Avoiding the air lock:

The need for online alcohol interventions

Mark Holmes, Telehealth Coordinator at HAGA, the alcohol action charity, on why technology may offer more people the support they need to make changes to their drinking.

The first time I was about to step into an alcohol service, I was petrified. I asked myself questions such as ‘What would I find behind the doors? Would there be intoxicated, violent or over familiar people there?’ As I entered through the heavy wooden door, I smelt the disinfectant and my anxieties heightened. The door slammed behind me with another door in front of me. Welcome to the ‘air lock.’ Behind the glass to my right was a worker, the scene akin to stepping into a secure facility.  The friendly worker asked me what I had come for and I explained that this was my first day at work as an Alcohol Nurse Specialist.

Once inside, I was met with energy and empathy from staff towards service-users and enthusiasm for specialism of the field of addiction. My first impressions of the ‘air lock’ nevertheless raised a question:  if I was scared to enter this building, how can we expect those that want (or, in many cases, don’t want) our support to overcome the fear they feel on entering our services?

There are many reasons why people may not seek support with their drinking.  The stigma of entering an alcohol service remains a major one.  We know that despite the high numbers excessively drinking, the majority of people at risk of alcohol-related harm are not accessing alcohol services.  Alcohol Concern (2013) highlighted in the publication 15:15 the Better case for Access to Alcohol Treatment that only 6% of dependent drinkers are in contact with treatment services at any one time.

Retention is also a problem with national and international statistics indicating that from 40% to 60% of people who enter alcohol treatment services drop out within as little as two sessions. If we want to achieve The Department of Health’s Alcohol Needs Assessment Research Project benchmark of engaging 15% of the problem drinkers in a given area into treatment, then alcohol services must not only deliver high quality specialist support but also find innovative approaches to reaching risky drinkers.  Telehealth technology is increasingly being looked to as one way to reach people with all sorts of health advice, information and support.

Is technology the answer to engaging the Higher Risk and Lower dependent drinker?

Nationally, NHS England (2013) in the document The NHS belongs to the people: a call to action is working to harness technology to fundamentally improve productivity, putting people in charge of their own health and care, and integrating more heath and care services: “It’s about changing the physiology of the NHS, not its anatomy.” The NHS is committed to delivering more care at home, yet too often patients have to travel to healthcare providers.

Research suggests that telehealth solutions are highly acceptable to those looking for support with alcohol problems (Muench et al 2013, Marsch and Dallery 2012). The most promising acceptability comes with Voice over Internet Protocol (VoIP). But what of the ‘therapeutic alliance’ and that magic ingredient, rapport, I hear you say? VoIP has been proven to be on par with face-to-face contact in terms of the quality of human interaction (Roberts, Vlahovic Dunbar 2013).

The acceptance of telehealth solutions to alcohol misuse and other health issues should not be a surprise with the general population spending more time online. Last year, Ofcom reported that the average time spent per month browsing online on PCs or laptops being 36 hours 49 minutes in March 2014 and counting…. “We’re now spending more time using media or communications than sleeping.  The convenience and simplicity of smartphones and tablets are helping us cram more activities into our daily lives” (Ofcom, 2014). Each household in the UK has, on average, three different types of Internet-enabled devices and 86% have at least one. 77% of adults have broadband (Ofcom, 2014).  Almost three in ten people have ever used VoIP services, like Skype or FaceTime, on mobile phones.  Nearly all 16-24s and 25-34s are now online (98%).  With so many people having access to the Internet and becoming increasingly comfortable with its use, there is a real opportunity for alcohol treatment providers to take alcohol interventions to an online audience.

Online alcohol intervention service launches

Since its establishment in 1981, HAGA, the alcohol action charity, based in North London, has gained a reputation for innovation.  Recently, HAGA has focussed on bringing a variety of technological innovations to the early identification and treatment of alcohol misuse.  In particular, they have strived to develop this area in order to attract those drinkers that are currently under-represented in alcohol services (typically those Increasing and Higher Risk drinkers scoring 8-19 on the Alcohol Use Disorders Identification Test (AUDIT)) and to offer them psychosocial interventions in the right place at the right time.

HAGA first developed an online screening, advice and referral tool, DontBottleItUp, and then DrinkCoach, a smartphone and tablet app.  40,000 people visited DontBottleItUp in 2014 and it is currently commissioned in seven local authorities (with four more due to launch in the next month).  Most recently, HAGA, working with Alcohol Concern, piloted offering VoIP-based interventions to Higher Risk and mildly dependent drinkers identified via DontBottleItUp (January-June 2014).

This initial pilot was successful with service-users and staff giving excellent feedback. Qualitative findings are soon to be published with service-users reporting ease of use; avoiding their concerns about going into an alcohol treatment service; and the relative anonymity of the interventions identified as the main advantages for service-users.  One service-user told us that: “the main appeal was that it was easy; I didn’t have to go anywhere. For me it was the only option, when other options weren’t available, time and distance.”

The pilot is now turning into a mainstay online alcohol Extended Brief Intervention appointment option launching in Haringey via DontBottleItUp in February 2015 and more widely in April 2015.

Even though ‘air locks’ have largely become a thing of the past, the poor image of alcohol services looms large in the public psyche. Developing online alcohol support is one way that HAGA is striving to break down the barriers experienced by people affected by alcohol misuse, and to open the door onto new options for change.