Iain Armstrong Improving Health and Wellbeing UK

1. Alcohol IBA – Effective in Primary Care will it work in Social Work? Iain ArmstrongImproving Health and Wellbeing UK Reducing the costs from alcohol–related harm

2. Risk Levels

4. Drinking categories 6.6m15.8% 26.3m 62.5% 6.9m16.5% 60% 15% 6.9m16.5% 1.6m3.8% 2.2m 5.2% Source: General Household Survey 2009 & mid-2009 population estimates (ONS) & Adult Psychiatric Morbidity Survey 2007 4

5. Cost to the NHS • 7% of all hospital admissions • In 2009/10 there were around 1.1 million alcohol related hospital admissions • an increase of 12% compared with 2008/9. • Up to 35% of all A&E attendance and ambulance costs may be alcohol-related • Up to 70% of A&E attendances at peak times on the weekends (between midnight and 5am) may be alcohol-related • Alcohol misuse is calculated to cost the health service £2.7bn per annum

6. Alcohol accounts for • Between 15,000 and 22,000 premature deaths annually in England and Wales each year • Nearly 5,000 (3.5%) cancer deaths per annum are attributable to alcohol • Cancers of the oral cavity and pharynx, larynx, oesophagus and liver • Suggestive but inconclusive data for role in rectal and breast cancer • A severe risk of cardiovascular disease • 1,200 associated deaths per year due to haemorrhagic stroke • 10% of deaths due to hypertension • Liver Cirrhosis is now the 5th most common cause of death and continues to rise • The top 4 conditions – HD, CVD, Chronic Lung Disease and Cancer deaths are all falling. • Alcohol accounts for 58% of all Liver Disease • 4,500 deaths, a 90% increase over the past decade

7. Crime-related Impact from alcohol • 986,000 violent incidents in England and Wales in 2009/10, where the victim believed the offender to be under the influence of alcohol (50% of all violent crimes) (Flatley et al., 2010) • Nearly half of all offences of criminal damage are alcohol-related • alcohol is implicated in domestic violence, sexual assaults, burglary, theft robbery and murder (Prime Minister‘s Strategy Unit, 2003) • In 2008 estimated 13,020 reported road casualties (6% of all road casualties) occurred when someone was driving whilst over legal limit. • The provisional number of people estimated to have been killed in drink-drive accidents was 430 in 2008 (17% of all road fatalities) (Department of Transport, 2009) • Approximately two thirds of male prisoners and over a third of female prisoners are hazardous or harmful drinkers and up to 70% of probation clients are hazardous or harmful drinkers (Singleton, et al., 1998)

8. Risks

9. QOF Registers

10. What Can Social Workers Do? • Identify those at risk • Deliver Brief Advice to those drinking at increasing and higher risk • Refer Dependent Drinkers to Specialist Services

11. Identification

12. Point of Clarification • Opportunistic alcohol case Identification and the delivery of Brief Advice (IBA) is the same as • Screening and Brief Interventions for alcohol misuse (SBI)

13. Alcohol Identification • Alcohol risk levels can be quickly ascertained using a simple screening tool

14. AUDIT – Gold Standard

15. AUDIT – Gold Standard • Developed by WHO • Validated screening tool • High specificity (94%) • High sensitivity (92%) • Adapted version for the UK • Various shortened adaptations for pre-screening • More accurate and economical than most bio-chemical tests

16. Brief Advice(or Brief Intervention)

17. FRAMES - six essential elements • Feedback - provides feedback on the client’s risk for alcohol problems • Responsibility - the individual is responsible for change • Advice - advises reduction or gives explicit direction to change • Menu - provides a variety of options for change • Empathy - emphasises a warm, reflective and understanding approach • Self-efficacy - encourages optimism about changing behaviour

18. Brief Advice • The recommended brief intervention is 5 minutes of advice developed by the WHO • In the UK, the University of Newcastle had refined this into a programme called How Much Is Too Much? • Content • Understanding units • Understanding risk levels • Knowing where they sit on the risk scale • Benefits of cutting down • Tips for cutting down

19. 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

20. 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

21. 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%)

22. 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.

23. IBA - Evidence

24. Evidence for IBA • There is a very large body of research evidence • 56 controlled trials (Moyer et al., 2002) all have shown the value of IBA • A recent Cochrane Collaboration review (Kaner et al., 2007) shows substantial evidence for IBA effectiveness • For every eight people who receive simple alcohol advice, one will reduce their drinking to within lower-risk levels (Moyer et al., 2002) • This compares favourably with smoking where only one in twenty will act on the advice given (Silagy & Stead, 2003)

25. Barriers • Staffing and staff attitudes • Don’t have time • Not my job • Uncomfortable commenting on patient’s personal life • To close to home • Don’t feel trained to intervene • Don’t believe it will do any good • Focus on dependence 25

26. Mitigation • Not my job • ‘Every contact counts’ • reduces problems caused by alcohol • Training • Less is more • E-learning 26

27. Can IBA be effective in non-health settings? • The SIPS study recently published findings of three randomised control trials on IBA using various screening tools, levels of intervention and in three different settings. • Primary Care • A&E • Probation 27

28. Can IBA be effective in non-health settings? In probation • Training crucial • Alcohol Health Worker support crucial • Senior management buy in crucial • But IBA can be equally effective in a non-health setting if adequately supported and delivered by well trained practitioners 28

29. Useful Links • IBA e-Learning module & Alcohol Learning Centre 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.nhs.uk/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 29