous drinking or increasing risk AUDIT score of 16 - 19 = Harmful drinking or higher risk Up to 10% of the population 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

31. 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

32. Drink diary A useful tool An easy way of obtaining a picture of someone's drinking Offers self-reflection and assessment of drinking behaviour

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

34. 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

35. Effect of a brief intervention 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)

36. Project TrEAT, 2002 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

37. When to refer to specialist services? 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.

38. Diagnosis of alcohol dependence 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 1 A strong desire or compulsion to take alcohol 2 Difficulties in controlling the use of alcohol 3 Neglect of alternative interests due to alcohol use 4 Persisting alcohol use despite evidence of harm 5 Tolerance to the effects of alcohol 6 Withdrawal symptoms

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

40.  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 Use Disorder 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

41. Whinge Drinkers