Alcohol Interventions: What the research tells us

1. Alcohol Interventions:What the research tells us Professor Colin Drummond

3. Alcohol use disorders: prevalenceDrummond et al., 2005 • 26% of the adult population have an alcohol use disorder (AUD) • Includes 38% of men & 16% of women aged 16-64 • 23% of the adult population are hazardous or harmful alcohol users (7.1 million people in England) • 21% of men and 9% of women engage in binge drinking • Prevalence of alcohol dependence is 3.6% overall, 6% among men, and 2% among women (1.1 million people in England) Alcohol dependence is considerably more prevalent than drug abuse Alcohol Needs Assessment Research Project, 2005

4. “The habit of drunkenness is a disease of the mind”

8. NICE Guidance 2010-11 • Alcohol use disorders • Preventing harmful drinking (PH24) • Diagnosis and clinical management of alcohol related physical complications (CG100) • Diagnosis, assessment and management of harmful drinking and alcohol dependence (CG) • Related guidance • Psychiatric comorbidity (CG) • Complex pregnancies (CG)

9. NICE Guidance 2010-11 • Alcohol use disorders • Preventing harmful drinking (PH24) • Diagnosis and clinical management of alcohol related physical complications (CG100) • Diagnosis, assessment and management of harmful drinking and alcohol dependence (CG) • Related guidance • Psychiatric comorbidity (CG) • Complex pregnancies (CG)

10. Preventing harmful drinking – evidence relevant to interventions • AUDIT high sensitivity and specificity • Laboratory markers poor screening tools • Brief interventions effective (27 systematic reviews) • Brief advice as effective as extended brief intervention ~ brief more cost effective • Brief interventions less effective in alcohol dependence than hazardous/harmful drinkers • Most evidence in primary care, limited for acute care & CJS settings

11. Preventing harmful drinking (PH24) • All NHS professionals and non-NHS • Routine alcohol screening • Universal • Targeted “if not feasible” • Validated screening tool (AUDIT, FAST etc) • Don’t use biological markers • Structured brief advice- all hazardous/harmful • Extended brief- non-responders • Referral of moderate/severe alcohol dependence/non-responders to brief interventions

12. Clinical management • Unplanned withdrawal: • Admit high risk, vulnerable and under 16s • Symptom triggered regime more cost effective • Benzodiazepine or carbamazepine • CIWA monitoring • Wernicke’s encephalopathy • Oral thiamine for most • Parenteral for malnourished, liver disease and in AED or admitted for acute illness or injury

13. Management of harmful drinking and alcohol dependence • Identification and assessment • Care coordination • Settings • Assisted withdrawal • Psychosocial interventions • Pharmacological interventions • Comorbidity • Children and young people

14. Identification and assessment • Competence • Motivational interviewing • Alcohol misuse, dependence, problems, risk, need for assisted withdrawal • Formal assessment tools (AUDIT, SADQ, LDQ, APQ, CIWA, MMSE) • Treatment goals • Children and young people

15. Care pathway – case identification and possible diagnosis for adults Screen (PAT, FAST, SASQ etc.) indicates possible alcohol use disorder Administer: AUDIT AUDIT 16–19 Harmful drinking AUDIT 20+ Probable alcohol dependence AUDIT < 8 AUDIT 8–15 Hazardous drinking Extended brief intervention(s) Referral to specialist assessment/withdrawal assessment Brief intervention Review of progress Referral to specialist assessment where no improve maintained Consider Tier 2 or 3 interventions/ immediate withdrawal assessment for acute inpatients settings and prisons Consider Tier 2 interventions

16. Interventions: delivery and setting • Competence, manuals, supervision • Care coordination • Case management – alcohol dependence • Stepped care and ACT • Inpatient withdrawal management • Structured intensive community programme • Moderate severe dependence, social support, complex needs • Residential rehabilitation • Moderate severe dependence AND homeless • 3 months

17. Interventions • Harmful/mild dependence • CBT, BT, Social Network therapy • BCT • Non-responders: offer acamprosate, naltrexone plus psychosocial • Moderate/severe dependence • Assisted withdrawal • Intensive community programme • Acamprosate or naltrexone plus • CBT, BT, SNT, BCT • Disulfiram (second line, suitability/preference) • Children and young people under 18 • Inpatient for withdrawal • CBT, multi-component programmes • Acamprosate or naltrexone (second line 16-18 only) • Families and carers • Assessment and intervention in their own right

18. Association between baseline severity and effect size in naltrexone versus placebo trials (logRR)

19. Assisted withdrawal • Threshold for assessment: >20 AUDIT >15 units/day • Community based withdrawal programme - most • Inpatient assisted withdrawal • >30 SADQ, fits or DTs • OR 15-30 plus benzodiazepine, mental or physical comorbidity, learning disability, cognitive impairment • Lower threshold for homeless, older, younger, pregnancy, homeless • Regimes • Community: fixed dose • Inpatient: fixed dose or symptom triggered

20. AUDIT AUDIT > 20 Consider need for alcohol withdrawal AUDIT < 20  Outcome of assessment SADQ < 15 Typical drinks per day < 15 SADQ 15–30 Typical drinks per day < 30 units Absence of comorbid features SADQ ≥ 30 Typical drinks per day ≥ 30 units Comorbid features present Outpatient (Tier 3 interventions): Assisted alcohol withdrawal Consider Tier 2 or 3 interventions: Psychological and pharmacological interventions Comprehensive assessment where comorbid features present Inpatient (Tier 4 interventions): Assisted alcohol withdrawal

22. Gap between need and access (PSUR) by region