Eilish Gilvarry

Individual and organizational determinants of alcohol screening and brief intervention implementation in emergency departments (SIPS-ED)

35th Annual Scientific Meeting of the Research Society on Alcoholism, June 23-27. San Francisco, California

Screening and Brief Alcohol Intervention in Routine Primary Care in the UK: SIPS Trial Outcomes at Six Months

To understand the effects of chronic alcohol misuse on synaptic signalling, we compare vulnerable and relatively spared cortical areas in brains taken at autopsy from alcoholics and matched controls. Cases with and without common comorbid diseases add important insights: cirrhosis, for example, has major sequelae for brain function because the failing liver cannot remove a range of toxins, especially ammonia. Male-female comparisons form another dimension, since there are well-known sex differences in susceptibility. We have developed a series of molecular techniques to study transcript and protein expression human autopsy brain, and are exploring interactions with markers brought to light by genetic studies. Using synaptosomal and synaptic membrane preparations from well-characterized cases and controls we can quantify receptor binding as well as the expression of isoform subunit transcripts and proteins. We find, in general, that alcoholics without comorbid disease show more marked differences from controls in GABA receptor parameters, whereas NMDA sites are more prominently affected in cirrhotic alcoholics. However, both genotype and gender can modify these outcomes. For example, the A1 allele in the ANKK1 gene, downstream of DRD2, modulates NMDA subunit expression differentially in males and females. As well as hypothesis-driven approaches we have applied discoverybased techniques and were the first to use microarray analysis with human brain. These approaches provide new, sometimes unexpected, leads. Proteomic studies have portrayed selective post-translational changes in the synaptosomal proteins that suggest that epigenetic processes can alter key components of the synaptic machinery. These alterations will have consequences for the efficacy of trans-synaptic signalling in damaged areas of the brain of the alcoholic.Background: Over the past 25 years, many trials of screening and brief alcohol nintervention in primary care have reported positive effects in terms of reducing nexcessive drinking. However, it is still not clear how applicable this evidence is to nroutine primary care. In addition, there is a need to identify an efficient screening nstrategy for busy medical practices. Lastly, the evidence-base in unclear on whether nbrief structured advice or motivational counselling is the required form of brief nintervention to produce positive behaviour change. This SIPS trial is a pragmatic nevaluation based in regular primary care practices and involving general practitioners nand nurses who deliver screening and brief alcohol intervention during their day-to-day nwork The aim of the trial is to evaluate the effectiveness and cost-effectiveness of ndifferent models of screening to identify excessive drinkers and differing intensities of nbrief intervention to reduce excessive drinking in routine practice. nMethod: GPs and nurses from 24 practices in England were recruited. Practices were nrandomly allocated to one of three brief intervention conditions: a leaflet-only control ngroup (n = 8); five minutes of brief structured advice (n = 8); and twenty minutes of brief nlifestyle counselling (n = 8). Practices were additionally randomised to either universal nor targeted screening and to use either a modified single item (M-SASQ) or the FAST nscreening tool. Practices in each of the three intervention conditions were asked nto recruit at least 31 hazardous or harmful drinkers who received a short baseline nassessment followed by brief intervention. Patients were subsequently followed up at nsix and twelve months after the intervention. nResults: Six month follow-up data will be completed by February 2010. With just one nmonth remaining, the follow-up rate is currently 86% and has included 560 patients. nThe majority of the follow-up work has been via telephone although postal and email nfollow-up have also been used. nDiscussion: The presentation will report not only drinking outcomes following brief nintervention but also quality of life measures and health service use data. The findings nwill answer the key question of whether brief intervention is effective in routine practice nand if structured advice is sufficient to change drinking behaviour in non-treatment nseeking patients or if motivational counselling is more impactful. Finally the costeffectiveness nof these approaches will be outlined.

Alcohol screening and brief intervention in criminal justice settings: prevalence and performance of screening tests

The SIPS study is a major UK evaluation of screening and brief intervention strategies for nalcohol users in primary care, emergency departments and criminal justice settings. Here we npresent the results of a pilot study of screening tools and the main study screening results in nprobation settings. In the pilot study 592 individuals in a variety of settings where approached nand 205 consented to take part in the study. The screening tools being evaluated were the nmodified Single Alcohol Screening Questionnaire and the Fast Alcohol Screening Test. The nGold standard comparison was AUDIT. The mean age in the pilot study was 31 years (SD 9) nand the majority were male. The overall prevalence of alcohol use disorders in the population nwas high at 70% with almost 50% at the dependent end of the spectrum. Those scoring npositive on AUDIT had significantly poorer overall health status and were greater users of nhealth and criminal justice services. A ROC analysis of the instruments demonstrated high nsensitivity and specificity for both M-SASQ and FAST and ROC analysis indicated a marginal nsuperiority of FAST over M-SASQ (AUC 0.97 vs. 0.92). The main study is a pragmatic nfactorial randomised controlled trial set in probation services in the UK. The study compares nscreening tool (FAST vs. M-SASQ) and 3 brief interventions (Patient information leaflet vs. nBrief advice vs. Brief Lifestyle Counselling). A total of 976 individuals were approached and n854 were eligible and screened with 573 screening positive. The initial results indicate a high nprevalence of alcohol use disorders in this population (68%). The sensitivity of M-SASQ and nFAST was high (81% vs. 92%) but FAST appears to be more sensitive than M-SASQ at nidentifying those with more severe alcohol use disorders with an odds ratio for FAST versus nM-SASQ of 2.69 (CI 1.55–4.67) for all alcohol use disorders and 1.58 (CI 1.11–2.24) for nharmful alcohol use disorders. FAST appears to be the most efficient screening mechanism in nthis population but we do not yet know how the screening mechanism interacts with the ntreatment intervention.

Screening and brief alcohol intervention in primary health care: extending the existing evidence base via the UK SIPS trial

The SIPS study is a major UK evaluation of screening and brief intervention strategies for nalcohol users in primary care, emergency departments and criminal justice settings. Here we npresent the results of a pilot study of screening tools and the main study screening results in nprobation settings. In the pilot study 592 individuals in a variety of settings where approached nand 205 consented to take part in the study. The screening tools being evaluated were the nmodified Single Alcohol Screening Questionnaire and the Fast Alcohol Screening Test. The nGold standard comparison was AUDIT. The mean age in the pilot study was 31 years (SD 9) nand the majority were male. The overall prevalence of alcohol use disorders in the population nwas high at 70% with almost 50% at the dependent end of the spectrum. Those scoring npositive on AUDIT had significantly poorer overall health status and were greater users of nhealth and criminal justice services. A ROC analysis of the instruments demonstrated high nsensitivity and specificity for both M-SASQ and FAST and ROC analysis indicated a marginal nsuperiority of FAST over M-SASQ (AUC 0.97 vs. 0.92). The main study is a pragmatic nfactorial randomised controlled trial set in probation services in the UK. The study compares nscreening tool (FAST vs. M-SASQ) and 3 brief interventions (Patient information leaflet vs. nBrief advice vs. Brief Lifestyle Counselling). A total of 976 individuals were approached and n854 were eligible and screened with 573 screening positive. The initial results indicate a high nprevalence of alcohol use disorders in this population (68%). The sensitivity of M-SASQ and nFAST was high (81% vs. 92%) but FAST appears to be more sensitive than M-SASQ at nidentifying those with more severe alcohol use disorders with an odds ratio for FAST versus nM-SASQ of 2.69 (CI 1.55–4.67) for all alcohol use disorders and 1.58 (CI 1.11–2.24) for nharmful alcohol use disorders. FAST appears to be the most efficient screening mechanism in nthis population but we do not yet know how the screening mechanism interacts with the ntreatment intervention.