Alcohol Misuse in Wales

Alcohol M

isuse in Wales

�

Contents

Page

Foreword 3

Summary 4

1 Overview 7�.� Context 7�.2 Definitions 8 �.2.� Alcoholmisuse 8 �.2.2 Hazardousdrinkers 8 �.2.3 Harmfuldrinkers 8 �.2.4 Dependentdrinkers 8�.3 The“SteppedCare”approachtotreatment 9

2 Treatingalcoholmisuseinprimarycareandother �� non-specialistsettings2.� Primarycare �� 2.�.� Identificationofdiseaserelatedtoalcoholmisuse �� 2.�.2 Provisionofmedicaladvicewherethelevelofalcohol �� consumptioniscausingorhasthepotentialtocause futureillhealth,socialand/orworkrelatedproblems eg“briefinterventions” 2.�.3 Referraltostatutoryandvoluntarysectorspecialist �2 services 2.�.4 Sharedcarearrangementswithspecialistservicesin �3 linewithacceptedbestpractice 2.�.5 Sharedcarearrangementswithspecialistalcohol �3 servicesinlinewithacceptedbestpractice2.2 AlcoholtreatmentinAccidentandEmergencysettings(AandE) �4 2.2.� IdentificationofalcoholmisuseinAandE �4 2.2.2 BriefinterventionsinAandE �42.3 Alcoholtreatmentsinothernon-specialistsettingsandselfhelp �4 2.3.� Non-NHSsettings �4 2.3.2 Hospital-basedsettings �5 2.3.3 Pharmacy �5 2.3.4 Selfhelp �5

2

3 Specialistalcoholservices �73.� Communitybasedapproach �73.2 Inter-agencyspecialistserviceworking �73.3 Clientgroupforspecialistservices �73.4 Theroleofspecialistalcoholservices �7 3.4.� Userengagement �8 3.4.2 Assessment �8 3.4.3 Careplanning �9 3.4.4 Interventions �9 3.4.5 PsychosocialTherapiesandSupport 20 3.4.6 PharmacologicalInterventions 20 3.4.7 Structureddaycareprogrammes 2� 3.4.8 SpecialistInpatientCareandResidentialRehabilitation 2�3.5 Specialistservicesupporttootherorganisations 2� 3.5.� Primarycareandnon-specialistsettings 2� 3.5.2 Alcoholliaisonserviceinhospital-basedsettings 2� 3.5.3 Peoplewithalcoholproblemswhoalsohavesignificant 22 mentalhealthordrugproblems 3.5.4 Criminaljusticeservices 22 3.5.5 Peoplewithhighlyspecialisedneeds 22 3.5.6 Commercialandnonpublicsectororganisations 22

4 Sourcesandreferences 23

3

Foreword

ThisframeworkreporthasbeenproducedbytheWelshAssemblyGovernmenttosupplementpreviousSubstanceMisuseTreatmentFrameworksalreadyissuedtostakeholdersinWales.

TheWelshAssemblyGovernmentsubstancemisusestrategyincludesalcoholandpreviousframeworkshaveaddressedthisalongwithdrugmisuse.

However,feedbackfromfocusgroupssuggestedthatitmightbehelpfultoproduceanalcoholspecificframeworktoofferspecificdirectioninthisareatoprovidersandcommissioners,andinparticularCommunitySafetyPartnershipsandHealthandSocialCareandWellBeingstrategygroups.

Thisframeworkaimstoassistthedevelopmentofservicestoadultsbyprovidingasummaryofguidanceongoodpracticeinthecontextofcurrentevidenceandprofessionalopinion.

Theimpactofalcoholmisuseuponindividuallives,communities,workplacesandpublicsectorserviceshasbeenwelldocumentedandisamajorpublichealthissue.ThecoststotheNHSinparticularhavebeenagrowingconcern.

Thereporthadbeenproducedbyasub-groupoftheWelshAssemblyGovernmentSubstanceMisuseProjectBoard.

ItisbaseduponreviewsundertakenbytheNationalPublicHealthServiceinWaleswhichareavailableontheNPHSwebsite.

Theequallyimportantissueoftheprimary preventionofalcoholmisuseandalcohol harm reductionwillbethesubjectoffurtherdiscussion.

TheframeworkneedstobereadinconjunctionwithpreviousmodulesproducedbyWelshAssemblyGovernmentforsubstancemisuse.

4

5

Summary

1. Investmentinevidencebasedalcoholtreatmentislikelytobecosteffective.

2. EveryAccidentandEmergencysettinginWalesprovidesanopportunityfortargetedscreeningandtheprovisionofbriefinterventionsviaanumberofevaluatedschemes.

3. ThereisconsiderablepotentialforprimarycaretomakeamajorcontributiontothedeliveryofinterventionsforalcoholrelatedproblemsinWalesthroughtheidentificationofpotentialandactualalcoholmisuse,provisionofbriefinterventionsandsharedcare.

4. NHSdistrictgeneralhospitalscanmakeacontributionbytheimplementationofpoliciesbothtoidentifyandmanagealcohol-relatedproblems,andtohelpreducealcohol-relatedfutureadmissions.

5. Specialistalcoholserviceprovidershaveacrucialroleincreatingacultureofengagementwithpotentialclients,providingarangeofevidencebasedinterventions,adoptingthegoodpracticeguidancedetailedinthisframeworkandbytheprovisionoftrainingtonon-specialistservices.

6. Ajointlyagreedreferralsystemfromprimarycaretolocalvoluntaryandstatutoryspecialistalcoholservicesrepresentsbestpractice.

7. Communitybasedinterventionsarethepreferredapproachbutsomeuserswillrequireinpatientandresidentialprogrammes.

8. ThedevelopmentofallWalesalcoholgoodpracticeguidanceforagenciessuchasthePolice,ProbationandSocialServicedepartmentshasthepotentialtosupportotherapproachesinthetreatmentofalcoholrelatedproblems.

6

7

1 Overview

1.1 ContextWithinWalesasintherestoftheUKdrinkingtakesplacewithinasocialcontext,whichhasapowerfulinfluenceontheamountandthepatternofdrinkinginthecommunity.

TherehasbeenasteadyincreaseintheamountofalcoholconsumedintheUKoverthepasttwodecadeswithWalesnowhavingamongstthehighestlevelsofalcoholconsumptioninEuropeinyoungpeople.

Themajorityofpeopleincludingdependentdrinkers,moveintoandoutofdifferentpatternsofdrinkingwithoutrecoursetoprofessionaltreatment.Unassistedornaturalrecoveryisoftenmediatedthroughself-help,familyandfriends,andmutualaidgroups.

Treatmenteffectivenessmaybeasmuchabouthowtreatmentisdeliveredasitisaboutwhatisdelivered.

Theevidencebasefortheeffectivenessofalcoholproblemsinterventionsisstrong.Thesecanachievereductionsinalcoholrelatedharmandmeasurableimprovementsinhealthandsocialfunctioning.

Interventionsofallkindsareonlyeffectivehoweverifdeliveredinaccordancewiththeircurrentdescriptionsofbestpracticeandcarriedoutbycompetentpractitioners.DANOSstandardsdescribethestandardsthatareapplicabletothisguidance.

Treatmentforalcoholproblemsiscost-effective.AlcoholmisusehasahighimpactonhealthandsocialcaresystemsinWales,wheremajorsavingscanbemade,drinkingalsoplacescostsonthecriminaljusticesystem,especiallywithregardtopublicorder.Overall,forevery£�.00spentontreatmentitisestimated£5.00issavedelsewhere.

ItisalsoimportanttopointoutthatpractionersareobligedtoinformclientsthattheDVLA(DriverandVehicleLicensingAgency)considersdependenceormisuseofalcohol,illicitdrugsorchemicalsubstances,whichmayincludeprescribedmedication)asanotifiablemedicalcondition.Itisthedutyofthelicence holdertonotifytheDVLAofanysuchnotifiablecondition(astheconditionmayimpairdriving).

(Detailed guidance on alcohol treatment provided by the National Treatment Agency in England in its “Models of Care for Alcohol Treatment - MoCAM, 2006 which is recommended reading.)

8

1.2 Definitions1.2.1 AlcoholMisuse

Inthisdocumentalcoholmisuseisgenerallyreferredtoasdrinkingabovethegovernmentdefinedsafelevelswhichare:

Formen-nomorethan3to4unitsofalcoholperdayandnomorethan2�unitsaweek.

ForWomen-nomorethan2to3unitsperdayandnomorethat�4unitsaweek.

1.2.2 Hazardousdrinkers

TheWorldHealthOrganisation(WHO)defineshazardoususeofapsychoactivesubstance,suchasalcohol,as‘apatternofsubstanceusethatincreasestheriskofharmfulconsequencesfortheuser…..incontrasttoharmfuluse,hazardoususereferstopatternsofusethatareofpublichealthsignificancedespitetheabsenceofanycurrentdisorderintheindividualuser.’

Hazardousdrinkersaredrinkingatlevelsoverthesensibledrinkinglimits,eitherintermsofregularexcessiveconsumptionorlessfrequentsessionsofheavydrinking.However,theyhavesofaravoidedsignificantalcohol-relatedproblems.Despitethis,hazardousdrinkers,ifidentified,maybenefitfrombriefadviceabouttheiralcoholuse.Binge drinkingisapatternofhazardousdrinkingdefinedasconsumingmorethan8unitsofalcoholatanyonesessionformen,and6unitsforwomen.

1.2.3 Harmfuldrinkers

TheWHOInternationalClassificationofDiseases(ICD-�0)definesharmfuluseofapsychoactivesubstance,suchasalcohol,as‘apatternofusewhichisalreadycausingdamagetohealth.Thedamagemaybephysicalormental.’Thisdefinitiondoesnotincludethosewithalcoholdependence.

Harmfuldrinkersareusuallydrinkingatlevelsabovethoserecommendedforsensibledrinking,typicallyathigherlevelsthanmosthazardousdrinkers.Unlikehazardousdrinkers,harmfuldrinkersshowclearevidenceofsomealcohol-relatedharm.Manyharmfuldrinkersmaynothaveunderstoodthelinkbetweentheirdrinkingandtherangeofproblemstheymaybeexperiencing.

1.2.4 Dependentdrinkers

Dependenceischaracterisedbybehaviourpreviouslydescribedaspsychologicaldependencewithanincreaseddrivetousealcoholanddifficultycontrollingitsuse,despitenegativeconsequences.Moreseveredependenceisusuallyassociatedwithphysicalwithdrawaluponcessation,butthisisnotessentialtothediagnosisoflessseverecases.

9

1.3 The“SteppedCare”approachtotreatment1.3.1 Serviceusersmayhaveanumberofexpectationsfromalcoholtreatmentincludingareductioninalcoholconsumptiontowithinsensiblelimitsorabstinence.Itisimportantthattherangeofservicesavailablereflectstheseexpectations.

1.3.2 Inthiscontextthisframeworksupportsthe“steppedmodelofcare”recommendedbytheNTAinEnglandwhichhastwobroadcomponents:

Provisionofbriefinterventionsforthosedrinkingexcessivelybutnotrequiringtreatmentforalcoholdependence.

Provisionofmorespecialisttreatmentforthosewithmoderateorseveredependenceandrelatedproblems.

Thesteppedcaremodelputsemphasiseontheclient’schoicewithregardtotreatmentoutcomesandinterventionrecognisingthateffectiveengagementwithhim/heriscrucialtosuccess.Bestpracticealsowouldsuggestthatallagenciesshouldputinplacesomeformofoutcomemeasurementthatisagreedwiththeuserinthecareplanningprocess.TheTreatmentOutcomeProfileintroducedbyWelshAssemblyGovernmentin2008setsthecontextforthis.

Thefollowingguidanceonthesettingsforalcoholspecifictreatmentinterventionsimplicitlyadvocatesthissteppedapproach.

•

•

�0

��

2 Treatingalcoholmisuseinprimarycareandothernonspecialistsettings

2.1 Primarycare2.1.1 ThereisstrongevidencebaseandpotentialforprimarycaretoplayaneffectiveroleinthetreatmentofalcoholmisuseinWales.GPsandothermembersoftheprimaryhealthcareteamarelikelytobeincontactwithlargenumbersofpatientswithalcoholmisuseproblemswhopresentwithothersymptoms.

Inadditiontoprovidingresponsivegeneralmedicalservicestomisusersthekeycharacteristicsofgoodpracticearesummarisedundertheheadingsof:

Identificationofpotentialandactualalcoholmisusethroughopportunisticandwhereappropriatetargetedconsultations.

Provisionofmedicaladvicewherethelevelofalcoholconsumptioniscausingorhasthepotentialtocausefutureillhealth,socialand/orworkrelatedproblemse.g.“briefinterventions”.

Referraltostatutoryandvoluntarysectorspecialistalcoholservices.

Sharedcarearrangementswithspecialistalcoholservicesinlinewithacceptedbestpractice.

2.1.2 Identificationofdiseaserelatedtoalcoholmisuse

Earlydetectionisanessentialelementofbroadeningthebaseoftreatmenttodetectproblemdrinkersbeforetheybecomemoredifficulttotreat.Screeningassessmentisabriefprocessthataimstoestablish:

whetheranindividualhasanalcoholproblem(hazardous,harmfulordependentuse);

thepresenceofco-existentproblems(includingillicitdrugmisuse);

whetherthereisanyimmediateriskfortheserviceuser.

Initialassessmentmayincorporateorbefollowedbyabrief interventionandshouldidentifythosewhorequirereferraltoalcoholtreatmentservices(fordependency)andtheurgencyofthereferral.

Atpresenttherearenosetcriteriaforassessmentofalcoholmisuseinprimarycare.

Routinequestionsregardingalcoholconsumptionmaybeaskedaspartofchronicdiseasemonitoring,medicationreview,newpatientmedicalorantenatalcareandalloftheseformoneormorepartsofthenewGMScontract.

Goodpracticeindicatesthatotheropportunitiesforidentificationwillincludepresentationofthefollowingconditions:

hypertension;

frequentaccidents;

gastrointestinaldisorders;

•

•

•

•

•

•

•

•

•

•

�2

cognitiveimpairment;

socialandpsychologicalpresentationssuchasproblemsatworkorfinancialproblems,marriageorrelationshipproblems;

insomnia;

depressionandanxiety;

domesticviolence.

Thereareanumberofvalidatedidentificationtoolsavailable.InparticularThe Alcohol Use Disorders Identification Test(AUDIT)hasahighlevelofsensitivityfordetectinghazardousandharmfuldrinkingamongpeoplenotseekingtreatmentforalcoholproblems.AUDITisregardedasbeingpreferabletotheMichigan Alcohol Screening Test(MAST)andCut Down, Annoy, Guilty, Eye Opener(CAGE)forthedetectionofhazardousandharmfuldrinking,althoughnotnecessarilyinthedetectionofsignificantalcoholdependence.

TheAUDITcanbeembeddedinageneralhealthquestionnairewithoutlossofefficiencyandshortenedversionscanbeusedinbusysettings.

Additionallythe“Fast Alcohol Screening Test”(FAST)offersarapidandefficientwayofscreeningforhazardousandharmfulalcoholconsumptionthatcanbeusedinavarietyofsettingsincludingprimarycare.

2.1.3 Provisionofprofessionaladvicewherethelevelofalcoholconsumptioniscausingorhasthepotentialtocausefutureillhealth,socialand/orworkrelatedproblemse.g.“briefinterventions”.

Aspartofmedicaladvicetheprovisionof“briefinterventions”maybeappropriate.Primarycareinterventionsmayrangefromverybriefencounterswheresimplebuteffectiveadvicemaybegiventoanindividual,throughtoaprogrammeofconsultations.Theycanbedeliveredbyarangeofsuitablytrainedstaffinprimarycareandshouldbetargetedatpeopledrinkingexcessivelybutnotyetexperiencingmajorproblemsfromtheirconsumption.Theyarenotdesignedfordependentdrinkers.

Briefinterventionsareaboutprovidinginformationandsupporttochangebehaviour,promotechoiceandautonomy,andpromoteselfefficacy.Theyinvolveofferingadviceonreducingconsumptioninanon-judgementalfashionandinamannerdesignedtobuildthepatientsselfconfidence.Theyshouldbepersonalisedcontaininganassessmentanddiscussionofthepatient’sconsumptionlevelandhowitrelatestogeneralpopulationconsumption.Thepractitionershould:

discussthepotentialhealthproblemsexcessivealcoholusecancauseandhelptheclientsetgoalsforloweringconsumption;

supporttheadvicebytheprovisionofself-helpmaterials;

provideamenuofalternativestrategiesforchangingbehaviour;and

whereappropriate,offerrecipientsafollowupappointment.

•

•

•

•

•

•

•

•

•

�3

Trainingandsupportshouldbecarefullyadaptedtomeettherolesandresponsibilitiesofindividualhealthcareprofessionalsandotherstaffwhomaydelivertheinterventions.Theprovisionofalcoholmisuseserviceswithinprimarycareneedstobesupportedbyarobustprogrammeofmultidisciplinaryeducationandtraining.TheprogrammeshouldprovidethefoundationforensuringbothqualityandconsistencyofserviceacrossWales.Whereappropriatethisshouldbesupplementedwithsupervisedexperienceandsupportfromspecialiststaff.AprogrammehasalreadycommencedinWales.

2.1.4 Referraltostatutoryandvoluntarysectorspecialistalcoholservices

Primarycareclearlyhasanimportantroleinreferringalcoholmisusersontootherspecialistservicesasappropriate.(Detail on specialist services is addressed later in this document.)Goodpracticeindicates:

PrimaryCareTeamsneedtohaveinformationandbeawareoftherangeofsupport/specialistservicesthatareavailable.

PrimaryCarereferraltotheNHSspecialistserviceshouldgenerallyonlyapplytopatientswithidentifiedalcoholdependency.

Inthecontextofreferralarrangementsajointlyagreedsystemwiththespecialistalcoholserviceprovidersrepresentsbestpracticeandisthepreferredoption.Thismayresultinasinglepointofentryifappropriate.

2.1.5 Sharedcarearrangementswithspecialistalcoholservicesinlinewithacceptedbestpractice

Whilstbriefinterventionsbytheprimarycareteamfocusonpatientswithharmfulorhazardousdrinking,interventionsgenerallyaimedatdependentdrinkerscanbeeffectivelydeliveredincommunitysettingsbyGPstosupportassistedwithdrawal(detoxification),promotionofabstinenceorrelapsepreventionandnutritionalsupplementation.

GPprescribingfordependentdrinkersneedstotakeplacewithclearreferencetoclinical governance arrangementsagreedwiththelocalNHSTrust(s)/LHBideallywhen:

aformalarrangementwiththespecialistalcoholservicesisinplacewithclearlyestablishedprotocols/guidelines;

additionaltraininghasbeenundertaken.

Sharedcareschemesforalcoholmisusemayneedtobepartofanover-archingschemeforthetreatmentofsubstancemisuseduetohighlevelsofpolydrugmisusewithdrugandalcoholmisuseco-occurring.

Thereareanumberofpotentialsharedcarearrangementsinplace.Itisamatteroflocalchoicewhichoneisusedbutallarrangementshavetobeinlinewithlocalclinicalgovernancearrangementsmentionedearlier.

•

•

•

•

�4

2.2 AlcoholtreatmentinAccidentandEmergencysettings(AandE)

AlargeproportionofpeopleattendingA&Edepartments(upto35%)dosoasaconsequenceofalcoholrelatedinjuries.BecauseofthisAandEdepartmentsprovidepragmaticsettingsfortheidentificationofalcoholmisusersandtheprovisionofbriefinterventions.

2.2.1 IdentificationofalcoholmisuseinAandE

WithregardstoscreeningtoolsThe Paddington Alcohol Test(PAT)hasbeendevelopedtofitinwiththedemandsofverybusyAandEdepartments.EitherthisortheFASTtoolpreviouslyreferredtoshouldbeusedinallAandEsettings.

2.2.2 BriefInterventionsinAandE

Followingscreening“briefinterventions”shouldbeavailableinAandEsettingsalongthesamelinesasindicatedforprimarycarein2.�.Thesecanbedeliveredinanumberofwaysfromarangeofevaluatedapproachesi.e:

byspecialistalcoholliaisonnurses;

bystaffspecificallytrainedwithinthetrust;

byliaisonstafffromspecialistalcoholserviceproviders.

ThechoiceofapproachtakenshouldbedecidedlocallybuttheprovisionofbriefinterventionsinAandEisakeyelementofacomprehensivelocalalcoholtreatmentservice.Theapproachshouldalsobeconsideredinthecontextof“Developing Emergency Care”,theWelshAssemblyGovernmentstrategylaunchedinFebruary2008.

2.3 Alcoholtreatmentinothernonspecialistsettingsandselfhelp

2.3.1 Non-NHSsettings

Despitetheexistenceofsomepotentiallyinnovativeapproaches,suchasaccesstospecialistnursesforindividualsarrestedshowingsignsofalcoholmisuse,theactualevidencebaseforalcoholinterventionsinsettingsoutsideofhealthcareislimited.

Howevergoodpracticewouldindicatethatallkeyagenciesshouldhave:

Alcoholawarenesstrainingappropriatetothesetting.(Thistrainingshouldbepartofcoreorganisationalinductione.g.forprobation,socialworkandpolicestaffandcouldbedeliveredbythelocalalcoholspecialistservice.)

Knowledgeofthelocalalcoholsupportservicesavailableandreferralguidelines.

Agencyspecificgoodpracticeguidanceonrespondingtoclientswhohavealcoholproblemse.g.intoxicatedoffendersincustodysuites.

•

•

•

•

•

•

�5

2.3.2 Hospital-basedsettings

IndividualswithalcoholproblemsmaybeincontactwithNHSsecondarycarehospitalservicessuchasante-natal,gastroenterology,maxillofacialsurgeryandpsychiatricservices,throughout-patient,accidentandemergencyorin-patientactivity.Thesehospitalwardsanddepartmentscanhelptoidentifyandaddresstheneedsofindividualswithalcoholproblems.

Duetothemagnitudeoftheburdenplacedbyalcoholonhospitalservices,policiesshouldbeinplaceto:

identifyandmanagealcohol-relateddisease;and

reducealcohol-relatedfutureadmissions.

Thesecouldinclude:

protocolscoveringtherecognitionofalcoholrelateddisease,liaisonwithGPs,managementofalcoholwithdrawal,useofthiamineandassessmentofneurologicalstatus;

mechanismsfortheearlyidentificationofalcoholrelateddiseaseinpregnancyandfast-trackreferralforsupport;

implementationofascreeningstrategyforearlyrecognitionofalcoholrelateddisease;

guidancefororalhealthcareworkerswhohavearoletoplayinidentifyingalcohol-relatedfacialinjuriesandarrangingappropriatesupport;

provisionofcrisismanagementservices(e.g.“sleepitoff”space,followedbyabriefinterventionoronwardreferral);

policiesfordischargeplanning,liaisonandreferraltospecialistcommunitybasedservices.

Theestablishmentofaclinicalnursespecialistforalcoholinageneralhospitalsettingisoneapproachtothedevelopmentandimplementationofthesepolicies.

2.3.3 Pharmacy

Therehavebeensomesmallscaleprojectslookingattheroleofcommunitypharmacyinthedeliveryofopportunisticbriefinterventions.AlthoughtheevidencebaseisnotyetstrongCommunitySafetyPartnershipsshouldconsiderthepotentialforacontributionfromcommunitypharmacyastheevidencebasedevelops.

2.3.4 SelfHelp

Commissionersandprovidersshouldbeawarethatselfhelpmanualsbasedoncognitivebehaviourprinciplesareaneffectiveadjuncttoformaltreatment.ThisincludessomeITbasedschemeswhichcanbehelpful.

Mutualaidorganisationscanalsobeeffectiveforcertainindividualswhoattendmeetingsregularlyandtheseshouldbeseenassignificantsupportinthetotalityofserviceprovision.

•

•

•

•

•

•

•

•

�6

�7

3 Specialistalcoholservices

3.1 CommunitybasedapproachInWalesspecialistcommunity-basedalcoholservicesareprovidedbyNHStrustteams,thevoluntarysectorandlocalauthorities.Theyshouldprovidearangeofservicesfromsimpleadvicegivingandthedeliveryofbriefinterventionstotheprovisionofcomplexcareprogrammesincludinginpatientcare.ManyalcoholtreatmentfacilitiesinWalesaresharedwiththosefordrugmisusers.

Communitysettingsappeartobepreferredforthetreatmentofthemajorityofdependentalcoholmisusers,bothbecauseindividualsneedtolearnhowtochangetheirdrinkingbehaviourintheirnormalsocialenvironmentandbecauseitiscost-effective.

3.2 Inter-agencyspecialistserviceworkingNHSspecialistalcoholservicesshouldworkeffectivelywithotherstatutoryandvoluntarysectorservicesinWales.Thestrengthsofeachcanbecombinedtoproduceeffectiveprogrammesforclients.

WhensuchpartnershipstakeplaceitisessentialthatprotocolsandguidelinesinplaceareagreedwithinlocalNHSclinical governancearrangements.

3.3 ClientgroupforspecialistservicesSpecialistalcoholagenciesinthevoluntaryandlocalauthoritysettingshouldprovidearangeofinterventionsforclientswhomaybehazardousorharmfuldrinkersaswellasforthosewithdependency.

Specialistservicesshouldalsoengagewithdrinkerswithcomplexproblemsi.e.thosewithadditionalandco-existingproblems,includingpeoplewithmentalhealthproblems,peoplewithlearningdisabilities,someolderpeople,andsomewithhousingandsocialproblems,andthosethatmaybeparticularlyvulnerable.Theseindividualsmayhavecomplexneedsthatrequiremoreintensiveorprolongedinterventions,evenatlowerlevelsofalcoholuseanddependence.

3.4 TheroleofspecialistalcoholservicesIngeneraltermsspecialistalcoholservicesshouldprovidethespecialistskillsnecessarytoworkwithindividualsreferredfromprimarycareandnon-specialistsettings.

Serviceusersmaylegitimatelywanttoachieveanumberofgoalssuchas:

areductioninalcoholconsumptiontowithinsensiblelimits;

abstinence;

achangeindrinkingpatterns.

Localserviceprovidersneedtoprovideafullrangeofservicestomeetallpotentialtreatmentgoalsconsistentwiththesteppedcaremodelreferredtoearlier.

•

•

•

�8

Animportantpartofthisserviceistheneedtohaveeffectiveprocessesinplacetoengagewithpotentialuserspriortofullassessment.Generalinformationandadvicehasthereforetobeavailableinamannertargetedatalcoholmisusers.

Thekeyrolesforspecialistservicesaresummarisedundertheheadingsof:

UserEngagement.

Assessment.

CarePlanning.

DeliveryofInterventions.

3.4.1 Userengagement

Specialistservicesneedtoaddresstheissueofengagingpotentialserviceusers.Thisshouldbediscussedandagreedataservicearealevelandreflectedintheservicephilosophyandapproach.Itiscrucialthatthisengagementandsubsequentassessmentistimelysincelongwaitsforaresponsewilloftendeterpotentialclientsfromseekinghelp.

Addressingproblematicalcoholuseischallengingandindividualsarenaturallyambivalent.Staffresponsescaneitherincreasethelikelihoodofbehaviourchangeordecreaseitdependingupontheirskills,attitudeandapproachestowardsthepotentialserviceuser.

Serviceinformation,leaflets,flyers,postersetcshouldcontainmessagesthatseektoovercomethebarrierstoengagement.Thereferralprocesslikewiseshouldbeeasy,accessibleandasproactiveaspossible.

Allstaffincontactwiththepublicandpotentialserviceusersshouldbetrainedinmotivationalapproachesandawareoftheimportantparttheycaneachplayintheprocessofengagement.

Awarenessofthefactthatpotentialserviceusersmaybeapprehensiveshouldbewidespread.Askilledworkersapproachcanreducethebarrierstosuccessfulengagementinservices.

3.4.2 Assessment

Whenusersareengagedwiththeserviceassessmentaimstodeterminetheexactnatureoftheserviceuser’salcoholandothersubstancemisuseproblems,includinghealth(mentalandphysical),socialfunctioning,offendingandlegalproblems.

Assessmentcanbeconductedbyoneormoremembersofamultidisciplinaryteam,orspecialistservicebecausedifferentcompetencesmaybenecessarytoassessdifferentareasofserviceuserneed(forexampleaprescriberforparticularprescribinginterventionsorapsychologisttoconductspecialistassessment).

Assessmentshouldbeseenasanongoingprocessratherthanasingleeventandcanbeanalcoholspecificassessmentoramorein-depth/comprehensiveexercisedependingontheindividualcircumstancesandexpectedoutcomes.

•

•

•

•

�9

Thelevelsofassessmentreflectdifferentlevelsofcomplexityandexpertiserequiredtocarryoutscreeningandassessmentateachstage.Anumberofvalidatedalcohol,misusescreeningandassessmenttoolsareavailableandanewapproachwasintroducedinWalesinApril2008i.e.WalesIn-depthIntegratedSubstanceMisuseAssessmentToolkit(WIISMAT).

Agreementoncommon‘standards’ofscreening,assessmentandrecording,isimportantindevelopinganintegratedsystemofcareinanyarea.

Assessingriskisanintegralelementinscreening,triageassessmentandcomprehensiveassessment.Itprovidesinformationthatwillinformthecareplanningprocess.Riskassessmentsshouldinclude:

risksassociatedwithalcoholuseorothersubstanceuse(suchasphysical/mentalhealthdamage,alcoholpoisoning);

riskofself-harmorsuicide;

riskofharmtoothers(includingchildprotectionandotherdomesticviolence,abusiveand/orexploitativerelationships,harmtotreatmentstaffandrisksofdrivingwhileintoxicated);

riskofharmfromothers(includingdomesticabuse);

riskofself-neglect.

Whenrisksareidentified,riskmanagementplansneedtobedevelopedandimplementedtomitigateimmediaterisk.

Ifaservicehasconcernsabouttheneedsandsafetyofchildrenofalcoholmisusers,orofvulnerableadultslocalprotocolsmustbefollowed.

3.4.3 Careplanning

Assessmentprovidesinformationthatwillcontributetothedevelopmentofacare plan,foraserviceuser.ThecareplanmayormaynotbeintegratedwiththeCareProgrammeApproachforpeopleusingspecialistalcoholtreatmentservices.

Thecareplanmustconformtolocallyagreedstandards,beagreedandsignedbyusersandneedsto:

Setthegoalsfortreatmentandmilestonesforachievement.

Indicateinterventionsplannedandbywhom.

Makeexplicitreferencetoriskmanagement.

Identifyinformationgiventootherprofessionals/agencies.

Indicatethenameofthekeyworker.

Identifydateforreview.

3.4.4 Interventions

Thecareplanwilldetailtheinterventionsthatanyserviceuserwillreceive.Themaininterventionsaredescribedbelowandgenerallyneedtobesupplementedbyadviceandsupportinrelationtohousing,employment,andfamilyrelationships.

•

•

•

•

•

•

•

•

•

•

•

20

3.4.5 PsychosocialTherapiesandSupport

Mosttreatmentforalcohol-relatedproblemsneedstoincludesomeformoftherapytosupporttheindividual’spsychologicalandsocialdevelopment.StandardsforpsychologicalinterventionsforsubstancemisusehavealreadybeenissuedbyWelshAssemblyGovernmentandcanbeaccessedat:http://new.wales.gov.uk/dsjr/publications/commmunitysafety/submisusetreatframework/frameworke?lang=en

Thefollowingaresomeoftheinterventionsthatneedtobeavailabletoserviceusersinthecontextofalcoholmisuse:

MotivationalEnhancementTherapy.

Twelve-StepFacilitationTherapy.

CopingandSocialSkillsTraining.

CommunityReinforcementApproach.

SocialBehaviourandNetworkTherapy.

BehaviouralSelf-ControlTraining.

Cognitive-BehaviouralMaritalTherapy.

Familybasedinterventions.

RelapsePrevention.

Thedifferenttherapiesarealldesignedtohelpalcoholmisuser’schangeormaintainchangedbehaviourinsomewayandthechoiceofapplicationwilldependupontheassessment.Theyoftenhelpalcoholmisusersdevelopnewskills,allowingthemtohandlehigh-riskdrinkingsituationswithoutrelapsinginthefuture.

(The therapies described can be added to as new, fully evaluated approaches become available.)

Arangeofmoreintensive,structuredpsychosocialtreatmentinterventionsmayberequiredforpeoplewithmoderateandseverealcoholdependence,forthosewithrecurrentalcoholproblems,forthosewithcomplexneedsandforthosewhomaybeparticularlyvulnerable.

3.4.6 PharmacologicalInterventions

Pharmacologicalinterventionsaremosteffectivewhenusedasenhancementstopsychologicaltherapiesaspartofanintegratedprogrammeofcare.Thefollowingshouldbeavailable:

Medicationfortreatingpatientswithwithdrawalsymptomsduringassistedalcoholwithdrawal.

Medicationtopromoteabstinenceorpreventrelapse,includinganti-cravingagentsandsensitisingagents.

Nutritionalsupplements,includingvitaminsupplements,asaharmreductionmeasureforheavydrinkersandhighdoseparenteralthiamineforthepreventionandtreatmentofindividualswithWernicke’sencephalopathy.

•

•

•

•

•

•

•

•

•

•

•

•

2�

3.4.7 Structureddaycareprogrammes

Thereisaroleforstructureddaycareprogrammesinthetreatmentofalcoholmisuseprovidedtheyarebasedonevidenceofeffectivenessandsubjecttolocalevaluation.

3.4.8 SpecialistInpatientCareandResidentialRehabilitation

Althoughmostdependentalcoholuserscanbetreatedeffectivelyincommunity/homesettingsaproportionwithseveredependencyandassociatedproblemswillrequireinpatientcareand/orresidentialrehabilitation.ThestandardsforthesehavealreadybeendescribedbyWelshAssemblyGovernmentandcanbeaccessedat:http://new.wales.gov.uk/dsjr/publications/commmunitysafety/submisusetreatframework/frameworke?lang=en

Thechoiceofsettingforanyindividualwilldependontherangeofaccompanyingphysical,psychological,orsocialproblemsincludingrisksposedtothedrinker,riskstoothersfromhis/herbehaviourandavailabilityofservices.

3.5 Specialistservicesupporttootherorganisations3.5.1 Primarycareandnon-specialistsettings

Itisacoreprincipleinthisframeworkthatspecialistalcoholservicesmustdeveloplinkswiththoseprovidingalcoholinterventionsinprimarycare.SharedcarearrangementswithGPsandotherprimarycareprofessionalsforthepurposeofaddressingalcoholproblemsprovideaframeworkfor:

Theprovisionofspecialistassessmentonassistedwithdrawal,relapsepreventionandfollow-upmonitoring.

Trainingandadvicetoprimarycarestaff.

Developmentofreferralguidance/criteriatospecialistservices.

Specialistservicesshouldalsodeveloplinksandworkingprotocolsasappropriatewithlocalorganisationsinthesocialcare/voluntarysector(e.g.homelessproviders)andtocommunitymentalhealthteams.

3.5.2 Alcoholliaisonserviceinhospital-basedsettings

Thosewithcomplexalcoholproblemsmayrequirehospitalisationfortheirotherneedse.g.liverdisease.Thismaybebestprovidedforthosehospitalservices,withspecialisedalcohol liaisonsupport.

Analcohol liaisonservicehasanimportantroleinidentifyingandaddressingalcoholproblems.Anumberofinterventionscanbeprovidedtohospitalwardsanddepartmentsinageneralhospitalsettingsuchas:

managementofscreeninginhospitalsettings;

managementofassessmentinhospitalsettings;

provisionofbriefinterventions,particularlytohazardousdrinkers;

managementofalcoholwithdrawal/detoxificationinthegeneralhospital;

planningofinterimcarepriortolinksbeingmadewithcommunityservices;

•

•

•

•

•

•

•

•

22

linkstosupportfromspecialistalcoholservicesasappropriate;

provisionofeducationandsupporttohospitalstaff.

3.5.3 Peoplewithalcoholproblemswhoalsohavesignificantmentalhealthordrugproblems

WelshAssemblyGovernmenthasalreadyissuedguidanceontheissueofco-occurringmentalhealthandsubstancemisuseandcanbeaccessedat:http://new.wales.gov.uk/dsjr/publications/commmunitysafety/submisusetreatframework/frameworke?lang=en

Serviceprovisionforindividualswithmentalhealthand/oralcoholproblemsshouldinclude:

arrangementswithlocalmentalhealthservicetoidentifyalcoholproblemsandintervenewhereappropriate;

protocolstoidentifyandmanagealcoholproblemsinhospitalwardsinsecondarycarepsychiatricsettings;

goodlinkswithotherpsychiatryandpsychologyservicesforcomplexproblems;

trainingforcommunitymentalhealthteams.

3.5.4 Criminaljusticeservices

Appropriatesupportandadvicemaybeneededforcriminaljusticeservicesinrelationtoindividualswithalcoholproblems.

Prisonerswithanalcoholproblemwillneedsupportimmediatelyafterarrestorsentencing(whentheriskofwithdrawalsymptomsishigh)andon-goingsupporttoaddressalcohol-relatedproblemsduringsentenceandthroughtoreturntothecommunity.TheprovisionofanalcoholreferralservicewithinPolicecustodymayhavesomepotential.

InWales,theprisonserviceprovidesscreening,assessment,care-planningandtreatment.TransitionalCareofferedbeforerelease,takesthecareplanforwardintothecommunity.

Servicesforprisonersneedtobeequitablewiththoseofferedinthecommunitywithrobustfollow-throughonrelease.

3.5.5 Peoplewithhighlyspecialisedneeds

Supportcanbeprovidedthroughliaisonandadvicetomulti-disciplinarygroupsthatprovidecarefortheseindividuals.Inparticulargoodpracticeadviceshouldbemadeavailabletothemidwiferyserviceonthelinksbetweenalcoholandpregnancy.

3.5.6 Commercialandnonpublicsectororganisations

Specialistprovidersalsohaveapotentialroleinofferingadviceandsupporttoorganisationsoutsideofthepublicsector.Adviceontherecognitionofalcoholproblemsandthelocalsupportavailableshouldbepartoftheircoreservice.

•

•

•

•

•

•

23

4 Sourcesandreferences

ThesubgroupconsideredtworeviewsfromtheNationalPublicHealthServiceforWalesVulnerableAdultsteamontreatmentinPrimaryandNonSpecialistSettingsandTreatmentinSpecialistSettings.TheseareavailableontheNPHSwebsite.Thereferencesbelowarequotedinthesetwodocuments.

�. OfficeofNationalStatistics(2000).LivinginBritain.TheStationaryOffice.London.

2. RoyalCollegeofPhysicians,PsychiatristsandGeneralPractitioners(�995).AlcoholandtheHeartinPerspective.SensibleLimitsReaffirmed.RoyalCollegeofPhysicians,PsychiatristsandGeneralPractitioners,London.

3. Modelsofcareforalcoholmisusers(MoCAM).NHS.NationaltreatmentAgencyforsubstancemisuse,2006.

4. InternationalconferenceonbriefinterventionsforalcoholproblemsINEBRIA.InauguralconferenceBarcelona20-2�October2004.

5. DuncanRaistrick,NickHeatherandChristineGodfrey.NTAforsubstancemisuse,2006.Reviewoftheeffectivenessoftreatmentforalcoholproblems.

6. CrawfordM,PattonR,TouquetR,DrummondC,ByfordS,BarretB,ReeceB,BrownA,HenryJ.ScreeningandreferralforbriefinterventionofalcoholmisusingpatientsinanA&Edepartment:ApragmaticRCT.

7. HuntleyJS,BlainC,HoodS,TouquetR.Improvingdetectionofalcoholmisuseinpatientspresentingtoanaccidentandemergencydepartment.BMJVol�8(2)200�.

8. ScottishintercollegiateGuidelinesNetwork.Managementofharmfuldrinkingandalcoholdependenceinprimarycare.September2003.

9. BertholetNicolas,DaepenJean-Bernard,WeitlisbachVincentetal.2005.Reductionofalcoholconsumptionbybriefalcoholinterventioninprimarycare.

�0. BienTH,MillerVR,ToniganJS.Briefinterventionsforalcoholproblems:areview.Addiction�993;88(3):3�5-336.

��. MillerWR,WilbournePL(2002)MessaGrande:amethodologicalanalysisofclinicaltrialsoftreatmentsforalcoholusedisorders.Addiction,97,265-277.

�2. Alcoholconcern,200�.Accessedatwww.alcoholconcern.org.ukon�5/6/06inPrimarycarealcoholInformationservice.Factsheet:Alcoholtreatmentoptionsandoutcomes.

�3. MattickR&JarvisT.(�993).Anoutlineforthemanagementofalcoholproblems:QualityAssuranceProject.NationalandAlcoholResearchCentre.Sydney.

24

�4. LondonDrugandAlcoholNetwork/AlcoholConcern.Treatmentsettingsandinterventionsforpeoplewithalcoholproblems.ServicesInNon-SpecialistSettings.http://www.localalcoholstrategies.org.uk/keyarea.php?k=5&s9=�[Accessed9thOct2006].

�5. Reviewoftheeffectivenessoftreatmentforalcoholproblems.NHS.NationalTreatmentAgencyforSubstanceMisuse,2006.

�6. FosterJH,HeatherN,(2005)Understandinghospital-basedalcoholservicesandaftercare.NursingTimes,�0�:35,32-35.

�7. UKATTResearchTeam(2005).UnitedKingdomAlcoholTreatmentTrial(UKATT):hypotheses,designandmethods,UKATT.

�8. Alcoholmisuseinterventions:guidanceondevelopingalocalprogrammeofimprovement.NHS.DepartmentofHealth,2005.

�9. ScottishExecutive(2002).AlcoholProblemsSupportandTreatmentServicesFramework.

20.RoyalCollegeofPhysicians(200�)Alcohol-cantheNHSaffordit?Recommendationsforacoherentalcoholstrategyforhospitals.AreportofaworkingpartyoftheRoyalCollegeofPhysicians.

2�. Slattery,J.,Chick,J.,Cochrane,M.etal()HealthTechnologyAssessmentReport3-Preventionofrelapseinalcoholdependence.HealthTechnologyBoardforScotland,NHSScotland.