Screening & brief alcohol interventions in primary care

1. Professor Nick Heather Dr Eileen Kaner Dr Paul Cassidy Session 1 - Background & Screening Screening & brief alcohol interventions in primary care

2. What is a standard unit of alcohol? • 1 Unit equals: 1 half pint of beer, lager or cider (3.5% abv) 1 pub measure (125ml) of wine (8% abv) 1 pub measure (50ml) of fortified wine (20% abv) 1 pub measure (25ml) of spirits (40% abv)

3. How much is too much?

4. Alcohol-related harm: acute • Homicide • Suicide • Other intentional injuries (i.e., interpersonal violence) • Domestic violence • Sexual assault • Unprotected sex • Motor vehicle accidents • Other accidents • Drowning • Burns • Public disorder

5. Alcohol-related harm: chronic • Liver cirrhosis and other forms of alcohol-related liver disease • Hypertension and haemorrhagic stroke • Cancers of the mouth, larynx, pharynx and oesophagus • Other cancers, including breast cancer • Foetal Alcohol Syndrome (FAS) and foetal alcohol effects • Mental illness • Alcohol Dependence Syndrome

6. Alcohol-related harm: social problems • Lower workplace productivity • Unemployment • To family & social networks • Truancy & school exclusion • Homelessness • Economic costs

7. Recommended limits • Adult Women: regular consumption of no more than 2-3 units per day and no more than 14 units per week • Adult Men: regular consumption of no more than 3-4 units per day and no more than 21 units per week • Lower limits in younger people (< 18 years) • 2 alcohol-free days after an episode of heavy drinking • Consistent consumption at the upper limit is not recommended • “Very heavy” drinking is defined as over 35 (women) or 50 (men) units/week

8. Terminology • Low-risk drinking - below medically recommended limits • Hazardous drinking - a pattern of consumption which increases the risk of harm (physical, psychological or social), i.e., drinking above recommended limits • Harmful drinking - a pattern which is likely to have already led to harm (physical, psychological or social) or, for some purposes, drinking at “very heavy” levels • Binge drinking – originally episodic heavy drinking but now heavy drinking in a single session, i.e., twice the daily limit, above 6 units for women 8 units for men • Alcohol dependence – a cluster of physiological, behavioural and cognitive phenomena conforming to the “alcohol dependence syndrome”.

9. How the English population drinks

10. Prevalence • 27% of adult (16+) males and 15% of adult females are hazardous drinkers or above • 6% of adult males and 3% of adult females are “very heavy drinkers” • In 2001, 21% of men and 9% of women reported “binge drinking” at least once in preceding week • Average GP sees 364 hazardous/harmful drinkers per year; however most GP’s have only 7 patients registered for alcohol problems • GPs may be missing as many as 98% of hazardous and harmful drinkers on their lists • In terms of years lost to poor health and premature death, excessive alcohol consumption is the 3rd most important risk factor after smoking and raised blood pressure • It has recently been estimated that alcohol-related harm costs England £20 billion each year

11. Screening for hazardous & harmful drinking • Screening is necessary to detect risky drinkers whose level of consumption may not be apparent • Short questionnaires are the most efficient way of screening • Biochemical markers (GGT, MCV, CDT) are relatively expensive, intrusive & no more accurate than questionnaires • Screening can be universal (nearly all patients attending PHC are screened) or targeted (specific groups screened) • Targeting can be directed at patients unlikely to object to questions about alcohol (e.g. new patient registrations) or patients whose condition makes alcohol relevant (e.g. diabetes & CHD clinics, Emergency contraception etc.) • Patients who under-estimate their alcohol consumption can be assumed not to wish to receive advice about it and have a prefect right to hold this view.

12. Screening tools suitable for primary care • Full AUDIT (10 items) • AUDIT-C (3 items) • FAST (1 item plus 3 further items depending on response to 1st item) • SASQ (1 item)

14. Harmful 16-19 Hazardous 8-15 Low risk 1-7 Abstainers 0 Drinker typology based on AUDIT scores Possible Dependence 20-40 Diagnose & refer to specialist service Brief counselling/follow-up Simple structured advice Positive reinforcement ? No action indicated

15. Shortened versions of AUDIT • The full AUDIT tool has the best sensitivity and specificity (overall accuracy) but takes longer to complete • In routine consultations a shortened version of AUDIT may be more feasible • However, there is a trade-off between shortness of the screening tool and its accuracy • Several practices in the Tyne & Wear HAZ Project used AUDIT-C and FAST and were satisfied with them.

16. AUDIT-C • Stands for AUDIT-consumption questions • Consists of first 3 items from the full AUDIT, q.v. • Takes 1 minute to administer • A score of 5+ is indicative of hazardous or harmful drinking • Men: 78% sensitivity & 75% specificity • Women: 50% sensitivity & 93% specificity • AUDIT-C cannot by itself be used to determine which level of brief intervention is appropriate or if a referral for treatment is called for. • In the event of a positive result on AUDIT-C, these decisions should be based on clinical judgement or administration of the full AUDIT

17. The Fast Alcohol Screening Test (FAST)

18. SASQ • Stands for Single Alcohol Screening Question • “When was the last time you had more than X drinks in 1 day”, where X=6 for women and X=8 for men • Never/ More than 12 months ago/ 3-12 months ago/ Within the past 3 months • “Within the past 3 months” = +ve response • Sensitivity and specificity = 86% for detecting hazardous drinking in past 3 months or alcohol use disorder in past year • Equally efficient among men and women

19. What do the finding of screening mean? • A positive screen indicates a high likelihood of alcohol-related risk or harm • Screening questionnaires are not diagnostic instruments • However, they are highly accurate • Patients who screen positively will benefit from brief intervention • Structured advice • Extended (motivational) intervention

20. What is brief alcohol intervention? • “… the giving of information, advice and encouragement to the patient to consider the positives and negatives of their drinking behaviour, plus support and help to the patient if they do decide they want to cut down on their drinking.” • “Brief interventions are usually ‘opportunistic’ – that is, they are administered to patients who have not attended a consultation to discuss their drinking” (from the Alcohol Harm Reduction Strategy for England, p.37)

21. Features of brief interventions • A family of interventions ranging from a few minutes simple but structured advice to 20 minutes counselling with repeat consultations • We recommend 2 levels of brief intervention: • (i) simple structured advice ~ 1-2 minutes to deliver • (ii) brief counselling (extended brief intervention) ~ 10-20 minutes • Brief interventions are delivered by generalists in community settings, e.g. GPs, practice nurses, health visitors, dieticians and other primary health care professionals in the normal course of their work • But they can also be delivered by more specialist workers (CPNs, lifestyle counsellors, alcohol health workers) or NHS health trainers if one is employed by the practice • Normally aimed at a goal of low-risk drinking (i.e., under medically-recommended levels) • But patients who prefer to become abstinent should not be discouraged

22. What is the rationale for screening and brief intervention? • Early intervention and secondary prevention, i.e., of medical and social harm but also more severe dependence • Contribution to public health – broadening the base of interventions against alcohol-related harm • Reduced use of health-care resources and cost-effectiveness

23. ADVANTAGES OF LOCATING SBI IN PRIMARY HEALTH CARE • 78% of population visit GP at least once a year • Stigma avoided • Intervention possible at “teachable moments” • Intervention in context of ongoing relationship with patient and family • Advice from GPs, practice nurses and other PHC staff likely to be respected

24. Who are the targets for SBI ? • Hazardous drinkers, including regular excessive drinkers & “binge drinkers” • Harmful drinkers, including regular excessive drinkers & “binge drinkers” • NOT “alcoholics”

25. Evidence of effectiveness • Over 56 controlled trials of effectiveness, most in primary care • At least 13 meta-analyses and/or systematic reviews, including 5 specifically focused on primary care and reaching favourable conclusions • In the best meta-analysis so far (Moyer et al., 2002), small to medium aggregate effect sizes in favour of brief interventions emerged across different follow-up points • At follow-up of 3-6 months or more, the effect for brief interventions compared to control conditions was significantly larger when individuals showing more severe alcohol problems were excluded from the analysis

26. Evidence of effectiveness cont… • Estimates of NNT range from 8 to 12 • This compared favourably smoking cessation advice (NNT = 20) • Some recent evidence of a reduction in mortality following SBI • Also evidence of reductions in number of alcohol-related problems • Effects of intervention still present after 4 years in one US study and after 10-16 years in a Swedish study, though an Australian study did not find an effect after 10 years

27. Summary • Screening and brief intervention (SBI) for hazardous and harmful drinkers in PHC is effective in reducing alcohol-related harm • SBI is highly cost-effective in terms of reducing future burden on NHS • Screening should be targeted rather than universal • Patients who have a positive screen should be offer simple structured advice • If resources permit, brief counselling would benefit harmful drinkers and more ‘interested’ patients • Patients with significant alcohol dependence should be referred for more intensive intervention