ALCOHOL MONITORING SYSTEMS

Professor Colin DrummondSt George’s

University of London

What is the point of alcohol monitoring systems?

• Burden of preventable alcohol related harm

• Economic impact of alcohol related harm

• Monitoring the impact of alcohol policy

• Alcohol treatment needs assessment

• Developing theory/evidence base to inform alcohol policy

• Persuading governments to take action

Top 10 risk factors for ill-health in the European Union

Anderson et al., in preparation

What causes problems? Acute effects

• Impaired judgement• Disinhibition• Aggressiveness• Loss of coordination• Drowsiness• Coma• Alcohol poisoning

What causes problems?Chronic effects

• Tissue damage• Chronic effects on the brain• Psychiatric comorbidity• Relationships (inc. marital and

parenting)• Loss of employment• Financial problems• Alcohol dependence

Source: WHO, 2004

Methods of monitoring alcohol consumption and related harm

• Per capita alcohol consumption• General population surveys• Indicators of alcohol related harm

– Hospital admissions– Morbidity– Mortality– Social and criminal justice– Treatment access

• Alcohol needs assessment

Per capita alcohol consumptionAlcohol production+imports-exports

Population >15yrs

• Pros• Closely linked to

alcohol related harm• Based on national

statistics• Time series• Inexpensive to collect• Single distribution

theory

• Cons• Unrecorded

consumption• Overseas• Duty free• Illicit consumption• Assumptions• % abstainers

General population surveys

• Pros• Measure subgroups• Individual level data -

associations• Greater detail –

unrecorded/illicit• Harmful patterns &

quanitites• Harmful consequences• Diagnostic categories

• Cons• Cost• Under-represented groups• Recall• Attribution• Response bias• Response rate• Recency

Alcohol survey measures

• Quantity/frequency• Patterns (binge, regular)• Last week/month/year• Alcohol related adverse consequences

– AUDIT questionnaire– Alcohol dependence– Alcohol-related health consequences– Alcohol-related consultations/help seeking

Different questions – different information

• 90% males, 80% females drink alcohol (16 and over)• 30% males, 19% females drink above “safe” weekly level (ONS,

2003) • 26% males, 15% females “binge drinkers” 6.4M• 32% males, 15% females “hazardous/harmful drinkers” AUDIT

8-15 (Drummond et al., 2005) 7M• 7% males, 3% females drink above 50/35 units/wk (ONS, 2003)• 6% males, 2% females “alcohol dependent” 16+ AUDIT

(Drummond et al., 2005) 1M

Indicators of alcohol related harm

• Pros

• Official statistics (e.g. ICD)

• Consequences rather than causes

• Not reliant on recall/bias

• Relatively stable methods over time

• Strong relationship with consumption

• Cons

• AAF

• Alcohol rarely recorded as cause

• Reliability of coroner’s verdicts/data collection

• Variation in bias e.g. policing over time/between countries

Source: WHO, 2004

Indicators of alcohol related harmAlcohol specific measures better

• Hospital admissions– E.g. alcohol dependence, alcoholic cirrhosis, alcoholic gastritis

• A&E departments– E.g. alcohol related attendances, recent alcohol use, hazardous/harmful

drinking, alcohol poisoning• Ambulance statistics

– E.g. alcohol related attendances• Coroner’s verdicts

– E.g. Alcoholic liver disease, alcohol dependence, alcohol related road accidents

• Health surveys– E.g. alcohol related consequences, injuries, consultations

• Crime surveys– E.g. alcohol related violence

• Primary care databases• Police statistics

– E.g. drink driving, alcohol related road accidents, drunk and disorderly

Source: ONS 2001

National A&E study Drummond et al., 2005

• Funded by Strategy Unit/Dept of Health• Maximum burden of alcohol on A&E departments• Regional variations & relationship to general

population measures• 36 randomly selected A&Es in England (18%)

stratified by region and urban/rural• 116 researchers, 25 regional coordinators • All A&E attenders between 0900 and 0859hr

Saturday/Sunday 28/29 June 2003

National A&E study- Results• Eligible 1789• Consented 1083 (61%)• ETOH+ 41%• Intoxicated 14%• FAST+ 43%• After midnight ETOH+ 70%

Hourly attendance at A&E for alcohol positive and negative attendees - proportions

0%

20%

40%

60%

80%

100%

Hour

%

ETOH-

ETOH+

National A&E Study. Drummond et al., 2005

0

10

20

30

40

50

60

% ETOH+

FAST+

National means:ETOH+ = 42%FAST+ = 43%

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– Male binge drinking r=0.83, p<0.001– Female binge drinking (ns)– Male weekly alcohol consumption r=0.90, p<0.001– Female weekly alcohol consumption r=0.93, p<0.001

Needs assessment: DefinitionsNARP - Drummond et al., 2005

• Purpose: to estimate the level of need, demand and access to alcohol treatment• Need: number of individuals in the general population with alcohol dependence

who could benefit from an alcohol intervention • Demand:

– “potential demand for health service” the estimated number of individuals in England with alcohol dependence who have consulted their GP in a year

– “potential demand for specialist alcohol services” (PDSA) the number of individuals who demanded some form of alcohol intervention, which is the number who accessed secondary care services (including general and mental heath hospitals) not necessarily with alcohol as the presenting problem

– “actual demand for specialist alcohol services” (ADSA) as the number of dependent drinkers referred to alcohol services.

• Service utilisation or access: the number of individuals with alcohol dependence that access specialist alcohol treatment in a year

• Gap or Prevalence-service utilisation ratio (PSUR): the number in need of interventions divided by the number of people accessing specialist alcohol interventions.

NARP methodologyDrummond et al., 2005

• Need: Psychiatric Morbidity Survey– Hazardous Drinking: people drinking above recognised safe

levels but not yet experiencing harm (>21/14U <50/35U)– 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+)

• Demand: – PDSA: General Practice Research Database– ADSA: Referrals to specialist agencies

• Access: National specialist alcohol treatment agency survey

• PSUR: Alcohol dependence/Access

Conclusions• Alcohol monitoring essential part of an effective

response to alcohol problems in society• Data gathering is a government responsibility• No one methodology answers all questions:

triangulation• Different methods, different costs, information• Indirect indicators are useful if bias constant over

time (control indicators)• Measures should be scientifically validated and

independently researched• Level of data relies on level of resources

References

• Anderson et al., Health Social and Economic Impact of Alcohol, forthcoming

• WHO, 2004, International Guide for Monitoring Alcohol Consumption and Related Harm

• Drummond et al., National Alcohol Research Project, forthcoming