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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.

Abstract

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.

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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!

How did IBA fare in the new national alcohol strategy?

12 Apr

IBA was not mentioned at all in the Drug Strategy 2010 and the focus was very much on “severe alcohol dependence” (3) and recovery.  So I have been waiting with bated breath to see what the alcohol strategy would bring.  Well IBA definitely fares better in the new alcohol strategy than treatment.  The new alcohol strategy makes some positive comments about the evidence base for IBA, encouraging local areas to implement IBA locally.  Reference is made specifically to learning lessons from SIPS; IBA delivered by Alcohol Liaison Nurses in hospital settings, particularly for pregnant women; and alcohol intervention pathways for offenders.  The most concrete gain for IBA in the UK is the introduction of alcohol into the NHS Health Checks which will extend primary care provision beyond new registrations.  The planned social marketing activity focused on young people will also improve prevention work nationally.

Two concerns (I’m sure there are more …):

  • Terminology: Cameron’s foreword reads like a modernised Hogarthian vision of a “Broken Britain” and the language throughout is not much better.  Why are we still talking about the “drunks” “drunken” “the drunks” in punitive terms?  Where is the language of Lower, Increasing and Higher Risk?  One of the major barriers to people accessing support for alcohol is terminology and stigma: how productive is Cameron’s language?
  • NHS Health Checks: Will local areas invest in IBA training for NHS Health Check practices AND clear local pathways into support?  As we know screening, Brief Advice and the pathways from alcohol Direct Enhanced Service (DES) screening are poor or patchy, we need to act now to ensure that this major improvement isn’t scuppered by poor delivery.

So that’s my first ever blog post done!   Hope it makes sense!

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