Why we need to get to grips with alcohol in Wessex.

Why we need to get to grips with alcohol in Wessex

http://www.merckserono.co.uk/en/

http://www.merckgroup.com/en/

Prescribing Observatory for Mental Health Audit:How can we manage alcohol use in Mental health Services?

Dr Shanaya Rathod/Dr Julia Sinclair

• To improve outcomes for patients with co-morbid alcohol use– Implementation of NICE guidance

• Screening• Brief interventions

• ?Consider– Develop and pilot a pathway within SHFT– Links with AHSN to evaluate and disseminate across

Wessex

Aims

Prevalence UKPsychiatric patients• CMHT (London) -44% harmful alcohol use

or recent substance use (Weaver 2003)

• Psychiatric IP - 49% harmful alcohol use (1/12)

(SW London) and 27% drug use (1/12) (Barnaby 2003)

• Psychiatric IP -50% men and 29% women

(Oxfordshire) harmful alcohol use (1/12)

(Sinclair 2008)

Barriers to effective care

• Definitions of ‘dual diagnosis’ – suggest “co-morbidity”

• Low levels of ‘Alcohol specific Health literacy’ in staff

• Culture – Details of patients addictive behaviours often poorly documented

(e.g Farrell 1988, WRISS 2001a, 2001b)

– Seen as not part of core role “refer on”

Context

NICE CG115:• “Staff working in services provided and funded by the NHS who care for people

who potentially misuse alcohol should be competent to identify harmful drinking

and alcohol dependence. They should be competent to initially assess the need

for an intervention or, if they are not competent, they should refer people who

misuse alcohol to a service that can provide an assessment of need”

NICE PH24:• “Brief interventions for adults should be delivered by Health and social care,

criminal justice and community and voluntary sector professionals in both NHS

and non-NHS settings who regularly come into contact with people who may be

at risk of harm from the amount of alcohol they drink.”

Alcohol specific health literacy

Quality improvement programme

Prescribing in substance misuse: alcohol detoxification

Baseline auditMarch 2014

Method

Participants:• 43 Mental Health Trusts participated• 174 clinical teams• 1,197 adult patients

Audit data collected:• Demographic, diagnosis, type of service• Documentation of alcohol misuse, physical and neurological assessments• Medication prescribed to treat alcohol withdrawal, dosage and details of regimen• Specialist advice sought during alcohol detoxification and for continuing management

Clinical service providing care for alcohol detoxification

Baseline N=1,197

Clinical service providing care

Sub-sample of patients whose admission for

alcohol detoxification was

planned N = 462 (39%)

Sub-sample of patients whose admission for

alcohol detoxification was

unplannedN = 735 (61%)

Total sampleAll patients who were admitted

for alcohol detoxification

N = 1,197

n (% of sub-sample) n (% of sub-sample)n (% of total

sample)

Acute adult psychiatric ward - detoxification overseen by a non-specialist adult psychiatrist

139 (30%) 694 (94%) 833 (70%)

Acute adult psychiatric ward - detoxification overseen by a specialist in alcohol/substance misuse

321 (69%) 24 (3%) 345 (29%)

Initial assessment: Documentation of past history of alcohol detoxification

Baseline N=1,197

Documentation of previous detoxifications

Sub-sample of patients whose

admission for alcohol detoxification was

planned N = 462 (39%)

Sub-sample of patients whose

admission for alcohol detoxification was

unplannedN = 735 (61%)

Total sampleAll patients who were admitted for alcohol

detoxificationN = 1,197

n (% of sub-sample) n (% of sub-sample) n (% of total sample)

1-4 previous alcohol detoxifications 224 (48%) 270 (37%) 494 (41%)

5 or more previous alcohol detoxifications

34 (7%) 40 (5%) 74 (6%)

First known alcohol detoxification

130 (28%) 175 (24%) 305 (25%)

Not documented 74 (16%) 250 (34%) 324 (27%)

Initial assessment: Standardised assessments/rating scales used

Baseline N=1,197

Standard assessments/rating scales

Total sampleAll patients who were admitted for alcohol


n (% of total sample)

CIWA-Ar (prior to starting detoxification regimen) 170 (14%)

CIWA-Ar (during detoxification regimen) 170 (14%)

SADQ 113 (9%)AUDIT 80 (7%)APQ 11 (1%)LDQ 7 (1%)None of the above 690 (58%)Other 65 (5%)

During admission: Documented brief intervention

Brief intervention

Total sampleAll patients who were admitted

for alcohol detoxificationN = 1,197

Documented 505 (42%)Not documented 692 (58%)

Discharge: Medication for relapse prevention prescribed at the point of discharge

Baseline N=1,197

Type of drug

Sub-sample of patients who were

admitted under non-specialist care N=

848 (71%)

Sub-sample of patients who were

admitted under specialist care N=349 (29%)

Total sampleAll patients who

were admitted for alcohol


n (% of type of drug)n (% of type of

drug)n (% of total

sample)

Acamprosate 115 (14%) 133 (38%) 248 (21%)Naltrexone 4 (<1%) 10 (3%) 14 (1%)Disulfiram 14 (2%) 45 (13%) 59 (5%)Nalmefene 0 0 0

Not on any of the relapse medication above

720 (85%) 178 (51%) 898 (75%)

Baclofen 2 (<1%) 0 2 (<1%)

Not applicable 17 (2%) 0 17 (1%)

Initial assessment: Documented drinking history

Proportion of patients who had a documented assessment of drinking history at admission

Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG

115, recommendation 1.3.4.5). b. A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10).

Initial assessment: Documented physical examination

Proportion of patients who had a documented physical assessment at admission

Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115,

recommendation 1.3.4.5). b. A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10).

Initial assessment: Documented assessments for the signs and symptoms of Wernicke’s encephalopathy

Proportion of patients who had documented assessments of the signs and symptoms of Wernicke’s encephalopathy

Implementation of NICE guidance• Screening• Brief interventions

How to improve outcomes for patients with co-morbid alcohol use?

Requesting help with alcohol problem New Presentation Periodic Review

Full screenAUDIT

AUDIT Score8-15

Increasing-risk

Consider joint working with

Specialist services

Full Assessment ExtendedBrief Advice

AUDIT Score16-19

Higher-risk

AUDIT Score20+

Possible Dependence

AUDIT Score 0-7

Lower-risk

Alcohol Care Pathway

No action

PositiveResult

NegativeResult

FAST AUDIT - CInitial Screening Tools

Brief Advice

Units of alcohol

2. Need to Actively Manage Alcohol Use as integral part of care

AssessmentDrinking reduction

DetoxRelapse Prevention

Ways to Optimise Treatment• Identification – CQUIN?

• Make management an integral part of the treatment plan

• Engender a culture of therapeutic optimism within the service

• Staff training in basic competencies

• Actively manage both conditions

• Drink diaries and motivational interviewing are effective tools – core part of MHS

• Don’t forget pharmacotherapy

www.warc.soton.ac.ukWessex Alcohol Research Collaborative

• To improve outcomes for patients with co-morbid alcohol use – where ever they present– Implementation of NICE guidance in MH Services

• Screening• Brief interventions• Active management of co-morbid alcohol use

Consider?– Develop and pilot a pathway for MH services– Links with AHSN to evaluate and disseminate across

Wessex

AHSN working together


Alcohol care in England’s Hospitals, an opportunity not to be wasted



Alcohol care in England’s hospitals:

An opportunity not to be wasted.

Jason MahoneyHead of Alcohol and Drugs, South East PHE Centres

Public Health England

Protecting and improving the nation’s health and wellbeing and reducing health inequalities.

www.gov.uk/phe

2525 Alcohol care in England’s hospitals

http://www.gov.uk/phe

Alcohol care in England’s hospitals

• Why alcohol concerns us

• What we can do about it

• How to do that

• So, what next?





Percentage change in standardised UK mortality rates (age 0-84) normalised to 100% in 1970

Liver

CirculatoryIschaemic heartCerebrovascularNeoplasmsRespiratoryEndocrine/metabolicDiabetes


Liver disease deaths compared with the other major killers

PHE FingertipsWessex PHE Centre Local Authorities compared to England

• Liver disease

• Alcohol specific hospital admissions

• Under 75 mortality rate – alcoholic liver disease

http://fingertips.phe.org.uk/profile/liver-disease/






Reducing consumption prevents ill health Regularly consuming

25g (3 units) daily Regularly consuming 50g (6 units) daily

Regularly consuming 100g (12 units) daily

Cancers Increase over standard risk

Increase over standard risk

Increase over standard risk

Mouth and throat 96% 211% 545% Colon 5% 10% 21%Oesophagus 39% 93% 259% Rectum 9% 19% 21% Liver 19% 40% 81% Larynx 43% 102% 286% Breast 25% (f) 55% (f) 141% (f)

CardiovascularHypertension 43% 104% 315% Ischaemic stroke -10% 17% 337% Haemorrhagic stroke 19% 82% 370% Cardiac arrhythmias 51% 123% 123%

Oesophageal varices 26% 854% 854%Unspecified liver disease 26% 854% 854% Acute and chronic pancreatitis 34% 74% 219%

Evidence into action: PHE Priorities

34

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366852/PHE_Priorities.pdf

Reducing harmful drinking

A reduction in the number of hospitaladmissions due to alcohol.



Alcohol as a public health priority

• Reducing harmful drinking: What works?- Social Marketing

- Licensing

- Identification and Brief Advice

- Alcohol care teams / hospital settings

- Specialist alcohol treatment




http://www.alcohollearningcentre.org.uk/_library/Alcohol_Care_in_Englands_Hospitals_An_opportunity_not_to_be_wasted_PHE_Nov_14.pdf

RCP 2001Dh 2009BSG, Alcohol Health Alliance UK 2010HM Govt 2012NHS evidence 2012 University of Stirling 2013

10+ years of recommendations


2001 “a dedicated alcohol health worker or an alcohol liaison nurse in each major acute hospital”

2009 “High impact change 5: Appoint an alcohol health worker”

2010 “a multidisciplinary Alcohol Care Team in each district hospital”

2012 “We encourage all hospitals to employ Alcohol Liaison Nurses“

2012 “Multidisciplinary alcohol care teams should organise systematic interventions”

2013 “Every acute hospital should have a specialist, multi-disciplinary alcohol care team tasked with meeting the alcohol-related needs of those attending the hospital and preventing readmissions.”


NICE quality and productivity proven case study:


http://arms.evidence.nhs.uk/resources/qipp/29420/attachment


Commissioning of services

Broad service types


Services are diverse, but fall into three broad categories:

• multi-disciplinary alcohol care teams – Supporting patient care from within the hospital and liaising with community services

• in-reach alcohol care teams – based in the community to support the care of hospital patients

• high impact user (HIU) services - identify and assertively engage with a relatively small number of those patients who attend A&E or are admitted most frequently


What’s recommendedHospital alcohol services, led by a senior clinician with dedicated time for the team and providing evidence-based interventions. Teams will facilitate identification of alcohol misusers in hospitals and appropriate packages of care provided by multi-disciplinary teams. Whether teams are large or small, set within the hospital or in-reach, they should be able to provide:

• case identification/Identification and Brief Advice (IBA)

• comprehensive alcohol use Assessment

• contribution to nursing and medical care planning

• psychotherapeutic interventions

• medically assisted alcohol withdrawal management

• discharge planning including referral to community services



42

Report recommendations• Every district general hospital should consider having effective specialist

alcohol provision

• Existing services should be maintained and developed

• Alcohol Care Teams to support training for colleagues in all clinical areas

• Ensure that existing services are adequately integrated across primary and secondary care and that new services are implemented where there are none

• Local partners should consider employing assertive out-reach or in-reach services for high impact service users in all major hospitals and existing services should be evaluated to assess their impact on hospital and community services

• System planning should ensure that community services are accessible and available to ensure continuation of detoxification with psychosocial interventions outside of the hospital



43

What PHE will do next• We will develop pro-forma service specifications

for each of the broad service types

• We will develop a core minimum dataset for alcohol care teams

• We will develop a pro-forma evaluation template to help ensure that service evaluations are comparable.

• We will re-run the survey of hospital services



So, what could you do?• Is there an alcohol care team at the local

hospital?

• How is it funded?

• Has it been evaluated?

• Does it reflect the recommendations?



Thank you

Jason Mahoney

Head of Alcohol and Drugs, South East PHE Centres

[email protected]

07787 005 689


mailto:[email protected]



James Linde Alliance Alcohol Related Liver Disease Priority Setting PartnershipBeccy Maeso, Senior Programme Manager, NIHR Evaluation, Trials and Studies Coordinating Centre



James Lind Alliance (JLA)

Alcohol Related Liver Disease Priority Setting Partnership

Beccy Maeso

The James Lind Alliance (JLA)

• Involving patients and clinicians in setting priorities for research

• Finding out what research is important to:• Patients / service users• Carers / relatives• Clinicians / healthcare professionals

What is the JLA?

•Established in 2004•Royal Society of Medicine – Dr John Scadding•James Lind Library - Sir Iain Chalmers•INVOLVE – Sir Nick Partridge

•Since April 2013: part of NETSCC•JLA Advisers•The Guidebook

Who was James Lind?

•James Lind (1716-1794)•A pioneer of clinical trials

Alcohol Related Liver Disease Priority Setting Partnership

• Bring patients and clinicians together to Identify uncertainties about the effects of treatments

• Agree by consensus a prioritised “top 10” list of uncertainties for research

• Publicise the methods and results of the PSP• Draw the results to the attention of research funders

independently of the JLA• More info jla.southampton.ac.uk

How do we do it?

The priority setting process:• Set up steering group • Invite partners• Gather uncertainties• Prioritise uncertainties • Promote priorities to researchers and

funders

Set up steering group• Patient, carer and clinician representatives • Resources and expertise

• Regular meetings• Publicising the project• Overseeing the process • Responsible for dissemination of results

• JLA chair – a neutral facilitator • Protocol

Gather uncertainties •What are treatment uncertainties?

•no up-to-date, reliable systematic reviews of research evidence addressing the uncertainty about the effects of treatment exists•up-to-date systematic reviews of research evidence show that uncertainty exists

ARLD steering groupPatient representative/s:

Diane Goslar, patient representative Andrew Langford, British Liver Trust Nick Rosland, patient representative Lynda Waters, carer representative

Clinical representative/s:

Dr Michael Allison, Consultant Hepatologist – Addenbrooke’s Hosptal Dr Jane Collier, Consultant Hepatologist – Oxford Aisling Considine, Acting Liver Pharmacy Team Leader – Kings College Ranjita Dhital, Community Pharmacist Dr Carsten Grimm, GP, Clinical Lead RCGP Alcohol Certificate Board Member,

Bradford Districts CCG Dr Zul Mirza, Consultant in Emergency Medicine Lynn Owens, Nurse Consultant- Alcohol Services Dr Steve Ryder, Consultant Hepatologist BSG representative Dr Nick Sheron, Consultant Hepatologist – British Association for the Study of Liver

Disease Dr Julia Sinclair, Associate Professor in Psychiatry

Gather uncertainties • Survey

• Patients and carers • Clinicians

• Research recommendations• UK Database of Uncertainties about the

Effects of Treatments (UK DUETs)• www.library.nhs.uk/duets

http://www.library.nhs.uk/duets

Check the uncertainties

• Prepare the dataset• Remove out of scope submissions• Categorise eligible submissions• Format the submissions

• PICO questions: Patient/Population, Intervention, Comparator, Outcome

• “Lumping and splitting” • Verify the uncertainties• Identify research recommendations• Prepare the long list

Prioritise uncertainties – step 1 (interim stage)

• From a long list to a short list • Top 10 uncertainties chosen by partners

• As individuals• On behalf of members• On behalf of colleagues• Representing an organisation

Prioritise uncertainties – step 2 (final)

•Priority setting workshop •Patients, carers and clinicians •A day of democratic discussion and ranking

•Nominal Group Technique•Prioritise the remaining uncertainties•Agree the top 10

Final priority setting

JLA Priority Setting Principles

• The principle of patients, carers and clinicians working together

• Methodological transparency• Declaration of interests• Working with UK Database of Uncertainties

about the Effects of Treatments www.library.nhs.uk/duets

http://www.library.nhs.uk/duets

Next steps

Promote priorities to researchers and funders• NIHR Evaluation, Trials and Studies

Coordinating Centre (NETSCC)• Dissemination of findings

• Publications• Conferences

Current Partnerships

•Anaesthesia •Depression•Hip and knee replacement for osteoarthritis•Inflammatory bowel disease•Intensive care•Late stillbirth•Mesothelioma•Neuro-oncology•Palliative and end of life care•Parkinson’s disease•Spinal cord injury•Common Shoulder problems

•Alopecia•Renal Transplantation• Surgical Treatment for Early Hip and Knee Osteoarthritis•Endometrial Cancer•Teenage and Young Adult cancer•Mild to moderate hearing loss•Alcohol related liver disease•Non alcohol related liver and gall bladder diseases•Cavernoma

Completed Partnerships•Asthma•Urinary incontinence•Vitiligo•Prostate cancer•Schizophrenia•Type 1 diabetes•ENT aspects of balance•Life after stroke•Eczema•Tinnitus•Cleft lip and palate

•Lyme disease•Pressure ulcers•Sight loss and vision •Dementia•Dialysis•Multiple sclerosis •Hidradenitis suppurativa•Acne•Pre-term birth•Childhood disability

What difference does it make?Asthma

• Funding has been awarded by NIHR HTA programme to fund research to provide better evidence on the effects of breathing exercises for asthma

Prioritised areas from PSP uncertainties

• Non-pharmacological interventions to reduce weight gain in people with schizophrenia prescribed antipsychotic medication

• Management of sexual dysfunction due to antipsychotic drug therapy

• Training to recognise the early signs of recurrence in schizophrenia (joint research call between NIHR and Australian National Health and Medical Research Council)

For more information…

• email [email protected] • More info www.jla.nihr.ac.uk• @lindalliance

@LindAlliance

mailto:[email protected]

http://www.jla.nihr.ac.uk/

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Why we need to get to grips with alcohol in Wessex.

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