IMPLEMENTING SCREENING AND BRIEF ALCOHOL INTERVENTION IN PILOT GP PRACTICES IN THE TYNE AND WEAR HEALTH ACTION ZONE

1
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
• 1ST SESSION (Background)

2
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)
3
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

4
Varieties of alcohol-related harmchronic

• 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

5
Other alcohol-related harms

• Lower workplace productivity
• Unemployment
• To family social networks
• Truancy school exclusion
• Homelessness
• Economic costs

6
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 (lt 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

7
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.

8
How the English adult population drinks
9
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 GPs 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 3rd 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

10
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.

11
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 1st item)
• SASQ (1 item)

12
(No Transcript)
13
   
Drinker typology based on AUDIT scores
Possible Dependence 20-40
Diagnose refer to specialist service
Brief counselling/follow-up
Simple structured advice
Positive reinforcement
? No action indicated
14
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.

15
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

16
The Fast Alcohol Screening Test (FAST)
17
SASQ

• Stands for Single Alcohol Screening Question
• When was the last time you had more than X
  drinks in 1 day, where X4 for women and X5 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

18
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)

19
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 10-20 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

20
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

21
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

22
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

23

• 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

24
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 10-16 years in a
  Swedish study, though an Australian study did not
  find an effect after 10 years

25
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