A meta-analysis of the efficacy of nonphysician brief interventions for unhealthy alcohol use: implications for the patient-centered medical home

Standardized Models for Identification and Intervention for Emergency Department Patients at Risk for Alcohol Use Disorder

Alcohol use disorder (AUD) is chronic, lasting a person's lifetime. An increase in driving under the influence of alcohol, as well as emergency department (ED) visits, has been reported. The Alcohol Use Disorder Identification Test Consumption (AUDIT-C) is utilized to assess hazardous drinking. The Screening, Brief Intervention, Referral to Treatment (SBIRT) model assists in early intervention and referral for treatment. The Transtheoretical Model standardized instrument assesses individual readiness to change. These tools may be used by nurses and nonphysicians in the ED to help reduce alcohol use and the consequences of its use.

Which interventions for alcohol use should be included in a universal healthcare benefit package? An umbrella review of targeted interventions to address harmful drinking and dependence

BACKGROUND

This study aimed to identify targeted interventions for the prevention and treatment of harmful alcohol use. Umbrella review methodology was used to summarise the effectiveness across a broad range of interventions, in order to identify which interventions should be considered for inclusion within universal health coverage schemes in low- and middle-income countries.

METHODS AND FINDINGS

We included systematic reviews with meta-analysis of randomised controlled trials (RCTs) on targeted interventions addressing alcohol use in harmful drinkers or individuals with alcohol use disorder. We only included outcomes related to alcohol consumption, heavy drinking, binge drinking, abstinence, or alcohol-attributable accident, injury, morbidity or mortality. PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and the International HTA Database were searched from inception to 3 September 2021. Risk of bias of reviews was assessed using the AMSTAR2 tool. After reviewing the abstracts of 9,167 articles, results were summarised narratively and certainty in the body of evidence for each intervention was assessed using GRADE. In total, 86 studies met the inclusion criteria, of which the majority reported outcomes for brief intervention (30 studies) or pharmacological interventions (29 studies). Overall, methodological quality of included studies was low.

CONCLUSIONS

For harmful drinking, brief interventions, cognitive behavioural therapy, and motivational interviewing showed a small effect, whereas mentoring in adolescents and children may have a significant long-term effect. For alcohol use disorder, social network approaches and acamprosate showed evidence of a significant and durable effect. More evidence is required on the effectiveness of gamma-hydroxybutyric acid (GHB), nalmefene, and quetiapine, as well as optimal combinations of pharmacological and psychosocial interventions. As an umbrella review, we were unable to identify the extent to which variation between studies stemmed from differences in intervention delivery or variation between country contexts. Further research is required on applicability of findings across settings and best practice for implementation. Funded by the Thai Health Promotion Foundation, grant number 61-00-1812.

Help-Seeking Patterns and Barriers to Care Among Latino Immigrant Men with Unhealthy Alcohol Use

Latino immigrant men have high rates of unhealthy alcohol use, a wide range of behaviors, from drinking above the recommended limits to severe alcohol use disorder, yet have low levels of treatment-seeking. Little is known about their preferred sources of care and barriers to care. Using survey data from a community-based sample of Latino immigrant men (N=121) with unhealthy alcohol use (AUDIT≥6), we described help-seeking patterns and perceived barriers to care. The mean AUDIT score was 20 (SD 10; range 6-40), and 49% of men had severe levels of unhealthy alcohol use (AUDIT score ≥ 20). We observed low help-seeking rates and high levels of perceived internal and external barriers. Thirty percent reported having sought help for drinking. Most men reported wanting to solve their drinking problem on their own (65%). Our findings were consistent with previous research. Future studies should further describe barriers to treatment among low-income Latino immigrant men with unhealthy alcohol use and identify ways to increase access to low-cost, high-quality treatment options.

Leveraging technology to address unhealthy drug use in primary care: Effectiveness of the Substance use Screening and Intervention Tool (SUSIT)

Background: Screening for unhealthy drug use is now recommended for adult primary care patients, but primary care providers (PCPs) generally lack the time and knowledge required to screen and deliver an intervention during the medical visit. To address these barriers, we developed a tablet computer-based 'Substance Use Screening and Intervention Tool (SUSIT)'. Using the SUSIT, patients self-administer screening questionnaires prior to the medical visit, and results are presented to the PCP at the point of care, paired with clinical decision support (CDS) that guides them in providing a brief intervention (BI) for unhealthy drug use. Methods: PCPs and their patients with moderate-risk drug use were recruited from primary care and HIV clinics. A pre-post design compared a control 'screening only' (SO) period to an intervention 'SUSIT' period. Unique patients were enrolled in each period. In both conditions, patients completed screening and identified their drug of most concern (DOMC) before the visit, and completed a questionnaire about BI delivery by the PCP after the visit. In the SUSIT condition only, PCPs received the tablet with the patient's screening results and CDS. Multilevel models with random intercepts and patients nested within PCPs examined the effect of the SUSIT intervention on PCP delivery of BI. Results: 20 PCPs and 79 patients (42 SO, 37 SUSIT) participated. Most patients had moderate-risk marijuana use (92.4%), and selected marijuana as the DOMC (68.4%). Moderate-risk use of drugs other than marijuana included cocaine (15.2%), hallucinogens (12.7%), and sedatives (12.7%). Compared to the SO condition, patients in SUSIT had higher odds of receiving any BI for drug use, with an adjusted odds ratio of 11.59 (95% confidence interval: 3.39, 39.25), and received more elements of BI for drug use. Conclusions: The SUSIT significantly increased delivery of BI for drug use by PCPs during routine primary care encounters.

The Role of Alcohol-Related Behavioral Research in the Design of HIV Secondary Prevention Interventions in the Era of Antiretroviral Therapy: Targeted Research Priorities Moving Forward

HIV secondary prevention focuses on averting onward HIV transmission, which can be realized when people living with HIV enact requisite HIV care continuum-related behaviors to achieve viral suppression, and engage in condom-protected sex when virally unsuppressed. Alcohol has been detrimentally linked to all aspects of HIV secondary prevention, and although a growing number of behavioral interventions account for and address alcohol use within this realm, further efforts are needed to fully realize the potential of such initiatives. The present article proposes a series of targeted priorities to inform the future design, implementation, and evaluation of alcohol-related behavioral intervention research within the scope of HIV secondary prevention. These priorities and corresponding approaches account for the challenges of resource-constrained clinic environments; capitalize on technology; and address key comorbidities. This framework provides the foundation for a range of alcohol-related behavioral interventions that could potentially enhance global HIV secondary prevention efforts in the years ahead.

Addressing Unhealthy Alcohol Use and the HIV Pre-exposure Prophylaxis Care Continuum in Primary Care: A Scoping Review

Individuals with unhealthy alcohol use are at increased risk for HIV acquisition and may benefit from receiving HIV pre-exposure prophylaxis (PrEP) in primary care settings. To date, literature synthesizing what is known about the impact of unhealthy alcohol use on the PrEP care continuum with a focus on considerations for primary care is lacking. We searched OVID Medline and Web of Science from inception through March 19, 2020, to examine the extent, range, and nature of research on PrEP delivery among individuals with unhealthy alcohol use in primary care settings. We identified barriers and opportunities at each step along the PrEP care continuum, including for specific populations: adolescents, people who inject drugs, sex workers, and transgender persons. Future research should focus on identification of candidate patients, opportunities for patient engagement in novel settings, PrEP implementation strategies, and stigma reduction.

Perceived appropriateness of alcohol screening and brief advice programmes in Colombia, Mexico and Peru and barriers to their implementation in primary health care - a cross-sectional survey

BACKGROUND

Providing alcohol screening and brief advice (SBA) in primary health care (PHC) can be an effective measure to reduce alcohol consumption. To aid successful implementation in an upper middle-income country context, this study investigates the perceived appropriateness of the programme and the perceived barriers to its implementation in PHC settings in three Latin American countries: Colombia, Mexico and Peru, as part of larger implementation study (SCALA).

METHODS

An online survey based on the Tailored Implementation for Chronic Diseases (TICD) implementation framework was disseminated in the three countries to key stakeholders with experience in the topic and/or setting (both health professionals and other roles, for example regional health administrators and national experts). In total, 55 respondents participated (66% response rate). For responses to both appropriateness and barriers questions, frequencies were computed, and country comparisons were made using Chi square and Kruskal-Wallis non-parametric tests.

RESULTS

Alcohol SBA was seen as an appropriate programme to reduce heavy alcohol use in PHC and a range of providers were considered suitable for its delivery, such as general practitioners, nurses, psychologists and social workers. Contextual factors such as patients' normalised perception of their heavy drinking, lack of on-going support for providers, difficulty of accessing referral services and lenient alcohol control laws were the highest rated barriers. Country differences were found for two barriers: Peruvian respondents rated SBA guidelines as less clear than Mexican (Mann-Whitney U = -18.10, P = 0.001), and more strongly indicated lack of available screening instruments than Colombian (Mann-Whitney U = -12.82, P = 0.035) and Mexican respondents (Mann-Whitney U = -13.56, P = 0.018).

CONCLUSIONS

The study shows the need to address contextual factors for successful implementation of SBA in practice. General congruence between the countries suggests that similar approaches can be used to encourage widespread implementation of SBA in all three studied countries, with minor tailoring based on the few country-specific barriers.

Community social determinants and health outcomes drive availability of patient-centered medical homes

The collaborative design of America's patient-centered medical homes places these practices at the forefront of emerging efforts to address longstanding inequities in the quality of primary care experienced among socially and economically marginalized populations. We assessed the geographic distribution of the country's medical homes and assessed whether they are appearing within communities that face greater burdens of disease and social vulnerability. We assessed overlapping spatial clusters of mental and physical health surveys; health behaviors, including alcohol-impaired driving deaths and drug overdose deaths; as well as premature mortality with clusters of medical home saturation and community socioeconomic characteristics. Overlapping spatial clusters were assessed using odds ratios and marginal effects models, producing four different scenarios of resource need and resource availability. All analyses were conducted using county-level data for the contiguous US states. Counties having lower uninsured rates and lower poverty rates were the most consistent indicators of medical home availability. Overall, the analyses indicated that medical homes are more likely to emerge within communities that have more favorable health and socioeconomic conditions to begin with. These findings suggest that intersecting the spatial footprints of medical homes in relation to health and socioeconomic data can provide crucial information for policy makers and payers invested in narrowing the gaps between clinic availability and the communities that experience the brunt of health and social inequalities.

Integrated stepped alcohol treatment for patients with HIV and at-risk alcohol use: a randomized trial

BACKGROUND

At-risk levels of alcohol use threaten the health of patients with HIV (PWH), yet evidence-based strategies to decrease alcohol use and improve HIV-related outcomes in this population are lacking. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among PWH and at-risk alcohol use.

METHODS

In this multi-site, randomized trial conducted between January 28, 2013 through July 14, 2017, we enrolled PWH and at-risk alcohol use [defined as alcohol consumption of ≥ 14 drinks per week or ≥ 4 drinks per occasion in men ≤ 65 years old or ≥ 7 drinks per week or ≥ 3 drinks per occasion in women or men > 65 years old]. ISAT (n = 46) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 47) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat principles.

RESULTS

Despite a multi-pronged approach, we only recruited 37% of the target population (n = 93/254). Among ISAT participants, 50% advanced to Step 2, among whom 57% advanced to Step 3. Participants randomized to ISAT and TAU had no observed difference in drinks per week over the past 30 days at week 24 (primary outcome) [least square means (Ls mean) (95% CI) = 8.8 vs. 10.6; adjusted mean difference (AMD) (95% CI) =  - 0.4 (- 3.9, 3.0)].

CONCLUSION

An insufficient number of patients were interested in participating in the trial. Efforts to enhance motivation of PWH with at-risk alcohol use to engage in alcohol-related research and build upon ISAT are needed. Trial registration Clinicaltrials.gov: NCT01410123, First posted August 4, 2011.

Conversations about alcohol in healthcare - cross-sectional surveys in the Netherlands and Sweden

Background

This study evaluated and compared the extent, duration, contents, experiences and effects of alcohol conversations in healthcare in the Netherlands and Sweden in 2017.

Methods

Survey data in the Netherlands and Sweden were collected through an online web panel. Subjects were 2996 participants (response rate: 50.8%) in Sweden and 2173 (response rate: 82.2%) in the Netherlands. Data was collected on socio-demographics, alcohol consumption, healthcare visits in the past 12 months, number of alcohol conversations, and characteristics of alcohol conversations (duration, contents, experience, effects).

Results

Results showed that Swedish respondents were more likely to have had alcohol conversations (OR = 1.99; 95%CI = 1.64–2.41; p = < 0.001) compared to Dutch respondents. In Sweden, alcohol conversations were more often perceived as routine (p = < 0.001), were longer (p = < 0.001), and more often contained verbal information about alcohol’s health effects (p = 0.007) or written information (p = 0.001) than in the Netherlands. In Sweden, 40+ year-olds were less likely to report a positive effect compared to the youngest respondents. In the Netherlands, men, sick-listed respondents, and risky drinkers, and in Sweden those that reported “other” occupational status such as parental leave, were more likely to have had alcohol conversations.

Conclusions

The results suggest that alcohol conversations are more common in healthcare practice in Sweden than in the Netherlands. However, positive effects of alcohol conversations were less likely to be reported among older respondents in Sweden. Our results indicate that alcohol preventative work should be improved in both countries, with more focus on risky drinkers and the content of the conversations in Sweden, and expanding alcohol screening in the Netherlands.

The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition

The Primary Care Behavioral Health (PCBH) model is a prominent approach to the integration of behavioral health services into primary care settings. Implementation of the PCBH model has grown over the past two decades, yet research and training efforts have been slowed by inconsistent terminology and lack of a concise, operationalized definition of the model and its key components. This article provides the first concise operationalized definition of the PCBH model, developed from examination of multiple published resources and consultation with nationally recognized PCBH model experts. The definition frames the model as a team-based approach to managing biopsychosocial issues that present in primary care, with the over-arching goal of improving primary care in general. The article provides a description of the key components and strategies used in the model, the rationale for those strategies, a brief comparison of this model to other integration approaches, a focused summary of PCBH model outcomes, and an overview of common challenges to implementing the model.

Mental health training, attitudes toward support, and screening positive for mental disorders

Public Safety Personnel (PSP; e.g. correctional workers, dispatchers, firefighters, paramedics, police) are frequently exposed to potentially traumatic events (PTEs). Several mental health training program categories (e.g. critical incident stress management (CISM), debriefing, peer support, psychoeducation, mental health first aid, Road to Mental Readiness [R2MR]) exist as efforts to minimize the impact of exposures, often using cognitive behavioral therapy model content, but with limited effectiveness research. The current study assessed PSP perceptions of access to professional (i.e. physicians, psychologists, psychiatrists, employee assistance programs, chaplains) and non-professional (i.e. spouse, friends, colleagues, leadership) support, and associations between training and mental health. Participants included 4,020 currently serving PSP participants. Data were analyzed using cross-tabulations and logistic regressions. Most PSP reported access to professional and non-professional support; nevertheless, most would first access a spouse (74%) and many would never, or only as a last resort, access professional support (43-60%) or PSP leaders (67%). Participation in any mental health training category was associated with lower (p < .01) rates for some, but not all, mental disorders, with no robust differences across categories. Revisions to training programs may improve willingness to access professional support; in the interim, training and support for PSP spouses and leaders may also be beneficial.

Distance Versus On-Site Educational Strategies for Competency-Based Screening, Brief Intervention, and Referral to Treatment Education

BACKGROUND

Although the individual and public health consequences of alcohol and drug use are substantial, nursing education programs generally lack content on addiction. The goal of this evaluation was to compare the initial outcomes of on-site versus distance methods for training graduate nurse practitioner students in Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance use.

METHOD

A nonrandomized two-group pretest-posttest design was used to compare knowledge, attitudes, and skills learning outcomes between on-site (n = 45) and distance (n = 18) family or adult/geriatric Master of Science in Nursing nurse practitioner students receiving SBIRT training.

RESULTS

Overall, students increased their knowledge, attitudes, and confidence about screening and intervening with patients who use substances; showed a high level of skills in conducting a brief intervention to motivate patients to reduce their substance use; and were highly satisfied with the education provided. Counseling confidence and gains in knowledge were similar across groups. Compared with distance students, on-site students reported significantly more positive attitudes about their role adequacy, role legitimacy, and role support for intervening with alcohol use and about their role support for intervening with drug use. On-site students had greater training satisfaction, but distance students' skills assessed through standardized patient interactions were significantly better.

CONCLUSIONS

Both on-site and distance training were effective instructional methods to increase SBIRT knowledge and skills. However, differences in attitudes, training satisfaction, and skills demonstration should be taken into account when designing addiction training using distance technologies.

Vida PURA: An assessment of the fidelity of promotor-delivered screening and brief intervention to reduce unhealthy alcohol use among Latino day laborers

We assessed the fidelity of promotores conducting screening and brief intervention (SBI) to reduce unhealthy alcohol use among Latino immigrant day laborers in the Vida PURA study. We reviewed 32 audio-recorded brief interventions to assess promotor adherence to the intervention protocol and to evaluate their motivational interviewing (MI) technique with the Motivational Interviewing Treatment Integrity (MITI) 4.2.1 tool. Promotores delivered three core intervention steps in 78% of recordings and achieved basic MI competence across all domains and proficiency in 50% of measures. Our results suggest that promotores can be trained to deliver SBI in community settings with fidelity.

A New Era of HIV Risk: It's Not What You Know, It's Who You Know (and How Infectious)

HIV is transmitted in social and sexual relationships, and HIV transmission risks, as well as protective actions, are evolving as HIV epidemics unfold. The current focus of HIV prevention is centered on antiretroviral medications used to reduce HIV infectiousness in persons already infected with HIV [treatment as prevention (TasP)]. The same medications used to treat infected persons can also be used by uninfected persons as pre-exposure prophylaxis (PrEP) to reduce the infectivity of HIV. Both PrEP and TasP are effective when adherence is high and individuals do not have co-occurring sexually transmitted infections. HIV prevention is most effective and efficient when delivered within sexual networks with high HIV prevalence. Specific network characteristics are recognized as important facilitators of HIV transmission; these characteristics include the degree of similarity among network members (homophily), gender role norms, and belief systems. Since 2011, HIV risk has been redefined based on infectiousness and infectivity, ushering in a new era of HIV prevention with the potential to end HIV epidemics.

Addressing Unhealthy Substance Use in Primary Care

Unhealthy substance use is common in primary care populations and is a major contributor to morbidity and mortality. Two key strategies to address unhealthy substance use in primary care are the process of screening, brief intervention, and referral to treatment (SBIRT), and integration of treatment for substance use disorders into primary care. Implementation of SBIRT requires buy-in from practice leaders, careful planning, and staff and primary care provider training. Primary care-based treatment of opioid and alcohol use disorders can be effective; more data are needed to better understand the benefits of these models and identify means of treating other substance use disorders in primary care.

Office-Based Addiction Treatment in Primary Care: Approaches That Work

Primary care is an important setting for delivering evidence-based treatment to address substance use disorders. To date, effective approaches to treat, care largely incorporate pharmacotherapy with counseling-based interventions and rely on multidisciplinary teams. There is strong support for primary care-based approaches to address alcohol and opioid use disorder with growing data focused on people living with human immunodeficiency virus and those experiencing incarceration. Future work should focus on the implementation of these effective approaches to decrease health disparities among people with substance use and to identify optimal approaches to address substance use in primary care and specialty settings.

A longitudinal assessment of the road to mental readiness training among municipal police

Police agencies increasingly implement training programs to protect mental health. The Road to Mental Readiness (R2MR) program was designed by the Canadian military to increase mental health resilience. A version of R2MR was adapted for municipal police by the Mental Health Commission of Canada (MHCC). The current research was designed to assess the R2MR program, as adapted and delivered by the MHCC, in a municipal police sample. Participants were 147 Canadian police agency employees (57% women) who received a single R2MR training session. Participants completed pre- and post-training self-report questionnaires, and follow-ups at 6 and 12 months. The questionnaires assessed mental health symptoms, work engagement, resiliency, mental health knowledge, and stigma. Multilevel modeling analyses assessed for within-participant changes over time. The results were consistent with other single session interventions; specifically, there were no significant changes in mental health symptoms, resilience, or work engagement (p > .05). There were small, but significant (p < .05), reductions in stigma at post-training that may facilitate help-seeking among police; relatedly, in open-ended response fields, participants commonly described the training as helpful for changing attitudes and improving communication. More engagement with the material may produce larger, sustained gains, but more published research is critically needed.

Moving Away from the Tip of the Pyramid: Screening and Brief Intervention for Risky Alcohol and Opioid Use in Underserved Patients

PURPOSE

Rates of risky substance use and substance use disorders are high in primary-care practices, yet the adoption of universal screening and brief intervention (SBI) has been slow and uneven. This study aimed to describe SBI-related attitudes, practices, and perspectives regarding practice change among medical providers in a minority-majority state.

METHODS

We conducted a cross-sectional, on-line survey of a practice-based research network of medical providers serving predominantly Hispanic/Latinx and Native American patients in rural and urban settings. The main variables were clinician 1) perspectives on the need to address substance use problems in primary care, 2) current screening and intervention practices, and 3) satisfaction with and willingness to make changes to their practices.

RESULTS

Although providers endorsed alcohol and opiate misuse to be significant problems in their practices, only 25% conducted universal screening. Providers reported focusing most of their screening efforts on those with substance use dependence. In general, providers rated importance of and ability to make practice changes moderately high. There was high interest in practice coordination with the community followed by interest in a collaborative care approach.

CONCLUSIONS

Providers mainly focus efforts on the relatively few patients at the tip of the pyramid (substance use dependence) rather than on the majority of patients who comprise the middle of the pyramid (risky substance use). Practice change strategies are needed to increase universal screening with a focus on risky substance use, particularly in practices serving racial/ethnic communities.

Factors associated with alcohol consumption among medical cannabis patients with chronic pain

INTRODUCTION

Chronic pain is the most common reason for medical cannabis certification. Data regarding alcohol use and risky drinking among medical cannabis patients with pain is largely unknown. Therefore, we examined the prevalence and correlates of alcohol use and risky drinking in this population.

METHODS

Participants completed surveys regarding demographics, pain-related variables, anxiety, cannabis use, and past six-month alcohol consumption. Alcohol use groups were defined using the AUDIT-C [i.e., non-drinkers, low-risk drinkers, and high-risk drinkers (≥4 for men and ≥3 for women)] and compared on demographic characteristics, pain measures, anxiety, and cannabis use.

RESULTS

Overall, 42% (n=330/780) were non-drinkers, 32% (n=251/780) were low-risk drinkers, and 26% (n=199/780) were high-risk drinkers. Compared to non-drinkers, low- and high-risk drinkers were significantly younger whereas a larger proportion of low-risk drinkers reported being African-American compared to non- or high-risk drinkers. High-risk drinkers reported significantly lower pain severity/interference compared to the other groups; high-risk drinkers were also less likely to be on disability compared to other groups. A multinomial logistic regression showed that patients reporting lower pain severity and less disability had greater odds of being classified a high-risk drinker.

CONCLUSIONS

High-risk drinking appears common among medical cannabis patients. Future research should examine whether such use is concurrent or consecutive, and the relationship of such co-use patterns to consequences. Nevertheless, individuals treating patients reporting medical cannabis use for pain should consider alcohol consumption, with data needed regarding the efficacy of brief alcohol interventions among medical cannabis patients.

Recent cannabis use among Veterans in the United States: Results from a national sample

BACKGROUND

Compared to civilians, little is known about cannabis use among Veterans in the general United States (US) population. This study aimed to examine the prevalence and correlates of recent medical and non-medical cannabis use among this important US sub-population.

METHOD

Data came from the 2014 National Survey on Drug Use and Health. Bivariate and multivariable analyses were conducted that were weighted to account for the complex survey design.

RESULTS

Approximately 9% of Veterans in the US reported past year cannabis use. Older, and female, Veterans had lower odds of past year cannabis use. Veterans who were unmarried, out of the work force, had greater functioning disability, nicotine dependence, heavy episodic alcohol use, alcohol use disorder, and drug use had greater odds of past year cannabis use. In states where medical cannabis was legal in 2014, approximately 41% of Veterans who used cannabis in the past year used medically. Those who used medically were older and less likely to engage in recent heavy episodic drinking or to meet criteria for alcohol abuse/dependence, compared to Veterans using non-medically.

CONCLUSION

Compared to non-Veterans in the US general population, recent cannabis use was similar or slightly lower among Veterans. However, among those with past year use, the proportion of those using medically was more than double that of the general population. Because only non-medical cannabis use was associated with higher rates of heavy episodic alcohol use and alcohol use disorder, it may be important to address problematic alcohol consumption among this high-risk group.

Single-Session Behavioral Interventions for Sexual Risk Reduction: A Meta-Analysis

BACKGROUND

Evidence-based, single-session STI/HIV interventions to reduce sexual risk taking are potentially effective options for implementation in resource-limited settings and may solve problems associated with poor participant retention.

PURPOSE

The purpose of the study is to estimate the efficacy of single-session, behavioral interventions in reducing unprotected sex or increasing condom use.

METHODS

Data sources were searched through April 2013 producing 67 single-session interventions (52 unique reports; N = 20,039) that included outcomes on condom use and/or unprotected sex.

RESULTS

Overall, participants in single-session interventions reduced sexual risk taking relative to control groups (d ₊  = 0.19, 95 % CI = 0.11, 0.27). Within-group effects of the interventions were larger than the between-groups effects when compared to controls.

CONCLUSIONS

Brief, targeted single-session sexual risk reduction interventions demonstrate a small but significant effect and should be prioritized.

Delivery of screening and brief intervention for unhealthy alcohol use in an urban academic Federally Qualified Health Center

Background

Screening and brief intervention (SBI) for unhealthy drinking has not been widely implemented in primary care partly due to reliance on physicians to perform it.

Methods

We implemented a model of nursing staff-delivered SBI for unhealthy drinking for adult patients receiving primary care at an academically-affiliated Federally Qualified Health Center in the Bronx, NY. Our model consisted of nursing staff screening all patients with the alcohol use disorders identification test consumption questions (AUDIT-C) and, if screening positive, providing BI or referral to specialty services. We developed a clinical decision support tool integrated into the electronic health record to guide nursing staff and record SBI provision. To evaluate this model, we determined overall SBI delivery to patients and factors associated with receiving SBI.

Results

Between October 2013 and September 2014, 9119 unique adult patients made 24,285 visits. Patients were majority women (67.5%) and Hispanic/Latino (54.5%). Overall, 46.2% were screened, with 19.0–35.8% of eligible patients screened in each month. Increasing age (OR: 0.82 [95% CI 0.80–0.85] for a 10-year increase), female sex (OR: 0.83 [95% CI 0.77–0.91]), and chronic conditions like hypertension (OR: 0.62 [95% CI 0.56–0.70]) and diabetes (OR: 0.66 [95% CI 0.58–0.75]), among others, were associated with a lower odds of being screened. Of all patients screened, 225 (5.3%) screened positive and of those patients, 122 (54.2%) received a BI. Patients with higher AUDIT-C scores were more likely to receive a BI (OR: 1.24 [95% CI 1.04–1.47] for a 1-point increase) and non-English speaking patients were less likely to receive a BI than those who spoke English (OR: 0.42 [95% CI 0.18–0.97]).

Conclusions

Our model of SBI resulted in screening of nearly half of all eligible patients and BI provision to over half of those screening positive. Future efforts to improve SBI delivery should focus on groups such as older adults, women, and those with chronic medical conditions.

Personalised digital interventions for reducing hazardous and harmful alcohol consumption in community-dwelling populations

BACKGROUND

Excessive alcohol use contributes significantly to physical and psychological illness, injury and death, and a wide array of social harm in all age groups. A proven strategy for reducing excessive alcohol consumption levels is to offer a brief conversation-based intervention in primary care settings, but more recent technological innovations have enabled people to interact directly via computer, mobile device or smartphone with digital interventions designed to address problem alcohol consumption.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of digital interventions for reducing hazardous and harmful alcohol consumption, alcohol-related problems, or both, in people living in the community, specifically: (i) Are digital interventions more effective and cost-effective than no intervention (or minimal input) controls? (ii) Are digital interventions at least equally effective as face-to-face brief alcohol interventions? (iii) What are the effective component behaviour change techniques (BCTs) of such interventions and their mechanisms of action? (iv) What theories or models have been used in the development and/or evaluation of the intervention? Secondary objectives were (i) to assess whether outcomes differ between trials where the digital intervention targets participants attending health, social care, education or other community-based settings and those where it is offered remotely via the internet or mobile phone platforms; (ii) to specify interventions according to their mode of delivery (e.g. functionality features) and assess the impact of mode of delivery on outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, ERIC, HTA and Web of Knowledge databases; ClinicalTrials.com and WHO ICTRP trials registers and relevant websites to April 2017. We also checked the reference lists of included trials and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effectiveness of digital interventions compared with no intervention or with face-to-face interventions for reducing hazardous or harmful alcohol consumption in people living in the community and reported a measure of alcohol consumption.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 57 studies which randomised a total of 34,390 participants. The main sources of bias were from attrition and participant blinding (36% and 21% of studies respectively, high risk of bias). Forty one studies (42 comparisons, 19,241 participants) provided data for the primary meta-analysis, which demonstrated that participants using a digital intervention drank approximately 23 g alcohol weekly (95% CI 15 to 30) (about 3 UK units) less than participants who received no or minimal interventions at end of follow up (moderate-quality evidence).Fifteen studies (16 comparisons, 10,862 participants) demonstrated that participants who engaged with digital interventions had less than one drinking day per month fewer than no intervention controls (moderate-quality evidence), 15 studies (3587 participants) showed about one binge drinking session less per month in the intervention group compared to no intervention controls (moderate-quality evidence), and in 15 studies (9791 participants) intervention participants drank one unit per occasion less than no intervention control participants (moderate-quality evidence).Only five small studies (390 participants) compared digital and face-to-face interventions. There was no difference in alcohol consumption at end of follow up (MD 0.52 g/week, 95% CI -24.59 to 25.63; low-quality evidence). Thus, digital alcohol interventions produced broadly similar outcomes in these studies. No studies reported whether any adverse effects resulted from the interventions.A median of nine BCTs were used in experimental arms (range = 1 to 22). 'B' is an estimate of effect (MD in quantity of drinking, expressed in g/week) per unit increase in the BCT, and is a way to report whether individual BCTs are linked to the effect of the intervention. The BCTs of goal setting (B -43.94, 95% CI -78.59 to -9.30), problem solving (B -48.03, 95% CI -77.79 to -18.27), information about antecedents (B -74.20, 95% CI -117.72 to -30.68), behaviour substitution (B -123.71, 95% CI -184.63 to -62.80) and credible source (B -39.89, 95% CI -72.66 to -7.11) were significantly associated with reduced alcohol consumption in unadjusted models. In a multivariable model that included BCTs with B > 23 in the unadjusted model, the BCTs of behaviour substitution (B -95.12, 95% CI -162.90 to -27.34), problem solving (B -45.92, 95% CI -90.97 to -0.87), and credible source (B -32.09, 95% CI -60.64 to -3.55) were associated with reduced alcohol consumption.The most frequently mentioned theories or models in the included studies were Motivational Interviewing Theory (7/20), Transtheoretical Model (6/20) and Social Norms Theory (6/20). Over half of the interventions (n = 21, 51%) made no mention of theory. Only two studies used theory to select participants or tailor the intervention. There was no evidence of an association between reporting theory use and intervention effectiveness.

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that digital interventions may lower alcohol consumption, with an average reduction of up to three (UK) standard drinks per week compared to control participants. Substantial heterogeneity and risk of performance and publication bias may mean the reduction was lower. Low-quality evidence from fewer studies suggested there may be little or no difference in impact on alcohol consumption between digital and face-to-face interventions.The BCTs of behaviour substitution, problem solving and credible source were associated with the effectiveness of digital interventions to reduce alcohol consumption and warrant further investigation in an experimental context.Reporting of theory use was very limited and often unclear when present. Over half of the interventions made no reference to any theories. Limited reporting of theory use was unrelated to heterogeneity in intervention 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.

Unhealthy Alcohol Use

Unhealthy alcohol use is common and routine screening is essential to identify patients and initiate appropriate treatment. At-risk or hazardous drinking is best managed with brief interventions, which can be performed by any provider and are designed to enhance patients' motivations and promote behavioral change. Alcohol withdrawal can be managed, preferably with benzodiazepines, using a symptom-triggered approach. Twelve-step programs and provider-driven behavioral therapies have robust data supporting their effectiveness and patients with alcohol use disorder should be referred for these services. Research now support the use of several FDA-approved medications that aid in promoting abstinence and reducing heavy drinking.

Binge drinking and perceived ethnic discrimination among Hispanics/Latinos: Results from the Hispanic community health study/study of Latinos sociocultural ancillary study

The study assessed whether overall perceived ethnic discrimination and four unique discrimination types were associated with binge drinking in participants from the Hispanic Community Health Study/Study of Latinos who also completed the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study (n = 5,313). In unadjusted analyses that were weighted for sampling strategy and design, each unit increase in discrimination type was associated with a 12-63% increase in odds of binge drinking; however, after adjusting for important demographic variables including age, sex, heritage group, language, and duration of U.S. residence, there was no longer an association between discrimination and binge drinking. Further research still needs to identify the salient factors that contribute to increased risk for binge drinking among Hispanics/Latinos.

Stigma, substance use and sexual risk behaviors among HIV-infected men who have sex with men: A qualitative study

Background

Public health HIV-service providers, including Medical Case Managers (case managers) and Disease Intervention Specialists (DIS) have a key role to play in identifying and addressing clients' complex mental health needs and substance use which contribute to sexual risk behaviors, yet their understanding and its consensus with HIV-infected men who have sex with men (MSM) have not been well characterized.

Methods

Together with an AIDS Service Organization and the Connecticut State Department of Public Health in 2011–2012, we conducted a focus group of case managers (n = 14) and interviewed DIS (n = 7) and HIV-infected MSM (n = 17) in Connecticut. We used the constant comparison method, grounded theory, and a community-based participatory approach to guide analysis.

Results

We identified three themes characterizing public health HIV-service providers' and MSM's perspectives regarding factors contributing to substance use and sexual risk behaviors in the context of HIV infection: 1) While both MSM and providers described a co-occurrence of HIV, stigma, substance use, and sexual risk behaviors, only MSM identified a causal relationship between these factors; 2) MSM and providers both described varying levels of self-efficacy in readiness to decrease substance use and sexual risk behaviors among MSM; both identified the social network as the key barrier to overcome; 3) Providers described how the co-occurrence of HIV, stigma and sexual risk behaviors leads to multi-faceted client needs for which they lacked sufficient training and collaboration.

Conclusions

Provider education, skills-based training, and interventions targeting social networks may decrease sexual risk behaviors among HIV-infected MSM.

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MSM recognize that HIV diagnosis may trigger substance use and sexual risk behaviors.

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HIV-service providers inconsistently prepared to facilitate behavior change among MSM

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Need social network-based interventions to decrease MSM's risk behaviors

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Provider training on interventions & stages of change theory to address risk behaviors warranted

Commentary on Gelberg et al. 2015: Alcohol and other drug screening and brief intervention--evidence in crisis

Most evidence suggests that drug screening and brief intervention (SBI) is not efficacious. Conflicting study results may be due to different interventions, and methodological differences may explain most positive SBI trial results. A renewed focus should be on objective outcomes and intervention details.

Together Achieving More: Primary Care Team Communication and Alcohol-Related Healthcare Utilization and Costs

BACKGROUND

Identifying and engaging excessive alcohol users in primary care may be an effective way to improve patient health outcomes, reduce alcohol-related acute care events, and lower costs. Little is known about what structures of primary care team communication are associated with alcohol-related patient outcomes.

METHODS

Using a sociometric survey of primary care clinic communication, this study evaluated the relation between team communication networks and alcohol-related utilization of care and costs. Between May 2013 and December 2013, a total of 155 healthcare employees at 6 primary care clinics participated in a survey on team communication. Three-level hierarchical modeling evaluated the link between connectedness within the care team and the number of alcohol-related emergency department visits, hospital days, and associated medical care costs in the past 12 months for each team's primary care patient panel.

RESULTS

Teams (n = 31) whose registered nurses displayed more strong (at least daily) face-to-face ties and strong (at least daily) electronic communication ties had 10% fewer alcohol-related hospital days (rate ratio [RR] = 0.90; 95% confidence interval [CI]: 0.84, 0.97). Furthermore, in an average team size of 19, each additional team member with strong interaction ties across the whole team was associated with $1,030 (95% CI: -$1,819, -$241) lower alcohol-related patient healthcare costs per 1,000 team patients in the past 12 months. Conversely, teams whose primary care practitioner (PCP) had more strong face-to-face communication ties and more weak (weekly or several times a week) electronic communication ties had 12% more alcohol-related hospital days (RR = 1.12; 95% CI: 1.03, 1.23) and $1,428 (95% CI: $378, $2,478) higher alcohol-related healthcare costs per 1,000 patients in the past 12 months. The analyses controlled for patient age, gender, insurance, and comorbidity diagnoses.

CONCLUSIONS

Excessive alcohol-using patients may fair better if cared for by teams whose face-to-face and electronic communication networks include more team members and whose communication to the PCP has been streamlined to fewer team members.

Effectiveness of brief interventions in primary health care settings to decrease alcohol consumption by adult non-dependent drinkers: a systematic review of systematic reviews

OBJECTIVE

To evaluate the effectiveness of brief interventions in the primary health care setting to decrease alcohol consumption in non-alcoholic adult drinkers.

METHOD

Systematic review of systematic reviews and meta-analyses of randomized clinical trials published in English and Spanish and indexed in EMBASE, MEDLINE (PubMed), Web of Science, Scopus, and The Cochrane Library, from their inception to January 2014. The quality of the studies was evaluated with the AMSTAR instrument.

RESULTS

Seven studies, published from 1999 to 2011, were included in the review (six meta-analyses, one systematic review). These studies were heterogeneous in terms of design, type and length of interventions analyzed, participants, responsible professionals, and results. Five studies reported a moderate decrease in alcohol consumption and four showed a decrease in the number of participants who consumed alcohol above the established risk level.

CONCLUSION

Brief interventions have a moderate effect on reducing alcohol consumption among excessive drinkers or people who consume excessive amounts of alcohol and as a consequence these interventions increased the number of people drinking alcohol below established limits of risk. Brief interventions with multiple contacts or follow-up sessions are the most effective.

Nursing students' experiences with screening, brief intervention, and referral to treatment for substance use in the clinical/hospital setting

Although Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an effective early intervention when used across healthcare settings, its implementation has been difficult, in part because of lack of training, healthcare providers' feelings of low self-efficacy in performing SBIRT, and negative attitudes about people who use alcohol and drugs. This study used qualitative descriptive methods to examine baccalaureate nursing students' experiences with practicing SBIRT in clinical rotations following in-depth classroom work and skill-based training. Fifty-five junior level nursing students participated in four focus groups. Three overarching themes describe students' experiences with SBIRT. Students expressed a positive impact of the training on their attitudes and feelings of self-efficacy regarding the use of SBIRT, differences in opinions about whether SBIRT should be used universally with all patients or as a targeted intervention with only some patients, and that SBIRT is a nursing responsibility. These results suggest that education and training can affect attitudes and efficacy, but that attention needs to be paid to how SBIRT is implemented within different healthcare settings.

[Comparative effectiveness and safety of screening and counselling interventions conducted by non-physicians and physicians: a systematic review]

BACKGROUND

Current forecasts project a future shortage of physicians which might compromise the quality of health care if not addressed adequately by health policy decisions. One proposed measure is to shift selected tasks and responsibilities from physicians to other medical staff, a strategy that has proven successful in some areas (e. g., chronic disease management). To date, no studies have systematically and objectively assessed whether the application of a similar strategy to screening and counselling in preventive medicine compromises patients' health outcomes and experiences.

METHODS

A systematic search was conducted in MEDLINE, the Cochrane Library, CINAHL, and EMBASE (January 2000 - June 2014). We dually reviewed articles and assessed the risk of bias.

RESULTS

3,315 citations were identified and five relevant articles located. Overall, the available evidence indicated that there were no substantial differences in benefits and harms of screening (colon cancer screening, sexual transmitted diseases, and mammography) and counselling (genetic breast cancer risk) between non-physicians and physicians. The quality of evidence, however, is very low for most comparisons. Reported statistically significant differences for some outcomes need to be viewed cautiously.

CONCLUSION

Shifting tasks from physicians to other medical staff for screening and counselling could be a viable strategy to address the shortage of practicing physicians. Adequate training by a physician, however, is a prerequisite for the safe and beneficial screening and counselling conducted by non-physicians.

Comparing the motivational interviewing integrity in two prevalent models of brief intervention service delivery for primary care settings

This quasi experimental study compared the motivational interviewing (MI) integrity in two prevalent brief intervention (BI) service delivery models for drug abuse. Routine primary care providers (RCPs) and non-routine care providers (NRCPs) performed BIs using an MI style within the same medical setting, patient population, and Screening, Brief Intervention, and Referral for Treatment (SBIRT) protocol. Interventionists (9 RCPs and 6 NRCPs) underwent similar MI training and performed a total of 423 audiorecorded BIs. We compared the MI integrity scores for all audio recorded sessions from these two SBIRT models for up to 40 months post MI training. Both groups met the lower standard (beginning proficiency in MI) on 4 of 5 MI integrity scores, but NRCPs met more of the higher standards (competency in MI) than RCPs. There may be limitations with regards to MI fidelity when using RCPs to conduct BIs in some primary care settings. Further experimental investigation is warranted to replicate this finding and identify casual factors of observed differences in MI fidelity.

Vida PURA: A Cultural Adaptation of Screening and Brief Intervention to Reduce Unhealthy Drinking Among Latino Day Laborers

BACKGROUND

Brief intervention is known to reduce drinking in primary care; however, because health care access is limited for Latino immigrants, traditional brief interventions are unlikely to reach this population.

METHODS

Using Barrera and Castro's framework, our study aims to culturally adapt a screening and brief intervention program to reduce unhealthy alcohol use among Latino day laborers, a particularly vulnerable group of Latino immigrant men. We conducted 18 interviews with Latino day laborers and 13 interviews with mental health and substance use providers that serve Latino immigrant men. Interviews were conducted until saturation of themes was reached. Themes from interviews were used to identify sources of mismatch between traditional screening and brief intervention in our target population.

RESULTS

Unhealthy alcohol use was common, culturally accepted, and helped relieve immigration-related stressors. Men had limited knowledge about how to change their behavior. Men preferred to receive information from trusted providers in Spanish. Men faced significant barriers to accessing health and social services but were open to receiving brief interventions in community settings. Findings were used to design Vida PURA, a preliminary adaptation design of brief intervention for Latino day laborers. Key adaptations include brief intervention at a day labor worker center provided by promotores trained to incorporate the social and cultural context of drinking for Latino immigrant men.

CONCLUSIONS

Culturally adapted brief intervention may help reduce unhealthy drinking in this underserved population.

Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial

IMPORTANCE

Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance).

OBJECTIVE

To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points.

INTERVENTIONS

Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433).

MAIN OUTCOMES AND MEASURES

The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior.

RESULTS

Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes.

CONCLUSIONS AND RELEVANCE

A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00877331.

Extended-release naltrexone for alcohol and opioid dependence: a meta-analysis of healthcare utilization studies

Through improved adherence, once-monthly injectable extended-release naltrexone (XR-NTX) may provide an advantage over other oral agents approved for alcohol and opioid dependence treatment. The objective of this study was to evaluate cost and utilization outcomes between XR-NTX and other pharmacotherapies for treatment of alcohol and opioid dependence. Published studies were identified through comprehensive search of two electronic databases. Studies were included if they compared XR-NTX to other approved medicines and reported economic and healthcare utilization outcomes in patients with opioid or alcohol dependence. We identified five observational studies comparing 1,565 patients using XR-NTX to other therapies over 6 months. Alcohol dependent XR-NTX patients had longer medication refill persistence versus acamprosate and oral naltrexone. Healthcare utilization and costs was generally lower or as low for XR-NTX-treated patients relative to other alcohol dependence agents. Opioid dependent XR-NTX patients had lower inpatient substance abuse-related utilization versus other agents and $8170 lower total cost versus methadone.

Are nurse-conducted brief interventions (NCBIs) efficacious for hazardous or harmful alcohol use? A systematic review

AIM

The aim of this study was to compare the efficacy of nurse-conducted brief interventions in reducing alcohol consumption, by looking at with treatment as usual compared with other treatments and general physician-delivered brief interventions within the literature.

BACKGROUND

Globally, the consumption of alcohol is at a worrying level and has significant effects on health when consumed to excess. Numerous studies have reported that brief intervention is effective in reducing excessive drinking. However, evidence on the efficacy of such interventions by nurses is still inconclusive.

METHODS

We included randomized controlled trials of brief interventions in which nurses were primarily involved as therapists, and were designed to achieve a reduction in alcohol consumption and related problems. We used online searches to locate randomized controlled trials in this area published from 1995 till 2012.

FINDINGS

Eleven trials were found meeting inclusion criteria, comparing nurse-conducted brief interventions with a control group or with other treatments. Five trials reported a statistically significant reduction in alcohol consumption in the intervention group with 6-12-month follow-up period and two trials concluded that brief interventions delivered by nurses was as efficacious as by physicians.

IMPLICATIONS FOR NURSING POLICY

The findings of the review have important policy implications for the preparation of nurses as therapists for brief interventions to reduce excessive drinking in a broad range of settings such as primary healthcare and hospital settings. The adoption of this intervention into contemporary nursing practice should be considered by the International Council of Nurses and nurses around the world as, according to the literature, it provides an evidence base for the independent functioning of nurses within the realms of nursing profession and addiction medicine.

CONCLUSION

The results of the review suggest that nurse-conducted brief interventions are an effective strategy for reducing alcohol consumption. We advocate more rigorous randomized controlled trials to underpin its efficacy in both research and real life scenario.

Medical specialists' views on the impact of reducing alcohol consumption on prognosis of, and risk of, hospital admission due to specific medical conditions: results from a Delphi survey

RATIONALE, AIMS AND OBJECTIVES

To find consensus, or lack thereof, on the impact of reducing alcohol consumption on prognosis and the risk of hospital admissions for a number of alcohol-attributable disorders.

METHODS

A modified two-round Delphi survey utilizing web-based questionnaires to collect quantitative and qualitative data was used. Alcohol treatment experts from cardiology, emergency medicine, gastroenterology and oncology in the United Kingdom were invited to participate. The main outcomes were median impact ratings (on a scale of 1-9) and consensus (unanimous, strong, moderate, weak or no consensus).

RESULTS

Of 192 experts invited to participate, 59 completed first questionnaires. The overall retention rate to the second questionnaires was about 51% (30/59). There was strong support that reducing alcohol consumption could result in improvement in prognosis for gastroenterology and emergency medicine patients; but uncertainty on the benefits for cardiology and oncology patients. Overall, the responses from the expert panel did not reflect the assumption that reducing alcohol consumption would result in benefits on hospital admissions for any of the specialties. The specialists viewed the severity of disorders as important when considering the impact of reducing alcohol consumption.

CONCLUSIONS

The highest impact of treatment for problem drinking in hospitals is considered to be for alcohol-related disorders associated with gastroenterology and emergency medicine. At policy level, if targeted screening for alcohol problems by presenting disease or condition is the strategy of choice, it would be logical to implement screening and easily accessible interventions or addiction specialists within these areas where alcohol treatment is considered as having a high impact.

From efficacy to effectiveness and beyond: what next for brief interventions in primary care?

BACKGROUND

Robust evidence supports the effectiveness of screening and brief alcohol interventions in primary healthcare. However, lack of understanding about their "active ingredients" and concerns over the extent to which current approaches remain faithful to their original theoretical roots has led some to demand a cautious approach to future roll-out pending further research. Against this background, this paper provides a timely overview of the development of the brief alcohol intervention evidence base to assess the extent to which it has achieved the four key levels of intervention research: efficacy, effectiveness, implementation, and demonstration.

METHODS

Narrative overview based on (1) the results of a review of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare and (2) synthesis of the findings of key additional primary studies on the improvement and evaluation of brief alcohol intervention implementation in routine primary healthcare.

RESULTS

The brief intervention field seems to constitute an almost perfect example of the evaluation of a complex intervention. Early evaluations of screening and brief intervention approaches included more tightly controlled efficacy trials and have been followed by more pragmatic trials of effectiveness in routine clinical practice. Most recently, attention has shifted to dissemination, implementation, and wider-scale roll-out. However, delivery in routine primary health remains inconsistent, with an identified knowledge gap around how to successfully embed brief alcohol intervention approaches in mainstream care, and as yet unanswered questions concerning what specific intervention component prompt the positive changes in alcohol consumption.

CONCLUSION

Both the efficacy and effectiveness of brief alcohol interventions have been comprehensively demonstrated, and intervention effects seem replicable and stable over time, and across different study contexts. Thus, while unanswered questions remain, given the positive evidence amassed to date, research efforts should maintain a continued focus on promoting sustained implementation of screening and brief alcohol intervention approaches in primary care to ensure that those who might benefit from screening and brief alcohol interventions actually receive such support.

The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews

Aims: The aim of the study was to assess the cumulative evidence on the effectiveness of brief alcohol interventions in primary healthcare in order to highlight key knowledge gaps for further research. Methods: An overview of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare published between 2002 and 2012. Findings: Twenty-four systematic reviews met the eligibility criteria (covering a total of 56 randomized controlled trials reported across 80 papers). Across the included studies, it was consistently reported that brief intervention was effective for addressing hazardous and harmful drinking in primary healthcare, particularly in middle-aged, male drinkers. Evidence gaps included: brief intervention effectiveness in key groups (women, older and younger drinkers, minority ethnic groups, dependent/co-morbid drinkers and those living in transitional and developing countries); and the optimum brief intervention length and frequency to maintain longer-term effectiveness. Conclusion: This overview highlights the large volume of primarily positive evidence supporting brief alcohol intervention effects as well as some unanswered questions with regards to the effectiveness of brief alcohol intervention across different cultural settings and in specific population groups, and in respect of the optimum content of brief interventions that might benefit from further research.

Interventions for reducing alcohol consumption among general hospital inpatient heavy alcohol users: a systematic review

BACKGROUND

There is growing interest in pro-active detection and provision of interventions for heavy alcohol use in the general hospital inpatient population. We aimed to determine, from the available evidence, the effectiveness of interventions in reducing alcohol consumption among general hospital inpatient heavy alcohol users.

METHODS

The following databases were searched for completed and on-going randomised and non-randomised controlled studies published up to November 2012: MEDLINE; C2-SPECTR; CINAHL; The Cochrane Library; Conference Proceedings Citation Index: Science; EMBASE; HMIC; PsycInfo; Public Health Interventions Cost Effectiveness Database (PHICED); and ClinicalTrials.gov. Studies were screened independently by two reviewers. Data extraction was performed by one reviewer and independently checked by a second.

RESULTS

Twenty-two studies which met the inclusion criteria enrolled 5307 participants in total. All interventions were non-pharmacological and alcohol focused. Results from single session brief interventions and self-help literature showed no clear benefit on alcohol consumption outcomes, with indications of benefit from some studies but not others. However, results suggest brief interventions of more than one session could be beneficial on reducing alcohol consumption, especially for non-dependent patients. No active intervention was found superior over another on alcohol consumption and other outcomes.

CONCLUSIONS

Brief interventions of more than one session could be beneficial on reducing alcohol consumption among hospital inpatients, especially for non-dependent patients. However, additional evidence is still needed before more definitive conclusions can be reached.

2012 Update in addiction medicine for the generalist

This article presents an update on addiction-related medical literature for the calendar years 2010 and 2011, focusing on studies that have implications for generalist practice. We present articles pertaining to medical comorbidities and complications, prescription drug misuse among patients with chronic pain, screening and brief interventions (SBIs), and pharmacotherapy for addiction.

Integrating substance abuse care with community diabetes care: implications for research and clinical practice

Cigarette smoking and alcohol use are prevalent among individuals with diabetes in the US, but little is known about screening and treatment for substance use disorders in the diabetic population. This commentary discusses the scope and clinical implications of the public health problem of coexisting substance use and diabetes, including suggestions for future research. Diabetes is the seventh leading cause of death in the US, and is associated with many severe health complications like cardiovascular disease, stroke, kidney damage, and limb amputations. There are an estimated 24 million adults in the US with type 2 diabetes. Approximately 20% of adults aged 18 years or older with diabetes report current cigarette smoking. The prevalence of current alcohol use in the diabetic population is estimated to be around 50%-60% in epidemiological surveys and treatment-seeking populations. Cigarette smoking is associated with an increased risk of type 2 diabetes in a dose-dependent manner and is an independent modifiable risk factor for development of type 2 diabetes. Diabetic patients with an alcohol or other drug use disorder show a higher rate of adverse health outcomes. For example, these patients experience more frequent and severe health complications as well as an increased risk of hospitalization, and require longer hospital stays. They are also less likely to seek routine care for diabetes or adhere to diabetes treatment than those without an alcohol or other drug use disorder. The Affordable Care Act of 2010 and the Mental Health Parity Act and Addiction Equity Act of 2008 provide opportunities for facilitating integration of preventive services and evidence-based treatments for substance use disorders with diabetes care in community-based medical settings. These laws also offer emerging areas for research.