Transcript RCGP Substance Misuse Unit

Steve Brinksman
GP South Birmingham PCT
RCGP West Midlands Regional Lead
[email protected]
Is it really a big deal?
Alcohol consumption in the UK: 1900 - 2000
Per capita consumption (100% alcohol)
Source: British Beer and Pub Association 2000
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
Alcohol related ill health and mortality
(2005/6)
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187,640 admissions to NHS hospitals aged 16
and above with a primary or secondary diagnosis
related to alcohol (almost double the 95/6
figures)
Children under 16 accounted for 5,280 alcoholrelated admissions to NHS hospitals (up by a
third on 95/6 figures)
6,570 deaths directly linked to alcohol
consumption (just under 2/3 from alcohol liver
disease)
Mortality from chronic liver disease and
cirrhosis in England
Alcohol and Mental Health
• The number of UK hospital admissions with a primary
or secondary diagnosis of “mental and behavioural
disorders due to alcohol” rose from 71,900 in 1995/96
to over 90,000 in 2002/03
• 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
Costs (per annum)
Health
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£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
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£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
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£6.4bn, 17m working days lost
Family and social
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20,000 street drinkers
Up to 1.3m children affected by alcohol misuse
Political context
Problem drinking costs UK society in
excess of £15bn per year
vs.
Drinks market generates £30bn and one
million jobs
The National Alcohol Strategy
Safe, Sensible, Social: the next steps in the national alcohol
strategy, June 2007
Aim of strategy
- reduce antisocial behaviour
- reduce health consequences of drinking
- and enable people to enjoy alcohol safely
Key targets groups
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Young people under 18 years of age who drink
18-24 year old binge drinkers causing public
disorder
Harmful drinkers
The National Alcohol Strategy
How will aims be delivered?
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Better education and communication
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Improving health and treatment services
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Tackling alcohol related crime and disorder
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Working with the alcohol industry
The National Alcohol Strategy
Next steps:
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Punitive action for drunken behaviour
Review NHS alcohol spending
More help for people who want to drink less
Toughen enforcement against underage drinkers
Provide trusted guidance for parents and young people
Public information campaigns to promote sensible drinking
culture
Public consultation on alcohol pricing and promotion
April 2008
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National target – Public Service Agreement
(PSA) 25: “To reduce the trend in the
increase of alcohol-related hospital
admissions”
Primary care service framework defines two
levels of intervention linked to harm
Reference to SIGN guidance
Alcohol Direct Enhanced Service (DES)
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Alcohol DES - helping to reduce the risk of adults, aged 16
years or over, drinking at hazardous and harmful levels
£2.33 for each new registered patient that has been
screened
Suite of supportive resources:
 Read codes
 Audit criteria
 Posters and presentations
 Support for self-care
 Recommendation to use SIGN as clinical guidance
Constraints
Financial
Health budget not cut but…..
Deficits within PCOs
Constraints
Time and Training
Increasing workload in Primary Care
Lack of established training
Ambivalence and Inertia
What next?
Setting standards
Across all parts NHS
Social Services
Education
Criminal Justice System
Prevention
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Education
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Change public perception
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Minimum pricing
Screening and brief
intervention
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Essential part of primary care practitioner
training
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RCGP training
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Increased provision alcohol workers in
Primary Care
Alcohol Screening
…is a method of identifying alcohol
consumption at a level sufficiently high to
cause concern.
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
Screening tools in primary care
AUDIT
alcohol use disorder identification test
FAST
fast alcohol screening test
AUDIT-C
AUDIT alcohol consumption questions
AUDIT-PC
AUDIT primary care
M-SASQ
modified single alcohol screening question
Brief Interventions
What is a brief intervention?
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There is no standard definition of a brief intervention
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Brief interventions can range from a short conversation with a doctor or
nurse to a number of sessions of motivational interviewing
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Levels of intervention relate to alcohol related harm
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Level 1 – for the hazardous drinker – identification and brief advice
Level 2 – for the harmful/dependent drinker – care-planned
prescribing/referral on
For the Harmful drinkers a more in depth motivational intervention
can be added.
When is a brief intervention a brief
intervention?
Primary goal of brief interventions are to help the
patient understand
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What consequences likely to be
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What they can do about it
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What help is available
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)
Project TrEAT, 2002
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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
Fleming, M.F.; Mundt, M.P.; French, M.T.; et al. Brief physician advice for problem drinkers: Long-term efficacy and benefit-cost analysis. Alcoholism:
Clinical and Experimental Research 26:36–43, 2002.
Detoxification
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Increase access to this both community
based and residential / inpatient
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Set minimum standards for waiting times
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Aftercare provision essential
Typology (general population)
Severely dependent drinkers (< 0.1%)
Moderatelydependent drinkers (< 0.4%)
Harmful drinkers (4.1%)
Hazardous drinkers (16.3%)
Low-riskdrinkers (67.1%)
Non-drinkers (12.0%)
DoH 2005
A sobering thought…..
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Detoxification is but one event in a continuing process
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It is a small, technical step between preparation and aftercare
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As a stand alone treatment can do more harm than good
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Detoxification from opiates and alcohol are two very different
events; detoxification from opiates is uncomfortable, but fairly
safe
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Detoxification from alcohol is potentially dangerous, and can be
permanently disabling or fatal
Alcohol withdrawal
Where can detoxifications take place?
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General Hospital
Psychiatric Hospital
Non statutory rehab or detoxification unit
Community
detoxification shows similar outcomes to inpatient – 75%
successful in community
 Community setting preferred by most patients
 Accessibility and trust in practitioner is key advantage
 Cost advantage
 Community
Stockwell T, Bolt L, Milner I, Russell G, Bolderston H, Pugh P (1991).
Home detoxification from alcohol; its safety and efficacy in comparison with inpatient care. Alcohol and Alcoholism;26(5-6):645-650.
Finney J, Hahn A, Moos R (1995). The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on
mediators and moderators of setting effect. Addiction;91(12):1773-1796
Aftercare
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Structured support for individuals
Psychosocial interventions are always a
crucial part of relapse prevention
Pharmacotherapy may be useful aid to
maintaining abstinence
Family/carer support
Managing post-detox symptoms
Self help/AA
Psychosocial
Cognitive behaviour therapies
change expectancies, build self efficacy, develop coping skills
Social network therapies
recruit social network for support, activities, risk reduction
Contingency management
reward schedules to promote achievement of goals
Psychosocial
Common to all therapies
empathy, support, goal directed, ‘working alliance’
Motivational therapies
create and resolve ambivalence, normative feedback,
strengthen change statements
Twelve step facilitation
abstinence emphasis, bonding with peer network, risk
avoidance
Core Competencies for
practitioners in Primary Care
• Understanding: models of behavioural change, the
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evidence for brief interventions
Awareness and knowledge: categories of problem
drinking, screening tools
Skill: deliver brief interventions, focus on Motivational
Interviewing
Ability: safe alcohol detoxification, knowing when to
refer
Insight: primary care’s role in aftercare
Overview: complementary approaches – AA, self help
National standards
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NICE guidance
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DES/LES
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QOF
National Standards
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First Nice Guidance just released
The Alcohol-use disorders: preventing the development of hazardous
and harmful drinking guidance provides detailed recommendations for
those working in The NHS and third sector in the prevention and early
identification of alcohol-use disorders among adults and adolescents.
Alcohol-use disorders: diagnosis and clinical management of
alcohol-related physical complications provides clinical guidelines for
a range of conditions including Wernicke's encephalopathy, acute
withdrawal, liver disease and pancreatitis.
Further guidance from NICE on alcohol dependence and harmful
alcohol use is due to publish in February 2011.
My Four Standards
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Core competencies
2 week max wait for assessment if felt to be
dependent
Development of cohesive aftercare
To reduce the underlying trend in mortality by
2020
“This is my truth now tell me yours”
Aneurin Bevan