North Devon HLP Alcohol IBA Evening. Graham Parsons Mark Stone. Tuesday 3 rd February 2015

Transcription

1 North Devon HLP Alcohol IBA Evening Graham Parsons Mark Stone Tuesday 3 rd February 2015

2 Introduction Is it really a problem? International, national and local perspective Harms and potential harms of alcohol How do we classify and diagnose alcohol use disorders (AUDs) Delivering alcohol Identification and Brief Advice (IBA) interventions Questions

3 Is alcohol really a problem? International, National and local perspectives

4 International and National perspective Responsible for around 4% of all deaths worldwide (WHO, 2011) 76.2 million people globally have a diagnosable AUD (WHO, 2011) In England, 1 in 3 and 1 in 4 drink more than the daily recommended limits at least once a week (ONS, 2012) There were 8790 alcohol-related deaths or 12.9 per 100,000 in the UK in 2010 (ONS 2012) Rates have almost doubled since the early 90 s (from 6.7 per 100k in 1992) (ONS, 2012) More in vs. (17.8 vs. 8.3 per 100k) and accounted for 67% of total number of alcohol related deaths (ONS 2012) Alcohol harm is estimated to cost society in England 2.7bn each year (2006/2007)

5 Liver Disease: Change in mortality

6 Litres of per alcohol consumption per capita, (UK)

7 Local Alcohol Profiles for England (LAPE) Months of life lost (male and female) Alcohol specific mortality (male and female) Mortality from Chronic Liver Disease (M&F) Alcohol attributable mortality (M&F) Alcohol specific hospital admissions (<18, M&F) Alcohol attributable hospital admissions (M&F) Admission episodes for alcohol attributable conditions (M&F) Alcohol related recorded crimes, violent crimes and sexual offences Claimants of incapacity benefits Mortality from land accidents Binge drinking Employees in bars Alcohol treatment prevalence per 1000 population AVAILABLE at

8 The Local Picture: North Devon Significantly higher in 5 areas Above national in 9 other areas Above regional average (Devon, Cornwall and Somerset) in 13/24 markers

9 Harms

10 Exercise 1 Alcohol is a contributing factor in more than 40 medical conditions and a range of social, legal and behavioural problems List as many problems as you can under the following sub-headings Physical Behavioural and psychological Social and legal As a group decide which of the problems you have listed are the worse three presentations

11 The health and social consequences of alcohol use Physical Health Problems can be separated into Acute and Chronic. ACUTE: GIT (gastritis, oesophagitis, pancreatitis) CV (arrhythmias, CV accidents) Neurological (seizures, CNS depression) Musculoskeletal (myopathy, rhabdomyolysis) Respiratory (aspiration pneumonia) Metabolic (hypoglycaemia, ketoacidosis) Accidents and injuries. Acute intoxication and coma

12 The Effects of alcohol.

13 CHRONIC: The health and social consequences of alcohol use Alcoholic Liver Disease or ALD (fatty liver-hepatitis-cirrhosis). GIT (as acute + malabsorption, malnutrition, peptic ulceration) CV (hypertension, cardiomyopathy, CHD, CV accidents, arrythmias) Cancers (mouth, orapharynx, larynx, oesophagus, liver, bowel, breast) Neurological (many! WK Syndrome) Musculoskeletal (gout, osteoporosis, myopathy) Endocrine (pseudo-cushings syndrome) Respiratory (LRTIs) Metabolic (wt gain, hyperlipidaemia) Haematological (anaemia, macrocytosis, Fe deficiency, neutropenia, thrombocytopenia) Gynaecological (impotence, infertility, sexual dysfunction, miscarriage, FAS) Skin disorders (psoriasis, discoid eczema) Accidents and injuries.

14 Parsons& Mills, 2014

15 The health and social consequences of alcohol use Psychiatric Co-morbidity. Depression complex relationship (which came 1 st, the chicken or the egg?) suicide risk (60-100x > risk for dependent drinkers esp. in men) Bipolar disorder Anxiety disorders (OR 1.9 in one US study) Schizophrenia (x3 > compared to general population) ASPD (21 x more likely than general population to have an alcohol-use disorder) Pathological jealousy and alcoholic hallucinosis.

16 Legal and Social consequences

17 The health and social consequences of alcohol use Family and relationship problems including divorce (30%), domestic violence (40%) and child abuse (20%). Problems at work including absenteeism and impaired performance (200k British workers have turned up to work from a night out hung-over) Housing and homelessness problems. Crime including violence, drink-driving and increased risk of being a victim of crime. Financial problems.

18 Positive Effects?? Ischaemic Stroke (statistically significant effect in one study up to 2 drinks per day) CHD (strong EB that light to moderate alcohol consumption is associated with risk of CHD) BHF states Moderate drinking between 1 or 2 units a day offers some protection against developing coronary heart disease; This is especially the case in women who have been through the menopause or men over 40??Linked to HDL cholesterol, BP, effects on insulin resistance, neurohormonal profile, alcohol metabolite acetate promoting vasodilation and alcohols effect on inflammation?? WHO have calculated that around 250K individuals globally benefit from low level alcohol use or about 2190 in the UK or 2 people in a City the size of Barnstable! (48K) (WHO 2011)

19 Positive Effects?? patients Alcohol consumption of up to 7 drinks/week at early/middle-age associated with risk of HF vs abstainers Less definite association in Patients consuming > 7 drinks/week = no risk of HF vs. abstainers BUT risk of all-cause mortality (EHJ, 2015)

20 PREGNANCY and ALCOHOL What are the current guidelines? Current DH alcohol advice states; pregnant women or women trying to conceive should avoid drinking alcohol and if they do choose to drink, to minimise the risk to the baby, they should drink no more than one to two units of alcohol once or twice a week and should not get drunk. A leaflet for patients can be obtained at: /Healthimprovement/Alcoholmisuse/ DH_ How many women drink during pregnancy? 40% of all mothers drank alcohol in 2005 (54% in 2005); 49% of women who drank before pregnancy gave up (34% in 2005); 46% of women drank less during pregnancy (61% in 2005); 2% reported no change (4% in 2005) (McAndrew et al, 2010)

21 How do we classify and diagnose alcohol use disorders (AUDs)

22 What are the current recommendations in the UK? Men should drink no more than 3-4 units of alcohol per day, and women should not regularly drink more than 2-3 units of alcohol per day. Both men and women should have some alcohol free days and go without alcohol for 48 hours following a heavy drinking session to give their liver and other body tissues time to recover. In terms of weekly limits, men are advised to drink no more than 21 units and women no more than 14 units per week. DEFINE BINGE DRINKING

23 Calculating Units

24 Calculating Units: Exercise 2 MR BENN drinks 2 bottles (750mls) of wine (10% ABV) on average each week. How many units does he consume in a typical week? 15 UNITS MISS HAPPY drinks 3 cans (500mls) of lager (8.5% ABV) on five days each week. How many units does she consume in i) a day and ii) a week? UNITS and UNITS MR SAD drinks 3 cans (440mls) of lager (4.0% ABV) on five days each week. How many units does he consume in i) a day and ii) a week? 5.28 UNITS and 26.4 UNITS

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26 Identifying Alcohol-use disorders the use of screening tools. Fast Alcohol Screening Test (FAST) CAGE AUDIT the gold standard. Developed by WHO 10 questions (freq/dependence/problems related to alcohol use) High sensitivity and specificity levels (92% and 94% respectively) Can be shortened to AUDIT-C (3 questions) but Sensitivity (87%) & Specificity (65%) BUT ideal for Pharmacy setting (can be delivered in less than a minute)

27 Identifying Alcohol-use disorders the use of screening tools. Interpreting AUDIT-C A total score of 5 indicates increasing or higher risk drinking and is described as AUDIT-C positive

28 Exercise 3 Undertake an AUDIT-C with a partner and feedback the results with some appropriate brief advice using the tool provided.

29 Identifying Alcohol-use disorders the use of screening tools. If 5 you COULD undertake the AUDIT tool to identify whether the patient is increasing, higher risk or a dependent drinker In summary:

30 PLEASE REMEMBER IF SOMEONE STATES THEY ARE A DEPENDENT DRINKER ALWAYS WARN THEM OF THE DANGERS OF STOPPING IMMEDIATELY STOPPING IMMEDIATELY IS DANGEROUS AND CAN LEAD TO SIGNIFICANT ALCOHOL WITHDRAWAL SYMPTOMS (AWS), DELIRIUM TREMENS (DTs) and DEATH (especially if patient drinking >10u/day [ ] or 15u/day [ ]) THEY SHOULD BE REFERRED TO THEIR GP OR SPECIALIST SERVICES AND IF THEY CHOOSE TO REDUCE THEIR DRINKING THIS SHOULD BE GRADUAL

31 Delivering alcohol Identification and Brief Advice (IBA) interventions 1 in 8 individuals drinking at increasing or higher risk levels and provided with an alcohol IBA moderate their drinking to low risk levels. This compares to 1 in 20 individuals offered smoking advice, increasing to 1 in 10 when nicotine replacements are offered as well.

32 Not mandatory but, in my opinion, essential especially for IBA pharmacist champion Specifically for the community pharmacy setting Five e-learning modules (20 mins each) Sixth session, an assessment of learning Ideal for CPD needs!

33 Delivering alcohol Identification and Brief Advice (IBA) interventions Number of stages to delivering an alcohol IBA 1. Raising the issue 2. Screen and give feedback 3. Listen for readiness to change 4. Provide advice 5. Exit strategy

34 1. Raising the issue: Exercise 4 What strategies can you use in your pharmacy to raise this issue? What barriers may prevent you? How can you overcome any barriers that you have identified?

35 2. Screen and give feedback The higher the AUDIT-C score, the greater the health risks e.g. increased mortality if 10 or above Chance of dependency if 10 or above is 75% for & 88% for In USA, recommended that anyone who scores 8 or more should be referred due to risk of complications of drinking (consider for full AUDIT?) Use the NHS Brief Advice tool to highlight consequences of drinking

36 3. Listen for readiness to change So you have fed-back the results using the appropriate literature (including the NHS brief advice tool) highlighting the risks for patients scoring 5 or more. Ask the patient: how has that left you feeling? or What are your thoughts about this? or What are your thoughts on your AUDIT score? What might the patient say that could indicate they have identified this is a problem? What information and advice might you give to help them reduce their AUDIT-C score a low-risk level?

37 4. Providing information and advice A structure of Brief Interventions Feedback (personalised) Responsibility (with patient) Advice (clear, practical) Menu (variety of options) Empathy (warm, reflective) Self-efficacy (boosts confidence)

38 4. Providing information and advice Realistic goal setting Practical tips Set a date to start cutting down Set a daily limit Alternate alcohol with non-alcoholic drinks Aim for at least TWO alcohol free days per week Provide leaflets (Change4Life Don t let drinking sneak up on you )

39 4. Providing information and advice: Drink Diaries Available at

40 Remember: 5. Exit Strategy Not all customers will want to discuss their results and may just want to leave this is OK! Provide them with a leaflet and signposting information if possible For dependent drinkers or people with high AUDIT-C scores that may want to discuss this further refer to GP, Specialist Services and/or mutual aid support organisations

41 Devon signposting Recovery and Integration Service (RISE) Tel: (Barnstable) UK SMART Recovery (online meetings) For details go to Alcoholics Anonymous (AA) For details go to Meetings/Find-a-Meeting Al-Anon and Alateen provide support to anyone whose life is, or has been, affected by someone else s drinking. (

42 Questions

43 Learning Resources Alcohol Learning Centre E-training package for pharmacists inc IBAs ( Royal Pharmaceutical Society (RPS): Alcohol Use Disorders ( Raistrick D, Heather N, Godfrey C. Review of the effectiveness of treatment for alcohol problems. NTA. November Local Alcohol Profiles for England (LAPE). ( NICE website (AUDs: physical complications [CG100]; Alcohol dependence and harmful alcohol use [CG115]; AUDs: preventing harmful drinking [PH24] )

44 References British Association of Psychopharmacology (2012) evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Psychopharmacology 0 (0) Goncalves, A et al (2015) Alcohol consumption and risk of heart failure: the Atherosclerosis Risk in Communities Study. European Heart Journal doi: /eurheart/ehu514 Office of National Statistics (2012) Alcohol-related Deaths in the UK, Parsons, G & Mills, S (2014) Alcohol interventions. Pharmaceutical Journal Vol. 293, No September 2014 pp McAndrew, F et al (2010) Infant Feeding Survey The Information Centre 2012 WHO (2012) Health topics: Alcohol. Available at WHO(2011) Global status report on alcohol and health.