Controlled evaluation of a general practice-based brief intervention for excessive drinking

Outcome of a "modified brief intervention" program delivered at work place for a population with hazardous alcohol use

INTRODUCTION

At the population level, screening and brief intervention (BI) is the most cost-effective method to reduce the burden of disease due to hazardous alcohol use. In delivering BI at individual level, trained workforce as well as time is a limiting factor. Hence, a study was conducted to assess the outcome of a "modified brief intervention" program delivered at workplace in a group setting for the participants identified with hazardous alcohol use pattern, as a secondary prevention measure.

MATERIALS AND METHODS

Study was a pre- and post-intervention study without a control group. Following an educational lecture, conducted by a mental health team including a psychiatrist, participants were screened using the WHO ASSIST questionnaire, V3.0 version. Those screened positive for hazardous alcohol use were given "modified brief intervention" in a group setting at their workplace which consisted of two semi-structured sessions of 1-h duration each. The sessions were spaced in a month. First session was based on motivation enhancement measures along with gathering of current alcohol use details and second session focused on relapse prevention. Three months later, the outcomes were assessed using a semistructured questionnaire and ASSIST was reapplied. The analysis was done using the R-commander from R-software.

RESULTS

No significant difficulty was experienced in conducting the interventions. Fifty (55.6%) participants stayed alcohol abstinent following second session and another 22 (24.44%) had reduced both the quantity and frequency of use. Paired t-tests revealed statistically significant reduction in all secondary outcome parameters (ASSIST scores, usual dose in one sitting, maximum dose, and number of days of use in month). Eighty (88.89%) participants reported the program to be effective. Only 3 months of observation is a limitation.

CONCLUSION

The study provides an efficient secondary prevention model to reduce hazardous drinking at the population level needing less workforce, cost, and time.

Development and differentiability of three brief interventions for risky alcohol use that include varying doses of motivational interviewing

BACKGROUND

While brief intervention (BI) for risky alcohol use generally yields positive effects among those identified by screening, effect sizes are small and there is unexplained heterogeneity in outcome. The heterogeneity may be related to differences in intervention style and content, including elements of motivational interviewing (MI). To date, it has been difficult to interpret the role of MI in BI and these gaps in knowledge interfere with efforts to train, disseminate and implement BI that retains and maximizes efficacy. This study sought to develop BI protocols with varying doses of MI and test their differentiability. Differentiable BI protocols could allow for future studies that prospectively evaluate the role MI plays in affecting BI outcome.

METHODS

We developed three intervention protocols: brief advice, standard BI (NIAAA Clinician's Guide), and MI-enhanced BI and administered them to 45 primary care patients who reported exceeding recommended drinking limits. We then rated the BI sessions for fidelity to the assigned protocol as well as MI consistency based on Motivational Interviewing Treatment Integrity (MITI) scale scores. The differentiability of BI protocols was determined by calculating fidelity to assigned protocols and comparing MITI scores using pairwise, Tukey-adjusted comparisons of least squares mean scores.

RESULTS

High rates of fidelity to each protocol were achieved. The three BI protocols were also highly differentiable based on MITI scores.

CONCLUSIONS

The three interventions can be used in future trials to prospectively examine the role MI has in determining BI outcome. Trial registration clinicaltrials.gov NCT02978027, retrospectively registered 11/28/16.

Effectiveness of brief alcohol interventions in primary care populations

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and metaregression analysis

BACKGROUND

While the efficacy and effectiveness of brief interventions for alcohol (ABI) have been demonstrated in primary care, there is weaker evidence in other settings and reviews do not consider differences in content. We conducted a systematic review to measure the effect of ABIs on alcohol consumption and how it differs by the setting, practitioner group and content of intervention.

METHODS

We searched MEDLINE, EMBASE, PsycINFO; CINAHL, Social Science Citation Index, Cochrane Library and Global Health up to January 2015 for randomised controlled trials that measured effectiveness of ABIs on alcohol consumption. We grouped outcomes into measures of quantity and frequency indices. We used multilevel meta-analysis to estimate pooled effect sizes and tested for the effect of moderators through a multiparameter Wald test. Stratified analysis of a subset of quantity and frequency outcomes was conducted as a sensitivity check.

RESULTS

52 trials were included contributing data on 29 891 individuals. ABIs reduced the quantity of alcohol consumed by 0.15 SDs. While neither the setting nor content appeared to significantly moderate intervention effectiveness, the provider did in some analyses. Interventions delivered by nurses had the most effect in reducing quantity (d=-0.23, 95% CI (-0.33 to -0.13)) but not frequency of alcohol consumption. All content groups had statistically significant mean effects, brief advice was the most effective in reducing quantity consumed (d=-0.20, 95% CI (-0.30 to -0.09)). Effects were maintained in the stratified sensitivity analysis at the first and last assessment time.

CONCLUSIONS

ABIs play a small but significant role in reducing alcohol consumption. Findings show the positive role of nurses in delivering interventions. The lack of evidence on the impact of content of intervention reinforces advice that services should select the ABI tool that best suits their needs.

Examining the Impact of Separate Components of a Multicomponent Intervention Designed to Reduce At-Risk Drinking Among Older Adults: The Project SHARE Study

BACKGROUND

Health promotion interventions often include multiple components and several patient contacts. The objective of this study was to examine how participation within a multicomponent intervention (Project SHARE) is associated with changes in at-risk drinking among older adults.

METHODS

We analyzed observational data from a cluster-randomized trial of 31 primary care physicians and their patients aged ≥60 years, at a community-based practice with 7 clinics. Recruitment occurred between 2005 and 2007. At-risk drinkers in a particular physician's practice were randomly assigned as a group to usual care (n = 640 patients) versus intervention (n = 546 patients). The intervention included personalized reports, educational materials, drinking diaries, in-person physician advice, and telephone counseling by health educators (HEs). The primary outcome was at-risk drinking at follow-up, defined by scores on the Comorbidity Alcohol Risk Evaluation Tool (CARET). Predictors included whether a physician-patient alcohol risk discussion occurred, HE call occurred, drinking agreement with the HE was made, and patients self-reported keeping a drinking diary as suggested by the HE.

RESULTS

At 6 months, there was no association of at-risk drinking with having had a physician-patient discussion. Compared to having had no HE call, the odds of at-risk drinking at 6 months were lower if an agreement was made or patients reported keeping a diary (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37 to 0.90), or if an agreement was made and patients reported keeping a diary (OR 0.52, CI 0.28 to 0.97). At 12 months, a physician-patient discussion (OR 0.61, CI 0.38 to 0.98) or an agreement and reported use of a diary (OR 0.45, CI 0.25) were associated with lower odds of at-risk drinking.

CONCLUSIONS

Within the Project SHARE intervention, discussing alcohol risk with a physician, making a drinking agreement, and/or self-reporting the use of a drinking diary were associated with lower odds of at-risk drinking at follow-up. Future studies targeting at-risk drinking among older adults should consider incorporating both intervention components.

The use of the cluster randomized crossover design in clinical trials: protocol for a systematic review

BACKGROUND

The cluster randomized crossover (CRXO) design is gaining popularity in trial settings where individual randomization or parallel group cluster randomization is not feasible or practical. In a CRXO trial, not only are clusters of individuals rather than individuals themselves randomized to trial arms, but also each cluster participates in each arm of the trial at least once in separate periods of time.We will review publications of clinical trials undertaken in humans that have used the CRXO design. The aim of this systematic review is to summarize, as reported: the motivations for using the CRXO design, the values of the CRXO design parameters, the justification and methodology for the sample size calculations and analyses, and the quality of reporting the CRXO design aspects.

METHODS/DESIGN

We will identify reports of CRXO trials by systematically searching MEDLINE, PubMed, Cochrane Methodology Register, EMBASE, and CINAHL Plus. In addition, we will search for methodological articles that describe the CRXO design and conduct citation searches to identify any further CRXO trials. The references of all eligible trials will also be searched. We will screen the identified abstracts, and retrieve and assess for inclusion the full text for any potentially relevant articles. Data will be extracted from the full text independently by two reviewers. Descriptive summary statistics will be presented for the extracted data.

DISCUSSION

This systematic review will inform both researchers addressing CRXO methodology and trialists considering implementing the design. The results will allow focused methodological research of the CRXO design, provide practical examples for researchers of how CRXO trials have been conducted, including any shortcomings, and highlight areas where reporting and conduct may be improved.

Interpreting null findings from trials of alcohol brief interventions

The effectiveness of alcohol brief intervention (ABI) has been established by a succession of meta-analyses but, because the effects of ABI are small, null findings from randomized controlled trials are often reported and can sometimes lead to skepticism regarding the benefits of ABI in routine practice. This article first explains why null findings are likely to occur under null hypothesis significance testing (NHST) due to the phenomenon known as "the dance of the p-values." A number of misconceptions about null findings are then described, using as an example the way in which the results of the primary care arm of a recent cluster-randomized trial of ABI in England (the SIPS project) have been misunderstood. These misinterpretations include the fallacy of "proving the null hypothesis" that lack of a significant difference between the means of sample groups can be taken as evidence of no difference between their population means, and the possible effects of this and related misunderstandings of the SIPS findings are examined. The mistaken inference that reductions in alcohol consumption seen in control groups from baseline to follow-up are evidence of real effects of control group procedures is then discussed and other possible reasons for such reductions, including regression to the mean, research participation effects, historical trends, and assessment reactivity, are described. From the standpoint of scientific progress, the chief problem about null findings under the conventional NHST approach is that it is not possible to distinguish "evidence of absence" from "absence of evidence." By contrast, under a Bayesian approach, such a distinction is possible and it is explained how this approach could classify ABIs in particular settings or among particular populations as either truly ineffective or as of unknown effectiveness, thus accelerating progress in the field of ABI research.

Income received during treatment does not affect response to contingency management treatments in cocaine-dependent outpatients

BACKGROUND

Prior studies find no effect of baseline income on response to contingency management (CM) interventions. However, income among substance disordered patients is variable, particularly at treatment entry. This study investigated the impact of during-treatment income, a more proximal estimate of economic resources at the time that CM is in effect, on response to standard treatment or the standard treatment plus CM.

METHOD

These secondary analyses included 418 cocaine dependent participants initiating community intensive outpatient treatment. We examined whether differences were present in pretreatment and during-treatment overall income, as well as specific income sources. We then conducted a series of regression models to investigate the impact of during-treatment income on treatment outcome.

RESULTS

Participants' during-treatment income was significantly lower compared to pretreatment income, and this difference was largely attributable to decreases in earned income, illegal income, and support from friends and family. Neither the main effect of income, nor the interaction of income and treatment condition, was significantly associated with treatment outcome. CM, however, was a significant predictor of improved treatment outcome relative to standard treatment. Income sources and some demographic characteristics were also significant predictors of outcomes; public assistance income was associated with improved outcomes and illegal income was associated with poorer outcomes.

CONCLUSIONS

These results suggest that substance abusers benefit from CM regardless of their income level, and these data add to the growing literature supporting the generalizability of CM across a variety of patient characteristics.

Screening and brief intervention for unhealthy drug use in primary care settings: randomized clinical trials are needed

The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.

Utilizing screening, brief intervention, and referral to treatment: teaching assessment of substance abuse

Although social workers regularly encounter clients with substance use problems, social work education rarely addresses addictions with any depth. This pilot study explored the use of screening, brief intervention, and referral to treatment (SBIRT) with 74 social work students. Students completed SBIRT training with pre- and post-questionnaires that assessed attitudes, knowledge, and skills concerning substance misuse. Statistically significant differences were demonstrated with students reporting more confidence in their ability to successfully assess for alcohol misuse and subsequently intervene.

Screening for alcohol and drug use disorders among adults in primary care: a review

BACKGROUND: The Patient Protection and Affordable Care Act of 2010 supports integration of substance abuse interventions and treatments into the mainstream health care system. Thus, effective screening and intervention for substance use disorders in health care settings is a priority. OBJECTIVE: This paper reviews the prevalence of alcohol and drug use disorders (abuse or dependence) in primary care settings and emergency departments, as well as current screening tools and brief interventions. METHODS: MEDLINE was searched using the following keywords: alcohol use, alcohol use disorder, drug use, drug use disorder, screening, primary care, and emergency departments. Using the related-articles link, additional articles were screened for inclusion. This review focuses on alcohol and drug use and related disorders among adults in primary care settings. CONCLUSION: Screening, brief intervention, and referral for treatment are feasible and effective in primary care settings, provided that funding for screening is available, along with brief interventions and treatment facilities to which patients can be referred and treated promptly.

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

BACKGROUND

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

METHODOLOGY/PRINCIPAL FINDINGS

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

CONCLUSIONS/SIGNIFICANCE

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

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

ISSUES

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

APPROACH

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

KEY FINDINGS

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

CONCLUSION AND IMPLICATIONS

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

Income does not affect response to contingency management treatments among community substance abuse treatment-seekers

The present study examined a commonly held belief that contingency management (CM) may be less effective for substance abusers with relatively more economic resources compared to those with relatively few resources. Using a combined sample of 393 treatment-seeking cocaine abusers from three clinical trials involving randomization to standard care or standard care plus CM conditions, we assessed the impact of past year income, alone and in combination with treatment condition, as well as income type (i.e., earned, illegal, unstable) on the longest duration of continuous verified abstinence (LDA) achieved during treatment. Results suggested that income had no effect on LDA in either condition, and that CM's effectiveness did not deteriorate among those with better economic resources in the present sample. This finding may be of value to clinicians and administrators who are considering the addition of CM to standard care treatments in community outpatient substance abuse clinics and have concerns about the generalizability of CM across clients with various economic resources.

Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers

Brief motivational interventions (BMIs) are usually effective for reducing alcohol use and consequences in primary care settings. We examined readiness to change drinking as a mediator of the effects of BMI on alcohol-related consequences. Participants were randomized into three conditions: (a) standard care plus assessment (SC), (b) SC plus BMI (BI), and (c) BI plus a booster session (BIB). At 12-month follow-up BIB patients had significantly reduced alcohol consequences more than had SC patients. Patients receiving BI or BIB maintained higher readiness scores 3 months after treatment than did patients receiving SC. However, readiness mediated treatment effects only for those highly motivated to change prior to the intervention but not for those with low pre-intervention motivation. BI and BIB for these patients decreased alcohol consequences in part because they enhanced and maintained readiness for those highly motivated prior to the intervention, but not for those with low motivation. Results are opposite of what would be expected from MI theory. An alternative explanation is offered as to why this finding occurred with this opportunistically recruited Emergency Department patient population.

Psychosocial interventions by general practitioners

BACKGROUND

Many patients visit their general practitioner (GP) because of problems that are psychosocial in origin. However, for many of these problems there is no evidence-based treatment available in primary care, and these patients place time-consuming demands on their GP. Therefore, GPs could benefit from tools to help these patients more effectively and efficiently. In this light, it is important to assess whether structured psychosocial interventions might be an appropriate tool for GPs. Previous reviews have shown that psychosocial interventions in primary care seem more effective than usual care. However, these interventions were mostly performed by health professionals other than the GP.

OBJECTIVES

To examine the effectiveness of psychosocial interventions by general practitioners by assessing the clinical outcomes and the methodological quality of selected studies.

SEARCH STRATEGY

The search was conducted using the CCDANCTR-Studies and CCDANCTR-References on 20/10/2005, The Cochrane Library, reference lists of relevant studies for citation tracking and personal communication with experts.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials and controlled patient preference trials addressing the effectiveness of psychosocial interventions by GPs for any problem or disorder. Studies published before November 2005 were eligible for entry.

DATA COLLECTION AND ANALYSIS

Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of selected trials were independently extracted by two review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. Results from studies that reported similar interventions and outcome measures were meta-analysed.

MAIN RESULTS

Ten studies were included in the review. Selected studies addressed different psychosocial interventions for five distinct disorders or health complaints. There is good evidence that problem-solving treatment by general practitioners is effective for major depression. The evidence concerning the remaining interventions for other health complaints (reattribution or cognitive behavioural group therapy for somatisation, cognitive behavioural therapy for unexplained fatigue, counselling for smoking cessation, behavioural interventions to reduce alcohol reduction) is either limited or conflicting.

AUTHORS' CONCLUSIONS

In general, there is little available evidence on the use of psychosocial interventions by general practitioners. Of the psychosocial interventions reviewed, problem-solving treatment for depression may offer promise, although a stronger evidence-base is required and the effectiveness in routine practice remains to be demonstrated. More research is required to improve the evidence-base on this subject.

Preventing alcohol-exposed pregnancies: a randomized controlled trial

BACKGROUND

Prenatal alcohol exposure is a leading preventable cause of birth defects and developmental disabilities in the United States.

DESIGN

A randomized controlled trial (2002-2005; data analyzed 2005-2006) of a brief motivational intervention to reduce the risk of an alcohol-exposed pregnancy (AEP) in preconceptional women by focusing on both risk drinking and ineffective contraception use.

SETTING/PARTICIPANTS

A total of 830 nonpregnant women, aged 18-44 years, and currently at risk for an AEP were recruited in six diverse settings in Florida, Texas, and Virginia. Combined settings had higher proportions of women at risk for AEP (12.5% overall) than in the general population (2%).

INTERVENTIONS

Participants were randomized to receive information plus a brief motivational intervention (n=416) or to receive information only (n=414). The brief motivational intervention consisted of four counseling sessions and one contraception consultation and services visit.

MAIN OUTCOME MEASURES

Women consuming more than five drinks on any day or more than eight drinks per week on average, were considered risk drinkers; women who had intercourse without effective contraception were considered at risk of pregnancy. Reversing either or both risk conditions resulted in reduced risk of an AEP.

RESULTS

Across the follow-up period, the odds ratios (ORs) of being at reduced risk for AEP were twofold greater in the intervention group: 3 months, 2.31 (95% confidence interval [CI]=1.69-3.20); 6 months, 2.15 (CI=1.52-3.06); 9 months, 2.11 (CI=1.47-3.03). Between-groups differences by time phase were 18.0%, 17.0%, and 14. 8%, respectively.

CONCLUSIONS

A brief motivational intervention can reduce the risk of an AEP.

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

AIMS

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

DESIGN

Longitudinal prospective intervention study of 1 year of duration.

SETTING

5 urban primary care physician's practices.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN MEASURES

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

RESULTS

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

CONCLUSIONS

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

Training medical providers to conduct alcohol screening and brief interventions

Although progress has been made in developing a scientific basis for alcohol screening and brief intervention (SBI), training packages are necessary for its widespread dissemination in primary care settings. This paper evaluates a training package developed for the Cutting Back SBI program. Three groups of medical personnel were compared before and after SBI training: physicians (n = 44), medical students (n = 88), and non-physicians (n = 41). Although the training effects were at times dependent on group membership, all changes were in a direction more conducive to implementing SBI. Physicians and medical students increased confidence in performing screening procedures, and students increased self-confidence in conducting brief interventions. Non-physicians perceived fewer obstacles to screening patients after training. Trained providers reported conducting significantly more SBI than untrained providers, and these differences were consistent with patients' reports of their providers' clinical activity. Thus, when delivered in the context of a comprehensive SBI implementation program, this training is effective in changing providers' knowledge, attitudes, and practice of SBI for at-risk drinking.

Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis

OBJECTIVE

To determine if brief alcohol interventions in trauma centers reduce health care costs.

SUMMARY BACKGROUND DATA

Alcohol-use disorders are the leading cause of injury. Brief interventions in trauma patients reduce subsequent alcohol intake and injury recidivism but have not yet been widely implemented.

METHODS

This was a cost-benefit analysis. The study population consisted of injured patients treated in an emergency department or admitted to a hospital. The analysis was restricted to direct injury-related medical costs only so that it would be most meaningful to hospitals, insurers, and government agencies responsible for health care costs. Underlying assumptions used to arrive at future benefits, including costs, injury rates, and intervention effectiveness, were derived from published nationwide databases, epidemiologic, and clinical trial data. Model parameters were examined with 1-way sensitivity analyses, and the cost-benefit ratio was calculated. Monte Carlo analysis was used to determine the strategy-selection confidence intervals.

RESULTS

An estimated 27% of all injured adult patients are candidates for a brief alcohol intervention. The net cost savings of the intervention was 89 US dollars per patient screened, or 330 US dollars for each patient offered an intervention. The benefit in reduced health expenditures resulted in savings of 3.81 US dollars for every 1.00 US dollar spent on screening and intervention. This finding was robust to various assumptions regarding probability of accepting an intervention, cost of screening and intervention, and risk of injury recidivism. Monte Carlo simulations found that offering a brief intervention would save health care costs in 91.5% of simulated runs. If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach 1.82 billion US dollars annually.

CONCLUSIONS

Screening and brief intervention for alcohol problems in trauma patients is cost-effective and should be routinely implemented.

Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis

OBJECTIVE

To determine if brief alcohol interventions in trauma centers reduce health care costs.

SUMMARY BACKGROUND DATA

Alcohol-use disorders are the leading cause of injury. Brief interventions in trauma patients reduce subsequent alcohol intake and injury recidivism but have not yet been widely implemented.

METHODS

This was a cost-benefit analysis. The study population consisted of injured patients treated in an emergency department or admitted to a hospital. The analysis was restricted to direct injury-related medical costs only so that it would be most meaningful to hospitals, insurers, and government agencies responsible for health care costs. Underlying assumptions used to arrive at future benefits, including costs, injury rates, and intervention effectiveness, were derived from published nationwide databases, epidemiologic, and clinical trial data. Model parameters were examined with 1-way sensitivity analyses, and the cost-benefit ratio was calculated. Monte Carlo analysis was used to determine the strategy-selection confidence intervals.

RESULTS

An estimated 27% of all injured adult patients are candidates for a brief alcohol intervention. The net cost savings of the intervention was 89 US dollars per patient screened, or 330 US dollars for each patient offered an intervention. The benefit in reduced health expenditures resulted in savings of 3.81 US dollars for every 1.00 US dollar spent on screening and intervention. This finding was robust to various assumptions regarding probability of accepting an intervention, cost of screening and intervention, and risk of injury recidivism. Monte Carlo simulations found that offering a brief intervention would save health care costs in 91.5% of simulated runs. If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach 1.82 billion US dollars annually.

CONCLUSIONS

Screening and brief intervention for alcohol problems in trauma patients is cost-effective and should be routinely implemented.

Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review

OBJECTIVE

To determine the effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting.

DESIGN

Systematic review.

DATA SOURCES

Medline, PsychInfo, Cochrane Library, reference lists from identified studies and review articles, and contact with experts.

MAIN OUTCOME MEASURE

Change in alcohol consumption.

RESULTS

Eight studies were retrieved. Most had methodological weaknesses. Only one study, with a relatively intensive intervention and a short follow up period, showed a significantly large reduction in alcohol consumption in the intervention group.

CONCLUSIONS

Evidence for the effectiveness of opportunistic brief interventions in a general hospital setting for problem drinkers is still inconclusive.

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

OBJECTIVE

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

DESIGN

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

SETTING

General practice.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

DESIGN

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

PARTICIPANTS

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

MAIN MEASURES

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

RESULTS

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

CONCLUSIONS

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

Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking

OBJECTIVE

This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared.

DESIGN

Cross-sectional analyses of audiotaped appointments collected over 6 months.

PARTICIPANTS AND SETTING

Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients ( N = 47) and providers ( N = 17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus.

INTERVENTION

Intervention providers received patient-specific results of positive alcohol-screening tests at each visit.

MEASURES AND MAIN RESULTS

Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected "resistance" to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P =.026).

CONCLUSIONS

During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted.

Use of marketing to disseminate brief alcohol intervention to general practitioners: promoting health care interventions to health promoters

Health research findings are of little benefit to patients or society if they do not reach the audience they are intended to influence. Thus, a dissemination strategy is needed to target new findings at its user group and encourage a process of consideration and adoption or rejection. Social marketing techniques can be utilized to aid successful dissemination of research findings and to speed the process by which new information reaches practice. Principles of social marketing include manipulating the marketing mix of product, price, place and promotion. This paper describes the development of a marketing approach and the outcomes from a trial evaluating the effectiveness and cost-effectiveness of manipulating promotional strategies to disseminate actively a screening and brief alcohol intervention (SBI) programme to general practitioners (GPs). The promotional strategies consisted of postal marketing, telemarketing and personal marketing. The study took place in general practices across the Northern and Yorkshire Regional Health Authority. Of the 614 GPs eligible for the study, one per practice, 321 (52%) took the programme and of those available to use it for 3 months (315), 128 (41%) actively considered doing so, 73 (23%) actually went on to use it. Analysis of the specific impact of the three different promotional strategies revealed that while personal marketing was the most effective overall dissemination and implementation strategy, telemarketing was more cost-effective. The findings of our work show that using a marketing approach is promising for conveying research findings to GPs and in particular a focus on promotional strategies can facilitate high levels of uptake and consideration in this target group.

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

OBJECTIVE

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

DESIGN

Retrospective study: review of clinical records.

SETTING

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

PATIENTS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Screening for problem drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test

OBJECTIVE

To compare self-administered versions of three questionnaires for detecting heavy and problem drinking: the CAGE, the Alcohol Use Disorders Identification Test (AUDIT), and an augmented version of the CAGE.

DESIGN

Cross-sectional surveys.

SETTING

Three Department of Veterans Affairs general medical clinics.

PATIENTS

Random sample of consenting male outpatients who consumed at least 5 drinks over the past year ("drinkers"). Heavy drinkers were oversampled.

MEASUREMENTS

An augmented version of the CAGE was included in a questionnaire mailed to all patients. The AUDIT was subsequently mailed to "drinkers." Comparison standards, based on the tri-level World Health Organization alcohol consumption interview and the Diagnostic Interview Schedule, included heavy drinking (> 14 drinks per week typically or > or = 5 drinks per day at least monthly) and active DSM-IIIR alcohol abuse or dependence (positive diagnosis and at least one alcohol-related symptom in the past year). Areas under receiver operating characteristic curves (AUROCs) were used to compare screening questionnaires.

MAIN RESULTS

Of 393 eligible patients, 261 (66%) returned the AUDIT and completed interviews. For detection of active alcohol abuse or dependence, the CAGE augmented with three more questions (AUROC 0.871) performed better than either the CAGE alone or AUDIT (AUROCs 0.820 and 0.777, respectively). For identification of heavy-drinking patients, however, the AUDIT performed best (AUROC 0.870). To identify both heavy drinking and active alcohol abuse or dependence, the augmented CAGE and AUDIT both performed well, but the AUDIT was superior (AUROC 0.861).

CONCLUSIONS

For identification of patients with heavy drinking or active alcohol abuse or dependence, the self-administered AUDIT was superior to the CAGE in this population.

Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers

OBJECTIVE

To assess the effectiveness of brief interventions in heavy drinkers by analyzing the outcome data and methodologic quality.

DESIGN

(1) Qualitative analysis of randomized control trials (RCTs) using criteria from Chalmers' scoring system; (2) calculating and combining odds ratios (ORs) of RCTs using the One-Step (Peto) and the Mantel-Haenszel methods. STUDY SELECTION AND ANALYSIS: A MEDLINE and PsycLIT search identified RCTs testing brief interventions in heavy alcohol drinkers. Brief interventions were less than 1 hour and incorporated simple motivational counseling techniques much like outpatient smoking cessation programs. By a single-reviewer, nonblinded format, eligible studies were selected for adult subjects, sample sizes greater than 30, a randomized control design, and incorporation of brief alcohol interventions. Methodologic quality was assessed using an established scoring system developed by Chalmers and colleagues. Outcome data were combined by the One-Step (Peto) method; confidence limits and chi 2 test for heterogeneity were calculated.

RESULTS

Twelve RCTs met all inclusion criteria, with an average quality score of 0.49 + or - 0.17. This was comparable to published average scores in other areas of research (0.42 + or - 0.16). Outcome data from RCTs were pooled, and a combined OR was close to 2 (1.91; 95% confidence interval 1.61-2.27) in favor of brief alcohol interventions over no intervention. This was consistent across gender, intensity of intervention, type of clinical setting, and higher-quality clinical trials.

CONCLUSIONS

Heavy drinkers who received a brief intervention were twice as likely to moderate their drinking 6 to 12 months after an intervention when compared with heavy drinkers who received no intervention. Brief intervention is a low-cost, effective preventive measure for heavy drinkers in outpatient settings.