alcohol identification and brief advice (iba) - messages for primary care don lavoie alcohol...

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?

2 IBA - Messages for Primary Care

What is the problem?


Alcohol consumption over the years


Annual Alcohol Consumption per UK Resident 1900-2010

0

2

4

6

8

10

12

19

00

19

05

19

10

19

15

19

20

19

25

19

30

19

35

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40

19

45

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50

19

55

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60

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65

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70

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75

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80

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85

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90

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95

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00

20

05

20

10

Sources:

1. HM Revenue and Customs clearance data

2. British Beer and Pub Association

3. Office for National Statistics mid-year population estimates

Pu

re A

lco

ho

l (li

tre

s)

Coolers/FABs

Spirits

Wine

Cider

Beer

Alcohol consumption vs. price


Alcohol consumption - Europe


Why is this a problem?


9 IBA - MESSAGES FOR PRIMARY CARE

Alcohol - adds to health risks


QOF registers and risky drinking


What can you do about it?


Don’t ignore itAny health-care professional can play their part

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


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?


Alcohol risk levels


AUDIT – gold standard



3 UNITS 2.3 UNITS

1 UNIT 1.7 UNITS 10 UNITS 2 UNITS

2.3 UNITS

Typical night in


8.4 UNITSHalf

Typical night out


14UNITSHalfHalf

Special night out


10 UNITS

Half

40% of alcohol drunk by 10%


0 0.0 0.01.6

3.4

5.9

9.8

13.3

20.7

44.9

0

5

10

15

20

25

30

35

40

45

50

1stDecile

2ndDecile

3rdDecile

4thDecile

5thDecile

6thDecile

7thDecile

8thDecile

9thDecile

10thDecile

% o

f to

tal a

lco

ho

l co

ns

um

ed

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


AUDIT - C


Drinking “At Risk” groups


Source: General Household Survey 2009 & mid-2009 population estimates (ONS) & Adult Psychiatric Morbidity Survey 2007

The numbers

FACTS FIGURES

LAs 152

Inc + High % 22

Dep % 3.8

Practices 8,261

GPs 33,364

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

47

Increasing and Higher Risk

9,849,277 64,798

1,192

295


Adult visiting GP

Requesting help with alcohol problem

New Registration Other health complaint

Full ScreenAUDIT

AUDIT Score8-15

Increasing-risk

Full Assessment

Consider Referral to Specialist Services

LifestyleCounselling

AUDIT Score16-19

Higher-risk

AUDIT Score20+

Possible Dependence

AUDIT Score 0-7

Lower-risk

Primary Care - Alcohol Care Pathway

No action

PositiveResult

NegativeResult

SASQ FAST AUDIT - C AUDIT - PCInitial Screening Tools

Brief Advice

IBA - Messages for Primary Care 30

31

AUDIT Score

Score Category0-7 Lower Risk8-15 Increasing Risk16-19 Higher Risk20+ Possible Dependence

IBA - Messages for Primary Care

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


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


Where do you sit?


Population by Risk Category

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Abstaining Lower risk Increasingrisk

Higher risk

Male

Female

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

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


IBA - Messages for Primary Care37

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?

This is one unit...

Half pint of regular beer,

lager or cider

1 very small glass of

wine

1 single measure of

spirits

1 small glass of sherry

1 single measure of

aperitifs

How many units did you drink

today?

A pint of 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

...and each of these is more than one unit

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 relaxationSociabilityReduced risk of heart disease (for men over 40 and post menopausal women)

Increasing Risk

More than 3-4 units per day on a regular basis

More than 2-3 units per day on a regular basis

Progressively increasing risk of: Low energy•Memory loss•Relationship problemsDepressionInsomnia•Impotence•Injury•Alcohol dependence•High blood pressure•Liver disease•Cancer

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

(9%)

“regular”

3

(12%)

For more detailed information on calculating units see - www.units.nhs.uk/

IBA - Messages for Primary Care38

Making your plan• 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

The benefits of cutting downPsychological/Social/Financial• Improved mood• Improved relationships• Reduced risks of drink driving• Save moneyPhysical• 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

What targets should you aim for?MenShould not regularly drink more than 3–4 units of alcohol a day. WomenShould 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.

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.

What’s everyone else like?% of Adult Population

What is your personal target?

Population by Risk Category

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Abstaining Lower risk Increasingrisk

Higher risk

Male

Female

Alcohol Learning Resources


IBA resources


e – Learning courses


Change 4 Life


IBA support for primary care

Incentives (payments)DES – New registrationsNHS Health Check

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


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


Useful links• IBA resources and e-Learning module

http://www.alcohollearningcentre.org.uk/

• NICE guidancehttp://guidance.nice.org.uk/PH24http://guidance.nice.org.uk/CG115

• Primary Care Frameworkhttp://www.pcc-cic.org.uk/article/alcohol

• SIPS Research Programmehttp://www.sips.iop.kcl.ac.uk/index.php

• Materials, Units Calculator and Drink Check http://www.nhs.uk/LiveWell/Alcohol/Pages/

Alcoholhome.aspx


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)


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)


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


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


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


Why don’t you do it?


Barriers to GP implementation 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


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)


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%


Government ambivalence


References 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 meta-analytic 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


alcohol identification and brief advice (iba) - messages for primary care don lavoie alcohol...

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