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