Prevalence and incidence of alcohol dependence: cross-sectional primary care analysis in Liverpool, UK

OBJECTIVES

Liverpool has high prevalence of alcohol use disorders (AUDs) compared with the rest of the UK. Early identification and referral in primary care would improve treatment for people with AUD. This study aimed to identify changes in prevalence and incidence of AUD in primary care in Liverpool, to identify local need for specialist services.

DESIGN

Cross-sectional retrospective analysis of electronic health records.

SETTING

National Health Service (NHS) Liverpool Clinical Commissioning Group (CCG) primary care. In total, 62 of the 86 general practitioner (GP) practices agreed to share their anonymised Egton Medical Information Systems (EMIS) data from 1 January 2017 to 31 December 2021.

PARTICIPANTS

Patients aged over 18 years with a SNOMED code for alcohol dependence (AD) or hazardous drinking (N=4936). Patients were excluded if they had requested that their data was not to be shared, and practices were excluded if they opted out (N=2) or did not respond to the data sharing request (N=22).

PRIMARY AND SECONDARY OUTCOMES

Prevalence and incidence of AUD diagnoses in primary care over the 5-year period; demographic profile of patients (sex, age, ethnicity, occupation); GP postcode; alcohol-related medications; and psychiatric and physical comorbidities.

RESULTS

There were significant decreases in incidence of AD and hazardous drinking diagnoses over the 5 years (p<0.001 in all cases). Prevalence showed less change over time. Diagnoses were significantly higher in more deprived areas (Indices of Multiple Deprivation decile 1 vs 2-10). Overall pharmacotherapy prescriptions were lower than national estimates.

CONCLUSIONS

There are low levels of identification of AUDs in primary care in Liverpool, and this is decreasing year on year. There was weak evidence to suggest patients in the most deprived areas are less likely to receive pharmacotherapy once diagnosed. Future research should seek to investigate practitioner and patient perspectives on barriers and facilitators to management of AUDs in primary care.

Prevalence and patterns of hospital use for people with frequent alcohol-related hospital admissions, compared to non-alcohol and non-frequent admissions: a cohort study using routine administrative hospital data

AIMS

This study compared prevalence and hospital use among individuals frequently admitted to hospital in England with wholly attributable alcohol-related diagnoses (WAAD), known as alcohol-related frequent attenders (ARFAs), with those of non-alcohol frequent attenders (NAFAs), non-frequent alcohol attenders (ARNFAs) and non-alcohol non-frequent attenders (NANFAs).

DESIGN

Cross-sectional and longitudinal analyses of 5 years of England's Hospital Episode Statistics (HES).

SETTING

Hospital inpatients in England, UK, 2011-16.

PARTICIPANTS

Two cohorts (2011/12 = 489 580/7 654 944 patients and 2015/16 = 490 384/7 660 108 patients) were selected from all adult patients aged ≥ 18 years, treated in English hospitals between 1 April 2011 and 31 March 2016. Patients were categorized as having alcohol-related admissions if diagnoses included a WAAD (ICD-10 classification, WHO, 2016) and frequent admissions if they had more than three hospital admissions during a single HES year.

MEASUREMENTS

Prevalence of ARFA, number of admissions (spells), occupied bed-days (OBDs), average length of stay (ALOS) and total admission costs over 5 years were compared among ARFAs, ARNFAs, NAFAs and NANFAs.

FINDINGS

On average, 0.7% of people admitted to hospital per annum in England 2011-15 were ARFAs and more than a quarter of all frequent attenders (for all causes) to hospitals had a wholly attributable alcohol diagnosis on admission. ARFAs had longer ALOS than the other patient groups [5.55 days versus ARNFA 4.7, NAFA 3.39 and NANFA 2.57 days, F = 1088.37 (3, 488 570, P < 0.001)] in the 2015/16 index year; but fewer spells than NAFAs [5.38 ARFAs versus 5.98 NAFAs, F = 20 536.25 (3, 490 380) P < 0.001]. The ARFA cohort reduced in size (from 51 934 ARFAs to 20 548) in the course of 5 years. ARFAs had the highest average total cost of admissions per person over 5 years at £38 189.

CONCLUSIONS

People with repeated admissions for alcohol-related problems in England appear to be a high-cost, high-need, complex group of patients that makes up more than a quarter of the country's alcohol admissions.

Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial

BACKGROUND

Alcohol-related hospital admissions have doubled in the last ten years to > 1.2 m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting.

METHODS

One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12 months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU + AOT and CAU at 6 and 12 months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12 months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12 months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up.

DISCUSSION

AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and cost-effectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first.

TRIAL REGISTRATION

International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016.

Development of an alcohol withdrawal risk stratification tool based on patients referred to an addiction liaison nursing service in Glasgow

Purpose

The purpose of this paper is to develop an alcohol withdrawal syndrome risk stratification tool that could support the safe discharge of low risk patients from the emergency department.

Design/methodology/approach

A retrospective cohort study that included all patients referred to the acute addiction liaison nursing service over one calendar month (n=400, 1–30 April 2016) was undertaken. Bivariate and multivariate modelling identified the significant variables that supported the prediction of severe alcohol withdrawal syndrome (SAWS) in the cohort population.

Findings

The Glasgow Modified Alcohol Withdrawal Scale (GMAWS), hours since last drink, fast alcohol screening test (FAST) and systolic blood pressure correctly identified 89 per cent of patients who developed SAWS and 84 per cent of patients that did not. Increasing each component by a score of one is associated with an increase in the odds of SAWS by a factor of 2.76 (95% CI 2.21, 3.45), 1.31 (95% CI 1.24, 1.37), 1.30 (95% CI 1.08, 1.57) and 1.22 (95% CI 1.10, 1.34), respectively.

Research limitations/implications

The research was conducted in a single healthcare system that had a high prevalence of alcohol dependence syndrome (ADS). Second, the developed risk stratification tool was unable to guarantee no risk and lastly, the FAST score previously aligned to severe ADS may have influenced the patients highest GMAWS score.

Practical implications

The tool could help redesign the care pathway for patients who attend the emergency department at risk of SAWS and link low risk patients with community alcohol services better equipped to deal with their physical and psychological needs short and long term supporting engagement, abstinence and prolongation of life.

Originality/value

The tool could help redesign the care pathway for emergency department patients at low risk of SAWS and link them with community alcohol services better equipped to deal with their physical and psychological needs, short and long term, supporting engagement, abstinence and prolongation of life.

Assertive Community Treatment For People With Alcohol Dependence: A Pilot Randomized Controlled Trial

Aims

A pilot randomized controlled trial (RCT) to assess the feasibility and potential efficacy of assertive community treatment (ACT) in adults with alcohol dependence.

Methods

Single blind, individually randomized, pilot RCT of 12 months of ACT plus treatment as usual (TAU) versus TAU alone in adults (age 18+ years) with alcohol dependence and a history of previous unsuccessful alcohol treatment attending specialist community alcohol treatment services. ACT aimed to actively engage participants for 12 months with assertive, regular, minimum weekly contact. ACT was combined with TAU. TAU comprised access to the full range of services provided by the community teams. Primary outcome is mean drinks per drinking day and percent days abstinent at 12 months follow up. Analysis of covariance was conducted using 80% confidence intervals, appropriate in the context of a pilot trial.

Results

A total of 94 participants were randomized, 45 in ACT and 49 in TAU. Follow-up was achieved with 98 and 88%, respectively at 12 months. Those in ACT had better treatment engagement, and were more often seen in their homes or local community than TAU participants. At 12 months the ACT group had more problems related to drinking and lower quality of life than TAU but no differences in drinking measures. The ACT group had a higher percentage of days abstinent but lower quality of life at 6 months. The ACT group had less unplanned healthcare use than TAU.

Conclusions

An trial of ACT was feasible to implement in an alcohol dependent treatment population.

Trial registration

ISRCTN22775534

Qualitative exploration of why people repeatedly attend emergency departments for alcohol-related reasons

Background

Understanding why people repeatedly attend Emergency Departments (EDs) for alcohol-related reasons is an important prerequisite to identifying ways of reducing any unnecessary demands on hospital resources. We use Andersen’s Behavioural Model of Health Services Use to explore factors that contributed to repeat ED attendances.

Methods

Qualitative interviews were conducted with 30 people who repeatedly attended EDs for alcohol-related reasons (≥10 attendances in the past 12 months). We recruited participants from 6 EDs in London, United Kingdom. Data on socio-demographic characteristics, substance use, contact with specialist addiction and other health services, most recent ED attendance, and previous ED attendances were analysed.

Results

Participants reported long-standing health problems, almost all were unemployed, and many had limited education and unstable housing. Most held positive health beliefs about EDs, despite some negative experiences. They reported limited community resources: poor social support, inaccessible primary care services, dislike or lack of information about specialist addiction services, and difficulties travelling to services. In contrast, EDs offered immediate, sympathetic care and free transport by ambulance. Participants’ perceived need for care was high, with physical injury and pain being the main reasons for ED attendance.

Conclusions

Push’ and ‘pull’ factors contributed to repeated ED use. ‘Push’ factors included individual-level problems and wider community service failings. ‘Pull’ factors included positive experiences of, and beliefs about, ED care. Community services need to better engage and support people with complex drinking problems, whilst ED staff can be more effective in referring patients to community-based services.

Treatment Resistant and Resistant to Treatment? Evaluation of 40 Alcohol Dependent Patients Admitted for Involuntary Treatment

AIMS

To describe the clinical outcomes for a group of patients with severe alcohol dependence discharged from an Involuntary Drug and Alcohol Treatment (IDAT) program.

METHODS

Forty patients admitted to an inpatient IDAT program were prospectively followed up over 6 months using standardized questionnaires.

RESULTS

Patients had high rates of mental health comorbidities (97.5%), cortical atrophy (40%) and socioeconomic disadvantage (92.5% were beneficiaries). Six months after discharge, 25% of patients were abstinent and living in the community and 17.5% had notably reduced alcohol use. A further 7.5% were abstinent due to involuntary hospitalization. A total of 10% of patients were deceased and 40% of patients had relapsed or were lost to follow-up. Number of admissions and admission days reduced by 51 and 45% respectively for the 17 abstinent or improved community-based patients. A total of 82% of this patient group were actively engaged with an Assertive Community Treatment (ACT) team.

CONCLUSIONS

While patient numbers are small, treatment responsiveness was evident for 42.5% of patients, most of whom were followed up with ACT. Evaluation with a comparator group is required to determine whether outcomes are a function of involuntary treatment or an assertive treatment approach.

Navigating the Alcohol Treatment Pathway: A Qualitative Study from the Service Users' Perspective

AIMS

Provision of effective treatment for dependent drinkers has been identified as a priority in England yet evidence suggests that access is problematic and there are low levels of retention. This qualitative study explores how the alcohol treatment system is experienced by service users, identifying barriers and facilitators that influence treatment outcomes.

METHODS

A total of 20 semi-structured face-to-face interviews were conducted with patients from community alcohol treatment services in three London boroughs in 2012. Interviews were undertaken one year after initially entering treatment. A thematic analysis was conducted, with the results further abstracted to relate them to specific aspects of the treatment journey.

RESULTS

Patients journeys were characterized by a perceived lack of control leading to help-seeking, with treatment outcomes influenced by an individuals' self-efficacy and the capabilities and skills of staff in actively engaging and supporting patients on the journey. A focus of services on the detoxification process and fragmented care pathways impacted negatively on engagement.

CONCLUSIONS

Current alcohol care pathways require significant levels of motivation and self-efficacy to navigate that few patients possess. Pathways need to better reflect the capacity and capabilities of patients to be successful in supporting recovery.

Salford alcohol assertive outreach team: a new model for reducing alcohol-related admissions

OBJECTIVE

Alcohol-related admissions are increasing. A significant number of these admissions are attributable to a small number of complex patients with other comorbidities who do not engage well with mainstream services. Assertive outreach teams have been used in the field of psychiatry to engage patients who are poorly compliant. This study examines whether an alcohol assertive outreach team (AAOT) can engage with this group and reduce hospital admissions.

DESIGN

The AAOT is a multidisciplinary team with medical, psychiatric, substance misuse, psychology, nursing and social work specialists. The team worked with patients with the highest number of alcohol-related admissions and case managed in a community setting for 6 months. The admission and emergency department attendances of the cohort were compared for the 3-month period before and after the intervention. Christo inventory for substance misuse services (CISS) scores were determined pre and post the intervention period.

RESULTS

54 patients were case managed. The total number of admissions in 3 months fell from 151 prior to the intervention period to 50 following the intervention. Emergency department attendances also fell from 360 in 3 months to 146 following the intervention period. CISS scores fell from 11 preintervention to eight postintervention.

CONCLUSIONS

An AAOT model appears to reduce hospital admissions and emergency department attendances in a complex group of patients that display high alcohol-related admissions.

Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse

BACKGROUND

Managed alcohol programmes (MAP) are a harm reduction strategy used to minimise the personal harm and adverse societal effects that alcohol dependence can lead to by providing an alternative to zero-tolerance approaches that incorporate drinking goals (abstinence or moderation) that are compatible with the needs of the individual, and promoting access to services by offering low-threshold alternatives. This enables clients to gain access to services despite continued alcohol consumption and works to help the patient understand the risks involved in their behaviour and make decisions about their own treatment goals.

OBJECTIVES

To assess the effectiveness of MAP treatment regimens (serving limited quantities of alcohol daily to alcoholics) on their own or as compared to moderate drinking (self-controlled drinking), screening and brief intervention using a harm reduction approach, traditional abstinence-based interventions (12 step programmes) and no intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsycINFO up to March 2012. This search was expanded by handsearching of high-yield journals and conference proceedings that had not already been handsearched on behalf of The Cochrane Collaboration, searching reference lists of all papers and relevant reviews identified, references to ongoing and recently completed clinical trials in the National Research Register and IFPMA Clinical Trials Database (which contains ClinicalTrials.gov, Centerwatch, Current Controlled Trials and ClinicalStudyResults.gov, and Osservatorio Nazionale sulla Sperimentazione Clinica dei Medicinali). Trials registers, grey literature and reference lists were also searched. Individuals, organisations and experts in the field were contacted.

SELECTION CRITERIA

Randomised control trials (RCT), controlled clinical trials (CCT), interrupted time series (ITS) studies, and control before and after (CBA) studies involving vulnerable people aged 18 years or older who were at high risk for alcohol abuse attending MAP, defined as a structured programme that provided clients with controlled amounts of alcohol on a daily schedule, comparing no treatment, moderate drinking, brief intervention or 12-step variants.

DATA COLLECTION AND ANALYSIS

All study citations were collated into a single database. Two review author independently screened titles and abstracts and selected references potentially relevant to the review. Differences between selection lists were resolved by discussion. Two review authors independently evaluated whether studies should be included or excluded according to the eligibility criteria. In the event of a disagreement, a third author was consulted.

MAIN RESULTS

No studies were included in the review. This systematic review was intended to assess the effectiveness of a brief MAP on the reduction of incidence of harmful behaviour; however, no evidence was available to make this comparison; 22 articles were considered possibly relevant and all were excluded. Most articles were excluded because they failed to compare or consider managed alcohol as the experimental or control intervention, as well as one study (Baker 2010), which was also excluded because study participants were under 18 years of age. No study reviewed offered an intervention that was compared with managed alcohol or considered it as the intervention of interest, providing insufficient evidence to address the objectives of the review. Four studies (Aalto 2001; Baker 2010; Bertholet 2005; Tracy 2007) considered alcohol reduction as an outcome of interest, while four engaged interventions in a shelter setting or targeted vulnerable people (Baker 2010; Bradford 2005; Lapham 1993; McGlynn 1993); only one study (Kidd 2011) offered a qualitative assessment of a participant being admitted to MAP, but offered no analysis of the programme itself. These results accurately reflect the use of MAPs in current practice as existing programmes are ongoing only in a small number of sample pilot projects that target individuals with severe alcohol dependence or who consume non-beverage alcohol.

AUTHORS' CONCLUSIONS

The lack of evidence does not allow for a conclusion regarding the efficacy of MAP on their own, or as compared to brief intervention, moderate drinking, no intervention or 12-step variants. It is the review authors' opinion that it is likely to be the objective of MAPs that reduce their reportability and use in current practice, rather than a failure to provide an intervention that reduces the effects of alcohol dependence. Aiming to reduce harmful or antisocial behaviour in vulnerable individuals through the regulation of daily alcohol intake, rather than reducing harmful alcohol intake over time, provides considerable difficulty in developing measures of success from self-reported data (low treatment thresholds), monitoring long-term efficacy or establishing causal links between programme admission and a reduction in targeted behaviours, owing to the fact that prolonged participation in the programme is likely to indicate a willingness in the individual to change their behaviour patterns. More effort is needed to develop reporting measures, as well as methodologies, which address these specific challenges.

Assertive Community Treatment for alcohol dependence (ACTAD): study protocol for a randomised controlled trial

BACKGROUND

Alcohol dependence is a significant and costly problem in the UK yet only 6% of people a year receive treatment. Current service provision based on the treatment of acute episodes of illness and emphasising personal choice and motivation results in a small proportion of these patients engaging with alcohol treatment. There is a need for interventions targeted at the population of alcohol dependent patients who are hard to engage in conventional treatment. Assertive Community Treatment (ACT), a model of care based on assertive outreach, has been used for treating patients with severe mental illnesses and presents a promising avenue for engaging patients with primary alcohol dependence. So far there has been little research on this.

METHODS/DESIGN

In this single blind exploratory randomised controlled trial, a total of 90 alcohol dependent participants will be recruited from community addiction services. After completing a baseline assessment, they will be assigned to one of two conditions: (1) ACT plus care as usual, or (2) care as usual. Those allocated to the ACT plus care as usual will receive the same treatment that is routinely provided by services, plus a trained key worker who will provide ACT. ACT comprises intensive and assertive contact at least once a week, over 50% of contacts in the participant's home or local community, and comprehensive case management across social and health care, for a period of one year. All participants will be followed up at 6 months and 12 months to assess outcome post randomisation. The primary outcome measures will be alcohol consumption: mean drinks per drinking day and percentage of days abstinent measured by the Time Line Follow Back interview. Secondary outcome measures will include severity of alcohol dependence, alcohol related problems, motivation to change, social network involvement, quality of life, therapeutic relationship and service use. Other outcome variables are treatment engagement including completion of assessment, detoxification and aftercare.

DISCUSSION

Results of this trial will help clarify the potential beneficial effects of ACT for people with alcohol dependence and provide information to design a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN22775534.