Steve Brinksman GP South Birmingham PCT RCGP West Midlands Regional Lead stevebrinksman@doctors.org.uk

1. Steve Brinksman GP South Birmingham PCT RCGP West Midlands Regional Lead stevebrinksman@doctors.org.uk

2. Is it really a big deal?

3. Alcohol consumption in the UK: 1900 - 2000 Per capita consumption (100% alcohol) Source: British Beer and Pub Association 2000

4. 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

5. 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)

6. Mortality from chronic liver disease and cirrhosis in England

7. Alcohol and Mental Health • 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

8. 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

9. Political context • Problem drinking costs UK society in excess of £15bn per year • vs. • Drinks market generates £30bn and one million jobs

10. 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

11. 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

12. 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

13. 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

14. 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

15. Constraints Financial Health budget not cut but….. Deficits within PCOs

16. Constraints Time and Training Increasing workload in Primary Care Lack of established training Ambivalence and Inertia

17. What next?

18. Setting standards Across all parts NHS Social Services Education Criminal Justice System

19. Prevention • Education • Change public perception • Minimum pricing

20. Screening and brief intervention • Essential part of primary care practitioner training • RCGP training • Increased provision alcohol workers in Primary Care

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

22. 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

23. Screening tools in primary care

24. Brief Interventions

25. 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.

26. 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

27. 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)

28. 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.

29. Detoxification • Increase access to this both community based and residential / inpatient • Set minimum standards for waiting times • Aftercare provision essential

30. Typology (general population) DoH 2005

31. 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

32. Alcohol withdrawal

33. 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 patients Accessibility and trust in practitioner is key advantage Cost 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

34. 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

35. 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

36. 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

37. 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

38. National standards • NICE guidance • DES/LES • QOF

39. 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.

40. 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

41. “This is my truth now tell me yours” Aneurin Bevan