Health Services Response to Alcohol Use Disorders Based on WHO Global Alcohol Strategy Building Capacity for National Alcohol Policies

Transcription

1 Health Services Response to Alcohol Use Disorders Based on WHO Global Alcohol Strategy Building Capacity for National Alcohol Policies Colin Drummond National Addiction Centre Institute of Psychiatry King s College London UK

2 Topics Alcohol problems: basic principles Alcohol interventions: evidence base Alcohol screening and brief interventions Interventions for alcohol dependence Importance of care pathways Organisation and delivery of treatment Monitoring and evaluation Conclusions South London as a case study of implementation and evaluation

3 Alcohol problems: basic principles

4 Alcohol: It s a drug Jim, but not as we know it.

5 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 200 diseases Psychiatric disorders Foetal alcohol effects Psychoactive effects: alcohol dependence 3 rd leading cause of disability after tobacco and hypertension No universally safe level

6 Alcohol Use Disorders: Definitions Hazardous drinking consumption of alcohol likely to cause harm Harmful drinking drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society at large, as well as the patterns of drinking that are associated with increased risk of adverse health outcomes. Alcohol dependence a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance [alcohol] use and that typically include a strong desire to take the drug [alcohol], difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.

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8 Alcohol use disorders: prevalence Drummond et al., % of the adult population have an alcohol use disorder (AUD) Includes 38% of men & 16% of women aged % 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) 1.2M alcohol related hospital admissions (304,000 wholly attributable; 916,000 partly attributable) Alcohol dependence is considerably more prevalent than drug abuse

9 Prevalence of AUD 0-16% worldwide: highest East & Central Europe Europe 6.1% males, 1.1% females Clinical settings Medical inpatients 20-30% Emergency departments 40% Psychiatric inpatients 50% Probation services 67% Considerable under-identification and undertreatment stigma, lack of training

10 Chronic liver disease and cirrhosis mortality rates per 100,000 population,

11 Alcohol interventions: evidence base

12 Alcohol strategy options Babor et al. (2003) Alcohol: No ordinary commodity High impact Taxation & pricing Restricting availability Limiting density of outlets Lower BAC limits Graduated driving licences Medium impact Brief interventions Treatment Safer drinking environment Heavier enforcement Low impact Unit labelling Sensible drinking campaigns Public education School based education Voluntary advertising restrictions ALCOHOL HARM REDUCTION STRATEGY FOR ENGLAND (AHRSE) 2004

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14 Matching interventions to severity of AUD

15 Framework of case identification and assessment

16 Alcohol screening and brief interventions: the evidence base

17 Evidence base for SBI Freemantle trials in primary care 24% drop in consumption (95% CI 18 to 31%) Moyer trials, 34 relevant to PHC Consistent positive effect, NNT 8-12 (smoking=20) Cost savings found at 4 years in the USA Kaner 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 National Institute for Healthcare and Clinical Excellence 2010 Public health guidelines recommend implementation

18 Screening and brief intervention in primary care 12 months outcomes (n=14) Study or Subgroup Europe Aalto et al., 2000 Beich et al., 2007 Cordoba et al., 1998 Huas et al., 2002 Kaner et al., 2013 Lock et al., 2006 Rubio et al., 2010 Wallace et al., 1988 Subtotal (95% CI) Heterogeneity: Tau² = 0.03; Chi² = 24.23, df = 7 (P = 0.001); I² = 71% Test for overall effect: Z = 2.67 (P = 0.008) Brief Intervention Control Std. Mean Difference Std. Mean Difference Mean SD Total Mean SD Total Weight 5.7% 8.7% 6.7% 8.1% 8.2% 3.8% 9.4% 9.4% 60.2% IV, Random, 95% CI 0.05 [-0.26, 0.37] 0.00 [-0.17, 0.17] [-0.72, -0.20] [-0.30, 0.10] [-0.25, 0.14] [-0.54, 0.35] [-0.48, -0.19] [-0.53, -0.24] [-0.32, -0.05] IV, Random, 95% CI Rest of the World Fleming et al., 1997 Fleming et al., 1999 Fleming et al., 2004 Maisto et al., 2001 Reiff-Hekking et al, 2005 Richmond et al., 1995 Subtotal (95% CI) % 5.4% 5.6% 5.8% 8.5% 5.2% 39.8% [-0.47, -0.18] [-0.98, -0.31] [-0.41, 0.23] [-0.40, 0.22] [-0.24, 0.14] 0.17 [-0.17, 0.51] [-0.37, 0.02] Heterogeneity: Tau² = 0.04; Chi² = 17.69, df = 5 (P = 0.003); I² = 72% Test for overall effect: Z = 1.78 (P = 0.08) Total (95% CI) Heterogeneity: Tau² = 0.03; Chi² = 41.97, df = 13 (P < ); I² = 69% Test for overall effect: Z = 3.36 (P = ) Test for subgroup differences: Chi² = 0.01, df = 1 (P = 0.94), I² = 0% 100.0% [-0.29, -0.08] Favours experimental Favours control

19 Alcohol Screening and Brief Intervention Research Programme SIPS A&E St. Mary s 'Scientia Vincit Timorem'

20 Interventions Patient Information Leaflet (PIL) DH How much is too much? Brief Advice (BA) 5 min of simple structured advice based on WHO Drinkless Programme modified for SIPS Brief Lifestyle Counselling 20 min motivational intervention based on WHO Drinkless programme modified for SIPS delivered by a trained Alcohol Health Worker (or Practice Nurse in PHC)

21 SIPS in numbers Staff trained (n) Approached (n) Eligible (n) % Positive (n) % Consent (n) % ED 278 5,992 3, , , PHC 195 3,562 2, CJS Totals ,521 7, , ,485 84

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23 PHC - Effectiveness Changes in the proportion of AUDIT positives overall and by intervention at 6 and 12 months

24 Cost effectiveness acceptability curve for PIL and BLC

25 ODHIN 6 country European trial of different SBI implementation strategies (Anderson et al., 2015) % change

26 Proportion in AUDIT groups offered SBI by PHC in England 12 (Alcohol Toolkit Survey Michie et al., 2014) Discussed drinking Offered advice on cutting down Offered support to cut down Referred to alcohol service

27 Scotland (MESAS) Brief interventions Target to deliver 210,500 BI in 3 years ( ) Trained 260 GPs (72%), 11% in A&E, 2% antenatal Funded by Local enhanced services contract Collected monitoring information 174,205 ABI delivered in 3 years Cost estimated M ( per BI) Represents 13-16% of the target population reached in 3 years

28 Developing and evaluating interventions for adolescent alcohol use disorders presenting through emergency departments Public Health England March 2014

29 % consumed 1 unit+ past 3 months by age 80 76, , ,8 25, , ,7 1,2 2, All

30 % AUDIT-C 3+ by age 60 55, , ,61 15, ,61 0 0,34 0,51 0,74 2, All

31 % Abuse and dependence by age (MINIKIDS) 7 6, ,61 4 3,89 3 Abuse Dependence 2 1,42 1,33 1,68 1, ,69 0,56 0,25 0, All

32 Smart phone app SIPS city High street concept Various buildings with ad hoc information My home for personalised feedback The user will explore the contents of each building and access information about alcohol and health. At different times of day, aspects of the street and buildings will look different, and different features will be available. Actions in the game and random events will have consequences elsewhere, with the goal of creating an intriguing and mysterious environment which the user will want to revisit. Quizzes to test the user's knowledge. Unlocking content and other features based on achievements

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34 Interventions for alcohol dependence

35 CG115: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence

36 Management of harmful drinking and alcohol dependence Identification and assessment Care coordination Settings Assisted withdrawal Psychosocial interventions Pharmacological interventions Comorbidity Children and young people

37 Prevention and treatment interventions Screening and brief interventions Treatment of alcohol dependence Care coordination, care pathways Detoxification (community, inpatient) Psychosocial interventions Pharmacotherapies Mutual aid Family support Treatment of people with complex needs Co-occurring mental, social, physical problems Criminal justice populations Fetal alcohol spectrum disorders Costs and cost effectiveness

38 Psychological therapies Need for greater training, competency, supervision Use of evidence based therapy manuals Motivational interventions as routine approach from point of first contact Some therapies have greater evidence of effectiveness: CBT, BT, SNT, BCT Should be time limited and provided against a background of care coordination/case management Delivery in structured day care for more severe/complex Limited indications for residential rehabilitation

39 Pharmacological therapies Naltrexone and acamprosate strongest evidence Better in dependent than harmful drinkers Disulfiram evidence base weaker, potential risks: therefore second line treatment Use with adjunctive psychosocial therapies and medical monitoring Duration 6-12 months Don t use GHB, antidepressants, benzodiazepines Some other promising medications, but currently lack sufficient evidence to recommend

40 Interventions based on severity Harmful/mild dependence CBT, BT, Social Network therapy Behavioural Couples Therapy Non-responders: offer acamprosate or naltrexone plus psychosocial Moderate/severe dependence Assisted withdrawal followed by: Intensive rehabilitation programme Structured community programme Residential rehabilitation: homeless Acamprosate or naltrexone plus CBT, BT, SNT, BCT Disulfiram (second line, preference or not suitable for first line)

41 Importance of care pathways

42 Care pathways Defines agreed national AND local system Defines patient characteristics and clinical criteria requiring different interventions Defines nature and content of interventions Defines which providers provide each component of the pathway Defines what to do on basis of response to interventions Defines funding and reimbursement for specific interventions AND pathways Goes beyond individual interventions and practitioners to define a PACKAGE of care

43 NICE care pathway case identification diagnosis Screen (FAST, SASQ, AUDIT-C) indicates possible alcohol use disorder Administer: AUDIT AUDIT < 8 AUDIT 8 15 AUDIT Hazardous drinking Harmful drinking AUDIT 20+ Probable alcohol dependence Brief intervention Extended brief intervention(s) Referral to specialist assessment Review of progress Referral to specialist assessment where no improve maintained Consider Tier 2 interventions Structured alcohol interventions Assisted withdrawal assessment

44 Care pathways for AUD

45 Organisation and delivery Access Need for universal access Funding models Availability, affordability, accessibility Planning, coordination, management, commissioning National, regional, local stakeholders Locally agreed care pathways linking generic and specialist care Needs assessment Planning and implementation Monitoring

46 Where do you start? Level 1: Basic health care implementation Low resource settings, across health/social care Includes SBI, managing complications, basic counselling, prescribing, follow up Level 2: Intermediate alcohol intervention Specialist alcohol counselling by specialist alcohol staff Level 3: Specialist alcohol service Comprehensive care for patients with complex needs Includes community and residential programmes Highly trained specialist staff N.B. value of specialist centres of excellence Catalyst for implementation, training, research and development of country specific service models, standards, advocacy

47 Infrastructure for implementation Human resources Training resources Task shifting for non-specialist care providers Facilities and materials Management and governance Clinical audit Risk management Information management Research and development Advocacy by health and social care professionals Combatting stigma

48 Barriers and facilitators to implementation Professional awareness and training Attitudes Time, reimbursement Human resources Tools, medications Support Policy priority Importance of clinical champions and specialist centres

49 History of alcohol treatment UK 1960s beginning of addiction psychiatry as a specialty regional NHS specialist inpatient units (n=10) 1980s heroin epidemic and growing effectiveness evidence increased funding for community drug and alcohol teams rapid increase in consultant addiction psychiatrists (n=253 in 2008) 2000s evidence on SBI but not led to wide scale implementation in primary care Now lots of strategies and guidelines but no increase in central funding localization NHS contracts third sector loss of NHS specialists and specialist training posts

50 Funding of alcohol treatment UK Pre 2012 Central government funding provided via NHS allocation to Primary Care Trusts (which funded all NHS services) on a locality basis population ~200, ,000 Most funding to NHS specialist mental health providers, smaller amount to 3 rd sector Annual spend ~ 217M per annum in England covering 63,000 patients ( 3,444/patient) Ring fenced

51 Funding alcohol treatment England Post 2012 NHS Health and Social Care Act Funding for addiction treatment allocated to Local Authorities and managed by Health and Wellbeing Boards as part of public health allocation Ring fencing removed; local authority funding cuts through austerity measures Marketisation results in movement of contract from NHS to 3 rd sector with reductions in funding overall (10-15%) Funding used for other priorities (e.g. frail elderly, looked after children) Loss of specialist clinical and associated training posts

52 Monitoring information Registration, monitoring, reporting of alcohol attributable morbidity and mortality Monitoring of alcohol interventions and treatment access E.g. NATMS as a case example Role of audit, research and evaluation in service improvement

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54 Prevalence Service Utilisation Ratio Gap between need and access (PSUR) by region North East Yorks and Humber Eastern South East East Midlands West Midlands South West London North West ENGLAND

55 ANARP Findings IV: Alcohol Treatment Agency Survey Survey identified 696 alcohol treatment agencies in England (43% more than previously known) 69% community-based, 31% residential 56% response rate Over half are non-statutory agencies, one third NHS, and 8% private sector Estimated annual spend = 217million Estimated treatment personnel in England = 4,250 Clients primarily alcohol dependent 91% of clients in residential agencies 71% of clients in community agencies Clients mostly self- or GP-referred 36% self-referral 24% GP/primary care referral Alcohol Needs Assessment Research Project 2005

56 Primary role of agency service type (% of respondents) Community Residential Drugs & Alcohol Alcohol Drugs Other Alcohol Needs Assessment Research Project 2005

57 Alcohol Use Disorder by treatment setting Community Residential Potential Actual Moderate Dep Severe Dep Potential = hazardous drinkers Actual = harmful drinkers Moderate Dep = moderate alcohol dependence Severe Dep = severe alcohol dependence Alcohol Needs Assessment Research Project 2005

58 80 Treatment Interventions Provided by Community Services Advice Brief Intervention Structured psych controlled Structured psych abstinence Drop-In Liaison service Detox Shared Care Detox At home Outreach Day programme abstinence Detox Clinic Based Acamprosate Other psychological Disulfiram Day programme controlled Alcohol Needs Assessment Research Project % provide detoxification Other pharmacological

59 Treatment Interventions provided by Residential/Inpatient Services Rehabilitation Inpatient Supported Housing Other Supported Non abstinence Special groups provision Alcohol Needs Assessment Research Project 2005 Crisis Centre 46% provide detoxification

60 Summary of Policy Implications of ANARP More agencies identified than previously known Valuable information for service planning, data gathering and service users Consideration should be given to incorporating alcohol treatment in National Drug Treatment Monitoring System and developing an infrastructure for data collection in alcohol agencies Level of PSUR is lower than previous international studies Considerable room for improvement in access to alcohol treatment Large regional variations in access to alcohol treatment Potential for improvement in screening, identification and referral People with alcohol dependence are heavy consumers of health services There are opportunities to increase identification and referral activity across primary and secondary health care, and in other agencies e.g. criminal justice & social services. Need for development and implementation of systematic referral criteria/integrated care pathways for AUDs Alcohol Needs Assessment Research Project 2005

61 What is NATMS? National Alcohol Treatment Monitoring System (NDTMS) DH commissioned system NTA managed Central Team Analysis Team Systems Development University of Manchester 9 regions Data collection from 1/04/ agencies via 152 Primary Care Trusts 109,683 patients in 2012/13 73,201 entered treatment in 2012/13

62 NATMS Structure Provider Performance Assurance NTA Data file NDEC Data file Regional NATMS National Collation National NATMS

63 NATMS Structure Initial of Client s First Name Initial of Client s Surname Date of birth of client Sex of client Ethnicity Nationality Referral Date Agency Code Client ID Episode ID Consent for NDTMS Previously treated Post Code Accommodation need Parental status DAT of residence PCT of residence Primary Problem Substance No 1 Age first use problem substance Route of Administration of Primary Substance Problem Substance 2 Problem Substance 3 Referral Source Triage Date Care Pan Started Date Injecting Status Children Pregnant Drinking Days Units of alcohol Dual Diagnosis Hep C (latest test date) Hep C interventions status Hep B vaccinations count Hep B intervention status Drug treatment health care assessment date Discharge Date Discharge Reason Treatment modality Date referred to modality Modality ID Date of First appointment offered for modality Modality Start Date Modality End Date Modality Exit Status TOP Date TOP ID Treatment Stage Alcohol Use Opiate Use Crack Use Cocaine Use Amphetamine Use Cannabis Use Other Drug Use IV Drug Use Sharing Shop Theft Drug Selling Other Theft Assault/Violence Psychological Health Status Paid Work Education Acute housing problem Housing risk Physical health status Quality of life

64 Treatment pathways for new clients in treatment , England Pathway n % Structured Psychosocial Intervention % Other Structured Intervention (OSI) % Prescribing (including key working) % Structured Day Programme (SDP) % Inpatient Treatment (IP) % Residential Rehabilitation (RR) 689 1% Young Persons Intervention 757 1% OSI and Psychosocial % Prescribing (including key working) and Psychosocial % OSI and Prescribing (including key working) % IP and OSI % Psychosocial and SDP 993 1% IP and Psychosocial 992 1% SDP and OSI 922 1% Psychosocial, OSI, IP 444 1% Psychosocial, OSI, SDP 478 1% Psychosocial, OSI, Prescribing (including key working) 746 1% All Other Combinations (inc IP and/or RR) % All Other Combinations 674 1% Missing/Unknown 803 1% TOTAL %

65 National drug treatment monitoring system (PHE): Number of patients entering specialist alcohol treatment per year Number of patients

66 Prevalence-Service Utilisation Ratio England Funding relatively static at ~ 220M per annum 2005 Prevalence Alcohol Dependence 1.1 million Number entering treatment 63,000 PSUR 6% Prevalence: AUDIT 16+ APMS 2000 Service utilisation: ANARP agency survey 2014 Prevalence Alcohol Dependence 1.6 million Number entering treatment 81,000 PSUR 5% Prevalence AUDIT 16+ APMS 2007 Service utilisation: NDTMS

67 Prevalence-Service Utilisation Ratio Scotland 2009 Estimated budget 61M per annum Prevalence Alcohol Dependence 206,000 Number entering treatment 17,000 PSUR 8% Prevalence: AUDIT 16+ SHeS 2003 Service utilisation: SANA survey Funding for alcohol services increased by 28M (50%) from 61M to 89M Prevalence Alcohol Dependence 220,000 (5%) Number entering treatment 31,796 PSUR 14.5% Prevalence AUDIT 16+ SHeS 2012 Service utilisation: Survey

68 Conclusions Response to AUD needs to be across all health (and social) care services, not just a specialist activity Need to enlist, train and support non-specialists Prevention and treatment has a public health impact Need for national and local strategies Need for coordination and monitoring Need for national and local champions/centres of excellence