Subhani, Mohsan
(2023)
Alcohol use disorder epidemiology and interventions to support behaviour change.
PhD thesis, University of Nottingham.
Abstract
Alcohol is a preventable leading cause of liver disease. In the United Kingdom (UK) 25% of the population drinks above the recommended level and 10% are harmful drinkers. Alcohol-related liver disease (ARLD) progresses silently, over 50% of patients are first diagnosed with liver disease after an emergency hospital admission at a stage when the scope of any medical and behavioural intervention is limited. Though the prevalence of alcohol use disorder is disproportionately higher among hospitalised patients as compared to the community, it is persistently underdiagnosed and undertreated in hospital settings.
There is a large burden of undiscovered, asymptomatic, but clinically significant liver disease in patients attending community substance misuse services. Early detection of liver disease followed by targeted interventions is a logical and effective way to reduce the risk of late presentation of liver disease and other alcohol-related end organ damage. Although, providing tailored feedback based on non-invasive tests (NITs) for liver disease to people at risk of liver disease may affect their drinking behaviour, at present these markers are not widely incorporated into alcohol treatment settings. Hence, the potential of combining early diagnostic interventions and advice has not been extensively explored in alcohol services.
First, I conducted a retrospective observational study to explore the epidemiology of alcohol use disorder among hospitalised patients. I demonstrated that one in six hospitalised were screened positive for alcohol use disorder (AUD) based on AUDIT-C alcohol assessment. Patients with AUD were more likely to be male, white, admitted as an emergency, and cared for by surgical specialities compared to those without AUD. Although there was an overall reduction in the number of hospital admissions, patients admitted during the pandemic compared to pre-pandemic were more likely to have possible alcohol dependence and mental disorders due to alcohol. Covid-19-positive patients with AUD died at a younger age compared to Covid-19-positive patients without AUD.
I then, conducted a systematic review and meta-analysis to determine the effectiveness of non-invasive tests (NITs) based advice compared to routine care in changing high-risk drinking behaviour. Twenty papers comprising 14 RCTs, 2 observational studies, and n=3763 participants were included. The meta-analysis demonstrated a greater reduction in self-reported alcohol intake and liver biomarkers for the intervention compared to the control group: the mean difference for weekly alcohol intake was -74.4 grams per week (95%CI -126.1, -22.6, p=0.005); and mean difference for gamma-glutamyl transferase (GGT) -19.7 IU/L (95% CI -33.1, -6.4, p=0.004). There was a higher incidence of alcohol-attributed mortality, number of days spent in the hospital, physician visits and sickness absence in the non-intervention group.
In addition to NITs based advice, I planned to include alcohol recovery video stories (ARVS) as part of the intervention in my future feasibility RCT. I conducted a systematic review and narrative synthesis and proposed a conceptual framework characterising alcohol recovery narratives. Based on the three-stage narrative synthesis approach I determined that alcohol recovery narratives are composed of eight principle narrative dimensions (genre, identity, recovery setting, drinking trajectory, drinking behaviours, stages, spirituality and religion, and recovery experience) each with types and subtypes. All dimensions were present in most subgroups. Shame was a prominent theme for female narrators, as a lack of sense of belonging for LGBTQ+ narrators, and alienation and inequality for indigenous Alaskan and Australian narrators. Moreover, spiritual awakening was more commonly sought rather than a religious affiliation in LGBTQ+ narratives.
Finally, I conducted a feasibility randomised control trial (KLIFAD) at three community settings in Nottingham, including adult patients presenting to any of these services with a primary problem of alcohol use disorder. Participants were randomised (1:1) to either continue routine care (control group) or in addition to routine care have feedback based on transient elastography results and watch alcohol recovery video stories (intervention group). I demonstrated that the integration of transient elastography into community alcohol services is feasible. Over 76% of eligible participants agreed to be part of the trial and gave informed consent and were randomised, 65% stayed in services for three months, and a six-month follow-up was available in 59%. Implementing opportunistic screening in otherwise asymptomatic high-risk individuals showed one in five had raised liver stiffness measure (LSM), and of concern one in seven of them were in the cirrhotic range. The provision of feedback based on transient elastography results was associated with higher rates of completion of the allocated treatment program, reduction in self-reported alcohol intake, or complete cessation of alcohol consumption. A normal liver stiffness measure did not provide false reassurance to study participants.
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