Cost effectiveness of brief interventions for reducing alcohol consumption

Investigating for Whom Brief Substance Use Interventions Are Most Effective: An Individual Participant Data Meta-analysis

Prior research suggests that brief interventions (BIs) for alcohol and other drug use may vary in effectiveness across patient sociodemographic factors. The objective of this individual participant data (IPD) meta-analysis was to explore for whom BIs delivered in general healthcare settings are more or less effective. We examined variability in BI effects by patient age, sex, employment, education, relationship status, and baseline severity of substance use using a two-stage IPD meta-analysis approach. All trials included in a parent aggregate data meta-analysis (k = 116) were invited to contribute IPD, and 29 trials provided patient-level data (12,074 participants). Among females, BIs led to significant reductions in binge alcohol consumption ([Formula: see text] = 0.09, 95% CI [0.03, 0.14]), frequency of alcohol consumption ([Formula: see text] = 0.10, 95% CI [0.03, 0.17]), and alcohol-related consequences ([Formula: see text] = 0.16, 95% CI [0.08, 0.25]), as well as greater substance use treatment utilization ([Formula: see text] = 0.25, 95% CI [0.21, 0.30]). BIs yielded larger reductions in frequency of alcohol consumption at 3-month follow-up for individuals with less than a high school level education ([Formula: see text] = 0.16, 95% CI [0.09, 0.22]). Given evidence demonstrating modest BI effects on alcohol use and mixed or null findings for BI effects on other drug use, BI research should continue to investigate potential drivers of effect magnitude and variation.  PROTOCOL REGISTRATION DETAILS: The protocol for this review was pre-registered in PROSPERO #CRD42018086832 and the analysis plan was pre-registered in OSF: osf.io/m48g6.

Interventions to prevent alcohol use: systematic review of economic evaluations

BACKGROUND

Alcohol use is a leading risk factor for death and disability worldwide.

AIMS

We conducted a systematic review on the cost-effectiveness evidence for interventions to prevent alcohol use across the lifespan.

METHOD

Electronic databases (EMBASE, Medline, PsycINFO, CINAHL and EconLit) were searched for full economic evaluations and return-on-investment studies of alcohol prevention interventions published up to May 2021. The methods and results of included studies were evaluated with narrative synthesis, and study quality was assessed by the Drummond ten-point checklist.

RESULTS

A total of 69 studies met the inclusion criteria for a full economic evaluation or return-on-investment study. Most studies targeted adults or a combination of age groups, seven studies comprised children/adolescents and one involved older adults. Half of the studies found that alcohol prevention interventions are cost-saving (i.e. more effective and less costly than the comparator). This was especially true for universal prevention interventions designed to restrict exposure to alcohol through taxation or advertising bans; and selective/indicated prevention interventions, which involve screening with or without brief intervention for at-risk adults. School-based interventions combined with parent/carer interventions were cost-effective in preventing alcohol use among those aged under 18 years. No interventions were cost-effective for preventing alcohol use in older adults.

CONCLUSIONS

Alcohol prevention interventions show promising evidence of cost-effectiveness. Further economic analyses are needed to facilitate policy-making in low- and middle-income countries, and among child, adolescent and older adult populations.

Telemedicine for unhealthy alcohol use in adults living with HIV in Alabama using common elements treatment approach: A hybrid clinical efficacy-implementation trial protocol

Background

Unhealthy alcohol use is an unaddressed barrier to achieving and maintaining control of the human immunodeficiency virus (HIV) epidemic. Integrated screening, treatment of common behavioral and mental health comorbidities, and telemedicine can improve alcohol treatment and HIV clinical and quality of life outcomes for rural and underserved populations.

Objective

In a randomized controlled clinical trial, we will evaluate the effectiveness and implementation of telephone-delivered Common Elements Treatment Approach (T-CETA), a transdiagnostic cognitive behavioral therapy protocol, on unhealthy alcohol use, HIV, other substance use and mental health outcomes among predominantly rural adults with HIV receiving care at community clinics in Alabama.

Methods

Adults with HIV receiving care at four selected community clinics in Alabama will receive a telephone-delivered alcohol brief intervention (BI), and then be assigned at random (stratified by clinic and sex) to no further intervention or T-CETA. Participants will be recruited after screening positively for unhealthy alcohol use or when referred by a provider. The target sample size is 308. The primary outcome will be change in the Alcohol Use Disorder Identification Test (AUDIT) at six- and 12-months post-enrollment. Additional outcomes include HIV (retention in care and viral suppression), patient-reported mental health (anxiety, depression, posttraumatic stress), and quality of life. A range of implementation measures be evaluated including T-CETA provider and client acceptability, feasibility, cost and cost-effectiveness.

Conclusions

This trial will inform alcohol treatment within HIV care programs, including the need to consider comorbidities, and the potential impact of alcohol interventions on HIV and quality of life outcomes.

Alcohol-focused and transdiagnostic treatments for unhealthy alcohol use among adults with HIV in Zambia: A 3-arm randomized controlled trial

BACKGROUND

Clinical and quality of life outcomes in people living with human immunodeficiency virus (PLWH) are undermined by unhealthy alcohol use (UAU), which is highly prevalent in this population and is often complicated by mental health (MH) or other substance use (SU) comorbidity. In sub-Saharan Africa, evidence-based and implementable treatment options for people with HIV and UAU are needed.

METHODS

We are conducting a hybrid clinical effectiveness-implementation trial at three public-sector HIV clinics in Lusaka, Zambia. Adults with HIV, who report UAU, and have suboptimal HIV clinical outcomes, will be randomized to one of three arms: an alcohol-focused brief intervention (BI), the BI with additional referral to a transdiagnostic cognitive behavioral therapy (Common Elements Treatment Approach [CETA]), or standard of care. The BI and CETA will be provided by HIV peer counselors, a common cadre of lay health worker in Zambia. Clinical outcomes will include HIV viral suppression, alcohol use, assessed by audio computer-assisted self-interview (ACASI) and direct alcohol biomarkers, Phophatidylethanol and Ethyl glucuronide, and comorbid MH and other SU. A range of implementation outcomes including cost effectiveness will also be analyzed.

CONCLUSION

Hybrid and 3-arm trial design features facilitate the integrated evaluation of both brief, highly implementable, and more intensive, less implementable, treatment options for UAU among PLWH in sub-Saharan Africa. Use of ACASI and alcohol biomarkers will strengthen understanding of treatment effects.

Screening and brief intervention for alcohol use disorder risk in three middle-income countries

Background

This study examined the prevalence of screening and brief intervention (SBI) for alcohol use disorder (AUD) risk in samples of adult drinkers in three middle-income countries (Brazil, China, South Africa), and the extent to which meeting criteria for AUD risk was associated with SBI.

Methods

Cross-sectional survey data were collected from adult samples in two cities in each country in 2018. Survey measures included past-year alcohol use, the CAGE assessment for AUD risk, talking to a health care professional in the past year, alcohol use screening by a health care professional, receiving advice about drinking from a health care professional, and sociodemographic characteristics. The prevalence of SBI was determined for past-year drinkers in each country and for drinkers who had talked to a health care professional. Logistic regression analyses were conducted to examine whether meeting criteria for AUD risk was associated with SBI when adjusting for sociodemographic characteristics.

Results

Among drinkers at risk for AUD, alcohol use screening rates ranged from 6.7% in South Africa to 14.3% in Brazil, and brief intervention rates ranged from 4.6% in South Africa to 8.2% in China. SBI rates were higher among drinkers who talked to a health care professional in the past year. In regression analyses, AUD risk was positively associated with SBI in China and South Africa, and with brief intervention in Brazil.

Conclusion

Although the prevalence of SBI among drinkers at risk for AUD in Brazil, China, and South Africa appears to be low, it is encouraging that these drinkers were more likely to receive SBI.

Supplementary information

The online version contains supplementary material available at 10.1186/s12889-022-14358-4.

Detecting Mental Health Behaviors Using Mobile Interactions: Exploratory Study Focusing on Binge Eating

BACKGROUND

Binge eating is a subjective loss of control while eating, which leads to the consumption of large amounts of food. It can cause significant emotional distress and is often accompanied by purging behaviors (eg, meal skipping, overexercising, or vomiting).

OBJECTIVE

The aim of this study was to explore the potential of mobile sensing to detect indicators of binge-eating episodes, with a view toward informing the design of future context-aware mobile interventions.

METHODS

This study was conducted in 2 stages. The first involved the development of the DeMMI (Detecting Mental health behaviors using Mobile Interactions) app. As part of this, we conducted a consultation session to explore whether the types of sensor data we were proposing to capture were useful and appropriate, as well as to gather feedback on some specific app features relating to self-reporting. The second stage involved conducting a 6-week period of data collection with 10 participants experiencing binge eating (logging both their mood and episodes of binge eating) and 10 comparison participants (logging only mood). An optional interview was conducted after the study, which discussed their experience using the app, and 8 participants (n=3, 38% binge eating and n=5, 63% comparisons) consented.

RESULTS

The findings showed unique differences in the types of sensor data that were triangulated with the individuals' episodes (with nearby Bluetooth devices, screen and app use features, mobility features, and mood scores showing relevance). Participants had a largely positive opinion about the app, its unobtrusive role, and its ease of use. Interacting with the app increased participants' awareness of and reflection on their mood and phone usage patterns. Moreover, they expressed no privacy concerns as these were alleviated by the study information sheet.

CONCLUSIONS

This study contributes a series of recommendations for future studies wishing to scale our approach and for the design of bespoke mobile interventions to support this population.

Effects of brief substance use interventions delivered in general medical settings: a systematic review and meta-analysis

AIMS

To estimate effects of brief substance use interventions delivered in general medical settings.

METHODS

A systematic review and meta-analysis of randomized trials conducted since 1990 of brief substance use interventions in patients of any age or severity level recruited in general medical settings. Primary outcomes were any measure of substance use or substance-related consequences (indexed with Hedges' g and risk ratios). Mixed-effects meta-regressions were used to estimate overall effects and predictors of effect variability. Analyses were conducted separately by brief intervention (BI) target substance: alcohol only or drugs.

FINDINGS

A total of 116 trials (64 439 participants) were identified; 111 (62 263 participants) provided effect size data and were included in the meta-analysis. Drug-targeted BIs yielded significant small improvements in multiple drug/mixed substance use (Hedges' g (g¯ ) = 0.08; 95% CI = 0.002, 0.15), but after adjusting for multiple comparisons, they did not produce significant effects on cannabis use ( g¯ = 0.06; 95% CI = 0.001, 0.12), alcohol use ( g¯ = 0.08; 95% CI = -0.0003, 0.17), or consequences ( g¯ = 0.05; 95% CI = 0.01, 0.10). Drug-targeted BIs yielded larger improvements in multiple drug/mixed substance use when delivered by a general practitioner ( g¯ = 0.19; 95% CI = 0.187, 0.193). Alcohol-targeted BIs yielded small beneficial effects on alcohol use ( g¯ = 0.12; 95% CI 0.08, 0.16), but no evidence of an effect on consequences ( g¯ = 0.05; 95% CI = -0.04, 0.13). However, alcohol-targeted BIs only had beneficial effects on alcohol use when delivered in general medical settings (g¯ = 0.17; 95% CI = 0.10, 0.24); the findings were inconclusive for those delivered in emergency department/trauma centers ( g¯ = 0.05; 95% CI = 0.00, 0.10).

CONCLUSIONS

When delivered in general medical settings, alcohol-targeted brief interventions may produce small beneficial reductions in drinking (equivalent to a reduction in 1 drinking day per month). There is limited evidence regarding the effects of drug-targeted brief interventions on drug use.

Conceptualizing Suicide Prevention in Firefighters Through the lens of the Interpersonal-Psychological Theory of Suicide: A Narrative Review

Suicide is the 10th leading cause of death in the United States and is a significant public health problem. Suicide has also become a major concern among career American firefighters with rates for suicidal ideation and attempts in firefighters two to three times higher than rates in the general population. Firefighter suicide and mental health are major issues facing fire service leaders, mental health professionals, and most recently suicide experts. Despite an increased focus on understanding suicide in the fire service, there is little empirical evidence on the effectiveness of prevention in this population. The juxtaposition of elevated suicide rates with a dearth of empirical prevention data specific to firefighters warrants new approaches and conceptualizations of suicide prevention in this population. Grounded in the framework of the interpersonal-psychological theory of suicide (IPTS), this narrative review integrates select relevant firefighter specific suicide risk/protective factors and multi-level intervention/prevention literature to provide a structured approach to identifying current suicide intervention/prevention efforts with promising transportability to firefighters. Several recommendations for future intervention research specific to firefighters are also proposed.

The efficacy of Personalized Normative Feedback interventions across addictions: A systematic review and meta-analysis

Personalized Normative Feedback (PNF) may help address addictive disorders. PNF highlights discrepancies between perceived and actual peer norms, juxtaposed against self-reported behavior. PNF can be self-directed and cost-efficient. Our study estimates the efficacy of PNF alone, and in combination with other self-directed interventions, to address frequency and symptom severity of hazardous alcohol use, problem gambling, illicit drug and tobacco use. We searched electronic databases, grey literature, and reference lists of included articles, for randomized controlled trials published in English (January 2000-August 2019). We assessed study quality using the Cochrane Risk of Bias tool. Thirty-four studies met inclusion criteria (k = 28 alcohol, k = 3 gambling, k = 3 cannabis, k = 0 tobacco). Thirty studies provided suitable data for meta-analyses. PNF alone, and with additional interventions, reduced short-term alcohol frequency and symptom severity. PNF with additional interventions reduced short-term gambling symptom severity. Effect sizes were small. PNF did not alter illicit drug use. Findings highlight the efficacy of PNF to address alcohol frequency and symptom severity. The limited number of studies suggest further research is needed to ascertain the efficacy of PNF for gambling and illicit drug use. Cost-effectiveness analyses are required to determine the scale of PNF needed to justify its use in various settings.

Common Elements Treatment Approach (CETA) for unhealthy alcohol use among persons with HIV in Zambia: Study protocol of the ZCAP randomized controlled trial

AIMS

Prevalence of unhealthy alcohol use and co-occurring mental health problems is high among persons living with HIV (PLWH) in sub-Saharan Africa (SSA). Yet, there is a dearth of evidence-based treatment options that can address both unhealthy alcohol use and comorbidities in SSA HIV care settings. Recent studies testing single-session alcohol brief interventions (BIs) among PLWH in SSA have suggested that more robust treatments are needed. This paper describes the protocol of a pilot randomized controlled superiority trial that will test the effectiveness of an evidence-based transdiagnostic multi-session psychotherapy, the Common Elements Treatment Approach (CETA), compared to a control condition consisting of a single session brief alcohol intervention (BI) based on CETA, at reducing unhealthy alcohol use, mental health problems, and other substance use among PLWH in urban Zambia.

METHODS

The study is a single-blind, parallel, individually randomized trial conducted in HIV treatment centers in Lusaka. 160 PLWH who meet criteria for unhealthy alcohol use + mental health or substance use comorbidities and/or have a more severe alcohol use disorder are eligible. Participants are randomized 1:1 to receive the single-session BI or CETA. Outcomes are assessed at baseline and a six-month follow-up and include unhealthy alcohol use, depression, trauma symptoms, and other substance use.

CONCLUSIONS

The trial is a first step in establishing the effectiveness of CETA at reducing unhealthy alcohol use and comorbidities among PLWH in SSA. If effectiveness is demonstrated, a larger trial featuring long-term follow-ups and HIV treatment outcomes will be undertaken.

Using the question-behavior effect to change multiple health behaviors: An exploratory randomized controlled trial

Asking questions about a behavior has been found to influence subsequent performance of that behavior, a phenomenon termed the question-behavior effect (QBE). The present study addressed two under-researched questions concerning the QBE: (1) Can the QBE be used to change multiple health behaviors, and (2) does enhancing dissonance during questionnaire completion increase the magnitude of the QBE? Participants (N = 1534) were randomized to one of three conditions (dissonance-enhanced QBE; standard QBE; control) that targeted three health-protective behaviors (eating fruit and vegetables, physical activity, dental flossing) and three health-risk behaviors (alcohol intake, sedentariness, unhealthy snacking). The dissonance-enhanced intervention comprised a message designed to pressurize participants into forming healthful behavioral intentions. Behavior was assessed via self-reports at four-week follow up. Findings showed significant overall effects of the QBE both in increasing performance of health-protective behaviors (p = .001) and in reducing performance of health-risk behaviors (p = .04). Compared to the standard QBE condition, the dissonance-enhanced QBE intervention increased performance of health-protective behaviors (p = .04) and marginally reduced performance of health-risk behaviors (p = .07). The dissonance-enhanced QBE intervention outperformed the control condition in all analyses. This is the first report that a brief QBE intervention influences performance of multiple health behaviors. Findings supported the idea that magnifying dissonance increases the impact of the QBE.

Modifying Alcohol Consumption to Reduce Obesity (MACRO): development and feasibility trial of a complex community-based intervention for men

BACKGROUND

Obese men who consume alcohol are at a greatly increased risk of liver disease; those who drink > 14 units of alcohol per week have a 19-fold increased risk of dying from liver disease.

OBJECTIVES

To develop an intervention to reduce alcohol consumption in obese men and to assess the feasibility of a randomised controlled trial (RCT) to investigate its effectiveness.

DESIGN OF THE INTERVENTION

The intervention was developed using formative research, public involvement and behaviour change theory. It was organised in two phases, comprising a face-to-face session with trained laypeople (study co-ordinators) followed by a series of text messages. Participants explored how alcohol consumption contributed to weight gain, both through direct calorie consumption and through its effect on increasing food consumption, particularly of high-calorie foodstuffs. Men were encouraged to set goals to reduce their alcohol consumption and to make specific plans to do so. The comparator group received an active control in the form of a conventional alcohol brief intervention. Randomisation was carried out using the secure remote web-based system provided by the Tayside Clinical Trials Unit. Randomisation was stratified by the recruitment method and restricted using block sizes of randomly varying lengths. Members of the public were involved in the development of all study methods.

SETTING

Men were recruited from the community, from primary care registers and by time-space sampling (TSS). The intervention was delivered in community settings such as the participant's home, community centres and libraries.

PARTICIPANTS

Men aged 35-64 years who had a body mass index (BMI) of > 30 kg/m² and who drank > 21 units of alcohol per week.

RESULTS

The screening methods successfully identified participants meeting the entry criteria. Trial recruitment was successful, with 69 men (36 from 419 approached in primary care, and 33 from 470 approached via TSS) recruited and randomised in 3 months. Of the 69 men randomised, 35 were allocated to the intervention group and 34 to the control group. The analysis was conducted on 31 participants from the intervention group and 30 from the control group. The participants covered a wide range of ages and socioeconomic statuses. The average alcohol consumption of the men recruited was 47.2 units per week, more than twice that of the entry criterion (> 21 units per week). Most (78%) engaged in binge drinking (> 8 units in a session) at least weekly. Almost all (95%) exceeded the threshold for a 19-fold increase in the risk of dying from liver disease (BMI of > 30 kg/m² and > 14 units of alcohol per week). Despite this, they believed that they were at low risk of harm from alcohol, possibly because they seldom suffered acute harms (e.g. hangovers) and made few visits to a general practitioner or hospital.

INTERVENTION

The intervention was delivered with high fidelity. A high follow-up rate was achieved (98%) and the outcomes for the full RCT were measured. A process evaluation showed that participants engaged with the main components of the intervention. The acceptability of the study methods was high.

CONCLUSIONS

This feasibility study developed a novel intervention and evaluated all of the stages of a RCT that would test the effectiveness of the intervention. The main stages of a trial were completed successfully: recruitment, randomisation, intervention delivery, follow-up and measurement of study outcomes. Most of the men recruited drank very heavily and were also obese. This places them at a very high risk of liver disease, making them a priority for intervention.

FUTURE WORK

A RCT to test the effectiveness and cost-effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN55309164.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 19. See the NIHR Journals Library website for further project information.

Sustaining SBIRT in the wild: simulating revenues and costs for Screening, Brief Intervention and Referral to Treatment programs

AIMS

To examine the conditions under which Screening, Brief Intervention and Referral to Treatment (SBIRT) programs can be sustained by health insurance payments.

DESIGN

A mathematical model was used to estimate the number of patients needed for revenues to exceed costs.

SETTING

Three medical settings in the United States were examined: in-patient, out-patient and emergency department. Components of SBIRT were delivered by combinations of health-care practitioners (generalists) and behavioral health specialists.

PARTICIPANTS

Practitioners in seven SBIRT programs who received grants from the US Substance Abuse and Mental Health Services Administration (SAMHSA).

MEASUREMENTS

Program costs and revenues were measured using data from grantees. Patient flows were measured from administrative data and adjusted with prevalence and screening estimates from the literature.

FINDINGS

SBIRT can be sustained through health insurance reimbursement in out-patient and emergency department settings in most staffing mixes. To sustain SBIRT in in-patient programs, a patient flow larger than the national average may be needed; if that flow is achieved, the range of screens required to maintain a surplus is narrow. Sensitivity analyses suggest that the results are very sensitive to changes in the proportion of insured patients.

CONCLUSIONS

Screening, Brief Intervention and Referral to Treatment programs in the United States can be sustained by health insurance payments under a variety of staffing models. Screening, Brief Intervention and Referral to Treatment programs can be sustained only in an in-patient setting with above-average patient flow (more than 2500 screens). Screening, Brief Intervention and Referral to Treatment programs in out-patient and emergency department settings can be sustained with below-average patient flows (fewer than 125 000 out-patient visits and fewer than 27 000 emergency department visits).

A microsimulation cost-utility analysis of alcohol screening and brief intervention to reduce heavy alcohol consumption in Canada

BACKGROUND AND AIMS

Screening and brief intervention (SBI) is a public health intervention that has been shown to be effective in reducing heavy alcohol consumption. The aim of this study is to estimate the cost-effectiveness of implementing universal alcohol SBI in primary care in Canada.

DESIGN

We developed a microsimulation model of alcohol consumption and its effects on 18 alcohol-related causes of death.

SETTING

The model simulates a Canadian population.

PARTICIPANTS

The model simulates individuals and their alcohol consumption on a continuous scale starting from age 17 years to death.

INTERVENTIONS

The reference case assumes no SBI in Canada. The base case assumes screening was conducted using the Alcohol Use Disorders Identification Test (AUDIT) at a threshold score of 8. Additional analyses included evaluating SBI using the AUDIT at threshold scores between 4 and 8 or the Derived Alcohol Use Disorders Identification Test (AUDIT-C) at threshold scores between 3 and 7.

MEASUREMENTS

The model estimates the direct health-care costs, life years gained and quality-adjusted life years (QALY) gained, which are then used to estimate the incremental cost-effectiveness ratio (ICER) of SBI versus no SBI.

FINDINGS

SBI with AUDIT (at a threshold score of 8) had an ICER of $8729/QALY. Our results suggest that using AUDIT thresholds between 8 and 4, inclusive, would be cost-effective for the whole population, as well as for men and women individually. Our results suggest that the AUDIT-C would be cost-effective at thresholds of 7 to 3, inclusive, for men, women and the whole population.

CONCLUSIONS

In Canada, screening and brief intervention via Alcohol Use Disorders Identification Test (AUDIT) and Derived Alcohol Use Disorders Identification Test (AUDIT-C) to reduce heavy alcohol consumption appears to be cost-effective for men and women at Alcohol Use Disorders Identification Test (AUDIT) thresholds of 8 and lower and at Derived Alcohol Use Disorders Identification Test (AUDIT-C) thresholds of 7 and lower.

A meta-analysis of brief alcohol interventions for adolescents and young adults: variability in effects across alcohol measures

BACKGROUND

Brief alcohol interventions are one approach for reducing drinking among youth, but may vary in effectiveness depending on the type of alcohol assessments used to measure effects.

OBJECTIVES

To conduct a meta-analysis that examined the effectiveness of brief alcohol interventions for adolescents and young adults, with particular emphasis on exploring variability in effects across outcome measurement characteristics.

METHOD

Eligible studies were those using an experimental or quasi-experimental design to examine the effects of a brief alcohol intervention on a post-intervention alcohol use measure for youth aged 11-30. A comprehensive literature review identified 190 unique samples that were included in the meta-analysis. Taking a Bayesian approach, we used random-effects multilevel models to estimate the average effect and model variability across outcome measurement types.

RESULTS

Brief alcohol interventions led to significant reductions in self-reported alcohol use among adolescents (g = 0.25, 95% credible interval [CrI 0.13, 0.37]) and young adults (g = 0.15, 95% CrI [0.12, 0.18]). These results were consistent across outcomes with varying reference periods, but varied across outcome construct type and assessment instruments. Among adolescents, effects were larger when measured using the Timeline Followback; among young adults, effects were smaller when measured using the Alcohol Use Disorders Identification Test.

CONCLUSION

The strength of the beneficial effects of brief alcohol interventions on youth's alcohol use may vary depending upon the outcome measure utilized. Nevertheless, significant effects were observed across measures. Although effects were modest in size, they were clinically significant and show promise for interrupting problematic alcohol use trajectories among youth.

SBIRT Implementation for Adolescents in Urban Federally Qualified Health Centers

BACKGROUND

Alcohol, tobacco, and other drug use remains highly prevalent among US adolescents and is a threat to their well-being and to the public health. Evidence from clinical trials and meta-analyses supports the effectiveness of Screening, Brief Intervention and Referral to Treatment (SBIRT) for adolescents with substance misuse but primary care providers have been slow to adopt this evidence-based approach. The purpose of this paper is to describe the theoretically informed methodology of an on-going implementation study.

METHODS

This study protocol is a multi-site, cluster randomized trial (N=7) guided by Proctor's conceptual model of implementation research and comparing two principal approaches to SBIRT delivery within adolescent medicine: Generalist vs. Specialist. In the Generalist Approach, the primary care provider delivers brief intervention (BI) for substance misuse. In the Specialist Approach, BIs are delivered by behavioral health counselors. The study will also examine the effectiveness of integrating HIV risk screening within an SBIRT model. Implementation Strategies employed include: integrated team development of the service delivery model, modifications to the electronic medical record, regular performance feedback and supervision. Implementation outcomes, include: Acceptability, Appropriateness, Adoption, Feasibility, Fidelity, Costs/Cost-Effectiveness, Penetration, and Sustainability.

DISCUSSION

The study will fill a major gap in scientific knowledge regarding the best SBIRT implementation strategy at a time when SBIRT is poised to be brought to scale under health care reform. It will also provide novel data to inform the expansion of the SBIRT model to address HIV risk behaviors among adolescents. Finally, the study will generate important cost data that offer guidance to policymakers and clinic directors about the adoption of SBIRT in adolescent health care.

Brief alcohol interventions for adolescents and young adults: a systematic review and meta-analysis

This study reports findings from a meta-analysis summarizing the effectiveness of brief alcohol interventions for adolescents (age 11-18) and young adults (age 19-30). We identified 185 eligible study samples using a comprehensive literature search and synthesized findings using random-effects meta-analyses with robust standard errors. Overall, brief alcohol interventions led to significant reductions in alcohol consumption and alcohol-related problems among adolescents (g = 0.27 and g = 0.19) and young adults (g = 0.17 and g = 0.11). These effects persisted for up to 1 year after intervention and did not vary across participant demographics, intervention length, or intervention format. However, certain intervention modalities (e.g., motivational interviewing) and components (e.g., decisional balance, goal-setting exercises) were associated with larger effects. We conclude that brief alcohol interventions yield beneficial effects on alcohol-related outcomes for adolescents and young adults that are modest but potentially worthwhile given their brevity and low cost.

LAT software induced savings on medical costs of alcohol addicts' care--results from a matched-pairs case-control study

Lesch Alcoholism Typology (LAT) is one of the most widely used clinical typologies of alcohol addiction. Study tested whether introduction of LAT software in clinical practice leaded to improved outcomes and reduced costs. Retrospective matched-pairs case-control cost comparison study was conducted at the Regional Addiction Center of the University Clinic in Serbia involving 250 patients during the four-year period. Mean relapse frequency followed by outpatient detoxification was 0.42 ± 0.90 vs. 0.70 ± 1.66 (LAT/non-LAT; p = 0.267). Adding relapses after inpatient treatment total mean-number of relapses per patient was 0.70 ± 1.74 vs. 0.97 ± 1.89 (LAT/non-LAT; p = 0.201). However, these relapse frequency differentials were not statistically significant. Total hospital costs of Psychiatry clinic based non-LAT addicts' care (€ 54,660) were significantly reduced to € 36,569 after initiation of LAT. Mean total cost per patient was reduced almost by half after initiation of LAT based treatment: € 331 ± 381 vs. € 626 ± 795 (LAT/non-LAT; p = 0.001). Mean cost of single psychiatry clinic admission among non-LAT treatment group was € 320 ± 330 (CI 95% 262-378) and among LAT € 197 ± 165 (CI 95% 168-226) (p = 0.019). Mean LAT software induced net savings on psychiatric care costs were € 144 per patient. Total net savings on hospital care including F10 associated somatic co-morbidities amounted to € 295 per patient. More sensitive diagnostic assessment and sub-type specific pharmacotherapy and psychotherapy following implementation of LAT software lead to significant savings on costs of hospital care.

What are the Implications for Policy Makers? A Systematic Review of the Cost-Effectiveness of Screening and Brief Interventions for Alcohol Misuse in Primary Care

INTRODUCTION

The efficacy of screening and brief interventions (SBIs) for excessive alcohol use in primary care is well established; however, evidence on their cost-effectiveness is limited. A small number of previous reviews have concluded that SBI programs are likely to be cost-effective but these results are equivocal and important questions around the cost-effectiveness implications of key policy decisions such as staffing choices for delivery of SBIs and the intervention duration remain unanswered.

METHODS

Studies reporting both the costs and a measure of health outcomes of programs combining SBIs in primary care were identified by searching MEDLINE, EMBASE, Econlit, the Cochrane Library Database (including NHS EED), CINAHL, PsycINFO, Assia and the Social Science Citation Index, and Science Citation Index via Web of Knowledge. Included studies have been stratified both by delivery staff and intervention duration and assessed for quality using the Drummond checklist for economic evaluations.

RESULTS

The search yielded a total of 23 papers reporting the results of 22 distinct studies. There was significant heterogeneity in methods and outcome measures between studies; however, almost all studies reported SBI programs to be cost-effective. There was no clear evidence that either the duration of the intervention or the delivery staff used had a substantial impact on this result.

CONCLUSION

This review provides strong evidence that SBI programs in primary care are a cost-effective option for tackling alcohol misuse.

The use of protective behaviors in relation to gambling among college students

The purpose of the current study was to evaluate a measure of gambling protective behaviors and examine the relationship between indices of gambling behavior, including frequency, quantity and problem severity, and the use of gambling protective behaviors. Undergraduates from a large public university (N = 4,014) completed a web-based screening survey comprising measures of gambling and health behaviors, from which those who gambled within the past 6-months (n = 1,922, 48 % of the entire sample) were invited to complete the baseline assessment, including the Gambling Protective Behavior Scale (GPBS). The GPBS was determined to have two subscales, primarily consisting of harm reduction strategies that reduce the money or time spent on gambling, or avoidance strategies that help to minimize engagement in gambling activities. Hierarchical multiple regressions found participants' sex moderated the relationship between use of protective behavioral strategies and gambling outcomes. However, effects were in the opposite direction to those hypothesized. Specifically, because women gambled less, had lower gambling problem severity, and reported more frequent use of gambling avoidance protective behaviors, the relationship between use of gambling protective behaviors and gambling outcomes was stronger for men than women. Men who used more avoidance strategies gambled less frequently compared to men who used fewer avoidance strategies. Similarly, men who used more harm reduction strategies spent fewer dollars on gambling and had lower scores on gambling problem severity compared to men using fewer harm reduction strategies for women these relationships were less pronounced. Implications of incorporating specific gambling protective behavioral strategies into prevention and treatment programs are discussed.

Can Substance Use Disorders be Managed Using the Chronic Care Model? Review and Recommendations from a NIDA Consensus Group

Brain imaging and genetic studies over the past two decades suggest that substance use disorders are best considered chronic illnesses. The passing of the Affordable Care Act in the United States has set the occasion for integrating treatment of substance use disorders into mainstream healthcare; and for using the proactive, team-oriented Chronic Care Model (CCM). This paper systematically examines and compares whether and how well the CCM could be applied to the treatment of substance use disorders, using type 2 diabetes as a comparator. The chronic illness management approach is still new in the field of addiction and research is limited. However comparative findings suggest that most proactive, team treatment-oriented clinical management practices now used in diabetes management are applicable to the substance use disorders; capable of being implemented by primary care teams; and should offer comparable potential benefits in the treatment of substance use disorders. Such care should also improve the quality of care for many illnesses now negatively affected by unaddressed substance abuse.

Costs of alcohol screening and brief intervention in medical settings: a review of the literature

OBJECTIVE

This article summarizes the literature on the implementation costs of alcohol screening and brief intervention (SBI) in medical settings.

METHOD

Electronic databases were searched using SBI- and cost-related terms. Methodological approaches and cost estimates were abstracted from each study and categorized based on the cost methodology. Costs were updated to 2009 U.S. dollars. To determine a summary cost measure, we excluded outliers and computed the median of the remaining cost estimates.

RESULTS

Seventeen studies with cost estimates were identified for further study. Costs ranged from $0.51 to $601.50 per screen and from $3.41 to $243.01 per brief intervention (BI). Cost estimates were lower when an activity-based cost methodology was used, in primary care settings, and when the provider was not a doctor. The median summary cost of a screen is approximately $4, and the median summary cost of a BI is approximately $48.

CONCLUSIONS

Screening cost estimates had more variation than BI cost estimates. Provider type and service delivery time drive the cost variation. Interpretation of cost differences was limited by insufficient reporting of the cost methodology. Cost estimates presented here are similar in size to the Healthcare Common Procedure Coding System and Current Procedural Terminology reimbursement amounts, suggesting that insurance-based service reimbursement may be sufficient to sustain alcohol SBI in practice.

Adolescent Substance Abuse and Mental Health: Problem Co-Occurrence and Access to Services

The purpose of this study is to identify factors associated with adolescent alcohol or drug (AOD) abuse/dependence, mental health and co-occurring problems; as well as factors associated with access to treatment. This is a secondary analysis of data from the National Survey on Drug Use and Health (NSDUH) 2000. The 12-month prevalence rate of adolescents with only mental health problems was 10.8%, 5.1% had only AOD abuse/dependence only, and 2.7% had co-occurring problems. Approximately 15% of youth reported receiving behavioral health treatment in the past 12 months. Several factors associated with having behavioral health problems and receiving treatment are presented.

Implementing a statewide Screening, Brief Intervention, and Referral to Treatment (SBIRT) service in rural health settings: New Mexico SBIRT

This is a report on the New Mexico Screening, Brief Intervention, and Referral to Treatment (SBIRT) project conducted over 5 years as part of a national initiative launched by the Substance Abuse and Mental Health Services Administration with the aim of increasing integration of substance use services and medical care. Throughout the state, 53,238 adults were screened for alcohol and/or drug use problems in ambulatory settings, with 12.2% screening positive. Baseline substance use behaviors among 6,360 participants eligible for brief intervention, brief treatment, or referral for treatment are examined and the process of implementation and challenges for sustainability are discussed.

Training and tailored outreach support to improve alcohol screening and brief intervention in Aboriginal Community Controlled Health Services

INTRODUCTION AND AIMS

Aboriginal Community Controlled Health Services (ACCHSs) are often the primary point of contact for Indigenous Australians experiencing alcohol-related harms. Screening and brief intervention (SBI) is a cost-effective treatment for reducing these harms. Factors influencing evidence-based alcohol SBI delivery in ACCHSs have been identified. Evaluations of strategies targeting these factors are required. The aim of this paper is to quantify the effect of training and tailored outreach support on the delivery of alcohol SBI in four Aboriginal Community Controlled Health Services (ACCHSs).

DESIGN AND METHODS

A pre- post- assessment of alcohol information recorded in computerised patient information systems of four ACCHSs.

RESULTS

For ACCHSs combined there was a statistically significant increase in the proportion of eligible clients with an electronic record of any alcohol information (3.2% to 7.5%, P < 0.0001) and a valid alcohol screen (1.6% to 6.5%, P < 0.0001), and brief intervention (25.75% to 47.7%, P < 0.0001). All four ACCHSs achieved statistically significant increases in the proportion of clients with a complete alcohol screen (10.3%; 7.4%; 2%, P < 0.0001 and 1.3%, P < 0.05), and two in the proportion with a heavy drinking screen (7% and 3.1%, P < 0.0001).

DISCUSSION AND CONCLUSIONS

Implementing evidence-based alcohol SBI in ACCHSs is likely to require multiple strategies tailored to the characteristics of specific services. Outreach support provided by local drug and alcohol practitioners and a one item heavy drinking screen offer considerable promise for increasing routine alcohol SBI delivery in ACCHSs. Training and outreach support appear to be effective for achieving modest improvements in alcohol SBI delivery in ACCHSs.

The cost of screening and brief intervention in employee assistance programs

Few studies examine the costs of conducting screening and brief intervention (SBI) in settings outside health care. This study addresses this gap in knowledge by examining the employer-incurred costs of SBI in an employee assistance program (EAP) when delivered by counselors. Screening was self-administered as part of the intake paperwork, and the brief intervention (BI) was delivered during a regular counseling session. Training costs were $83 per counselor. The cost of a screen to the employer was $0.64; most of this cost comprised the cost of the time the client spent completing the screen. The cost of a BI was $2.52. The cost of SBI is lower than cost estimates of SBI conducted in a health care setting. The low costs for the current study suggest that only modest gains in outcomes would likely be needed to justify delivering SBI in an EAP setting.

A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries

AIMS

This study evaluated the effectiveness of a brief intervention (BI) for illicit drugs (cannabis, cocaine, amphetamine-type stimulants and opioids) linked to the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The ASSIST screens for problem or risky use of 10 psychoactive substances, producing a score for each substance that falls into either a low-, moderate- or high-risk category.

DESIGN

Prospective, randomized controlled trial in which participants were either assigned to a 3-month waiting-list control condition or received brief motivational counselling lasting an average of 13.8 minutes for the drug receiving the highest ASSIST score.

SETTING

Primary health-care settings in four countries: Australia, Brazil, India and the United States.

PARTICIPANTS

A total of 731 males and females scoring within the moderate-risk range of the ASSIST for cannabis, cocaine, amphetamine-type stimulants or opioids.

MEASUREMENTS

ASSIST-specific substance involvement scores for cannabis, stimulants or opioids and ASSIST total illicit substance involvement score at baseline and 3 months post-randomization.

FINDINGS

Omnibus analyses indicated that those receiving the BI had significantly reduced scores for all measures, compared with control participants. Country-specific analyses showed that, with the exception of the site in the United States, BI participants had significantly lower ASSIST total illicit substance involvement scores at follow-up compared with the control participants. The sites in India and Brazil demonstrated a very strong brief intervention effect for cannabis scores (P < 0.005 for both sites), as did the sites in Australia (P < 0.005) and Brazil (P < 0.01) for stimulant scores and the Indian site for opioid scores (P < 0.01).

CONCLUSIONS

The Alcohol, Smoking and Substance Involvement Screening Test-linked brief intervention aimed at reducing illicit substance use and related risks is effective, at least in the short term, and the effect generalizes across countries.

Challenges to alcohol and other drug discussions in the general practice consultation

BACKGROUND

There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity.

AIM

To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered.

DESIGN

Analysis of video-recorded primary care consultations.

SETTING

New Zealand General Practice.

METHODS

Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings.

RESULTS

AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change.

CONCLUSIONS

Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.

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.

The relationship between services delivered and substance use outcomes in New Mexico's Screening, Brief Intervention, Referral and Treatment (SBIRT) Initiative

BACKGROUND

Recent years have seen increased diffusion of Screening, Brief Intervention, Referral and Treatment (SBIRT) in healthcare environments. This study examined the relationship between substance use outcomes and service variables within the SBIRT model.

METHODS

Over 55,000 adult patients were screened for substance misuse at rural health clinics throughout New Mexico during the SBIRT Initiative. This naturalistic pre-post services study used administrative baseline, 6 month follow-up, and services data for adult participants in the New Mexico SBIRT evaluation (n=1208). Changes in self-reported frequency of illicit drug use, alcohol use, and alcohol intoxication were examined as a function of service level (brief intervention - BI vs. brief treatment/referral - BT/RT) and number of service sessions.

RESULTS

Participants reported decreased frequency of illicit drug use, alcohol use, and alcohol intoxication 6 months after receipt of SBIRT services (p<.001 for each). Compared to those who received BI, participants who received BT/RT had sharper reductions in frequency of drinking (IRR=.78; p<.05) and alcohol intoxication (IRR=.75; p<.05). Number of service sessions was associated with reduced frequency of alcohol use (IRR=.84; p<.01) and intoxication (IRR=.82; p<.05), but only among those who received BI.

CONCLUSIONS

Substance-using patients with disparate levels of use may benefit from SBIRT. In a real-world, multi-site rural SBIRT program, services of higher intensity and (within the BI modality) frequency were associated with greater magnitude of change in drinking behaviors. Reductions in illicit drug use, while substantial, did not differ significantly based on service variables. Future studies should identify the preferred service mix in the SBIRT model as it continues to expand.

Conducting economic evaluations of screening and brief intervention for hazardous drinking: Methods and evidence to date for informing policy

ISSUES

Many policy review articles have concluded that alcohol screening and brief intervention (SBI) is both cost-effective and cost-beneficial. Yet a recent cost-effectiveness review for the United Kingdom's National Institute for Health and Clinical Excellence suggests that these conclusions may be premature.

APPROACH

This article offers a brief synopsis of the various types of economic analyses that may be applied to SBI, including cost analysis, cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis and other types of economic evaluation. A brief overview of methodological issues is provided, and examples from the SBI evaluation literature are provided.

KEY FINDINGS, IMPLICATIONS AND CONCLUSIONS

The current evidence base is insufficient to draw firm conclusions about the cost, cost-effectiveness or cost-benefit of SBI and about the impact of SBI on health-care utilisation.[Cowell AJ, Bray JW, Mills MJ, Hinde JM. Conducting economic evaluations of screening and brief intervention for hazardous drinking: Methods and evidence to date for informing policy.

Substance Abuse Treatment as Part of a Total System of Community Response

Treatment of substance abuse in many communities throughout the world is often separated from other social and health responses to alcohol and other drug harms. Current responses exist like silos within the community. In addition, there are population-level policy approaches concerning the distribution and sales of alcohol and the restrictions on and enforcement of illegal drugs which also exist only loosely connected to treatment (or prevention for that matter). A systems approach to substance abuse and related problems is described in which evaluation addresses both clinical patient needs as well as overall performance demonstration. Effectiveness can be measured both by population level reductions in use and associated problems, a second level of accountability, i.e., documented reductions in problems of at risk groups or clients whose drinking or drug use patterns place them at risk for future problems, and a third level of response for individuals with clearly identified substance-related problems, which requires intervention at the person level (typically called treatment). Thus within such a comprehensive system, treatment and prevention would lose their separate identities and would be employed according to local needs and the potential to achieve desired effects where the overall system is required to select the mix of strategies which maximizes effectiveness at each level.

Reducing alcohol related harm experienced by Indigenous Australians: identifying opportunities for Indigenous primary health care services

OBJECTIVE

Identify key issues and opportunities relating to the dissemination of cost-effective interventions for alcohol in Indigenous-specific settings.

METHODS

Update previous reviews of the Indigenous alcohol literature, particularly in relation to intervention and dissemination studies aimed at identifying and integrating into routine clinical care those strategies that are most cost-effective in reducing alcohol-related harm.

RESULTS

The harmful use of alcohol has been identified as a major public health issue, which has a disproportionately high negative impact on Indigenous Australians. While the disproportionately high burden of harm borne by Indigenous Australian communities is well documented in descriptive studies, attempts to redress this imbalance through well controlled intervention and dissemination studies appear to have been inadequate to date. There is compelling evidence from the non-Indigenous community that brief intervention is an effective treatment for harmful alcohol use, compared to the relatively lower levels of evidence for primary and tertiary level interventions. The effectiveness of brief intervention for alcohol in Indigenous Australian communities should, therefore, be examined.

CONCLUSIONS AND IMPLICATIONS

An opportunity exists to implement brief intervention into Indigenous primary health care settings, as an evidence-based strategy using established resources. There is the possibility that such Indigenous-specific health services research will lead the dissemination field in demonstrating how the implementation process can be successfully tailored to specific and defined clinical settings.

Modelling lifetime QALYs and health care costs from different drinking patterns over time: a Markov model

The negative health consequences of alcohol use and its treatment account for significant health care expenditure worldwide. Long-term modelling techniques are developed in this paper to establish a link between drinking patterns, health consequences and alcohol treatment effectiveness and cost-effectiveness. The overall change in health related quality and quantity of life which results from changes in health-related behaviour is estimated. Specifically, a probabilistic lifetime Markov model is presented where alcohol consumption in grams of alcohol per day and drinking history are used for the categorization of patients into four Markov states. Utility weights are assigned to each drinking state using EQ-5D scores. Mortality and morbidity estimates are state, gender and age specific, and are alcohol-related and non-alcohol-related. The methodology is tested in a case study. This represents a major development in the techniques traditionally used in alcohol economic models, in which short-term costs and outcomes are assessed, omitting potential longer term cost savings and improvements in health related quality of life. Assumptions and implications of the approach are discussed.

Methodological assessment of economic evaluations of alcohol treatment: what is missing?

AIM

The aim of this study is to review the methodology that has been adopted in previous economic evaluations of alcohol treatment and offer research recommendations with a view to enhancing the consistency and harmonization of economic evaluations in the alcohol field.

METHODS

Published full economic evaluations of alcohol treatment were retrieved using a systematic search. The studies were analysed in terms of the identification, measurement and valuation methods used to assess the society-level consequences and the methods used to carry out the analysis of individual-level consequences and costs of the intervention. A taxonomy of alcohol-related consequences was developed and used as a framework for the methodology extraction.

RESULTS

Twenty- seven studies were selected. Almost half of the studies did not include society-level consequences in their analysis. Some consequences of alcohol treatment at a societal level, such as the impact of treatment on health-related quality of life of family and friends of the drinker, have never been considered in the economic analysis. There was no agreement regarding the individual health consequences used in the evaluations. Measures capturing life years and morbidity have not been extensively used in the alcohol field. The level of reporting treatment costs on the reviewed studies is generally well detailed.

CONCLUSION

The literature is still rather sparse in this area and further research is required to fulfil the gaps. If a common methodology is adopted in future economic evaluations of alcohol treatment, more stable cost-effectiveness estimates will be produced and informed decisions for resources allocation to alcohol treatments will be possible.

Cost-effectiveness of interventions to prevent alcohol-related disease and injury in Australia

AIMS

To evaluate cost-effectiveness of eight interventions for reducing alcohol-attributable harm and determine the optimal intervention mix.

METHODS

Interventions include volumetric taxation, advertising bans, an increase in minimum legal drinking age, licensing controls on operating hours, brief intervention (with and without general practitioner telemarketing and support), drink driving campaigns, random breath testing and residential treatment for alcohol dependence (with and without naltrexone). Cost-effectiveness is modelled over the life-time of the Australian population in 2003, with all costs and health outcomes evaluated from an Australian health sector perspective. Each intervention is compared with current practice, and the most cost-effective options are then combined to determine the optimal intervention mix.

MEASUREMENTS

Cost-effectiveness is measured in 2003 Australian dollars per disability adjusted life year averted.

FINDINGS

Although current alcohol intervention in Australia (random breath testing) is cost-effective, if the current spending of $71 million could be invested in a more cost-effective combination of interventions, more than 10 times the amount of health gain could be achieved. Taken as a package of interventions, all seven preventive interventions would be a cost-effective investment that could lead to substantial improvement in population health; only residential treatment is not cost-effective.

CONCLUSIONS

Based on current evidence, interventions to reduce harm from alcohol are highly recommended. The potential reduction in costs of treating alcohol-related diseases and injuries mean that substantial improvements in population health can be achieved at a relatively low cost to the health sector.

Detection of and intervention for excessive alcohol and tobacco use among adult hospital in-patients

Early detection and intervention for alcohol problems have been shown to reduce subsequent health consequences. However, the extent to which these practices have been implemented is unclear. The study assessed among hospital in-patients (1) the prevalence of at-risk drinking and smoking, (2) current practice in detection and intervention for at-risk drinking and smoking and (3) self-reported effect of any intervention. A brief self-administered questionnaire was administered to adult in-patients addressing alcohol use [Alcohol Use Disorders Identification Test (AUDIT) questionnaire], smoking and self-reported effect of any recent intervention for drinking or smoking. The participant's smoking status and alcohol use as recorded by medical and nursing staff was compared to self-reports. Of 448 in-patients, 50% (226) participated in the study; 38% (170) were ineligible and 12% (52) refused. Participants were aged 61.3 (+/-18.9) years. A higher number of problem drinkers (11.9% vs. 3.5%, p < 0.0001) and current smokers (17.3% vs. 9.3%, p < 0.0001) were identified by the questionnaire compared to the medical records. Hospital staff quantified smoking more consistently than alcohol (54% vs. 42%, p = 0.02). Of those who recalled an intervention, 19% of drinkers and 27% of smokers said they had stopped drinking or smoking for a period since that intervention. Further improvement is required in the rates of detection and interventions for alcohol use disorders and smoking in the hospital setting.

Therapeutics for alcoholism: what's the future?

As with other addictions, human alcoholism is characterised as a chronically relapsing condition. Consequently, the therapeutic goal is the development of clinically effective, safe drugs that promote high adherence rates and prevent relapse. These products can then be used in conjunction with psychosocial approaches. In this review, preclinical studies are highlighted that indicate the mechanism of action of currently used anti-craving medications or demonstrate the potential of novel pharmacological agents for the treatment of alcohol use disorders. While current pharmacological strategies are far from ideal, there are a number of candidate molecules that may ultimately be developed into therapeutic agents. In addition, prescribing clinicians should also consider strategies such as combinations of various drugs to aid in the regulation of aberrant alcohol consumption.

General practitioners' role in preventive medicine: scenario analysis using alcohol as a case study

The purpose of this analysis is threefold: first, to extract from the literature, current levels of GP detection of at-risk drinking by their patients, rates at which general practitioners (GPs) offer an intervention; and the effectiveness of these interventions; secondly, to develop a model based on this literature to be used in conjunction with scenario analysis; and thirdly, to consider the cost implications of current efforts and various scenarios. This study deals specifically with Australian general practice. A two-step procedure is used in the scenario analysis, which involves identifying opportunities for detection, intervention, effectiveness and assigning probabilities to outcomes. The results suggest that increasing rates of GP intervention achieves greatest benefit and return on resource use. For every 5% point increase in the rate of GP intervention, an additional 26 754 at-risk drinkers modify their drinking behaviour at a cost of dollars 231.45 per patient. This compares with a cost per patient modifying drinking behaviour of dollars 232.60 and dollars 208.31 for every 5% point increase in the rates of detection and effectiveness, respectively. The knowledge, skill and attitude of practitioners toward drinking are significant, and they can be the prime motivators in persuading their patients to modify drinking behaviour.

Comparative cost-effectiveness of policy instruments for reducing the global burden of alcohol, tobacco and illicit drug use

Alcohol, tobacco and illicit drug use together pose a formidable challenge to international public health. Building on earlier estimates of the demonstrated burden of alcohol, tobacco and illicit drug use at the global level, this review aims to consider the comparative cost-effectiveness of evidence-based interventions for reducing the global burden of disease from these three risk factors. Although the number of published cost-effectiveness studies in the addictions field is now extensive (reviewed briefly here) there are a series of practical problems in using them for sector-wide decision making, including methodological heterogeneity, differences in analytical reference point and the specificity of findings to a particular context. In response to these limitations, a more generalised form of cost-effectiveness analysis (CEA) is proposed, which enables like-with-like comparisons of the relative efficiency of preventive or individual-based strategies to be made, not only within but also across diseases or their risk factors. The application of generalised CEA to a range of personal and non-personal interventions for reducing the burden of addictive substances is described. While such a development avoids many of the obstacles that have plagued earlier attempts and in so doing opens up new opportunities to address important policy questions, there remain a number of caveats to population-level analysis of this kind, particularly when conducted at the global level. These issues are the subject of the final section of this review.

Cost-effectiveness of an opportunistic screening programme and brief intervention for excessive alcohol use in primary care

BACKGROUND

Effective prevention of excessive alcohol use has the potential to reduce the public burden of disease considerably. We investigated the cost-effectiveness of Screening and Brief Intervention (SBI) for excessive alcohol use in primary care in the Netherlands, which is targeted at early detection and treatment of 'at-risk' drinkers.

METHODOLOGY AND RESULTS

We compared a SBI scenario (opportunistic screening and brief intervention for 'at-risk' drinkers) in general practices with the current practice scenario (no SBI) in The Netherlands. We used the RIVM Chronic Disease Model (CDM) to extrapolate from decreased alcohol consumption to effects on health care costs and Quality Adjusted Life Years (QALYs) gained. Probabilistic sensitivity analysis was employed to study the effect of uncertainty in the model parameters. In total, 56,000 QALYs were gained at an additional cost of 298,000,000 euros due to providing alcohol SBI in the target population, resulting in a cost-effectiveness ratio of 5,400 euros per QALY gained.

CONCLUSION

Prevention of excessive alcohol use by implementing SBI for excessive alcohol use in primary care settings appears to be cost-effective.

A systematic review of work-place interventions for alcohol-related problems

AIMS

The aims of this study were to (1) gauge any improvement in methodological quality of work-place interventions addressing alcohol problems; and (2) to determine which interventions most effectively reduce work-place-related alcohol problems.

METHODS

A literature search was undertaken of the data bases, Ovid Medline, PsychINFO, Web of Science, Scopus, HSELINE, OSHLINE and NIOSHTIC-2 for papers published between January 1995 and September 2007 (inclusive). Search terms varied, depending on the database. Papers were included for analysis if they reported on interventions conducted at work-places with the aim of reducing alcohol problems. Methodological adequacy of the studies was assessed using a method derived from the Cochrane Collaboration guidelines.

RESULTS

Ten papers reporting on work-place alcohol interventions were located. Only four studies employed randomized controlled trials (RCT), but all these had methodological problems. Weaknesses in all studies related to representativeness of samples, consent and participation rates, blinding, post-test time-frames, contamination and reliability, and validity of measures used. All except one study reported statistically significant differences in measures such as reduced alcohol consumption, binge drinking and alcohol problems.

CONCLUSIONS

The literature review revealed few methodologically adequate studies of work-place alcohol interventions. Study designs, types of interventions, measures employed and types of work-places varied considerably, making comparison of results difficult. However, it appears from the evidence that brief interventions, interventions contained within health and life-style checks, psychosocial skills training and peer referral have potential to produce beneficial results.

At-risk drinking among diabetic patients

Diabetes Mellitus is a serious chronic disease, affecting an increasing number of individuals worldwide. Adherence to diabetes self-care behaviors is key to the successful management of the disease. At-risk drinking is common among diabetic patients and is associated with inferior diabetes treatment adherence and outcomes, resulting in increased mortality and morbidity. Furthermore, individuals with diabetes who engage in at-risk drinking are also in danger of incurring the negative consequences of at-risk drinking found in the general population. Research suggests that alcohol use screening and intervention do not commonly occur during the course of primary care treatment for diabetes. While methods for reducing alcohol use in this population have been largely unexplored to date, brief interventions to reduce at-risk drinking have been well-validated in other patient populations and offer the promise to reduce at-risk drinking among diabetic patients, resulting in improved diabetes treatment adherence and outcomes.

Brief Image-based Health Behavior Messages for Adolescents and Their Parents

This study tested the efficacy of brief image-based print mediated parent/caregiver and adolescent messages integrating physical activity with alcohol use avoidance. A total of 684 high school students were randomly assigned to either the parent postcard or adolescent flyer arm, with baseline and four-month post-intervention data collections. A significant repeated measures interaction (group × time) was found (F(4,344)=2.48, p=.04), with univariate tests showing less alcohol use frequency and problems (p's<.05) among adolescents exposed to parent materials. Repeated measures factorial MANOVAs for group × time × prior current drug use were significant, with drug using adolescents receiving parent print messages showing less alcohol initiation and frequency, and marijuana initiation and frequency (p's<.05). Very brief print materials sent to parents/caregivers may hold some promise for influencing substance use among adolescents, particularly those already using drugs.

Measuring the benefits of health promotion programmes: application of the contingent valuation method

Economic evaluation of health promotion programmes presents well documented challenges. These programmes often generate significant non-health benefits which are typically ignored within economic evaluation. This study explored the use of the contingent valuation (CV) method to value the broader benefits of a women's group programme to improve maternal and newborn health in Nepal. Interviews were conducted with 93 women's group members, 70 women non-members and 33 men. Respondents were asked to give reasons for their willingness-to-pay (WTP) in terms of health and/or non-health benefits. WTP was regressed against socio-economic and demographic variables using ordinary least squares. Seventy eight percent of respondents were willing-to-pay for the women's groups. There was no significant difference between the WTP of women's group members compared to female non-members. Men were willing-to-pay significantly more than women. WTP reflected non-health benefits in over 80% of cases. At least 11% of women attending meetings and 38% of those not attending were WTP for altruistic motives. Future research should address the relative value of non-health compared to health benefits; and motivations behind non-user values and their consistency across settings.

Asking patients about their drinking. A national survey among primary health care physicians and nurses in Sweden

AIMS

To investigate the extent to which Swedish primary health care (PHC) general practitioners (GPs) and nurses discuss alcohol issues with their patients, their reasons for and against addressing alcohol issues, their perceived importance of these issues, and factors that could facilitate increased alcohol intervention activity among the PHC professionals.

METHODS

All Swedish GPs and nurses who have the authority to issue prescriptions were surveyed with a postal questionnaire. The questionnaire was returned by 1821 GPs (47% response rate) and 3125 nurses (55% response rate).

RESULTS

Fifty percent of the GPs and 28% of the nurses stated that they "frequently" discussed alcohol with their patients. The two most common reasons for asking patients about their drinking were that the GPs and nurses considered it part of their routines and the belief that the patient had alcohol-related symptoms. GPs said that improved opportunities for referral to specialists and provision of more knowledge about counselling techniques for use when alcohol-related symptoms are evident were the most important facilitators to increased intervention activity. Concerning the nurses, 93% stated that more time devoted to health-oriented work could facilitate increased alcohol intervention activity.

CONCLUSIONS

The findings highlight a considerable gap between the recognition of the significance of the alcohol problem and Swedish PHC intervention activity.