Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses

Screening and brief interventions for alcohol use in college health centers: a review

OBJECTIVES

to provide a critical review of the efficacy of brief interventions for alcohol use in college health centers.

METHODS

studies were included if (a) they examined brief intervention trials that were conducted in college- or university-based student health centers or emergency departments, and (b) they provided pre-post data to estimate change.

RESULTS

twelve studies suggested that screening and brief interventions in these settings are acceptable, feasible, and promote risk reduction.

CONCLUSIONS

findings support continued use of time-limited, single-session interventions with motivational interviewing and feedback components.

Screening and brief interventions for hazardous and harmful alcohol use in probation services: a cluster randomised controlled trial protocol

BACKGROUND

A large number of randomised controlled trials in health settings have consistently reported positive effects of brief intervention in terms of reductions in alcohol use. However, although alcohol misuse is common amongst offenders, there is limited evidence of alcohol brief interventions in the criminal justice field. This factorial pragmatic cluster randomised controlled trial with Offender Managers (OMs) as the unit of randomisation will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in probation and different intensities of brief intervention to reduce excessive drinking in probation clients.

METHODS AND DESIGN

Ninety-six OMs from 9 probation areas across 3 English regions (the North East Region (n = 4) and London and the South East Regions (n = 5)) will be recruited. OMs will be randomly allocated to one of three intervention conditions: a client information leaflet control condition (n = 32 OMs); 5-minute simple structured advice (n = 32 OMs) and 20-minute brief lifestyle counselling delivered by an Alcohol Health Worker (n = 32 OMs). Randomisation will be stratified by probation area. To test the relative effectiveness of different screening methods all OMs will be randomised to either the Modified Single Item Screening Questionnaire (M-SASQ) or the Fast Alcohol Screening Test (FAST). There will be a minimum of 480 clients recruited into the trial. There will be an intention to treat analysis of study outcomes at 6 and 12 months post intervention. Analysis will include client measures (screening result, weekly alcohol consumption, alcohol-related problems, re-offending, public service use and quality of life) and implementation measures from OMs (the extent of screening and brief intervention beyond the minimum recruitment threshold will provide data on acceptability and feasibility of different models of brief intervention). We will also examine the practitioner and organisational factors associated with successful implementation.

DISCUSSION

The trial will evaluate the impact of screening and brief alcohol intervention in routine probation work and therefore its findings will be highly relevant to probation teams and thus the criminal justice system in the UK.Ethical approval was given by Northern & Yorkshire REC.

TRIAL REGISTRATION NUMBER

ISRCTN 19160244.

Effectiveness and cost-effectiveness of a stepped care intervention for alcohol use disorders in primary care: pilot study

BACKGROUND

Screening for alcohol use disorders identifies a wide range of needs, varying from hazardous and harmful drinking to alcohol dependence. Stepped care offers a potentially resource-efficient way of meeting these needs, but requires evaluation in a randomised controlled trial.

AIMS

To evaluate the feasibility, effectiveness and cost-effectiveness of opportunistic screening and a stepped care intervention in primary care.

METHOD

A total of 1794 male primary care attendees at six practices in South Wales were screened using the Alcohol Use Disorders Identification Test (AUDIT). Of these, 112 participants who scored 8 or more on the AUDIT and who consented to enter the study were randomised to receive either 5 minutes of minimal intervention delivered by a practice nurse (control group) or stepped care intervention consisting of three successive steps (intervention group): a single session of behaviour change counselling delivered by a practice nurse; four 50-minute sessions of motivational enhancement therapy delivered by a trained alcohol counsellor; and referral to a community alcohol treatment agency.

RESULTS

Both groups reduced alcohol consumption 6 months after randomisation with a greater, although not significant, improvement for the stepped care intervention. Motivation to change was greater following the stepped care intervention. The stepped care intervention resulted in greater cost savings compared with the minimal intervention.

CONCLUSIONS

Stepped care was feasible to implement in the primary care setting and resulted in greater cost savings compared with minimal intervention.

Packages of care for alcohol use disorders in low- and middle-income countries

In the fourth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Vivek Benegal and colleagues discuss the treatment of alcohol use disorders.

Screening and brief interventions for hazardous and harmful alcohol use in primary care: a cluster randomised controlled trial protocol

BACKGROUND

There have been many randomized controlled trials of screening and brief alcohol intervention in primary care. Most trials have reported positive effects of brief intervention, in terms of reduced alcohol consumption in excessive drinkers. Despite this considerable evidence-base, key questions remain unanswered including: the applicability of the evidence to routine practice; the most efficient strategy for screening patients; and the required intensity of brief intervention in primary care. This pragmatic factorial trial, with cluster randomization of practices, will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in primary care and different intensities of brief intervention to reduce excessive drinking in primary care patients.

METHODS AND DESIGN

GPs and nurses from 24 practices across the North East (n=12), London and South East (n=12) of England will be recruited. Practices will be randomly allocated to one of three intervention conditions: a leaflet-only control group (n=8); brief structured advice (n=8); and brief lifestyle counselling (n=8). To test the relative effectiveness of different screening methods all practices will also be randomised to either a universal or targeted screening approach and to use either a modified single item (M-SASQ) or FAST screening tool. Screening randomisation will incorporate stratification by geographical area and intervention condition. During the intervention stage of the trial, practices in each of the three arms will recruit at least 31 hazardous or harmful drinkers who will receive a short baseline assessment followed by brief intervention. Thus there will be a minimum of 744 patients recruited into the trial.

DISCUSSION

The trial will evaluate the impact of screening and brief alcohol intervention in routine practice; thus its findings will be highly relevant to clinicians working in primary care in the UK. There will be an intention to treat analysis of study outcomes at 6 and 12 months after intervention. Analyses will include patient measures (screening result, weekly alcohol consumption, alcohol-related problems, public service use and quality of life) and implementation measures from practice staff (the acceptability and feasibility of different models of brief intervention.) We will also examine organisational factors associated with successful implementation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN06145674.

[Validation of the MALT-S questionnaire for the diagnosis of alcoholism among the adult population]

OBJECTIVE

To validate the subjective part of the MALT questionnaire (MALT-S) for the detection of alcoholism among the adult population.

DESIGN

A descriptive study on the validation of a diagnostic tool.

SETTING

Two primary health care centres, a centre for drug addicts and a centre for alcoholics in Cordoba (Spain).

PARTICIPANTS

614 patients, between 18 and 80 years.

MEASUREMENTS

Through personal interviews the MALT, AUDIT and SCAN questionnaires were given. The internal reliability, stability and both the criterion and convergent validity were analysed.

RESULTS

The mean age of the population' was 43+/-1.43 (SD) years and 17.4% of them showed Alcohol Dependence Syndrome. The Kappa coefficients of the test items ranged from 0.568 to 0.969. The Cronbach alpha of the complete MALT was 0.919, of the MALT-S, 0.939 and of the MALT-O, 0.737. The area under the ROC curve of the MALT-S was 0.946 and that of the complete MALT was 0.953. For a cut-off point of four, the sensitivity of the MALT-S is 92.7% while its specificity was 90.9%. The correlation coefficient of the MALT-S and AUDIT was 0.86 (P<0.001).

CONCLUSIONS

The MALT-S questionnaire is as valid and reliable as the complete MALT; therefore, it can be used on its own for the diagnosis of alcoholism.

Television-supported self-help for problem drinkers: a randomized pragmatic trial

OBJECTIVES

To test the effectiveness of a television-supported self-help intervention for problem drinking.

METHODS

Dutch television viewers (N=181) drinking in excess of the guidelines for low-risk alcohol use were randomly assigned either to the Drinking Less TV self-help course (consisting of five televised sessions supplemented by a self-help manual and a self-help website) or to a waitlisted control group. To ensure trial integrity, intervention delivery was mimicked beforehand by sending intervention participants weekly DVDs in advance of the actual telecasts in 2006. Pre-post assessments were carried out on both groups, as well as a 3-month follow-up assessment on the intervention group to study effect maintenance. The primary outcome measure was low-risk drinking.

RESULTS

The intervention group was more successful than the waitlist group in achieving low-risk drinking at post-intervention (OR=9.4); the effects were maintained in the intervention group at 3-month follow-up.

CONCLUSIONS

The low-threshold television-based course Drinking Less appears effective in reducing problem drinking.

Curbing problem drinking with personalized-feedback interventions: a meta-analysis

CONTEXT

The effectiveness of personalized-feedback interventions to reduce problem drinking has been evaluated in several RCTs and systematic reviews. A meta-analysis was performed to examine the overall effectiveness of brief, single-session personalized-feedback interventions without therapeutic guidance.

EVIDENCE ACQUISITION

The selection and analyses of studies were conducted in 2008. Fourteen RCTs of single-session personalized-feedback interventions without therapeutic guidance were identified, and their combined effectiveness on the reduction of problematic alcohol consumption was evaluated in a meta-analysis. Alcohol consumption was the primary outcome measure.

EVIDENCE SYNTHESIS

The pooled standardized-effect size (14 studies, 15 comparisons) for reduced alcohol consumption at post-intervention was d=0.22 (95% CI=0.16, 0.29; the number needed to treat=8.06; areas under the curve=0.562). No heterogeneity existed among the studies (Q=10.962; p=0.69; I(2)=0).

CONCLUSIONS

The use of single-session personalized-feedback interventions without therapeutic guidance appears to be a viable and probably cost-effective option for reducing problem drinking in student and general populations. The Internet offers ample opportunities to deliver personalized-feedback interventions on a broad scale, and problem drinkers are known to be amenable to Internet-based interventions. More research is needed on the long-term effectiveness of personalized-feedback interventions for problem drinking, on its potential as a first step in a stepped-care approach, and on its effectiveness with other groups (such as youth obliged to use judicial service programs because of violations of minimum-age drinking laws) and in other settings (such as primary care).

Change over time in alcohol consumption in control groups in brief intervention studies: systematic review and meta-regression study

Reactivity to assessment has attracted recent attention in the brief alcohol intervention literature. This systematic review sought to examine the nature of change in alcohol consumption over time in control groups in brief intervention studies. Primary studies were identified from existing reviews published in English language, peer-reviewed journals between 1995 and 2005. Change in alcohol consumption and selected study-level characteristics for each primary study were extracted. Consumption change data were pooled in random effects models and meta-regression was used to explore predictors of change. Eleven review papers reported the results of 44 individual studies. Twenty-six of these studies provided data suitable for quantitative study. Extreme heterogeneity was identified and the extent of observed reduction in consumption over time was greater in studies undertaken in Anglophone countries, with single gender study participants, and without special targeting by age. Heterogeneity was reduced but was still substantial in a sub-set of 15 general population studies undertaken in English language countries. The actual content of the control group procedure itself was not predictive of reduction in drinking, nor were a range of other candidate variables including setting, the exclusion of dependent drinkers, the collection of a biological sample at follow-up, and duration of study. Further investigations may yield novel insights into the nature of behaviour change with potential to inform brief interventions design.

Drinking habits and prevalence of heavy drinking among occupational healthcare patients

OBJECTIVE

To estimate the proportion of heavy drinkers among occupational healthcare patients and evaluate their characteristics.

DESIGN

Patients visiting their doctor in six occupational health clinics were asked to complete a questionnaire containing the Alcohol Use Disorders Identification Test (AUDIT) and other questions concerning health.

SETTING

Occupational health services.

SUBJECTS

A total of 757 patients participated in the study.

MAIN OUTCOME MEASURE

Heavy drinking was defined as having a score of 10 or more (men) or 8 or more (women) in the AUDIT questionnaire.

RESULTS

Of the men 114 (29%) and of the women 48 (13%) were heavy drinkers. Only smoking differentiated both male and female heavy drinkers from moderate drinkers among the clinically relevant characteristics.

CONCLUSION

There are a considerable number of heavy drinkers among occupational healthcare patients. Heavy drinkers do not have any particularly specific characteristics except for the drinking that distinguish them from other patients. Thus, screening is necessary to identify heavy drinkers in occupational healthcare settings.

Predicting successful treatment outcome of web-based self-help for problem drinkers: secondary analysis from a randomized controlled trial

BACKGROUND

Web-based self-help interventions for problem drinking are coming of age. They have shown promising results in terms of cost-effectiveness, and they offer opportunities to reach out on a broad scale to problem drinkers. The question now is whether certain groups of problem drinkers benefit more from such Web-based interventions than others.

OBJECTIVE

We sought to identify baseline, client-related predictors of the effectiveness of Drinking Less, a 24/7, free-access, interactive, Web-based self-help intervention without therapist guidance for problem drinkers who want to reduce their alcohol consumption. The intervention is based on cognitive-behavioral and self-control principles.

METHODS

We conducted secondary analysis of data from a pragmatic randomized trial with follow-up at 6 and 12 months. Participants (N = 261) were adult problem drinkers in the Dutch general population with a weekly alcohol consumption above 210 g of ethanol for men or 140 g for women, or consumption of at least 60 g (men) or 40 g (women) one or more days a week over the past 3 months. Six baseline participant characteristics were designated as putative predictors of treatment response: (1) gender, (2) education, (3) Internet use competence (sociodemographics), (4) mean weekly alcohol consumption, (5) prior professional help for alcohol problems (level of problem drinking), and (6) participants' expectancies of Web-based interventions for problem drinking. Intention-to-treat (ITT) analyses, using last-observation-carried-forward (LOCF) data, and regression imputation (RI) were performed to deal with loss to follow-up. Statistical tests for interaction terms were conducted and linear regression analysis was performed to investigate whether the participants' characteristics as measured at baseline predicted positive treatment responses at 6- and 12-month follow-ups.

RESULTS

At 6 months, prior help for alcohol problems predicted a small, marginally significant positive treatment outcome in the RI model only (beta = .18, P = .05, R(2) = .11). At 12 months, females displayed modest predictive power in both imputation models (LOCF: beta = .22, P = .045, R(2) = .02; regression: beta = .27, P = .01, R(2) = .03). Those with higher levels of education exhibited modest predictive power in the LOCF model only (beta = .33, P = .01, R(2) = .03).

CONCLUSIONS

Although female and more highly educated users appeared slightly more likely to derive benefit from the Drinking Less intervention, none of the baseline characteristics we studied persuasively predicted a favorable treatment outcome. The Web-based intervention therefore seems well suited for a heterogeneous group of problem drinkers and could hence be offered as a first-step treatment in a stepped-care approach directed at problem drinkers in the general population.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 47285230; http://www.controlled-trials.com/isrctn47285230 (Archived by WebCite at http://www.webcitation.org/5cSR2sMkp).

Organizational contexts of primary care approaches for managing problem drinking

Little is known about the organizational contexts associated with different primary care (PC) approaches to managing PC patients with drinking problems. Relying upon the Chronic Care Model and a theoretically based taxonomy of health care systems, we identified organizational factors distinguishing PC practices using PC-based approaches (managed by PC providers, mental health specialists, or jointly with specialty services) versus referral-based management in the Veterans Affairs health care system. Data were obtained from a national survey of 218 PC practices characterizing usual management approaches as well as practices' leadership, delivery system design, information system, and decision support characteristics and from a national survey of substance use disorder specialty programs. PC- and referral-based practices did not differ on the sufficiency of their structural resources, physician staffing, or on the availability of specialty services. However, PC-based practices were found to take more responsibility for managing patients' chronic conditions and had more staff for decision support activities.

The relationship between recent alcohol use and sexual behaviors: gender differences among sexually transmitted disease clinic patients

BACKGROUND

Binge drinking is associated with risky sexual behaviors and sexually transmitted diseases (STDs). Few studies have investigated this by gender or in an STD clinic. This cross-sectional study examined the association between binge drinking and risky sexual behaviors/STDs among patients attending an urban STD clinic.

METHOD

A total of 671 STD clinic patients were tested for STDs, and queried about recent alcohol/drug use and risky sexual behaviors using audio computer-assisted-self-interview. The association between binge drinking and sexual behaviors/STDs was analyzed using logistic regression adjusting for age, employment, and drug use.

RESULTS

Binge drinking was reported by 30% of women and 42% of men. Gender differences were found in rates of receptive anal sex which increased linearly with increased alcohol use among women but did not differ among men. Within gender analyses showed that women binge drinkers engaged in anal sex at more than twice the rate of women who drank alcohol without binges (33.3% vs. 15.9%; p < 0.05) and 3 times the rate of women who abstained from alcohol (11.1%; p < 0.05). Having multiple sex partners was more than twice as common among women binge drinkers than women abstainers (40.5% vs. 16.8%; p < 0.05). Gonorrhea was nearly 5 times higher among women binge drinkers compared to women abstainers (10.6% vs. 2.2%; p < 0.05). The association between binge drinking and sexual behaviors/gonorrhea remained after controlling for drug use. Among men, rates of risky sexual behaviors/STDs were high, but did not differ by alcohol use.

CONCLUSION

Rates of binge drinking among STD clinic patients were high. Among women, binge drinking was uniquely associated with risky sexual behaviors and an STD diagnosis. Our findings support the need to routinely screen for binge drinking as part of clinical care in STD clinics. Women binge drinkers, in particular, may benefit from interventions that jointly address binge drinking and risky sexual behaviors. Developing gender-specific interventions could improve overall health outcomes in this population.

Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention

AIMS

To determine the effect of an intervention to improve alcohol screening and brief counseling for hypertensive patients in primary care.

DESIGN

Two-year randomized, controlled trial.

SETTING/PARTICIPANTS

Twenty-one primary care practices across the United States with a common electronic medical record.

INTERVENTION

To promote alcohol screening and brief counseling. Intervention practices received site visits from study personnel and were invited to annual network meetings to review the progress of the project and share improvement strategies.

MEASUREMENTS

Main outcome measures included rates of documented alcohol screening in hypertensive patients and brief counseling administered in those diagnosed with high-risk drinking, alcohol abuse or alcohol dependence. Secondary outcomes included change in blood pressure among patients with these diagnoses.

FINDINGS

Hypertensive patients in intervention practices were significantly more likely to have been screened after 2 years than hypertensive patients in control practices [64.5% versus 23.5%; adjusted odds ratio (OR) = 8.1; 95% confidence interval (CI) 1.7-38.2; P < 0.0087]. Patients in intervention practices diagnosed with high-risk drinking, alcohol abuse or alcohol dependence were more likely than those in control practices to have had alcohol counseling documented (50.5% versus 29.6%; adjusted OR = 5.5, 95% CI 1.3-23.3). Systolic (adjusted mean decline = 4.2 mmHg, P = 0.036) and diastolic (adjusted mean decline = 3.3 mmHg, P = 0.006) blood pressure decreased significantly among hypertensive patients receiving alcohol counseling.

CONCLUSIONS

Primary care practices receiving an alcohol-focused intervention over 2 years improved rates of alcohol screening for their hypertensive population. Implementation of alcohol counseling for high-risk drinking, alcohol abuse or alcohol dependence also improved and led to changes in patient blood pressures.

Do brief interventions which target alcohol consumption also reduce cigarette smoking? Systematic review and meta-analysis

Brief interventions are known to be effective in changing both substance use and other health-compromising behaviors. It is unknown whether they may have secondary effects on behaviors which are not specifically targeted. The literature on brief alcohol interventions was selected to explore this possibility, with a study focus on secondary impact on cigarette smoking. The CINAHL, EMBASE, MEDLINE and PSYCINFO bibliographic databases were searched for reviews of brief alcohol intervention studies published in English language, peer-reviewed journals between 1995 and 2005. Authors of primary studies identified in the reviews were contacted to ascertain whether or not their studies had collected cigarette smoking data and, if available, to obtain data. Random effect models were used to pool data for meta-analysis. Eleven review papers reported the results of 41 individual primary studies which were included in this systematic review. Fourteen of these studies collected cigarette smoking outcome data, of which 7 studies still had information available and provided these data for meta-analysis. There were no between-group differences in smoking cessation or reduction across these studies. High levels of smoking cessation were detected in both brief intervention and control groups with much heterogeneity between studies. Brief alcohol interventions do not also reduce cigarette smoking, and it appears unlikely that there exist other important secondary effects. The behavioral consequences of brief intervention study participation itself warrant further study.

The effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care (AESOPS) - a randomised control trial protocol

BACKGROUND

There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption. In older populations excessive alcohol consumption is associated with increased risk of coronary heart disease, hypertension, stroke and a range of cancers. Alcohol consumption is also associated with an increased risk of falls, early onset of dementia and other cognitive deficits. Physiological changes that occur as part of the ageing process mean that older people experience alcohol related problems at lower consumption levels. There is a strong evidence base for the effectiveness of brief psychosocial interventions in reducing alcohol consumption in populations identified opportunistically in primary care settings. Stepped care interventions involve the delivery of more intensive interventions only to those in the population who fail to respond to less intensive interventions and provide a potentially resource efficient means of meeting the needs of this population.

METHODS/DESIGN

The study design is a pragmatic prospective multi-centre two arm randomised controlled trial. The primary hypothesis is that stepped care interventions for older hazardous alcohol users reduce alcohol consumption compared with a minimal intervention at 12 months post randomisation. Potential participants are identified using the AUDIT questionnaire. Eligible and consenting participants are randomised with equal probability to either a minimal intervention or a three step treatment approach. The step treatment approach incorporates as step 1 behavioural change counselling, step 2 three sessions of motivational enhancement therapy and step 3 referral to specialist services. The primary outcome is measured using average standard drinks per day and secondary outcome measures include the Drinking Problems Index, health related quality of life and health utility. The study incorporates a comprehensive economic analysis to assess the relative cost-effectiveness of the interventions.

DISCUSSION

The paper presents a protocol for the first pragmatic randomised controlled trial evaluating the effectiveness and cost-effectiveness of stepped care interventions for older hazardous alcohol users in primary care.

TRIAL REGISTRATION

ISRCTN52557360.

Nursing interventions for preventing alcohol-related harm

Harrington-Dobinson and Blows recently provided a three-part series of articles on alcohol, its consequences for health and wellbeing, and the role of the nurse. Their third article outlined the health education and health promotion role of the nurse. They outlined basic principles for nursing practice in relation to the patient with alcohol dependence in the acute general hospital. The authors of this article believe that much more can, and must, be said in relation to the vital issue of nurses' clinical interventions for alcohol. This article builds on the third article from Harrington-Dobinson and Blows by outlining, in more concrete terms, how nurses in all settings can effectively intervene with patients. It introduces the current evidence-based guidelines in this area and use the 'consensus model' contained within them to describe the process of effective alcohol intervention. Using dialogue examples to illustrate the research, the authors introduce the literature on brief interventions and motivational interviewing to the nursing audience.

Improving substance abuse screening and intervention in a primary care clinic

Despite recent efforts to educate primary care providers in the identification and management of patients presenting with substance abuse problems, many opportunities to identify and intervene with these patients are overlooked. This project was designed to identify factors that interfere with rates of screening and brief intervention (SBI) of substance abuse problems in a primary care clinic in a major academic medical center in New York City. Six informants representing the disciplines of medicine, nursing, and social work in the primary care clinic provided information regarding SBI. Analysis was focused on substantiation of the need for enhanced diffusion of knowledge related to screening for substance abuse problems to improve rates of SBI in primary care. Recommendations for improvement included continued promotion of SBI by influential role models and opinion leaders, improvement in primary care providers' perceptions of the perceived characteristics of SBI to improve rates of adoption, implementation of interdisciplinary educational initiatives toward the goal of improving rates of SBI in the primary care clinic, and initiation of translational research at the clinic supporting SBI in primary care.

Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: a randomized controlled trial

BACKGROUND

Brief interventions for problem drinking in medical settings are effective but rarely conducted, mainly due to insufficient time. A stepped care approach (starting with a very brief intervention and intensifying efforts in case of no success) could save resources and enlarge effectiveness; however, research is lacking. The present study compares a full care brief intervention for patients with at-risk drinking, alcohol abuse or dependence with a stepped care approach in a randomized controlled trial.

METHODS

Participants were proactively recruited from general practices in two northern German cities. In total, 10,803 screenings were conducted (refusal rate: 5%). Alcohol use disorders according to DSM-IV were assessed with the Munich-Composite International Diagnostic Interview (M-CIDI). Eligible participants were randomly assigned to one of three conditions: (1) stepped care (SC): a computerized intervention plus up to three 40-min telephone-based interventions depending on the success of the previous intervention; (2) full-care (FC): a computerized intervention plus a fixed number of four 30-min telephone-based interventions that equals the maximum of the stepped care intervention; (3) an untreated control group (CG). Counseling effort in the intervention conditions and quantity/frequency of drinking were assessed at 12-month follow-up.

RESULTS

SC participants received roughly half of the amount of intervention in minutes compared to FC participants. Both groups did not differ in drinking outcomes. Compared to CG, intervention showed small to medium effect size for at-risk drinkers.

CONCLUSIONS

Study results reveal that a stepped care approach can be expected to increase cost-effectiveness of brief interventions for individuals with at-risk drinking.

Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to the delivery of early intervention and treatment services through universal screening for persons with substance use disorders and those at risk. This paper describes research on the components of SBIRT conducted during the past 25 years, including the development of screening tests, clinical trials of brief interventions and implementation research. Beginning in the 1980s, concerted efforts were made in the US and at the World Health Organization to provide an evidence base for alcohol screening and brief intervention in primary health care settings. With the development of reliable and accurate screening tests for alcohol, more than a hundred clinical trials were conducted to evaluate the efficacy and cost effectiveness of alcohol screening and brief intervention in primary care, emergency departments and trauma centers. With the accumulation of positive evidence, implementation research on alcohol SBI was begun in the 1990s, followed by trials of similar methods for other substances (e.g., illicit drugs, tobacco, prescription drugs) and by national demonstration programs in the US and other countries. The results of these efforts demonstrate the cumulative benefit of translational research on health care delivery systems and substance abuse policy. That SBIRT yields short-term improvements in individuals' health is irrefutable; long-term effects on population health have not yet been demonstrated, but simulation models suggest that the benefits could be substantial.

Estimating regression to the mean and true effects of an intervention in a four-wave panel study

OBJECTIVES

First, to analyse whether a taxation-related decrease in spirit prices had a similar effect on spirit consumption for low-, medium- and high-level drinkers. Secondly, as the relationship between baseline values and post-intervention changes is confounded with regression to the mean (RTM) effects, to apply different approaches for estimating the RTM effect and true change.

SAMPLE

Consumption of spirits and total alcohol consumption were analysed in a four-wave panel study (one pre-intervention and three post-intervention measurements) of 889 alcohol consumers sampled from the general population of Switzerland.

METHODS

Two correlational methods, one method quantitatively estimating the RTM effect and one growth curve approach based on hierarchical linear models (HLM), were used to estimate RTM effects among low-, medium- and high-level drinkers.

RESULTS

Adjusted for RTM effects, high-level drinkers increased consumption more than lighter drinkers in the short term, but this was not a persisting effect. Changes in taxation affected mainly light and moderate drinkers in the long term. All methods concurred that RTM effects were present to a considerable degree, and methods quantifying the RTM effect or adjusting for it yielded similar estimates.

CONCLUSION

Intervention studies have to consider RTM effects both in the study design and in the evaluation methods. Observed changes can be adjusted for RTM effects and true change can be estimated. The recommended method, particularly if the aim is to estimate change not only for the sample as a whole, but for groups of drinkers with different baseline consumption levels, is growth curve modelling. If reliability of measurement instruments cannot be increased, the incorporation of more than one pre-intervention measurement point may be a valuable adjustment of the study design.

The effect of brief interventions on alcohol consumption among heavy drinkers in a general hospital setting

AIMS

(i) To evaluate the effect of receiving one of two brief interventions in reducing alcohol consumption among general hospital patients compared with usual care. (ii) To assess whether a brief intervention of self-efficacy enhancement was superior to a self-help booklet in reducing alcohol consumption.

DESIGN

A three-arm cluster randomized controlled trial.

SETTING

Seven general medical, six general surgical, one dermatology and two otolaryngology wards of a large teaching hospital covering a large urban and rural area.

PARTICIPANTS

A total of 215 of 789 in-patients aged 18-75 years, who screened positive for alcohol consumption in excess of national recommended limits according to a 7-day retrospective drinking diary.

INTERVENTIONS

Participants were allocated to receive one of three interventions: (i) face-to-face self-efficacy enhancement; (ii) a self-help booklet; or (iii) usual care.

MEASUREMENTS

The primary outcome measure was change in reported alcohol consumption at 6-month follow-up as measured by a 7-day retrospective drinking diary. Secondary outcomes were change in: number of alcohol drinking days in last week; the maximum units of alcohol consumed on any one day in last week; and Drinking Refusal Self-efficacy Expectancy Questionnaire score.

FINDINGS

Compared to the usual care group the self-efficacy enhancement group (-10.1 units 95% CI -16.1 to -4.1) and the self-help booklet group (-10.0 units 95% CI -16.0 to -3.9) had greater reductions in self-reported weekly alcohol consumption. There was no evidence that self-efficacy enhancement was superior to the self-help booklet (P = 0.96).

CONCLUSIONS

Brief interventions delivered in hospital offer simple means of helping heavy drinkers to reduce their alcohol consumption.

The DYD-RCT protocol: an on-line randomised controlled trial of an interactive computer-based intervention compared with a standard information website to reduce alcohol consumption among hazardous drinkers

BACKGROUND

Excessive alcohol consumption is a significant public health problem throughout the world. Although there are a range of effective interventions to help heavy drinkers reduce their alcohol consumption, these have little proven population-level impact. Researchers internationally are looking at the potential of Internet interventions in this area.

METHODS/DESIGN

In a two-arm randomised controlled trial, an on-line psychologically enhanced interactive computer-based intervention is compared with a flat, text-based information web-site. Recruitment, consent, randomisation and data collection are all on-line. The primary outcome is total past-week alcohol consumption; secondary outcomes include hazardous or harmful drinking, dependence, harm caused by alcohol, and mental health. A health economic analysis is included.

DISCUSSION

This trial will provide information on the effectiveness and cost-effectiveness of an on-line intervention to help heavy drinkers drink less.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number Register ISRCTN31070347.

Primary health care physicians' definitions on when to advise a patient about weekly and binge drinking

OBJECTIVE

Little is known about the level of alcohol consumption at which physicians think that they should advise their patients to reduce drinking. This is especially true concerning the amounts consumed per one drinking occasion. The aim of the present study was to examine these issues and also characteristics of physicians possibly associated with their different opinions.

METHOD

Cross-sectional self-administered questionnaire survey to all 3193 primary health care physicians in Finland. Response rate was 61.0%.

RESULTS

The physicians reported that on average 14.8 drinks (one drink=12 g of absolute alcohol)/week for males and 10.6 drinks/week for females to be the threshold that would cause them to advise their patients. Corresponding figures for one drinking occasion were 6.6 and 4.9 drinks/week. In linear regression analyses physicians' AUDIT scores, use of brief intervention, experience as a physician and age explained the variance of all or some reported thresholds, but all the variables explained only about 10% of the phenomena.

CONCLUSIONS

Compared to the official Finnish recommendations regarding the definition of heavy drinking, the physicians reported similar levels of drinking per occasion for deciding to advise their patients, but rather low levels concerning weekly drinking. This may lead to extra workload for physicians and thus hamper implementation of brief intervention. Physicians' characteristics seem to be a decidedly minor issue in implementing drinking limits in health care.

Internet-based interactive health intervention for the promotion of sensible drinking: patterns of use and potential impact on members of the general public

Background

Heavy drinking is responsible for major health and social problems. Brief interventions have been shown to be effective, but there have been difficulties in reaching those who might benefit from them. Pilot studies have indicated that a Web-based intervention is likely to be acceptable to heavy drinkers and may produce some health benefits. However, there are few data on how many people might use such a program, the patterns of use, and potential benefits.

Objectives

The aim was to examine the demographic characteristics of users of a free, Web-based, 6-week intervention for heavy drinkers and to describe the methods by which users identified the site, the pattern of site use and attrition, the characteristics associated with completing the program, and the self-reported impact on alcohol-related outcomes.

Methods

Cohort study. Visitors to the Web site were offered screening with the Fast Alcohol Screening Test, and those scoring above the cutoff for risky drinking were invited to register with the program. Demographic information was collected routinely at registration, and questionnaires were completed at the end of weeks 1 and 6. The outcome measures assessed dependency (Short Alcohol Dependency Data Questionnaire), harms (modified Alcohol Problems Questionnaire), and mental health (Clinical Outcomes in Routine Evaluation–Outcome Measure).

Results

The records of 10000 users were analyzed. The mean age was 37.4 years, 51.1% were female, 37.5% were single, and 42.4% lived with children. The majority were White British, lived in the United Kingdom, and reported occupations from the higher socioeconomic strata. Over 70% connected to the Down Your Drink (Down Your Drink) site from another Internet-based resource, whereas only 5.8% heard about the site from a health or other professional. Much of the Web site use (40%) was outside normal working hours. Attrition from the program was high, with only 16.5% of registrants completing the whole 6 weeks. For those who completed the program, and the final outcome measures, measures of dependency, alcohol-related problems, and mental health symptoms were all reduced at week 6.

Conclusions

The Web-based intervention was highly used, and those who stayed with the program showed significant reductions in self-reported indicators of dependency, alcohol-related problems, and mental health symptoms; however, this association cannot be assumed to be causal. Programs of this type may have the potential to reach large numbers of heavy drinkers who might not otherwise seek help. There are significant methodological challenges and further research is needed to fully evaluate such interventions.

A formative evaluation to develop a school health nursing early intervention model for adolescent substance use

OBJECTIVE

To improve an early intervention (EI) triggered by the Adolescents' Substance Use Measurement (ADSUME) as a method to prevent substance abuse among adolescents. We assessed how ADSUME and EI work in practice and how EI could be improved.

DESIGN AND SAMPLE

School health nurses (n=10) tested ADSUME and EI on 14- to 18-year-old adolescents (n=228). Six months later, these nurses and their professional partners were invited to assess EI in focus group interviews.

METHODS

Four focus group interviews involving a total of 24 nurses and partners were implemented. Interview data were analyzed with qualitative content analysis.

RESULTS

ADSUME concretized assessment, activated profound dialogue, and proved to be an important part of EI. It was important to assess the adolescent's resources in addition to the ADSUME score. EI worked well in confidential dialogues after the adolescent and the PHN reached a consensus on the level of concern about the adolescent's substance use. The recommended EI enabled individual brief intervention in all four stages of substance use, from abstinence or experimental use to hazardous use.

CONCLUSIONS

EI was improved practically, and the contents of the intervention were reformulated. It is important to integrate EI with the preventive efforts of the school.

Effectiveness of brief alcohol interventions in primary care populations

BACKGROUND

Many trials reported that brief interventions are effective in reducing excessive drinking. However, some trials have been criticised for being clinically unrepresentative and unable to inform clinical practice.

OBJECTIVES

To assess the effectiveness of brief intervention, delivered in general practice or based primary care, to reduce alcohol consumption

SEARCH STRATEGY

We searched the Cochrane Drug and Alcohol Group specialised register (February 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), CINAHL (1982 to February 2006), PsycINFO (1840 to February 2006), Science Citation Index (1970 to February 2006), Social Science Citation Index (1970 to February 2006), Alcohol and Alcohol Problems Science Database (1972 to 2003), reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials, patients presenting to primary care not specifically for alcohol treatment; brief intervention of up to four sessions.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, sub-group, sensitivity analyses, and meta-regression were conducted.

MAIN RESULTS

The meta-analysis included 21 RCTs (7,286 participants), showing that participants receiving brief intervention reduced their alcohol consumption compared to the control group (mean difference: -41 grams/week, 95% CI: -57 to -25), although there was substantial heterogeneity between trials (I2 = 52%). Sub-group analysis (8 studies, 2307 participants) confirmed the benefit of brief intervention in men (mean difference: -57 grams/week, 95% CI: -89 to -25, I2 = 56%), but not in women (mean difference: -10 grams/week, 95% CI: -48 to 29, I2 = 45%). Meta-regression showed a non-significant trend of an increased reduction in alcohol consumption of 1.1, 95%CI: -0.05 to 2.2 grams/week, p=0.06, for each extra minute of treatment exposure, but no relationship between the reduction in alcohol consumption and the efficacy score of the trial. Extended intervention when compared with brief intervention was associated with a non-significantly greater reduction in alcohol consumption (mean difference = -28, 95%CI: -62 to 6 grams/week, I2 = 0%)

AUTHORS' CONCLUSIONS

Brief interventions consistently produced reductions in alcohol consumption. When data were available by gender, the effect was clear in men at one year of follow up, but unproven in women. Longer duration of counselling probably has little additional effect. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature had clear relevance to routine primary care. Future trials should focus on women and on delineating the most effective components of interventions.

Do brief measures of readiness to change predict alcohol consumption and consequences in primary care patients with unhealthy alcohol use?

BACKGROUND

Assessing readiness to change is recommended as part of brief interventions for patients with unhealthy alcohol use. However, the utility and predictive validity of readiness measures have not been well established.

METHODS

In a prospective cohort study, we assessed primary care patients with unhealthy alcohol use (past-month drinking of risky amounts, or any amount and an affirmative response to CAGE alcohol screening questionnaire) and reassessed them 6 months later. At study entry, we assessed readiness to change using 1 multi-item measure of stage of change, and 5 single-item measures (readiness per se, importance of changing, confidence in ability to change, intention to cut down, intention to abstain). Outcomes included alcohol consumption and alcohol-related consequences. Multivariable regression models were fit for each measure of readiness and each outcome.

RESULTS

Of 312 patients with unhealthy alcohol use, 228 (73%) were assessed at study entry and 6 months later and had complete data. Among readiness measures, only confidence and intention to abstain (1 point changes on single-item measures) were associated with consumption 6 months later: less heavy episodic drinking [adjusted odds ratio (AOR) 0.88, 95% CI 0.80-0.98 and AOR 0.79, 0.64-0.98, respectively], and less drinking of risky amounts (AOR 0.89, 0.79-1.00 and AOR 0.78, 0.62-0.98, respectively). Intention to abstain was also associated with more abstinence (AOR 1.43, 1.09-1.88). Single-item measures of readiness, importance, and intention to cut down were significantly associated with higher odds of alcohol consequences. Greater confidence (single item) was associated with a lower odds of any consequences (AOR 0.88, 0.79-0.98).

CONCLUSIONS

Greater readiness, as measured by several brief assessments, was associated with more consequences and was not predictive of consumption. However, assessing confidence in the ability to change one's alcohol use may have a role in predicting subsequent decreases in both consumption and consequences in primary care patients.

Alcohol Screening Scores and Risk of Hospitalizations for GI Conditions in Men

BACKGROUND

Alcohol misuse is a common cause of liver disease, upper gastrointestinal (GI) bleeding, and pancreatitis, but it is not known whether alcohol screening questionnaires can identify patients at increased risk for hospitalizations due to these conditions.

OBJECTIVE

To evaluate the association of alcohol screening scores with the risk of subsequent hospitalization for alcohol-related GI conditions.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Male general medicine outpatients from 7 Veterans Affairs (VA) medical centers who returned mailed questionnaires.

MEASUREMENTS

The CAGE questionnaire (0-4 points) and the Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C; 0-12 points) were included on mailed surveys. The main outcome, "GI hospitalization," was a primary VA or Medicare discharge diagnosis indicating liver disease, upper GI bleeding, or pancreatitis.

RESULTS

Among 31,311 patients followed, a median of 3.75 years, patients with CAGE scores >or=2 points or AUDIT-C scores >or=6 points were at a significantly increased risk for GI hospitalizations. Adjusted hazard ratios (HR(adj)) ranged from 1.6 (95% CI 1.2-2.0) for CAGE score 2, to 1.7 (1.4-2.2) for CAGE 4, and from 1.4 (1.01-2.0) for AUDIT-C scores from 6 to 7, to 2.7 (1.9-3.8) for AUDIT-C scores from 10 to 12. Secondary analyses demonstrated that the association was the strongest among patients less than 50 years of age who reported drinking in the past year.

CONCLUSIONS

Brief alcohol screening questionnaires predict subsequent hospitalizations for alcohol-related GI conditions.

School health nurses and substance use among adolescents - towards individual identification and early intervention

Adolescents' health is today threatened by the use of alcohol and other psychoactive substances. It is therefore important to develop interventions related to substance use in school health care. The aim of this study was to examine the empowering or risk background factors related to substance use among adolescents, and the ability of school nurses (PHN) to identify these factors and to provide needed individual early intervention. The data were collected by semistructured questionnaires completed by 14- to 18-year-old adolescents (n = 326, response rate 79) and PHNs (n = 10) in 2004. The adolescent questionnaire consisted of items related to the respondents' background and Adolescents' Substance Use Measurement (ADSUME). Following individual consent, adolescents' ADSUME responses were sent to the PHNs for intervention. The PHNs assessed the adolescents' empowering background factors and intervention using the questionnaire, and 70% (n = 228) of their answers matched the adolescents' answers. The data were analysed with the SPSS software using the chi-squared test, Fisher's exact test, kappa coefficient and agreement percentages. Substance use among adolescents was associated with parental support, mother's education and smoking, the adolescents' knowledge about substances, peer support and hobbies. The PHNs' assessments regarding supportive background were not in agreement with the assessments of adolescents who were using hazardous substances. One-fifth of the adolescents received the brief intervention, although many of them might have needed extra support and follow-up on the basis of their ADSUME results. The research findings can be generalized only for alcohol use, because only 3% of the study informants used substances other than alcohol. Further research is warranted concerning PHNs' ability to identify hazardous substance use and to ensure preventive early intervention and requisite support among substance-using adolescents in order to improve evidence-based health promotion.

Brief interventions for high-risk drinkers

AIMS AND OBJECTIVES

The purpose of this paper is to explore the literature on brief alcohol intervention and to review the literature that examines the status of the clinic nurse in the delivery of these interventions. The objective is to review critically the literature on brief intervention to create links for nurse developed and delivered brief intervention to high-risk drinkers.

BACKGROUND

Population estimates suggest that more than one-third of North Americans drink excessively with even higher rates for individuals treated in primary care settings. Alcohol use has been identified as the third leading cause of mortality in the United States. This problem is not unique to the US and, worldwide, agencies and governmental offices and ministries have issued recommendations to screen patients for alcohol misuse and deliver brief interventions to individuals considered to be high-risk drinkers. Numerous randomized controlled trials and recent meta-analyses have supported the use of screening and brief intervention for reducing alcohol consumption in primary healthcare settings. The vast majority of studies reporting on brief interventions have focused on the role of the physician with minimal if any involvement of the clinic nurse. A scant number of studies have been conducted that define and assess the role or potential role of the clinic nurse in providing screening and brief intervention to high-risk drinkers in the primary care setting.

METHODS

Systematic review.

RESULTS

Six systematic reviews and meta-analyses from an international base of studies support the use of brief intervention in the primary care setting. Three randomized control trials have highlighted the role of the staff or clinic nurse but there are no meta-analyses addressing nurse-delivered brief interventions. Numerous studies have explored factors effecting the implementation of brief intervention into the primary care setting.

CONCLUSION

Brief intervention is recognized as a legitimate nursing role but little has been done to develop and define the role of the nurse in delivering brief interventions to high-risk drinkers. This represents a major lacuna in both the nursing and alcoholism literature, where only a handful of studies have investigated nurse-delivered brief intervention.

RELEVANCE TO CLINICAL PRACTICE

As health screening and health promotion are hallmarks of nursing care, nurses need to explore the use of brief intervention in their daily practice.

Fast Alcohol Consumption Evaluation: A Screening Instrument Adapted for French General Practitioners

BACKGROUND

To meet the needs of French general practitioners (GPs), we created a short (5 questions) interview/screening test for alcohol-related problems that is similar to AUDIT in terms of (1) test values and (2) identification of 3 groups: (a) abstainers and low-risk drinkers; (b) heavy drinkers; and (c) alcohol abusers or showing dependence.

METHOD

Nine questions (from AUDIT, CAGE, TWEAK, Five-shot Questionnaire) were given systematically to their patients (aged 18 or more) by 41 volunteer GPs. Before the consultation, patients confidentially completed the AUDIT questionnaire in the waiting room. After the consultation, an addiction specialist evaluated each patient's alcohol consumption and DSM-IV criteria for alcohol abuse and dependence and these were used as gold standards.

RESULTS

The analysis included 564 patient records and used stepwise logistic regression to select 7 questions, from which a second selection resulted in a 5-item questionnaire. These questions are: AUDIT questions 1 (Frequency) and 2 (Usual quantity), CAGE questions 2 (Annoyed) and 4 (Eye-opener), and TWEAK question 5 (Black-out), with each question scored 0 to 4. High levels of sensitivity and specificity were obtained for each diagnosis (sensitivity 75%-87.8%; specificity 74%-95.8%).

CONCLUSION

FACE is an appropriate screening method for French general practitioners.

How primary care providers talk to patients about alcohol: a qualitative study

BACKGROUND

Alcohol misuse is a common and well-documented source of morbidity and mortality. Brief primary care alcohol counseling has been shown to benefit patients with alcohol misuse.

OBJECTIVE

To describe alcohol-related discussions between primary care providers and patients who screened positive for alcohol misuse.

DESIGN

An exploratory, qualitative analysis of audiotaped primary care visits containing discussions of alcohol use.

PARTICIPANTS

Participants were 29 male outpatients at a Veterans Affairs (VA) General Internal Medicine Clinic who screened positive for alcohol misuse and their 14 primary care providers, all of whom were participating in a larger quality improvement trial.

MEASUREMENTS

Audiotaped visits with any alcohol-related discussion were transcribed and coded using grounded theory and conversation analysis, both qualitative research techniques.

RESULTS

Three themes were identified: (1) patients disclosed information regarding their alcohol use, but providers often did not explore these disclosures; (2) advice about alcohol use was typically vague and/or tentative in contrast to smoking-related advice, which was more common and usually more clear and firm; and (3) discomfort on the part of the provider was evident during alcohol-related discussions.

LIMITATIONS

Generalizability of findings from this single-site VA study is unknown.

CONCLUSION

Findings from this single site study suggest that provider discomfort and avoidance are important barriers to evidence-based brief alcohol counseling. Further investigation into current alcohol counseling practices is needed to determine whether these patterns extend to other primary care settings, and to inform future educational efforts.

Does socio-economic status influence the acceptability of, attendance for, and outcome of, screening and brief interventions for alcohol misuse: a review

AIMS

To determine whether socio-economic status (SES) influences (i) willingness to participate in brief intervention (BI) research, (ii) attendance to receive BI once allocated, and (iii) treatment outcome.

METHODS

Systematic review of published, randomised controlled trials of BI for non-dependent alcohol misuse in primary health care settings.

RESULTS

Eighteen papers met inclusion criteria. There is evidence that once recruited, and following attendance for intervention, participants' SES does not influence treatment outcome. However, the effect of choosing to participate remains unclear, and the generalizability of results to the whole primary care population remains equivocal. Socio-economic status may influence willingness to participate in BI treatment research, and may influence attendance to receive such interventions where allocated.

CONCLUSION

Brief interventions should remain available to all non-dependent hazardous and harmful drinkers in primary care. However, fidelity to research design is suggested to allow for any participation effects to occur. Benefits of such an approach exist for both clinicians and patients. The characteristics of those who participate in BI trials, compared to those who do not, should be studied in detail. Socio-economic variables should be included as potentially important characteristics. The impact of BI on drinking style as well as consumption needs further attention.

Challenges applying alcohol brief intervention in diverse practice settings: populations, outcomes, and costs

This article summarizes the proceedings of a symposium at the 2005 Research Society on Alcoholism, Santa Barbara, California. The purpose of the symposium was to address challenges that arise in translating evidence for efficacy of alcohol brief intervention (BI) into diverse clinical settings and populations by reviewing the literature and describing 4 research studies. Dr. Saitz reviewed the limitations in evidence for efficacy of BIs and then described results of a randomized clinical trial of brief motivational intervention for medical inpatients drinking risky amounts. Dr. Svikis presented alternative methods for identifying pregnant women in prenatal care at risk for alcohol and drug problems (including nicotine and caffeine) and BIs to reduce or eliminate use. Dr. D'Onofrio discussed results of a randomized trial of the brief negotiated interview in emergency department patients. Dr. Kraemer presented results of a decision analytic and computer-simulation model regarding the cost-effectiveness of alcohol screening and intervention in primary care settings. Finally, Dr. Perl discussed the salient issues and suggested future directions for work in the area of alcohol BI.

The management of alcohol, tobacco and illicit drug use problems by general practitioners in Australia

The aim of this study was to document the frequency of the management of illicit drug, alcohol and tobacco problems in general practice in Australia. Data from the Bettering the Evaluation and Care of Health (BEACH) study of general practice, April 1998 to March 2003, were analysed. BEACH is an ongoing national study of general practice in Australia. Each year a random sample of approximately 1000 general practitioners (GPs) participate, each providing details of 100 patient encounters. Samples are drawn from the Medicare data held by the Health Insurance Commission. Patient demographic breakdowns, medication, other treatment, referrals and other medical procedures ordered were examined for all problems labelled by GPs as illicit, alcohol and tobacco problems. Annually in Australia, it was estimated that 615,000 GP encounters--or 0.6% of all encounters--involved the management of illicit drug use problems presumably most commonly for problematic heroin use. Despite a much higher population prevalence of use and use disorders, the management of alcohol or tobacco use problems was less common, with 0.4% and 0.3% of encounters, respectively, comprising treatment of these problems. Clear demographic differences existed across the groups. The management of problems also differed, with illicit drug use problems more likely to involve provision of medication, and alcohol and tobacco treatment more likely to involve counselling and/or health advice. Despite higher rates of alcohol and tobacco use problems among patients seeing GPs in Australia, the rate of treatment for such problems was relatively lower than it was for illicit drug use problems. More efforts need to be directed towards assisting GPs to identify and target problematic alcohol and tobacco use among their patients.

Effectiveness of nurse-led brief alcohol intervention: a cluster randomized controlled trial

AIM

This paper reports an evaluation of the effectiveness and cost-effectiveness of nurse-led screening and brief intervention in reducing excessive alcohol consumption among patients in primary health care.

BACKGROUND

Excessive alcohol consumption is a major source of social, economic and health problems. However, such consumption is responsive to brief alcohol intervention. To date, brief intervention research in primary health care has focused on general practitioner-led interventions, and there is only circumstantial evidence of effectiveness in nurse-led interventions. However, nurses are increasingly taking a lead in health promotion work in primary care.

METHODS

A pragmatic cluster-randomized controlled trial was carried out between August 2000 and June 2003 to evaluate the effects of a brief intervention compared with standard advice (control condition). A total of 40 general practice clusters (intervention = 21 and control = 19) recruited 127 patients (intervention = 67 and control = 60) to the trial. Excessive consumption was identified opportunistically via the Alcohol Use Disorders Identification Test. After baseline assessment, patients received either a 5-10 minutes brief intervention using the 'Drink-Less' protocol or standard advice (control condition). Follow-up occurred at 6 and 12 months postintervention.

RESULTS

Analysis of variance weighted for cluster size revealed no statistically significant differences between intervention and control patients at follow up. A majority of patients in both conditions reduced their alcohol consumption between assessment and subsequent measurement. Economic analysis suggested that the brief intervention led to no statistically significant changes in subsequent health service resource use relative to standard treatment.

CONCLUSION

The brief intervention evaluated in this trial had no effect over standard advice delivered by nurses in primary health care. However, there was a reduction in excessive drinking across both arms of the trial over time. Due to nurse drop-out, this trial was significantly underpowered. Future research should explore barriers to nurses' involvement in research trials, particularly with an alcohol focus. A larger trial is required to evaluate the effectiveness of nurse-led screening and brief alcohol intervention in primary care.

Translation as a function of modality: the potential of brief interventions

The purpose of this article is to examine the potential of brief intervention (BI) as a modality for translating health behavior intervention research into practice. We discuss common definitions of BI, applications within common models of translation research, effects of BI on a range of health behaviors and across various populations, current and potential mechanisms, and uses for dissemination to practice. A number of advantages of BI suggest they are well suited for translating behavioral research. In addition, findings from 13 systematic reviews of BI effects show their potential versatility. Basic research on motivation, decision making, and persuasion may be applied to the design of BIs (Type 1 translation). Suggestions for translating BI research into practice are discussed (Type 2 translation). The article concludes that efforts to use BIs to translate research into practice are currently underdeveloped. Recommendations are provided for using BI in translating research into practice.

PATIENT ATTITUDES TOWARDS SELF-REPORT AND BIOMARKER ALCOHOL SCREENING BY PRIMARY CARE PHYSICIANS

AIMS

One of the many barriers to more frequent alcohol screening by primary care physicians is a reported concern that patients may be offended by questions about drinking. However, evidence suggests that patients do not object to alcohol screening and actually expect physicians to ask about lifestyle factors that influence their health. The aim of this study was to provide more detailed information on patient attitudes toward self-report and biomarker alcohol screening and to explore whether demographic variables were related to these attitudes.

METHODS

We administered (i) a survey about attitudes towards alcohol screening, and (ii) the Alcohol Use Disorders Identification Test-C (AUDIT-C) to primary care outpatients at the time of their medical appointments. The survey contained 10 items on patient opinions about being screened for at-risk drinking by physicians. Participants rated their levels of agreement with each statement using a 5-point Likert scale. Participants also provided demographic information.

RESULTS

The majority of patients reported that they were supportive of physician screening about alcohol use. Responses on 3 of the 10 statements were related to patient race, age, and/or AUDIT-C results.

CONCLUSIONS

In general, results support the fact that patients are in favour of being screened for at-risk drinking by their physicians whether the screening instrument was a self-report measure or an alcohol biomarker laboratory test. In addition, the majority of patients are open to advice from physicians about their alcohol use.

Opportunistic screening for alcohol use disorders in primary care: comparative study

OBJECTIVE

To evaluate the efficacy and relative costs of different screening methods for the identification of alcohol use disorders in an opportunistic screening programme in primary care in the United Kingdom.

DESIGN

Comparative study.

SETTING

Six general practices in south Wales.

PARTICIPANTS

194 male primary care attendees aged 18 or over who completed an alcohol use disorders identification test (AUDIT) questionnaire.

MAIN OUTCOME MEASURES

Scores on alcohol use disorders identification test and measures of gamma-glutamyltransferase, aspartate aminotransferase, per cent carbohydrate deficient transferrin, and erythrocyte mean cell volume. Hazardous alcohol consumption, weekly binge consumption, and monthly binge consumption were ascertained using the time line follow back method over the previous 180 days. Alcohol dependence was determined using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Unit costs were established from published resource references and from actual costs of analysing the biochemical tests.

RESULTS

A significant correlation was observed be alcohol consumption and score on the alcohol use disorders identification test (Pearson's correlation coefficient r = 0.74) and measures of gamma-glutamyltransferase (r = 0.20) and per cent carbohydrate deficient transferrin (r = 0.36) but not aspartate aminotransferase (r = 0.08) or erythrocyte mean cell volume (r = 0.02). The alcohol use disorders identification test exhibited significantly higher sensitivity, specificity, and positive predictive value than all of the biochemical markers for hazardous consumption (69%, 98%, and 95%), weekly binge consumption (75%, 90%, and 71%), monthly binge consumption (66%, 97%, and 91%), and alcohol dependence (84%, 83%, and 41%). The questionnaire was also more cost efficient, with a lower cost per true positive for all consumption outcomes.

CONCLUSION

The alcohol use disorders identification test questionnaire is an efficient and cost efficient diagnostic tool for routine screening for alcohol use disorders in primary care.

Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. A systematic review

OBJECTIVE

To review systematically the available literature on implementation of brief alcohol interventions in primary healthcare in order to determine the effectiveness of the implementation efforts by the health are providers. KEY QUESTION: To what extent have the efforts to implement brief alcohol interventions in primary healthcare environments been successful?

METHOD

Literature search from Medline, Cinahl, PsychLIT, Cochrane.

SETTING

Primary healthcare.

MATERIAL

A total of 11 studies encompassing 921 GPs, 266 nurses, 88 medical students, and 44 "non-physicians" from Europe, the USA, and Australia.

MAIN OUTCOME MEASURES

Material utilization, screening, and brief intervention rates.

ANSWER

Intervention effectiveness (material utilization, screening, and brief intervention rates) generally increased with the intensity of the intervention effort, i.e. the amount of training and/or support provided. Nevertheless, the overall effectiveness was rather modest. However, the studies examined were too heterogeneous, not scientifically rigorous enough, and applied too brief follow-up times to provide conclusive answers.

HEAVY DRINKING OCCASIONS AND DEPRESSION

AIMS

To assess the risk of depression for subjects with or without heavy drinking occasions after adjusting for the average long-term alcohol consumption, age, gender, marital status, employment status, and chronic diseases.

METHODS

In a cross-sectional population survey (N = 3124) carried out in Finland in 1997, long-term average alcohol consumption was assessed by a self-administered quantity-frequency questionnaire. A heavy drinking occasion was defined as six or more drinks for men and four or more drinks for women consumed at one session. The self-administered 21-item Beck Depression Inventory score of > or = 10 was classified as clinically significant depression.

RESULTS

Ex-drinkers and subjects with heavy drinking occasions had more often clinically significant depression compared with lifelong abstainers and individuals without heavy drinking occasions. In addition to the drinking habit, the risk for clinically significant depression increased also with age. Men aged 45-64 years with heavy drinking occasions had 2.3 times higher risk for depression compared with young men (aged 25-34 years) without heavy drinking occasions. The respective risk for old women was 2.2 times higher.

CONCLUSIONS

Drinking pattern with heavy drinking occasions is independently associated with clinically significant depression irrespective of average long-term alcohol consumption.