1. How brief can you go?
A history of IBAs and
Brief Literature Review
Andrew MacDonald

2. Prolonged drinking leads to...
Acute & Chronic Issues
Acute settings
• 70% of accident and emergency
• 1,000 suicides per annum
• 44% domestic abuse cases
Chronic settings
• liver cirrhosis
• Obesity
• Hypertension
• Coronary heart disease
• Pancreatitis
• Various cancers
• Mental health problems
(Faculty of Public Health, 2012)
And doesn’t taste nice...
‘...His mouth had been used
as a latrine by some small
creature of the night, and
then as it’s mausoleum...’
(Kingsley Amis, 1954)

3. And it costs...££££££££££££££££
NHS
• The cost of alcohol related
harm in England to the NHS
alone is currently estimated
at £2.7bn per annum
(LGA 2013)
NW Economy
• The cost to the North West
economy in 2010-2011 has
been estimated at over
£3bn across NHS, Social
Care, Workforce, and
Community Safety
(Drink Wise North West, 2012)

4. Professor Griffith Edwards
‘...Good luck to the specific therapies,
psychological and pharmacological...
... let’s not put them down, but at the
centre is still the...little understood core
of the change process... ’
Drummond & Ashton, 1999

5. Where did it all begin?
Origins Scotland 1980s
• Davies, 1962, Edwards, 1977
Resolution of ‘Abstinence’
versus ‘Controlled Drinking’
controversy
• Jellinek, 1960 Up to the 1960s,
‘alcoholism’ disease of the
individual and not a matter for
public health
• Heather & Robertson, 2006
Last 50 years assumption
strongly challenged – with
support even chronic recover
3 seminal articles
• Edwards et al., 1977 signalled
end ‘disease’ model - shift to
community with specialist
support
• Chick et al., 1985 screening
hospital and IBA reduced
problems
• Wallace et al., 1988 IBA via
non-specialist GPs persisting
reductions consumption of
patients screened for
excessive drinking

6. And so on...
NICE 2007:
Sociologists cited for IBAs!
• Babor et al., 2001a, 2001b AUDIT
and IBAs
• Bourdieu, 1977 ‘Habitus’
• Giddens,1984, Putnam, 2000
‘Society’ and ‘Social Capital’
• Ajzen ,1991, 1992 ‘Theory of
Planned Behaviour’ and
‘Persuasive Communication’
• Bandura, 1994 ‘Self-Efficacy’
• Prochaska & DiClemente 1986
Stages of Change and initiation of
recovery
• Marlatt & Gordon 1987 Relapse
Prevention – Triggers
Contrast with ‘Recovery’
• Raistrick et al., 2006 Help-seeking =
prolonged problems = after attempts
unassisted change have failed
• White & Kurtz, 2005 Several
attempts several years
• Winnick, 1962, Vaillant, 1995 5%
problem drinkers recover ‘naturally’
every year – tend to have better
‘Social Assets’

7. IBA in a nutshell
Who and What
• Alcohol ‘brief intervention’ is
good public health advice on
alcohol use delivered by non-
alcohol specialist in the normal
course of their work.
• Offered to drinkers who are
not complaining about or
seeking help for an alcohol
problem but who have met a
‘risk’ screening threshold
based on 4 simple questions
What and Why
• Intensity from 5 minutes of
‘advice’ to up to 1 hour of
‘intervention’ or ‘talking
therapy’ over 1-4 sessions
• Advice is normally
accompanied by some form of
self-help material
• Advice is usually seen as early
intervention; any ‘helping’
professional can identify risk,
advise and refer on

8. At first sight IBAs look compelling
ANARP and after 2004
• Moyer et al., 2002 56 RCTs VFM
1:8 people (15%) act on simple
alcohol advice reduce < lower-risk
levels
• Kaner et al., 2007 Cochrane
Review
• Silagy & Stead, 2003 compares
favourably with smoking (biggest
killer) 1:20 act on advice (1:10
NRT)
• Wallace et al, 1988 IBA reduction
higher-risk to lower-risk 250,000
men 67,500 women each year
And on...key studies
• Wilk et al., 1997 higher risk and increasing
risk drinkers IBA twice as likely to moderate
their drinking 6 to 12 months post
intervention compared to no intervention
• Whitlock et al, 2004 IBA reduce weekly
drinking 13% to 34%, with a significant effect
on recommended or safe alcohol use
• Miller et al, 2005 Further, reductions in
alcohol consumption associated significant
dose-dependent lowering mean systolic and
diastolic blood pressure
• Fleming et al, 2004 IBA can reduce alcohol
use in primary care patients being treated
for Type 2 diabetes and hypertension

9. ANARP 2004 Assumptions
Synthetic Estimates
Babor, 2001 (AUDIT – IBA - WHO)
• Hazardous Drinking: people drinking
above recognised safe levels but not
yet experiencing harm (weekly >21/14
units, daily >8/6 units)
• Harmful Drinking: people drinking
above safe levels and experiencing
harm (AUDIT 8 -15)
• Alcohol Dependence: people drinking
above safe levels and experiencing
harm and symptoms of alcohol
dependence (AUDIT 16+)
Prevalence Service Utilisation Ratio (PSUR)
• PSUR low by international standards
• Considerable room for improvement
• GPs under identify alcohol use
• Haz / Harm: 1/67 males, 1/82 females
• Dep: 1/28 males, 1/20 females
• Younger less than older patients
• Demand moderated by low level
enquiry & finding alternatives (e.g. AA)
• Most patients self refer
• GPs welcome the possibility of more
training in alcohol issues

10. ANARP to SIPS
ANARP to SIPS
• Alcohol Needs Assessment Research
Project (ANARP) under the leadership
of Professor Colin Drummond
(Drummond et al., 2004)
• Department of Health funded
‘Screening and Intervention
Programme for Sensible Drinking’
(SIPS) (Drummond et al., 2012)
• SIPS 2012 Evidence seems to point to
a modest and targeted future for
IBAs
SIPS results
• SIPS 2012 - Straightforward
warning based on screening
achieves all that can be achieved,
training and resource may be
substantially reduced
• Consistent with earlier Cochrane
Review of primary care brief
alcohol intervention no extra
benefit extended interventions
(Kaner et al., 2007)
• Scottish hospital study giving heavy
drinking inpatients a guide to
sensible drinking led to decline
consumption as great as extended
advice (Holloway et al., 2007)

11. Scottish Government
Scottish Alcohol Strategy
• Target NHS Health Scotland deliver
149,449 IBAs primary care, Accident &
Emergency and antenatal care, by 2011
• Evaluation process of implementation
using ‘mixed’ quantitative and qualitative
methodology – they asked people!
• When setting targets for screening it is
crucial to emphasize the targeted
approach in Scotland assumed 19% of
adult patients would present to services
with conditions possibly related to
drinking and be screened for excessive
drinking, of whom 20% would screen
positive and 75% of these at-need
patients would actually be counselled.
Factors which support implementation:
 Available funding;
 Nationally co-ordinated and locally
supported training opportunities;
 National, health board and setting level
‘leaders’ able to support and encourage
implementation
Factors which hinder progress:
 Competing priorities
 Inadequate training & auditing of delivery;
 Issues in recording delivery which made it
difficult to accurately determine or
compare who the programme was
reaching
Nonetheless, delivery targets were met
Parkes et al., 2011

12. Salford Services Picture
Salford – 1400 AUDIT 16+
• 40,400 hazardous drinkers
(23%) AUDIT scores of 8-15
PSUR ratio 5.6% and ANARP
synthetic construct 2262 per
annum likely seek treatment
• 13,200 harmful drinkers (7.5%)
present AUDIT scores 16-19
PSUR ratio 5.6% and ANARP
synthetic 739 per annum
• 4,200 dependent drinkers,
present AUDIT scores 20+
PSUR ratio 5.6% and ANARP
synthetic 235 per annum
ANARP and PSUR
• Professor Griffith Edwards,
put it, looking back on a
long career:
• ‘...Good luck to the specific
therapies, psychological and
pharmacological, let’s not
put them down, but at the
centre is still the...little
understood core of the
change process... ’
Drummond & Ashton, 1999

13. Clinical Commissioning Group
Imperatives
• LES and DES
• CQUIN
• GP QOF
• Over 40s NHS Health Check.
Advice
• E-Learning
http://www.alcohollearningcentre.org.uk/eLearning/IBA/inex.cfm
• Incentives
• Sensible Targets
• 10,000 IBAs = 40 lives
• 5,000 Salford Royal alone
• MECC / WWW Portal
• 5 minute script plus leaflet
• GP, Hospital, CJS

14. Any Questions?