West Midlands Mental Health Commissioning Network

Alcohol - a Primary Care Perspective

Steve Brinksman Clinical Director (SMMGP) - Substance

Misuse Management in General Practice

www.SMMGP.org.uk

The scale of the problem

Why primary care needs to be involved

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

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 suicidesCrime• £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 problemsWorkplace• £6.4bn, 17m working days lostFamily and social• 20,000 street drinkers• Up to 1.3m children affected by alcohol misuse

Liver disease

600

500

400

300

200

100

0

Valu

e

19

70

19

72

19

74

19

76

19

78

19

80

19

82

19

84

19

86

19

88

19

90

19

92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

Year

CirculatoryIschaemic heartBrainCancerRespiratoryLiverEndocrineDiabetesBlood

Death rates for people under age 65 from major diseases compared with

1970 – UK

Sheron et al.

• 2x increase in consumption

• 5x increase in death rates

The relentless rise of liver deaths in the UK!

British Liver Trust analysis of Office for National Statistics mortality statistics covering all deaths related to liver

dysfunction, January 2009

WHO Drinking Risk Levels

EMA treatment guidelines (WHO International guide for monitoring alcohol consumption and related harm. © WHO, 2000

1 UK unit = 8g alcohol

Drinking risk levels TAC (g/day) – women

TAC (g/day) – men

Very high-risk consumption >60 g >100 g

High-risk consumption 40–60 g 60–100 g

Medium-risk consumption 20–40 g 40–60 g

Low-risk consumption 1–20 g 1–40 g

According to this definition, ‘high-risk’ drinking equates to just 7.5 units per day (e.g. ¾ of an average 750ml

bottle of 13% wine or just 3 pints of 4.4% beer) for men and 5 units per day for women.

Typology (general population)

1) McManus S et al. NHS Information Centre 2009

Severely dependent drinkers (0.1%)Moderately dependent drinkers (0.4%)

Harmful drinkers (3.8%)

Hazardous drinkers (20.4%)

Low-risk drinkers (55.9%)

Non-drinkers (14.0%)

Mildly dependent drinkers (5.4%)

Total Alcohol Dependence =

5.9%

Alcohol Use Disorders in England

Hazardous use of alcohol:1

24% population

33% males

16% females

Alcohol Dependent 5.9%2 (1.6 milllion3)

3.3% F; 8.7% M

Severe AD0.1%2

The latest 2012 estimate is that alcohol misuse costs the NHS in England £3.5bn each year3

1) Clinical Guideline 115 Alcohol Use Disorders. National Institute of Health and Clinical Excellence 2011

2) McManus S et al. NHS Information Centre 2009 3) National Treatment Agency for Substance Misuse, 2012

Alcohol consumption is the third highest risk factor for ill-health

1) Lim S et al. Lancet. 2013; 380(9859): 2224-60.2) World Health Organization (WHO). Global Status Report on Alcohol &

Health, 2011

Disability-adjusted life-years (%)

High blood pressure

–0.5 2 4 6 8

Tobacco smoking, including second-hand smoking

Alcohol use

Household air pollution from solid fuels

Diet low in fruits

High body-mass index

High fasting plasma glucose

Childhood underweight

Ambient particulate matter pollution

Physical inactivity and low physical activity

0

Burden of disease in 2010 by risk factor (male and female)

% o

f all d

eath

s by a

ge g

rou

pN

um

ber

of

dea

ths

2,500

2,000

1,500

1,000

500

0

30

25

20%

15

10

5

016–24 25–34 35–44 45–54 55–64 65–74 75+

Age group

Male deaths from alcohol in the UK by age band (2005)1

In England in 2010, 15,500 deaths were estimated to be attributable to alcohol consumption2

Wholly attributable conditions

Partially attributable acute conditions

Partially attributable chronic conditions

% of all deaths by age group

Alcohol – a common reason for death in men under 50

1. Jones et al 2012: http://www.nwph.net/nwpho/publications/alcoholattributablefractions.pdf

2. National Treatment Agency for Substance Misuse, 2012

Relative risk of comorbid disease by alcohol consumption

White et al. BMJ 2002;325(7357):191

0 10 20 30 40 50 60 70 80

Alcohol (units/week)

0 10 20 30 40 50 60 70 80

Alcohol (units/week)

0 10 20 30 40 50 60 70 80

Alcohol (units/week)

0 10 20 30 40 50 60 70 80

Alcohol (units/week)

0 10 20 30 40 50 60 70 80

Alcohol (units/week)

5.0

4.0

3.0

2.0

1.0

0.0

Rela

tive

ris

k

5.0

4.0

3.0

2.0

1.0

0.0

Rela

tive

ris

k

5.0

4.0

3.0

2.0

1.0

0.0

Rela

tive

ris

k

Lip, pharynx, and oral cancer Oesophageal cancer Colon cancer Rectal cancer Ischaemic heart disease

Liver cancer Laryngeal cancer Breast cancer Essential hypertension Injuries

Ischaemic stroke Haemorrhagic stroke Cirrhosis Non-cirrhotic chronic liver diseaseChronic pancreatitis

WomenMenMen and women

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

Brief Interventions are to help the patient understand

• What consequences likely to be

• What they can do about it

• What help is available

Screening and Brief Interventions

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

AUDIT

• Developed by the WHO specifically for use in primary care

• Validated in more than 22 countries• Sensitivity and specificity are high for criteria that

define current hazardous use• Seen as gold standard in screening tools• Takes five minutes to complete, one minute to score• Sensitivity 92% and specificity 94% to identify

increased, higher risk and possible dependent drinking

Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Addiction. 1993 Jun;88(6):791-804.

• AUDIT score of 8 - 15 = Hazardous drinking or increasing risk

• AUDIT score of 16 - 19 = Harmful drinking or higher risk• 10% of the population • often binge drinkers • At risk of suffering problems with the four Ls: Liver, Lover,

Livelihood, Law

• AUDIT 20 + = severe problems• Approximately 6% of the population • Includes alcohol dependency syndrome

AUDIT scores

When to screen - targetingPatients 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

Brief Interventions – FRAMES

A structure of Brief Interventions

Feedback (personalised)

Responsibility (with patient)

Advice (clear, practical)

Menu (variety of options)

Empathy (warm, reflective)

Self-efficacy (boosts confidence)

Bien, T. H., Miller, W. R. and Tonigan, J. (1993) Brief interventions for alcohol problems: a review. Addiction 88, 315–336.

Effect of a brief intervention1 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

Lifetime risk of death due to alcohol-related injury

Potential benefits of reduction on mortality

Rehm et al. Addiction 2011;106(Suppl 1):11–19

Men

Women

0 20 40 60 80 100

Alcohol consumption (g/day)

18

12

4

0

Ris

k o

f d

eath

(%

)

16

8

10

2

14

6

Reductions in high consumers big health benefits

Reducing unhealthy alcohol consumption reduces health harms

• Improvements in:– Blood pressure1

– Depression2

• Lowers lifetime risk of developing:3,4

– Cancer– Cardiovascular disease– Diabetes– Epilepsy– Stroke– Liver Disease

Rapid remission of depressionin patients with alcohol dependence2

N=191

1) Xin X et al. Hypertension 2001; 38 (5): 1112–11172) Brown SA & Schuckit MA. J Stud Alcohol 1988; 49 (5): 412–417

3) Gastfriend DR et al.. J Subst Abuse Treat 2007; 33 (1): 71–804) Rehm J et al. Addiction 2011; 106 (suppl 1): 11-19

Brown & Schuckit 1988

6%

42%

0

20

40

60

Admission 4 weeks afteralcohol

withdrawal

Pe

rce

nta

ge

of

pa

tie

nts

wit

h d

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n (

%)

When to refer to specialist services?

Patients should be referred to specialist services who:

• Have a high level of alcohol dependence ( see later)

• Have a high level of alcohol-related harm, with poor physical and mental health and social situation

• Are harmful drinkers who have not benefited from brief counselling and wish to receive further help for their alcohol problems.

Diagnosis of alcohol dependenceICD-10 classification of alcohol dependence1

• A diagnosis of alcohol dependence should be made when any three or more of the following criteria have been present simultaneously during the past year

WHO. ICD-10, F10–F19

Cognitive/Behavioural

1 A strong desire orcompulsion to take alcohol2 Difficulties in controlling the use of alcohol

Consequences

3 Neglect of alternative interests due to alcohol use4

Persisting alcohol use despite evidence of harm

Physiological

5 Tolerance to the effects of alcohol6 Withdrawal symptoms

Only 6% of people with alcohol dependence receive treatment each year1

In 2009, under 10% of drinkers had discussed their alcohol consumption with a healthcare professional2

Treating additional dependent drinkers will save significant amounts of NHS expenditure

Alcohol dependence is significantly under-diagnosed and under-treated in the UK

1) Alcohol Concern 2010, NHS 2) The Health and Social Care Information Centre 2011

Intervening with dependent drinkers • Assessment (AUDIT> 35)• Need for medically assisted withdrawal and

assessment of co-morbidity • Motivation to change • Preparatory investigations• Case management approach/shared care

Healthcare professionals can use quick and simple, validated tools that are recommended by NICE to help identify patients that may benefit from reduction1

Psychosocial support is the backbone of an effective management strategy for alcohol dependence. Brief interventions and counselling are effective tools for primary healthcare professionals to help people to achieve their goals2

Overwhelming evidence suggests that through appropriate treatment, people with alcohol misuse problems can change their behaviour2,3

Management of alcohol dependence can be implemented in primary and secondary care

1) Clinical Guideline 115. Alcohol-use disorders. National Institute for Health and Clinical Excellence February 2011

2) British Liver Trust. 20113) Dawson DA et al. Addiction 2005; 100 (3): 281–292

Ridiculous £20 a bottle

It would only be a fiver in Birmingham

Whinge Drinkers