26.6 Changing unhealthy behaviours 6524 26.6.1 Bri

26.6 Changing unhealthy behaviours 6524 26.6.1 Brief interventions for excessive alcohol consumption 6524 Amy O’Donnell, Eileen Kaner, and Nick Heather

CONTENTS 26.6.1 Brief interventions for excessive alcohol
consumption   6524 Amy O’Donnell, Eileen Kaner, and Nick Heather 26.6.2 Obesity and weight management   6529 Susan Jebb and Paul Aveyard 26.6.3 Smoking cessation   6533 Paul Aveyard 26.6.1  Brief interventions for
excessive alcohol consumption Amy O’Donnell, Eileen Kaner, and Nick Heather ESSENTIALS The treatment and prevention of alcohol-​related harm requires that attention is paid not only to alcohol dependence, but also to haz- ardous and harmful drinking. The prevalence of these problems is high, amounting to about one in four of the adult population of the United Kingdom. The usual goal of intervention is to reduce drinking to low-​risk levels, although it may also be abstinence. Screening pa- tients for alcohol problems and providing brief interventions to those identified are potentially effective ways of improving patients’ health and reducing their risk of future harm. The intervention of simple, structured advice can be delivered without extensive training in 3 to 5 minutes. More intensive brief behavioural counselling requires training and takes 20 to 30 minutes, often with follow-​up visits. Introduction Alcohol is a significant risk to public health. Globally it is the fifth leading cause of morbidity and premature death after high blood pressure, tobacco smoking, household air pollution from solid fuels, and a diet low in fruits. Excessive alcohol consumption is causally related to over 60 dif- ferent medical conditions, including liver cirrhosis, cancer, and cardiovascular disease. There are additional wider social and eco- nomic consequences which extend beyond the individual drinker to their families, local communities, and society as a whole. Alcohol-​related harm is associated with fewer years in formal education and, ultimately, educational underachievement. In the workplace, excessive alcohol consumption increases the risk of unemployment and can lead to disciplinary problems and low productivity. Heavy alcohol consumption is also associated with family dis- ruption, child abuse, and neglect, with homicide, crime, and drink-​driving fatalities, and is a contributory factor for risky sexual behaviour, sexually transmitted diseases, and HIV infection. When those at risk of harm are added to those who have al- ready incurred it, the number of individuals whose lives may be adversely affected in some way by their drinking approaches one in four of the adult population. This is comparable to the number whose health is directly affected by smoking. It is important to note that most alcohol-​related problems that occur in a popula- tion are not due to the most problematic drinkers but to a much larger group of hazardous and harmful drinkers:  this is known as the prevention paradox. A prior focus on the concept of alco- holism has distracted attention from full range of alcohol-​related problems. Consequently, the scope of treatment and preventive ef- forts should be broadened to reach all those at risk. Brief interven- tions in medical practice have a crucial role to play in this strategy (Fig. 26.6.1.1). The problem Excessive drinking Excessive drinking can be defined as drinking beyond the limits re- commended by medical authorities. These are based on the level of consumption identified by epidemiological evidence as the point where the risk of harm begins to increase. In this respect, there is a recognized continuum of both alcohol consumption and harm, meaning that abstinence represents the most effective approach to minimizing risk. If adults choose to continue to drink, less is better, and limiting consumption to no more than 20 g of alcohol per day will keep the lifetime risk of dying from an alcohol-​related condition to less than one in a hundred. Currently in the United Kingdom, government guidance is that adult men and women should not regularly drink more than 14 26.6 Changing unhealthy behaviours

26.6.1  Brief interventions for excessive alcohol consumption 6525 units of alcohol a week on a regular basis (where one unit = 8 g (10 ml) of pure alcohol), should spread their drinking evenly over three or more days, and should have several drink-​free days each week. However, there is a need for clearer, evidence-​based guidelines for specific population groups, such as younger and older people, and pregnant women. Hazardous and harmful drinking The International Statistical Classification of Diseases and Health-​ related Problems, tenth revision (ICD-​10), defines harmful use of a psychoactive substance as a pattern of use which is already causing damage to physical or mental health. Hazardous use is defined in the World Health Organization’s lexicon of alcohol and drug terms as a pattern of substance use that increases the risk of harmful consequences for the user. Thus, hazardous drinking can be defined as consumption at a level, or in such a pattern, that increases an individual’s risk of physical or psychological conse- quence, while harmful drinking is defined by the presence of these consequences. Single occasion heavy (‘binge’) drinking There is a substantially increased risk of short-​term harms (acci- dents, injuries, and even deaths) faced by people who drink high levels of alcohol within a single day. The risks of injury have been found to rise between 2–​5 times when 5–​7 units are drunk in a 3–​ 6 hour period. Such high intensity drinking is sometimes called ‘binge drinking’, and binge drinkers may or may not drink on a regular basis. The opportunity Physicians see many people whose presentation is a consequence of drinking or whose future health is at risk from drinking. Patients with alcohol problems consult general practitioners nearly twice as often as others. The most common presentations are gastrointestinal, hypertensive, psychiatric, and following ac- cidents. However, it is likely that less than half of these primary care patients will have their alcohol problem identified. In general medical and surgical hospital wards, as many as 30% of all male admissions and 15% of female admissions are excessive drinkers. Again, few of these patients will be identified as hazardous or harmful drinkers. Among emergency department attenders, 40% are excessive drinkers. Alcohol attributable hospital admissions in the United Kingdom were over 1.22 million in 2011/​12, a 139% increase since 2002/​03. Intensive specialist treatment (e.g. detoxification in hospital, combined with residential rehabilitation) Treatments and interventions (examples) Level of alcohol problem Severely dependent Harmful Hazardous Not yet developed Moderately dependent THE RANGE OF ALCOHOL TREATMENTS AND INTERVENTIONS Public health education programmes NOTES Not yet developed: people who currently have no level of alcohol misuse. Hazardous: drinking applies to anyone drinking over the limits recommended by the UK Department of Health. Harmful: showing clear evidence of alcohol-related problems. Moderately dependent: Likely to have increased tolerance of alcohol, suffer withdrawal symptoms, and have lost some degree of control over their drinking. Severely dependent: may have withdrawal fits (delirium tremens: e.g. confusion or hallucinations usually starting between two or three days after the last drink); may drink to escape from or avoid these symptoms. Individual drinkers may move between categories of alcohol problem over time and the boundaries between categories are not clear-cut. Likewise, the treatments are indicative and may, in some circumstances, be appropriate for the other categories of alcohol problem. Source: Adapted from Broadening the Base of Treatment for Alcohol Problems, Institute of Medicine, 1990 Short (5–10 minutes) medical advice (’brief advice’) in mainstream health or other, nonhealth settings (e.g. by a GP) An extended period of medical advice (’extended brief advice’) in mainstream health or other settings Specialist treatment in generalist or specialist settings (e.g. detoxification at home, with counselling) Fig. 26.6.1.1  The range of alcohol treatments and interventions. National Audit Office. Reducing Alcohol Harm: health services in England for alcohol misuse. London: National Audit Office, 2008.

SECTION 26  Psychiatric and drug-related disorders 6526 Brief interventions aim to detect alcohol problems at an early stage when they are most amenable to adjustment, and to pro- mote positive behaviour change, thus avoiding the development of more serious future problems. Brief intervention assumes that drinking behaviour results from an interaction between an indi- vidual, their behaviour, and the social and physical environment. Thus, drinking behaviour is influenced not only by an individual’s attitudes towards alcohol, their knowledge about its risks, and their perceptions of its reinforcing effects, but also by the attitudes of family members and friends towards drinking, and the patterns of use within their social group. Brief interventions are ‘oppor- tunistic’ because they take advantage of medical consultations whether related to alcohol problems or not. They are normally re- stricted to excessive drinkers with little or no evidence of alcohol dependence. Those more seriously impaired are usually referred to specialist services. Identifying hazardous and harmful drinkers Screening is the process used to identify patients whose alcohol con- sumption places them at increased risk of physical or psychological complications, and who might benefit from a brief preventive inter- vention. Laboratory tests are one way of screening. Tests that may be abnormal include the mean corpuscular volume (MCV), γ-​glutamyl transferase (GGT), carbohydrate-​deficient transferrin (CDT), and the ratio of alanine aminotransferase (ALT) to asparatate aminotransferase (AST). However, standardized questionnaires have better sensitivity and specificity than laboratory indicators, particularly in terms of their ability to successfully identify exces- sive yet non​dependent drinkers. In addition, questionnaire-​based screening is less costly than laboratory analysis, is far less intrusive, and is more acceptable to patients. The alcohol use disorders identification test (AUDIT) was the first standardized instrument designed specifically by the World Health Organization to detect hazardous and harmful drinking in primary healthcare. AUDIT is a 10-​item questionnaire that includes items on drinking frequency, quantity, and intensity (heavy drinking episodes), together with experience of alcohol-​related problems and dependence (Fig. 26.6.1.2). At an indicative score of 8+ out of a possible 40, the ability of AUDIT to detect genuine excessive drinkers (sensitivity) and to exclude false cases (specificity) is 92% and 93%, respectively. Although relatively brief with only 10 items, the full AUDIT might be considered too lengthy for use in routine practice, especially if screening is carried out during the consultation. For this reason, shorter versions of the AUDIT have been developed, including the following: • AUDIT-​C—​the first three (consumption) items of the AUDIT. A score of 5+ indicates hazardous or harmful drinking. • Fast alcohol screening test (FAST)—​a two-​stage screening pro- cedure based on four of the AUDIT items. Item 3 is asked first and classifies over half of respondents as either non​hazardous (Never) or hazardous (Weekly/​Daily or almost daily). Only those not classified at the first stage (those responding Less than monthly/​Monthly) go on to the second stage which consists of AUDIT items 5, 8, and 10 (see Fig. 26.6.1.2). A response other than ‘never’ to any of these three items classifies the respondent as a hazardous drinker. • Single alcohol screening questionnaire (SASQ): ‘When was the last time you had more than ‘x’ drinks in one day?’ (where x = five for men and four for women (United States values), eight for men, and six for women (UK values)). Possible responses are: never; over 12 months; 3–​12 months; within 3 months. The last response suggests hazardous or harmful drinking. These shorter scales are quicker to administer but less accurate. They are therefore recommended as a pre-​screening procedure to quickly filter out negative cases, leaving the full AUDIT questions to the smaller pool of cases to provide an accurate and differential assessment of alcohol-​related risk or harm. There is debate about whether all patients attending medical clinics should be screened or only predefined groups. The latter might include new patient registrations in general practice, special types of clinic or ward where hazardous and harmful drinkers are more likely to be found, and emergency department services for presentations associated with hazardous or harmful drinking. The National Institute for Health and Clinical Excellence (NICE) re- commends that screening should be a routine part of practice but that, where universal screening is not practicable, it should focus on patients at increased risk of harm from alcohol and those with an alcohol-​related condition. Intervening to help patients reduce their intake Interventions aim to help the patient reduce consumption or abstain before seriously adverse consequences arise, and before alcohol de- pendence and problems have reached levels that make treatment difficult. Brief interventions can be effective in helping patients reduce their alcohol consumption. The evidence is particularly strong in primary care, where the ‘number needed to treat’ (NNT: the number of hazardous or harmful drinkers that need to receive a brief intervention for one to reduce drinking to low-​risk levels) is about 10. The effectiveness of brief alcohol intervention in emer- gency care, general hospital, obstetric or antenatal care, social care and educational, and/​or community settings shows less consistent benefit, but this may reflect a lack of evidence rather than lack of efficacy in these settings. It seems unlikely that an intervention that is effective in primary would not work in sec- ondary care, if delivered well. However, it is important to note that substantial reductions, even though short of reaching low-​ risk drinking, are also a valuable contribution to individual and public health. While brief interventions vary in length, content, and theor- etical orientation, two basic forms of intervention may be de- scribed:  simple brief advice (brief, structured intervention) and extended brief intervention (brief behavioural counselling). These two forms of brief intervention are included in the NICE guidance on the prevention of harmful and hazardous drinking. Simple brief advice This consists of simple advice to cut down or abstain from drinking. The advice is personalized to take into account the particular

26.6.1  Brief interventions for excessive alcohol consumption 6527 circumstances of the individual patient and their level of consump- tion in relation to population norms for their sex, and to appeal to any specific alcohol-​related difficulties they may recognize as applying to them. These may include social and psychological dif- ficulties as well as medical problems. The delivery of simple brief interventions should, as far as possible, follow the principles de- scribed by the acronym FRAMES: • structured and personalized feedback on risk and harm • emphasis on the patient’s personal responsibility for change AUDIT Scoring system Your score 0 1 2 3 4 How often do you have a drink containing alcohol? Never Monthly or less 2–4 times per month 2–3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1–2 3–4 5–6 7–9 10+ 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 ? Never Less than monthly Monthly Weekly Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily How often during the last year have you found that you were not able to stop drinking once you had started? Never Monthly Weekly How often during the last year have you failed to do what was normally expected from you because of your drinking? Never Monthly Weekly How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never Monthly Weekly How often during the last year have you had a feeling of guilt or remorse after drinking? Never Monthly Weekly How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Monthly Weekly Have you or somebody else been injured as a result of your drinking? No Yes, but not in the last year Yes, but not in the last year Yes, during the last year Yes, during the last year Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Scoring: 0–7 Lower risk, 8–15 Increasing risk, 16–19 Higher risk, 20+ Possible dependence SCORE This is one unit of alcohol… Half pint of regular beer, lager, or cider 1 small glass of wine Pint of regular beer/lager/ cider 2 3 1.5 440 ml 440 ml 4 2 2 9 Pint of premium beer/lager/ cider Alcopop or can/bottle of regular lager Can or premium lager or strong beer Can of super strength lager Glass of wine (1.75 ml) Bottle of wine 1 small glass of sherry 1 single measure of aperitifs 1 single measure of spirits …and each of these is more than one unit Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Fig. 26.6.1.2  The AUDIT screening questionnaire. Scoring: 0—​7 Lower risk, 8—​15 Hazardous, 16—​19 Harmful, 20+ Possible dependence. From Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-​II. Addiction 88: 791−804.

SECTION 26  Psychiatric and drug-related disorders 6528 • clear advice to the patient to make a change in drinking • a menu of alternative strategies for making a change in behaviour • delivered in an empathic and non​judgemental fashion • increase the patient’s confidence in being able to change; self-​efficacy Advice can be supported by self-​help material and a follow-​up ap- pointment to check on progress. Repeat GGT readings or other laboratory markers of alcohol consumption can be a powerful mo- tivator. All this can be accomplished in a 5–​10 minute consultation. Specially developed brief intervention packages are available. One such package is the SIPS (Alcohol Screening and Brief Intervention Pilots) Brief Advice Tool, available online (https://​www.sips.iop.kcl. ac.uk). Only one or two sessions of didactic and experiential training are needed. Simple brief advice should be offered to patients who score be- tween 8 and 15 on the full AUDIT and those whom the practitioner suspects on other grounds of drinking in a hazardous fashion. It should also be offered as a minimum to patients who are thought to need more intensive intervention but who decline it. Ideally, the delivery of this brief advice should be immediately after a patient has been screened, otherwise an appointment should be offered as soon as possible thereafter. Extended brief intervention An extended brief intervention typically takes 20–​30 minutes to deliver and can involve up to four additional sessions. It is often a condensed form of ‘motivational interviewing’ which aims to elicit, rather than impose, an increase in motivation to change behaviour. The level of training required to carry out this form of brief interven- tion effectively is substantially greater than that for simple advice, and should involve an emphasis on experiential learning. Again, further information, guidance, and training materials are avail- able from the SIPS website (SIPS Brief Lifestyle Counselling Tool). Clinical guidelines on brief interventions and training materials are also available from the Primary Healthcare European Project on Alcohol (http://​www.phepa.net). Extended brief intervention should ideally be offered to individ- uals who are showing symptoms of physical or psychological harm due to their drinking (indicative AUDIT range 16–​19). It may also be suitable for hazardous drinkers who are ambivalent about their drinking and wish to discuss it with a healthcare professional, or for those who have not responded to simple advice and want further assistance in reducing drinking to lower risk levels. Extended brief intervention is suitable for use by practitioners (medical, nursing, or others) with a special interest in alcohol-​related problems. Electronic brief interventions Electronic screening and brief interventions, delivered via com- puter, the internet, and mobile phones, are another way of dealing with excessive drinking. Electronic interventions include some of the same features as face-​to-​face interventions (e.g. personalized feedback, engaging the participant in creating coping strategies, and goal-​based plans) to motivate the participant to reduce their alcohol consumption over time. For some people the security, flexibility and anonymity of this approach is more acceptable than traditional (face-​to-​face) methods. For practitioners, they provide a means of avoiding the need to engage their patients in a discussion about alcohol and offer an acceptable and cost-​effective alternative. Evidence on electronic brief interventions is encouraging, sug- gesting they can reduce weekly drinking by around three standard (UK) drinks per week. However given these effects are generally short term, electronic interventions may be most appropriate when used either as an adjunct to face-to-face advice delivered by practi- tioners, or for those who are unlikely to visit their doctor or nurse. Patients with possible dependence Patients who score 20 or above on the full AUDIT should be re- ferred to a specialist services for assessment of an alcohol depend- ence syndrome. Some recent research has reported promising findings on the effectiveness of extended brief interventions among patients with alcohol dependence identified in emergency depart- ments and general hospital wards who would otherwise be unlikely to receive any kind of help. There is a clear need to better integrate programmes to reduce excessive and dependent drinking into gen- eral medical care. Prognosis For lifestyle interventions, this is best thought of as the likely length of any intervention effect. Meta-​analysis conducted as part of the 2018 Cochrane review of alcohol interventions in primary care found that brief intervention reduced the quantity of alcohol drunk by an average 20 g per week at one year following intervention compared to usual care. Other positive outcomes include a reduction in alcohol-​related problems, healthcare utilization, and mortality outcomes. Most trials report 12-​month outcomes, at which time effect sizes are small but consistently positive. Positive effects have also been reported up to 48 months, but there is limited information on longer-​term outcomes. More research on this is needed, including the role of booster sessions in maintaining or reinstating reductions in drinking. FURTHER READING Babor TF, et al. (2001). AUDIT: The alcohol use disorders identification test. Guidelines for use in primary care, 2nd edition. World Health Organization, Geneva. Kaner EFS, et al. (2017). Personalised digital interventions for redu- cing hazardous and harmful alcohol consumption in community- dwelling populations. Cochrane Database Syst Rev, (9), CD011479. Kaner EFS, et al. (2018). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev, (2), CD004148. National Institute for Health and Clinical Excellence (NICE) (2010). Alcohol use disorders:  preventing the development of hazardous and harmful drinking. NICE Public Health Guidance [PH24]. NICE, London. http://​www.nice.org.uk/​guidance/​PH24 O’Donnell A, et al. (2014). The impact of brief alcohol interventions in primary healthcare: A systematic review of reviews. Alcohol Alcohol, 49, 66–​78. Rollnick S, Miller W, Butler C (2008). Motivational interviewing in health care: Helping patients change. Guilford Press, New York.