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.)
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.
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.
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.