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Alcohol Identification and Brief Advice (IBA) - Messages for Primary Care. Don Lavoie Alcohol Programme Manager. 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?. What is the problem?.

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alcohol identification and brief advice iba messages for primary care

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

Don Lavoie

Alcohol Programme Manager

what i hope to cover
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

what is the problem
What is the problem?

IBA - Messages for Primary Care

alcohol c onsumption o ver the years

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

alcohol consumption vs price
Alcohol consumption vs. price

IBA - Messages for Primary Care

alcohol consumption europe
Alcohol consumption - Europe

IBA - Messages for Primary Care

why is this a problem
Why is this a problem?

IBA - Messages for Primary Care

alcohol adds to health risks
Alcohol - adds to health risks

IBA - Messages for Primary Care

qof registers and risky drinking
QOF registers and risky drinking

IBA - Messages for Primary Care

what can you do about it
What can you do about it?

IBA - Messages for Primary Care

don t ignore it
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

typical alcohol i dentification q uestions
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

alcohol risk l evels
Alcohol risk levels

IBA - Messages for Primary Care

audit gold s tandard
AUDIT – gold standard

IBA - Messages for Primary Care

slide21

2.3 UNITS

2.3 UNITS

3 UNITS

1 UNIT

10 UNITS

2 UNITS

1.7 UNITS

IBA - Messages for Primary Care

typical night in
Typical night in

8.4

UNITS

Half

IBA - Messages for Primary Care

typical night out
Typical night out

14

UNITS

Half

Half

IBA - Messages for Primary Care

special night out
Special night out

Half

10 UNITS

IBA - Messages for Primary Care

40 of alcohol d runk by 10
40% of alcohol drunk by 10%

IBA - Messages for Primary Care

public perception of alcohol risk
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

audit c
AUDIT - C

IBA - Messages for Primary Care

drinking at risk groups
Drinking “At Risk” groups

Source: General Household Survey 2009 & mid-2009 population estimates (ONS) & Adult Psychiatric Morbidity Survey 2007

IBA - Messages for Primary Care

the numbers
The numbers

IBA - Messages for Primary Care

29

slide30

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

audit score
AUDIT Score

IBA - Messages for Primary Care

brief advice frames
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

alcohol brief advice
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

where do you sit
Where do you sit?

IBA - Messages for Primary Care

benefits of cutting down
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

tips for cutting down
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

slide37

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

slide38

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

alcohol learning resources
Alcohol Learning Resources

IBA - Messages for Primary Care

iba resources
IBA resources

IBA - Messages for Primary Care

e learning courses
e – Learning courses

IBA - Messages for Primary Care

change 4 life
Change 4 Life

IBA - Messages for Primary Care

iba support for p rimary care
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

the message for primary care
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

useful links
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

does iba work
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

impact of iba
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

iba is cost effective
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

sips findings
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

smmgp rcgp sips statement
SMMGP / RCGP – SIPS Statement
  • Alcohol screening, followed by simple feedback, supported by written alcohol information is an accessible and easy way to make a difference
  • BUT – this is “more than just a leaflet” – appropriate feedback about the screening results and appropriate tailored information pertaining to the patients situation need to be delivered – supported by a leaflet or written alcohol information
  • Longer forms of advice and brief lifestyle counselling did not appear to confer extra benefit and should be reserved for patients who do not respond to simple advice
  • All primary care teams are encouraged to implement this strategy
  • Although targeted screening approaches are more efficient, SMMGP & RCGP, in line with NICE guidance, universal screening in primary care should be considered

IBA - Messages for Primary Care

why don t you do it
Why don’t you do it?

IBA - Messages for Primary Care

barriers to gp implementation
Barriers to GP implementation
  • Doctors are just too busy dealing with the problems people present with
  • Doctors are not trained in counselling for reducing alcohol consumption
  • Doctors have a disease model training and they don’t think about prevention
  • Doctors are not sufficiently encouraged to work with alcohol issues in the current GMS contract
  • Doctors do not believe that patients would take their advice and change their behaviour
  • Doctors do not know how to identify problem drinkers who have no obvious symptoms of excess consumption
  • Doctors themselves have a liberal attitude to alcohol
  • Doctors themselves may drink more than what is healthy for them
  • Doctors think that preventive health should be the patients’ responsibility, not theirs
  • Doctors believe that patients would resent being asked about their alcohol consumption
  • Doctors feel awkward about asking questions about alcohol consumption because saying someone has an alcohol problem could be seen as accusing them of being an alcoholic

IBA - Messages for Primary Care

gps suggestions
GPs suggestions
  • General support services (self-help/counselling) were readily available to refer to
  • Early intervention for alcohol was proven to be successful
  • Patients requested health advice about alcohol consumption
  • Quick and easy counselling materials were available
  • Quick and easy screening questionnaires were available
  • Training programmes for early intervention for alcohol were available
  • Public health education campaigns in general made society more concerned about alcohol
  • Providing early intervention for alcohol was included in the Quality and Outcomes Framework (QOF)

IBA - Messages for Primary Care

gp suggested policies
GP suggested policies
  • Policy Effective % agreement
  • Improve alcohol education in schools 71%
  • Further regulation of alcohol off-sales (e.g. supermarkets)57%
  • Institute minimum pricing for units of alcohol 55%
  • Increase restrictions on TV & cinema alcohol advertising54%
  • Lower blood alcohol concentration limit for drivers 53%
  • Make public health a criterion for licensing decisions 49%
  • Raise minimum legal age for purchasing alcohol 48%
  • General changes in alcohol price through taxation 48%
  • Statutory regulation of alcohol industry 43%
  • Raise minimum legal age for drinking alcohol 39%
  • Government monopoly of retail sales of alcohol 27%

IBA - Messages for Primary Care

government ambivalence
Government ambivalence

IBA - Messages for Primary Care

references
References
  • Anderson, P. (2008) Reducing heavy drinking and alcohol admissions (Unpublished) Department of Health.
  • Fleming, M.F., Marlon, M.P., French, M.T., Manwell, L.B., Stauffacher, E.A. and Barry, K.L. (2000) Benefit cost analysis of brief physician advice with problem drinkers in primary care settings, Medical Care, 31(1): 7-18.
  • Kaner E, Beyer F, Dickinson H, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Bernand B. Brief interventions for excessive drinkers in primary health care settings. Cochrane Database of Systematic Reviews 2007, Issue 2. Art No.: CD004148 DOI: 10.1002/14651858.CD004148.pub3.
  • Kaner E, et.al .Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. BMJ 2013;346:e8501
  • Moyer, A., Finney, J., Swearingen, C. and Vergun, P. (2002) Brief Interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment -seeking and non-treatment seeking populations, Addiction, 97, 279-292.
  • University of Sheffield (2009) Modelling to assess the effectiveness and cost effectiveness of public health related strategies and interventions to reduce alcohol attributable harm in England using the Sheffield alcohol policy model version 2.0 [online]. Available from www.nice.org.uk/guidance/PH24
  • Whitlock, E.P., Polen, M.R., Green, C.A., Orleans, T. and Klein, J. (2004) Behavioral counselling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the US Preventive Services Task Force. Annals of Internal Medicine, 140, 557-568.
  • Wilk, A.I., Jensen, N.M. and Havighurst, T.C. (1997) Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers, Journal of General Internal Medicine, 12, 274-283.
  • NICE GUIDANCE:
  • http://guidance.nice.org.uk/PH24

IBA - Messages for Primary Care