We recently attended the
North West Alcohol Conference in Liverpool. I, along with Natasha Clarke and Inge
Kersbergen summarise the highlights. (A slightly different version of this blog can be found at the University of Liverpool's Addiction Group Blog.)
Natasha
Clarke
Professor David Walker,
Deputy Chief Medical Officer of the NHS, gave the first talk. This focussed on The
National Alcohol Strategy; the proposal put forward by the government
to tackle our society’s harmful use of alcohol. The key issue raised was the disappointment
of Public Health England with the government’s reluctance to
introduce minimum unit pricing (MUP), despite initial plans to implement it. Evidence
from Canada and
the Sheffield
Alcohol Policy Model indicate the implementation of a 45p MUP may
decrease alcohol consumption and reduce hospital admissions, yet the strategy
states that more evidence is needed. The sudden backtrack is suggested to be
due to intense lobbying from the alcohol industry; for example, the Wine and
Spirit Trade Association (WTSA) launched a campaign against the
proposal and claim that MUP would unfairly penalise the majority of responsible
consumers. Previous
research has shown that the industry can use evidence to support
policies that are in line with their commercial interests and WHO
stress that industry should have no role in forming alcohol policy.
So
what is being done? The government has committed to a ban of “below cost
sales”, with cost being duty + VAT. This is equal to roughly 21p per unit for
beer and 28p per unit for spirits, prices significantly lower than the original
proposed MUP. It
is estimated that only 1.3% of all units of alcohol would
be affected by this and that a threshold of 45p would have a considerably
larger impact. The government also mentions a pledge through the responsibility
deal
to take 1 billion units out of the market by 2015; the Health Committee doesn’t
think this will have any significant
impact. A further emphasis was placed on education campaigns,
despite evidence
showing their ineffectiveness in reducing alcohol-related harm.
What
was clear is that the government are not doing enough. Words and promises
(especially ones that are broken) will not produce changes in the nations’
health. An audience member asked David Walker… “Can you change culture?” The
answer was “Yes, we can”. Using smoking and driving behaviours as previous
examples he explained that these are health aspects to which our outlook as a
nation has changed. Smoking attitudes took decades to alter and faced similar
pressure from the industry. The verdict was that we must continue to fight for
better policy, but an equal match of input from public health and industry is
continuing to prove difficult.
Inge
Kersbergen
Discussions
then continued in different breakout sessions. Colin Shevills and Ali Wheeler
made a compelling case for changing licensing regulations. Licensed premises
are popping up everywhere in the country. You can now buy alcohol in a large
variety of places: in cinemas, indoor playgrounds, and even hairdressers’. And
the more traditional licensed premises keep growing in number as well. All
whilst we know from research that the density of licensed premises is related
to more alcohol-related harm and crime. The licensing act is still operating
under the premise that licenses are granted where possible, even if licensing
committees and communities want to limit the amount of licensed premises in an
area. Licensing committees have very
limited power when it comes to restricting licenses in high density areas or
taking licenses away. However, they do possess two powerful tools to limit
alcohol availability: Early Morning Alcohol Restriction Orders (EMROs) and
Late Night Levys (LNLs).
An
EMRO restricts sales of alcohol in a specific area at a set time between
midnight and 6am. Premises that are in violation of this order will receive a
fine. The LNL is an additional fee for licensed premises if they want to sell
alcohol between midnight and 6am. At first glance these policies seem very
similar. The difference lies in how voluntarily businesses restrict their
selling times. At the start of November 2013 a LNL has been introduced in the
city of Newcastle. So far, it seems like
this levy has the effect of an EMRO, as many businesses voluntarily decided not
to pay the additional fee, but to stop selling alcohol at midnight instead. The
proposed EMRO in Blackpool, on the other hand, was met with a lot of resistance
from the business owners. The speakers argue that it is therefore important
that businesses do not feel forced into restricting their selling hours to get
their full cooperation. Local licensing committees should make more use of the
tools they have, get more freedom to limit licensed premises in their area and
be able to involve the local community in their decision making.
Jay
Duckworth
Further
suggestions for policy change came from Mark Gilman, Strategic Recovery Lead at
Public
Health England and the National Treatment Agency for Substance
Misuse. Gilman, a man who speaks with an almost paradoxical
sense of passion and levity, offered advice which he
concedes many see as “unscientific,
folky [and] quirky”. His idea is that we need to place more emphasis on 12-step
programs in which addicts are forced to confront matters of “spirituality”.
Initiatives such as Alcoholics
Anonymous (AA) are of this breed, asking addicts to admit they are
“powerless over alcohol” and to
recognise that a “Power greater than they
can restore their sanity”. As Gilman admits, this may be a difficult pill
to swallow for many. First, non-spiritual individuals will find it problematic to
attain the “spiritual awakening” necessary
for success in many 12-step approaches. Additionally, though AA is effective at
reducing rates of drinking there are many equally effective treatments
available which come without the mystical baggage.
That
being said, there is an essential feature of 12-step programs which Gilman is
right to say should be an active focus of substance dependence treatments across
the country: social networks. Social support provided in 12-step programs appears
to be one of the primary mechanisms of action, accounting for as much as 1/3 of
treatment effects in reducing harmful use. In fact, one study’s authors
even remarked that “The addition of just one abstinent person to a social
network increased the probability of abstinence for the next year by 27%”. Clearly, emphasis on social change is vital.
The subsequent speaker was Wim van den Brink, Professor
of Psychiatry and Addiction at the Academic Medical Centre of the University of Amsterdam. Taking advantage of the passionate but light-hearted
tone set by Gilman, van den Brink lamented a presentimental partial rebuke to his
predecessor, “I agreed with almost
everything you said, but I’m going to disagree on some points just to make it
interesting…” And so he did. He focused on his own recently published research which
tested the efficacy of the drug Nalmefene on an alcohol-dependent population
(though patients were simultaneously given a motivational and
adherence-enhancing intervention).
Two clinical trials had shown that Nalmefene reduced
drinking significantly in patients relative to placebo. However, what’s really
interesting about these results is van den Brink’s post hoc analyses of the data. These analyses were directly
relevant to the previous presentation as they show us what can be done for
patients who may not respond so favourably to social intervention. The analyses compared the
effects of the drug on those whose drinking improved between screening and
randomization and those whose did not. This latter subpopulation of the
original studies – labeled “non-reducers” – was categorized as excessive
drinkers who remained as such despite minimal interventions; contrarily, the
former – labeled “reducers” – were
those patients whose drinking reduced simply after the assessment of their
problem by clinicians. To put it simply, Nalmefene works, but it works so much
better in patients whose drinking patterns are not reduced by initial clinical assessment.
At this point, van den Brink highlighted the main flaw in
viewing social networking and cultural change as a panacea (not that this was
necessarily the viewpoint of any of the aforementioned speakers) – substance
dependence is not merely cultural, it’s biological too. “For those patients who don’t respond to programs like AA, what shall we
say to them… shall we tell them to f**k off?!” I believe was his gentle phrasing.
The important take-home message it seems is that for improvements to be seen
with regards to substance dependence, governments need to pay attention to the
evidence, and advances in policy and research – both cultural and psychopharmacological
– need to be made.
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