18 | themedicalindependent | mindo.ie 3 April 2014

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the Government will deliver an ef-fective set of proposals.”

Industry believes that the “failure to focus on education was a lost op-portunity,” says the spokesperson, who suggests that education on al-cohol should have been legislated for. “The bill contains an over-em-phasis on marketing restrictions, without clear evidence that these proposals will address under-age drinking and binge-drinking. Such restrictions are anti-business and anti-jobs and more importantly, will not deliver the Government’s aim to reduce alcohol misuse.”

Asked if it had received any sub-missions from doctors’ organisa-tions or individual doctors on the effects of alcohol or had met with any such organisations to discuss the issue, the spokesperson re-sponds: “We would definitely wel-come an approach from medics, but unfortunately, increasingly the medical community, the health lob-by and the Department of Health refuse to engage with industry. In other markets, for example the UK, there is a very high level of engage-ment between industry and the medical community and govern-ment departments and NGOs.”

The HSE had not responded by press time to MI’s request for com-ment on its work on tackling alco-hol misuse. However, Dr Steph-anie O’Keeffe, National Director for Health and Wellbeing, HSE, speak-ing upon the recent publication of the HSE report, Alcohol’s Harm to Others in Ireland, said its findings “support the HSE investment in al-cohol prevention measures, partic-ularly screening and brief interven-tions carried out by health profes-sionals in the context of their work with patients”.

Headline statistics on alco-hol that accompanied the Gov-ernment announcement in Octo-ber were startling. Alcohol was re-sponsible for at least 88 deaths eve-ry month in 2008. It increases the risk of more than 60 medical condi-tions, such as cancers. Alcohol-re-lated illness cost the healthcare sys-tem €1.2 billion in 2007.

Furthermore, Alcohol’s Harm to Others in Ireland noted that 28 per cent of people experienced at least one or more negative consequences as a result of someone else’s drink-ing – family problems, passenger with a drunk driver, assault, prop-erty vandalised and money prob-lems, for example.

A potential outcome of irrespon-sible drinking that has received rel-atively little publicity, however, is that of alcohol-related brain inju-ry (ARBI). Alcohol Forum, a Don-egal-based charity that is co-ordi-nating National Alcohol Awareness Week 2014 (31 March-4 April), pro-duced a report in 2011 on Assess-ment of Incidences of Alcohol-Re-lated Brain Injury (ARBI) in HSE West and Western Health and So-cial Care Trust (WHSCT), North-ern Ireland. Some 163 people were admitted to acute hospitals across Donegal, Sligo, Leitrim and Ro-scommon over a five-year period, and 151 people were admitted with-in this time frame in the WHSCT area.

Psychologist Dr Helen McMona-gle, ARBI Rehabilitation Co-ordi-nator at Alcohol Forum, says these numbers are likely to be a signifi-cant underestimation and there is no established national prevalence rate. Worldwide autopsy studies

have shown that about one in every eight people who are dependent on alcohol will develop ARBI.

Studies have identified that groups of individuals particularly vulnerable to developing this con-dition include, for example, those who have been drinking in a harm-ful way for five-to-10 or more years; men who are regularly drinking 35 or more standard drinks per week, and women regularly drinking 28 or more standard drinks per week.

Dr McMonagle believes there is a lack of awareness among both the general public and professionals in healthcare. The stigmatisation at-tached to cognitive impairment and brain injury is also a barrier to peo-ple presenting.

There is a “strong need” for a pub-lic information campaign to “al-low people to make informed choic-

es about their drinking behaviours,” says Dr McMonagle. “Further to this, a need for ARBI-specific modules on training courses across professional disciplines will serve to raise profes-sional awareness and dialogue about the condition,” she adds.

Prognosis is good for about 75 per cent of affected individuals if they receive the right treatment, she underlines.

More broadly, Dr McMonagle emphasises the importance of rou-tine dialogue around alcohol and cognitive impairment between al-cohol users and medical profes-sionals. “We will be failing some very vulnerable people if we do not start asking questions about cogni-tive functioning in high-risk drink-ing populations,” she stresses.

GPs have a crucial role to play in the identification of people affected

by this condition, but some may feel they do not have sufficient knowl-edge in this area, she acknowledges.

“This highlights the need for ARBI specialist training through CPD-ap-proved workshops and GP training schemes in Ireland,” says Dr Mc-Monagle. “But GPs cannot work in isolation. They also require links with specialist services who have expertise in the condition. For ex-ample, in Donegal we have an Ear-ly Intervention Clinic, which is placed in primary care and allows GPs to refer those high-risk drink-ers where possible cognitive and/or functional decline has been ob-served. This is a fledgling service, but the aim is to increase pre-clin-ical detection rates.”

The Alcohol Forum has developed a case co-ordination approach in Co Donegal with support from the HSE.

“We now have a clear referral pathway for people affected by this condition and an identifiable pro-fessional with expertise in ARBI to co-ordinate rehabilitation and re-covery. This has led to an improve-ment in inter-agency working in relation to these service users, in-creased access to services, and a re-duction in fractured care.”

There is a critical need for pro-fessional leadership in developing ARBI-specific guidelines and ser-vice responses at a national level, says Dr McMonagle.

young peopleYoung people tend not to expect

that, one day, their health and lives may be compromised by chronic or life-limiting illnesses connect-ed with their drinking, says Dr Mi-chael Byrne, Head of the Student Health Department, UCC, who spoke at a major Alcohol Forum conference this week, alongside Dr McMonagle.

He notes that alcohol is a reality of Irish social life in villages, towns and colleges nationwide and is en-joyed by many students. What is vi-tally important is how messages on alcohol are communicated, he indi-cates.

“We have reframed the whole de-bate and the students have grasped it – that this is actually a health and safety issue,” Dr Byrne told MI.

UCC’s award-winning approach to this issue has involved the devel-opment of an evidence-based Alco-hol Action Plan, which is regularly updated, and of key performance indicators to monitor its imple-mentation and effectiveness.

“We in essence recognised the value of education but that it has a limit, and that education alone is not enough and you have to ac-tually have a style of education that will change behaviour,” Dr Byrne adds. “So we chose a piece of soft-ware that we would make available to our students, initially very much on an ad hoc and as-and-when ba-sis, but increasingly now expected of all incoming first-year students that they would complete an online behavioural change module around alcohol.”

He continues: “We introduced that first in about 2009, even be-fore the introduction of the plan, but once we introduced the plan we strongly encouraged and made it semi-mandatory for incoming stu-dents. It resulted in now over 80 per cent of our first-year students completing this 45-minute online intervention… Does that have an effect? Well, we do know from re-search in the States that it chang-es the behaviour of between 4 and 8 per cent of drinkers. We can make a big difference in that space.”

Dr Byrne praises the decision of the Union of Students in Ireland (USI) to end its association with Drinkaware, which is funded by the drinks industry.

“It was absolutely crucial that the students reflected on their re-lationship with Drinkaware,” says Dr Byrne. “The problem is, there is then a vacuum: how do you actual-ly get across a message that will res-onate, particularly with young peo-ple, in a fashion that is attractive, that they can relate to and doesn’t sound preachy?”

Dr Byrne says he hopes Govern-ment funding becomes available so that such material can be produced to fill this gap.

Smoking and alcohol — twin demons hand-in-handCigarettes and alcohol often go hand-in-hand – quite literally. But this is much less the case

since the workplace smoking ban came into effect in March 2004. Speaking to the Medical Independent (MI) just in advance of the 10th anniversary of the

ban, Dr Pat Doorley, Chair of the Tobacco Policy Group, RCPI, has a suggestion on the title of this piece: ‘Ending the tobacco epidemic.’

Indeed, the public health specialist refers more than once to an “endgame”. He believes that if the concepts enshrined in the Government’s policy document ‘Tobacco Free Ireland’ are im-plemented, smoking prevalence can be reduced to the target of five per cent by 2025. “The poli-cy document itself should be seen as a call to action, not just action by the Department of Health and the Government, but all of us: doctors, frontline health professionals, non-governmental organisations, and others. It is a very ambitious target but it is achievable if we implement all of those actions — and very intensively.”

In 2013, the National Tobacco Control Office reported that 21.5 per cent of Irish adults smoked, representing a decline of 2.2 per cent since 2010, and a decline of 7.5 per cent since 2007. One-in-two smokers will die from a tobacco-related illness.

In a new position paper, the RCPI Policy Group on Tobacco is recommending that the Gov-ernment continues to increase taxes annually on tobacco, that all expectant mothers should be offered comprehensive and structured support to quit smoking and that there is a complete smoking ban in cars wherever children are present (preparation of relevant legislation on the car issue is reportedly nearing conclusion).

“Tobacco taxation is the most effective way of cutting smoking rates, and therefore smoking deaths,” Dr Doorley tells MI. “Generally speaking, in developed countries, for every 10 per cent you put up the price of tobacco, you decrease tobacco consumption by 4 per cent. But among children it is higher, at about 8 per cent.”

Speaking on the Government’s commitment to implement plain packaging, Dr Doorley said a systematic review of the evidence by Moodie et al, in the University of Sterling, showed that the usual pack is attractive to smokers — and particularly to children. “Smokers like them; they think they are cool.

“They don’t like the plain packs and they tend to take more notice of the health warnings on the plain packs, whereas the colours and the embossing on the packs tend to detract from the health messages. The thrust of those studies showed that the pack is an advertising medium and it makes tobacco more attractive.”

He says a tactic of the tobacco industry is to “try to bully and scare governments about this, threatening litigation,” but the RCPI expects that the plain packaging measure will proceed ac-cordingly.

Global tobacco giant Philip Morris International confirmed to MI that it had “shared” with the Irish Government “a legal paper examining standardised packaging and potential issues”.

A spokesperson said: “As the Government contemplates this policy, we believe it is our re-sponsibility to ensure that the serious legal issues — as well as the negative consequences of plain packaging, not just for our business but also for the wider economy overall — are part of the debate.”

Psychologist Dr helen McMonagle, arBi rehabilitation Co-Ordinator at alcohol Forum

Worldwide autopsy studies have shown that about one in every eight

people who are dependent on alcohol will develop an alcohol-related brain

injury... prognosis is good for about 75 per cent of affected individuals if they receive the right treatment

Allergic rhinitis relieffluticasone furoate

Relieving the symptoms of allergic rhinitis1

Abridged Prescribing Information (please see SPC for full prescribing information).

Trade name: AVAMYS 27.5 micrograms/spray nasal spray suspension. Quantity of active ingredient per unit dose: Each spray actuation delivers 27.5 mcg of fluticasone furoate. Presentation: Avamys is available in a 120 sprays device. Therapeutic indications: Adults, adolescents and children (6 and over): Treatment of the symptoms of allergic rhinitis. Posology and method of administration: Posology: Adults and Adolescents (12 years and over): The recommended starting dose is two sprays in each nostril once daily (total daily dose, 110 mcg fluticasone furoate). Once adequate control is achieved, dose reduction to one spray in each nostril may be effective for maintenance. The dose should be titrated to the lowest effective dose required to maintain control of symptoms. Children (6 to 11 years of age): The recommended starting dose is one spray in each nostril once daily (total daily dose, 55mcg fluticasone furoate). Patients not responding to one spray in each nostril once daily may use two sprays in each nostril once daily (total daily dose, 110 mcg). Once control of symptoms is achieved, dose reduction to one spray in each nostril once daily is recommended. Regular, scheduled usage is recommended. Onset of action has been observed as early as 8 hours after initial administration. However, it may take several days of treatment to achieve maximum benefit. The duration of treatment should be restricted to the period that corresponds to allergenic exposure. Children under 6 years of age: Safety and efficacy in this group has not been established (see SPC for further information). Elderly Patients and Renal Impairment: No dose adjustment required. Hepatic Impairment: No dose adjustment required in mild to moderate hepatic impairment. There are no data in patients with severe hepatic impairment. Caution should be exercised when dosing patients with severe hepatic impairment. Administration: Intranasal route only. Shake the device before use. Prime the device by pressing the button for six sprays actuations, whilst holding the device upright. Re-prime if the cap is left off for 5 days or the device has not been used for 30 days. Clean after use and replace the cap. Contraindications: Hypersensitivity to any of the ingredients.

Special warnings and precautions: Systemic effects may occur, particularly at high doses prescribed for prolonged periods. Treatment with higher than recommended doses may result in clinically significant adrenal suppression. The total systemic burden of corticosteroids should be considered whenever other forms of corticosteroid treatment are prescribed concurrently. If there is any reason to believe that adrenal function is impaired, care must be taken when transferring patients from systemic steroid treatment to fluticasone furoate. Close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma and/or cataracts.Growth retardation has been reported in children receiving some nasal corticosteroids at licensed doses. A reduction in growth velocity has been observed in children treated with fluticasone furoate 110 mcg daily for one year; children should be maintained on the lowest possible efficacious dose which delivers adequate symptom control. The growth of children receiving prolonged treatment should be monitored. If growth is slowed, therapy should be reviewed. Caution is advised when treating patients with severe liver disease. Concomitant administration with ritonavir is not recommended. Drug interactions: Concomitant administration with ritonavir is not recommended. Caution is recommended when co-administering fluticasone furoate with potent CYP3A4 inhibitors as an increase in systemic exposure cannot be ruled out. Fertility, pregnancy and lactation: Fluticasone furoate should be used only if the benefits to the mother outweigh the potential risks to the foetus or child. There are no fertility data in humans. Effects on ability to drive and use machines: No or negligible influence on the ability to drive and use machines. Undesirable effects: Very common (≥1/10): Epistaxis. Common (≥1/100 to <1/10): Headache, nasal ulceration. For less frequent undesirable effects, please see SPC. MA number: EU/1/07/434/003. MA holder: Glaxo Group Ltd, 980 Great West Road, Brentford, Middlesex, TW8 9GS, United Kingdom Legal category: POM. For further information please contact: GlaxoSmithKline (Ireland) Ltd, Stonemasons Way, Rathfarnham, Dublin 16. Telephone: 01-4955000. Job number: IE/FF/0017/13. Date of preparation: April 2013

Adverse events should be reported directly to the IMB; Pharmacovigilance Section, Irish Medicines Board, Kevin O’Malley House, Earlsfort Centre, Earlsfort Terrace, Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517, Website: www.imb.ie, e-mail: imbpharmacovigilance@imb.ie.

Adverse events should also be reported to GlaxoSmithKline on Free phone 1800 244 255, Fax 01 4938839 or e-mail: ireland.drugsurveillance@gsk.com.

Reference: 1.Avamys Summary of Product Characteristics, available on www.medicines.ie, accessed January 2014.

Date of preparation: January 2014. IE/FF/0001/14

Not actual sizeAvamys® is a registered trademark of the GlaxoSmithKline group of companies. © GlaxoSmithKline group of companies 2014.

IE_FF_0001_14_Avamys_advert_Summerhouse_Medical Independent_Jan2014.indd 1 16.01.2014 11:08:41

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