Alcohol Policy UK

Drug and alcohol guidance for IAPT workers released by NTA and Drugscope

A guide for IAPT mental health workers for supporting those with co-existing mental health and substance misuse problems has been released by the NTA and Drugscope:

Positive practice guide for working with people who use drugs and alcohol [pdf]

Improving Access to Psychological Therapies (IAPT) services support those with common mental health issues such as anxiety or depression, both closely linked to alcohol misuse - however IAPT services are not typically required or trained to work with drug and alcohol issues.

The guide was therefore developed to support IAPT workers to work confidently and inclusively with those who have common mental health problems and non-severe drug or alcohol problems. It explains how simple assessment can identify IAPT clients whom will be suitable for brief interventions for their drug or alcohol misuse.

The guide highlights that substance misuse clients with mental health problems should have access to NICE-recommended psychological interventions, including CBT for depression and anxiety. It states there is no evidence that substance misuse per se makes key psychological therapies ineffective. Between 70 and 80 per cent of clients in drug and alcohol services have common mental health problems, largely anxiety, depression and trauma.

However the guide highlights the expertise available within drug and alcohol treatment services to provide evidence-based psychological interventions for mental health issues will often be limited. IAPT services may therefore crucially provide one of the only local resources for clients of drug and alcohol services to access psychological therapies for common mental health problems.

Routine assessment or 'identification' of current use of drugs and alcohol is  recommended for all IAPT clients. Many of the general cognitive and behavioural techniques used by psychological therapy workers are transferable to working with drug or alcohol use, where a non-judgemental approach should be maintained.

Alcohol and mental health factsheets are available here from the Mental Health Foundation, the Institute of Alcohol Studies and Alcohol Concern.

Find out more on IAPT services here. For further information on mental health see NHS Choices mental health pages, MIND, the Mental Health Foundation or Centre for Mental Health. The Samaritans offer a 24/7 confidential support service for anyone experiencing feelings of distress or despair.

New Guidance for Mental Health Liaison services highlights role of alcohol in mental health problems

The Royal College of Psychiatrists has released guidance for Commissioners of Mental Health Liaison Services in Acute Care. The guidance document is one of a suite of four documents for commissioners covering all aspects of mental health commissioning.

There is a strong connection with substance use and mental health issues. The Institute of Alcohol Studies reports that up to 6% of patients with two or more neurotic disorders are alcohol dependent, as opposed to 2% of the general population.

Frequently alcohol is implicated in self-harm, whether as a substance of regular misuse or as an agent for the self harm. A briefing paper by Alcohol Concern echoes the links between alcohol use and mental health co-morbidity, stating that alcohol is a significant factor in suicides, with up to 65% involving alcohol misuse. With the advent of community care, people with severe mental health problems are more likely to be living in the community and exposed to easy access to alcohol.

Identifying and supporting people with mental health and alcohol problems as they enter Acute Care is a challenge. The new guidance showcases the Birmingham Rapid Assessment Interface and Discharge (RAID) model as good practice. The RAID service offers consultant and liaison support to A&E, MAU, Medical, Maternity and Surgical wards. It offers a holistic approach which addresses the patient's mental health, physical health and social needs. This inclused assessment and support for addictions and an important "all age appropriate" service.

The guidance calls for the better assessment, management and signposting of mental health issues, including alcohol-related problems. The benefits of better liaison services would include: reduced Out Patient attendances, reduced hospital admissions and re-admissions and better protection of patients from avoidable harms. Both alcohol and mental health problems carry huge stigma, and it is hoped that by following a holistic approach to patient care this could be significantly reduced.

The guidance documents are launched a year after the DH released No Health without Mental Health, the cross government mental health outcomes strategy.

Latest Findings alcohol research: licesning, treatment and student based interventions

Recent research from the drug and alcohol Bank:

Licensing

Late opening for pubs and bars aggravates alcohol-related harm

UK research is inconclusive, but international research from developed nations reviewed for a national US task force supports the belief that increasing on-licence opening hours leads to more drinking and more alcohol-related harm.

Weekend alcohol sales equals more weekend alcohol-related harm

International research from developed nations reviewed for a national US task force offers some support for the belief that allowing or disallowing Saturday or Sunday alcohol sales affects drinking and alcohol-related harm.

Treatment and recovery

Home visits cost-effectively aid alcohol treatment

In Brazil adding home visits to a three-month alcohol detoxification and treatment programme cost-effectively increased the abstinence rate at the end of treatment. British study suggests that what happens in such visits is critical.

Group therapy wins on cost-effectiveness grounds

For US problem drinkers and drug users not at the severest end of the spectrum, four sessions of group were as effective as four of individual therapy but required far fewer therapist hours per patient. The little research we have suggests this a common finding, commending group approaches on cost-effectiveness grounds.

Student and college based interventions

Group motivational interviewing works for college drinkers

US students who broke college drinking rules and were required to undertake an alcohol programme responded better to three hours of group motivational interviewing than six of alcohol education; enhanced confidence that they could resist risky drinking was the key. For colleges it offers an effective but economical response to problem drinkers.

Drink moderation strategies ineffective unless students want to cut down

What happens when instead of asking students to cut drinking, you ask them to use more moderation strategies such as spacing drinks or avoiding heavy drinking situations? The results of this US study suggest that changes in strategy use can bear little relation to changes in drinking, and that intention to cut back is the most important factor.

Brief motivational interviewing works best for thinkers

This US study found that different types of heavy-drinking college students responded best to different types of brief intervention to promote moderation. In particular, those who as well as hard drinking liked hard thinking were most affected by being led to reflect via motivational interviewing on how their drinking compared to that of the average student.

'Don't let drink sneak up on you' - new Change4Life alcohol campaign launched

A new Change 4 Life alcohol campaign, 'Don't let the drinks sneak up on you', has been launched - see the press release, TV advert and Change4Life alcohol pages including a new tool to check your drinking.

The campaign warns against drinking above lower risk guidelines, highlighting the potential impacts on long term health. A TV advert warns that regularly drinking just 2 large glasses of wine or 2 strong pints of lager a day can triple the risk of developing mouth cancer and double the risk of getting high blood pressure. A supporting leaflet [pdf] is also available to order.

A survey as part of the campaign revealed that most people are unaware of the serious illnesses caused by regularly drinking above the guidelines. For example 85% of people did not realise it increases the risk of developing breast cancer and 59% did not realise it increases the risk of mouth, throat and neck cancer (see press release for more). The campaign follows a recent call for recognition of the need for at least 2 alcohol-free days per week.

Secretary of State, Andrew Lansley said: 

 “It’s crucial we support people to know about how drinking too much poses risks to their health and how they can take control of their drinking. It can be easy to slip into the habit of having a few extra drinks each day, especially when drinking at home. But there can be serious health risks. Don't let drinking sneak up on you.”

Chief Medical Officer Professor Dame Sally Davis said:

"Drinking too much is a major public health issue. This campaign highlights how easy it can be to use a glass of wine or beer to unwind at the end of a busy day but these drinks stack up and can increase your risk of high blood pressure, cancer or liver disease.”

See reports in the Guardian, BBC and The Telegraph.

The campaign follows previous Government-led activity such as the alcohol effects, Know Your Limits (materials here) and support for areas to develop local social marketing activity. Existing alcohol communications are also run through NHS Choices and the industry funded Drinkaware trust.

The campaign had been previously announced as part of the Government's new alcohol strategy to be released later this year. But may health policy groups have expressed concern over an excessive focus on on 'nudge' or 'personal responsibility' approaches delivered in part through the Responsibility Deal. They warn that to significantly reduce alcohol misuse multi-strand action that includes addressing price, availability and marketing must also take place. 

'Tackling alcohol misuse: Should abstinence be our preferred approach?' British Liver Trust call for public health action on alcohol

The British Liver Trust have released a new report outlining the need for a comprehensive approach to tackling alcohol misuse. It warns against a "one size fits all approach for treatment" for a range of problem drinkers "each of whom will need tailored approach with the interventions and appropriate treatment goals."

Download 'Reducing alcohol harm: recovery and informed choice for those with alcohol related health problems'

A supporting commentary piece by Andrew Langford, Chief Executive of the British Liver Trust also appeared in the Guardian.

The report highlights that alcohol accounts for 80% of all deaths from liver disease, the prevention of which should be the core focus of alcohol policy debates. GPs, nurses and other health professionals should screen for alcohol misuse more widely, to ensure that those drinking at harmful levels are identified and offered appropriate support, advice and treatment.

The report chimes with a recent call from 2020 health to focus on 'risky drinking' and the prevention of alcohol problems, as well as a more traditional focus on treatment for a smaller number of dependent drinkers. Both reports call for public health approaches in response to the growing impact of alcohol related harm, as also set out in NICE public health alcohol guidance, Alcohol Concern reports, Department of Health commissioning guidance and calls to mainstream brief interventions.

Further information on alcohol and 'risky drinking' can be found from NHS Choices alcohol pages, Drinkaware, and resources and guidance are available from the Alcohol Learning Centre.

Alcohol Concern urges action on minimum pricing ahead of new national alcohol strategy

Alcohol Concern are calling on the public to urge MPs to push for minimum pricing ahead of the forthcoming national alcohol strategy. Alcohol Concern state:

The next few weeks will be our last chance to influence the shape of the alcohol strategy, which will shape public policy on reducing alcohol harm for years to come. We must act now to counteract the lobbying power of the drinks industry and major retailers.

The Prime Minister has come out in support of minimum pricing, but the Secretary of State for Health has not- this is the moment when we need MPs to call for minimum pricing and help ensure that it becomes government policy.

Up until now, the government has relied largely on voluntary measures by the drinks industry to reduce consumption. Given that the turnover and profitability of the drinks industry is entirely reliant on maintaining or increasing alcohol consumption, there is a clear conflict of interest involved in this approach.

Alcohol Concern are urging people to write to their MP to call for minimum pricing, stating the business case for action. The charity have provided a list of key facts and possible questions to include and a minimum pricing briefing paper. They are also promoting a Twitter hashtag #ActNowOnAlcohol

The Prime Minister David Cameron recently instructed Whitehall officials to look at minimum pricing options according to a Daily Telegraph report. Cameron has repeatedly spoken out on the issue of cheap alcohol, but the Health Secretary Andrew Lansley prefers voluntary action through the controversial Responsibility Deal. The public appear divided on the subject.

Minimum pricing has been at the forefront of the national alcohol policy debate, particularly since the release of research from the University of Sheffield modelling the likely benefits. Supporters cite the link between rising consumption with the falling relative price of alcohol.

However opponents of minimum pricing, such as sections of the alcohol industry and retailers, argue minimum pricing is a blunt measure and could contravene EU legislation. Scotland is currently seeking to introduce a minimum price and so could soon test this, whilst the IFS advise lobbying for EU law changes to allow tax restructuring to achieve a minimum pricing effect.

A 'below cost ban' is due to come in under forthcoming Licensing changes, but  the ban is not expected to not expected to affect prices under a 'Duty + VAT' definition of cost. See here for information on why a below cost ban is not minimum pricing and further reports.

Small rise in alcohol-related deaths in 2010

A slight rise in alcohol-related deaths has been reported for 2010, according to the ONS (bulletin here). Figures show a rise of 126 to 8,790 from 8,664 in 2009. Last year a slight fall was reported, though Alcohol Concern Chief Executive Don Shenker attributed the drop to a fall in consumption triggered by the recession. See BBC and Press Association reports.

Key points from the bulletin include:

• In 2010 there were 8,790 alcohol-related deaths in the UK, 126 more than in 2009 (8,664)
• There are more alcohol-related deaths in males than in females, with 67 per cent of all alcohol-related deaths in the UK in 2010 being male
• Alcohol-related death rates were highest for those aged 55-74 and lowest for those aged under 35 over the last ten years
• UK males aged 55-74 years showed a sharp and statistically signficant increase in alcohol-related death rate from 41.8 per 100,000 in 2009 to 45.2 per 100,000 in 2010
• Alcohol-related death rates varied between the regions of England and tended to be highest in the North and lowest in the East of England over the last ten years

Last year alcohol-related hospital admissions passed the one million per year mark and are still rising. However the definition maybe reviewed following news of the changes to the public health outcomes framework. See the Statistics on Alcohol: England, 2011 report for wider data on alcohol-related consumption trends and harm.

Alcohol research updates - web based reviews: online peer support; web-based self-help; online feedback to students

The role of online peer-support?

A new Insight from Alcohol Research UK has explored the value of alcohol-related online support groups to their users. The Insight Problem Drinking and Peer Support in Cyberspace looked at the experiences and motives in using online support groups. Reasons included dissatisfaction with AA, accessibility & convenience, anonymity and the ability to connect to others. Positives were also cited as ready access to connect with others and find information. However disadvantages were also identified, including misunderstandings, lack of social contact, group dynamics, a lack of response and dis-inhibited behaviour.

Given the growth in online resources and groups, the Insight emphasises the importance of sites maintaining up to date, accurate and reliable information. Moderators play an important role in providing good online peer support, whilst users ought to be made aware of the pros and cons.

Best evidence yet for web-based alcohol self-help

Also highlighted on the Alcohol Research UK blog, the Findings review of the potential effectiveness of web-based self-help resources. Given the rise and rise of the web, it explores the significance and potential effectiveness of online self-help and who may benefit most.

Providing web-based feedback and social norms information to reduce student alcohol intake

A further Insight has explored the feasibility and effectiveness of a web-based intervention including feedback on consumption and social norms. It indicated some small reduction in drinking and concluded that monitoring alone is likely to reduce weekly consumption. However keeping students engaged in online programmes required further work.

Public Health Outcomes Framework released: spend should reflect local needs; alcohol admissions data to be reviewed

The NHS Public Health Outcomes Framework has been published, aiming to tackle public health challenges through moving public health back into local government. It outlines 'a shift away from the focus of process targets' to a framework that describes two 'high level' outcomes: an increase in healthy life expectancy and a reduction in life expectancy gaps across communities.

A DH press release, states:

'Public health will be measured against a framework which sets out 66 health measures so councils and the Government are able to see real improvements being made and take any action needed.

From April next year, councils will be given a ring-fenced budget – a share of around £5.2 billion based on 2012/13 funding – and will be able to choose how they spend it according to the needs of their population. Those who make the most improvements will be rewarded with a cash incentive.'

Investment in alcohol treatment and prevention will be locally determined, and should be reflected in each area's Joint Strategic Needs Assessment and Joint Health and Well-being Strategy.

The 66 indicators will be grouped into four main domains: 'Improving the wider determinants of health'; 'Health Improvement'; 'Health Protection' and lastly, 'Healthcare public health and preventing premature mortality'. Alcohol is addressed within the Health Improvement domain, alongside other lifestyles factors. A set of indicators on premature mortality includes preventable mortality from liver disease.

A specific alcohol indicator will remain for alcohol-related hospital admissions, though the indicator definition is due to be reviewed by NWPHO - 2.18 of the technical specifications states: 'the preferred option is for an indicator based on just alcohol-related primary diagnoses, to minimise the risk of perverse consequences from any changes in coding practice so the indicator rewards local areas for good performance.'

Recently the Health Committee warned over risks to public health budgets within the changes, concerns echoed by the Shadow Health Minister Diane Abbott - see a Press Association release. The Responsibility Deal, a key strand of Lansley's public health strategy, has also been heavily controversial and the 'nudge' focus has been criticised by a Lord's committee.

Last month the DH released a series of factsheets about the new public health system. See news reports in the Daily Mail and Daily Telegraph.

Scientists gleam further insight into alcohol's effect on brain reward system

Further insight into the effect of alcohol on the brain's reward system has been reported in the journal of Science Translational Medicine. It found alcohol effects the orbitofrontal cortex and results in a release of endorphins, previously only proven in animal studies. These naturally produced pain relieving proteins have an action akin to morphine, leading to drinkers experiencing pleasurable feelings.

The study found that heavier drinkers found alcohol more pleasant than non-drinkers. It also describes how the endogenous opioid function in the brains of chronic drinkers appears to change, in a sense 'over-learning' problem drinking behaviours. See reports in the Telegraph and Daily Mail.

The study may help to explain the mechanism by which antagonists such as Naltrexone work successfully, which could lead to the further development of pharmacological treatment approaches. Nonetheless, from the position that environment and learned behaviours also contribute to the development of problem drinking, successful alcohol treatment approaches emphasise the role of psychosocial as well as medical interventions. See here for the review into the effectiveness of alcohol treatment and NICE guidance.

Recently the message of a little but not often came out for preventing the development of alcohol problems. Sir Iain Gilmore, Chair of the Alcohol Health Alliance stated that having at least 2 alcohol free days each week was "a very good indicator of not being addicted". He emphasised the key is not to let regular consumption and rising tolerance end up as daily dependence, as experienced by as many as 1.6 million people in England.

This echoes calls from the Science and Technology Committee of MPs recently to urgently review alcohol guidelines and help the public to understand units better. The Change4Life website now contains public health messages about alcohol use within the context of a healthy lifestyle, and NHS Choices has useful tips for cutting down.