NICE work if you can get it:NICE work if you can get it:

Screening & brief intervention as a Public Screening & brief intervention as a Public Health strategy to reduce hazardous & Health strategy to reduce hazardous &

harmful drinking in England.harmful drinking in England.

Professor Eileen KanerProfessor Eileen Kaner

Overview of the presentationOverview of the presentation

Why do we need guidelines?Why do we need guidelines?• Despite lots of evidence SBI is not routinely Despite lots of evidence SBI is not routinely

delivereddelivered• Needs top-down prioritisationNeeds top-down prioritisation

General policies are not enoughGeneral policies are not enough Specific guidance on ‘what should happen’Specific guidance on ‘what should happen’

• Policy makers need to consider impact & costPolicy makers need to consider impact & cost Their interest is ‘why should we prioritise this’Their interest is ‘why should we prioritise this’ How might it happen with minimal disruptionHow might it happen with minimal disruption

So much evidenceSo much evidence

Freemantle 1993 - 6 trials in primary care Freemantle 1993 - 6 trials in primary care • 24% drop in consumption (95% CI 18 to 31%)24% drop in consumption (95% CI 18 to 31%)

Moyer 2002 – 56 trials, 34 relevant to PHCMoyer 2002 – 56 trials, 34 relevant to PHC• Consistent +ve effect, NNT 8-12 (smoking is 20)Consistent +ve effect, NNT 8-12 (smoking is 20)• Cost savings found at 4 years in the USACost savings found at 4 years in the USA

Kaner 2007 – 29 trials in PHC & A&EKaner 2007 – 29 trials in PHC & A&E• Consistent positive effects ~7 drinks less/weekConsistent positive effects ~7 drinks less/week• Evidence strongest for men, less work on womenEvidence strongest for men, less work on women• No significant benefit of longer versus shorter BINo significant benefit of longer versus shorter BI

So little practiceSo little practice

Majority of GPS may be missing up to 98% of Majority of GPS may be missing up to 98% of excessive drinkers in PHC (Kaner et al. 1999)excessive drinkers in PHC (Kaner et al. 1999)

NAO 2008 report on recent activityNAO 2008 report on recent activity• 58% PCTs have an alcohol strategy58% PCTs have an alcohol strategy• 69% provided data on expenditure69% provided data on expenditure• Spend is ~£600,000 on alcoholSpend is ~£600,000 on alcohol• About 0.1% of PCT annual expenditure of £460MAbout 0.1% of PCT annual expenditure of £460M

General policiesGeneral policies

Alcohol harm reduction strategy 2004Alcohol harm reduction strategy 2004 Choosing Health White paper 2004Choosing Health White paper 2004 Prison Service Alcohol strategy, 2004Prison Service Alcohol strategy, 2004 DH Local Implementation guidance 2005 DH Local Implementation guidance 2005 Models of Care for Alcohol misuse 2006Models of Care for Alcohol misuse 2006 National Probation Service / NOMS 2006National Probation Service / NOMS 2006 Safe, Sensible, Social – next steps 2007Safe, Sensible, Social – next steps 2007 BMA tackling the alcohol epidemic 2008BMA tackling the alcohol epidemic 2008 Safe, Sensible, Social: further action, 2008Safe, Sensible, Social: further action, 2008 Healthcare Commission on choosing health, 2008Healthcare Commission on choosing health, 2008

Practitioners want prioritisation: Practitioners want prioritisation: their ‘to do’ listtheir ‘to do’ list

National Institute for Health and Clinical National Institute for Health and Clinical Excellence (NICE)Excellence (NICE)

• Independent organization responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health

•Topics referred by government initially

• NICE produces guidance in three areas of health:• public health – Prevention goes beyond NHS• health technologies – Drugs and interventions• clinical practice – Appropriate delivery of care

Like buses!Like buses!

Three separate referrals on alcohol to NICE Three separate referrals on alcohol to NICE • PreventionPrevention• Physical treatmentPhysical treatment• Mental Health ManagementMental Health Management

These came to separate parts of NICEThese came to separate parts of NICE• Complex agendaComplex agenda• Is carving it up the best way to deal with it?Is carving it up the best way to deal with it?

Prevention guidelines due March 2010

Scope: The prevention of alcohol-use disorders in people 10 years and older, covering:

interventions affecting the price, advertising and availability of alcohol;

how best to detect alcohol misuse both in and outside primary care;

brief interventions to manage alcohol misuse in these settings.

Clinical Management guidelinesdue May 2010

Scope: The assessment and clinical management in adults and young people 10 years and older covering:

acute alcohol withdrawal including delirium tremens;

liver damage including hepatitis and cirrhosis; acute and chronic pancreatitis;

management of Wernicke’s encephalopathy

Dependence guidelinesdue January 2011

Scope: The diagnosis and management of alcohol dependence and harmful alcohol use in people 10 years and older covering:

Identification and assessment

pharmacological and psychological/psychosocial interventions,

prevention and management of neuropsychiatric complications of alcohol dependence or harmful alcohol use

Acute drunken episode/presentation to primary/

secondary care

Alcohol-related diseases

Longer-term alcohol withdrawal and

abstinence

*Opportunistic case finding- ‘Screening’ questionnaires e.g., AUDIT

SettingA & E

Psycho-social therapy

Treatment for alcohol abstinence

Alcohol-specific disease

Management and assessment of:*Liver damage including hepatitis and cirrhosis*Acute and chronic pancreatitis

Prevention and medical management of Wernicke’s encephalopathy

Specialist services

Common presentationsAdolescents: Head injury, assaults

Older adults: Falls

Brief interventionsaimed at getting patient to recognise the problem rather than ‘treatment’

EncephalopathiesBrain damageNutritional disorders

Communication between health professionals

Patient education

Mental health

NCC-CC

Public Health

Mental health

Excluded/Not covered

The management of alcohol use disorders in adults and young people

Contact details: Dr Sharon Swain, NCC-CC Research Fellow, Telephone no. 020 7935 1174 ext 318.Taryn Krause, NCC-CC Project Manager, Telephone no. 020 7935 1174 ext 575

Version 6 – NCC-MH consulted

Draft V5

Planned detoxUnplanned detox

Alcohol-associated

diseaseE.g., breast

cancer

Assessment*Biochemical and clinical indicators of alcohol misuse

PharmacotherapyAcute alcohol withdrawal & management of DTs

Acute alcohol withdrawal & management EXCLUDING DTs

Levels of preventionLevels of prevention

Primary prevention – strategies that aim to deter people Primary prevention – strategies that aim to deter people from drinking heavily (whole population approaches, from drinking heavily (whole population approaches, media campaigns, labelling)media campaigns, labelling)

Secondary prevention – early identification of clinical Secondary prevention – early identification of clinical risk or harm and intervention to modify itrisk or harm and intervention to modify it

Tertiary prevention – intervention in early stage disease Tertiary prevention – intervention in early stage disease that aims to slow or stop its progression to more that aims to slow or stop its progression to more advanced or irreparable disease advanced or irreparable disease

UpstreamUpstream

Down streamDown stream

Primary prevention question 1Primary prevention question 1

Price:Price:

What type of price controls are effective What type of price controls are effective and cost effective in reducing alcohol and cost effective in reducing alcohol consumption and/or alcohol-related harm consumption and/or alcohol-related harm in adults and young people?in adults and young people?

Primary prevention question 2Primary prevention question 2

AvailabilityAvailability: :

Which interventions are effective and cost Which interventions are effective and cost effective at managing alcohol availability effective at managing alcohol availability to reduce levels of consumption and/or to reduce levels of consumption and/or alcohol-related harm in adults and young alcohol-related harm in adults and young people? people?

Primary prevention question 3Primary prevention question 3

Promotion: Promotion:

Which strategies for the control of alcohol Which strategies for the control of alcohol promotion are effective and cost effective promotion are effective and cost effective in reducingin reducing levels of consumption and/or levels of consumption and/or alcohol-related harm in adults and young alcohol-related harm in adults and young people?people?

Primary prevention outcomesPrimary prevention outcomes

Expected outcomes: Expected outcomes: aa change in the change in the levels of alcohol consumption across the levels of alcohol consumption across the populationpopulation• alcohol sales, availability, marketing activityalcohol sales, availability, marketing activity

• From these we can assume a subsequent From these we can assume a subsequent impact on alcohol-related health or social impact on alcohol-related health or social problems across the populationproblems across the population

CaveatsCaveats

How robust is the evidence?How robust is the evidence? Difficult work methodologicallyDifficult work methodologically

How specific is the evidence?How specific is the evidence? To adults &/or young peopleTo adults &/or young people

How relevant is it to England?How relevant is it to England? Can we make inferences from other countriesCan we make inferences from other countries

Secondary prevention question 4Secondary prevention question 4

Context – targeting for practitioners: Context – targeting for practitioners:

What key factors increase the risk of What key factors increase the risk of hazardous and harmful drinking? When are hazardous and harmful drinking? When are individualsindividuals most vulnerable to excessive most vulnerable to excessive drinking?drinking?

Secondary prevention question 5Secondary prevention question 5

Identification/screening: Identification/screening:

Are alcohol screening questionnaires, Are alcohol screening questionnaires, biochemical markers or clinical indicators biochemical markers or clinical indicators an effective and cost effective way of an effective and cost effective way of identifying adults and young people who are identifying adults and young people who are at risk due to drinking? at risk due to drinking?

Secondary prevention question 6Secondary prevention question 6

Brief Intervention: Brief Intervention:

Are brief interventions effective and cost Are brief interventions effective and cost effectiveeffective in managing hazardous and in managing hazardous and harmful drinking among adults and young harmful drinking among adults and young people?people?

And across all groups within our populationAnd across all groups within our population

Secondary prevention question 7Secondary prevention question 7

Implementation: Implementation:

What areWhat are the key barriers to that influence the key barriers to that influence practitioners’ ability to help adults and practitioners’ ability to help adults and young people manage their drinking young people manage their drinking behaviour? What are the key facilitators?behaviour? What are the key facilitators?

Secondary prevention outcomesSecondary prevention outcomes list of the key factors (contexts) associated with an increase list of the key factors (contexts) associated with an increase

in alcohol–related risk or harm - who may be at risk.in alcohol–related risk or harm - who may be at risk.

an efficient way of identifying adults and young people who an efficient way of identifying adults and young people who are at risk due to their drinking.are at risk due to their drinking.

a reductiona reduction in hazardous and/or harmful drinking in adults in hazardous and/or harmful drinking in adults and young people.and young people.

System requirements to enable SBI to occurSystem requirements to enable SBI to occur• Training/supportTraining/support• MaterialsMaterials• TimeTime• Referral routesReferral routes

CaveatsCaveats

Imperfect evidenceImperfect evidence• Methodological flawsMethodological flaws• Realistic evaluation of complex problemsRealistic evaluation of complex problems• How relevant is SBI evidence to England specificallyHow relevant is SBI evidence to England specifically

Volume of evidenceVolume of evidence• Summary of published reviews for BI – blunt approachSummary of published reviews for BI – blunt approach• But are young people, BME groups adequately covered?But are young people, BME groups adequately covered?

Making reasonable extrapolationsMaking reasonable extrapolations• How far can you extend beyond published studies?How far can you extend beyond published studies?

The NICE way of workingThe NICE way of working

Evidence produced by independent contractorsEvidence produced by independent contractors Considered by large/diverse committee (PDG)Considered by large/diverse committee (PDG) Initial evidence – goes out to public consultationInitial evidence – goes out to public consultation Feedback responded to – public processFeedback responded to – public process Final evidence presented to PDGFinal evidence presented to PDG

PDG develops recommendationsPDG develops recommendations Recommendation consultationRecommendation consultation Field work & testing with practitionersField work & testing with practitioners Final guidance publishedFinal guidance published

ChallengesChallenges NICE made up of different organisational culturesNICE made up of different organisational cultures

• Public health works differently to chronic condition etc.Public health works differently to chronic condition etc.• 3 groups with ownership over the 3 scopes3 groups with ownership over the 3 scopes

Overlaps & gapsOverlaps & gaps• prevention and early treatment eg harmful drinkersprevention and early treatment eg harmful drinkers

• ccan we separate an we separate physical and mental health management?physical and mental health management? planned & unplanned detoxification?planned & unplanned detoxification?

Can this formal (rigid) process capture complexityCan this formal (rigid) process capture complexity The continuum of risk/harm/dependenceThe continuum of risk/harm/dependence Remitting nature of alcohol related problemsRemitting nature of alcohol related problems

Bringing it all togetherBringing it all together

• Different timescale for the 3 sets of guidanceDifferent timescale for the 3 sets of guidance• Integrated care pathways will be challengingIntegrated care pathways will be challenging• What impact will the consultation & field work What impact will the consultation & field work

testing processes have on the sciencetesting processes have on the science• Will the ‘plain English’ editing strengthen/dilute Will the ‘plain English’ editing strengthen/dilute

the contentthe content• Making policy-level recommendationsMaking policy-level recommendations• If a general election is called, NICE goes into If a general election is called, NICE goes into

‘purdah’‘purdah’

Nice work if you can get it.Nice work if you can get it.And you can get it - if you try.And you can get it - if you try.

George & Ira Gershwin 1937George & Ira Gershwin 1937

But it takes a lot of time and workBut it takes a lot of time and workAnd sometimes a little diplomacyAnd sometimes a little diplomacy

Eileen Kaner 2009Eileen Kaner 2009