Nuts and Bolts Management of Alcohol Problems in Primary Care

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Nuts and Bolts Management of Alcohol Problems in
Primary Care

• Dr Shahid Mohamed Dadabhoy, GP, Partner, Trainer
  and Tutor
• The Microfaculty, 107-109 Chingford Mount Road,
  Chingford, London E4 8LT
• shahid.dadabhoy_at_nhs.net

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How do I make all of this Alcohol stuff work in
the cold harsh unforgiving fluorescent light of a
NHS Primary Care Monday morning?
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A party political broadcast from the NHS Party
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Who are these two men?
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Outline

• Why manage alcohol problems in Primary Care at
  all?
• How should we be managing Alcohol problems in
  Primary Care?
• Identification and Brief Advice (IBA)
• The Alcohol Use Disorders Identification Test
  (AUDIT) and why we should use it?
• Putting it all together
• RCGP Certificate In the Management of Alcohol
  Problems in Primary Care

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Why manage alcohol problems in Primary Care at
all?
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The scale of the problem
More than 20 of adults registered with a GP will
drink in at least one of the following
ways Higher risk (Harmful)
gt 50 u/week men

gt 35 u/week women Increasing Risk (Hazardous)
22 49 u/week men
15
35 u/week women Binge
gt 8 units at once men
gt 6 units at once
women  
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Why? (1)

• Alcohol continues to have a harmful impact on
  many Individuals families and communities
• 26 (around 10 million) of adults in England
  drink more than the lower-risk guidelines
• 34 units of alcohol a day for men
• and
• 23 units of alcohol a day for women
• Estimated cost of alcohol related harm to the NHS
  in England is 2.7 billion per year.
• (Statistics on alcohol England 2009)
• 
  

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Why? (2)

• Between 15,000 and 22,000 premature deaths
  annually in England and Wales
• Nearly 5,000 (3.5) cancer deaths per annum are
  attributable to alcohol
• 1,200 associated deaths per year due to
  haemorrhagic stroke
• 10 of deaths due to hypertension
• Liver Cirrhosis is now the 5th most common cause
  of death and
• continues to rise

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Why? (3) Alcohol misuse in London

• London has a higher proportion of dependent
  drinkers than any other region in England
  
  (Local Alcohol Profiles for England)
• 
  
• 11 to 15 year olds in London now drink the
  equivalent of 180,000 bottles of lager a week
  
  (London Assembly June 09)
• 
  
• Hospital rate for 11 to 15 year young women
  almost double for young men of same age
• (Profile of young Londoners drinking,
  2009)

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The Why (4)- It Costs.

• Alcohol related ambulance call out
  188.00
• Alcohol related hospital admission
  716.00
• Alcohol related A/E attendance
  75.00
• Cost of Alcohol related Liver transplant
  80,000
• National Audit
  office 2008

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Why? (5) Rate of alcohol-related admissions per
100,000 population (EASR)
NI 39 VSC 26 NI 39 VSC 26 Rate of alcohol-related admissions per 100,000 population (EASR) Rate of alcohol-related admissions per 100,000 population (EASR) Rate of alcohol-related admissions per 100,000 population (EASR) Rate of alcohol-related admissions per 100,000 population (EASR) Rate of alcohol-related admissions per 100,000 population (EASR) Rate of alcohol-related admissions per 100,000 population (EASR)  
Waltham Forest and Neighbouring PCTs Waltham Forest and Neighbouring PCTs Waltham Forest and Neighbouring PCTs   2008/09 (provisional annual refresh) 2008/09 (provisional annual refresh) 2008/09 (provisional annual refresh) 2008/09 (provisional annual refresh)  
 PCT Q1 Q2 Q3 Q4 Total increase from 2007/08  
5NC Waltham Forest 398 421 416 410 1645 10  
5A4 Havering 324 358 359 358 1399 6  
5C2 Barking and Dagenham 457 467 463 452 1839 5  
5C5 Newham 441 481 502 536 1960 3  
5NA Redbridge 346 376 360 365 1448 7  
  London 367 376 372 373 1488 7  
  England 385 393 389 395 1562 6  
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Why? (6) PCT Comparison of rise in the Rate of
admissions
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Why? (7) Thinking laterally about Alcohol

• Mental Health contacts e.g. QoF reviews for SMI,
  Depression etc
• Overall lifestyle advice
• Domestic violence
• Other substance misuse
• Injury
• Contacts with Unscheduled Care
• Contacts with Criminal Justice
• Sexual Health contacts e.g. Emergency
  Contraception
• Alcohol is both the most commonly used over he
  counter hypnotic and psychotropic agent.

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Why? (8) Knowledge on Alcohol amongst Health
Professionals can be poor?

• Undergraduates and Postgraduates training grades
  are still taught the CAGE questionnaire.
• Knowledge focussed on dependent drinkers
• Little Practical Knowledge of how to address
  issues in Primary Care

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• The key to providing the most cost-effective care
  is to through a preventative and early
  intervention strategy to provide as little care
  as possible

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How should we be managing Alcohol problems in
Primary Care?
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How?

• At every opportunity!
• Proactively- go looking for problem drinking
• In a wide range of presentations and contexts
• By everybody in the practice.
• Primary Care is well placed to do this

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Alcohol Harm reduction StrategyImprove primary
care responses

• Actions to support these objectives
• Provide Identification and Brief advise (IBA)
  to Higher risk and Increasing risk drinkers and
  refer those dependent on alcohol, into
  specialist treatment.
• Develop guidance on management of alcohol in
  primary care.

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The Dundee Story

• Since the 1970s
• Professor James David Edgar Knox, FRCP Edin Died
  10/08/2010
• The Dundee Courier
• Dundee Sheriffs Court Proceedings on Thursdays

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Identification and Brief Advice (IBA)
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What is IBA?

• Identification and Brief Advice
• - Understanding units
• - Understanding risk levels
• - Knowing where the patient sits on the risk
  scale
• - Benefits of cutting down
• - Tips for cutting down

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IBA Evidence base

• - For every eight people who receive simple
  alcohol advice, one will reduce their drinking to
  within lower-risk levels
  (Moyer et
  al., 2002)
• - This compares favourably with smoking cessation
  where only one in twenty will act on the advice
  given. (This improves to one in ten with
  nicotine replacement therapy.)
  (Silagy
  Stead, 2003).

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Benefits of IBA

• would result in the reduction from higher-risk to
  lower-risk drinking
• in 250,000 men and 67,500 women each year
  (Wallace et al, 1988).
• Risky drinkers are twice as likely to moderate
  their drinking 6 to 12 months
• when compared to drinkers receiving no
  intervention (Wilk et al, 1997).
• Can reduce weekly drinking between 13 and 34,
• resulting in 2.9 to 8.7 fewer mean drinks per
  week,
• with a significant effect on recommended or safe
  alcohol use
• (Whitlock et al, 2004).
• Reductions in alcohol consumption are associated
  with a
• significant dose-dependent
• lowering of mean systolic and diastolic blood
  pressure (Miller et al, 2005).

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What is a unit? How to calculate units?

• One unit is equivalent to 10ml or 8g of pure
  alcohol
• You can calculate the Units -
• 
  Volume (mls) X ABV( )
• 
  __________________
• 
  1000
• Tip In a litre of any alcoholic drink its
  strength (age)
• is also the total number of units, e.g. in one
  litre bottle of
• 40 strength vodka there are 40 units
• Drink Diary

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What are the recommended lower-risk guidelines?

• 34 units of alcohol a day for men and
• 23 units of alcohol a day for women

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The Alcohol Use Disorders Identification Test
(AUDIT) and why we should use it?
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Screening Tools in Primary care

• Audit Alcohol use and disorder
  identification (10 Questions)
• Audit-C Audit alcohol consumption questions
  (first 3 Questions of Audit)
• Audit-PC Audit primary care (5 questions of
  Audit)
• FAST Fast alcohol screening test (4
  questions from Audit starting with a single
  screening question)
• M-SASQ Modified single alcohol screening
  question

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AUDIT Questions

• How often do you have a drink containing alcohol?
• How many drinks containing alcohol do you have on
  a typical day when you are drinking?
• How often do you have six or more drinks on one
  occasion?
• How often during the last year have you found
  that you were not able to stop drinking daily
  once you had started?
• How often during the last year have you failed to
  do what was normally expected of daily you
  because of drinking?
• How often during the last year have you needed a
  first drink in the morning to get yourself daily
  going after a heavy drinking session?
• How often during the last year have you had a
  feeling of guilt or remorse after drinking?
• How often during the last year have you been
  unable to remember what happened the night daily
  before because of your drinking?
• Have you or someone else been injured because of
  not in the during the your drinking?
• Has a relative, friend, doctor, or other health
  care worker been not in the during the concerned
  about your drinking last year last year or
  suggested you cut down?

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Why use the AUDIT family of assessment tools?

• Cross-national standardization the AUDIT was
  validated on primary healthcare patients in six
  countries It is the only screening test
  specifically designed for international use
• Identifies hazardous and harmful alcohol use, as
  well as possible dependence
• Brief, rapid, and flexible
• Designed for primary health care workers
• Consistent with ICD-10 definitions of alcohol
  dependence and harmful alcohol use
• Focuses on recent alcohol use.
• Integrated into GP software (if you actually look)

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Audit-C and Audit

• c.90 accuracy for detecting heavy drinking (Bush
  et al)
• Currently regarded as the gold standard
• Audit C Scoring
• A total of 5 indicates increasing or higher risk
  drinking.
• An over all total score of 5 or above is Audit-C
  positive.
• Proceed to next 7 questions to complete full Audit

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Full Audit Scoring

• 0 7 Lower risk,
• 8 15 Increasing risk,
• 16 19 Higher risk,
• 20 Possible dependence
• If Q. 4, 5 or 6 gt zero possible emergent or
  established dependence.

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Putting it all together
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Prochaska and DiClemente (1982)

• Pre-contemplation (no consideration of changing)
• Contemplation (thinking about changing)
• Preparation (making plans to change)
• Action (actually in the process of changing)
• Maintenance (working to prevent relapse)

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Measurement as an Intervention

• Hawthorne Effect
• Promoting Insight
• Booze gave me that John Wayne Feeling

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Delivering IBA First two tasks

• 1) Share the AUDIT score with the Patient,
• - How do you feel about this score ?
• Refer patient to the graph on the patient
  information leaflet
• measuring patients consumption against the
  general population.
• 2) Attempt to interest them in the idea that
  their drinking is possibly
• increasing risk or higher risk or dependent
  drinking
• It suggests you are drinking at a level that will
  be risky/ very risky
• for your health
• Would you be prepared to talk a little more about
  this?
• Refer patient to the common physical and
  emotional effects
• on the information sheet.

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Delivering IBA next two tasks

• 3) If they are interested, explore what benefits
  they might get from
• cutting down - Refer patient to this section
  of the information sheet
• Here is a list of benefits of cutting down
  do any of them appeal to you?
• - Scaling Question for assessing readiness
  for change
• On a scale of 1-10, how important is it to you
  to be cutting down your drinking?
• 4) Discuss tips to cut down and ask the patient
  to keep a drink diary
• - Book a Follow-up appointment
• - Refer to alcohol services for extended
  advice as appropriate
• - Refer to specialist services if the score
  is 20

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What advice should I give to a person who is
dependent on alcohol?

• Whilst waiting for a specialist assessment,
  advise the person to-
• reduce alcohol consumption somewhat where
  possible, but not
• to stop suddenly where there are concerns about
  precipitating
• problems from alcohol withdrawals
• Avoid activities where alcohol misuse may be
  hazardous
• (e.g. caring for children, swimming, driving).
• To consider involving friends and family in the
  treatment process,
• where possible.

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Outcomes

• Patients scoring 0 7 Lower risk, give patient
  information leaflet.
• For score of 8 15 (Increasing risk) and 16 19
  (Higher risk) provide brief advice, give patient
  information leaflet and refer patients for
  extended advice if necessary to- e.g.Turning
  Point
• For score of 20 (Possible alcohol dependence)
  Community Drug and Alcohol Team (CDAT)

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For more information

• IBA
• Alcohol Learning Centre website
• http//www.alcohollearningcentre.org.uk/eLearning/
  IBA/
• http//www.alcohollearningcentre.org.uk/eLearning/
  Training/CommIBATrain/IBATrainRes/

AUDIT http//whqlibdoc.who.int/hq/2001/WHO_MSD_MS
B_01.6a.pdf
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A couple of notes for commissioners.

• Always remember that your weapon was made by the
  lowest bidder
• US Military
• No bucks.No Buck Rodgers
• NASA

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RCGP Certificate In the Management of Alcohol
Problems in Primary Care
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RCGP Certificate in the Management of Alcohol
Problems in Primary Care

• Launched September 2009
• 1200 healthcare professionals have completed it
• Epidemiology and Evidence Base of alcohol
  problems from a Primary Care perspective
• Assessing Alcohol Intake
• Screening for Alcohol Problems with the new tools
  AUDIT
• Delivering IBA at the coalface-the bulk of the
  day involving key points in consulting styles.
• Initial management of more dependent alcohol
  usage Medical Issues, Community Detox and Care
  Planning

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The How ? (1) RCGP Certificate in the Management
of Alcohol Problems in Primary Care

• The Department of Health Alcohol identification
  and Brief Advice
• e-learning course
• (done before the face to face training, 75
  passmark)
• http//www.alcohollearningcentre.org.uk/eLearning/
  IBA/
• One day training event.
• Self completed work book.

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The How ? (2) Accessing the training day

• National Events (check the website)
• Local Events (pester your educationalists)

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The How ? (3) Local training days

• You need
• A RCGP Approved Trainer
• A minimum number of 5 people to attend any
• local event in order for it to be recognized by
  the RCGP.
• You also need (and the RCGP will not pay for)
• The Gig- the venue
• The Kit- the equipment (presentation AV)
• The Grub(s?!)- Catering

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The How Much? the sordid question of coin

• National Events- 250
• Local Events- 150 per course participant before
  the event covers
• - registration for the certificate
• - educational pack materials
• It does not cover the cost of venue, approved
  trainers, equipment hire etc.

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For more information

• www.rcgp.org.uk/substancemisuse.
• Ask me! Shahid Dadabhoy
• shahid.dadabhoy_at_nhs.net
• Alcohol Certificate Coordinator
• RCGP Substance Misuse Unit
• Alcohol_at_rcgp.org.uk

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Any questions?