Alcohol Detection by Clinicians

Alex J Mitchell, University of Leicester

Information to Support Publication:Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. British Journal of Psychiatry August 2012

Royalty free slides for personal use, providing author credit given

ajm80@le.ac.uk

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Rates of recognition of alcohol problems in routine clinical practice using clinical judgment

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Some Definitions of Alcohol Problems

• Hazardous drinking – A pattern of alcohol consumption that increases someone’s risk of harm

(WHO)

• Harmful drinking – A pattern of alcohol consumption that is causing mental or physical damage

• Alcohol dependence – A cluster of behavioural, cognitive and physiological factors that typically

include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. (DSM-IV) (American Psychiatric Association 2000) / (ICD-10) (World Health Organization 2007).

• Alcohol Use Disorder– Harmful use or alcohol dependence

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Magnitude of Problem Drinking

• 24% of adults are hazardous or harmful drinkers (7M)– Defined as scoring 8 or more on the Alcohol Use Disorders Identification

Test (AUDIT) [slide 16] (McManus et al. 2009)

• 4% alcohol dependent (1M) (Drummond et al., 2005)

• 7% of hospital admissions (1M) (North West Public Health Observatory 2010)

• 40% of hospital presentations with AUD (of 10k screened in SIPS)

• Consumption doubled in adolescents in past 10 yrs

• 3rd leading cause of disability in EuropeDrummond DC, Oyefes, N, Phillips T et al. (2005) Alcohol needs assessment research project: the 2004 national alcohol needs assessment for England. Department of Health, LondonMcManus S, Meltzer H, Brugha T et al. (2009) Adult psychiatric morbidity in England, 2007: results of a household survey. NHS Information Centre for Health and Social Care, LeedsNorth West Public Health Observatory (2010) Local alcohol profiles for England. www.nwph.net/alcohol/lape/

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Drug harms in the UKNutt DJ, King LA, Phillips LD; Independent Scientific Committee on Drugs. Drug harms in the UK: a multicriteria decision analysis. Lancet. 2010 Nov 6;376(9752):1558-65. Epub 2010 Oct 29.

Scores represent opinions of Members of the Independent Scientific Committee on Drugs

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Mitchell et al (2012) – Detection Meta-analysis

• Meta-analysis of studies involving 20,000 patients assessed for alcohol problems by medical staff

• GPs identified 40% of problem drinkers• Hospital doctors identified 50% of problem drinkers • Mental health specialists recognised 55% of problem

drinkers. • A&E clinicians detected 90% of alcohol intoxication• Clinicians correctly recorded a diagnosis in the case-

notes for only 1 in 3 people who had an alcohol problem

Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. British Journal of Psychiatry August 2012

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HSROC Estimate Clinical Judgement vs AUD

Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. British Journal of Psychiatry August 2012

• Across all studies, clinicians sensitivity was 40.0%

• Across all studies, clinicians specificity was 91.0%

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Mitchell et al (2012) – Detection Summary

• Assuming 2 /10 GP attendees have problem drinking

Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. British Journal of Psychiatry August 2012

Clinicians would correctly identify 7+1 miss 1 misidentify 1

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Poor Access to Treatment

• Only about 5% of those alcohol dependent receive treatment each year

• About 80% with AUD do not access / receive any treatment

• The average delay in seeking help for alcohol problems is 6-7 years

Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B. and Kessler, R. C. (2005) Failure and delay in initial treatment contact after first onset of mental disorders in the national comorbidity survey replication. AGP 62, 603-613. Oakley Browne, M. A., Wells, J. E. and McGee, M. A. (2006) Twelve-month and lifetime health service use in Te Rau Hinengaro: The New Zealand Mental Health Survey. ANZJP 40, 855- 864. Oleski J, Mota N, Cox BJ, Sareen J. Perceived need for care, help seeking, and perceived barriers to care for alcohol use disorders in a national sample. Psychiatr Serv. 2010 Dec;61(12):1223-31.

Oleski et al (2010)

Wang et al (2005)

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Barriers to Help Seeking

• Younger age• Married• Higher income• Higher education• Low comorbidity Oleski et al (2010)

Oleski J, Mota N, Cox BJ, Sareen J. Perceived need for care, help seeking, and perceived barriers to care for alcohol use disorders in a national sample. Psychiatr Serv. 2010 Dec;61(12):1223-31

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Receipt of Advice and Treatment

• 50% of heavy drinkers who had been asked about their alcohol use had not been advised about it

• Of 7301 primary care patients, 28.3% screened positive. Of these, 55% received no advice

• 62% of risky drinkers were given advice by practice nurses

Edlund M. J., Unützer J.,Wells K. B. Clinician screening and treatment of alcohol, drug, and mental problems in primary care. Med Care 2004; 42: 1158–66.Lock C. A., Kaner E. F. Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice? Fam Pract 2004; 21: 270–5Mäkelä P, Havio M, Seppä K.Alcohol-related discussions in health care--a population view. Addiction. 2011 106(7):1239-48.

Edlund et al (2004)

Lock & Kaner, 2004

Mäkelä et al (2011)

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Barriers to Detection and Treatment

• Low rates of enquiry by clinicians• Low use of validated tools• lack of resources• Lack of training• Excess workload• Poor attitudes to AUD• Unclear responsibility• Uncertainty re how to help

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Patients’ Views of Being Asked @ Drinking

• 90% have positive attitudes towards being asked

• Typically only 3% of GP attendees are typically asked about alcohol in 12mo

• Typically only 10% of at risk drinker are typically asked about alcohol in 12mo

• Typically only 1 in 3 problem drinkers are typically asked about alcohol in 12mo

Foulds J, Wells JE, Lacey C, Adamson S, Mulder R. Harmful drinking and talking about alcohol in primary care: New Zealand population survey findings. Acta Psychiatr Scand. 2012 Apr 26Mäkelä P, Havio M, Seppä K.Alcohol-related discussions in health care--a population view. Addiction. 2011 106(7):1239-48.

Foulds et al (2012)

Foulds et al (2012)

Mäkelä et al (2011)

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Rates of Enquiry @ Drinking by AUDIT Score

2.5

1.11.7 1.6

2.9

5

9.2

14.4

33.6

9.4

3.2

0

5

10

15

20

25

30

35

Zero One 2–3 4–5 6–7 8–9 10–14 15–19 20–40 8 or higher All Patients

Foulds J, Wells JE, Lacey C, Adamson S, Mulder R. Harmful drinking and talking about alcohol in primary care: New Zealand population survey findings. Acta Psychiatr Scand. 2012 Apr 26

Foulds et al (2012)

AUD

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Suggested Screening ProtocolCredit: Alcohol Learning Centre Al

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Audit Screening Test: 10 Questions1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are

drinking? 3. How often do you have five or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking

once you had started? 5. How often during the last year have you failed to do what was normally expected of

you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get

yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after

drinking? 8. How often during the last year have you been unable to remember what happened

the night before because of your drinking? 9. Have you or someone else been injured because of your drinking? 10. Has a relative, friend, doctor, or other health care worker been concerned about

your drinking or suggested you cut down?

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Basic Principles of Engagement

1. Offer a private, comfortable consultation2. Use a Non-judgemental attitude3. Foster Trust4. Avoid arguments5. Show Empathy6. Guage Severity7. Promote Self-efficacy8. Promote motivation to change9. Engage caregivers

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Recommended alcohol limits: Units1 Unit = 10ms / 10g Al

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Help Online

• NHS Handout on Alcoholhttp://www.alcohollearningcentre.org.uk/alcoholeLearning/learning/IBA03/IBA_03_004/pdf/structured_advice_tool.pdf

• Brief Alcohol Intervention Onlinehttp://www.alcohollearningcentre.org.uk/alcoholeLearning/learning/IBA03/IBA_03_004/D/ALC_Session/300/overview.html

• NHS How Much is Too Much Workbookhttp://www.sips.iop.kcl.ac.uk/documents/gnr/dhpil.pdf

• SIPS Information from King’s Collegehttp://www.sips.iop.kcl.ac.uk/documents/gnr/sipsBA.pdfhttp://www.sips.iop.kcl.ac.uk/documents/gnr/sipsBLC.pdf

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National Help

• Drinkline - National Alcohol Helpline– Helpline: 0800 917 8282 Monday - Friday, 9am - 11pm , Weekends 6pm - 11pm

Offers help to callers worried about their own drinking and support to the family and friends of people who are drinking. Advice to callers on where to go for help.

• Alcoholics Anonymous – PO Box 1, 10 Toft Green, York, YO1 7ND

Helpline: 0845 769 7555 Web: www.alcoholics-anonymous.org.ukThere are over 3000 meetings held in the UK each week with over 40,000 members. The only requirement for membership is a desire to stop drinking.

• AL-Anon Family Groups– 61 Great Dover Street, London, SE1 4YF

Tel: 020 7403 0888 Web: www.al-anonuk.org.ukOffers support for families and friends of alcoholics whether the drinker is still drinking or not.

• National Association for Children of Alcoholics– PO Box 64, Fishponds, Bristol, BS16 2UH

Helpline: 0800 358 3456 Web: www.nacoa.org.ukServices include information, advice and support to children of alcoholics through its free helpline, and training to professionals who come into contact with children of alcoholics.

• Know Your Units campaign– From the NHS

Web: www.units.nhs.ukAims to tell drinkers how many units are in their drinks and help them stick to their limits.

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NICE Guidance

• Part 1 - Public health guidance

•Alcohol use disorders in adults and young people: prevention and early identification (published June 2010) - Centre for Public Health Excellence (CPHE) at NICE

•Part 2 - Clinical guideline

•Alcohol use disorders in adults and young people: clinical management (published June 2010) - National Collaborating Centre for Chronic Conditions (NCC-CC)

•Part 3 - Clinical guideline

•Alcohol use disorders: management of alcohol dependence (publication expected February 2011) - National Collaborating Centre for Mental Health (NCC-MH)

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Alcohol Detection by Clinicians

Alex J Mitchell, University of Leicester

Information to Support Publication:Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. British Journal of Psychiatry August 2012

Royalty free slides for personal use, providing author credit given

Alex

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Rates of recognition of alcohol problems in routine clinical practice using clinical judgment