Transcript Alcohol: What’s the problem?

Introduction to SIPS
Professor Colin Drummond
Institute of Psychiatry
King’s College London
Topics
• What do we already know about
screening and brief interventions?
• What research questions will SIPS
address?
• What is SIPS and how did it come
about?
• What will come out of SIPS over the
next year?
What do we already know?
Binge-drinking in last month
Average number of occasions
2 .1 to 2 .6 (4)
1 .6 to 2 .1 (2)
1 .1 to 1 .6 (5)
0 .6 to 1 .1 (4)
Source: Anderson & Baumberg, 2006
Alcohol:
It’s a drug Jim, but
not as we know it.
Alcohol is a toxic and dependence
producing DRUG
• Acute effects
– Highly variable
– Pleasure, relaxation
– Impaired judgement,
coordination, balance
– Mood effects
– Argumentativeness
and aggression
– Drowsiness
– Impaired
consciousness
– Coma, respiratory
depression and death.
• Chronic effects
– Toxic effects on
organs
– Over 60 diseases
– Psychiatric disorders
– Foetal alcohol effects
– Psychoactive effects:
alcohol dependence
– 3rd leading cause of
disability after tobacco
and hypertension
– No universally “safe”
level
Alcohol use disorders: prevalence
Drummond 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
Chronic liver disease and cirrhosis mortality rates per 100,000
population, 1950-2006
National A&E study
Drummond et al., 2003
• Funded by Strategy Unit/Dept of Health
• Maximum burden of alcohol on A&E
departments
• Regional variations
• 36 randomly selected A&Es in England (18%)
stratified by region and urban/rural
• 116 researchers, 25 regional coordinators
• All A&E attenders > 18 years between 0900 and
0859hr Saturday/Sunday
Hourly attendance at A&E for alcohol positive and negative attendees - proportions
ETOHETOH+
100%
80%
%
60%
40%
20%
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0%
Hour
National A&E study
• Predictors of ETOH+
– Young, white, males, single/divorced, unemployed,
living with parents or NFA, frequent attenders (1.6x)
– More often brought by police/ambulance
• Reasons for attendance
– Violent assaults involving weapons, RTA, psychiatric
emergency, DSH
– Weapons: fists, knives, shoes, glasses
– Locations: clubs, pubs, public transport
• Correlations with general population data
• Fridays and Saturdays: Estimated 1,000,000
alcohol related A&E attendances per annum
Screening and referral to an alcohol
health worker in AED (Crawford et al.,
2004, Barratt et al., 2005)
• Pragmatic RCT comparing leaflet with
referral to Alcohol Health Worker
• Screening using Paddington Alcohol Test
• 599 randomised
• AHW group less drinking than leaflet
• Fewer AED attendances (mean 0.5)
• AHW more cost effective
SBI in primary care
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Prevalence ~20-30%
Frequent attenders
Screening & health promotion role
Early detection & intervention
Effect of alcohol intervention on
health outcomes
• 5-30 min of targeted advice
Evidence-Base for SBI
 Freemantle 1993 - 6 trials in primary care
– 24% drop in consumption (95% CI 18 to 31%)
 Moyer 2002 – 56 trials, 34 relevant to PHC
– Consistent positive effect, NNT 8-12 (smoking=20)
– Cost savings found at 4 years in the USA
 Kaner 2007 – 29 trials in PHC & A&E
– Consistent positive effects ~7 drinks less/week
– Evidence strongest for men, less work on women
– No significant benefit of longer versus shorter BI
What is known already about SBI?
• A&E: SBI is effective and cost effective in academic
centres (e.g. St Mary’s Model)
• Primary Health Care: SBI is effective and some evidence
of cost effectiveness across range of international
settings
• General Hospital: SBI less effective
• General lack of research in UK
• In all cases SBI effective for opportunistic intervention in
non-treatment seeking populations. Less effective for
treatment seeking/alcohol dependent patients
What is not known about SBI?
• A&E: can it be effectively implemented outside
academic centres in UK?
• PHC: is it cost effective and can it be
implemented in “typical” PHC setting?
• CJS: is it feasible to implement SBI, and is it
effective?
• All settings:
– What are the best screening tools (short vs longer)
and method (universal vs targeted)?
– Is extended BI better than 5 min advice?
– What are the barriers/facilitators for implementation in
the “typical” setting?
– Effectiveness in females, young, BME
Alcohol Screening and Brief
Intervention Research Programme
SIPS
A&E St. Mary’s
'Scientia Vincit
Timorem'
Programme design
• Funded by Department of Health for 3 years
• Jointly led by IOP & Newcastle University
• 3 cluster randomised clinical trials of alcohol
screening and brief intervention (PHC, AED,
CJS) to assess:
– What are the barriers/facilitators to implementation in
a “typical setting”?
– What is the most effective screening method?
– What is the most effective and cost effective
intervention approach?
• Total target of 2,403 subjects, completed 2,600
July 2009
• 6 and 12 months follow up, currently 80% @ 6
months (mainly phone)
King’s College London
Prof C Drummond (CI)
Dr J Myles PI
Dr P Deluca PI
Mr T Phillips PI
Ms K Perryman PI
Dr M Cochrane
Ms D Jeffery
Dr M Hobbs
Ms R Cappello
Mr S Keating
Ms L James
Ms L Rail
Ms J Reid
Ms R Lee
Mr S Gordon
Ms L Floodgate
Mr D Kerr
Mr H Mosaheb
Ms C Elzerbi
St George’s
Dr A Oyefeso PI
York
Prof S Coulton PI (now Kent Univ)
Prof C Godfrey PI
Mr S Parrott PI
Prof M Bland PI
SIPS Research
Newcastle
Prof E Kaner (DCI)
Project Group
Prof C Day PI
Dr E Gilvarry PI
Dr P Cassidy PI
Dr D Newbury-Birch PI
Prof Nick Heather PI
Ms K Jackson
Ms N Brown
Ms M Clifford
Ms E Phinn
Ms C Shaw
Ms R McGovern
Ms A Hindhaugh
Ms G Hawdon
Ms D Carpenter
Mr G Scott
Ms J Armstrong
Ms D MacDonald
Imperial College and St Mary’s Hospital
Dr M Crawford PI
Prof R Touquet PI
Alcohol Concern
Mr D Shenker PI
Primary Care Research Network
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Mental Health Research Network
9 Clusters
1 AED
2/3 PHC
2/3 CJS
Newcastle General
1 AED
2/3 PHC
2/3 CJS
Darlington Memorial
1 AED
2/3 PHC
2/3 CJS
1 AED
2/3 PHC
2/3 CJS
1 AED
2/3 PHC
2/3 CJS
Winchester
South Tyneside
Hexham
1 AED
2/3 PHC
2/3 CJS
1 AED
2/3 PHC
2/3 CJS
1 AED
2/3 PHC
2/3 CJS
King’s College
St Thomas’s
Central Middlesex
1 AED
2/3 PHC
2/3 CJS
North Middlesex22
How will we assess effectiveness?
• Effectiveness of implementation
– Extent of screening and intervention activity
– Attitudes to SBI implementation
• Patient outcome measures
– Alcohol consumption (extended AUDIT-C)
– Alcohol related problems
– Health related quality of life
– Health related and wider societal costs
Website
www.sips.kcl.ac.uk
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Training and intervention tools
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Presentations
• Accident and Emergency study: Dr Paolo
Deluca
• Primary care study: Prof Eileen Kaner
• Criminal justice study: Dr Dorothy
Newbury-Birch
• Early findings on screening: Prof Simon
Coulton
• Discussant: Dr Peter Anderson