Alcohol Detection by Clinicians

1
Alcohol Detection by Clinicians
Alex J Mitchell (2012)
Rates of recognition of alcohol problems in
routine clinical practice using clinical judgment

• Alex J Mitchell, University of Leicester
• Information to Support Publication
• Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical
  recognition and recording of
• alcohol disorders by clinicians in primary and
  secondary care meta-analysis.
• British Journal of Psychiatry August 2012

ajm80_at_le.ac.uk
Royalty free slides for personal use, providing
author credit given
2
Some Definitions of Alcohol Problems
Alex J Mitchell (2012)

• Hazardous drinking
• A pattern of alcohol consumption that increases
  someones risk of harm (WHO)
• Harmful drinking
• A pattern of alcohol consumption that is causing
  mental or physical damage
• Alcohol dependence
• A cluster of behavioural, cognitive and
  physiological factors that typically include a
  strong desire to drink alcohol and difficulties
  in controlling its use. Someone who is alcohol
  dependent may persist in drinking, despite
  harmful consequences. They will also give alcohol
  a higher priority than other activities and
  obligations. (DSM-IV) (American Psychiatric
  Association 2000) / (ICD-10) (World Health
  Organization 2007).
• Alcohol Use Disorder
• Harmful use or alcohol dependence

3
Magnitude of Problem Drinking
Alex J Mitchell (2012)

• 24 of adults are hazardous or harmful drinkers
  (7M)
• Defined as scoring 8 or more on the Alcohol Use
  Disorders Identification Test (AUDIT) slide 16
  (McManus et al. 2009)
• 4 alcohol dependent (1M) (Drummond et al., 2005)
• 7 of hospital admissions (1M) (North West Public
  Health Observatory 2010)
• 40 of hospital presentations with AUD (of 10k
  screened in SIPS)
• Consumption doubled in adolescents in past 10 yrs
• 3rd leading cause of disability in Europe

Drummond DC, Oyefes, N, Phillips T et al. (2005)
Alcohol needs assessment research project the
2004 national alcohol needs assessment for
England. Department of Health, London McManus S,
Meltzer H, Brugha T et al. (2009) Adult
psychiatric morbidity in England, 2007 results
of a household survey. NHS Information Centre for
Health and Social Care, Leeds North West Public
Health Observatory (2010) Local alcohol profiles
for England. www.nwph.net/alcohol/lape/
4
Drug harms in the UK
Nutt DJ, King LA, Phillips LD Independent
Scientific Committee on Drugs. Drug harms in the
UK a multicriteria decision analysis. Lancet.
2010 Nov 6376(9752)1558-65. Epub 2010 Oct 29.
Alex J Mitchell (2012)
Scores represent opinions of Members of the
Independent Scienti?c Committee on Drugs
5
(No Transcript)
6
Mitchell et al (2012) Detection Meta-analysis
Alex J Mitchell (2012)

• Meta-analysis of studies involving 20,000
  patients assessed for alcohol problems by medical
  staff  
• GPs identified 40 of problem drinkers
• Hospital doctors identified 50 of problem
  drinkers
• Mental health specialists recognised 55 of
  problem drinkers.
• AE clinicians detected 90 of alcohol
  intoxication
• Clinicians correctly recorded a diagnosis in the
  case-notes for only 1 in 3 people who had an
  alcohol problem

Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical
recognition and recording of alcohol disorders
by clinicians in primary and secondary care
meta-analysis. British Journal of Psychiatry
August 2012
7
HSROC Estimate Clinical Judgement vs AUD
Alex J Mitchell (2012)

• Across all studies, clinicians sensitivity was
  40.0
• Across all studies, clinicians specificity was
  91.0

Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical
recognition and recording of alcohol disorders
by clinicians in primary and secondary care
meta-analysis. British Journal of Psychiatry
August 2012
8
Mitchell et al (2012) Detection Summary
Alex J Mitchell (2012)

• Assuming 2 /10 GP attendees have problem drinking

Clinicians would correctly identify 71
miss 1
misidentify 1
Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical
recognition and recording of alcohol disorders
by clinicians in primary and secondary care
meta-analysis. British Journal of Psychiatry
August 2012
9
Poor Access to Treatment
Alex J Mitchell (2012)

• Only about 5 of those alcohol dependent receive
  treatment each year
• About 80 with AUD do not access / receive any
  treatment
• The average delay in seeking help for alcohol
  problems is 6-7 years

Oleski et al (2010)
Wang et al (2005)
Wang, P. S., Berglund, P., Olfson, M., Pincus, H.
A., Wells, K. B. and Kessler, R. C. (2005)
Failure and delay in initial treatment contact
after first onset of mental disorders in the
national comorbidity survey replication. AGP 62,
603-613. Oakley Browne, M. A., Wells, J. E. and
McGee, M. A. (2006) Twelve-month and lifetime
health service use in Te Rau Hinengaro The New
Zealand Mental Health Survey. ANZJP 40, 855-
864. Oleski J, Mota N, Cox BJ, Sareen J.
Perceived need for care, help seeking, and
perceived barriers to care for alcohol use
disorders in a national sample. Psychiatr Serv.
2010 Dec61(12)1223-31.
10
Barriers to Help Seeking
Alex J Mitchell (2012)

• Younger age
• Married
• Higher income
• Higher education
• Low comorbidity

Oleski et al (2010)
Oleski J, Mota N, Cox BJ, Sareen J. Perceived
need for care, help seeking, and perceived
barriers to care for alcohol use disorders in a
national sample. Psychiatr Serv. 2010
Dec61(12)1223-31
11
Receipt of Advice and Treatment
Alex J Mitchell (2012)

• 50 of heavy drinkers who had been asked about
  their alcohol use had not been advised about it
• Of 7301 primary care patients, 28.3 screened
  positive. Of these, 55 received no advice
• 62 of risky drinkers were given advice by
  practice nurses

Mäkelä et al (2011)
Edlund et al (2004)
Lock Kaner, 2004
Edlund M. J., Unützer J.,Wells K. B. Clinician
screening and treatment of alcohol, drug, and
mental problems in primary care. Med Care 2004
42 115866. Lock C. A., Kaner E. F.
Implementation of brief alcohol interventions by
nurses in primary care do non-clinical factors
influence practice? Fam Pract 2004 21
2705 Mäkelä P, Havio M, Seppä K.Alcohol-related
discussions in health care--a population view.
Addiction. 2011 106(7)1239-48.
12
Barriers to Detection and Treatment
Alex J Mitchell (2012)

• Low rates of enquiry by clinicians
• Low use of validated tools
• lack of resources
• Lack of training
• Excess workload
• Poor attitudes to AUD
• Unclear responsibility
• Uncertainty re how to help

13
Patients Views of Being Asked _at_ Drinking
Alex J Mitchell (2012)

• 90 have positive attitudes towards being asked
• Typically only 3 of GP attendees are typically
  asked about alcohol in 12mo
• Typically only 10 of at risk drinker are
  typically asked about alcohol in 12mo
• Typically only 1 in 3 problem drinkers are
  typically asked about alcohol in 12mo

Foulds et al (2012)
Foulds et al (2012)
Mäkelä et al (2011)
Foulds J, Wells JE, Lacey C, Adamson S, Mulder R.
Harmful drinking and talking about alcohol in
primary care New Zealand population survey
findings. Acta Psychiatr Scand. 2012 Apr
26 Mäkelä P, Havio M, Seppä K.Alcohol-related
discussions in health care--a population view.
Addiction. 2011 106(7)1239-48.
14
Rates of Enquiry _at_ Drinking by AUDIT Score
Alex J Mitchell (2012)
Foulds et al (2012)
AUD
Foulds J, Wells JE, Lacey C, Adamson S, Mulder R.
Harmful drinking and talking about alcohol in
primary care New Zealand population survey
findings. Acta Psychiatr Scand. 2012 Apr 26
15
Suggested Screening Protocol
Alex J Mitchell (2012)
Credit Alcohol Learning Centre
16
Audit Screening Test 10 Questions
Alex J Mitchell (2012)

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

17
Basic Principles of Engagement
Alex J Mitchell (2012)

• Offer a private, comfortable consultation
• Use a Non-judgemental attitude
• Foster Trust
• Avoid arguments
• Show Empathy
• Guage Severity
• Promote Self-efficacy
• Promote motivation to change
• Engage caregivers

18
Recommended alcohol limits Units
Alex J Mitchell (2012)
1 Unit 10ms / 10g
19
Help Online
Alex J Mitchell (2012)

• NHS Handout on Alcohol
• http//www.alcohollearningcentre.org.uk/alcoholeLe
  arning/learning/IBA03/IBA_03_004/pdf/structured_ad
  vice_tool.pdf
• Brief Alcohol Intervention Online
• http//www.alcohollearningcentre.org.uk/alcoholeLe
  arning/learning/IBA03/IBA_03_004/D/ALC_Session/300
  /overview.html
• NHS How Much is Too Much Workbook
• http//www.sips.iop.kcl.ac.uk/documents/gnr/dhpil.
  pdf
• SIPS Information from Kings College
• http//www.sips.iop.kcl.ac.uk/documents/gnr/sipsBA
  .pdf
• http//www.sips.iop.kcl.ac.uk/documents/gnr/sipsBL
  C.pdf

20
National Help
Alex J Mitchell (2012)

• Drinkline - National Alcohol Helpline
• Helpline 0800 917 8282 Monday - Friday, 9am -
  11pm , Weekends 6pm - 11pmOffers help to callers
  worried about their own drinking and support to
  the family and friends of people who are
  drinking. Advice to callers on where to go for
  help.
• Alcoholics Anonymous
• PO Box 1, 10 Toft Green, York, YO1 7NDHelpline
  0845 769 7555 Web www.alcoholics-anonymous.org.uk
  There are over 3000 meetings held in the UK each
  week with over 40,000 members. The only
  requirement for membership is a desire to stop
  drinking.
• AL-Anon Family Groups
• 61 Great Dover Street, London, SE1 4YFTel 020
  7403 0888 Web www.al-anonuk.org.ukOffers
  support for families and friends of alcoholics
  whether the drinker is still drinking or not.
• National Association for Children of Alcoholics
• PO Box 64, Fishponds, Bristol, BS16 2UHHelpline
  0800 358 3456 Web www.nacoa.org.ukServices
  include information, advice and support to
  children of alcoholics through its free helpline,
  and training to professionals who come into
  contact with children of alcoholics.
• Know Your Units campaign
• From the NHSWeb www.units.nhs.ukAims to tell
  drinkers how many units are in their drinks and
  help them stick to their limits.

21
NICE Guidance
Alex J Mitchell (2012)

• Part 1 - Public health guidance
• Alcohol use disorders in adults and young people
  prevention and early identification (published
  June 2010) - Centre for Public Health Excellence
  (CPHE) at NICE
• Part 2 - Clinical guideline
• Alcohol use disorders in adults and young people
  clinical management (published June 2010) -
  National Collaborating Centre for Chronic
  Conditions (NCC-CC)
• Part 3 - Clinical guideline
• Alcohol use disorders management of alcohol
  dependence (publication expected February 2011) -
  National Collaborating Centre for Mental Health
  (NCC-MH)

22
Alcohol Detection by Clinicians
Alex J Mitchell (2012)
Rates of recognition of alcohol problems in
routine clinical practice using clinical judgment

• Alex J Mitchell, University of Leicester
• Information to Support Publication
• Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical
  recognition and recording of
• alcohol disorders by clinicians in primary and
  secondary care meta-analysis.
• British Journal of Psychiatry August 2012

Royalty free slides for personal use, providing
author credit given