New research has been released assessing the prevalence of alcohol dependence in England, including the first estimates of dependence by local area. The analysis also explores the number of children likely to be living with dependent adults and the proportion of dependent drinkers wishing to reduce their alcohol use.
The key findings indicate:
- There are 595,131 adults with alcohol dependence in England, which represents 1.393% of the 18+ population
- The majority of these (313,753) are displaying mild dependence, followed by those with moderate severity (173,399) and severe dependence (107,979)
- 120,419 alcohol dependent adults are estimated to have children living with them in the household, with a total of 207,617 children thought to live with an adult with dependence
- 57% of alcohol dependent adults are estimated to have a desire to cut down their drinking, including 41% who intend to do so in the near future
The analysis was conducted by researchers from the University of Sheffield and King's College London using a range of data sources including the recent Adult Psychiatric Morbidity Survey (APMS) 2014, the Alcohol Toolkit Study (ATS) and hospital admissions data. The estimates are mainly based on a combination of alcohol assessment instruments the AUDIT and SADQ. The AUDIT is considered the gold standard alcohol assessment tool for identifying risk levels amongst those scoring 8+, but with scores of 20+ indicating a level of probable dependence. SADQ however is specifically geared to assessing severity of physical dependence.
In addition to estimating national prevalence, significant variations were found by area, sex and age as would be expected based on existing research. Higher severity of alcohol dependence was most likely to be seen in those who had higher AUDIT scores, of younger age and male, white and living in more deprived areas. A sixfold difference in alcohol dependence was found between the lowest and highest Upper Tier Local Authorities.
Measuring alcohol dependence: where to draw the line?
Those with a close eye on prevalence data may note the significant differences in figures cited for alcohol dependence in England. Last year a PHE resource on harmful drinking and dependence stated there was an estimated 1.6 million adults in England who 'may have some level of alcohol dependence', though highlighted not all would need specialist treatment.
A discrepancy of around one million dependent drinkers though does not represent significant changes in actual prevalence, rather than how it may be defined. Figures of around 1.6 million were also cited in the extensive 2011 NICE guidance, suggesting over 1.3 million mildly dependent drinkers scoring 16+ on AUDIT and a low score on SADQ (<16). The recent estimate however excludes those scoring 16-19 on the AUDIT as dependent, unless they also scored 16 or more on the SADQ (see below).
Essentially the revised estimate sets a higher threshold for dependence, particularly given the SADQ as a tool is geared towards identifying physical dependence. Indeed mild dependence is largely associated with psychosocial rather than physical signs, as may be better reflected by the Leeds Dependence Questionnaire (LDQ).
Ultimately, drawing a distinct line between any categories of alcohol use is artificial to a large extent, and a strict reliance on exact scoring cut-offs can be ill-advised in practise. However seeking to understand the numbers of people who may benefit from the various interventions that may be offered is important from commissioning and policy perspectives, particularly with regards to assessing optimum levels of treatment capacity.
How many dependent drinkers want to change?
Debates over what level of alcohol treatment should be made available have been long running as the mooted 15% capacity target has not yet been seen in England. As such, new data indicating the possible extent of motivation to cut down alcohol use will be of relevance for treatment capacity and possible interventions to increase uptake. The report describes 'amenability to treatment' for the 57.3% of dependent drinkers who indicated they wished to reduce their drinking and the 41.2% who intended to do so in the near future.
Higher motivation to change was associated with higher AUDIT scores and was also more likely amongst women, those aged 35+, of non-white ethnicity, and also by region. Harmful drinkers scoring AUDIT 16-19 were three times more likely to express motivation to change than those scoring less than 16, whilst those scoring AUDIT 20+ were at least six times as likely. Indeed a wealth of previous research has demonstrated severity of problems as a significant indicator of readiness to change, whilst many at-risk drinkers who may not yet be experiencing or aware of harm do not consider their drinking problematic.
Dependence in Primary Care: an issue of detection?
A separate study has also been released exploring alcohol dependence in Primary Care, though identifying far lower prevalence of 8.3 and 3.7 per 10,000 male and female patients respectively. The study used a specific criteria for identifying records of Primary Care patients, though acknowledged the likelihood of it only detecting those with more moderate or severe dependence. Indeed significant questions over the identification of less severe alcohol problems in Primary Care have been raised, particularly in relation to efforts to embed brief intervention (IBA); less than 10% of higher risk drinkers report having been asked about their alcohol use compared to over 50% of smokers.
Remembering 'stepped care' models: where next?
Evidently a tension exists between the real world complexity of alcohol problems and the need to identify distinct groups of problem drinkers for policy and commissioning purposes. Nonetheless, falls in population consumption since 2004 have been identified as largely confined to increasing risk drinkers rather than amongst those with harmful or dependent levels.
In 2006 'Models of Care for Alcohol Misusers' (MoCAM) described the 'stepped care' model in the context of commissioning alcohol interventions. The provision of IBA as key brief intervention approach has been widely sought since and looks set to continue, as with hospital based alcohol care teams. However the questions over actual extent of IBA delivery are largely unanswered, whilst significant regional variation in treatment capacity has remained.
Whilst those with more severe levels of dependence tend to have significant impacts on a range of public services, arguably a gap for larger numbers of harmful or mildly dependent drinkers who are less likely to seek or receive help exists. Many such drinkers may not consider their problems serious enough to seek formal treatment, but may benefit from further behavioural support than 'brief advice', though the addition of pharmacological support in the form of Nalmefene has been controversial. However few roles outside of treatment services offer extended brief interventions (EBI) or brief treatment packages as outlined in the stepped care model and advocated by the NICE CG115 costing report.
One indirect response to this may have been the rise in popularity of digital interventions, online peer support groups and potentially Dry January. Certainly an emerging evidence base seems to suggest digital IBA approaches can have a small but significant effect, whilst the information age has significant advantages for the many people who decide to self-help. Nonetheless, face to face interventions are still considered the gold standard, though treatment services have continued to face ongoing pressures in the context of cuts to local authority public health budgets. Questions have also been asked over the issue of parental alcohol misuse and the impact on children, with a recent camaign calling for specific local level strategies.
As such, few may be expecting any positive trends in the prevalence of alcohol dependency in the near term, albeit that most dependent drinkers reportedly wish to cut down and many thousands do receive statutory help each year. However wider population consumption and harm trends will continue to be subject to intense policy debates, whilst any movement on minimum unit pricing would be expected to have implications for future dependency rates.