Early interventions in alcohol problems – a European Perspective in Primary Health Care

Antoni GualAddictions Unit.

Psychiatry Dept. Neurosciences Institute. Hospital Clínic de Barcelona. IDIBAPS.

tgual@clinic.cat

Conflicts of interest

2

Interest Name of organisation

Current roles and affiliations

Addictions Unit, Psychiatry Department, Neurosciences Institute, Hospital Clinic, University of Barcelona; IDIBAPS; Vice President of INEBRIA

Grants Lundbeck, D&A Pharma, FP7, SANCO

Honoraria Lundbeck, D&A Pharma, Servier, Lilly, Abbvie

Advisory board/consultant

Lundbeck, D&A Pharma, Socidrogalcohol (Alcohol Clinical Guidelines) 2013

Index

• Prevalence of AUD in PHC• Attitudes of patients and PHC professionals

towards alcohol• Diagnosis of AUD in PHC• The double gap

Alcohol Dependence In Primary Health Settings. The

Size Of The Problem:

APC STUDYAlcohol use disorders and treatment utilization in 6 European

countries – a large-scale representative epidemiological study in primary

care

The research was financially supported by an investigors’ initiated grant by Lundbeck.

APC groupCo – PIs:

Antoni Gual, Jürgen Rehm, Marcin WojnarCountry Investigators:

Germany: Hans-Ulrich Wittchen, Lars Pieper Hungary: Zsuzsanna Elekes Italy 1: Piero Luigi Struzzo Italy 2: Allaman Allamani, Fabio Voller Latvia: Marcis Trapencieris Poland: Marcin Wojnar, Andrzej Jakubczyk Spain: Antoni Gual, Jose Moreno

Analysis team: Jakob Manthey, Charlotte Probst, Jürgen Rehm

APC Study

Background• Low AUD recognition among GPs. Estimated treatment

rate of AD in Europe: 10%• Potential barriers:

– high stigma, denial of problems– perceived low effectiveness of treatment, – financial reasons– low perceived treatment need, – lack of knowledge, – lack of treatment options attractive to patients

• Key role of GPs in – Identification– Interventions – Referral

APC Study

Key objectives

1. What is the prevalence of AD and AUD in primary health care?

2. How many clients with AD and AUD are being recognized by GPs, and what is the proportion receiving professional treatment?

3. What characteristics of the client are linked to recognition and treatment provision?

APC Study

Methods – Regions and drinking patterns

1. Germanya: East Germany2. Hungaryb: entire country3. Latviab: entire country4. Italy 1c: Friuli-Venezia Giulia5. Italy 2c: Tuscany6. Polandb: Łódź & Podkarpackie provinces7. Spainc: Catalonia

a Central-western drinking style: frequent drinking partly with, partly without food, beer is favourite beverage

b Eastern European drinking style: drinking often irregular (almost no daily drinking) with heavy drinking occasions; mostly outside of meals

c Southern European Mediterranian drinking style: drinking often daily, usually wine alongside with meals, few heavy drinking occasions

APC Study

Methods

APC Study

Sampling by country

Methods - Data collectionGP assessment of 13,003 clients

Sociodemographics Main health characteristics Questions on AU, AUD (and treatment) of patient

Interview of 7,901 clients Sociodemographics WHO-DAS 2.0 K10+ CIDI and questions on AUD treatment Smoking Service Utilization Questionnaire

APC Study

Index

• Prevalence of AUD in PHC• Attitudes of patients and PHC professionals

towards alcohol• Diagnosis of AUD in PHC• The double gap

Attitudes of PHC professionals towards alcohol

Attitudes of PHC professionals towards alcohol

Attitudes of PHC professionals towards alcohol

Nalmefene blocks the μ-opioid receptor3

Nalmefene modulates the -opioid receptor3

Percentage of patients

Reasons given for not receiving alcohol treatment in the past year by persons who needed treatment and who perceived a need for it: 2009 to 2012Survey of approx. 67500 interviewed persons in the US SAMHSA. Results from the 2012 National Survey on Drug Use and Health, 2013SAMHSA. Results from the 2012 National Survey on Drug Use and Health, 2013

Attitudes of patients towards alcohol

How to identify and decrease barriers

• Meyers, R. J., Miller, W. R., Smith, J. E., & Tonigan, J. S. (2002). • Miller, Sovereign and Krege (1988)

How to identify and decrease barriers

Respondents Indicating “Important” or “Very Important”

% Reason not to ask for treatment78.5 I liked getting drunk.

64.7 I thought I could handle it on my own.

60.0 I didn’t want to be told to stop using alcohol.

58.8 Using alcohol was a way of life for me.

56.9 I didn’t think of myself as an alcoholic.

54.9 I liked alcohol and didn't want to give it up.

Most relevant reasons for not asking for treatment

Index

• Prevalence of AUD in PHC• Attitudes of patients and PHC professionals

towards alcohol• Diagnosis of AUD in PHC• The double gap

Comparing AD diagnoses by GP & CIDI

APC Study

APC Study

12-months prevalence of AD in %

Comparing AD diagnoses by GP & CIDI

Index

• Prevalence of AUD in PHC• Attitudes of patients and PHC professionals

towards alcohol• Diagnosis of AUD in PHC• The double gap

The double treatment gap

1st GAP 2nd GAP

THE PROBLEM:•Effect size of BIs decreases if dependent patients are included•BIs not effective for dependent drinkers•BIs do not show an effect on alcohol related problems

The solutions

• Brief motivational interventions show equal effectiveness than other interventions in alcohol dependent patients. They focus on problems perceived by the individual.

• New pharmacological approaches aiming at a reduction goal, rather than abstinence, may increase the acceptance by patients and the uptake by GPs.

Reduction using Brenda & TLFB (Sense study)

Change f

rom

base

line in H

DD

s per

month

Change f

rom

base

line in T

AC

(g/d

ay)

Monthly period Monthly period

HDDs TAC

Placebo arm

HDD/TAC: change from baseline in the 1-year study – patients with at least high DRL at baseline and randomisation

100 g/day100 g/day

33 g/day33 g/day

19 HDDs19 HDDs

7 HDDs7 HDDs

Difference: -3.6 HDDs, p=0.0164

Difference: -17.3 g/day, p=0.0129

SENSE – change in TACSENSE – change in HDDs

MMRM (OC) FAS estimates and SE; *p<0.05; MMRM=mixed-effect model repeated measure; OC=observed cases; FAS=full analysis set; SE=standard error

MMRM (OC) FAS estimates and SE; *p<0.05; MMRM=mixed-effect model repeated measure; OC=observed cases; FAS=full analysis set; SE=standard error van den Brink et al. SENSE. Poster at EPA 2013; Data on filevan den Brink et al. SENSE. Poster at EPA 2013; Data on file

Summary• Alcohol use disorders are very prevalent accross

PHC settings in Europe• Underdiagnosis is frequent, specially in younger

populations• There is a double gap: low levels of identification

and lower levels of treatment• SBIRT programs may help to reduce the

identification gap• New psychological and pharmacological

techniques may help to fill the treatment gap

Early interventions in alcohol problems – a European Perspective in Primary Health Care

Antoni GualAddictions Unit.

Psychiatry Dept. Neurosciences Institute. Hospital Clínic de Barcelona. IDIBAPS.

tgual@clinic.cat

VIELEN DANK !!!