Selincro & IBA

21 Nov

Really interesting post by Dylan Kerr Clinical Nurse Manager at HAGA today on Alcohol Policy UK about Selincro…a new drug for treatment of mild to moderate dependence in conjunction with psychosocial interventions.

This post raises some very important issues and concerns – about medicalisation, and how appropriately the drug will be used in practice.

For me these issues relate to whether the drug will lead to medicalisation of a level of alcohol problem that would not normally be medicated.  The issue of medicalisation is well recognised, and relates to the impact of marketing activities on perceptions of health and illness such that issues and problems that people experience, become highlighted in such a way that more people are led to believe they have medical conditions which can, or even ought, to be treated with medication.  This process is at its most stark as described previously by Moynihan.

With Selincro, the problem it is seeking to tackle (mild alcohol dependence) clearly exists. In re-defining responses to it, however, there is a risk that it moves the alcohol treatment field a little further away from behavioural approaches and backwards (I would argue) to a medicalised view of alcohol problems…to a place where people could see themselves as having less control over their own behaviour.  The idea of personal responsibility and control is a central tenet of IBA and brief motivational interventions in general.

Given previous posts about why professionals are reluctant to talk about alcohol anyway, many will be attracted to the idea of Selincro if they (mistakenly) feel that it offers a quick way to deal with this middle group of drinkers.  The history of off-label or inappropriate use of medicines (some would argue as a result of the marketing activities of pharmaceutical companies) (Orlowski,1992), also suggests that Dylan’s concerns about it being used without the psychosocial interventions may not be not entirely unreasonable.  We can already see extensive marketing efforts from Lundbeck in sponsoring alcohol conferences (most recently Alcohol Concern 2013, and INEBRIA 2013), and may wonder at the purpose, influence, and appropriateness of such funding.

What training will be provided to doctors prescribing Selincro to deliver the psychosocial intervention?  Will that training also describe the evidence base for psychosocial interventions alone?  Will it discuss natural recovery from alcohol dependence?  As the IBA/BI field seeks to fill gaps in knowledge about what effective content in BI looks like, will optimal psychosocial interventions represent a better investment?  And if the health service spent the cost of Selincro on improving delivery of BIs over multiple sessions, would that be more effective and cost-effective?  The gaps in research about effective BI content provide a ripe marketplace for Selincro, and make further independent research not only important, but urgent.

As a postscript, I just signed up to the Selincro website for health professionals (I am a registered pharmacist).  2 of the first headlines flashing at me do not fill me with confidence either on the medicalisation or marketing issues.

First headline I see: Selincro (nalmefene) reduces alcohol consumption by 61%.  Studies have shown that patients taking Selincro reduced consumption from 10.5 to 4 bottles of wine per week after 6 months’ treatment.

No mention of the fact that the effective treatment was Selincro (nalmefene) with psychosocial intervention…here.  This information appears as a footnote in the page ‘about Selincro’.

Second headline I see: Alcohol dependence is a medical illness.   Alcohol dependence is a chronic relapsing brain disease that is characterised by compulsive alcohol seeking and use, despite harmful consequences.

Now this may be true when you look at treatment populations but fails to recognise the much larger group of people who recover by themselves.  The problems with the term ‘chronic relapsing disorder’  (never mind ‘brain disease’) are discussed by Jim McCambridge in his recent FEAD video post.

2 Responses to “Selincro & IBA”

  1. Peter Ward January 6, 2014 at 11:07 am #

    I am profoundly disappointed but not particularly surprised to find that the hype surrounding Selincro seems to be based more on the skills of Lundbeck’s PR department than on a substantial medical breakthrough.

    As someone for whom psychosocial intervention has not been successful but who would otherwise fit the criteria for Selincro, the revelation in Dylan’s original piece that there was very little difference in outcome between the Selincro groups with intervention and the control groups with intervention was disheartening.

    I instinctively see medication as a last resort and you and Dylan have together persuaded me there is precious little evidence that Selincro is likely to be of any benefit for someone for whom psychosocial intervention has proved ineffective. Disappointed, yes, but grateful to you for providing the evidence to allow me to see through the hype.

  2. James Morris January 31, 2014 at 12:05 am #

    Such a good post Niamh. I expect it wouldn’t be so hard to model “if the health service spent the cost of Selincro on improving delivery of BIs over multiple sessions, would that be more effective and cost-effective?”

    I really do worry most about it being prescribed without psychosocial intervention that the studies show as crucial. What monitoring of this will there be? It may well also serve to further ‘medicalise’ alcohol problems which are not anywhere near a ‘chronic relapsing phase’.

    If there were proper assurances in place I would be interested to see further work on Selincro. The banners you saw on the website are offering anything but assurances of this! Perhaps we should be trying to work with Lundbeck on this.

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