Doug Sellman Professor of Psychiatry & Addiction Medicine National Addiction Centre University of Otago, Christchurch

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1 How to intervene effectively with heavy drinkers in primary care GPCME 2015 Doug Sellman Professor of Psychiatry & Addiction Medicine National Addiction Centre University of Otago, Christchurch Acknowledgement: James Foulds, Senior Lecturer, University of Otago, Christchurch

2 Ruth Ruth is a 34 year old office manager who has been drinking regularly since age 17 and enjoys craft beer. Two weeks ago, she slipped on the stairs following one of her craft beer club evenings and badly twisted her ankle. She has completed the AUDIT and scored 20.

3 Inhabitants of forests in Bossou, southeastern Guinea, enjoy rich, alcoholic brew fermented from sugary sap Chimpanzees observed engaging in habitual drinking (Guardian 2015, quoting Royal Society Open Science)

4 Life can t be enjoyed without alcohol

5 Social events aren t proper events without alcohol

6 To be in the in-crowd means drinking with the in-crowd

7 Alcohol: No Ordinary Commodity (2010)

8 Marketing Pricing Accessibility 5+ Solution MPAAD+ Age of purchase Drink-driving PLUS: Increase treatment opportunities for heavy drinkers

9 How effective are these strategies? Effectiveness (0, +, ++, +++) 1. Dismantle advertising and sponsorship +/++ 2. (Minimum pricing) and excise tax increases Restriction on alcohol trading hours Raise purchase age Lower BAC for driving +++ Alcohol education programmes 0

10 How effective are these strategies? Effectiveness (0, +, ++, +++) 1. Dismantle advertising and sponsorship +/++ 2. (Minimum pricing) and excise tax increases Restriction on alcohol trading hours Raise purchase age Lower BAC for driving +++ PLUS: Brief intervention for at-risk drinkers +++

11

12 Two groups of primary care attendees with alcohol problems Those we know about, who present with symptoms directly related to excess alcohol use (the tip of the iceberg) The rest (below the waterline)

13 Alcohol related presentations in primary care Hypertension Injuries Dyspepsia Abnormal LFTs Depression Marital problems

14 Drinking Continuum No Low-risk Hazardous Mild Moderate Severe drinking drinking drinking AUD AUD AUD Focussed behavioural change related to lowrisk drinking ADDICTION Lifestyle change related to abstinence

15 Shifts in the diagnosis of alcoholism over the past 60 years DSM-I (1952) DSM-II / ICD8 (1968) (1969) ICD9 / DSM-III / DSM-IIIR / ICD10 / DSM-IV (1977) (1980) (1987) (1991) (1994) DSM-5 (2013) Alcohol Abuse Alcoholism Alcoholism Alcohol Use Disorder Alcohol Dependence Sociopathic Personality Disturbance Antisocial Personality Antisocial Personality Disorder Antisocial Personality Disorder

16 DSM-5 criteria for alcohol use disorder based on severity weightings (Saha et al., 2006) Dyscontrol Use is often longer than intended Unsuccessful attempts to cut down/stop Use when physically hazardous Physiological changes Withdrawal evidence Acquired tolerance Compulsion to use Craving Use despite physical/psychological problems Social and interpersonal problems Salience A lot of time spent Neglect of roles Activities given up

17 Drinking Continuum No Low-risk Hazardous Mild Moderate Severe drinking drinking drinking AUD AUD AUD Focussed behavioural change related to lowrisk drinking ADDICTION Lifestyle change related to abstinence

18 Brief Interventions Modest but robust long term effect especially in men (mean reduction in alcohol intake 57g/week) (Kaner et al Cochrane review) Combining a motivational enhancement approach (REDS) with specific education relevant to patient s problem area(s) Main barriers to implementing: Lack of time GPs not trained in technique Lack of specific funding to deliver intervention

19 Motivational Enhancement Approach Roll with resistance Express empathy Develop discrepancy Support self-efficacy I learn what I believe from what I hear myself speak

20 HPA low- risk drinking guidelines (15/5, 10/4)

21 Blood alcohol concentrations (BACs) when drinking over three hours % >0.04 % >0.05 Women 55kg 75kg 55kg 75kg 4sd sd sd Men 70kg 90kg 70kg 90kg 5sd sd sd

22 AHMRC low-risk guidelines 14/4 HPA low-risk guidelines 15/5, 10/4 Possible future low-risk guidelines 10/2

23

24 30ml spirits: = 330ml can of beer: = 100ml glass of wine: =

25 Take home messages Brief interventions could be the best way of changing New Zealand s heavy drinking culture (in the presence of a timid government) Routinely find out what every patient is drinking - weekly amounts and per occasion amounts - typical and heaviest amounts over past 12 months and compare with guideline Routinely spend a few minutes with every patient who is drinking more than guideline (or AUDIT>8) with the aim of helping them convince themselves (REDS) to drink less (abstinence if mod-severe AUD)

26 Ruth Ruth is a 34 year old office manager who has been drinking regularly since age 17 and enjoys craft beer. Two weeks ago, she slipped on the stairs following one of her craft beer club evenings and badly twisted her ankle. She has completed the AUDIT and scored 20.

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