Alex J Mitchell (2012)
Alcohol Detection by Clinicians
Rates of recognition of alcohol problems in routine clinical practice using clinical judgment
Alex J Mitchell, University of Leicester
ajm80@le.ac.uk
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
• 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
Alex J Mitchell (2012)
Some Definitions of Alcohol Problems
• 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 Europe
Drummond DC, Oyefes, N, Phillips T et al. (2005) Alcohol needs assessment research project: the 2004 national alcohol needs
assessment for England. Department of Health, London
McManus 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, Leeds
North West Public Health Observatory (2010) Local alcohol profiles for England. www.nwph.net/alcohol/lape/
Alex J Mitchell (2012)
Magnitude of Problem Drinking
Scores represent opinions of Members of the
Independent Scientific Committee on Drugs
Alex J Mitchell (2012)
Drug harms in the UK
Nutt 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.
Alex J Mitchell (2012)
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 casenotes 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
Alex J Mitchell (2012)
HSROC Estimate Clinical Judgement vs AUD
• Across all studies,
clinicians sensitivity
was 40.0%
• Across all studies,
clinicians specificity
was 91.0%
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
Alex J Mitchell (2012)
Mitchell et al (2012) – Detection Summary
• Assuming 2 /10 GP attendees have problem drinking
Clinicians would correctly identify 7+1
miss 1
misidentify 1
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
Alex J Mitchell (2012)
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
Oleski et al (2010)
• The average delay in seeking help for alcohol
problems is 6-7 years
Wang et al (2005)
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.
Alex J Mitchell (2012)
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
• 50% of heavy drinkers who had been asked about their
alcohol use had not been advised about it Mäkelä et al (2011)
• Of 7301 primary care patients, 28.3% screened positive.
Of these, 55% received no advice
Edlund et al (2004)
• 62% of risky drinkers were given advice by practice
nurses
Lock & Kaner, 2004
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: 270–5
Mäkelä P, Havio M, Seppä K.Alcohol-related discussions in health care--a population view. Addiction. 2011 106(7):1239-48.
Alex J Mitchell (2012)
Receipt of Advice 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
Alex J Mitchell (2012)
Barriers to Detection and Treatment
• 90% have positive attitudes towards being asked
• Typically only 3% of GP attendees are typically
Foulds et al (2012)
asked about alcohol in 12mo
• Typically only 10% of at risk drinker are typically
Foulds et al (2012)
asked about alcohol in 12mo
• Typically only 1 in 3 problem drinkers are typically
Mäkelä et al (2011)
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 26
Mäkelä P, Havio M, Seppä K.Alcohol-related discussions in health care--a population view. Addiction. 2011 106(7):1239-48.
Alex J Mitchell (2012)
Patients’ Views of Being Asked @ Drinking
Alex J Mitchell (2012)
Rates of Enquiry @ Drinking by AUDIT Score
Foulds et al (2012)
35
33.6
30
25
AUD
20
14.4
15
10
9.4
9.2
5
5
3.2
2.9
2.5
1.1
1.7
1.6
2–3
4–5
0
Zero
One
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
Credit: Alcohol Learning Centre
Alex J Mitchell (2012)
Suggested Screening Protocol
1. 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?
Alex J Mitchell (2012)
Audit Screening Test: 10 Questions
1.
2.
3.
4.
5.
6.
7.
8.
9.
Offer a private, comfortable consultation
Use a Non-judgemental attitude
Foster Trust
Avoid arguments
Show Empathy
Guage Severity
Promote Self-efficacy
Promote motivation to change
Engage caregivers
Alex J Mitchell (2012)
Basic Principles of Engagement
1 Unit = 10ms / 10g
Alex J Mitchell (2012)
Recommended alcohol limits: Units
• NHS Handout on Alcohol
http://www.alcohollearningcentre.org.uk/alcoholeLearning/learni
ng/IBA03/IBA_03_004/pdf/structured_advice_tool.pdf
• Brief Alcohol Intervention Online
http://www.alcohollearningcentre.org.uk/alcoholeLearning/learni
ng/IBA03/IBA_03_004/D/ALC_Session/300/overview.html
• NHS How Much is Too Much Workbook
http://www.sips.iop.kcl.ac.uk/documents/gnr/dhpil.pdf
• SIPS Information from King’s College
http://www.sips.iop.kcl.ac.uk/documents/gnr/sipsBA.pdf
http://www.sips.iop.kcl.ac.uk/documents/gnr/sipsBLC.pdf
Alex J Mitchell (2012)
Help Online
• 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.uk
There 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.uk
Offers 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.uk
Services 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.uk
Aims to tell drinkers how many units are in their drinks and help them stick to their
limits.
Alex J Mitchell (2012)
National Help
• 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)
Alex J Mitchell (2012)
NICE Guidance
Alex J Mitchell (2012)
Alcohol Detection by Clinicians
Rates of recognition of alcohol problems in routine clinical practice using clinical judgment
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