Good evening my name is Jim Bueller I’m on the faculty of the Dorn seif School of Public Health at Drexel University that I’m standing here tonight because I chair the section on public health and preventive medicine here at the college and on behalf of the section and the colleagues I’d like to welcome all of you here tonight for.
The launch of our public health.
Grand Rounds series this is the fourth year that we’ve done this it’s been very successful and it’s great to see all of all of you here this evening I.
Just have a few background comments to make those of you who have been to Grand Rounds before have heard that the purpose of this forum is to address important public health issues here in the the Philadelphia region we emphasize local speakers but we also welcome people from Washington.
DC who are willing to come up on.
The train and to join our conversation about how we address problems here the format is a series of brief presentations from people that are working on these issues from different perspectives we hope that by having these conversations that will generate.
New ideas provide new opportunities for collaboration and strengthen our our public health communities so that we’re better prepared to address the problems that we’re addressing we’re very.
Thankful in the section for the the co-sponsorship of both the College of Physicians and the Philadelphia Department of Public Health at I especially like to acknowledge dr.
George wall Reich who’s the the president and CEO of the college and dr.
Tom Farley who’s the health commissioner here in the city of Philadelphia and they’ve both been big champions of this of this.
Program would also like to thank the independence foundation which has provided.
Important support one other person who might like to acknowledge is Carrie young-dal we benefit from the support of many staff people here in the College Kerry has been our point here for several years.
And this is will be the last public health Grand Rounds sessions that she’s attending she’s then.
Nabbed away by the International AIDS vaccine initiative I avi in New York City is a tremendous opportunity to for her we will miss her and carry wherever you are thank you for all that you’ve done support the section and the Grand Rounds following the Grand Rounds we finish up around 7:00 but but before we finish and leave the room.
We encourage you to come up and ask questions at microphones for that we go through all the talks and then have an opportunity for all of you.
To to offer comments or questions we ask that you complete the evaluation form that feedback is very useful to.
Us we urge all of you to become members of the section on public health and preventive medicine you don’t need to.
Be a fellow in the college you don’t need to be a physician any the only qualifications that you care about public health and in our community and then please at seven o’clock will.
Break and go into an adjacent room for the reception.
Chance to continue the conversations that are started here historically the past three years we’ve done three sessions.
Per year but this year we’ve expanded to four so mark your calendars the dates are also in your brochure in November we’ll be talking about STDs and HIV in.
Philadelphia in February on access to primary care and in May hypertension prevention and control I would also like to acknowledge dr.
Michael Halperin who is the member of our section who.
Is responsible on behalf of the section for working with colleagues to put the Grand Rounds together know he worked very closely with dr. better call to arrange this evening’s presentation.
He unfortunately he couldn’t be here this evening it’s my great pleasure to introduce dr. Cheryl betta call who is the director of the division of chronic disease prevention also known as get healthy Philly at the Philadelphia Department of Health and she will introduce the speakers and serve as.
Our moderator this evening Thanks thanks very much Jim and thank you all for being here in particular thanks to our speakers who came from out of town Chris Morrison from.
New York and Aaron Williams from from Washington we really appreciate you coming to share your thoughts with us today and I am definitely shorter than you Jim so for at least 9,000 years human beings and diverse cultures around the world have been fermenting fruit or grains to make alcoholic drinks those drinks have fueled social interactions and trade and for millennia before we understood what bacteria were they provided a.
Safer alternative than drinking contaminated water but even thousands of years ago observers noted the links between alcohol and violence in the words of an ancient Greek poet host served their guests a.
First Bowl for health another for pleasure and a third for sleep we might disagree with some of that but when this bowl is drunk up.
Wise guests go home the fourth Bowl.
Is ours no longer if it belongs to violence the fifth – uproar the sixth two drunken rebel the seventh – black eyes the eighth is.
The policeman’s the ninth belongs to biliousness and the tenth – madness and the hurling of furniture so these links are nothing new we’ve known for thousands of years this this is a problem.
And continues to be a problem but lacks gun laws and lack of state enforcement of existing alcohol regulations combined in Philadelphia and in other large cities to escalate the lethality of that link on street corners and low-income neighborhoods young men congregate as early as 10:00 in the morning to drink at local stop and ghost.
Gun violence experts talk about the confluence of high-risk persons and high-risk places as epicenters of danger in our communities alcohol sales and individual use of alcohol are an important component of how those epicenters function to increase risk tonight’s discussion will help us to better understand those forces as well as what we as health and public health professionals can do to change them so to start us off I want to invite Aaron.
Williams to talk with us about.
Screening brief intervention and referral to treatment or expert which is a practical tool for change Aaron’s the senior director of training and technical assistance for substance abuse for.
The Samsa hearses Center for integrated health solutions at the National Council for behavioral health he leads the National Council Center for integrated health solutions strategic initiatives on substance use screening and treatment and he.
Provides direct training and technical assistance services that promote primary and behavioral healthcare integration with special attention to addiction treatment providers welcome don’t see me okay okay all right so I wanna first thank the college for thank the.
College for inviting me and thank you all for coming today.
So we would spend a few minutes today talking to you about a public health approach to addressing alcohol Esper so screening brief intervention and referral to treatment so I’ll talk a little about alcohol where we stand now and then talk about you know this particular approach and how it can be used in public health settings right so start the song this is data from the latest National Household Survey the say the federal government collects data from households across the country about seventy thousand people participate in.
The survey the survey talks asked about use of a number of different substances including alcohol so one of the data points that came out of the latest survey is looking at alcohol initiatives so this is when people begin to start using alcohol so as you can see there’s still a large number of people who start using alcohol.
Between ages of twelve and seventeen probably you know what you’d expect another pretty significant cohort around age 18 to 25 you know if you think about 12 to 17 you know and all of the effects of alcohol on youth in terms of brain development and other things that’s a pretty high number for people to be starting using that early and then also a number.
Of people who actually started using it 26 or late okay all right so I’m just think I’m missing a slide here but so and when you think about the total number of alcohol users or people with alcohol dependence the National Survey for 2017 data estimates about ten point four million people right now above the age of 26 have some sort of alcohol use disorder there’s a.
People who have alcohol use disorders whether it’s mild moderate severe and alcohol use disorders are implicated in a number of other public health issues so as we discussed earlier crime violence they also if you look at other health conditions cancer hepatitis HIV use of alcohol is a significant risk factor for all of those so as you begin thinking about.
Alcohol certainly I’m given it’s pervasive in the society when you think about what.
Is it approach to reduce the burden societal burden on around alcohol use so one of the approaches or one of the main approaches in public health is Esper so we had a screening brief intervention and referral to treatment and what expert really is is a framework which allows you to identify people who may have an alcohol.
Use disorder or even other substance use disorder and provide them services where they are so meeting them where they are in terms of you know severity of this very disorder and then moving them into appropriate levels of care so again when you think about this you’re really thinking about a framework it’s an opportunity to intervene and intervene early so really meet people where they are to reduce the consequences of long-term alcohol use again it’s it’s.
Designed to be used in a wide variety of settings public health settings so you think about hospitals health centers STD clinics other places that meet the public where there.
May be some risks for people using alcohol in really risky ways so these.
Are some of the some of the settings again where you can.
Think about this there are other settings out in the public where people have implemented experts hype prods and projects or expert type you know initiatives again it’s really meant to be very flexible but the idea is to identify people that may need some services and get them to appropriate care sooner rather than later so when we think about alcohol right this is a alcohol pyramid have folks seen this before anybody seen this before okay.
That’s all right so we think about alcohol use disorder and you look at sort of the top.
In that 5% up here these are people who have severe alcohol use or dependence then you have folks about 20% here who may have high-risk use then some moderate use here and then again at the bottom which is the bulk of the population you know really abstinence to low risk and expert is really designed to work right here in.
This target area so looking at moderate to high risk it’s really the target population for expert you’re really designed to people that may be using alcohol too much for some underlying condition may be having some difficulties in school or at home you know may have some other circumstances but maybe.
Don’t meet you know full-on sort of abuse or dependence yet you’re really looking.
To target services here in order to head off you know any problems that may lead to longer term issues with alcohol so this is really the target here and again public.
Health setting is our very good place to look at putting in some of these some of these resources so when you think about esperan think about some of the support here some of the evidence for a spurt how many folks have heard of the United States Preventive Services Task Force okay couple through that okay all right so for those that haven’t heard of it so the task force is essentially it says the combat governmental body made up of researchers which look at the evidence behind particular screens and other things that.
Can be used in hospitals or other primary care.
Settings and essentially they go through screens maybe screening for say colonoscopy screening for HIV other things and they provide a score meaning you know it’s its efficacy being used widespread in some of these settings so we look at experts so alcohol misuse screening and behavioral health counseling it has.
A B rating oh excuse me sorry.
About that has a B rating to be it has a beaver he was basically means that this is something that can be used done in primary care settings and there’s no copay you also see the other things that are kind of associated so screening for alcohol to be rating tobacco is a rating I think folks.
Have some awareness of some of the public health issues associated with alcohol use and certainly also HIV certainly we understand that is a public health issue as well so in terms of some of the evidence the alcohol misuse in behavioral health counseling for adults is really right up there in terms of its efficacy being used in.
Some of these settings there’s a lot of research out there around expert and its efficacy going back early 2000s even earlier these are just a couple of some of the newer research articles that are out again looking at its.
Efficacy also looking at how it.
Can be implemented in public health and other.
Settings again so there’s very good efficacy particularly around screening for alcohol misuse in adults there’s a lot of emerging literature around expert in its use for substance use as well as screening for adolescents there’s a lot of data and a lot of folks are very interested in you.
Know looking and adding to the body of evidence particularly around using it in public health settings for adolescents as well alright so this is sort of a wallet sort of a workflow so if you were thinking about in any public health setting implementing expert you know what would that actually look like so you’d have essentially a some sort of screening evidence-based tools based screening which we’ll talk about in a second.
If someone screams negative certainly you know you kind of stop there if someone screens positive there a number of options right so if they screen positive from out some moderate use you can go down and start doing some what we call brief interventions if they screen for moderate to high or dependence you can kind of move forward doing some brief interventions but potentially doing some referral.
To more treatment and in his follow-up so so really it’s a it’s a really sort of simple model which a number of organizations you can follow and implement in your setting that really helps you figure out what’s.
Best for any particular individual who comes in who may.
Be having some difficulty so when we talk about screening we’re really talking about the use of evidence-based screening tools so tools that have good efficacy in their research and really do a good job of identifying people who may be at risk and what the risk levels are for substance use so here we have a couple there a number of these different screenings on our website at the Center for integrated health solutions we have a ton of.
Other screening tools and manuals about how to use them but here is just some of the kind of major.
Ones so to audit which is a very common screening tool for substance use and adult values alcohol use in adults the DAST which is for drug use in adults the assister which is a combination to developed by the.
World Health Organization which screens for.
Alcohol drugs and tobacco the craft is one of the major screening tools for adolescent substance use the s 2 bi is a newer.
Screening tool for adolescents we also have a through in here the phq-9 which is a screening tool for depression the tweak in T a switch our screening tools for pregnant women so if folks are working with that particular population and.
Also a number of screening tools have been developed around aces so the adverse childhood experiences inventory these are number of screening tools that are used in public health settings that allow you to screen for some of these conditions and again using the s pert sort of framework you can then you know move very quickly to get them the services they.
Need right hope you ever seen this.
Okay so many of the screening tools particularly.
For alcohol essentially are based on what we call the drinking guidelines if folks have never seen these it’s actually good.
You know if you are someone who hasn’t seen.
Particularly if you do drink and have some idea of sort of.
You know where you are on some of these scales so typically when we think about this you know the drinking guidelines for men no more than for drinks in any given day and no more than I think was at 14.
Drinks in a week for women no more than three drinks on a given day and no more than seven in a week for folks aged 65.
Or older or men aged 65 or older the guidance shifts down towards the three drinks in any day and no more than seven and a week this is sort of the the drinking guidelines in which a number of the screening tools are based on you know considerate consent considered to be sort of you know a low level risk drinking you know there’s a lot of research now coming about coming out around.
Whether or not there is you know a such thing as sort of low level risk drinking you.
Know and there’s a lot of debate happening currently about this but currently this is.
Where we are in terms of some of the standardized you know drinking guidelines so if you didn’t know sort of way you are this is a.
Way for you to kind of you know measure that and have a sense.
Of sort of what’s happening all right so after you’ve done your screen you’ve identified some level of risk.
Let’s say you’ve got that about someone who has a moderate risk around alcohol or someone that is using too much because of an underlying condition say diabetes or some other thing you know you can potentially do something called a brief intervention so brief interventions are really about 10.
To 15 minute conversations you know with people about their alcohol use or even substance use if you’re doing something more broad you know really your the awareness around the issue.
And you’re talking to them about you know where they are in terms of some motivation to change you know that behavior may be.
Reducing cutting back or even quitting it that’s you know where they are so here the main elements in this conversation well you really.
Want to do is raise the subject so ask questions like hey we got the results back from your screen we want to I would like to talk to you about those results may I talk to you about them you know start talking to them about where.
They are in terms of their risk you know.
Confirm the screening results ask more detailed questions if you need to about why they use what’s going on maybe there’s a life circumstance that may have changed their drinking habits or some.
Other thing and then really you.
Know having a dialogue and creating a framework you’re very often particularly if you’re talking about adolescents you know you as a trained public health official or healthcare.
Person maybe the first time anyone has ever had a conversation about their alcohol use so you know beyond talking to their friends or their peers so it’s also an opportunity to correct any misinformation that they may have you know particularly with young people they may think that you know their drinking is okay or because it’s legal they’re at some low risk or mate when they probably aren’t but then thinking of then once you move past that and really sort of you know having that dialogue and.
That conversation you want to then begin assessing their readiness to change you know you know giving where you are and give me what you talk to me about you know what do you think about making.
Alcohol use what a change for you look like.
So really starting that dialogue again this is not meant to be a long.
You know thirty minute an hour process it’s really to begin to start this conversation you know see where they are examine their motivation for change and potentially putting in place a plan if that’s something that’s warranted and then following up so the idea where.
Expert and the idea with this framework is that asking questions particularly.
About alcohol and asking questions.
Particularly around substance use in general become a routine part of practice so asking about behavioral health asking behavioral health questions whether it’s depression substance use so really be a part of healthcare and public health in general so this is a way in which you can make this more routine so one of the things that can help you in this conversation around brief intervention is what we call readiness rulers so it’s a.
Great way to gauge people about where they are both in terms their motivation for change and their confidence in being able to make a change and their confidence in being able.
To make a change so on a scale of one to ten how ready are you to make a change well I’m a five well while you were five instead of say a seven it’s a way to kind of create that dialogue how confident argue that if you wanted to make a change you could actually make it well I’m out of three why have three instead.
Of a two so really you know having that conversation and moving that forward for some people really only the data suggests that you know maybe about 10% of the folks who come.
In and are initially screened for alcohol those or substance use will ultimately need a.
Referral to treatment some settings may be different depends on the population you’re working with but in general settings is somewhere around that so the Florida treatment is essentially where you move them into more formalized treatment services so you essentially may.
Have a partner with an addiction treatment provider or some other service that they may need these are for folks who have more severe problems and really need that specialized kind of care so a little.
Into making sure that you have those appropriate referrals and those connections you know set up to address this you know it’s you won’t see a lot of these lot of people who come in you know needing this particular service but when they do need it they really need it because they’re at higher level of risk.
So when you think about this and the work you’re doing very often some of the brief interventions you’re maybe more designed.
To get folks to comfortable with taking a referral in some cases you may know from the initial screening that they may need a referral to treatment but they aren’t ready to go yet so part of your work.
In that in that way is to help them become very comfortable with actually moving into a referral process or taking.
A referral to treatment again this is a part of the expert framework it allows you to begin to develop all of these you know movements and processes in a very.
Routine way number of resources out there around expert that I would invite you all to take a look at again the center of integrated health solutions has expert clearinghouse with a number of different resources and manuals you can go to certainly Massachusetts you know one of the northern states has a very good resource around expert in screening the national alcohol certainly have a number of different.
Resources there the addiction Technology Transfer Center has a number of resources around treatment and expert as well there’s also a number of different tools around how to do this in medical settings you know as well so with.
That I’ll stop and if there’s time for questions now or later I don’t know okay that’s right all right thank you folks thank you very much so and I’ll just add that it’s really useful to know for anybody who’s thinking about implementing expert either in a clinical or a systems level that Samsa does provide these kinds of resources and technical assistance so next we’re gonna zoom out to to hear from Chris remark Morrison about retail alcohol outlets and alcohol-related violence what does.
The evidence tell us Chris is an assistant professor in the Department of Epidemiology at the Columbia University Mailman School of Public Health he’s a social epidemiologist who specializes in spatial analyses of risks for injuries particularly alcohol-related injuries his research examines the way physical and social environments affect the effect these risks dr. Morrison completed a postdoc fellowship at the University of Pennsylvania Perelman School of Medicine we heard he likes Philadelphia better than New York and thank you for joining us tonight thank you.
Very much sure that’s I’ve only just moved to New.
York in the last few months and so I’m always looking for an excuse to.
Get back here so thank you for inviting me am I going the right way haha there we go all right so we’ve just.
Had a fine presentation from Aaron talking about interventions to reduce alcohol consumption and alcohol related harms among.
Individuals we’re going to change tack now and the work that I’ll present is looking at interventions to reduce alcohol consumption and alcohol related harms at a.
Population level through environmental prevention strategies where we change the environment through which alcohols available to individuals into the population the content that I have to present for you is in three parts first I’ll present to you give you a summary of the international literature in this area it’s a rich literature that goes back over four decades and so I’ll give a really high-level summary of the literature then we’ll move to Philadelphia and I’ll presents some some studies.
That have been done in this city there’s some fine scholarship that’s been conducted in this this city and I’ll talk through a few of the studies in the area and then finally I’ll present some of the work that I completed with my colleagues when I was based at the University of Pennsylvania over the last couple of years so we’ve heard from.
Sheryl that alcohol has a long history of use people the World Health Organization put out a report just recently.
That estimated that there were around 2.
People in the world who enjoy alcohol at least once over the last 12 months that enjoyment of alcohol comes at a cost there’s that same report estimated.3 percent of all deaths worldwide are attributable to alcohol in some way and in the US the estimate is that around 88,000 deaths per year are attributable to alcohol excessive alcohol consumption moving to focus on violence and violent crime around about 10 percent of those deaths those alcohol attributable deaths are due to violent violent acts which equates to around 22 people dying per day and we know that the burden.
Of Public Health the public health burden due to alcohol consumption isn’t solely due to mortality we know around 1/3 of people who are admitted to emergency departments for injuries or alcohol affected and there’s also a considerable economic cost associated with that morbidity and mortality fortunately public health is not without strings to its bow in this regard we one of we’ve heard about the brief interventions at.
An individual level another very effective approach is to regulate the alcohol environment which is most commonly achieved through regulating retail alcohol outlets most alcohol so consumed in this country is purchased in regulated alcohol outlets now I’m very aware of the sedative power of.
A slide that’s entitled theoretical mechanisms but this is important I think to understand how we might get from retail alcohol outlets to violence now one possible pathway is through alcohol consumption itself we know from laboratory studies that people who are alcohol affected at increased risks for violence and aggression in 1975 the hypothesis was first put forward that we’re alcoholics essa’ bilal qahal consumption within the population would be greater so that gives us a link to from alcohol outlets to.
Violence through alcohol consumption the sociology and criminology literature gives us an alternate pathway which is directly from alcohol outlets to violence not necessarily through alcohol consumption itself we know alcohol outlets tend to be located in areas that are.
More disordered or lower-income which tend to have higher incidents of alcohol violence and alcohol outlets may attract people who.
Are more predisposed to risks for being victims or perpetrating violence to test these hypotheses there are two different approaches that we can take either ecological or individual.
Level analyses in an ecological study we might take a geographic area say.
For example a city and partition it within spacial units so say for example the grey box represents the city.
And there’s the partitions there might be a zip codes or census tracts some sort of geographic unit within each of the geographic units we.
Take counts of alcohol outlets bars restaurants which are commonly known as on-premise outlets or liquor stores which are off-premise outlets licensed for the consumption of alcohol off premises relating counts of exposures the outlets to outcomes within a regression analysis will test that aggregate level.
Association alternately we might have survey data for individuals and these individuals might be geo-referenced we might know where these people are located within Geographic space and we can then estimate their exposure to alcohol outlets within that Geographic space now that geo-reference might be a person’s residence it can.
Also be a location that they were at a specific time so for example when they were injured there are many different approaches to address to conduct these these analyses and I’ll be happy to talk to them later if you’re interested so as I mentioned this literature goes back over four decades there’s been an enormous number of studies conducted testing different elements of these.
Associations between alcohol outlets alcohol consumption and alcohol-related violence in fact they’ve been many systematic reviews conducted so many in fact that we could if we so desired conduct.
A systematic review of some.
Systematic review in this area the first study.
Was the first systematic review was in 2009 which found generally in support of the theoretical mechanisms I presented on the previous slide.
Followed shortly after by another systematic.
Review in 2009 two more in 2010 another in 2012 2014-2015 and for good measure one more this year now these studies all look at different elements of the associations between retail alcohol sales and and alcohol consumption and.
Violence some look at Geographic concentrations of alcohol outlets.
Some look at days and hours of service for these outlets but generally not with standings theoretical some methodological shortcomings in the studies which in fact some of the systematic reviews explicitly examined the methodological shortcomings of the of different studies.
But generally taken as a whole we find evidence in support of these mechanisms moving to the second part of my presentation which is to look at studies within Philadelphia we’re blessed.
In this city to have a rich history.
Of scholarship in this area looking at a sample.
Of the studies that have been conducted the at the ecological level we see studies recently from 2015 looking at relating density to increased incidents of robbery but only at nighttime and late night only at daytime in late night hours another association.
Another study by my former colleagues sung-hoon.