Alcohol a national concern NCEPOD measuring the

Alcohol : a national concern NCEPOD: measuring the units Professor Martin Lombard

Alcohol related disease NHS response to Problems & Admissions Public Health Interventions ALCOHOL Social behaviours & attitudes Public Policy & regulation

Pattern of deaths in England, by age, in 2007 Total: 500, 000 deaths 100% 90% Genitourinary Other GI & Liver 80% RESPIRATORY Alcohol 70% Mental Endocrine 60% CIRCULATORY SUICIDE 50% Alcohol 40% GI cancers ACCIDENTAL DEATH 30% Alcohol 20% ALL CANCERS 10% 0% < 1 01 -04 05 -09 10 -14 15 -19 20 -24 25 -29 30 -34 35 -39 40 -44 45 -49 50 -54 55 -59 60 -64 65 -69 70 -74 75 -79 80 -84 Source: ONS Death Registry Deaths from mental disorders - For younger people (under 50) - these deaths are mostly people dying from mental/behavioural disorders associated with alcohol or drug use. For older people (over 50) these deaths are almost entirely due to dementia 85+

Liver mortality: ‘mind the gap’ 2. International– Liver disease mortality trend dramatic increase relative to other major countries SDR, chronic liver disease and cirrhosis, 0 -64 per 100000 Source: WHO/Europe, European HFA Database, January 2012 1. England– rising 5% pa 1990’s, now 1. 7% pa. France Italy England

Chronic Liver Disease (1) Mortality - 1993 & 2009 Rates per 100, 000 population North East • 5. 7 up to 13. 7 North West • 7. 3 up to 15. 2 Yorks & Humber • 4. 8 up to 10. 2 Rapid increase across the country in the last 16 years (1) Metric: Mortality from chronic liver disease including cirrhosis (ICD v 10: K 70, K 73, K 74) Source: National Centre for Health Outcomes Development (NCHOD), part of NHS Information Centre Data: SHA level data, standardised for age and gender using European Standard population. Figures are rates per 100, 000 population.

Community Liver Disease ‘Typical’ GP pop 10, 000 (<75 yrs=9, 210) Expect 88 deaths pa Age <75 dying per annum = Lung Cancer: Acute myocardial infarction: Breast cancer: Liver disease 29 2. 8 1. 6 1. 8 2. 2 Chronic liver disease Established cirrhosis: Hepatocellular cancer: 60 6. 0 0. 6 Dependent drinkers: Risk cirrhosis from NASH: Number with hepatitis C: Number with hepatitis B: 640 250 40+ 30+ Total ‘at risk’ 16 -75 years: >10% Abnormal liver tests if checked: 10*20%

Death due to ALD/Cirrhosis age 35 -69 per 100, 000 living in UK

Alcohol strategy • Individual responsibility • Local level policies & strategy • Taxation • • 2% >rpi escalator Min juice cider rate for beer ABV>7. 5% Support EU changes for wine • Relationship with price • MUP (consult, propose 40 p) • Ban multi-buy in off sales (consult) • Advertising: definite link, proportionate measures • Self regulation • Tighten rules esp <18 • Emerging issues: – Fraud, illegal alcohol – Liver strategy

Outcomes Framework Domains

NHS Ten steps to address Liver disease Test Conserve Assess Refer / Monitor Think LIVER Support Patients & Carers & EOLC Rescue events Monitor / Review Surveillance for Complication Treat

NHS aspects of alcohol strategy • • • PH to commission Identification & BIs Alcohol liaison nurses in A&E “Make every contact count” (www. liver. nhs. uk) Health checks – identification (40 -75 yrs) Treatment – Addiction services – Prisons (NHSCB) – Mental health (strategy)

Thiamine vs. Combined Acamprosate and Disulfiram 4000 3500 Thiamine Prescriptions 3000 2500 PCT 2000 Linear(PCT) R 2 = 0. 2515 1500 1000 500 0 0 1000 2000 3000 4000 Combined Acamprosate and Disulfiram Prescriptions 5000 6000

Alcohol related Liver Disease • Awareness & Education (Professional attitudes) • Identify people at risk –Audit-C –Trauma & violence –Obesity & DM • Use/Agree pathways/Test –Disperse expertise –Fibrosis markers –Follow up & repeat interventions –Join up services • Brief & extended interventions • Addiction services • Social services • Influence your • Resilience community & leaders • Change attitudes & behaviours!

ALCOHOL: whose problem is it? OURS!