Alcohol Misuse in Wales · 2019-02-25 · 8 1.2 Definitions 1.2.1 Alcohol Misuse In this document...
Transcript of Alcohol Misuse in Wales · 2019-02-25 · 8 1.2 Definitions 1.2.1 Alcohol Misuse In this document...
Alcohol Misuse in Wales
Alcohol M
isuse in Wales
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Contents
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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
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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
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Foreword
ThisframeworkreporthasbeenproducedbytheWelshAssemblyGovernmenttosupplementpreviousSubstanceMisuseTreatmentFrameworksalreadyissuedtostakeholdersinWales.
TheWelshAssemblyGovernmentsubstancemisusestrategyincludesalcoholandpreviousframeworkshaveaddressedthisalongwithdrugmisuse.
However,feedbackfromfocusgroupssuggestedthatitmightbehelpfultoproduceanalcoholspecificframeworktoofferspecificdirectioninthisareatoprovidersandcommissioners,andinparticularCommunitySafetyPartnershipsandHealthandSocialCareandWellBeingstrategygroups.
Thisframeworkaimstoassistthedevelopmentofservicestoadultsbyprovidingasummaryofguidanceongoodpracticeinthecontextofcurrentevidenceandprofessionalopinion.
Theimpactofalcoholmisuseuponindividuallives,communities,workplacesandpublicsectorserviceshasbeenwelldocumentedandisamajorpublichealthissue.ThecoststotheNHSinparticularhavebeenagrowingconcern.
Thereporthadbeenproducedbyasub-groupoftheWelshAssemblyGovernmentSubstanceMisuseProjectBoard.
ItisbaseduponreviewsundertakenbytheNationalPublicHealthServiceinWaleswhichareavailableontheNPHSwebsite.
Theequallyimportantissueoftheprimary preventionofalcoholmisuseandalcohol harm reductionwillbethesubjectoffurtherdiscussion.
TheframeworkneedstobereadinconjunctionwithpreviousmodulesproducedbyWelshAssemblyGovernmentforsubstancemisuse.
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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.
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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.)
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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.
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1.3 The“SteppedCare”approachtotreatment1.3.1 Serviceusersmayhaveanumberofexpectationsfromalcoholtreatmentincludingareductioninalcoholconsumptiontowithinsensiblelimitsorabstinence.Itisimportantthattherangeofservicesavailablereflectstheseexpectations.
1.3.2 Inthiscontextthisframeworksupportsthe“steppedmodelofcare”recommendedbytheNTAinEnglandwhichhastwobroadcomponents:
Provisionofbriefinterventionsforthosedrinkingexcessivelybutnotrequiringtreatmentforalcoholdependence.
Provisionofmorespecialisttreatmentforthosewithmoderateorseveredependenceandrelatedproblems.
Thesteppedcaremodelputsemphasiseontheclient’schoicewithregardtotreatmentoutcomesandinterventionrecognisingthateffectiveengagementwithhim/heriscrucialtosuccess.Bestpracticealsowouldsuggestthatallagenciesshouldputinplacesomeformofoutcomemeasurementthatisagreedwiththeuserinthecareplanningprocess.TheTreatmentOutcomeProfileintroducedbyWelshAssemblyGovernmentin2008setsthecontextforthis.
Thefollowingguidanceonthesettingsforalcoholspecifictreatmentinterventionsimplicitlyadvocatesthissteppedapproach.
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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;
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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;
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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.
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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.
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�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.