SAFER
Facilitate access to screening, brief interventions and treatment
WHO, in collaboration with international partners, launched the SAFER initiative in 2018. "SAFER" is an acronym for the 5 most cost effective interventions to reduce alcohol related harm.
Facilitate access to screening, brief interventions and treatment
Health professionals have an important role in helping people to reduce or stop their drinking to reduce health risks, and health services have to provide effective interventions for those in need of help and their families.
What to do?
Several concrete steps could be taken by governments to facilitate access to screening, brief interventions and treatment.
For instance:
- the capacity of health and social welfare systems can be increased in order to deliver prevention, treatment and care for alcohol use disorders, alcohol-induced disorders and comorbid conditions, including the provision of support and treatment for affected families and support for mutual help or self-help activities and programmes;
- initiatives for screening and brief interventions for hazardous and harmful alcohol intake can be supported in primary health care and other settings. Such initiatives should include early identification and management of alcohol use – especially heavy alcohol intake – among pregnant women and women of childbearing age;
- strategies and services can be developed and coordinated for integrated and/or linked prevention, treatment and care of alcohol use disorders and comorbid conditions – including drug use disorders, depression, suicides, HIV/ AIDS and tuberculosis; and
- universal access to health can be provided – including through enhanced availability, accessibility and affordability of treatment services for groups of low socioeconomic status.
Why do it?
Access to health services is central to tackling alcohol-related harms at individual level. Health professionals have an important role in helping people to reduce or stop their alcohol use in order to reduce health risks, and health services must provide effective interventions both for those in need of help and for their families. There is extensive and consistent evidence that brief advice in health-care settings reduces alcohol-related
harm. Evidence strongly supports the widespread implementation of programmes of early identification and brief advice in primary care settings for persons with hazardous and harmful alcohol consumption. There is also some evidence that similar programmes implemented in emergency departments can be effective, as can programmes in reproductive health services for women (before and during pregnancy). However, there is not yet enough evidence to determine the effectiveness of such programmes outside primary care settings. There is consistent evidence that behavioural and pharmacological therapies are effective in treating alcohol use disorders. Brief psychosocial interventions have been assessed as an effective intervention for NCD prevention.
Comprehensive systems of screening, brief interventions and treatment have the potential not only to reduce but also to prevent alcohol-related harm (e.g. to spouses or children of parents with alcohol use disorders).
How to do it?
The health service response should be sufficiently strengthened and funded so that it is commensurate with the magnitude of the public health problems caused by harmful use of alcohol. Governments should support the widespread use of the health interventions listed above by promulgating guidelines, providing training, establishing quality assurance/performance metrics, providing services, and ensuring adequate reimbursement of providers where applicable.
Health-care professionals should use a structured and tested tool, such as the AUDIT (Alcohol Use Disorders Identification Test) questionnaire, to assess the level of risk for alcohol use disorders in all patients.
Patients scoring high on the AUDIT tool should be offered brief intervention in the form of motivational interviewing. This approach typically involves one or a few short sessions that focus on helping the patient to understand his or her pattern of alcohol consumption and to develop strategies to reduce consumption and risk. Health- care professionals should be given access to online and/or in-person training to familiarize them with motivational interviewing techniques.
Patients with alcohol dependence, or whose harmful consumption is persistent, may require referral for specialized treatment – which may include outpatient care, inpatient treatment, mutual self-help groups and supportive services. Governments should promote and support only those treatments with a strong evidence base, specifically recommended by WHO or by national governmental or professional associations following careful review of the scientific evidence of their impact.
Since comorbidities are common, screening and brief intervention should be delivered systematically in primary care and other frontline clinical settings (such as TB or HIV clinics, the emergency room in case
of an injury, reproductive health clinics, or during prenatal care) by primary care professionals. Treatment for alcohol dependence can be provided by primary care practitioners with support from specialists (as in the “collaborative care” model), or directly by specialists, where available. Support services include social services, rehabilitation and self-help groups in the community.
It is necessary to decide whether to implement a universal and systematic screening programme to enable primary care providers to offer the identification and brief advice programme to every adult coming to a consultation, or whether to opt for an incremental programme whereby identification and brief advice are offered every time a patient registers with a new doctor, comes for a health check or comes with a new condition such as hypertension or tuberculosis.
Primary care providers find it easier to undertake this intervention when they are supported by specialist services to which they can refer cases that are difficult to manage. In the management of alcohol use disorders, the transition from primary to specialist care should ideally be seamless but in many countries there is a scarcity of services that are available, accessible or affordable. Specialist services for managing alcohol withdrawal and treating alcohol use disorders should be offered to those who need them. The trend has been to move away from lengthy inpatient treatment to outpatient and community-based treatment. Compulsory treatment is no longer recommended. Court-mandated treatment can be considered for repeated drink–drivers, as some evidence has shown that it can be effective.
Whom to work with?
One key stakeholder is the clinical body or institute for clinical excellence that is responsible for developing clinical guidelines and which, therefore, can be asked to prepare guidelines for early identification and brief advice.
Another major stakeholder group consists of health professionals – and especially primary care providers, medical doctors, nurses, midwives and social workers. Their involvement will help to ensure that the guidelines reflect their professional perspective and will help to secure their endorsement and support for early identification and brief advice programmes.
A third stakeholder category in some countries encompasses the public bodies and private organizations that fund and provide primary care services. This category includes the national health service, local trusts and commissioning services, insurance companies and local communities and municipalities. These stakeholders need to be persuaded of the case for funding and managing early identification and brief advice programmes. To make this case effectively, it may be helpful to model the impact and cost–effectiveness of different scenarios for implementing these programmes.
A fourth stakeholder category includes civil society and community-based organizations that provide treatment and recovery programmes – often in underserved, low-resource settings – that play a key role in serving the most vulnerable and marginalized people and communities.
Publications
11 December 2019
The SAFER technical package
- five areas of intervention at national and subnational levels.
27 September 2018
The SAFER brochure
WHO, in collaboration with international partners, launched the SAFER initiative towards a world free from alcohol related harm in 2018. This brochure...
WHO resources
Manual for use in primary care
The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was developed for the World Health Organization (WHO) by an international group...
Substance use problems can arise as a result of acute intoxication, regular use or dependence - and from the way in which substances are used. This guide...
