Guest blog by Don Shenker, Director and Founder of the Alcohol Health Network.
Heavy drinking is one of the major causes of preventable disease and mortality in the world, ranked eighth globally among the leading risk factors for preventable deaths and third for preventable disease. In spite of the general trend showing fewer adults drinking in the UK, heavy drinking by a sizeable minority does not seem to be abating.
The latest Statistics on Alcohol for England for 2013 from the Health and Social Care Information Centre show a 41% increase from 2002-3 in hospital admissions where the primary diagnosis was attributable to alcohol consumption.
The report shows that nearly a quarter of men (23%) and nearly a fifth of women (18%) drank more than the recommended levels on a weekly basis, including 6% of men and 4% of women whose drinking was at the higher risk category (drinking above 50 units weekly for men / 35 units weekly for women).
Indeed over half of drinkers exceeded the recommended guidelines at least once in the previous week (56% of men, 52% of women), while over a quarter drank more than twice the guideline (31% of men, 25% of women).
One of the government’s main strategies for reducing alcohol harm at the local level outlined in last year’s Alcohol Strategy has been to increase the level of assessment and brief advice within primary and now more frequently secondary care. This allows practitioners to use short standardised alcohol screening tools to identify problem drinkers and then provide them with around 5 minutes of brief advice from the practitioner as well as NHS leaflets on drinking to read later. This is now common among many GP surgeries for new patients and since April this year will apply to 40-75 year olds receiving an NHS Health Check. A recent study published in the BMJ (known as the SIPS trial) showed that providing a leaflet with brief information was as effective in reducing heavy drinking as more ‘intensive’ interventions such as 20-minutes of 1-1 advice from a trained practitioner.
If reducing alcohol harm is as simple as offering a short standardised test on drinking and providing brief advice, surely this can be also be done online, saving GPs valuable time? Well, apparently so, although we are still learning what works from this new approach.
Around 80% of the UK population have access to the internet, although older people and those who are more marginalised are obvious sub-populations which may have a higher risk of alcohol misuse and yet little internet access.
On the other hand web-based alcohol assessment and brief advice offers individuals greater levels of privacy and anonymity, as well as 24-hour flexibility, thereby reducing the perceived threat of stigmatisation from community-based practitioners. Internet alcohol feedback can be personalised to the individual user, easily updated (to reflect new technology, guidelines or research) and with its public health scalability, is potentially more cost-effective over time.
Use of web-based alcohol interventions has a growing evidence base according to a systematic review by UCL, particularly with student populations, showing in a small number of studies that they are as effective as face-to-face interventions.
A number of studies are now looking at how the internet can be used to increase the number of people self-assessing their alcohol intake. This can occur in a number of ways. Firstly, patients can be referred to alcohol websites by their GP. A GP may be more likely to ask patients about their drinking if they know there is a website they can refer them to, providing a leaflet with a hyperlink for patients to log onto after their session. The ODHIN study will examine whether GPs are more likely to engage with this issue if such websites are available, or which other ‘incentives’ are required.
Alternatively, online assessments can be used as an aide by healthcare practitioners to jointly assess drinking at consultations – for example pharmacists completing an alcohol assessment online with patients as part of an individual face-to-face intervention. This way, the patient receives non-judgemental assessment of their drinking risks through the computer score and the practitioner can reinforce messages in the consulting room.
Finally, individuals can be alerted to alcohol assessment websites through their workplace, as part of health at work initiatives. Alcohol Health Network is piloting this approach with several companies and the results are quite revealing. It may be that such approaches attract a high number of staff concerned about their drinking who are happy to use a confidential online tool, but who have not used occupational health or primary care services due to the usual concerns about stigma or other consequences.
We are still learning what works, how effective online interventions are in the long term and how to engage and appeal to all groups. Until then we must embrace the new and ensure it is evidence based and cost-effective.