Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 20 March 2014

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents

NICE sees no reason to alter its call for minimum unit pricing for alcohol. Why in health terms this is preferable to tax rises is apparent from New York state. Waste of time to screen employees for cannabis use, suggests review. Patients stay longer on methadone than buprenorphine – not universally seen as a good thing.

UK alcohol prevention guidance updated ...

Does raising alcohol tax rates save lives? ...

Little evidence for widespread staff testing for cannabis ...

Methadone’s ‘stickiness’; strength or liability? ...


Alcohol-use disorders: Preventing the development of hazardous and harmful drinking.

National Institute for Health and Clinical Excellence
National Institute for Health and Clinical Excellence, 2010.
Unable to obtain a copy by clicking title? Try this alternative source.

In these UK national prevention guidelines, experts prioritised population-wide changes like price rises and outlet restrictions which affect everyone, independent of the choices they make. But in England government prefers to target what they see as the troublesome minority, not the responsible majority.

Summary The UK Department of Health asked the National Institute for Health and Clinical Excellence (NICE) to produce public health guidance on the prevention and early identification of alcohol-use disorders Alcohol-use disorders cover a wide range of mental health problems as recognised within the international disease classification systems (ICD-10, DSM-IV). These include hazardous and harmful drinking and alcohol dependence. among adults and adolescents. The guidance is for government, industry and commerce, the NHS and all those whose actions affect the population’s attitude to – and use of – alcohol. This includes commissioners, managers and practitioners working in local authorities, education and the wider public, private, voluntary and community sectors.

When writing the recommendations, the Programme Development Group considered evidence of effectiveness (including cost-effectiveness), fieldwork data and comments from stakeholders and experts.

Population versus individual approach

A combination of interventions are needed to reduce alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. – to the benefit of society as a whole.

Population-level approaches are important because they can help reduce the aggregate level of alcohol consumed and therefore lower the whole population’s risk of alcohol-related harm. Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. They can help:
• those who are not in regular contact with the relevant services;
• those who have been specifically advised to reduce their alcohol intake, by creating an environment that supports lower-risk Regularly consuming 21 UK units (8g alcohol per unit) per week or less (adult men) or 14 units per week or less (adult women). drinking.

They can also help prevent people from drinking harmful A pattern of alcohol consumption that is causing mental or physical damage. or hazardous A pattern of alcohol consumption that increases someone’s risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. amounts in the first place.

Interventions aimed at individuals can help make people aware of the potential risks they are taking (or harm they may be doing) at an early stage. This is important, as they are most likely to change their behaviour if it is tackled early. In addition, an early intervention could prevent extensive damage.

This NICE guidance provides authoritative recommendations, based on a robust analysis of the evidence, which support current government activities. The recommendations could form part of a national framework for action. National-level action to reduce the population’s alcohol consumption requires coordinated government policy. It also needs government, industry and key non-governmental organisations to work together.

Policy and practice

This guidance makes the case that alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. is a major public health problem. On the basis of the best available evidence, it also identifies the policy options that are most likely to be successful in combating such harm. Policy recommendations (recommendations 1 to 3) are based on extensive and consistent evidence which suggests that the issues identified deserve close attention. This evidence also suggests that policy change is likely to be a more effective – and more cost-effective – way of reducing alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. among the population than actions undertaken by local health professionals. Practice recommendations (4 to 12) support, complement – and are reinforced by – these policy options. They include screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and brief interventions. This can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists.

RECOMMENDATIONS FOR POLICY

The Chief Medical Officer should coordinate the alcohol harm-reduction strategy for England across government, supported by the Department of Health.

The following departments and national agencies should also be involved:
• Advertising Standards Authority;
• Department for Business, Innovation and Skills;
• Department for Children, Schools and Families;
• Department for Culture, Media and Sport;
• Department for Environment, Food and Rural Affairs;
• Department of Communities and Local Government;
• HM Treasury;
• Home Office;
• Ministry of Justice;
• National Treatment Agency;
Ofcom;
• Office of Fair Trading.

Organisations that should be consulted include:
• advertisers;
• alcohol producers;
• national non-governmental organisations (for example, Alcohol Concern and the Royal Medical Colleges);
• off- and on-sale retailers.

Recommendation 1: price

Making alcohol less affordable is the most effective way of reducing alcohol-related harm. Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. The current excise duty varies for different alcoholic products (for historical reasons and under EU legislation). This means that the duty does not always relate directly to the amount of alcohol in the product. In addition, an increase in the duty levied does not necessarily translate into a price increase as retailers or producers may absorb the cost. There is extensive international and national evidence (within the published literature and from economic analyses) to justify reviewing policies on pricing to reduce the affordability of alcohol.

What action could be taken?

Consider introducing a minimum price per unit. A UK unit is 8g alcohol. Set the level by taking into account the health and social costs of alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. and its impact on alcohol consumption. Consider initiating a review of the excise duty regime with fellow EU member states. The aim would be to obtain a pan-EU agreement on harmonisation which links alcohol duty to the strength of each product.

Regularly review the minimum price per unit A UK unit is 8g alcohol. and alcohol duties to ensure alcohol does not become more affordable over time.

Recommendation 2: availability

International evidence suggests that making it less easy to buy alcohol, by reducing the number of outlets selling it in a given area and the days and hours when it can be sold, is another effective way of reducing alcohol-related harm. Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. In Scotland, protection of the public’s health is among the objectives of licensing decisions.

What action could be taken?

Consider revising legislation on licensing to ensure:
• protection of the public’s health is one of its objectives;
• health bodies are responsible authorities; Responsible authorities have to be notified of all licence variations and new applications and can make representations regarding them. The Licensing Act 2003 lists responsible authorities. They include the police, environmental health and child protection services, fire and rescue and trading standards.
• licensing departments can take into account the links between the availability of alcohol and alcohol-related harm Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. when considering a licence application (that is, they can take into account the number of alcohol outlets in a given area and times when it is on sale and the potential links to local crime and disorder and alcohol-related illnesses and deaths);
• immediate sanctions can be imposed on any premises in breach of their licence, following review proceedings.

Consider reducing personal import allowances to support the introduction of a minimum price per unit A UK unit is 8g alcohol. of alcohol.

Recommendation 3: marketing

There is evidence that alcohol advertising does affect children and young people. It shows that exposure to alcohol advertising is associated with the onset of drinking among young people and increased consumption among those who already drink. All of the evidence suggests that children and young people should be protected as much as is possible by strengthening the current regulations.

What action could be taken?

Ensure children and young people’s exposure to alcohol advertising is as low as possible by considering a review of the current advertising codes. This review would ensure:
• the limits set by the Advertising Standards Authority for the proportion of the audience under age 18 are appropriate;
• where alcohol advertising is permitted there is adequate protection for children and young people;
• all alcohol marketing, particularly when it involves new media (for example, web-based channels and mobile phones) and product placement, is covered by a stringent regulatory system which includes ongoing monitoring of practice.

Ofcom, the Advertising Standards Authority and the government should keep the current regulatory structure under review.

Assess the potential costs and benefits of a complete alcohol advertising ban to protect children and young people from exposure to alcohol marketing.

RECOMMENDATIONS FOR PRACTICE

Recommendation 4: licensing

Who is the target population?

Alcohol licence-holders and designated supervisors of licensed premises.

Who should take action?

• Local authorities;
• Trading standards officers;
• The police;
• Magistrates;
• Revenue and customs.

What action should they take?

Use local crime and related trauma data to map the extent of alcohol-related problems before developing or reviewing a licensing policy. If an area is ‘saturated’ Describes a specific geographical area where there are already a lot of premises selling alcohol – and where the awarding of any new licences to sell alcohol may contribute to an increase in alcohol-related disorder. with licensed premises and the evidence suggests that additional premises may affect the licensing objectives, adopt a ‘cumulative impact’ policy. If necessary, limit the number of new licensed premises in a given area.

Ensure sufficient resources are available to prevent under-age sales, sales to people who are intoxicated, proxy sales (that is, illegal purchases for someone who is under-age or intoxicated), non-compliance with any other alcohol licence condition and illegal imports of alcohol.

Work in partnership with the appropriate authorities to identify and take action against premises that regularly sell alcohol to people who are under-age, intoxicated or making illegal purchases for others.

Undertake test purchases (using ‘mystery’ shoppers) to ensure compliance with the law on under-age sales. Test purchases should also be used to identify and take action against premises where sales are made to people who are intoxicated or to those illegally purchasing alcohol for others.

Ensure sanctions are fully applied to businesses that break the law on under-age sales, sales to those who are intoxicated and proxy purchases. This includes fixed penalty and closure notices (the latter should be applied to establishments that persistently sell alcohol to children and young people).

Recommendation 5: resources for screening and brief interventions

Who is the target population?

Professionals who have contact with those aged 16 and over.

Who should take action?

• Chief executives of NHS and local authorities;
• Commissioners of NHS healthcare services;
• Commissioners from multi-agency joint commissioning groups;
• Managers of NHS-commissioned services.

What action should they take?

Chief executives of NHS and local authorities should prioritise alcohol-use disorder Alcohol-use disorders cover a wide range of mental health problems as recognised within the international disease classification systems (ICD-10, DSM-IV). These include hazardous and harmful drinking and alcohol dependence. prevention as an ‘invest to save’ measure.

Commissioners should ensure a local joint alcohol needs assessment is carried out in accordance with World class commissioning and Signs for improvement. They should also ensure locally defined integrated care pathways for alcohol treatment are reviewed.

Commissioners should ensure their plans include screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and brief interventions This can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists. for people at risk of an alcohol-related problem – hazardous A pattern of alcohol consumption that increases someone’s risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. drinkers – and those whose health is being damaged by alcohol – harmful A pattern of alcohol consumption that is causing mental or physical damage. drinkers. This includes people from disadvantaged groups.

Commissioners should make provision for the likely increase in the number of referrals to services providing tier two, three and four structured alcohol treatments as a result of screening. For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. These services should be properly resourced to support the stepped care approach recommended in Models of care for alcohol misusers.

Commissioners should ensure at least one in seven dependent drinkers can get treatment locally, in line with Signs for improvement.

Commissioners should include formal evaluation within the commissioning framework so that alcohol interventions and treatment are routinely evaluated and followed up. The aim is to ensure adherence to evidence-based practice and to ensure interventions are cost effective.

Managers of NHS-commissioned services must ensure an appropriately trained nurse or medical consultant, with dedicated time, is available to provide strategic direction, governance structures and clinical supervision to alcohol specialist nurses and care givers.

Managers of NHS-commissioned services must ensure community and voluntary sector providers have an appropriately trained professional who can provide strategic direction, governance structures and supervision to those providing screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and brief interventions. This can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists.

Managers of NHS-commissioned services must ensure staff have enough time and resources to carry out screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and brief intervention This can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists. work effectively. Staff should have access to recognised, evidence-based packs. These should include: a short guide on how to deliver a brief intervention, This can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists. a validated screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. questionnaire, a visual presentation (to compare the person’s drinking levels with the average), practical advice on how to reduce alcohol consumption, a self-help leaflet and possibly a poster for display in waiting rooms.

Managers of NHS-commissioned services must ensure staff are trained to provide alcohol screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and structured brief advice. A brief intervention that takes only a few minutes to deliver. If there is local demand, staff should also be trained to deliver extended brief interventions. This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’.

Recommendation 6: supporting children and young people aged 10 to 15 years

Who is the target population?

Children and young people aged 10 to 15 years who are thought to be at risk from their use of alcohol.

Who should take action?

Any professional with a safeguarding responsibility for children and young people and who regularly comes into contact with this age group.

What action should they take?

Use professional judgement to routinely assess the ability of these children and young people to consent to alcohol-related interventions and treatment. Some will require parental or carer involvement.

Obtain a detailed history of their alcohol use (for example, using the Common Assessment Framework as a guide). Include background factors such as family problems and instances of child abuse or under-achievement at school.

Use professional judgement to decide on the appropriate course of action. In some cases, it may be sufficient to empathise and give an opinion about the significance of their drinking and other related issues that may arise. In other cases, more intensive counselling and support may be needed.

If there is a reason to believe that there is a significant risk of alcohol-related harm, Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. consider referral to child and adolescent mental health services, social care or to young people’s alcohol services for treatment, as appropriate and available.

Ensure discussions are sensitive to the child or young person’s age and their ability to understand what is involved, their emotional maturity, culture, faith and beliefs. The discussions (and tools used) should also take into account their particular needs (health and social) and be appropriate to the setting.

Recommendation 7: screening young people aged 16 and 17 years

Who is the target population?

Young people aged 16 and 17 years who are thought to be at risk from their use of alcohol.

Who should take action?

Health and social care, criminal justice and community and voluntary professionals in both NHS and non-NHS settings who regularly come into contact with this group.

What action should they take?

Complete a validated alcohol screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. questionnaire with these young people. Alternatively, if they are judged to be competent enough, ask them to fill one in themselves. In most cases, AUDIT should be used. If time is limited, use an abbreviated version (such as AUDIT-C, AUDIT-PC, CRAFFT, SASQ or FAST). Screening tools should be appropriate to the setting. For instance, in an emergency department, FAST or the Paddington Alcohol Test (PAT) would be most appropriate.

Focus on key groups that may be at an increased risk of alcohol-related harm. Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of alcohol, it is known as ‘alcohol-specific’. If it is only partly caused by alcohol it is described as ‘alcohol-attributable’. This includes those:
• who have had an accident or a minor injury;
• who regularly attend genito-urinary medicine (GUM) clinics or repeatedly seek emergency contraception;
• involved in crime or other antisocial behaviour;
• who truant on a regular basis;
• at risk of self-harm;
• who are looked after;
• involved with child safeguarding agencies.

When broaching the subject of alcohol and screening, For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. ensure discussions are sensitive to the young person’s age and their ability to understand what is involved, their emotional maturity, culture, faith and beliefs. The discussions should also take into account their particular needs (health and social) and be appropriate to the setting.

Routinely assess the young person’s ability to consent to alcohol-related interventions and treatment. If there is doubt, encourage them to consider involving their parents in any alcohol counselling they receive.

Recommendation 8: extended brief interventions with young people aged 16 and 17 years

Who is the target population?

Young people aged 16 and 17 years who have been identified via screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. as drinking hazardously A pattern of alcohol consumption that increases someone’s risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. or harmfully. A pattern of alcohol consumption that is causing mental or physical damage.

Who should take action?

Health and social care, criminal justice and community and voluntary sector professionals in both NHS and non-NHS settings who regularly come into contact with this group.

What action should they take?

Ask the young person’s permission to arrange an extended brief intervention This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. for them.

Appropriately trained staff should offer the young person an extended brief intervention. This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’.

Provide information on local specialist addiction services to those who do not respond well to discussion but who want further help. Refer them to these services if this is what they want. Referral must be made to services that deal with young people.

Give those who are actively seeking treatment for an alcohol problem a physical and mental assessment and offer, or refer them for, appropriate treatment and care.

Recommendation 9: screening adults

Who is the target population?

Adults.

Who should take action?

Health and social care, criminal justice and community and voluntary sector professionals in both NHS and non-NHS settings who regularly come into contact with people who may be at risk of harm from the amount of alcohol they drink.

What action should they take?

NHS professionals should routinely carry out alcohol screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. as an integral part of practice. For instance, discussions should take place during new patient registrations, when screening for other conditions and when managing chronic disease or carrying out a medicine review. These discussions should also take place when promoting sexual health, when seeing someone for an antenatal appointment and when treating minor injuries.

Where screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. everyone is not feasible or practicable, NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and those with an alcohol-related condition. This includes people:
• with relevant physical conditions (such as hypertension and gastrointestinal or liver disorders);
• with relevant mental health problems (such as anxiety, depression or other mood disorders);
• who have been assaulted;
• at risk of self-harm;
• who regularly experience accidents or minor traumas;
• who regularly attend GUM clinics or repeatedly seek emergency contraception.

Non-NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and people who have alcohol-related problems. For example, this could include those:
• at risk of self-harm;
• involved in crime or other antisocial behaviour;
• who have been assaulted;
• at risk of domestic abuse;
• whose children are involved with child safeguarding agencies;
• with drug problems.

When broaching the subject of alcohol and screening, For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. ensure the discussions are sensitive to people’s culture and faith and tailored to their needs.

Complete a validated alcohol questionnaire with the adults being screened. For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. Alternatively, if they are competent enough, ask them to fill one in themselves. Use AUDIT to decide whether to offer them a brief intervention This can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). Both aim to help someone reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-alcohol specialists. (and, if so, what type) or whether to make a referral. If time is limited, use an abbreviated version (such as AUDIT-C, AUDIT-PC, SASQ or FAST). Screening tools should be appropriate to the setting. For instance, in an emergency department FAST or PAT would be most appropriate.

Do not offer simple brief advice to anyone who may be dependent on alcohol. Instead, refer them for specialist treatment (see recommendation 12). If someone is reluctant to accept a referral, offer an extended brief intervention This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. (see recommendation 11).

Use professional judgement as to whether to revise the AUDIT scores downwards when screening:
• women, including those who are, or are planning to become, pregnant;
• younger people (under the age of 18);
• people aged 65 and over;
• people from some black and minority ethnic groups.
If in doubt, consult relevant specialists. Work on the basis that offering an intervention is less likely to cause harm than failing to act where there are concerns.

Consult relevant specialists when it is not appropriate to use an English language-based screening questionnaire, for example, when dealing with people whose first language is not English or who have a learning disability.

Biochemical measures including of blood alcohol concentration should not be used as a matter of routine to screen For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. someone to see if they are drinking hazardously A pattern of alcohol consumption that increases someone’s risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. or harmfully. A pattern of alcohol consumption that is causing mental or physical damage. Biochemical measures may be used to assess the severity and progress of an established alcohol-related problem, or as part of a hospital assessment, including assessments carried out in emergency departments.

Recommendation 10: brief advice for adults

Who is the target population?

Adults who have been identified via screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. as drinking a hazardous A pattern of alcohol consumption that increases someone’s risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. or harmful A pattern of alcohol consumption that is causing mental or physical damage. amount of alcohol and who are attending NHS or NHS-commissioned services or services offered by other public institutions.

Who should take action?

Professionals who have received the necessary training and work in:
• primary healthcare;
• emergency departments;
• other healthcare services (hospital wards, outpatient departments, occupational health, sexual health, needle and syringe exchange programmes, pharmacies, dental surgeries, antenatal clinics and those commissioned from the voluntary, community and private sectors);
• the criminal justice system;
• social services;
• higher education;
• other public services.

What action should they take?

Offer a session of structured brief advice A brief intervention that takes only a few minutes to deliver. on alcohol. If this cannot be offered immediately, offer an appointment as soon as possible thereafter.

Use a recognised, evidence-based resource that is based on FRAMES Feedback (on the client’s risk of having alcohol problems), responsibility (change is the client’s responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change). principles. It should take 5–15 minutes and should:
• cover the potential harm caused by their level of drinking and reasons for changing the behaviour, including the health and wellbeing benefits;
• cover the barriers to change;
• outline practical strategies to help reduce alcohol consumption, to address the ‘menu’ component of the FRAMES Feedback (on the client’s risk of having alcohol problems), responsibility (change is the client’s responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change). model;
• lead to a set of goals.

Where there is an ongoing relationship with the patient or client, routinely monitor their progress in reducing their alcohol consumption to a low-risk level. Where required, offer an additional session of structured brief advice. A brief intervention that takes only a few minutes to deliver. or, if there has been no response, offer an extended brief intervention. This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’.

Recommendation 11: extended brief interventions for adults

Who is the target population?

Adults who have not responded to structured brief advice. A brief intervention that takes only a few minutes to deliver. on alcohol and require an extended brief intervention This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. or would benefit from this for other reasons.

Who should take action?

NHS and other professionals in the public, private, community and voluntary sectors who are in contact with adults and have received training in extended brief intervention This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. techniques.

What action should they take?

Offer an extended brief intervention This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. to help people address their alcohol use. This could take the form of motivational interviewing or motivational-enhancement therapy. Sessions should last from 20 to 30 minutes. They should aim to help people to reduce the amount they drink to low risk levels, reduce risk-taking behaviour as a result of drinking, or to consider abstinence.

Follow up and assess people who have received an extended brief intervention. This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. Where necessary, offer up to four additional sessions or referral to a specialist alcohol treatment service (see recommendation 12).

Recommendation 12: referral

Who is the target population?

Those aged 16 years and over who attend NHS or other public services and may be alcohol-dependent. (For those under 16 see recommendation 6.)

Who should take action?

NHS and other professionals in the public, private, community and voluntary sectors who have contact with anyone aged 16 and over.

What action should they take?

Consider making a referral for specialist treatment if one or more of the following has occurred. They:
• show signs of moderate or severe alcohol dependence; A cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations.
• have failed to benefit from structured brief advice A brief intervention that takes only a few minutes to deliver. and an extended brief intervention This is motivationally-based and can take the form of motivational-enhancement therapy or motivational interviewing. The aim is to motivate people to change their behaviour by exploring with them why they behave the way they do and identifying positive reasons for making change. In this guidance, all motivationally-based interventions are referred to as ‘extended brief interventions’. and wish to receive further help for an alcohol problem;
• show signs of severe alcohol-related impairment or have a related co-morbid condition (for example, liver disease or alcohol-related mental health problems).

An update on the evidence behind the report was published in March 2014. None of the new findings were considered to possibly requires changes to the original guidance. Among these, new studies on alcohol pricing were considered to strengthen the original recommendations and in particular the call for a minimum unit price. Similarly considered strengthened were calls for controls on availability and in particular restricting the concentration of alcohol outlets and controlling marketing. Evidence from the SIPS studies in England on primary care screening and brief interventions was considered unlikely to have an impact on the original recommendations.


Findings logo commentary The expert group responsible for the featured report were all in a position to be well aware of the dangers of drinking and/or involved in initiatives to curtail these, and their remit was to recommend ways to cut the risks. There were no alcohol industry representatives or ‘ordinary’ members of the (overwhelmingly) drinking public. The report which emerged focused almost entirely on dangers; the only benefit acknowledged was a possible reduction in the risk of some cardiovascular diseases among certain sections of the population; overall, the verdict was that “drinking alcohol is never without risk”.

Most eggs in pricing and availability baskets

When it came to how to reduce the risks, their report firmly prioritised national policy initiatives to tighten the alcohol availability environment in ways which affect the entire population, independent of each individual’s choices. Most importantly of all, alcohol would become less affordable (by setting a minimum price per unit A UK unit is 8g alcohol. of alcohol), but it would also become less available in other ways (by reducing the number of outlets and times they can sell) and less visible and visibly acceptable (through the implementation of stringent controls on marketing, particularly of the kind which might influence young people).

Such actions are thought “likely to be a more effective – and more cost-effective – way of reducing alcohol-related harm among the population than actions undertaken by local health professionals”. The expected impact was to cut average consumption across the nation and with it the population’s risk of alcohol-related harm. Benefits will it was thought be experienced across the board. Even dependent drinkers are expected to cut back and/or become fewer. This will happen because the average level of drinking across a population is linked to the extent of excessive drinking. As the former recedes, so too will the latter, cutting the tally of people with severe alcohol-related problems. This new environment is expected to be more conducive to individual-level interventions, helping tip the balance towards moderation in the way individuals respond to advice to cut back, brief interventions, and treatment.

These lines of argument are plausible and backed by considerable evidence, though little which directly tests the underlying assumptions. More below.

In the British context, the reliability of the links between average consumption and the prevalence of excessive drinking and harm seem challenged by experience from 1990 to 2010, when a drop in average consumption was paired with a rise in heavy episodic drinking. Rather than the two varying together, it has been argued that there was a “polarisation of the distribution of consumption ... heavy drinkers drink even higher volumes whilst moderate drinkers appear to have decreased their average intake”. In turn it was argued, this partly explains why the expected co-variation of average consumption and harm failed to materialise. Instead there was a “continuing increase in alcohol related morbidity and mortality, despite a recent downturn in population level consumption”.

While this calls in to question the presumed impact of availability restrictions on excessive drinking, it by no means invalidates it. What caused recent per capita drinking reductions is unclear, but it was certainly not explicit policies to cut availability. It could be that a reduction caused by such policies would reduce excessive drinking and related harm. This was the conclusion of research led by the author responsible for the questioning observations referred to above, though largely on the basis of studies which related harm to each individual’s intake, rather than the average across a society. Also, health gains among moderate drinkers of the kind associated with slightly lowering consumption (such as a gradual cumulative impact on chronic diseases) take years or decades to become apparent, while some associated with fewer heavy drinkers (such as reduced accidents and injuries) are immediate or more rapid. Given these time scales, it could be that the recent reduction in average consumption in Britain really will be associated with the expected improvement in health across the population.

Support for the report’s priorities comes from two recent reviews. One judged there was strong evidence that raising alcohol taxes reduced both excessive alcohol consumption and related harms, though it relied primarily on North American studies; even within Europe, a given consumption change has impacts which differ greatly across nations. Another gap in the analysis was that it was unable to explicitly account for the potential impact of drinkers switching to other beverages. The second review focused on tax and price impacts on health. It found a weak but statistically significant link between higher prices and taxes and better health, mortality and other health and social improvements, which was probably due to higher prices curbing consumption. However, all but one study fell short of assessing the impact on all deaths from whatever cause; the others may have missed some impacts positive or negative. The exception which did assess overall mortality found this weakly related to US state alcohol taxes, such that higher taxes were associated with fewer deaths, but the link was not strong enough to eliminate the possibility According to the conventional criterion of a less than a 1 in 20 chance that the findings were due to chance. that it was due to chance rather than to a real causal effect.

Screening: not universal but still important

Mass screening in GPs’ surgeries, accident and emergency departments, hospitals and elsewhere was recently seen as a feasible and effective way to reduce the public health burden of drinking which exceeds national ‘safe drinking’ guidelines. Now the ambition in England and Scotland has been scaled back to screening new patients and/or those thought possibly at risk, diluting the hoped-for public health benefits of a mass programme. This change is reflected in the featured report, which without being entirely explicit, encourages screening to take place only in circumstances where both patient and doctor might feel it was ‘natural’ and justified to ask about a patient’s drinking. The evidence appendix cautions that, “Clinical consultations for non-alcohol-related medical problems can be an inappropriate time to discuss alcohol use, given that users are focused on the condition for which they are seeking advice”, and recognises the greater acceptability of discussing drinking “in a context that is related to the purpose of the visit (such as lifestyle assessment or chronic condition monitoring)”. Quality standards developed by NICE and based partly on the featured report are however explicit that the expectation is that staff will screen “opportunistically”, meaning as the opportunity presents itself, which is in turn expected to be in certain types The standards say that NHS professionals should consider discussing alcohol consumption during new patient registrations at a GP practice, when screening for other conditions, and when managing chronic disease or carrying out a medicine review. Discussions should also take place when promoting sexual health, when seeing someone for an antenatal appointment and when treating minor injuries.
Social care professionals should focus on people who may be at an increased risk of harm and people who have alcohol-related problems.
of medical encounters but not others.

Even in this less ambitious form, screening remains important. Diligently implementing it in the recommended circumstances and for the recommended patients (which include new patient registrations and medicine reviews) could cumulate over the years to a high-coverage programme, and minor gains per individual can sum to appreciable public health gains.

Whether this will happen depends on how widely screening and brief interventions are implemented and how effective they are. On both counts the SIPS studies in England give little reassurance. A report has been published on the primary care findings and informal reports were made available on the study’s emergency department and probation trials. NICE’s update report considered these findings unlikely to have an impact on the original recommendations, but this itself seems unlikely.

In all the SIPS studies it seems that a year later the proportion of risky drinkers had fallen by about a sixth, and whatever the intervention, it made no substantial difference. Most basic was a simple warning that the patient or offender was drinking “above safe levels, which may be harmful to you” plus advice to read the alcohol information and advice booklet handed to the client. Supplementing this with an individualised brief intervention based on relatively sophisticated counselling techniques and scientific understandings made no difference, seemingly undermining the featured report’s specification that brief interventions should use a recognised, evidence-based resource based on FRAMES Feedback (on the client’s risk of having alcohol problems), responsibility (change is the client’s responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change). principles. In SIPS too, even among what should have been the most promising settings, numbers screened also seem to have been small and achieving them often required specialist support – a finding which might shake confidence in whether such initiatives can affect population-wide health unless backed by sufficiently persuasive carrots and/or sticks to encourage widespread and effective implementation.

One in seven?

NICE’s report follows its predecessors in stipulating that provision be made for at least one in seven dependent drinkers to be treated in each local area. This Findings analysis reveals that this proportion is based on assumptions and findings of questionable relevance to the UK, and that depending on how you define treatment need, treatment services in England may be capturing numbers equivalent to an abysmal 7% of harmful drinkers ranging up to a creditable 40% or more of those also at least moderately dependent. The conclusion is that while we may suspect that in 2012/13 capturing 110,000 of England’s problem drinkers in treatment was not enough, there is no clear way to determine whether this was the case.

Policy plusses and minuses

For more see these hot topics on pricing policy, on controlling alcohol-related disorder including licensing law and allied developments, and on brief interventions.

In 2011 the UK government’s Home Office hedged its bets on the key tactic recommended in the featured report – an across-the-board and appreciable price rise – judging that “on balance” the evidence “suggests” that increasing the price of alcohol “may” reduce alcohol-related harms. It also pointed out that there were other influences on consumption and harm which operate at the level of the individual or of drinking cultures and environments rather than national taxation and availability restrictions.

So far it is these more restricted levers which the UK government prefers to rely on most, applying them to what is perceived as particularly troublesome drinkers/drinking patterns (especially young ‘binge’ drinkers), while avoiding population-wide measures of the kind advocated by NICE and other public health and alcohol experts. The following year, the 2012 alcohol strategy’s commitment to a minimum per unit price for England was abandoned on the grounds that it might penalise responsible drinkers. However, the Scottish government is pressing ahead with legislation which may yet be derailed by arguments that minimum pricing contravenes UK devolution and/or European Union free trade laws. Despite this being introduced seemingly successfully in Scotland, elsewhere in the UK it was a similar story with respect to the now abandoned proposal to ban off-licence promotions offering discounts contingent on buying several drinks at once.

Outside Scotland, the major pricing initiative is a ‘below-cost’ price ban to be implemented subject to parliamentary approval by April 2014. It will affect very few promotions and is intended to target ‘problem’ drinkers, on whom it is projected to have little impact. Additionally, Public Health Responsibility Deal agreements with the alcohol industry loosely commit them to implement guidelines on issues such as under-age sales, responsible marketing, and labelling.

Some of what the featured report wanted on licensing law has been implemented, but not in England and Wales making health impact a relevant issue in licensing decisions, seen as a key change by campaigners for more health-oriented alcohol policies. In Scotland prevention of health harm has for several years been among the objectives which must be considered while making licensing decisions. However, in what may prove a step in this direction, as called for by the featured report, from 2012 licensing authorities in England and Wales have themselves been ‘responsible authorities’ under licensing law, meaning they can initiate action for example to oppose new licences or review an existing licence.

For the great majority of drinkers in England and Wales, little will change as a result of these initiatives and nor will their drinking change, unless they choose to make these changes in response to other influences.

Action on brief interventions in England includes an expectation that Directors of Public Health will include these among attempts to address the population-wide determinants of ill health. As yet no decision has been made to incorporate alcohol screening and brief intervention in to the national quality framework for primary care, a major national practice driver. However, screening remains among the practices commissioners must offer to incentivize through cash rewards. From April 2013 this work was also incorporated in the NHS Health Check for older adults.

Scottish national policy is more prescriptive, prioritising screening and brief intervention, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions supported by dedicated funding. The target was exceeded and has been extended to later years. An evaluation found that “healthcare staff saw the delivery of [alcohol brief interventions] as a worthwhile activity for NHS staff”, but of the three settings, only primary care practices really accepted the challenge. Even there it seems most risky drinkers were not screened and the quality of the work was unclear; emergency departments and ante-natal clinics accounted for few patients.

Related guidance

Other related NICE guidance documents are listed below.

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence Assessment of what evaluation research means for alcohol dependence treatment in Britain, featuring reviews of the literature on the topics it covers.

Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications Clinical guidelines on the medical care of people suffering acute alcohol withdrawal or alcohol-related lack of thiamine, liver disease, or inflammation of the pancreas.

Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults Guidance for commissioners on how to organise and procure alcohol treatment and brief intervention services in an area which implement related national clinical guidance and satisfy policy requirements.

Alcohol dependence and harmful alcohol use quality standard Concise statement of 13 practices which constitute high quality health care for problem drinkers and good practice in identifying and advising hazardous drinkers. The standards may be used to assess and reward providers and health service commissioning authorities.

Thanks for their comments on the original entry to Iain MacAllister of the Health Analytical Services Division of the Scottish Government and Eileen Kaner of the Institute of Health and Society at Newcastle University who chaired the expert group behind the report. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 12 March 2014. First uploaded 05 November 2010

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DOCUMENT 2012 The government's alcohol strategy

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STUDY 2014 Monitoring and evaluating Scotland’s alcohol strategy. Fourth annual report

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STUDY 2008 Independent review of the effects of alcohol pricing and promotion





Effects of alcohol taxes on alcohol-related disease mortality in New York state from 1969 to 2006.

Delcher, C., Maldonaldo-Molina, M.M., Wagenaar, A.C.
Addictive Behaviours: 2012(37) p.783–789
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Delcher at chris.delcher@gmail.com. You could also try this alternative source.

Changing alcohol tax rates in New York state mostly did not significantly affect the number of people who died from alcohol related diseases, perhaps as overall tax rates were still very low, and increases or decreases not always applied to all types of alcohol at once.

Summary Unusually for the USA, New York state has increased and decreased alcohol taxes, sometimes for only one type of beverage, and sometimes for several. Researchers aimed to exploit this variety to examine whether tax rises reduce alcohol-related deaths, and reductions increase deaths. They also aimed to see whether tax changes for just one type of beverage – beer, for example – had a different effect compared to changes that applied to all types. The study was for New York state, which has average drinking levels, and excluded New York City, which levies separate taxes. They focused on the relatively poorly researched issue of deaths from alcohol-related diseases, such as cirrhosis, rather than alcohol consumption or alcohol-related injuries and suicide.

The method involved collecting data for the number of alcohol-related deaths in New York state each month, for 456 months from 1969-2006. The researchers included deaths which were registered as 100 per cent attributable to alcohol, such as those from alcohol poisoning or alcoholic liver disease, and deaths from certain diseases which are in part caused by alcohol, including for example liver cirrhosis. They then examined legal records and calculated the different tax rates for beer, wine and spirits over the years, noting nine occasions when the tax rates for at least one of these changed. Statistical analysis was then performed to see the effect that the tax changes had on mortality rates. An attempt was made to exclude influences All analyses also adjusted for inflation and changes in average income in the state. other than tax changes by checking whether trends in alcohol-related disease death rates in New York state departed from those in other parts of the USA, and from trends in other deaths in New York state. If departures were linked to New York state’s tax changes, it would suggest these tax changes had indeed affected the numbers who died from alcohol-related diseases.

Main findings

Overall between 1969 and 2006, it was estimated that a $1 per gallon increase in the tax on beer would have been associated with 89 fewer alcohol-related deaths per month. This corresponds to a reduction of just under one (0.82) death per 100,000 of the state’s population, amounting to 34% of all alcohol-related deaths. Extrapolating the figures further, it was estimated that doubling beer taxes would have been associated with a 7% fall in alcohol-related deaths.

In 1990, both beer (from $0.11 per gallon to $0.21) and spirits ($5.29 to $6.44) taxes rose substantially, afterwards alcohol-related deaths fell by 7% per 100,000 of the state population. Proportionately slightly greater tax rises the year before, along with a substantial increase in wine taxes, were not associated with a statistically significant increase in the death rate, but did seem to have obscured the full impact of the later rises.

Smaller simultaneous tax increases on beer, wine and spirits in 1983 were not significantly associated with alcohol-related disease deaths. Neither were a substantial increase in sprits taxes in 1972, nor four small decreases in beer taxes.

The authors' conclusions

Tax increases for all kinds of alcohol simultaneously are more effective at reducing alcohol-related deaths than increases only on one specific kind of alcoholic drink. It should be noted that changes in the alcohol tax rates in New York state can make relatively little difference to the overall price that the consumer pays, with some beer tax reductions amounting to only one to two cents per gallon, which may be too little to have any effect on alcohol mortality.

Simultaneously increasing tax on all kinds of alcohol reduces alcohol-related disease deaths more than increases limited to one kind of drink. The impacts are most noticeable the greater the increases.

One reason for the non-significant results could be that that many of the tax changes were too small to greatly affect the price to the consumer. Results may be most applicable to other US states with, in US terms, an average level of drinking.


Findings logo commentary Nearly 90 fewer alcohol-related disease deaths per month for every $1 per gallon increase in beer tax sounds impressive, but this is a hypothetical figure, extrapolated from increases which at most reached $0.10 per gallon. Nonetheless, the 7% reduction in alcohol-related disease deaths following the near-doubling of beer duty in 1990, with a concurrent rise in spirit tax, does appear encouraging. Given that other tax changes, both increases and decreases, were not associated with significant changes in mortality, the take-home message seems to be that tax rises have to be both substantial and across the main types of beverages if they are to prevent deaths due alcohol-related disease – not surprising given that, as the researchers note, many of the tax changes were very small and may not have been passed on to consumers.

Although they have examined in detail the relationship between alcohol excise taxes and mortality, the researchers have not produced data on two important links in the causal chain: the overall consumer price of alcohol, and the level of alcohol consumption. If excise taxes lower alcohol-related mortality, they probably do so by raising overall consumer alcohol prices, nudging drinkers to buy and consume less alcohol. But in this study we cannot know whether tax rises did actually lead to higher prices; perhaps retailers lowered profit margins to compensate. Indeed, the ability of retailers to absorb alcohol duty increases, and concerns about below-cost sale of alcohol as a loss leader, have led the UK to consider a minimum price per unit of alcohol rather than duty increases. Likewise, if tax rises had immediately led to falls in consumption followed by decreased mortality, it would have been safer to assume a causal relationship. Given that many of the studied tax price changes were small and close together, and alcohol-related diseases might take many years to develop and result in death, without the consumption data it is harder to securely link mortality to tax.

This finding chimes with the results of one major review, which found strong evidence that tax rises can be effective for reducing alcohol consumption and related harms, but that the impact of this can be expected to be proportional to the size of the consequent price rise. As noted in the Findings analysis of that review, it is well established that higher prices lead to less consumption, but the relationship between taxes and prices is complex - a general rise in tax will not lead to the same proportionate rise in prices across different types of drink sold under different licensing conditions.

It must also be noted that the findings hinge largely on comparing New York state alcohol deaths with those elsewhere in the USA, but we are not provided with any information as to what changes in alcohol taxes may have occurred elsewhere. It is possible, for example, that the apparent decrease in deaths after the 1990 tax increases in New York are really a reflection of other states reducing taxes. Similarly, perhaps the 1989 tax increases did not have a significant impact because other states also increased taxes at that time. An explanation for the lack of impact of these increases is needed, as the increases were larger – especially for wine – than the changes in 1990, which were judged to have an impact.

Importantly, the rates of alcohol duty in New York state quoted in the study, even at their highest, were much lower than in the UK. Quick calculations The current rate of alcohol duty in the UK for spirits is £28.22 per litre of pure alcohol. There are 3.8 litres in a US gallon, meaning a rate of £107 per gallon of pure alcohol. This gives a UK duty rate of roughly £43 per US gallon for a spirit of 40% alcohol by volume, which would have attracted only $6.44 duty in New York state at any time between 1990 and the end of the study period in 2006. UK duty on a hectolitre of wine of between 5.5% and 15% alcohol by volume is £267. With 26.4 US gallons in a hectolitre, and the New York state wine duty at $0.19 per gallon since 1989, the New York equivalent to that £267 is just $5., whilst not adjusting for inflation, make this clear. A US gallon of 40% alcohol spirit would currently attract £43 in UK duty, compared with only $6.44 in New York state at any time between 1990 and the end of the study period in 2006. A hectolitre of normal strength wine attracts £267 in UK duty, but in New York state any time since 1989 would have attracted just $5. We do not even need to attempt to convert currencies to see that alcohol tax rates are many times greater in the UK.

For more information on current UK duty rates, as well as on plans to make it illegal to sell alcohol for less than the price of duty plus VAT, see this Home Office guidance document.

To see analysis of much more research around alcohol pricing and taxation, see this Findings search, and for a discussion of minimum alcohol pricing, see this Hot Topic.

Last revised 25 February 2014. First uploaded 18 February 2014

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Testing for cannabis in the work-place: a review of the evidence.

Macdonald S., Hall W., Roman P. et al.
Addiction: 2010, 105, p. 408–416.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Macdonald at scottmac@uvic.ca. You could also try this alternative source.

A review of 20 years of research on cannabis testing at work found that the patchy evidence permitted few strong conclusions about effectiveness. Given the lack of evidence, it seems wise for UK guidance to limit workplace testing to those who really warrant it because of their jobs, rather than advocating widespread testing as a deterrent.

Summary Reviewing 20 years of scientific literature, researchers aimed to assess the evidence behind various aspects of workplace cannabis testing. As in many other countries in Europe, in the UK workplace drug testing is limited primarily to professions where drug use might cause a significant risk to safety, such as transport or the military. By contrast, in the United States workplace drug testing is much more common (80% of Fortune 1000 companies have a drug testing programme) and aims not only to prevent risks to safety but primarily to reduce drug use by employees.

As the most commonly used and most commonly detected drug, the review was limited to cannabis, detected in just over 2% of workplace drug tests in the USA compared to compared to about 0.6% for cocaine. To examine the evidence behind workplace cannabis testing, the reviewers searched for research which could help answer the following questions:
• Do the acute effects of cannabis impair performance?
• Does cannabis withdrawal impair performance?
• Are long-term cannabis users at increased risk of job accidents?
• Are those who test positive for cannabis or who self-report use at increased risk for injuries or accidents?
• Does workplace drug testing deter drug use among employees?
• Does workplace drug testing reduce injuries or accidents?

In assessing the findings greater weight was given to well-designed studies with a lower risk of bias or inaccuracy.

Main findings

Comprehensive research reviews have found that the immediate effects of cannabis can cause performance deficits, affecting perceptual and motor skills, attention, decision-making, learning and short-term memory. These effects last roughly four hours after smoking cannabis. It was judged unlikely that deficits would persist until the next day. One much cited study which found otherwise was so poorly designed that its results could not be relied on. Well designed studies using blood tests have generally found a link between cannabis use and being involved in motor vehicle crashes, and the weight of the evidence suggests that cannabis use impairs driving performance – and that it might therefore impair performance at work.

There is some evidence that heavy cannabis users who stop using suddenly may suffer mild agitation, appetite changes and disturbance to sleep. It is unlikely that these effects appreciably affect workplace performance.

Some studies have found that long-term heavy use of cannabis could impair cognitive functioning, but problems with the design of the studies make it difficult to draw firm conclusions; other studies have not found such an effect, and even if it is real, its relevance to functioning in daily life and the risk of accidents is unclear.

Many studies have tried to find out if people who either test positive or report using cannabis are more likely to have injuries or accidents compared to those who do not. The results are mixed, and even if there is a link, it is unclear whether this is an effect of cannabis use or some other factor, such as people prone to taking risks also being more likely to use cannabis; in this scenario it is their risk-taking that causes accidents, not their cannabis use. Studies based on urine testing have generally not found that drivers who have crashed or been responsible for an accident are more likely to test positive for cannabis than other drivers, and those which did find this were often undermined by methodological limitations.

It is not possible to draw firm conclusions from the mixed results of the research, but it is probable that after workplace drug testing is implemented, the proportion of employees testing positive falls. It is not known if this is because employees stop using cannabis or if over time they learn to cheat the tests.

Evaluations of whether drug testing programmes have led to fewer injuries or accidents suffer from serious methodological flaws. Typically, testing was only one of a number of safety improvements put in place at the same time, making it impossible to attribute any reduction in accidents to testing itself. Sometimes too what appears to be an impact of testing may simply reflect generally declining workplace accidents and injuries. Since few employees use cannabis, and accidents have a very wide range of causes, large samples are needed to detect what is likely to be at most a small effect.

The authors’ conclusions

Many of the studies of the effects of workplace drug testing suffer from design and analysis weaknesses, making it easy to draw conclusions not actually supported by the evidence. The best studies have examined the relationship between driving crashes and cannabis. In those which relied on blood tests, people who had crashed were between 1.4 and 6.6 times more likely to have used cannabis, but studies based on urine tests failed to find any association. The lesson is that blood testing is a more accurate way to assess impairment than urine testing, but this should be weighed against its greater intrusiveness. Employees should at least be given the option to request the more accurate blood test before being punished as a result of a finding from a urine test.

In the USA the primary aim of workplace drug testing is to deter drug use, but declining numbers of employees testing positive for cannabis cannot securely be attributed to drug testing. Possibly this reflects a general trend of declining drug use or more people finding better ways to ‘cheat’ the tests. Due to limitations of the research, it is also not possible to say that testing programmes reduce accidents or injuries. Employers should consider the relative merits of testing for alcohol rather than drugs, given that more people drink than use drugs, and the consequences may be worse – in particular in relation to road crashes, with which alcohol is associated much more strongly than cannabis.


Findings logo commentary Taking its questions in turn, the answers from this review appear to be:
• Do the acute effects of cannabis impair performance? Yes, but only for the few hours it remains active in the body.
• Does cannabis withdrawal impair performance? Not known but unlikely to be any appreciable impact.
• Are long-term cannabis users at increased risk of job accidents? No direct evidence and findings and implications of studies of cognitive impairment are unclear.
• Are those who test positive for cannabis or who self-report use at increased risk for injuries or accidents? Unclear; findings mixed and research methodologically unsound.
• Does workplace drug testing deter drug use among employees? Probably, but could be other explanations for dips in positive tests.
• Does workplace drug testing reduce injuries or accidents? Unclear due to methodological limitations of the research.

The most repeated finding was that methodological weaknesses in the research meant few strong conclusions could be drawn, in particular about whether it is worth employers instigating drug testing programmes. But if they do, in respect of cannabis the conclusion that there may be a large difference between blood and urine test results, and that the former are a better indicator of impairment, should be noted by any organisation basing its programme on urine tests only.

Given the weakness of the evidence base, it seems wise that UK government guidance specifies that employers must have the consent of their employees to undertake drug testing, usually as part of wider health and safety policy agreed in a contract or staff handbook. The widespread use of drug testing as a preventative measure seen in the USA is not recommended in the UK, where guidance advises employers to limit testing to those who need to be tested, ensure that within this group, testing is random, and not to single out particular employees unless the nature of their jobs requires this. While there may be some leeway depending on the definition of those “that need to be tested”, it seems clear that drug testing in the UK might be appropriate for train drivers or airline pilots, where there is a clear safety risk, but not for most workers.

The featured review focused on cannabis, but possibly relevant too are studies of drug testing programmes in general, in which cannabis is likely to be the most detected drug. A rigorous review conducted for the Cochrane collaboration found just two studies of people who drive for a living which met its quality and relevance criteria. Echoing the featured review, the conclusion was that evidence was insufficient to be able to advise for or against drug and alcohol testing of occupational drivers as the sole long-term solution to preventing injuries.

This draft entry is currently subject to consultation and correction by the study authors and other experts.

Last revised 05 March 2014. First uploaded 03 March 2014

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Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.

Mattick R.P., Breen C., Kimber J. et al.
Cochrane Database of Systematic Reviews: 2014, 2, art. no.: CD002207.

Authoritative analysis of clinically relevant trials of buprenorphine versus methadone maintenance for heroin dependence confirms that buprenorphine has less ‘holding power’, and that among patients who are retained, there are equivalent reductions in illegal drug use. But is methadone’s ‘stickiness’ an advantage or a liability?

Summary Oral methadone and sublingual (absorbed under the tongue) buprenorphine are the main medications prescribed long-term (on a ‘maintenance’ basis) to patients to substitute for heroin and other opiate-type drugs on which they have become dependent. Substituting legal opioids in known doses and purity provides an opportunity to stabilise the patient by eliminating withdrawal, craving, participation in obtaining illegal opioids, and injecting.

This updated review for the Cochrane Collaboration, one of the world’s most trusted sources for research analyses, included 31 trials totalling 5430 participants compared to the 24 and 4497 of the 2008 version. It focused on studies which allowed clinicians to adjust the dose depending on how the patient has reacted; these more closely reflect actual and recommended clinical practice than fixed-dose studies.

The review sought trials which had randomly allocated patients dependent on heroin or allied drugs to buprenorphine maintenance, versus either a placebo or maintenance on methadone. Where possible, results of similar studies were statistically pooled. Of the 31 trials, 15 were from North America and nine Europe. Most (22) were reportedly ‘double-blind’, meaning neither patients nor clinicians were told which preparation the patient was taking. When methadone was compared with buprenorphine, concealment entailed requiring all patients to take two preparations, one the active medication, the other a placebo version of the second medication. Urine tests results were based on the number of tests indicative of continuing illegal heroin use. [Editor’s note: All else being equal, the method used in the review favoured preparations which do less well at retaining patients in treatment and which therefore offer less scope for patients to accumulate tests indicative of continuing illegal drug use. Another common method is to assume missed tests would have indicated a return to drug use, favouring medications which best retain patients.]

Main findings

Dosing levels were flexible in 11 studies which compared the two medications. Across these, the chances of a patient leaving treatment during study periods ranging from six weeks to a year was 17% lower on methadone. This means for example that if 60 out of 100 patients are retained on buprenorphine, had they instead been prescribed methadone, typically another 12 would have stayed in treatment. Results were similar and more consistent across the five double-blind studies in which neither patients nor clinicians were told which medication the patient was taking. Among the remaining six non-blinded studies, methadone’s retention advantage was not quite statistically significant and varied considerably between studies.

Across the eight flexible-dose studies which provided this data, numbers of urine tests indicative of continuing heroin use only slightly and non-significantly favoured buprenorphine. The same was true for the patients’ own accounts of their heroin use. There were also no significant differences in use of cocaine or benzodiazepines, though in both cases there was a slight advantage for methadone. Just two studies contributed to the analysis of criminal activity, cumulating to no significant difference between the medications.

In the fixed-dose studies which compared buprenorphine with methadone, retention was only significantly different (patients stayed longer on methadone) in the low-dose comparisons of less than 16mg of buprenorphine versus less than 40mg of methadone. In no dose range did one medication versus the other result in significantly fewer urine tests or self-reports from the patients indicative of heroin use.

Across the 11 studies which compared buprenorphine to a placebo, buprenorphine in whatever dose range retained patients better in treatment. However, only high-dose (at least 16mg per day) buprenorphine led to fewer urine tests indicative of continuing illegal heroin use.

Among all 31 studies, the few to compare rates of unwelcome possible side effects found no differences between buprenorphine and placebo or methadone, with the exception of one study which found more methadone than buprenorphine patients experienced sedation.

The authors’ conclusions

Broad practice implications remain unchanged from 2008. Buprenorphine is an effective medication, bettering a placebo on retention, and in high doses also in urine test results indicative of continued heroin use. Prescribed at flexible doses, superior retention means methadone should be the default maintenance medication, with buprenorphine reserved for situations where higher dose methadone is not possible, for patients who do not react well to methadone, or to provide patient and clinician choice. Though both medications suppress illegal heroin use, on this criterion they did not significantly differ. Despite these findings, buprenorphine may have advantages in some settings and under some policies where its relative safety and ability to be taken every other day are particularly useful.

Findings in respect of consequences which take time to become noticeably different, including mortality, adverse side effects and crime, may have suffered from the typically short duration of randomised trials.


Findings logo commentary The analysts’ verdict was that given adequate doses, methadone was the more effective treatment, but not by such a margin that buprenorphine could positively be advised against. Greater retention was the key advantage – important, because over the periods represented in the studies, when patients leave, relapse to dependent illicit opiate use is the norm. When (as in normal practice in Britain) patients and clinicians choose either medication, the retention advantage of methadone has been much greater than in trials where patients accept being randomly allocated. Perhaps partly because patients who want this choose buprenorphine, and partly due to its opiate-blocking properties, while in treatment patients who opt for the drug also use illegal opiates less often (1 2), a contrast to the equivalence found across randomised trials.

The analysts’ rider that buprenorphine might be offered simply to create choice is more important than the minor mention warranted in a review of studies in which patients did not have a choice. Choice is likely to help engage and retain patients in treatment who want or expect different things from their medications. In one English study, the consequences of a mismatch between user preferences and service policies was visible in the early drop-out of would-be patients denied buprenorphine, which many valued for what they saw as its superior opiate-blocking properties. Buprenorphine’s better safety profile and its attraction for a less severely affected caseload commend it particularly to primary care settings; in Birmingham for example, it was twice as likely to be prescribed as a maintenance drug by GPs as by specialist addiction services.

Randomised but still not a level playing field

Limitations in the featured analysis and in the flexible-dosing studies it relied on introduce considerable uncertainty over the meaning of the findings. Some of these limitations probably meant methadone’s advantage would have been greater in everyday practice. Even when in many studies they could have got methadone elsewhere, patients were prepared to accept allocation to an unfamiliar medication. Possibly they were keen on trying a new medication with less strong opiate-type effects. In most of the studies they were (compared to UK caseloads) either early in their addiction or treatment careers, relatively young, or relatively socially included. One of the questions marks over buprenorphine is its suitability for more dependent, high-dose heroin users.

Also perhaps disdavantaging methadone was the way the urine test comparison was calculated. This appears to have ignored missed tests rather than treating them as positive (shorter retention means buprenorphine patients probably missed more) and to have credited to buprenorphine results from patients who avoided positive tests by switching to methadone.

On the other hand, buprenorphine patients too might have been disadvantaged. The drug permits non-daily dosing and perhaps an earlier shift to unsupervised consumption. For many patients, this offers a more attractive regimen than daily supervised methadone. The key studies sacrificed these advantages to ‘blind’ patients and staff to which drug was being taken.

NICE verdict

Since it drew on this data, these sources of uncertainty were also incorporated in an assessment for the UK’s National Institute for Health and Clinical Excellence (NICE), which itself added further layers of uncertainty. It found that methadone’s retention advantage in flexible-dose studies translated in to slightly greater improvements in (largely health-related) quality of life. Since methadone also resulted in lower health care costs, it was judged more cost-effective than buprenorphine.

For the featured reviewers, similar findings meant methadone should be the default choice, but experts and advisers convened by NICE put a different spin on largely the same evidence. Their advice was that the choice between the medications should be made “case by case”, based on issues like whether buprenorphine’s safety was a priority in that individual case, whether the patient was aiming to withdraw from opiate-type drugs altogether (easier with buprenorphine), and patient preference. When for an individual the medications were equally appropriate, methadone might take precedence because it cost less and on average extended the benefits of being in treatment. UK prescribing guidelines take a similar line.

Neither the Cochrane nor the NICE assessment fully accounted for the cost-savings and convenience possible due to buprenorphine’s extended action and relative safety, such as being able to allow more unsupervised dosing. These are not just theoretical, but have been taken advantage of in Britain. Also not fully accounted for were the ways in which buprenorphine might further enhance quality of life. However, neither did the assessments fully account for the benefits of greater retention on methadone.

How to choose?

Uncertainty about overall advantage, allied with differences in the safety and effects of the drugs and feasible dispensing arrangements, suggest that some patients will be best suited to methadone, others to buprenorphine. Unfortunately, there is little in the research to indicate who will be in which camp. Buprenorphine possibly helps depressed patients more than those not suffering depression, while patients dependent on large doses of opiates may find it inadequate because there is a ceiling beyond which higher doses do not augment opiate-type effects. Patients who value the ‘wrapped in cotton wool’ feeling typical of heroin are likely to prefer methadone; those who value a clearer head might prefer buprenorphine. Patients aiming for a relatively rapid break from all opiate-type drugs might do best to opt for buprenorphine initially, or to switch to it after stabilising on methadone, but have to accept the risk that instead they will drop out and return to dependence on illegal drugs.

Methadone is likely to remain the mainstay of maintenance prescribing due to its wider appeal to patients and lower cost, but the case for considering buprenorphine is strong and may get stronger if potential cost savings are further realised, and as methadone’s major advantage – greater retention – comes to be seen as an impediment to leaving treatment. Until recently, in Britain retention for 12 weeks was the prime benchmark of effective treatment and partly determined local funding. Now the emphasis (1 2) is on moving patients through and out of treatment to (it is hoped) secure recovery via social reintegration. In line with policy, ‘successful’ treatment exit features strongly as a goal in ‘payment by results’ commissioning criteria in England. Against this backdrop, buprenorphine’s ability to help patients take a half-step away from reliance on opiate-type effects and its greater ‘leavability’ could become valued more, while methadone’s ‘stickability’ is being seen not (or not only) as a strength, but a liability. However, buprenorphine’s leavability is itself a liability if it means (as in this British study) that many more patients drop out and still only a small minority leave after successful detoxification.

The previous version of the review was analysed by Finding on the basis of an extended analysis of the eight flexible dose studies then available. This still seems a valid basis for assessing the review’s implications. None of the three new to the current version were among the double-blind studies which constitute the most stringent comparison of the two medications prescribed flexibly. In one retention actually meant completing treatment while in prison, another was a small German study which found retention about equal, and the last was a Norwegian trial which was arguably an invalid comparison because methadone doses could vary while buprenorphine was fixed at 16mg.

For clinical guidance on how to use buprenorphine see UK prescribing guidelines and a review from three leading US researchers.

Thanks for their comments on the original entry to Tom Carnwath, then consultant psychiatrist at the Tees, Esk & Wear Valleys NHS Trust in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 11 March 2014. First uploaded 11 January 2008

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