Progressive stage transition does mean getting better: a further test of the Transtheoretical Model in recovery from alcohol problems

AIMS

To test two central assumptions of the Transtheoretical Model (TTM) regarding recovery from alcohol problems: (i) individuals making a forward transition from pre-action to action stages will show greater drinking improvements than those remaining in pre-action stages; and (ii) individuals remaining in pre-action stages will not demonstrate improvements in drinking outcomes.

DESIGN AND SETTING

Large, multi-centre, randomized controlled trial of treatment for alcohol problems [United Kingdom Alcohol Treatment Trial (UKATT)].

MEASUREMENTS

Stage of change, drinks per drinking day and percentage days abstinent at baseline, 3- and 12-month follow-ups.

FINDINGS

In support of TTM assumption 1, improvements in drinking outcomes were consistently greater among clients who showed a forward stage transition (Cohen's d = 0.68) than among those who did not (d = 0.10). Two tests of assumption 2 showed a significant improvement in drinking outcomes in non-transition groups, inconsistent with the TTM; one test showed a significant deterioration and the other showed equivalent drinking outcomes across time. An explanation is offered as to why, under the relevant assumption of the TTM, clients in non-transition groups showed small changes in drinking outcomes.

CONCLUSIONS

In contrast to a previous study by Callaghan and colleagues, our findings largely support the TTM account of recovery from alcohol problems in treatment. The discrepancy can be explained by the use in our study of a more reliable and valid method for assigning stage of change.

Restrictions on tobacco and alcohol use in Australian work-places

In a telephone survey of 455 of the top 600 companies in Australia, around three-quarters reported the existence of restrictions on both smoking and alcohol in the workplace. Forty-six percent of companies had a total ban on smoking at work, 31% had designated limited areas where employees were permitted to smoke, and 23% had no policy on smoking. Seventy-seven percent of companies encouraged a total alcohol-free work environment. The larger the company, the more likely it was to have restrictions on smoking in the work-place, but there was no relationship between the size of the company and alcohol restrictions. Government organizations were more likely to have restrictions on smoking than non-government organizations, but this difference was not apparent for alcohol restrictions. The major reasons given for smoking restrictions were related to health and comfort, while those for alcohol were related to work productivity and safety.

Australian Aborigines and alcohol: a review

Following a summary of the relevant historical and legislative background, this article reviews the literature on: (i) rates of alcohol usage and problem drinking in Aboriginal populations; (ii) adverse effects of drinking; (iii) suggested causes of problem drinking among Aborigines; and (iv) treatment and preventive initiatives. The need to examine Aboriginal alcohol use in the wider context of socio-economic deprivation and rapid social change is emphasized. Key issues warranting further research attention are identified and, while recognizing the difficulties inherent in doing so, suggestions are made as to how the quality of research in the area might be raised. It is concluded that, without long-term planning and commitment of the necessary resources by government, little progress will be made in reducing the problems associated with Aboriginal use of alcohol.

Results of screening for excessive drinkers in four Sydney teaching hospitals

In-patients from selected wards at four Sydney teaching hospitals were screened using a self-completed general health questionnaire. Screening was carried out between January 1990 and December 1991 as part of a larger study of brief interventions for excessive alcohol consumers detected in the general hospital setting. Comparison with other screening studies of excessive drinkers in hospitals is difficult, due to factors such as the different screening instruments used and the varying population targeted. However, similar trends among excessive drinkers were found, such as age and gender factors. The routine employment of simple screening instruments to detect excessive drinkers among hospital in-patients is once more urged.

Effects of brief counselling among male heavy drinkers identified on general hospital wards*

Although the prevalence of heavy alcohol consumption among patients of general hospitals is well documented, no study has yet reported an effect of counselling on the ward in reducing the level of consumption among such patients after discharge. This study was designed to evaluate brief counselling to reduce alcohol consumption among male heavy drinkers identified on general hospital wards. Male patients were screened on wards of four teaching hospitals in Sydney, Australia. Identified heavy drinkers (n = 174) showing predominantly low levels of alcohol dependence were allocated to one of two forms of brief counselling (skills-based counselling or brief motivational interviewing) or to a non-intervention control group. Blind follow-up for 123 patients (71%) was carried out approximately 6 months after discharge from hospital and self-reports of alcohol consumption were compared with collateral sources of information. Patients who received counselling showed a significantly greater mean reduction in a quantity-frequency measure of weekly alcohol consumption than controls but there were no significant differences in reduced consumption between the two intervention groups. However, patients who were deemed "not ready to change" showed greater reductions if they had received brief motivational interviewing than if they had received skills-based counselling. The implications of these findings for counselling male in-patients to reduce alcohol consumption are discussed.

Cue exposure in the treatment of drug dependence: the potential of a new method for preventing relapse

Cue exposure has been used successfully in the treatment of neurotic disorders. Its application to the treatment of drug dependence is founded on the premise that craving for drugs can become classically conditioned to internal and external drug-related cues and that such conditioned craving responses play an important part in relapse to drug use. This article reviews the theoretical background for the use of cue exposure, research on cue reactivity in samples of drug-dependent persons and the role of cue reactivity in relapse. What evidence exists on the clinical effectiveness of cue exposure is reviewed in some detail and a number of clinical issues relating to its practical application are discussed. It is concluded that controlled trials of the effectiveness of cue exposure treatment for drug dependence should be implemented without further delay.

Groundwork for a research programme on harm reduction in alcohol and drug treatment

The aim of this article is to set out the groundwork for a research programme for harm reduction in alcohol and drug treatment. First, attitudes to science of those who work in the harm reduction field are discussed and it is argued that hostility to the introduction of conventional scientific methods to this field is seriously misguided. Harm reduction activity is then defined as an attempt to ameliorate the adverse health, social or economic consequences of mood-altering substances without necessarily requiring a reduction in the consumption of these substances, and this definition is amplified. Finally, issues relevant to the measurement of outcome from harm reduction interventions are discussed by comparing Newcombe's classification of drug-related harms with an existing instrument designed to measure outcomes from interventions in the drugs field (the Opiate Treatment Index).

Development of a Readiness Ruler for use with alcohol brief interventions

BACKGROUND

A quick method of assessing readiness to change was needed for a major study of implementing screening and alcohol brief intervention in England. For this purpose, a Readiness Ruler that had been validated among a sample of male college students in the USA was adapted and applied to a sample of excessive drinkers in a general medical practice located in a deprived area of Gateshead, England.

METHODS

72 participants identified as excessive drinkers by health professionals completed a single-item Readiness Ruler, the 12-item Readiness to Change Questionnaire (RCQ) and the AUDIT questionnaire.

RESULTS

In terms of concurrent validity, the relationships between the Readiness Ruler, on the one hand, and either stage of change allocation or a dimensional score derived from the RCQ, on the other hand, were highly significant but weaker than expected. When patients who endorsed the "maintenance" point on the Readiness Ruler were excluded from the analysis, the above relationships were considerably strengthened for reasons that are discussed. On this basis and with another small change, a final Readiness Ruler was developed.

CONCLUSION

If the validity of the Readiness Ruler is confirmed in subsequent research, a quick and simple way of measuring readiness to change will be available for research or clinical work with alcohol brief interventions.

A review of the literature on the cognitive effects of alcohol hangover

AIMS

Alcohol misuse is a prime social and health problem in the UK. This paper presents a critical review of literature on the performance effects in the morning after binge drinking - during the alcohol hangover. Several pathophysiological changes that both follow and outlast acute intoxication may give rise to alcohol hangover effects. We have identified 27 English language peer-reviewed studies that investigate aspects of psychological performance during alcohol hangover following controlled alcohol ingestion. However, the majority of studies had basic methodological shortcomings. Of eight laboratory studies rigorous enough to warrant serious attention, only two showed effects. We interpret these largely negative findings as evidence of an insensitivity that is intrinsic to laboratory-based studies of performance under the influence of alcohol. Several studies have investigated the cognitive consequences of hangover subsequent to naturalistic consumption, where participants have chosen what and where to drink. Although these studies have tended to show effects, participants were always informed at the outset that hangover effects were to be assessed, and participants knew which was the hangover condition. Under these circumstances expectancy effects have possibly contaminated the results significantly. Therefore, naturalistic alcohol consumption studies (and laboratory studies that did not employ a placebo) can be considered as being suggestive of hangover effects, but should not be interpreted as providing definitive evidence of such effects. In conclusion, although there is empirical evidence showing impaired performance as a result of the alcohol hangover, future studies should confirm these findings and overcome the shortcomings of previous research.

[Early screening and brief intervention among excessive alcohol users: mobilizing general practitioners in an efficient way]

OBJECTIVE

The program "Boire moins, c'est mieux" (BMCM--"The less alcohol, the better") initiated by the ANPAA offered 550 general practitioners (GPs) in 2003 to follow training courses so as to perform "early screening and brief intervention" (ESBI) in general practice. Phone calls to the medical offices, a financial compensation offer and a media campaign in the immediate environment of general practitioners were used. The study aimed at assessing the respective efficiency of these three methods.

METHOD

Mailing was the control mobilization method. Phone calls were used in addition to mailing for one GP out of two, according to a previous draw. Financial compensation (2 + for each questionnaire filled out, and 10 + for each BI delivered) was used when GPs were invited a second time to attend the training. Community-based mobilization only occurred in the site in Saint-Quentin-en-Yvelines (France). The primary endpoint was the actual participation to the training evenings. The secondary endpoints were the registration to trainings and the ESBI activity following the training.

RESULTS

Phone calls enabled to multiple by 7 the number of participants attending training sessions, as compared to the impact of mailing only (p < 10-7); phone calls had no proper impact on ESBI activity following the training. Financial compensation had a powerful impact on the level of ESBI activities (p = 10-4); however, announcing it had no effect on registrations and barely modified the impact of phone calls. The proportion of the population benefiting from a screening action doubled in the site where a community-based action occurred (p < 10-7).

CONCLUSION

A mere phone call was particularly efficient in increasing the number of trained GPs. Financial incentive led to an activity level very close to systematic screening. Community-based approach increased significantly the proportion of the screened population.

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.

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.

COST AND OUTCOME ANALYSIS OF TWO ALCOHOL DETOXIFICATION SERVICES

AIM

To examine the relationship between service use and outcomes (individual and wider consequences) using an economic analysis of a direct-access alcohol detoxification service in Manchester (the Smithfield Centre) and an NHS partial hospitalization programme in Newcastle upon Tyne (Newcastle and North Tyneside Drug and Alcohol Service, Plummer Court).

METHODS

A total of 145 direct-access admissions to the Smithfield Centre and 77 admissions to Plummer Court completed a battery of questionnaires shortly after intake and were followed up 6 months after discharge. Full economic data at follow-up were available for 54 Smithfield admissions and 49 Plummer Court admissions.

RESULTS

Mean total cost of treatment per patient was pound1113 at the Smithfield Centre and pound1054 at Plummer Court in 2003-04 prices. Comparing the 6 months before treatment with the 6 months before follow-up, social costs fell by pound331 on average for each patient at Plummer Court but rose by pound1047 for each patient at the Smithfield Centre. When treatment costs and wider social costs were combined, the total cost to society at Smithfield was on average pound2159 per patient whilst at Plummer Court it was pound723 per patient. Combining the cost of treatment with drinking outcomes yielded a net cost per unit reduction in alcohol consumption of pound1.79 at Smithfield and pound1.68 at Plummer Court.

CONCLUSIONS

Both services delivered a flexible needs-based service to very disadvantaged population at a reasonable cost and were associated with statistically significant reductions in drinking. For some patients, there was evidence of public sector resource savings but for others these detoxification services allowed those not previously in contact with services to meet health and social care needs. These patterns of cost through time are more complex than in previous evaluations of less severely dependent patients and difficult to predict from drinking patterns or patient characteristics. More research is required to judge the suitability of generic health state measures commonly in use for health economic evaluations for assessing the short-term outcomes of alcohol treatment.

Understanding hospital-based alcohol services and aftercare

Many patients are admitted to general hospitals with conditions that are alcohol related but they may be unaware that their drinking has contributed to their admission. A general hospital provides an excellent opportunity for health promotion, advice and referral tospecialist services. This article looks at the importance of asking patients questions relating too their alcohol consumption as well as introducing hospital and community-based alcohol support services.

Level of impaired control predicts outcome of moderation-oriented treatment for alcohol problems

AIMS

To examine the ability of the Impaired Control Scale (ICS) to predict outcome of moderation-oriented treatment for alcohol problems and to compare this predictive ability directly with that of a widely used measure of alcohol dependence, the Severity of Alcohol Dependence Questionnaire (SADQ).

DESIGN

Prospective follow-up study.

SETTING

Out-patient treatment centres.

PARTICIPANTS

A combined sample 154 problem drinkers taking part in two clinical trials of Moderation-oriented Cue Exposure in the UK and Australia. Clients were followed-up 6 (UK) and 8 (Australia) months after the end of treatment.

MEASUREMENTS

Outcome was categorized by combining drinking behaviour at follow-up with changes on the Alcohol Problems Questionnaire from before treatment to follow-up. Controlling for research site, baseline scores on Part 2 of the ICS (substitution method) and the SADQ-C were entered in logistic regression analyses with three outcome dichotomies as dependent variables.

FINDINGS

Five per cent of clients were abstinent at follow-up, 13% non-problem drinkers, 25% much improved, 24% somewhat improved and 34% unimproved. Location of treatment and ICS2 scores were significant predictors of whether or not clients achieved a successful outcome (abstinence or non-problem drinking). Using a cut-point of 25 on the ICS, two-thirds of outcomes were classified correctly as either treatment successes or failures. SADQ-C score was not a significant predictor of treatment outcome.

CONCLUSIONS

The ICS predicts outcome of moderation-oriented treatment among moderately dependent problem drinkers recruited mainly via newspaper advertisements. The ICS should replace the SADQ as the basis for advice to clients in this population of problem drinkers regarding whether or not a moderation goal of treatment should be pursued.

Brief interventions for alcohol problems in hospital settings

Many patients present to general hospitals with alcohol-related problems, but most of them are not identified as such. This article summarises the evidence base for screening and brief interventions delivered by nurses in general hospital medical/surgical wards and A&E departments. It also suggests how screening and brief interventions can operate in these environments.