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Thank you for the invitation to talk to you today about brief interventions two point o, a new agenda for alcohol policy practice and research. I’m doctor Mary Madden, and the ideas I’m presenting today are from a paper written with my co authors Jim McCambridge and Duncan Stewart.
The paper draws on two recent programs of alcohol research. I won’t spend time spelling out all the acronyms on the screen here but the National Institute of Health Research funded CHAMP one program pays close attention to interaction about alcohol at the practice level. It looks at how to incorporate discussions of alcohol into medication consultations with a particular focus on a new clinical pharmacy role in NHS primary care in England.
The Wellcome Trust funded TRAPS programme is pitched at a more macro policy level, specifically on how the alcohol industry influences science, the science policy interface and policy making.
Our call for a reset, which we’re calling Brief Interventions two point o, draws on the historical evidence base and findings from both of these programmes.
A quick overview of three areas I’m going to briefly touch on today: why we think the brief intervention paradigm is outdated, what inhibits interaction about alcohol in a contemporary health system Today I’m drawing on our work in the NHS and where we want to go with brief interventions in terms of practice, which is to open up meaningful, service focused and policy relevant alcohol conversations.
So fundamentals.
What are alcohol brief interventions?
Evidence informed, routine, non confrontational interactions.
These are to motivate and support a person to think about and or plan a change in their drinking, to reduce the amount they drink and risk of harm.
They originate around half a century ago with the rise of the new public health movement which sought to make health promotion and disease prevention central to improving population health.
The World Health Organization brought together alcohol researchers in a major program that developed the AUDIT screening tool and a randomised trial that demonstrated it was possible to have conversations with people in primary care that led them to reduce drinking.
So while the brief intervention paradigm has shown proof of concept, those trial findings rarely seem to survive implementation in actual routine practice.
There have been few high quality process or implementation studies.
The literature there is shows that health professionals tasked with talking about alcohol have concerns about their role adequacy, their role legitimacy and role support.
Over the half century of brief interventions we’ve also seen the rise of neoliberal reforms promoting free markets, individual responsibility and minimal state intervention.
We’ve had a rise in non communicable disease and a global pandemic.
The NHS and social care services in England have been under unprecedented pressure with an increasing focus on downstream reactive services rather than upstream prevention in a fragmented health and care system.
The culturally available ways to think and talk about alcohol make it a loaded topic. Our recent observations of pharmacists show that despite a proliferating discourse of person centred care, routine practice is highly time pressured, task focused and target driven.
Pharmacists with no specific training about alcohol have been asked to include it in their medication reviews. Where they do this, and those most uncomfortable with it avoid it altogether, is as part of an of an add on lifestyle section tagged on the end.
They ask about units consumed, often having to explain what a unit is, and issue the same guidance to everyone on limiting their intake.
Some patients are asked the same thing by many different health professionals with no clear record kept of their answers.
NHS record management systems continue to remain frustrating and largely unsuccessful at recording alcohol.
When asked, patients say they do not mind being asked about their drinking, but they and the pharmacist asking them see it as an issue only really relevant for a small group of heavy out of control drinkers, which kind of begs why why they’re asked being asked in the first place.
Pharmacists who do identify someone drinking heavily are unsure what to say other than to give details of somewhere people might refer themselves to.
During the life of the brief interventions paradigm, a culture of encouraged alcohol consumption has therefore continued to grow. We have low prices, increased availability, widespread acceptability and aggressive marketing.
In comparison with tobacco, tobacco, the threat that alcohol poses to health is much less understood by policy communities and health professionals across the board.
While service documents mention brief interventions, specific alcohol training can be limited or absent.
The policy measures that evidence has shown for decades are needed to reduce alcohol and tobacco harms are actually market interventions that increase price, reduce access, and restrict marketing.
While there have been big moves to stop tobacco influence at this level, there’s been limited success in translating evidence informed alcohol public health ideas into policy.
There’s also been a wholesale change in the alcohol industry, which is now much more concentrated into fewer global companies, and this includes mergers with the tobacco industry.
There’s overlapping ownership and overlapping playbooks.
There’s been huge corporate investments in shaping drinking norms, distracting from evidence on alcohol harms, and presenting the industry as part of the solution.
We now clamp down hard on tobacco marketing and would not rely on the tobacco industry for health messaging, but alcohol messaging is dominated by the industry fund funded organisation DrinkAware.
Lacking specific training, the pharmacists we observed had little more evidence informed knowledge about alcohol than those being advised and unwittingly reproduced common sense industry favorable messages, not least that the damage done by alcohol is down to a small group of deviant drinkers.
If focused more clearly upstream than on the harm already caused to heavy drinkers, brief interventions could help identify the relationship between alcohol and common chronic conditions and how wider policy measures are needed to prevent harm. Labelling people as problem drinkers invites moralising and shuts down meaningful conversations.
Alcohol, ethanol, is an overlooked drug in clinical settings, including by these pharmacists who are drug specialists.
As well as being addictive, it’s a central nervous system depressant. It slows down brain functioning and neural activity. It’s a teratogen. It causes developmental malformations.
It’s a neurotoxin. It’s a poison which acts on the nervous system. It’s a carcinogen. It causes cancer. And it’s an immunosuppressant.
It decreases the body’s immune response.
While heavy drinkers are most at risk, all drinkers are at risk of alcohol harms, as are non drinkers around them.
Alcohol dosage and interaction with other drugs and conditions clearly matter for physical and mental health, yet it remains a clinical blind spot. One of the problems with the current approach is that alcohol is being seen as an optional public public health add on rather than integral to the reasons people are using services.
The adequacy of the theorisation of motivation and support for the current healthcare context is also a key issue given the time pressured, fixed and closed formats that can dominate real world practice.
Pharmacy professional training is framed in the familiar language of person centred care common in the NHS but delivery on the ground is often compliance focused and this is not unique to pharmacists.
A person centred conversation would need to start from a position of seeking to understand the person’s own concerns and perspective and not just delivering a predetermined output within a fixed time scale.
Developing person centred communication skills about sensitive topics requires capacity building, especially to make the maximum use of limited times available.
To close, alcohol alcohol brief interventions are challenging, complex interventions.
Motivation and support is relational, and we need to pay close attention to how people talk about alcohol in different contexts.
We need more interaction studies. We can also help to open up perspectives on alcohol beyond the narrow industry friendly frame. Alcohol brief interventions may have a more useful and cumulative impact in health and social care services if we integrate alcohol into services and professional roles rather than add it on, so that, for example, alcohol becomes seen as the clinically relevant health harming drug that it is, if we think in terms of talking with people rather than intervening on them, so that we invite people to talk on their own terms, explore links with their individual presenting concerns, and pay attention to how alcohol interferes with the lives people want to live. And importantly, if we use brief interventions to reframe stigmatising notions that locate responsibility for alcohol harm solely in the agency of those drinking rather than the properties of the product itself or its producers and retailers.
This means not just focusing in on the individual, but finding ways to link this with the wider policy issues that impact our drinking.
Thank you.