Archive | May, 2012

Extended Brief Interventions: who, when, where, and other questions?

29 May

Last year, I did a study Evaluating EBI in alcohol settings – May 2011 as part of a Certificate in Drug and Alcohol Studies at University of Stirling which I thought might be useful for other people looking to offer EBI/Brief Treatment in alcohol settings delivered by alcohol specialists.  It is very small scale and, of course, biased by my position in relation to the research participants, and was my first foray into the Social Sciences but hoping it will be of some use.


While Increasing Risk drinkers can access Brief Advice (short, structured advice) through generalists, and High Risk/dependent drinkers can access specialist alcohol treatment, the needs of those drinkers who fall between these two groups—known as Higher Risk drinkers—are often overlooked by both generalist services and specialist alcohol settings.  Extended Brief Interventions (EBI)—short motivational sessions with follow-ups—have been recommended in national guidance as a means of filling this gap in provision.  The present study sought to explore and evaluate the effectiveness of alcohol specialists delivering EBI as a form of Brief Treatment (BT).

A literature review was conducted, focusing first on the evidence regarding the comparative efficacy of Brief Advice (BA) and EBI, and then on comparative studies of EBI with more intensive treatment.  In reviewing the literature, it was concluded that, whilst there is a broad consensus that BA is as effective as EBI and that BT can be as effective as intensive treatment, it does not follow that either EBI or more intensive treatment is ineffective or unnecessary.  In spite of some patent flaws in the evidence base, EBI and BT are legitimate modalities for Higher or High Risk individuals who require more than BA and less than treatment proper.

In January 2011, a local alcohol service in North London, HAGA—the author’s employer—introduced EBI as a new treatment option.  Under this new treatment pathway, all clients were to be screened at entry and exit using the Alcohol Use Disorders Identification Test (AUDIT) in addition to the Treatment Outcomes Profile (TOPS).   All appropriate Higher Risk drinkers (AUDIT score 16-19) were to be offered one to four EBI sessions instead of longer-term treatment.

The researcher undertook analysis of data relating to HAGA’s EBI client cohort (January-March 2011), conducted semi-structured interviews with members of this cohort, and sought commissioner perspectives on EBI through an online questionnaire

During the period under analysis, twelve individuals were allocated as EBI clients; of which 75% (n=9) received EBI.  All twelve clients were approached to take part in semi-structured interviews and 41.67% (n=5) took part; of which 80% had received EBI.  The interviews explored client’s experiences of EBI, and the advantages and disadvantages of alcohol services providing EBI.

At follow-up, all EBI clients had improved AUDIT and TOPS scores, which while subject to biasing effects, were not negligible.  There was a 53.6% reduction in the mean TOPS drinking days over the last month from entry to follow-up.  This is a substantial short-term change in cohort drinking levels. 100% of EBI clients reported either sustained abstinence or controlled drinking.

Commissioning leads were not so much interested in debates around terminology but rather driven by a perceived need to fill an identified gap in provision for Higher Risk and motivated High Risk drinkers with EBI (or other BT modalities).

The provision of EBI as a form of BT in a specialist service appears to have met the needs of the majority (80% n=4)) of the follow-up cohort assessed here.  The findings of this study further support the idea that local alcohol services should integrate EBI (and/or other BT modalities) into their service provision.  In order to reach those individuals put off by the stigma of attending an alcohol service and less motivated to seek treatment, commissioners should seriously consider specialist-led EBI satellites in primary care and other settings.

A large-scale longitudinal study of the short- and long-term outcomes for treatment-seeking Higher Risk and suitable High Risk drinkers allocated to three different study groups who would either receive EBI as BT in an alcohol setting, receive EBI from a specialist in a primary care setting, or remain in primary care and receive no support (or only BA) would test these recommendations.

INEBRIA Conference 2012

28 May

9th Conference of INEBRIA: International Network on Brief Interventions for Alcohol and Other Drugs

Conference theme: From Clinical practice to Public Health: The two dimensions of brief interventions.

Dates: 27th – 28th September 2012

Location: Barcelona, Spain

View conference flyer

The conference aims to:

  • Enhance research on EIBI/SBI implementation as a public health tool
  • Expand EIBI/SBI in emerging economies.
  • Promote expansion of EIBI/SBI to other drugs
  • Continue promoting the use of new technologies on the implementation of EIBI/SBI
  • Review the major achievements on EIBI/SBI research in the last 9 years since INEBRIA was launched and the INEBRIA contribution to them.

Audiovisual resources can be invaluable in IBA training

24 May

About ten slides in everyone loses the will to live and groans at the thought of role play … we’ve all been there.  Well one quick trick I’ve found is to just re-brand role play as “Skills Practice” which engages people’s egos by acknowledging them as already skilled practitioners even where they aren’t.  Alongside “skills practice,” often as a precursor to it, I always use audiovisual resources and ask trainees to critique the strengths and weaknesses of these.  You could use the Department of Health’s videos from the e-learning module which cover screening and Brief Advice or the SIPS videos of Brief Advice and Brief Lifestyle Counselling (also known as Extended Brief Interventions).  The critique of these mounted by most trainees is that they are not representative of the barriers that patients and/or service-users typically put up and the challenges faced by practitioners.  Both, for example, feature white middle-class, educated women.  The DoH videos do cover a range of potential reactions, including anger and denial, and show the GP negotiate these.  The SIPS videos are excellent examples of a relaxed and non-judgmental style and adept rapport-building.

Where you are training people in an A&E setting, you could make use of HAGA‘s IBA videos which cover use of the Paddington Alcohol Test (PAT) which feature Professor Robin Touquet introducing the background to the tool and its use in A&E, how to screen using the PAT, and PAT screening in action.  I won’t critique these as we did them!

Now all you need to do is get some good speakers and you are away!

Is self-completing the AUDIT OK for IBA?

22 May

Potential IBA’ers often ask if they can hand out the AUDIT or other screening tool for people to self-complete. Although better than not doing so, generally its a wasted opportunity if the person is able to go through it with them.

The main issue is what happens after a person has self-completed a screening tool rather than worked through it with a practioner. Where a practitioner has gone through the AUDIT with the drinker, this should flow nicely into ‘feedback’ and ‘brief advice’. The practitioner will probably have gotten a feel for the person’s alcohol use and a sense of whether they might be starting to contemplate their alcohol use.

Going through the AUDIT may be a crucial chance to build rapport with the drinker, and perhaps reassure them that you are adopting a non-judgemental and empathic approach. Other benefits, such as being able to check or clarify units knowledge are also missed by self-completion approaches.

In contrast, handing back a completed AUDIT seems to me a bit like handing in some homework and waiting for the teacher’s verdict. Not exactly in line with motivational principles. Worse still, I know some GP practices have been handing out screening tools for new registrations to self complete, but fail to follow it up with drinkers. This is unacceptable, especially given they are receiving a payment as part of the DES.

One of the key things some of the evidence seems to show is that screening itself appears to be a significant trigger for ‘contemplation’ that leads to change. Feedback and brief advice can capitalise on that process, helping the drinker to weigh up the pros and cons and perhaps identify a plan. Self-completing AUDIT  seems to mean that opportunity may be missed.

Nonetheless, self-completing an AUDIT is still likely to be beneficial when accompanied by feedback and an information leaflet. It’s also the foundation of online brief intervention approaches which are gaining recognition as having a valuable role to play in the overall IBA agenda. So in conclusion, someone self-completing an AUDIT + feedback can be valuable, but talking through it and being ready to guide someone (i.e brief advice) would be an opporutunity that I wouldn’t want to miss.

A breath of fresh air: when GPs do IBA

20 May

Recently I spoke at an alcohol event on the new national alcohol strategy, but I almost struggled to compose myself. It wasn’t nerves though, it was excitement. Speaking before me, a local GP had shown a level of enthusiasm for IBA beyond what I’d seen anywhere else. As an audience member, he was trying to convince me about the need for widespread IBA – I nearly burst into early applause several times!

I don’t want to knock GPs – I’ve had and worked with some excellent ones, but it’s no secret that overall they’re not exactly grabbing the IBA agenda with both hands. Despite overwhelming evidence of IBA effectiveness (especially for Primary Care) and payment incentives, GPs are not routinely delivering IBA. Of course there are many reasons behind it, and in part these need to be addressed through stronger policy, better commissioning arrangements and proper support/training and referral options.

Dr Dadabhoy wasn’t complaining about any of these barriers though. Given the cost of alcohol misuse to society and individuals, and the effectiveness of IBA, there should be no “that’s not my job” excuses. For that I applaud him.

See Dr Dadabhoy’s presentation on alcohol management and IBA in Primary Care here.

Dentists urged to ask about alcohol

16 May

Originally posted by Deryn Bishop on Alcohol Policy UK:

Dentists are being urged to ask patients about their alcohol consumption, in an article in the Royal College of Surgeons’ Dental Journal. Professor Jonathan Shepherd, the main author of the paper, states that asking about alcohol consumption should be routine, and that there is a “need to introduce a screening tool” to support this process.

Alcohol is linked to problems with oral health, including oral cancers, Dentistwhich have doubled in males aged 40-49 years over the past 20 years. Alcohol can also cause dental erosion in young people, increased tooth decay due to the sugars and acids in alcoholic drinks, poor oral hygiene and slower recovery from dental surgery.

Professor Shepherd is an Oral Maxillofacial surgeon who has often been at thespearheadof attempts to tackle alcohol harms. He insists that dental surgeries can offer a “major contribution to Government health priorities” and that currently dentists are missing an “untapped opportunity” to ask and advise about alcohol and oral health. See BBC report.

Earlier this year Ministers backed calls for health professionals to ‘make every contact count’ by delivering lifestyle interventions. See here for a report ‘Brief interventions: achieving widespread delivery? which explores opportunities and threats for mainstreaming alcohol interventions.

SIPS: largest ever UK study into alcohol brief interventions

15 May

Orginally posted on Alcohol Policy UK:

SipsFindings from the SIPS trial, the largest UK alcohol screening and brief intervention study, have been released.

The study took place across key settings of Primary Care, Emergency Departments and Probation and tested the effectiveness of a range of brief intervention approaches and screening tools. A conference event took place on the 5th of March 2012 to launch the findings, with presentations available to download.

SIPS covered 9 Emergency Departments, 29 GP surgeries and 20 Probation Offices across London, the South East and the North East of England. During the 13-month data collection period 10,530 patients were screened with 2,481 recruited into the study. The trial tested three key ‘brief intervention’ approaches of:

  1. Feedback [of screening result] + Patient Information Leaflet (PIL)
  2. Feedback + five minutes of structured advice using the SIPS brief advice tool + PIL
  3. Feedback + 20 minutes of ‘Brief Lifestyle Counselling’ (BLC) + PIL

For Emergency Departments, the Modified Single Alcohol Screening Question (M-SASQ) was found to be the most efficient and effective screening tool. However successful implementation in EDs required champions and dedicated staff. In terms of results, all three approaches showed positive outcomes on drinking behaviours, with greater effects at 12 than 6 months. However when compared to simple feedback and leaflet, brief structured advice or longer 20 minute lifestyle counselling did not offer any significant advantage in terms of drinking behaviour or alcohol use disorder outcomes. However lifestyle counselling was considered to have a greater cost impact due to greater QALY gains and a greater reduction in societal costs.

In Primary Care settings, the FAST alcohol screening tool was the most efficient and effective screening tool. Successful implementation though required financial incentives, training and ongoing specialist support, though longer lifestyle/extended interventions were harder to implement. All brief intervention approaches resulted in reductions in alcohol use, but when compared to simple feedback and leaflet, brief structured advice or longer 20 minute lifestyle counselling did not offer any significant advantage in terms of drinking behaviour or alcohol use disorder outcomes. Feedback and leaflet was found to be the most cost-effective approach.

In Probation (Criminal Justice) settings, the FAST was also found to be the most effective screening tool. Successful implementation was challenging, requiring managerial support and ongoing specialist input to maintain activity. For ‘increasing risk’ [hazardous drinkers] who scored between 8-15 on the AUDIT, simple feedback and leaflet was as effective as longer interventions or lifestyle counselling. However for ‘higher risk’ [harmful] drinkers scoring 16 or more on the AUDIT, more intensive interventions were beneficial.

See the SIPS website for forthcoming further analysis and details of the SIPS ‘junior’ trial which will explore the impact of brief intervention approaches on young people.

IBA in Wider Settings: Conference Report

9 May

Social work, criminal justice, pharmacy, housing, homelessness, police: all these settings are becoming increasingly the focus of research and implementation initiatives relating to IBA.  A recent conference (27th March 2012) organised by Edinburgh Cyrenians, in association with Comic Relief, Create Consultancy, Alcohol Research UK and INEBRIA was attended by professionals and researchers from all these fields.  With a key note address on the state of the evidence base for IBA by Dr. Richard Saitz, and a following presentation ‘How to decide what to do, whatever the evidence‘ from Dr. Andrew Tannahill, the day got off to an intriguing start.

Further presentations focused on how to implement IBA into routine practice, an example of how Edinburgh Cyrenians rolled out alcohol interventions across their frontline homelessness services, and a discussion of the place of alcohol in the lives of hard to reach groups.  Workshops discussed selection of screening tools, training, gender issues and web technology relating to IBA.

The full list of speakers and presentations from the conference are available.

Last year the Alcohol Academy held an event and published a briefing paper exploring ways to achieve widespread IBA delivery.