Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption

Does Advice Based on Biomarkers of Liver Injury or Non-Invasive Tests of Liver Fibrosis Impact High-Risk Drinking Behaviour: A Systematic Review With Meta-analysis

BACKGROUND AND AIMS

Alcohol dependence affects over 240 million people worldwide and attributed to 3 million deaths annually. Early identification and intervention are key to prevent harm. We aim to systematically review literature on the effectiveness of adding advice based on biomarkers of liver injury or non-invasive tests of liver fibrosis (intervention-based advice) to prevent alcohol misuse.

METHODS

Electronic search was conducted on Ovid Medline, PubMed, EMBASE, Psychinfo and CINAHL for articles published up to end of February 2020. Additionally, we searched study citations, Scopus, Ethos and Clinical trials. The primary outcome measure was changed in self-reported alcohol consumption analysed by random-effects meta-analysis. Secondary outcomes included change to liver blood markers and alcohol-related health outcomes.

RESULTS

Fourteen randomized controlled trials (RCTs) and two observational studies comprising n = 3763 participants were included. Meta-analyses showed a greater reduction in alcohol consumption and liver biomarkers for the intervention compared to control group: mean difference for weekly alcohol intake was -74.4 g/week (95% confidence interval (CI) -126.1, -22.6, P = 0.005) and mean difference for gamma-glutamyl transferase (GGT) -19.7 IU/l (95% CI -33.1, -6.4, P = 0.004). There was a higher incidence of alcohol-attributed mortality, number of days spent in the hospital, physician visits and sickness absence in the non-intervention group. The quality of the included studies was moderate for RCTs and high for observational studies.

CONCLUSIONS

The review confirmed a significant association between the addition of intervention-based advice in routine care to the reduction of harmful alcohol consumption, GGT and alcohol-related mortality. The findings support the inclusion of this type of advice in routine alcohol care.

Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Unhealthy alcohol use is common, increasing, and a leading cause of premature mortality.

OBJECTIVE

To review literature on the effectiveness and harms of screening and counseling for unhealthy alcohol use to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through October 12, 2017; literature surveillance through August 1, 2018.

STUDY SELECTION

Test accuracy studies and randomized clinical trials of screening and counseling to reduce unhealthy alcohol use.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction by 2 reviewers. Counseling trials were pooled using random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, drinks per week, exceeding recommended limits, heavy use episodes, abstinence (for pregnant women), and other health, family, social, and legal outcomes.

RESULTS

One hundred thirteen studies (N = 314 466) were included. No studies examined benefits or harms of screening programs to reduce unhealthy alcohol use. For adolescents (10 studies [n = 171 363]), 1 study (n = 225) reported a sensitivity of 0.73 (95% CI, 0.60 to 0.83) and specificity of 0.81 (95% CI, 0.74 to 0.86) using the AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) to detect the full spectrum of unhealthy alcohol use. For adults (35 studies [n = 114 182]), brief screening instruments commonly reported sensitivity and specificity between 0.70 and 0.85. Two trials of the effects of interventions to reduce unhealthy alcohol use in adolescents (n = 588) found mixed results: one reported a benefit in high-risk but not moderate-risk drinkers, and the other reported a statistically significant reduction in drinking frequency for boys but not girls; neither reported health or related outcomes. Across all populations (68 studies [n = 36 528]), counseling interventions were associated with a decrease in drinks per week (weighted mean difference, -1.6 [95% CI, -2.2 to -1.0]; 32 studies [37 effects; n = 15 974]), the proportion exceeding recommended drinking limits (odds ratio [OR], 0.60 [95% CI, 0.53 to 0.67]; 15 studies [16 effects; n = 9760]), and the proportion reporting a heavy use episode (OR, 0.67 [95% CI, 0.58 to 0.77]; 12 studies [14 effects; n = 8108]), and an increase in the proportion of pregnant women reporting abstinence (OR, 2.26 [95% CI, 1.43 to 3.56]; 5 studies [n = 796]) after 6 to 12 months. Health outcomes were sparsely reported and generally did not demonstrate group differences in effect. There was no evidence that these interventions could be harmful.

CONCLUSIONS AND RELEVANCE

Among adults, screening instruments feasible for use in primary care are available that can effectively identify people with unhealthy alcohol use, and counseling interventions in those who screen positive are associated with reductions in unhealthy alcohol use. There was no evidence that these interventions have unintended harmful effects.

Effectiveness of brief alcohol interventions in primary care populations

BACKGROUND

Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person's alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.This is an update of a Cochrane Review published in 2007.

OBJECTIVES

To assess the effectiveness of screening and brief alcohol intervention to reduce excessive alcohol consumption in hazardous or harmful drinkers in general practice or emergency care settings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and 12 other bibliographic databases to September 2017. We searched Alcohol and Alcohol Problems Science Database (to December 2003, after which the database was discontinued), trials registries, and websites. We carried out handsearching and checked reference lists of included studies and relevant reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. The comparison group was no or minimal intervention, where a measure of alcohol consumption was reported. 'Brief intervention' was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 minutes. Any more was considered an extended intervention. Digital interventions were not included in this review.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We carried out subgroup analyses where possible to investigate the impact of factors such as gender, age, setting (general practice versus emergency care), treatment exposure and baseline consumption.

MAIN RESULTS

We included 69 studies that randomised a total of 33,642 participants. Of these, 42 studies were added for this update (24,057 participants). Most interventions were delivered in general practice (38 studies, 55%) or emergency care (27 studies, 39%) settings. Most studies (61 studies, 88%) compared brief intervention to minimal or no intervention. Extended interventions were compared with brief (4 studies, 6%), minimal or no intervention (7 studies, 10%). Few studies targeted particular age groups: adolescents or young adults (6 studies, 9%) and older adults (4 studies, 6%). Mean baseline alcohol consumption was 244 g/week (30.5 standard UK units) among the studies that reported these data. Main sources of bias were attrition and lack of provider or participant blinding. The primary meta-analysis included 34 studies (15,197 participants) and provided moderate-quality evidence that participants who received brief intervention consumed less alcohol than minimal or no intervention participants after one year (mean difference (MD) -20 g/week, 95% confidence interval (CI) -28 to -12). There was substantial heterogeneity among studies (I² = 73%). A subgroup analysis by gender demonstrated that both men and women reduced alcohol consumption after receiving a brief intervention.We found moderate-quality evidence that brief alcohol interventions have little impact on frequency of binges per week (MD -0.08, 95% CI -0.14 to -0.02; 15 studies, 6946 participants); drinking days per week (MD -0.13, 95% CI -0.23 to -0.04; 11 studies, 5469 participants); or drinking intensity (-0.2 g/drinking day, 95% CI -3.1 to 2.7; 10 studies, 3128 participants).We found moderate-quality evidence of little difference in quantity of alcohol consumed when extended and no or minimal interventions were compared (-14 g/week, 95% CI -37 to 9; 6 studies, 1296 participants). There was little difference in binges per week (-0.08, 95% CI -0.28 to 0.12; 2 studies, 456 participants; moderate-quality evidence) or difference in days drinking per week (-0.45, 95% CI -0.81 to -0.09; 2 studies, 319 participants; moderate-quality evidence). Extended versus no or minimal intervention provided little impact on drinking intensity (9 g/drinking day, 95% CI -26 to 9; 1 study, 158 participants; low-quality evidence).Extended intervention had no greater impact than brief intervention on alcohol consumption, although findings were imprecise (MD 2 g/week, 95% CI -42 to 45; 3 studies, 552 participants; low-quality evidence). Numbers of binges were not reported for this comparison, but one trial suggested a possible drop in days drinking per week (-0.5, 95% CI -1.2 to 0.2; 147 participants; low-quality evidence). Results from this trial also suggested very little impact on drinking intensity (-1.7 g/drinking day, 95% CI -18.9 to 15.5; 147 participants; very low-quality evidence).Only five studies reported adverse effects (very low-quality evidence). No participants experienced any adverse effects in two studies; one study reported that the intervention increased binge drinking for women and two studies reported adverse events related to driving outcomes but concluded they were equivalent in both study arms.Sources of funding were reported by 67 studies (87%). With two exceptions, studies were funded by government institutes, research bodies or charitable foundations. One study was partly funded by a pharmaceutical company and a brewers association, another by a company developing diagnostic testing equipment.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that brief interventions can reduce alcohol consumption in hazardous and harmful drinkers compared to minimal or no intervention. Longer counselling duration probably has little additional effect. Future studies should focus on identifying the components of interventions which are most closely associated with effectiveness.

Managing Alcohol Use Disorder in Primary Health Care

PURPOSE OF REVIEW

The aim of this study is to summarise the current literature on both the impact and the implementation of primary health care-based screening and advice programmes to reduce heavy drinking, as an evidence-based component of managing alcohol use disorder in primary health care.

RECENT FINDINGS

Systematic reviews of reviews find conclusive evidence for the impact of primary health care delivered screening and brief advice programmes in reducing heavy drinking. The content, length of advice and which profession delivers the advice seems less important than the actual encounter between provider and patient. Despite the global burden of disease due to heavy drinking and the evidence that this can be reduced by screening and brief advice programmes delivered in primary health care, such programmes remain poorly implemented. Were such programmes widely implemented, there would be substantial health and productivity gains. Systematic reviews and international studies indicate that improved implementation requires tailoring of training and programme content to match the needs of providers, training and ongoing support and embedding of programmes within local community support, championed by local leaders. The next stage of implementation and scale-up of evidence-based screening and brief advice programmes should take place embedded within supportive local community action, with appropriate research to demonstrate impact.

Harm reduction-a systematic review on effects of alcohol reduction on physical and mental symptoms

Based on the knowledge that alcohol misuse causes a multitude of diseases and increased mortality, this systematic review examines whether a reduction of the individual alcohol consumption can contribute to a minimization of health risks within a harm reduction approach. In fact, the reviewed 63 studies indicate that interventions aiming at alcohol reduction (including total abstinence as one possible therapeutic aim) indeed resulted in or were associated with positive effects in harmful, hazardous or alcohol-dependent drinkers. Major benefits were observed for reducing alcohol-associated injuries, recovery of ventricular heart function in alcoholic cardiomyopathy, blood pressure lowering, normalization of biochemical parameter, body weight reduction, histological improvement in pre-cirrhotic alcohol-related liver disease and slowed progression of an already existing alcohol-attributable liver fibrosis. Furthermore, reduced withdrawal symptoms, prevalence of psychiatric episodes and duration of in-patient hospital days, improvement of anxiety and depression symptoms, self-confidence, physical and mental quality of life, fewer alcohol-related adverse consequences as well as lower psychosocial stress levels and better social functioning can result from reduced alcohol intake. The reviewed literature demonstrated remarkable socioeconomic cost benefits in areas such as the medical health-care system or workforce productivity. Individuals with heightened vulnerability further benefit significantly from alcohol reduction (e.g. hypertension, hepatitis C, psychiatric co-morbidities, pregnancy, but also among adolescents and young adults). Concluding, the reviewed studies strongly support and emphasize the importance and benefits of early initial screening for problematic alcohol use followed by brief and other interventions in first contact medical health-care facilities to reduce alcohol intake.

Substance use outcomes of patients served by a large US implementation of Screening, Brief Intervention and Referral to Treatment (SBIRT)

AIMS

To estimate changes in the substance use behaviors of patients who received services as part of the US Substance Abuse and Mental Health Services Administration's (SAMHSA) Screening, Brief Intervention and Referral to Treatment (SBIRT) grant program.

METHODS

We use a pre-post design and performance monitoring data collected by SBIRT organizations. For a sample of 17 575 patients, we compare pre-SBIRT substance use with substance use 6 months after receipt of SBIRT services. SBIRT's correlation with changes in substance use was estimated using generalized linear mixed models to account for the clustering of patients within health-care facility and US state.

RESULTS

From pre- to post-SBIRT we found large and statistically significant decreases for almost every measure of substance use. Model-adjusted means indicate that the prevalence of alcohol use was lower 6 months later by 35.6%, heavy drinking by 43.4% and illicit drug use by 75.8%. Greater intervention intensity was associated with larger decreases in substance use. The study design does not support causal conclusions and estimated decreases in reported substance use are due, at least in part, to a well-known set of confounders and natural substance use patterns that may be unrelated to any particular SBIRT intervention.

CONCLUSIONS

Compared with previously published findings on the Screening, Brief Intervention and Referral to Treatment grant program, our estimates of substance use reduction were smaller, but still consistently large in absolute magnitude and within ranges of estimates from past trials of Screening, Brief Intervention and Referral to Treatment.

A comparison of the efficacy of brief interventions to reduce hazardous and harmful alcohol consumption between European and non-European countries: a systematic review and meta-analysis of randomized controlled trials

AIMS

The extent of variation attributable to regional differences for the efficacy of brief intervention (BI) to reduce hazardous and harmful alcohol consumption is unclear. The primary aim of this study was to determine overall efficacy of BI at 6- and 12-month follow-up in primary health care (PHC) and emergency department (ED) studies. The secondary aim was to examine whether variance in study outcome can be explained by the geographical region in which trials have taken place (European versus non-European).

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) published before August 2014 was undertaken. Twenty RCTs conducted in PHC settings with a total of 8226 participants (European = 4564/non-European = 3662) and eight RCTs conducted in ED settings with a total of 4799 participants (European = 2465/non-European = 2334) were eligible. Primary outcome measure was reduction in grams of alcohol consumed per week for BI and control groups at 6- and 12-month follow-up. An inverse variance model was applied to measure the effect of treatment in mean differences for BI and control groups at 6- and 12-month follow-up. Variance between study outcomes was explored using subgroup analysis of European versus non-European countries.

RESULTS

For PHC trials at 6-month follow-up, statistically significant benefits of BI were indicated [mean difference (MD) = -21.98 g/week; 95% confidence interval (CI) = -37.40 to -6.57; P = 0.005]. At 12-month follow-up, statistically significant benefit of BI was evident (MD = -30.86 g/week; 95% CI = -46.49 to -15.23; P = 0.0001). For ED trials at 6-month follow-up, statistically significant benefits of BI were indicated (MD = -17.97 g/week; 95% CI = -29.69 to -6.24; P =  .003). At 12-month follow-up, statistically significant benefit in favour of BI was evident (MD = -18.21 g/week; 95% CI = -26.71 to -9.70; P < 0.0001). No statistically significant differences were detected in subgroup analyses of outcomes for European versus non-European studies.

CONCLUSIONS

Brief intervention (BI) to reduce alcohol consumption is associated with reducing grams of alcohol consumed per week among hazardous and harmful drinkers at 6- and 12-month follow-up in primary health care and emergency department trials. The geographical region in which trials are undertaken does not appear to explain the variance in trial outcomes for reducing alcohol consumption.

The efficacy-effectiveness distinction in trials of alcohol brief intervention

Three recent sets of null findings from trials of alcohol brief intervention (BI) have been disappointing to those who wish to see a reduction in alcohol-related harm through the widespread dissemination of BI. Saitz (7) has suggested that these null findings result from a failure to translate the effects of BI seen in efficacy trials, which are thought to contribute mainly to the beneficial effects of BI shown in meta-analyses, to effectiveness trials conducted in real-world clinical practice. The present article aims to: (i) clarify the meaning of the terms “efficacy” and “effectiveness” and other related concepts; (ii) review the method and findings on efficacy-effectiveness measurement in the 2007 Cochrane Review by Kaner and colleagues; and (iii) make suggestions for further research in this area. Conclusions are: 1) to avoid further confusion, terms such as “efficacy trial”, “effectiveness trial”, “clinical representativeness”, etc. should be clearly defined and carefully used; 2) applications of BI to novel settings should begin with foundational research and developmental studies, followed by efficacy trials, and political pressures for quick results from premature effectiveness trials should be resisted; 3) clear criteria are available in the literature to guide progress from efficacy research, through effectiveness research, to dissemination in practice; 4) to properly interpret null findings from effectiveness studies, it is necessary to ensure that interventions are delivered as intended; 5) in future meta-analyses of alcohol BI trials, more attention should be paid to the development and application of a psychometrically robust scale to measure efficacy-effectiveness or clinical representativeness; 6) the null findings under consideration cannot be firmly attributed to a failure to translate effects from efficacy trials to real-world practice, because it is possible that the majority of trials included in meta-analyses on which the evidence for the beneficial effects of alcohol BI was based tended to be effectiveness rather than efficacy trials; and 7) a hypothesis to explain the null findings in question is that they are due to lack of fidelity in the implementation of BI in large, organizationally complex, cluster randomized trials.

The potential cost-effectiveness of general practitioner delivered brief intervention for alcohol misuse: evidence from rural Australia

OBJECTIVE

This paper aims to model General Practitioner (GP) delivered screening and brief intervention (BI), and to identify the costs per additional risky drinker who reduces alcohol consumption to low-risk levels, relative to current practice.

METHOD

A decision model and nine different scenarios were developed to assess outcomes and costs of GP-delivered screening and BI on the potential number of risky drinkers who reduce their alcohol consumption to low-risk levels in 10 rural communities in New South Wales, Australia.

FINDINGS

Based on evidence from current practice, approximately 19% of all risky drinkers visiting GPs annually would reduce alcohol consumption to low-risk levels, of which 0.7% would do so because of GP-delivered screening and BI. If rates of screening and BI are increased to 100%, 36% of these risky drinkers would reduce their drinking to low risk-levels. Alternatively, increments of 10% and 20% in GP-delivered screening and BI would reduce the proportion of risky drinkers by 2.1% and 4.2% respectively. The most cost-effective outcome per additional risky drinker reducing their drinking relative to current practice would be if all of these risky drinkers are screened alone with an ICER of AUD$197.

CONCLUSION

These findings indicate that increments in rates of screening and BI delivered by GPs can result in cost-effective reductions per additional risky drinkers reducing their drinking to low-risk levels, relative to current practice. They also imply that achieving substantial reductions in the prevalence of risky drinking in a community will require strategies other than opportunistic screening and BIs by GPs.

Can simply answering research questions change behaviour? Systematic review and meta analyses of brief alcohol intervention trials

BACKGROUND

Participant reports of their own behaviour are critical for the provision and evaluation of behavioural interventions. Recent developments in brief alcohol intervention trials provide an opportunity to evaluate longstanding concerns that answering questions on behaviour as part of research assessments may inadvertently influence it and produce bias. The study objective was to evaluate the size and nature of effects observed in randomized manipulations of the effects of answering questions on drinking behaviour in brief intervention trials.

METHODOLOGY/PRINCIPAL FINDINGS

Multiple methods were used to identify primary studies. Between-group differences in total weekly alcohol consumption, quantity per drinking day and AUDIT scores were evaluated in random effects meta-analyses. Ten trials were included in this review, of which two did not provide findings for quantitative study, in which three outcomes were evaluated. Between-group differences were of the magnitude of 13.7 (-0.17 to 27.6) grams of alcohol per week (approximately 1.5 U.K. units or 1 standard U.S. drink) and 1 point (0.1 to 1.9) in AUDIT score. There was no difference in quantity per drinking day.

CONCLUSIONS/SIGNIFICANCE

Answering questions on drinking in brief intervention trials appears to alter subsequent self-reported behaviour. This potentially generates bias by exposing non-intervention control groups to an integral component of the intervention. The effects of brief alcohol interventions may thus have been consistently under-estimated. These findings are relevant to evaluations of any interventions to alter behaviours which involve participant self-report.

The effectiveness of brief alcohol interventions in primary care settings: a systematic review

ISSUES

Numerous studies have reported that brief interventions delivered in primary care are effective in reducing excessive drinking. However, much of this work has been criticised for being clinically unrepresentative. This review aimed to assess the effectiveness of brief interventions in primary care and determine if outcomes differ between efficacy and effectiveness trials.

APPROACH

A pre-specified search strategy was used to search all relevant electronic databases up to 2006. We also hand-searched the reference lists of key articles and reviews. We included randomised controlled trials (RCT) involving patients in primary care who were not seeking alcohol treatment and who received brief intervention. Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, subgroup and sensitivity analyses and meta-regression were conducted.

KEY FINDINGS

The primary meta-analysis included 22 RCT and evaluated outcomes in over 5800 patients. At 1 year follow up, patients receiving brief intervention had a significant reduction in alcohol consumption compared with controls [mean difference: -38 g week(-1), 95%CI (confidence interval): -54 to -23], although there was substantial heterogeneity between trials (I(2) = 57%). Subgroup analysis confirmed the benefit of brief intervention in men but not in women. Extended intervention was associated with a non-significantly increased reduction in alcohol consumption compared with brief intervention. There was no significant difference in effect sizes for efficacy and effectiveness trials.

CONCLUSIONS

Brief interventions can reduce alcohol consumption in men, with benefit at a year after intervention, but they are unproven in women for whom there is insufficient research data. Longer counselling has little additional effect over brief intervention. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care.

Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking

ISSUES

Although screening and brief intervention (BI) in the primary-care setting reduces unhealthy alcohol use, its efficacy among patients with dependence has not been established. This systematic review sought to determine whether evidence exists for BI efficacy among patients with alcohol dependence identified by screening in primary-care settings.

APPROACH

We included randomised controlled trials (RCTs) extracted from eight systematic reviews and electronic database searches published through September 2009. These RCTs compared outcomes among adults with unhealthy alcohol use identified by screening who received BI in a primary-care setting with those who received no intervention.

KEY FINDINGS

Sixteen RCTs, including 6839 patients, met the inclusion criteria. Of these, 14 excluded some or all persons with very heavy alcohol use or dependence; one in which 35% of 175 patients had dependence found no difference in an alcohol severity score between groups; and one in which 58% of 24 female patients had dependence showed no efficacy.

CONCLUSION AND IMPLICATIONS

Alcohol screening and BI has efficacy in primary care for patients with unhealthy alcohol use, but there is no evidence for efficacy among those with very heavy use or dependence. As alcohol screening identifies both dependent and non-dependent unhealthy use, the absence of evidence for the efficacy of BI among primary-care patients with screening-identified alcohol dependence raises questions regarding the efficiency of screening and BI, particularly in settings where dependence is common. The finding also highlights the need to develop new approaches to help such patients, particularly if screening and BI are to be disseminated widely.[Saitz R. Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking.

Brief intervention for women with risky drinking and medical diagnoses: a randomized controlled trial

This is a randomized controlled trial of 511 eligible women treated for diabetes, hypertension, infertility, or osteoporosis on an outpatient basis to test the hypothesis that those randomized to a brief intervention (BI) will drink less than those in the control condition 12 months later. A secondary goal was to identify the characteristics associated with changes in drinking outcome. All 511 completed the initial alcohol assessment, and 96% completed the 12-month follow-up interview. Those receiving the BI also had 3- and 6-month interviews. Four outcomes were assessed: (a) mean drinks per drinking day, (b) percent drinking days, (c) binge episodes defined as four or more drinks per occasion, and (d) weeks of drinking exceeding the National Institute on Alcohol Abuse and Alcoholism sensible drinking limits. Overall, there were no differences in drinking outcome by treatment group. Characteristics associated with changes in drinking, however, were identified to provide possible direction for future investigation.

A systematic review and meta-analysis of health care utilization outcomes in alcohol screening and brief intervention trials

OBJECTIVE

This systematic review and meta-analysis examines the effect of screening and brief intervention (SBI) on outpatient, emergency department (ED), and inpatient health care utilization outcomes. Much of the current literature speculates that SBI provides cost savings through reduced health care utilization, but no systematic review or meta-analysis examines this assertion.

METHOD

Publications were abstracted from online journal collections and targeted Web searches. The systematic review included any publications that examined the association between SBI and health care utilization. Each publication was rated independently by 2 study authors and assigned a consensus methodological score. The meta-analysis focused on those studies examined in the systematic review, but it excluded publications that had incomplete data, low methodological quality, or a cluster-randomized design.

RESULTS

Systematic review results suggest that SBI has little to no effect on inpatient or outpatient health care utilization, but it may have a small, negative effect on ED utilization. A random effects meta-analysis using the Hedges method confirms the ED result for SBI delivered across settings (standardized mean difference = -0.06, I = 13.9%) but does not achieve statistical significance (confidence interval: -0.15, 0.03).

CONCLUSIONS

SBI may reduce overall health care costs, but more studies are needed. Current evidence is inconclusive for SBI delivered in ED and non-ED hospital settings. Future studies of SBI and health care utilization should report the estimated effects and variance, regardless of the effect size or statistical significance.

Mechanisms of change in control group drinking in clinical trials of brief alcohol intervention: implications for bias toward the null

ISSUES

Reductions in control group consumption over time that are possibly related to research design affect the impact of brief alcohol interventions (BAI) in clinical settings.

APPROACH

We conducted a systematic review to identify research design factors that may contribute to control group change, strategies to limit these effects and implications for researchers. Studies with control group n > 30 were selected if they published baseline and outcome consumption data, conducted trials in clinical settings in Anglophone countries and did not censor gender or age.

KEY FINDINGS

Among 38 studies cited in 20 reviews through October 2009, 16 met criteria (n = 31-370). In 54%, controls received alcohol specific handouts, advice and/or referral. Both the number and depth of assessments were highly variable. The percentage change in consumption ranged from-0.10 to-0.84 (mean-0.32), and effect size from 0.04 to 0.70 (mean 0.37). Published data were insufficient for meta-analysis.

IMPLICATIONS

Researchers should consider strategies to reduce the impact of research design factors, such as procedures to enhance sample diversity, blind subjects to study purpose to limit social desirability bias, reduce the number and depth of instruments (assessment reactivity), and finally, analytic techniques to decrease the impact of outliers and regression to the mean.

CONCLUSIONS

This review identifies problems with retrospective analysis of predictors of control group change, and underscores the need to design prospective studies to permit identification, quantification and adjustment for potential sources of bias in BAI trials.

Exact method for computing absolute percent change in a dichotomous outcome from meta-analytic effect size: improving impact and cost-outcome estimates

OBJECTIVES

Meta-analyses typically compute a treatment effect size (Cohen's d), which is readily converted to another common measure, the binomial effect size display (BESD). BESD is the correlation coefficient and represents a percentage difference in outcome attributable to an intervention. Both d and BESD are in arbitrary units; neither measures the absolute change resulting from intervention. The method used to estimate absolute change from BESD assumes both a 50-50 split of the outcome and a balanced design. Consequently, inaccurate assumptions underpin most meta-analytic estimates of the gain resulting from an intervention (and of its cost effectiveness). This article develops an exact formula without these assumptions.

METHODS

The formula is developed algebraically from 1) the formula for the correlation coefficient represented as a 2-by-2 contingency table constructed from the relative size of the treatment and control groups and the percentage of people who would have the condition absent intervention, and 2) the BESD correlation coefficient formula showing change in success probability with treatment.

RESULTS

Simulation reveals that BESD only approximates the reduction in the outcome an intervention might well achieve when the problem outcome occurs in 35%-65% of cases. For less common outcomes, BESD substantially overestimates the impact of an intervention. Even when BESD accurately estimates the likely percentage change in outcome, it paints a misleading picture of the proportion of cases that will achieve a positive outcome.

CONCLUSION

It is time to retire BESD. Our equations can also guide effect size estimation from difficult articles.

Moderators and mediators of two brief interventions for alcohol in the emergency department

OBJECTIVE

To evaluate moderators and mediators of brief alcohol interventions conducted in the emergency department.

METHODS

Patients (18-24 years; n = 172) in an emergency department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1- and 3-month booster sessions and 6- and 12-month follow-ups. Gender, alcohol status/severity group [ALC+ only, Alcohol Use Disorders Identification Test (AUDIT+) only, ALC+/AUDIT+], attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self-efficacy and alcohol treatment seeking.

RESULTS

Alcohol status, attribution and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ only group those who received MI showed lower rates of alcohol-related injury at follow-up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found.

CONCLUSIONS

Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.

Moderators and mediators of two brief interventions for alcohol in the emergency department

OBJECTIVE

To evaluate moderators and mediators of brief alcohol interventions conducted in the emergency department.

METHODS

Patients (18-24 years; n = 172) in an emergency department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1- and 3-month booster sessions and 6- and 12-month follow-ups. Gender, alcohol status/severity group [ALC+ only, Alcohol Use Disorders Identification Test (AUDIT+) only, ALC+/AUDIT+], attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self-efficacy and alcohol treatment seeking.

RESULTS

Alcohol status, attribution and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ only group those who received MI showed lower rates of alcohol-related injury at follow-up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found.

CONCLUSIONS

Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.

Analysis of the Uniform Accident And Sickness Policy Provision Law: lessons for social work practice, policy, and research

The Uniform Accident and Sickness Policy Provision Law (UPPL) is a state statute that allows insurance companies in 26 states to deny claims for accidents and injuries incurred by persons under the influence of drugs or alcohol. Serious repercussions can result for patients and health care professionals as states enforce this law. To examine differences within the laws that might facilitate amendments or reduce insurance companies' ability to deny claims, a content analysis was carried out of each state's UPPL law. Results showed no meaningful differences between each state's laws. These results indicate patients and health professionals share similar risk related to the UPPL regardless of state.

Prevention of fetal alcohol spectrum disorders

Alcohol use among women of childbearing age is a leading, preventable cause of birth defects and developmental disabilities in the United States. Although most women reduce their alcohol use upon pregnancy recognition, some women report drinking during pregnancy and others may continue to drink prior to realizing they are pregnant. These findings emphasize the need for effective prevention strategies for both pregnant and nonpregnant women who might be at risk for an alcohol-exposed pregnancy (AEP). This report reviews evidence supporting alcohol screening and brief intervention as an effective approach to reducing problem drinking and AEPs that can lead to fetal alcohol spectrum disorders. In addition, this article highlights a recent report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect that describes effective interventions to reduce alcohol use and AEPs, and outlines recommendations on promoting and improving these strategies. Utilizing evidence-based alcohol screening tools and brief counseling for women at risk for an AEP and other effective population-based strategies can help achieve future alcohol-free pregnancies.

Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy

BACKGROUND

It is estimated that more than 20% of pregnant women worldwide consume alcohol. Current research suggests that alcohol intake of seven or more standard drinks (one standard drink = 13.6 grams of absolute alcohol) per week during pregnancy places the baby at risk of serious, lifelong developmental and cognitive disabilities. Psychological and educational interventions may help women to reduce their alcohol intake during pregnancy.

OBJECTIVES

To determine the effectiveness of psychological and educational interventions to reduce alcohol consumption during pregnancy in pregnant women or women planning pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2008), CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE (1966 to November 2007), EMBASE (1980 to November 2007), CINAHL (1982 to November 2007), Counsel.Lit (1980 to November 2007), PsycLIT (1974 to November 2007) and PsycINFO (1967 to November 2007) and checked cited references from retrieved articles.

SELECTION CRITERIA

Randomized controlled trials examining the effectiveness of psychological and educational interventions for reducing consumption of alcohol among pregnant women, or women planning for pregnancy.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted information from the results sections of the included studies.

MAIN RESULTS

Four studies met the inclusion criteria (715 pregnant women), and reported on at least one of the outcomes of interest. We performed no meta-analyses as the interventions and outcomes measured in the studies were not sufficiently similar. For most outcomes there were no significant differences between groups; and results relating to abstaining or reducing alcohol consumption were mixed. Results from individual studies suggest that interventions may encourage women to abstain from alcohol in pregnancy. There was very little information provided on the effects of interventions on the health of mothers and babies.

AUTHORS' CONCLUSIONS

The evidence from the limited number of studies suggests that psychological and educational interventions may result in increased abstinence from alcohol, and a reduction in alcohol consumption among pregnant women. However, results were not consistent, and the paucity of studies, the number of total participants, the high risk of bias of some of the studies, and the complexity of interventions limits our ability to determine the type of intervention which would be most effective in increasing abstinence from, or reducing the consumption of, alcohol among pregnant women.

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.

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.

Allowing for uncertainty due to missing data in meta-analysis--part 2: hierarchical models

We propose a hierarchical model for the analysis of data from several randomized trials where some outcomes are missing. The degree of departure from a missing-at-random assumption in each arm of each trial is expressed by an informative missing odds ratio (IMOR). We require a realistic prior for the IMORs, including an assessment of the prior correlation between IMORs in different arms and in different trials. The model is fitted by Monte Carlo Markov Chain techniques. By applying the method in three different data sets, we show that it is possible to appropriately capture the extra uncertainty due to missing data, and we discuss in what circumstances it is possible to learn about the IMOR.

Low identification of alcohol use disorders in general practice in England

AIMS

The prevalence of alcohol use disorders (AUDs) in the United Kingdom is estimated at 25%, and primary care has been identified as the first line of treatment for this population. However, there is a paucity of evidence regarding the current rates of identification of AUDs in primary care. The aim of the present study was to compare the observed rates of AUDs in general practice with expected rates, which are based on general population prevalence rates of AUDs.

DESIGN, PARTICIPANTS AND MEASUREMENTS

Epidemiological data on individuals aged 16-64 years with an AUD was obtained from the General Practice Research Database. General population prevalence rates of AUDs were obtained from the Psychiatric Morbidity Survey. Chi(2) tests and identification ratios were used to analyse the data.

RESULTS

There was a significant relationship between type of AUD and identification (chi(2)=1466.89, P<0.001), and general practitioners were poorer at identifying harmful/hazardous drinkers when compared with dependent drinkers. No gender differences in the identification of hazardous/harmful drinking were found, but female dependent drinkers were significantly more likely to be identified than males (identification ratio 0.07; 95% confidence interval 0.06-0.07). The identification of AUDs was significantly lower for the 16-24-year age group compared with all other age groups.

CONCLUSION

Despite attempts at targeting hazardous/harmful drinkers for brief interventions in primary care, the present findings suggest that this group are still under-identified. Furthermore, this under-identification is even more apparent in men and in young people who have high general population prevalence rates for AUDs. In conclusion, increasing identification rates could be incorporated into brief intervention strategies in primary care.

Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness

BACKGROUND

The U.S. Preventive Services Task Force (USPSTF) has recommended screening and behavioral counseling interventions in primary care to reduce alcohol misuse. This study was designed to develop a standardized rating for the clinically preventable burden and cost effectiveness of complying with that recommendation that would allow comparisons across many recommended services.

METHODS

A systematic review of the literature from 1992 through 2004 to identify relevant randomized controlled trials and cost-effectiveness studies was completed in 2005. Clinically preventable burden (CPB) was calculated as the product of effectiveness times the alcohol-attributable fraction of both mortality and morbidity (measured in quality-adjusted life years or QALYs), for all relevant conditions. Cost effectiveness from both the societal perspective and the health-system perspective was estimated. These analyses were completed in 2006.

RESULTS

The calculated CPB was 176,000 QALYs saved over the lifetime of a birth cohort of 4,000,000, with a range in sensitivity analysis from -43% to +94% (primarily due to variation in estimates of effectiveness). Screening and brief counseling was cost-saving from the societal perspective and had a cost-effectiveness ratio of $1755/QALY saved from the health-system perspective. Sensitivity analysis indicates that from both perspectives the service is very cost effective and may be cost saving.

CONCLUSIONS

These results make alcohol screening and counseling one of the highest-ranking preventive services among the 25 effective services evaluated using standardized methods. Since current levels of delivery are the lowest of comparably ranked services, this service deserves special attention by clinicians and care delivery systems.

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.

Assessment may conceal therapeutic benefit: findings from a randomized controlled trial for hazardous drinking

CONTEXT

The concept that assessment of a person's health status without subsequent intervention has beneficial effects in itself has stimulated much interest in underlying psychological mechanisms, methodological implications and its public health potential. There have, however, been few experimental studies of assessment effects.

AIM

To test the hypothesis that assessment in itself produces a reduction in hazardous drinking.

DESIGN AND SETTING

Two conditions (group A, leaflet only and group B, leaflet and assessment but no intervention) of a four-arm randomized controlled trial with enrollment in March-April 2003.

PARTICIPANTS

A total of 975 students (17-29 years) attending a primary health-care clinic completed a web-based Alcohol Use Disorders Identification Test (AUDIT) questionnaire. Of 599 who scored >or= 8576 consented to follow-up and were included in the full four-arm trial, of whom 293 (153 women) were assigned to groups A and B.

INTERVENTION

Group A received an information leaflet at baseline. Group B received the information leaflet and 10 minutes of web-based assessment 4 weeks later.

MEASUREMENTS

Drinking frequency, typical quantity, heavy episode frequency, personal problems and academic problems.

FINDINGS

Baseline mean AUDIT scores were 15.0 (SD = 5.4) and 14.9 (SD = 5.0) in groups A and B, respectively. Twelve months after baseline, relative to group A, group B reported lower overall consumption (geometric means ratio 0.82, 95% CI: 0.68-0.98), fewer heavy drinking episodes (0.66, 0.47-0.91), fewer problems (0.81, 0.67-0.99) and lower AUDIT scores (beta = -1.63, -0.62 to -2.65).

CONCLUSIONS

Brief assessment appeared to reduce hazardous drinking. Controlled trials that rely on assessment may therefore underestimate treatment effects. Limitations include the possibility of measurement artefact due to social desirability bias.

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.

[Screening and effectiveness evaluation of a brief intervention in risk drinkers seen in primary health care]

AIMS

To evaluate the screening, the effectiveness of an antialcoholic brief intervention for risk drinkers, the acceptation level to participate in this study, and the analytical parameters evolution associated to the alcohol consumption after of the intervention.

DESIGN

Longitudinal prospective intervention study of 1 year of duration.

SETTING

5 urban primary care physician's practices.

PARTICIPANTS

Of an aleatory pattern of 681 patients, men and women of 18-65 years old, were selected 78 risk drinkers. Patients with exclusion criteria (n=10), didn't wanted to participate (n=24) and had suspicion of alcoholic dependence syndrome (ADS) (n=11), didn't participated in this intervention.

INTERVENTIONS

Were offered antialcoholic brief counselling with written supporter and were followed with alcohol consumption rate and analytical control at 2 and 12 months.

MAIN MEASURES

Was estimated the prevalence of risk drinkers, the acceptation level to participate in this study, alcohol consumption and risk drinkers decreased at 2 and 12 months, analytical parameters evolution after of the intervention.

RESULTS

Prevalence of risk drinkers: 11.5% (95% confidence interval [CI], 8.3%-14.7%). Acceptation level to participate in this study: 64.7%. Significative alcohol consumption decreased at 2 and 12 months (P<.05). Risk drinkers decreased: at 2 months were 57.6% (95% CI, 50.3%-64.9%; P=.01) and at 12 months were 42.4% (95% CI; 35.9%-48.9%) (P=.003). GGT, MCV, cholesterol, and triglycerides significative decreased.

CONCLUSIONS

Low prevalence of risk drinkers without suspicion of ADS in our setting; high effectiveness of antialcoholic brief counselling and high acceptation level to participate in this study; reduction of the GGT, MCV, cholesterol, and triglycerides after of the intervention.

A better widget? Three lessons for improving addiction treatment from a meta-analytical study

OBJECTIVE

To discuss how to develop more effective treatment programmes than those currently available for addictive disorders.

DATA SOURCES

The Swedish SBU report, published in English in 2003, was used as a database. It includes 641 randomized controlled trials and seven longitudinal prospective studies.

METHODS

Meta-analytical calculations were performed in several areas using standardized mean differences (d) effect-size estimate and homogeneity testing. Three critical issues have been the focus of the present analysis: the early intervention phase, treatment procedures and their additive properties and the transitional period between early and late effects of treatment.

RESULTS

The main findings while integrating the results in a new way were that intervention studies with one single session showed a small but robust homogeneous effect size, whereas studies of interventions with several sessions were heterogeneous with large and small effect sizes among the included studies. Similar effect sizes were found in alcohol, opioid and cocaine treatment studies. Agonist treatment yielded the highest effect sizes. Some evidence was found for a possible additive effect for cognitive behaviour therapy and naltrexone as well as for aversive treatment (disulfiram) and psychosocial treatment in alcohol dependence. So far studies on the transition period between short- and long-term outcome are few and inconclusive.

CONCLUSIONS

There is a prospect of improving addiction treatment, and the following areas are suggested by meta-analysis for future research: (a) to examine in more detail the process between the first and second session of intervention; (b) to randomize simultaneously for independent categories of psychosocial and psychopharmacological treatment; and (c) to intensify studies on the transitional period between short- and long-term outcome.

The effects on mortality of brief interventions for problem drinking: a meta-analysis

AIMS

Brief interventions for problem drinking may result in decreased mortality rates. Long-term follow-up studies of brief interventions do not produce a clear answer to the question as to whether these interventions reduce mortality or not.

METHODS

We conducted a meta-analysis of randomized studies comparing brief interventions with a control group, using the fixed-effects model. A systematic literature search produced four studies in which the mortality status of subjects was verified at follow-up. Six more studies reported some deaths at follow-up but did not verify mortality in death registers, and 22 further studies did not report the mortality status of the included subjects.

FINDINGS

The pooled relative risk (RR) of dying was 0.47 for the four studies with verified mortality rates (95% CI: 0.25, 0.89). The pooled RR of all 32 studies was comparable (RR = 0.57; 95% CI: 0.38, 0.84), as were the RRs of several other subsamples of studies. The prevented fraction was 0.33 in the studies with verified mortality rates.

CONCLUSIONS

Although the overall death rate was low in the population of problem drinkers, brief interventions do appear to reduce mortality.

Treatment of alcohol abuse: an evidence-based review

This article represents the proceedings of a symposium at the 2002 annual meeting of the Research Society on Alcoholism in San Francisco, CA, organized and cochaired by Mats Berglund and Sten Thelander. The presentations were (1) Preventive interventions against hazardous consumption of alcohol, by Mikko Salaspuro; (2) Treatment of alcohol withdrawal, by Johan Franck; (3) Psychosocial treatment for alcohol problems, by Sven Andréasson and Agneta Ojehagen; and (4) Pharmacological treatment of alcohol dependence, by Mats Berglund.

Brief interventions for hazardous drinkers delivered in primary care are equally effective in men and women

BACKGROUND

Despite the accumulated evidence on the efficacy of brief interventions in hazardous drinkers some ambiguity remains regarding their differential effectiveness by gender.

METHODS

Meta-analysis of independent studies conducted in primary health care settings with a follow-up of 6-12 months which report results separately by gender. Two outcome measures were selected: the quantity of typical weekly alcohol consumption and the frequency of drinkers who reported consumption below hazardous levels after the intervention.

RESULTS

Seven studies were included in the meta-analysis. The standardized effect sizes for the reduction of alcohol consumption were similar in men (d=- 0.25; 95% CI=- 0.34 to -0.17) and women (d=- 0.26; 95% CI=- 0.38 to - 0.13). The odds ratios (OR) for the frequency of individuals who drank below harmful levels were also similar (four studies; OR for men=2.32; 95% CI=1.78-2.93; OR for women=2.31; 95% CI=1.60-3.17). The difference between genders was negligible.

CONCLUSION

Our results support the equality of outcomes among men and women achieved by brief interventions for hazardous alcohol consumption in primary care settings.

I. Veterans Affairs Cooperative Study of Polyenylphosphatidylcholine in Alcoholic Liver Disease: Effects on Drinking Behavior by Nurse/Physician Teams

BACKGROUND

This multicenter prospective, randomized, double-blind placebo-controlled trial was designed to evaluate the effectiveness of polyenylphosphatidylcholine against the progression of liver fibrosis toward cirrhosis in alcoholics. Seven hundred eighty-nine alcoholics with an average intake of 16 drinks per day were enrolled. To control excessive drinking, patients were referred to a standard 12-step-based alcoholism treatment program, but most patients refused to attend. Accordingly, study follow-up procedures incorporated the essential features of the brief-intervention approach. An overall substantial and sustained reduction in drinking was observed. Hepatic histological and other findings are described in a companion article.

METHODS

Patients were randomized to receive daily three tablets of either polyenylphosphatidylcholine or placebo. Monthly follow-up visits included an extensive session with a medical nurse along with brief visits with a study physician (hepatologist or gastroenterologist). A detailed physical examination occurred every 6 months. In addition, telephone consultations with the nurse were readily available. All patients had a liver biopsy before entry; a repeat biopsy was scheduled at 24 and 48 months.

RESULTS

There was a striking decrease in average daily alcohol intake to approximately 2.5 drinks per day. This was sustained over the course of the trial, lasting from 2 to 6 years. The effect was similar both in early dropouts and long-term patients, i.e., those with a 24-month biopsy or beyond.

CONCLUSIONS

In a treatment trial of alcoholic liver fibrosis, a striking reduction in alcohol consumption from 16 to 2.5 daily drinks was achieved with a brief-intervention approach, which consisted of a relative economy of therapeutic efforts that relied mainly on treatment sessions with a medical nurse accompanied by shorter reinforcing visits with a physician. This approach deserves generalization to address the heavy drinking problems commonly encountered in primary care and medical specialty practices.

Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of programmes of screening in general practice for excessive alcohol use and providing brief interventions.

DESIGN

Systematic review and meta-analysis of randomised controlled trials that used screening as a precursor to brief intervention.

SETTING

General practice.

MAIN OUTCOME MEASURES

Number needed to treat, proportion of patients positive on screening, proportion given brief interventions, and effect of screening.

RESULTS

The eight studies included for meta-analysis all used health questionnaires for screening, and the brief interventions included feedback, information, and advice. The studies contained several sources of bias that might lead to overestimates of the effects of intervention. External validity was compromised because typically three out of four people identified by screening as excessive users of alcohol did not qualify for the intervention after a secondary assessment. Overall, in 1000 screened patients, 90 screened positive and required further assessment, after which 25 qualified for brief intervention; after one year 2.6 (95% confidence interval 1.7 to 3.4) reported they drank less than the maximum recommended level.

CONCLUSIONS

Although even brief advice can reduce excessive drinking, screening in general practice does not seem to be an effective precursor to brief interventions targeting excessive alcohol use. This meta-analysis raises questions about the feasibility of screening in general practice for excessive use of alcohol.

A meta-analysis of the effectiveness of bibliotherapy for alcohol problems

There has been increased interest in the use of brief interventions and the delivery of alcohol treatment services through nonspecialist health care settings. One possible resource for reaching untreated individuals is "bibliotherapy," the provision of self-help materials to motivate and guide the process of changing drinking behavior. Research on the effectiveness of self-help materials for problem drinkers has been done for three decades. This report summarizes a meta-analytic review of 22 studies evaluating the effectiveness of such self-help materials. Each study was rated on 12 methodological criteria, and effect sizes of bibliotherapy were computed. The methodological quality of studies was generally high relative to other treatment-outcome studies. Modest support was found for the efficacy of self-help materials in decreasing at-risk and harmful drinking. The weighted mean pre/post-effect size for bibliotherapy was .80 with self-referred individuals seeking help for drinking problems, and .65 for individuals identified through health screening. Between-group comparisons of bibliotherapy with no-intervention controls appear to have a small to medium effect, with a weighted mean effect size of .31 with self-referred drinkers; effect size was more variable in opportunistic interventions based on health screening. Finally, between-group comparisons of effects on drinking of bibliotherapy versus more extensive interventions yielded effect size values near zero. These findings provide support for the cost-effective use of bibliotherapy with problem drinkers seeking such help to reduce their consumption, and to a lesser extent with drinkers who are identified through screening as at risk.

[Effectiveness of medical counseling for alcoholic patients and patients with excessive alcohol consumption seen in primary care]

AIM

To determine the effectiveness of medical counseling for alcohol abuse, when it is provided in primary care centers.

DESIGN

Quasi-experimental, open, multicenter before-after study.Setting. 14 primary care physician's practices (7 rural, 7 urban) in the province of Córdoba (Spain).

PARTICIPANTS

306 patients of both sexes, recruited with a case-finding strategy, who consumed >=35 (men) or >=21 (women) IU per week, or who had alcohol dependence syndrome (ADS) (MALTS score O>=11). Interventions. All patients were offered brief counseling to reduce drinking, and all were followed to evaluate their status 3 months, 1 year and 2 years later.

MAIN MEASURES

The response variable was self-reported alcohol consumption together with normal GGT values or confirmation of alcohol consumption by a relative. The results were subjected to intention-to-treat analysis.

RESULTS

Of the 306 patients included in the study, 95.1% were men and 78.4% had ADS. After 2 years 38.89% (95% CI, 32.2%-44.3%) had attained their treatment goal: 23.85% were in complete abstinence, and 15.0% consumed moderate amounts of alcohol below the limit considered to indicate risk. Starting excessive consumption at less than 16 years of age (odds ratio [OR], 3.0885), living in a slum (OR, 3.2103), smoking (OR, 1.7187), and a positive CAGE test (OR, 1.9949) were associated with failure of the intervention (P<.05).

CONCLUSIONS

Counseling provided by the family doctor was highly effective under the usual conditions of general practice, both for patients with excessive alcohol consumption and for patients with con ADS.

Outcomes for untreated individuals involved in randomized trials of alcohol treatment

Summarizing the relative effects of different treatments for alcohol use disorders is challenging because there is no standard treatment against which experimental treatments can be contrasted and comparisons to no-treatment control groups are rare. As alternative reference points, we examined outcomes and improvement for untreated participants (i.e., those in wait-list, no-treatment, and placebo conditions) in randomized trials of alcohol treatment over the last three decades. At followup, the average abstinence rate was 21% (n = 17 studies) and the mean level of alcohol consumption was 31 drinks per week (n = 29 studies). The reduction in drinking from baseline was.19 of a SD unit, or a 14% decrease from a baseline mean of 37 drinks per week (n = 17 studies). These values provide approximations of success and improvement that an active treatment for alcohol use disorders should surpass to be considered more beneficial than no treatment.

Brief interventions for problem drinking and women

Early identification and intervention among problem drinking women may avert the more severe, adverse consequences of alcohol abuse and dependence. Screening and brief interventions, while generally effective, have not been adequately examined among subgroups, such as women. The purpose of this review article is to examine the efficacy of brief interventions for the population of women in need of some alcohol treatment. Representative studies with random assignment to treatment conditions and either substantial numbers of women, or a special focus on women, were included. Findings suggest brief interventions are not consistently helpful to women drinkers.

Matching substance abuse aftercare treatments to client characteristics

This study investigated matching client attributes to different aftercare treatments. A naturalistic sample of adults entering substance abuse treatment was randomized into either Structured Relapse Prevention (RP, n=61) or a 12-Step Facilitation (TSF, n=72) aftercare program. Four patient attributes were matched to treatment: age, gender, substance abuse profile, and psychological status. Substance use outcomes were assessed 3 and 6 months posttreatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple substance abuse profile reported better alcohol outcomes with TSF aftercare than their cohorts exposed to RP aftercare. Individuals with high psychological distress at treatment entry were able to maintain longer periods of posttreatment abstinence with TSF aftercare compared to their cohorts exposed to RP. Inversely, RP was found to maintain abstinence significantly longer for individuals reporting low distress compared to those with high distress. Finally, better outcomes were achieved when random assignment to aftercare was consistent with participant preference. Overall, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use outcomes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is targeted. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.

Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations

Brief interventions for alcohol use disorders have been the focus of considerable research. In this meta-analytic review, we considered studies comparing brief interventions with either control or extended treatment conditions. We calculated the effect sizes for multiple drinking-related outcomes at multiple follow-up points, and took into account the critical distinction between treatment-seeking and non-treatment-seeking samples. Most investigations fell into one of two types: those comparing brief interventions with control conditions in non-treatment-seeking samples (n = 34) and those comparing brief interventions with extended treatment in treatment-seeking samples (n = 20). For studies of the first type, small to medium aggregate effect sizes in favor of brief interventions emerged across different follow-up points. At follow-up after > 3-6 months, the effect for brief interventions compared to control conditions was significantly larger when individuals with more severe alcohol problems were excluded. For studies of the second type, the effect sizes were largely not significantly different from zero. This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals to non-treatment-seeking samples. The results concur with previous reviews that found little difference between brief and extended treatment conditions. Because the evidence regarding brief interventions comes from different types of investigation with different samples, generalizations should be restricted to the populations, treatment characteristics and contexts represented in those studies.

[Effectiveness of preventive activities analyzed within the framework of health centers involved in the Program for Preventive Activities and Health Promotion (PAPPS) of the semFYC. Group for the Evaluation of PAPPS]

OBJECTIVE

To find the effectiveness of a programme of preventive activities for adults (hypertension, tobacco and alcohol) measured by the number of cases identified, the evaluation of the initial interventions and the degree of control over the identified factors.

DESIGN

Retrospective study: review of clinical records.

SETTING

Primary care. Multi-centre study: health centres from the whole of Spain.

PATIENTS

7562 clinical records of patients over 20, who participated voluntarily and were extracted by systematic sampling from 378 care units (doctor and nurse) at 85 health centres committed to the Programme of Preventive Activities and Health Promotion (PAPPS) of the Spanish Society of Family and Community Medicine (semFYC). The study period was from May 1 1995 to April 30 1997.

MEASUREMENTS AND MAIN RESULTS

Age, sex, data on tobacco habit, alcohol consumption and blood pressure were obtained through a questionnaire (recording the actions taken, date of diagnosis, initial assessment and subsequent monitoring). 28.3% were tobacco-dependent, 6.9% consumed too much alcohol, and 22.2% had hypertension. About 20% cases of each risk factor were detected during the study period. Giving up tobacco was recorded in 7.6% of smokers, and giving up alcohol in 19.7% of excess drinkers. 78.6% of hyperintense patients had acceptable-optimum control.

CONCLUSIONS

The number of cases detected shows that the PAPPS programme performs acceptably. The tobacco and drink given up and the hypertension control attained due to the intervention are similar to the published trials. The PAPPS is an effective programme for controlling risk factors in primary care.

Evaluation of a workplace brief intervention for excessive alcohol consumption: the workscreen project

BACKGROUND

The workplace provides a useful setting for early identification and intervention with individuals who have unhealthy lifestyles. The objective was to evaluate the effects of a workplace-based lifestyle intervention (Workscreen) to reduce excessive drinking.

METHOD

There were eight Australia Post networks randomly allocated to experimental and control conditions, comprising 67 worksites and 1206 employees. The experimental condition involved a broad spectrum lifestyle campaign, incorporating support from management, employee awareness of health, and brief interventions for high-risk behaviors, including excessive alcohol use. Focus groups identified relevant cultural factors. Changes in workplace culture and employee behavior were assessed 10 months after baseline. Males and females were analyzed separately.

RESULTS

Over half of APOST employees participated at each screening point. In the experimental condition 61% of employees overall and 58% of those identified as excessive drinkers in Phase 1 responded to the lifestyle campaign by attending health assessments. Analyses focusing on the organization as a whole did not reveal significant reductions in excessive alcohol consumption among men or women. However, a significant reduction in number of drinks was observed in the experimental condition among women for whom completion of baseline and follow-up could be confirmed (P < 0.001).

CONCLUSIONS

The present study indicates that a workplace-based lifestyle campaign can assist self-selected employees in reducing their alcohol consumption. There was a moderately high level of participation among those identified as drinking excessively, which supports our approach of embedding a low-intensity alcohol program within the context of a broader health promotion campaign.

Minimal interventions for problem drinkers: a review of the literature

There is an increasing body of literature concerning the role in health promotion for nurses working in many health care settings. It has been argued that this role should include identifying those individuals whose life-style increases their risk of developing health problems, as well as providing appropriate advice and information. Life-style factors which may contribute to ill-health include problem drinking. This literature review presents a critique of studies of brief, or minimal, interventions for problem drinkers which have been conducted in both primary care and acute settings. The concept of minimal interventions is explored and the potential for nurses to assume a role in delivering such interventions is discussed.