Alcohol Identification and Brief Advice (IBA) - Messages for Primary Care

1. Alcohol Identification and Brief Advice (IBA) - Messages for Primary Care Don Lavoie Alcohol Programme Manager

2. 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? IBA - Messages for Primary Care

3. What is the problem? IBA - Messages for Primary Care

4. Annual Alcohol Consumption per UK Resident 1900-2010 12 10 Pure Alcohol (litres) 8 Coolers/FABs 6 Spirits Wine 4 Cider Beer 2 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 1945 1935 1940 2005 1930 2010 1900 1905 1910 1915 1920 1925 Sources: 1. HM Revenue and Customs clearance data 2. British Beer and Pub Association 3. Office for National Statistics mid-year population estimates Alcohol consumption over the years IBA - Messages for Primary Care

5. Alcohol consumption vs. price IBA - Messages for Primary Care

6. Alcohol consumption - Europe IBA - Messages for Primary Care

7. Why is this a problem? IBA - Messages for Primary Care

8. IBA - Messages for Primary Care

9. IBA - Messages for Primary Care

10. IBA - Messages for Primary Care

11. IBA - Messages for Primary Care

12. IBA - Messages for Primary Care

13. IBA - Messages for Primary Care

14. Alcohol - adds to health risks IBA - Messages for Primary Care

15. QOF registers and risky drinking IBA - Messages for Primary Care

16. What can you do about it? IBA - Messages for Primary Care

17. Don’t ignore it • Any 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 IBA - Messages for Primary Care

18. 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? IBA - Messages for Primary Care

19. Alcohol risk levels IBA - Messages for Primary Care

20. AUDIT – gold standard IBA - Messages for Primary Care

21. 2.3 UNITS 2.3 UNITS 3 UNITS 1 UNIT 10 UNITS 2 UNITS 1.7 UNITS IBA - Messages for Primary Care

22. Typical night in 8.4 UNITS Half IBA - Messages for Primary Care

23. Typical night out 14 UNITS Half Half IBA - Messages for Primary Care

24. Special night out Half 10 UNITS IBA - Messages for Primary Care

25. 40% of alcohol drunk by 10% IBA - Messages for Primary Care

26. 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 IBA - Messages for Primary Care

27. AUDIT - C IBA - Messages for Primary Care

28. Drinking “At Risk” groups Source: General Household Survey 2009 & mid-2009 population estimates (ONS) & Adult Psychiatric Morbidity Survey 2007 IBA - Messages for Primary Care

29. The numbers IBA - Messages for Primary Care 29

30. Primary Care - Alcohol Care Pathway Adult visiting GP Requesting help with alcohol problem New Registration Other health complaint Initial Screening Tools SASQ FAST AUDIT - C AUDIT - PC PositiveResult NegativeResult Full Screen AUDIT No action AUDIT Score 20+ Possible Dependence AUDIT Score 16-19 Higher-risk AUDIT Score 8-15 Increasing-risk AUDIT Score 0-7 Lower-risk Consider Referral to Specialist Services Lifestyle Counselling Brief Advice IBA - Messages for Primary Care Full Assessment

31. AUDIT Score IBA - Messages for Primary Care

32. 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 IBA - Messages for Primary Care

33. 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 IBA - Messages for Primary Care

34. Where do you sit? IBA - Messages for Primary Care

35. 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 IBA - Messages for Primary Care

36. 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 Care

37. This is one unit... For more detailed information on calculating units see - www.units.nhs.uk/ 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? How many units did you drink today? 1 very small glass of wine 1 single measure of spirits Half pint of regular beer, lager or cider 1 small glass of sherry 1 single measure of aperitifs (9%) ...and each of these is more than one unit 3 A pint of “strong”/”premium” beer, lager or cider Alcopop or a 275ml bottle of regular lager A pint of regular beer, lager or cider 440ml can of “regular” lager or cider 440ml can of “super strength” lager 250ml glass of wine (12%) Bottle of wine “regular” (12%) IBA - Messages for Primary Care

38. The benefits of cutting down • Psychological/Social/Financial • Improved mood • Improved relationships • Reduced risks of drink driving • Save money • Physical • 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’s everyone else like? % of Adult Population What targets should you aim for? Men Should not regularly drink more than 3–4 units of alcohol a day. Women Should 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. • 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 What is your personal target? 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. IBA - Messages for Primary Care

39. Alcohol Learning Resources IBA - Messages for Primary Care

40. IBA resources IBA - Messages for Primary Care

41. e – Learning courses IBA - Messages for Primary Care

42. Change 4 Life IBA - Messages for Primary Care

43. IBA support for primary care • Incentives (payments) • DES – New registrations • NHS 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 IBA - Messages for Primary Care

44. 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 IBA - Messages for Primary Care

45. Useful links • IBA resources and e-Learning module • http://www.alcohollearningcentre.org.uk/ • NICE guidance • http://guidance.nice.org.uk/PH24 • http://guidance.nice.org.uk/CG115 • Primary Care Framework • http://www.pcc-cic.org.uk/article/alcohol • SIPS Research Programme • http://www.sips.iop.kcl.ac.uk/index.php • Materials, Units Calculator and Drink Check http://www.nhs.uk/LiveWell/Alcohol/Pages/ • Alcoholhome.aspx IBA - Messages for Primary Care

46. IBA - Messages for Primary Care

47. 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) IBA - Messages for Primary Care

48. 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 - Messages for Primary Care

49. 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 IBA - Messages for Primary Care

50. 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 IBA - Messages for Primary Care