steve brinksman gp south birmingham pct rcgp west midlands regional lead...

Steve BrinksmanGP South Birmingham PCT

RCGP West Midlands Regional Lead

stevebrinksman@doctors.org.uk

Is it really a big deal?

Alcohol consumption in the UK: 1900 - 2000Per 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)

• 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 alcohol-related 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

• 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

Alcohol and Mental Health

Costs (per annum)

Health• £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• £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• £6.4bn, 17m working days lost

Family and social• 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• Young people under 18 years of age who drink• 18-24 year old binge drinkers causing public

disorder• Harmful drinkers

How will aims be delivered?

• Better education and communication

• Improving health and treatment services

• Tackling alcohol related crime and disorder

• Working with the alcohol industry

The National Alcohol Strategy

Next steps:

• 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

The National Alcohol Strategy

April 2008

• 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)• 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 TrainingIncreasing workload in Primary CareLack of established training

Ambivalence and Inertia

What next?

Setting standards

Across all parts NHSSocial ServicesEducationCriminal Justice System

Prevention

Education

Change public perception

Minimum pricing

Screening and brief intervention

Essential part of primary care practitioner training

RCGP training

Increased provision alcohol workers in Primary Care

…is a method of identifying alcohol consumption at a level sufficiently high to cause concern.

Alcohol Screening

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?• There is no standard definition of a brief intervention

• Brief interventions can range from a short conversation with a doctor or nurse to a number of sessions of motivational interviewing

• Levels of intervention relate to alcohol related harm • 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

• What consequences likely to be

• What they can do about it

• 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• 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

Increase access to this both community based and residential / inpatient

Set minimum standards for waiting times

Aftercare provision essential

Typology (general population)

Severely dependent drinkers (< 0.1%)

Moderately dependent drinkers (< 0.4%)

Harmful drinkers (4.1%)

Hazardous drinkers (16.3%)

Low-risk drinkers (67.1%)

Non-drinkers (12.0%)

DoH 2005

A sobering thought…..• Detoxification is but one event in a continuing process

• It is a small, technical step between preparation and aftercare

• As a stand alone treatment can do more harm than good

• Detoxification from opiates and alcohol are two very different events; detoxification from opiates is uncomfortable, but fairly safe

• Detoxification from alcohol is potentially dangerous, and can be permanently disabling or fatal

Alcohol withdrawal

Where can detoxifications take place?

• General Hospital• Psychiatric Hospital• Non statutory rehab or detoxification unit• Community

Community detoxification shows similar outcomes to inpatient – 75% successful in community

Community setting preferred by most patientsAccessibility and trust in practitioner is key advantageCost advantage

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• 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

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

NICE guidance

DES/LES

QOF

National Standards

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

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