Public Health England (PHE) have released alcohol treatment figures in England for 2016-2017 within a combined report of drug and alcohol treatment data.
The reports states 80,454 alcohol only clients received treatment, a decline of 5% from last year (85,035) and a 12% fall from the 91,651 peak seen in 2013-14. A further 28,242 also accessed treatment for an alcohol problem alongside non-opiate drug use. Reporting no longer identifies primary drug where more than one substance is identified.
An overall reduction in numbers engaging in substance misuse services to 279,793 was also seen; a 3% reduction from the previous year (288,843). However a 20% increase in the number of people entering treatment for crack, and a 12% rise in people being treated for crack and opiate problems was recorded, thought to be partly driven by a rise in affordability and purity of crack and cocaine.
The alcohol treatment gap?
PHE identify a recent report estimating alcohol dependence prevalence of 595,131 adults in England, representing 1.4% of the 18+ population. However this figure is significantly less than the 1.6 million previously cited, though reflects a different methodology rather than any identified change in dependence prevalence. Indeed APMS data has shown that whilst risky drinking has declined alongside falls in younger drinkers, harmful and dependent drinking has appeared steady.
The previous figure of 1.6 million dependent drinkers was however based on the prevalence of those scoring 16 or above on the AUDIT (Alcohol Use Disorders Identification Test), arguably a tenuous figure given not only the AUDIT's limitations as a dependency measure but also the common threshold of 20+ as a more common cut-off for indicating probable dependence. Whilst not meaning those scoring less than 20 cannot have signs of dependence, other more specific measures may be better suited. Indeed the lower figure of just under 600,000 utilised the SADQ and excluded most drinkers scoring under 20 on the AUDIT. Nonetheless the SADQ itself may also be considered more geared towards assessing physical dependence. Instead mild dependence is largely associated with psychosocial indications, as may be better captured by the Leeds Dependence Questionnaire (LDQ) and thus likely to identify a wider population.
Such issues may seem a technicality except for the public health and potentially political issue of how many drinkers should be engaged in treatment. The commonly cited 15% capacity target has arguably never been seen in England, hence long running calls for further investment in treatment services. However PHE's use of a more recent but significantly lower figure suggest that actually over 13% of dependent drinkers are in treatment. However given the severity of dependence and thus potential exclusion of those with milder dependence of harmful drinking - for whom treatment should also arguably be offered to - few would argue that current levels of engagement are sufficient. Indeed writing in a PHE Blog, Rosanna O'Connor, Director of Alcohol, Drugs & Tobacco concluded that
"Questions need to be asked about whether local alcohol dependent populations are being identified, offered and supported into treatment. PHE will be keen to assist local areas to reflect on what can be done to address a clear unmet need."
Last year PHE sought to help keep momentum through a resource to support the 'commissioning and delivery of evidence based treatment interventions to address harmful drinking and alcohol dependence in adults', building on a comprehensive set of NICE and other guidance. This was also followed by a briefing by the Recovery Partnership which called for further engagement with problem drinkers via 'more work to target populations who may not see their drinking as a problem, do not realise the potential harms to their health, are afraid of seeking treatment or are resistant to changing their drinking behaviours'.
Few would disagree that engaging more harmful drinkers 'upstream' would be beneficial to prevent potential health conditions, dependency or other problems developing. Many harmful drinkers though are not 'help seeking' and do not want referral into specialist services or peer support. Under the stepped care model, extended brief interventions or 'brief treatment' in non-treatment settings would be offered, but few example currently exist, arguably leaving a 'gap' between simple brief interventions and specialist treatment services. One indirect response to this may have been the rise in popularity of digital interventions, online peer support groups and potentially Dry January, but such approaches may still be seen as self-help rather than the opportunity to offer NICE backed face to face interventions.
PHE will no doubt seek to continue to promote and support local areas in delivering the most effective alcohol interventions, though will be well aware of the ongoing cuts to public health budgets. Engaging significantly larger groups of dependent and harmful drinkers as resources continue to tighten may seem wishful thinking, though the forthcoming CQUIN may be hoped to generate further treatment referrals via widespread brief intervention in hospitals.
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