Alex J Mitchell Alcohol Detection by Clinician (Aug2012)

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Powerpoint slides on detection and identification of alcohol problems (alcohol use disorder) by clinicians.

See related paper:
http://bjp.rcpsych.org/content/201/2/93.abstract

Royalty free for personal use, but please cite with credit to AJMitchell (Leicester)

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  • Acute alcohol withdrawal The physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time. 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. For further information, please refer to: ‘Diagnostic and statistical manual of mental disorders’ (DSM-IV) (American Psychiatric Association 2000) and International statistical classification of diseases and related health problems – 10 th revision (ICD-10) (World Health Organization 2007). Coeliac axis block P ain relief by nerve block of the coeliac plexus Decompensated liver disease Liver disease complicated by the development of jaundice, ascites or abnormal bleeding and/or hepatic encephalopathy. Harmful drinking A pattern of alcohol consumption that is causing mental or physical damage. Hazardous drinking A pattern of alcohol consumption that increases someone’s risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. The term is currently used by WHO to describe this pattern of alcohol consumption. It is not a diagnostic term. Malnourishment A state of nutrition in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on tissue/body form, composition, function or clinical outcome. Medically assisted alcohol withdrawal The deliberate withdrawal from alcohol by a dependent drinker under the supervision of medical staff. Prescribed medication may be needed to relieve the symptoms. It can be carried out at home or in a hospital or other inpatient facility. Medicines licensing matters The guideline assumes that prescribers will use a drugs summary of product characteristics to inform decisions made with individual patients. This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. In each case informed consent should be obtained and documented. These medications will display a * next to them in this presentation and the reader should refer to the NICE guideline for more details.
  • 24% of the adult population in England, including 33% of men and 16% of women, consumes alcohol in a way that is potentially or actually harmful to their health or well being (Defined as scoring 8 or more on the Alcohol Use Disorders Identification Test AUDIT) (McManus et al. 2009). 4% of adults in England are alcohol dependent (6% men; 2% women) (Defined as scoring 16 or more on the AUDIT) (Drummond et al. 2005). Alcohol related hospital admissions increased by 85% between 2002–03 and 2008–09, accounting for 945,000 admissions with a primary or secondary diagnosis wholly or partly related to alcohol in 2006–07, 7% of all hospital admissions (North West Public Health Observatory 2010). To clarify the terms used in association with alcohol consumption and its risks, the Department of Health now recommends the use of terms: lower risk, increasing risk and higher risk because these are more readily understood by the general public and reflect the level of risk incurred by drinkers as their consumption increases. These terms differ from the categories of alcohol dependence identified on the previous slide. Alcohol dependence is a type of drinking that develops in regular excessive drinkers, mainly in those drinking at higher risk levels (Department of Health’s Learning Centre. E-learning for primary care, 2009. Available at www.alcohollearningcentre.org.uk/alcoholeLearning/learning/IBA/Module1_v2/D/ALC_Session/443/tab_580.html ). For more information about the terms lower risk, increasing risk and higher risk, visit the alcohol learning centre www.alcohollearningcentre.org.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.
  • Detection sensitivity was 0.400561 (95% CI = 0.340314 to 0.462357) all studies Detection specificty was 0.914843 (95% CI = 0.880441 to 0.943872) across all studies
  • Detection sensitivity was 0.400561 (95% CI = 0.340314 to 0.462357) all studies Detection specificty was 0.914843 (95% CI = 0.880441 to 0.943872) across all studies
  • 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. Australian and New Zealand Journal of Psychiatry 40, 855- 864. Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B. and Kessler, R. C. (2005a) Failure and delay in initial treatment contact after first onset of mental disorders in the national comorbidity survey replication. Archives of General Psychiatry 62, 603-613. 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.
  • 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. Addiction. 2011 Jul;106(7):1239-48. doi: 10.1111/j.1360-0443.2010.03356.x. Epub 2011 Mar 7. Alcohol-related discussions in health care--a population view. Mäkelä P , Havio M , Seppä K .
  • 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. doi: 10.1111/j.1600-0447.2012.01871.x. [Epub ahead of print]
  • 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
  • CAGE (King, 1986) MAST (Selzer, 1971) AUDIT (Babor et al., 1989)
  • 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) Nice suggests Complete a validated alcohol screening questionnaire with these young people. Alternatively, if they are judged to be competent enough, ask them to fill one in themselves. In most cases, AUDIT 8 (alcohol use disorders identification test) should be used. If time is limited, use an abbreviated version (such as AUDIT-C, AUDIT-PC, CRAFFT, SASQ or FAST). Screening tools should be appropriate to the setting. For instance, in an emergency department, FAST or the Paddington Alcohol Test (PAT) would be most appropriate.
  • Alex J Mitchell Alcohol Detection by Clinician (Aug2012)

    1. 1. Alex J Mitchell (2012)Alcohol Detection by CliniciansRates 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
    2. 2. Alex J Mitchell (2012)Some Definitions of Alcohol Problems• 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
    3. 3. Alex J Mitchell (2012)Magnitude of Problem Drinking • 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 EuropeDrummond DC, Oyefes, N, Phillips T et al. (2005) Alcohol needs assessment research project: the 2004 national alcohol needsassessment for England. Department of Health, LondonMcManus S, Meltzer H, Brugha T et al. (2009) Adult psychiatric morbidity in England, 2007: results of a household survey. NHSInformation Centre for Health and Social Care, LeedsNorth West Public Health Observatory (2010) Local alcohol profiles for England. www.nwph.net/alcohol/lape/
    4. 4. Alex J Mitchell (2012) Nutt DJ, King LA, Phillips LD; Independent ScientificDrug harms in the UK Committee on Drugs. Drug harms in the UK: a multicriteria decision analysis. Lancet. 2010 Nov 6;376(9752):1558-65. Epub 2010 Oct 29. Scores represent opinions of Members of the Independent Scientific Committee on Drugs
    5. 5. 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 case- notes for only 1 in 3 people who had an alcohol problemMitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians inprimary and secondary care: meta-analysis. British Journal of Psychiatry August 2012
    6. 6. 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 inprimary and secondary care: meta-analysis. British Journal of Psychiatry August 2012
    7. 7. 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 1Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians inprimary and secondary care: meta-analysis. British Journal of Psychiatry August 2012
    8. 8. 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 firstonset 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 ZealandMental 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 nationalsample. Psychiatr Serv. 2010 Dec;61(12):1223-31.
    9. 9. 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 usedisorders in a national sample. Psychiatr Serv. 2010 Dec;61(12):1223-31
    10. 10. Alex J Mitchell (2012)Receipt of Advice and Treatment • 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, 2004Edlund 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 factorsinfluence practice? Fam Pract 2004; 21: 270–5Mäkelä P, Havio M, Seppä K.Alcohol-related discussions in health care--a population view. Addiction. 2011 106(7):1239-48.
    11. 11. Alex J Mitchell (2012)Barriers to Detection 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
    12. 12. Alex J Mitchell (2012)Patients’ Views of Being Asked @ Drinking • 90% have positive attitudes towards being asked • Typically only 3% of GP attendees are typically asked about alcohol in 12mo Foulds et al (2012) • Typically only 10% of at risk drinker are typically asked about alcohol in 12mo Foulds et al (2012) • Typically only 1 in 3 problem drinkers are typically asked about alcohol in 12mo Mäkelä et al (2011)Foulds J, Wells JE, Lacey C, Adamson S, Mulder R. Harmful drinking and talking about alcohol in primary care: New Zealandpopulation survey findings. Acta Psychiatr Scand. 2012 Apr 26Mäkelä P, Havio M, Seppä K.Alcohol-related discussions in health care--a population view. Addiction. 2011 106(7):1239-48.
    13. 13. Alex J Mitchell (2012)Rates of Enquiry @ Drinking by AUDIT ScoreFoulds et al (2012) 35 33.6 30 25 AUD 20 15 14.4 10 9.2 9.4 5 5 2.9 3.2 2.5 1.7 1.6 1.1 0 Zero One 2–3 4–5 6–7 8–9 10–14 15–19 20–40 8 or higher All PatientsFoulds J, Wells JE, Lacey C, Adamson S, Mulder R. Harmful drinking and talking about alcohol in primary care: New Zealandpopulation survey findings. Acta Psychiatr Scand. 2012 Apr 26
    14. 14. Alex J Mitchell (2012)Suggested Screening Protocol Credit: Alcohol Learning Centre
    15. 15. Alex J Mitchell (2012)Audit Screening Test: 10 Questions 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?
    16. 16. Alex J Mitchell (2012)Basic Principles of Engagement1. Offer a private, comfortable consultation2. Use a Non-judgemental attitude3. Foster Trust4. Avoid arguments5. Show Empathy6. Guage Severity7. Promote Self-efficacy8. Promote motivation to change9. Engage caregivers
    17. 17. Alex J Mitchell (2012)Recommended alcohol limits: Units 1 Unit = 10ms / 10g
    18. 18. Alex J Mitchell (2012)Help Online• NHS Handout on Alcohol http://www.alcohollearningcentre.org.uk/alcoholeLearning/learning• Brief Alcohol Intervention Online http://www.alcohollearningcentre.org.uk/alcoholeLearning/learning • 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
    19. 19. Alex J Mitchell (2012)National Help• 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.
    20. 20. Alex J Mitchell (2012)NICE Guidance • 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)
    21. 21. Alex J Mitchell (2012)Alcohol Detection by CliniciansRates 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

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