Submission to Joint Committee on Health and Children

Joint Committee on Health and Children

Meeting

14th December 2011

Submission

on

The health effects and consequences for the health service of alcohol abuse

Health Service Executive

Submission to Joint Committee on Health and Children

The health effects and consequences for the health service of alcohol abuse

Introduction

Of all the WHO regions, Europe has the highest intake of alcohol. Within Europe, Ireland has been shown in repeated studies to be amongst the highest users of alcohol1. This use is compounded by our high level of binge drinking 2, 3. Alcohol consumption is linked to more than 60 diseases and conditions affecting nearly every organ in the human body and is the third highest risk factor for premature death and ill-health in the European Union. Alcohol-related harms include such problems as accidents, injuries, chronic ill-health, premature death, public safety, violence, child neglect, marital problems and lost productivity due to absenteeism or poor performance at work. The toll of alcohol-related harm includes harms experienced by the drinker and also harms experienced by people other than the drinker.

There is extensive harm caused by alcohol in Ireland. Numerous reports have been published in Ireland outlining the extent of the harm caused to individuals and the population as a whole. These reports include amongst others: Social consequences of harmful use of alcohol in Ireland4, Report of the Government Alcohol Advisory 5, Health related consequences of problem alcohol use6, Alcohol and injuries in the accident and emergency department- a national perspective7, the Reports of Strategic Task Force on Alcohol 8,9 and Alcohol related deaths among people who were alcohol dependant in Ireland10.

The large increase in alcohol consumption in Ireland in the late 1990’s has resulted in a huge and corresponding increase in alcohol related harm as outlined in the reports mentioned above. The morbidity and mortality in Ireland as a result of alcohol presents a huge burden on individuals, the health services, industries, local communities and the state.

The per capita consumption of alcohol in Ireland was not always as high, as seen in Figure 1 which shows whilst, the average per capita consumption has been falling in OECD countries as a group since the early 1970’s, Ireland’s consumption had been steadily rising since 1960 until recent years.

Even though there has been a drop in consumption since the peak in 2001, Irish adults (those aged 15 years and over) drank on average 11.9 litres of pure alcohol in 2010. This is equivalent to 482 pints of lager or 45 bottles of spirits (e.g. vodka or gin). That is almost the equivalent of one bottle of vodka or gin per person per week. Given that 19% of adults in Ireland do not drink alcohol, the actual amount of alcohol consumed per adult drinker is much higher.

Repeated ESPAD studies 11 show Ireland’s young people to be amongst the very highest for consumption and for binge drinking. This bodes very badly for the future. It is therefore vital to delay the age of onset of drinking by young people, as recommended by the WHO.

However, our alcohol problems cannot not be blamed on young people or on the minority of drinkers. Over half of drinkers in Ireland have a hazardous drinking pattern12 and another study carried out in December 2009 and January 2010 of patients attending four Emergency Departments showed, as seen in Table 1, that almost half had a drinking pattern that required an intervention13.

Table 1 Attendees at Emergency Departments requiring further intervention in respect of their alcohol consumption.

Waterford Regional / Letterkenny / Naas / Cork University / Total
No intervention required / 46% / 60% / 41% / 19% / 49%
Brief advice / 41% / 30% / 33% / 56% / 36%
Referral to specialist services / 11% / 3.5% / 12.5% / 16% / 9%
Declined to take part / 25 / 6.5% / 13.5% / 9% / 6%

The health related consequences of alcohol use in Ireland

The following are examples of the alcohol related harm and consequences

1.  Alcohol kills at least one person in Ireland every 7 hours

1. Alcohol-related deaths also increased during the period 1995- 2004, from 3.8deaths per 100,000 to 7.1deaths per 100,000

3.  Alcohol is a contributory factor in half of all suicides in Ireland.

4.  Alcohol was consumed in four out of ten episodes of self-harm in Ireland in 2010.

5.  2,000 acute hospital beds are occupied on average each night as a result of alcohol.

1. Alcohol-related admissions to acute hospitals doubled between 1995 and 2008.
2. High levels of alcohol use and heavy drinking among young women are reflected in the fact that one in four women discharged from hospital for alcohol-related conditions were aged under30, compared to 17% of men under 30discharged.
3. Between 1995 and 2004, there was an increase of 29% in the proportion of teenage girls aged under18 discharged from hospital for alcohol-related conditions compared to an increase of 9% for males under18.
4. Alcoholic liver disease rates and deaths almost trebled (190% increase) between 1995 and 2007.
5. The figures also reveal considerable increases of alcohol liver disease among younger age groups.
6. Among 15-34 years olds, the rate of alcohol liver disease discharges increased by 247%,
7. Among 35-49 age group, the rate increased by 224%.
8. These increases occurred in parallel with increases in alcohol consumption and harmful drinking patterns
9. Chronic alcohol-related conditions are becoming increasingly common among young age groups. Between 2005 and 2008, 4,129 people aged under 30 were discharged from hospital with chronic diseases or conditions of the type normally seen in older people.
10. One in four of those attending accident and emergency departments have alcoholrelated injuries, almost half of which occurred to people aged under 30 years14.
11. Alcohol is a factor in one in four traumatic brain injuries15.

15.  Alcohol was the main drug responsible for 7,940 admissions to specialised addiction treatment centres in 2008.

16.  There were alcohol related 1,798 admissions to mental hospitals in 2010. This was the fourth commonest cause of admission overall and 3rd commonest reason for male admission16.

17.  More than one in eight patients seen the Sexual Assault Unit in Dublin's Rotunda Hospital last year had so much alcohol consumed, they were unsure if they had been attacked. The highest number of assaults was among women aged 18-2517.

1. Alcohol is a trigger in one third of cases ofdomestic abuse.
2. chronic diseases or conditions of the type normally seen in older people

20.  Alcohol, even at low-risk levels of consumption, increases the risk of many major diseases including numerous cancers and gastrointestinal conditions.

21.  Low levels of alcohol consumption is associated with a small increase in breast cancer risk, with the most consistent measure being cumulative alcohol intake throughout adult life. Alcohol intake both earlier and later in adult life was independently associated with risk. Binge drinking, but not frequency of drinking, was associated with breast cancer risk after controlling for cumulative alcohol intake.

22.  Consuming alcohol during pregnancy increases the risk of Foetal Alcohol Spectrum Disorder. However, almost two-thirds of women report drinking alcohol during pregnancy with 7% drinking 6 or more units per week18.

The above facts highlight the extensive alcohol problem we have in Ireland. In addition, it is worth noting that most of these harms occur not in alcoholics or people with alcohol dependence but rather among regular drinkers who drink at hazardous or harmful levels-unfortunately over 50% of all drinkers in Ireland. To characterise Ireland's drinking problem as occurring in a small minority of 'irresponsible' drinkers is incorrect.

Difficulties experienced in Emergency Departments with respect to alcohol consumption

Alcohol carries a significant burden for Emergency Services in Acute Hospitals in Ireland in terms of the numbers in attendance, the range of presenting injuries and the level of repeat visits. In excess of 1 million patients attend Ireland’s Emergency Departments annually.

A few facts14:

·  In up to 25% of ED attendances alcohol is a significant presenting factor.

·  Nationally, nearly 30% of patients presenting to an Emergency Department with injury have alcohol as a contributing factor. This is primarily as a result of the patient’s own drinking prior to the injury event but in some instances is caused by a third party many of whom who also have consumed alcohol.

·  For alcohol related injuries, attendance is highest on Saturdays and Sundays and the peak-time is between Midnight and 4am. Alcohol consumption is commonly associated with other “recreational” drug use.

·  While the majority of injuries are unintentional, one in three of alcohol related injuries, in comparison to one in twenty of non alcohol related injuries, are intentional and perpetrated by someone else.

·  Six out of every ten patients presenting to an Emergency Department with alcohol related injuries have engaged in harmful drinking (12+ drinks) in the six hours prior to the accident/injury. Clinical assessment demonstrates that three-quarters of patients attending with alcohol related injuries are moderately to severely intoxicated.

·  For the vast majority of patients the pub, hotel or other drinking place (in distinction to home) is the drinking environment prior to injury.

Emergency Department Environment

Emergency Departments in Ireland are busy clinical environments and can experience significant crowding. With an aging population the majority of patients waiting in an emergency department are elderly frail patients. The complexity of healthcare needs for this elderly cohort is increasing.

Patients who have consumed alcohol who present to an Emergency Department with an acute illness or injury require specialist emergency medical management. The clinical condition often warrants significant department resource: medical, nursing and security. The management of a patient who has consumed significant amounts of alcohol presenting with an emergent medical or trauma condition is made more difficult by the effect of alcohol on the brain. An overcrowded department makes this assessment and management extremely difficult.

Patients under the influence of alcohol, by and large, behave the same way in an emergency department as they would in a public house or street. The aggression, emotion and threatening behaviour seen in public places is also seen in the emergency department environment, some times culminating in assault of staff (or other patients).

Financial costs

The cost of the alcohol related harm to the healthcare system has been estimated to be €1.2 billion a year (2007) 19 with costs of €500 million in the acute hospital sector, €574 million in general practice and allied health services and €104 million in mental health services. The cost of alcohol related suicides has been estimated to be €167 million and the cost of alcohol related fatalities on the roads has been estimated to be €526 million.

The HSE provides a wide range of services in respect of alcohol related harm. These include health promotion activities and campaigns, outreach and counselling services, addiction services, family support, treatment of patients presenting with alcohol related harm in acute hospitals and support of voluntary organisations. Attached to this submission at Appendix 1 is a list of the range of services and supports provided.

Evidence based interventions work

In 2005 there were 397 persons killed on the roads in Ireland. In 2006 random breath testing was introduced. The number of persons killed on the roads fell immediately to 365 in 2006. By 2010 this had reduced to 211, a 47% reduction.

In addition emergency admissions to acute hospital following road traffic crashes have decreased by 22% from 3,118 in 2006, when random breath testing was introduced, to 2,435 in 2010.

Effective Strategies to reduce alcohol related harm

The more a population consumes the greater the degree of alcohol related harm. A national strategy should as a priority concentrate on reducing our overall consumption as stated by The Strategic Task Force on Alcohol in its interim report 8. The most effective strategies to reduce the overall consumption have been outlined by The Strategic Task Force on Alcohol where the reports made recommendations for reducing alcohol-related harm in Ireland based on the scientific evidence.

The following strategies are required to reduce consumption and alcohol related harm:

An increase in price through taxation

Increases in taxation are particularly important as they reduce the alcohol consumption of young people and have a bigger impact on heavy drinkers than light drinkers 20, 21. Tax increases also need to be sustained in the longer term as recent study showed that a reduction in taxes in 2004 in Finland resulted in a 17% increase in alcohol related mortality 22.

A minimum price on alcohol in particular for off sales

The Government Alcohol Advisory Group was concerned, that mixed trading premises in particular, were selling cheaper alcohol to attract customers in the expectation that they will purchase other products and recommended that alcohol products must be sold on the basis of a unit price. This means that the promotion, supply or sale of alcohol products either free of charge or at a reduced price on purchase of one or more units of the product should be prohibited. The HSE supports this recommendation and also recommends a new tax on alcohol sold for consumption off the premises in which it is sold.

A decrease in the number of outlets selling alcohol

The most effective strategies to reduce alcohol consumption and thereby alcohol related harm are making alcohol less affordable and reducing the physical available of alcohol through the number of retail outlets and the number of hours during which alcohol can be sold.

The HSE recommends a reduction in the number of premises available to sell alcohol and maintaining the revised opening hours introduced following the Intoxicating Liquor Act 2008.

A ban on advertising

A ban on advertising of alcohol including a ban on sponsorship of sporting events by alcohol companies. Research has shown that alcohol advertising is influential in adolescents starting to drink earlier and more if they are already drinkers23.

Given the high level of teenage drinking and the level of teenage binge drinking in Ireland compared to other countries11 it is essential that the promotion of alcohol though advertising and other promotions is addressed in the national strategy.