The Cochrane 2018 Review on Brief Interventions in Primary Care for Hazardous and Harmful Alcohol Consumption: A Distillation for Clinicians and Policy Makers

AIMS

An updated Cochrane systematic review assessed effectiveness of screening and brief intervention to reduce hazardous or harmful alcohol consumption in general practice or emergency care settings. This paper summarises the implications of the review for clinicians.

METHODS

Cochrane methods were followed. Reporting accords with PRISMA guidance. We searched multiple resources to September 2017, seeking randomised controlled trials 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. 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 min. Our primary outcome was alcohol consumption, measured as or convertible to grams per week. We conducted meta-analyses to assess change in consumption, and subgroup analyses to explore the impact of participant and intervention characteristics.

RESULTS

We included 69 studies, of which 42 were added for this update. Most studies (88%) compared brief intervention to control. The primary meta-analysis included 34 studies and provided moderate-quality evidence that brief intervention reduced consumption compared to control after one year (mean difference -20 g/wk, 95% confidence interval -28 to -12). Subgroup analysis showed a similar effect for men and women.

CONCLUSIONS

Brief interventions can reduce harmful and hazardous alcohol consumption in men and women. Short, advice-based interventions may be as effective as extended, counselling-based interventions for patients with harmful levels of alcohol use who are presenting for the first time in a primary care setting.

Effectiveness of brief alcohol interventions in primary care populations

BACKGROUND

Many trials reported that brief interventions are effective in reducing excessive drinking. However, some trials have been criticised for being clinically unrepresentative and unable to inform clinical practice.

OBJECTIVES

To assess the effectiveness of brief intervention, delivered in general practice or based primary care, to reduce alcohol consumption

SEARCH STRATEGY

We searched the Cochrane Drug and Alcohol Group specialised register (February 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), CINAHL (1982 to February 2006), PsycINFO (1840 to February 2006), Science Citation Index (1970 to February 2006), Social Science Citation Index (1970 to February 2006), Alcohol and Alcohol Problems Science Database (1972 to 2003), reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials, patients presenting to primary care not specifically for alcohol treatment; brief intervention of up to four sessions.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, sub-group, sensitivity analyses, and meta-regression were conducted.

MAIN RESULTS

The meta-analysis included 21 RCTs (7,286 participants), showing that participants receiving brief intervention reduced their alcohol consumption compared to the control group (mean difference: -41 grams/week, 95% CI: -57 to -25), although there was substantial heterogeneity between trials (I2 = 52%). Sub-group analysis (8 studies, 2307 participants) confirmed the benefit of brief intervention in men (mean difference: -57 grams/week, 95% CI: -89 to -25, I2 = 56%), but not in women (mean difference: -10 grams/week, 95% CI: -48 to 29, I2 = 45%). Meta-regression showed a non-significant trend of an increased reduction in alcohol consumption of 1.1, 95%CI: -0.05 to 2.2 grams/week, p=0.06, for each extra minute of treatment exposure, but no relationship between the reduction in alcohol consumption and the efficacy score of the trial. Extended intervention when compared with brief intervention was associated with a non-significantly greater reduction in alcohol consumption (mean difference = -28, 95%CI: -62 to 6 grams/week, I2 = 0%)

AUTHORS' CONCLUSIONS

Brief interventions consistently produced reductions in alcohol consumption. When data were available by gender, the effect was clear in men at one year of follow up, but unproven in women. Longer duration of counselling probably has little additional effect. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature had clear relevance to routine primary care. Future trials should focus on women and on delineating the most effective components of interventions.