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The Evidence of Effectiveness & Standards for IBA: Hospital & Criminal Justice settings

16 Jul

Further guidance for IBA delivery has been released, outlining the evidence for IBA and minimum standards for delivery in Hospital and Criminal Justice settings.

Download: IBA hospital settings

Guidance for community health settings was also released earlier this year – full report here [pdf].

Although the documents share many of the same sections in terms of explaining IBA and the evidence base, setting specific implications and invest to save rationale are included.

  • Alcohol misuse costs the NHS £3.5 billion per annum; much of this burden is from hospital care.
  • In 2010/2011 there were 1.2 million alcohol-related hospital admissions. This equated to 7% of all hospital admissions and offers a substantial opportunity to intervene.
  • Over 14 million people are treated in ED in England each year. The Department of Health estimates that 35% of ED attendances in the UK are attributable to alcohol, increasing to 70% between midnight and 5am.
  • Almost one third of London fire deaths are alcohol related.
  • 11% of male high blood pressure is alcohol related.
  • Over 4,000 people die each year as a result of alcoholic liver disease.51
  • A National Statistics study found that 27% of people with severe and enduring mental health problems had an AUDIT score of 8 or more in the year before interview, including 14% who were classified as alcohol dependent.IBA Criminal Justice

For Criminal Justice Settings, the rationale for IBA is also convincing:

  • The prevalence of individuals with an alcohol use disorder in the criminal justice setting
    is three times greater than in the general population.
  • As many as 75% of arrestees may be risky drinkers and therefore appropriate for brief advice.
  • In 2010/2011 1.4 million people were arrested in England and Wales highlighting police custody as an effective setting to reach around 3% of the adult population annually.
  • Self-reported associations between drinking alcohol and the offence were identified in two fifths of respondents and for 50% of violent crimes.
  • 47 % of violent crime is believed to be alcohol related.
  • 45% of victims of domestic violence say their attacker had been drinking.
  • The national cost of domestic violence to criminal justice, health, social, housing and legal services as well as the economy amounts to more than £5.7 billion a year.
  • A study of arrestees and offenders who had been given brief advice and treatment in police custody or referred elsewhere identified that 40% of respondents found the advice useful.
  • 74% of probation clients in a study in South London were AUDIT-C positive

The guidance was commissioned by the Safe Sociable London Partnership, a regional body aiming to supports alcohol improvement work in London.

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The Evidence of Effectiveness & Minimum Standards for IBA in Community Health Settings

31 Mar

A new document outlining the evidence for IBA and standards for delivery in a range of settings has been released. Commissioned by the Safe Sociable London Partnership, the document provides an overview of the evidence base for IBA as a short ‘brief intervention’, and suggests how it should be delivered in key community health settings.IBA evidence and standards_community health

The Evidence of Effectiveness & Minimum Standards for the Provision of Alcohol Identification and Brief Advice in Community Health Settings [pdf]

‘Identification and Brief Advice’ has been central to England’s alcohol policy, particularly given its effectiveness in comparison to other individual level interventions. Brief intervention is most likely to ‘work’ because a combination of ‘identifying’ a level of risk – and ‘feedback’ to the drinker to inform them of this – may trigger a process of change.

In contrast, just handing someone a booklet means even if it is read, a risky drinker may not realise the information is relevant to them and assume they are fine. Brief advice may also give added benefits, such as helping build a person’s motivation or belief in their ability to change.

As such, the guides summarises the evidence base behind IBA, for example it states:

“On average, following intervention, individuals reduced their drinking by 15%. While this may not be enough to bring the individual’s drinking down to lower risk levels, it will reduce their alcohol-related hospital admissions by 20% and “absolute risk of lifetime alcohol-related death by some 20%” as well as have a significant impact on alcohol–related morbidity.”

As well as setting out an interpretation of how IBA should be delivered, it provides specific suggestions and statements for key community health roles including:nurse IBA

  • Primary Care Staff
  • Community Pharmacists
  • Midwives and Health Visitors
  • Mental Health Service Staff
  • Drug Service Staff
  • Delivery by Sexual Health Workers

The report also addresses the crucial issue of ‘making it happen’ through what it describes as ensuring ‘organisational ownership’, as well as the need for training, materials and inter-linking IBA with related issues and policy.

Some of the statements within the report will still be subject to debate. In particular, exactly what ‘brief advice’ consists of, and whether IBA should be implemented in all community health settings without more setting specific evidence.

Exactly what ‘IBA’ is as a form of brief intervention has been explored in the ‘Clarifying brief interventions’ briefing [pdf], and IBA in non-health settings has been explored in recent research report.

IBA for young people: a promising picture?

12 Aug

A common question about IBA is ‘does it work for young people?’ – and a straightforward answer isn’t easy, though we are getting closer. Recently two new publications have reviewed the evidence for IBA in children and adolescents:

The good news is the reviews are broadly in agreement and make some useful points, notably that AUDIT and CRAFT screening tools are considered the most effective and should be be used with adolescents for IBA. The bad news is, as you might expect, more research is needed as many issues remain largely unanswered. Fortunately SIPS Junior is under-way and will shed some further light, especially given the absence of UK based evidence for young people’s IBA.

One of the key issues is the significant differences between young children and older adolescents. In particular, any alcohol use may be considered problematic in younger children (especially under 15), whereas ‘lower risk’ drinking in older adolescents may not be of such concern. However what is considered ‘low risk’ for adults is not considered ‘low risk’ for adolescents based on the CMO guidance, so lower scoring cut-offs on screening tools are deemed necessary – but not yet researched. And given the broad but important age range covering children and young people, it won’t be straight-forward.

The reviews do however identify a number of research trials that identified positive effects of brief interventions (as well as some null-findings, which another paper recently suggested should not be interpreted as showing IBA not to be effective). Some evidence was also found of indications that electronic forms of brief intervention (or e-BI, or e-BA if ‘IBA-ing’ it) were effective, but also one meta-analysis found traditional face-to-face approaches superior.

All in all, IBA for young people seems an important opportunity where we can make it happen effectively, even if the research, tools and guidance aren’t up to speed with that for adults. As listed in this blog’s 2012 post on this subject, here are some IBA and young people centred resources:

#UKalcohol – Twitter discussion on IBA/brief interventions

30 Jul

A planned Twitter discussion on addressing alcohol harms will take place on Wednesday the 13th August at 8pm (= 20.00 BST = 19.00 GMT = 3pm/15.00 EDT) on the theme of alcohol brief advice and brief interventions.  This follows on from an initial discussion on alcohol-related hospital admissions which you can read here.

Who can take part?

The aim of the #UKalcohol discussions is to identify and discuss key issues facing those working in the alcohol field – either as commissioners, researchers, service providers or policy roles. It is hoped a different ‘theme’ will be addressed each month, reflecting key areas of interest.

#UKalcohol discussion 13th August: alcohol brief advice, brief interventions

The 2nd planned discussion is intended to cover the broad theme of design, delivery, support and monitoring of alcohol brief advice in addressing alcohol-related risks and harm.

The following issues may be used as needed as prompts/themes for discussion:

  1. What is brief advice, what is a brief intervention, does it matter?
  2. How widely should we implement brief advice/interventions on the basis of current evidence?
  3. What is needed to support brief advice/interventions in practice? How do the needs of different settings differ?
  4. How should brief advice/interventions on alcohol fit with attempts to address other lifestyle issues?
  5. What monitoring and evaluation of these interventions is needed and is it feasible?

Partnership

This 2nd discussion is being brought to you by the UK Centre for Tobacco and Alcohol Studies with the support from a range of partners and stakeholders who will be jointly supporting the alcohol Twitter discussion, and may initiate further themed discussions in future.

Next steps

If you are interested in participating in the proposed Twitter discussion either as an individual or on behalf of your organisation simply sign in via Twitter on Wednesday the 13th August at 8pm and use the #UKalcohol. Discussion may be subsequently captured and shared via Storify.  You can also follow @ukctas to see tweets about this in advance.

If you’d like to ask any questions or help with Twitter please do get in touch via niamh.fitzgerald@stir.ac.uk or james@alcoholacademy.net.

Full AUDIT screening Vs shorter tools (FAST, AUDIT-C etc) for IBA

16 May

The 10 question full AUDIT is the ‘gold standard’ screening tool for the identification of alcohol use disorders. But does IBA always require the full AUDIT to be completed, or can shorter versions like FAST and AUDIT-C alone be used for effective brief intervention?quantity-versus-quality

Using the full AUDIT tool for IBA has two clear advantages. Firstly, it is proven to be more accurate. That is, it will correctly identify more at-risk or harmful drinkers who may potentially have been missed by a shorter tool. Additionally it is less likely to score a ‘false-positive’ whereby a lower risk drinker might be identified as at-risk. Of course screening scores to some degree are artificial cut-offs, but their role in ‘identification’ is the crucial cog in triggering contemplation.

However perhaps the main benefit of the full AUDIT is that the score specifically identifies one of four main drinking categories: low risk, increasing risk (hazardous), higher risk (harmful), or possibly dependent. Shorter versions only indicate either a lower risk or a ‘positive score’ – that is falling into one of the other three categories. Crucially we know that those with probable dependency (AUDIT score of 20+) are typically best suited to something beyond brief advice, so an offer of a referral to a treatment service should be suggested.

Shorter versions alone do not allow us to identify whether a referral for treatment should be offered, but they can of course save time. This is why many approaches to IBA start with shorter versions, which when positive, result in the remaining AUDIT questions being asked to give a full AUDIT score. This seems like the best of both worlds – busy practitioners can save time by using shorter versions, but accurately identify possible dependence by completing the remaining AUDIT questions when necessary. A useful integrated AUDIT C + remaining AUDIT questions tool is available.

Can shorter tools be used alone for IBA?

So what about using shorter tools to lead directly to brief advice for all positive scores, without asking the remaining full AUDIT questions? Some areas and indeed research trials have taken this approach. Certainly for the primary aim of IBA in identifying at-risk drinkers to deliver brief advice this is sufficient. But what about those who may be possibly dependent?

Following the SIPS trial, there is some concern that an over-emphasis may be placed on leaflet giving as part of IBA. Crucially it is identification of that person’s level of risk followed by feedback that is crucial (e.g. “your answers indicate you are placing your health at risk. How do you feel about that?”). A leaflet may well help a person to reflect further, and identify steps to cut down. A leaflet can also offer information on where to get further help, either listing local services or at least the Drinkline number (0800 917 8282).

Like many challenges, the ‘gold standard’ approach is not always achievable in the real world, so a practical compromise has to be made. Convincing busy A&E workers to ask 10 extra questions is understandably unlikely. One alcohol question (e.g the SASQ), resulting in some quick feedback and a leaflet has a greater chance. A common conclusion is arrived at – a good full AUDIT brief intervention with the opportunity for some brief advice discussion should be the goal. But in the real world, worthwhile benefits are still likely to arise from shorter approaches, as long as clients know where to go for further help or support.

IBA for children and young people: evidence, guidance and resources?

11 Jun

Although NICE advises that IBA be offered to those aged 16 and over, there is limited evidence as to the effectiveness and best delivery approaches for children and young people. However a new SIPS junior trial is getting underway focussing on younger adolescents presenting to A&E departments (but don’t expect the results anytime too soon – it’s a 5 year project!). The SIPS junior website has a good summary of the issue though, highlighting:

“advice to children under 15 years (2009) is to abstain from alcohol due to risks of harm, and 15-17 year olds are advised not to drink, but if they do drink it should be no more than 3-4 units and 2-3 units per week in males and females, respectively. In contrast, alcohol use is increasing in adolescents in the UK: the average amount consumed by 11-15 year olds doubled in the last 13 years to 2007. Adolescents in the UK are now amongst the heaviest drinkers in Europe.

Excessive drinking in adolescents is associated with increased risk of accidents, injuries, self harm, unprotected and regretted sex, violence and disorder, poisoning and accidental death. Early drinking in adolescence is associated with intellectual impairment and an increased risk of more serious alcohol problems in later life. Methods of alcohol screening and early intervention have been developed for adolescents in the USA, and show evidence of benefit, but have not been studied in the UK. Further these methods have several shortcomings including not providing screening and intervention methods appropriate to the age and developmental stage of the younger adolescent.”

In the meantime, I believe there is still a good case for IBA with younger adolescents as long as safeguarding and other risks are covered (see NICE PH24 recommendation 6). If IBA opportunities present, practitioners should be able to use a combination of common sense and good IBA skills. For instance it’s broadly accepted that children and young people are more likely to be motivated around risks to their personal safety, injuries, appearance or other more immediate harms. So highlighting things like risks to high blood pressure probably aren’t going to be the most effective approaches for framing IBA for younger groups. Nonetheless, we shouldn’t overlook that we have been seeing a trend in younger and younger adults presenting with liver disease.

Here are a few useful IBA resources aimed at practitioners working with children and young people:

One of the key things SIPS Junior will reveal will be which screening (identification) tools may be best suited for younger adolescents. For children aged 10-15 in contact with professionals, NICE suggests consent and use of the Common Assessment Framework (CAF) to obtain a detailed history of their alcohol use, including background factors such as family problems or other issues.

A comprehensive list of further guidance, resources and reports relating to children and young people is available here from the Alcohol Learning Centre.

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.

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.