Screening and Intervention Programme for Sensible Drinking (SIPS) National Brief Intervention Research Consortium

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Screening and Intervention Programme for Sensible
Drinking (SIPS) National Brief Intervention
Research Consortium
AE St. Marys


'Scientia Vincit Timorem'
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Training Objectives

• Content of this session
• Pre-Training Staff Survey
• Part 1 Background to the study
• Alcohol prevalence, effects and issues in England
• Hazardous/harmful drinking
• The AED Trial
• Alcohol screening and brief interventions
• The SIPS programme
• Parts 2 Triage Stage
• Provide you with the knowledge and skills to
• Implement study procedures in accordance with the
  protocol
• Introduce the study and gain verbal consent
• Administer and score the screening questionnaire
  (FAST)
• Part 3 Treating Clinician Stage
• Obtain consent and check baseline questionnaire

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Staff survey

• This is a short survey on your attitudes towards
  alcohol screening/brief interventions and
  relevant pre-training experience
• Your feedback on the experience of alcohol
  screening and brief interventions will make an
  important contribution to the study
• We will ask you to complete the same
  questionnaire after the training session, and
  once again after recruitment to the study has
  been complete
• Please read through the Information Sheet and
  sign two copies of the consent form if you agree
  to fill it in.

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Part 1 Background
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• What do you think constitutes an alcohol problem?

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Alcohol Use Definitions

• Low-risk drinking - below medically recommended
  limits (2-3 units per day for women 3-4 units
  per day for men, with at least two alcohol free
  days a week)
• Hazardous drinking - a pattern of consumption
  which increases the risk of harm (physical,
  psychological or social), i.e., drinking above
  recommended limits
• Harmful drinking - a pattern which is likely to
  have already led to harm (physical, psychological
  or social) or, for some purposes, drinking at
  very heavy levels
• Binge drinking originally episodic heavy
  drinking but now heavy drinking in a single
  session, i.e., twice the daily limit, above 6
  units for women 8 units for men
• Alcohol dependence a cluster of physiological,
  behavioural and cognitive phenomena conforming to
  the alcohol dependence syndrome

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Alcohol use disorders prevalence

• 26 of the adult population have an alcohol use
  disorder (AUD)
• Includes 38 of men 16 of women aged 16-64
• 23 of the adult population are hazardous or
  harmful alcohol users (7.1 million people in
  England)
• 21 of men and 9 of women engage in binge
  drinking

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Percentage of people in England with an alcohol
use disorder by age

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Alcohol-related harm acute

• Homicide
• Suicide
• Other intentional injuries (i.e., interpersonal
  violence)
• Domestic violence
• Sexual assault
• Unprotected sex
• Motor vehicle accidents
• Other accidents
• Drowning
• Burns
• Public disorder

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Alcohol-related harm chronic

• Liver cirrhosis and other forms of
  alcohol-related liver disease
• Hypertension
• Cancers of the mouth, larynx, pharynx and
  oesophagus
• Other cancers, including breast cancer
• Foetal Alcohol Syndrome (FAS) and foetal alcohol
  effects
• Mental illness
• Alcohol Dependence Syndrome

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Alcohol-related harm social problems

• Lower workplace productivity
• Unemployment
• Family social networks
• Homelessness
• Economic costs

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Alcohol and AEDs

• 24 hour prevalence survey of alcohol-related
  attendances at 32 AEDs in England
• 40 of AED attendances are alcohol related
• Between midnight and 5am this number increases to
  70
• Reasons for alcohol related attendance were
  significantly more commonly
• a violent assault
• incident involving weapons
• road traffic accidents
• psychiatric emergencies
• deliberate self harm episodes

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St Marys AED Trial

• Screening and Brief Interventions for alcohol
  misuse in an accident emergency department is
• feasible
• associated with lower levels of alcohol
  consumption over the following 6 months
• reduces reattendance
• Those referred to the alcohol health worker had a
  mean of 0.5 fewer visits to the AED over the
  following 12 months
• For every 2 patients referred to an AHW there is
  one less reattandence in the following year!

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Costs/Benefits

• Screening and referral to the AHW has a cost, but
  this should be offset against the savings gained
  by reducing attendance
• For every 1000 patients screened, costs are
  approximately 2500 (including the cost of the
  AHW for those referred), and savings of 4000
• Net 1500 savings

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Screening for hazardous harmful drinking

• Screening is necessary to detect risky drinkers
  whose level of consumption may not be apparent
• Short questionnaires are the most efficient way
  of screening
• Screening for hazardous/harmful alcohol users,
  not for dependent drinkers

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What is brief alcohol intervention?

• the giving of information, advice and
  encouragement to the patient to consider the
  positives and negatives of their drinking
  behaviour, plus support and help to the patient
  if they do decide they want to cut down on their
  drinking.
• Brief interventions are usually opportunistic
  that is, they are administered to patients who
  have not attended a consultation to discuss their
  drinking

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What is the SIPS Programme

• A national research consortium led by the
  Institute of Psychiatry, Kings College London and
  Newcastle University, with expertise in screening
  and brief interventions in the alcohol field
• Funded by the Department of Health 3.2 million,
  as part of the Alcohol Harm Reduction Strategy
  for England (2004)
• To investigate the effectiveness and cost
  effectiveness of alcohol SBI in
• Accident Emergency Departments
• Primary Health Care
• Criminal Justice Services

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Cluster Randomised Controlled Design

• Within 3 different regions of England North
  East, South East and London, in
• 24 Primary Health Care practices 9 Accident
  Emergency Departments 9 probation offices
• Cluster 1 AED, 2-3 PHC sites, 1 probation
  office
• Study is comparing the effectiveness of
• 2 screening approaches (targeted vs. universal)
• 3 screening tools (M-SASQ SIPS-PAT FAST)
• 3 brief interventions (PIL Brief Advice Brief
  Lifestyle Counselling)
• ??????????? has been assigned
• ???????? Screening ????? ?????????
• 131 Patients to be recruited at this site

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Objectives of the AED Trial

• Identify best screening tool
• Compare effectiveness and cost effectiveness of
  different models of brief intervention
• Assess implementation of different screening and
  brief intervention (SBI) approaches by staff
• Identify factors that predict successful
  implementation of SBI in routine AED care

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Summary of SIPS in your AED

• Assess patient for treatment as normal
• Brief introduction of study
• Gain verbal consent to check eligibility and
  screen
• Screen for alcohol misuse
• If negative end their involvement in the study
• If positive hand them a study pack

Triage Stage
Patient in waiting room to read study pack
including the research participant information
sheet, sign both copies of the consent form if
they are happy to participate and complete the
baseline survey.

• Research participant hands over study pack
• Staff ensures both consent form is signed by the
  research participant and then countersigns the
  forms, giving the patient a copy of this to take
  away with the information sheet.
• Check baseline survey is completed
• Issue patient information leaflet and conduct
  brief structured advice
• Store study pack in secure place for SIPS
  research staff to collect

Treating Clinician Stage

• Research participant hands over study pack
• Staff ensures both consent forms are signed by
  the research participant and then countersigns
  the forms, giving the patient a copy to retain
  along with the information sheet.
• Check baseline survey is completed
• Conduct Brief Advice and issue Patient
  Information Leaflet
• Store study pack in secure place for SIPS
  research staff to collect

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Part 2 Triage Stage
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Participant Baseline Questionnaire - AED
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Introducing the study

• We are currently working with a team of
  researchers led by the Institute of Psychiatry,
  who are conducting a study on behalf of the
  Department of Health. The aim of the study is to
  find out how to provide help to people who are
  drinking alcohol in ways that might be harming
  their health. Would you mind if I asked you a few
  questions to see if you meet the eligibility
  criteria to take part in the study, and if you do
  I would then like to ask you a few questions
  about your drinking in the last six months. Would
  this be ok?

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Eligibility criteria
Recruiting patients to participate

• The patient
• Is aged 18 or over
• Is alert and orientated i.e. the ability to
  understand the information presented, retain it
  and make an informed decision competence
• Is resident within 20 miles
• Is able to speak, read and write English
  sufficiently well to take part in the study

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Eligibility continued...

• Is not severely injured
• Is not suffering with a serious mental health
  problem e.g. acute psychotic episode or severely
  distressed
• Is not grossly intoxicated
• Is not currently seeking help for alcohol
  problems
• Is not involved in any other alcohol research
  study
• Has a fixed abode
• Has provided verbal consent to be screened

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Patient demographic information
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What is a standard unit of alcohol?
The alcohol screening process
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Fast Alcohol Screening Test (FAST)
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Examples Fast Alcohol Screening Test (FAST)
Example 1 In response to question 1 of the FAST,
the man says

• Most Fridays after work I usually have a couple
  of pints of Guinness, and then share a bottle of
  wine over dinner with my wife, followed by a
  whisky.

• Calculate the number of standard drinks that the
  man had
• 4 (Guinness) 4.5 (wine) 1 (whisky) 9.5
  standard drinks
• 2. How would you record and score the answer to
  this question using the FAST?
• More than 8 standard drinks every week weekly
• 3. Why would you not continue with the remaining
  3 questions?
• He has more than 8 units on one occasion every
  week positive. Therefore no need to ask any
  more questions

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Examples Fast Alcohol Screening Test (FAST)
Example 2 In response to question 1 of the FAST,
the woman says

• I normally have a couple of glasses of wine when
  I go out, but on my birthday I will get through a
  whole bottle!

• How would you score question 1 on the fast?
• Less than monthly not necessarily positive but
  scores 1 point and you need to ask the other
  questions

In response to question 2 she says
Only a couple times in the last six months . . .

• How would you record her response on the FAST?
• Less than monthly 1 point

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Examples Fast Alcohol Screening Test (FAST)
Example 2 (continued) In response to question 3
she says

• A few times I have missed a class at the gym
  because of the heavy night before. But this has
  happened very occasionally definitely less than
  monthly.

• How would you record this response?
• Less than monthly 1 point

Nobody has ever expressed any concern about my
drinking habits or suggested that I cut down.
In response to question 4 she says
4) How would you record this response? No 0
points 5) Would she screen positive or negative
using the FAST? She has 3 points in total so she
would be positive
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Examples Fast Alcohol Screening Test (FAST)
Example 3 In response to question 1 of the FAST,
a man says

• I have a can of beer every evening and then 3
  pints when I watch my team play football

• Calculate the number of standard drinks that the
  man had
• 3 pints 6 9 standard drinks depending on
  strength of beer
• 2. How would you record and score the answer to
  this question using the FAST?
• Need to ask him how often he watches his team
  and type of beer he drinks. To which he says

The wife only lets me out once a month so I only
get to watch my team about once a month. I always
drink Stella.
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Examples Fast Alcohol Screening Test (FAST)

• 3. How would you score his response for question
  1 of the FAST?
• 3 pints Stella 9 standard drinks one a month
  answer would be monthly.
• What next?
• He might not be positive so you give him 2
  points and ask the other 3 questions.

In response to question 2 of the FAST, the man
says

• Only on my stag night 8 years ago!

5. How would you score his response for question
2 of the FAST? Never 0 points. He therefore
still only has 2 points.
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Examples Fast Alcohol Screening Test (FAST)
In response to question 3 of the FAST, the man
says
Its never stopped me doing anything as far as I
remember.
6. How would you score his response on question 3
of the FAST? Never 0 points. He therefore
still only has 2 points.
In response to question 4 of the FAST, the man
says
No, never.
7. How would you score his response on question 4
of the FAST? Never 0 points. Again he still
only has 2 points.
8. Would he screen positive or negative? He has
only 2 points overall and is negative.
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SIPS Modified Paddington Alcohol Test (SIPS-PAT)
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Examples SIPS-PAT
Example 1 A woman presents to the AE department
with injuries from a fall so you screen her using
the SIPS-PAT. You ask her if she feels her
attendance here is related to her drinking. The
woman responds

• No it was the heels on these new shoes.

So what do you do? It was not drinking related so
you go on to ask the woman question 2 of the
SIPS-PAT and you ask her how often she has 6 or
more drinks on one occasion. She replies
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Examples SIPS-PAT
Example 1 (continued)

• When I go out after work I usually have a couple
  of single vodkas, at the weekend maybe a bit
  more, say 4 or 5 single vodkas. But never more
  than that on one occasion.

• Calculate the number of standard drinks the
  woman has.
• 4 5 standard drinks
• What box would you cross in question 2?
• Never
• 3) Would she screen negative or positive using
  the SIPS-PAT?
• Negative

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Examples SIPS-PAT
Example 2 A man comes into the AE department
with head injuries so you screen him using the
SIPS-PAT. You ask him if he feels his attendance
here is related to his drinking. The man
responds

• No, it isnt to do with drink, I tripped on an
  uneven pavement and hit my head.

1) So what do you do? It was not drinking related
so you go on to ask the man question 2 of the
SIPS-PAT and you ask him how often he has 6 or
more drinks on one occasion. He replies
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Examples SIPS-PAT
Example 2 (continued)

• I go out to the pub most weeks and I usually
  only drink about 3 pints, very rarely more than
  that.

2) Calculate the number of standard drinks the
man has. 6 standard drinks if regular strength
beer but more if strong/premium strength so you
ask him what pints he normally drinks, he replies
Kronenbourg, if theyve got it.
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Examples SIPS-PAT
Example 2 (continued)
3) Taking into account this new information
recalculate the number of standard drinks the man
has. 9 standard drinks 4) What box would you
cross in question 2? Weekly 5) Would he screen
negative or positive using the SIPS-PAT? Positive
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Examples SIPS-PAT
Example 3 A man presents to the AE department
with injuries from a fall so you screen him using
the SIPS-PAT. You ask him if he feels his
attendance here is related to his drinking. The
man responds

• No I fell off a ladder whilst decorating

So what do you do? It was not drinking related so
you go on to ask the man question 2 of the
SIPS-PAT and you ask him how often he has 8 or
more drinks on one occasion. He replies
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Examples SIPS-PAT
Example 3 (continued)

• I usually go out after work and have a couple of
  pints of Stella and 2 double whiskey and cokes.

• Calculate the number of standard drinks the man
  has.
• 2 pints of Stella 6 standard drinks Whisky
  4 standard drinks
• What box would you cross in question 2?
• Weekly
• 3) Would he screen negative or positive using the
  SIPS-PAT?
• Positive

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Modified Single Alcohol Screening Questionnaire
(M-SASQ)
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Examples M-SASQ

• Example 1
• In response to the M-SASQ question, the man says

I normally have a glass of wine with dinner most
nights, but on a Saturday I have a whole bottle.

• Calculate the number of standard drinks the man
  consumes.
• 1-2 units per day and 9 at the weekend
• What response would you give him on the M-SASQ?
• weekly
• 3) Would he screen negative or positive using the
  M-SASQ?
• positive

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Examples M-SASQ

• Example 2
• In response to the M-SASQ question, the woman
  says

I usually drink about 3 or 4 pints on a Friday
night after work, but never more than this.
1) Calculate the number of standard drinks the
woman has. 6 12 standard drinks (depending
whether ordinary or strong beer) 2) What response
would circle on the M-SASQ? Weekly 3) Would
she screen negative or positive using the
M-SASQ? Positive
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Examples M-SASQ

• Example 3
• In response to the M-SASQ question, a man says

I have about 4 beers a night and about 8 on a
Saturday night. After all mans not a camel!
1) Calculate the number of standard drinks the
man consumes. 4 beers 8 units 8 beers
16 Total 24 per week 2) What response would
you give him on the M-SASQ? Daily 3) Would
he screen negative or positive using the M-SASQ?
Positive
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Screening Results

• If patient is negative, thank them for their
  interest in the study and terminate their
  involvement at this point
• If patient is positive, provide with Research
  Participant Information Sheet and attempt to
  obtain written consent

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Issuing Research Participant Information Sheet

• I have looked over the results of your
  questionnaire, and from your answers it appears
  that you may be drinking at a rate that increases
  your risk of harm. The research team are trying
  to find ways of helping people who may be
  drinking in ways that are harmful to health.
  They would like about 10 minutes of your time to
  help with their research, by completing a short
  questionnaire for which you will receive a 10
  voucher. You will then receive an information
  leaflet about alcohol / and 5 minutes brief
  advice about alcohol/ and we will arrange an
  appointment for you to see an Alcohol Health
  Worker to discuss your drinking further (delete
  as appropriate) The research team will contact
  you again in 6 months and 12 months to complete
  another short questionnaire, for which you will
  receive another 10 voucher for each time.
  Please take the time to read this information
  leaflet carefully, and feel free to ask any
  questions you wish.

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AED Research Participant Information Sheet
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Part 3 Treating Clinician Stage
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Consent

• Patient will hand baseline pack to clinician who
  will check consent form.
• Informed consent is an agreement entered into
  with complete knowledge of all relevant facts.
• Ensure they have read through the consent form
  and signed both copies.
• If they consent make sure you countersign both
  copies and detach patient copy.

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Consent Forms
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Consent

• If the patient does not consent to participate in
  the study, offer them the Patient Information
  Leaflet and no further action is taken.

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Instructions to patients
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Patient personal information sheet
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Alcohol Use Disorders Identification Test (AUDIT)
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EQ5D health status questionnaire
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Service Use Questionnaire (SUQ)
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Readiness to Change Ruler (RCR)
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• Please check participants have filled in all
  sections of the baseline questionnaire!

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Patient Information Leaflet How Much Is Too Much?
Winchester Alcohol Service 555 5555 5555
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The Principles of the PIL

• an intervention in itself
• contains useful information regarding personal
  alcohol use
• is not confrontational or judgmental.
• free resource for people to take away
• easy to read format

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How to issue the Patient Information Leaflet (PIL)

• Brief Advice and the PIL must be delivered in the
  same manner for each patient.
• When handing over the PIL please say
• Thank the patient, inform them they will receive
  a letter from the research team in 2 weeks that
  will contain a 10 voucher.

• This leaflet describes what we have just
  discussed in more detail. Please take this away
  and read through it. There are contact details on
  the back should you need further help/advice.

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Pilot Days

• An opportunity to practice screening and
  providing Brief Advice
• Triage nurse to screen patients and refer those
  positive to the study doctors/ENPs
• Doctors/ENPs will have a go at offering the Brief
  Advice
• No research materials will be used
• Ensures potential problems can be solved before
  active recruitment to study begins
• Sam, Malcolm and Lisa will be on site during
  pilot for support and feedback

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Winchester Flow Chart
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Support and supervision

• Who to contact if Im worried about a patient in
  the study?
• Please contact your alcohol health worker
• Lisa Rail Julia Reid
• Tel [phone] Tel [phone]
• Email lisa.rail_at_iop.kcl.ac.uk Email
  julia.reid_at_iop.kcl.ac.uk
• Or refer patients to alcohol services as outlined
  in the Patient Information Leaflet
• Drinkline
• Tel [phone]
• Alcoholics Anonymous
• Tel [phone]
• Alternatively instruct the patients to contact
  their GP for referral to local alcohol services

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Useful links

• www.sips.iop.kcl.ac.uk/
• www.alcoholconcern.org.uk
• www.dh.gov.uk
• www.nhs.uk