The feasibility of providing community pharmacy-based services for alcohol misuse: a literature review

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1 Review IJPP 2009, 17: ß 2009 The Authors Received January 07, 2009 Accepted March 27, 2009 DOI /ijpp/ ISSN The feasibility of providing community pharmacy-based services for alcohol misuse: a literature review Margaret C. Watson a,b and Alison Blenkinsopp c a Department of General Practice and Primary Care, University of Aberdeen, b NHS Grampian, Aberdeen and c Department of Medicines Management, University of Keele, Keele, Staffordshire ST5 5BG, UK Abstract Objectives Excessive consumption of alcohol is a major public health concern. The use of community pharmacies and pharmacists as sources of public health information and services is gaining greater recognition. The objective of this review was to provide an overview of the evidence on the feasibility, effectiveness and acceptability of providing community pharmacy-based services to address the excessive consumption of alcohol. Methods Electronic databases were searched for the period to identify relevant evidence. Searches were also conducted of relevant pharmacy and addiction journals. Information was sought from key contacts in pharmacy and alcohol research. Studies were included if they were conducted in a community pharmacy setting. Key findings The review comprised three feasibility studies which included 14 pharmacies and 500 customers. Non-significant reductions in alcohol consumption were reported with two studies following brief interventions by pharmacists. Between 30% and 53% of pharmacy customers were identified as having hazardous or harmful drinking behaviour. Customer opinion of the pharmacy-based alcohol services was not reported. Conclusions There has been little empirical evaluation of the effectiveness of community pharmacy-based services for alcohol misuse. The evidence presented in this review suggests that community pharmacy-based screening is feasible. Organisations and individuals involved with tackling excessive alcohol consumption should consider the inclusion of community pharmacies and pharmacists as part of their strategies to address this problem. Large-scale studies are needed to evaluate the short- and long-term effects and cost-effectiveness of community pharmacy-based interventions to reduce excessive alcohol consumption, as well as to explore the acceptability of the service to users. Keywords alcohol; community pharmacy; drinking; literature review; screening Introduction Excessive alcohol consumption has major implications for public health. Two billion people consume alcohol worldwide, of whom 76 million have a diagnosable alcohol use disorder. [1] Excessive alcohol consumption is associated with substantial mortality and morbidity, resulting in 1.8 million deaths annually. [1] Alcohol misuse incurs considerable societal costs, in terms of health, criminal justice, emergency services and general human costs (e.g. employment problems). Hazardous drinking is defined as the regular consumption of more than the recommended upper limit of alcohol. [2] Harmful drinking is a pattern of drinking that causes damage to physical health (e.g. liver) or mental health (e.g. episodes of depression secondary to heavy consumption of alcohol). [3] Correspondence: Dr M. C. Watson, Department of General Practice and Primary Care, University of Aberdeen, Westburn Road, Aberdeen, Scotland AB25 2AY, UK. m.c.watson@abdn.ac.uk Community pharmacists and public health Harm-reduction methods include education and identification of at-risk drinkers and communication with individuals regarding their alcohol consumption. [4] Opportunistic advice, brief interventions and offering floor space to other health professionals are areas where community pharmacy could make a contribution. [5] 199

2 200 International Journal of Pharmacy Practice 2009; 17: However, until recently, public health activities in relation to alcohol misuse have rarely featured in community pharmacies, with some notable exceptions. [6 9] Lack of pharmacy and pharmacist engagement with these activities may have been due to inappropriate facilities (i.e. for private consultations), as well as difficulties associated with identifying, approaching and engaging pharmacy customers in discussion about alcohol-related issues. The Scottish Intercollegiate Guidelines Network (SIGN) issued guidelines that relate to the management of harmful drinking and alcohol dependence in primary care. [2] The guidelines are internationally relevant and the sections relating to Detection and Assessment, and Brief Interventions, are of particular relevance to community pharmacists. [2] Alcohol screening The feasibility of screening for excessive alcohol consumption is influenced by the screening tool which is used, in terms of its ease and speed of use. Screening tools should have good sensitivity (to identify true positives, i.e. individuals who consume excessive amounts of alcohol) and specificity (to identify true negatives, i.e. individuals who do not consume excessive amounts of alcohol). The SIGN Guideline recommends the following tools for use in primary care: AUDIT (Alcohol Use Disorders Identification Test) or a modified version of AUDIT, FAST (Fast Alcohol Screening Test) or CAGE (Cut, Annoyed, Guilty, Eye opener) plus two additional questions [2] (Table 1). CAGE is used to identify dependent drinkers and may be of less use in the community pharmacy setting compared with AUDIT or FAST. Interventions for reducing excessive alcohol consumption There is considerable evidence of the effectiveness of brief interventions for the management of hazardous and harmful drinking. [10] Brief interventions last between 5 and 45 min [2,11] and may include the use of a protocol or guidelines to provide a specific service. [11] Four levels of intervention can be delivered depending upon the level of risk identified, [10] including: alcohol education; simple advice; simple advice plus brief counselling and continued monitoring; and referral to specialist for diagnostic evaluation and treatment. It has been recommended that primary care health professionals should opportunistically identify hazardous and harmful drinkers and deliver a brief (10 min) intervention [2] and this approach has been endorsed by the Primary Health Care European Project on Alcohol (PHEPA), which also issued guidance on brief intervention use. [12] Objective The objective of this review was to identify and combine the evidence of the feasibility, effectiveness and acceptability of providing community pharmacy services for the management of excessive alcohol consumption. Methods A variety of methods was used to identify evidence to inform this review. Table 1 Comparison of screening tools Screening tool Type of drinking screening tool will identify Effectiveness/accuracy Length of time to complete Ease of use Ease of scoring AUDIT Hazardous, harmful and mild dependence High 92% sensitivity 94% specificity AUDIT PC Hazardous, harmful and mild dependence Medium Men: 68% sensitivity 84% specificity Women: 56% sensitivity 95% specificity AUDIT C Hazardous, harmful and mild dependence Medium Men: 78% sensitivity 75% specificity Women: 50% sensitivity 93% specificity FAST Hazardous, harmful and mild dependence Medium Detects 90% of those AUDIT detects CAGE Dependency: focuses on lifetime drinking Medium 60 90% sensitivity 40 95% specificity Long 2 4 min Short 1 2 min Short 1 min Very short 12 s 1 min Short 1 min Moderate This is a modified version of a table from

3 Community services for alcohol misuse Margaret C. Watson and Alison Blenkinsopp 201 Rapid literature review Electronic databases (Medline, EMBASE) were searched for the period , using the search terms: alcohol, alcohol drinking, alcohol misuse, primary health care and community pharmacy. The Cochrane Collaboration Library was also searched (with no date of publication restriction), for alcohol in the title, abstract or keywords. The searches were not limited by language. In addition, the following electronic journals were searched (for the same time period) for relevant articles: Pharmaceutical Journal, International Journal of Pharmacy Practice, Pharmacy World and Science, Annals of Pharmacotherapy, Alcohol and Alcohol and Alcoholism. Studies that evaluated the effect of community pharmacy-based services to manage excessive alcohol consumption were included. Additional information The review authors also contacted individuals and organisations involved in the research of the management of excessive alcohol consumption in the community pharmacy setting and pharmacy practice research in general to provide any additional, relevant information (Table 2). An advert was placed in the Pharmaceutical Journal, requesting readers to contact the review authors with any information about evaluations of services relevant to this review. In addition, the results of a critical literature review of brief interventions to reduce excessive alcohol consumption that was conducted by a group of third-year medical students and supervised by M.C.W. were also used to inform this review. Supplementary information was identified that related to community pharmacists other public health roles (particularly those related to lifestyle modification), as well as evidence derived from (non-pharmacy) primary care studies, Table 2 Key informants C. Anderson, University of Nottingham P.D. Anderson, Public Health Consultant, UK M. Armstrong, PharmacyHealthLink C. Bond, University of Aberdeen T. Chen, University of Sydney W. Chung, Chief Pharmacist, Humber Mental Health Trust R. Dhital, King s College, London K. Farris, University of Iowa N. Fitzgerald, Create Consultancy V. Fryer, Hull Teaching Primary Care Trust C. Hughes, Queen s University, Belfast E.F.S. Kaner, University of Newcastle C. Matheson, University of Aberdeen M. Rossi, Consultant in Public Health Medicine (Health Protection, specifically Drugs and Alcohol), NHS Grampian K. Ryan, University of Bournemouth Scottish Specialists in Pharmaceutical Public Health (SSiPPH) J. Sheridan, University of Auckland S. Taylor, Devon Local Pharmaceutical Committee K. Tuhaise, Community Pharmacist, Hull National Pharmacy Association (NPA) Table 3 Organisation which could be used to inform the development and evaluation of community pharmacy-based services to reduce excess alcohol consumption (Table 3). Results Additional information sources/resources International Network on Brief Interventions for Alcohol Problems Primary Health Care European Project on Alcohol (PHEPA) PharmacyHealthLink (including Pharmacy Aide Memoire Care (Alcohol)) Create Consultancy Website Evidence of effectiveness of community pharmacy-based services for alcohol misuse Three feasibility studies were identified that evaluated the effect of screening and brief interventions as community pharmacy-based services for the management of excess alcohol consumption, all of which were conducted in the UK [6,8,9] (Table 4 [6 9,13] ). The study by Dhital was conducted in London in 2004 in a single community pharmacy. [8] One-third of people screened by the pharmacist were categorised as harmful or hazardous drinkers. The pharmacist intervention included increasing client awareness about alcohol, assessing current drinking behaviour, conducting screening with a validated tool and providing a brief intervention based upon the results. Training was provided for the pharmacist prior to their involvement in the study. Non-significant reductions in alcohol consumption were reported by customers who received a brief intervention. This was a small-scale, uncontrolled study in one pharmacy (n = 73 customers recruited). No sample size calculation was presented. A feasibility study was conducted in 2005 by Fitzgerald and Stewart. [6] Self-selected pharmacists from eight pharmacies in one geographical area participated. The pharmacists training included information sessions describing screening and brief interventions and exploration of their attitudes towards alcohol. The training methods included roleplay, group discussion and question-and-answer sessions. Of the 70 customers who participated, 10% and 43% were categorised as harmful drinkers and hazardous drinkers, respectively. Non-hazardous/nonharmful drinkers (n = 29) had shorter consultations on average (9 min) compared with hazardous/harmful drinkers (n = 30) (12 min) and harmful drinkers (n = 7) (16 min). [13] Nonsignificant reductions in alcohol consumption were demonstrated. No sample-size calculation was presented. Pharmacists attitudes and knowledge were also explored during this study. Whereas pharmacists reported no problems with aggressive patients, some suggested that this could have been due to the types of customers who they approached for the intervention (i.e. the pharmacists may have been less likely to approach clients perceived to be more likely to give

4 202 International Journal of Pharmacy Practice 2009; 17: Table 4 Comparison of three community pharmacist-based alcohol-screening and brief intervention studies Dhital 2004 [7,8] Fitzgerald 2006 [6,13] Goodall 2006 [9] Location of study London Glasgow Leeds Duration of education programme 2 days 2 days Unspecified Duration of study (months) Pharmacists recruited/trained (n) Counter staff recruited/trained (n) 0 13 Total not specified Clients recruited (n) Clients approached Not reported Not reported Not reported Clients followed-up, n (%) 40 (55%) 19 (27%) Not specified Clients identified as harmful 26 (36%) 37 (53%) 105 (30%; all hazardous) or hazardous drinkers, n (%) Duration of follow-up (months) Screening tool used AUDIT FAST FAST Research design Uncontrolled, before-andafter study Modified from an original table by Dhital (2008). [7] Uncontrolled, before-andafter study Uncontrolled, before-andafter study a negative response). A barrier to the delivery of this service was workload and a facilitator to the recruitment of clients was the use of posters to advertise the service. Some pharmacists reported targeting specific patient populations, for example clients accessing smoking-cessation services, and this targeted approach may explain why this study achieved the highest percentage of hazardous/harmful drinkers of all the studies included in this review. The third study was conducted in 2006 in Leeds, England and involved six community pharmacies. [9] The study assessed whether pharmacists could opportunistically identify patients who were hazardous drinkers. The pharmacists training included attendance at tutorials about the effect of excessive alcohol on health, the use of the FAST questionnaire and the delivery of brief interventions. Regular meetings were held to discuss the progress of the study, identify barriers and share experiences. One of the six pharmacists withdrew prior to patient recruitment. One of the five remaining pharmacists recruited 83% of all patients and achieved this by adopting various strategies to enhance his recruitment rate. The pharmacists in the four remaining pharmacies reported difficulties with workload, embarrassment and time constraints. Factors that were associated with the high recruitment rate in the fifth pharmacy included the involvement of counter staff (who were trained) to perform the screening test, using specific times of day when the pharmacist was more likely to be available during which the staff would actively screen and providing staff with incentives to recruit customers. An additional finding of this study was 80% of participants reported being concerned about a friend or colleague s drinking behaviour. No sample-size calculation was presented. The four low-recruitment pharmacists reported that the intervention was well accepted by patients, and that with greater resources they would have been able to deliver the service as planned. The pharmacists also suggested that knowing their patients enabled them to deliver the service. The participants also recommended raising the subject of alcohol during consultations for other purposes, for example during medicine reviews. The three community pharmacy-based studies reviewed above had small sample sizes (in terms of participating pharmacies), all of them were uncontrolled, and none reported customer attitudes towards the interventions. Considerable loss to follow-up of client participants occurred with two studies, [6,8] and is a problem reported with other studies that have targeted excess alcohol consumption in primary care. [14] Additional information was derived from three studies which examined community pharmacists attitudes towards providing services relating to excess alcohol consumption. A postal survey was conducted by Kotecki, with a random sample of community pharmacists in the USA who sold alcohol from their premises. [15] The response rate was 74.4% (n = 476). Less than one-quarter (23%) of respondents reported that they inquired about their patients alcohol consumption. Respondents reported being more likely to engage in discussions about alcohol with their patients if they (the pharmacists) believed alcohol to be an important cause of morbidity. A survey of 101 randomly selected community pharmacists was conducted in a region of France. [16] The purpose of the survey was to explore the pharmacists attitudes towards the use of alcohol and alcohol-related problems. No response rate was presented. Although it was reported that the respondents perceived that they had an important role in the prevention of excess alcohol consumption they stated that initiating discussions with patients about this subject was difficult. These results, combined with those from Kotecki s survey, suggest that attitudinal barriers among some community pharmacists reduce the likelihood of them initiating discussions with their customers about alcohol. A survey of community pharmacists attitudes towards and knowledge of excess alcohol consumption conducted in New Zealand achieved a response rate of 39%. [17] Whereas knowledge of alcohol content of drinks and recommended safe drinking limits was poor, the pharmacists responses indicated that they were well-motivated towards undertaking a role to address excess alcohol consumption but that they lacked skills and confidence.

5 Community services for alcohol misuse Margaret C. Watson and Alison Blenkinsopp 203 Three local primary care organisations in the UK were identified as having undertaken work on the management of excess alcohol consumption as part of community pharmacy public health campaigns. One campaign in Hull, England, focused on the use of drugs and alcohol (V. Fryer, personal communication). Pharmacies were given resources to promote issues associated with drugs and alcohol and to assist in the provision of advice to patients. A training evening was also held during which the primary care trust worked in partnership with colleagues from Hull City Safe to talk about the impact of drugs and alcohol in the local area. It was reported that the pharmacy staff enjoyed the interactive session especially as it did not focus solely on specific drugs or types of alcohol, but explored the wider impact on the community and gave advice on how to deal with situations or patients who presented within the pharmacy suffering from the effects of drug or alcohol misuse. An alcohol awareness campaign was run in Glasgow, Scotland, in 2004 and was co-ordinated by the pharmaceutical public health team (E. Grant, personal communication). Approximately 100 community pharmacies participated. The main focus of the campaign was alcohol awareness, particularly the recommended units for men and women. A poster was produced in the Health Board s graphics department, and leaflets on units of alcohol in various drinks, sensible drinking and related topics such as depression, coping with caring and smoking were supplied to the pharmacies along with pens, balloons and key rings. Excess alcohol consumption was one of six community pharmacy public health campaigns in Leeds, England, in A questionnaire was sent to the 156 pharmacies in the area and 56 pharmacists responded. [18] Only 25% of respondents agreed that the campaign increased their pharmacy s activity around the topic, and 12% agreed that elements of the campaign presented problems. Spontaneous comments indicated that most pharmacies had not taken a proactive approach with the campaign. Evidence for the effectiveness of brief interventions for reducing excess alcohol consumption To supplement the evidence identified above, information was also included in this review regarding the use of brief interventions to reduce excess alcohol consumption conducted in non-pharmacy primary care settings. A Cochrane review has been published on this topic, [14] comprising 28 randomised controlled trials and 7286 participants, only 499 (6.8%) of whom were women. The studies were conducted in general practice (n = 23) and emergency departments (n = 5). Brief interventions achieved statistically significant reductions in alcohol consumption, and were more effective with male participants compared with females, achieving a reduction of six units per week on average. Interventions of greater duration than brief interventions achieved nonsignificant reductions in alcohol consumption. As well as under-representation of female participants, young people and ethnic minorities were not well represented in these trials. Most trials were conducted in Western Europe or North America. Many studies reported large losses to follow-up. An additional systematic review of trials in general practice [19] concluded that universal screening of patients for alcohol misuse might not be an effective method of identifying harmful or hazardous drinkers. There has been little evaluation of the long-term effect of brief interventions. Wutzke et al. [20] conducted a 9-month and 10-year follow-up of a cohort of 554 hazardous or harmful drinkers recruited from primary care or health screening services in Australia. At 9 months, of the 89% participants who were followed up, those who had received the intervention had significantly lower weekly alcohol consumption than controls. At 10 years, 78% of the cohort was followed up and no difference was shown with alcohol consumption between intervention and control participants. A cohort of 338 at-risk alcohol drinkers in Norway, who were originally randomised to one of three trial groups, reported the persistence of beneficial effects of brief interventions at 9-year follow-up. [21] Only 73% (n = 247) of the original cohort was included, with differential followup across the original groups. Significant reductions in serum g-glutamyltransferase were observed at follow-up compared with baseline for the entire cohort. Discussion There is a paucity of empirical evidence of the effectiveness of community pharmacy-based services for the management of excess alcohol consumption. The evidence presented in this review suggests that interventions that have been delivered in non-pharmacy primary care settings for the management of excessive alcohol consumption may be feasible for delivery in the community pharmacy setting. The studies included in this review demonstrate that screening, signposting and brief interventions are feasible in this setting. The effectiveness and cost-effectiveness of delivering services in community pharmacies to manage excess alcohol consumption needs to be tested in a definitive study. The supplementary information provided by the surveys from the USA, France and New Zealand showed that while pharmacists supported the need to target excess alcohol consumption, they reported little current involvement in the delivery of this type of service. Pharmacists future involvement with this type of service would require enhancement of their knowledge, skills and confidence. In particular, barriers to the provision of alcohol management services need to be addressed, including strategies to incorporate the service into the daily workload, and encouraging pharmacists (and staff) to be more proactive in approaching potential clients for thus type of service. [9,22] Strengths and limitations This review was conducted using a systematic approach; however, few studies were identified and included. All three studies of community pharmacy-based management of excessive alcohol consumption were conducted in the UK, which may limit the generalisability of the results to other countries. In addition to conducting systematic searches, the use of an information request notice in the Pharmaceutical

6 204 International Journal of Pharmacy Practice 2009; 17: Journal, as well as contacting experts in pharmacy-based alcohol management services, increased the likelihood of identifying unpublished studies and evaluations suitable for inclusion in this review. Possible ways forward for pharmacy-based services Opportunistic screening for excess alcohol consumption could be provided as a generic service from all community pharmacies, or targeted in specific areas where there is an identified need. Community pharmacy-based services for the management of excess alcohol consumption could be targeted at specific populations at increased risk of adverse outcomes due to alcohol misuse for example, adolescents and pregnant women to provide an efficient use of resources. Pharmacists could also target patients at risk of adverse events due to interactions between alcohol and their medication; for example, warfarin and metronidazole. Furthermore, pharmacists could deliver opportunistic interventions to patients or customers who present with prescriptions or requests for medicines associated with conditions that may be associated with excess alcohol consumption; for example, dyspepsia, headache and fatigue. Community pharmacy-based alcohol screening could be incorporated into consultations for other pharmacy services including smokers/ex-smokers receiving smoking-cessation counselling, young adults accessing chlamydia screening and drug misusers accessing methadone maintenance services. In countries where pharmacists provide medication review and lifestyle consultations, questions regarding alcohol consumption could be included to identify patients at risk due to excess alcohol consumption. Referral to specialist services No information was provided by any of the studies included in the review regarding referral pathways available for pharmacists when dealing with patients whose needs are beyond the scope of the pharmacy service. Delays in referral time may reduce the likelihood of attendance at specialist clinics. [2] Future service development involving community pharmacists in the management of excess alcohol consumption should ensure that relevant patients can be referred to specialist services when required. Conclusions There has been little empirical evaluation of the effectiveness of community pharmacy-based services for the management of excess alcohol consumption. The available evidence suggests that community pharmacy-based screening services are feasible. Large-scale studies are needed to determine whether community pharmacy-based services to reduce excess alcohol consumption are effective and cost-effective, and acceptable to pharmacy customers and patients. Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose. Funding This study was funded by a grant from the Royal Pharmaceutical Society of Great Britain (RPSGB). Acknowledgment A parallel version of this review was combined with a policy review and published by the RPSGB. We thank all the key informants who contributed to this review. Particular thanks go to Ms R. Dhital, Dr C. Matheson, Professor C. Bond and Dr M. Rossi. We are also grateful to the following third-year medical students (University of Aberdeen), who identified some of the empirical work included in this review: Ms N. Finnie, Mr A. Clark, Mr M. Scullion and Mr D. Middleton. References 1. World Health Organization. Global Status Report on Alcohol Geneva: World Health Organization, Scottish Intercollegiate Guidelines Network. The Management of Harmful Drinking and Alcohol Dependence in Primary Care. 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