How brief can you go? A history of IBAs and

Brief Literature Review Andrew MacDonald

Prolonged drinking leads to...Acute & Chronic Issues

Acute settings

• 70% of accident and emergency• 1,000 suicides per annum • 44% domestic abuse cases

Chronic settings

• liver cirrhosis• Obesity• Hypertension• Coronary heart disease• Pancreatitis• Various cancers• Mental health problems

(Faculty of Public Health, 2012)

And doesn’t taste nice...

‘...His mouth had been used as a latrine by some small creature of the night, and then as it’s mausoleum...’

(Kingsley Amis, 1954)

And it costs...££££££££££££££££

NHS

• The cost of alcohol related harm in England to the NHS alone is currently estimated at £2.7bn per annum

(LGA 2013)

NW Economy

• The cost to the North West economy in 2010-2011 has been estimated at over £3bn across NHS, Social Care, Workforce, and Community Safety

(Drink Wise North West, 2012)

Professor Griffith Edwards

‘...Good luck to the specific therapies, psychological and pharmacological...

... let’s not put them down, but at the centre is still the...little understood core of the change process... ’

Drummond & Ashton, 1999

Where did it all begin?

Origins Scotland 1980s• Davies, 1962, Edwards, 1977

Resolution of ‘Abstinence’ versus ‘Controlled Drinking’ controversy

• Jellinek, 1960 Up to the 1960s, ‘alcoholism’ disease of the individual and not a matter for public health

• Heather & Robertson, 2006 Last 50 years assumption strongly challenged – with support even chronic recover

3 seminal articles• Edwards et al., 1977 signalled

end ‘disease’ model - shift to community with specialist support

• Chick et al., 1985 screening hospital and IBA reduced problems

• Wallace et al., 1988 IBA via non-specialist GPs persisting reductions consumption of patients screened for excessive drinking

And so on...NICE 2007:

Sociologists cited for IBAs!

• Babor et al., 2001a, 2001b AUDIT and IBAs

• Bourdieu, 1977 ‘Habitus’• Giddens,1984, Putnam, 2000

‘Society’ and ‘Social Capital’• Ajzen ,1991, 1992 ‘Theory of

Planned Behaviour’ and ‘Persuasive Communication’

• Bandura, 1994 ‘Self-Efficacy’• Prochaska & DiClemente 1986

Stages of Change and initiation of recovery

• Marlatt & Gordon 1987 Relapse Prevention – Triggers

Contrast with ‘Recovery’

• Raistrick et al., 2006 Help-seeking = prolonged problems = after attempts unassisted change have failed

• White & Kurtz, 2005 Several attempts several years

• Winnick, 1962, Vaillant, 1995 5% problem drinkers recover ‘naturally’ every year – tend to have better ‘Social Assets’

IBA in a nutshell

Who and What • Alcohol ‘brief intervention’ is

good public health advice on alcohol use delivered by non-alcohol specialist in the normal course of their work.

• Offered to drinkers who are not complaining about or seeking help for an alcohol problem but who have met a ‘risk’ screening threshold based on 4 simple questions

What and Why• Intensity from 5 minutes of

‘advice’ to up to 1 hour of ‘intervention’ or ‘talking therapy’ over 1-4 sessions

• Advice is normally accompanied by some form of self-help material

• Advice is usually seen as early intervention; any ‘helping’ professional can identify risk, advise and refer on

At first sight IBAs look compelling

ANARP and after 2004• Moyer et al., 2002 56 RCTs VFM

1:8 people (15%) act on simple alcohol advice reduce < lower-risk levels

• Kaner et al., 2007 Cochrane Review

• Silagy & Stead, 2003 compares favourably with smoking (biggest killer) 1:20 act on advice (1:10 NRT)

• Wallace et al, 1988 IBA reduction higher-risk to lower-risk 250,000 men 67,500 women each year

And on...key studies • Wilk et al., 1997 higher risk and increasing

risk drinkers IBA twice as likely to moderate their drinking 6 to 12 months post intervention compared to no intervention

• Whitlock et al, 2004 IBA reduce weekly drinking 13% to 34%, with a significant effect on recommended or safe alcohol use

• Miller et al, 2005 Further, reductions in alcohol consumption associated significant dose-dependent lowering mean systolic and diastolic blood pressure

• Fleming et al, 2004 IBA can reduce alcohol use in primary care patients being treated for Type 2 diabetes and hypertension

ANARP 2004 Assumptions

Synthetic Estimates Babor, 2001 (AUDIT – IBA - WHO)

• Hazardous Drinking: people drinking above recognised safe levels but not yet experiencing harm (weekly >21/14 units, daily >8/6 units)

• Harmful Drinking: people drinking above safe levels and experiencing harm (AUDIT 8 -15)

• Alcohol Dependence: people drinking above safe levels and experiencing harm and symptoms of alcohol dependence (AUDIT 16+)

Prevalence Service Utilisation Ratio (PSUR)

• PSUR low by international standards • Considerable room for improvement • GPs under identify alcohol use• Haz / Harm: 1/67 males, 1/82 females• Dep: 1/28 males, 1/20 females • Younger less than older patients • Demand moderated by low level

enquiry & finding alternatives (e.g. AA) • Most patients self refer • GPs welcome the possibility of more

training in alcohol issues

ANARP to SIPS

ANARP to SIPS • Alcohol Needs Assessment Research

Project (ANARP) under the leadership of Professor Colin Drummond (Drummond et al., 2004)

• Department of Health funded ‘Screening and Intervention Programme for Sensible Drinking’ (SIPS) (Drummond et al., 2012)

• SIPS 2012 Evidence seems to point to a modest and targeted future for IBAs

SIPS results • SIPS 2012 - Straightforward

warning based on screening achieves all that can be achieved, training and resource may be substantially reduced

• Consistent with earlier Cochrane Review of primary care brief alcohol intervention no extra benefit extended interventions (Kaner et al., 2007)

• Scottish hospital study giving heavy drinking inpatients a guide to sensible drinking led to decline consumption as great as extended advice (Holloway et al., 2007)

Scottish Government

Scottish Alcohol Strategy

• Target NHS Health Scotland deliver 149,449 IBAs primary care, Accident & Emergency and antenatal care, by 2011

• Evaluation process of implementation using ‘mixed’ quantitative and qualitative methodology – they asked people!

• When setting targets for screening it is crucial to emphasize the targeted approach in Scotland assumed 19% of adult patients would present to services with conditions possibly related to drinking and be screened for excessive drinking, of whom 20% would screen positive and 75% of these at-need patients would actually be counselled.

Factors which support implementation:

Available funding; Nationally co-ordinated and locally

supported training opportunities; National, health board and setting level

‘leaders’ able to support and encourage implementation

Factors which hinder progress:

Competing priorities Inadequate training & auditing of delivery; Issues in recording delivery which made it

difficult to accurately determine or compare who the programme was reaching

Nonetheless, delivery targets were met

Parkes et al., 2011

Salford Services Picture

Salford – 1400 AUDIT 16+• 40,400 hazardous drinkers

(23%) AUDIT scores of 8-15 PSUR ratio 5.6% and ANARP synthetic construct 2262 per annum likely seek treatment

• 13,200 harmful drinkers (7.5%) present AUDIT scores 16-19 PSUR ratio 5.6% and ANARP synthetic 739 per annum

• 4,200 dependent drinkers, present AUDIT scores 20+ PSUR ratio 5.6% and ANARP synthetic 235 per annum

ANARP and PSUR• Professor Griffith Edwards,

put it, looking back on a long career:

• ‘...Good luck to the specific therapies, psychological and pharmacological, let’s not put them down, but at the centre is still the...little understood core of the change process... ’ Drummond & Ashton, 1999

Clinical Commissioning Group

Imperatives

• LES and DES • CQUIN • GP QOF • Over 40s NHS Health Check.

Advice

• E-Learninghttp://www.alcohollearningcentre.org.uk/eLearning/IBA/inex.cfm

• Incentives • Sensible Targets • 10,000 IBAs = 40 lives • 5,000 Salford Royal alone• MECC / WWW Portal • 5 minute script plus leaflet • GP, Hospital, CJS

Any Questions?