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Tackling problem drinking

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Tackling problem drinking

Despite recession-driven declining income and hard-hitting public health initiatives, the UK retains a seemingly unquenchable thirst for alcohol

During 2012, 14 per cent of men and nine per cent of women in Great Britain drank frequently (on at least five days a week). On their heaviest drinking day, 29 per cent of male drinkers and 21 per cent of female drinkers consumed more than eight and six units respectively1. While these sobering statistics are an improvement on those for 2005 – when 22 per cent of men and 13 per cent of women drank frequently – there’s no room for complacency.

Alcohol increases the risk of about 40 conditions, including cirrhosis, several cancers, haemorrhagic stroke, ischaemic heart disease, drowning, fires and other accidents. Alcohol abuse costs NHS England about £3.5bn a year, while alcohol-related conditions contribute to eight per cent of hospital admissions1. Against this background, NICE recently recommended nalmefene for alcoholdependent men and women drinking more than 60g (7.5 units) and 40g (5 units) a day respectively.

Almost 600,000 people in the UK, more than the population of Glasgow, could be eligible for nalmefene2.Recent evidence also suggests that community pharmacists can deliver Identification and Brief Advice (IBA) – but will either make a real difference?

Nalmefene

Nalmefene is the first drug for alcohol abuse licensed for people who are not abstinent. Ideally, patients take nalmefene – an antagonist at mu and delta opioid receptors, and a partial agonist of kappa receptors – one to two hours before they anticipate a risk of drinking. According to Lundbeck’s ESENSE studies, nalmefene seems to reduce the urge to drink. The studies enrolled adults reporting at least six heavy drinking days (HDD) and an average alcohol consumption of at least 40g (5 units) daily for men and 20g (2.5 units) a day for women during the previous four weeks. Patients took placebo or nalmefene 18mg daily as needed for 24 weeks. Both groups received psychosocial support2,3.

Almost 600,000 people in the UK, more than the population of Glasgow, could be eligible for nalmefene

ESENSE 1 enrolled 604 adults. Patients receiving nalmefene had, on average, 2.3 fewer HDDs a month compared to placebo and their alcohol consumption declined by 11.0g a day during the last month3. In ESENSE 2, which treated 718 adults, patients receiving nalmefene had, on average, 1.7 fewer HDDs a month. The 5.0g per day reduction in alcohol consumption during the last month was not statistically significant4. Researchers also examined specifically the 667 heavy drinkers – men and women who drank more than 60g and 40g a day respectively. Heavy drinkers receiving nalmefene had, on average, 3.2 fewer HDDs a month. Alcohol consumption declined by 14.3g (1.8 units) daily5.

However, the Drugs and Therapeutics Bulletin remarks that “the clinical significance of such reductions” and the impact on physical and mental disorders, social factors and other patient-oriented outcomes await further investigation. The DTB added that the exclusion criteria (including altered liver function tests and concomitant psychological illness) and “the large proportion of participants who reduced their drinking between screening and randomisation” – 18 and 33 per cent in ESENSE 1 and 2 respectively – makes generalising the results difficult6.

 

Key Facts

• Alcohol abuse costs NHS England about £3.5bn a year

• According to the ESENSE studies, nalmefene seems to reduce the urge to drink

• The Department of Health is committed to involving community pharmacists in IBA

 

IBA in the pharmacy

ESENSE also offers circumstantial support for psychological support and IBA. For instance, in the analysis of heavy drinkers, average daily consumption in the placebo arm – i.e. those who received psychological support – declined from 12.9 to 6.4 units. Moreover, the large number of people who reduced drinking between screening and randomisation supports suggestions that simple interventions can reduce alcohol consumption.

Overall, one in every eight people who receive an alcohol brief intervention reduces their consumption to safer levels7. IBA also offers the opportunity to reach people who do not access primary care or hospital services (see box). A recent report8 from Middlesex University, funded by Alcohol Research UK, remarked that community pharmacists “are well placed” to deliver IBA to the public.

Furthermore, “given the right environment, many customers are willing to accept” IBA from pharmacists. In other words, delivering IBA in pharmacies seems logical. IBA fits within the profession’s commitment to improving public health7 and the Department of Health is committed to involving community pharmacists in IBA8. Unfortunately, relatively few studies examine whether IBA delivered in pharmacy reduces hazardous alcohol use so pharmacists, public health officials and policy-makers all await the results of an on-going clinical study with interest. This study will compare IBA delivered by community pharmacists (a 10-minute motivational discussion) to control patients who received an alcohol information leaflet without further discussion9.

Similar problems

Pharmacists face similar problems to other healthcare professionals delivering IBA, such as role legitimacy, adequacy and support but also face specific issues, such as concerns over privacy6. “While many people will prefer a private consultation, the first part of IBA – the threequestion AUDIT-C – can easily be done as part of a survey in-store, using a scratch card at the counter etc.,” says Liz Stafford, external relations & policy development manager, at Rowlands Pharmacy, and an expert on delivering alcohol services in pharmacies. “Community pharmacists are, on the whole, well experienced at knowing when, how and where to engage with people.”

In addition, pharmacists can link IBA to public health campaigns and other services, such as weight management, she says. During a recent study from West Yorkshire, pharmacy staff used a scratch card containing the AUDIT-C questions to engage with and identify individuals with potentially increasing or harmful drinking. Men access health services less frequently than women yet men completed 54 per cent of the 1,420 scratch cards. Of those who completed a scratch card, 62.0 per cent of men and 57.5 per cent of women received alcohol brief advice, while 4.0 per cent of men and 2.7 per cent of women were referred to specialist services.

Fragmented

Currently, IBA and other alcohol services are fragmented and best practice often isn’t shared effectively and efficiently. “We need to continually collate evidence where services are being delivered to work with commissioners to determine the most cost-effective way to deliver IBAs on a large scale,” Liz Stafford told Pharmacy Magazine. “In the meantime, pharmacists should talk to local authorities, alcohol commissioners, public health professionals and local pharmaceutical committees about delivering IBA in their community.” Alcohol has been a part of human culture for at least 9,000 years – longer than the wheel.

Alcohol is so embedded in the UK’s culture that there’s no simple, single answer to abuse but IBA delivered by community pharmacists certainly seems to be part of the solution. “Providing alcohol IBA services in pharmacies is feasible, reaches relevant sections of the population, and is regarded by stakeholders and service users as desirable,” Liz Stafford concludes. “Indeed, pharmacists can make a unique contribution by normalising conversations about alcohol in everyday health settings and tackling risky use of alcohol in the general population.”

 

A Missed Opportunity

During 2011-12, one person every 20 minutes – 27,899 people – referred themselves to alcohol services – 38 per cent of the total number of people entering services. In contrast, referrals from GP surgeries and A&E accounted for 19 and one per cent of the intake respectively. However, about one in five people seeing a GP drinks more than “lower-risk levels” and about 35 per cent of A&E attendances are alcohol-related10.

 

References

1. ons.gov.uk/ons/dcp171778_338863.pdf

2. nice.org.uk/news/press-and-media/nice-recommends-nalmefene-to-reduce-alcohol-dependence

3. Biol Psychiatry 2013;73:706-13

4. Eur Neuropsychopharmacol 2013;23:1432-42

5. Alcohol and Alcoholism 2013; 48: 570–578

6. dtb.bmj.com/content/52/5/54.long

7. wales.nhs.uk/sitesplus/888/page/71715

8. tinyurl.com/kgoq24u

9. BMC Public Health 2013;13:152

10. www.nta.nhs.uk/uploads/alcoholcommentary2013final.pdf

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