Transcript Alcohol Identification and Brief Advice (IBA)

Alcohol Identification and Brief
Advice (IBA) Messages for Primary Care
Don Lavoie
Alcohol Programme Manager
What I hope to cover
• What is the problem?
• Why is this a problem?
• What can you do about it?
• How do you do it?
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What is the problem?
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Alcohol consumption over the years
Annual Alcohol Consumption per UK Resident 1900-2010
Pure Alcohol (litres)
12
10
8
Coolers/FABs
6
Spirits
Wine
4
Cider
Beer
2
Sources:
1. HM Revenue and Customs clearance data
2. British Beer and Pub Association
3. Office for National Statistics mid-year population estimates
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2010
2005
2000
1995
1990
1985
1980
1975
1970
1965
1960
1955
1950
1945
1940
1935
1930
1925
1920
1915
1910
1905
1900
0
Alcohol consumption vs. price
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Alcohol consumption - Europe
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Why is this a problem?
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Alcohol - adds to health risks
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QOF registers and risky drinking
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What can you do about it?
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Don’t ignore it
Any health-care professional can play their part
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Identify risk
Provide simple advice
Support and encourage change
Refer those who may need specialist assessment and
help
This process is Identification and Brief Advice - IBA
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Typical alcohol identification questions
• Common questionnaires
– MAST – Michigan Alcohol Screening Test
– CAGE
• Have you ever tried to Cut down on your drinking?
• Have you ever felt Angered by someone talking about your
drinking?
• Have you ever felt Guilty about your drinking?
• Have you ever had to have an “Eye opener” drink in the morning?
• How many Units do you drink a week?
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Alcohol risk levels
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AUDIT – gold standard
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2.3 UNITS
3 UNITS
1 UNIT
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1.7 UNITS
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10 UNITS
2.3 UNITS
2 UNITS
Typical night in
Half
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8.4
UNITS
Typical night out
Half
Half
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UNITS
Special night out
Half
10
UNITS
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40% of alcohol drunk by 10%
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44.9
45
% of total alcohol consumed
40
35
30
25
20.7
20
13.3
15
9.8
10
5.9
5
0
0.0
0.0
1st
Decile
2nd
Decile
3rd
Decile
1.6
3.4
0
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4th
Decile
5th
Decile
6th
Decile
7th
Decile
8th
Decile
9th
Decile
10th
Decile
Public perception of alcohol risk
 Most people are unaware that they are drinking above the lower-risk
guidelines
 Many do not see drinking above the lower-risk guidelines as a
problem
 Many aware that alcohol caused liver problems, but few aware of its
contribution to cancers
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AUDIT - C
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Drinking “At Risk” groups
Source: General Household Survey 2009 & mid-2009 population estimates (ONS) & Adult Psychiatric Morbidity Survey 2007
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The numbers
ENGLAND
LAs
PRACTICE
GP
Total Population
53,588,218
352,554
6,487
1,606
Adult Population
43,580,873
286,716
5,275
1,306
Dependent
drinkers
1,568,911
10,322
190
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Increasing and
Higher Risk
9,849,277
64,798
1,192
295
FACTS
LAs
FIGURES
152
Inc + High %
22
Dep %
3.8
Practices
GPs
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8,261
33,364
Primary Care Alcohol Care Pathway
Requesting help with
alcohol problem
Initial
Screening
Tools
SASQ
Adult visiting GP
New Registration
FAST
Other health complaint
AUDIT - C
AUDIT - PC
Positive
Result
Negative
Result
Full Screen
AUDIT
AUDIT Score
20+
Possible Dependence
Consider Referral to
Specialist Services
Full Assessment
AUDIT Score
16-19
Higher-risk
AUDIT Score
8-15
Increasing-risk
Lifestyle
Counselling
Brief Advice
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No action
AUDIT Score
0-7
Lower-risk
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AUDIT Score
Score
0-7
8-15
16-19
20+
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Category
Lower Risk
Increasing Risk
Higher Risk
Possible Dependence
Brief advice - FRAMES
 Feedback - provide feedback on the client’s risk for
harm
 Responsibility - the individual is responsible for change
 Advice - advise reduction or give explicit direction to
change
 Menu - provide a variety of options for change
 Empathy – take a warm, reflective and understanding
approach
 Self-efficacy - encourage optimism about changing
behaviour
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Alcohol brief advice
• Content
 Understanding units
 Understanding risk levels
 Knowing where they sit on the risk scale
 Benefits of cutting down
 Tips for cutting down
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Where do you sit?
Population by Risk Category
70.0%
60.0%
50.0%
40.0%
Male
Female
30.0%
20.0%
10.0%
0.0%
Abstaining Low er risk
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Increasing
risk
Higher risk
Benefits of cutting down
Physical
• Reduced risk of injury
• Reduced risk of high blood
pressure
• Reduced risk of cancer
• Reduced risks of liver disease
• Reduced risks of brain damage
• Sleep better
• More energy
• Lose weight
• No hangovers
• Improved memory
• Better physical shape
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Psychological/Social/Financial
• Improved mood
• Improved relationships
• Reduced risks of drink driving
• Save money
Tips for cutting down
• Have an alcohol-free day once or twice a week
• Plan activities and tasks at those times you usually drink
• When bored or stressed have a workout instead of
drinking
• Explore other interests such as cinema, exercise, etc.
• Avoid going to the pub after work
• Have your first drink after starting to eat
• Quench your thirst with non-alcohol drinks before alcohol
• Avoid drinking in rounds or in large groups
• Switch to low alcohol beer/lager
• Avoid or limit the time spent with “heavy” drinking friends
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This is one unit...
1 very small
glass of
wine(9%)
Half pint of
regular
beer, lager
or cider
For more detailed information on calculating units see - www.units.nhs.uk/
1 single
measure of
spirits
1 small glass
of sherry
1 single
measure of
aperitifs
How many
units did
you drink
today?
...and each of these is more than one unit
3
A pint of
regular
“regular”
beer, lager
or cider
A pint of
“strong”/
”premium”
beer, lager
or cider
Alcopop or a
275ml bottle
of regular
lager
440ml can
of “regular”
lager or
cider
440ml can
of “super
strength”
lager
250ml glass
of wine
(12%)
Bottle of
wine
(12%)
Risk
Men
Women
Common Effects
Lower Risk
No more than
3-4 units per
day on a
regular basis
No more than
2-3 units per
day on a
regular basis
Increased relaxation
Sociability
Reduced risk of heart
disease (for men over 40 and
post menopausal women)
Increasing
Risk
More than 34 units per
day on a
regular basis
More than 2-3
units per day
on a regular
basis
Higher Risk
More than 8
units per day
on a regular
basis or more
than 50 units
per week
More than 6
units per day
on a regular
basis or more
than 35 units
per week
Progressively increasing
risk of:
Low energy
•Memory loss
•Relationship problems
Depression
Insomnia
•Impotence
•Injury
•Alcohol dependence
•High blood pressure
•Liver disease
•Cancer
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There are times when
you will be at risk even
after one or two units.
For example, with
strenuous exercise,
operating heavy
machinery, driving or if
you are on certain
medication.
If you are pregnant or
trying to conceive, it is
recommended that you
avoid drinking alcohol.
But if you do drink, it
should be no more than
1-2 units once or twice a
week and avoid getting
drunk.
Your screening score
suggests you are drinking
at a rate that increases
your risk of harm and
you might be at risk of
problems in the future.
What do you think?
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The benefits of cutting down
What’s everyone else like?
% of Adult Population
Population by Risk Category
70.0%
60.0%
50.0%
40.0%
Male
Female
30.0%
20.0%
10.0%
What targets should you aim for?
0.0%
Abstaining Low er risk
Increasing
risk
Higher risk
Making your plan
•
•
•
•
•
•
•
•
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Psychological/Social/Financial
•Improved mood
•Improved relationships
•Reduced risks of drink driving
•Save money
Physical
•Sleep better
•More energy
•Lose weight
•No hangovers
•Reduced risk of injury
•Improved memory
•Better physical shape
•Reduced risk of high blood pressure
•Reduced risk of cancer
•Reduced risks of liver disease
•Reduced risks of brain damage
When bored or stressed have a
workout instead of drinking
Avoid going to the pub after work
Plan activities and tasks at those times
you would usually drink
When you do drink, set yourself a limit
and stick to it
Have your first drink after starting to
eat
Quench your thirst with non-alcohol
drinks before and in-between alcoholic
drinks
Avoid drinking in rounds or in large
groups
Switch to low alcohol beer/lager
Avoid or limit the time spent with
“heavy” drinking friends
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Men
Should not regularly drink more than 3–4
units of alcohol a day.
Women
Should not regularly drink more than 2–3
units a day
‘Regularly’ means drinking every day or
most days of the week.
You should also take a break for 48 hours
after a heavy session to let your body
recover.
What is your personal target?
This brief advice is based on the “How Much Is
Too Much?” Simple Structured Advice
Intervention Tool, developed by Newcastle
University and the Drink Less materials originally
developed at the University of Sydney as part of a
W.H.O. collaborative study.
Alcohol Learning Resources
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IBA resources
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e – Learning courses
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Change 4 Life
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IBA support for primary care
 Incentives (payments)
DES – New registrations
NHS Health Check
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Primary Care Service Framework
Identification tools
Brief advice scripts
Leaflets and written information
Care pathway
e-Learning modules
Read codes
Templates for GP computer systems
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The message for primary care
 There are 9+million adults drinking above lower risk and
putting their future health at jeopardy
 Identifying these individuals and delivering brief advice
can make a big difference in cutting this risk
 Primary care is well placed to provide this intervention
 Research has shown this is effective
 The intervention does not have to be intensive
 Vast amounts of training are not needed
 You do not have to be an “alcohologist” to do this
 It is well worth a few minutes of your time
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Useful links
• IBA resources and e-Learning module
http://www.alcohollearningcentre.org.uk/
• NICE guidance
http://guidance.nice.org.uk/PH24
http://guidance.nice.org.uk/CG115
• Primary Care Framework
http://www.pcc-cic.org.uk/article/alcohol
• SIPS Research Programme
http://www.sips.iop.kcl.ac.uk/index.php
• Materials, Units Calculator and Drink Check
http://www.nhs.uk/LiveWell/Alcohol/Pages/
Alcoholhome.aspx
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Does IBA work?
 Very large body of international research over 30 years supporting
IBA
 56 controlled trials (Moyer et al., 2002) all have shown the value of
IBA
 Cochrane Collaboration Review (Kaner et al., 2007) shows
substantial evidence for IBA effectiveness
 NICE Public Health Guidance – PH 24: Alcohol-use disorders:
preventing the development of hazardous and harmful drinking
(2010) recommends all healthcare workers should deliver IBA
 SIPS research programme confirmed effectiveness of IBA in
England (Kaner et al., 2013)
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Impact of IBA
 For every eight people who receive simple alcohol advice, one will
reduce their drinking to within lower-risk levels (Moyer et al., 2002)
 Higher risk and increasing risk drinkers who receive brief advice are
twice as likely to moderate their drinking 6 to 12 months after an
intervention when compared to drinkers receiving no intervention
(Wilk et al, 1997)
 Brief advice can reduce weekly drinking by between 13% and 34%,
resulting in 2.9 to 8.7 fewer mean drinks per week with a significant
effect on risky alcohol use (Whitlock et al, 2004)
 A reduction from 50 units/week to 42 units/week will reduce the
relative risk of alcohol-related conditions by some 14%, the
attributable fractions by some 12%, and the absolute risk of lifetime
alcohol-related death by some 20% (Anderson 2008)
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IBA is cost effective
 Project TrEAT showed a return of 5 to 1 {US$56,263 in societal
savings for every US$10,000 in intervention costs} (Fleming et.al.,
2000)
 Findings from Kaner et al. (2007) and the analysis from the
University of Sheffield (2009) it would appear safe to assume that
screening and brief advice will result in long-term savings to the
NHS and personal social services
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SIPS findings
• PC findings published (Kaner, BMJ 2013)
 A&E and Criminal Justice studies currently ‘in publication’
• Brief findings
 Delivering alcohol brief advice does work in England
 It is possible to implement in ‘real life’ settings
 It can be delivered by front line staff
 Staff can have confidence that it is effective and worthwhile
 Targeted screening more efficient, but you miss a lot of people
picked up by universal screening
• A BIG GENERALISATION – BUT “Less
is More”
 In most of the studies, the briefer intervention (feedback +
leaflet) worked as well as the longer interventions
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SMMGP / RCGP – SIPS Statement
 Alcohol screening, followed by simple feedback, supported by
written alcohol information is an accessible and easy way to make a
difference
 BUT – this is “more than just a leaflet” – appropriate feedback about
the screening results and appropriate tailored information pertaining
to the patients situation need to be delivered – supported by a leaflet
or written alcohol information
 Longer forms of advice and brief lifestyle counselling did not appear
to confer extra benefit and should be reserved for patients who do
not respond to simple advice
 All primary care teams are encouraged to implement this strategy
 Although targeted screening approaches are more efficient,
SMMGP & RCGP, in line with NICE guidance, universal screening in
primary care should be considered
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Why don’t you do it?
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Barriers to GP implementation
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Doctors are just too busy dealing with the problems people present with
Doctors are not trained in counselling for reducing alcohol consumption
Doctors have a disease model training and they don’t think about prevention
Doctors are not sufficiently encouraged to work with alcohol issues in the current
GMS contract
Doctors do not believe that patients would take their advice and change their
behaviour
Doctors do not know how to identify problem drinkers who have no obvious
symptoms of excess consumption
Doctors themselves have a liberal attitude to alcohol
Doctors themselves may drink more than what is healthy for them
Doctors think that preventive health should be the patients’ responsibility, not theirs
Doctors believe that patients would resent being asked about their alcohol
consumption
Doctors feel awkward about asking questions about alcohol consumption because
saying someone has an alcohol problem could be seen as accusing them of being an
alcoholic
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GPs suggestions
 General support services (self-help/counselling) were readily
available to refer to
 Early intervention for alcohol was proven to be successful
 Patients requested health advice about alcohol consumption
 Quick and easy counselling materials were available
 Quick and easy screening questionnaires were available
 Training programmes for early intervention for alcohol were
available
 Public health education campaigns in general made society more
concerned about alcohol
 Providing early intervention for alcohol was included in the Quality
and Outcomes Framework (QOF)
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GP suggested policies
Policy
Effective % agreement
 Improve alcohol education in schools
71%
 Further regulation of alcohol off-sales (e.g. supermarkets)
57%
 Institute minimum pricing for units of alcohol
55%
 Increase restrictions on TV & cinema alcohol advertising
54%
 Lower blood alcohol concentration limit for drivers
53%
 Make public health a criterion for licensing decisions
49%
 Raise minimum legal age for purchasing alcohol
48%
 General changes in alcohol price through taxation
48%
 Statutory regulation of alcohol industry
43%
 Raise minimum legal age for drinking alcohol
39%
 Government monopoly of retail sales of alcohol
27%
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Government ambivalence
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References
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Anderson, P. (2008) Reducing heavy drinking and alcohol admissions (Unpublished) Department of Health.
Fleming, M.F., Marlon, M.P., French, M.T., Manwell, L.B., Stauffacher, E.A. and Barry, K.L. (2000) Benefit cost
analysis of brief physician advice with problem drinkers in primary care settings, Medical Care, 31(1): 7-18.
Kaner E, Beyer F, Dickinson H, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Bernand B. Brief
interventions for excessive drinkers in primary health care settings. Cochrane Database of Systematic Reviews
2007, Issue 2. Art No.: CD004148 DOI: 10.1002/14651858.CD004148.pub3.
Kaner E, et.al .Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic
cluster randomised controlled trial. BMJ 2013;346:e8501
Moyer, A., Finney, J., Swearingen, C. and Vergun, P. (2002) Brief Interventions for alcohol problems: a metaanalytic review of controlled investigations in treatment -seeking and non-treatment seeking populations,
Addiction, 97, 279-292.
University of Sheffield (2009) Modelling to assess the effectiveness and cost effectiveness of public health related
strategies and interventions to reduce alcohol attributable harm in England using the Sheffield alcohol policy
model version 2.0 [online]. Available from www.nice.org.uk/guidance/PH24
Whitlock, E.P., Polen, M.R., Green, C.A., Orleans, T. and Klein, J. (2004) Behavioral counselling interventions in
primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the US Preventive
Services Task Force. Annals of Internal Medicine, 140, 557-568.
Wilk, A.I., Jensen, N.M. and Havighurst, T.C. (1997) Meta-analysis of randomized control trials addressing brief
interventions in heavy alcohol drinkers, Journal of General Internal Medicine, 12, 274-283.
NICE GUIDANCE:
http://guidance.nice.org.uk/PH24
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