BRIEF INTERVENTIONS IN THE TREATMENT OF ALCOHOL USE DISORDERS IN RELEVANT SETTINGS

Transcription

1 BRIEF INTERVENTIONS IN THE TREATMENT OF ALCOHOL USE DISORDERS IN RELEVANT SETTINGS Project BISTAIRS: First results and Status quo Christiane Sybille Schmidt, Dipl. Psych Hamburg University (CIAR), Hamburg, Germany

2 Acknowledgements Institute of Health & Society, Newcastle University Newcastle Upon Tyne (UK): Addition Research Hamburg (Germany): Amy O Donnell, Dr. Dorothy Newbury-Birch Prof. Eileen Kaner Prof. Peter Anderson Bernd Schulte Dr. Silke Kuhn Johann Grimm Prof. Jens Reimer

3 Content 1) Introduction Screening and brief interventions (SBI) The BISTAIRS project 2) Evidence of effectiveness of SBI in different settings 3) Expert survey: SBI implementation status in EU member states 4) Discussion of barriers & recommendations 5) Next project steps

4 Screening and brief interventions (SBI) Secondary prevention in time-limited settings Aim to raise awareness, share knowledge, and get a person to think about making changes Key components SBI(RT): Screening, Brief interventions, Referral to treatment Different lengths and concepts: Brief Advice Extended Brief Intervention / Motivational Interviewing Various additional components (including e-health interventions)

5 Screening and brief interventions (SBI) Screening example: AUDIT / AUDIT-C AUDIT- C Questions How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Scoring system Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week Never Less than monthly Monthly Weekly Daily or almost daily TOTAL : Your score

6 Screening and brief interventions (SBI) Target groups for SBI, defined by AUDIT scores Score 0-7 low risk drinkers Score 8-15 risky/ hazardous drinkers Score harmful drinkers Score 20 points to an alcohol dependence

7 The BISTAIRS project Key specifications Project title Acronym Main Partner Associated partners 6 Starting time Brief interventions in the treatment of alcohol use disorders in relevant settings BISTAIRS Ending time CIAR, UKE Hamburg University

8 The BISTAIRS project Aims & Purpose SBI: most effective for non treatment-seeking harmful drinkers Most evidence of effectiveness gathered in primary health care BISTAIRS aims to extend SBI implementation to further settings Emergency care Workplaces / workplace health services Social services

9 Introduction Effectiveness Survey Discussion Next steps Nordic drug and alcohol conference 2013 The BISTAIRS project Structure

10 The BISTAIRS project Partners Partner University of Hamburg (CIAR) Hamburg, Germany University of Newcastle upon Tyne (UNEW) Newcastle, United Kingdom Fundacio Clinic per al la Recera Biomedica (FCRB) Barcelona, Spain (Catalonia) Instituto Superiore Di Santa (ISS) Rome, Italy Generalität de Catalunya (GENCAT) Barcelona, Spain (Catalonia) National Institute of Public Health (NIPH) Prague, Czech Republic Institute on Drugs and Drug Addiction (IDT) Lisbon, Portugal Function Work package leader National field test coordinator Work package leader Work package leader Work package leader National field test coordinator National field test coordinator National field test coordinator National field test coordinator

11 Effectiveness of SBI in different settings Systematic reviews Emergency care, workplaces, social services Primary health care: review of reviews (RoR) Systematic searches in electronic databases (e.g. MEDLINE) Timeframe: 2000+, published in English language Other specific inclusion criteria: Intervention length, measurements of effectiveness, study design

12 Primary health care Robust evidence base 26 eligible reviews / meta analyses What we know: Effective in reducing harmful (non-dependent) drinking Can be delivered by a range of practitioners Short, simple as effective as longer, more complex interventions Majority of evidence: middle-aged men; high-income countries Barriers to implementation

13 Primary health care Robust evidence base 26 eligible reviews / meta analyses What we don t know: Impact on younger / older people; pregnant women; dependent drinkers Low /middle income countries Longer term effectiveness Active ingredients of SBI, effectiveness of control interventions Potential of e-sbi

14 Emergency care settings Mixed evidence 34 primary studies (randomised controlled trials, RCTs) Setting: emergency departments and trauma units Target population: injury patients Highly heterogeneous outcome criteria: AUDIT score, heavy episodic drinking days, rehospitalization, DWI arrests, negative consequences, etc.

15 Number of studies Emergency care settings Mixed evidence primary studies (RCTs) SBI superior than control condition SBI effect only for subgroups Short term effect vanished at followup No significant effect Control groups showed equal improvements

16 Workplaces Difficult field for SBI research 8 primary studies (RCTs) 7 of 8 studies: (partly) revealed superiority of SBI All at large companies or Employee Assistance Programs, mainly from USA Difficulties for research: recruitment, protecting privacy, preventing group contamination Potential for e-sbi

17 Social services (& criminal justice) - Small evidence base in heterogenous settings 6 primary studies (controlled trials) Target groups: homeless people, clients of community-based drug-counselling centres, driving & violent offenders Heterogeneity in outcome criteria and intervention intensity Inconclusive evidence Target group specific aims and strategies are needed

18 Effectiveness of SBI conclusive summary Larger evidence base for medical settings Effects of control interventions are important Especially in non-medical settings: considerable heterogeneity (target groups, outcomes, interventions) Future research should examine Reachability, acceptance and effectiveness among specific target groups Active ingredients, optimum SBI frequency, factors for longerterm effectiveness.

19 SBI implementation survey Electronic questionnaire on Alcohol prevention and SBI implementation efforts Estimates on the availability and potential impact of BI Experts retreived from alcohol and SBI research networks (e.g. ODHIN, INEBRIA) Sent out to 324 experts from all 27 EU member states

20 SBI implementation survey Country UK (England & Scotland) 8 Italy 5 Poland 4 Catalonia & Spain 4 Czech Republic Netherlands Portugal Ireland Austria Belgium Denmark Finland Sweden Germany Greece Lithuania Slovakia Total 47 Number of respondents 3 each 2 each 1 each 47 responses from 17 countries 10 EU countries did not respond: Bulgaria, Cyprus, Estonia, France, Hungary, Latvia, Luxembourg, Malta, Romania, Slovenia

21 SBI implementation survey ,77 2,93 2,82 2,67 primary health care workplace health emergency care social services Mean estimates of SBI implementation status per setting. 0 = not at all implemented, 10 = fully implemented

22 Introduction Effectiveness Survey Discussion Next steps Nordic drug and alcohol conference 2013 SBI implementation survey , ,8 5,7 5,0 4,8 4,1 3,5 3,4 3,1 2,9 2,3 2,0 2,0 1,8 1,5 1,5 1,0 0,5 0,0 Finland Scotland Netherlands Catalonia Sweden Belgium England Italy Czech Republic Ireland Portugal Austria Slovakia Spain Germany Poland Denmark Lithuania Greece Mean estimates (over all settings) of SBI implementation per country. 0 = not at all implemented, 10 = fully implemented.

23 Introduction Effectiveness Survey Discussion Next steps Nordic drug and alcohol conference 2013 SBI implementation survey 10 8,07 8 6, ,91 4,76 4,27 4,21 3,89 3,80 3,74 3,51 2,31 1,77 0 addiction specialists psychiatrists general practitioners psychologists nurses working in general practise counsellors social workers doctors in hospital obstetricians nurses working in hospitals pharmacists dentists To what extent do you think that professionals consider alcohol advice as part of their routine clinical practice? (0 = not at all, 10 = fully )

24 Introduction Effectiveness Survey Discussion Next steps Nordic drug and alcohol conference 2013 SBI implementation survey Screening Delivery of BI Referral to treatment primary health care workplace health emergency care employment agencies schools/universities criminal justice system youth welfare services accomodation offices Estimated ability of different settings to provide SBI(RT): 0 = not at all, 10 = fully able/adequate

25 SBI implementation survey Six main prerequisites for further SBI implementation (identified via pre-defined and open questions): Supportive policies/ nationwide strategies Allocation of financial resources Extensive provision of education and training (on an institutional basis) Networking (treatment referral, integrated care pathways) Evidence of effectiveness in settings beyond PHC Discussion of feasibility with practitioners

26 Discussion of barriers and recommendations General barriers to implementation of SBI: Lack of training, time, reimbursement & referral options Setting-specific, additional barriers: Primary health care: therapeutic relationship Emergency care settings: time constraints, high staff turnover Workplaces: privacy, career preservation Social services: diversity of services teams

27 Possible SBI pathways: Primary health care Initial Screening Tools New Registration AUDIT Positive Result No response No response / key indicators Adults visiting GP AUDIT Score 8+ / AUDIT-C Score 5 (M)/4(W)+ Brief Advice (x 2) Extended Advice (x 4) Specialist referral Annual health check / Related health complaint AUDIT - C On-going monitoring of patient No action Negative Result

28 Possible SBI pathways: Emergency care Initial Screening Tools Positive Result AUDIT No response / key indicators Adults attending ED Related injury / co-morbidity AUDIT Score 8+ / AUDIT-C Score 5 (M)/4(W)+/ M-SASQ 6(M)/5(W)+ Brief Advice Specialist referral M-SASQ Information Leaflet AUDIT - C No action Negative Result

29 Possible SBI pathways: Workplaces Initial Screening Tools Positive Result AUDIT Adults workers Reduced performance/accidents / operating machinery etc AUDIT Score 8+ / AUDIT-C Score 5 (M)/4(W)+/ M-SASQ 6(M)/5(W)+ No response / key indicators Brief Advice Specialist referral AUDIT - C No action Negative Result

30 Possible SBI pathways: Social services Initial Screening Tools Universal (all clients) AUDIT Positive Result No response No response / key indicators Adult clients AUDIT Score 8+ / AUDIT-C Score 5 (M)/4(W)+ Brief Advice (x 2) Extended Advice (x 4) Specialist referral Targeted (CJS / domestic violence) AUDIT - C No action Negative Result

31 Primary health care: Implementation milestones Locally relevant clinical guidelines Supporting materials & Training Inclusion of all PHC healthcare professions (nurses) Systems for monitoring SBI programmes Improving financial support Available specialist services & referral networks

32 Emergency care: Recommendations Develop and disseminate clinical and operational guidelines Programme sustainability enhanced by: Clinical champion on-site Managerial support Clear responsibilities (not entire ED staff trained) Alcohol health worker External specialist support for alcohol

33 Workplace setting: Advice to employers Privacy & career preservation essential Tailored SBI programmes: acceptable steps, flexibility SBI as part of health promotion programmes Actions beyond SBI: Clear written policies for addressing alcohol issues and ensure all staff aware Inclusive models of prevention (drug-free workplaces)

34 Social service settings: Recommendations Embedding SBI into routine practice requires long-term perspective Bottom-up approach in developing materials External alcohol specialist support More research needed! Reachability of target groups Adequacy and acceptance of SBI

35 Next project steps: Field test preparations One field test per setting (PHC, emergency, workplace, social) and per country (Catalonia, Czech Republic, Germany, Italy, Portugal) Toolkit (recommendations & practical tools) circulated 12/2013 Consensus meeting in mid-december 2013 Field test period: 01/ /2014; evaluation focus groups in 05/2014 Re-Aim evaluation dimensions (reach, effectiveness, adoption, implementation, maintenance) Qualitative and quantitative data

36 Thank you for your attention. Project website: